W. Va. Code R. § 114-55-5

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

Section 114-55-5 - Certification of Creditable Coverage

5.1. A certificate of creditable coverage must be provided, without charge, for individuals and dependents, who are or were covered under an individual accident and sickness insurance policy as follows:

a. An automatic certificate must be provided within a reasonable time period consistent with State law after the individual ceases to be covered under the policy.

b. A request for a certificate may be made by, or on behalf of, an individual within 24 months after coverage ends. After the request is received, an insurer must provide the certificate promptly. A certificate must be provided even if the individual has previously received an automatic certificate under subdivision a of this subsection.

c. An insurer must establish a procedure for individuals and dependents to request and receive certificates under subdivision b of this subsection.

5.2. 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).

a. A certificate of creditable coverage must include the following:

1. The date the certificate is issued;

2. The name of the individual or dependent for whom the certificate applies, and any other information necessary for the insurer providing the coverage specified in the certificate to identify the individual, such as the individual's identification number under the policy and the name of the policyholder if the certificate is for, or includes, a dependent;

3. The name, address, and telephone number of the insurer required to provide the certificate;

4. The telephone number to call for further information regarding the certificate (if different from paragraph 3 of this subdivision);

5. Either one of the following:

A. A statement that the individual has at least 18 months (for this purpose, 546 days is deemed to be 18 months) of creditable coverage, disregarding days of creditable coverage before a significant break in coverage;

B. Both the date the individual first sought coverage, as evidenced by a substantially complete application, and the date creditable coverage began; and

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

b. No written certificate of creditable coverage must be provided if the following occurs:

1. An individual is entitled to receive a certificate;

2. The individual requests that the certificate be sent to another plan or insurer instead of to the individual;

3. The plan or insurer that would otherwise receive the certificate agrees to accept the required information through means other than a written certificate; and

4. The receiving plan or insurer receives the information from the sending insurer in the prescribed form within the time periods required in subsection 5.1 of this rule.

c. No certificate of creditable coverage is required to be furnished with respect to excepted benefits. If excepted benefits are provided concurrently with other creditable coverage (so that the coverage does not consist solely of excepted benefits), information concerning the benefits may be required to be disclosed under subsection 5.8 of this rule.

5.3. If an automatic certificate is provided under subdivision a of subsection 5.1 of this rule, the period that must be included on the certificate is the last period of continuous coverage ending on the date coverage ceased. If an individual requests a certificate under subdivision b of subsection 5.1 of this rule, a certificate must be provided for each period of continuous coverage ending within the 24-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.

5.4. The certificate of creditable coverage is required to be provided, without charge, to each individual described in subsection 5.1 of this rule or an entity requesting the certificate on behalf of the individual. The certificate may be provided by first-class mail.

a. An insurer may provide a single certificate for both an individual and the individual's dependents if it provides all the required information for each individual and dependent, and separately states the information that is not identical.

b. If the certificate or certificates are provided to the individual and the individual's spouse at the individual's last known address, the requirements of this subsection are satisfied with respect to all individuals and dependents residing at that address.

c. If a dependent does not reside at the individual's last known address, a separate certificate must be provided to the dependent at the dependent's last known address.

d. If separate certificates are provided by mail to individuals and dependents who reside at the same address, separate mailings of each certificate are not required.

5.5. If an automatic certificate is required to be provided under subdivision a of subsection 5.1 of this rule, and the individual or dependent entitled to receive the certificate designates another individual or entity to receive the certificate, the insurer responsible for providing the certificate may provide the certificate to the designated party. If the certificate must be provided upon request under subdivision b of subsection 5.1, and the individual entitled to receive the certificate designates another individual or entity to receive the certificate, the insurer responsible for providing the certificate must provide the certificate to the designated party.

