Current through Rules and Regulations filed through March 20, 2024
The following words and terms, when used in this Regulation,
shall have the following meanings unless the context clearly indicates
otherwise:
(a) Allowable Expenses.
1. "Allowable Expense" means 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.
2. Notwithstanding the above definition,
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 item of expense may
limit its definition of Allowable Expenses to like items of expense.
3. When a plan provides benefits in the form
of service, the reasonable cash value of each service will be considered as
both an Allowable Expense and a benefit paid.
4. The difference between the cost of a
private hospital room and the cost of a semiprivate 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 in terms of generally
accepted medical practice.
5. When
COB is restricted in its use to 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.
6. When benefits are reduced under a Primary
Plan because a covered person does not comply with the plan provisions, the
amount of such reduction will not be considered an Allowable Expense. Examples
of such provisions are those related to second surgical opinions,
precertification of admissions or services, and preferred provider
arrangements.
(i) Only benefit reductions
based upon provisions similar to those described above and which are contained
in the Primary Plan may be excluded from Allowable Expenses.
(ii) This provision shall not be used by a
Secondary Plan to refuse to pay benefits because an HMO member has elected to
have health care services provided by a non-HMO provider and the HMO, pursuant
to its contract, is not obligated to pay for providing those
services.
(iii) This subparagraph
(6) is not intended to allow a Secondary Plan to exclude expenses that are
applied towards the satisfaction of the deductible, copayments or coinsurance
amounts required by the Primary Plan, except for the benefit reductions
expressly described in this paragraph.
(b) Claim. A request that benefits of a plan
be provided or paid is a claim. 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.
(c)
Claim Determination Period. This is the period of time, which must not be less
than twelve (12) consecutive months, over which Allowable Expenses are compared
with total benefits payable in the absence of COB, to determine whether
overinsurance exists and how much each plan will pay or provide.
1. The Claim Determination Period is usually
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 the 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. That
determination is subject to adjustment as later Allowable Expenses are incurred
in the same Claim Determination Period.
(d) Coordination of Benefits. This is a
provision establishing an order in which plans pay their claims.
(e) Hospital Indemnity Benefits. These are
benefits 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.
(f) Plan. Plan means 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 definition.
1. The definition shown in the Model COB
Provision, attached to this Regulation as Appendix A, is an example of what may
be used. Any definition that satisfies this subparagraph may be used.
2. This Regulation uses the term "plan."
However, a group contract may, instead, use "program" or some other
term.
3. Plan may include:
(i) Group insurance and group subscriber
contracts;
(ii) Uninsured
arrangements of group or group-type coverage;
(iii) Group or group-type coverage through
HMOs and other prepayment, group practice and individual practice
plans;
(iv) Group-type contracts.
Group-type 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 the 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"). Individually underwritten and issued guaranteed renewable policies
would not be considered "group-type" even though purchased through payroll
deduction at a premium savings to the insured since the insured would have the
right to maintain or renew the policy independently of continued employment
with the employer.
(v) The amount
by which group or group-type hospital indemnity benefits exceed $100 per
day;
(vi) The medical benefits
coverage in group, group-type and individual automobile "no-fault" and
traditional automobile "fault" type contracts; and
(vii) Medicare or other governmental
benefits, except as provided in subparagraph (g) below. That part of the
definition of plan may be limited to the hospital, medical and surgical
benefits of the governmental program.
4. Plan shall not include:
(i) Individual or family insurance
contracts;
(ii) Individual or
family subscriber contracts;
(iii)
Individual or family coverage through Health Maintenance Organizations
(HMOs);
(iv) Individual or family
coverage under other prepayment, group practice and individual practice
plans;
(v) Group or group-type
hospital indemnity benefits of $100 per day or less;
(vi) School accident-type coverages. These
contracts cover grammar, high school and college students for accidents only,
including athletic injuries, either on a twenty-four-hour basis or on a "to and
from school" basis; and
(vii) A
State plan under Medicaid, and shall not include a law or plan when, by law,
its benefits are in excess of those of any private insurance plan or other
nongovernmental plan.
(g) Primary Plan. A Primary Plan is a plan
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 of the following conditions are true:
1. The plan either has no order of benefit
determination rules, or it has rules which differ from those permitted by this
Regulation. There may be more than one Primary Plan; or
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.
(h) Secondary Plan. A Secondary Plan is a
plan 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.
(i) 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 because 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.
O.C.G.A. Sec.
33-2-9.
