Connecticut Administrative Code
Title 38a - Insurance Department
480 - Coordination of Benefits
Section 38a-480-5 - Rules for coordination of benefits
Current through March 14, 2024
(a) Order of Benefits.
(Reference: subsections 38a-480-4(c) and 38a-480-4(d) (2) (C) above.)
(Reference: subsections 38a-480-4(d) (3) (B) (ii) above.)
(Reference: subsection 38a-480-4(d) (3) (B) (v) above.)
(b) Reasonable Cash Value of Services. A Secondary Plan which provides benefits in the form of services may recover the reasonable cash value of providing the services from the Primary Plan, to the extent that benefits for the services are covered by the Primary Plan and have not already been paid or provided by the Primary Plan. Nothing in this provision shall be interpreted to require a Plan to reimburse a covered person in cash for the value of services provided by a Plan which provides benefits in the form of services.
(c) Excess and Other Nonconforming Provisions.
(Reference: subsections 38a-480-4(d) (4), (5), (6) and (7) above.)
(d) Allowable Expense. A term such as "usual and customary," "usual and prevailing" or "reasonable and customary," may be substituted for the term "necessary, reasonable and customary." Terms such as "medical care" or "dental care" may be substituted for "health care" to describe the coverages to which the COB provisions apply.
(Reference: subsection 38a-480-4(d) (2) (D) above.)
(e) Subrogation. The COB concept clearly differs from that of subrogation. Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other.
(Reference: subsections 38a-480-4(d) (4), (5), (6) and (7) above.)