Idaho Administrative Code
Title IDAPA 18 - Insurance, Department of
Rule 18.04.14 - COORDINATION OF BENEFITS
Section 18.04.14.022 - RULES FOR COORDINATION OF BENEFITS
Universal Citation: ID Admin Code 18.04.14.022
Current through August 31, 2023
01. Order of Benefit Payments. When a person is covered by two (2) or more plans, the rules for determining the order of benefit payments are as follows: (3-31-22)
a. The primary plan pays or provides its
benefits as if the secondary plan or plans did not exist. (3-31-22)
b. If the primary plan is a closed panel plan
and the secondary plan is not a closed panel plan, the secondary plan pays or
provides benefits as if it were the primary plan when a covered person uses a
non-panel provider, except for emergency services or authorized referrals that
are paid or provided by the primary plan. (3-31-22)
c. When multiple contracts providing
coordinated coverage are treated as a single plan under this rule, Section
022 of this chapter applies only to
the plan as a whole, and coordination among the component contracts is governed
by the terms of the contracts. If more than one (1) carrier pays or provides
benefits under the plan, the carrier designated as primary within the plan is
responsible for the plan's compliance with this rule. (3-31-22)
d. If a person is covered by more than one
(1) secondary plan, the order of benefit determination requirements of this
rule decide the order in which secondary plan benefits are determined in
relation to each other. Each secondary plan takes into consideration the
benefits of the primary plan or plans and the benefits of any other plan,
which, under the requirements of this rule, has its benefits determined before
those of that secondary plan. (3-31-22)
02. Consistent Order of Benefit Provisions. Except as provided in Paragraph 022.02.a. of this chapter, a plan that does not contain order of benefit determination provisions that are consistent with this rule is always the primary plan unless the provisions of both plans, regardless of the provisions of Subsection 022.02 of this chapter, state that the complying plan is primary. (3-31-22)
a. Coverage that is obtained by virtue of
membership in a group and designed to supplement a part of a basic package of
benefits may provide that the supplementary coverage is excess to any other
parts of the plan provided by the contract holder. Examples of these types of
situations are major medical coverages that are superimposed over base plan
hospital and surgical benefits, and insurance type coverages that are written
in connection with a closed panel plan to provide out-of-network benefits.
(3-31-22)
b. A plan may take into
consideration the benefits paid or provided by another plan only when, under
the requirements of this rule, it is secondary to that other plan.
(3-31-22)
03. Order of Benefit Determination. Each plan determines its order of benefits using the first of the following rules that applies. (3-31-22)
a. The plan that covers the person other than
as a dependent, for example, as an employee, member, subscriber, policyholder
or retiree, is the primary plan and the plan that covers the person as a
dependent is the secondary plan. However, if the person is a Medicare
beneficiary and, as a result of the provisions of Title XVIII of the Social
Security Act and implementing rules, Medicare is: (3-31-22)
i. Secondary to the plan covering the person
as a dependent; and (3-31-22)
ii.
