Iowa Admin. Code r. 191-71.15 - Methods of counting creditable coverage
(1) For purposes of reducing any preexisting
condition exclusion period, a group health plan or a carrier offering group
health insurance coverage shall determine the amount of an individual's
creditable coverage by using the standard method described in subrule 71.15(2),
except that the plan or carrier may use the alternative method under subrule
71.15(3) with respect to any or all of the categories of benefits described
under paragraph 71.15(3)"b."
(2) Under the standard method, a group health
plan and a health insurance carrier offering group health insurance coverage
shall determine the amount of creditable coverage without regard to the
specific benefits included in the coverage.
a.
For purposes of reducing the preexisting condition exclusion period, a group
health plan or a health insurance carrier offering group health insurance
coverage shall determine the amount of creditable coverage by counting all the
days that the individual has under one or more types of creditable coverage . If
on a particular day, an individual has creditable coverage from more than one
source, all the creditable coverage on that day is counted as one day. Further,
any days in a waiting period for a plan or policy are not creditable coverage
under the plan or policy.
b. Days
of creditable coverage that occur before a significant break in coverage are
not required to be counted.
c.
Notwithstanding any other provision of paragraph 71.15(2)"b,"
for purposes of reducing a preexisting condition exclusion period, a group
health plan and a health insurance carrier offering group health insurance
coverage may determine the amount of creditable coverage in any other manner
that is at least as favorable to the individual as the method set forth in
paragraph 71.15(2)"b."
(3) Under the alternative method, a group
health plan or a health insurance carrier offering group health insurance
coverage shall determine the amount of creditable coverage based on coverage
within any category of benefits described in subparagraph
71.15(3)"b"(2) and not based on coverage. The plan may apply a
different preexisting condition exclusion period with respect to each category
and may apply a different preexisting condition exclusion period for benefits
that are not within any category. The creditable coverage determined for a
category of benefits applies only for purposes of reducing the preexisting
condition exclusion period with respect to that category. An individual's
creditable coverage for benefits that are not within any category for which the
alternative method is being used is determined under the standard method of
paragraph 71.15(3)"a."
a. A
plan or carrier using the alternative method is required to apply it uniformly
to all participants and beneficiaries in the plan or policy. The use of the
alternative method must be set forth in the plan.
b. The alternative method for counting
creditable coverage may be used for coverage for any of the following
categories of benefits:
(1) Mental
health.
(2) Substance abuse
treatment.
(3) Prescription
drugs.
(4) Dental care .
(5) Vision care.
c. If the alternative method is used, the
plan is required to:
(1) State prominently
that the plan is using the alternative method of counting creditable coverage
in disclosure statements concerning the plan, and state this to each enrollee
at the time of enrollment under the plan;
(2) Include in these statements a description
of the effect of using the alternative method, including an identification of
the category's uses; and
(3) Under
the alternative method, the group health plan or carrier counts creditable
coverage within a category if any level of benefits is provided within the
category.
Notes
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