- What Is HIPAA?
- HIPAA, pre-existing condition exclusions, and creditable coverage
- HIPAA, your health history, and health insurance coverage
- Making benefits claims
- HIPAA and certain policy provisions
- Information sharing
- Who enforces HIPAA?
- Getting and keeping health insurance coverage under HIPAA
- Glossary of terms
- To learn more
Who enforces HIPAA?
States enforce the legal requirements on health insurance issuers. If a state does not act in its areas of responsibility, the Secretary of Health and Human Services may decide that the state has failed to “substantially enforce” the law. Federal authority can be used, through the Centers for Medicare and Medicaid Services, to enforce the law and penalize the insurers.
The US Secretary of Labor also has the authority to enforce the health care portability requirements on group health plans under ERISA (Employee Retirement Income Security Act), including self-insured arrangements. And participants and beneficiaries can file lawsuits to enforce their rights under ERISA, as amended by HIPAA.
Can states change HIPAA’s insurance requirements?
Yes, in certain circumstances. States may impose stricter requirements on health insurance issuers in the 7 areas listed below. States may:
- Shorten the 6-month “look-back” period before the enrollment date to decide what’s a pre-existing condition
- Shorten the 12-month maximum pre-existing condition exclusion periods (or the late enrollee’s 18-month maximum condition exclusion)
- Count prior insurance coverage as creditable even though there’s been more than a 63-day break in coverage
- Increase the 30-day period for newborns, adopted children, and children placed for adoption to enroll in the plan so that no pre-existing condition exclusion period may be applied thereafter
- Further limit the circumstances in which a pre-existing condition exclusion period may be applied beyond the “exceptions” described in federal law (the “exceptions” under federal law are for certain newborns, pregnancy, and genetic information in the absence of a diagnosis). Remember also that the new Affordable Care Act law will not allow insurance plans to deny coverage based on pre-existing conditions to Americans of all ages starting in 2014.
- Require more periods of special enrollment
- Reduce the maximum HMO affiliation period to less than 2 months (3 months for late enrollee)
States may sometimes impose other requirements on insurance companies and HMOs. If your health coverage is offered through an HMO or an insurance policy issued by an insurance company, you can check with your state insurance department’s office to find out the rules in your state. Find your State Insurance Department in the blue pages of your local phone book, or visit the National Association of Insurance Commissioners on the web at www.naic.org/state_web_map.htm.
Last Medical Review: 09/16/2013
Last Revised: 09/16/2013