HIPAA Questions

• The Health Insurance Portability and Accountability Act of 1996, or HIPAA, is a federal law covering employer-provided health insurance. HIPAA restricts employers' ability to implement new plans that exclude coverage for pre-existing conditions. It also offers opportunities for employees to enroll in group health plans if they lose coverage or are affected by certain life events.

  Additionally, HIPAA prohibits discrimination against employees and their families based on health factors. Finally, HIPAA guarantees health care access to certain individuals. The law can be confusing, and many employers and employees have questions about applying its provisions.

Does HIPAA Require Employers to Offer Health Coverage?

• HIPAA does not require employers to offer any health coverage. Additionally, HIPAA does not require that an employer's new health plan cover conditions that currently affect an employee. Furthermore, HIPAA does not prevent an employer from imposing an exclusion period for a pre-existing condition if the employee was treated for that condition during the past six months. HIPAA does require that whatever health coverage an employer chooses to offer does not discriminate against employees for certain health issues.

Can a Plan Deny Benefits for Chronic Illnesses or Injuries?

• The answer to this question depends on how recently the employee was treated for the condition. If the employee received medical advice, treatment, care or diagnosis within six months before enrolling the new plan, the pre-existing condition may be subject to an exclusion.

Does Pregnancy Count as a Pre-Existing Condition?

• Pregnancy cannot be subject to a pre-existing condition exception under HIPAA. This is true even if the pregnant woman had no prior coverage before enrolling in the new plan.

How Does HIPAA Affect Family Members of Coverd Employees?

• If a group health plan has a provision that extends coverage to an insured individual's dependent family members, those family members are given the same HIPAA protections as the insured employee. Note, however, that no requirement exists that the group health plan cover dependent family members.

Can an Employee Lose Eligibility for Coverage?

• Several events can trigger a loss of eligibility for the employee or his dependents. These include a divorce or legal separation; a young dependent, such as a son or daughter, reaching a particular age or graduating from college so as to be excluded from the plan; the employee's work hours are reduced to the point at which the employee no longer qualifies for coverage; an employee's health claim exceeds the lifetime limit on benefits for the plan; or the employee moves outside the plan's geographical service area.