"HIPAA eligible" individuals must have exhausted all options for coverage under any group plan and must meet all of the following criteria:
- Have had continuous coverage for a minimum of 18 months with the most recent period under a group health plan without a significant break in coverage of more than 63 days in a row.
- Have been offered the option for continuation of COBRA coverage, and have elected and exhausted it, or are ineligible for continuation of COBRA coverage altogether, or other similar state programs
- Did not have their group coverage terminated because of nonpayment of premiums or fraud
- Are not eligible for coverage under another group plan, Medicaid, or Medicare.
In this case, only applicable individual health policies or state high risk pool plans may not exclude coverage for pre-existing conditions nor turn down an application for coverage only if all of the criteria is met as a "HIPAA eligible" individual and the individual applied within 63 days of the last date of coverage under a group plan.
Individual market carriers may elect their two most popular individual health policies or "representative plans" for "HIPAA eligible" individuals. These are the only plans that may not impose pre-existing condition exclusions, but HIPAA does not limit premium rates on these individual policies.
*Note: all "HIPAA eligible" individuals must apply to the appropriate entity as mandated by their state of residency. For instance, some states guarantee access to healthcare for "HIPAA eligible" individuals to high risk pools only, while other states guarantee access to all individual markets carriers, or both.
Individual market carriers may impose a wait period for pre-existing conditions or deny coverage to "HIPAA eligible" individuals if access to non-group healthcare is provided by state high risk pools only.