5.6. An insurer must use reasonable efforts to determine any information needed for a certificate relating to dependent coverage. If an automatic certificate must be furnished with respect to a dependent under subdivision a of subsection 5.1 of this rule, no individual certificate must be furnished until the insurer knows (or making reasonable efforts should know) of the dependent's cessation of coverage under the policy.

a. If a certificate furnished by an insurer does not provide the name of any dependent of an individual covered by the certificate, the individual may, if necessary, use the procedures described in subdivision c of subsection 5.10 of this rule for demonstrating dependent status. An individual may, if necessary, use these procedures to demonstrate that a child was enrolled within 30 days of birth, adoption, or placement for adoption, in which case the child would not be subject to a preexisting condition exclusion under subsection 4.2 of this rule.

5.7. An insurer that cannot provide the names of dependents, or related coverage information, for purposes of providing a certificate of creditable coverage for a dependent may satisfy the requirements of paragraph 2 of subdivision a of subsection 5.2 of this rule by providing the name of the policyholder and specifying that the type of coverage provided in the certificate is for dependent coverage.

a. For purposes of certificates provided on the request of, or on behalf of, an individual under subdivision b of subsection 5.1 of this rule, an insurer must make reasonable efforts to obtain and provide the names of any dependent covered by the certificate if the information is requested. If an insurer responsible for providing a certificate does not provide the name of any dependent of an individual covered by the certificate, the individual may, if necessary, use the procedures described in subdivision c of subsection 5.10 of this rule for submitting documentation to establish that the creditable coverage in the certificate applies to the dependent.

b. An insurer providing an automatic certificate that does not contain the name of a dependent must furnish a certificate within 21 days after the individual ceases to be covered under the policy.

c. This subsection applies to certifications provided with respect to an event occurring before July 1, 1998.

d. This subsection applies to events described in subdivision a of subsection 5.6 of this rule that occur on or after October 1, 1996 but before June 1, 1997. An insurer offering individual accident and sickness insurance coverage is deemed to satisfy subsections 5.1 and 5.2 of this rule if a notice is provided in accordance with the provisions of this subsection.

5.8. If an individual enrolls in a group health plan and the plan or insurer uses the alternative method of determining creditable coverage described in 114 CSR 54, the individual provides a certificate of creditable coverage under subsection 5.1 or demonstrates creditable coverage subsection 5.9, and the plan or coverage in which the individual enrolls requests from the prior entity, the prior entity must:

a. Promptly identify for the requesting entity the categories of benefits and services used by the individual for which the requesting entity uses the alternative method of crediting coverage, and any specific information that the requesting entity requests to determine the individual's creditable coverage. The prior entity must promptly disclose to the requesting entity the creditable coverage information.

b. The prior entity furnishing the information under this subsection may charge the requesting entity for the reasonable cost of disclosing the information.

5.9. Individuals may establish creditable coverage (and waiting or affiliation periods) through means other than certificates. If the accuracy of a certificate is contested or a certificate is unavailable when needed by the individual, the individual has the right to demonstrate creditable coverage through the presentation of documents or other means. For example, the individual may make a demonstration if one of the following occurs:

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 of the coverage;

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

d. The individual has an urgent medical condition that necessitates a determination before the individual can deliver a certificate to the plan; or

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

5.10. An insurer must take into account all 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 or not an individual has 18 months of creditable coverage. An insurer must treat the individual as having furnished a certificate if the individual attests to the period of creditable coverage, the individual presents relevant corroborating evidence of some creditable coverage during the period, and the individual cooperates with the insurer's efforts to verify the individual's coverage. For this purpose, cooperation includes providing, upon the insurer's request, a written authorization for the insurer to request a certificate on behalf of the individual, and cooperating in efforts to determine the validity of the corroborating evidence and dates of coverage. While an insurer may refuse to credit coverage if the individual fails to cooperate with the insurer's efforts to verify coverage, the insurer may not consider an individual's inability to obtain a certificate to be evidence of the absence of creditable coverage.

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

b. Creditable coverage (and waiting period and affiliation period information) may be established through means other than documentation, such as by a telephone call from the insurer to a third party verifying creditable coverage.

c. If in the course of providing evidence, including a certificate, of creditable coverage an individual is required to demonstrate dependent status, the insurer must treat the individual as having furnished a certificate showing the dependent status if the individual attests to the dependency and the period of the status and the individual cooperates with the insurer's efforts to verify the dependent status.

W. Va. Code R. § 114-55-5