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HIPAA amended the Employee Retirement Income Security Act
(ERISA), 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:
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Limit exclusions for preexisting conditions
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Prohibit discrimination against employees and
dependents based on their health status
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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:
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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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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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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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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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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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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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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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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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Group health plans and health insurance issuers are
required to furnish a certificate of coverage to an individual to provide
documentation of the individual's prior creditable coverage. A
certificate of creditable coverage:
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Must be provided automatically by the plan or
issuer when an individual either loses coverage under the plan or
becomes entitled to elect COBRA continuation coverage and when an
individual's COBRA continuation coverage ceases
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Must also be provided, if requested, before the
individual loses coverage or within 24 months of losing coverage
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May be provided through the use of the
model
certificate
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Under HIPAA, an employee's former group health plan and
any insurance company or HMO providing such coverage is required to
provide the employee with a statement of prior health coverage, commonly
referred to as a certificate of creditable coverage.
This certificate must be provided automatically to you
when you lose coverage under the plan or otherwise become entitled to
elect COBRA continuation coverage as well as when COBRA continuation
coverage ceases.
You may also request a certificate, free of charge,
until 24 months after the time your coverage ended. For example, you
may request a certificate even before your coverage ends.
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If you do not receive a certificate by the time you
should have received it or by the time you need it, your first step should
be to contact the plan administrator of the plan responsible for providing
the certificate and request one. If any part of your creditable
coverage was through an insurance company, you can also contact the
insurance company for a certificate that reflects that part of your
creditable coverage as long as you make the request within 24 months of
your coverage ceasing under the insurance policy. Group health plans
and insurers that fail or refuse to provide such certificates are subject
to penalties under HIPAA.
In any event, if you do not receive a certificate, you
may demonstrate to your new plan that you have creditable coverage (as
well as the time you were in any waiting periods) by producing
documentation or other evidence of creditable coverage (such as pay stubs
that reflect a deduction for health insurance, explanation of benefits
forms (EOBs) or verification by a doctor or your former health care
benefits provider that you had prior health insurance coverage).
Accordingly, you should keep these records and documentation in case you
need them.
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Yes.
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Yes. To avoid duplication of certificates, a plan
may contract with the issuer to provide the certificate.
Furthermore, if any entity (including a third-party administrator)
provides a certificate to an individual, no other party is required to
provide the certificate.
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Plans and issuers must furnish the certificate
automatically to:
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An individual who is entitled to elect COBRA
continuation coverage, at a time no later than when a notice is
required to be provided for a qualifying event under COBRA.
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An individual who loses coverage under a group
health plan and who is not entitled to elect COBRA continuation
coverage, within a reasonable time after coverage ceases.
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An individual who has elected COBRA continuation
coverage, either within a reasonable time after the plan learns that
COBRA continuation coverage ceased or, if applicable, within a
reasonable time after the individual's grace period for the payment of
COBRA premiums ends.
Plans and issuers must also generally provide a
certificate to you if you request one, or someone requests one on your
behalf (with your permission), at the earliest time that a plan or issuer,
acting in a reasonable and prompt fashion, can provide the certificate. |
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Yes. If you, your new plan, and your old plan all
agree, the information may be transferred by telephone. You are also
entitled to request a written certificate for your records when your
coverage information is provided by telephone.
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Yes. A plan or issuer must make reasonable
efforts to collect the necessary information for dependents and issue the
dependent a certificate of creditable coverage. If the coverage
information for a dependent is the same for the employee, one certificate
with both the employee and dependent information can be provided.
However, an automatic certificate for a dependent is
not required to be issued until the plan or issuer knows (or, making
reasonable efforts, should know) of the dependent's loss of coverage.
This information can be collected annually, such as during an open
enrollment period.
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It depends on whether the certificate is issued
automatically or upon request:
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For a certificate that is issued automatically, the
certificate should reflect the most recent period of continuous
coverage.
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For a certificate that is issued upon request, the
certificate should reflect each period of continuous coverage ending
within 24 months prior to the date of the request.
At no time must the certificate reflect more than 18
months of creditable coverage that is not interrupted by a break in
coverage of 63 days or more. |
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A preexisting condition is a medical
condition present before your enrollment date in any new group health
plan.
Under HIPAA, the only preexisting conditions that may
be excluded under a preexisting condition exclusion are those for which
medical advise, diagnosis, care or treatment was recommended or received
within the 6-month period before your enrollment date. (Your
enrollment date is your first day of coverage, or if there is a waiting
period to get into the plan, the first day of the waiting period.)
If you had a medical condition in the past, but have
not received any medical advise, diagnosis, care or treatment within the 6
months prior to your enrollment date in the plan, your old condition is
not a preexisting condition to which an exclusion can be
applied. Moreover, under HIPAA, preexisting condition exclusions
cannot be applied to pregnancy, regardless of whether the woman had
previous health coverage.
In addition, a preexisting condition exclusion cannot
be applied to a newborn, adopted child under age 18, or a child under age
18 placed for adoption as long as the child became covered under health
coverage within 30 days of the birth, adoption or placement for adoption
and provided that the child does not incur a subsequent 63-day break in
coverage.
Finally, genetic information may not be treated as a
preexisting condition in the absence of a diagnosis. If your
coverage is through an insurance company or offered through an HMO, state
law may provide additional protections.
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The maximum length of a preexisting condition exclusion
period is 12 months after your enrollment date (18 months in the case of a
late enrollee). A late enrollee is an individual who
enrolls in a plan other than on the earliest date on which coverage can
become effective under the terms of the plan and other than on a special
enrollment date.
