What is Credible Coverage?
HHS regulations no longer require a Certificate of Credible Coverage after 12.2014. HN Bulletin
This is pretty much an Historical Page.
Whenever and for whatever reason you change or lose your Employer Group Health Plan, Individual Medical coverage or apply for HIPAA guaranteed issue coverage, a Certificate of Creditable Coverage proves that you had prior Insurance and is mandated in the HIPAA Application.
This page may be all out of date with Health Care Reform…??? At the end of the year you will get a IRS Form 1095 A B or C to show you had coverage to reconcile subsidies or prove coverage to avoid the mandate penalty.
Having prior Insurance waives the Pre-Existing Waiting Period, typically six months, as the new Insurance company must honor time that you were covered under a prior carrier. Definitions of Creditable Coverage are provided by CA Insurance Code and Federal Law 300 gg.
This certificate (Sample DOL) must be mailed to you whenever coverage changes or terminates. (DOL FAQ’s). Check with your HR department or your employer’s Insurance Agent to get a copy. We are not authorized to do this for you, unless your employer is a client of ours.
If you have any questions, please send us an email and we will add them to our FAQ section.
If you or family members are healthy, try using our Quote Engine and see if you can qualify for a standard plan to save $$$.
Technical Information and Links
Creditable Coverage – Code Definitions
HIPAA Federal Law (300-gg)
§ 146.115 Certification and disclosure of previous coverage.
Small Group Health Reform (AB 1672, §10700 R)
CA Insurance Code
“Creditable coverage” (Certificate) under §10198.6 (d) means:
(1) Any individual or group policy, contract or program, that is written or administered by a disability insurance company (Health Insurer Ins. Code §106), health care service plan, fraternal benefits society, self-insured employer plan, or any other entity, in this state or elsewhere, and that arranges or provides medical, hospital, and surgical coverage not designed to supplement other private or governmental plans. The term includes continuation or conversion coverage but does not include accident only, credit, coverage for onsite medical clinics, disability income, Medicare supplement, long-term care insurance, dental, vision, coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(2) The federal Medicare program pursuant to Title XVIII of the Social Security Act.
(3) The Medicaid program pursuant to Title XIX of the Social Security Act.
(4) Any other publicly sponsored program, provided in this state or elsewhere, of medical, hospital and surgical care.
(5) 10 U.S.C. Chapter 55 (commencing with Section 1071) (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
(6) A medical care program of the Indian Health Service or of a tribal organization.
(7) A state health benefits risk pool.
(8) A health plan offered under 5 U.S.C. Chapter 89 (commencing with Section 8901) (Federal Employees Health Benefits Program (FEHBP)).
(9) A public health plan as defined in federal regulations authorized by Section 2701(c)(1)(I) of the Public Health Service Act, as amended by Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996.
(10) A health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. Sec. 2504(e)).
(11) Any other creditable coverage as defined by subsection (c) of Section 2701 of Title XXVII of the federal Public Health Services Act (42 U.S.C. Sec. 300gg(c)). or 300 gg c
300gg Federal Increased portability through limitation on preexisting condition exclusions
(c) Rules relating to crediting previous coverage
(1) “Creditable coverage” defined
For purposes of this subchapter, the term “creditable coverage” means, with respect to an individual, coverage of the individual under any of the following:
(A) A group health plan.
(C) Part A or part B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.].
(D) Title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], other than coverage consisting solely of benefits under section 1928 [42 U.S.C. 1396s].
(E) Chapter 55 of title 10.
(F) A medical care program of the Indian Health Service or of a tribal organization.
(H) A health plan offered under chapter 89 of title 5.
(I) A public health plan (as defined in regulations).
(J) A health benefit plan under section 2504 (e) of title 22.
Such term does not include coverage consisting solely of coverage of excepted benefits (as defined in section 300gg–91 (c)
of this title).
(2) Not counting periods before significant breaks in coverage
(A) In general
A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, there was a 63-day period
during all of which the individual was not covered under any creditable coverage.
(B) Waiting period not treated as a break in coverage
For purposes of subparagraph (A) and subsection (d)(4) of this section, any period that an individual is in a waiting period for any coverage under a group health plan (or for group health insurance coverage) or is in an affiliation period (as defined in subsection (g)(2) of this section) shall not be taken into account in determining the continuous period under subparagraph (A).
§ 146.113 Rules relating to creditable coverage. Federal Code of Regulations
||Rules relating to creditable coverage.
||Evidence of creditable coverage.access.gpo.gov
(a)Group health plan
The term “group health plan” means an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income Security Act of 1974 [29
]) to the extent that the plan provides medical care (as defined in paragraph (2)) and including items and services paid for as medical care) to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise.
The term “medical care” means amounts paid for—
(A) the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body,
(B) amounts paid for transportation primarily for and essential to medical care referred to in subparagraph (A), and
(C) amounts paid for insurance covering medical care referred to in subparagraphs (A) and (B).
(3)Treatment of certain plans as group health plan for notice provision
A program under which creditable coverage described in subparagraph (C), (D), (E), or (F) of section 300gg(c)(1)
of this title is provided shall be treated as a group health plan for purposes of applying section 300gg(e)
of this title.
(b)Definitions relating to health insurance
(1)Health insurance coverage
The term “health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer.
(2)Health insurance issuer
The term “health insurance issuer” means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined in paragraph (3)) which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974 [29
]). Such term does not include a group health plan.
(3)Health maintenance organization
The term “health maintenance organization” means—
(A) a Federally qualified health maintenance organization (as defined in section 300e (a) of this title),
(B) an organization recognized under State law as a health maintenance organization, or
(C) a similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization.
(4)Group health insurance coverage
The term “group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with such plan.
