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Hipaa and Creditable Coverage

HIPAA and Creditable Coverage

Nursing and medical students must understand HIPAA regulations. This includes creditable coverage. If you need research or a research project on any aspect of HIPAA, Paper Masters has writers that can assist you with your research project, even writing the research for you. Contact us to day to learn more or place your request online for immediate assistance.

One of the major HIPAA Provisions has to do with pre-existing conditions and "creditable coverage." A pre-existing condition is rigidly defined by HIPAA. The Center For Medicare and Medicaid Services internet pamphlet, "Employer Questions and Answers About HIPAA," (2002) has noted that a pre-existing condition is, under the Act:

  1. Any physical or mental condition for which, a person received medical advice and/or diagnosis
  2. And/or care and/or a recommendation for treatment
  3. And/or treatment itself within 6 months before enrolling in a plan or a policy

A group health plan can exclude treatment, i.e. refuse to pay for it, for such a condition for 12 months after enrollment or 18 months for a late enrollee. However, this period of exclusion is reduced by an individual's prior "creditable coverage."

Creditable Health Coverage

Creditable coverage includes most types of health coverage including group and individual insurance, and a variety of government sponsored forms of coverage such as Medicare and Medicaid. Periods of prior creditable coverage count against the exclusionary period if there has been no break in the coverage of 63 days or more. If there has been such a break, then only the period of credible coverage after the break counts as an offset against the exclusion period.

Medical Insurance Plans

A newly hired employee usually notifies the new employer and/or the employer's insurance carrier by means of a certificate which he/she obtains either from the previous employer or that employer's insurance carrier. If a company's medical insurance plan does make use of the pre-existing condition exclusionary period, then the employer has the burden of obtaining the new hire's certificate and passing it on to the carrier. There are therefore some circumstances in which companies-rather than carriers-are required to issue and to receive this documentation and this task would logically fall within the purview of the Human Resources Department.

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