230 R.I. Code R. 230-RICR-20-30-10.8

Current through December 3, 2024

Section 230-RICR-20-30-10.8 - Certification and Disclosure of Prior Creditable Coverage

A. Creditable coverage.

1. In general.

a. Small employer carriers shall provide written certification of creditable coverage, as that term is defined in R.I. Gen. Laws § 27-50-3(i), to individuals in accordance with § 10.8 of this Part.

b. A small employer carrier shall be deemed to have satisfied the certification requirements of § 10.8 of this Part if another person provides the certificate, but only to the extent that information relating to the individual's creditable coverage and waiting or affiliation period has been provided by the other person.

c. To the extent coverage under a health benefit plan consists of group health benefit plan coverage, the plan shall be deemed to have satisfied the certification requirements of § 10.8 of this Part if the small employer carrier offering the coverage is required to provide the certificates of creditable coverage to individuals pursuant to an agreement between the plan and the carrier.

d. A small employer carrier is not required to provide information regarding health benefit plan coverage provided to an individual by another person.

e. If an individual's coverage under a policy ceases before the individual's coverage under the group health plan ceases, the entity that issued the policy shall provide sufficient information to the small employer carrier, or to another person designated by the carrier, to enable the carrier, or other person, to provide a certificate that reflects the period of coverage under the policy, after the individual's coverage under the group health plan ceases.

(1) The provision of the information pursuant to § 10.8(A)(1)(e) of this Part to the carrier shall satisfy the entity's obligation to provide an automatic certificate pursuant to § 10.8(A) and (B) of this Part

(2) The entity providing the information pursuant to § 10.8(A)(1)(e) of this Part shall cooperate with the carrier in responding to any request made under § 10.8(F) of this Part.

(3) If the individual's coverage under the group health plan ceases at the time the individual's coverage under the policy ceases, the entity that issued the policy shall provide an automatic certificate pursuant to § 10.8(A)(2) or (3) of this Part.

(4) An entity that issued the policy may presume that an individual whose coverage ceases at a time other than the effective date for changing enrollment options has ceased to be covered under the group health plan.

2. Certification of creditable coverage.

a. A small employer carrier shall provide a certification of creditable coverage, without charge, to eligible employees or dependents who are or were covered under the group health plan as follows:

(1) for an individual who is a qualified beneficiary entitled to elect COBRA continuation coverage, automatically at the time the individual would lose coverage under the plan in the absence of COBRA continuation coverage or alternative coverage elected instead of COBRA continuation coverage; or

(2) for an individual who is not a qualified beneficiary entitled to elect COBRA continuation coverage, automatically at the time the individual ceases to be covered under the group health plan.

b. A small employer carrier satisfies the requirements of § 10.8(A)(2)(a) ((1)) of this Part if the carrier provides the certificate no later than the time a notice is required to be furnished for a qualifying event as specified in federal regulations.

c. A small employer carrier satisfies § 10.8(A)(2)(a) ((2)) of this Part if the carrier provides the certification within a reasonable time after coverage under the group health plan ceases.

d. For an individual who is entitled to elect to continue coverage under a state program similar to COBRA and who receives the certificate pursuant to § 10.8(A)(2)(a) ((2)) of this Part not later than the time a notice is required to be furnished under the state program, the certification shall be deemed to be provided within a reasonable time period after the cessation of coverage under the plan.

3. COBRA continuation coverage.

a. For an individual who is a qualified beneficiary and has elected COBRA continuation coverage, or whose coverage has continued after the individual became entitled to elect COBRA continuation coverage, a small employer carrier shall provide a certificate automatically at the time the individual's COBRA continuation coverage under the plan ceases.

b. A small employer carrier satisfies § 10.8(A)(3)(a) of this Part if the carrier provides the certificate within a reasonable time after the coverage ceases or after the expiration of any grace period for nonpayment of premiums.

c. A small employer carrier shall provide a certificate under § 10.8(A)(3)(a) of this Part to an individual regardless of whether the individual previously has received a certificate under § 10.8(A)(2)(a) ((1)) of this Part.

4. Request for a certificate.

a. Procedure.

(1) A small employer carrier shall provide a certificate at the time a request is made by or on behalf of an individual if the request is made within twenty-four months after the date the individual's coverage has ceased under the plan.

(2) Each small employer carrier shall establish a reasonable procedure for individuals to request and promptly receive certificates hereunder.

b. Upon receipt of the request, the small employer carrier shall provide the certificate by the earliest date that the carrier, acting in a reasonable and prompt fashion, can provide the certificate.

c. A small employer carrier shall provide a certificate as required under this Part even if the individual previously received such a certificate.

B. Requirements.

1. Certificate must be in writing, except as provided in § 10.8(B)(1)(b) of this Part.

a. Except as provided in§ 10.8(B)(1)(b) of this Part, a certificate provided under § 10.8(A) of this Part shall be in writing.

b. A written certificate is not required to be provided pursuant to § 10.8(A)(2), (3) or (4) of this Part if:

(1) an individual is entitled to receive a certificate;

(2) the individual requests that the certificate be sent to another health benefit plan instead of the individual;

(3) the health benefit plan that would otherwise receive the written certificate agrees to accept the information described in § 10.8(B)(2) of this Part through means other than a written certificate; and

(4) the receiving health benefit plan receives the information from the sending health benefit plan in such form within the time periods required under § 10.8(A)(2), (3) or (4) of this Part.

