[Code of Federal Regulations]
[Title 26, Volume 17]
[Revised as of April 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 26CFR54.9801-5T]

[Page 365-373]
 
                       TITLE 26--INTERNAL REVENUE
 
    CHAPTER I--INTERNAL REVENUE SERVICE, DEPARTMENT OF THE TREASURY 
                               (CONTINUED)
 
PART 54_PENSION EXCISE TAXES--Table of Contents
 
Sec. 54.9801-5T  Certification and disclosure of previous coverage (temporary).

    (a) Certificate of creditable coverage--(1) Entities required to 
provide certificate--(i) In general. A group health plan is required to 
furnish certificates of creditable coverage in accordance with this 
paragraph (a). (See PHSA section 2701(e) and ERISA section 701(e) under 
which this obligation is also imposed on a health insurance issuer 
offering group health insurance coverage.)

[[Page 366]]

    (ii) Duplicate certificates not required. An entity required to 
provide a certificate under this paragraph (a)(1) 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. For 
example, a group health plan is deemed to have satisfied the 
certification requirement with respect to a participant or beneficiary 
if any other entity actually provides a certificate that includes the 
information required under paragraph (a)(3) of this section with respect 
to the participant or beneficiary.
    (iii) Special rule for group health plans. To the extent coverage 
under a plan consists of group health insurance coverage, the plan is 
deemed to have satisfied the certification requirements under this 
paragraph (a)(1) if any issuer offering the coverage is required to 
provide the certificates pursuant to an agreement between the plan and 
the issuer. For example, if there is an agreement between an issuer and 
the employer sponsoring the plan under which the issuer agrees to 
provide certificates for individuals covered under the plan, and the 
issuer fails to provide a certificate to an individual when the plan 
would have been required to provide one under this paragraph (a), then 
the plan does not violate the certification requirements of this 
paragraph (a) (though the issuer would have violated the certification 
requirements pursuant to section 2701(e) of the PHSA and section 701(e) 
of ERISA).
    (iv) Special rules relating to issuers providing coverage under a 
plan--(A)(1) Responsibility of issuer for coverage period. See 29 CFR 
2590.701-5 and 45 CFR 146.115, under which an issuer is not required to 
provide information regarding coverage provided to an individual by 
another party.
    (2) Example. The rule referenced by this paragraph (a)(1)(iv)(A) is 
illustrated by the following example:

    Example. (i) A plan offers coverage with an HMO option from one 
issuer and an indemnity option from a different issuer. The HMO has not 
entered into an agreement with the plan to provide certificates as 
permitted under paragraph (a)(1)(iii) of this section.
    (ii) In this Example, if an employee switches from the indemnity 
option to the HMO option and later ceases to be covered under the plan, 
any certificate provided by the HMO is not required to provide 
information regarding the employee's coverage under the indemnity 
option.

    (B) (1) Cessation of issuer coverage prior to cessation of coverage 
under a plan. If an individual's coverage under an issuer's policy 
ceases before the individual's coverage under the plan ceases, the 
issuer is required (under section 2701(e) of the PHSA and section 701(e) 
of ERISA) to provide sufficient information to the plan (or to another 
party designated by the plan) to enable a certificate to be provided by 
the plan (or other party), after cessation of the individual's coverage 
under the plan, that reflects the period of coverage under the policy. 
The provision of that information to the plan will satisfy the issuer's 
obligation to provide an automatic certificate for that period of 
creditable coverage for the individual under paragraph (a)(2)(ii) and 
(3) of this section. In addition, an issuer providing that information 
is required to cooperate with the plan in responding to any request made 
under paragraph (b)(1) of this section (relating to the alternative 
method of counting creditable coverage). If the individual's coverage 
under the plan ceases at the time the individual's coverage under the 
issuer's policy ceases, the issuer must provide an automatic certificate 
under paragraph (a)(2)(ii) of this section. An issuer may presume that 
an individual whose coverage ceases at a time other than the effective 
date for changing enrollment options has ceased to be covered under the 
plan.
    (2) Example. The rule of this paragraph (a)(1)(iv)(B) is illustrated 
by the following example:

