Standard Requirements of Group Health Plans Under HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) ensures implementation of group health plan security and privacy measures and legally enforces the requirements. HIPAA levies stiff penalties against non-compliant entities for violations of prescribed regulations. HIPAA provides standard rights and protection that prohibits discrimination against employees and dependents based on health status, and regulates certain rights for continuous health insurance coverage.

Pre-existing Conditions

• HIPAA prohibits using pre-existing condition exclusions to deny coverage; however, group plans may impose waiting periods for pre-existing conditions of no more than 12 months from the first day of coverage (18 months for late enrollment). Plans can look back only six months for pre-existing conditions.

  Group health plans cannot require individuals to present evidence of insurability for enrollment purposes.

Special Enrollment

• Group health plans must allow employees and dependents to enroll in the health plan based on life-changing events that include marriage, birth, adoption or placement for adoption. Coverage must be effective on the date of birth, adoption or placement for adoption. Marriage coverage commences no later than the first day of the first calendar month following the special enrollment request.

Childbirth

• Healthcare professionals are not required to obtain preauthorization from the health plan to cover 48-hour (normal delivery) or 96-hour (Cesarean section) hospitalization stays for childbirth.

Premiums

• HIPAA forbids group plans from charging higher individual premiums based on personal health-related factors and conditions.

Certificate of Coverage

• Group health plans must automatically issue certificates of creditable coverage at no charge when an individual becomes eligible for COBRA coverage. Certificates must be issued upon request for up to 24 months.

  HIPAA guarantees that certain individuals will have access to individual health insurance coverage and provides opportunities to enroll in a new group if an individual loses coverage.