2. A certificate provided pursuant to § 10.8(B) of this Part shall include the following:

a. the date the certificate was issued;

b. the name of the group health plan that provided the coverage described in the certificate;

c. the name of the participant and/or dependent with respect to whom the certificate applies, and any other information necessary for the plan providing the coverage specified in the certificate to identify the individual, such as the individual's identification number under the plan and the name of the participant if the certificate is for, or includes, a dependent;

d. the name, address, and telephone number of the plan administrator required to provide the certificate;

e. the telephone number to call for further information regarding the certificate if different from the phone number of the plan administrator;

f. either:

(1) a statement that the individual has at least eighteen months of creditable coverage, disregarding days of creditable coverage before a significant break in coverage; or

(2) the date any waiting period or affiliation period, if applicable, began and the date creditable coverage began; and

(3) the date creditable coverage ended, unless the certificate indicates that creditable coverage is continuing as of the date of the certificate.

3. If an automatic certificate is provided pursuant to § 10.8(A)(2) of this Part, the period included on the certificate shall be the last period of continuous coverage ending on the date the coverage ceased.

4. For a certificate requested pursuant to § 10.8(A)(4) of this Part, the certificate must be provided for each period of continuous coverage ending within the twenty-four month period ending on the date of the request or continuing on the date of the request. A separate certificate may be provided for each period of continuous coverage.

5. A certificate may provide the information required pursuant to § 10.8(B)(2) of this Part with respect to both a participant and the participant's dependents if the information is identical for each individual. If the information required pursuant to § 10.8(B)(2) of this Part is not identical, certificates may be provided on one form if the form provides all the required information for each individual and separately states the information that is not identical.

6. Appendix B issued in a bulletin promulgated for that purpose contains a model certificate that a small employer carrier may use to satisfy the requirements of § 10.8(B)(2) of this Part.

7. A small employer carrier is not required to provide a certificate with respect to excepted benefits, as described in R.I. Gen. Laws § 27-50-3(v)(2), (3), (4) and (5), except if the excepted benefits are being provided concurrently with other creditable coverage. Under such circumstances, a small employer carrier may be required to disclose information concerning the benefits under § 10.8(F) of this Part.

C. Providing the certificate of coverage.

1. Small employer carriers may provide a certificate required to be provided pursuant to § 10.8 of this Part by first-class mail.

2. The address where the certificate is sent.

a. If a small employer carrier provides the certificate or certificates to the participant and the participant's spouse at the participant's last known address, the carrier has satisfied the requirements of § 10.8 of this Part with respect to all individuals residing at that address.

b. If the last known address of a dependent of the participant is different from the participant's last known address, a small employer carrier shall provide a separate certificate to the dependent at the dependent's last known address.

c. If a small employer carrier is providing separate certificates by mail to individuals who reside at the same address, the carrier is not required to mail each certificate separately.

3. Designating another individual or person to receive the certificate.

a. If a small employer carrier is required to provide a certificate automatically to an individual pursuant to § 10.8(A)(2) or (3) of this Part, and the individual entitled to receive the certificate designates another individual or person to receive the certificate, the carrier may provide the certificate to the designated party.

b. If a small employer carrier is required to provide a certificate upon request pursuant to § 10.8(A)(4) of this Part and the individual entitled to receive the certificate designates another individual or person to receive the certificate, the carrier shall provide the certificate to the designated party.

D. Reasonable efforts.

1. A small employer carrier shall use reasonable efforts to determine the information needed for a certificate relating to dependent coverage.

2. For certificates required to be provided automatically pursuant to § 10.8(A)(2) or (3) of this Part, an individual certificate is not required to be provided until the small employer carrier knows or, using reasonable efforts, should know of the dependent's cessation of coverage under the plan.

3. If a certificate provided by a small employer carrier does not provide the name of a dependent of an individual covered by the certificate, the individual may, if necessary, use the procedures described in § 10.8(G)(5) of this Part for demonstrating dependent status. In addition, an individual may, if necessary, use the procedures described in § 10.8(G)(5) of this Part to demonstrate that a child was enrolled within thirty days of birth, adoption or placement for adoption.

E. Certificate provided for coverage not subject to the Act. Small employer carriers shall provide certificates of creditable coverage to individuals under § 10.8 of this Part even if the coverage is provided in connection with an entity or program that is not itself required to provide a certificate because the entity or program is not subject to the Act. This requirement applies to coverage provided in connection with: creditable coverage described in R.I. Gen. Laws § 27-50-3(j)(1)(b) through (j) and coverage subject to §2721(b)(1)(B) of the PHSA.