    Example. (i) A group health plan provides coverage under an HMO 
option and an indemnity option with a different issuer, and only allows 
employees to switch on each January 1. Neither the HMO nor the indemnity 
issuer has entered into an agreement with the plan to provide 
certificates as permitted under paragraph (a)(1)(iii) of this section.
    (ii) In this Example, if an employee switches from the indemnity 
option to the HMO option on January 1, the issuer must provide

[[Page 367]]

the plan (or a person designated by the plan) with appropriate 
information with respect to the individual's coverage with the indemnity 
issuer. However, if the individual's coverage with the indemnity issuer 
ceases at a date other than January 1, the issuer is instead required to 
provide the individual with an automatic certificate.

    (2) Individuals for whom certificate must be provided; timing of 
issuance--(i) Individuals. A certificate must be provided, without 
charge, for participants or dependents who are or were covered under a 
group health plan upon the occurrence of any of the events described in 
paragraph (a)(2)(ii) or (iii) of this section.
    (ii) Issuance of automatic certificates. The certificates described 
in this paragraph (a)(2)(ii) are referred to as automatic certificates.
    (A) Qualified beneficiaries upon a qualifying event. In the case of 
an individual who is a qualified beneficiary (as defined in section 
4980B(g)(1)) entitled to elect COBRA continuation coverage, an automatic 
certificate is required to be provided at the time the individual would 
lose coverage under the plan in the absence of COBRA continuation 
coverage or alternative coverage elected instead of COBRA continuation 
coverage. A plan satisfies this requirement if it provides the automatic 
certificate no later than the time a notice is required to be furnished 
for a qualifying event under section 4980B(f)(6) (relating to notices 
required under COBRA).
    (B) Other individuals when coverage ceases. In the case of an 
individual who is not a qualified beneficiary entitled to elect COBRA 
continuation coverage, an automatic certificate is required to be 
provided at the time the individual ceases to be covered under the plan. 
A plan satisfies this requirement if it provides the automatic 
certificate within a reasonable time period thereafter. In the case of 
an individual who is entitled to elect to continue coverage under a 
State program similar to COBRA and who receives the automatic 
certificate not later than the time a notice is required to be furnished 
under the State program, the certificate is deemed to be provided within 
a reasonable time period after the cessation of coverage under the plan.
    (C) Qualified beneficiaries when COBRA ceases. In the case of an 
individual who is a qualified beneficiary and has elected COBRA 
continuation coverage (or whose coverage has continued after the 
individual became entitled to elect COBRA continuation coverage), an 
automatic certificate is to be provided at the time the individual's 
coverage under the plan ceases. A plan satisfies this requirement if it 
provides the automatic certificate within a reasonable time after 
coverage ceases (or after the expiration of any grace period for 
nonpayment of premiums). An automatic certificate is required to be 
provided to such an individual regardless of whether the individual has 
previously received an automatic certificate under paragraph 
(a)(2)(ii)(A) of this section.
    (iii) Any individual upon request. Requests for certificates are 
permitted to be made by, or on behalf of, an individual within 24 months 
after coverage ceases. Thus, for example, a plan in which an individual 
enrolls may, if authorized by the individual, request a certificate of 
the individual's creditable coverage on behalf of the individual from a 
plan in which the individual was formerly enrolled. After the request is 
received, a plan or issuer is required to provide the certificate by the 
earliest date that the plan, acting in a reasonable and prompt fashion, 
can provide the certificate. A certificate is required to be provided 
under this paragraph (a)(2)(iii) even if the individual has previously 
received an automatic certificate under paragraph (a)(2)(ii) of this 
section.
    (iv) Examples. The following examples illustrate the rules of this 
paragraph (a)(2):

    Example 1. (i) Individual A terminates employment with Employer Q. A 
is a qualified beneficiary entitled to elect COBRA continuation coverage 
under Employer Q's group health plan. A notice of the rights provided 
under COBRA is typically furnished to qualified beneficiaries under the 
plan within 10 days after a covered employee terminates employment.
    (ii) In this Example 1, the automatic certificate may be provided at 
the same time that A is provided the COBRA notice.
    Example 2. (i) Same facts as Example 1, except that the automatic 
certificate for A is

