What is HIPAA?

The Health Insurance Portability and Accountability Act was passed by Congress in 1996. The law makes it easier for Americans to keep their health coverage, and protects their personal medical information.

HIPAA has two parts, or “Titles.” Title I contains rules about health insurance coverage. Title II contains rules about medical records.

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Title I: Health Care Access, Portability, and Renewability

Title I of HIPAA allows people to change health plans and keep coverage for any pre-existing medical conditions.

When you enroll in a new health insurance plan, it will typically exclude coverage for pre-existing health conditions — called an “exclusion period.” This exclusion period can last up to a year.

But what if you change jobs, and enroll in a new employer-sponsored plan? Will you have full coverage?

Under HIPAA, the new plan could not exclude coverage for your health condition as long as:

  • You had coverage for a year under your old plan.
  • You didn’t go without coverage for more than 63 days between your old and new plans.

If you were covered less than a year under your old plan, the exclusion period can still be reduced. For example, if you had coverage for 8 months under a previous plan, your exclusion period could be reduced by 8 months.

The coverage you had under your old plan is called “creditable coverage.” Nearly all group health plans, individual health plans, Medicare, and Medicaid plans are considered creditable coverage under HIPAA. You may need to provide your new health plan with a “Certificate of Creditable Coverage.” Contact your old health insurance company to get this certificate.

HIPAA Eligibility for Individual Coverage

HIPAA guarantees you the right to buy an individual health plan. You must meet certain criteria in order to be “HIPAA-eligible” for individual coverage. These criteria are:

  • You must have had at least 18 months of continuous creditable coverage.
  • The last day of this coverage must have been under a group health plan.
  • You must have used up all your COBRA coverage.
  • You cannot be eligible for Medicare, Medicaid, or a group health plan.
  • You cannot have health insurance.
  • You must apply for your individual health plan within 63 days of losing your previous coverage.

If you meet these criteria, any insurance company that offers individual health coverage in your state must accept you regardless of your health status. However, it is up to the insurance company which health plan it offers to HIPAA-eligible individuals.

Want to see what kind of individual health plans are available in your area? Get an instant online quote to start comparing plans now.

Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform

Title II is a bit more complicated — mostly because the law is vague about what it requires. There are three rules defined by Title II.

The Privacy Rule covers the use of Personal Health Information, which refers to your medical record and your medical payment history. The Privacy Rule says that health care providers, health plans, and other related organizations may disclose Personal Health Information to facilitate health care services or payment for those services. But they must only disclose the minimum amount of information needed to fulfill the service. The Privacy Rule also gives you the right to request access to Personal Health Information, and to request that errors in it are corrected.

The Security Rule covers the protection of Personal Health Information, particularly when this information is stored in electronic format. It requires health care providers, health plans, and other related organizations to take a series of steps to safeguard your Personal Health Information. These steps include defining who has access to this information, providing proper training to employees with access to this information, and making sure any computer containing this information is not easily accessible by the public.

The Transactions and Code Sets Rule defines a series of codes health care providers must use to file electronic Medicare claims. This rule is designed to streamline the system of Medicare payments.

You can learn more about HIPAA at the United States Department of Health and Human Services.