HIPAA Information

You may qualify for a plan that is available as a result of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).

In some circumstances, insurance carriers are required to offer certain plans to people who cannot qualify for any regular plans for individuals because of their health. Your Application for Nongroup Coverage includes a list of questions that will help us determine whether you are eligible for a HIPAA plan. If you qualify for a HIPAA plan, you will not have to complete a health history form or be medically approved for coverage, and you won’t have to wait for coverage of preexisting conditions. However, the cost of this coverage is substantially higher than the cost of our other plans.

The HIPAA plans offered through Blue Cross and Blue Shield of Missouri are:

• The HIPAA Alliance PPO (Preferred Provider Organization) program. This program has a choice of annual deductibles – either $300 or $1,000. Maternity benefits for the subscriber or covered spouse may be added at an additional cost and, if purchased, will not begin until after a one-year wait. (Note: This one-year wait is not a preexisting conditions provision.)
• The BlueCHOICE HMO (Health Maintenance Organization) program. Maternity benefits are included, with no waiting period, for subscriber or covered spouse and for covered dependent daughters.

To be eligible for one of the HIPAA plans, you must meet all of the following requirements:

1. You must have at least 18 months of “creditable” coverage, and you must not have had a break in continuous coverage for more than 63 consecutive days.

Creditable coverage includes a health plan provided by an employer or purchased by you, Medicare, Medicaid, a federal employee plan, an Indian health service or tribal organization plan, a Peace Corps plan, a military health plan, a state high-risk pool plan, a public health plan and a short-term medical plan.

Coverage that is not considered creditable coverage includes accident-only plans; liability, auto, disability income or workers’ compensation insurance; specific-disease plans; hospital supplemental plans; Medicare supplemental plans; long-term care plans; credit-only insurance; on-site medical clinic coverage, and limited-scope dental or vision coverage.

Countable creditable coverage: If you had creditable coverage under more than one plan, it can all be counted toward reducing or eliminating the preexisting condition exclusion period – as long as there was not a break between coverages of more than 63 consecutive days. Any coverage before a break of more than 63 days is not countable creditable coverage.

Waiting/Probationary Period: Any time you spent in a waiting or probationary period before coverage began does not count as creditable coverage.

2. Your most recent coverage must have been through a group, church or governmental health plan, and it must not have been canceled due to fraud or failure to pay premiums. (Except, your most recent coverage could not have been through Medicare, Medicaid or a state high-risk pool plan.)
3. If you were eligible for COBRA and/or state Continuation Coverage, and if you were offered or advised of that coverage, you must have elected that coverage. You may apply for coverage in the HIPAA plan before the end of your COBRA and/or state Continuation Coverage, but you must have used up all of that coverage by your effective date of coverage in the HIPAA plan.
4. You must not be eligible for coverage under a group plan, Medicare or Medicaid.
5. You must not have any other health coverage.
6. You must live in the service area.

To prove your eligibility, you must provide the following, along with your completed application:

1. One or more certification forms showing that you, and each person to be included on your application, have at least 18 months of creditable coverage. Insurance carriers and group health plans are required to provide these Certifications of Prior Health Coverage to you.

Certain children are eligible even if they do not have 18 months of creditable coverage. They must have had creditable coverage within 30 days of birth, adoption or placement for adoption.

If you cannot obtain a certification of prior coverage, you may submit other proof, such as explanation of benefits for the period you had coverage with your prior plan, paycheck stubs that show a deduction for health insurance or a letter from your prior group administrator or insurance company. If you cannot provide any of these items right away, you may attest in writing that you and those you want covered had prior countable creditable coverage. Your letter must include the name and address or phone number of both your prior employer or group and your prior insurance company. However, you still must submit all requested documentation within 31 days after you submit your completed application.

2. A letter or other documentation certifying A) the dates that you and each person included on your application began COBRA and/or state Continuation Coverage and the date(s) that coverage will end or B) that you and/or the person(s) listed on your application were not eligible for, or were not offered or advised of, COBRA and/or state Continuation Coverage.

If you cannot obtain this documentation right away, you may attest in writing that you and those you want covered have used up all available COBRA and/or state Continuation Coverage. Your letter must include the name and address or phone number of both your prior employer or group and your prior insurance company. However, you still must submit all requested documentation within 31 days after you submit your completed application.