(a) "Plan" means
any plan providing benefits or services for or on account of medical or dental
care or treatment.
(i) "Plan" includes:
(A) Group and non-group insurance contracts
and subscriber contracts;
(B)
Uninsured arrangements of group or group-type coverage;
(C) Group and non-group coverage through
closed panel plans;
(D) Group-type
contracts;
(E) Medicare or other
governmental benefits, as permitted by law, except as provided in Paragraph
(ii)(H) of this Subsection. That part of the definition of plan may be limited
to the hospital, medical, and surgical benefits of the governmental program;
and
(F) Group and non-group
insurance contracts and subscriber contracts that pay or reimburse for the cost
of dental care.
(ii)
"Plan" does not include:
(A) Hospital
indemnity coverage benefits or other fixed indemnity coverage;
(B) Accident only coverage;
(C) Specified disease or specified accident
coverage;
(D) Limited benefit
health coverage;
(E) School
accident-type coverages that cover students for accidents only, including
athletic injuries, either on a twenty-four-hour basis or on a "to and from
school" basis;
(F) Benefits
provided in long-term care insurance policies for non-medical services; for
example, personal care, adult day care, homemaker services, assistance with
activities of daily living, respite care and custodial care or for contracts
that pay a fixed daily benefit without regard to expenses incurred or the
receipt of services;
(G) Medicare
supplement policies;
(H) A state
plan under Medicaid; or
(I) A
governmental plan, which, by law, provides benefits that are in excess of those
of any private insurance plan or other non-governmental plan.
(b) The term "Plan"
shall be construed separately with respect to each policy, contract, or other
arrangement for benefits or services and separately with respect to that
portion of any such policy, contract, or other arrangement which reserves the
right to take the benefits or services of other plans into consideration in
determining its benefits and that portion which does not.
(c) The definition of a "Plan" within the
Coordination of Benefits provision of a group contract shall enumerate the
types of coverage which the insurer may consider in determining whether over
insurance exists with respect to a specific claim. Such definition:
(i) Shall not include individual or family
policies, or individual or family subscriber contracts, except as provided in
this Subsection.
(ii) May include
all group policies or group subscriber contracts as well as such group-type
contracts as are not available to the general public and can be obtained and
maintained only because of the covered person's membership in or connection
with a particular organization or group. Such group-type contracts may be
included in the definition, at the option of the insurer, whether or not
individual policy forms are utilized and whether the group-type coverage is
designated as "franchise" or "blanket" or in some other fashion.
(iii) Shall not include group or group-type
hospital indemnity benefits written on a non-expense incurred basis unless they
are characterized as reimbursement type benefits and are designed or
administered so as to give the insured the right to elect indemnity type
benefits, in lieu of such reimbursement type benefits, at the time of
claim.
(iv) School accident type
coverages written on either an individual, group, blanket, or franchise basis
shall not be taken into consideration in coordination of benefits.
(v) If "Medicare" or similar governmental
benefits are included in the definition of a "Plan," such benefits shall be
considered without expanding any of the definitions of this provision beyond
the hospital, medical, and surgical benefits as may be provided by the
governmental program.
(vi) A plan
may not coordinate or design benefits so that the benefits payable are altered
solely on the basis that:
(A) another plan
exists; or
(B) the claimant is or
could have been covered under another plan; or
(C) the claimant has elected an option under
another plan providing a lower level of benefits than another option for which
the claimant was eligible.
(vii) Shall not include any policy providing
coverage for a specified disease.
(d) "Allowable Expense" means any necessary,
reasonable and customary item of expense at least a portion of which is covered
under at least one of the plans covering the person for whom claim is
made.
(e) When a plan provides
benefits in the form of services rather than cash payments, the reasonable cash
value of each service rendered shall be deemed to be both an allowable expense
and a benefit paid.
