Current through August 31, 2023
As used in this chapter, these words and terms have the
following meanings, unless the context clearly indicates otherwise:
(3-31-22)
01.
Allowable
Expense. Any health care expense including coinsurance or copayments,
and without reduction for any applicable deductible that is covered in full or
in part by any of the plans covering the person. If a plan is advised by a
covered person that all plans covering the person are high-deductible health
plans and the person intends to contribute to a health savings account
established in accordance with Section
223 of the Internal Revenue Code of
1986, the primary high-deductible health plan's deductible is not an allowable
expense, except for any health care expense incurred that will not be subject
to the deductible as described in Section
223(c) (2) (C) of
the Internal Revenue Code of 1986. An expense that a provider by law or in
accordance with contractual agreement is banned from charging a covered person
is not an allowable expense. An expense or a portion of an expense that is not
covered by any of the plans is not an allowable expense. (3-31-22)
a. The following are examples of expenses or
services that are not an allowable expense: (3-31-22)
i. If a covered person is confined in a
private hospital room, the difference between the cost of a semi private room
in the hospital and the private room (unless the patient's stay in the private
hospital room is medically necessary in terms of generally accepted medical
practice, or one of the plans provides coverage for private hospital rooms) is
not an allowable expense. (3-31-22)
ii. If a person is covered by two (2) or more
plans that compute their benefit payments on the basis of usual and customary
fees, or relative value schedule reimbursement or other similar reimbursement
methodology, any amount charged by the provider in excess of the highest
reimbursement amount for a specified benefit is not an allowable expense.
(3-31-22)
iii. If a person is
covered by two (2) or more plans that provide benefits or services on the basis
of negotiated fees, any amount in excess of the highest of the negotiated fees
is not an allowable expense. (3-31-22)
iv. If a person is covered by one plan that
calculates its benefits or services on the basis of usual and customary fees or
relative value schedule reimbursement or other similar reimbursement
methodology and another plan that provides its benefits or services on the
basis of negotiated fees, the primary plan's payment arrangement is the
allowable expense for all plans. However, if the provider has contracted with
the secondary plan to provide the benefit or service for a specific negotiated
fee or payment amount that is different than the primary plan's payment
arrangement and if the provider's contract permits, that negotiated fee or
payment is the allowable expense used by the secondary plan to determine its
benefits. (3-31-22)
b.
The definition of the "allowable expense" may exclude certain types of coverage
or benefits such as dental care, vision care, prescription drug or hearing
aids. A plan that limits the application of COB to certain coverages or
benefits may limit the definition of Allowable Expenses in its contract to
expenses that are similar to the expenses that it provides. When COB is
restricted to specific coverages or benefits in a contract the definition of
"Allowable Expense" includes similar expenses to which COB applies.
(3-31-22)
c. When a plan provides
benefits in the form of service, the reasonable cash value of each service will
be considered as an allowable expense and a benefit paid. (3-31-22)
d. The amount of the reduction may be
excluded from allowable expense when a covered person's benefits are reduced
under a primary plan: (3-31-22)
i. Because the
covered person does not comply with the plan provisions concerning second
surgical opinions or precertification of admissions or services: or
(3-31-22)
ii. Because the covered
person has a lower benefit because the covered person did not use a preferred
provider. (3-31-22)
02.
Birthday. Refers only to
month and day in a calendar year and does not include the year in which the
individual is born. (3-31-22)
03.
Claim. A request that benefits of a plan be provided or paid. The
benefits claimed may be in the form of: (3-31-22)
a. Services (including supplies);
(3-31-22)
b. Payment for all or a
portion of the expenses incurred; (3-31-22)
c. A combination of Paragraphs 010.03.a. and
010.03.b. of this chapter; or (3-31-22)
d. An indemnification.
(3-31-22)
04.
Closed Panel Plan. A plan that provides health benefits to covered
persons primarily in the form of services through a panel of providers that
have contracted with or are employed by the plan, and that excludes benefits
for services provided by other providers, except in cases of emergency or
referral by a panel member. (3-31-22)
05.
Consolidated Omnibus Budget
Reconciliation Act of 1985 or "COBRA". Coverage provided under a right
of continuation pursuant to federal law. (3-31-22)
06.