Primary to the plan covering the person as other than a dependent (e.g. a
retired employee), then the order of benefits is reversed so that the plan
covering the person as an employee, member, subscriber, policyholder or
retiree, is the secondary plan and the other plan covering the person as a
dependent is the primary plan. (3-31-22)
b. Unless there is a court decree stating
otherwise, plans covering a dependent child determine the order of benefits as
follows: (3-31-22)
i. For a dependent child
whose parents are married or are living together, whether or not they have ever
been married: (3-31-22)
(1) The plan of the
parent whose birthday falls earlier in the calendar year is primary plan; or
(3-31-22)
(2) If both parents have
the same birthday, the plan that has covered the parent longest is the primary
plan. (3-31-22)
ii. For a
dependent child whose parents are divorced or separated or are not living
together, whether or not they have ever been married: (3-31-22)
(1) If a court decree states that one of the
parents is responsible for the dependent child's health care expenses or health
care coverage and the plan of that parent has actual knowledge of those terms,
that plan is primary. If the parent with responsibility has no health care
coverage for the dependent child's health care expenses, but that parent's
spouse does, that parent's spouse's plan is the primary plan. This does not
apply with respect to any plan year during which benefits are paid or provided
before the entity has actual knowledge of the court decree provisions;
(3-31-22)
(2) If a court decree
states that both parents are responsible for the dependent child's health care
expenses or health care coverage, the provisions of Subparagraph 022.03.b.i. of
this chapter determine the order of benefits; (3-31-22)
(3) If a court decree states that the parents
have joint custody without specifying that one (1) parent has responsibility
for the health care expenses or health care coverage of the dependent child,
the provisions of Subparagraph 022.03.b.i. of this chapter determine the order
of benefits; or (3-31-22)
(4) If
there is no court decree allocating responsibility for the child's health care
expenses or health care coverage, the order of benefits for the child are as
follows: (3-31-22)
(a) The plan covering the
custodial parent; (3-31-22)
(b) The
plan covering the custodial parent's spouse; (3-31-22)
(c) The plan covering the noncustodial
parent; and then (3-31-22)
(d) The
plan covering the noncustodial parent's spouse. (3-31-22)
(5) For a dependent child covered under more
than one plan of individuals who are not the parents of the child, the order of
benefits is determined, as applicable under Subparagraph 022.03.b.i. or
022.03.b.ii. of this chapter as if those individuals were parents of the child.
(3-31-22)
(6) For a dependent child
who has coverage under either or both parents' plans and also has their own
coverage as a dependent under a spouse's plan, the provisions of Paragraph
022.02.e. apply. In the event the dependent child's coverage under the spouse's
plan began on the same date as the dependent child's coverage under either or
both parents' plans, the order of benefits is determined by applying the
birthday rule in Subparagraph 022.02.b.i. to the dependent child's parent(s)
and the dependent's spouse. (3-31-22)
c. The plan that covers a person as an active
employee; that is, an employee who is neither laid-off nor retired or as a
dependent of an active employee is the primary plan. The plan covering that
same person as a retired or laid-off employee or as a dependent of a retired or
laid-off employee is the secondary plan. If the other plan does not have this
rule and if, as a result, the plans do not agree on the order of benefits, this
rule is ignored. Coverage provided an individual as a retired worker and as a
dependent of that individual's spouse as an active worker will be determined
under Paragraph 022.03.a. of this chapter. (3-31-22)
d. If a person whose coverage is provided
pursuant to COBRA or under a right of continuation pursuant to federal or state
law is covered under another plan, the plan covering the person as an employee,
member, subscriber or retiree or covering the person as a dependent of an
employee, member, subscriber or retiree is the primary plan and the plan
covering that same person pursuant to COBRA or under a right of continuation
pursuant to state or other federal law is the secondary plan. If the other plan
does not have this rule and if, as a result, the plans do not agree on the
order of benefits, this rule is ignored. This provision does not apply if the
rule in Paragraph 022.03.a. of this chapter can determine the order of
benefits. (3-31-22)
e. If the
preceding rules do not determine the order of benefits, the plan that covered
the person for the longer period of time is the primary plan and the plan that
covered the person for a shorter period of time is the secondary plan.
(3-31-22)
i. To determine the length of time a
person has been covered under a plan, two (2) successive plans are treated as
one (1) if the covered person was eligible under the second plan within
twenty-four (24) hours after the coverage under the first plan ended.
(3-31-22)
ii. The start of a new
plan does not include: (3-31-22)
(1) A change
in the amount or scope of a plan's benefits; (3-31-22)
(2) A change in the entity that pays,
provides or administers the plan's benefits; or (3-31-22)
(3) A change from one type of plan to another
such as from a single employer plan to a multiple employer plan.
(3-31-22)
iii. The
person's length of time covered under a plan is measured from the person's
first date of coverage under that plan. If that date is not readily available
for a group plan, the date the person first became a member of the group is
used as the date from which to determine the length of time the person's
coverage under the present plan has been in force.
(3-31-22)
f. If none of
the preceding rules determines the order of benefits, the allowable expenses
are shared equally between the plans. (3-31-22)
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