(C) Meade & Roach, LLP HIPAA Portability Final Regulations Michael C. Roach, Esq. Bridget C. Kevin, RN, Esq. Meade & Roach, LLP May 25, 2005

(C) Meade & Roach, LLP Overview Preexisting condition exclusion Preexisting condition exclusion First notice First notice Individuals and conditions not subject to preex exclusion Individuals and conditions not subject to preex exclusion Creditable coverage Creditable coverage Dependent coverage Dependent coverage Special enrollment Special enrollment HMO affiliation periods HMO affiliation periods Excepted benefits Excepted benefits

(C) Meade & Roach, LLP Preexisting Condition Exclusions New definition: exclusion based on fact that condition was present before “effective date of coverage” whether or not any medical advice, care, or treatment was recommended before that date New definition: exclusion based on fact that condition was present before “effective date of coverage” whether or not any medical advice, care, or treatment was recommended before that date Used to be “first day of coverage”Used to be “first day of coverage” Addresses successor issuesAddresses successor issues Thus, expands definitionThus, expands definition

(C) Meade & Roach, LLP Preexisting Condition Exclusions Six month look back Six month look back MaximumMaximum Advice, care, or treatment during that timeAdvice, care, or treatment during that time By someone licensed or similarly authorized by the State and in scope of such license or authorizationBy someone licensed or similarly authorized by the State and in scope of such license or authorization

(C) Meade & Roach, LLP First Notice of Exclusion Must be provided as part of application materials Must be provided as part of application materials If do not distribute such materials, by earliest date following request for enrollment that it can be provided acting in a “reasonable and prompt” fashion If do not distribute such materials, by earliest date following request for enrollment that it can be provided acting in a “reasonable and prompt” fashion

(C) Meade & Roach, LLP Content of Notice Terms Terms Length of look back period Length of look back period Length of exclusion period Length of exclusion period Length of waiting period Length of waiting period Description of creditable coverage rights Description of creditable coverage rights Person to contact Person to contact Address and phone numberAddress and phone number

(C) Meade & Roach, LLP Enrollment Date Enrollment date is the 1 st date of coverage under the plan, or if there is a waiting period, the 1 st day of the waiting period. Enrollment date is the 1 st date of coverage under the plan, or if there is a waiting period, the 1 st day of the waiting period. Remains the same even if the enrollee changes benefit package options, or if the plan changes insurer. Remains the same even if the enrollee changes benefit package options, or if the plan changes insurer.

(C) Meade & Roach, LLP Waiting Periods In the individual market, the waiting period begins on the date a substantially completed application was submitted. In the individual market, the waiting period begins on the date a substantially completed application was submitted.

(C) Meade & Roach, LLP Individuals and Conditions Not Subject to Preex Exclusion Pregnancy- a preexisting exclusion cannot be applied to pregnancy. Pregnancy- a preexisting exclusion cannot be applied to pregnancy.

(C) Meade & Roach, LLP Individuals not subject to Preexisting Exclusion Newborn, adopted child or child placed for adoption if the child has been covered under a plan within 30 days of birth, adoption or being placed for adoption Newborn, adopted child or child placed for adoption if the child has been covered under a plan within 30 days of birth, adoption or being placed for adoption

(C) Meade & Roach, LLP Conditions not Subject to Preexisting Exclusion Plan may NOT impose a preexisting condition exclusion based solely on genetic information. Plan may NOT impose a preexisting condition exclusion based solely on genetic information. Plan may impose an exclusion if the individual is diagnosed with a condition related to genetic information, as long as the condition is in alignment with other HIPAA regulations. Plan may impose an exclusion if the individual is diagnosed with a condition related to genetic information, as long as the condition is in alignment with other HIPAA regulations.

(C) Meade & Roach, LLP Creditable Coverage Interim rules listed 10 categories of creditable coverage Interim rules listed 10 categories of creditable coverage S-CHIP enacted since the interim rules, therefore added as creditable coverage. S-CHIP enacted since the interim rules, therefore added as creditable coverage.

