Getting and keeping health insurance coverage under HIPAA
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.
If I can’t get group coverage and have no other options, what do I do?
There’s 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 cannot be 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. 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 does assure 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’re 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’s 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 online at www.naic.org/state_web_map.htm.
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 the ACA does not allow companies to charge more for a plan based on health status or history. Under the ACA, people below certain income levels may qualify for help buying an individual policy. For information on how your state law may limit premium rates for individual insurance policies, 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’s 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. Your insurance may also be canceled or discontinued if you failed to pay premiums, committed fraud, terminated the policy, or moved outside the service area. Note that the Affordable Care Act does not allow insurance companies to retroactively take away a person’s legitimate (paid-up) health insurance because of a small technical error or mistake on the application.
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. However, the ACA sets up certain requirements for what new health insurance plans must cover.
Does HIPAA require employers to offer health coverage or require plans to provide specific benefits?
No. An 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. The ACA requires some employers to offer health coverage and also cover certain basic benefits. For more on these points, see our document called Health Insurance and Financial Assistance for the Cancer Patient.
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’ve 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 called “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?
- 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