[[Page 368]]

not completed by the time the COBRA notice is furnished to A.
    (ii) In this Example 2, the automatic certificate may be provided 
within the period permitted by law for the delivery of notices under 
COBRA.
    Example 3. (i) Employer R maintains an insured group health plan. R 
has never had 20 employees and thus R's plan is not subject to the COBRA 
continuation coverage provisions. However, R is in a State that has a 
State program similar to COBRA. B terminates employment with R and loses 
coverage under R's plan.
    (ii) In this Example 3, the automatic certificate may be provided 
not later than the time a notice is required to be furnished under the 
State program.
    Example 4. (i) Individual C terminates employment with Employer S 
and receives both a notice of C's rights under COBRA and an automatic 
certificate. C elects COBRA continuation coverage under Employer S's 
group health plan. After four months of COBRA continuation coverage and 
the expiration of a 30-day grace period, Employer S's group health plan 
determines that C's COBRA continuation coverage has ceased due to 
failure to make a timely payment for continuation coverage.
    (ii) In this Example 4, the plan must provide an updated automatic 
certificate to C within a reasonable time after the end of the grace 
period.
    Example 5. (i) Individual D is currently covered under the group 
health plan of Employer T. D requests a certificate, as permitted under 
paragraph (a)(2)(iii) of this section. Under the procedure for Employer 
T's plan, certificates are mailed (by first class mail) 7 business days 
following receipt of the request. This date reflects the earliest date 
that the plan, acting in a reasonable and prompt fashion, can provide 
certificates.
    (ii) In this Example 5, the plan's procedure satisfies paragraph 
(a)(2)(iii) of this section.

    (3) Form and content of certificate--(i) Written certificate--(A) In 
general. Except as provided in paragraph (a)(3)(i)(B) of this section, 
the certificate must be provided in writing (including any form approved 
by the Secretary as a writing).
    (B) Other permissible forms. No written certificate is required to 
be provided under paragraph (a) with respect to a particular event 
described in paragraph (a)(2) (ii) or (iii) of this section if----
    (1) An individual is entitled to receive a certificate;
    (2) The individual requests that the certificate be sent to another 
plan or issuer instead of to the individual;
    (3) The plan or issuer that would otherwise receive the certificate 
agrees to accept the information in this paragraph (a)(3) through means 
other than a written certificate (e.g., by telephone); and
    (4) The receiving plan or issuer receives such information from the 
sending plan or issuer in such form within the time periods required 
under paragraph (a)(2) of this section.
    (ii) Required information. The certificate must include the 
following----
    (A) The date the certificate is issued;
    (B) The name of the group health plan that provided the coverage 
described in the certificate;
    (C) The name of the participant or dependent with respect to whom 
the certificate applies, and any other information necessary for the 
plan providing the coverage specified in the certificate to identify the 
individual, such as the individual's identification number under the 
plan and the name of the participant if the certificate is for (or 
includes) a dependent;
    (D) The name, address, and telephone number of the plan 
administrator or issuer required to provide the certificate;
    (E) The telephone number to call for further information regarding 
the certificate (if different from paragraph (a)(3)(ii)(D) of this 
section);
    (F) Either--
    (1) A statement that an individual has at least 18 months (for this 
purpose, 546 days is deemed to be 18 months) of creditable coverage, 
disregarding days of creditable coverage before a significant break in 
coverage, or
    (2) The date any waiting period (and affiliation period, if 
applicable) began and the date creditable coverage began; and
    (G) The date creditable coverage ended, unless the certificate 
indicates that creditable coverage is continuing as of the date of the 
certificate.
    (iii) Periods of coverage under certificate. If an automatic 
certificate is provided pursuant to paragraph (a)(2)(ii) of this 
section, the period that must be included on the certificate is the last 
period of continuous coverage ending on the date coverage ceased. If an 
individual requests a certificate pursuant

