What Is HIPAA?

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Glossary of terms

Affordable Care Act of 2010 (ACA) or the Patient Protection and Affordable Care Act (PPACA): A federal law aimed at increasing the number of people with health insurance, which also offers certain protections for those who buy health insurance. Parts of it start at different times until it’s in full effect in 2015.

Certificate of creditable coverage: A written certificate issued by a group health plan or health insurance issuer that shows a person was covered under that health plan. A certificate must be issued automatically and free of charge when an individual loses coverage under a plan, when an individual is entitled to elect COBRA continuation coverage, and/or when a person loses COBRA continuation coverage. A certificate must also be provided free of charge upon request while the individual has health coverage or within 24 months after their coverage ends. See also Creditable coverage.

COBRA (Consolidated Omnibus Budget Reconciliation Act): COBRA gives a person who loses their health benefits in certain circumstances the right to choose to keep group health benefits provided by their health plan for a limited time. COBRA allows the employee to buy health insurance back from the employer even though they no longer work there or no longer work full-time. When COBRA coverage runs out, some people have special eligibility for individual health coverage.

COBRA also lets family members choose to keep health insurance after your job loss or other qualifying event that would normally cause them to lose the coverage they have through your employer. COBRA applies to nearly all employers with 20 or more employees. See the section “If I can’t get group coverage and have no other options, what do I do?” under “Getting and keeping health insurance coverage under HIPAA.”

Creditable coverage: This can be health coverage of an individual under a group health plan, (including while on COBRA continuation coverage), individual health insurance coverage, Medicare, Medicaid, a state health insurance risk pool, a public health plan, and certain other health programs. It may be used to offset time from any pre-existing condition exclusion if no significant break in coverage (generally 63 days) happened before starting a new group health plan.

ERISA (Employment Retirement Income Security Act of 1974): ERISA is a federal law that oversees employee benefit plans (such as group health plans) that private sector employers, employee organizations (such as unions), or both, offer to their workers and families.

Enrollment date: The first day of coverage or, if there’s a waiting period, the first day of the waiting period. For people who enroll when first eligible, the enrollment date is often the first day of employment.

Explanation of benefits (EOB): A written document that explains what part of a medical or health claim was paid and/or what was not. There may also be information on how to start an appeal.

Fully insured group health plan: A health insurance plan an employer or union buys from an insurance company, an HMO, or a health care service plan. Benefits, premiums and other aspects of the plan are subject to state regulation. Compare with self-insured group health plan.

Genetic information: Information about genes, gene products, and inherited characteristics that may come from the individual or a family member. This includes information about carrier status and information from lab tests that identify mutations in specific genes or chromosomes, physical medical exams, family histories, and direct testing of genes or chromosomes.

Group health plan: An employee benefit plan set up or maintained by an employer or by an employee organization (such as a union), or both, to the extent that the plan provides medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise.

Health insurance issuer: An insurance company, insurance service, or insurance organization (including an HMO), that’s required to be licensed to engage in the business of insurance in a state and that’s subject to state laws that oversee insurance.

Late enrollee: A late enrollee is a person who does not enroll in a plan on the earliest date on which coverage can become effective under the terms of the plan or does not enroll during a special/open enrollment period. Under HIPAA, a late enrollee may be subject to a maximum pre-existing condition exclusion of up to 18 months.

Pre-existing condition exclusion: A limitation or exclusion of health coverage for a condition based on the fact that the condition was present before the first day of coverage.

Pre-existing Condition Insurance Plan (PCIP): Programs in each state that offer insurance to people who have been unable to get it because of a pre-existing condition. These programs stopped accepting new enrollees in 2012. They end in 2014, when insurers must begin to cover adults with pre-existing conditions.

Self-insured group health plan: Plans set up by employers or unions which put aside funds to pay their employees’ health claims, and the employer or union is acting as its own insurer. Self-insured plans often hire insurance companies to administer them (for instance, handling enrollment, paying claims, etc.), so the insurance company may be mistaken for being the actual insurer. Employers must let health plan enrollees know if an insurance company is responsible for actually insuring them or only for administering the plan. If the insurer is only administering the plan, it’s self-insured. The US Departments of Labor and Treasury regulate self-insured plans under ERISA; they are not subject to state law.

Significant break in coverage: As defined by HIPAA, a break in coverage of 63 days or more. May be longer if your state law allows the break in coverage to be longer while still counting the previous creditable coverage time.

SPD: A summary of the plan description of the health insurance policy.

SMM: Summary of material modifications is information (often a document) that employers are required to give to employees. The SMM informs participants and beneficiaries of “material reductions in covered services or benefits” (for example, reductions in benefits or increases in deductibles and co-payments), generally within 60 days of putting the changes into practice.

Waiting period: The period of time that an employer sets which must pass before an employee or dependent is eligible to be covered under the terms of a group health plan.


Last Medical Review: 12/31/2013
Last Revised: 12/31/2013