HIPAA-eligible Coverage

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. HIPAA established special protections for certain people -- called “federally eligible individuals” or “HIPAA eligible individuals” -- when they lose group health coverage. Once people become HIPAA-eligible, they are guaranteed an offer of at least two health insurance policies that do not impose pre-existing condition exclusion periods. HIPAA is silent on what people can be charged for such coverage.

Insurance coverage under HIPAA

HIPAA's requirement to guarantee issue coverage with no pre-existing conditions varies between states. In some states, HIPAA rules apply to all private insurance companies that sell coverage in the individual health insurance market. Some states, however, have made alternative arrangements to guarantee these HIPAA protections only from the state high-risk pool. Private insurers in these states are still free to medically underwrite their policies and deny applicants and impose pre-ex periods, even for HIPAA eligible individuals.

A number of states also limit how much insurers can charge HIPAA eligible individuals (and often other residents) for coverage.

Becoming HIPAA-eligible

To be HIPAA-eligible, you must meet all of the following criteria.

• You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan (including those offered by public employers and churches).

• You also must have used up any COBRA or state continuation coverage for which you were eligible.

• You must not be eligible for Medicare, Medicaid or a group health plan.

• You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be federally eligible.)

• You must apply for health insurance for which you are federally eligible within 63 days of losing your prior coverage.

To find out more about coverage available to you under HIPAA, see Georgetown University's “A Consumer Guide to Getting and Keeping Health Insurance” for your state.

This information was drawn from "Health Insurance Resource Manual" prepared for the American Diabetes Association by Georgetown University's Health Policy Institute, ©2003, Georgetown University. All rights reserved.