2920 Certificates of Creditable Coverage

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that group health plans furnish certificates of creditable coverage whenever an individual's health coverage ceases. HIPAA lists Medicaid, along with Medicare and most health insurance plans, as forms of creditable coverage. CHIP and MediKan are also considered creditable coverage. The purpose of the certificate is to document that the individual had prior health coverage and thus reduce or eliminate any preexisting condition exclusion under subsequent health benefit coverage the individual may obtain. As long as an individual's creditable coverage is not interrupted by a significant break (defined has a break of 63 or more full days where no creditable coverage exists), creditable coverage may be combined from different periods. A group health plan must reduce the length of any preexisting condition exclusion period they apply by the amount of the individual's creditable coverage. A coverage period of 18 months or more would eliminate any exclusion period.

Certificates of creditable coverage are issued to Medicaid and MediKan recipients under any program, including those covered under the SOBRA provisions, those losing automatic medical coverage as a result of termination of cash assistance, and persons terminated from TransMed. Certificate issuance is the responsibility of the Fiscal Agent. Certificates are sent out once a month to all individuals whose medical eligibility terminated the first day of the prior month. The certificate documents all periods of creditable coverage in the past 24 months. Periods when the individual was only QMB, LMB, QWD, or TB eligible are not considered creditable and are not listed on the certificate. In addition, for spenddown clients, only the base periods in which the spenddown is actually met are considered creditable and, in such instance, all six months are credited. Certificates are not sent to individuals with a date of death on file.

NOTE : Certificates for CHIP eligible individuals will be the responsibility of the contracting HMO to issue.

Replacement certificates can be sent to individuals, employers or insurance companies upon request. These certificates are also to be issued through the MMIS.