General, COBRA and HIPAA FAQs for employers and organizations

Aetna will provide the following standard communication materials to new members:

• Member ID cards
• Claim forms
• Summary plan descriptions
• Enrollment forms
• Member handbooks

There may be a charge associated with certain materials.

New employees are eligible for medical coverage effective on their date of hire and are allowed 31 days to complete their enrollment information. Their coverage becomes effective after complete enrollment data has been received.

We must receive the request to enroll newborns or adopted children within 31 days of the date of birth or adoption. On late enrollment requests, if adding the newborn/adopted child would have generated no additional premium at the time of the event, the effective date is the date of birth or adoption.

With our innovative health and wellness programs, we offer special health education, preventive care and wellness programs. These programs provide our members with resources - in conjunction with care and advice from their physician - that promote a healthy lifestyle and good health.

Yes, as defined in federal HIPAA legislation, COBRA coverage qualifies as creditable coverage.

COBRA requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end.

The law covers group health plans maintained by employers with 20 or more employees in the prior year. It applies to plans in the private sector and those sponsored by state and local governments. Provisions of COBRA covering state and local government plans are administered by the Department of Health and Human Services.

For additional information about COBRA requirements and other Department of Labor (DOL) regulations, refer to the Department of Labor website.

HIPAA is directed at health insurance carriers and plan sponsors. Anyone covered under a full-risk health benefits plan issued by a carrier or covered under a self-insured health benefits plan offered by a plan sponsor, is subject to federal HIPAA.

In determining prior creditable coverage held by an individual, we will recognize 90 days* as the allowable maximum gap in coverage, from the date prior creditable coverage terminated, to the enrollment date of the individual under the group health plan.

In addition, we will apply credit for prior creditable coverage to the pre-existing conditions exclusion under the group health plan as follows:

• if an individual has any prior creditable coverage within the 90 days* prior to his or her enrollment date, we will waive the pre-existing conditions exclusion period under the plan.
• if an individual has no prior creditable coverage within the 90 days* prior to his or her enrollment date, we will apply the plan's pre-existing conditions exclusion (to a maximum period of 365 days, or as mandated by state law).

* If a state law mandates a gap period greater than 90 days, that longer gap period will be used to determine creditable coverage.

The new HIPAA provisions in the American Recovery and Reinvestment Act of 2009 impose additional restrictions on the use and disclosure of personally-identifiable health information and increase the financial penalties for failure to comply with HIPAA regulations. There are also new requirements for notifying affected individuals about security breaches. We are making changes to our information technology systems, business policies and processes to comply with all of the new requirements. However, conforming to specific HIPAA requirements will not impact the products we offer, just how they are administered.

Creditable coverage, as defined under federal HIPAA, is considered as "creditable coverage" by Aetna, including: group health plan coverage (including a governmental or church plan), group or individual health insurance coverage, Medicare, Medicaid, military-sponsored health care (CHAMPUS), a program of the Indian Health Service, a state health benefits risk pool, the FEHBP, a public health plan as defined in the federal HIPAA regulations, and any health benefits plan under section 5(e) of the Peace Corps Act. Not included as creditable coverage is any coverage that is exempt from the law; for example, dental-only coverage, or dental coverage that is provided in a separate policy or even in the same policy as medical, if such coverage is separately elected and results in additional premium.

An employer-imposed waiting period does not count in the consideration of whether or not an individual has a break in coverage.

The employee must provide proof of prior creditable coverage by presenting a Certification of Prior Group Health Plan Coverage, or other acceptable means of proof.

When a potential pre-existing condition claim is received, the claim office will request the Certification of Prior Group Health Plan Coverage to determine if an individual has had prior creditable coverage within the 90 days prior to enrollment. The member should retain the Certification until the claim office requests that form.

The employee must provide proof of prior creditable coverage by presenting a Certification of Prior Group Health Plan Coverage, or other acceptable means of proof.

Employers and organizations: Notification of changes, eligibility and provider network FAQs

Employers and organizations: Claims FAQ

Main FAQs