[[Page 369]]

to paragraph (a)(2)(iii) of this section, a certificate must be provided 
for each period of continuous coverage ending within the 24-month period 
ending on the date of the request (or continuing on the date of the 
request). A separate certificate may be provided for each such period of 
continuous coverage.
    (iv) Combining information for families. A certificate may provide 
information with respect to both a participant and the participant's 
dependents if the information is identical for each individual or, if 
the information is not identical, certificates may be provided on one 
form if the form provides all the required information for each 
individual and separately states the information that is not identical.
    (v) Model certificate. The requirements of paragraph (a)(3)(ii) of 
this section are satisfied if the plan provides a certificate in 
accordance with a model certificate authorized by the Secretary.
    (vi) Excepted benefits; categories of benefits. No certificate is 
required to be furnished with respect to excepted benefits described in 
Sec. 54.9831-1T. In addition, the information in the certificate 
regarding coverage is not required to specify categories of benefits 
described in Sec. 54.9801-4T(c) (relating to the alternative method of 
counting creditable coverage). However, if excepted benefits are 
provided concurrently with other creditable coverage (so that the 
coverage does not consist solely of excepted benefits), information 
concerning the benefits may be required to be disclosed under paragraph 
(b) of this section.
    (4) Procedures--(i) Method of delivery. The certificate is required 
to be provided to each individual described in paragraph (a)(2) of this 
section or an entity requesting the certificate on behalf of the 
individual. The certificate may be provided by first-class mail. If the 
certificate or certificates are provided to the participant and the 
participant's spouse at the participant's last known address, then the 
requirements of this paragraph (a)(4) are satisfied with respect to all 
individuals residing at that address. If a dependent's last known 
address is different than the participant's last known address, a 
separate certificate is required to be provided to the dependent at the 
dependent's last known address. If separate certificates are being 
provided by mail to individuals who reside at the same address, separate 
mailings of each certificate are not required.
    (ii) Procedure for requesting certificates. A plan or issuer must 
establish a procedure for individuals to request and receive 
certificates pursuant to paragraph (a)(2)(iii) of this section.
    (iii) Designated recipients. If an automatic certificate is required 
to be provided under paragraph (a)(2)(ii) of this section, and the 
individual entitled to receive the certificate designates another 
individual or entity to receive the certificate, the plan or issuer 
responsible for providing the certificate is permitted to provide the 
certificate to the designated party. If a certificate is required to be 
provided upon request under paragraph (a)(2)(iii) of this section and 
the individual entitled to receive the certificate designates another 
individual or entity to receive the certificate, the plan or issuer 
responsible for providing the certificate is required to provide the 
certificate to the designated party.
    (5) Special rules concerning dependent coverage--(i)(A) Reasonable 
efforts. A plan is required to use reasonable efforts to determine any 
information needed for a certificate relating to dependent coverage. In 
any case in which an automatic certificate is required to be furnished 
with respect to a dependent under paragraph (a)(2)(ii) of this section, 
no individual certificate is required to be furnished until the plan 
knows (or making reasonable efforts should know) of the dependent's 
cessation of coverage under the plan.
    (B) Example. The rules of this paragraph (a)(5) are illustrated by 
the following example:

    Example. (i) A group health plan covers employees and their 
dependents. The plan annually requests all employees to provide updated 
information regarding dependents, including the specific date on which 
an employee has a new dependent or on which a person ceases to be a 
dependent of the employee.
    (ii) In this Example, the plan has satisfied the standard in this 
paragraph (a)(5)(i) that it make reasonable efforts to determine the 
cessation of dependents' coverage and the related dependent coverage 
information.


