 |
|
|
|
|
|
HIPAA: Your rights to health
insurance portability
The Kassebaum-Kennedy Act, also known as the Health Insurance Portability and Accountability Act of 1996, was designed to allow workers to move from one company to another without the fear of losing health insurance coverage.
Your pre-existing conditions are covered
Many health insurance companies like to exclude pre-existing conditions when they offer coverage. They do this as a way to hold down their costs by limiting claims.
Pre-existing conditions are any conditions that you have before buying the health plan. There is a lot of debate in the insurance world concerning pre-existing conditions.
Before HIPAA, if you had a medical condition, you might find it near impossible to switch jobs. If you did, you were facing a new insurance company that would consider your medical condition as pre-existing. The company would refuse to cover any treatment in regards to the condition. You would have to pay for all of your medical treatment for the condition out of your own pocket.
This situation made it impossible for many employees to move jobs.
HIPAA imposes a limit on group health plans that want to exclude pre-existing conditions. For example, if you have health insurance for 12 straight months with no lapse in coverage of over 63 days, a new group health plan cannot use the pre-existing condition exclusion. It must cover your medical problems.
The previous coverage must be creditable. It can be a group health plan, Medicare, Medicaid, a military-sponsored health care plan, Indian Health Services, state high-risk insurance pool, federal Employees Health Benefit Program, a public health plan or a Peace Corp member plan.
If you are not switching from a creditable health policy upon enrolling in a new group plan, your new insurer can refuse to pay for your existing medical conditions, except for pregnancy. Maternity restrictions are only legal for a maximum of 12 months.
Some group health plans are known for excluding pre-existing conditions for 18 months. This helps them to offset costs incurred.
What does HIPAA mean to you?
HIPAA ensures that group health plans cannot deny your application for coverage based only on your health status. It limits the exclusion on pre-existing conditions by health insurance providers. You cannot be denied coverage based on mental illness, genetic information, disability or your past claims history.
Group health plans that offer maternity coverage are not allowed to consider a current pregnancy a pre-existing condition. They must provide coverage for prenatal care and delivery, no matter your employment or health insurance history. This is true for the insured and the dependents.
Every employer group health plan with two participants or more are required to follow HIPAA's rules. Some states even apply the rules to groups that only contain one employee. They use it as a way to protect the self-employed. Some states have added additional laws that protect health insurance applicants, offering employees more rights.
The only exception is that there is no protection when switching from one individual health plan to another individual health plan.
Other conditions of HIPAA
There are many exceptions, conditions and loopholes that come with HIPAA. You should fully understand your rights in regards to your situation before you change your health plan.
Employers are not required to offer or pay for part or all of an employee health insurance plan. Your employer can choose not to offer health insurance as a benefit. Some employers offer only medical insurance, with no coverage for mental health of maternity. Others offer the whole package.
HIPAA allows you full coverage of your medical conditions, yet it doesn't guarantee the same level of benefits, deductibles and claim limits as your former insurance. These factors are set by the company and employer.
HIPAA requirements do not apply to:
-Coverage for accidental death or
dismemberment
-Disability insurance coverage
-Liability
insurance
-Workers compensation
-MedPay
-Credit-only
insurance
-Coverage for on-site medical
facilities
Lapses in coverage
If you have had a lapse in your health insurance
coverage, you may face a period of exclusion for pre-existing conditions.
For example, if you haven't had health insurance for six months, you may
have to take a 12-month exclusion period on your pre-existing conditions
with your new health insurance.
In order to have continuous full coverage, you cannot have a lapse in your health insurance coverage that is over 63 days. This is where COBRA comes in.
If you leave a company before you start with a new one, you should seriously consider maintaining your COBRA coverage. This is expensive, but will allow you to maintain continuous coverage with no exclusion period for pre-existing conditions.
When you leave a health plan, make sure you get a "certificate of creditable coverage" from that plan. It will list your coverage dates, policy ID number, insurer's name and address and the dependents on the plan. This will make it easier to document your rights under HIPAA.
You can also use your pay stubs that show deduction of health insurance premiums, Explanation-of-benefit forms, benefit-termination notice or verification from your doctor that says you had prior coverage.
The individual plan and HIPAA
If your employer drops your group health coverage, HIPAA can make it easier to obtain an individual health policy. You may be able to buy an individual plan without facing exclusions for pre-existing conditions.
You must be an eligible individual to qualify for individual health coverage under HIPAA. This means you must:
-Have at least 18 months of continuous coverage prior to
changing plans.
-Have been covered by a group plan, a government plan
or a church plan.
-Not be eligible for coverage under a group health
plan, Medicare or Medicaid.
-Have no other health insurance.
-Have
not lost your coverage due to non-payment of premiums of fraud.
-Have elected and exhausted
your COBRA that was available under your previous plan.
There are no limits
placed by HIPAA on the amount of premiums you could be charged for
individual health insurance. Your application will not be rejected, but
the premiums could be quite high if you have medical conditions.
This makes it important to shop around for the best rates.