The Health Insurance Portability and Accountability Act of 1996 is Federal and was signed into law on August 21, 1996. This law includes important new protections for millions of working Americans and their families who have pre-existing medical conditions or who might suffer discrimination in health coverage based on a factor that relates to the individual's health. HIPAA includes provisions that:

• limit exclusions for pre-existing conditions;
• prohibit discrimination based on health factors; and
• guarantee renewability and availability of health coverage to certain employees and individuals.

Please note that certain HIPAA provisions ONLY apply with regard to GROUP health insurance coverage; all the below information DOES NOT apply to individual coverage.

A group plan or a health insurance issuer offering group health coverage may impose a pre-existing condition exclusion only if the following conditions are satisfied:

• the exclusion must relate to a condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6 month period prior to the enrollment;
• the exclusion may not last more than 12 months (18 months for late enrollees) from the enrollment date (Caution: this language is from the Federal law. Each state may be more generous or less restrictive. For example for NJ Small group, the limitation is only 6 months and the penalty for a late enrollee is that pre-existing applies).
• the 12 or 18 month period must be reduced by the number of days of prior creditable coverage, excluding coverage before any break of 63 days or more (Note: the break for NJ Small Group is 90 days).

Most health coverage is creditable, such as under a group health plan (including COBRA continuation coverage), individual health, Medicaid or Medicare.

Certain types of coverage offered through schools are not creditable. You may want to confirm with the insurance carrier.

Note: effective July 1, 2005 previous coverage from socialized medicine from a foreign country is also creditable.

Days in a waiting period are not creditable however they are NOT counted against the member in determining a significant break (63 days or more).

Yes. On a group plan, an exclusion can never apply to pregnancy, regardless of whether the woman had previous coverage (or the size of the group plan). In addition a pre-existing condition exclusion cannot apply to a newborn or child placed in the home for adoption under age 18 as long as the child became covered within 30 days of birth or placement for adoption, and provided the child does not incur a subsequent 63 day or longer break in coverage (Note: states may vary with the number of days a break in coverage is permitted before the exclusion applies).

Important:  With regard to Individual Coverage, pregnancy can be considered a pre-existing condition if the member had a lapse in Individual, not Group, coverage of more than 31 days.

Group health plans and health insurance issuers are required to furnish a Certificate of Creditable Coverage (COCC). The certificate must be provided automatically when coverage is lost as well as when COBRA continuation ceases.

A member may also request a certificate, free of charge, until 24 months after the time coverage ends. A certificate may also be requested even before coverage ends.

No. Any waiting period imposed by the employer plan does not count towards the "significant break".

Under the Privacy Rule members and patients must give specific authorization before entities can use or disclose information. It is designed to restrict use and disclosure of health related information to appropriate purposes and to ensure it is not used against individuals in connection with their employment. Privacy relates to Protected Health Information (PHI) which is any information which is individually identifiable and is transmitted in any form.

Covered entities are required to use, disclose and request only the minimum necessary PHI to accomplish the purpose of the request. This concept is called "minimum necessary" under the Privacy Rule.

Yes. Each insurance carrier has created an authorization form to use for this purpose. Please contact your representative for more information or to obtain one of these forms.

on the web at:

www.hhs.gov/ocr/hipaa (OCR is the office of Civil Rights)

www.hhs.gov/ocr/hipaa/privruletxt.txt for the Privacy Rules

or call toll free 866-627-7748 (for privacy information)