Specific
rules
When there is a basis for a claim under the patient’s plan
and another plan, the patient’s plan determines its order of benefits using
the first of the following rules which applies:
1. There is no rule in
the other plan. If the other plan does not have rules coordinating its benefits
with those of the patient’s plan, the benefits of the other plan are determined
first.
2. Non-dependent or dependent. The benefits of the plan that covers
the person as an employe, member or subscriber are determined before those of
the plan that covers the person as a dependent of an employe, member or subscriber.
3.
Dependent child-parents not separated or divorced. Except as stated in point “c”,
when the patient’s plan and another plan cover the same child as a dependent
of different persons, called “parents”:
a. The benefits of the
plan of the parent whose birthday falls earlier in a year are determined before
those of the plan of the parent whose birthday falls later in that year; but
b.
If both parents have the same birthday, the benefits of the plan which covered
the parent longer are determined before those of the plan which covered the other
parent for a shorter period of time.
c. However, if the other plan does not
have the rule described in point “a”, but instead has a rule based upon
the gender of the parent, and if, as a result, the plans do not agree on the order
of benefits, the rule in the other plan shall determine the order of benefits,
d.
The word “birthday” refers only to month and day in a calendar year,
not the year in which the person was born.
4. Dependent child-separated
or divorced parents. If 2 or more plans cover a person as a dependent child of
divorced or separated parents, benefits for the child are determined in this order:
a.
First, the plan of the parent with custody of the child;
b. Then, the plan
of the spouse of the parent with custody of the child; and
c. Finally, the
plan of the parent not having custody of the child,
d. However, if the specific
terms of a court decree state that one of the parents is responsible for the health
care expenses of the child and the insurer obligated to pay or provide the benefits
of the plan of that parent has actual knowledge of those terms, the benefits of
the plan of the responsible parent are determined first. Important: the insurer
must know that a court imposed these terms or this paragraph does not apply.
e.
If the specific terms of a court decree state that the parents have joint custody
of the child and do not specify that one parent has responsibility for the child’s
health care expenses or if the court decree states that both parents shall be
responsible for the health care needs of the child but gives physical custody
of the child to one parent, and the insurers obligated to pay or provide the benefits
of the respective parents’ plans have actual knowledge of those terms, benefits
for the dependent child shall be determined according to the rules under Point
3 for “dependent child-parents not separated or divorced.”
5.
Active or inactive employe. The benefits of a plan which covers a person as an
employee who is neither laid off or retired, or as that employee’s dependent,
are determined before those of a plan which covers that person as a laid off or
retired employee, or as that employee’s dependent. 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.
5m. Continuation coverage. If a person has
continuation coverage under federal or state law and is also covered under another
Plan, the following shall determine the order of benefits:
a. First, the
benefits of a plan covering the person as an employe, member or subscriber or
as a dependent of an employe, member or subscriber,
b. Second, the benefits
under the continuation coverage.
5s. If the other plan does not have the
rule described in point “5m” and if, as a result, the plans do not agree
on the order of benefits, this point is ignored.
6. Longer or shorter
length of coverage. If none of the above rules determines the order of benefits,
the benefits of the plan which covered an employe, member or subscriber longer
are determined before those of the plan which covered that person for the shorter
time.
6m. To determine the length of time a person has been covered under
a plan, 2 plans shall be treated as one if the claimant was eligible under the
second within 24 hours after the first ended. Thus, the start of a new plan does
not include:
d. A change in the amount or scope of a plan’s benefits;
e.
A change in the entity which pays, provides or administers the plan’s benefits;
or
f. A change from one type of plan to another, such as, from a single employer
plan to that of a multiple employer plan.
6s. The claimant’s length
of time covered under a plan is measured from the claimant’s first date of
coverage under that plan. If that date is not readily available, the date the
claimant first became a member of the group shall be used as the date from which
to determine the length of time the claimant’s coverage under the present
plan has been in force.
c. If a dependent is a Medicare beneficiary and
if, under the Social Security Act of 19Q5 as amended, Medicare is secondary to
the plan covering the person as a dependent of an active employe, the federal
Medicare regulations shall supersede this subsection.
