This overview briefly summarizes our understanding of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). The laws governing HIPAA are very detailed and complex, so, if you have questions about any of the HIPAA regulations, we recommend you consult with your legal counsel for advice on your specific situation.
HIPAA, in general, is designed to make health coverage more portable for individuals who change jobs or health plans by limiting the coverage exclusions that can be imposed when such a change occurs. HIPAA includes changes that:
Generally, both group health plans and health insurance insurers offering group health insurance coverage must comply with HIPAA's portability, special enrollment, and nondiscrimination requirements. A plan (including a self-insured plan) is considered a group health plan under HIPAA if it has at least two employees on the first day of the plan year, if it provides health care, and if it is maintained by an employer. The employer sponsoring the plan is generally held responsible for compliance with HIPAA.
HIPAA is applicable to plans providing medical care, including HMOs, individual medical insurance policies, individual short-term limited duration medical insurance policies, group medical insurance policies, self-insured medical plans, medical plans sponsored by the federal government, and medical plans sponsored by churches.
HIPAA also applies to medical plans sponsored by nonfederal governments (state, county, city, village, town, or school district). However, a self-funded nonfederal government plan may elect to be excluded from the following HIPAA requirements:
HIPAA does not apply to:
HIPAA requires any plan that includes a preexisting condition exclusion (PCE) to comply with the following requirements:
HIPAA provides for special mid-year enrollment opportunities for employees and their eligible dependents in the following circumstances:
Plans must notify eligible individuals of their special enrollment rights at or before the time the individuals are given the opportunity to enroll in the plan.
Both group health plans and health insurance carriers are required to provide a Certificate to an individual in the following circumstances:
We will also provide a Certificate when an individual's Wisconsin's continuation coverage ceases. A Certificate is not required, however, when an individual changes from one plan option to another.
To avoid duplication, if any entity (employer, carrier, or third-party administrator) provides a Certificate to an individual, HIPAA doesn't require any other party to provide the Certificate. However, all parties are still accountable for incomplete information or failure to provide a Certificate. A plan may contract with a carrier to provide the Certificates for individuals covered under the plan (the contract must be in writing). If so, the plan itself is not required to provide the Certificates and is not liable for missing information or failure to provide a Certificate.
The Certificate must include the date any probationary period began, the date coverage began, and the date coverage ended or indicate if coverage is continuing, including any period of COBRA continuation or Wisconsin continuation coverage. A continuation period doesn't have to be separately identified. A Certificate doesn't need to reflect more than 18 months of creditable coverage provided it's uninterrupted for 63 days or more. A plan may combine information for members of the same family who live together.
HIPAA prohibits group health plans and health insurers from discriminating against individuals with regard to eligibility, premiums or contributions based on any health status-related factor. For example, a plan may not require an individual to pay a premium greater than do similarly-situated individuals enrolled on the basis of any health status-related factor. A health status-related factor includes, health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.
Group health insurers are subject to HIPAA's group market rules including:
Plans may be amended at renewal time.