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Re: applying to new insurance- need help hok

Posted by noa on April 24, 2003, at 8:29:35

In reply to applying to new insurance- need help hok, posted by Dr. Bob on April 23, 2003, at 8:23:40


The HIPAA web site provides the information you need, along with what you will need to know from your STATE health insurance commisioner's office.

It will depend on a few things.

First, is the insurance you are losing a GROUP plan?

Have you had continuous coverage (see below)?

Are you now enrolling in an INDIVIDUAL plan or a GROUP plan?

Why are you losing benefits and have you used up your COBRA option?

Here are some helpful links at the HIPAA site:

If it is a GROUP plan, you are protected under these federal rules in that you cannot be charged higher premiums based on pre-existing conditions, or answers on the health questionnaire.

But in an individual plan, it is possible.

BUT, your state may provide protection.

As for being DENIED coverage on the basis of pre-existing conditions, or having pre-existing conditions excluded from coverage, whether you are protected under HIPAA (and remember to check State rules which could be even more protective, depending on the state) it depends on whether you are coming from group coverage, and have continuous coverage with no significant breaks.

Am I HIPAA-eligible for individual coverage?

It will take you through a series of questions to determine if you are a "HIPAA eligible individual".

Description of HIPAA eligible individual:

"If you are HIPAA-eligible, also called an eligible individual, you have the right to get individual coverage without preexisting condition exclusions.

General Rule
You are HIPAA-eligible if ALL of the following are true at the time you apply for individual coverage:

You have at least 18 months of continuous creditable coverage without any significant breaks
Your most recent coverage was under a group health plan
You are not eligible for coverage under another group health plan
Your most recent health coverage was not cancelled because you did not pay your premiums or because you committed fraud
You are not eligible for Medicare or Medicaid
If you were offered COBRA, Temporary Continuation of Coverage (TCC), or State continuation coverage, you purchased and exhausted the coverage
You did not accept a conversion policy or a short-term limited duration policy"

What is guaranteed availability of individual coverage?

I am also copying the text of this one here, but do see the link because it has a link to State info:

"Under HIPAA, guaranteed availability of individual coverage means that if you are HIPAA-eligible, you cannot be denied the right to buy individual coverage, regardless of your health history. In addition, a preexisting condition exclusion cannot be applied to your coverage.

The particular coverage you are entitled to buy will depend on how your State has chosen to apply the HIPAA requirements.

In some States, you may be entitled to buy any individual policy sold in the State
In some States, you will only be able to buy specific policies identified by the insurance issuer
In other States, you may only be entitled to coverage through the State's high-risk pool
Click next to find out what your State does."

Can I be charged more because of my health condition?

The answer they give is "maybe" because HIPAA doesn't regulate premiums. BUt they do urge you to check the State laws.

And other questions are at:

Regarding what pre-existing conditions exclusion periods, and "continuous coverage":


"In group health plans, a preexisting condition exclusion period cannot be longer than 12 months, or 18 months if you are a late enrollee. The length of the exclusion period must be reduced by the number of days of continuous creditable coverage* you have.

Note: Contact your State Insurance Department to find out if your State has stronger consumer protections regarding the length of preexisting condition exclusions."

* From

"Continuous creditable coverage includes most kinds of health benefits, but does not include any coverage you had before a significant break in coverage of 63 or more full days in a row."

Ok the way I understand all this is that if you have had continuous health insurance coverage, with no breaks of 63 days or more, the exclusion period for pre-existing conditions is reduce by the length of continuous coverage. Since pre-existing condition exclusion periods are maximum 12 months (if you enroll immediately when eligible or during an open enrollment period) or 18 months (if you enroll some time after becoming eligible), if you have at least that amount of time of continuous coverage, ther should be no exclusion period.




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