HIPAA - Health Insurance Portability and Accountability Act
In 1996 the federal government passed into law the Health Insurance Portability and Accountability Act (HIPAA). HIPAA law provides eligible individuals who have recently lost their employer sponsored group health plan the opportunity to purchase health insurance coverage even if they have a pre-existing health condition. If you meet the definition of an eligible individual, all health insurance companies who sell individual plans must offer you health insurance regardless of your medical history. This requirement to issue insurance is called "guaranteed issue." You may not be declined coverage based on medical reasons. In order to qualify as an eligible individual you must meet the following conditions:

• Your last health care coverage must have been under an employer sponsored group health plan, which includes COBRA continuation coverage, for at least 18 months. This prior 18-month coverage is referred to as "creditable coverage."
  
• All available COBRA continuation coverage has been elected and exhausted. If you qualify for COBRA you are required to accept the coverage and continue the coverage for the maximum time period allowed. (When an employer terminates its existing group health plan entirely, COBRA coverage ends and is considered exhausted.)
  
• You are not eligible under a group health plan, Medicare, Medi-Cal, and/or do not have other health insurance coverage.
  
• You did not lose your most recent health coverage due to nonpayment of premium or fraud.

Once COBRA has been exhausted, you have 63 days to file an application to purchase a guaranteed issue HIPAA policy with an insurance company or health plan. All carriers that sell individual health care policies must offer their two most marketed individual plans to HIPAA eligible individuals regardless of your health status. If you accept a conversion policy or a short-term policy after exhausting COBRA, you give up your HIPAA eligibility. It is important to understand that a conversion policy is not a HIPAA policy.

When applying for a HIPAA policy you can present a Certificate of Creditable Coverage from your insurance company or health plan as part of the application process. The Certificate of Creditable Coverage is a written statement from your insurance company or health plan showing the length of time you have been covered. The Certificate can be used as proof of your 18 months continuous creditable coverage when applying for a HIPAA policy.

Important Points to Remember About HIPAA:

• HIPAA gives eligible individuals who have lost group coverage the opportunity to purchase individual health coverage.
• HIPAA eligible individuals are not subject to medical underwriting.
  
• HIPAA policies must be issued to eligible individuals on a guaranteed issue basis regardless of any preexisting medical condition.
  
• You have only 63 days after COBRA has been exhausted to file an application to purchase a HIPAA policy.
  
• HIPAA policies are not conversion policies. Accepting a conversion or short-term policy terminates your HIPAA eligibility.
  
• You may contact the CDI or the DMHC depending on the type of coverage you have (indemnity or HMO) if you are experiencing problems with HIPAA.

Health Maintenance Organizations (HMOs or Managed Care)
Membership in a Health Maintenance Organization (HMO) requires plan members to obtain their health care services from doctors and hospitals affiliated with the HMO. It is common practice in HMOs for the plan member to choose a primary care physician who treats and directs health care decisions and who coordinates referrals to specialties within the HMO network. The doctors and hospital personnel may be employees of the HMO or contracted providers. Since HMOs operate in restricted geographic regions, this may limit coverage for plan members if medical treatment is obtained outside the HMO network or coverage area.

The intent of managed care products is to create less costly delivery of health care services while maintaining quality health care by specifying provider choice. HMOs offer access to a comprehensive package of covered health care services in return for a prepaid monthly amount (premium). Most HMOs charge a small copayment depending upon the type of service provided.

If you have a complaint with an HMO, contact the member services department of your HMO. HMOs are required to have an internal complaint/grievance process in place. If you file a grievance and it has not been resolved within 30 days or there is some question as to the HMOs decision, then you may contact the DMHC for assistance.

Important Points to Remember About Health Maintenance Organizations:

• You must obtain health care services from HMO providers, except in certain emergency situations.
  
• Your choice of primary care physician is important because he/she directs your care. Also, your primary care physician often coordinates referrals to specialties within the HMO.
  
• Your options may be limited by the geographic restrictions of the HMO network.
  
• You may be charged a small copayment each time you utilize an HMO covered service.
  
• You can seek assistance from the DMHC on all HMO and managed care questions.