Can my new employer refuse to five me The exclusionary period for a pre-existing What counts as “credible coverage”? health insurance if I have a pre-existing medical condition can last up to 12 months after medical condition? your enrollment date. (However, if you do not Most forms of health care coverage count. This enroll in the new health plan when you are first includes group health plans, Cobra coverage, No, but pre-existing medical conditions may be able to enroll, you are considered a late enrollee, HMO coverage, individual health insurance excluded for up to 12 or 18 months. HIPAA and the exclusion can last up to 18 months). policies, Medicaid, Medicare and military (the Health Insurance Portability and One of the great features about HIPAA is that coverage. It does not include coverage that is Accountability Act of 1996) is a federal law that the exclusionary period is reduced by the number only for one type of benefit, such as vision or limits the amount of time a group health of months of prior insurance coverage you had. dental coverage only. Also, it does not include insurance policy can refuse to cover pre-existing You must have had “creditable coverage” with the waiting period for a new health plan. medical conditions. HIPAA allows people who no “significant break” in coverage. This means However, the waiting period does not count as a are changing jobs to join their new employer’s that if you had other health insurance for the last significant break in coverage. health insurance plan with little or no 12 or months (or 18 months for late enrollees), exclusionary period. HIPAA makes it easier for your new plan could not refuse to cover pre- How do you prove you had prior “creditable you to get health insurance coverage for pre- existing conditions. If you had prior health coverage”? existing medical conditions. However, it does insurance for less than 12 months, the length of not require employers to offer health insurance that coverage would reduce the amount of time Under HIPAA, health care plans must provide or to provide any specific benefits, and it does you would not be covered for pre-existing you (and any of your covered dependents) with a not limit the costs of insurance premiums. conditions. document that tells the amount of creditable coverage you have earned. They are required to What is a pre-existing medical condition? For example, if you had health insurance for the provide you with this documentation at specified last 4 months before your new coverage began, times. These times include: A pre-existing condition is a health/medical those 4 months would count toward the 12- condition that you had before you enrolled in a month exclusion on pre-existing conditions and ♦ When you lose coverage under the plan (for new health plan. Under HIPAA, health/medical you would have to wait only 8 months until your example, when you change employers or conditions can be excluded only if medical pre-existing conditions would be covered. your employer switches to a new health care advice, diagnosis, or treatment was plan). recommended or received within 6 months What is a “significant break” in coverage? before enrolling in the new plan. Even then, the ♦ When you become eligible to choose condition can be excluded only for a limited A “significant break in coverage” is when you COBRA coverage and again when your period of time (up to 12 or 18 months). have been without health coverage for 63 days or COBRA coverage ends. longer. If you have a significant break in Pregnancy is not a pre-existing condition under coverage, the coverage you had before the break ♦ Upon request, free of charge, before losing HIPAA, and newborns and newly adopted cannot be used as credit against the exclusion for coverage or within 24 months of losing children cannot be considered as having pre- a pre-existing condition. For example, if you had coverage. existing conditions as long as they are enrolled in health insurance through your employer for 12 the health care plan within 30 days of their birth months, and then had no insurance for 3 When you receive a certificate of coverage, you or adoption. months, you had a “significant break in should check it over carefully to make sure it is coverage.” You then cannot count the 12 correct. If it is wrong, you should contact the How long can an insurance company months of previous insurance against the plan administrator to have it corrected and exclude coverage for a pre-existing exclusionary period on your new policy. You reissued. You will need it if you enroll in a new condition? employer must still provide you with the health plan and want to establish your creditable insurance, but your pre-existing medical coverage to avoid an exclusionary period. If it is condition can now be excluded for 12 months. wrong by even a day it can make a difference, so Where can I get more information? you should get any errors fixed. HEALTH You can contact the US Department of Labor at INSURANCE AND Does HIPAA prevent “medical 1-800-998-7542 and request a free booklet called discrimination?” “Questions and Answers: Recent Changes in PRE-EXISTING Health Care Law.” You can also get more In certain instances, yes. It provides that information on the internet at: CONDITIONS individuals may not be excluded from coverage www.dol.gov/dol/topic/healthiplans/portability. under the terms of a group health plan or htm. You can contact the Indiana Department charged more for health benefits based on their of Insurance at 1-800-622-4461. You can get mental or physical condition, past insurance more information from the Indiana Department claims experience, past history of medical care, of Insurance and fill out a complaint form at their medical history, their genetic information, www.in.gov/idoi/. Prepared by: or evidence of disability. A person also cannot be required to take a physical to be eligible for a Last Revised 03/2003 Special Code:1030803 Indiana Legal Services, Inc. group medical plan.

Can I enroll in my employer’s health insurance plan any time?

ILS Office Contact Numbers No. Employers usually have only certain times The production of this pamphlet is made possible by a grant when you can enroll in the health insurance plan. Bloomington: Hammond: from the Indiana Bar Foundation. However, HIPAA requires the employer to allow (812) 339-7668 special enrollment for marriage, birth, adoption, (219) 853-2360 or if you have lost health insurance coverage 1-800-822-4774 under another plan. Indianapolis: This pamphlet is for information only. It is NOT legal advice. Columbus: (317) 631-9410 For legal advice, contact a private attorney or a lawyer at the What if I have a problem? (812) 372-6918 1-800-869-0212 1-866-644-6407 nearest Legal Services Office. HIPAA provides three ways of handling Lafayette: Laws and Policies change. Please look at the last revised date problems and complaints. If you have a Evansville: (765) 423-5327 to make sure the information is still current. problem, you can: (812) 426-1295 1-800-382-7581 1-800-852-3477 Information Available on the web 1. Make a complaint to the Indiana New Albany: Department for Insurance. Fort Wayne: (812) 945-4123 www.indianajustice.org (260) 424-9155 1-800-892-2776 2. Make a complaint to the US 1-888-442-8600 Department of Labor. South Bend: Gary: (574) 234-8121 3. Hire an attorney and bring your own (219) 886-3161 1-800-288-8121 lawsuit against a group health plan. 1-888-255-5104