Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-48 - GROUP COORDINATION OF BENEFITS
Rule 120-2-48-.05 - Rules for Coordination of Benefits

1. The Primary Plan must pay or provide its benefits as if the Secondary Plan or Plans did not exist. A Plan that does not include a coordination of benefits provision may not take the benefits of another Plan as defined in Rule 120-2-48-.03 into account when it determines its benefits. There is one exception: a contract holder's coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder.

2. A Secondary Plan may take the benefits of another plan into account only when, under these rules, it is Secondary to that other plan.

3. The benefits of the plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the plan which covers the person as a dependent.

1. The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year;

2. If both parents have the same birthday, the benefits of the plan which covered the parent longer are determined before those of the plan which covered the other parent for a shorter period of time.

3. The word "birthday" refers only to month and day in a calendar year, not the year in which the person was born;

4. A group contract which includes COB and which is issued or renewed, or which has an anniversary date on or after sixty (60) days after the effective date of this Regulation shall include the substance of the provision in subparagraphs (b)1., 2., and 3. above. Until that provision becomes effective, the group contract may instead contain wording such as: "Except as stated in paragraph (3) below, the benefits of a plan which covers a person as a dependent of a male are determined before those of a plan which covers the person as a dependent of a female."

5. If the other plan does not have the rule described in subparagraphs (b)1., 2., and 3. above, but instead has a rule based upon the gender of the parent; and if; as a result, the plans do not agree on the order of benefits, the rule based upon the gender of the parent will determine the order of benefits.

1. First, the plan of the parent with custody of the child;

2. Then, the plan of the spouse of the parent with the custody of the child; and

3. Finally, the plan of the parent not having custody of the child.

4. If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent shall be the Secondary Plan. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge.

5. If the specific terms of the court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined in subparagraph (b) above.

1. To determine the length of time a person has been covered under a plan, two plans shall be treated as one if the claimant was eligible under the second within twenty-four (24) hours after the first ended.

2. The start of a new plan does not include:

3. The claimant's length of time covered under a plan is measured from the claimant's first date of coverage under that plan. If that date is not readily available, the date the claimant first became a member of the group shall be used as the date from which to determine the length of time the claimant's coverage under the present plan has been in force.