Missouri Code of State Regulations
Title 20 - DEPARTMENT OF COMMERCE AND INSURANCE
Division 400 - Life, Annuities and Health
Chapter 2 - Accident and Health Insurance in General
Section 20 CSR 400-2.030 - Group Coordination of Benefits
Universal Citation: 20 MO Code of State Regs 400-2.030
Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule restricts the use of coordination of benefits provisions in group health insurance plans to those situations where they may be equitably applied.
(1) Applicability. The purpose of this rule is to-
(A) Permit, but not require, plans to
include a coordination of benefits (COB) provision;
(B) Establish an order in which plans pay
their claims;
(C) Provide the
authority for orderly transfer of information needed to pay claims
promptly;
(D) Reduce duplication of
benefits by permitting a reduction of the benefits paid by a plan where the
plan, pursuant to rules established by this rule, does not have to pay its
benefits first;
(E) Reduce claims
payment delays; and
(F) Make all
contracts that contain a COB provision consistent with this rule.
(2) Definitions. The following words and terms, when used in this rule, shall have the following meanings unless the context clearly indicates otherwise:
(A) Allowable expenses.
1. 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.
2. Notwithstanding this definition, items of
expense under coverages, such as dental care, vision care, prescription drug or
hearing-aid programs, may be excluded from the definition of allowable expense.
A plan which provides benefits only for any of these items of expense may limit
its definition of allowable expenses to like items of expense.
3. When a plan provides benefits in the form
of service, the reasonable cash value of each service will be considered as
both an allowable expense and a benefit paid.
4. The difference between the cost of a
private hospital room and the cost of a semi-private hospital room is not
considered 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.
5. When
COB is restricted in its use 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 COB applies.
6. When benefits are reduced under a primary
plan because a covered person does not comply with the plan provisions, the
amount of this reduction will not be considered an allowable expense. Examples
of these provisions are those related to second surgical opinions,
precertification of admissions or services and preferred provider arrangements.
A. Only benefit reductions based upon
provisions similar in purpose to those described previously and which are
contained in the primary plan may be excluded from allowable
expenses.
B. This provision shall
not be used by a secondary plan to refuse to pay benefits because a health
maintenance organization (HMO) member has elected to have health care services
provided by a non-HMO provider and the HMO, pursuant to its contract, is not
obligated to pay for providing those services. Note: Paragraph (2)(A)6. is not
intended to allow a secondary plan to exclude expenses that are applied towards
the satisfaction of the deductible, copayments or coinsurance amounts required
by the primary plan, except for the benefit reductions expressly described in
this paragraph;
(B) Claim. A request for benefits of a plan
to be provided or paid is a claim. The benefit claimed may be in the form of-
1. Services (including supplies);
2. Payment for all or a portion of the
expenses incurred;
3. A combination
of paragraphs (2)(B)1. and 2.; or
4. An indemnification;
(C) Claim determination period. This is the
period of time, which must not be less than twelve (12) consecutive months over
which allowable expenses are compared with total benefits payable in the
absence of COB, to determine whether overinsurance exists and how much each
plan will pay or provide.
1. 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.
2. As each claim is
submitted, each plan is to determine its liability and pay or provide benefits
based upon allowable expenses incurred to that point in the claim determination
period. That determination is subject to adjustment as later allowable expenses
are incurred in the same claim determination period;
(D) Coordination of benefits. This is a
provision establishing an order in which plans pay their claims;
(E) Hospital indemnity benefits. These are
benefits 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;
(F) 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 which will be considered in
applying the COB provision of that contract. The right to include a type of
coverage is limited by the rest of this definition.
1. The definition of plan shown in the sample
COB provision, attached to this rule as Appendix A, is an example of what may
be used. Any definition that satisfies this subsection may be used.
2. This rule uses the term plan. However, a
group contract instead may use program or some other term.