[[Page 370]]


    (ii) Special rules for demonstrating coverage. If a certificate 
furnished by a plan or issuer does not provide the name of any dependent 
of an individual covered by the certificate, the individual may, if 
necessary, use the procedures described in paragraph (c)(4) of this 
section for demonstrating dependent status. In addition, an individual 
may, if necessary, use these procedures to demonstrate that a child was 
enrolled within 30 days of birth, adoption, or placement for adoption. 
See Sec. 54.9801-3T(b), under which such a child would not be subject 
to a preexisting condition exclusion.
    (iii) Transition rule for dependent coverage through June 30, 1998--
(A) In general. A group health plan that cannot provide the names of 
dependents (or related coverage information) for purposes of providing a 
certificate of coverage for a dependent may satisfy the requirements of 
paragraph (a)(3)(ii)(C) of this section by providing the name of the 
participant covered by the group health plan and specifying that the 
type of coverage described in the certificate is for dependent coverage 
(e.g., family coverage or employee-plus-spouse coverage).
    (B) Certificates provided on request. For purposes of certificates 
provided on the request of, or on behalf of, an individual pursuant to 
paragraph (a)(2)(iii) of this section, a plan must make reasonable 
efforts to obtain and provide the names of any dependent covered by the 
certificate where such information is requested to be provided. If a 
certificate does not include the name of any dependent of an individual 
covered by the certificate, the individual may, if necessary, use the 
procedures described in paragraph (c) of this section for submitting 
documentation to establish that the creditable coverage in the 
certificate applies to the dependent.
    (C) Demonstrating a dependent's creditable coverage. See paragraph 
(c)(4) of this section for special rules to demonstrate dependent 
status.
    (D) Duration. This paragraph (a)(5)(iii) is only effective for 
certifications provided with respect to events occurring through June 
30, 1998.
    (6) Special certification rules for entities not subject to Chapter 
100 of Subtitle K of the Internal Revenue Code--(i) Issuers. For rules 
requiring that issuers in the group and individual markets provide 
certificates consistent with the rules in this section, see section 
701(e) of ERISA and sections 2701(e), 2721(b)(1)(B), and 2743 of the 
PHSA.
    (ii) Other entities. For special rules requiring that certain other 
entities, not subject to Chapter 100 of Subtitle K of the Internal 
Revenue Code, provide certificates consistent with the rules in the 
section, see section 2791(a)(3) of the PHSA applicable to entities 
described in sections 2701(c)(1) (C), (D), (E), and (F) (relating to 
Medicare, Medicaid, CHAMPUS, and Indian Health Service), section 
2721(b)(1)(A) of the PHSA applicable to nonfederal governmental plans 
generally, and section 2721(b)(2)(C)(ii) of the PHSA applicable to 
nonfederal governmental plans that elect to be excluded from the 
requirements of Subparts 1 through 3 of Part A of Title XXVII of the 
PHSA.
    (b) Disclosure of coverage to a plan, or issuer, using the 
alternative method of counting creditable coverage--(1) In general. If 
an individual enrolls in a group health plan with respect to which the 
plan (or issuer) uses the alternative method of counting creditable 
coverage described in Sec. 54.9801-4T(c), the individual provides a 
certificate of coverage under paragraph (a) of this section, and the 
plan (or issuer) in which the individual enrolls so requests, the entity 
that issued the certificate (the prior entity) is required to disclose 
promptly to a requesting plan (or issuer) (the requesting entity) the 
information set forth in paragraph (b)(2) of this section.
    (2) Information to be disclosed. The prior entity is required to 
identify to the requesting entity the categories of benefits with 
respect to which the requesting entity is using the alternative method 
of counting creditable coverage, and the requesting entity may identify 
specific information that the requesting entity reasonably needs in 
order to determine the individual's creditable coverage with respect to 
any such category. The prior entity is required to disclose promptly to 
the requesting entity the creditable coverage information so requested.

