28 Tex. Admin. Code § 21.1107 - Creditable Coverage Established Through Means Other Than Written Certificate
(a) An individual
may establish creditable coverage through means other than a written
certificate of creditable coverage as provided in §
21.1103 of this title (relating to
Timing of Issuance of a Written Certificate of Creditable Coverage) if the
accuracy of a written certificate is contested or if a written certificate is
unavailable when needed by the individual. For example, the individual may make
such a demonstration, including but not limited to, the following
circumstances:
(1) an entity has failed to
provide a certificate within the required time period;
(2) the coverage is for a period before July
1, 1996;
(3) the individual has an
urgent medical condition that necessitates a determination of whether prior
creditable coverage existed before the individual can deliver a certificate to
the health benefit plan; or
(4) the
individual lost a certificate he or she had previously received and is unable
to obtain another certificate.
(b) No written certificate is required to be
provided if the following conditions are met:
(1) an individual is entitled to receive a
certificate;
(2) the individual
requests that the certificate be sent to another issuer of a health benefit
plan instead of to the individual;
(3) the issuer of the health benefit plan
that would otherwise receive the certificate agrees to accept the information
regarding creditable coverage through means other than a written certificate
(for example, by telephone); and
(4) the issuer of the health benefit plan
receives the information from the sending issuer of the health benefit plan
within the time periods required under §
21.1103 of this title (relating to
Timing of Issuance of a Written Certificate of Creditable Coverage to an
Individual).
(c)
Documents that may establish creditable coverage (and waiting or affiliation
periods) in the absence of a written certificate of coverage, include but are
not limited to, the following:
(1)
explanations of benefit claims or other correspondence from a health benefit
plan or issuer indicating coverage;
(2) pay stubs showing a payroll deduction for
health benefit coverage;
(3) health
benefit plan identification card;
(4) a certificate of coverage under a health
benefit plan;
(5) records from
medical care providers indicating health benefit plan coverage;
(6) third party statements verifying periods
of coverage; and
(7) other relevant
documents that evidence periods of health benefit plan coverage.
(d) An issuer of a health benefit
plan shall take into account all information that it obtains or that is present
on behalf of an individual to make a determination, based on the relevant facts
and circumstances, whether an individual has creditable coverage and is
entitled to offset all or a portion of any preexisting condition exclusion
period.
(e) An issuer of a health
benefit plan shall treat the individual as having furnished a written
certificate of creditable coverage 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 issuer of the health benefit plan's efforts to verify the individual's
coverage.
(f) For purposes of
subsection (e) of this section, cooperation includes providing, upon request, a
written authorization for the issuer of the health benefit plan to request a
certificate on behalf of the individual, and cooperating in efforts to
determine the validity of the corroborating evidence and the dates of
creditable coverage.
(g) An issuer
of a health benefit plan may refuse to credit coverage if the individual fails
to cooperate with the issuer's efforts to verify coverage. However, an issuer
of a health benefit plan shall not consider an individual's inability to obtain
a certificate to be evidence of the absence of creditable coverage.
(h) Creditable coverage may also be
established through means other than documentation, such as by a telephone call
from the health benefit plan or provider to a third party verifying creditable
coverage.
(i) Nothing contained in
this subchapter shall be construed to prohibit an issuer of a health plan from
providing coverage on the contractual effective date and receiving premium for
such coverage while creditable coverage information is being
determined.
Notes
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