The Health Insurance Portability and Accountability Act (HIPAA) of 1996 provides protection for employees and dependents who have pre-existing medical conditions or might be denied health coverage based on factors related to an individual’s health.
HIPAA includes changes that:
- Limit exclusion for pre-existing conditions
- Prohibit discrimination against employees and dependents based on their health status
- Guarantee renewability and availability of health coverage to certain employers and individuals; and
- Protect many workers who lose health coverage by providing better access to individual health insurance coverage
Under HIPAA, the employer may impose a pre-existing condition exclusion with respect to an employee, dependent, or beneficiary only if the following requirements are satisfied:
- A pre-existing condition exclusion must relate to a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the 6-month period prior to an individual’s enrollment date;
- A pre-existing condition exclusion may not last for more than 12 months after an individual’s enrollment date; and
- This 12-month period must be reduced by the length of time of the individual’s prior creditable coverage, excluding coverage before any break in coverage of 90 days or more
How Portability Affects City of Atlanta Active Employees
Effective January 1, 1998, you and your dependents do not have to satisfy a pre-existing condition waiting period if you provide certification of prior creditable coverage sufficient to satisfy the respective pre-existing condition waiting periods.
When an Employee Terminates Coverage
HIPAA requires that your insurance carrier provide you (and your dependents) with certificates of coverage automatically upon termination of coverage.
Special Enrollment Periods
There are special enrollment periods for you and your dependents who:
- Originally declined coverage because of other coverage, and
- Who exhausted COBRA benefits, lost eligibility for prior coverage, or employer contributions toward coverage were terminated, and
- An individual declining coverage must certify in writing that they are covered by another health program when they initially decline coverage under this group in order to later qualify under this special enrollment. A person declining coverage will be given notice of the consequences when they originally decline coverage.
In addition, there also are special enrollment periods for new dependents resulting from marriages, births, or adoptions. An unenrolled member may enroll within 31 days of such a special qualifying event.
Important Notes
- Individuals or dependents must request coverage within 31 days of qualifying event (i.e. marriages, exhaustion of COBRA, etc.).
- Evidence of prior creditable coverage is required. Please refer to your benefit booklet for more information concerning Portability Provisions and Requirements.
All new hires should submit a copy of the HIPAA Form received from their previous employer to the DHR – Employee Benefits for proper credit.