More
than one primary or secondary plan
There may be more than one Primary
Plan. A plan is a Primary Plan if either on of the following points is true.
1.
The plan either has no order of benefit determination rules, or it has rules that
differ from those detailed above.
2. All plans that cover the person are complying
plans and, under the rules detailed above, the plan determines its benefits first.
When there are more than 2 plans covering a person, the patient’s plan
may be a primary plan as to one or more other plans and may be a secondary plan
as to a different plan or plans.
If a person is covered by more than one
secondary plan, the order of benefit determination rules decide the order in which
the benefits are determined in relation to each other, The benefits of each secondary
plan may take into consideration the benefits of the primary plan or plans and
the benefits of any other plan which, under the rules of this section, has its
benefits determined before those of that secondary plan.
Payment
as a secondary plan
In accordance with coordination of benefit rules
listed above, when the patient’s plan is a secondary plan as to one or more
other plans, the benefits of the patient’s plan may be reduced as follows:
1. The benefits of the patient’s plan shall be reduced when the sum of
the following exceeds the allowable expenses in a claim determination period:
a.
The benefits that would be payable for the allowable expenses under the patient’s
plan in the absence of this COB provision, and
b. The benefits that would be
payable for the allowable expenses under the other plans, in the absence of provisions
with a purpose like that of this COB provision, whether or not claim is made.
2. If point 1 applies, the benefits of the patient’s plan will be reduced
so that they and the benefits payable under the other plans do not equal more
than the total allowable expenses. When the benefits of the patient’s plan
are reduced as described, each benefit is reduced in proportion and is then charged
against any applicable benefit limit of this plan.
If the benefits of the
patient’s plan are reduced under point 1 (b) a secondary plan may reduce
its benefits so that the total benefits paid or provided by all plans during that
year (or other claim period) are not more than the total allowable expenses. The
amount by which the secondary plan’s benefits are reduced shall be used by
the secondary plan to pay allowable expenses not otherwise paid, which were incurred
during the year (or other claim period) by the person for whom the claim is made.
As each claim is submitted, the secondary plan determines its obligation to pay
for allowable expenses based on all claims which were submitted up to that point
in time during the year (or other claim period).
An
insurer’s right to information
An insurer has the right to decide
the facts it needs to apply the coordination of benefits rules. It may get needed
facts from or give them to any other organization or person without the consent
of the insured as long as they need the information to apply these rules. The
insurer must still follow all of the requirements regarding the confidentiality
of the patient’s health care records.
The person claiming health care
benefits must give the insurer any facts it needs to pay the claim. The individual
may not hide information about their other health care policies in order to get
additional reimbursement from one or more insurers.
Payment
errors
A payment made under another plan may include an amount that
should have been paid under the patient’s plan. If it does, the insurer responsible
for payment may pay that amount to the insurer that made that payment. That amount
will then be treated as though it were a benefit paid under the patient’s
plan. The insurer will not have to pay that amount again.
If the amount
of the payments made by the insurer responsible for payment is more than it should
have paid under a coordination of benefits rule, it may recover the excess from
one or more of:
• The persons it has paid or for whom it has paid;
(Note if you accepted assignment on the claim then the insurance company may collect
from you and you would be responsible for collecting from the patient.
•
Insurance companies; or
•Other organizations.
Coordination
with non-complying plans (see simplified explanation after point “e”)
Except for expenses covered by worker’s compensation, employer’s
liability insurance, Medicare, medical assistance, or traditional automobile “fault”
contracts, a plan with coordination of benefits language that complies with the
rules listed above (complying plan) may coordinate benefits with a non-complying
plan in the following way.
(a) If the complying plan is the primary plan,
it must pay its benefits on a primary basis.
(b) If the complying plan
is the secondary plan, it must pay its benefits first, but the amount of the benefits
payable shall be determined as if the complying plan were the secondary plan.
In this situation occurs, the payment made by the complying plan is the limit
of their liability.
