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

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HIPAA is a federal law that protects the rights of people with disabilities and their dependents to employer-sponsored or individual health coverage when they change jobs, lose their job, or want to add a family member to their health insurance policy. It also contains important provisions on health care accountability and reporting.

By what other name is HIPAA known?

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HIPAA is also referred to as the Kennedy/Kassebaum Act.

Is HIPAA health coverage?

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No. HIPAA is a federal law guaranteeing access to employer-sponsored health coverage to individuals with pre-existing medical conditions who are transitioning from any type of health coverage (public or private). HIPAA also guarantees access to individual health coverage in certain circumstances if you are ineligible for any other type of coverage.

What are some of HIPAA's protections?

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HIPAA:
  • Prohibits employer-sponsored health plans from denying you or your dependents coverage due to the status of your health or that of any of your dependents.
  • Defines a pre-existing condition as a condition you were diagnosed with or treated for within the six months prior to enrollment in employer-sponsored health coverage.
  • Limits pre-existing condition exclusionary periods to 12 months (18 for late enrollees).
  • Allows you to use creditable coverage from your previous health plan (public or private) to reduce pre-existing condition exclusionary periods when entering new group health coverage. The gap between plans generally has to be less than 63 days.
  • Allows you to use previous coverage to access individual coverage if you lose your ability to access your existing other types of health coverage.
  • Allows you to enroll in employer-sponsored health coverage without having to wait for the next regular enrollment period.

What is a pre-existing medical condition?

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For the purposes of HIPAA, a pre-existing medical condition is any physical or mental condition that you received or were recommended treatment, advice, diagnosis, or care within the six months prior to enrollment in a new employer-sponsored health plan. This would include consulting a nurse or doctor or being prescribed medication.

What is a pre-existing condition exclusionary period?

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A pre-existing condition exclusionary period is the period of time when a plan will not cover you for treatment related to your pre-existing condition.

What is creditable coverage?

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Creditable coverage refers to prior enrollment in public or private health coverage. Creditable coverage is used to reduce pre-existing exclusionary periods when enrolling in a new plan. Many forms of health coverage are considered creditable coverage, including private employer-sponsored, association-sponsored, or individual plans; continuation coverage, and coverage under public health benefits such as Medi-Cal and Medicare.

How do I use creditable coverage from prior health coverage to reduce or eliminate a pre-existing condition exclusionary period under my new employer-sponsored health plan?

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Pre-existing condition exclusionary periods are reduced by the amount of time you had creditable coverage under a previous plan. If you had 4 months of creditable coverage under your previous plan, your pre-existing condition exclusionary period will be reduced by 4 months. To utilize creditable coverage, you must not have had a gap between prior coverage and new employer-sponsored coverage of more than 63 days. In California, if your prior coverage was through an employer, and you lost that coverage because your job ended, or you employer stopped offering or contributing to health coverage, that gap can be up to 180 days.

Does HIPAA allow me to use all types of previous private health coverage to reduce pre-existing condition exclusionary periods?

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Are there any medical eligibility requirements for HIPAA and similar California protections?

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No.

Does what I have in the bank or what I own, such as a home or car, affect my HIPAA protections?

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No. There are no limitations on what you own or have in the bank to use HIPPA and similar California protections.

How do I prepare to use HIPAA and similar California protections? What do I need?

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When transitioning between health plans, your new provider may request proof of coverage from your previous plan. This is known as a certificate of coverage. If you request this information and do not receive it, contact the plan administrator - your previous provider must supply you and your new provider with this information. If for some reason they don't, pay stubs from your previous job or an explanation of benefits form (EOB) may be used to document creditable coverage instead.

Can Medi-Cal or Medicare coverage qualify as previous coverage for HIPAA and similar California protections?

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Yes. Medi-Cal and Medicare coverage are considered creditable coverage under HIPAA and similar California protections. You can use them to reduce or eliminate pre-existing condition exclusionary periods.

Are there further health coverage protections in California?

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Yes. AB 1672 and other California law offer more generous protections to people in certain circumstances. When they apply, these laws can provide:
  • Shorter maximum pre-existing condition exclusionary periods
  • Further protections for employees of small employers
  • A longer gap between plans allowed for creditable coverage
  • Protections for those entering the individual market who aren't "HIPAA-eligible"

The Program Description for HIPAA and California Protections goes into details about who these further protections apply to, and when they are applicable.

California also has further continuation coverage protections, and further protection for domestic partners.

Are there rules for immigrants to qualify for HIPAA protections?

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No. The only immigration rules that need to be considered would relate to your legal residency status and whether you are legally authorized to work in California.

What is a "HIPAA-eligible" individual?

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This term refers to HIPAA's individual coverage protections. To be eligible for these protections, you must meet the following conditions:
  • You have had continuous creditable coverage for a total of at least 18 months without a significant break in coverage (63 days or more).
  • Your most recent health coverage was through a group plan.
  • You prior group coverage did not end due to fraud or nonpayment of premiums.
  • You used up your COBRA benefit (if it was available to you).
  • You are ineligible for Medicare, Medi-Cal or any other insurance coverage including group plans.

If you are HIPAA-eligible, companies selling individual plans must offer you a choice of two plans, and there are no pre-existing condition exclusionary periods.

If you aren't HIPAA-eligible, individual insurance companies can deny you based on your medical history, but California laws limits the length of pre-existing condition exclusionary periods.