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It's HIPAA with a Double "A," Not HIPP with a Double "P"
Your Benefits and You

By Steve Berg

May 2001

The name of the game here is acronyms. You've mastered the public disability benefits SDI, SSI and SSDI. Now, welcome to the world of health insurance. Here it's CARE/HIPP, Medi-Cal/HIPP and now HIPAA.


Federal Law

While the HIPP programs pay insurance premiums, HIPAA is an important federal law covering a wide range of health insurance issues. The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in 1996 and became effective June 30, 1997. An important feature of this law is the protections it created for employees with a pre-existing medical condition.

An understanding of a few of HIPAA's basic provisions is invaluable in guiding you through a maze of employer health insurance issues. First off, HIPAA generally lays to rest the issue of, "Now that I'm HIV-positive, I can never leave my job and get new health insurance" or "I can never go back to work and get medical benefits with my new employer." HIPAA prohibits employer health plans from denying eligibility or enrollment due to a medical condition. Furthermore, an employee with a pre-existing medical condition cannot be dropped from the plan based on medical claims submitted or be charged higher premiums because of this condition.

However, the employer plan can impose a "pre-existing exclusion or waiting period" of up to 12 months (six months in California) for those new enrollees without prior health insurance coverage or with a gap in coverage in excess of 63 days. During this exclusion period, any claims submitted for the medical condition would not be paid. Not all plans apply a pre-existing condition exclusion period. Generally, only PPO plans do. A plan must inform the employee if this exclusion exists and provide the employee the opportunity to reduce (or eliminate entirely) the length of the exclusion period based on the number of days of prior creditable coverage. Employer health plans, COBRA continuation coverage, individual health insurance policies, MRMIP, Medi-Cal and Medicare are all creditable coverage. Also, HIPAA requires group health plans and health insurance issuers to furnish the individual a "certificate of creditable coverage" upon termination of the plan as proof of prior coverage.


Other Situations

Then there are other situations that come up: "I'm on my partner's employer's plan as a domestic partner and we're breaking up. I'm being dropped from the plan and I just found out that I'm not entitled to COBRA." Or "I'm losing my COBRA because my former employer went bankrupt and the group plan terminated." And "My 18 months of COBRA is ending and my SSDI claim is still under appeal so I'm not going to be eligible for the OBRA extension" or "My 18 months of COBRA is ending and my new employer doesn't offer any health benefits."

HIPAA may be the solution for these situations, too. In many cases, HIPAA guarantees access to individual health coverage once group employer coverage is lost. This individual policy must be purchased from a health insurance company (or through an agent) within 63 days from the termination of the employer group plan. Again, the certificate of creditable coverage is used as documentation in applying for this policy.

There are specific eligibility requirements. First, the terminating plan must have been an employer group plan. Termination cannot be due to fraud or nonpayment of premiums. Prior to termination, there must be at least 18 months of continuous coverage. If there were a series of coverage during those 18 months, there cannot be a gap between coverage greater than 63 days. If COBRA continuation coverage is available, it must be accepted and exhausted without termination due to nonpayment of premiums. You cannot be enrolled in Medi-Cal, Medicare, or any other health insurance coverage including COBRA conversion plans.

Unfortunately, HIPAA does not restrict the premium rates charged. If you meet CARE/HIPP's eligibility criteria, short-term premium payment assistance may be available. Also, it is important that you review your policy options carefully prior to purchase since you will not be able to change your mind and switch insurance companies or plans. While this is a federal law and good throughout the United States, please check with your State Insurance Commissioner's Office for any provision modifications or enhancements.

For more HIPAA information, contact the U.S. Department of Labor, Pension and Welfare Benefits Administration Publications Hotline at (800) 998-7542 or http://www.dol.gov/dol/pwba. Additional on-line information is available from HCFA at http://hipaa.hcfa.gov.

Steve Berg is an insurance specialist in AIDS Project Los Angeles' Benefits program. He can be reached by calling (213) 201-1474 or by e-mail at sberg@APLA.org.

If you have a question about insurance, you can ask it at The Body's Ask the Expert Forum.


This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).




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