The Health Insurance Portability and Accountability Act (HIPAA), which Congress passed in 1996, provides a variety of protections for individuals both in getting healthcare coverage and in keeping medical information private. Features include limits on what can be considered a preexisting condition, limits on exclusions from coverage for preexisting conditions, guaranteed coverage for people who lose qualified coverage, and limits on sharing of sensitive medical information by agencies.
Preexisting Conditions
Insurance plans often exclude coverage for any condition an individual already had before the policy took effect. HIPAA limits the definition of a preexisting condition. According to the U.S. Department of Labor, a preexisting condition is one for which "medical advice, diagnosis, care or treatment was recommended or received" within the six months before the enrollment date for healthcare. So a condition treated over six months ago can not be considered a preexisting condition. HIPAA also prevents insurance companies from treating pregnancy and specific genetic information as preexisting conditions.
Preexisting Condition Exclusions
HIPAA also limits the amount of time for which an insurance company can deny coverage for a preexisting coverage to 12 months in most cases. Thus, employees who maintain coverage through their employer are subject to the exclusion only for the first 12 months of coverage, and then are entitled to coverage for any preexisting conditions as long as they maintain their insurance.
Replacing Coverage
HIPAA provides protection for people who lose their group insurance when they lose their job or the employer stops offering insurance and for those who change employers. In those situations, any individual who has maintained coverage continuously for at least 18 months without a break over 63 days can either obtain an individual policy or qualify for a new group policy without being subject to preexisting condition exclusions. Options include continuing the same coverage with a conversion plan from the employer's insurance company, obtaining a HIPAA plan from any insurance company offering individual plans, or qualifying for a state high-risk pool.
Limitations
HIPAA does not require employers to provide health insurance benefits, nor does it guarantee that insurance plans cover specific conditions for all policyholders. Also while it requires that insurance companies offer their two most popular plans as HIPAA plans, it does not limit the amount they may charge for such coverage or for conversion plans. Also, an employee who loses group insurance must first use up any benefits available through the (COBRA) before becoming eligible for a HIPAA or conversion plan.
Privacy Regulations
HIPAA also provides privacy protection for information about an individual's physical and mental health when that information is handled and electronically transmitted by healthcare plans and healthcare providers. It requires that agencies make available written documentation of privacy practices and respond to an individual's request for health information or for disclosure of other parties who have requested that information.
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