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Multiple Sclerosis, HIPAA, and Your Coverage

Several complex federal laws are designed to help protect people who have or who are seeking insurance, including those with multiple sclerosis (MS). Among them, the Health Insurance Portability and Accountability Act (HIPAA) is one you’ll want to pay attention to because it specifically provides protection to people with a history of health problems.

Here’s the gist of what HIPAA does:

  • It provides antidiscrimination protections. HIPAA guarantees that you can’t be denied enrollment in a group health plan (generally an employment-based plan) on the basis of your health status, and you can’t be charged a higher premium because of a disease or disability.

  • It limits preexisting condition exclusions. HIPAA limits the length of time (12 months for first-time enrollment in a health plan and 18 months if you enroll any time other than the official open-enrollment period) that a health plan can deny coverage for a preexisting condition.

    A preexisting condition is any health problem for which you saw a health professional or were treated (including taking a prescribed medication) during the six-month period before your new plan started. As of 2010, group health plans are prohibited from imposing this exclusion on children up to age 19. This change is the first step toward phasing out preexisting condition exclusion periods altogether.

HIPAA also gives you (and your covered dependents) credit for the amount of time you were insured by your previous plan (referred to as prior coverage) and applies that credit to the preexisting condition exclusion period of your new plan. This is called creditable coverage.

To help you prove your creditable coverage, HIPAA requires health plans to give anyone who leaves a plan a certificate of coverage indicating the amount of time he or she was covered. However, keep in mind that prior coverage is not creditable if you have a gap of 63 or more days without coverage.

HIPAA’s protections apply to most but not all health plans. Exceptions include so-called “temporary” health policies, certain student plans, catastrophic or disease-specific policies, private disability policies, and dental or vision coverage.

When considering the purchase of any health insurance policy, be sure to ask if it would be considered creditable coverage under HIPAA. For more information about HIPAA, consult your employer, your health plan administrator, or your state department of insurance.

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