When a person is covered by two (2) or more plans, the rules
for determining the order of benefit payments are as follows:
006.01(A) The primary plan shall pay or
provide its benefits as if the secondary plan or plans did not exist.
006.01(B) 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.
006.01(C) 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 plan's compliance with
this regulation.
006.01(D) 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.
006.02(A) Except as provided in Paragraph
006.02(B), 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.
006.02(B) 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.
006.03 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.
006.04 Order of Benefit
Determination
Each plan determines its order of benefits using the first of
the following rules that applies:
006.04(A) Non-Dependent or Dependent
006.04(A)(i) Subject to Subparagraphs
006.04(A)(ii)(a)
through
006.04(A)(ii)(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.
006.04(A)(ii)(a)
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:
006.04(A)(ii)(a)(1) Secondary to the plan
covering the person as a dependent; and
006.04(A)(ii)(a)(2) Primary to the plan
covering the person as other than a dependent (e.g. a retired employee),
006.04(A)(ii)(b) 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.
006.04(B) 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:
006.04(B)(i) For a
dependent child whose parents are married or are living together, whether or
not they have ever been married:
006.04(B)(i)(a) The plan of the parent whose
birthday falls earlier in the calendar year is the primary plan; or
006.04(B)(i)(b) If both parents have the same
birthday, the plan that has covered the parent longest is the primary
plan.
006.04(B)(ii) For
a dependent child whose parents are divorced or separated or are not living
together, whether or not they have ever been married:
006.04(B)(ii)(a) If a court decree states
that one of the parents is responsible for the dependent child's 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 child's health
care expenses, but that parent's spouse does, that parent's spouse's 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;
006.04(B)(ii)(b) If a court decree states
that both parents are responsible for the dependent child's health care
expenses or health care coverage, the provisions of Subparagraph
006.04(B)(i)
through
006.04(B)(i)(b)
of this paragraph shall determine the order of benefits;
006.04(B)(ii)(c) 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
006.04(B)(i)
through
006.04(B)(i)(b)
of this paragraph shall determine the order of benefits; or
006.04(B)(ii)(d) If there is no court decree
allocating responsibility for the child's health care expenses or health care
coverage, the order of benefits for the child are as follows:
006.04(B)(ii)(d)(1) The plan covering the
custodial parent;
006.04(B)(ii)(d)(2) The plan covering the
custodial parent's spouse;
006.04(B)(ii)(d)(3) The plan covering the
non-custodial parent; and then
006.04(B)(ii)(d)(4) The plan covering the
non-custodial parent's spouse.
006.04(B)(iii) 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
006.04(B)(i)
through
006.04(B)(i)(b)
or
006.04(B)(ii)
through
006.04(B)(ii)(d)(4)
of this paragraph as if those individuals were parents of the child.
006.04(B)(iv)(a) 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 spouse's plan, the rule in Paragraph
006.04(E)applies.
006.04(B)(iv)(b) In the event the dependent
child's coverage under the spouse's plan began on the same date as the
dependent child's coverage under either or both parents' plans, the order of
benefits shall be determined by applying the birthday rule in Paragraph
006.04(B) to be the dependent child's parent(s) and the dependent's
spouse.
006.04(C) Active
Employee or Retired or Laid-Off Employee
006.04(C)(i) 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.
006.04(C)(ii) 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.
006.04(C)(iii) This rule does not apply if
the rule in Paragraphs
006.04A through
006.04(A)(ii)(b)can
determine the order of benefits .
006.04(D) COBRA or State Continuation
Coverage
006.04(D)(i) 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.
006.04(D)(ii) 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.
006.04(D)(iii) This rule does not apply if
the rule in Paragraph
006.04(A) through
006.04A(ii)(b)
can determine the order of benefits
006.04(E) Longer or Shorter Length of
Coverage
006.04(E)(i) 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.
006.04(E)(ii) 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
twenty-four (24) hours after coverage under the first plan ended.
006.04(E)(iii) The start of a new plan does
not include:
006.04(E)(iii)(1) A change in
the amount or scope of a plan's benefits;
006.04(E)(iii)(2) A change in the entity that
pays, provides or administers the plan's benefits; or
006.04(E)(iii)(3) A change from one type of
plan to another, such as, from a single employer plan to a multiple employer
plan.
006.04(E)(iv) The
person's length of time covered under a plan is measured from the person's
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 person's
coverage under the present plan has been in force.
006.04(F) If none of the preceding rules
determines the order of benefits, the allowable expenses shall be shared
equally between the plans.
