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The Health Insurance Portability and
Accountability Act (HIPAA), signed into law on August 21, 1996, offers new
protections for millions of American workers that improve portability and
continuity of health insurance coverage.
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Limiting exclusions for
preexisting medical conditions (known as preexisting conditions)
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Providing credit against maximum
preexisting condition exclusion periods for prior health coverage and
a process for providing certificates showing periods of prior coverage
to a new group health plan or health insurance issuer
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Providing new rights that allow
individuals to enroll for health coverage when they lose other health
coverage, get married or add a new dependent
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Prohibiting discrimination in
enrollment and in premiums charged to employees and their dependents
based on health status-related factors
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Guaranteeing availability of
health insurance coverage for small employers and renewability of
health insurance coverage for both small and large employers
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Preserving the states’ role in
regulating health insurance, including the states’ authority to
provide greater protections than those available under federal law
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Improving disclosure about group
health plans
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HIPAA is effective for all plans and
issuers with respect to the certification requirements of HIPAA beginning
June 1, 1997. However, the other HIPAA provisions are generally effective
for plan years beginning after June 30, 1997.
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The law defines a preexisting
condition as one for which medical advice, diagnosis, care, or
treatment was recommended or received during the 6-month period prior
to an individual’s enrollment date (which is the earlier of the
first day of health coverage or the first day of any waiting period
for coverage)
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Group health plans and issuers
may not exclude an individual’s preexisting medical condition from
coverage for more than 12 months (18 months for late enrollees) after
an individual’s enrollment date
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Under HIPAA, a new employer’s
plan must give individuals credit for the length of time they had
prior continuous health coverage, without a break in coverage of 63
days or more, thereby reducing or eliminating the 12-month exclusion
period (18 months for late enrollees)
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Includes prior coverage under
another group health plan, an individual health insurance policy,
COBRA, Medicaid, Medicare, CHAMPUS, the Indian Health Service, a state
health benefits risk pool, FEHBP, the Peace Corps Act, or a public
health plan
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Certificates of creditable
coverage must be provided automatically and free of charge by the plan
or issuer when an individual loses coverage under the plan, becomes
entitled to elect COBRA continuation coverage or exhausts COBRA
continuation coverage. A certificate must also be provided free of
charge upon request while you have health coverage or anytime within
24 months after your coverage ends
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Certificates of creditable
coverage should contain information about the length of time you or
your dependents had coverage as well as the length of any waiting
period for coverage that applied to you or your dependents
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If a certificate is not received,
or the information on the certificate is wrong, you should contact
your prior plan or issuer. You have a right to show prior creditable
coverage with other evidence — like pay stubs, explanation of
benefits, letters from a doctor — if you cannot get a certificate
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Are provided for individuals who
lose their coverage in certain situations, including on separation,
divorce, death, termination of employment and reduction in hours.
Special enrollment rights also are provided if employer contributions
toward the other coverage terminates
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Are provided for employees, their
spouses and new dependents upon marriage, birth, adoption or placement
for adoption
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Plans are required to:
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Furnish a summary of any
“material reduction in covered services or benefits” generally
within 60 days after the change has been adopted by the plan
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If an insurance company is used
by the plan, list in the SPD the name and address of the insurer, the
services it provides, and an explanation of whether benefits under the
plan are guaranteed under an insurance contract or policy
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Include in their SPD information
about where participants and beneficiaries can get assistance or
information from the Department of Labor about their rights under
ERISA, including rights under HIPAA
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The disclosure rules also provide
guidance on the use of electronic media (e.g., email) to furnish
covered workers with required group health plan disclosures
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