HIPAA Rules - Kaiser State Health Facts

Non-Group Coverage Rules for HIPAA Eligible Individuals, 2008

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	State HIPAA Approach	Qualifications?	Insurer?	Are There Limits on What Can be Charged?	Are There Minimum Standards for What Must be Covered?

United States	NA	NA	NA	NA	NA

Alabama	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Alaska	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Arizona	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
Arkansas	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
California	Federal Fallback	HIPAA eligible	All individual market carriers	Yes	No
Colorado	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Connecticut	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Delaware	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
District of Columbia	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
Florida	Alternative Mechanism1	HIPAA eligible	Prior group carrier or Federal Fallback	Yes, prior group carrier No, Federal Fallback	Yes, prior group carrier No, Federal Fallback1
Georgia	Alternative Mechanism	HIPAA eligible	Prior group carrier or assigned individual market carriers2	Yes	Yes2
Hawaii	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
Idaho	Alternative Mechanism	HIPAA eligible	All individual market carriers	Yes	Yes
Illinois	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Indiana	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Iowa	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Kansas	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Kentucky	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Louisiana	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Maine	Alternative Mechanism	HIPAA eligible	All individual market carriers	Yes	Yes
Maryland	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Massachusetts	Alternative Mechanism	HIPAA eligible	All individual market carriers	Yes	Yes
Michigan	Alternative Mechanism	HIPAA eligible	Blue Cross Blue Shield	Yes	No
Minnesota	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Mississippi	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Missouri	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Montana	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Nebraska	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Nevada	Federal Fallback	HIPAA eligible	All individual market carriers	Yes	Yes
New Hampshire	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
New Jersey	Alternative Mechanism	HIPAA eligible	All individual market carriers	Yes	Yes
New Mexico	Alternative Mechanism	HIPAA eligible	High Risk Pool or New Mexico Health Insurance Alliance	Yes	Yes
New York	Alternative Mechanism	HIPAA eligible	All individual market carriers	Yes	Yes
North Carolina	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
North Dakota	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Ohio	Alternative Mechanism	HIPAA eligible	All individual market carriers	Yes	Yes
Oklahoma	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Oregon	Alternative Mechanism	HIPAA eligible	All individual market carriers or High Risk Pool3	Yes	Yes3
Pennsylvania	Alternative Mechanism	HIPAA eligible	Blue Cross Blue Shield plans	Yes	No
Rhode Island	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
South Carolina	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
South Dakota	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Tennessee	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
Texas	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Utah	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Vermont	Alternative Mechanism	HIPAA eligible	All individual market carriers	Yes	Yes
Virginia	Federal Fallback	HIPAA eligible	All individual market carriers	No	No
Washington	Alternative Mechanism	HIPAA eligible	All individual carriers or High Risk Pool4	Yes	Yes4
West Virginia	Alternative Mechanism	HIPAA eligible	High Risk Pool5	Yes	Yes5
Wisconsin	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes
Wyoming	Alternative Mechanism	HIPAA eligible	High Risk Pool	Yes	Yes

(show/hide notes)

Notes:	This chart is applicable to HIPAA eligible individuals. For rules that apply to non-HIPAA eligible individuals, refer to Individual Market Guaranteed Issue
Sources:	Data as of December 2008. Data compiled through review of state laws and regulations and interviews with state health insurance regulatory staff. Data collection and analysis at the Health Policy Institute, Georgetown University. Special Data Request, February 2009.
Definitions:	"HIPAA Eligible" individuals are guaranteed the right to purchase individual coverage with no pre-existing condition exclusion periods when they leave group coverage. To be HIPAA Eligible, a person must have had at least eighteen months of prior coverage, not interrupted by a gap of more than sixty-three days in a row, and the last day of prior coverage must have been in a group health plan. In addition, upon leaving group coverage one must elect and exhaust any available COBRA continuation coverage or similar state continuation coverage. A HIPAA eligible individual cannot be eligible for any other group coverage or Medicare, and must apply within sixty-three days for HIPAA coverage. HIPAA requires all coverage sold in the individual market must be available to eligible individuals, unless insurers elect to make only two policies available. Insurers can designate their two most popular individual market policies for federally eligible people, or they can designate two "representative" policies that are similar to others they sell in the individual market. These policies cannot impose pre-existing condition exclusions, but HIPAA does not limit premiums that can be charged. This is called the Federal Fallback approach. State can adopt different approaches to guarantee access to non-group coverage to HIPAA eligible individuals and most states have done so. For example, some states require community rating from guaranteed issue HIPAA policies. Many states guarantee access to non group coverage in a high risk pool instead of in the private health insurance market. These different approaches are called Alternative Mechanisms.
Footnotes:	In Florida, HIPAA eligible individuals leaving fully insured coverage are guaranteed the choice of two standardized conversion policies. A second approach--Federal fallback--applies to individuals leaving self-insured plans, who are entitled to the guaranteed issue of any carrier's two most popular policies. There are no benefit standards or rate restrictions on these policies. However, if the administrator of a self insured plan offers a conversion product that is identical to the state''s conversion product and that has been filed and approved by the department, an individual's choice under HIPAA is limited to those conversion products, instead of the guaranteed issue of any carrier's two most popular plans. In Georgia, HIPAA eligible individual leaving fully insured coverage are guaranteed a conversion policy from their prior group carrier. HIPAA eligible individuals leaving self-insured group health plans are assigned, by the state of Georgia, to an individual market carrier that must then guarantee issue a conversion policy. Minimum benefit standards apply to all HIPAA policies. In addition, there are limits on what insurers can charge for all HIPAA policies. In Oregon, HIPAA eligible individual leaving fully insured coverage are guaranteed a portability plan from individual market insurers. HIPAA eligible residents leaving self-insured group health plans are guaranteed issue a portability plan from the state high risk pool. Minimum standards must be covered by all portability plans. In addition, there are limits on what can be charged for a portability plan. In Washington, HIPAA eligible individuals are guaranteed issue in the individual market under the HIPAA standard, however individuals that live in counties where individual health insurance policies are not actively marketed are guaranteed the right to buy health insurance through the high risk pool. In West Virginia, a second approach-Federal fallback-is available. Besides the state High Risk Pool, HIPAA eligible individuals are entitled to the guaranteed issue of any carrier''s two most popular policies. There are no benefit standards or rate restrictions on these policies.

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