Health Insurance Portability and Accountability Act Regulations

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that helps consumers get and keep health insurance coverage. HIPAA limits exclusions for coverage for preexisting conditions, prohibits discrimination based on prior health conditions and genetic information and guarantees access to health care insurance.

Preexisting Conditions and Getting Coverage

• One of HIPAA's most important facets is that group health plans are only allowed to look at the previous six months when looking at preexisting conditions. Plans are only allowed to exclude medical conditions from coverage if you received treatment, medical care, advice or a diagnosis in the six months prior to applying for a plan. Plans are prohibited from counting pregnancy or genetic information as a preexisting condition for coverage purposes.

Preexisting Condition Exclusion Period

• If a potential plan member has a preexisting condition that is excluded from coverage on a new health care plan, HIPAA places restrictions on how long that coverage can be limited for. For most people, the exclusion period is a maximum 12 months or 18 months if you enroll late. Plan members may be able to reduce the time period a condition is excluded for if they provide a certificate of credible coverage.

Conditions That Cannot be Excluded

• Certain conditions cannot be excluded from coverage even if that condition has been treated in the last six months. For example, conditions in newborn children or a child under the age of 18 who is placed for adoption or adopted cannot be excluded as long as the child is enrolled in the health plan within 30 days of being born, adopted or placed for adoption. Results from genetic tests cannot be used as a reason to deny coverage, nor can an existing pregnancy.

Limitations

• Although HIPAA protects many people against denial of coverage or losing benefits, the law does have its limitations. HIPAA doesn't require employers to offer health plan benefits, so if your new employer doesn't offer insurance, you may find yourself without coverage. If your new employer does offer a health plan, there's no requirement in HIPAA that the plan has to cover all conditions. For example, the plan may not cover major medical procedures.