Basically, "Creditable Coverage"  is health  insurance coverage. It is a concept created by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is relevant in two instances:

• HIPAA provides that when you obtain health insurance from a new employer, you cannot be subjected to a waiting period during which your existing health condition will not be covered if you previously had what is referred to as "Creditable Coverage." 
• HIPAA also provides that if you lose your employer based health insurance you can convert to an individual health insurance policy.

In both instances, the protections are triggered by having a history of "Creditable Coverage." Proof of that history is contained in a Certificate of Creditable Coverage.

NOTE: If a new employer or insurer do not ask about prior coverage, submit the Certificate voluntarily. (We provide a sample cover letter.) It will save a time delaying hassle if you have a claim.

For additional information, see:

• General
  • What is Creditable Coverage?
  • How does Creditable Coverage benefit me?
  • How do I prove my Creditable Coverage?
  • What do I do with the Certificate when I get it?
• A Certificate of Creditable Coverage
  • How do I get a Certificate of Creditable Coverage?
  • What should be in a Certificate of Creditable Coverage?
  • When will I receive a Certificate of Creditable Coverage?
  • What if I don't receive a Certificate of Creditable Coverage?
• Frequently Asked Questions
  • What if I was with my last employer for less than 18 months?
  • What if my prior insurance wasn't as comprehensive as the new one?

Creditable coverage is health insurance coverage of almost any type. Creditable coverage includes health coverage under:

• A group health plan, whether the plan is through an insurance company or is self insured by the employer
• An individual health insurance policy of almost every type, including fee-for-service (indemnity) plans, HMOs, PPOs, and POS.(For more information on these plans, see Health Insurance). Policies which cover hospitalization, but not medical services are included. Limited benefit Hospital Indemnity-type plans that pay, for example $100 per day of hospital confinement, do not count as Creditable Coverage
• COBRA (provided the COBRA coverage occurred without a break in coverage of 63 days or more).
• Medicare
• Medicaid
• Federal Employees Health Benefits
• Coverage under the Indian Health Service
• Coverage through the Peace Corps
• A state health insurance high risk pool
• Military health insurance (CHAMPUS)
• Health coverage provided by a government entity such as Guam's StayWell Insurance or even a foreign country's national health plan

If you want to move from one employer to another

HIPAA does not require that your new employer offer you health insurance. It merely provides what happens if the new employer with 2 or more employees offers health insurance to people in a position similar to yours.

If your new employer would normally offer health insurance to someone in your position, the employer cannot refuse to give it to you because of your medical history or current medical condition. 

The amount of time you had Creditable Coverage can be applied to the Pre-Existing Conditions Waiting Period of your new employer's health insurance. (See HIPAA- Pre-Existing Conditions and HIPAA- Portability.)

If you want to leave your employer and obtain individual coverage

By having a history of Creditable Coverage for at least 18 months, the last day of which was group insurance or group insurance extended under COBRA, you have the right under HIPAA to purchase an individual health insurance plan.

Which plan you can purchase depends on the state in which you reside. In some states your only right is to purchase coverage from a state plan. In the others, you have the right to purchase insurance from any insurance company offering health insurance in your state upon losing the group coverage. To learn more, see: Obtaining Health Insurance.)

HIPAA does not guarantee you the right to purchase an individual policy:

• if you already have other health insurance including Medicare or Medicaid or if you are eligible for Medicare or Medicaid.
• If you are leaving another individual health insurance plan. For example, if you are leaving one state in which you have your own HMO coverage, HIPAA does not guarantee you the right to purchase health insurance in another state. If you need coverage in this circumstance, see Obtaining Health Insurance.

HIPAA provides that you must prove your Creditable Coverage with a Certificate of Creditable Coverage. The easiest method of proof is a certificate from the group where you had your coverage. HIPAA requires that you be given such a certificate.  If you cannot get it from the group, contact the insurer.

Under HIPAA, a plan must issue a Certificate of Creditable Coverage:

• Automatically upon your loss of coverage for any reason. For example, if you drop your coverage because you elect to be covered under a spouse's health plan or you terminate employment, or your coverage under COBRA expires.
• Upon your request at any time within 24 months after coverage under the plan ends (including requests prior to termination of coverage).

You have a right to request a Certificate of Creditable Coverage at any time, including up to 24 months after coverage under the plan ends -- no matter what kind of plan you had or whether it was continued under COBRA or similar laws.

You can contact the administrator of the former plan and request a Certificate. If the creditable coverage was insured or provided through an HMO, you can also contact the insurer or HMO for a certificate. (The law requires both the plan and the "issuer" (insurer or HMO) to provide a certificate).

Since the 63 day period is critical if you are going from employer to employer, or employer to individual coverage, keep in mind that the period starts the day you lose coverage, not the date you get your Certificate.

First of all, don't look for a real certificate. Even though they're called certificates, don't expect something with a fancy border that's suitable for framing. A Certificate of Creditable Coverage is usually just a computer generated letter that gives the start and stop dates of your coverage.

