MODEL CERTIFICATION OF CREDITABLE HEALTH CARE COVERAGE

The following model certification of creditable coverage was released jointly by the Internal Revenue Service, the Department of Labor and the Department of Health and Human Services in the preamble to the interim final regulations explaining how the agencies will enforce the portability and accessibility requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The model certification may be used to meet a group health plan's or an insurer's duty to provide a certificate of creditable coverage when an individual loses coverage under a group health plan or when COBRA continuation coverage ends.

IMPORTANT--This certificate provides evidence of your prior health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll. This certificate may need to be provided if medical advice, diagnosis, care or treatment was recommended or received for the condition within the six-month period prior to your enrollment in the new plan. If you become covered under another group health plan, check with the plan administrator to see if you need to provide this certificate. You may also need this certificate to buy, for yourself or your family, an insurance policy that does not exclude coverage for medical conditions that are present before you enroll.

1.       Date of this certificate:___________________________________

2.       Name of group health plan:__________________________________

3.       Name of participant:________________________________________

4.       Identification number of participant:_______________________

5.       Names of any dependents to whom this certificate applies:__________

6.       ____________________________________________________________

7.       Name, address and telephone number of plan administrator or issuer responsible for providing this certificate:
____________________________________
____________________________________
____________________________________

8.       For further information, call:______________________________

9.       If the individuals identified in line 3 and line 5 have at least 18 months of creditable coverage (disregarding periods of coverage before a 63-day break), check here _____ and skip lines 9 and 10.

10.   Date waiting period or affiliation period (if any) began:____________________________

11.   Date coverage began:____________

12.   Date coverage ended:____________(or check if coverage is continuing as of the date of this certificate:____)

Note: Separate certificates will be furnished if information is not identical for the participant and each beneficiary.

Reprinted with permission. © CCH