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					Health Insurance Portability & Accountability Act of 1996
(HIPAA)

 If you cannot find the information you're looking for or you need additional
 assistance, please contact Amy Webb, President and CEO.


    1.

         What is HIPAA ?




    2.

         What are the Pre-Existing Exclusion rules ?




    3.

         What is meant by "Creditable Coverage" ?




    4.

         Are there pre-existing conditions that cannot be excluded from coverage ?




    5.

         How does a member prove prior creditable coverage to the new carrier ?




    6.

         Is a "significant break" in coverage affected by a waiting period that may
         exist with a new employer ?




    7.

         What is a HIPAA "Special Enrollment" ?
   8.

         What changes were made to Portability of coverage July 1, 2005 ?




   9.

         What exactly does "guaranteed renewability" mean in the HIPAA ?




   10.

         What are the rules with regard to Privacy ?




   11.

         Are there authorizations available whereby a member can permit a producer
         to speak on a member's behalf ?




   12.

         Where can I obtain more information on the HIPAA ?




Related Information

Please refer to the following documents for additional information:

Magellan PHI Release.pdf     (HIPAA Privacy Release)

Aetna Authorization to Release PHI.pdf    (Privacy Information Release)

AmeriHealth HIPAA-PHI Authorization.pdf

CIGNA - HIPAA - PHI Authorization Form.pdf

Horizon BCBSNJ HIPAA Privacy Authorization Form.doc

Oxford HIPAA Member Authorization Form - new groups.doc       (HIPAA Member
Authorization Form)

Oxford Member Authorization form.pdf

COCC.pdf   (Certificate of Creditable Coverage - Federal Version)




   1. What is HIPAA ?




      The Health Insurance Portability and Accountability Act of 1996 is Federal
      and was signed into law on August 21, 1996. This law includes important
      new protections for millions of working Americans and their families who
      have pre-existing medical conditions or who might suffer discrimination in
      health coverage based on a factor that relates to the individual's health.
      HIPAA includes provisions that:

      * limit exclusions for pre-existing conditions;

      * prohibit discrimination based on health factors; and

      * guarantee renewability and availability of health coverage to certain
      employees and individuals.




   2. What are the Pre-Existing Exclusion rules ?




      A group plan or a health insurance issuer offering group health coverage
      may impose a pre-existing condition exclusion only if the following
      conditions are satisfied:

      * the exclusion must relate to a condition for which medical advice,
      diagnosis, care or treatment was recommended or received during the 6
      month period prior to the enrollment;

      * the exclusion may not last more than 12 months (18 months for late
      enrollees) from the enrollment date (Caution: this language is from the
      Federal law. Each state may be more generous or less restrictive. For
      example for NJ Small group, the limitation is only 6 months and the penalty
      for a late enrollee is that pre-existing applies).

      * the 12 or 18 month period must be reduced by the number of days of
   prior creditable coverage, excluding coverage before any break of 63 days
   or more (Note: the break for NJ Small Group is 90 days).




3. What is meant by "Creditable Coverage" ?




   Most health coverage is creditable, such as under a group health plan
   (including COBRA continuation coverage), individual health, Medicaid or
   Medicare.




   Certain types of coverage offered through schools are not creditable. You
   may want to confirm with the insurance carrier.




   Creditable Coverage means, with respect to an Employee [or Dependent],
   coverage of the Employee [or Dependent] under any of the following: a
   Group Health Plan; a group or individual Health Benefits Plan; Part A or Part
   B of Title XVIII of the federal Social Security Act (Medicare); Title XIX of the
   federal Social Security Act (Medicaid), other than coverage consisting solely
   of benefits under section 1928 of Title XIX of the federal Social Security Act
   (the program for distribution of pediatric vaccines); chapter 55 of Title 10,
   United States Code (medical and dental care for members and certain
   former members of the uniformed services and their dependents); a medical
   care program of the Indian Health Service or of a tribal organization; a state
   health benefits risk pool; a health plan offered under chapter 89 of Title 5,
   United States Code; a public health plan as defined by federal regulation; a
   health benefits plan under section 5(e) of the “Peace Corps Act”; or
   coverage under any other type of plan as set forth by the Commissioner of
   Banking and Insurance by regulation.

   Creditable Coverage does not include coverage which consists solely of the
   following: coverage only for accident or disability income insurance, or any
   combination thereof; coverage issued as a supplement to liability insurance;
   liability insurance, including general liability insurance and automobile
   liability insurance; workers’ compensation or similar insurance; automobile
   medical payment insurance; credit only insurance; coverage for on-site
   medical clinics; coverage as specified in federal regulation, under which
   benefits for medical care are secondary or incidental to the insurance
   benefits; and other coverage expressly excluded from the definition of
   Health Benefits Plan.
   Note: effective July 1, 2005 previous coverage from socialized medicine
   from a foreign country is also creditable.




   Days in a waiting period are not creditable however they are NOT counted
   against the member in determining a significant break (63 days or more).




4. Are there pre-existing conditions that cannot be excluded from coverage ?




   Yes. An exclusion can never apply to pregnancy, regardless of whether the
   woman had previous coverage (or the size of the group plan). In addition a
   pre-existing condition exclusion cannot apply to a newborn or child
   placed in the home for adoption under age 18 as long as the child
   became covered within 30 days of birth or placement for adoption, and
   provided the child does not incur a subsequent 63 day or longer break in
   coverage (Note: states may vary with the number of days a break in
   coverage is permitted before the exclusion applies).




5. How does a member prove prior creditable coverage to the new carrier ?




   Group health plans and health insurance issuers are required to furnish a
   Certificate of Creditable Coverage (COCC). The certificate must be provided
   automatically when coverage is lost as well as when COBRA continuation
   ceases.

   A member may also request a certificate, free of charge, until 24 months
   after the time coverage ends. A certificate may also be requested even
   before coverage ends.

   A sample COCC is attached in the forms section.

   Note: this sample COCC is the new 2005 Federal version. Certain states are
   less restrictive in the number of days considered a "break in coverage".
6. Is a "significant break" in coverage affected by a waiting period that may exist
   with a new employer ?




   No. Any waiting period imposed by the employer plan does not count
   towards the "signficant break".




7. What is a HIPAA "Special Enrollment" ?




   Enrollment due to Loss of Other Coverage (per HIPAAs Special Enrollment
   Provision):
   If an Employee initially waived coverage under the Policy and the Employee
   stated at that time that such waiver was because he or she was covered
   under another group plan, and Employee (and dependents) now elects to
   enroll under the Policy, the Carrier will not consider the Employee and
   Dependents to be Late Enrollee[s], provided the coverage under the other
   plan ends due to loss of eligibility for the other plan.

   The Employee must enroll under the Policy within 90 days (for NJ Small
   Group) of the loss of eligibility. Coverage will take effect as of the date the
   applicable event occurs. In order to accommodate a retroactive effective
   date, the member may have to provide proof that the prior coverage ended
   due to loss of eligibility. A COCC is only used to credit time served for any
   pre-existing exclusion and does not prove loss of eligibility. Contact your
   Savoy service team as to what is required by the specific carrier in your
   situation.

   If an Employee initially waived coverage under the Policy because of
   coverage under COBRA and the Employee requests coverage under the
   Policy within 30 days of the date the COBRA continuation ended, they will
   not be considered a Late Enrollee. Coverage will take effect as of the date
   the COBRA continuation ended.




8. What changes were made to Portability of coverage July 1, 2005 ?




   Socialized medicine from foreign countries will count as creditable coverage
   in the satisfaction of any pre-existing exclusion. Note that time served is
   credited, not waived.




9. What exactly does "guaranteed renewability" mean in the HIPAA ?




   The guaranteed renewability requirements apply to employers whose size
   shifts between small and large group markets after purchasing coverage in
   one or the other of these markets. Insurance issuers (carriers) must renew
   plans at the option of the plan sponsor (employer). Generally this means
   that the employer must remain in exactly the same plan as originally
   purchased.

   An issuer may nonrenew only for the following reasons:

   * the employer fails to pay premium timely;

   * there are no longer any plan enrollees living, residing or working in the
   service area of a plan with a network requirement; or

   * the issuer is ceasing to offer coverage in a market.




10. What are the rules with regard to Privacy ?




   Under the Privacy Rule members and patients must give specific
   authorization before entities can use or disclose information. It is designed
   to restrict use and disclosure of health related information to appropriate
   purposes and to ensure it is not used against individuals in connection with
   their employment. Privacy relates to Protected Health Information (PHI)
   which is any information which is individually identifiable and is transmitted
   in any form.

   Covered entities are required to use, disclose and request only the minimum
   necessary PHI to accomplish the purpose of the request. This concept is
   called "minimum necessary" under the Privacy Rule.




11. Are there authorizations available whereby a member can permit a producer to
    speak on a member's behalf ?
   Yes. Each carrier has created authorizations and they can be found in the
   forms section.




12. Where can I obtain more information on the HIPAA ?




   on the web at:

   www.hhs.gov/ocr/hipaa

   (OCR is the office of Civil Rights)




   www.hhs.gov/ocr/hipaa/privruletxt.txt for the Privacy Rules

   or call toll free 866-627-7748 (for privacy information)




   or you may email our inhouse expert awebb@saratogabenefits.com or call
   her on her office: 856-642-2949.

				
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