(c) If the non-complying plan does not provide the
information needed by the complying plan to determine its benefits within a reasonable
time after it is requested to do so, the complying plan shall assume that the
benefits of the non-complying plan are identical to its own and must pay its benefits
accordingly, However, the complying plan may adjust any payments it makes based
on that assumption if information becomes available as to the actual benefits
of the non-complying plan.
(d) The complying plan shall advance to the
patient an amount equal to the difference if the non-complying plan reduces its
benefits so that the patient receives less in benefits than he or she would have
received had the complying plan paid or provided its benefits as the secondary
plan and the non-complying plan paid or provided its benefits as the primary plan.
(e) In no event may the complying plan advance more than the complying
plan would have paid had it seen the primary plan less any amount it previously
paid. In consideration of such advance, the complying plan shall be subrogated
to all rights of the patient against the non-complying plan. Such advance by the
complying plan shall also be without prejudice to any claim it may have against
the non-complying plan in the absence of such subrogation.
Simplified explanation:
If the non-complying plan is unwilling to provide the complying plan with the
necessary information, the complying plan should assume the primary position in
order to avoid undue claim delays and hardship to the insured. The complying plan
may, through its subrogation rights, seek reimbursement for the payments. Undue
delay in paying the claim may subject the complying plan to a violation of Wi.
Admin. Code 6.11.
Practical
advice
Even in slightly simplified form this language the coordination
of benefits rules are very difficult to understand. Here are a couple of points
to remember:
• Most insurance companies are pretty smart. They have
attorneys that draft their policy language so that it is usually impossible for
a patient to collect twice for a claim without cheating.
• If you know
that you or your patient has already been reimbursed for a claim and the patient
asks you to file with another insurance company – be careful. These rules
state that the patient (or any chiropractor acting on their behalf) has an obligation
to tell an insurer when they have another health care policy that covers the same
services. Unless you have informed the insurer of the additional policy, you risk
being charged with fraud if you duplicate bill for services.
• If an
insurance company claims that another insurance company should be billed first,
you have two possible courses of action.
1. Ask them to show you the language
in their policy that states that they are always secondary to the other insurer.
2.
Ask them to show you the language in the other insurer’s policy that states
that they are always the primary carrier.
4 You and your staff set the expectations
of the patient regarding coverage from their health insurers. If you give the
patient the expectation that you have complete responsibility for resolving the
differences between primary and secondary carriers and that they do not have to
pay you until those issues are resolved, you may wait a very long time for payment.
On the other hand, if the patient is expected to make full or partial payments
while issues between primary and secondary carriers are being resolved they will
be more interested in helping you resolve the problems between the carriers.
Statute
excerpts
Ins 3.40 Coordination of benefits provisions in group and blanket
disability insurance policies.
(1) PURPOSE.
(a) This section establishes
authorized coordination of benefits provisions for group and blanket disability
insurance policies pursuant to s. 631.23, Stats. It has been found that these
clauses are necessary to provide certainty of meaning. Regulation of contract
forms will be more effective, and litigation will be substantially reduced if
there is uniformity regarding coordination of benefits provisions in health insurance
policies.
(b) A Coordination of benefits
(COB) provision as defined in sub. (3) (e) avoids claim payment delays by establishing
an order in which Plans pay their claims and by providing the authority for the
orderly transfer of information needed to pay claims promptly. It avoids duplication
of benefits by permitting a reduction of the benefits of a Plan when, by the rules
established by this section, a Plan does not have to pay its benefits first.
(c)
Coordinating health benefits has been found to be an effective tool in containing
health care costs. However, minimum standards of protection and uniformity are
needed to protect the insured’s and the public’s interest.
(2)
SCOPE. This section applies to all group and blanket disability insurance policies
subject to s. 63 1.01(1), Stats., that provide 24-hour continuous coverage for
medical or dental care, treatment or expenses due to either injury or sickness
that contain a coordination of benefits provision, an “excess,” “anti-duplication,”
“non-profit” or “other insurance” exclusion by whatever name
designated under which benefits are reduced because of other insurance, other
than an exclusion for expenses covered by worker’s compensation, employer’s
liability insurance, or individual traditional automobile “fault” contracts.
