HIPAA: the Health Insurance Portability and Accountability Act

In 1996, the Employee Retirement Income Security Act (ERISA), which regulates employee benefit plans, was amended to include the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is split into two major parts - Title I protects employed Americans from discrimination in connection to their health coverage. Title II requires doctors and medical professionals to keep patient records confidential.

HIPAA Title I - Health Care Access, Portability, and Renewability

The protections of HIPAA Title I make it easier for you to change jobs without losing your health coverage. Title I limits your new health plan's ability to deny coverage based on a medical condition you had before obtaining the new coverage -- called a preexisting condition. It also provides you with added opportunities to enroll in a new group health plan or individual health insurance policy and prohibits discrimination against you or your family by the new plan or insurance provider. Besides these HIPAA protections, you are protected by the laws of the state you reside in, and the recent Affordable Care Act regulations.

Protections for Preexisting Conditions

Under HIPAA, employer health plans are no longer allowed to refuse health coverage for a new employee with preexisting conditions, as long as the employee follows certain procedures for approval. Note that HIPAA protects you from being denied health care due to a preexisting condition if you are seeking health insurance under an employer's plan, whereas if you are applying for individual health insurance or any coverage not part of an employer's plan, you are protected from preexisting condition discrimination by the Affordable Care Act (ACA or Obamacare).

However, exercise caution when switching plans, because HIPAA doesn’t protect against the following:

  • Employers don’t need to offer health coverage.
  • Your new employer's health plan isn’t required to cover every medical condition you have (or have had in the past).
  • Your new plan can require that you satisfy a preexisting condition exclusion period, meaning if you have been treated for a condition within the past 6 months, the new plan is allowed to exclude it.

The procedure for ensuring your preexisting conditions are protected by HIPAA is very complex, so you should contact the Department of Labor's Employee Benefits Security Administration if you have any questions. Remember that a health plan is never allowed to classify a pregnancy, conditions present in a newborn or an adopted child under 18 (with limited exceptions), or genetic conditions discovered through genetic testing as preexisting conditions.

Special Enrollment Opportunities for Those Who Previously Declined Coverage

HIPAA also provides an opportunity for those who have previously declined health coverage (with their own plan) to enroll at a date outside of the plan's open enrollment period. For example, special enrollment situations occur when:

  • Divorce or separation causes you to lose coverage under your spouse's insurance.
  • You are a young dependent and you find yourself no longer covered under your parent's plan.
  • Your spouse dies and leaves you without coverage.
  • Your spouse's employment ends, terminating plan coverage.
  • Your employer reduces your work hours and you no longer qualify to be covered under the plan.
  • Your plan no longer offers you coverage because your employer has eliminated the eligibility of certain groups of employees (e.g. part-time).
  • You no longer live or work in the HMO's service area.
  • You have a health claim that will meet or exceed the plan's lifetime limit on benefits.

Protections Against Discrimination

Under HIPAA, you and your family cannot be denied eligibility or benefits or charged more for the coverage based on certain health factors. Your health plan cannot use health status, medical conditions (physical or mental), claims experience, past receipt of health care, medical history, genetic information, evidence of insurability, or disability as reasons for denying you medical coverage. Evidence of insurability includes participation in activities like motorcycling, snowmobiling, horseback riding, skiing, and other sports, or proof that you were a victim of domestic violence.

HIPAA Title II - Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform

Title II ordered the U.S. Department of Health and Human Services (HHS) to create standards for the protection of your electronically stored medical information and placed mandatory guidelines on the rules, contracts, and procedures used by the administrators of medical offices. In response, the HHS enacted what is called "The Privacy Rule," which requires doctors and medical professionals to protect any individually identifiable information that relates to the physical or mental condition or the provision of health care to an individual. There are situations in which the medical professional is allowed to share a patient's medical information, such as when the patient gives them permission, if the doctor or patient needs help and is unable to make medical decisions, if the government requires it (i.e. birth and death records), or if the patient makes their health an issue in court.

Have a Legal Question Concerning HIPAA? Contact an ERISA Attorney

Every American has certain rights under HIPAA, which is part of the larger ERISA. Navigating the law and knowing whether your rights are being honored can be quite difficult for non-attorneys. If you have concerns about your HIPAA-guaranteed health care rights, you may want to speak with an attorney who specializes in matters covered by ERISA.

Next Steps

Contact a qualified health care attorney to help navigate legal issues around your health care.

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