For Health Insurers
The following protections in health insurance take effect on May 21, 2009.
GINA covers genetic information of an individual and the genetic information of family members (for example, in determining family health history of disease). GINA does not cover an individual's manifested disease or condition - a condition from which an individual is experiencing symptoms, being treated for, or that has been diagnosed.
GINA outlines the following activities as unlawful insurance practices and discriminatory on the basis of genetic information:
- The requirement that individuals provide genetic information or the genetic information of a family member in determining eligibility, coverage, underwriting, or premium-setting decisions, in the group, Medicare supplemental policy, or individual health insurance markets. However, a health insurer may request that an individual provide genetic information if coverage of a particular claim may be appropriate only if there is a known genetic risk. For additional information, please read the Q&A portion below, entitled "What information can insurers request in making coverage determinations for specific claims?";
- The use genetic information either collected with intent, or incidentally, to make enrollment or coverage decisions;
- The request or requirement that an individual or an individual's family member undergo a genetic test; and;
- The use of genetic information as a preexisting condition in the Medicare supplemental policy and individual health insurance markets.
Research exception: For joint research activities conducted in collaboration with external research entities, a health insurer in either the group or individual market may request, but not require, in writing that an individual undergo a genetic test. The compliance by the individual with such a request is voluntary, and noncompliance shall not have a negative effect on the premium or enrollment status of the individual. Genetic information may only be used for research and not for underwriting purposes.
What information can insurers request in making coverage determinations for specific claims?
An insurer can require genetic information to make coverage determinations for a specific claim. For example, the insurer may request information about an individual's BRCA status to determine coverage for prophylactic mastectomy. The insurer may request only the minimum amount of information necessary for decision-making. An individual can elect not to submit genetic information to the insurer about such a claim, and pay for the treatment, test, or service out-of-pocket.
Last Updated: November 10, 2008