Except as permitted under s. 632.32 (4) (b), Stats., this section applies to the
medical benefits provisions in an automobile “no fault” type or group
or group type “fault” policy. A policy subject to this section may reduce
benefits because of Medicare only to the extent permitted by federal law and shall
comply with s. 632.755, Stats., when reducing benefits because of coverage by
or eligibility for medical assistance.
(3) DEFINITIONS. In this section:
(a)
“Allowable expense” means the necessary, reasonable, and customary item
of expense for health care, when the item of expense is covered at least in part
by one or more Plans covering the person for whom the claim is made, except as
provided in sub. (4).
(b) “Claim” means a request that benefits
of a Plan be provided or paid. The benefits claimed may be in the form of any
of the following:
1. Services, including supplies.
2. Payment for all
err a portion of the expenses incurred.
3. A combination of subds. 1. and
2.
4. Indemnification.
(c) “Claim determination period” means
the period of time over which allowable expenses are compared with total benefits
payable in the absence of COB to determine whether over-insurance exists and how
much each Plan will pay or provide. However, it does not include any part of a
year before the date this COB provision or a similar provision takes effect.
(d) “Complying Plan” means a Plan with order of benefit determination
rules which comply with this section.
(e)
A “Coordination of benefits (COB) provision” means an insurance contract
provision intended to avoid claims payment delays and duplication of benefits
when a person is covered by 2 or more plans providing benefits or services for
medical, dental or other care or treatment.
(f) “Group-type contracts”
means contracts which are not available to the general public and may be obtained
and maintained only because of membership in or connection with a particular organization
or group. Group-type contracts answering this description may be included in the
definition of Plan at the option of the insurer issuing group-type plans or the
service provider and its contract-client, whether or not uninsured arrangements
or individual contract forms are used and regardless of how the group-type coverage
is designated (for example, “franchise” or “blanket”). The
use of payroll deductions by the employe, subscriber or member to pay for the
coverage is not sufficient, of itself, to make an individual contract part of
a group-type plan. Group-type contracts do not include individually underwritten
and issued, guaranteed renewable policies that may be purchased through payroll
education at a premium savings to the insured.
(g) “Hospital indemnity
benefits” means benefits for hospital confinement which are not related to
expenses incurred but does not include plans that reimburse a person for actual
hospital expenses incurred even if the plans are designed or administered to give
the insured the right to elect indemnity-type benefits at the time of claim.
(h) “Non-complying Plan” means
a Plan that declares its benefits to be “excess” or “always secondary”
or that uses order of benefit determination rules inconsistent with those contained
in this section.
(i) “Plan” means a form of coverage providing
benefits for medical or dental care, except as limited under sub. (6), with which
coordination is allowed.
(j) “Primary
Plan” means a health care plan, determined by the order of benefit determination
rules, whose benefits shall be determined before those of the other Plan and without
taking the existence of any other Plan into consideration.
(k)
“Secondary Plan” means a plan which is not a Primary Plan according
to the order of benefit determination rules and whose benefits are determined
after those of another Plan and may be reduced because of the other plan’s
benefits.
(L) ‘“This Plan” means the part of the group
contract that provides the health care benefits to which the COB provision applies
and which may be reduced because of the benefits of other Plans. Any other part
of the group contract providing health care benefits is separate from This Plan.
(4) ALLOWABLE EXPENSE USES AND LIMITATIONS.
(a) Items of expense under
dental care, vision care, prescription drug or hearing aid programs may be excluded
from the definition of allowable expense. A Plan which provides benefits only
for these items may limit its definition of allowable expense to these items of
expense.
(b) When a Plan provides benefits in the form of services, the
reasonable cash value of each service rendered shall be considered as both an
allowable expense and a benefit paid.
(c) The difference between the cost
of a private hospital room and the cost of a semi-private hospital room is not
considered an allowable expense under the above definition unless the patient’s
stay in a private hospital room is medically necessary in terms of generally accepted
medical practice or as specifically defined in the Plan.
(d) When COB
is restricted in its use to a specific coverage in a contract, for example, major
medical or dental, the definition of allowable expense shall include the corresponding
expenses or services to which COB applies.
