What is “prima facie” evidence that an early retiree or the early retirees spouse, surviving spouse or dependent paid his or her portion of the claim?
Prima facie evidence is evidence that shows that a claim was incurred by an early retiree or the early retiree’s spouse, surviving spouse or dependent during a plan year, and that shows that the claim was actually paid. A receipt for a health care item or service could satisfy this requirement. Some parties have suggested to HHS that an explanation of benefits should meet this requirement. However, an explanation of benefits does not show that a claim was actually incurred or that a claim was actually paid, as is required by the statute and regulations. An explanation of benefits only shows what a plan would have paid had a claim been incurred.
Related Questions
- Is there a cost limit for an early retiree or early retirees spouse, surviving spouse or dependent, for whom a plan sponsor is requesting reimbursement under the Early Retiree Reinsurance Program?
- May an early retirees spouse, surviving spouse, or dependent, while receiving health benefits from a plan sponsor under COBRA, be considered an early retiree?
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