Treas. Reg. § 54.9801-4

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Rules relating to creditable coverage.

eCFR editorial change effective 2016-12-30 · current · last amended by T.D. 9656, 79 FR 10304, Feb. 24, 2014

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(a) General rules

(1) Creditable coverage. For purposes of this section, except as provided in paragraph (a)(2) of this section, the term creditable coverage means coverage of an individual under any of the following:

(i) A group health plan as defined in § 54.9831-1(a).

(ii) Health insurance coverage as defined in § 54.9801-2 (whether or not the entity offering the coverage is subject to Chapter 100 of Subtitle K, and without regard to whether the coverage is offered in the group market, the individual market, or otherwise).

(iii) Part A or B of title XVIII of the Social Security Act (Medicare).

(iv) Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928 of the Social Security Act (the program for distribution of pediatric vaccines).

(v) Title 10 U.S.C. Chapter 55 (medical and dental care for members and certain former members of the uniformed services, and for their dependents; for purposes of title 10 U.S.C. Chapter 55, uniformed services means the armed forces and the Commissioned Corps of the National Oceanic and Atmospheric Administration and of the Public Health Service).

(vi) A medical care program of the Indian Health Service or of a tribal organization.

(vii) A State health benefits risk pool. For purposes of this section, a State health benefits risk pool means—

(A) An organization qualifying under section 501(c)(26);

(B) A qualified high risk pool described in section 2744(c)(2) of the PHS Act; or

(C) Any other arrangement sponsored by a State, the membership composition of which is specified by the State and which is established and maintained primarily to provide health coverage for individuals who are residents of such State and who, by reason of the existence or history of a medical condition—

(1) Are unable to acquire medical care coverage for such condition through insurance or from an HMO, or

(2) Are able to acquire such coverage only at a rate which is substantially in excess of the rate for such coverage through the membership organization.

(viii) A health plan offered under title 5 U.S.C. Chapter 89 (the Federal Employees Health Benefits Program).

(ix) A public health plan. For purposes of this section, a public health plan means any plan established or maintained by a State, the U.S. government, a foreign country, or any political subdivision of a State, the U.S. government, or a foreign country that provides health coverage to individuals who are enrolled in the plan.

(x) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e)).

(xi) Title XXI of the Social Security Act (State Children's Health Insurance Program).

(2) Excluded coverage. Creditable coverage does not include coverage of solely excepted benefits (described in § 54.9831-1).

(b) Counting creditable coverage rules superseded by prohibition on preexisting condition exclusion. See section 2704 of the Public Health Service Act, incorporated into section 9815 of the Code, and its implementing regulations for rules prohibiting the imposition of a preexisting condition exclusion.

Source credit, amendments & notes

[T.D. 9166, 69 FR 78746, Dec. 30, 2004, as amended by T.D. 9656, 79 FR 10304, Feb. 24, 2014]

Treas. Reg. § 54.9801-4 — Rules relating to creditable coverage. · eCFR editorial change effective 2016-12-30 · https://pensionresource.website/EAMain?content=EAMain.Law&id=cfr26-54.9801-4 · printed Oct 16, 2026

Cited by (code & regs)

Treas. Reg. § 54.9801-2 Definitions.
Treas. Reg. § 54.9801-2T Definitions (temporary).

Guidance addressing this section

IRS / Treasury

Proposed Rules

REG-130370-04Proposed Feb 22, 2005 — Proposed regulations under section 9801of the Code would provide guidance on the HIPAA portability requirements relating to interaction with the Family and Med… (b)(2)(iii)

Also cited in 4 other documents

IRS / Treasury

Final Rules

86 FR 36872 Jul 13, 2021 — Requirements Related to Surprise Billing; Part I (a)(a)(1)(ix)(a)(1)(vii)(b)(2)(iii)
79 FR 10296 Feb 24, 2014 — Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act

Proposed Rules

78 FR 17313Proposed Mar 21, 2013 — Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act Comments due May 20, 2013

Treasury Decisions

T.D. 9166 Feb 22, 2005 — Final regulations under section 9801 of the Code provide guidance on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) portability requir… (a)(a)(1)(ix)(a)(1)(vii)(b)(2)(iii)(c)

No court rulings in the library cite this provision yet.

No private letter rulings in the library cite this provision yet.

Each row is a version of the text as published by the official source. Code dates are the edition/release point that first reflected the change; regulation dates are eCFR effective dates. The library checks the official sources automatically, so new versions appear here on their own; “run” opens the sync that recorded a version.

Effective	Through	Source	Amended by
Apr 1, 2005	Mar 31, 2014	CFR 2013 annual edition (revised as of 2013-04-01) run 127	T.D. 9166, 69 FR 78746, Dec. 30, 2004	View
Apr 1, 2014	Mar 31, 2015	CFR 2014 annual edition (revised as of 2014-04-01) run 127	T.D. 9166, 69 FR 78746, Dec. 30, 2004	View · Redline (sign in)
Apr 1, 2015	current	eCFR editorial change effective 2016-12-30 run 6	T.D. 9656, 79 FR 10304, Feb. 24, 2014	View · Redline (sign in)

Provision-level history (blame)