Getting and keeping health insurance coverage under HIPAA

What if I am unable to get group coverage?

HIPAA guarantees access to an individual insurance policy issued by an insurance company to certain "eligible individuals." The Affordable Care Act of 2010 also provides Pre-Existing Condition Insurance Plans in each state. These plans may be state or federal plans.

You may have the chance to buy an individual insurance policy whether you are laid off, fired, or quit your job. For information on individual insurance policies or Pre-Existing Condition Insurance Plans, contact your State Insurance Department. For more on "eligible individuals", see the next question.

If I can't get group coverage and have no other options, what do I do?

There is a special provision of the HIPAA law, which is intended to allow people to get health coverage after other options are exhausted. But before HIPAA can help a person with no insurance options get coverage, special requirements must be met, and you have to act quickly after you lose your coverage:

• You need to have had 18 months of group health coverage without a break of more than 63 days and your most recent coverage must have been through a creditable health plan.
• You cannot be eligible for Medicare or Medicaid, or be eligible for a group health insurance plan.
• You need to have elected and exhausted (used up) your COBRA coverage or any similar ongoing coverage, or you are not eligible for COBRA continuation coverage (or continuation coverage under a similar state program).
• You did not lose your group coverage because of fraud or non-payment of premiums.

People who meet these requirements are called "HIPAA eligible individuals." If you are eligible and act within 63 days of losing your coverage, HIPAA guarantees that you can buy some type of coverage and that you will have a choice of at least 2 options. This may include Pre-Existing Condition Insurance Plans set up by the Affordable Care Act. HIPAA can help those left out of health coverage after they've lost eligibility for group plans and COBRA.

HIPAA does not limit what health insurance companies charge (although some state laws do), but it can be sure that some coverage is offered. Again, depending on the health plan and the situation, HIPAA prevents an insurance plan from denying coverage based on a person's health history or a pre-existing condition.

People often do not take advantage of this because they don't know that they are eligible. Sometimes people find out they would have been eligible, but it may not help if the 63-day time limit has passed. If you think you might qualify for this, contact your state insurance department or commission right away to find out what is available to you. You can find your State Insurance Department in the blue pages of your phone book, or visit the National Association of Insurance Commissioners on the Internet at www.naic.org/state_web_map.htm.

Keep in mind that the Affordable Care Act has created special insurance for all states, and it is available to "eligible individuals." These may be other options you can look into. See the section called "Does the 2010 Affordable Care Act affect HIPAA?" for more information on this.

What if I can't afford the premiums for an individual insurance policy? Things have been pretty tight since my wife has been diagnosed with cancer.

HIPAA does not limit premium rates. HIPAA does not have control over state laws that regulate the cost of insurance. But some states limit insurance premiums. For information on how your state law may limit premium rates for individual insurance policies or for information on state high-risk pools, contact your State Insurance Commissioner's Office. You can also find more information in our document, Health Insurance and Financial Assistance for the Cancer Patient.

Is my individual insurance policy renewable? Can it be taken away?

It is generally your option to renew or continue individual health coverage. Most individual health insurance policies expire each year and must be renewed. Federal and state laws do not allow insurers to refuse to renew health insurance policies because of the health status of the individual. Note that this is not true of short-term policies that are sold as non-renewable (see below).

There are some exceptions to the guaranteed renewability of a policy if the insurer is unable to meet their financial obligations or leaves the market. It may also be canceled or discontinued if you failed to pay premiums, committed fraud, terminated the policy, moved outside the service area, or ended the membership in the association that is part of the group policy.

Some insurers sell short-term policies that are clearly marketed as non-renewable. If you buy a short-term non-renewable policy and then get sick, you will not have the right to renew the policy when it expires.

If I change jobs, can HIPAA guarantee the same benefits that I have under my current plan?

No. When a person moves into a new plan, the benefits the person receives will be those provided under the new plan. Coverage under the new plan can be different from the coverage under the former plan.

Does HIPAA require employers to offer health coverage or require plans to provide specific benefits?

No. The employer voluntarily provides health coverage. HIPAA does not require specific benefits nor does it bar a plan from restricting the amount or nature of benefits for groups of people in similar situations.

Does HIPAA extend COBRA continuation coverage?

In general, no. But HIPAA makes 2 changes to the length of the COBRA continuation coverage period.

• Qualified beneficiaries who are found to be disabled under the Social Security Act within the first 60 days of COBRA continuation coverage will be able to buy an additional 11 months of coverage beyond the usual 18-month coverage period. This extension of coverage is also available to non-disabled family members who are entitled to COBRA continuation coverage.
• COBRA rules now ensure that children who are born or adopted during the continuation coverage period are treated as "qualified beneficiaries" in plans that offer family or dependent coverage.

Even though it doesn't extend COBRA, HIPAA may still help you if you have used all of your COBRA coverage and are not eligible for other kinds of insurance. You may qualify for special HIPAA eligibility for other health coverage. See the section "If I can't get group coverage and have no other options, what do I do?" for more information.

Does HIPAA apply to self-insured group health plans?

Yes.