21 Frequently Asked Question on DC HIPAA Top Twenty-One Questions Asked About DC Health Insurance Portability And Accountability Act (DC HIPAA) Who is covered by the provisions of DC HIPAA? When do the protections under DC HIPAA start to apply to you? Are all health insurers subject to provisions of DC HIPAA? Is there guaranteed issue of health coverage? Is there guaranteed renewability of health coverage? Are there times when a health insurer does not have to renew health care coverage? When can preexisting condition exclusion be imposed? What does portability mean? Does it apply to all health plans? What is creditable coverage? How does an individual establish his/her creditable coverage? What is an automatic certificate? When do you begin accumulating creditable coverage? When must health plans or health care insurers have to issue certificates of creditable coverage? Can eligibility rules be based on health status-related factors? Can an employer establish limits or restrictions on health care coverage? If a health insurer denies health coverage in the individual market for a network plan, how long would the insurer be precluded from the market? Can a health insurer deny health coverage to an eligible individual in the individual market? If the health insurer denies coverage in a service area based on financial capacity, can it offer coverage in the individual market? Can a health insurer decide to discontinue offering a particular type of health insurance coverage offered in the individual market? Can a health insurer decide to discontinue offering all health insurance coverage in the individual market? Who is covered by the provisions of DC HIPAA? Group Market: Generally, this Act applies to all "employer provided group health plans. The terms of the health plan govern your eligibility for the plan not your health status or your dependent's health status. Individual Market: Eligible Individuals. This person must have the following: at least 18 months of previous creditable coverage; most recent coverage in a group plan, governmental plan, or church plan, or health insurance coverage offered in connection with any such plan; not eligible for Medicare or Medicaid; not have other insurance coverage; not have had your most recent coverage canceled for nonpayment of premiums or fraud; and must have elected and exhausted COBRA or similar District of Columbia Law. When do the protections under DC HIPAA start to apply to you? Group Market: The provisions of this Act applies to group health benefit plans issued or renewed after July 1, 1997. This means that these protections are available with new plan years or the renewal date of your employers plan beginning on or after July 1, 1997. Individual Market: The provisions of this Act applies to individual health benefit plans issued or renewed on or after January 1, 1998. Are all health insurers 1 subject to provisions of DC HIPAA? Group Market: No. Health insurers offering group health coverage in the District of Columbia must meet the following conditions to be subject to the provisions of DC HIPAA: Any portion of the premiums or benefits is paid by or on behalf of the employer; The eligible employee or dependent is reimbursed for any portion of the premium by or on behalf of the employer; or The employer or covered individual treats the health benefit plan or program as part of a plan or program for the purpose of section 106, 125, or 162 of the United States Internal Revenue Code. Individual Market: No. Only the health insurers that elect to sell individual market products. Is there guaranteed issue of health coverage? Group Market: Yes. DC HIPAA requires health insurers that offer coverage in the small group market to offer and make available health care coverage to every small employer who applies for it. Individual Market: Yes. Individual health insurers are required to offer coverage under all policy forms to eligible individuals (guaranteed issue). However, an insurer can elect to limit the number of policy forms offered, if the insurer offers at least two different policy forms which are designed for and actively marketed in the individual market. In addition, the two policy forms must have the largest or next to the largest premium volume or the two policy forms must include a high level and a low level policy form which includes benefits substantially similar to other individual health insurance coverage offered by the health insurer in the District of Columbia. The election is effective for two years. Health Maintenance Organizations that offer only one individual plan are required to offer only one HIPAA individual policy. Is there guaranteed renewability of health coverage? Group Market: Yes. Every health insurer that offers health insurance coverage in the group market must renew the coverage of all the insureds at the option of the employer. Individual Market: Yes. Generally, a health insurer is required to renew or continue in force your individual health coverage. Are there times when a health insurer does not have to renew health care coverage? Group Market: Yes. The exceptions to the requirement that health insurers must renew health care coverage are listed below: Nonpayment or late payment of required premiums by the policyholder or contract holder; Health