Health Insurance Portability and Accountability Act [HIPAA] - Healthcare Access and Renewability

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Healthcare Access and Renewability

HIPAA regulates the availability of certain individual health insurance policy covers and group health plans. With the introduction of Title I HIPAA, suitable amendments were made to legislative acts such as:

a) Employee Retirement Security Act

b) Internal Revenue Code

c) Public Health Service Act

In case of individuals, Title I permits for reduction in exclusion period related to pre-existing diseases, provided such individuals had availed a "creditable coverage" prior to enrolling in the health-insurance plan without any "significant breaks" in coverage. Such a “creditable coverage” could include an individual health insurance policy or a group health plan. Title I limits the restrictions on a group health plan with respect to pre-existing diseases. Group health plan may provide coverage for pre-existing diseases only after a waiting period/claim-free period of 12 months after enrollment in the plan or provide coverage after a gap of 18 months in case of late enrollment. "Creditable coverage" is a well defined term and incorporates nearly all individual and group health plans. A "significant break" in insurance policy coverage is defined as absence of any creditable coverage for 63 days period after the expiry of the previous health policy.

Certain healthcare plans such as long-term health plans and limited-scope plans comprising of dental or vision plans that are offered individually from other general health plans are exempted from Title I requirements. HIPAA still applies to such benefits, if the benefits are a part of the general health plan.

Under Title I, there is an alternative method of calculating creditable continuous coverage available pertaining to health policy cover. Applicants to a general group health plan cannot obtain certificates of creditable continuous coverage for independent limited-scope plans such as dental, vision etc to apply towards exclusion periods of the new insurance policy covers that do not incorporate coverage pertaining to limited-coverage insurance policies that are excluded from HIPAA regulations. As a result, an individual cannot avail benefits pertaining to Pre-Existing Diseases due to lack of creditable continuous coverage.

Exclusion periods that remain hidden and are not highlighted are not valid under Title I of HIPAA. Necessary amendments should be made to incorporate such clauses under HIPAA.

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