HIPAA Policies for HIPAA Eligible Individuals

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When am I eligible for a HIPAA policy?

· If you have recently left group coverage and meet other requirements, you will be considered “HIPAA eligible” and must be offered a choice of individual health insurance policies.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy individual health insurance and are exempted from pre-existing condition exclusion periods. To be HIPAA eligible, you must meet all of the following:

· You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.

· You also must have used up any COBRA or state continuation coverage for which you were eligible.

· You must not be eligible for Medicare, Medicaid or a group health plan.

· You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)

· You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.

HIPAA eligibility ends when you enroll in an individual plan, because the last day of your continuous health coverage must have been in a group plan. You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.

· The type of HIPAA policy you are eligible for depends on the type of group coverage you most recently had.

If your most recent coverage was under a fully insured group plan, the insurance company that provided that group coverage must offer you a choice of at least two policies called enhanced conversion policies.

If your most recent coverage was a self-insured group plan, the state will assign an insurer from the individual insurance market to offer you a choice two policies called HIPAA assignment system policies.

If you are not sure what kind of HIPAA policy applies to you, contact the Georgia Office of Insurance at (800) 656-2298 for more information. This office can also provide you with an application for assignment.

What does a HIPAA policy cover?

· It depends. Generally, Georgia requires insurers to offer two policies, including a high and a low benefit option, to HIPAA eligible individuals. These policies must include coverage for hospitalization care, outpatient surgery care, limited mental health, limited substance abuse treatment, child wellness services, maternity care, as well as prescription drug coverage. These policies may have high deductibles such as a calendar year deductible of $2000 or $2500 per year per individual. In addition to these policies options, insurers may offer alternative policies with higher cost sharing and less covered benefits.

What about coverage for my pre-existing condition?

· HIPAA policies cannot impose a pre-existing exclusion period.

How much can I be charged for my HIPAA Policy?

· There are some limits on what you can be charged for a HIPAA policy.

Premiums charged for enhanced conversion policies are limited to 150% of the normal group rate for all of the group policies sold by your insurer.

Premiums charged for HIPAA assignment system policies are limited to 150% of the rates typically charged for comparable individual health insurance sold in the individual market in Georgia.

Can my HIPAA policy coverage be canceled?

· Your coverage cannot be canceled because you get sick. This is called guaranteed renewability. You have this protection provided that you pay the premiums, do not defraud the company, and, in the case of managed care plans, continue to live in the plan service area. However, your premiums can increase substantially as you age and other factors.


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