Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 20 - ADVERTISEMENTS OF HEALTH INSURANCE
Section 836-020-0785 - Rules for Coordination of Benefits
Universal Citation: OR Admin Rules 836-020-0785
Current through Register Vol. 63, No. 9, September 1, 2024
When a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows:
(1)
(a) The
primary plan shall pay or provide its benefits as if the secondary plan or
plans did not exist.
(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.
(c) When multiple
contracts providing coordinated coverage are treated as a single plan under OAR
836-020-0770 to 836-020-0805,
this rule 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
836-020-0770 to
836-020-0805.
(d) If a person is
covered by more than one secondary plan, the order of benefit determination
rules of OAR 836-020-0770 to 836-020-0805
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 that, under the
rules of 836-020-0770 to 836-020-0805,
has its benefits determined before those of that secondary plan.
(2)
(a) Except as provided in subsection (b) of
this section, a plan that does not contain order of benefit determination
provisions that are consistent with OAR
836-020-0770 to 836-020-0805 is
always the primary plan unless the provisions of both plans, regardless of the
provisions of this subsection, state that the complying plan is
primary.
(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.
(3) A plan may take into consideration the benefits paid or provided by another plan only when, under the rules of OAR 836-020-0770 to 836-020-0805, it is secondary to that other plan.
(4) Order of benefit determination: Each plan must determine its order of benefits using the first of the following rules that applies:
(a) Rule regarding non-dependent
or dependent:
(A) Subject to paragraph (B) of
this subsection, the plan that covers the person other than as a dependent, for
example as an employee, member, subscriber or retiree, is the primary plan and
the plan that covers the person as a dependent is the secondary plan.
(B)
(i) 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:
(I) Secondary to the plan covering the
person as a dependent; and
(II)
Primary to the plan covering the person as other than a dependent (e.g. a
retired employee),
(C) Then the order of benefits is reversed so
that the plan covering the person as an employee, member, subscriber or retiree
is the secondary plan and the other plan covering the person as a dependent is
the primary plan.
(b)
Rule regarding 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:
(A) For a dependent child whose parents are
married or are living together, whether or not they have ever been married:
(i) The plan of the parent whose birthday
falls earlier in the calendar year is the primary plan; or
(ii) If both parents have the same birthday,
the plan that has covered the parent longest is the primary
plan.
(B) For a dependent
child whose parents are divorced or separated or are not living together,
whether or not they have ever been married:
(i) 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 subparagraph
does 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;
(ii) 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 paragraph (A) of this
subsection determines the order of benefits;
(iii) 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 paragraph (A) of this subsection determines
the order of benefits; or
(iv) 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:
(I) The plan covering the custodial
parent;
(II) The plan covering the
custodial parent's spouse;
(III)
The plan covering the non-custodial parent; and then
(IV) The plan covering the non-custodial
parent's spouse.
(C) 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 paragraph (A) or (B) of this
subsection as if those individuals were parents of the child.
(c) Rule regarding
active employee or retired or laid-off employee:
(A) 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.
(B) 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.
(C) This rule does
not apply if the rule in subsection (a) of this section can determine the order
of benefits.
(d) Rule
regarding COBRA or state continuation coverage:
(A) 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.
(B) 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.
(C) This rule
does not apply if the rule in subsection (a) of this section can determine the
order of benefits
(e)
Rule regarding longer or shorter length of coverage:
(A) If the preceding rules in this section 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.
(B) 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 24 hours after
coverage under the first plan ended.
(C) 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 that pays, provides or administers the plan's benefits; or
(iii) A change from one type of plan to
another, such as from a single employer plan to a multiple employer
plan.
(D) 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.
(f) If none of the preceding rules of this
section determines the order of benefits, the allowable expenses shall be
shared equally between the plans.
Stat. Auth: ORS 731.244, 743.552
Stats. Implemented: 743.549, 743.552
Disclaimer: These regulations may not be the most recent version. Oregon 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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