The main Federal law that that deals with preexisting conditions for health coverage is called the Health Insurance and Portability and Accountability Act, or HIPAA. This law has two functions with regard to health insurance coverage. The law protects health insurance for individuals if they lose their current job or switch to a new one. The law also is designed to prevent abuse and potential fraud by setting penalties for offenses that have been outlined in the act.
Limitations
The law prevents the inclusion of a preexisting inclusion for group health insurance plans based on specific criteria. This includes the status of an individual's health, medical history as well as a disability or any type of health information, such as a genetic marker. HIPAA also has limitations such as not guaranteeing the same level of benefits from a previous group health plan. The law was only designed to provide protection against a waiting period for coverage if a preexisting condition exists.
Requirements
HIPAA does have certain requirements that need to be met in order for a preexisting condition to not apply. This includes having a health insurance plan in place without a significant lapse of coverage for at least 12 months. If this condition is met, a new group insurance plan is required to cover medical expenses as soon as an individual has enrolled in the group plan.
Illnesses or Injury
HIPAA sets certain types of illnesses that cannot be included in a preexisting exclusion that is used for health coverage. These include pregnancy, conditions present in a newborn or adopted child or genetic markers. Pregnancy is a condition that cannot be excluded from coverage in a new group plan even if no prior coverage existed. A condition that is present in a newborn child or adopted child under 18 cannot be excluded if the child is enrolled within 30 days of birth or adoption. Genetic information also cannot be included in a preexisting exclusion unless a disease has been diagnosed.
Rights
HIPAA does not require employers to carry health insurance coverage. The rules for this act apply to every employer that has a group plan with at least two members. Some states can also apply HIPAA rules to a "group" of one that can help many self-employed individuals. The rights guaranteed under HIPAA do not apply when an individual switches from one individual health plan to another.
Coverage
Coverage for group health plans under HIPAA require continuous coverage in order for a preexisting exclusion to not apply. There can be breaks in coverage but they cannot be longer than 63 days. Any amount of time that an individual had group coverage before a break can be used to offset a preexisting exclusion, providing it is not more than 63 days.
Tags: health insurance, preexisting exclusion, group health, group plan, adopted child, cannot excluded
