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.
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.
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