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COMAR 10.09.24.12

1216 State of Maryland Medical Assistance Manual Revised July 2012

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) requires that all Medicaid program issue Certificates of Creditable Coverage to any recipient whose eligibility is terminated, or who requests a certificate at any time. “Creditable Coverage” means any comprehensive insurance coverage.

A Certificate of Creditable Coverage verifies that the individual had coverage prior to requesting enrollment in a new health plan. This is important because many health plans refuse to cover individuals with costly medical conditions, or may refuse to pay for services related to such conditions. These coverage exclusions are based on the premise that the condition was preexisting. Change in federal law under HIPPA now prevent insurers from excluding persons or services from coverage based on preexisting conditions if it can be shown that the person was continuously covered by any health plan. For Medical Assistance recipients, this is very important because those who are able to get jobs and become financially independent need to be able to obtain private insurance coverage for themselves and their children. To meet the requirements of the law, the certificate must include the following information:

Date the certificate is issued Name of the Program, i.e. Maryland Medical Assistance Name of Recipient The Date Coverage began, or the date 180 months prior to the certificate issue date, whichever is later, The name, address, and telephone number of the issuer The end date of coverage, or if coverage is ongoing as of the date of the certificate, a statement to that effect. A telephone number to call for further information

The Law Requires that Certificate is issued:

Upon request. Whenever a person requests a certificate, the Program is obligated to provide one. This is true whether the eligibility has been terminated or is ongoing. A person may request a certificate up to 24 months after termination of coverage and the Program is obligated to provide it. The Program may elect to provide certificates beyond that time frame but is not required to do so by the law. Upon termination of creditable coverage. Whenever a person loses eligibility in a coverage group that is considered creditable, a certificate must be issued. Loss of eligibility would be a complete cancellation of eligibility, or a change in coverage group from a group that is creditable to one that is non-creditable, e.g. a change in certification from Primary Adult Care Program (PAC). A loss of eligibility is defined as a gap in coverage for more that 63 days; therefore, a briefer period of ineligibly does not require that a certificate be issued. Not all of Maryland‟s Medical Care Programs are creditable. Some of our Medical Care Programs offer only limited health benefits. These include the Primary Adult Care (PAC) and the Maryland Family Planning Program (MPP).

1200.4 Tardy Redeterminations