What Is HIPAA?
Disclaimer: The American Cancer Society does not offer legal advice. This information is intended to provide general background in this area of the law.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a law that was created to protect millions of working Americans and their family members with medical problems. These people often had trouble getting health insurance because of a medical problem they had before they tried to buy health insurance (called a pre-existing condition). In fact, before the important protections of the health care law known as the Affordable Care Act took effect, many people with serious health problems couldn’t get health insurance.
Now, many of the provisions of HIPAA are no longer needed because of the stronger protections of the newer health care law. But people who have older health plans – known as grandfathered plans – can still benefit from HIPAA protections. These protections are discussed in more detail here.
Does the Affordable Care Act affect HIPAA?
The Affordable Care Act (ACA) passed in 2010 has changed the way health insurance companies manage coverage for pre-existing conditions.
- Before ACA became law, HIPAA helped protect people with pre-existing conditions like cancer. Now, most people with pre-existing conditions will be able to get coverage more easily. That’s because group plans, including employer-based plans and new individual health plans are no longer allowed to deny coverage to people with pre-existing conditions.
- People under individual health plans that existed before September 23, 2010 – known as grandfathered plans, will still be allowed to use pre-existing condition exclusions. Plans issued or renewed on or after September 23, 2010 must follow the ACA rules.
This document will discuss HIPAA’s effects on the older “grandfathered” plans and point out the changes that will happen later due to newer health care laws.
How does HIPAA help people with cancer?
The following information applies 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.
HIPAA includes several parts that may help people with cancer who are under older grandfathered individual health plans.
- It limits what’s considered a pre-existing condition. An employer health plan can exclude a medical condition from coverage only if the person had a gap in coverage longer than 63 days, and also had or was recommended to have treatment or medical advice in the 6 months before enrolling in the plan.
- It limits the time a new employer plan can exclude the pre-existing condition from being covered. An employer health plan can avoid covering costs of medical care for a pre-existing condition for no more than 12 months after the person is accepted into the plan.
- It gives certain people the right to buy individual health insurance if no group health plan coverage is available, and the person has exhausted COBRA or other continuation coverage. (For more information on COBRA, see our document What is COBRA?) Certain conditions and time limits must be met.
- It does not allow employers or their health insurers to discriminate or act unfairly against employees and their dependents based on their health status or genetic information.
- It guarantees certain people the ability to get or renew individual health insurance coverage.
HIPAA also protects privacy and gives you more access to your medical records.
In 2002, the HIPAA laws were expanded to give patients greater access to their own medical records. The expanded law also gave patients more control over how their personally identifiable health information is used. In general, health information may not be shared without written permission of the patient. The law requires health care providers and health insurance plans to protect the privacy of patient health information, too. Medical records must be kept under lock and key and are available only on a need-to-know basis.
What doesn’t HIPAA do?
Even though HIPAA offers protections and makes it easier to switch jobs without fear of losing health coverage for a pre-existing condition, the law has limits. For instance, HIPAA:
- Does not require employers to offer health coverage, though the new health care law will require some to offer it
- Does not require employers that offer coverage for employees to also cover their families or dependents
- Does not guarantee that you can afford the health coverage your employer offers
- Does not keep an employer from imposing a pre-existing condition exclusion period if you have been treated for a condition during the past 6 months and have had an interruption in your coverage (group plans can’t do this after January 1, 2014)
- Does not replace your state as the main regulator of insurance where you live
Even so, HIPAA has generally made it much easier to switch health plans or change jobs without losing coverage if you have a health problem.
- 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