Wyoming Administrative Code
Agency 044 - Insurance Dept
Sub-Agency 0002 - General Agency, Board or Commission Rules
Chapter 10 - COORDINATION OF BENEFITS
Section 10-3 - Order of Benefit Determination
Universal Citation: WY Code of Rules 10-3
Current through September 21, 2024
Each plan determines its order of benefits using the first of the following rules that applies:
(a) Non-Dependent or Dependent
(i) Subject to
Subparagraph (A) of this paragraph, the plan that covers the person other than
as a dependent, for example as an employee, member, subscriber, policyholder or
retiree, is the primary plan and the plan that covers the person as a dependent
is the secondary plan.
(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 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),
(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.
(b) Dependent Child Covered Under More Than One Plan
(i) 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 a 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 item shall 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 Subparagraph (A) of this paragraph
shall determine 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 Subparagraph (A) of this paragraph shall
determine 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:
(1.) The plan covering the custodial
parent;
(2.) The plan covering the
custodial parent's spouse;
(3.) The
plan covering the non-custodial parent; and then
(4.) 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 Subparagraph (A) or (B) of
this paragraph as if those individuals were parents of the child.
(D) For a dependent child who has coverage
under either or both parents' plans and also has his or her own coverage as a
dependent under a spouse's plan, the rule in subsection (e) applies.
(E) In the event the dependent child's
coverage under the spouse's plan began on the same date as the dependent
child's coverage under either or both parents' plans, the order of benefits
shall be determined by applying the birthday rule in Subparagraph (A) of this
paragraph to the dependent child's parent(s) and the dependent's
spouse.
(c) Active Employee or Retired or Laid-Off Employee
(i) The plan that covers a person as an
active employee - meaning 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.
(ii) 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.
(iii) This rule
does not apply if the rule in Subsection (a) of this Section can determine the
order of benefits.
(d) COBRA or State Continuation Coverage
(i) 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.
(ii) 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.
(iii) This
rule does not apply if the rule in Subsection (a) of this Section can determine
the order of benefits.
(e) Longer or Shorter Length of Coverage
(i) If the preceding rules 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.
(ii) 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 twenty-four (24)
hours after coverage under the first plan ended.
(iii) The start of a new plan does not
include:
(A) A change in the amount or scope
of a plan's benefits;
(B) A change
in the entity that pays, provides or administers the plan's benefits;
or
(C) A change from one type of
plan to another, such as, from a single employer plan to a multiple employer
plan.
(iv) 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 determines the order of benefits, the allowable expenses shall be shared equally between the plans.
(g) If none of the preceding rules determines the order of benefits, the allowable expenses shall be shared equally between the plans. If the plans cannot agree on the order of benefits within forty-five (45) calendar days after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities following payment, except that no plan shall be required to pay more than it would have paid had it been the primary plan.
Disclaimer: These regulations may not be the most recent version. Wyoming 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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