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The Health Insurance Portability and Accountability Act (HIPAA), signed into
law on August 21, 1996, offers new protections for millions of American
workers that improve portability and continuity of health insurance
coverage.
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Limiting exclusions for preexisting medical
conditions (known as preexisting conditions)
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Providing credit against maximum preexisting
condition exclusion periods for prior health coverage and a process
for providing certificates showing periods of prior coverage to a new
group health plan or health insurance issuer
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Providing new rights that allow individuals to enroll
for health coverage when they lose other health coverage, get married
or add a new dependent
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Prohibiting discrimination in enrollment and in
premiums charged to employees and their dependents based on health
status-related factors
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Guaranteeing availability of health insurance
coverage for small employers and renewability of health insurance
coverage for both small and large employers
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Preserving the states’ role in regulating health
insurance, including the states’ authority to provide greater
protections than those available under federal law
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Improving disclosure about group health plans
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HIPAA is effective for all plans and issuers with respect to the
certification requirements of HIPAA beginning June 1, 1997. However, the
other HIPAA provisions are generally effective for plan years beginning
after June 30, 1997.
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The law defines a preexisting condition as one for
which medical advice, diagnosis, care, or treatment was recommended or
received during the 6-month period prior to an individual’s
enrollment date (which is the earlier of the first day of health
coverage or the first day of any waiting period for coverage)
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Group health plans and issuers may not exclude an
individual’s preexisting medical condition from coverage for more
than 12 months (18 months for late enrollees) after an individual’s
enrollment date
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Under HIPAA, a new employer’s plan must give
individuals credit for the length of time they had prior continuous
health coverage, without a break in coverage of 63 days or more,
thereby reducing or eliminating the 12-month exclusion period (18
months for late enrollees)
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Includes prior coverage under
another group health plan, an individual health insurance policy,
COBRA, Medicaid, Medicare, CHAMPUS, the Indian Health Service, a state
health benefits risk pool, FEHBP, the Peace Corps Act, or a public
health plan
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Certificates of creditable coverage must be provided
automatically and free of charge by the plan or issuer when an
individual loses coverage under the plan, becomes entitled to elect
COBRA continuation coverage or exhausts COBRA continuation coverage. A
certificate must also be provided free of charge upon request while you
have health coverage or anytime within 24 months after your coverage
ends
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Certificates of creditable coverage should contain
information about the length of time you or your dependents had coverage
as well as the length of any waiting period for coverage that applied to
you or your dependents
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If a certificate is not received, or the information on
the certificate is wrong, you should contact your prior plan or issuer.
You have a right to show prior creditable coverage with other evidence
— like pay stubs, explanation of benefits, letters from a doctor —
if you cannot get a certificate
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Are provided for individuals who lose their coverage
in certain situations, including on separation, divorce, death,
termination of employment and reduction in hours. Special enrollment
rights also are provided if employer contributions toward the other
coverage terminates
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Are provided for employees, their spouses and new
dependents upon marriage, birth, adoption or placement for adoption
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Plans are required to:
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Furnish a summary of any “material
reduction in covered services or benefits” generally within 60 days
after the change has been adopted by the plan
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If an insurance company is used by the
plan, list in the SPD the name and address of the insurer, the services
it provides, and an explanation of whether benefits under the plan are
guaranteed under an insurance contract or policy
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Include in their SPD information about
where participants and beneficiaries can get assistance or information
from the Department of Labor about their rights under ERISA, including
rights under HIPAA
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The disclosure rules also provide
guidance on the use of electronic media (e.g., email) to furnish covered
workers with required group health plan disclosures
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