F. Alternative method of counting creditable coverage-information required. If an individual enrolls in a group health plan with respect to which the small employer carrier uses the alternative method of counting creditable coverage described in R.I. Gen. Laws § 27-50-7(d)(3) and the individual provides a certificate received pursuant to § 10.8 of this Part, at the request of the small employer carrier through which the individual has enrolled, the entity that provided the certificate to the individual shall promptly disclose to the carrier the information sufficient to identify to the small employer carrier the categories of benefits with respect to which the carrier is using the alternative method of counting creditable coverage. The small employer carrier requesting the information may identify specific information that the carrier reasonably needs in order to determine the individual's creditable coverage with respect to a category. The entity providing the information may charge the small employer carrier requesting the information for the reasonable cost of providing the information.

G. Establishing creditable coverage through other means.

1. An individual may establish creditable coverage through means other than a certificate if:

a. the accuracy of the certificate is contested; or

b. a certificate is unavailable at the time the certificate is needed by the individual.

2. § 10.8(G)(1) applies, but is not limited to, the following circumstances:

a. an entity has failed to provide a certificate within the required time period;

b. the individual has creditable coverage, but an entity may not be required to provide a certificate under § 10.8 of this Part;

c. the individual has an urgent medical condition that requires a determination as to creditable coverage prior to the time the individual can provide a certificate to the health benefit plan; or

d. the individual lost a certificate that the individual had previously received and is unable to obtain another certificate.

3. A small employer carrier shall take into account all of the information that it obtains or that is presented on behalf of an individual to make a determination, based on the relevant facts and circumstances, whether an individual has creditable coverage and is entitled to offset all or a portion of any preexisting condition exclusion period.

4 A small employer carrier shall treat the individual as having provided a certificate pursuant to § 10.8 of this Part if the individual:

a. attests to the period of creditable coverage;

b. presents relevant corroborating evidence of some creditable coverage during the period; and

c. cooperates with the carrier's efforts to verify the individual's coverage.

5. A small employer carrier may refuse to credit coverage where an individual fails to cooperate with the carrier's efforts to verify the individual's coverage. The carrier shall not consider the individual's inability to obtain a certificate as evidence of the absence of creditable coverage.

6. For the purpose of § 10.8(G)(4)(c) and (G)(5) of the Part, "cooperate" includes providing, upon request of the small employer carrier, a written authorization for the carrier to request a certificate on behalf of the individual and cooperating in efforts to determine the validity of the corroborating evidence and the dates of creditable coverage.

7. Documents that may establish creditable coverage and waiting or affiliation periods in the absence of a certificate include:

a. explanation of benefit (EOB) or other correspondence from a carrier indicating health benefit plan coverage;

b. pay stubs showing a payroll deduction for health benefit plan coverage;

c. a health insurance identification card;

d. a certificate of coverage under a group health plan;

e. records from health care providers, indicating health benefit plan coverage;

f. third party statements verifying periods of health benefit plan coverage; and

g. any other relevant documents that evidence periods of health benefit plan coverage.

8. In addition to documentation set out in § 10.8(G)(7) of this Part, creditable coverage and waiting or affiliation period information may be established through other means, such as by a telephone call from the carrier or provider to a third party verifying creditable coverage.

9. If, in the course of providing evidence of creditable coverage, including a certificate of creditable coverage pursuant to § 10.8 of this Part, an individual is required to demonstrate dependent status, the small employer carrier shall treat the individual as having furnished a certificate showing the dependent status if the individual:

a. attests in writing to the dependency and period of dependency; and

b. the individual cooperates with the carrier's efforts to verify dependent status.

10. The procedures used by a small employer carrier pursuant to § 10.8 of this Part to determine creditable coverage shall apply to determine an individual's creditable coverage with respect to any category under § 10.8(F) of this Part relating to determining creditable coverage under the alternative method.

H. Determination of creditable coverage; preexisting condition exclusion.

1. Within a reasonable time period following the date of receiving information under § 10.8 of this Part with respect to creditable coverage of an individual, the small employer carrier shall make a determination regarding the individual's period of creditable coverage and notify the individual of the determination in accordance with the requirements of § 10.8(H)(3) of this Part.

2. Whether a determination and notification regarding an individual's creditable coverage is made within a reasonable time period shall be determined based on the relevant facts and circumstances, including whether the carrier's application of a preexisting condition exclusion would prevent the individual from having access to urgent medical care services.

3. A small employer carrier seeking to impose a preexisting condition exclusion shall disclose, in writing, to the individual its determination of any preexisting condition exclusion period that applies to the individual and the basis for the determination, including the source and substance of any information on which the carrier relied in making the determination. A small employer carrier shall include in the disclosure an explanation of any appeal procedures established by the carrier and provide the individual with a reasonable opportunity to submit additional evidence of creditable coverage.

4. Nothing in this § 10.8(G) or (H) of this Part shall prevent a small employer carrier from modifying an initial determination of creditable coverage for an individual if the carrier determines that the individual did not have the creditable coverage, as claimed, if:

a. the carrier provides a notice of reconsideration to the individual; and

b. until the final determination regarding creditable coverage, the carrier, for the purpose of approving access to medical care, acts in a manner consistent with the initial determination.

230 R.I. Code R. 230-RICR-20-30-10.8