Wisconsin Health Insurance Credible Coverage and Administrative Simplification

What is Creditable Coverage?

As described in the section titled, "What is Portability?" any preexisting condition waiting period under a group health benefit plan must be reduced by the period of time an individual had prior "creditable coverage," provided there is not a break in coverage longer than 62 days. Creditable coverage includes another group or individual health plan, governmental plans including Medicare and Medicaid, military coverage, a state high-risk plan, and coverage provided through the Indian Health Service, the federal Peace Corps Act, and other public health plans. Creditable coverage does not include plans consisting solely of coverage of excepted benefits, such as vision and dental. Periods of creditable coverage are established and portability is obtained under a group health benefit plan when an individual presents the plan a certificate of creditable coverage or other proof of having prior or current creditable coverage, such as premium receipts, pay stubs, etc., at the time of enrollment.

Certificates of Creditable Coverage

Insurers that provide health benefit plan coverage must provide to an individual a certificate of creditable coverage when the individual ceases to be covered under a health benefit plan or when the individual becomes eligible for federal group continuation coverage. A certificate of creditable coverage must again be provided to the individual at the end of federal group continuation coverage, and also upon the request of an individual if made within 24 months after an individual's coverage ceases. The certificate of creditable coverage must include the period of time the individual was covered under the health benefit plan, and the waiting period, if any, under the plan.

How Does Administrative Simplification Apply to Me?

HIPAA's administrative simplification provisions establish standards regarding electronic transactions, privacy protections of protected health information (PHI), and security protections for electronically maintained information. The administrative simplification requirements are designed to streamline and simplify the health care payment system by requiring that insurance companies and health care providers use the HIPAA standards for transmitting and processing claims. These standards are meant to protect your health information during the handling, storage, and processing of your insurance claims.