No matter what form is used, it must contain the following information:

• The date coverage was started.
• The name of the group plan providing the coverage.
• The name of the employee or dependent to which the Certificate applies as well as any information needed to identify the person under the plan such as the plan Identification numbers or, for dependents, the employee's name.
• The name, address, and telephone number of the plan or insurer required to provide the certificate.
• A telephone number to call for further information if the telephone number is different than the phone number of the plan or insurer required to provide the Certificate.
• Either (1) a statement that the person has at least 18 months creditable coverage without a significant break or (2) the date any waiting period began and the date Creditable Coverage began.
• The date Creditable Coverage ended or an indication that it is still continuing.

A single Certificate may provide information for the participant and dependents even if the information is different, as long as the different information is separately stated.

Certificates of Creditable Coverage must be issued within 14 days following termination of coverage. Certificates must be provided in writing to the person losing coverage unless:

• The person losing coverage requests it be sent to another party (such as the new insurance carrier); and
• The receiving party agrees to accept the information in another form.

According to HIPAA, your last insurance company is required to track your coverage history for at least 18 months prior to a potential loss of coverage and retain records of such coverage for at least 24 months after your coverage ends.

However, if the Certificate you receive doesn't show a full 18 months of coverage even though you had coverage for those 18 months, you will need to contact both the last insurance company and the company that had the prior plan to get an additional certificate that will show a total of 18 months.

HIPAA allows health plans the option of refusing to give complete "credit" for prior coverage that was less comprehensive than the coverage under the new plan.

HIPAA requires that basic health care be credited. Beyond that, HIPAA allows employers to break down health coverage into 5 types of services:

• Mental health services
• Substance abuse treatment
• Prescription drugs
• Dental care
• Vision care

Employers can impose separate pre-existing condition exclusions for each of the five types of services. If the prior plan did not cover one of those services, a new employer may impose a Pre-Existing Conditions Waiting Period but only on those services that were not covered under the prior plan.

For example, Jennie takes medication for high cholesterol. She moved from one job to another. The health insurance under her old job did not cover prescription drugs. The new plan has to give her credit for the old coverage towards the Pre-Existing Waiting Period except that the new plan can provide that coverage for her medications is postponed until she has been covered for 12 months since her prior plan did not cover prescriptions.

Although you should receive a Certificate of Creditable Coverage automatically, if you don't receive one, contact the Plan Administrator of the former plan. You can also contact the insurer or HMO for a certificate if the creditable coverage was insured or provided by an HMO.

If you receive resistance, consider reminding the person that the law provides you have a right to the Certificate at any time.

If the plan was insured, also consider speaking with the insurance broker or agent for your employer. He or she should be able to contact the right people at the insurance company and get you a Certificate. Of course if you haven't told the employer yet that you're leaving, consider waiting to obtain the Certificate until you do.

Generally, you need to present the Certificate Of Coverage to the new insurance company as proof that you are eligible for the HIPAA benefits.

To avoid a new Pre-Existing Conditions Waiting Period.

Call the new employer's insurance company. Tell them that you have a Certificate of Creditable Coverage and want to send it to them so they will waive the Pre-Existing Conditions Waiting Period. Ask for a name and mailing address. Send it in a manner that provides proof of receipt (such as registered mail, return, receipt requested or via an overnight service.) Include a cover letter which:

• Identifies you and your employer.
• States you are enclosing a Certificate of Creditable Coverage.
• Mention the number of months covered by the Certificate.
• Includes a telephone number in case the company has to contact you.

To obtain individual coverage due to HIPAA.

Present the Certificate of Creditable Coverage to the insurance company providing the individual policy. A reminder: You must start the new coverage within 63 days of the old coverage terminating for the full HIPAA protections to apply.

If an insurance company follows the general practice and does not request information about your previous coverage at enrollment, you're not out of the water. The standard practice is for health insurance companies to wait until a claim is submitted, then examine it to see if the claim relates to a "pre-existing" condition. If it does, many companies just go ahead and deny claims relating to pre-existing conditions and leave it to you to show that it should be covered.

To avoid that delay and hassle, we suggest:

• As soon as you become covered under a new plan, call the Claims office of the new insurance company. The telephone number will be on your insurance ID card.
• Tell the claims person that you are newly insured and want to provide the insurance company with your Certificate of Creditable Coverage so any pre-existing claims will not be denied.
• Don't let the person at the insurance company distract you with questions about a particular condition and whether or not it's pre-existing. You just want to present the Certificate so the issue does not come up at a later time.
• Ask for a name and mailing address of the person to whom the Certificate should be sent.
• Make a copy of the Certificate for yourself. Then send the original of the Certificate via a means by which you can get a receipt showing delivery (by Registered mail, Return Receipt Requested or by an overnight service), with a cover letter such as the following sample: