Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Scope.
The following words and terms, when used in parts 4685.0905
to 4685.0950, have the following meanings unless the context clearly indicates
otherwise.
Subp. 2.
Allowable expense.
A. "Allowable
expense" means the necessary, reasonable, and customary item of expense for
health care when the item of expense is covered at least in part under any of
the plans involved, except where a statute requires a different
definition.
B. Notwithstanding this
definition, items of expense under coverages such as dental care, vision care,
or prescription drug or hearing aid programs may be excluded from the
definition of allowable expense. A plan that provides benefits only for such
items of expense may limit its definition of allowable expenses to those items
of expense.
C. When a plan provides
benefits in the form of service, the reasonable cash value of each service is
both an allowable expense and a benefit paid.
D. The difference between the cost of a
private hospital room and the cost of a semiprivate hospital room is not an
allowable expense under this definition unless the patient's stay in a private
hospital room is medically necessary in terms of generally accepted medical
practice.
E. When coordination of
benefits is restricted to specific coverage in a contract, for example, major
medical or dental, the definition of allowable expense must include the
corresponding expenses or services to which coordination of benefits
applies.
F. When benefits are
reduced under a primary plan because a covered person does not comply with the
plan provisions, the amount of such reduction will not be considered an
allowable expense. Examples of such provisions are those related to second
surgical opinions, precertification of admissions or services, and preferred
provider arrangements.
(1) Only benefit
reductions based upon provisions similar in purpose to those described above
and which are contained in the primary plan may be excluded from allowable
expenses.
(2) This provision shall
not be used by a secondary plan to refuse to pay benefits because a health
maintenance organization enrollee has elected to have health care services
provided by a nonhealth maintenance organization provider and the health
maintenance organization, pursuant to its contract is not obligated to pay for
providing those services.
Subp. 3.
Claim.
"Claim" means a request that benefits of a plan be provided
or paid. The benefits claimed may be in the form of:
A. services, including supplies;
B. payment for all or a portion of the
expenses incurred;
C. a combination
of items A and B; or
D. an
indemnification.
Subp.
4.
Claim determination period.
A. "Claim determination period" means the
period of time over which allowable expenses are compared with total benefits
payable in the absence of coordination of benefits, to determine whether
overinsurance exists and how much each plan will pay or provide. The claim
determination period must not be less than 12 consecutive months.
B. The claim determination period is usually
a calendar year, but a plan may use some other period of time that fits the
coverage of the group contract. A person may be covered by a plan during a
portion of a claim determination period if that person's coverage starts or
ends during the claim determination period.
C. As each claim is submitted, each plan must
determine its liability and pay or provide benefits based upon allowable
expenses incurred to that point in the claim determination period. The
determination may be adjusted as allowable expenses are incurred later in the
same claim determination period.
Subp. 5.
Coordination of
benefits.
"Coordination of benefits" means a provision establishing the
order in which plans pay their claims.
Subp. 6.
Hospital indemnity
benefits.
"Hospital indemnity benefits" are not related to expenses
incurred. The term does not include reimbursement-type benefits even if they
are designed or administered to give the insured the right to elect
indemnity-type benefits at the time of claim.
Subp. 7.
Plan.
"Plan" means a form of coverage with which coordination is
allowed. The definition of plan in the group contract must state the types of
coverage that will be considered in applying the coordination of benefits
provision of that contract. The right to include a type of coverage is limited
by the rest of this definition.
A. The
definition shown in the Model Coordination of Benefits Provisions in part
4685.0950 is an example of what may be used. Any definition that satisfies this
subpart may be used.
B. Instead of
"plan," a group contract may use "program" or some other term.
C. Plan includes:
(1) Group insurance and group subscriber
contracts.
(2) Uninsured
arrangements of group or group-type coverage.
(3) Group or group-type coverage through
health maintenance organizations and other prepayment, group practice, and
individual practice plans.
(4)
Group-type contracts. Group-type contracts are contracts that are not available
to the general public and can be obtained and maintained only because of
membership in or connection with a particular organization or group. Group-type
contracts may be included in the definition of plan, at the option of the
insurer or the service provider and the contract client, whether or not
uninsured arrangements or individual contract forms are used and regardless of
how the group-type coverage is designated, for example, franchise or blanket.
Individually underwritten and issued guaranteed renewable policies are not
group-type even though purchased through payroll deduction at a premium savings
to the insured since the insured would have the right to maintain or renew the
policy independently of continued employment with the employer.
(5) The amount by which group or group-type
hospital indemnity benefits exceed $100 a day.
(6) The medical benefits coverage in group,
group-type, and individual automobile no-fault and traditional automobile
fault-type contracts.
(7) Medicare
or other governmental benefits, except as provided in item D, subitem (7). That
part of the definition of plan may be limited to the hospital, medical, and
surgical benefits of the governmental program.
D. Plan does not include:
(1) individual or family insurance
contracts;
(2) individual or family
subscriber contracts;
(3)
individual or family coverage through health maintenance
organizations;
(4) individual or
family coverage under other prepayment, group practice, and individual practice
plans;
(5) group or group-type
hospital indemnity benefits of $100 a day or less;
(6) school accident-type coverages that cover
grammar, high school, and college students for accidents only, including
athletic injuries, either on a 24-hour basis or on a to and from school basis;
and
(7) a state plan under
Medicaid, or a law or plan when, by law, its benefits are in excess of those of
any private insurance plan or other nongovernmental plan.
Subp. 8.
Primary
plan.
"Primary plan" means a plan that requires benefits for a
person's health care coverage to be determined without taking into
consideration the existence of any other plan. A plan is a primary plan if
either of the following is true:
A.
The plan either has no order of benefit determination rules or it has
provisions that differ from those permitted by parts 4685.0905 to 4685.0950.
There may be more than one primary plan.
B. All plans that cover the person use the
order of benefit determination rules required by parts 4685.0905 to 4685.0950
and, under those rules, the plan determines its benefits first.
Subp. 9.
Secondary
plan.
"Secondary plan" means a plan that is not a primary plan. If
a person is covered by more than one secondary plan, the order of benefit
determination rules in parts 4685.0905 to 4685.0950 determine the order in
which their benefits are determined in relation to each other. The benefits of
each secondary plan may take into consideration the benefits of the primary
plan or plans and the benefits of any other plan which under these rules has
its benefits determined before those of that secondary plan.
Subp. 10.
This plan.
In a coordination of benefits provision, "this plan" refers
to the part of the group contract providing the health care benefits to which
the coordination of benefits provision applies and that may be reduced because
of the benefits of other plans. Any other part of the group contract providing
health care benefits is separate from this plan. A group contract may apply one
coordination of benefits provision to certain of its benefits, such as dental
benefits, coordinating only with like benefits, and may apply other separate
coordination of benefits provisions to coordinate other benefits.
Statutory Authority: MS s
62D.08;
62D.182;
62D.20