A plan must reduce an individual's preexisting
condition exclusion period by the number of days of an individual's
creditable coverage. However, a plan is not required to take into
account any days of creditable coverage that precede a break in coverage
of 63 days or more (significant break in coverage).
A plan generally receives information about an
individual's creditable coverage from a certificate furnished by a prior
plan or health insurance issuer (e.g., an insurance company or HMO).
A certificate of creditable coverage must be provided automatically to you
by the plan or issuer when you lose coverage under the plan or become
entitled to elect COBRA continuation coverage and when your COBRA
continuation coverage ceases. You also have a right to receive a
certificate when you request one from your previous plan or issuer within
24 months of when your coverage ceases.
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Under HIPAA, the only preexisting conditions that may
be excluded under a preexisting condition exclusion are those for which
medical advice, diagnosis, care or treatment was recommended or received
within the 6-month period ending on your enrollment date. Your enrollment date is your first day of coverage, or if there is
a waiting period, the first day of your waiting period (typically, your
date of hire).
If you had a medical condition in the past, but have
not received any medical advice, diagnosis, care or treatment for it
within the 6 months prior to your enrollment date in the plan, your old
condition is not a preexisting condition to which an exclusion
can be applied.
This 6-month look-back period may be
shortened 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 shorter look-back period applies to
you.
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Many plans do not exclude coverage for preexisting
conditions. A plan must tell you if it has a preexisting condition
exclusion period (and can only exclude coverage for a preexisting
condition after you have been notified). The plan must also notify
you of your right to show that you have prior creditable coverage to
reduce the preexisting condition exclusion period.
If the plan does apply a preexisting condition
exclusion period, the plan must make a determination regarding your
creditable coverage and the length of any preexisting condition exclusion
period that applies to you. Generally, within a reasonable time
after you provide a certificate or other information relating to
creditable coverage, a plan is required to make this determination.
You are required to be notified of this determination
if, after considering all evidence of creditable coverage, the plan will
still impose a preexisting condition exclusion period with respect to any
preexisting condition you may have. The notice must also tell you
the basis of the determination, including the source and substance
of any information on which the plan relied and any appeal procedure that
is available to you.
The plan may modify its initial determination if it
later determines that you do not have the creditable coverage you claimed.
In this circumstance, the plan must notify you of its reconsideration and,
until a final determination is made, the plan must act in accordance with
its initial determination for purposes of covering medical services.
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On the date your plan becomes subject to the
HIPAA provisions, the plan may not exclude coverage for any preexisting
condition for more than 12 months after your enrollment date (18 months
for a late enrollee). This period may have already passed. If
this period has not passed, your plan is required to use any creditable
coverage without a significant break in coverage that you had accumulated
prior to your enrollment date to reduce your remaining preexisting
condition exclusion period.
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HIPAA does not prohibit a plan or issuer from
establishing a waiting period. For group health plans, a waiting
period is the period that must pass before an employee or a dependent is
eligible to enroll under the terms of the plan. Some plans have
waiting periods and preexisting condition exclusion periods.
However, if a plan has a waiting period and a preexisting condition
exclusion period, the preexisting condition exclusion period begins when
the waiting period begins.
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A group health plan is required to allow special
enrollment for certain individuals to enroll in the plan without having to
wait until the plan's next regular enrollment season.
Group health plans and health insurance issuers are
required to provide special enrollment periods during which individuals
who previously declined coverage for themselves and their dependents may
be allowed to enroll (without having to wait until the plan's next open
enrollment period).
A special enrollment opportunity occurs if an
individual with other health insurance loses that coverage or if a person
becomes a new dependent through marriage, birth, adoption or placement for
adoption. However, you must notify the plan of your request for
special enrollment within 30 days after losing your other coverage or
within 30 days of having (or becoming) a new dependent.
If you enroll as a special enrollee, you may not be
treated as a late enrollee for purposes of any preexisting condition
exclusion period. Therefore, the maximum preexisting condition
exclusion period that may be applied is 12 months, reduced by your
creditable coverage (rather than 18 months, reduced by creditable
coverage).
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You should:
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Ensure that the information is accurate; (contact
the plan administrator of your former plan if any information is
wrong).
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Keep the certificate in case you need it; (you will
need the certificate if you enroll in a new group health plan that
applies a preexisting condition exclusion period or if you purchase an
individual policy from an insurance company).
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Group health plans and health insurance issuers may not
establish rules for eligibility (including continued eligibility) of any
individual to enroll under the terms of the plan based on health
status related factors. These factors include:
Plans generally may not require an individual to pay a
premium or contribution that is greater than that for a similarly situated
individual based on a health status related factor. |
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You may be able to purchase an individual insurance
policy. HIPAA guarantees access to individual policies to eligible individuals. Eligible individuals:
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Have had coverage for a least 18 months without a significant break in coverage where the most recent period
of coverage was under a group health plan
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Did not have their group coverage terminated
because of fraud or nonpayment of premiums
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Are ineligible for COBRA continuation coverage or
if offered COBRA continuation coverage (or continuation coverage under
a similar state program), have both elected and exhausted their
continuation coverage
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Information On Categories Of Benefits
Date of original certificate:
Name of group health plan providing the coverage:
Name of participant:
Identification number of participant:
Name of individual to whom this information
applies:
The following information applies to the coverage
in the certificate that was provided to the individual identified
above:
Mental Health:
Substance Abuse Treatment:
Prescription Drugs
Dental Care
Vision Care
For each category above, enter N/A if the
individual had no coverage within the category or either:
Enter both the date that the individual's coverage
within the category began and the date that the individual's coverage
within the category ended (or indicate if continuing)
Enter same on the line if the beginning
and ending dates for coverage within the category are the same as the
beginning and ending dates for the coverage in the certificate.
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