Certificates of Creditable Coverage - PowerPoint
Certificates of Creditable Coverage document sample
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Final HIPAA Portability Rules What is HIPAA Portability? • Interim rules initially issued by the Internal Revenue Service (IRS), Center for Medicare and Medicaid Services (CMS), and Department of Labor (DOL) in 1997 • The HIPAA portability rules allow workers to change jobs and group health plans more easily without being denied benefits under the new health plan because they had a pre-existing health condition. • More specifically, the HIPAA portability rules place limits on the ability of group health plans or health insurance issuers (such as an insurance company or HMO) to include a pre-existing condition exclusion in their plans, and then, based on the exclusion, deny benefits because the person has a pre-existing condition. Specifications • Effective for plan years beginning on or after July 1, 2005 • The Final Rules do not significantly modify the HIPAA Portability interim rules issued in 1997 Overview • Changes and clarifications to the 1997 interim rules include: – Clarification on definition of Dependent – General Notice of Pre-existing condition exclusion – Limitations on Pre-existing condition exclusions – Creditable coverage including certificates – Special enrollment periods – Excepted benefits Definitions • The final rules add a clarification definition of “dependent.” A dependent is “any individual who is or may become eligible for coverage under the terms of a group health plan because of a relationship to a participant.” • In other words, for the purposes of HIPAA, the definition of dependent in a group health plan document determine who is or is not a dependent. For example, plan terms control the age at which a child of a participant ceases to be eligible for coverage as a dependent. General Notice of Pre-existing Condition Exclusion • Provides clarification of the requirement of a general notice explaining the pre-existing condition exclusion of a plan – Must be provided at the same time as written application materials are distributed for enrollment by the Employer. – Must be provided prior to imposing the exclusion – The information provided in the SPD is not sufficient to satisfy this requirement – Must contain a contact title and phone number • Sample language is provided that an Employer can use as a basis for their own notice – there is no requirement to use the sample language. Limitations on Pre-existing Condition Exclusions • Retains the general definition of a pre-existing condition as in the interim rule • Clarifies that an exclusion is any limitation or exclusion of benefits relating to a pre-existing condition • Clarifies that the required notice informing an individual that a pre-existing condition exclusion period will apply to him/her must identify the last day on which the pre-existing condition exclusion applies to the individual. Creditable Coverage • Specifies the following count as creditable coverage – Foreign country public health coverage – The State Children’s Health Insurance Program (CHIP) – Coverage from a state or federal penitentiary – Plans maintained by the U.S. Government • Clarifies a Plan may not impose any limit on amount of time an individual has to present a certificate or other evidence of creditable coverage – This does not prevent a plan from denying a claim under a pre- existing condition exclusion to comply with applicable claims regulations. – Once a claim has been denied, other laws (such as §503 of ERISA) may set forth timing rules for an individual to appeal a denied claim. Creditable Coverage (Continued) • Requires a change to certificates of creditable coverage to include information notifying individuals of their rights under HIPAA. A model statement is included in the final rules. • Requires an automatic certificate be issued when an individual reaches the maximum lifetime limit on all benefits • Deleted the term “insurance” so that ANY coverage provided by a governmental entity is creditable coverage without regard to whether it has risk- shifting or risk-distributing characteristics of insurance. Creditable Coverage (Continued) • Requires that procedures for requesting certificates be in writing • Certificate of Coverage must be in writing, however, the final rules: – Allow creditable coverage information to be provided by other means (such as by telephone) – when requested by the plan participant to supply information to another plan (and the other plan agrees) Creditable Coverage (Continued) • Includes two examples on counting a significant break in creditable coverage – Tolling a significant break under Trade Act of 2002 • This amended COBRA to allow a second opportunity to elect COBRA for those individuals who qualify for trade adjustment assistance but did not initially elect COBRA • The days between the date coverage was lost and the first day of the 2nd COBRA election period are not counted as a significant break in coverage – Tolling a significant break in the individual market • Refers to the case of individuals seeking coverage in the individual market • This does not apply to a group health plan Special Enrollment • Clarifies what constitutes a loss of eligibility for special enrollment rights to arise – Conditions for special enrollment • Loss of eligibility for coverage as a result of: – legal separation, divorce, loss of dependent status, death of employee, termination of employment – an individual no longer resides, lives, or works in the service area and no other benefit package is available – an individual incurring a claim that would meet or exceed a lifetime limit on all benefits – a plan no longer offers benefits to certain classes of individuals (e.g. part-time employees) Special Enrollment (Continued) – Conditions for special enrollment (continued) • Termination of Employer contributions • Exhaustion of COBRA Continuation Coverage – Loss of Medicaid does not create a special enrollment period Special Enrollment (Continued) • Provided model notice of Special Enrollment period that must be provided on or before the time an employee is offered the opportunity to enroll • Restates that if an employee/dependent enrolls as a late enrollee or special enrollee, any period before such late or special enrollment is not a waiting period – In other words, the date of enrollment for late/special enrollees is used in determining the beginning and ending of a look-back period and the beginning of a pre-existing condition exclusion period Excepted Benefit Plans • Retains rule that the following benefits are excepted from compliance with portability requirements: – Accident only or accidental death and dismemberment – Disability income coverage – Liability insurance (including auto and general liability) – Supplemental coverage – Workers’ compensation – Automobile medical payment insurance – Credit-only insurance (e.g., mortgage insurance) – Coverage for on-site medical clinics Excepted Benefit Plans (Continued) • Retains rule that limited-scope dental benefits, limited-scope vision benefits, or long-term care benefits, if not an integral part of a group health plan, are excepted – Clarifies the definition of “integral” with two requirements • Participants have right to elect not to receive coverage for the benefit, and • If coverage is elected, participant pays an additional premium or contribution for that coverage Partnerships Clarified • Health plans sponsored by partnerships are subject to the HIPAA portability rules, even if the plans only cover business partners and are considered exempt from ERISA. Business partners are considered employees for HIPAA portability purposes. Available Resources • Final Rule (available in PDF format) – Federal Register, December 30, 2004 • http://a257.g.akamaitech.net/7/257/2422/06jun20 041800/edocket.access.gpo.gov/2004/pdf/04- 28112.pdf Questions? If you have any questions or need any assistance, please contact: JI Specialty Services, Inc.