3. Plan may include:
A. Group insurance and group subscriber
contracts;
B. Uninsured
arrangements of group or group-type coverage;
C. Group or group-type coverage through HMOs
and other prepayment, group practice and individual practice plans;
D. Group-type contracts. Group-type contracts
are contracts which 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 answering this description 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 designed (for example, franchise or blanket). Individually
underwritten and issued guaranteed renewable policies would not be considered
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. Note: The
purpose and intent of this provision are to identify certain plans of coverage
which may utilize other than a group contract but are administered on a basis
more characteristic of group insurance. These group-type contracts are
distinguished by two (2) factors-1) they are not available to the general
public, but may be obtained only through membership in, or connection with, the
particular organization or group through which they are marketed (for example,
through an employer payroll withholding system) and 2) they can be obtained
only through that affiliation (for example, the contracts might provide that
they cannot be renewed if the insured leaves the particular employer or
organization, in which case they would meet the group-type definition). On the
other hand, if these contracts are guaranteed renewable allowing the insured
the right to renewal regardless of continued employment or affiliation with the
organization, they would not be considered group-type;
E. Group or group-type hospital indemnity
benefits which exceed one hundred dollars ($100) per day;
F. The medical benefits coverage in group,
group-type and individual automobile no-fault type contracts but, as to
traditional automobile fault contracts, only the medical benefits written on a
group or group-type basis may be included; and
G. Medicare or other governmental benefits,
except as provided in subparagraph (2)(F)4.F. That part of the definition of
plan may be limited to the hospital, medical and surgical benefits of the
governmental program.
4.
Plan shall not include:
A. Individual or
family insurance contracts;
B.
Individual or family subscriber contracts;
C. Individual or family coverage under other
prepayment, group practice and individual practice plans;
D. Group or group-type hospital indemnity
benefits of one hundred dollars ($100) per day or less;
E. School accident-type coverages. These
contracts cover grammar, high school and college students for accidents only,
including athletic injuries, either on a twenty-four (24)-hour basis or on a
to-and-from-school basis; and
F. A
state plan under Medicaid and shall not include a law or plan when its benefits
are in excess of those of any private insurance plan or other nongovernmental
plan;
(G)
Primary plan. A primary plan is a plan whose benefits for a person's health
care coverage must be determined without taking the existence of any other plan
into consideration. A plan is a primary plan if either of the following
conditions is true:
1. The plan either has no
order of benefit determination rules or it has rules which differ from those
permitted by this rule. There may be more than one (1) primary plan;
or
2. All plans which cover the
person, use the order of benefit determination rules required by this rule and
under those rules the plandetermines its benefits first;
(H) Secondary plan. A secondary plan is a
plan which is not a primary plan. If a person is covered by more than one (1)
secondary plan, the order of benefit determination provisions of this rule
decide 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(s) and the benefits of any other plan which, under
the provisions of this rule, has its benefits determined before those of that
secondary plan; and
(I) This plan.
In a COB provision, this term refers to the part of the group contract
providing the health care benefits to which the COB provision applies and which
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 (1) COB provision to certain of its benefits (such
as dental benefits), coordinating only with like benefits, and may apply other
separate COB provisions to coordinate other benefits.
(3) Model COB Contract Provision.
(A) General Appendix A contains a model COB
provision for use in group contracts. That use is subject to the provisions of
subsections (3)(B) and (C) and to the provisions of section (4).
(B) Flexibility. A group contract's COB
provision does not have to use the words and format shown in Appendix A.
Changes may be made to fit the language and style of the rest of the group
contract or to reflect the difference among plans which provide services, which
pay benefits for expenses incurred and which indemnify. No other substantive
changes are allowed.
(C) Prohibited
Coordination of Benefit Design.
1. Contracts
meeting the definition of plan as defined in subsection (2)(F) may not reduce
benefits on the basis that-
A. Another plan
exists;
B. A person is or could
have been covered under another plan, except with respect to Part B of
Medicare; or
C. A person has
elected an option under another plan providing a lower level of benefits than
another option which could have been elected.
2. No contract may contain a provision that
its benefits are excess or always secondary to any plan as defined in this
regulation, except in accord with the rules permitted by this
regulation.
(4) Rules for Coordination of Benefits- Order of Benefits.
(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(s) did not exist. A
plan that does not include a coordination of benefits provision may not take
the benefits of another plan as defined in subsection (2)(F) into account when
it determines its benefits. There is one (1) 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 shall be excess to any other parts
of the plan provided by the contract holder; and
2. A secondary plan may take the benefits of
another plan into account only when, under these rules, it is secondary to that
other plan.
