Utah Administrative Code
Topic - Insurance
Title R590 - Administration
Rule R590-131 - Accident and Health Coordination of Benefits Rule
Section R590-131-3 - Definitions

Universal Citation: UT Admin Code R 590-131-3

Current through Bulletin 2024-06, March 15, 2024

Terms used in this rule are defined in Section 31A-1-301. Additional terms are defined as follows:

(1) "Allowable expense" means a health care expense, including coinsurance or a copayment without reduction for any applicable deductible, that is covered in full or in part by any plan covering an enrollee.

(a) If an enrollee advises an insurer that each plan covering the enrollee is a high-deductible health plan and the enrollee intends to contribute to a health savings account established in accordance with Section 223 of the Internal Revenue Code of 1986, then the primary high-deductible health plan's deductible is not an allowable expense, except for a health care expense incurred that is not subject to the deductible as described in Section 223(c)(2)(C) of the Internal Revenue Code of 1986.

(b) An expense or a portion of an expense that is not covered by any plan is not an allowable expense.

(c) Any expense that a provider, by law or in accordance with a contractual agreement, is prohibited from charging an enrollee is not an allowable expense.

(d) The examples in this subsection (1)(d) are not an allowable expense.
(i) If an enrollee is confined in a private hospital room, the difference between the cost of a semi-private room and the private room is not an allowable expense, unless one of the plans provides coverage for a private hospital room expense.

(ii) If an enrollee is covered by two or more plans that compute their benefit on the basis of a usual and customary fee, a relative value schedule, or other similar reimbursement methodology, any amount charged by the provider in excess of the highest reimbursement amount for a specified benefit is not an allowable expense.

(iii) If an enrollee is covered by two or more plans that provide a benefit or service on the basis of a negotiated fee, any amount in excess of the highest negotiated fee is not an allowable expense.

(iv) If an enrollee is covered by one plan that calculates its benefit or service on the basis of a usual and customary fee, a relative value schedule, or other similar reimbursement methodology and another plan that provides its benefit or service on the basis of a negotiated fee, then the primary plan's payment arrangement shall be the allowable expense for each plan.

(v) If a provider has a contract with the secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan's payment arrangement, and if the provider's contract permits, that negotiated fee or payment shall be the allowable expense used by the secondary plan to determine its benefits.

(e) The definition of "allowable expense" may exclude certain types of coverage or benefits such as dental care, vision care, prescription drugs, or hearing aids.
(i) A plan that limits the application of COB to certain coverages or benefits may limit the definition of "allowable expense" in its contract to expenses that are similar to the expenses that it provides.

(ii) When COB is restricted to specific coverages or benefits in a contract, the definition of "allowable expense" shall include similar expenses to which COB applies.

(f) When a plan provides benefits in the form of a service, the reasonable cash value of each service will be considered an allowable expense and a benefit paid.

(g) The amount of a reduction may be excluded from allowable expense when an enrollee's benefits are reduced under a primary plan because the enrollee does not comply with the plan provisions concerning a second surgical opinion or pre-certification of an admission or a service.

(2)

(a) "Birthday" means the month and day the enrollee was born.

(b) "Birthday" does not include the year the enrollee was born.

(3) "Child" means a:

(a) child as defined in Section 78B-12-102; or

(b) dependent child who is provided coverage pursuant to Sections 31A-22-610, 31A-22-610.5, and 31A-22-611.

(4)

(a) "Claim" means a request that a plan's benefits be provided or paid.

(b) A benefit claimed may be in the form of:
(i) a service, including a supply;

(ii) payment for all or a portion of the expenses incurred;

(iii) a combination of Subsections (4)(b)(i) and (4)(b)(ii); or

(iv) an indemnification.

(5) "Closed panel plan" means a plan that:

(a) provides benefits to an enrollee primarily in the form of services through a panel of providers that have contracted with or are employed by an insurer; and

(b) excludes a benefit for a service provided by a non-panel provider, except in the case of:
(i) an emergency; or

(ii) a referral by a panel provider.

(6)

(a) "Conforming plan" or "Plan" means a plan that allows COB.

(b) "Conforming plan" or "Plan" includes:
(i) an individual, group, or group-type accident and health insurance contract, including a closed panel plan;

(ii) a group or group-type uninsured arrangement;

(iii) a medical care benefit in a long-term care contract that provides reimbursement for an incurred expense, rather than an indemnity benefit; and

(iv) a Medicare or other governmental benefit, as permitted by law.

(7) "Continuation coverage" or "COBRA" means coverage provided under the Consolidated Omnibus Budget Reconciliation Act of 195, Section 31A-22-722, or another state extension required by law.

(8) "Coordinated package" means multiple plans or separate parts of a plan that are intended to be part of a coordinated plan of benefits.

(9) "Coordination of benefits" or "COB" means a plan provision that establishes an order in which a plan pays a coordination of benefit claim, and a plan, other than a primary plan, to reduce the plan benefits so that the combined benefit of all plans do not exceed the total allowable expense.

(10) "Custodial parent" means:

(a) the parent awarded custody of a child by a court order; or

(b) in the absence of a court order, the parent with whom the child resides more than one -half of the calendar year without regard to any temporary visitation.

(11)

(a) "Group-type contract" means a contract that:
(i) is not available to the general public; and

(ii) is obtained and maintained only because of membership in, or a connection with, a particular organization or group, including blanket coverage.

(b) "Group-type contract" does not mean an individually underwritten guaranteed renewable policy even if the policy is purchased through payroll deduction at a premium savings and the enrollee has the right to maintain or renew the policy independently of continued employment with the employer.

(12) "High-deductible health plan" means a high-deductible plan as defined in Section 223, Internal Revenue Code.

(13)

(a) "Hospital indemnity benefit" or "fixed indemnity benefit" means a benefit that is not related to actual incurred expenses.

(b) "Hospital indemnity benefit" or "fixed indemnity benefit" does not include a reimbursement-type benefit designed or administered to give the enrollee the right to elect an indemnity-type benefit at the time of a claim.

(14)

(a) "Non-conforming plan" means a plan that may not coordinate benefits.

(b) "Non-conforming plan" includes:
(i) hospital indemnity benefits or fixed indemnity benefits;

(ii) accident-only coverage;

(iii) specified disease or specified accident coverage;

(iv) limited benefit health coverage described in Section R590-126-7;

(v) school accident coverage that covers a student for accidents only, including athletic injuries, either on a 24-hour basis or on a to-and-from-school basis;

(vi) benefits provided in a long-term care contract for a non-medical service, including:
(A) personal care, adult day care, homemaker services, assistance with activities of daily living, respite care, and custodial care; and

(B) a contract that pays a fixed daily benefit without regard to an expense incurred or the receipt of a service;

(vii) a Medicare supplement contract;

(viii) a state plan under Medicaid; and

(ix) a governmental plan that, by law, provides benefits that are in excess to any private insurance plan or other nongovernmental plan.

(15)

(a) "Primary plan" means a plan whose benefits for an enrollee's health care coverage must be determined without considering any other plan.

(b) A plan is a primary plan if:
(i) a plan either:
(A) has no order of benefit determination; or

(B) has a benefit determination provision that differs from the provisions in this rule; or

(ii) a plan uses this rule's order of benefit determination and under Section R590-131-6 the plan determines its benefits first.

(16) "Retiree employee benefit plan" means an employee benefit plan as defined in the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1002(3).

(17) "Secondary plan" means a plan that is not a primary plan.

Disclaimer: These regulations may not be the most recent version. Utah 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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