Understanding the key terms will help you get the coverage you need.
(HEALTH)
Stands for the Consolidated Omnibus Budget Reconciliation Act of 1985. It’s a federal law that gives you the right to temporarily (for 18 months or more, in most cases) continue with the group insurance plan of your employer even after you leave a job—voluntarily or involuntarily—or when you reduce your hours, such as from full-time to part-time.
Creditable coverage
Almost any health-insurance policy (see "excepted benefits")—such as an employer-provided health plan, an HMO, an individual health-insurance policy, Medicare, or Medicaid—that you were covered by before signing up for a new policy. A certificate of creditable coverage, which is a written document issued by the health insurer, will state how long you were covered under your former policy; that amount of time offsets any preexisting-condition exclusion period imposed by your new health-insurance plan. If you were insured continuously (with no significant break in coverage) for 12 months prior to joining a new plan, for instance, there will be no preexisting-condition exclusion imposed.
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Certain types of insurance that do not qualify as "creditable," and therefore will not help establish continuous coverage for the purpose of avoiding a preexisting-condition exclusion under a new health plan. Some examples: accident-only insurance, disability income insurance, and workers’ compensation. These are not considered health coverage. Certain other benefits, such as dental or vision coverage, or long-term care coverage, are excepted if they are offered separately or are not an integral part of a health plan.
HIPAA
Health Insurance Portability and Accountability Act. It is a federal law that determines your rights regarding preexisting-condition exclusions, special enrollment in health plans when certain life or work events occur, and availability and renewability of health coverage, among other things.
Late enrollee
An individual who joins a group health plan on a date other than either a) the earliest date on which coverage can begin under the plan terms or b) on a special enrollment date. Under HIPAA, a late enrollee may be subject to a maximum preexisting-condition exclusion of up to 18 months.
MHPA
The Mental Health Parity Act is a federal law that requires health plans to provide mental health benefits that are equivalent to the plan’s medical benefits. MHPA applies only to employers with more than 50 employees.
Preexisting condition
An illness or condition that existed before the start of a person’s coverage under a group health plan.
Preexisting-condition exclusion
A limitation or exclusion of benefits for a condition that you had before your enrollment date in the group health plan. Under HIPAA, a preexisting-condition exclusion may only be applied if a) you had a significant break in coverage during the 12 months prior to your enrollment in the plan and b) received medical advice or treatment for the condition in the six months before your enrollment. The exclusion may not be longer than 12 months (18 months for a late enrollee).
Significant break in coverage
Generally, a significant break in coverage is a period of 63 consecutive days during which you have no creditable coverage. In some states, the period is longer if your plan coverage is provided through an insurance policy or HMO.
Special enrollment
Joining a group health plan when certain work or life events occur, regardless of the plan’s regular enrollment dates. Generally, special enrollment is available when you, your spouse, or your dependents lose other coverage; when you marry; or when you have a child. The plan must give you at least 30 days to request special enrollment.
Source: Adapted from the U.S. Department of Labor’s Health Benefits Advisor Glossary