The Health Insurance Portability and Accountability Act

(Page 2 of 2 of Getting the Most From Your Health Insurance )

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The Health Insurance Portability and Accountability Act (HIPAA) provides a range of protection to millions of working Americans who have some sort of health-related condition or characteristic that makes them vulnerable to exclusions, limitations, and discrimination in group health coverage. HIPAA applies mainly to employer-based health coverage. Therefore, if you get your health insurance through your employer, and if you have what is called a "preexisting condition" (see below) or some other health-related characteristic that makes you "undesirable" in the eyes of an insurance company, you should get to know HIPAA so that you can use it to protect yourself and your family.

A preexisting condition is a condition for which you received medical advice, diagnosis, care, or treatment in the six months prior to enrolling in your current health plan. Cancer and high blood pressure are common pre-existing conditions. For example, you may have received treatment for breast cancer in June, and enrolled in a new group health plan in July. Prior to this Act, you faced the possibility that your new health plan would not cover your breast cancer treatment for several years -- or at all -- simply because you received treatment for it previously.

The intent of HIPAA is to turn the tables on health plans and insurance companies by limiting the ways in which they can exclude coverage of such conditions:

  • Pregnancy is no longer considered a preexisting condition. Therefore, if you are pregnant and want to switch group health plans, you can do so without risking a break in your coverage. But be careful: There are some large loopholes in this protection. HIPAA applies only to women who switch from one group health plan to another. Therefore, if you had no coverage and then obtained group coverage through a new job after you got pregnant, your pregnancy may not be covered or you may have to wait for a period of time before it gets covered. (Ironically, this waiting period may last longer than your pregnancy.) Similarly, if you had individual coverage and then switched to either group coverage or to another individual plan after you got pregnant, your pregnancy may not be covered at all or for a specified period of time.
  • Health plans and insurers cannot apply the pre-existing condition exclusion to newborns or to children younger than 18 who are adopted or who are put up for adoption so long as the newborn or the child entered the health plan within 30 days of birth, adoption or placement for adoption.
  • Genetic information may not be treated as a preexisting condition in the absence of a diagnosis. If your coverage is through an insurance company or offered through a health maintenance organization, state law may provide additional protections.
  • The Act places a six-month "look back" limit on identifying preexisting conditions. This means that if you have a condition for which you received medical advice, diagnosis, care, or treatment longer than six months prior to enrolling in your new plan, that condition is not preexisting and cannot be excluded from coverage on that basis.
  • If you do have a preexisting condition and you have group health insurance, you face shorter preexisting condition exclusion periods than you would have faced prior to HIPAA. In other words, you can get covered for your condition faster than before. The maximum exclusion period is generally 12 months from the date on which you enrolled in the plan.
  • If you switch from one group health plan to another as the result of a job change, you will not face new pre-existing condition exclusions so long as there is no more than a 63-day break in your health coverage. This enables you to switch jobs despite your health status without fear that you will lose coverage for certain conditions.

In addition to protecting you from exclusions based on preexisting conditions, HIPAA also protects you from discrimination based on health-related characteristics. The Act prohibits health plans and insurers from excluding you from coverage or charging you more for coverage because of your health status.

Finally, HIPAA requires health care providers, including doctors and hospitals, to improve their efforts to keep your medical records and health information confidential.

The Women's Health and Cancer Rights Act of 1998

If you are a woman who must have a mastectomy due to breast cancer or another medical condition, this law places some requirements on how your group health plan, insurance company, or health maintenance organization must treat you. Under the Act, you are entitled to:

  • reconstruction of the breast on which the mastectomy was performed
  • reconstruction of your other breast to produce symmetrical appearance, and
  • prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.

The Women's Health Act applies only to plans that already provide medical and surgical benefits with respect to a mastectomy. If your plan does not provide such benefits, then it is not covered by this Act and you are not entitled to the Act's protections.

Want More Information?

To learn more about important federal laws affecting your health insurance benefits, visit the U.S. Department of Labor website at www.dol.gov. For more information on health insurance as it relates to the workplace, see Your Rights in the Workplace, by Barbara Kate Repa (Nolo). And if you need a lawyer's help, the Nolo Lawyer's Directory will help you find one in your area. 

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