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Health Insurance Reform for Consumers

Five Steps to Understanding HIPAA

  1. Understand the different types of individual (non-employment based) health coverage and group health coverage that are affected by the Health Insurance Portability & Accountability Act of 1996 (HIPAA.)  Generally, HIPAA may apply to  four types of coverage:
  • Self-funded group health plans (CMS has jurisdiction over self-funded public sector (non federal governmental) plans while the Department of Labor 866-444-3272 has jurisdiction over private sector self-funded group health plans.);
  • Fully insured group health plans;
  • Individual (non-employment based) health insurance policies; and
  • Comparable coverage through State high risk pools, if applicable in your State.
  1. Evaluate the impact of a pre-existing condition that you have which may trigger the need for HIPAA's limited protections. Traditionally, many employer-sponsored group health plans and health insurance issuers in both the group and individual (non-employment based) markets limit and deny coverage of health conditions in exclusions known as pre-existing condition exclusions.
  2. Determine how much-if any-creditable coverage you have.  Under HIPAA's group  rules, creditable coverage can be used to reduce or eliminate pre-existing condition exclusions that might be applied to you under a future plan or policy.
  3. Understand the other HIPAA coverage protections you have.  You should obtain general information about special enrollment rights to other coverage, how your health status can affect your access to care, other coverage choices that may help you take advantage of HIPAA protections, and your rights to renew group and individual (non-employment based) market coverage.
  4. Know where to go for more information if you have questions. 


Contact your state's insurance department to find out about whether additional protections apply to your coverage if you are in a fully insured group health plan or have individual market (non-employment based) health coverage.


Employment related group health plans that provide benefits through insurance are known as fully insured group health plans. Employment related group health plans that pay for coverage directly, without purchasing health insurance from an issuer, are called self-funded group health plans.  Contact your plan administrator to find out if your group coverage is fully insured or self-funded.  Non-employment related individual health insurance policies are sold to individual policy holders.  If applicable, your State of residence may offer comparable coverage through a State high risk pool.


For additional information you may e-mail us at phig@cms.hhs.gov.


Note:  A non federal government employer that provides self-funded group health plan coverage to its employees (coverage that is not provided through an insurer) may elect to exempt its plan (opt-out) from most requirements of title XXVII of the Public Health Service (PHS) Act, with the exception of requirements pertaining to the certification and disclosure of an individual's creditable coverage under the plan.




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Page Last Modified: 05/27/2008 11:24:01 AM
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