Current through March 14, 2024
(a)
Plan.
(1) A "Plan" is a form of coverage with which
coordination is allowed. The definition of Plan in the group contract must
state the types of coverage which will be considered in applying the COB
provision of that contract. The right to include a type of coverage is limited
by the rest of this subsection
38a-480-3(a).
(2) The definition shown in the COB Provision
in Section
38a-480-4
is an example of what may be used. Any definition that satisfies this
subsection
38a-480-3(a)
may be used.
(3) This regulation
uses the term "Plan." However, a group contract may, instead, use "Program" or
some other term.
(4) "Plan" shall
not include individual or family:
(A)
insurance contracts;
(B) subscriber
contracts;
(C) coverage through
Health Maintenance Organizations (HMOs); or
(D) coverage under other prepayment, group
practice and individual practice plan; except as provided in (5) and (6)
below.
(5) "Plan" may
include:
(A) group insurance and group
subscriber contracts;
(B) uninsured
arrangements of group or group-type coverage;
(C) group or group-type coverage through HMOs
and other prepayment, group practice and individual practice plans;
and
(D) group-type contracts.
Group type contracts are contracts which are not available to
the general public and can be obtained and maintained only because of
membership in or connection with a particular organization or group. Group-type
contracts answering this description may be included in the definition of Plan,
at the option of the insurer or the service provider and its contract-client,
whether or not uninsured arrangements or individual contract forms are used and
regardless of how the group-type coverage is designated (for example,
"franchise" or "blanket"). The use of payroll deductions by the employee,
subscriber or member to pay for the coverage is not sufficient, of itself, to
make an individual contract part of a group-type plan.
(6) "Plan" may include the medical
benefits coverage in group, group-type, and individual automobile "no-fault"
and traditional automobile "fault" type contracts.
(7) "Plan" may include Medicare or other
governmental benefits. That part of the definition of "Plan" may be limited to
the hospital, medical and surgical benefits of the governmental program.
However, "Plan" shall not include a state plan under Medicaid, and shall not
include a law or plan when, by law, its benefits are excess to those of any
private insurance plan or other non-governmental plan.
(8) "Plan":
(A) shall not be construed to include group
or group-type hospital indemnity benefits of $30 per day or less; but
(B) may be construed to include the amount by
which group or group-type hospital indemnity benefits exceed $30 per day.
"Hospital indemnity benefits" are those not related to expenses
incurred. The term does not include reimbursement-type benefits even if they
are designed or administered to give the insured the right to elect
indemnity-type benefits at the time of claim.
(9) "Plan" shall not include student accident
or student accident and health coverages for which the student or parent pays
the entire premium.
(10) "Plan"
shall not include:
(A) group contracts issued
by or reinsured through the Health Reinsurance Association; or
(B) subscriber contracts issued by a residual
market mechanism established by hospital and medical service corporations and
providing comprehensive health care coverage as provided in Chapter 700a of
Connecticut General Statutes.
(b)
This Plan. In a COB
provision, this term refers to the part of the group contract providing the
health care benefits to which the COB provision applies and which may be
reduced on account of the benefits of other Plans. Any other part of the group
contract providing health care benefits is separate from This Plan. A group
contract may apply one COB provision to certain of its benefits (such as dental
benefits), coordinating only with like benefits, and may apply other separate
COB provisions to coordinate other benefits.
(c)
Primary Plan. A Primary Plan
is one whose benefits for a person's health care coverage must be determined
without taking the existence of any other Plan into consideration. A Plan is a
Primary Plan if either (1) or (2) below is true:
(1) The Plan either has no order of benefit
determination rules, or it has rules which differ from those permitted by this
regulation.
(2) All plans which
cover the person use the order of benefit determination rules required by this
regulation and under those rules the Plan determines its benefits first. There
may be more than one Primary Plan (for example, two Plans which have no order
of benefit determination rules).
(d)
Secondary Plan. A Secondary
Plan is one which is not a Primary Plan. If a person is covered by more than
one Secondary Plan, the order of benefit determination rules of this regulation
decide the order in which their benefits are determined in relation to each
other. The benefits of each Secondary Plan may take into consideration the
benefits of the Primary Plan or Plans and the benefits of any other Plan which,
under the rules of this regulation, has its benefits determined before those of
that Secondary Plan.
(e)
Allowable Expense.
(1) "Allowable
Expense" is the necessary, reasonable, and customary item of expense for health
care, when the item of expense is covered at least in part under any of the
Plans involved, except where a statute requires a different definition.
However, items of expense under coverages such as dental care, vision care,
prescription drug or hearing aid programs may be excluded from the definition
of Allowable Expense. A plan which provides benefits only for any such items of
expense may limit its definition of Allowable Expenses to like items of
expense.
(2) When a Plan provides
benefits in the form of services, the reasonable cash value of each service
will be considered as both an Allowable Expense and a benefit paid.
(3) The difference between the cost of a
private hospital room and the cost of a semi-private hospital room is not
considered an Allowable Expense under the above definition unless the patient's
stay in a private hospital room is medically necessary either in terms of
generally accepted medical practice, or as specifically defined in the
Plan.
(4) When COB is restricted in
its use to a specific coverage in a contract (for example, major medical or
dental), the definition of "Allowable Expense" must include the corresponding
expenses or services to which COB applies.
(f)
Claim. A request that
benefits of a Plan be provided or paid. The benefits claimed may be in the form
of:
(1) services (including
supplies);
(2) payment for all or a
portion of the expenses incurred;
(3) a combination of (1) and (2) above;
or
(4) an
indemnification.
(g)
Claim Determination Period.
(1)
This is the period of time, which must be not less than twelve consecutive
months, over which Allowable Expenses are compared with total benefits payable
in the absence of COB, to determine:
(A)
whether overinsurance exists; and
(B) how much each Plan will pay or provide.
It usually is a calendar year, but a Plan may use some other
period of time that fits the coverage of the group contract. A person may be
covered by a Plan during a portion of a Claim Determination Period if that
person's coverage starts or ends during that Claim Determination Period.
(2) As each claim is
submitted, each Plan is to determine its liability and pay or provide benefits
based upon Allowable Expenses incurred to that point in the Claim Determination
Period; but that determination is subject to adjustment as later Allowable
Expenses are incurred in the same Claim Determination Period.