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Ask the Health Insurance Expert

We recently had to switch from an employer sponsored health insurance plan to purchasing our own insurance when my husband was laid off and got a new job. We have never had a lapse in coverage between the employer plan and COBRA enrollment. However, our newly purchased insurance refuses to cover my pre-existing conditions. I can understand the carrier not covering infertility treatments but it is also refusing to cover a hormone condition and diabetes. (I don't even have diabetes but am at risk due to the hormone condition.) Are they allowed to do this through HIPAA? I was unsure if HIPAA applied to employer-paid insurance only or all insurance coverage? My plan says they are excluded "indefinitely."

Your frustration is certainly understandable. Let's talk about infertility treatment first. Even if you are eligible for protection under HIPAA, you won't get coverage for infertility treatment if the plan does not offer that benefit. So first check whether the new plan offers infertility treatment coverage.

Under HIPAA, you might be able to buy an individual health insurance plan or qualify for a state high-risk insurance pool without the threat of exclusions for pre-existing conditions if you qualify as an "eligible individual."

To be eligible you have to meet all of the following, according to the U.S. Department of Labor's "FAQs about portability of health coverage and HIPAA":

  • Maintained coverage for at least 18 months, most recently in a group health plan, without a significant break
  • Lost group coverage but not because of fraud or nonpayment of premiums
  • Are not eligible for COBRA coverage, or elected and exhausted COBRA if it was offered under federal or state law
  • Are not eligible for coverage under another group health plan (including a spouse's), Medicare or Medicaid; or have any other health insurance coverage

State laws complement HIPAA and in some cases offer more generous protection. Contact your state insurance department to learn about the regulations where you live. To find links to your state insurance department's website, go to the National Association of Insurance Commissioners' map of jurisdictions, and click on the state where you live.

See more about HIPPA: Your rights to health insurance portability.

Last updated: Nov. 23, 2010
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