W. Va. Code R. § 114-54-4

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-54-4 - Application of Creditable Coverage to Reduce Preexisting Condition Exclusion Period

4.1. For purposes of reducing any preexisting condition exclusion period under terms of a health benefit plan, a health insurer shall take into account all information that it obtains or that is presented on behalf of an individual to determine, based on relevant facts and circumstances, whether an individual has creditable coverage and is entitled to offset all or a portion of any preexisting condition exclusion.

4.2. For purposes of reducing any preexisting condition exclusion period under terms of a health benefit plan, a health insurer may elect to determine an individual's days of creditable coverage:

a. By the standard method described in subsection 4.3;

b. Subject to other applicable requirements, in any other manner that is at least as favorable to the individual as the standard method described in subsection 4.3; or

c. By the alternative method described in subsection 4.4 with respect to any or all categories of benefits described in subsection 4.4.

4.3. A health insurer electing the standard method shall determine the days of creditable coverage by counting all the days the individual has under one or more types of creditable coverage, without regard to specific benefits included in the coverage, but:

a. Any days in a waiting period for coverage are not days of creditable coverage; and

b. Days of creditable coverage that occur before a significant break in coverage are not required to be counted.

4.4. A health insurer electing the alternative method:

a. Shall apply the alternative method uniformly to all persons covered under the health benefit plan, but creditable coverage for a category of benefits applies only for purposes of reducing a preexisting condition exclusion;

b. Shall set forth its use of the alternative method in the health benefit plan;

c. For each type of health benefit plan offered, shall state its use of the alternative method prominently in disclosure statements concerning the health benefit plan and to each potential policyholder at the time of offer or sale of the health benefit plan, describing in such statements the effect of using the alternative method;

d. Shall determine the days of creditable coverage based on coverage within any or all of the following categories of benefits and not based on coverage for any other benefits:

1. Mental health benefits;

2. Substance abuse treatment;

3. Prescription drugs;

4. Dental care; and

5. Vision care;

e. Shall count creditable coverage if any level of benefits is provided within the category, but coverage under a reimbursement account or arrangement, such as a flexible spending arrangement defined in section 106(c)(2) of the Internal Revenue Code, does not constitute coverage within any category;

f. Shall:

1. First determine the amount of the individual's creditable coverage that may be counted under subsection 4.3, over a period ("determination period") of up to a total of 365 days of the most recent creditable coverage (546 days for a late enrollee);

2. Then count, for the category specified under the alternative method, all days of coverage within the category that occurred during the determination period, whether or not a significant break in coverage for that category occurs; and

3. Reduce the individual's preexisting condition exclusion period for that category by the number of days counted under paragraph 2 of subdivision f of subsection 4.4;

g. Shall use the standard method described in subsection 4.3 to determine days of creditable coverage for benefits not within any category listed in subdivision d of subsection 4.4; and

h. May, if the group health plan so chooses, apply a different preexisting condition exclusion period for benefits that are not within any category listed in subdivision d of subsection 4.4 and a different preexisting condition exclusion period with respect to each category.

4.5. An individual may demonstrate creditable coverages and waiting or affiliation periods, for a determination under either the standard or the alternative method, through:

a. Presentation of one or more certificates of creditable coverage issued by a group health plan, health insurer or other entity that previously provided coverage for medical care; or

b. Documents or other means if the accuracy of a certificate of creditable coverage is contested or if a certificate is unavailable when needed by an individual, such as when:

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

2. An entity is not required under federal law to provide a certificate;

3. The coverage is for a period before July 1, 1996;

4. The individual has an urgent medical condition that necessitates a determination before the individual can deliver a certificate of creditable coverage to the group health plan; or

5. The individual lost a certificate of creditable coverage and is unable to obtain another certificate.

4.6. If, in the course of providing evidence (including a certificate) of creditable coverage, an individual must demonstrate dependent status, the health insurer shall treat the individual as having furnished a certificate of creditable coverage if the individual attests to such dependency and the period of such status and cooperates with the health insurer's efforts to verify the dependent status.

4.7. A health insurer may refuse to credit coverage if the individual fails to cooperate with the health insurer's efforts to verify coverage but may not consider an individual's inability to obtain a certificate of creditable coverage to be evidence of the absence of creditable coverage. A health insurer shall treat an individual as having furnished a certificate of creditable coverage if the individual attests to the period of creditable coverage, presents relevant corroborating evidence of some creditable coverage during the period, including periods before July 1, 1996, and cooperates with the health insurer's efforts to verify the individual's coverage.

a. For purposes of this subsection, cooperation includes providing, upon the health insurer's request, written authorization for the health insurer to request a certificate on behalf of the individual and cooperating in efforts to determine the validity of corroborating evidence and the dates of creditable coverage.

b. Documents that may establish creditable coverage and waiting periods or affiliation periods in the absence of a certificate include explanations of benefit claims or correspondence from a group health plan or health insurer indicating coverage, pay stubs showing a payroll deduction for health coverage, a health insurance identification card, a certificate of coverage under a health benefit plan, records from medical care providers indicating health coverage, third party statements verifying periods of coverage and any other relevant documents that evidence periods of health coverage.

c. Creditable coverages and waiting or affiliation periods may be established through means other than documentation.

4.8. A health insurer receiving information with respect to creditable coverage shall, within a reasonable time following receipt of the information:

a. Determine the application of the individual's creditable coverage to any preexisting condition exclusion period and notify the individual of the determination; and

b. For any individual on whom the health insurer seeks to impose a preexisting condition exclusion period, disclose to the individual in writing:

1. Any applicable preexisting condition exclusion period;

2. The basis for the health insurer's determination, including the source and substance of any information on which it relied; and

3. Any appeal procedures established by the group health plan or the health insurer, with a reasonable opportunity to submit additional evidence of creditable coverage.

4.9. A health insurer may modify an initial determination of creditable coverage if it determines that the individual did not have the claimed creditable coverage, if it provides a notice of reconsideration to the individual and acts in a manner consistent with the initial determination until the final determination is made.

W. Va. Code R. § 114-54-4