HIPAA Eligible Individual

Guaranteed To Purchase Coverage
A Health Insurance Portability and Accountability Act (HIPAA) eligible individual is a person who is guaranteed the right to purchase coverage under the South Carolina Health Insurance Pool (SCHIP) in which the waiting period and pre-existing condition exclusions are waived. In order to be guaranteed the right to purchase the SCHIP coverage you must meet the definition of a federally defined eligible individual. A federally defined eligible individual means an individual:
  • For whom, as of the date on which the individual seeks coverage under this chapter, the aggregate of the periods of creditable coverage is 18 or more months
  • Whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan or health insurance coverage offered in connection with one of these plans
  • Who is not eligible for coverage under a group health plan, Part A or B of Title XVIII of the Social Security Act, or a state plan under Title XIX of the Social Security Act, or any successor program and who does not have other health insurance coverage
  • With respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud
  • Who, if offered the option of continuation coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation provision or under a similar state program, elected the coverage
  • Who, if the individual elected the continuation coverage, has exhausted the continuation coverage under the provision or program