[[Page 371]]

    (3) Charge for providing information. The prior entity furnishing 
the information under paragraph (b) of this section may charge the 
requesting entity for the reasonable cost of disclosing such 
information.
    (c) Ability of an individual to demonstrate creditable coverage and 
waiting period information--(1) In general. The rules in this paragraph 
(c) implement section 9801(c)(4), which permits individuals to establish 
creditable coverage through means other than certificates, and section 
9801(e)(3), which requires the Secretary to establish rules designed to 
prevent an individual's subsequent coverage under a group health plan or 
health insurance coverage from being adversely affected by an entity's 
failure to provide a certificate with respect to that individual. If the 
accuracy of a certificate is contested or a certificate is unavailable 
when needed by the individual, the individual has the right to 
demonstrate creditable coverage (and waiting or affiliation periods) 
through the presentation of documents or other means. For example, the 
individual may make such a demonstration when--
    (i) An entity has failed to provide a certificate within the 
required time period;
    (ii) The individual has creditable coverage but an entity may not be 
required to provide a certificate of the coverage pursuant to paragraph 
(a) of this section;
    (iii) The coverage is for a period before July 1, 1996;
    (iv) The individual has an urgent medical condition that 
necessitates a determination before the individual can deliver a 
certificate to the plan; or
    (v) The individual lost a certificate that the individual had 
previously received and is unable to obtain another certificate.
    (2) Evidence of creditable coverage--(i) Consideration of evidence. 
A plan is required to take into account all information that it obtains 
or that is presented on behalf of an individual to make a determination, 
based on the relevant facts and circumstances, whether an individual has 
creditable coverage and is entitled to offset all or a portion of any 
preexisting condition exclusion period. A plan shall treat the 
individual as having furnished a certificate under paragraph (a) of this 
section if the individual attests to the period of creditable coverage, 
the individual also presents relevant corroborating evidence of some 
creditable coverage during the period, and the individual cooperates 
with the plan's efforts to verify the individual's coverage. For this 
purpose, cooperation includes providing (upon the plan's or issuer's 
request) a written authorization for the plan to request a certificate 
on behalf of the individual, and cooperating in efforts to determine the 
validity of the corroborating evidence and the dates of creditable 
coverage. While a plan may refuse to credit coverage where the 
individual fails to cooperate with the plan's or issuer's efforts to 
verify coverage, the plan may not consider an individual's inability to 
obtain a certificate to be evidence of the absence of creditable 
coverage.
    (ii) Documents. Documents that may establish creditable coverage 
(and waiting periods or affiliation periods) in the absence of a 
certificate include explanations of benefit claims (EOBs) or other 
correspondence from a plan or issuer indicating coverage, pay stubs 
showing a payroll deduction for health coverage, a health insurance 
identification card, a certificate of coverage under a group health 
policy, records from medical care providers indicating health coverage, 
third party statements verifying periods of coverage, and any other 
relevant documents that evidence periods of health coverage.
    (iii) Other evidence. Creditable coverage (and waiting period or 
affiliation period information) may also be established through means 
other than documentation, such as by a telephone call from the plan or 
provider to a third party verifying creditable coverage.
    (iv) Example. The rules of this paragraph (c)(2) are illustrated by 
the following example:

    Example. (i) Individual F terminates employment with Employer W and, 
a month later, is hired by Employer X. Employer X's group health plan 
imposes a preexisting condition exclusion of 12 months on new enrollees 
under the plan and uses the standard method of determining creditable 
coverage. F fails to receive a certificate of prior coverage from the 
self-insured group health plan maintained by F's prior employer, 
Employer

[[Page 372]]

W, and requests a certificate. However, F (and Employer's X's plan, on 
F's behalf) is unable to obtain a certificate from Employer W's plan. F 
attests that, to the best of F's knowledge, F had at least 12 months of 
continuous coverage under Employer W's plan, and that the coverage ended 
no earlier than F's termination of employment from Employer W. In 
addition, F presents evidence of coverage, such as an explanation of 
benefits for a claim that was made during the relevant period.
    (ii) In this Example, based solely on these facts, F has 
demonstrated creditable coverage for the 12 months of coverage under 
Employer W's plan in the same manner as if F had presented a written 
certificate of creditable coverage.

