Health Insurance Portability & Accountability Act (HIPAA)

PROOF-READ THIS & MOVE THE "CREDITABLE COVERAGE" PART

There are two types of Portability rights under the Federal HIPAA (Health Insurance Portability & Accountability Act) Laws.  

• One is for those enrolling in Group Plans (known as HIPAA "Certificate of Creditable Coverage" Portability)

• The other is for those enrolling in an Individual / Family Plan (known as HIPAA "Guaranteed Issue" Portability)

These laws allow those who have had prior health insurance coverage to join a Group plan, or an Individual / Family plan, with rights to coverage.  There are several rules & time frames that must be met.  

HIPAA "Certificate of Creditable Coverage" Portability (for those enrolling in Group Plans) reduces or eliminates the Group Plan's pre-existing condition waiting period, by giving you "credit" (month-for-month), for the prior coverage that you have had.  Some of the main issues are:

• This type of Portability is for those enrolling in GROUP plans only
• You will get credit (month-for-month) for prior coverage that you have had.  This credit will be used to reduce or eliminate your pre-existing conditions waiting period on the new Group Plan.
• You must not have had a lapse in coverage of 63 days or more (the waiting period for new-hires to become eligible for their Employer's plan is not included in the 63 days).
• You can use any combinations of "Creditable Coverage" to prove that you have had prior coverage.  This includes Individual Plans and Group Plans.  More information about "Creditable Coverage" follows below.  

HIPAA "Guaranteed Issue" Portability (for those enrolling in INDIVIDUAL/FAMILY plans).  This allows you to purchase an Individual/Family plan, without medical underwriting (meaning there will be no health questions asked before you are approved).  The Individual/Family plans are identical to the ones marketed to the general public, except for three points - there is no waiting period for pre-existing conditions, you may not be turned down due to medical conditions, and the premium is far more expensive.  Some of the main issues are:

• This type of Portability is for those enrolling in INDIVIDUAL/FAMILY Plans only.
• You must have been insured for the prior 18 months.  
• You must not have had a lapse in coverage of 63 days or more (the waiting period for new-hires to become eligible for their Employer's plan is not included in the 63 days).
• your most recent coverage must be GROUP coverage (COBRA is also considered Group).  Caution - Enrollment in a Short-Term plan, or any other Individual plan will disqualify you.
• You must have exhausted all COBRA rights that were available to you
• You must not be eligible for other Group health insurance, Medicaid, Medicare or AHCCCS
• You may not be covered under any other health insurance

For more information about all the eligibility rules, and about the benefits & premiums, contact the Insurance Company of your choice & ask about their HIPAA (Guaranteed Issue) Portability plans.

Creditable Coverage - Both types of HIPAA Portability require you to have prior coverage.  This must be "Creditable Coverage".  When you leave an Insurance plan, you will receive a "Certificate of Creditable Coverage" from your prior Insurer.  Use this document as proof of your prior coverage.  If you do not have this document, order another one, or use other documentation to prove that you had coverage (such as proof of claims payments, proof of premium payments, copies of old ID cards, etc.)  Most Insurance Companies will work with you to accept valid proof of prior coverage.  Many of them will even call your prior Insurance Company to verify that you were covered.  

Caution - be sure that you know which types of Insurance plans qualify as "Creditable".  Most Group & Individual plans qualify, if they are traditional types of health insurance, such as HMO's, PPO's, HSA's, etc.  Also, Governmental plans qualify, such as Medicare, Medicaid, AHCCCS, Indian Health Services, etc.  You can have any combination of these plans, with several Insurers and/or several different jobs.  However, limited-benefit types of plans DO NOT qualify as "Creditable".  Examples of Limited Benefit Plans include Medical Discount Plans, Hospital Indemnity Plans, Specific Disease Plans (such as Cancer Plans), etc.  

Remember, if you are applying for HIPAA "Guaranteed Issue" Portability (for Individual/Family plans), your most recent coverage must have been GROUP coverage.

This brief description of HIPAA Portability rights is not intended to be a full description, nor is it intended to be legal advice.  Most Insurance Companies will provide you with more information about your Portability rights, if you call them directly and ask for it. 

Last updated 2/2/2007