Current through Register Vol. 49, No. 13, September 23, 2024
Subpart
1.
General.
The general order of benefits is as follows:
A. 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 provision may not take into account the benefits of
another plan as defined in part 4685.0910 when it determines its benefits. The
one exception is that a contract holder's coverage 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.
B. A secondary plan may
take the benefits of another plan into account only when, under this part, it
is secondary to that other plan.
C.
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.
Subp. 2.
Dependent child: parents not
separated or divorced.
Benefits for a dependent child when the parents are not
separated or divorced must be coordinated according to the procedures in items
A to E.
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.
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 time.
C. The word "birthday" refers only to month
and day in a calendar year, not the year in which the person was
born.
D. A group contract that
includes coordination of benefits and is issued or renewed or that has an
anniversary date on or after 60 days after October 9, 1989, must include the
substance of the provisions in items A to C. Until October 9, 1989, the group
contract may contain wording such as: "Except as stated in subpart 3, the
benefits of a plan that covers a person as a dependent of a male are determined
before those of a plan that covers the person as a dependent of a
female."
E. If one parent's plan
contains the coordination plan described in items A to C, and the other
parent's plan contains the coordination plan based on the gender of the parent,
and if, as a result, the parents' plans do not agree on the coordination of
benefits, the coordination plan based on the gender of the parent determines
the order of benefits.
Subp.
3.
Dependent child: separated or divorced parents.
If two or more plans cover a person as a dependent child of
divorced or separated parents, benefits for the child are coordinated according
to this subpart. If a court orders one of the parents to pay the health care
expenses of the child, and the entity that pays or provides the parent's plan
knows of the order, the benefits of that parent's plan are determined first.
The plan of the other parent is the secondary plan. This paragraph does not
apply to any claim determination period or plan year during which benefits are
actually paid or provided before the entity knows of the order. If a court
order does not require one of the parents to pay the child's health care
expenses, benefits are coordinated according to items A to C.
A. The benefits of the plan of the parent
with custody of the child are determined first.
B. The benefits of the plan of the spouse of
the parent with the custody of the child are determined second.
C. The benefits of the plan of the parent
without custody of the child are determined last.
D. In the case of joint custody, the primary
plan will be determined according to subpart 2.
Subp. 4.
Active/inactive
employee.
The benefits of a plan that covers a person as an employee,
who is neither laid off nor retired, or as a dependent of that employee are
determined before benefits of a plan that covers that person as a laid-off or
retired employee or as a dependent of that employee. 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 does not apply.
Subp. 5.
Longer/shorter length of
coverage.
If none of these rules 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.
A. To determine the length of
time a person has been covered under a plan, two plans are treated as one if
the claimant was eligible under the second plan within 24 hours after the first
ended.
B. The start of a new plan
does not include:
(1) a change in the amount
of scope of a plan's benefits;
(2)
a change in the entity that pays, provides, or administers the plan's benefits;
or
(3) a change from one type of
plan to another, such as from a single employer plan to that of a multiple
employer plan.
C. 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 is the date used to
determine the length of time the claimant's coverage under the present plan has
been in force.
Statutory Authority: MS s
62D.08;
62D.182;
62D.20
