I was doing some research on the HIPPA law and found the following information that I thought might be useful to some people struggling round and round with insurance companies. All of this information was found at the following site:
http://www.hep-c-alert.org/links/hippa.html
"Preexisting Condition Exclusions
Under HIPAA, a group health plan or a health insurance issuer offering group health insurance coverage may impose a preexisting condition exclusion with respect to a participant or beneficiary only if the following requirements are satisfied:
a preexisting condition 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 an individual's enrollment date;
a preexisting condition exclusion may not last for more than 12 months (18 months for late enrollees) after an individual's enrollment date; and
this 12- (or 1
month period must be reduced by the number of days of the individual's prior creditable coverage, excluding coverage before any break in coverage of 63 days or more."
"Can states modify HIPAA's portability requirements?
Yes, in certain circumstances. States may impose stricter obligations on health insurance issuers in the seven areas listed below. States may:
shorten the 6-month "look-back" period prior to the enrollment date to determine what is a preexisting condition;
shorten the 12- and 18-month maximum preexisting condition exclusion periods;
increase the 63-day significant break in coverage period;
increase the 30-day period for newborns, adopted children and children placed for adoption to enroll in the plan so that no preexisting condition exclusion period may be applied thereafter;
expand the prohibitions on conditions and people to whom a preexisting condition exclusion period may be applied beyond the "exceptions" described in federal law (the "exceptions" under federal law are for certain newborns, adopted children, children placed for adoption and pregnancy);
require additional special enrollment periods; and
reduce the maximum HMO affiliation period to less than 2 months (3 months for late enrollees).
Therefore, if your health coverage is offered through an HMO or an insurance policy issued by an insurance company, you should check with your State Insurance Commissioner's Office to find out the rules in your state. (See Appendix.)"
Crediting Prior Health Coverage For Purposes of
Reducing A Preexisting Condition Exclusion Period
A preexisting condition exclusion period is not permitted to extend for more than 12 months (or 18 months for late enrollees) after an individual's enrollment date in the plan. The period of any preexisting condition exclusion that would apply under a group health plan is generally reduced by the number of days of creditable coverage.
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What is "creditable coverage"?
Most health coverage is creditable coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO, individual health insurance policy, Medicaid or Medicare.
Creditable coverage does not include coverage consisting solely of "excepted benefits," such as coverage solely for dental or vision benefits.
Days in a waiting period during which you have no other coverage are not creditable coverage under the plan, nor are these days taken into account when determining a significant break in coverage (a break of 63 days or more).
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How does "crediting" for prior coverage work under HIPAA?
Most plans will use the "standard method" of crediting coverage.
Under the standard method, you will receive credit for your previous coverage that occurred without a break in coverage of 63 days or more. Any coverage occurring prior to a break in coverage of 63 days or more will not be credited against a preexisting condition exclusion period.
To illustrate, suppose an individual had coverage for 2 years followed by a break in coverage of 70 days and then resumed coverage for 8 months. That individual would only receive credit for 8 months of coverage; no credit would be given for the 2 years of coverage prior to the break in coverage of 70 days.
It is also important to remember that during any preexisting condition exclusion period under a new plan you may be entitled to COBRA continuation coverage under your former plan. "COBRA" is the name for a federal law that provides workers and their families the opportunity to purchase group health coverage through their employer's health plan for a limited period of time (generally 18, 29 or 36 months) if they lose coverage due to specified events including, termination of employment, divorce or death. Workers in companies with 20 or more employees generally qualify for COBRA. Some states have laws similar to COBRA that may apply to smaller companies.
Julie
http://www.hep-c-alert.org/links/hippa.html
"Preexisting Condition Exclusions
Under HIPAA, a group health plan or a health insurance issuer offering group health insurance coverage may impose a preexisting condition exclusion with respect to a participant or beneficiary only if the following requirements are satisfied:
a preexisting condition 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 an individual's enrollment date;
a preexisting condition exclusion may not last for more than 12 months (18 months for late enrollees) after an individual's enrollment date; and
this 12- (or 1
month period must be reduced by the number of days of the individual's prior creditable coverage, excluding coverage before any break in coverage of 63 days or more.""Can states modify HIPAA's portability requirements?
Yes, in certain circumstances. States may impose stricter obligations on health insurance issuers in the seven areas listed below. States may:
shorten the 6-month "look-back" period prior to the enrollment date to determine what is a preexisting condition;
shorten the 12- and 18-month maximum preexisting condition exclusion periods;
increase the 63-day significant break in coverage period;
increase the 30-day period for newborns, adopted children and children placed for adoption to enroll in the plan so that no preexisting condition exclusion period may be applied thereafter;
expand the prohibitions on conditions and people to whom a preexisting condition exclusion period may be applied beyond the "exceptions" described in federal law (the "exceptions" under federal law are for certain newborns, adopted children, children placed for adoption and pregnancy);
require additional special enrollment periods; and
reduce the maximum HMO affiliation period to less than 2 months (3 months for late enrollees).
Therefore, if your health coverage is offered through an HMO or an insurance policy issued by an insurance company, you should check with your State Insurance Commissioner's Office to find out the rules in your state. (See Appendix.)"
Crediting Prior Health Coverage For Purposes of
Reducing A Preexisting Condition Exclusion Period
A preexisting condition exclusion period is not permitted to extend for more than 12 months (or 18 months for late enrollees) after an individual's enrollment date in the plan. The period of any preexisting condition exclusion that would apply under a group health plan is generally reduced by the number of days of creditable coverage.
Back to index
What is "creditable coverage"?
Most health coverage is creditable coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO, individual health insurance policy, Medicaid or Medicare.
Creditable coverage does not include coverage consisting solely of "excepted benefits," such as coverage solely for dental or vision benefits.
Days in a waiting period during which you have no other coverage are not creditable coverage under the plan, nor are these days taken into account when determining a significant break in coverage (a break of 63 days or more).
Back to index
How does "crediting" for prior coverage work under HIPAA?
Most plans will use the "standard method" of crediting coverage.
Under the standard method, you will receive credit for your previous coverage that occurred without a break in coverage of 63 days or more. Any coverage occurring prior to a break in coverage of 63 days or more will not be credited against a preexisting condition exclusion period.
To illustrate, suppose an individual had coverage for 2 years followed by a break in coverage of 70 days and then resumed coverage for 8 months. That individual would only receive credit for 8 months of coverage; no credit would be given for the 2 years of coverage prior to the break in coverage of 70 days.
It is also important to remember that during any preexisting condition exclusion period under a new plan you may be entitled to COBRA continuation coverage under your former plan. "COBRA" is the name for a federal law that provides workers and their families the opportunity to purchase group health coverage through their employer's health plan for a limited period of time (generally 18, 29 or 36 months) if they lose coverage due to specified events including, termination of employment, divorce or death. Workers in companies with 20 or more employees generally qualify for COBRA. Some states have laws similar to COBRA that may apply to smaller companies.
Julie