Creditable Health Insurance

Purpose

To provide process steps on determining if an insurance is creditable.

Intended Audience

CHIP Unit (CU) and Self Reliance Staff.

Overview

The CHIP Unit is responsible for processing the Creditable Insurance Determination requests from the Regional SRS staff to determine if a family or child has private pay insurance that falls within the definition of creditable insurance.

“Most health coverage is creditable coverage, including prior coverage under a group health plan (including governmental or church plan), health insurance coverage (either group or individual), Medicare, Medicaid, a military-sponsored health care program, a State high risk pool, the Federal Employee Health Benefit program, a public health plan, and a health benefit plan provided for Peace Corps members.  Creditable coverage does not include coverage consisting solely of expected benefits such as coverage only for accidents, disability income insurance, liability insurance, supplemental policies to liability insurance, worker’s compensation insurance, automobile medical payment insurance, credit-only insurance, coverage for on-site medical clinics, or limited-scope dental, vision, or long-term care insurance.”  Health Insurance Portability and Accountability Act of 1996.

To view rules affecting determination of Creditable Insurance visit the following web pages

• Idaho Department of Administrative Procedures http://www2.state.id.us/adm/adminrules/rules/idapa16/0301.pdf

• Code of Federal Regulations http://frwebgate.access.gpo.gov/cgi-bin/get-cfr.cgi

WHAT HEALTH INSURANCE IS "CREDITABLE"?

Most health coverage is creditable coverage. Coverage under any of the plans listed below is creditable coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA):

• A group health plan. Group health plans include governmental or church plans. This is an employee health benefit plan. It provides medical care to employees or their dependents:

  • Directly,

  • Through insurance,

  • Reimbursement, or

  • Other methods.

• Group or individual health insurance coverage. This provides medical care under a:

  • Hospital or medical service policy or certificate,

  • Hospital or medical service plan contract, or

  •  HMO contract officer by a health care issuer.

• Part A or B of Medicare,

•  Medicaid coverage,

• CHAMPUS. This is medical and dental care for members of the uniformed services, or their dependents. CHAMPUS is a military-sponsored health care program.

•  A state health benefits risk pool,

•  Federal Employees Health Benefits Program,

•  A health benefit plan provided for Peace Corps members, or

• A health insurance plan of a state, county, or other political subdivision of a state.

 WHAT HEALTH INSURANCE IS NOT CREDITABLE?

Coverage consisting solely of the following benefits is not creditable coverage:

• Excepted benefits, such as coverage only for accidents,

•  Disability income insurance,

•  Liability insurance,

•  Supplemental policies to liability insurance,

•  Workers' compensation insurance,

• Automobile medical payment insurance,

• Credit-only insurance,

• Coverage for on-site medical clinics,

•  Limited-scope dental, vision, or long-term care insurance, or

• Sports participation insurance.

QUESTIONS TO ASK TO DETERMINE CREDITABLE HEALTH INSURANCE:

What type of health coverage does the child currently have?

•      Group Plan (employer or state/federal coverage),

•      Individual Plan, or

•      Military.

What areas of coverage does the plan include?

•      Inpatient Hospital Care,

•      Outpatient Hospital Care,

•      Physician Services, or

•      Lab and X-Ray Services.

Process

Determination Process

1.    The Regional SRS staff is responsible for completing the CHIP Verification Form, called Request for Creditable Insurance Determination and faxing it to the CHIP Unit.  Include a copy of the client’s insurance card.   If the SRS does not send a copy of the card, call or email the SRS to request the required information from the family. If the family does not cooperate with the SRS in obtaining the information, the case is closed due to noncompliance,

2.       Upon receipt of the Verification form, the CHIP Unit contacts the insurance company and asks the following questions:

• “I am calling to verify if (the parent’s name) has the following children listed on their insurance policy...”

• (If an active policy) “ I need to verify that the policy includes the following benefits” In-Patient care, Out-Patient care, Lab/X-Ray services, and Physician services.”

•  CHIP Unit does not need to verify if the policy covers pharmacy benefits, vision benefits, dental benefits, or to inquire what is the client’s deductible or co-pay. The deductible/co-pay and the pharmacy, dental vision services are not to be considered when making a creditable insurance determination.

• However, if a child is covered by a managed care plan that does not offer services in the area the child resides, the insurance should not be determined not creditable.  For example, if a non-custodial parent has a child on HMO coverage in California, but child lives in Twin Falls.  If the HMO plan does not have a service provider in Twin Falls, the child does not have access to creditable coverage.

3.     If the private insurance does cover all of the required services, the verification form is marked as being a creditable insurance.  If the policy does not include all of the required benefits, the verification form is marked as being not creditable,

4.    The form must be signed, dated, and faxed back to the requesting SRS within five working days.  A cover sheet should accompany the determination.  Include the date faxed and the SRS’ name and fax number,

5.      Email the SRS worker to let them know that a the determination was sent and have them call if they do not receive the fax,

6.      Once the determination is faxed place a copy and fax coversheet in the appropriate month’s creditable determination file,

7.      If there are any questions about determining creditability, they should be referred to the CHIP Unit Supervisor, and

8.      If unable to complete the form within five days, contact the SRS by phone or e-mail to notify them of the status.

Creditable Determination Records

1.     Create a file for each month to include all verifications.

2.     Collate the following information for each verification and fasten together:

• Original verification form,

• Fax cover sheet,

• Decision of the Creditability determination, and

• Correspondence with the SRS or insurance company.

3.    Keep records for a minimum of five years.

4.   The CHIP Unit will fax a copy of each verification to Robin Pewtress, Medicaid Policy for tracking and reporting. 

Creditable Health Insurance Form