(Published July 14, 2008)
Last week, on request, I gave you a very general overview of the privacy aspect of the Health Insurance Portability and Accountability Act (HIPAA) as it relates to employment. The other part of HIPAA has to do with its portability. You won't have to do a whole lot with that in HR; your insurance company will take care of most of it. But you might be asked a lot of questions. So, once again, for those looking for a primer, here's a very generalized, simplified overview.
If your health insurance plan doesn't have a pre-existing condition clause, you can skip the rest of this blog because it doesn't apply to you. For the rest of you, the most frequently asked questions, in my experience, are these:
How long can I be without insurance before a pre-existing condition clause can kick in? If there has been a gap in coverage of over 63 days, any pre-existing condition clause can go into effect.
I'm pregnant, and I was pregnant before my new insurance went into effect, but I didn't know about it until after my new policy started. Will it be considered a pre-existing condition? No. The HIPAA portability provision specifically excludes pregnancy from any pre-ex clauses. Pregnancy cannot be considered pre-existing on an employer-sponsored group plan.
How far back will the insurance carrier look for treatment of my condition? Under HIPAA, the look-back period is six months. If you have not had any treatment for your condition for six months, it will not be considered pre-ex.
How long will the insurance company refuse to pay for my condition? That depends on how much creditable coverage you have. Assuming that you were not a late enrollee, the maximum time that your condition can be considered pre-ex is 12 months. Figure out how many months of creditable coverage you had. Subtract that from 12. Whatever is left is the length of time your condition can be considered pre-ex.
So, what if I'm a late enrollee? Then substitute 18 for 12, above.
Remind me what creditable coverage is, again? Almost any kind of insurance coverage can be considered creditable. Previous group health, individual, Medicare, Medicaid, CHAMPUS, and others can all be considered creditable coverage.
How do I prove my creditable coverage? Your former employer, your former insurance carrier, or both, are required to provide you with a Certificate of Creditable Coverage, which you can supply to your new carrier if there is a question.
Catherine Bannon is an HR consultant in Marshfield, MA (catherine.bannon@gmail.com). Bannon worked for 10 years in HR management before starting her consulting practice.
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