HIPAA Portability Final Regulations Michael C Roach Esq

HIPAA Portability Final Regulations Michael C. Roach, Esq. Bridget C. Kevin, RN, Esq. Meade & Roach, LLP May 25, 2005 (C) Meade & Roach, LLP 2005 1

Overview n n n n Preexisting condition exclusion First notice Individuals and conditions not subject to preex exclusion Creditable coverage Dependent coverage Special enrollment HMO affiliation periods Excepted benefits (C) Meade & Roach, LLP 2005 2

Preexisting Condition Exclusions n New definition: exclusion based on fact that condition was present before “effective date of coverage” whether or not any medical advice, care, or treatment was recommended before that date • • • Used to be “first day of coverage” Addresses successor issues Thus, expands definition (C) Meade & Roach, LLP 2005 3

Preexisting Condition Exclusions n Six month look back • Maximum • Advice, care, or treatment during that time • By someone licensed or similarly authorized by the State and in scope of such license or authorization (C) Meade & Roach, LLP 2005 4

First Notice of Exclusion n n Must be provided as part of application materials If do not distribute such materials, by earliest date following request for enrollment that it can be provided acting in a “reasonable and prompt” fashion (C) Meade & Roach, LLP 2005 5

Content of Notice n n n Terms Length of look back period Length of exclusion period Length of waiting period Description of creditable coverage rights Person to contact • Address and phone number (C) Meade & Roach, LLP 2005 6

Enrollment Date n n Enrollment date is the 1 st date of coverage under the plan, or if there is a waiting period, the 1 st day of the waiting period. Remains the same even if the enrollee changes benefit package options, or if the plan changes insurer. (C) Meade & Roach, LLP 2005 7

Waiting Periods n In the individual market, the waiting period begins on the date a substantially completed application was submitted. (C) Meade & Roach, LLP 2005 8

Individuals and Conditions Not Subject to Preex Exclusion n Pregnancy- a preexisting exclusion cannot be applied to pregnancy. (C) Meade & Roach, LLP 2005 9

Individuals not subject to Preexisting Exclusion n Newborn, adopted child or child placed for adoption if the child has been covered under a plan within 30 days of birth, adoption or being placed for adoption (C) Meade & Roach, LLP 2005 10

Conditions not Subject to Preexisting Exclusion n n Plan may NOT impose a preexisting condition exclusion based solely on genetic information. Plan may impose an exclusion if the individual is diagnosed with a condition related to genetic information, as long as the condition is in alignment with other HIPAA regulations. (C) Meade & Roach, LLP 2005 11

Creditable Coverage n n Interim rules listed 10 categories of creditable coverage S-CHIP enacted since the interim rules, therefore added as creditable coverage. (C) Meade & Roach, LLP 2005 12

Creditable Coverage n n n Refined definition of a public health plan Any health coverage provided by a governmental entity is a public health plan Includes any coverage provided under a plan sponsored by a foreign government (C) Meade & Roach, LLP 2005 13

Counting Creditable Coverage n n n Interim rules adopted with some stylistic changes Standard method-based on days, days before significant break in coverage not counted, significant break = 63 days, tolling a significant break Alternative method- counting specific benefits (C) Meade & Roach, LLP 2005 14

Evidence of Creditable Coverage n n To enable any individual to establish prior creditable coverage in order to reduce or eliminate any preexisting condition exclusion Generally, must be in writing May be requested at any time Automatic notice provided at termination of coverage and/or with COBRA notice (C) Meade & Roach, LLP 2005 15

Model Certificate n n Regulations list necessary language Must include a HIPAA educational statement Use of the model certificate satisfies government requirements Found in the December 30, 2004 Federal Register (69 Fed. Reg. 78726 -29) (C) Meade & Roach, LLP 2005 16

Dependent Coverage n n n Any individual who is or may become eligible under the plan because of their relationship to the participant. Notice of creditable coverage may be included in one notice as long as all have the same address A reasonable effort to provide notice to another address is required (C) Meade & Roach, LLP 2005 17

Special Enrollment n Initial opportunity to enroll not only time individual with other coverage may decline coverage and preserve special enrollment rights upon loss of other coverage (C) Meade & Roach, LLP 2005 18

Loss of Coverage Leading to Special Enrollment Rights n n Individual HMO coverage and individual no longer resides, lives, or works in the service area and HMO does not provide coverage for that reason Aging out (C) Meade & Roach, LLP 2005 19

Special Enrollment n n Plan no longer offers coverage to a class of similarly situated employees Dependent has special enrollment rights (C) Meade & Roach, LLP 2005 20

Special Enrollment n Employer contributions to coverage terminate • Even if employee continues other coverage by paying entire premium n Surpassing lifetime maximum • Rights last for 30 days after denied claim • Do not need to wait for denial (C) Meade & Roach, LLP 2005 21

Special Enrollment n Rights exist even if other subsequent coverage opportunities exist • Do not have to elect and exhaust COBRA • Rights exist after exhausting COBRA (C) Meade & Roach, LLP 2005 22

HMO Affiliation Periods n n Period of time that must expire before HMO coverage becomes effective May be imposed only if • • No preex exclusion No premium during period Not discriminatory Two-month maximum (three months for late enrollees) • Runs concurrent with any waiting period and • Begins on enrollment date (C) Meade & Roach, LLP 2005 23

Excepted Benefits n n n Excepted benefits- Workers Compensation, accident only, credit only, liability coverage, auto Limited Excepted benefits- limited scope dental, vision, or long term care. Provided under a separate plan or NOT an integral part of a plan subject to HIPAA (C) Meade & Roach, LLP 2005 24

Questions Michael C. Roach MRoach@Meade. Roach. com 312. 255. 1773 Bridget C. Kevin BKevin@Meade. Roach. com 312. 953. 9251 (C) Meade & Roach, LLP 2005 25