    (3) Demonstrating categories of creditable coverage. Procedures 
similar to those described in this paragraph (c) apply in order to 
determine an individual's creditable coverage with respect to any 
category under paragraph (b) of this section (relating to determining 
creditable coverage under the alternative method).
    (4) Demonstrating dependent status. If, in the course of providing 
evidence (including a certificate) of creditable coverage, an individual 
is required to demonstrate dependent status, the group health plan or 
issuer is required to treat the individual as having furnished a 
certificate showing the dependent status if the individual attests to 
such dependency and the period of such status and the individual 
cooperates with the plan's or issuer's efforts to verify the dependent 
status.
    (d) Determination and notification of creditable coverage--(1) 
Reasonable time period. In the event that a group health plan receives 
information under paragraph (a) of this section (certifications), 
paragraph (b) of this section (disclosure of information relating to the 
alternative method), or paragraph (c) of this section (other evidence of 
creditable coverage), the plan is required, within a reasonable time 
period following receipt of the information, to make a determination 
regarding the individual's period of creditable coverage and notify the 
individual of the determination in accordance with paragraph (d)(2) of 
this section. Whether a determination and notification regarding an 
individual's creditable coverage is made within a reasonable time period 
is determined based on the relevant facts and circumstances. Relevant 
facts and circumstances include whether a plan's application of a 
preexisting condition exclusion would prevent an individual from having 
access to urgent medical services.
    (2) Notification to individual of period of preexisting condition 
exclusion. A plan seeking to impose a preexisting condition exclusion is 
required to disclose to the individual, in writing, its determination of 
any preexisting condition exclusion period that applies to the 
individual, and the basis for such determination, including the source 
and substance of any information on which the plan relied. In addition, 
the plan is required to provide the individual with a written 
explanation of any appeal procedures established by the plan, and with a 
reasonable opportunity to submit additional evidence of creditable 
coverage. However, nothing in this paragraph (d) or paragraph (c) of 
this section prevents a plan from modifying an initial determination of 
creditable coverage if it determines that the individual did not have 
the claimed creditable coverage, provided that--
    (i) A notice of such reconsideration, as described in this paragraph 
(d), is provided to the individual; and
    (ii) Until the final determination is made, the plan, for purposes 
of approving access to medical services (such as a pre-surgery 
authorization), acts in a manner consistent with the initial 
determination.
    (3) Examples. The following examples illustrate this paragraph (d):

    Example 1. (i) Individual G is hired by Employer Y. Employer Y's 
group health plan imposes a preexisting condition exclusion for 12 
months with respect to new enrollees and uses the standard method of 
determining creditable coverage. Employer Y's plan determines that G is 
subject to a 4-month preexisting condition exclusion, based on a 
certificate of creditable coverage that is provided by G to Employer Y's 
plan indicating 8 months of coverage under G's prior group health plan.
    (ii) In this Example 1, Employer Y's plan must notify G within a 
reasonable period of time following receipt of the certificate that G is 
subject to a 4-month preexisting condition exclusion beginning on G's 
enrollment date in Y's plan.
    Example 2. (i) Same facts as in Example 1, except that Employer Y's 
plan determines that G has 14 months of creditable coverage

[[Page 373]]

based on G's certificate indicating 14 months of creditable coverage 
under G's prior plan.
    (ii) In this Example 2, Employer Y's plan is not required to notify 
G that G will not be subject to a preexisting condition exclusion.
    Example 3. (i) Individual H is hired by Employer Z. Employer Z's 
group health plan imposes a preexisting condition exclusion for 12 
months with respect to new enrollees and uses the standard method of 
determining creditable coverage. H develops an urgent health condition 
before receiving a certificate of prior coverage. H attests to the 
period of prior coverage, presents corroborating documentation of the 
coverage period, and authorizes the plan to request a certificate on H's 
behalf.
    (ii) In this Example 3, Employer Z's plan must review the evidence 
presented by H. In addition, the plan must make a determination and 
notify H regarding any preexisting condition exclusion period that 
applies to H (and the basis of such determination) within a reasonable 
time period following receipt of the evidence that is consistent with 
the urgency of H's health condition. (This determination may be modified 
as permitted under paragraph (d)(2) of this section.)

[T.D. 8716, 62 FR 16932, Apr. 8, 1997; 62 FR 31669, 31691, June 10, 
1997, as amended by T.D. 8741, 62 FR 66952, Dec. 22, 1997]