(5) CLAIM DETERMINATION PERIOD
USES AND LIMITATIONS.
(a) A claim determination period may not be less
than 12 months and usually is a calendar year, but a Plan may use some other period
of time that fits the coverage of the group contract. A person may be covered
by a Plan during a portion of a claim determination period if that person’s
coverage starts or ends during that claim determination period.
(b) As
each claim is submitted, each Plan shall determine its liability and pay or provide
benefits based upon allowable expenses incurred to that point in the claim determination
period. However, that determination is subject to adjustment as later allowable
expenses are incurred in the same claim determination period.
(6) PLAN USES,
LIMITATIONS AND VBRIATIONS.
(a) The definition of Plan in the group contract
shall state the types of coverage which shall be considered in applying the COB
provision of that contact. The right to include a type of coverage is limited
by the rest of this subsection.
(b) The definition of Plan shown in the
model COB provision in APPENDIX A is an example of what may be used. Any definition
that satisfies sub. (3) (i) and this subsection may be used.
(c) Notwithstanding
the fact that this section uses the term “Plan,” a group contract may
instead use “Program” or some other term.
(d) “Plan”
shall not include individual or family insurance or subscriber cent-acts or individual
or family coverage through health maintenance organizations (HMOs), limited service
health organizations (LSHOs), or any other prepayment, group practice or individual
practice plan except as provided in pars. (e) and (f).
(e) “Plan”
may include: group insurance and group subscriber contracts; uninsured arrangements
of group or group type coverage; group or group-type coverage through HMOs, LSHOs
and other prepayment, group practice and individual practice plans; and group-type
contracts.
(f) “Plan” may include the medical benefits coverage
in group, group-type, and individual automobile “no-fault” contacts;
but, as to the traditional automobile “fault” contracts, only the medical
benefits written on a group or group-type basis may be included.
(g) If
“Plan” includes Medicare or other governmental benefits, that part of
the definition of “Plan” may be limited to the hospital, medical and
surgical benefits of the governmental program. However, “Plan” shall
not include a state plan under Medicaid (Title XIX, Grants to State for Medical
Assistance Programs, of the United States Social Security Act as amended from
time to time) and shall not include a law or plan whose benefits, by law, are
excess to those of any private insurance plan or other non-government plan.
(h) “Plan” shall not include group or group-type hospital indemnity
benefits of $100 per day or less but may include the amount by which group or
group-type hospital Indemnity
benefits exceed $108 per Bay.
(i) “Plan”
shall not include school accident-type coverages that cover grammar, high school,
and college students for accidents only, Including athletic injuries, either on
a 24-hour basis or on a “to and from school” basis.
(j) Each
contract or other arrangement for coverage is a separate Plan. If an arrangement
has 2 parts and COB rules apply only to one of the 2, each of the parts is a separate
Plan.
(7) PRIMARY PLAN AND SECONDARY PLAN USES AND LIMITATIONS. (a) The
order of benefit determination rules state whether This Plan is a Primary Plan
or Secondary Plan as to another plan covering the person.
(b) There may
be more than one Primary Plan. A Plan is a Primary Plan if either subd. 1. or
2. is true:1. The Plan either has no order of benefit determination rules,
or it has rules that differ from sub. (11).
2. All plans that cover the person
are complying plans and, under sub. (ii), the Plan determines its benefits first.
(c) When there are more than 2 plans covering the person, This Plan may be
a Primary Plan as to one or more other Plans and may be a Secondary Plan as to
a different Plan or Plans.
(d) If a person is covered by more than one
Secondary Plan, the order of benefit determination rules of this section decide
the order in whish the benefits are determined in relation to each other, The
benefits of each Secondary Plan may take into consideration the benefits of the
Primary Plan or Plans and the benefits of any other Plan which, under the rules
of this section, has its benefits determined before those of that Secondary Plan.
(8)
APPLICABILITY.
