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Ask the Health Insurance Expert

I have multiple sclerosis. I am covered through a group health plan through COBRA. This will expire by the end of the year. If I find a group health plan through an organization (not an employer), can I be refused coverage under a group health plan? I've had continuous creditable group coverage since 1994. I've been told that I would not be eligible.

You're probably thinking of the Health Insurance Portability and Accountability Act (HIPAA), which helps people with pre-existing conditions get health insurance coverage through employer-sponsored group plans.

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Among other things, HIPAA limits the amount of time employer-sponsored group plans can impose exclusions for pre-existing conditions. Under HIPAA, a new employer cannot impose any pre-existing condition exclusion for an employee who had creditable health insurance coverage for the last 12 months, with no breaks of 63 consecutive days or more--COBRA counts as creditable health insurance coverage.

However, HIPAA applies only to employer-sponsored plans. According to Families USA, a health care advocacy group, association health plans--group policies offered through an organization for a purpose other than doing business--are technically considered individual plans under HIPAA. Although association plans must offer coverage to any member of the organization, they are not restricted in how long they can refuse to cover pre-existing conditions.

What you should know about HIPAA eligibility

When your COBRA coverage expires, you will be "HIPAA-eligible." To qualify for HIPAA eligibility, you must have been covered by health insurance for the last 18 months with no breaks of 63 days or more; had coverage under an employer-sponsored group, church or government plan; be ineligible for COBRA or exhausted COBRA coverage; and be ineligible for Medicare, Medicaid or any other employer-sponsored plan.

HIPAA eligibility gives you the right to buy some type of individual health insurance without pre-existing condition exclusions, but the type depends on your state. In some states you can enroll in any plan that sells individual policies, and in others, you can enroll in individual health plans that are designated for HIPAA-eligible people.

Contact your state insurance department for information. You can find contact information through the National Association of Insurance Commissioners.

For more, see HIPAA: Your rights to health insurance portability.

Last updated: May. 12, 2011
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