State Laws and HIPAA Coverage..

By: Taylor


Before we can look at what the individual states laws can affect HIPPA, it’s important to have a clear understanding of what it is. We highly recommend that you read the following page before continuing: Health Insurance Portability and Accountability Act.

What the Individual States Can Do:

Through the enactment of laws, each state has the right to offer more protection than the federal law known as HIPPA – Health Insurance Portability and Accountability Act. These individual state laws apply to health insurance plans which provide benefits through an insurance company or a health maintenance organization (HMO). You can determine if your plan offers HIPPA coverage by consulting the Summary Plan Description of your policy or contact your plans administrator.

The areas where state laws can complement the Health Insurance Portability and Accountability Act (HIPAA)’s pre-existing condition and special enrolment provisions are as follows:

Insurance companies have the ability to ‘look-back’ into your medical records to determine if you have a pre-existing condition. Under Federal HIPPA, the time period they are allowed to look-back is six months. States can reduce that look-back period to a period of only three months. The look-back period begins the day you enroll in a plan.
Federal HIPPA laws allow an insurance company to exclude a pre-existing condition from coverage for a period of up to 12 months. Individual states laws may reduce that period to 6 months.
Federal HIPPA allows for an18 month exclusion for late enrollees – Individual states may reduce that time period as well.
Federal HIPPA allows for a break in coverage period of up to 63 days. Individual states may extend that period up to 100 days.
Federal HIPPA has an enrollment period for newborns, adopted children and children placed for adoption (without a pre-existing condition) of 30 days, however, the individual states may increase that number to 60 days.
Federal HIPPA prohibits the exclusion of certain pre-existing conditions such as: Pregnancy, Any condition present in a newborn or child under the age of 18 who is either adopted or placed for adoption and Genetic Information: As an example a woman who is found to have the gene which indicates she is at higher risk for breast cancer. Individual states may include other conditions to the non-exclusion list – even if treatment for the condition has been received in the last six months before enrollment.
States may ask for additional requirements or additional circumstances to offer special enrolment periods under HIPAA beyond those in the Federal law.
States are also entitled to reduce the 2 month HMO affiliation period prior to enrollment. (Three months for late enrollees).
State laws may also supplement the Health Insurance Portability and Accountability Act (HIPAA) in other areas such as protections from discrimination.

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