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Frequently Asked Questions |
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Final Regulations for HIPAA Health Coverage Portability
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Model Certificate •
Press Release
HHS
Issues Final Regulation on Access to Group Health Coverage
(12/29/2004, HHS)
Text of Final HIPAA
Portability Regulations (PDF) (Internal Revenue
Service, Employee Benefits Security Administration, Centers for Medicare
& Medicaid Services)
Text of Proposed
HIPAA Portability Regulation Modifying Break in Coverage, Special
Enrollment Period (PDF) (Internal Revenue Service,
Employee Benefits Security Administration, Centers for Medicare &
Medicaid Services)
Review of
New HIPAA Rules from HHS, EBSA and the IRS (Attorney B.
Janell Grenier via Benefitsblog.com)
Overview:
Agencies Issue Final HIPAA Regulations -- Some New Interpretations
Provided (PDF) (2005 Mellon Financial Corporation)
Managed-Care Pre-existing Condition Denials? What Does an Unanimous
US
Supreme Court
Say?
On June 21, 2004, an unanimous US Supreme
Court ruled that claim processing (Pre-existing Condition limitation,
Exclusions & Denials) and denials of benefits under the
employer-sponsored health plans,
ERISA-regulated benefit
plans,
for
both self-insured and
fully-insured (through purchase of insurance) health plans,
are completely governed by federal law ERISA, that supersedes and
invalidates state laws.
ERISAclaim.com: "employer-sponsored group health plans"
=
"ERISA-regulated benefit
plans",
both self-insured and
fully-insured (through purchase of insurance) health plans,
(ERISA - Title 29, Chapter 18.
Sec.
1002.)
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ERISAclaim.com -
Supreme Court Managed Care ERISA Watch
Aetna Health Inc. v. Davila
06/21/04
Opinion of the
Court
"Held:
Respondents’ state causes of action fall
within ERISA§502(a)(1)(B), and are therefore completely
pre-empted by ERISA §502 and removable to federal court.
Pp. 4–20."
"We hold that
respondents’ causes of action, brought to
remedy only the denial of benefits under
ERISA-regulated benefit
plans, fall within the scope of, and are completely pre-empted
by, ERISA §502(a)(1)(B), and thus removable to federal
district court. The judgment of the Court of Appeals is
reversed, and the cases are remanded for further proceedings
consistent with this opinion.7
It is so ordered."
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(Federal Regulations on
Pre-existing Condition Denials)
(Selected
Only, Click DOL Links for Updated Official Documents) |
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What is HIPAA
(portability of health coverage)?
The Health Insurance Portability and
Accountability Act of 1996 (HIPAA), amended the Employee Retirement
Income Security Act to provide new rights and protections for
participants and beneficiaries in group health plans.
Understanding this amendment is important to your decisions about
future health coverage. HIPAA contains protections both for
health coverage offered in connection with employment (group health
plans) and for individual insurance policies sold by insurance
companies (individual policies).
If you find a new job that offers
health coverage, or if you are eligible for coverage under a family
member's employment-based plan, 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
Allow a special opportunity to enroll
in a new plan to individuals in certain circumstances
If you choose to apply for an
individual policy for yourself or your family, HIPAA includes
protections for individual policies that:
Guarantee access to individual
policies for people who qualify
Guarantee renewability of individual
policies
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What is creditable
coverage?
Most health coverage is creditable
coverage, such as coverage under a group health plan (including
COBRA continuation coverage), HMO, individual health insurance
policy, Medicaid or Medicare.
Creditable coverage does not include
coverage consisting solely of excepted benefits, such as coverage
solely for limited-scope dental or vision benefits.
Days in a waiting period during which
you have no other coverage are not creditable coverage under the
plan, nor are these days taken into account when determining a
significant break in coverage (generally a break of 63 days or
more). This 63-day break period may be extended under state
law if your coverage is insured through an insurance company or
offered through an HMO. Check with your State Insurance
Commissioner's Office to see whether a longer break period applies
to you. |
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How does crediting for
prior coverage work under HIPAA?
Most plans use the standard method of
crediting coverage.
Under the standard method, you receive
credit for your previous coverage that occurred without a break in
coverage of 63 days or more. Any coverage occurring prior to a
break in coverage of 63 days or more is not credited against a
preexisting condition exclusion period.