(a) This coordination of benefits (COB) prevision applies
to This Plan when an employee or the employee’s covered dependent has health
care coverage under more than one Plan,
(b) if this COB provision applies,
the order of benefit determination rules shall be looked at first. Those rules
determine whether the benefits of this Plan are determined before or after these
of another Plan,
(c) The benefits of This Plan shall not be reduced when,
under the order of benefit determination rules, This Plan is primary and determines
its benefits before another Plan.
(d) The benefits of This Plan may be
reduced when, under the order of benefit determination rules, another Plan determines
its benefits first.
(9) FLEXIBILITY AND CONSISTENCY WITH THIS SECTION.
(a) APPENDIX A shall be considered authorized clauses pursuant to s. 631.23,
Stats., for use in policy forms subject to this section and shall only be changed
as provided in this section.
(b) This section permits but does not require
the use of COB or “other insurance” provisions. However, if such provisions
are used, they must conform with this section and substantially conform to the
clauses contained in APPENDIX A. Liberalization of the prescribed language in
APPENDIX A, including rearrangement of the order of the clauses, is permitted
provided that the modified language is not less favorable to the insured person.
(c) Policy language which reduces benefits because of other insurance and
which is inconsistent with this section violates the criteria of s. 631.20, Stats.,
and shall not be used.
(d) A Plan that includes a CQB provision inconsistent
with this section shall not take the benefits of another Plan into account when
it determines its benefits. There is one exception: a contract holder’s coverage
that is designed to supplement a part of a basic package of benefits may provide
that the supplementary coverage shall be excess to and other parts of the Plan
provide8 by the contract holder,
(e) A group contract’s COB provision
does not have to use the words and format contained in APPENDIX A. Changes may
be made to fit the language and style of the rest of the group contract or to
reflect the differences among Plans which provide services, which pay benefits
for expenses incurred, and which indemnify. Substantive changes are allowed only
as set forth in this section.
(f) A term such as “usual and customary,”
“usual and prevailing, “or “reasonable and customary” may
be substituted for the term “necessary, reasonable and customary”. Terms
such as “medical care” or “dental care” may be substituted
for “health care “to describe the coverages to which the COB provisions
apply.
(g) A group contract may apply one COB provision to certain of
its benefits (such as dental benefits), coordinating only with like benefits,
and may apply other separate C8B provisions to coordinate other: benefits.
(10)
PROHIBITED COORDINATION AND BENEFIT DESIGN.
(a) A group contact shall not
reduce benefits on the basis that:
1. Another Plan exists;
2. Except
with respect to Part B of Medicare, that a person is or could have been covered
under another Plan; or
3. A person has elected an option under another Plan
providing a lower level of benefits than another option which could have been
elected.
(b) No contract shall contain a provision that its benefits are
“excess” or “always secondary” to any Plan defined in sub.
(3) (i), except as permitted under this section.
(11)
ORDER OF BENEFIT DETRMINATION RULES. (a)
1. The Primary Plan shall pay or provide its benefits as if the Secondary Plan
or Plans did not exist,
2. A Secondary
Plan may take the benefits of another Plan into account only when, under the rules
in par. (b), it is secondary to that other Plan.
(b) When there is a basis
for a claim under This Plan and another Plan, This Plan determines its order of
benefits using the first of the following rules which applies:
1.
No rule in another plan. If the other Plan does not have rules coordinating its
benefits with these of This Plan, the benefits of the other Plan are determined
first.
2.
Non-dependent or dependent. The benefits of the Plan that covers the person as
an employe, member or subscriber are determined before those of the Plan that
covers the person as a dependent of an employe, member or subscriber.
3.
Dependent child-parents not separated or divorced. Except as stated in subpar.
c., when This Plan and another Plan cover the same child as a dependent of different
persons, called “parents”:
a. The benefits of the Plan of the
parent whose birthday falls earlier in a year are determined before those of the
Plan of the parent whose birthday falls later in that year; but
b. If both
parents have the same birthday, the benefits of the Plan which covered the parent
longer are determined before those of the Plan which covered the other parent
for a shorter period of time.
c, However, if the other Plan does not have
the rule described in sub par. st., but instead has a rule based upon the gender
of the parent, and if, as a result, the Plans do not agree on the order of benefits,
the rule in the other Plan shall determine the order of benefits,
d. In
this subdivision, the word “birthday” refers only to month and day in
a calendar year, not the year in which the person was born.
