When you buy health insurance, you're backed by federal and state law. Your rights to coverage and privacy are guaranteed by the Health Insurance Portability and Accountability Act, known as HIPAA.


HIPAA protects people who currently have a diagnosed health condition or had one in the past — called a pre-existing condition — or some other health-related factor that might deter an insurer from offering them coverage. You have protections whether you are applying for insurance in the group market or the individual market.


Protections vary by state. Read this section and contact your state insurance department to learn your rights — should you be denied coverage, they can clarify your protections and tell you which options you would need to act on right away. Some of these protections are time-sensitive, so don't delay if you lose or think you might lose your health insurance coverage.


Keep in mind that this information gives you general guidelines. Your rights may vary depending on your situation and state.


Job-based Plans

If you are applying for a job-based plan, HIPAA offers the following protections:

  • Your coverage cannot be denied or discontinued due to illness or a medical condition.
  • You cannot be required to pass a physical exam to become eligible for the new health plan.
  • You cannot be charged more than similar employees in the same health plan due to your health condition.

Pre-existing conditions

Many job-based plans do not exclude coverage for pre-existing conditions. In some cases, however, your company may deny coverage of a pre-existing condition for up to 12 months (or 18 months, if you don't enroll in the plan at the earliest date you are eligible).


Job-based plans are only allowed to deny you coverage under certain conditions — for example, if you received medical advice, diagnosis, care or treatment for that condition up to six months before enrollment. Here are some important qualifications:


  • Pregnancy can't be treated as a pre-existing condition.
  • If you had coverage from a previous plan or from COBRA, that coverage counts toward your waiting period, as long as you didn't have a break in coverage for more than 63 days. (Your state may allow a longer break in coverage.) For example, 11 months of coverage at your old job would require you to wait only one month to complete a 12-month exclusion period.
  • Regulations vary, so contact your state insurance department for specifics.

Adding coverage for life changes

Your company's plan must allow special enrollment periods to cover certain life events, as long as you request enrollment within 30 days of the changes -- for example, if you:

  • become divorced and lose your spouse's coverage
  • get married and want to cover your spouse
  • give birth or adopt a child

Be sure to note that HIPAA does not guarantee universal coverage, control policy costs, require employers to pay for coverage, or allow people to keep the same coverage from job to job. For details, visit the website of the U.S. Department of Health & Human Services, Centers for Medicare and Medicaid Services.


Individual insurance

If you are applying for insurance on your own, HIPAA may offer protections if you meet these conditions:


  • You do not currently have health insurance.
  • You had coverage for at least 18 months before you applied, most recently from an employer-based plan.
  • You didn't lose your previous health plan because of fraud or nonpayment.
  • You've accepted and used up any extension of health benefits from your previous plan through COBRA or a state program.
  • You aren't eligible for any employer-based health insurance, Medicare or Medicaid.
  • You're requesting the coverage within 63 days of losing your old coverage.

If you meet the HIPAA requirements, you generally are guaranteed the right to buy certain kinds of health coverage — pre-existing conditions included. However, HIPAA does not control the amount an insurer may charge you for coverage.


Once you purchase an individual health insurance policy, HIPAA requires the insurance company to continue your coverage even if you come down with an illness or medical condition.


States have flexibility in how they implement HIPAA. For example, some states may limit the cost of the policy. Your state may also have other options, such as a high -risk pool. Call your state insurance department for details.