Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter K - CERTIFICATION OF CREDITABLE COVERAGE
Section 21.1107 - Creditable Coverage Established Through Means Other Than Written Certificate

Universal Citation: 28 TX Admin Code § 21.1107

Current through Reg. 50, No. 13; March 28, 2025

(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.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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