Current through Register Vol. 48, No. 12, March 22, 2024
I. APPLICABILITY
A. This Coordination of Benefits ("COB")
provision applies to This Plan when an enrollee or the enrollee's covered
dependent has health care coverage under more than one Plan. "Plan" and "This
Plan" are defined in Section II.
B.
If this COB provision applies, the order of benefit determination rules should
be looked at first. Those rules determine whether the benefits of This Plan are
determined before or after those of another plan. The benefits of This Plan:
(1) Shall not be reduced when, under the
order of benefit determination rules, This Plan determines its benefits before
another plan; but
(2) May be
reduced when, under the order of benefits determination rules, another plan
determines its benefits first. The reduction is described in Section IV "Effect
on the Benefits of This Plan."
II. DEFINITIONS
A. "Plan" is any of the following that
provides benefits or services for, or because of, medical or dental care or
treatment:
(1) Individual or group insurance
or group-type coverage, whether insured or uninsured. This includes prepayment,
group practice or individual practice coverage. It also includes coverage other
than school accident-type coverage.
(2) Coverage under a governmental plan, or
coverage required or provided by law. This does not include a state plan under
Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the
United States Social Security Act (
42 USC
301 et seq.), as amended from time to time).
Each contract or other arrangement for coverage under (1) or
(2) is a separate plan. Also, if an arrangement has two parts and COB rules
apply only to one of the two, each of the parts is a separate
plan.
B. "Plan"
does not include:
(1) Hospital indemnity
coverage benefits or other fixed indemnity coverage;
(2) Accident only coverage;
(3) Specified disease or specified accident
coverage;
(4) Limited benefit
health coverage;
(5) School
accident-type coverages that cover students for accidents only, including
athletic injuries, either on a 24-hour basis or on a "to and from school"
basis;
(6) Benefits provided in
long-term care insurance policies for nonmedical services, for example,
personal care, adult day care, 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;
(7) Medicare supplement
policies;
(8) A state plan under
Medicaid;
(9) A governmental plan
that, by law, provides benefits that are in excess of those of any private
insurance plan or other nongovernmental plan; or
(10) Disability income protection
coverage.
C. "This Plan"
is the part of the contract that provides benefits for health care
expenses.
D. "Primary
Plan/Secondary Plan:" The order of benefit determination rules state whether
This Plan is a Primary Plan or Secondary Plan as to another plan covering the
person.
When This Plan is a Primary Plan, its benefits are determined
before those of the other plan and without considering the other plan's
benefits.
When This Plan is a Secondary Plan, its benefits are determined
after those of the other plan and may be reduced because of the other plan's
benefits.
When there are more than two plans covering the person, This
Plan may be a Primary Plan as to one or more other plans, and may be a
Secondary Plan as to a different plan or plans.
E. "Allowable Expense" means a necessary,
reasonable and customary item of expense for health care, when the item of
expense is covered at least in part by one or more plans covering the person
for whom the claim is made.
The difference between the cost of a private hospital room and
the cost of a semi-private hospital room is not considered an Allowable Expense
under this definition unless the patient's stay in a private hospital room is
medically necessary either in terms of generally accepted medical practice or
as specifically defined in the plan.
When a plan provides benefits in the form of services, the
reasonable cash value of each service rendered will be considered both an
Allowable Expense and a benefit paid.
F. "Claim Determination Period" means a
calendar year. However, it does not include any part of a year during which a
person has no coverage under This Plan, or any part of a year before the date
this COB provision or a similar provision takes effect.
III. ORDER OF BENEFIT DETERMINATION RULES
A. General. When there is a basis for a claim
under This Plan and another plan, This Plan is a Secondary Plan that has its
benefits determined after those of the other plan, unless:
(1) The other plan has rules coordinating its
benefits with those of This Plan; and
(2) Both those rules and This Plan's rules
(see Section III(B)), require that This Plan's benefits be determined before
those of the other plan.
B. Rules. This Plan determines its order of
benefits using the first of the following rules that applies:
(1) Non-Dependent/Dependent. The benefits of
the plan that covers the person as an employee, member or subscriber (that is,
other than as a dependent) are determined before those of the plan that covers
the person as a dependent, except that, if the person is also a Medicare
beneficiary, Medicare is:
(a) Secondary to the
plan covering the person as a dependent; and
(b) Primary to the plan covering the person
as other than a dependent, for example a retired employee.