insurer no longer offers coverage in the small or large group market in accordance with this Act; Fraud or misrepresentation by the employer concerning their coverage; Fraud or misrepresentation by the employee concerning his/her coverage; Failure to follow the health benefit plan's contribution and participation requirements; Failure to follow health benefit plans provisions approved by Commissioner; When a health insurer offers health coverage through a network plan and there is no longer an enrollee in such plan that lives, resides, or works in the health insurer's service area or its area authorized to do business, the health insurer can deny enrollment with respect to the plan in accordance with this Act; When health coverage is offered through one or more bona fide associations in the group market only and the employer's membership in the association ceases (termination must be done uniformly without regard to any health status related factor to any covered individual); When a health insurer discontinues offering a particular type of group health insurance coverage in the small or large group market after notice must be given to each plan sponsor, participants and beneficiaries covered 90 days prior to the discontinuation; or When the health insurer elects to discontinue offering all health coverage in the small or large group market, it must give notice to the Commissioner of Insurance, Securities and Banking at least 180 days prior to discontinuance; and all health coverage issued or delivered for issuance in the market are discontinued and coverage under the health insurance plan in the market is not renewed. The health insurer cannot issue health coverage in this market for a period of 5 years beginning on the date of discontinuance of the last insurance coverage not renewed. Individual Market: Yes. Your health coverage can be non-renewed or discontinued for the following reasons: You failed to pay your premiums; You committed fraud or made an intentional misrepresentation of material fact; The insurer stops offering coverage in the individual market in accordance with the act; You moved outside the service area; or You ended your membership in an association. When can preexisting condition exclusion be imposed? Group Market: A preexisting condition exclusion may be imposed by a health care insurer if it relates to a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within a six month period ending on the enrollment date. This exclusion period may be imposed for a period not longer than twelve months. For a late enrollee this exclusion period is limited to eighteen months. The exclusion period may be reduced by aggregate periods of creditable coverage. Health Maintenance Organizations (HMOs) may use affiliation periods not to exceed two months or not to exceed three months for late enrollees instead of the preexisting condition exclusion. The affiliation period must begin on the enrollment date and it must run concurrently with any waiting period under the plan. An affiliation period must be applied uniformly without regard to any health status related factors. An alternative method to an affiliation period may be used by the HMOs, if it is approved by the Commissioner prior to its use. Individual Market: The exclusion period may be reduced by aggregate periods of creditable coverage. What does portability mean? Portability means that once a person has health coverage, that coverage may be used to offset the pre-existing condition exclusion time period that may apply to the individual under a future plan or policy. Portability is a way to receive credit for maintaining health coverage, even though coverage may be under different policies/plans. Does it apply to all health plans? No. Portability applies when a person moves from one group plan to another, from a group plan to an individual policy or from an individual policy to a group health plan. It does not apply if you move from one individual health plan to another individual health plan. In this case, pre-existing condition limits will still apply. What is creditable coverage? Creditable coverage is used to reduce the preexisting condition exclusion periods when you move 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. DC HIPAA allows a lapse in health care coverage for a period not greater than sixty-three days. After this period, coverage will not longer be creditable. Creditable Coverage means coverage of the individual under any of the following: A group health plan (including church plans and governmental plans); Health insurance coverage; Medicare; Medicaid; Civil Health and Medical Program of the Uniformed Services; A medical care program of the Indian Health Service or a tribal organization; A state health benefits risk pool; Federal Employees Health Benefits Plans; A public health plan; and A health benefit plan under section 5(e) of the Peace Corps Act How does an individual establish his/her creditable coverage? You should request a certificate from your current plan or issuer. The request for a certificate can be made at any time and issued free of charge. It should be in writing. However, new plans or issuers may accept creditable coverage information over the telephone. If you cannot get a certificate to prove your creditable