Rules for HIPAA Portability Insurance

The Health Insurance Portability and Accountability Act (HIPAA) provides rights and protections for participants and beneficiaries of employer-sponsored group health plans to prevent workers or their families from being denied health care coverage. The regulation develops guidelines for health plans that prohibit them from excluding anyone from coverage based on a preexisting medical condition. The rule prohibits health plans from using a health status to determine eligibility. HIPAA gives certain individuals the right to join a plan outside of its open enrollment period as well as a right to purchase individual coverage.

Considerations

• Before HIPAA, some group health plans limited medical coverage or denied a new employee coverage for health conditions he had before enrolling. HIPAA outlaws this practice. Plans only can exclude coverage for a preexisting condition if the patient received medical advice, diagnosis, care or treatment for the condition during the six months prior to his enrollment date. If a new patient received treatment during that time period, the health plan can exclude coverage, but only for a maximum of 12 months. HIPAA also prohibits plans from applying a preexisting condition exclusion on care for newborn and adopted children under 18, care related to a pregnancy and care to patients who have a genetic predisposition for an illness.

Special Enrollment Opportunities

• Individuals who previously decline health coverage from a group health plan can enroll in the plan under HIPAA's special enrollment provision. If a person was covered by a spouse's or a parent's plan and loses that coverage as a result of a job loss, death or a divorce, or the loss of a dependent status, she can apply for coverage under a plan that was previously declined, regardless of the plan's open enrollment period. This provision also allows employees, spouses and new dependents to enroll after a marriage, birth, adoption or placement for adoption. An individual must request to enroll within 30 days of the loss of initial coverage or the life event that triggers the need for coverage.

Equal Opportunity

• Under HIPAA, a health plan can't deny an individual or his family members eligibility or benefits based on medical history at the time of enrollment. Specifically, HIPAA prohibits discrimination against prior medical conditions, including physical and mental illnesses, previous claims experience, disability or genetic information. The plan can't charge a person more for coverage than similarly situated individuals based on any of these health factors. Additionally, the plan can't require an individual to pass a physical exam to be eligible for coverage. However, the plan may require a medical examination or a health questionnaire as part of the application for enrollment.

Coverage Access

• HIPAA grants certain people who have lost health coverage the right to enroll in or renew coverage under an individual insurance policy or as part of a state high-risk pool. The rule applies to individuals who had coverage under a group health plan for at least 18 months without a significant break, lost group coverage for reasons other fraud or nonpayment of premiums, have exhausted coverage under COBRA continuation of benefits, don't have coverage and fall outside of eligibility for coverage under another group health plan, including the federal programs Medicare and Medicaid.