Current through Register Vol. 48, No. 12, March 22, 2024
a) General
The general order of benefits is as follows:
1) The primary plan must pay or provide its
benefits as if the secondary plan or plans do not exist. A plan that does not
include a coordination of benefits provision may not take the benefits of
another plan 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 is
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
standards, it is secondary to that other plan.
3) 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.
b) Dependent Child/Parents not Separated or
Divorced
The standards for the order of benefits for a dependent child
when the parents are not separated or divorced are as follows:
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 that covered the parent longer are determined before
those of the plan that 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 contract that includes
COB and that is issued or renewed, or that has an anniversary date on or after
January 7, 1989, shall include the substance of subsections (b)(1), (2) and
(3).
5) If the other plan does not
reflect the standards of subsections (b)(1), (2) and (3), but instead has a
standard based upon the gender of the parent and, if, as a result, the plans do
not agree on the order of benefits, the standard based upon the gender of the
parent will determine the order of benefits.
c) Dependent Child/Separated or Divorced
Parents
1) If two or more plans cover a
person as a dependent child of divorced or separated parents, benefits for the
child are determined in the following 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.
2)
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 been informed of
those terms, the benefits of that plan are determined first. The plan of the
other parent shall be the secondary plan. This subsection 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.
d) 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 plan covering the
child shall follow the order of benefit determination outlined in subsection
(b).
e) Young
Adult/Dependent
For a dependent child who has coverage under either or both
parents' plans and also has his or her own coverage as a dependent under a
spouse's plan, subsection (h) applies. 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
shall be determined by applying the birthday rule of subsection (b) to the
dependent child's parent or parents and the dependent's
spouse.
f) Active/Inactive
Employees
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 standard and if, as a result, the plans do not agree on the order of
benefits, this subsection (f) shall not apply.
g) Continuation Coverage
1) 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.
2) If the other plan does not contain the
order of benefits determination described in subsection (g)(1) and, if, as a
result, the plans do not agree on the order of benefits, this subsection (g)
shall not apply.
h)
Longer/Shorter Length of Coverage
If none of the other standards of this Section 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.
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 24
hours after the first ended.
2) The
start of a new plan does not include:
A) A
change in the amount of scope of a plan's benefits;
B) A change in the entity that pays, provides
or administers the plan's benefits; or
C) A change from one type of plan to another
(such as, from a single employer plan to that of a multiple employer
plan).
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.