4.
Dependent child-separated or divorced parents. If 2 or more Plans cover a person
as a dependent child of divorced or separated parents, benefits for the child
are determined in this order:
a. First, the Plan of the parent with custody
of the child;
b. Then, the plan of the spouse of the parent with custody
of the child; and
c. Finally, the Plan of the parent not having custody
of the child,
d. However, if the specific terms of a court decree state
that one of the parents is responsible for the health care expenses of the child
and the entity obligated to pay or provide the benefits of the Plan of that parent
has actual knowledge of those terms, the benefits of the Plan of the responsible
parent are determined first. This subparagraph does not apply with respect to
any Claim Determination Period or plan year during which any benefits are actually
paid or provided before the entity has that actual knowledge.
e. If the
specific terms of a court decree state that the parents have joint custody of
the child and do not specify that one parent has responsibility for the child’s
health care expenses or if the court decree states that both parents shall be
responsible for the health care needs of the child but gives physical custody
of the child to one parent, and the entities obligated to pay or provide the benefits
of the respective parents’ Plans have actual knowledge elf those terms, benefits
for the dependent child shall be determined according to subd. 3.
5.
Active or inactive employe. ‘The benefits of a Plan which covers a person
as an employee who is neither laid off or retired, or as that employee’s
dependent, are determined before those of a Plan which covers that person as a
laid off or retired employee, or as that employee’s dependent. 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.
5m,
Continuation coverage. If a person has continuation coverage under federal-law
or s. 632,897 (3) (a), Stats., and is also covered under another Plan, the following
shall determine the order of benefits:
a. First, the benefits of a Plan
covering the person as an employe, member or subscriber or as a dependent of an
employe, member or subscriber,
b. Second, the benefits under the continuation
coverage.
5s. If the other Plan does not have the rule described in subd.
5ml and if, as a result, the Plans do not agree on the order of benefits, this
subdivision is ignored.
6.
Longer or shorter length of coverage. If none of the above rules determines the
order of benefits, the benefits of the Plan which covered an employe, member or
subscriber longer are determined before those of the Plan which covered that person
for the shorter time,
6m. To determine the length of time a person has
been covered under a Plan, 2 Plans shall be treated as one if the claimant was
eligible under the second within 24 hours after the first ended. Thus, 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 which 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 that of a multiple employer
plan.
6s. The claimant’s length of time covered under a. Plan
is measured from the claimant’s first date of coverage under that Plan. If
that date is not readily available, the date the claimant first became a member
of the group shall be used as the date from which to determine the length of time
the claimant’s coverage un6fer the present Plan has been in force.
(c)
If a dependent is a Medicare beneficiary and if, under the Social Security Act
of 19Q5 as amened, Medicare is secondary to the Plan covering the person as a
dependent of an active employe, the federal Medicare regulations shall supersede
this subsection,
(12) PAYMENT AS
A SECONDARY PLAN. (a) In accordance with order of benefit determination rules
under sub. (11), when This Plan is a secondary Plan as to one or more other Plans,
the benefits of This Plan may be reduced as provided in par. (b). The other Plan
or Plans are referred to as “the other Plans” in par. (b).
(b)
1. The benefits of This Plan shall be reduced when the sum of the following exceeds
the allowable expenses in a claim determination period:
a. The benefits
that would be payable for the allowable expenses under This Plan in the absence
of this COB provision, and
b. The: benefits that would be payable for the
allowable expenses under the other Plans, in the absence of provisions with a
purpose like that of this COB provision, whether or not claim is made.
2.
If subd. 1. applies, the benefits of This Plan will be reduced so that they and
the benefits payable under the other Plans do not equal more than the total allowable
expenses. When the benefits of This Plan are reduced as described, each benefit
is reduced in proportion and is then charged against any applicable benefit limit
of this Plan.
(c) If the benefits of This Plan are reduced under par.
