HIPAA - Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act (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; prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances. HIPAA might also give you a right to purchase individual coverage if you 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.
Pre-existing Condition Exclusions:
- The law defines a preexisting condition as one for which medical advice, diagnosis, care, or treatment was recommended or received during the 6-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).
- Includes prior coverage under another group health plan, an individual health insurance policy, COBRA, Medicaid, Medicare, CHAMPUS, the Indian Health Service, a state health benefits risk pool, FEHBP, the Peace Corps Act, or a public health plan.
Certificates of Creditable Coverage:
- Certificates of creditable coverage must be provided automatically and free of charge by the plan or issuer when an individual loses coverage under the plan, becomes entitled to elect COBRA continuation coverage or exhausts COBRA continuation coverage. A certificate must also be provided free of charge upon request while you have health coverage or anytime within 24 months after your coverage ends.
- Certificates of creditable coverage should contain information about the length of time you or your dependents had coverage as well as the length of any waiting period for coverage that applied to you or your dependents.
- For plan years beginning on or after July 1, 2005, certificates of creditable coverage should also include an educational statement that describes individuals' HIPAA portability rights. A new model certificate is available on EBSAs Web site.
- If a certificate is not received, or the information on the certificate is wrong, you should contact your prior plan or issuer. You have a right to show prior creditable coverage with other evidence — like pay stubs, explanation of benefits, letters from a doctor — if you cannot get a certificate.
Special Enrollment Rights:
- Are provided for individuals who lose their coverage in certain situations, including on separation, divorce, death, termination of employment and reduction in hours. Special enrollment rights also are provided if employer contributions toward the other coverage terminates
- Are provided for employees, their spouses and new dependents upon marriage, birth, adoption or placement for adoption
- Ensure that individuals are not excluded from coverage, denied benefits, or charged more for coverage offered by a plan or issuer, based on health status-related factors
Related Department of Labor Web pages:
Provides publications and other materials to assist employers and employee benefit plan practitioners in understanding and complying with the requirements of the Employment Retirement Income Security Act (ERISA) for the administration of pension and health plans.
Compliance Assistance for Group Health Plans: HIPAA and Other Recent Health Care Laws
Assists in complying with the Health Insurance Portability and Accountability Act, the Newborns' and Mothers' Health Protection Act, the Mental Health Parity Act and the Women's Health and Cancer Rights Act.
Consumer Information on Health Plans
Provides fact sheets, booklets, and other health plan information from the Department's Employee Benefits Security Administration (EBSA).
Frequently Asked Questions for Participants & Beneficiaries Related to the Events of September 11th
Provides answers to the most frequently asked questions by workers and their families whose pension and/or health plan benefits have been impacted by the events of September 11, 2001.
Frequently Asked Questions for Reservists Being Called to Active Duty Related to their Pension and Health Benefits
Provides answers to the most frequently asked questions about pension and health benefits by National Guard and Reserve members being called to active duty as a result of the events of September 11, 2001.
Health Benefits Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) (PDF)
COBRA gives workers and their family members who lose their health benefits in certain circumstances the right to choose to continue group health benefits provided by their health plan. This publication provides a detailed overview of the law.
Life Changes Require Health Choices - (Español)
Provides guidance on making health benefit decisions following key life events such as marriage or the birth or adoption of a child.
Pension & Health Care Coverage... Questions& Answers for Dislocated Workers
Provides answers to commonly asked questions by dislocated workers about their pension and health benefits.
Questions & Answers: Portability of Health Coverage (HIPAA)
Provides answers to commonly asked questions about HIPAA.
Questions & Answers: Recent Changes in Health Care Law (PDF)
Provides information about major provisions of HIPAA, the Newborns' and Mothers' Health Protection Act, the Mental Health Parity Act, and the Women's Health and Cancer Rights Act
The Health Insurance Portability & Accountability Act (HIPAA)
Provides a brief overview of HIPAA.
Top 10 Ways to Make Your Health Benefits Work for You - (Español)
Provides 10 tips to help make your health benefits work better for you.
Work Changes Require Health Choices - (Español)
Provides information on protecting your health care rights when your work life changes.
Your Employer's Bankruptcy: How Will it Affect Your Employee Benefits?
Provides information on bankruptcy’s effect on pension plans and group health plans.