Current through Rules and Regulations filed through March 20, 2024
(a) Any insurer issuing a group health
insurance policy or contract or individual insurance policy or contract must
furnish a certification of creditable coverage described in subparagraph (1) in
accordance with subparagraphs (2) through (6) of this paragraph.
(1) The certification of creditable coverage
must be in writing and include the following information:
(A) the date the certification is
issued;
(B) the name of the insurer
that provided the coverage described in the certification;
(C) the name of the insured (including any
covered dependents) with respect to whom the certification applies, and any
other information necessary for the insurer providing the coverage specified in
the certification to identify the insured, such as the insured's insurance
indentification number and the name of the employee or group member under group
health insurance coverage, or the policyholder under individual health
insurance coverage, if the certification is for (or includes) a
dependent;
(D) the name, address,
and telephone number of the insurer or plan administrator required to provide
the certification;
(E) the
telephone number to call for further information regarding the
certification;
(F) either;
(i) a statement that an insured has at least
eighteen (18) months of creditable coverage, or
(ii) the date any applicable waiting or
affiliation period began, and the date creditable coverage began; and
(G) the date creditable coverage
ended, unless the certification indicates that creditable coverage is
continuing as of the date of the certification.
(2) An insurer issuing a group health
insurance policy or contract must provide a written certification for (i) the
most recent period of continuous creditable coverage ending with events
described in (A) and (B) of this subparagraph, or (ii) each period of
continuous coverage as permitted in (C) of this subparagraph without charge, to
insureds or former insureds, or any other person designated by an insured or
former insured, or any other individual, insurer, employer health benefit
arrangement, or administrator requesting on behalf of an insured or former
insured. An insurer must issue such certification within fourteen (14) days
after receipt of notice that any of the following events have occurred:
(A) Coverage for an insured has ceased or
terminated for any reason;
(B) An
insured has terminated or exhausted federal or state continuation of benefits;
or
(C) A request has been made
within twenty-four (24) months after coverage ceased, regardless of whether the
former insured has previously received a certification from the insurer. An
insurer must make reasonable efforts to ascertain whether any of the above
events have occurred.
(3) An insurer issuing an individual health
insurance policy or contract must provide a written certification for (i) the
most recent period of continuous creditable coverage ending with an event
described in (A) of this subparagraph, or (ii) each period of continuous
coverage as permitted in (B) of this subparagraph without charge, to insureds
or former insureds, or any other person designated by an insured or former
insured, or any other individual, insurer, employer health benefit arrangement,
or administrator requesting on behalf of an insured or former insured. An
insurer must issue such certification within fourteen (14) days after receipt
of notice that any of the following events have occurred:
(A) Coverage for an insured has ceased or
terminated for any reason; or
(B) A
request has been made within twenty-four (24) months after coverage ceased,
regardless of whether the former insured has previously received a
certification from the insurer.
(4) A certification may provide information
with respect to an insured and the insured's covered dependents if the
information is identical for each individual. If not, certifications may be
provided on one form if the form provides all the required information for the
insured and covered dependents and separately states the information that is
not identical.
(5) The insurer may
satisfy the requirement to provide a certification of creditable coverage by
sending a certification via first-class mail to the last known address of the
insured or former insured for all covered individuals residing at that address.
If a covered dependent's or spouse's last known address is different than the
former insured's last known address, a separate certification is required to be
provided to the covered dependent or spouse at the dependent's or spouse's last
known address. If separate certifications are being provided by mail to
insureds or former insureds who reside at the same address, separate mailings
of each certification are not required.
(6) An insurer must use reasonable efforts to
determine any information needed for a certification relating to coverage of a
dependent. In any case in which a certification is required to be furnished
with respect to a dependent for events described in subparagraphs (a)(2)(A) or
(B) or (a)(3)(A), no dependent certification is required to be furnished until
the insurer knows, or making reasonable efforts, should know, of the
dependent's cessation of coverage under the policy or contract. The following
transition rules apply to certifications for termination or cessation of
coverage occurring before June 30, 1998:
(A)
an insurer that cannot provide the names (or related coverage information) of
dependents of an insured or former insured for purposes of providing a
certification of coverage for a dependent may satisfy the requirements of
subparagraph (a)(1)(C) by providing the name of the insured or former insured
and specifying that the type of coverage described in the certification is for
dependent coverage, such as, for example, family coverage or enrollee and
spouse coverage;
(B) an insurer
must make reasonable efforts to obtain and provide the names of any dependent
covered by the certification where such information is requested to be
provided; and
(C) an insurer
providing a certification for an insured in accordance with subparagraph (6)(A)
must furnish a certification within twenty-one (21) days after the insured
ceases to be covered under an individual health insurance policy or
contract.