To illustrate, suppose an individual
had coverage for 2 years followed by a break in coverage of 70 days
and then resumed coverage for 8 months. That individual would
only receive credit for 8 months of coverage; no credit would be
given for the 2 years of coverage prior to the break in coverage of
70 days. |
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Is there another way that
a group health plan or issuer can credit coverage under HIPAA?
Yes. A plan or issuer may elect
the alternative method for crediting coverage for all employees.
Under the alternative method of
counting creditable coverage, the plan or issuer determines the
amount of an individual's creditable coverage for any of the five
specified categories of benefits. Those categories are mental
health, substance abuse treatment, prescription drugs, dental care
and vision care. The standard method is used to determine an
individual's creditable coverage for benefits that are not within
any of the five categories that a plan or issuer may use. (The
plan or issuer may use some or all of these categories.)
When using the alternative method, the
plan or issuer looks to see is an individual has coverage within a
category of benefits (regardless of the specific level of benefits
provided within that category).
For example, if an individual who is a
regular enrollee (not a late enrollee) has 12 months of creditable
coverage, but coverage for only 6 of those months provided benefits
for dental care, a preexisting condition exclusion period may be
imposed with respect to that individual's dental care benefits for
up to 6 months (irrespective of the level of dental care benefits).
If your employer's plan requests
information from your former plan regarding any of the five
categories of benefits under the alternative method, your former
plan must provide the information regarding coverage under the
categories of benefits. One way to provide this information is
to use the
Model for Categories of Benefits. |
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Can I receive credit for
previous COBRA continuation coverage?
Yes. Under HIPAA any period of
time that you are receiving COBRA continuation coverage is counted
as previous health coverage as long as the coverage occurred without
a break in coverage of 63 days or more.
For example, if you were covered
continuously for 5 months by a previous health plan and then
received 7 months of COBRA continuation coverage, you would be
entitled to receive credit for 12 months of coverage by your new
group health plan. |
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I began employment with
my current employer 45 days after my previous group health
plan coverage terminated. I had coverage under my previous
employer's plan for 24 continuous months prior to the termination.
I had no other coverage before my enrollment date in my new plan,
Will I be subject to the 12-month preexisting condition exclusion
period imposed by my new employer?
Not if you enroll when you are first
eligible. The 45-day break in coverage does not count as a
significant break in coverage under HIPAA. Under federal law,
a significant break in coverage is a break in coverage of at least
63 consecutive days. Since you had over 12 months of
creditable coverage from your previous group plan without a
significant break, you would not be subject to the preexisting
condition exclusion period imposed by your new employer's plan if
you enroll when you are first eligible. |
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I began employment with
my current employer 100 days after my previous group health plan
coverage terminated. I had been covered by my previous
employer's plan for 36 continuous months prior to termination.
I had no other coverage before my enrollment date in my current
employer's plan. Will I be subject to the 12-month preexisting
condition exclusion period imposed by my current employer's plan?
It depends. Your break in
coverage of 100 days is a significant break in coverage under
federal law, so under federal law you will not be able to count the
36 months of previous coverage as creditable coverage.
However, the length of time that passes
before a significant break in coverage is reached may be longer
under state law that applies to HMO's and health insurance. If
your current plan provides health insurance coverage through an
insurance policy or an HMO (an insured plan), check with your State
Insurance Commissioner's Office to find out if you are entitled to a
longer break in coverage. If your current plan is an insured
plan and State law requires that a break in coverage be 100 days (or
longer), you would be able to count the 36 months as creditable
coverage. |
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How can I avoid a 63-day
break in coverage?
There are several things you can do.
If your last coverage was under a group health plan, you may be able
to elect COBRA continuation coverage. COBRA is the name for a
federal law that provides workers and their families the opportunity
to purchase group health coverage through their employer's health
plan for a limited period of time (generally 18, 29, or 36 months)
if they lose coverage due to specified events, including termination
of employment, divorce or death. Workers in companies with 20
or more employees generally qualify for COBRA. Some states
have laws similar to COBRA that apply to smaller companies.
You may also try to purchase an individual health insurance policy. |
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What can I do if I don't
have enough creditable coverage to offset a preexisting condition
exclusion period?
During any preexisting condition
exclusion period under a new plan you may be entitled to COBRA
continuation coverage under your former plan. You may also try
to purchase an individual health insurance policy. |
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