The Health Insurance Portability and Accountability Act largely affects health plans provided by employers. It complements federal laws on health insurance to protect people with certain medical conditions and traits that might make it more difficult to get insurance. They cannot be excluded from coverage or charged a higher fee for coverage than people without those conditions. HIPAA provides other protections to consumers as well, such as requiring doctors, hospitals, and other health care providers to preserve the confidentiality of a patient’s records.
While the Affordable Care Act goes beyond HIPAA in some areas, HIPAA remains relevant in many cases. Thus, it is still an important law for consumers to understand.
Rules on Pre-Existing Conditions
The law defines a pre-existing condition as a condition for which an individual received medical advice, diagnosis, treatment, or other care within the six-month period before the individual is seeking to enroll in a new health insurance plan. An insurer cannot exclude people from coverage under HIPAA based on advice, diagnosis, treatment, or care for a medical condition more than six months before seeking to enroll in the plan.
Pre-existing condition = a condition for which an individual received medical advice, diagnosis, treatment, or other care within the six-month period before enrolling in their current health plan
People who do have a pre-existing condition (as defined by HIPAA) are entitled to receive coverage for that condition within no more than 12 months after enrolling in the plan. This reduces the waiting period for coverage, allowing many Americans to obtain care more promptly for serious conditions.
If you have certain genetic information that makes you unattractive to insurers, this cannot be counted as a pre-existing condition. State laws often provide additional protections for consumers with certain genetic traits but no active medical condition.
Further Protections Under HIPAA
If exclusions in policies can be seen as exceptions, HIPAA rules can be seen as exceptions to the exceptions. Many of the rules relate to children and pregnant women. For example, pre-existing conditions cannot serve as a basis for exclusions with regard to babies who entered a health insurance plan within 30 days of their birth. They also cannot serve as a basis for exclusions with regard to children who are adopted or put up for adoption if they enter the plan within 30 days of being adopted or put up for adoption. Pregnant women are free to join a new group health insurance plan at will, since HIPAA has provided that pregnancy cannot be considered a pre-existing condition.
Did You Know?
Pregnancy is not a pre-existing condition.
Some employees may be concerned about creating a gap in their coverage if they change jobs, since this will result in changing their health insurance plan as well. HIPAA provides a 63-day window in which you have a right to change your job and your plan without encountering a new exclusion based on a pre-existing condition.
Know Your Rights Outside the Insurance Context
If you are suffering from a disability or another serious medical condition, you should be aware that you may have additional legal protections in the workplace or other public settings under state and federal laws. For example, the Americans with Disabilities Act provides protections against discrimination and rights to reasonable accommodations.