(b)
An insurer is not required to provide a written certification to individuals as
required in paragraph (a) if:
(1) An insurer
did not provide the creditable coverage, in which case the insurer is not
required to provide information regarding coverage provided to an individual by
another party;
(2) An insured or
former insured entitled to receive a certification requests that the
certification be sent to another insurer, administrator, or employer health
benefit arrangement and such insurer, administrator, or employer health benefit
arrangement agrees to accept, and actually receives from the insurer within
fourteen (14) days, the information in subparagraph (a)(1) telephonically or by
other means;
(3) There is a written
agreement or contract in which an employer, administrator, or other third party
is made responsible for the issuing of certifications of creditable coverage,
or otherwise, if another party provides the certifications, but only to the
extent that information relating to the individual's creditable coverage and
waiting or affiliation period is provided by the other party; or
(4) With regard to certification requirements
relating to paragraphs (a)(2)(A) and (B), an insured's coverage under the group
health insurance policy or contract ceases prior to the cessation of coverage
under the employer health benefit arrangement, or because of the election of
any other group health insurance option offered therein, although in any event
the insurer must provide sufficient information reflecting the insured's or
former insured's period of creditable coverage under the policy or contract to
the employer health benefit arrangement or its delegate to enable a
certification to be provided by the arrangement or its delegate after cessation
of the individual's coverage under the arrangement. An insurer may presume that
an insured whose coverage ceases at a time other than the group's effective
date for changing enrollment options is concurrently ceasing coverage under the
employer health benefit arrangement and must consequently issue certifications
as required by paragraph (a)(2) for events described in paragraphs (a)(2)(A)
and (B).
(c) For the
purposes of demonstrating previous creditable coverage upon becoming eligible
for coverage under a group health insurance policy or contract, if there is no
available certification demonstrating prior creditable coverage with an
insurance company or employer health benefit arrangement, or if the accuracy of
a certificate is contested, it shall be the responsibility of the newly
eligible insured to provide an insurer with the information necessary to verify
the type of plan and the effective date of his or her previous
coverage.
(d) An insurer shall take
into account all information that it obtains or that is presented on behalf of
a newly eligible insured, based on the relevant facts and circumstances, to
determine whether an individual has creditable coverage and is entitled to
offset all or a portion of any preexisting condition exclusion period. An
insurer shall accept an attestation from a newly eligible insured as to periods
of creditable coverage, or periods spent in affiliation or waiting periods, if
such attestation is accompanied by evidence of some form of creditable coverage
during the period, and the insured cooperates with the insurer's efforts to
verify the insured's previous creditable coverage. Such evidence includes the
following:
(1) explanations of benefit
claims;
(2) correspondence from an
insurer, administrator, or employer health benefit arrangement indicating
coverage;
(3) pay stubs showing a
payroll deduction for health coverage;
(4) a health insurance identification
card;
(5) a certificate of coverage
under a group health insurance;
(6)
records from medical care providers indicating health coverage;
(7) statements from third parties verifying
periods of coverage;
(8) telephone
calls by the insurer to a previous insurer, administrator, employer, or other
third party verifying coverages; and
(9) any other relevant documents that
demonstrate coverage at any point during the period of time to which the
insured attests coverage.
(e) Provisions of this subsection permitting
attestation, evidence, and verification shall be applicable to demonstrating
categories of creditable coverage relating to the alternative method as
permitted in this Regulation Chapter, and in demonstrating coverage as a
dependent under another individual's coverage.
(f) If relevant information is not provided
by the insured or otherwise obtained by the insurer after reasonable attempts,
or if the insured fails to cooperate with the insurer's efforts to verify
coverage, the insurer may apply a twelve (12) month preexisting exclusion
period provison.
(g) In the event
an insurer receives information via a certification or through means permitted
in paragraph (c) of this Rule and intends to impose any preexisting condition
exclusion or limitation under the terms of a group health insurance policy or
contract, the insurer is required, within a reasonable time period following
receipt of the information, to disclose to the insured in writing a
determination regarding the insured's period of creditable coverage which
includes the basis for such determination, a written explanation of any appeal
procedures established by the insurer, and a reasonable opportunity to submit
additional evidence of creditable coverage. A time frame for disclosure is
considered reasonable if it is based on the relevant facts and circumstances of
the case, including whether the application of a preexisting condition
exclusion would prevent an insured from having access to urgent medical
services.
(h) An insurer may modify
an initial determination of creditable coverage if it determines, upon
verification or the discovery of additional evidence, that the insured did not
have the claimed creditable coverage, provided that:
(1) a notice of the reconsideration is
provided to the insured; and
(2)
until the final determination is made, the insurer, for purposes of approving
access to medical services (such as pre-surgery authorization) acts in a manner
consistent with the initial determination.
(i) Any administrator or designee of an
insurer responsible for the provision of certifications of creditable coverage
under this section must comply with all the relevant provisions of this section
as they apply to the issuing of certifications of creditable coverage by
insurers.
(j) The term
"certification" as used in this section shall have the same meaning as
"certification" as used in the federal Public Health Service Act, Section
2701(e). Nothing in this section shall be construed to prevent insurers from
using model certificate forms approved by the Health Care Financing
Administration for the purposes of complying with certification
requirements.
O.C.G.A. Sec.
33-2-9.
