W. Va. Code R. § 114-54-5

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

Section 114-54-5 - Certification of Creditable Coverage

5.1. A health insurer shall furnish information as provided in this section, without charge, for individuals covered under a health benefit plan (including a health benefit plan issued in connection with an entity or program, other than a group health plan, for which certificates are required, as provided in rules governing the entity or program) except to the extent that:

a. Coverage was provided by another party;

b. Another party agrees to provide information regarding coverage provided by the health insurer and actually provides a certificate of creditable coverage including all information required under subsection 5.4 of this section; or

c. Coverage consisted of excepted benefits, but the health insurer may be required to disclose information concerning the benefits to another group health plan or health insurer that uses the alternative method of counting creditable coverage and provides coverage to an individual previously covered by the first health insurer.

5.2. For an individual whose coverage under a health benefit plan issued by the health insurer, but not the individual's participation in the group health plan, ceases, the health insurer shall provide sufficient information to the group health plan or a party designated by the group health plan to permit the group health plan or designated party to provide a certificate of creditable coverage, reflecting coverage under the health insurer's health benefit plan, upon termination of the individual's participation in the group health plan.

5.3. A health insurer shall provide a certificate of creditable coverage for periods after June 30, 1996, for each individual whose coverage under the group health plan and a health benefit plan issued by the health insurer ceases:

a. Without request by or on behalf of the covered individual, showing the last period of continuous coverage ending on the date coverage ceased:

1. For a qualified beneficiary (as defined in section 607(3) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. '1167(3); section 2208 of the Public Health Service Act, 42 U.S.C. '300bb-8(3); and section 4980B(g)(1) of the Internal Revenue Code, 26 U.S.C. '4980B(g)(1)) who is entitled to elect coverage under a COBRA continuation provision, as defined in W. Va. Code '33-15-2a(c), no later than the time notice is required to be furnished for a qualifying event under section 606 of the Employee Retirement Income Security Act of 1974, 29 U.S.C. '1166; section 2206 of the Public Health Service Act, 42 U.S.C. '300bb-6; and section 4980B(f)(6) of the Internal Revenue Code, 26 U.S.C. '4980B(f)(6);

2. For a qualified beneficiary who has elected coverage under a COBRA continuation provision (or whose coverage has continued under the group health plan after the individual became entitled to COBRA continuation coverage) and whose coverage ceases, within a reasonable time after coverage ceases or the expiration of any grace period for nonpayment of premiums, regardless of whether the individual received a certificate under paragraph 1 of subdivision a of subsection 5.3; or

3. For a covered individual other than a qualified beneficiary entitled to elect COBRA continuation coverage, within a reasonable time after coverage ceases; and

b. Upon request by or on behalf of an individual within twenty-four months after the individual's coverage ceases, showing each period of continuous coverage ending within the twenty-four month period ending (or continuing) on the date of the request, by the earliest date that the health insurer, acting in a reasonable or prompt fashion, can provide it, even if the individual previously received a certificate under subdivision a of subsection 5.3 or this subdivision. The health insurer:

1. Shall establish a procedure for individuals to request and receive certificates under this subdivision;

2. Shall, if the individual designates another individual or entity to receive the certificate, provide the certificate to the designated party; and

3. May provide a separate certificate for each period of continuous coverage.

5.4. Every certificate of creditable coverage shall contain:

a. The date the certificate is issued;

b. The name of the group health plan under which the health insurer provided the coverage described in the certificate;

c. The name of the individual to whom the certificate applies and any other information necessary for the group health plan or the health insurer to identify the individual;

d. The name, address, telephone number of the health insurer providing the certificate and the telephone number to call for further information, if different from the health insurer's telephone number;

e. Either:

1. A statement that an individual has at least eighteen months (for this purpose, 546 days is deemed to be eighteen months) of creditable coverage, disregarding days of creditable coverage before a significant break in coverage; or

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

f. The date creditable coverage ended, unless the certificate indicates that creditable coverage is continuing as of the date of the certificate.

5.5. Except as otherwise provided in this section, an insurer must provide a certificate of creditable coverage in writing. The requirements of this subsection are satisfied if the insurer provides the required information on a form certificate prescribed by the Commissioner, or in accordance with a model certificate as provided by the Health Care Financing Authority (HCFA), unless:

a. An individual entitled to receive a certificate requests that the certificate be sent to another group health plan or health insurer instead of to the individual;

b. The group health plan or health insurer that would receive the certificate agrees to accept the information contained in the certificate by another means such as by telephone; and c. The receiving group health plan or health insurer receives the information from the sending group health plan or health insurer within the time periods required under subsection 5.3 of this section.

5.6. A certificate of creditable coverage may provide information with respect to both an eligible employee and dependents if the information is identical for each individual, or, if the information 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.

a. A health insurer shall use reasonable efforts to determine any information needed for a certificate of creditable coverage relating to dependent coverage.

1. For a certificate required to be provided for a dependent under subdivision a of subsection 5.3, no individual certificate is required to be provided until the health insurer knows, or making reasonable efforts should know, of the dependent's cessation of coverage. If a certificate does not contain the name of any dependent of an individual covered by the certificate, the individual may demonstrate dependent status or that a child was enrolled within thirty days of birth, adoption or placement for adoption as provided in section four of this rule.

2. With respect to dependent coverage and events occurring through June 30, 1998, a health insurer:

A. May, if it cannot provide the names of dependents or related coverage information, satisfy the requirements of subdivision c, subsection 5.4 of this section, by providing the name of the eligible employee through whom a dependent is covered and specifying that the type of coverage described in the certificate is dependent coverage, such as family coverage or employee-plus-spouse coverage; and

B. Shall make reasonable efforts to obtain and provide the names of any dependent covered by the certificate where such information is requested to be provided. If a certificate does not contain the name of any dependent of an individual covered by the certificate, the individual may demonstrate that creditable coverage in the certificate covers a dependent.

5.7. If a health insurer has issued a certificate of creditable coverage for an individual who enrolls in a group health plan or health benefit plan that uses the alternative method of counting creditable coverage, the first health insurer:

a. Shall, upon request from the second group health plan or health insurer, promptly disclose to the requesting entity:

1. The categories of benefits with respect to which the requesting entity is using the alternative method of counting creditable coverage; and

2. If requested by the requesting entity, specific information that the requesting entity reasonably needs to determine the individual's creditable coverage with respect to a category; and

b. May charge the requesting entity for the reasonable cost of disclosing the information.

5.8. A health insurer shall be deemed to have satisfied the requirement for delivery of certificates of creditable coverage to individuals described in subsection 5.3 if it provides by first-class mail:

a. One certificate or separate certificates with respect to all covered individuals residing at an eligible employee's last known address, to the eligible employee and the employee's spouse at that address; and

b. A separate certificate with respect to a dependent whose last known address is different from the eligible employee's last known address, to the dependent at that individual's last known address.

5.9. If an individual described in subdivision a of subsection 5.3 designates another individual or entity to receive a certificate with respect to the individual, the health insurer may deliver a certificate to the designated party. If an individual described in subdivision b of subsection 5.3 designates another individual or entity to receive a certificate with respect to the individual, the health insurer shall deliver a certificate to the designated party.

5.10. If the accuracy of a certificate of creditable coverage is contested, or if a certificate is unavailable when needed by an individual, the individual may demonstrate creditable coverages and waiting or affiliation periods as provided in section four of this rule.

W. Va. Code R. § 114-54-5