(B) Order of
Benefit Determination. Use the first of the following rules which applies:
1. Nondependent/dependent. The benefits of
the plan which covers the person as an employee, member or subscriber (that is,
other than as a dependent) are determined before those of the plan which covers
the person as a dependent, except that, if the person is also a Medicare
beneficiary and as a result of the rule established by Title XVIII of the
Social Security Act and implementing regulations, 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), then the benefits of the plan covering the person as a dependent are
determined before those of the plan covering that person as other than a
dependent;
2. Dependent
child/parents not separated or divorced. The rules for the order of benefits
for a dependent child when the parents are not separated or divorced are as
follows:
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 which covered the parent longer are determined before
those of the plan which covered the other parent for a shorter period of
time;
C. The word birthday refers
only to the month and day in a calendar year, not the year in which the person
was born; and
D. If the other plan
does not have the rule described in subparagraphs (4)(B)2.A.-C. and if, as a
result, the plans do not agree on the order of benefits, the rule in the other
plan will determine the order of benefits;
3. Dependent child/separated or divorced
parents. If two (2) or more plans cover a person as a dependent child of
divorced or separated parents, benefits for the child are determined in this
order:
A. First, the plan of the parent with
custody of the child;
B. Then, the
plan of the spouse of the parent with the custody of the child; and
C. Finally, the plan of the parent not having
custody of the child;
D. If the
specific terms of a court decree state that one (1) 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 actual knowledge
of those terms, the benefits of that plan are determined first. The plan of the
other parent or spouse of the other parent shall be the secondary plan(s). This
subparagraph 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; or
E. If the specific terms of the court decree
state that the parents shall share joint custody, without stating that one (1)
of the parents is responsible for the health care expenses of the child, the
plans covering the child shall follow the order of benefit determination rules
outlined in paragraph (4)(B)2., dependent child/parents not separated or
divorced;
4.
Active/inactive employee. The benefits of a plan which 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 which covers that person as a laid off or
retired employee (or as that employee's dependent). 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. Note: This paragraph does not supersede
paragraph (4)(B)1. Coverage provided an individual as a retired worker and as a
dependent of that individual's spouse as an active worker will be determined
under paragraph (4)(B)1. This rule covers the situation where one (1)
individual is covered under one (1) policy as an active worker and under
another policy as a retired worker. It would also apply to an individual
covered as a dependent under both of those policies;
5. Continuation coverage.
A. 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:
(I) First, the benefits of a plan covering
the person as an employee, member or subscriber (or as that person's
dependent); and
(II) Second, the
benefits under the continuation coverage.
B. If the other plan does not have the rule
described previously and if, as a result, the plans do not agree on the order
of benefits, this rule is ignored. Note: The Consolidated Omnibus Budget
Reconciliation Act of 1987 (COBRA) originally provided that coverage under a
new group health plan caused the COBRA coverage to end. An amendment passed as
part of H.R. 3299 (1989) allows the COBRA coverage to continue if the other
group plan contains any preexisting condition limitation. In this instance, two
(2) policies will cover an individual and the previous rule will be used to
determine which of them assumes the primary position; and
6. Longer/shorter length of coverage. If none
of these rules determines the order of benefits, the benefits of the plan which
covered an employee, member or subscriber longer are determined before those of
the plan which covered that person for the shorter term.
A. To determine the length of time a person
has been covered under a plan, two (2) plans shall be treated as one (1) if the
claimant was eligible under the second within twenty-four (24) hours after the
first ended.
B. The start of a new
plan does not include:
(I) A change in the
amount or scope of a plan's benefits;
(II) A change in the entity which pays,
provides or administers the plan's benefits; or
(III) A change from one (1) 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 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.
(5) Procedure to be Followed by Secondary Plan-Total Allowable Expenses.
(A) When it is
determined pursuant to section (4) that a plan is a secondary plan, it may
reduce its benefits so that the total benefits paid or provided by all plans
during a claim determination period are not more than total allowable expenses.
The amount by which the secondary plan's benefits have been reduced shall be
used by the secondary plan to pay allowable expenses, not otherwise paid, which
were incurred during the claim determination period by the person for whom the
claim is made. As each claim is submitted, the secondary plan determines its
obligation to pay for allowable expenses based on all claims which were
submitted up to that point in time during the claim determination
period.