(b), a Secondary Plan may reduce its benefits so that the total benefits paid
or provided by all Plans during a claim determination period are not more than
the total allowable expenses. The amount by which the Secondary Plan’s benefits
are reduced shall be used
by the Secondary Plan to pay allowable expenses not
otherwise paid, which were incurred during the claim determination period by the
person for whom the claim is made. As each claim is submitted, the Secondary Plan
determines its obligation to pay for allowable expenses based on all claims which
were submitted up to that point in time during the claim determination period.
(14) RIGHT To RECEIVE AND RELEASE NEEDED
INFORMATION. An insurer has the right to decide the facts it needs to apply the
COB rules. It may get needed facts from or give them to any other organization
or person without the consent of the insured but only as needed to apply the provisions
of this section, This subsection does not relieve the insurer of the requirements
of s. 146.82, Stats. Each person claiming benefits under This Plan shall give
the insurer any facts it needs to pay the claim.
(15) FACILTY OF PAYMENT.
A payment made under another Plan may include an amount which should have been
paid under This Plan. If it does, the insurer responsible for payment may pay
that amount to the organization which made that payment. That amount will then
be treated as though it were a benefit paid under This Plan. The insurer will
not have to pay that amount again. The term “payment made” includes
providing benefits in the form of services, in which case “payment made”
means reasonable cash value of the benefits provided in the form of services.
(16)
RIGHT OF RECOVERY. If the amount of the payments made by the insurer responsible
for payment, including the reasonable cash value of any benefits provided in the
form of services, is more than it should have paid under a COB provision, it may
recover the excess from one or more of:
(a) The persons it has paid or for
whom it has paid;
(b) Insurance companies; or
(c) Other organizations.
(17) REASONABLE CASH VALUE OF SERVICES. A Secondary Plan which provides benefits
in the form of services may recover the reasonable cash value of providing the
services from the Primary Plan, to the extent that benefits for the services are
covered by the Primary Plan and have not already been paid or provided by the
Primary Plan. Nothing in this provision shall be interpreted to require a Plan
to reimburse a covered person in cash for the value of services provided by a
Plan which provides benefits in the form of services.
(18)
COORDINATION WITH NON-COMLYING PLANS. Except for expenses covered by worker’s
compensation, employer’s liability insurance, Medicare, medical assistance,
or traditional automobile “fault” contracts, a Complying Plan may coordinate
its benefits with a Non-complying Plan that may not be subject to insurance regulation
on the following basis:
(a) If the Complying Plan is the Primary Plan,
it shall pay or provide its benefits on a primary basis.
(b) If the Complying
Plan is the Secondary Plan, it shall pay or provide its benefits first, but the
amount of the benefits payable shall be determined as if the Complying Plan were
the Secondary Plan. In such a situation, the payment shall be the limit of the
Complying Plan’s liability.
(c) If the non-complying Plan does not
provide the information needed by the Complying Plan to determine its benefits
within a reasonable time after it is requested to do so, the Complying Plan shall
assume that the benefits of the Non-complying Plan are identical to its own and
shall pay its benefits accordingly, However, the complying Plan shall adjust any
payments it makes based on such assumption whenever information becomes available
as to the actual benefits of the Non-complying Plan.
(d) The Complying
Plan shall advance to or on behalf of the employe, subscriber, or member an amount
equal to the difference if the Non-complying Plan reduces its benefits so that
the employe, subscriber, or member receives less in benefits than he or she would
have received had the Complying Plan paid or provided its benefits as the Secondary
Plan and the Non-complying Plan paid or provided its benefits as the Primary Plan.(e)
In no event shall the Complying Plan advance more than the Complying Plan would
have paid had it seen the Primary Plan less any amount it previously paid. In
consideration of such advance, the Complying Plan shall be subrogated to all rights
of the employe, subscriber, or member against the Non-complying Plan. Such advance
lay the Complying Plan shall also be without prejudice to any claim it may have
against the Non-complying Plan in the absence of such subrogation.
(19)
SUBROGATION. The C0B concept differs from that of subrogation. Provision for one
may be included in health care benefits contracts without compelling the inclusion
or exclusion of the other.
