What are HIPAA's nondiscrimination requirements?
Under HIPAA, a group health plan may not discriminate on the basis of certain health factors against participants and beneficiaries with respect to eligibility to enroll, waiting periods, or contribution levels.
Health factors upon which plans may not discriminate include:
- health status;
- medical conditions (including both physical and mental illnesses);
- claims experience;
- receipt of health care;
- medical history;
- genetic information;
- evidence of insurability (including conditions arising out of acts of domestic violence, or the fact that a participant/beneficiary engages in high-risk sports such as skiing and snowmobiling); and
- disability.
Eligibility. Discrimination is prohibited with respect to plan eligibility. "Eligibility" is defined broadly to include rules relating to:
- plan enrollment;
- the effective date of coverage;
- waiting or affiliation periods;
- late and special enrollment;
- eligibility for benefit packages;
- covered benefits, benefit restrictions, cost-sharing mechanisms such as coinsurance, copayments and deductibles;
- continued eligibility; and
- terminating coverage.
Note, HIPAA limits the waiting period for HMOs, but not other types of plans.
Similarly situated individuals. Although plans are not required to provide coverage for any particular benefit to any group of similarly situated individuals, benefits provided under a plan or group health insurance coverage must be uniformly available to all similarly situated individuals. Likewise, any restrictions on benefits must apply uniformly to similarly situated individuals, and cannot be directed at individual participants or beneficiaries based on health factors.