(B) The benefits of the
secondary plan will be reduced when the sum of the benefits that would be
payable for the allowable expenses under the secondary plan, in the absence of
this COB provision, and the benefits that would be payable for the allowable
expenses under the other plans, in the absence of provisions with a purpose
like that of this COB provision, whether or not claim is made exceeds those
allowable expenses in a claim determination period. In that case, the benefits
of the secondary plan will be reduced so that they and the benefits payable
under the other plans do not total more than those allowable expenses.
1. When the benefits of this plan are reduced
as described previously, each benefit is reduced in proportion. It is then
charged against any applicable benefit limit of this plan.
2. Paragraph (5)(B)1. may be omitted if the
plan provides only one (1) benefit, or may be altered to suit the coverage
provided.
(6) Miscellaneous Provisions.
(A) Reasonable Cash
Values of Services. A secondary plan which provides benefits in the form of
services may recover the reasonable cash value of providing 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 the services provided by a
plan which provides benefits in the form of services.
(B) Excess and Other Nonconforming
Provisions.
1. Some plans have order of
benefit determination provisions not consistent with this rule which declare
that the plan's coverage is excess to all others or always secondary. This
occurs because certain plans may not be subject to insurance regulation or
because some group contracts have not been conformed yet with this
regulation.
2. A plan with order of
benefit determination rules which comply with this rule (complying plan) may
coordinate its benefits with a plan which is excess or always secondary or
which uses order of benefit determination provisions which are inconsistent
with those contained in this rule (noncomplying plan) on the following basis:
A. If the complying plan is the primary plan,
it shall pay or provide its benefits on a primary basis;
B. If the complying plan is the secondary
plan, it shall pay or provide its benefits first, nevertheless, but the amount
of the benefits payable shall be determined as if the complying plan were the
secondary plan. In this situation, the payment shall be the limit of the
complying plan's liability; and
C.
If the noncomplying 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
noncomplying plan are identical to its own, and shall pay its benefits
according-l y. However, the complying plan must adjust any payments it makes
based on this assumption whenever information becomes available as to the
actual benefits of the noncomplying plan.
3. If the noncomplying plan reduces its
benefits so that the employee, subscriber or member receives less in benefits
than s/he would have received had the complying plan paid or provided its
benefits as the secondary plan and the noncomplying plan paid or provided its
benefits as the primary plan, then the complying plan shall advance to or on
behalf of the employee, subscriber or member an amount equal to that
difference. However, 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. In consideration of this advance, the complying plan shall be
subrogated to all rights of the employee, subscriber or member against the
noncom-plying plan. This advance by the complying plan also shall be without
prejudice to any claim it may have against the noncomplying plan in the absence
of that subrogation.
(C)
Allowable Expense. A term, such as usual and customary, usual and prevailing or
reasonable and customary, may be substituted for the term necessary, reasonable
and customary. Terms, such as medical care or dental care, may be substituted
for health care to describe the coverages to which the COB provisions
apply.
(D) Facility of Payment and
Recovery.
1. Whenever payments which should
have been made under a plan have been made under any other plans, the insurer
or service plan shall have the right, exercisable alone and in its sole
discretion, to pay over to any organizations making the other payments any
amounts it shall determine to be warranted in order to satisfy the intent of
this rule and amounts so paid shall be deemed to be benefits paid under that
plan and to the extent of these payments, the insurer or service plan shall be
fully discharged from liability under its plan.
2. Whenever payments have been made by the
insurer with respect to allowable expenses in a total amount at any time, in
excess of the maximum amount of payment necessary at that time to satisfy the
intent of this rule, the insurer or service plan shall have the right to
recover these payments, to the extent of the excess, from among one (1) or more
of the following, as the insurer or service plan shall determine: any persons
to, or for, or with respect to whom the payments were made; any other insurers,
service plans; or any other organizations.
3. Subrogation will not be allowed in any
plan as distinguished from the rights to recovery.
(7) Effective Date, Existing Contracts.
(A) This subsection is applicable
to every group contract which provides health care benefits and which is issued
on or after the effective date of this rule (July 1, 1972).
(B) A group contract which provides health
care benefits, is in force at the time of promulgation of these rules and which
contains a COB provision not fully in compliance with these rules shall be
brought into compliance with this rule by the later of-
1. The next anniversary date or renewal date
of the group contract; or
2. The
expiration of any applicable collectively bargained contract pursuant to which
it was written.
