To Lorster etal. PreExisting Conditions and HIPPA | Arthritis Information

 

What is the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?
HIPAA's is a federal law that:

• Limits the ability of a new employer plan to exclude coverage for preexisting conditions;

• Provides additional opportunities to enroll in a group health plan if you lose other coverage or experience certain life events;

• Prohibits discrimination against employees and their dependent family members based on any health factors they may have, including prior medical conditions, previous claims experience, and genetic information; and

• Guarantees that certain individuals will have access to, and can renew, individual health insurance policies.

HIPAA is complemented by state laws that, while similar to HIPAA, may offer more generous protections. You may want to contact your state insurance commissioner's office to ask about the law where you live. A good place to start is the Web site of the National Association of Insurance Commissioners at www.naic.org.

One of the most important protections under HIPAA is that it helps those with preexisting conditions get health coverage. In the past, some employers' group health plans limited, or even denied, coverage if a new employee had such a condition before enrolling in the plan. Under HIPAA, that is not allowed. If the plan generally provides coverage but denies benefits to you because you had a condition before your coverage began, then HIPAA applies.

Under HIPAA, a plan is allowed to look back only 6 months for a condition that was present before the start of coverage in a group health plan. Specifically, the law says that a preexisting condition exclusion can be imposed on a condition only if medical advice, diagnosis, care, or treatment was recommended or received during the 6 months prior to your enrollment date in the plan. As an example, you may have had arthritis for many years before you came to your current job. If you did not have medical advice, diagnosis, care, or treatment – recommended or received – in the 6 months before you enrolled in the plan, then the prior condition cannot be subject to a preexisting condition exclusion. If you did receive medical advice, diagnosis, care, or treatment within the past 6 months, then the plan may impose a preexisting condition exclusion for that condition (arthritis). In addition, HIPAA prohibits plans from applying a preexisting condition exclusion to pregnancy, genetic information, and certain children.

If you have a preexisting condition that can be excluded from your plan coverage, then there is a limit to the preexisting condition exclusion period that can be applied. HIPAA limits the preexisting condition exclusion period for most people to 12 months (18 months if you enroll late), although some plans may have a shorter time period or none at all. In addition, some people with a history of prior health coverage will be able to reduce the exclusion period even further using “creditable coverage.” Remember, a preexisting condition exclusion relates only to benefits for your (and your family’s) preexisting conditions. If you enroll, you will receive coverage for the plan’s other benefits during that time.

Although HIPAA adds protections and makes it easier to switch jobs without fear of losing health coverage for a preexisting condition, the law has limitations. For instance, HIPAA:

• Does not require that employers offer health coverage;

• Does not guarantee that any conditions you now have (or have had in the past) are covered by your new employer's health plan; and

• Does not prohibit an employer from imposing a preexisting condition exclusion period if you have been treated for a condition during the past 6 months.

Can a plan deny benefits for chronic illnesses or injuries, like carpal tunnel syndrome, diabetes, heart disease, and cancer using a preexisting condition exclusion?
It depends on whether you received medical advice, care, diagnosis, or treatment within the 6 months prior to enrolling in a new employer’s plan. If you did, you can be subject to a preexisting condition exclusion.

Are there illnesses or injuries that cannot be subject to a preexisting condition exclusion?
Yes, as follows:

• Pregnancy, even if the woman had no prior coverage before enrolling in her current employer's plan.

• Conditions present in a newborn or a child under 18 who is adopted or placed for adoption (even if the adoption is not yet final), as long as the child is enrolled in health coverage within 30 days of birth, adoption, or placement for adoption. In addition, the child must not have a subsequent, significant break in coverage (defined as 63 days). For instance, a significant break might occur if a parent lost his job and health coverage for himself and his family shortly after a child’s birth. This break will be discussed in the Creditable Coverage section.

• Genetic information. For example, if a woman is found to have a gene indicating she is at a higher risk for breast cancer, she cannot be denied coverage if there is no diagnosis of the

  continued on the link with many examples of different preexisting scenarios.

FROM INSURE.COM:

. . . HIPAA might make it easier to get an individual health insurance policy.

Under HIPAA, you might be able to buy an individual health plan without the threat of exclusions for pre-existing conditions. In order to do so, you have to qualify as an "eligible individual."

In some states, if you qualify for individual health insurance under HIPAA, any company offering individual health plans in that state must sell you coverage. Your state’s insurance department can explain the rules.