(5)Individual health insurance coverage
The term “individual health insurance coverage” means health insurance coverage offered to individuals in the individual market, but does not include short-term limited duration insurance.
For purposes of this subchapter, the term “excepted benefits” means benefits under one or more (or any combination thereof) of the following:
(1)Benefits not subject to requirements
(A) Coverage only for accident, or disability income insurance, or any combination thereof.
(B) Coverage issued as a supplement to liability insurance.
(C) Liability insurance, including general liability insurance and automobile liability insurance.
(D) Workers’ compensation or similar insurance.
(E) Automobile medical payment insurance.
(F) Credit-only insurance.
(G) Coverage for on-site medical clinics.
(H) Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
(2)Benefits not subject to requirements if offered separately
(A) Limited scope dental or vision benefits.
(B) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
(C) Such other similar, limited benefits as are specified in regulations.
(3)Benefits not subject to requirements if offered as independent, noncoordinated benefits
(A) Coverage only for a specified disease or illness.
(B) Hospital indemnity or other fixed indemnity insurance.
(4)Benefits not subject to requirements if offered as separate insurance policy
Medicare supplemental health insurance (as defined under section 1395ss(g)(1)
of this title), coverage supplemental to the coverage provided under chapter 55
of title 10
, and similar supplemental coverage provided to coverage under a group health plan.
(1)Applicable State authority
The term “applicable State authority” means, with respect to a health insurance issuer in a State, the State insurance commissioner or official or officials designated by the State to enforce the requirements of this subchapter for the State involved with respect to such issuer.
The term “beneficiary” has the meaning given such term under section 3(8) of the Employee Retirement Income Security Act of 1974 [29
(3)Bona fide association
The term “bona fide association” means, with respect to health insurance coverage offered in a State, an association which—
(A) has been actively in existence for at least 5 years;
(B) has been formed and maintained in good faith for purposes other than obtaining insurance;
(C) does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee);
(D) makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to such members (or individuals eligible for coverage through a member);
(E) does not make health insurance coverage offered through the association available other than in connection with a member of the association; and
(F) meets such additional requirements as may be imposed under State law.
(4)COBRA continuation provision
The term “COBRA continuation provision” means any of the following:
(A) Section 4980B of title 26, other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines.
(B) Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1161 et seq.], other than section 609 of such Act [29 U.S.C. 1169].
(C) Subchapter XX of this chapter.
The term “employee” has the meaning given such term under section 3(6) of the Employee Retirement Income Security Act of 1974 [29
The term “employer” has the meaning given such term under section 3(5) of the Employee Retirement Income Security Act of 1974 [29
], except that such term shall include only employers of two or more employees.
The term “church plan” has the meaning given such term under section 3(33) of the Employee Retirement Income Security Act of 1974 [29
(A) The term “governmental plan” has the meaning given such term under section 3(32) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002 (32)] and any Federal governmental plan.
(B)Federal governmental plan.— The term “Federal governmental plan” means a governmental plan established or maintained for its employees by the Government of the United States or by any agency or instrumentality of such Government.
(C)Non-Federal governmental plan.— The term “non-Federal governmental plan” means a governmental plan that is not a Federal governmental plan.
(9)Health status-related factor
The term “health status-related factor” means any of the factors described in section 300gg–1(a)(1)
of this title.
The term “network plan” means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care (including items and services paid for as medical care) are provided, in whole or in part, through a defined set of providers under contract with the issuer.
The term “participant” has the meaning given such term under section 3(7) of the Employee Retirement Income Security Act of 1974 [29
(12)Placed for adoption defined
The term “placement”, or being “placed”, for adoption, in connection with any placement for adoption of a child with any person, means the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child’s placement with such person terminates upon the termination of such legal obligation.
The term “plan sponsor” has the meaning given such term under section 3(16)(B) of the Employee Retirement Income Security Act of 1974 [29
The term “State” means each of the several States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
The term “family member” means, with respect to any individual—
(A) a dependent (as such term is used for purposes of section 300gg (f)(2) of this title) of such individual; and
(B) any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual or of an individual described in subparagraph (A).
The term “genetic information” means, with respect to any individual, information about—
(i) such individual’s genetic tests,
(ii) the genetic tests of family members of such individual, and
(iii) the manifestation of a disease or disorder in family members of such individual.
(B)Inclusion of genetic services and participation in genetic research
Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such individual.
The term “genetic information” shall not include information about the sex or age of any individual.
The term “genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detects genotypes, mutations, or chromosomal changes.
The term “genetic test” does not mean—
(i) an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes; or
(ii) an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved.
The term “genetic services” means—
(A) a genetic test;
(B) genetic counseling (including obtaining, interpreting, or assessing genetic information); or
(C) genetic education.
The term “underwriting purposes” means, with respect to any group health plan, or health insurance coverage offered in connection with a group health plan—
(A) rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the plan or coverage;
(B) the computation of premium or contribution amounts under the plan or coverage;
(C) the application of any pre-existing condition exclusion under the plan or coverage; and
(D) other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.
(e)Definitions relating to markets and small employers
For purposes of this subchapter:
The term “individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.
(B)Treatment of very small groups
(i) In general Subject to clause (ii), such terms includes coverage offered in connection with a group health plan that has fewer than two participants as current employees on the first day of the plan year.
(ii) State exception Clause (i) shall not apply in the case of a State that elects to regulate the coverage described in such clause as coverage in the small group market.
The term “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 51 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year.
(3)Large group market
The term “large group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer.
The term “small employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year.
(5)Small group market
The term “small group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a small employer.
(6)Application of certain rules in determination of employer size
For purposes of this subsection—
(A)Application of aggregation rule for employers
all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414
of title 26 shall be treated as 1 employer.
(B)Employers not in existence in preceding year
In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.
Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.