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Your Health Insurance Rights Under HIPAA Posted: March 17th, 2010

By Maryalene LaPonsie

Maryalene LaPonsie

If you have seen a doctor in the last decade, the term HIPAA is familiar to you. The 1996 law created a slew of paperwork regarding privacy and health care rights that health care providers must use when treating patients.

In addition to limiting who can view your health history, HIPAA also made fundamental changes to how insurance companies offer coverage and who has access to medical insurance.

The Health Insurance Portability and Accountability Act

In 1996, with technology growing at an unparalleled pace, there was a concern that patient privacy would become a thing of the past. Some advocacy groups feared that third parties would be able to easily access medical records and sensitive, personal information.

To address these and other issues, Congress passed the Health Insurance Portability and Accountability Act (HIPAA). Going beyond patient privacy, the law also made a number of changes to how Americans get and keep health insurance.

The major provisions of the act include:

  • Limiting an insurance company's ability to exclude pre-existing conditions.
  • Creating new opportunities for individuals to find group health insurance.
  • Prohibiting discrimination against employees based on their health records.
  • Guaranteeing most people access to individual health plans.

HIPAA was most recently updated in 2009 when a provision in the American Recovery and Reinvestment Act (commonly referred to as the Stimulus Bill) expanded the law's privacy and security requirements.

HIPAA, Group Health Insurance and You

If you are one of the scores of Americans who are uninsured or underinsured, your real question may be how HIPAA can help you find affordable health insurance. Perhaps the greatest benefit of HIPAA is that it gives individuals with pre-existing conditions the right to secure group coverage -- among the cheapest health insurance available.

Previously, group plans could either deny coverage to individuals with pre-existing coverage, or place severe limitations on any benefits for existing health conditions. While employers may still apply a waiting period for coverage of pre-existing condition exclusions, the time period is restricted.

For example, insurers can now only look back 6 months into someone's health history to determine whether a condition is pre-existing. So if you had back surgery 9 months ago and have not received any further treatment since that time, your group health insurance plan cannot classify your back condition as a pre-existing condition.

Even if a pre-existing condition waiting period does apply, insurance companies can only deny coverage for conditions for one year, and even then must give you "credit" for the time you were previously insured. So if the exclusion period is one year, and you have "creditable coverage" for the past 12 months, there's no waiting period.

Creditable coverage means that you previously had health insurance even with your pre-existing condition. This could be health insurance through Medicaid, Medicare, COBRA coverage, another group plan, or an individual policy. The important thing is that you do not have a gap more than 63 days in continuous health coverage. If you go more than 63 days without insurance coverage, you lose your HIPAA rights to have your pre-existing conditions covered under your next health plan.

Finally, there are certain situations that can never be classified as a pre-existing condition by group health plans. These include:

  • Pregnancy
  • Conditions present at the time of birth or adoption, as long as the newborn or adopted child is enrolled in the health plan within 30 days
  • Genetic predispositions (i.e. individuals with a gene indicating they are at risk for cancer cannot be excluded unless they have actually been diagnosed with cancer)

How HIPAA Impacts Individual Health Plans

HIPAA does not offer the same level of protection to those seeking individual health insurance. Individual insurance policies are allowed to continue to deny coverage based on pre-existing conditions or institute lengthy exclusion periods. (Under the health reform law, insurers will no longer be able to deny people with medical conditions beginning in 2014.)

However, HIPAA can help you find individual health insurance if you previously had group coverage. HIPAA guarantees access to individual plans or a state high-risk pool if any of the following applies:

  • You had health insurance for at least 18 months without a significant break and your most recent coverage was a group plan.
  • You lost your group coverage through a reason other than fraud or non-payment of premiums.
  • You are not eligible for COBRA coverage.
  • You elected COBRA coverage, but your benefits have since run out.
  • You are not eligible for any group health insurance plan, Medicaid or Medicare.

Recent HIPAA Changes

As more health care provider look for ways to cut costs, many medical practices are switching to electronic patient records. Amendments were made to HIPAA in 2009 to ensure that your privacy has protections in the digital age.

The new provisions state:

  • Health care professionals and organizations must notify you if there has been a breach of security involving your personal medical record.
  • You can request that certain health information not be released to commercial health insurance companies if you pay the entire cost of treatment out-of-pocket.
  • An electronic copy of your health record must be provided to you within 30 days of your request.
  • Any business that is associated with an entity covered by HIPAA must also follow HIPAA requirements.
  • As of January 1, 2011, health care professionals and organizations are required to provide you with information regarding how your personal medical file is disclosed to others.

These protections are in addition to the original HIPAA safeguards enacted in 1996. Those rules prohibited a health care provider from sharing your private medical information without your written approval.

When comparing health insurance quotes, it is important to know how HIPAA can help you out when you choose a plan.

Maryalene LaPonsie