• HIPPA prohibits discrimination against employees and dependents in enrollment and premiums based on “health factors,” such as preexisting conditions, claims experience, and genetic information.
• HIPPA provides individuals a SEP to enroll in a new plan due to loss of other health coverage or other qualifying life event trigger.
• Life events that may trigger a SEP include loss of other health coverage, marriage, birth, adoption, or placement of a child for adoption.

In general, the Health Insurance Portability and Accountability Act (HIPAA) improves portability and continuity of health insurance coverage by requiring employer group health plans and group health insurance issuers to:

• Prohibit discrimination against employees and dependents in enrollment and premiums based on “health factors,” (i.e., preexisting conditions, claims experience, and genetic information); and
• Provide individuals a special enrollment period (SEP) to enroll in a new plan under certain circumstances, such as loss of other health coverage, marriage, birth, adoption, or placement of a child for adoption.

The employee must request the SEP within 30 days of the loss of coverage or life event triggering need.

Preexisting condition exclusions

The Affordable Care Act (ACA) has prohibited all preexisting condition exclusions since 2014.

Employer wellness programs

The ACA and HIPPA also prohibit discrimination based on health factors in an employer wellness program that are related to group health plan coverage. For example, programs that encourage employees to stop smoking, exercise, or reach a target cholesterol level must be designed to promote good health and not to collect health information on an employee or family member to shift more of the cost of health insurance to the employee.

Special enrollment period (SEP)

HIPAA allows individuals who previously declined to enroll in an employer’s health plan to enroll outside of the plan’s annual enrollment period (AEP) in certain special circumstances.

For example, if an employee declines employer health coverage because a spouse’s employer already provides coverage for the family, and then the spouse’s coverage is lost, HIPPA requires that the employer’s plan and issuer permit the employee to enroll in available coverage without having to wait for the next AEP. This is called a SEP.