Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 3 - Regulation 32-Coordination of Benefits
Section XIII-307 - Rules for Coordination of Benefits
Universal Citation: LA Admin Code XIII-307
Current through Register Vol. 50, No. 9, September 20, 2024
A. When a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows.
1. The primary plan shall pay or provide its
benefits as if the secondary plan or plans did not exist.
2. If the primary plan is a closed panel plan
and the secondary plan is not a closed panel plan, the secondary plan shall pay
or provide 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. When multiple contracts providing
coordinated coverage are treated as a single plan under this regulation, this
section 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
carrier pays or provides benefits under the plan, the carrier designated as
primary within the plan shall be responsible for the plans compliance with this
regulation.
4. If a person is
covered by more than one secondary plan, the order of benefit determination
rules of this regulation decide the order in which secondary plans benefits are
determined in relation to each other. Each secondary plan shall take into
consideration the benefits of the primary plan or plans and the benefits of any
other plan, which, under the rules of this regulation, has its benefits
determined before those of that secondary plan.
5. Except as provided in Paragraph 2 of this
Subsection, a plan that does not contain order of benefit determination
provisions that are consistent with this regulation is always the primary plan
unless the provisions of both plans, regardless of the provisions of this
Paragraph, state that the complying plan is primary.
6. 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 shall be 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.
B. A plan may take into consideration the benefits paid or provided by another plan only when, under the rules of this regulation, it is secondary to that other plan.
C. Order of Benefit Determination. Each plan determines its order of benefits using the first of the following rules that applies:
1.
Non-Dependent or Dependent
a. Subject to
Subparagraph b of this Paragraph, 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.
b. If the
person is a Medicare beneficiary, and, as a result of the provisions of title
XVIII of the Social Security Act and implementing regulations, Medicare is:
i. secondary to the plan covering the person
as a dependent; and
ii. primary to
the plan covering the person as other than a dependent (e.g. a retired
employee).
c. 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.
2. Dependent Child
Covered Under More Than One Plan. Unless there is a court decree stating
otherwise, plans covering a dependent child shall determine the order of
benefits as follows:
a. For a dependent child
whose parents are married or are living together, whether or not they have ever
been married:
i. the plan of the parent whose
birthday falls earlier in the calendar year is the primary plan; or
ii. if both parents have the same birthday,
the plan that has covered the parent longest is the primary plan.
b. For a dependent child whose
parents are divorced or separated or are not living together, whether or not
they have ever been married:
i. if a court
decree states that one of the parents is responsible for the dependent childs
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 childs health care
expenses, but that parents spouse does, that parents spouses plan is the
primary plan. This item shall 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 provision;
ii. if
a court decree states that both parents are responsible for the dependent
childs health care expenses or health care coverage, the provisions of
Subparagraph a of this Paragraph shall determine the order of
benefits;
iii. if a court decree
states that the parents have joint custody without specifying that one parent
has responsibility for the health care expenses or health care coverage of the
dependent child, the provisions of Subparagraph a of this Paragraph shall
determine the order of benefits; or
iv. if there is no court decree allocating
responsibility for the childs health care expenses or health care coverage, the
order of benefits for the child are as follows:
(a). the plan covering the custodial
parent;
(b). the plan covering the
custodial parents spouse;
(c). the
plan covering the non-custodial parent; and then
(d). the plan covering the non-custodial
parents spouse.
c. For a dependent child covered under more
than one plan of individuals who are not the parents of the child, the order of
benefits shall be determined, as applicable, under Subparagraph a or b of this
Paragraph as if those individuals were parents of the child.
d. For a dependent child covered under
spouses plan
i. 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 spouses plan, the rule in Paragraph 5 of this
Subsection applies.
ii. In the
event the dependent childs coverage under the spouses plan began on the same
date as the dependent childs coverage under either or both parents plans, the
order of benefits shall be determined by applying the birthday rule in
Subparagraph a of this Paragraph to the dependent childs parent(s) and the
dependents spouse.
3. Active Employee or Retired or Laid-Off
Employee
a. 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.
b. If the other plan does not have this rule,
and as a result, the plans do not agree on the order of benefits, this rule is
ignored.
c. This rule does not
apply if the rule in Paragraph 1 of this Subsection can determine the order of
benefits.
4. COBRA or
State Continuation Coverage
a. If a person
whose coverage is provided pursuant to COBRA or under a right of continuation
pursuant to state or other federal 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.
b. 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.
c.
This rule does not apply if the rule in Paragraph 1 of this Subsection can
determine the order of benefits
5. Longer or Shorter Length of Coverage
a. 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 the
shorter period of time is the secondary plan.
b. To determine the length of time a person
has been covered under a plan, two successive plans shall be treated as one if
the covered person was eligible under the second plan within 24 hours after
coverage under the first plan ended.
c. The start of a new plan does not include:
i. a change in the amount or scope of a plans
benefits;
ii. a change in the
entity that pays, provides or administers the plans benefits; or
iii. a change from one type of plan to
another, such as, from a single employer plan to a multiple employer
plan.
d. The persons
length of time covered under a plan is measured from the persons 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 shall be used as
the date from which to determine the length of time the persons coverage under
the present plan has been in force.
6. If none of the preceding rules determines
the order of benefits, the allowable expenses shall be shared equally between
the plans.
AUTHORITY NOTE: Promulgated in accordance with R.S. 22:3.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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