What Is HIPAA?

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HIPAA, your health history, and health insurance coverage

The following questions and answers apply to grandfathered plans, those that existed before September 23, 2010. Check with your employer to find out your health care plan’s start date, to learn if it’s grandfathered. If it isn’t, this section does not apply to you.

Under HIPAA, can I lose or be charged more for coverage if my health changes? I have been treated for cancer.

Group health plans and issuers may not set up rules for one person’s eligibility (including continued eligibility) to enroll under the terms of the plan based on “health status-related factors.” These factors include your health status, medical conditions (physical or mental), past medical claims, receipt of health care, medical history, genetic information, and evidence of insurability or disability. For example, you cannot be excluded or dropped from coverage under your group health plan just because you develop cancer.

Also, group plans and issuers may not require a person to pay a premium or contribution that’s greater than that for a similarly situated person based on a health status-related factor. So, you cannot be charged more just because you’ve had cancer in the past. On the other hand, if the employer raised everyone’s rates or completely stopped offering health coverage, it would not violate HIPAA.

Can a group health plan or group health insurance issuer require me to pass a physical exam before I can enroll in the plan? I have some side effects from the cancer treatment that may take a long time to go away.

No. A group health plan or group health insurance issuer cannot make you pass a physical exam for enrollment. Even if you’re a late enrollee, you cannot be required to pass a physical exam to get coverage.

My group health plan requires that I complete a detailed health history questionnaire and subtracts Health Points for prior or current health conditions. In order to enroll in the plan, I must score 70 out of 100 total points. I scored only 50 points and was denied eligibility in the plan. Is this allowed?

No. But the HIPAA non-discrimination provisions do not automatically forbid health care questionnaires. It depends on how the information on them is used. In this case, the plan requires people to score a certain number of Health Points that are related to current medical conditions in order to enroll in the plan. This is not allowed and is considered discrimination in rules for eligibility based on a health factor.

My group health plan has a 12-month pre-existing condition exclusion period but, after the first 6 months, the exclusion period is dropped for people who have not had any claims since enrollment. Is this allowed under HIPAA?

No. A group health plan may impose a pre-existing condition exclusion period, but the exclusion must be applied in the same way to all similarly situated people. Here, the plan’s provisions do not apply uniformly because people who have medical claims in the first 6 months after enrollment are not treated the same as those with no claims during that time. This means the plan provision violates the HIPAA non-discrimination provisions.

My group health plan excludes coverage for benefits for a health condition that I have (no matter whether it pre-existed or not). Is my plan violating HIPAA’s non-discrimination provisions by imposing this exclusion?

Group health plans may decide not to cover a certain disease. They may limit or exclude benefits for certain types of treatments or drugs, or limit or exclude benefits based on their decision of whether the benefits are experimental or medically needed. But they can only do this if the benefit restriction is applied uniformly to all people in similar situations and is not directed at anyone in the plan based on a health factor. So, if the same standard applies to everyone in the group, it may be allowed. An example might be coverage of a treatment that has not been scientifically proven.

My health plan had a $500,000 lifetime limit on all benefits covered under the plan. The plan also had a $5,000 annual limit on all benefits provided for one of my health conditions. Are these limits allowed under HIPAA?

HIPAA no longer governs these issues, but the Affordable Care Act (ACA) passed in 2010 does. Lifetime limits are not allowed in any plan, even grandfathered plans.

I like to sky-dive. Can I be excluded from enrolling in my employer’s health plan because I sky-dive?

No. You may not be denied eligibility to enroll in your employer’s plan because you sky-dive. But sky-diving injuries might not be covered under your health plan. See below.

Can my health plan or issuer deny benefits for an injury based on the source of that injury? When my mother developed cancer, I became very depressed and I took an overdose of sleeping pills.

If the injury results from a medical condition or an act of domestic violence, the health plan or issuer may not deny benefits for the injury, as long as it’s an injury the plan would otherwise cover.

For example, a plan may not exclude coverage for self-inflicted injuries (or injuries resulting from attempted suicide) for a person in the plan if the injuries are otherwise covered by the plan and if the injuries are the result of a medical condition, such as depression.

But a plan or issuer is not required to cover injuries that do not result from a medical condition or domestic violence. This means that injuries sustained in high-risk activities, such as bungee jumping, sky-diving, or whitewater rafting may not be covered.

Still, a plan cannot exclude people from enrollment because of their high-risk hobby. And it would still cover treatment for other medical conditions that were not related to the high-risk activity. Check with your insurance plan about their coverage of injuries related to risky sports.

I have a history of high claims. As a person with cancer, I’ve had 3 different types of treatment and many medicines. Can I be charged more than similarly situated people based on my claims?

No. Group health plans and group health insurance issuers cannot charge one person more for coverage than a similarly situated person based on any health factor.


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