008.01 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.
008.02(A) 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 (noncomplying plan) on the following basis:
008.02(A)(i) If the complying plan is the
primary plan, it shall pay or provide its benefits first;
008.02(A)(ii) 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 plan's liability; and
008.02(A)(iii) 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 accordingly. If, within two (2) years of
payment, the complying plan receives information as to the actual benefits of
the noncomplying plan, it shall adjust payments accordingly.
008.02(B) If the noncomplying 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 noncomplying 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.
008.02(C) 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 noncomplying
plan. The advance by the complying plan shall also be without prejudice to any
claim it may have against a noncomplying plan in the absence of
subrogation.
008.03 COB
differs from subrogation. Provisions for one may be included in health care
benefits contracts without compelling the inclusion or exclusion of the
other.
008.04 If the plans cannot
agree on the order of benefits within thirty (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.
