The Health Insurance Portability and Accountability Act (HIPAA) was enacted to reform healthcare in America. Through HIPAA, the government is able to:
- Protect health insurance coverage for working Americans who have pre-existing medical conditions when they change or lose their jobs
- Reduce healthcare fraud and abuse
- Enforce standards for health information
- Guarantee security and privacy of health information
- What Is a Pre-Existing Medical Condition?
- How Does HIPAA Protect American Workers?
- What If I Do Have a Pre-Existing Medical Condition?
- Are There Any Limitations to HIPAA Protections?
- What Can I Do to Ensure That My Rights Are Protected under HIPAA?
- Do I Need a Lawyer to Help Me with My HIPAA Problem?
A pre-existing medical condition is a health condition for which you received medical advice, diagnosis, care or treatment prior to enrolling in a new health care plan. Cancer is an all-too common example of a pre-existing condition. Before HIPAA was enacted, your new employer’s health plan would have probably refused to cover the cancer treatment for several years, if at all, if you had been treated for the cancer prior to your enrollment.
HIPAA protects working Americans who are seeking to switch into a new group health plan, which is common when changing jobs. First, under HIPAA, health insurers cannot deny you coverage or charge you more for your coverage because of your health status.
Second, HIPAA limits pre-existing medical conditions to a condition for which you received medical advice, diagnosis, care or treatment 6 months prior to enrolling in a new health plan. A condition that has not received medical attention within the last 6 months is not pre-existing, and a group health plan cannot exclude the condition from your coverage.
If you do have a pre-existing medical condition (i.e. one that was treated in the last 6 months), your new group health plan can only exclude the condition from your coverage for a maximum of 12 months.
Moreover, the new insurance company must give you credit for continuous health coverage that you had prior to enrolling in the new plan. Therefore, if you had 4 months of continuous coverage before switching health plans, the new health plan can only exclude your condition for a maximum of 8 months. If you have 12 months of continuous coverage before switching health plans, the new health plan cannot exclude your condition from coverage at all.
Anything shorter than a 63-day break in health coverage qualifies as "continuous coverage." Individual insurance plans, Medicare, and Medicaid generally qualify as creditable insurance coverage.
Your protections under the HIPAA laws will be limited if there is more than a 63-day break in your health coverage. Additionally, HIPAA offers the most protection to individuals switching into a group health plan. Individuals who are switching from a group health plan to individual insurance only have very limited protections under HIPAA. Additionally, HIPAA does not protect anyone switching between individual insurance plans.
Whenever you leave any health plan, make sure that you get a "certificate of creditable coverage" in writing. Your certificate should include:
- Your coverage dates
- Your policy ID number
- The insurer’s name and address
- Any family members included under your coverage
This certificate will help you prove that you have had continuous coverage and aid you in getting coverage for any pre-existing medical conditions sooner than 12 months.
Interpreting the HIPAA laws can be complicated. An experienced attorney can help you understand your rights under the HIPAA laws. If you believe your health insurance company is acting in bad faith and improperly denying you coverage, an attorney will know all the ins-and-outs of taking on a big health insurance company.