Appendix A Model COB Provisions
Coordination of the Group Contracts Benefits With Other Benefits
I. APPLICABILITY
A. This coordination of benefits (COB)
provision applies to this plan when an employee or the employee's covered
dependent has health care coverage under more than one (1) plan. Plan and this
plan are defined here.
B. If this
COB provision applies, the order of benefit determination rules should be
looked at first. Those rules determine whether the benefits of this plan are
determined before or after those of another plan. The benefits of this plan-
(1) Shall not be reduced when, under the
order of benefit determination rules, this plan determines its benefits before
another plan; but
(2) May be
reduced when, under the order of benefits determination rules, another plan
determines its benefits first. This reduction is described in Section I V.
Effect on the Benefits of This Plan-
II. DEFINITIONS
A. Plan is any of these which provides
benefits or services for, or because of, medical or dental care or treatment:
(1) Group insurance or group-type coverage,
whether insured or uninsured. This includes prepayment, group practice or
individual practice coverage. It also includes coverage other than school
accident-type coverage.
(2)
Coverage under a governmental plan, or coverage required or provided by law.
This does not include a state plan under Medicaid (Title XIX, Grants to States
for Medical Assistance Programs, of the United States Social Security Act).
Each contract or other arrangement for coverage under (1) or (2) is a separate
plan. Also, if an arrangement has two (2) parts and COB rules apply only to one
(1) of the two (2), each of the parts is a separate plan.
B. This plan is the part of the group
contract that provides benefits for health care expenses.
C. Primary plan/secondary plan. The order of
benefit determination rules state whether this plan is a primary plan or
secondary plan as to another plan covering the person. When this plan is a
primary plan, its benefits are determined before those of the other plan and
without considering the other plan's benefits. When this plan is a secondary
plan, its benefits are determined after those of the other plan and may be
reduced because of the other plan's benefits. When there are more than two (2)
plans covering the person, this plan may be a primary plan as to one (1) or
more other plans and may be a secondary plan as to a different
plan(s).
D. Allowable expense means
a necessary, reasonable and customary item of expense for health care, when the
item of expense is covered at least in part by one (1) or more plans covering
the person for whom the claim is made. The difference between the cost of a
private hospital room and the cost of a semi-private hospital room is not
considered an allowable expense under this definition unless the patient's stay
in a private hospital room is medically necessary either in terms of generally
accepted medical practice or as specifically defined in the plan. When a plan
provides benefits in the form of services, the reasonable cash value of each
service rendered will be considered both an allowable expense and a benefit
paid. When benefits are reduced under a primary plan because a covered person
does not comply with the plan provisions, the amount of that reduction will not
be considered an allowable expense. Examples of these provisions are those
related to second surgical opinions, precertification of admissions or
services, and preferred provider arrangements.
E. Claim determination period means a
calendar year. However, it does not include any part of a year during which a
person has no coverage under this plan or any part of a year before the date
this COB provision or similar provision takes effect.
III. ORDER OF BENEFIT DETERMINATION RULES
A. General. When there is a basis for a claim
under this plan and another plan. This plan is a secondary plan which has its
benefits determined after those of the other plan, unless-
(1) The other plan has rules coordinating its
benefits with those of this plan; and
(2) Both those rules and this plan's rules,
in subsection III.B., require that this plan's benefits be determined before
those of the other plan.
B. Rules. This plan determines its order of
benefits using the first of the following rules which applies:
(1) Nondependent/dependent. The benefits of
the plan which covers the person as an employee, member or subscriber (that is,
other than as a dependent) are determined before those of the plan which covers
the person as a dependent; except that-if the person is also a Medicare
beneficiary, and as a result of the rule established by Title XVIII of the
Social Security Act and implementing regulations, 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), then the benefits of the plan covering the person as a dependent are
determined before those of the plan covering that person as other than a
dependent.
(2) Dependent
child/parents not separated or divorced. Except as stated in paragraph
III.B.(3), when this plan and another plan cover the same child as a dependent
of different persons, called parents-
(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; but
(b) If both parents
have the same birthday, the benefits of the plan which covered one (1) parent
longer are determined before those of the plans which covered the other parent
for a shorter period of time. However, if the other plan does not have the rule
described previously in III.B.(2)(a) or (b) and if, as a result, the plans do
not agree on the order of benefits, the rule in the other plan will determine
the order of benefits.