(C) Meade & Roach, LLP Creditable Coverage Refined definition of a public health plan Refined definition of a public health plan Any health coverage provided by a governmental entity is a public health plan Any health coverage provided by a governmental entity is a public health plan Includes any coverage provided under a plan sponsored by a foreign government Includes any coverage provided under a plan sponsored by a foreign government

(C) Meade & Roach, LLP Counting Creditable Coverage Interim rules adopted with some stylistic changes Interim rules adopted with some stylistic changes Standard method-based on days, days before significant break in coverage not counted, significant break = 63 days, tolling a significant break Standard method-based on days, days before significant break in coverage not counted, significant break = 63 days, tolling a significant break Alternative method- counting specific benefits Alternative method- counting specific benefits

(C) Meade & Roach, LLP Evidence of Creditable Coverage To enable any individual to establish prior creditable coverage in order to reduce or eliminate any preexisting condition exclusion To enable any individual to establish prior creditable coverage in order to reduce or eliminate any preexisting condition exclusion Generally, must be in writing Generally, must be in writing May be requested at any time May be requested at any time Automatic notice provided at termination of coverage and/or with COBRA notice Automatic notice provided at termination of coverage and/or with COBRA notice

(C) Meade & Roach, LLP Model Certificate Regulations list necessary language Regulations list necessary language Must include a HIPAA educational statement Must include a HIPAA educational statement Use of the model certificate satisfies government requirements Use of the model certificate satisfies government requirements Found in the December 30, 2004 Federal Register (69 Fed. Reg ) Found in the December 30, 2004 Federal Register (69 Fed. Reg )

(C) Meade & Roach, LLP Dependent Coverage Any individual who is or may become eligible under the plan because of their relationship to the participant. Any individual who is or may become eligible under the plan because of their relationship to the participant. Notice of creditable coverage may be included in one notice as long as all have the same address Notice of creditable coverage may be included in one notice as long as all have the same address A reasonable effort to provide notice to another address is required A reasonable effort to provide notice to another address is required

(C) Meade & Roach, LLP Special Enrollment Initial opportunity to enroll not only time individual with other coverage may decline coverage and preserve special enrollment rights upon loss of other coverage Initial opportunity to enroll not only time individual with other coverage may decline coverage and preserve special enrollment rights upon loss of other coverage

(C) Meade & Roach, LLP Loss of Coverage Leading to Special Enrollment Rights Individual HMO coverage and individual no longer resides, lives, or works in the service area and HMO does not provide coverage for that reason Individual HMO coverage and individual no longer resides, lives, or works in the service area and HMO does not provide coverage for that reason Aging out Aging out

(C) Meade & Roach, LLP Special Enrollment Plan no longer offers coverage to a class of similarly situated employees Plan no longer offers coverage to a class of similarly situated employees Dependent has special enrollment rights Dependent has special enrollment rights

(C) Meade & Roach, LLP Special Enrollment Employer contributions to coverage terminate Employer contributions to coverage terminate Even if employee continues other coverage by paying entire premiumEven if employee continues other coverage by paying entire premium Surpassing lifetime maximum Surpassing lifetime maximum Rights last for 30 days after denied claimRights last for 30 days after denied claim Do not need to wait for denialDo not need to wait for denial

(C) Meade & Roach, LLP Special Enrollment Rights exist even if other subsequent coverage opportunities exist Rights exist even if other subsequent coverage opportunities exist Do not have to elect and exhaust COBRADo not have to elect and exhaust COBRA Rights exist after exhausting COBRARights exist after exhausting COBRA

(C) Meade & Roach, LLP HMO Affiliation Periods Period of time that must expire before HMO coverage becomes effective Period of time that must expire before HMO coverage becomes effective May be imposed only if May be imposed only if No preex exclusionNo preex exclusion No premium during periodNo premium during period Not discriminatoryNot discriminatory Two-month maximum (three months for late enrollees)Two-month maximum (three months for late enrollees) Runs concurrent with any waiting period andRuns concurrent with any waiting period and Begins on enrollment dateBegins on enrollment date

(C) Meade & Roach, LLP Excepted Benefits Excepted benefits- Workers Compensation, accident only, credit only, liability coverage, auto Excepted benefits- Workers Compensation, accident only, credit only, liability coverage, auto Limited Excepted benefits- limited scope dental, vision, or long term care. Limited Excepted benefits- limited scope dental, vision, or long term care. Provided under a separate plan or NOT an integral part of a plan subject to HIPAA Provided under a separate plan or NOT an integral part of a plan subject to HIPAA

(C) Meade & Roach, LLP Questions Michael C. Roach Bridget C. Kevin