HIPAA Portability The "P" of HIPAA The P in HIPAA stands for portability of medical coverage. This part of HIPAA went into effect on July 1, 1997. On the date the plan or insurer becomes subject to the HIPAA provisions, the plan or insurer may not exclude coverage for any pre-existing medical conditions for more than 12 months after an individual's enrollment date (18 months for a late enrollee).  In addition, the medical plan must count any creditable coverage that individuals accumulated prior to their enrollment date to reduce their remaining pre-existing condition exclusion period. So what does this mean? Suppose a new employee has had continuous creditable coverage for 9 months prior to the effective date of the new employer coverage. The new medical plan can enforce a waiver of any pre-existing conditions for a maximum of three more months. After 12 months of continuous creditable coverage, all pre-existing conditions must be covered as any other illness. It also means that if the employee has had at least 12 months of coverage prior to the new coverage, then no pre-existing conditions can be waived.  A late enrollee is an employee that does not elect coverage when offered and delays joining the medical plan. The creditable coverage period can be extended to 18 months. However, if the employee still has 18 continuous months of coverage, pre-existing conditions are still covered. The concept of portability means an individual receives credit for maintaining health coverage, even though it may be under different health plans or policies. Portability does not mean that individuals can carry current health benefits or their current plan or policy with them when moving from one health plan or policy to another (such as when changing or losing jobs). Whatever the new plan covers is the coverage received. It means that the new plan can not exclude pre-existing conditions. HIPAA also guarantees access to health coverage for small employers. Small firms (50 or fewer employees) are guaranteed access to health insurance, and generally, no insurer can exclude a worker or family member from employer-sponsored coverage based on health status. Insurers are required to renew coverage to all groups, regardless of the health status of any member. This is effective July 1, 1997. Pre-existing Conditions A "preexisting condition exclusion" is a limitation or exclusion of health benefits based on the fact that a physical or mental condition was present before the first day of coverage. However, HIPAA limits the extent to which a plan or issuer can apply a pre-existing condition exclusion. A pre-existing condition exclusion is limited to a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 month period ending on the enrollment date in a plan or policy. During the pre-existing condition exclusion period, the plan or issuer may opt not to cover or pay for treatment of a medical condition based on the fact that the condition was present prior to an individual's enrollment date under the new plan or policy. (The plan or insurer must, however, pay for any unrelated covered services or conditions that arise once coverage has begun.) The enrollment date is the first day of coverage, or if there is a waiting period before coverage takes effect, the first day of the waiting period. Creditable Coverage The concept of creditable coverage is that an individual should be given credit for previous health coverage against the application of a pre-existing condition exclusion period when moving from one group health plan to another, from a group health plan to an individual policy, or from an individual policy to a group health plan. An individual will receive credit for previous coverage that occurred without a break of 63 days or more. However, any coverage occurring prior to a break in coverage of 63 days or more would not have to be credited against a pre-existing condition exclusion period. (Some States' laws may provide greater protections.) If 63 days pass without coverage, then the 12/18 month period starts over. Most health coverage is creditable coverage, including prior coverage under: a group health plan (including a governmental or church plan) health insurance coverage (either group or individual) Medicare Medicaid  military-sponsored health care program such as CHAMPUS a program of the Indian Health Service a State high risk pool the Federal Employees Health Benefit Program a public health plan established or maintained by a State or local government and a health benefit plan provided for Peace Corps members. Creditable Coverage Certificate A certificate of creditable coverage is a written document specifying the period of an employee's creditable coverage. In certain circumstances, the certification information may be provided by telephone if that is acceptable to the new plan or issuer, the individual, and the source of prior coverage. All employees must be given a "certificate of creditable coverage" by you, if you are self insured, or through the insurer offering health coverage. A certificate of creditable coverage must be provided without charge and  within a reasonable time period. The certificate must be furnished automatically to: an individual whose group coverage has ended, such as when they leave or quit a job. The certificate then must be provided within a reasonable length of time. an individual who loses health coverage and who is not entitled to elect COBRA continuation coverage. Then, the certificate must be provided within a reasonable time after coverage ceases. (Typically, this would happen in small-employer plans that are not subject to COBRA.) The certificate must be provided no later than when a notice would be provided under an applicable State program that is similar to COBRA. A certificate also must be provided promptly in States that do not have such a law. an individual who is qualified for COBRA and has elected COBRA continuation coverage or after the expiration of any grace period for the payment of COBRA premiums. Certificates on request: Employees and their dependents also can ask for a certificate, which can be done any time within the 24 months following loss of coverage. The plan or issuer must provide certificates at the earliest feasible time after they are requested. In general, employees should receive a certificate from their prior plan or issuer when they cease coverage. This certificate contains information that will demonstrate creditable coverage. If employees do not have a certificate available, they can use a variety of evidence to prove creditable coverage. Acceptable documentation includes: pay stubs that reflect a coinsurance deduction, explanation of benefit forms (EOBs), verification by a doctor or former health care benefits provider that the employee had prior health coverage, and a benefit termination notice from Medicare or Medicaid. Sample Certificate of Coverage click here HIPAA is not the same as COBRA HIPAA responsibilities do not eliminate or replace small employers' responsibilities under COBRA, but there are some places where they are coordinated. HIPAA makes three changes to COBRA's continuation coverage. These changes were effective on January 1, 1997, regardless of when the event occurs that entitles the individual to continuation coverage. A disabled individual (as determined under the Social Security Act) is entitled to 29 months of COBRA continuation coverage. Under prior law, the individual had to be disabled at the time of termination of employment or reduction in hours. Under HIPAA, an individual is entitled to 29 months of COBRA coverage if he/she becomes disabled at any time during the first 60 days of COBRA coverage. The extension of continuation coverage to 29 months also is available to any non-disabled family members of the disabled individual who are entitled to COBRA continuation coverage. COBRA continuation coverage generally can be terminated when an individual becomes covered under another group health plan. COBRA cannot be terminated because of other coverage where the plan limits or excludes coverage for any pre-existing condition of the individual. HIPAA limits the circumstances under which a plan may impose a pre-existing condition exclusion period on individuals. If a plan is precluded under HIPAA from imposing an exclusion period on an individual, i.e., it must cover the individual's pre-existing condition, COBRA continuation coverage may be terminated. COBRA rules also are modified to provide that children who are born, adopted, or placed for adoption with the covered employee during the continuation coverage period are treated as "qualified beneficiaries." (Under prior law, to be a "qualified beneficiary" the child would have to have been covered under a group health plan on the day before the COBRA qualifying event.)