coverage, acceptable documentation includes pay stubs that show a premium deduction, explanation of benefit forms; a benefit termination notice from Medicare or Medicaid and verification by a doctor or your former health care benefits provider that you had prior health coverage. A requested certificate should cover each period of continuous coverage under the plan ending within the twenty-four months prior to the date of request. What is an automatic certificate? It is a certificate that individuals receive when they lose health care coverage, and begin or end COBRA or upon request within twenty-four months after they lose coverage. This certificate will only reflect the most recent period of continuous coverage under a particular option under a plan. COBRA is an abbreviation for the Consolidated Omnibus Budget Reconciliation Act of 1985. It allows employees or their family members to continue their group health insurance coverage at group rates, but at their own expense when coverage is lost due to divorce, death of the supporting spouse, loss of a job or other situations. When do you begin accumulating creditable coverage? Generally, people began accumulating creditable coverage on July 1, 1996. When must health plans or health care insurers have to issue certificates of creditable coverage? June 1, 1997, health plans and health care insurers must begin issuing certificates of creditable coverage. By July 1, 1998, health plans or health care insurers must issue dates of coverage of all dependents. Can eligibility rules be based on health status-related factors? No. Health status; physical or mental condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, or disability can not be used to establish eligibility for enrollment in group health care plans. Can an employer establish limits or restrictions on health care coverage? Yes. An employer can establish limits or restrictions on benefits or health care coverage for people similarly situated. Plan benefits or covered services may be changed by an employer, if proper notification is given. If a health insurer denies health coverage in the individual market for a network plan, how long would the insurer be precluded from the market? When the Commissioner of Insurance, Securities and Banking approves the action of the insurer in denying coverage in the network plan, the insurer may not offer coverage in the individual market within the service area for a period of 180 days after the coverage is denied. Can a health insurer deny health coverage to an eligible individual in the individual market? Yes. The health insurer must demonstrate to the Commissioner of Insurance, Securities and Banking the following: It does not have sufficient financial reserves needed to underwrite additional coverage; and This denial is being applied uniformly to all individuals in the District of Columbia's individual market. Also the denial must be consistent with District law, without regard to health status-related factors; and without regard to whether individuals are eligible individuals. If the health insurer denies coverage in a service area based on financial capacity, can it offer coverage in the individual market? Yes. However, the health insurer is suspended from offering coverage in the individual market in that service area for the later of 180 days from the date of denial; or until the insurer demonstrates to the Commissioner, that it has sufficient financial reserves to underwrite additional coverage. Can a health insurer decide to discontinue offering a particular type of health insurance coverage offered in the individual market? Yes. Health insurance coverage may be discontinued in regards to a particular type of coverage by the health insurer if (1) the health insurer gives notice to each individual covered by this type of coverage at least 90 days prior to the date of the discontinuation of such coverage; (2) the health insurer offers an option to purchase any other individual health insurance coverage currently marketed by the health insurer in such market; and (3) the health insurer must act uniformly without regard to any health status-related factor of enrolled individual or individual who become eligible for such coverage. The health insurer may not provide any health insurance coverage in the District of Columbia's individual market for 5years beginning on the date of discontinuation. Can a health insurer decide to discontinue offering all health insurance coverage in the individual market? Yes. All health insurance coverage may be discontinued by the health insurer if (1) the health insurer gives notice of the discontinuation to the Commissioner and each individual at least 180 days prior to the expiration of the coverage; and (2) all health insurance issued or delivered in the District of Columbia is discontinued and coverage under such health insurance coverage in the individual market is not renewed. 1Health insurer means any person that provides one or more health benefit plans or insurance in the District including an insurer, a hospital and medical services corporation, a fraternal benefit society, a Health Maintenance Organization, a multiple employer welfare arrangement or any other person providing a plan of health insurance subject to the Commissioner's authority.