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HIPAA Provisions

With respect to availability of coverage one of the most important HIPAA provisions noted in research papers concerns coverage in the small group market (2 to 50 employees). HIPAA provides that if an insurer does business in this market in a given state, then it is required to accept every small group that applies for coverage in that state. Moreover, as Black and Skipper have also noted, HIPAA requires that insurers renew or continue in-force coverage for a group, no matter how small, except under certain, well-defined circumstances. These circumstances are:

1. Non-payment of premiums;

2. Fraud;

3. Violation of participation and contribution rules; and

4. The existence of a group of enrollees in a network plan who no longer live or work in the area covered by the plan.

Discontinuance of Coverage

HIPAA Provisions

A fifth acceptable reason for discontinuance of coverage is a decision on the part of an insurer to exit the market for the kind of coverage in question.  These HIPAA provisions make it much easier to find coverage and maintain that coverage once it has been obtained.  It puts an end to the ability of insurers to terminate coverage for a particular group when covering that group is deemed unprofitable.

COBRA Coverage

A change in COBRA coverage is mandated by HIPAA.  HIPAA provisions research papers have noted that, under COBRA, group health plans are required to allow employees and their beneficiaries to retain their health coverage at group rates for as much as 36 months after a “qualifying event,” terminates their eligibility for coverage under a plan’s usual provisions. Qualifying events include such things as the death of the covered employee or the termination of the employee for anything other than gross misconduct.  At passage COBRA defined “qualified beneficiaries” as an employee, the employee’s spouse if covered on the day before the qualifying event, and the employee’s dependent children if covered the day before the qualifying event.  HIPAA added to this list any child born or adopted during the period of COBRA coverage.

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