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HIPAA, etc.
Feb 6, 2004

You recently responsed to a question I had regarding HIPAA vs. Major Risk Medical. I agree that the HIPAA coverage is better, but the cost is quite a problem right now. My question is do I have to pick one over the other as long as I don't have a lapse greater than the 63 days you mentioned? In other words, if I choose to take Major Risk, can I switch over to HIPAA in a matter of months or do I need to stay with Major Risk? I am on the waiting list currently for Major Risk in California and they said I would be able to take HIPAA if a spot didn't open up in time before my COBRA ends, so I assume it would be all right to go from HIPAA to Major Risk. Can one go back and forth from HIPAA to Major Risk is necessary because of finances?

Also, is the 63 days continuous or accumulative. In other words, if someone, for instance, took HIPAA for 3 months, then chose to have no insurance for 60 days because of finances, then back on HIPAA for a period of time, then no insurance for 60 days, etc., would they be able to maintain their insurance and avoid future pre-existing clause exclusions? Or, is the 63 days accumulative--in other words, "cannot be without insurance for more than 63 days" period.

Lastly, to clarify my coverage when I go back to working a job with health benefits. Say I use my COBRA up and then go onto HIPAA with no laspe in coverage, my new employer has to grant me health coverage from the day I start working since my HIPAA coverage combined with my COBRA coverage combined with my last job coverage adds up to well over 12 months, thereby eliminating any pre-existing condition clause?

Thank you for all your advice.

Response from Ms. Franzoi

Eligibility for the Major Risk Plan includes a requirement that you prove you were unable to secure adequate coverage. One way to do this is to demonstrate that you were offered an individual policy in the prior 12 months with a premium that was in excess of the Major Risk Plan rate. Based on your previous question to this site, I believe this is the case. Therefore, you would be able to have a HIPAA policy and drop it for the Major Risk Plan. You can voluntarily disenroll from the Major Risk Plan prior to the 36 month automatic disenrollment. You would then be eligible for a HIPAA policy. I recommend that you verify this with Kaiser since you are looking at their Major Risk Plan and their HIPAA policy.

With respect to the 63-day break in creditable coverage, each break is looked at separately. Creditable coverage periods do not have to be continuous. Periods prior to and after a break of less than 63 days are aggregated.

If you use up your COBRA, elect a HIPAA policy and then become employed by a company with a group health plan, the plan would not be able to impose a pre-existing condition clause on you (assumes that you did not have a 63-day break in coverage). However, if the plan has a waiting period before coverage begins, you would still be subject to the waiting period but the waiting period would not be considered a break in coverage.



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