Section 191.35.28. Certificates of creditable coverage.

       35.28(1) Group health plans, carriers, or ODSs shall issue certificates of creditable coverage to persons losing coverage. A group health plan, carrier, or ODS required to provide a certificate under this rule for an individual is deemed to have satisfied the certification requirements for that individual if another party provides the certificate, 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. Certificates shall be issued within a reasonable amount of time following termination to employees and dependents:

        a.           Automatically upon the termination of an individual’s group coverage;

        b.           Automatically upon the termination of COBRA coverage;

        c.           Upon request within 24 months after coverage ends.

       35.28(2) Certificates in writing. Certificates of coverage must be in writing unless all of the following conditions are met:

        a.           The individual requesting the certificate is not entitled to receive a certificate;

        b.           The individual requests that the certificate be sent to another plan, carrier, or ODS;

        c.           The plan, carrier, or ODS receiving the certificate agrees to accept the information through means other than a written certificate;

        d.           The plan or carrier receiving the certificate receives the certificate within a reasonable amount of time.

       35.28(3) Required information. The certificate shall include the following information:

        a.           The date the certificate is issued;

        b.           The name of the group plan providing coverage;

        c.           The name of the employee or dependent to whom the certificate applies, other relevant identifying information, and the name of the employee if the certificate is for a dependent;

        d.           The plan administrator’s name, address and telephone number;

        e.           A telephone number to call for further information if different from above;

        f.            Either a statement that the person has at least 18 months’ creditable coverage without a significant break of coverage or the date any waiting period and creditable coverage began;

        g.           The date creditable coverage ended or an indication that the coverage is in force.

       35.28(4) Family information. Information for families may be combined on one certificate. Any differences in creditable coverages shall be clearly delineated.

       35.28(5) Dependent coverage transition rule. A group health plan, carrier, or ODS that does not maintain dependent data is deemed to have satisfied the requirement to issue dependent certificates by naming the employee and specifying that the coverage on the certificate is for dependent coverage.

       35.28(6) Delivering certificates. The certificate shall be given to the individual, plan, carrier, or ODS requesting the certificate. The certificates may be sent by first-class mail. When a dependent’s last-known address differs from the employee’s last-known address, a separate certificate shall be provided to the dependent at the dependent’s last-known address. Separate certificates may be mailed together to the same location.

      35.28(7) A group health plan, carrier, or ODS shall establish a procedure for individuals to request and receive certificates.

       35.28(8) A certificate is not required to be furnished until the group health plan, carrier, or ODS knows or should have known that dependent’s coverage terminated.

       35.28(9) Demonstrating creditable coverage. An individual has the right to demonstrate creditable coverage, waiting periods, and affiliation periods when the accuracy of the certificate is contested or a certificate is unavailable. A group health plan, carrier, or ODS shall consider information obtained by it or presented on behalf of an individual to determine whether the individual has creditable coverage.