What is the Health Insurance Portability and Accountability Act (HIPAA)?

The Health Insurance Portability and Accountability Act (HIPAA) provides a range of protections to millions of working Americans.

The Health Insurance Portability and Accountability Act (HIPAA) is one of many federal laws governing health insurance. 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. If you get your health insurance through your employer, and if you have what is called a "preexisting condition" or some other health-related characteristic that makes you undesirable in the eyes of an insurance company, HIPAA protects you when it comes to getting health insurance. HIPAA also requires doctors and medical professionals to keep a patient’s records confidential.

Currently, many of HIPAA’s provisions aren’t needed because of the stronger protections in the newer 2010 health care law, the Affordable Care Act. But because it’s impossible to know what the future will hold for the Affordable Care Act—and because those who have older health plans can still benefit from HIPAA protections—you should get to know the basics about HIPAA so that you can use it to protect yourself and your family if necessary.

What’s a Preexisting Condition?

Under HIPAA, 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.

HIPAA places what's called 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 can’t be excluded from coverage on that basis. But, a group health plan can impose a preexisting condition exclusion on new enrollees for conditions for which medical advice, diagnosis, care, or treatment was received or recommended within the six-month period prior to the enrollment date.

What’s HIPAA's Purpose? What Protections Does It Provide?

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 certain conditions. Here are a few of the protections HIPAA provides:

  • Pregnancy is no longer considered a preexisting condition. If you’re pregnant and want to switch group health plans, you can do so without risking a break in your coverage.
  • Protections for newborns and adopted children. Health plans and insurers can’t apply the preexisting 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 can’t 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.
  • Shorter preexisting condition exclusion periods. 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.
  • Protection if you change jobs. If you switch from one group health plan to another as the result of a job change, you will not face new preexisting 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.

Want More Information?

To learn more about important federal laws affecting your health insurance benefits, including HIPAA, visit the U.S. Department of Labor website. For more information on health insurance as it relates to the workplace, see Your Rights in the Workplace, by Barbara Kate Repa (Nolo). For more information about the Affordable Care Act, go to HealthCare.gov.

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