HIPAA stands for the Health Insurance
Portability and Accountability Act of 1996. HIPAA enacted reforms in both
the group and individual health insurance markets, in part, to help many individuals
maintain insurance coverage if they lose or leave their jobs. HIPAA requires all
health insurance issuers offering coverage in the individual market to accept any
"eligible individuals" who apply for coverage, without imposing a
. A health insurance issuer means
an insurance company, insurance service, or insurance organization (including an HMO)
that is licensed to engage in the business of insurance in a state
Am I covered by HIPAA's provisions?
In order to qualify as an "eligible individual" and be covered by HIPAA's provisions,
you must meet the following criteria:
- You must have at least 18 months of
creditable coverage without
break in coverage.
- Your most recent coverage must have been under an employment-related
group health plan, governmental plan or church plan (or health insurance offered
in connection with such plans).
- You must not be eligible for coverage under a group health plan,
Medicare or Medicaid.
- You must not have any other health insurance coverage.
- Your most recent coverage must not have been canceled for nonpayment of premiums or fraud.
- You must have elected and exhausted any option for continuation of coverage (i.e., coverage under the Federal "COBRA" law or a similar State law) that was available under your prior plan.
If you meet the above criteria, you are considered to be an "eligible individual,"
which means that you must be provided with individual health care coverage without a
pre-existing condition exclusion. The premium rates for such coverage are determined
by the state law applicable to the health insurance issuer.
Certain children are deemed eligible even if they do not have 18 months of
prior creditable coverage. This exception applies to children who were covered under
any creditable coverage within 30 days of birth, adoption or placement for adoption,
and who did not have a significant break in coverage.