Subject 120-2-48 GROUP COORDINATION OF BENEFITS
This Regulation is adopted and promulgated by the Commissioner of Insurance pursuant to the authority set forth in O.C.G.A. Section 33-2-9.
The purpose of this Regulation is to:
|(a)||Permit, but not require, plans to include a coordination of benefits (COB) provision;|
|(b)||Establish an order in which plans pay their claims;|
|(c)||Provide the authority for the orderly transfer of information needed to pay claims promptly;|
|(d)||Reduce duplication of benefits by permitting a reduction of the benefits paid by a plan when the plan, pursuant to rules established by this Regulation, does not have to pay its benefits first;|
|(e)||Reduce claims payments delays; and|
|(f)||Make all contracts that contain a COB provision consistent with this Regulation.|
The following words and terms, when used in this Regulation, shall have the following meanings unless the context clearly indicates otherwise:
|(a)|| Allowable Expenses.
|(b)|| Claim. A request that benefits of a plan
be provided or paid is a claim. The benefits claimed may be in the form of:
Claim Determination Period. This is the period of time, which must not be less
than twelve (12) consecutive months, over which Allowable Expenses are compared
with total benefits payable in the absence of COB, to determine whether
overinsurance exists and how much each plan will pay or provide.
|(d)||Coordination of Benefits. This is a provision establishing an order in which plans pay their claims.|
|(e)||Hospital Indemnity Benefits. These are benefits not related to expenses incurred. The term does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.|
|(f)|| Plan. Plan means a form
of coverage with which coordination is allowed. The definition of Plan in the
group contract must state the types of coverage which will be considered in
applying the COB provision of that contract. The right to include a type of
coverage is limited by the rest of this definition.
|(g)|| Primary Plan. A Primary Plan is a plan
whose benefits for a person's health care coverage must be determined without
taking the existence of any other plan into consideration. A plan is a Primary
Plan if either of the following conditions are true:
|(h)||Secondary Plan. A Secondary Plan is a plan which is not a Primary Plan. If a person is covered by more than one Secondary Plan, the order of benefit determination rules of this Regulation decide the order in which their 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 Regulation, has its benefits determined before those of that Secondary Plan.|
|(i)||This Plan. In a COB provision, this term refers to the part of the group contract providing 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. 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 COB provisions to coordinate other benefits.|
|(1)||General. Appendix A contains a model COB provision for use in group contracts. That use is subject to the provisions of(2) and (3) below and to the provisions of Rule 120-2-48-.05.|
|(2)||Flexibility. A group contract's COB provision does not have to use the words and format shown at Appendix A. Changes may be made to fit the language and style of the rest of the group contract or to reflect the difference among plans which provide services, which pay benefits for expenses incurred, and which indemnify. No other substantive changes are allowed.|
Coordination and Benefit Design.
|(1)|| Order of Benefits.
|(1)|| Total Allowable Expenses.
|(1)||Reasonable Cash Values 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.|
|(2)|| Excess and Other Nonconforming
|(1)||This Regulation is applicable to every group contract which provides health care benefits and which is issued on or after the effective date of this Regulation.|
|(2)|| A group contract which provides health
care benefits and was issued before the effective date of this Regulation shall
be brought into compliance with this Regulation by the later of: