Your Health Plan and HIPAA: Making the Law Work for You
Perhaps you have heard of HIPAA -- the Health Insurance Portability & Accountability Act -- during a visit to your doctor¿s office. The doctor¿s staff may have handed you a ¿HIPAA privacy notice¿ advising you of protections for your personal health information. But HIPAA covers a lot more than privacy. At the time HIPAA was passed, a lot of people were afraid to switch jobs because they might lose the insurance coverage they needed for their families. This report explains how HIPAA¿s protections make it easier to change employers without losing health coverage for your (& your family¿s) medical conditions. It focuses on HIPAA¿s coverage as it applies to private-sector group health plans only. Includes a glossary of terms. Illustrations.
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12 months 30 days 63 days break in coverage carpal tunnel syndrome certificate of creditable COBRA continuation coverage condition exclusion period creditable coverage deny benefits domestic violence eligibility for coverage eligible for COBRA employer's health plan employer's plan enrollment dates example exclude coverage genetic information group health plan groups of similarly health information health insurance policy health plan coverage HIPAAs protections impose a preexisting individual health insurance insurance commissioner's office insured plan late enrollees lifetime limit loss of eligibility maximum preexisting condition Medicaid medical condition Medicare Newborns Pay stubs periods of health placed for adoption placement for adoption plan description SPD preexisting condition exclusion prior coverage prior health coverage PRIOR HEALTH PLAN PROTECTIONS FROM DISCRIMINATION Q My group request a certificate request enrollment significant break similarly situated individuals special enrollment opportunity special enrollment right spouse's plan summary plan description Typical Questions U.S. Department waiting period www.naic.org
Page 4 - ... a preexisting condition exclusion must relate to a condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6month period prior to an individual's enrollment date...
Page 16 - These include: health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), and disability.
Page 17 - When are individuals similarly situated? Distinctions among groups of individuals may not be based on a health factor. Instead, plans must base any such distinctions on bona fide employmentbased classifications that are consistent with the employer's usual business practice. For example, part-time and full-time employees, employees working in different geographic locations, and employees with different dates of hire or lengths of service could be treated as distinct groups of similarly situated individuals,...
Page 19 - ... additional facts indicated that the change was made independent of the claim).22 • A plan may not exclude individuals from coverage due to their participation in motorcycling, snowmobiling, all-terrain vehicle riding, skiing, and other similar recreational activities.23 However, the plan may exclude coverage for injuries that do not result from a medical condition or domestic violence,24 such as injuries sustained in bungee jumping and other high-risk activities.25 These are referred to as...
Page 18 - Group health plans cannot charge an individual more for coverage than a similarly situated individual based on any health factor.
Page 3 - State and local government employees should contact the Centers for Medicare and Medicaid Services at the US Department of Health and Human Services fwww.cms.hhs.gov) about whether they have comparable protections.
Page 17 - After the first 6 months, however, it is waived for individuals who have not had any claims since enrollment. Is this practice allowed?