(2) Dependent Child/Parents not Separated or
Divorced. Except as stated in Section III(B)(3), when This Plan and another
plan cover the same child as a dependent of a different person (i.e.,
"parent"):
(a) 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;
but
(b) If both parents have the
same birthday, the benefits of the plan that covered the parent longer are
determined before those of the plan that covered the other parent for a shorter
period of time.
However, if the other plan does not have the rule described in
Section III(B)(2)(a), 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 in the other plan will determine the order of
benefits.
(3)
Dependent Child/Separated or Divorced. If two or more plans cover a person as a
dependent child of divorced or separated parents, benefits for the child are
determined in this order:
(a) First, the plan
of the parent with custody of the child;
(b) Then, the plan of the spouse of the
parent with custody of the child; and
(c) Finally, the plan of the parent not
having custody of the child.
However, if the specific terms of a court decree state that one
of the parents is responsible for the health care expense 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 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.
(4)
Dependent Child/Joint Custody. If the specific terms of a 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 Section III(B)(2).
(5)
Active/Inactive Employee. The benefits of a plan that covers a person as an
employee who is neither laid off nor retired (or as that employee's dependent)
are determined before those of a plan that covers that person as a laid-off or
retired employee (or as that employee's dependent). 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 Section III(B)(5) shall not apply.
(6) Continuation Coverage. If a person whose
coverage is provided under a right of continuation pursuant to federal or State
law also is covered under another plan, the following shall be the order of
benefit determination:
(a) First, the
benefits of a plan covering the person as an employee, member or subscriber (or
as that person's dependent);
(b)
Second, the benefits under the continuation coverage.
If the other plan does not contain the order of benefits
determination described in this Section III and if, as a result, the plans do
not agree on the order of benefits, this requirement shall be
ignored.
(7)
Longer/Shorter Length of Coverage. If none of the rules in this Section III
determines the order of benefits, the benefits of the plan that covered an
employee, member or subscriber longer are determined before those of the Plan
that covered that person for the shorter term.
IV. EFFECT ON THE BENEFITS OF THIS PLAN
A. When This Section Applies. This Section IV
applies when, in accordance with Section III "Order of Benefit Determination
Rules", This Plan is a Secondary Plan as to one or more other plans. In that
event the benefits of This Plan may be reduced under this Section IV. The other
plan or plans are referred to as "the other plans" in Section IV(B).
B. Reduction in This Plan's Benefits.
(1) The benefits of This Plan will be reduced
when:
(a) The benefits that would be payable
for the Allowable Expense under This Plan in the absence of this COB provision;
and
(b) The benefits that would be
payable for the Allowable Expenses under the other plans, in the absence of
provisions with a purpose like that of this COB provision, whether or not claim
is made;
exceeds those Allowable Expenses in a Claim Determination
Period. In that case, the benefits of This Plan will be reduced so that they
and the benefits payable under the other plans do not total more than those
Allowable Expenses.
(2) When the benefits of This Plan are
reduced as described in Section IV(B)(1), each benefit is reduced in
proportion. It is then charged against any applicable benefit limit of This
Plan.
V.
RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION
Certain facts are needed to apply these COB rules. [Insurer]
has the right to decide which facts it needs. It may get needed facts from or
give them to any other organization or person. [Insurer] need not tell, or get
the consent of, any person to do this. Each person claiming benefits under This
Plan must give [insurer] any facts it needs to pay the claim.
VI. FACILITY OF PAYMENT
A payment made under another plan may include an amount that
should have been paid under This Plan. If it does, [insurer] may pay that
amount to the organization that made the payment under the other plan. That
amount will then be treated as though it were a benefit paid under This Plan.
[Insurer] will not have to pay that amount again. The term "payment made"
includes providing benefits in the form of services, in which case "payment
made" means reasonable cash value of the benefits provided in the form of
services.
VII. RIGHT OF
RECOVERY
If the amount of the payments made by [insurer] is more than it
should have paid under this COB provision, it may recover the excess from one
or more of:
A. The persons it has paid
or for whom it has paid;
B.
Insurance companies; or
C. Other
organizations.
The "amount of the payments made" includes the reasonable cash
value of any benefits provided in the form of services.