28 Tex. Admin. Code § 21.1104 - Form and Content of Written Certificate of Creditable Coverage
(a) Except as otherwise provided in §
21.1107 of this title (relating to
Creditable Coverage Established Through Means Other Than Written Certificate),
a certificate of creditable coverage must be provided in writing.
(b) The written certificate of creditable
coverage shall include the following:
(1) The
date the certificate is issued;
(2)
The name of the issuer of the health benefit plan that provided the coverage
described in the certificate;
(3)
The individual's or dependent's name for which the certificate of creditable
coverage is issued;
(4) Any other
information necessary for the health benefit plan providing the coverage
specified in the certificate to identify the individual, including but not
limited to, the individual's identification number under the health benefit
plan;
(5) The name, address and
telephone number of the third party administrator, plan sponsor, or issuer of
the health benefit plan providing the certificate;
(6) A telephone number to call for further
information regarding the certificate of creditable coverage, if different than
paragraph (5) of this section;
(7)
Either one of the following:
(A) the date any
waiting period (or affiliation period, if applicable) began and the date
creditable coverage began; or
(B) a
statement indicating the individual has:
(i)
18 months of creditable coverage for individual coverage; or
(ii) 12 months of creditable coverage for
group coverage; and
(8) The date creditable coverage ended, or a
statement that creditable coverage is continuing.
(c) A carrier may use either:
(1) Form CCC provided at Figure 1 of §
21.1110(b) of
this title (relating to Form CCC) to comply with subsection (a) of this
section; or
(2) a form that is
substantially similar to Form CCC and complies with subsection (a) of this
section; or
(3) the model contained
in federal rules with modifications to reflect the applicable 12 or 18 month
time period.
(d) If a
certificate is provided under §
21.1103(a) of
this title (relating to Timing and Issuance of a Written Certificate of
Creditable Coverage to an Individual), the period that must be included on the
certificate is the last period of continuous coverage, ending on the date
coverage ceased.
(e) If an
individual requests a certificate under §
21.1103(b) of
this title (relating to Timing and Issuance of a Written Certificate of
Creditable Coverage to an Individual), a certificate shall be provided for each
period of continuous creditable 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 shall be provided for each such period of continuous
creditable coverage.
(f) A
certificate of creditable coverage may provide information on both an
individual and the individual's dependents if the information is identical for
each individual. If the information is not identical, the certificates of
creditable coverage 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.
(g) Delivery
of a certificate of creditable coverage prior to the adoption of this
subchapter shall be deemed to comply with this subchapter, provided the
certificate complied with the federal regulations and properly reflected the
creditable time period applicable to Texas residents.
Notes
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