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Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Statement of HIPAA Portability Rights

IMPORTANT - KEEP THIS CERTIFICATE. This certificate is evidence of your coverage under this plan. Under a federal law known as HIPAA, you may need evidence of your coverage to reduce a pre-existing condition exclusion period under another plan, to help you get special enrollment in another plan, or to get certain types of individual health coverage even if you have health problems.

Pre-existing condition exclusions. Some group health plans restrict coverage for medical conditions present before an individuals enrollment. These restrictions are known as "pre-existing condition exclusions." A pre-existing condition exclusion can apply only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 months before your "enrollment date." Your enrollment date is your first day of coverage under the plan, or, if there is a waiting period, the first day of your waiting period (typically, your first day of work). In addition, a pre-existing condition exclusion cannot last for more than 12 months after your enrollment date (18 months if you are a late enrollee). Finally, a pre-existing condition exclusion cannot apply to pregnancy and cannot apply to a child who is enrolled in health coverage within 30 days (31 days if enrolled with ODS) after birth, adoption, or placement for adoption.

If a plan imposes a pre-existing condition exclusion, the length of the exclusion must be reduced by the amount of your prior creditable coverage. Most health coverage is creditable coverage, including group health plan coverage, COBRA continuation coverage, coverage under an individual health policy, Medicare, Medicaid, State Childrens Health Insurance Program (SCHIP), and coverage through high-risk pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates like this one. If you do not receive a certificate for past coverage, talk to your new plan administrator.

You can add up any creditable coverage you have, including the coverage shown on this certificate. However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a plan may not have to count the coverage you had before the break.

Therefore, once your coverage ends, you should try to obtain alternative coverage as soon as possible to avoid a 63-day break. You may use this certificate as evidence of your creditable coverage to reduce the length of any pre-existing condition exclusion if you enroll in another plan.

Right to get special enrollment in another plan. Under HIPAA, if you lose your group health plan coverage, you may be able to get into another group health plan for which you are eligible (such as a spouses plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days (31 days if requesting enrollment with ODS). Additional special enrollment rights may be triggered by marriage, birth, adoption, and placement for adoption.

Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a spouses plan), you should request special enrollment as soon as possible.

Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on certain health factors. Also, a group health plan may not charge you (or your dependents) more for coverage, based on those health factors, than the amount charged a similarly situated individual.

Right to individual health coverage. Under HIPAA, if you are an "eligible individual," you have a right to buy certain individual health policies without a pre-existing condition exclusion. In Oregon, these individual health policies are called Portability plans. To be an eligible individual, you must meet the following requirements. To qualify for Oregon Portability coverage, an eligible individual must also be an Oregon resident and apply for Portability coverage within 63 days of losing group coverage issued by an Oregon carrier.

You have had coverage for at least 18 months without a break in coverage of 63 days or more;

Your most recent coverage was under a group health plan (which can be shown by this certificate);

Your group coverage was not terminated because of fraud or nonpayment of premiums;

  • You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or continuation coverage under a similar state provision); and
  • You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other health insurance coverage.

The right to buy individual coverage is the same whether you are laid off, fired or quit your job. Therefore, if you are interested in obtaining individual coverage and you meet the other criteria to be an eligible individual, you should apply for this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break.

State flexibility. This certificate describes minimum HIPAA protections under federal law. States may require insurers and HMOs to provide additional protections to individuals in that state.

For more information. If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor (DOL), Employee Benefits Security Administration (EBSA) toll-free at 1-866-444-3272 (for free HIPAA publications ask for publications concerning changes in health care laws.) You may also contact the CMS publication hotline at 1-800-633-4227 (ask for "Protecting Your Health Insurance Coverage"). These publications and other useful information are also available on the Internet at http://www.dol.gov/ebsa, the DOLs interactive web pages - Health Elaws, or http://www.cms.hhs.gov/hipaa1.

Important Continuation of Coverage Information

You may be able to continue your group benefits through COBRA or Oregon Continuation. Contact your group administrator for continuation information. You may also have the right to enroll in an individual Portability plan if you are an Oregon resident and have been covered continuously by an Oregon group health benefit plan for 180 days or more, and apply within 63 days of your group coverage termination date. Contact your medical carrier for more Portability information.