Hipaa

[bnichols0330]

Alabama

I am currently in the process of changing jobs. I have been under the same health insurance goup policy for the past 14 months. My wife is currently pregnant and my new employer states that they consider this diagnosis a pre-existing condition for which they impose a 270 day waiting period for coverage. It is my understanding that the HIPAA act of 1996 prevents an employer from imposing pre-existing conditions when moving from one group policy to another. When I asked the human resources about this, I was told that my employer "opted out of the HIPAA act". I further delved into, "how do you opt out of a federal act?" For which the reply was, I don't know but our administrators say that ALL new employess have to wait out a 270 day waiting period for coverage.

My question is primarily, can an employer "opt" out of following a federal act? And secondly, how should I proceed in investigating this and trying to make them cover this?

Thank you.

[cbg]

No, an employer cannot opt out of a Federal law. Your recourse is to file a complaint with the US DOL.

Here is the relevant link. Scroll about two thirds of the way down to the question, What is a Pre-Existing Condition?

[url]http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html[/url]

[AL HR]

Are they saying they won't Offer health coverage for your first 270 days, or that they will offer it, but nothing that is preexisting is covered? I'm assuming the second, but it almost sounded like the first, which is legal.

[bnichols0330]

They are saying that they will offer coverage, but require a 270 day waiting period for coverage of anything that is considered pre-existing including pregnancy (based on conception date not diagnosis date).

[cbg]

They are in for a very nasty shock.

[ecmst12]

Under HIPAA, pregnancy can NEVER be considered a pre-existing condition, even if there was no prior creditable coverage under another group plan. I forsee problems in your employer's future...

[moburkes]

UH ohhhhhhhhhhhhhhhhhhhhhhhhh!

[ecmst12]

My only thought is maybe this is a little tiny company and the health insurance is not a section 125 plan?

[cbg]

Wouldn't matter even if that were the case. HIPAA's prohibition against pregnancy being considered pre-ex is not dependent on there being a Section 125 plan. It's prohibited, period.

[TIMMAAYY]

HIPPA says that pregnancy can not be pre x'd.... ever. If your employer has a 270 waiting period, that's fine. But they can't give you coverage on some things, and pre x pregnancy.

I can start a brand new company tomorrow with my pregnant wife, and get group insurance, and she will be covered. 7 months in. Pregnancy can not be pre x'd, and anyon who thinks they can "opt" out of HIPPA is in for a visit from the Feds.

If this is just a standard group plan, they have to take maternity. If they are doing any kind of self funding, they may be able to write their own plan document with restrictions... which in THAT case, they may be able to pre x something, as long as they do it for everyone. They just can't discriminate, covering it for one, and not for another.

I'll get back to you on that... I have to look something up and I'll give you a better answer.

[ecmst12]

HIPAA is a federal law and self funding will not get you out of it. Besides the fact that this thread was resolved 3 weeks ago, the answer remains the same - it's not legal for any group plan to treat pregnancy as a pre existing condition.

[lkc15507]

I will take a wild guess that your new employer is a non-federal government employer. ie state or municipal government employer that self-funds its employer group plan. (State or city government, utility, university etc.) Those groups were indeed allowed to "opt out" of HIPAA compliance if they chose. That "opt out" must be renewed with each new plan year.

Of course, state law will apply in that case. Check your state's law regarding pregnancy and prex if indeed your new employer falls into the category I just described. And, I'm not sure why, but my brain is telling me that the ultimate answer is that prex does not apply to pregnancy even IF your new employer falls into the group I described, although I cannot yet find the applicable statutes right now. Probably because federal law prohibits applying prex to pregnancy and state laws must be at least as generous as federal and cannot be less so. I will also refer to the earlier posts inquiring as to whether your new employer is imposing a routine waiting period for eligibility under the plan or a prex period. Be absolutely sure you know which they are referring to.

Research on this subject is difficult because it is not often that it is remembered that this rare animal of the self-funded non-federal government employee / employer (or perhaps even an employee of a charitable entity--not just not-for-profit--but tax exempt) exception even exists. One can find a great deal of information on self-funded plans, but few remember to include this exception. Most research will reveal that self-funded plans are ERISA plans under the jurisdiction of the US DOL as opposed to state regs like fully insured plans. However, self-funded non-ERISA (HIPAA compliant) AND non-ERISA "opted-out" (HIPAA non-compliant) plans do exist.

Never-the-less, I simply wanted to point out that certain groups were indeed allowed to "opt out" of HIPAA compliance. lkc15507

[TIMMAAYY]

Just a question regarding the above...

HIPAA covers a lot of things, such as creditable coverage, not assessing higher premiums to individuals in a group because of health conditions, privacy of health records, etc.

So if you "opt out of HIPAA".... what exactly are you opting out of.... everything? If that's the case, you are wide open for being reamed without it. An employer could do whatever they wanted with you in regards to health insurance, and HIPAA wouldn't protect you.

[lya]

Originally Posted by cbg

Wouldn't matter even if that were the case. HIPAA's prohibition against pregnancy being considered pre-ex is not dependent on there being a Section 125 plan. It's prohibited, period.

Just a curiosity question to you, cbg:

If all employees are held to a 270-day waiting period for insurance (are not eligible for enrollment in the group insurance plan), is that, in and of itself, legal?

Even though HIPAA does not allow pregnancy to be considered as a pre-existing condition, it does allow for an interruption of insurance coverage when changing jobs leads to a mandated waiting period of eligibility. It is possible for a pregnant woman to go without any insurance coverage, except through COBRA, until her spouse (the primary insured person) becomes eligible via his "new" employer.

I am trying to understand your answers in this thread; trying to gain knowledge via understanding, not trying to argue your points.

I am not interested in answers other than from you. (not intending to slight anyone)

[Ozark_Sophist]

Originally Posted by lya

Just a curiosity question to you, cbg:


I am not interested in answers other than from you. (not intending to slight anyone)

Cbg, You have a stalker...