Coordination of Benefits
(COB). A provision establishing an order in which plans pay their
claims, and permitting secondary plans to reduce their benefits so that the
combined benefits of all plans do not exceed total allowable expenses.
(3-31-22)
07.
Custodial
Parent. The parent awarded custody by a court decree. In the absence of
a court decree, the parent with whom the child resides more than one half of
the calendar year without regard to any temporary visitation.
(3-31-22)
08.
Group-Type
Contract. A contract that is not available to the general public and is
obtained and maintained only because of membership in or a connection with a
particular organization or group, including blanket coverage. Group-type
contract does not include an individually underwritten and issued guaranteed
renewable policy even if the policy is 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. (3-31-22)
09.
High-Deductible Health Plan. Has the meaning given the term under
Section 223 of the
Internal Revenue Code of 1986, as amended by the Medicare Prescription Drug,
Improvement and Modernization Act of 2003. (3-31-22)
10.
Hospital Indemnity Benefits.
The 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.
(3-31-22)
11.
Plan. A
form of coverage with which coordination is allowed. Separate parts of a plan
for members of a group that are provided through alternative contracts that are
intended to be part of a coordinated package of benefits are considered one
plan and there is no COB among the separate parts of the plan. If a plan
coordinates benefits, its contract states the types of coverage that will be
considered in applying the COB provision of that contract. Whether the contract
uses the term "plan," or some other term such as "program," the contractual
definition may be no broader than this definition. The definition of "plan" in
the incorporated Appendix A is an example. (3-31-22)
a. Plan includes: (3-31-22)
i. Group and nongroup insurance contracts and
subscriber contracts; (3-31-22)
ii.
Uninsured group or group-type coverage arrangements; (3-31-22)
iii. Group and nongroup coverage through
closed panel plans; (3-31-22)
iv.
Group-type contracts; (3-31-22)
v.
The medical care components of long-term care contracts, such as skilled
nursing care; (3-31-22)
vi.
Medicare or other governmental benefits, except as provided in Subparagraph
010.11.b.ix. of this chapter. That part of the definition of plan may be
limited to the hospital, medical and surgical benefits of the governmental
program. (3-31-22)
vii. The medical
benefits coverage in automobile "no fault" and traditional automobile "fault"
type contracts. No plan is prescribed to coordinate benefits provided that it
pays benefits as a primary plan. If a plan coordinates benefits, it will do so
in compliance with the provisions of this chapter. (3-31-22)
viii. Group and nongroup insurance contracts
and subscriber contracts that pay or reimburse for the cost of dental or vision
care. (3-31-22)
b. Plan
does not include: (3-31-22)
i. Hospital
indemnity coverage or other fixed indemnity coverage; (3-31-22)
ii. School accident-type coverages, such as
contracts that cover students for accidents only, including athletic injuries,
either on a twenty-four (24) hour basis or on a "to and from school" basis;
(3-31-22)
iii. Specified disease or
specified accident coverage; (3-31-22)
iv. Accident only coverage;
(3-31-22)
v. Benefits provided in
long-term care insurance policies for non-medical service; for example,
personal care, adult daycare, homemaker services, assistance with activities of
daily living, respite care, and custodial care or for contracts that pay a
fixed daily benefit without regard to expenses incurred or the receipt of
services; (3-31-22)
vi. Limited
benefit health coverage as defined in IDAPA 18.04.08, "Individual Disability
and Group Supplemental Disability Insurance Minimum Standards Rule."
(3-31-22)
vii. Medicare supplement
policies; (3-31-22)
viii. A state
plan under Medicaid; or (3-31-22)
ix. A governmental plan which, by law,
provides benefits that are in excess of those of any private insurance plan or
other nongovernmental plan. (3-31-22)
12.
Policyholder. The primary
insured named in a non-group insurance policy. (3-31-22)
13.
Primary Plan. A plan whose
benefits for a person's health care coverage needs to be determined without
taking the existence of any other plan into consideration. A plan is a primary
plan if; (3-31-22)
a. The plan either has no
order of benefit determination rules, or its rules differ from those permitted
by this rule; or (3-31-22)
b. All
plans that cover the person use the order of benefit determination prescribed
by this rule, and under those rules the plan determines its benefits first.
(3-31-22)
14.
Secondary Plan. A plan that is not a primary plan.
(3-31-22)
