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.