(3) Dependent child/separated or divorced. If
two (2) or more plans cover a person as a dependent child of divorced or
separated parents, benefits for the child are determined in this order:
(a) First, the plan of the parent with
custody of the child;
(b) Then, the
plan of the spouse of the parent with the custody of the child; and
(c) Finally, the plan of the parent not
having custody of the child. However, if the specific terms of a court decree
state that one (1) of the parents is responsible for the health care expense of
the child and the entity obligated to pay or provide the benefits of the plan
of that parent or spouse of the other parent has actual knowledge of those
terms, the benefits of that plan are determined first. The plan of the other
parent shall be the secondary plan. This paragraph 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.
(4) Joint
custody. If the specific terms of a court decree state that the parents shall
share joint custody, without stating that one (1) of the parents is responsible
for the health care expenses of the child, the plans covering the child shall
follow the order of benefit determination rules outlined in paragraph
III.B.(2).
(5) Active/inactive
employee. The benefits of a plan which covers a person as an employee who is
neither laid off nor retired are determined before those of a plan which covers
that person as a laid off or retired employee. The same would hold true if a
person is a dependent of a person covered as a retiree and an 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 (5) is ignored.
(6) Continuation coverage. 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); and
(b) Second, the benefits under the
continuation coverage. If the other plan does not have the rule described here
and if, as a result, the plans do not agree on the order of benefits, this rule
is ignored.
(7)
Longer/shorter length of coverage. If none of the previous rules determines the
order of benefits, the benefits of the plan which covered an employee, member
or subscriber longer are determined before those of the plan which covered that
person for the shorter term.
IV. EFFECT ON THE BENEFITS OF THIS PLAN
A. When This Section Applies. This section I
V. applies when, in accordance with section III., Order of Benefit
Determination Rules, this plan is a secondary plan as to one (1) or more other
plans. In that event the benefits of this plan may be reduced under this
section. Other plan(s) are referred to as the other plans in IV.B. immediately
following.
B. Reduction in this
plan's benefits. The benefits of this plan will be reduced when the sum of:
(1) The benefits that would be payable for
the allowable expense under this plan in the absence of this COB provision;
and
(2) The benefits that would be
payable for the allowable expenses under the other plans, in the absence of
provisions with a purpose like that of this COB provision, whether or not claim
is made, exceeds those allowable expenses in a claim determination period. In
that case, the benefits of this plan will be reduced so that they and the
benefits payable under the other plans do not total more than those allowable
expenses. When the benefits of this plan are reduced as described previously,
each benefit is reduced in proportion. It is then charged against any
applicable benefit limit of this plan.
V. RIGHT TO RECEIVE AND RELEASE NEEDED
INFORMATION
Certain facts are needed to apply these COB rules. (Insurer) has the right to decide which facts it needs. It may get needed facts from or give them to any other organization or person. (Insurer) need not tell, or get the consent of, any person to do this. Each person claiming benefits under this plan must give (insurer) any facts it needs to pay the claim.
VI. FACILITY OF PAYMENT
A payment made under another plan may include an amount which should have been paid under This Plan. If it does, (insurer) may pay that amount to the organization which made the payment. That amount will then be treated as though it were a benefit paid under this plan. (Insurer) will not have to pay that amount again. The term, payment made includes providing benefits in the form of services, in which case payment made means reasonable cash value of the benefits provided in the form of services.
VII. RIGHT OF RECOVERY
If the amount of the payments made by (insurer) is more than it should have paid under this COB provision, it may recover the excess from one (1) or more of-
A. The person it
has paid or for whom it has paid;
B. Insurance companies; or
C. Other organizations. The amount of the
payments made includes the reasonable cash value of any benefits provided in
the form services.
VIII.
Subrogation will not be allowed in any plan as distinguished from the rights to
recovery.
*Original authority: 354.120, RSMo 1973, amended 1983; 374.045, RSMo 1967; and 376.405, RSMo 1959, amended 1984.
Disclaimer: These regulations may not be the most recent version. Missouri 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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