HIPAA Eligible Individual

A HIPAA eligible individual is someone who meets specific criteria under the Health Insurance Portability and Accountability Act, qualifying for special protections when transitioning between health plans. While HIPAA is most commonly associated with medical privacy rules, its portability provisions ensure certain people can access coverage without pre-existing condition exclusions.

To be HIPAA eligible, you generally must have had at least 18 months of prior creditable coverage, with the most recent coverage being through a group plan. You must have exhausted any COBRA or state continuation coverage available to you, you must not be eligible for Medicare, Medicaid, or other group coverage, and you must apply for individual coverage within 63 days of losing your prior coverage.

Before the ACA, HIPAA eligibility was critically important. It meant insurance companies in the individual market had to sell you a policy without pre-existing condition exclusions, even if you had a serious health condition. Without HIPAA eligibility, you could be denied coverage entirely.

Since the ACA, HIPAA's portability protections have become largely redundant for the individual market, since guaranteed issue and the ban on pre-existing condition exclusions apply to everyone. However, HIPAA eligibility can still matter in specific situations, like enrollment in certain grandfathered plans or state-specific coverage programs that predate the ACA.

The privacy provisions of HIPAA (protecting your medical records and health information) remain fully in effect and are separate from the portability and coverage provisions described here.