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Home > Resources > PAF Publications > PAF Guides & Major Publications > National Underinsured Resource Directory Booklet > Protections

Protections

The need to maintain or secure health coverage is a concern to everyone, but when you are diagnosed with a progressive or chronic disease, it is critical. Having insurance coverage ensures that you are able to continue necessary medical treatment both now and in the future. There are laws that have been put in place that provide protection to qualified individuals. Under the Health Insurance Portability and Accountability Act (HIPAA), beneficiaries covered by group health plans are safeguarded. Under private or individual plans, the insurer may impose a complete pre-existing exclusion of anything related to your diagnosis.

Health Insurance Portability and Accountability Act (HIPAA)
You have privacy rights under this federal law, passed in 1996, that protects your health information. These rights are important for you to know. As a consumer, you can exercise these rights, ask questions about them, and file a complaint if you think your rights are being denied or your health information is not being protected.

Who must follow this law?
  • Most doctors, nurses, pharmacies, hospitals, clinics, nursing homes, and many other healthcare providers.
  • Health insurance companies, HMOs, most employer group health plans.
  • Certain government programs that pay for healthcare, such as Medicare and Medicaid.


HIPAA provides insurance protections for beneficiaries covered by group health plans. It accomplishes this by:
  • Limiting exclusions for pre-existing conditions.
  • Prohibiting discrimination against employees and dependents based on their health status.
  • Guaranteeing renewability and availability of health coverage to certain employees and individuals.


In order to be protected against pre-existing condition exclusions under HIPAA, there can be no lapse or break in health insurance coverage of more than 62 consecutive days, and you must have 12 months of continuous coverage prior to the effective date of a new group policy. You may be eligible for partial credit against pre-existing conditions if you have less than 12 months continuous coverage.

Once you are no longer covered by a health insurance plan, a certificate of credible coverage will be issued for you to provide to your new insurance company. To learn more about the protections under HIPAA, visit http://www.dol.gov/ or call 1-866-444-3272.

Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA is a federal law that requires certain employers with 20 or more full-time employees or equivalent in the previous 12 months to offer continuation of healthcare coverage to qualified beneficiaries.

Under COBRA, the status of the qualifying beneficiary and the qualifying event determines the length of time COBRA coverage is available. The usual length of COBRA coverage is 18 months unless there are other circumstances or state laws that would require the employer to extend the benefits to a maximum of 36 months. Some of these circumstances include:

  • A Social Security Disability award is a requirement for patients seeking 11 month COBRA extension. To qualify you would need to be deemed disabled by Social Security Administration (SSA) within 60 days of enrolling in COBRA and you must notify your previous employer.


  • Divorce, death, legal separation or when a dependent child grows older and is no longer considered a dependent, may qualify you for the full 36 months. If the employee becomes entitled to Medicare coverage prior to leaving employment their family members can qualify for up to 36 months of COBRA coverage.


  • If a worker becomes entitled to Medicare prior to leaving employment, his/her family member may qualify for up to 36 months of coverage.


If an individual is eligible for coverage under a COBRA plan, the state may provide benefits in the form of premium payments and allow the individual to maintain current coverage rather than be covered by Medicaid benefits. To find out if your state offers this benefit you can contact your local Medicaid office. Some states have rules in place that require employers with less than 20 employees to offer "mini-COBRA". The amount of coverage varies upon state and you must contact the insurer directly to enroll. For more information,
contact your human resource department or visit www.cobrahealth.com.

Cost of COBRA:
You will find that the premium for COBRA is more expensive than you were paying while employed, as the employer no longer pays their portion of the premium payment. Under COBRA you have to pay up to 102% of the premium, including an administration fee. Some states offer premium assistance through their Medicaid program; this may be an option if you qualify for Medicaid and are struggling to afford your COBRA premiums. You can find out whether your state has a provision that allows this by contacting your local Medicaid office. There may be other programs offered through your state or federal government inquire with your Department of Labor or local state Department of Insurance.

It is your responsibility to pay your premiums. Read all paperwork you receive carefully. This will tell you where to send your insurance premium payments and whether or not you will receive monthly bills. Failure to pay the premium on time will cancel the coverage with no option for reinstatement. For additional information on COBRA you can link to the Department of Labor at www.dol.gov/ebsa or call 1-866-444-3272.