Department of Civil Service

NY97-26
PE97-22
PA97-12

TO: Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)
DATE: September 23, 1997

Requirement

The Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that certificates of creditable coverage be provided to individuals and their dependents who meet the following criteria:

1. those who disenroll from a group plan or
2. those who become covered under COBRA or
3. those who leave or exhaust their COBRA benefits or
4. those who lose coverage under a group health plan or insurer.

The provision of a certificate may enable an individual to reduce a pre-existing condition exclusion imposed on the individual by any subsequent group plan.

Automatic Certificate Issuance

Empire Blue Cross Blue Shield has responsibility for providing certificates for the Empire Plan. HMOs will provide HIPAA certificates for their members who lose coverage. Agencies will not issue HIPAA certificates nor will they have to assist in the certificate preparation process in any way.

Timely Transaction Processing

It is extremely important that health insurance termination transactions be completed in a timely manner so that HIPAA certificates can be mailed promptly.

When HIPAA Certificates Are Produced

Enrollees will receive HIPAA certificates every time they lose coverage under a plan. This includes option changes and cancellations for non-payment during leave without pay. Former employees who lose NYSHIP eligibility will receive a HIPAA certificate after termination and, if they choose COBRA coverage, another when COBRA coverage terminates.

HIPAA certificates will be generated on or about the 15th of each month by Empire Blue Cross Blue Shield; HMOs may have different schedules.

Information Included on Certificates

Certificates will show the name of the group plan, the name of the subscriber and/or dependent to whom the certificate applies and the effective and termination dates of the most recent period(s) of coverage.

Breaks In Coverage

If a break of coverage of more than 63 days has occurred, only the most recent coverage after the 63 day break will be listed.

First Mailing

September 19th Empire Blue Cross Blue Shield will begin sending certificates to all enrollees who lost coverage between July 1, 1996 and July 1, 1997. The certificates will not contain information on the length of new employment waiting periods. If the coverage reported on the certificate is less than 18 months employees may ask HBAs for this information. Time spent in a new employment waiting period may also be used to offset a pre-existing condition waiting period.

Sample Certificate

A sample certificate for the Empire Plan is attached. HMO HIPAA certificates will be similar.

Requested Certificates

In addition to the automatic certificate, HIPAA also requires that a certificate be provided upon the request of, or on behalf of, an individual. When the request is made within 24 months after the individual loses coverage under the plan. The certificate is required to be provided at the earliest time that the plan or issuer, acting in a reasonable and prompt fashion, can provide the certificate.

How Individuals Request Empire Plan Certificates

Former NYSHIP participants wishing additional certificates should contact Empire Blue Cross Blue Shield for Empire Plan certificates or their former HMO for periods of HMO coverage. Former Empire Plan enrollees seeking certificates should call:

Empire Blue Cross Blue Shield at 1-800-342-9815 or 518-367-0009; or, they may write to:

Empire Blue Cross Blue Shield
New York State Service Center
P0 Box 11815
11 Corporate Woods Boulevard
Albany, New York 12211-0815

How to Request HMO Certificates

Former HMO enrollees should contact the HMO.

Requests for HIPAA certificates should not be sent to the Department of Civil Service.

Pre-existing Conditions

Since NYSHIP does not impose any pre-existing condition exclusion periods, no certificate of coverage from prior plans is necessary when an individual is enrolled in the New York State Health Insurance Program. In addition, it is not necessary for you to request, or to save, HIPAA certificates from other employers. We are reviewing our late enrollment waiting periods and their relationship to HIPAA; if a change is necessary, you will be notified.

Former enrollees seeking information on the pre-existing condition implications of HIPAA should be told to discuss it with their new group plan.

HIPAA Interim Regulations

The recently issued HIPAA regulations are interim final regulations. If the final regulations require any changes to our procedures, we will notify you.

Questions? Contact Program Services Staff

If you have any questions regarding the above, please contact our Program Services Unit at (518) 457-5754 (Albany area) or 1-800-833-4344 then press 1-6-7-2 to speak with a representative.

IMPORTANT NOTICE

This notice is to inform you of recent changes in Federal law that may affect you if you are enrolled or become eligible to enroll in a health plan that excludes coverage for preexisting medical conditions.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage rnay be excluded for preexisting medical conditions present before you enroll. Under the law, a preexisting condition exclusion generally may not be imposed for more than 12 months (18 months for late enrollees). The 12 month (or 18 month) exclusion period is reduced by your prior aggregate health coverage. Beginning June 1, 1997, we are required to provide a Certificate of Prior Coverage to individuals (and their dependents) who disenroll from a group plan, become covered under COBRA and those who leave or exhaust their COBRA benefits. Please contact your State Insurance Department for more information regarding the law. If you or your dependents are not currently covered by Empire Blue Cross Blue Shield, check with your new plan administrator to see if you need to provide a certificate or other documentation of previous coverage.

Enclosed you will find an Empire Blue Cross Blue Shield Certificate of Prior Coverage which provides pertinent information regarding your most recent period of coverage. If you have changed employers or have otherwise disenrolled from your group health plan more than once since October 1, 1996 you may receive more than one Certificate. Each Certificate provides evidence of creditable coverage whlch may or may not be cumulative depending on the amount of time between periods of coverage. Keep the enclosed Certificate for your records.

CERTIFICATE OF GROUP HEALTH PLAN COVERAGE

09/15/1997

Important - This certificate provides evidence of 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 6-month period prior to 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 family, an insurance policy that does not exclude coverage for medical conditions that are present before you enroll.

1. Name of Group Health Plan
2. Name of Subscriber:
3. Identification or Contract Number of Subscriber:
4. Name of Subscriber and/or dependents to whom this certificate applies:

Subscriber Name:

Coverage Effective Date:

Coverage Termination Date:

IF DEPENDENT(S) WERE ON FILE, PLEASE SEE REVERSE SIDE.

5. Name and address of issuer responsible for providing this certification:

Empire Blue Cross Blue Shield
NEW YORK STATE SERVICE CENTER
11 CORPORATE WOODS BOULEVARD
ALBANY, NEW YORK 12211-2345

This certificate does not contain information about employment new hire waiting periods that you may have served. If the coverage period reported on this certificate is less than 18 months, you should contact your former employing agency for a report of any new employee waiting period served prior to the start of this coverage. These waiting periods may also be used to reduce a pre-existing condition exclusion period in the new plan.

NOTE: This certificate only reflects the effective and termination dates of your most recent period of coverage under the Empire Plan. If you need to obtain documentation of previous periods of Empire Plan coverage, please call l-800-342-9815 or 518-367-0009.

If you need to obtain documentation of periods of coverage by an HMO under the NYS Health Insurance Program, please call the HMO directly.