Health Insurance Portability & Accountability Act of 1996
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What is HIPAA ?
What are the Pre-Existing Exclusion rules ?
What is meant by "Creditable Coverage" ?
Are there pre-existing conditions that cannot be excluded from coverage ?
How does a member prove prior creditable coverage to the new carrier ?
Is a "significant break" in coverage affected by a waiting period that may
exist with a new employer ?
What is a HIPAA "Special Enrollment" ?
What changes were made to Portability of coverage July 1, 2005 ?
What exactly does "guaranteed renewability" mean in the HIPAA ?
What are the rules with regard to Privacy ?
Are there authorizations available whereby a member can permit a producer
to speak on a member's behalf ?
Where can I obtain more information on the HIPAA ?
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
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
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
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
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
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
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
12. Where can I obtain more information on the HIPAA ?
on the web at:
(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 firstname.lastname@example.org or call
her on her office: 856-642-2949.