| (a) Except as otherwise provided in §21.1107 of this title (relating to Creditable Coverage Established Through Means Other Than Written Certificate), a certificate of creditable coverage must be provided in writing. (b) The written certificate of creditable coverage shall include the following: (1) The date the certificate is issued; (2) The name of the issuer of the health benefit plan that provided the coverage described in the certificate; (3) The individual's or dependent's name for which the certificate of creditable coverage is issued; (4) Any other information necessary for the health benefit plan providing the coverage specified in the certificate to identify the individual, including but not limited to, the individual's identification number under the health benefit plan; (5) The name, address and telephone number of the
third party administrator, plan sponsor, or issuer of the health benefit plan providing the certificate; (6) A telephone number to call for further information regarding the certificate of creditable coverage, if different than paragraph (5) of this section; (7) Either one of the following: (A) the date any waiting period (or affiliation period, if applicable) began and the date creditable coverage began; or (B) a statement indicating the individual has: (i) 18 months of creditable coverage for individual coverage; or (ii) 12 months of creditable coverage for group coverage; and (8) The date creditable coverage ended, or a statement that creditable coverage is continuing. (c) A carrier may use either: (1) Form CCC provided at Figure 1 of §21.1110(b) of this title (relating to Form CCC) to comply with
subsection (a) of this section; or (2) a form that is substantially similar to Form CCC and complies with subsection (a) of this section; or (3) the model contained in federal rules with modifications to reflect the applicable 12 or 18 month time period. (d) If a certificate is provided under §21.1103(a) of this title (relating to Timing and Issuance of a Written Certificate of Creditable Coverage to an Individual), the period that must be included on the certificate is the last period of continuous coverage, ending on the date coverage ceased. (e) If an individual requests a certificate under §21.1103(b) of this title (relating to Timing and Issuance of a Written Certificate of Creditable Coverage to an Individual), a certificate shall be provided for each period of continuous creditable 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 shall be provided for each such period of continuous creditable coverage. (f) A certificate of creditable coverage may provide information on both an individual and the individual's dependents if the information is identical for each individual. If the information is not identical, the certificates of creditable coverage 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. (g) Delivery of a certificate of creditable coverage prior to the adoption of this subchapter shall be deemed to comply with this subchapter, provided the certificate complied with the federal regulations and properly reflected the creditable time period applicable to Texas residents.
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