[Code of Federal Regulations] [Title 45, Volume 1] [Revised as of October 1, 2002] From the U.S. Government Printing Office via GPO Access [CITE: 45CFR146.125] [Page 605-607] TITLE 45--PUBLIC WELFARE AND HUMAN SERVICES PART 146--REQUIREMENTS FOR THE GROUP HEALTH INSURANCE MARKET--Table of Contents Subpart B--Requirements Relating to Access and Renewability of Coverage, and Limitations on Preexisting Condition Exclusion Periods Sec. 146.125 Applicability dates. (a) General applicability dates--(1) Non-collectively bargained plans. Part A of title XXVII of the PHS Act and Secs. 146.101 through 146.119, Sec. 146.143, Sec. 146.145, 45 CFR part 150, and this section apply with respect to group health plans, and health insurance coverage offered in connection with group health plans, for plan years beginning after June 30, 1997, except as otherwise provided in this section. (2) Collectively-bargained plans. Except as otherwise provided in this section (other than paragraph (a)(1) of this section), in the case of a group health plan maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers ratified before August 21, 1996, Part A of Title XXVII of the PHS Act and Secs. 146.101 through 146.119, Sec. 146.143, Sec. 146.145, 45 CFR part 150, and this section do not apply to plan years beginning before the later of July 1, 1997, or the date on which the last of the collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after August 21, 1996). For these purposes, any plan amendment made under a collective bargaining agreement relating to the plan, that amends the plan solely to conform to any requirement of such part, is not treated as a termination of the collective bargaining agreement. (3) Preexisting condition exclusion periods for current employees. (i) General rule. Any preexisting condition exclusion period permitted under Sec. 146.111 is measured from the individual's enrollment date in the plan. This exclusion period, as limited under Sec. 146.111, may be completed before the effective date of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for his or her plan. Therefore, on the date the individual's plan becomes subject to part A of title XXVII of the PHS Act, no preexisting condition exclusion may be imposed with respect to an individual beyond the limitation in Sec. 146.111. For an individual who has not completed the permitted exclusion period under HIPAA, upon the effective date for his or her plan, the individual may use creditable coverage that the person had as of the enrollment date to [[Page 606]] reduce the remaining preexisting condition exclusion period applicable to the individual. (ii) Examples. The following examples illustrate the requirements of this paragraph (a)(3): Example 1: (i) Individual A has been working for Employer X and has been covered under Employer X's plan since March 1, 1997. Under Employer X's plan, as in effect before January 1, 1998, there is no coverage for any preexisting condition. Employer X's plan year begins on January 1, 1998. A's enrollment date in the plan is March 1, 1997, and A has no creditable coverage before this date. (ii) In this Example, Employer X may continue to impose the preexisting condition exclusion under the plan through February 28, 1998 (the end of the 12-month period using anniversary dates). Example 2: (i) Same facts as in Example 1, except that A's enrollment date was August 1, 1996, instead of March 1, 1997. (ii) In this Example, on January 1, 1998, Employer X's plan may no longer exclude treatment for any preexisting condition that A may have; however, because Employer X's plan is not subject to HIPAA until January 1, 1998, A is not entitled to claim reimbursement for expenses under the plan for treatments for any preexisting condition received before January 1, 1998. (b) Effective date for certification requirement--(1) General. Subject to the transitional rule in Sec. 146.115(a)(5)(iii), the certification rules of Sec. 146.115 apply to events occurring on or after July 1, 1996. (2) Period covered by certificate. A certificate is not required to reflect coverage before July 1, 1996. (3) No certificate before June 1, 1997. Notwithstanding any other provision of this part, in no case is a certificate required to be provided before June 1, 1997. (c) Limitation on actions. No enforcement action is to be taken, under, against a group health plan or health insurance issuer with respect to a violation of a requirement imposed by part A of title XXVII of the PHS Act before January 1, 1998, if the plan or issuer has sought to comply in good faith with such requirements. Compliance with this part is deemed to be good faith compliance with the requirements of part A of title XXVII of the PHS Act. (d) Transition rules for counting creditable coverage. An individual who seeks to establish creditable coverage for periods before July 1, 1996 is entitled to establish such coverage through the presentation of documents or other means in accordance with the provisions of Sec. 146.115(c). For coverage relating to an event occurring before July 1, 1996, a group health plan and a health insurance issuer are not subject to any penalty or enforcement action with respect to the plan's or issuer's counting (or not counting) such coverage if the plan or issuer has sought to comply in good faith with the applicable requirements under Sec. 146.115(c). (e) Transition rules for certification of creditable coverage--(1) Certificates only upon request. For events occurring on or after July 1, 1996 but before October 1, 1996, a certificate is required to be provided only upon a written request by or on behalf of the individual to whom the certificate applies. (2) Certificates before June 1, 1997. For events occurring on or after October 1, 1996 and before June 1, 1997, a certificate must be furnished no later than June 1, 1997, or any later date permitted under Sec. 146.115(a)(2) (ii) and (iii). (3) Optional notice--(i) General. This paragraph (e)(3) applies with respect to events described in Sec. 146.115(a)(2)(ii), that occur on or after October 1, 1996 but before June 1, 1997. A group health plan or health insurance issuer offering group health coverage is deemed to satisfy Secs. 146.115 (a)(2) and (a)(3) if a notice is provided in accordance with the provisions of paragraphs (e)(3)(i) through (e)(3)(iv) of this section. (ii) Time of notice. The notice must be provided no later than June 1, 1997. (iii) Form and content of notice. A notice provided under this paragraph (e)(3) must be in writing and must include information substantially similar to the information included in a model notice authorized by CMS. Copies of the model notice are available at the following website--www.cms.gov (or call (410) 786-1565). (iv) Providing certificate after request. If an individual requests a certificate following receipt of the notice, the certificate must be provided at the time of the request as set forth in Sec. 146.115(a)(2)(iii). [[Page 607]] (v) Other certification rules apply. The rules set forth in Sec. 146.115(a)(4)(i) (method of delivery) and (a)(1) (entities required to provide a certificate) apply with respect to the provision of the notice. [62 FR 16958, Apr. 8, 1997; 62 FR 31694, June 10, 1997, as amended at 66 FR 1420, Jan. 8, 2001; 66 FR 14078, Mar. 9, 2001]