West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-28 - Coordination Of Health Benefits
Section 114-28-4 - Rules for Coordination of Benefits
Universal Citation: 114 WV Code of State Rules 114-28-4
Current through Register Vol. XLI, No. 38, September 20, 2024
When a person is covered by two (2) or more plans, the rules for determining the order of benefit payments are as follows:
4.1.
4.1.a. The
Primary Plan must pay or provide its benefits as if the Secondary Plan or Plans did
not exist. .
4.1.b. If the Primary Plan
is a closed panel plan and the Secondary Plan is not a closed planel 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.
4.1.c. When multiple contracts providing
coordinated coverage are treated as a single plan under this rule, 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 rule.
4.1.d. If a person is covered by more than one
secondary plan, the order of benefit determination rules of this rule 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 rule,
has its benefits determined before those of that secondary plan.
4.2.
4.2.a. Except as provided in subdivision b of this
subsection, a plan that does not contain an order of benefit determination
provisions that are consistent with this rule 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.
4.2.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.
4.3. A plan may take into consideration the benefits paid or provided by another plan only when, under this rule, it is secondary to that other plan.
4.4. Order of Benefit Determination. Each plan determines its order of benefits using the first of the following rules that applies:
4.4.a. Non-Dependent or Dependent
4.4.a.1. Subject to paragraph 2 of this
subdivision, the plan that covers the person other than as a dependent, for example
as an employee, member or subscriber, policyholder or retiree, is the primary plan
and the plan that covers the person as a dependent is the secondary plan.
4.4.a.2.
4.4.a.2.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 rules, Medicare is:
4.4.a.2.A.1. Secondary to the plan covering the
person as a dependent; and
4.4.a.2.A.2.
Primary to the plan covering the person as other than a dependent (e.g. a retired
employee).
4.4.a.2.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.
4.4.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:
4.4.b.1. For a dependent child whose parents are
married or are living together, whether or not they have ever been married:
4.4.b.1.A. The of the parent whose birthday falls
earlier in a calendar year is the primary plan; or
4.4.b.1.B. If both parents have the same birthday,
the plan that has covered the parent longest is the primary plan.
4.4.b.2. For a dependent child whose
parents are divorced or separated or are not living together, whether or not they
have ever been married:
4.4.b.2.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 this court decree
provision;
4.4.b.2.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 A of this paragraph
shall determine the order of benefits;
4.4.b.2.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, the provisions of
subparagraph A of this paragraph shall determine the order of benefits; or
4.4.b.2.D. If there is no court decree allocating
responsibility for the child's health care expenses or health care coverage, the
order of benefits are as follows:
4.4.b.2.D.1. The
plan covering the parent with custody of the child;
4.4.b.2.D.2. The plan covering the spouse of the
parent with the custody of the child;
4.4.b.2.D.3. The plan covering the parent not
having custody of the child; and
4.4.b.2.D.4. The plan covering the spouse of the
parent not having custody of the child.
4.4.c. Active Employee or Retired or Laid-Off
Employee. The plan that covers a person as an active employee who is neither laid
off nor retired (or as that employee's dependent) 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. 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. This rule does not apply if the rule in subdivision a of this
subsection can determine the order of benefits.
4.4.d. COBRA or State Continuation Coverage
4.4.d.1. 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.
4.4.d.2. 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.
4.4.d.3. This rule does
not apply if the rule in paragraph 1 can determine the order of benefits.
4.4.e. Longer or Shorter Length of
Coverage.
4.4.e.1. If the preceding rules do not
determine the order of benefits, the plan which covered the person for the longer
period of time is the primary plan and the plan which covered the person for the
shorter period of time is the secondary plan.
4.4.e.2. 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 within twenty-four (24) hours after
coverage under the first plan ended.
4.4.e.3. The start of a new plan does not include:
4.4.e.3.A. A change in the amount or scope of a
plan's benefits;
4.4.e.3.B. A change in
the entity that pays, provides or administers the plan's benefits; or
4.4.e.3.C. A change from one type of plan to
another (such as, from a single employer plan to that of a multiple employer
plan).
4.4.e.4. 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.
4.4.f. If none of the preceding rules determines
the order of benefits, the allowable expenses shall be shared equally between the
plans.
Disclaimer: These regulations may not be the most recent version. West Virginia 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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