Current through Register Vol. 50, No. 9, September 20, 2024
A. A
secondary plan that provides benefits in the form of services may recover the
reasonable cash value of the services from the primary plan, to the extent that
benefits for the services are covered by the primary plan and have not already
been paid or provided by the primary plan. Nothing in this provision shall be
interpreted to require a plan to reimburse a covered person in cash for the
value of services provided by a plan that provides benefits in the form of
services.
1. A plan with order of benefit
determination rules that comply with this regulation (complying plan) may
coordinate its benefits with a plan that is "excess" or "always secondary" or
that uses order of benefit determination rules that are inconsistent with those
contained in this regulation (non-complying plan) on the following basis:
a. if the complying plan is the primary plan,
it shall pay or provide its benefits first;
b. if the complying plan is the secondary
plan, it shall pay or provide its benefits first, but the amount of the
benefits payable shall be determined as if the complying plan were the
secondary plan. In such a situation, the payment shall be the limit of the
complying plans liability; and
c.
if the non-complying plan does not provide the information needed by the
complying plan to determine its benefits within a reasonable time after it is
requested to do so, the complying plan shall assume that the benefits of the
non-complying plan are identical to its own, and shall pay its benefits
accordingly. If, within two years of payment, the complying plan receives
information as to the actual benefits of the non-complying plan, it shall
adjust payments accordingly.
2. If the non-complying plan reduces its
benefits so that the covered person receives less in benefits than the covered
person would have received had the complying plan paid or provided its benefits
as the secondary plan and the non-complying plan paid or provided its benefits
as the primary plan, and governing state law allows the right of subrogation
set forth below, then the complying plan shall advance to the covered person or
on behalf of the covered person an amount equal to the difference.
3. In no event shall the complying plan
advance more than the complying plan would have paid had it been the primary
plan less any amount it previously paid for the same expense or service. In
consideration of the advance, the complying plan shall be subrogated to all
rights of the covered person against the non-complying plan. The advance by the
complying plan shall also be without prejudice to any claim it may have against
a non-complying plan in the absence of subrogation.
B. COB differs from subrogation. Provisions
for one may be included in health care benefits contracts without compelling
the inclusion or exclusion of the other.
C. If the plans cannot agree on the order of
benefits within 30 calendar days after the plans have received all of the
information needed to pay the claim, the plans shall immediately pay the claim
in equal shares and determine their relative liabilities following payment,
except that no plan shall be required to pay more than it would have paid had
it been the primary plan.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
22:3.
