HIPAA and certain policy provisions

Is it OK for a health insurance issuer to charge a higher premium to one group health plan that covers people with costly health problems, than it charges another employer for their group health plan which covers fewer people with costly health problems?

As of 2014, health plans are no longer be able to take health factors into account when determining rates. Only age and where you live can be used to determine the cost of a plan.

My group health plan has a “non-confinement provision.” It states that if a person is confined to a hospital at the time they would normally become eligible for enrollment, they aren’t eligible until they leave the hospital. What if I’m in the hospital with a low white cell count due to chemotherapy at the time I become eligible for enrollment? Is this allowed?

No. Even grandfathered group health plans may not restrict a person’s eligibility, benefits, or the effective date of coverage based on the person being in a hospital or other health care facility. Also, a health plan may not set a person’s premium based on their being in the hospital.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Last Medical Review: May 19, 2016 Last Revised: May 19, 2016

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