The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides rights and protections for participants and beneficiaries in group health plans. HIPAA includes protections for coverage under group health plans that limit exclusions for preexisting conditions; prohibits discrimination against employees and dependents based on their health status; and allows a special opportunity to enroll in a new plan to individuals in certain circumstances. HIPAA may also give employees a right to purchase individual coverage if they have no group health plan coverage available and have exhausted COBRA or other continuation coverage.
HIPAA protects workers and their families by:
- limiting exclusions for preexisting medical conditions (known as preexisting conditions);
- providing credit against maximum preexisting condition exclusion periods for prior health coverage and a process for providing certificates showing periods of prior coverage to a new group health plan or health insurance issuer;
- providing new rights that allow individuals to enroll for health coverage when they lose other health coverage, get married, or add a new dependent;
- prohibiting discrimination in enrollment and in premiums charged to employees and their dependents based on health status-related factors;
- guaranteeing availability of health insurance coverage for small employers and renewability of health insurance coverage for both small and large employers;
- preserving the states’ role in regulating health insurance, including the states’ authority to provide greater protections than those available under federal law; and
- improving disclosure about group health plans
Preexisting condition exclusions
- The law defines a preexisting condition as one for which medical advice, diagnosis, care, or treatment was recommended or received during the six-month period prior to an individual’s enrollment date (which is the earlier of the first day of health coverage or the first day of any waiting period for coverage).
- Group health plans and issuers may not exclude an individual’s preexisting medical condition from coverage for more than 12 months (18 months for late enrollees) after an individual’s enrollment date.
- Under HIPAA, a new employer’s plan must give individuals credit for the length of time they had prior continuous health coverage without a break in coverage of 63 days or more, thereby reducing or eliminating the 12-month exclusion period (18 months for late enrollees).