5160:1-1-51.3 Medicaid: certificate of creditable coverage and privacy notice.

 

 

 

TO BE RESCINDED

 

5160:1-1-51.3              Medicaid: certificate of creditable coverage and privacy notice.

 

 

 

(A)    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law requiring the administrative agency to issue a certificate of creditable coverage and a privacy notice.

 

(B)  Administrative agency responsibilities: The administrative agency shall:

 

(1)   Ensure appropriate safeguards are taken in accordance with rule 5160:1-1-51.1 of the Administrative Code.

 

(2)     Issue all individuals of medical assistance programs a privacy notice, as described in 45 C.F.R. 164.520 (as in effect September 1, 2013), outlining the following descriptions of uses and disclosures, and procedures:

 

(a)       A description of the types of uses and disclosures of PHI the administrative agency is permitted with examples for each of the following purposes:

 

(i)   Payment;

 

(ii)   Treatment; and

 

(iii)   Healthcare operations.

 

(b)    A description of uses and disclosures permitted without the individual's written consent or authorization;

 

(c)    A statement that other uses and disclosures will be made only with the individual's written authorization;

 

(d)  Complaint procedure;

 

(e)   Request for restriction procedure;

 

(f)  Request for amendment procedure;

 

(g)   Request for accounting procedure; and,

 

 

 

 

(h)   A name, or title, and telephone number of a person to contact for further information.

(3)     Issue the JFS 03748, "Certificate of Group Health Plan Coverage" (rev. 11/2013) or its electronic equivalent, for any medicaid eligible individual, as set forth in 45 C.F.R. 146.115 (as in effect September 1, 2013). The administrative agency may create its own certificate provided it contains all of the following information:

(a)   The date the certificate is issued.

(b)   The name of the group health plan that provided the coverage.

(c)   The name(s) of the individual(s).

(d)  The medicaid identification number.

(e)    The name, address and telephone number of the administrative agency member who is responsible for issuing certificates and accepting telephone inquiries regarding the certificates.

(f)   A statement that an individual has at least eighteen months of creditable coverage before a significant break in coverage or, if less than eighteen months, the beginning date of creditable coverage.

(g)   Date the creditable coverage ended.

(h)   An educational statement regarding HIPAA explaining:

(i)   The restrictions on the ability of a health plan or issuer to impose a pre-existing condition exclusion against an individual including an individual's ability to reduce a pre-existing condition exclusion by creditable coverage;

(ii)   Special enrollment rights;

(iii)   The prohibitions against discrimination based on any health factor;

(iv)   The right to individual health coverage;

(v)    The fact that state law may require issuers to provide additional protections to individuals; and

(vi)   Where to get more information.

(4)      Provide the certificate of coverage to all medicaid-eligible individuals, dependents or to an entity requesting the certificate on behalf of the individual. The certificate shall be available for up to no less than twenty-four months after coverage ceases.

(a)   The certificate shall be mailed to the individual's last known address.

(b)   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.

Effective:                                                             01/01/2016

Five Year Review (FYR) Dates:                         10/16/2015

CERTIFIED ELECTRONICALLY

Certification

12/21/2015

Date

Promulgated Under:                           111.15

Statutory Authority:                           5162.031, 5163.02

Rule Amplifies:                                  5162.031, 5163.02

Prior Effective Dates:                         10/1/98, 10/6/03, 11/1/09