To be eligible as an individual under HIPAA, you must:

• Have at least 18 months of continuous creditable coverage without a gap of more than 63 days.
• Have been covered under a group health plan, a government health plan or church plan (or health insurance offered in connection with such plans, such as COBRA) during the most recent period of creditable coverage. If you do not have a creditabe coverage certificate, you can talk to the health plan to find out if there are other ways you can prove you had 18 months of coverage.
• Not be eligible for coverage under a group health plan (including a spouse's plan), Medicare or Medicaid.
• Not have other health insurance.
• Have not lost your most recent health coverage due to nonpayment of premiums or fraud (unless it was your employer that failed to pay premiums).
• Have elected and exhausted any option for continuation of coverage under COBRA (or a similar state law) that was available under your prior plan.

HIPAA does not limit the premiums individual health plans can charge. While your application for insurance won't be rejected because of health problems, the premiums for individual coverage can be much higher than for group plans.

http://www.insure.com/articles/healthinsurance/HIPAA.html

Joie2009-09-24 15:25:22This is good info. In 1996 I had my gallbladder removed. an 8 day off work turned into 2 months when the CO2 machine they were using pumped 40x the normal dose into my abdomen blowing my cystic, bile ducts. I developed pancreatitis, pneumonia and peritinitis. I eventually went to Seattle for higher level care due to sphincter of oddi dysfunction. . I missed two months of work. A month into this nightmare, I received a letter from my insurance company stating they were not covering any of this as it was preexisting.They were dropping me. The unfortunate part was my employer was self insured so i appealed to the highest level and was denied at all levels. I had to do what no one ever wants to do and that is to sue my insurance company which meant..sueing my employer. It took 18 months to settle and it got very ugly for me at work and the person who denied my appeal to this day hates me. But I won and it all got paid for including attorney fees. It is not a story I tell many people because it was the most stressful time of my entire life. It does not just happen to other people. It can happen to you. Insurance companies will get away with what they can.

The Obama town hall meeting I attended was about people who get their insurance coverage dropped for preexisting conditions. The woman who denied my appeal...and who still works for the same company stood right behind me in line at that town hall meeting. There is a god.That is a horrible story, Lorster... I am glad it turned out well for you... I think we all agree that there are changes and improvements that need to be made... I think we disagree in the feasibility of some of the plans, on the ability to pay for said plans and what the results will be with certain moves... I wish they'd go at this nice and slow and figure out all the details BEFORE trying to jump his to a vote on a 1000 page bill that no one reads...Lor,

Your insurer claimed your gallbladder problem was a pre existing condition?  Yet, they had accepted your insurance app and you had been paying premiums?

Sounds like the insurance practice of rescission.  From a former insurance executive testimony before a congressional committee:

" . . . insurers routinely dump policyholders who are less profitable or who get sick. Insurers have several ways to cull the sick from their rolls. One is policy rescission. They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment. Asked directly about this practice just last week in the House Energy and Commerce Committee, executives of three of the nation's largest health insurers refused to end the practice of cancelling policies for sick enrollees. Why? Because dumping a small number of enrollees can have a big effect on the bottom line. Ten percent of the population accounts for two-thirds of all health care spending. The Energy and Commerce Committee's investigation into three insurers found that they canceled the coverage of roughly 20,000 people in a five-year period, allowing the companies to avoid paying 0 million in claims."

Joie, they knew my entire history and still pre approved the surgery. It was not until everything went wrong that they decided they many not want to pay this one. The sad part was, it was this very hospitals equipment that failed, that caused all the problems....you would have thought they would have been glad to pay the bill in hopes that I did not sue them for their failure. The surgeon informed me the next day of what went wrong and went out of his way to make it right and I appreciated his honesty and integrity. I learned a lot about the process at the time. I just never want to repeat it.


Something that I learned though was that if the gallbladder sugery would not have been covered due to the time line, any complication of the surgery would have to be covered under the new policy. Something to think about.I did not realize that 10 percent of the population is responsible for 2/3s of spending. Is that the insurance population...or does that include medicare/medicade? I would "guess" that statement refers to the entire U.S. population.  That statement was from testimony given by Wendell Potter, a former insurance executive, before a congressional committee.

I did come across these statistics from a May 2009 Kaiser Foundation report --"Health Care Costs: A Primer," March 2009, page 5: A small share of people accounts for a significant share of expenses in any year.  In 2006, almost half of all health care spending was used to treat just 5 percent of the population, which included individuals with health expenses at or above ,601.  Under a quarter of health spending went towards the treatment of the 1 percent of the population who had total health expenses above ,580 in 2006. Joie2009-09-24 18:17:33If where I work is representative of this statistic , I can totally believe those statistics Joie. sorry to hear that happened to you, lorster...  I am glad you fought the good fight and won...
Copyright ArthritisInsight.com