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The Standard Requirements in HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that affects all areas of health care practice in the United States, including the ability of individuals to keep, renew and establish eligibility for health care coverage. Protecting the privacy of employees' health information and standardizing health care transactions and record keeping procedures are also goals of HIPAA. For health care consumers, HIPAA's rules about protecting the confidentiality of health care records as well as protecting the interests of those with pre-existing conditions are of particular interest.

  1. Employer Protection of Health Information

    • If an employer offers group health coverage, HIPAA requires the employer to protect the privacy of employees' health records. Protections include the designation of a staff member to oversee health care privacy, the implementation of privacy policies and the requirement that employers notify employees of their privacy rights.

    COBRA Rights

    • Under HIPAA, those who are disabled (according to the Social Security Act) are entitled to 29 months of COBRA coverage instead of the standard 18. Children born to or adopted by COBRA recipients are also entitled to COBRA coverage.

    Pre-Existing Conditions Exclusion

    • Under HIPPA, a group health insurance plan cannot refuse to provide benefits for someone with a pre-existing condition if she had no significant break (defined as 63 days) in health insurance coverage prior to joining that plan. If the individual did have a significant break in coverage or was not covered under a group health plan, the insurance provider can only consider whether the individual received medical advice, treatment or a diagnosis for a pre-existing condition during the six months prior to enrolling in a group health plan. If that person did receive treatment, advice or a diagnosis during that six month period, the insurance company can only exclude benefits for that condition for 12 months after enrollment (or 18 months if she was a late enrollee).

    Certificate of Creditable Coverage

    • Under HIPAA, health insurance companies are required to provide an enrollee a "Certificate of Creditable Coverage" when that enrollee terminates insurance coverage. This certificate can be used to prove that there are no significant gaps in insurance coverage such that pre-existing condition exclusions might be enforced.

    Protection Against Discrimination

    • Under HIPAA, individuals and their dependents cannot be discriminated against in receiving group health insurance coverage because of factors such as use of health care in the past, a disability, participation in certain "high-risk" activities, such as motorcycling, or "genetic information."

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