Health Insurance Portability and Accountability Act

HIPAA's Title I

HIPAA sets the guidelines for
HIPAA sets the guidelines for
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As mentioned in the previous section, HIPAA's Title I primarily involves group health insurance plans and their access to you. First, HIPAA ensures that a group health plan can't deny coverage or establish the amount of your monthly premium based on your health status, which includes your medical history, genetic information or any disability you may have. This means, for example, that you'll be offered the same coverage that your older, diabetic co-worker is offered, both at the same premium amount.

Secondly, Title I establishes rules on how a group plan handles a pre-existing condition. Before HIPAA, there were many people who were completely denied health insurance based on chronic medical conditions, regardless of how well the condition was controlled. Today, thanks to HIPAA, group health insurance plans must follow rules regarding what's considered a pre-existing condition and how long they can exclude coverage for these conditions.

Specifically, under the HIPAA guidelines, the maximum amount of time that you have to wait in order to get coverage for your pre-existing condition can't exceed 12 months, or 18 months for late enrollees (someone who doesn't enroll during general open enrollment). However, most of us who go from one job's group insurance plan to another without a break won't have to endure an exclusion period at all. In these cases, HIPAA uses what's known as "credible coverage" in order to reduce, or eliminate, this pre-existing condition exclusion period. "Credible coverage refers to any health care insurance you had before your new insurance plan as long as it wasn't interrupted by a period of 63 or more days. This time period can be longer depending on your state laws and the type of insurance plan you were on.

Once you've proven that you've had uninterrupted insurance, that insurance coverage can be added up and credited toward any pre-existing condition exclusion you may have. In fact, if you had at least one year of group health insurance at one job and then received health insurance at a new job without a break of more than 63 days, the new health insurance plan can't impose a pre-existing condition exclusion on you at all. But if the break in coverage was greater than 63 days, no health insurance coverage before the break is counted toward your pre-existing condition exclusion period.

In addition to governing group insurance plans, HIPAA does have some power over individual insurance plans. In cases where someone moves from a group plan to an individual plan, an "eligible individual" can't be denied health coverage or given a pre-existing condition exclusion [source: AARP]. However, these individual plans can hike up your monthly premium based on your health status, and oftentimes, the offered plans have higher monthly premiums and fewer benefits than those offered in a group plan. To qualify as an eligible individual you must have been covered by a group health plan for a minimum of 18 months without a 63-day break in coverage. In addition, the loss of your group coverage couldn't be because you failed to pay your premiums or you committed insurance fraud. Finally, you may be considered eligible if you can't get any other type of insurance like COBRA, Medicaid or Medicare.

Now that HIPAA has helped ensure you get health care, it can also make sure that your care is kept private. We'll find out more about Title II of HIPAA in our next section.