Ins 3.40(11)(b)4.d.
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.
Ins 3.40(11)(b)4.e.
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 of those terms, benefits for the dependent child shall be determined according to subd.
3. Ins 3.40(11)(b)5.
5. `Active or inactive employee.' 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.
Ins 3.40(11)(b)5m.
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:
Ins 3.40(11)(b)5m.a.
a. First, the benefits of a Plan covering the person as an employee, member or subscriber or as a dependent of an employee, member or subscriber.
Ins 3.40(11)(b)5s.
5s. If the other Plan does not have the rule described in subd.
5m. and if, as a result, the Plans do not agree on the order of benefits, this subdivision is ignored.
Ins 3.40(11)(b)6.
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 employee, member or subscriber longer are determined before those of the Plan which covered that person for the shorter time.
Ins 3.40(11)(b)6m.
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:
Ins 3.40(11)(b)6m.b.
b. A change in the entity which pays, provides or administers the Plan's benefits; or
Ins 3.40(11)(b)6m.c.
c. A change from one type of Plan to another, such as, from a single employer plan to that of a multiple employer plan.
Ins 3.40(11)(b)6s.
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.
Ins 3.40(11)(c)
(c) If a dependent is a Medicare beneficiary and if, under the Social Security Act of 1965 as amended, Medicare is secondary to the Plan covering the person as a dependent of an active employee, the federal Medicare regulations shall supersede this subsection.
Ins 3.40(12)(a)
(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).
Ins 3.40(12)(b)1.1. The benefits of This Plan shall be reduced when the sum of the following exceeds the allowable expenses in a claim determination period:
Ins 3.40(12)(b)1.a.
a. The benefits that would be payable for the allowable expenses under This Plan in the absence of this COB provision, and
Ins 3.40(12)(b)1.b.
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.
Ins 3.40(12)(b)2.
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.
Ins 3.40(12)(c)
(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.
Ins 3.40(14)
(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.
Ins 3.40(15)
(15)
Facility 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.
Ins 3.40(16)
(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:
Ins 3.40(17)
(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.
Ins 3.40(18)
(18)
Coordination with noncomplying 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 Noncomplying Plan that may not be subject to insurance regulation on the following basis:
Ins 3.40(18)(a)
(a) If the Complying Plan is the Primary Plan, it shall pay or provide its benefits on a primary basis.
Ins 3.40(18)(b)
(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.
Ins 3.40(18)(c)
(c) If the Noncomplying 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 Noncomplying 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 Noncomplying Plan.
Ins 3.40(18)(d)
(d) The Complying Plan shall advance to or on behalf of the employee, subscriber, or member an amount equal to the difference if the Noncomplying Plan reduces its benefits so that the employee, 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 Noncomplying Plan paid or provided its benefits as the Primary Plan.
Ins 3.40(18)(e)
(e) In no event shall the Complying Plan advance more than the Complying Plan would have paid had it been 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 employee, subscriber, or member against the Noncomplying Plan. Such advance by the Complying Plan shall also be without prejudice to any claim it may have against the Noncomplying Plan in the absence of such subrogation.
Ins 3.40 Note
Note:
In sub. (18) if the Noncomplying 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 such payments. Undue delay in paying the claim may subject the Complying Plan to a violation of s.
Ins 6.11.
Ins 3.40(19)
(19)
Subrogation. The COB 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.
Ins 3.40 History
History: Cr.
Register, July, 1980, No. 295, eff. 9-1-80; am. (2),
Register, January, 1981, No. 301, eff. 2-1-81; r. and recr. (7) (d) and (e), r. (19) under s. 13.93 (2m) (b) 16., Stats., renum. (8) to (18) to be (9) to (19), am. (20),
Register, July, 1985, No. 355, eff. 8-1-85; r. and recr.
Register, December 1986, No. 372, eff. 1-1-87; am. (2), (6) (d) and (f), (18) (b) (intro.) and Appendix A, cr. (11) (b) 4. e.,
Register, August, 1989, No. 404, eff. 9-1-89; am. (2), (3) (b), (c) and (k), (6) (b) and (c), (7) (b), (11) (b) 2., (12) (a) and (b), (14) and Appendix A, r. (12) (b) (intro.), (c) and (d), (13) (b) to (f), (18) (a) and (20), cr. (11) (b) 5m., and (c), renum. (13) (a) and (18) (b) to be (12) (c) and (18) and am. (12) (c) and (18) (intro.),
Register, October, 1991, No. 430, eff. 1-1-92; correction in (11) made under s. 13.93 (2m) (b) 1., Stats.,
Register, April, 1992, No. 436; reprinted to correct error in (3) (c),
Register, September, 1992, No. 441; correction in (2) made under s. 13.92 (4) (b) 7., Stats.,
Register May 2010 No. 653; correction in (2) made under s. 13.92 (4) (b) 7., Stats.,
Register May 2014 No. 701.
Ins 3.40 APPENDIX A
Model COB Provision
This appendix provides model COB provision language. The terms and conditions of all insurance contracts containing a COB provision must comply with Ins 3.40
COORDINATION OF THE GROUP CONTRACT'S BENEFITS WITH OTHER BENEFITS
(I) Applicability.
(A) This Coordination of Benefits (“COB") provision applies to This Plan when an employee or the employee's covered dependent has health care coverage under more than one Plan. “Plan" and “This Plan" are defined below.
(B) If this COB provision applies, the order of benefit determination rules shall be looked at first. The rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits of This Plan:
(i) shall not be reduced when, under the order of benefit determination rules, This Plan determines its benefits before another Plan; but
(ii) may be reduced when, under the order of benefit determination rules, another Plan determines its benefits first. This reduction is described in Section (IV) Effect on the Benefits of This Plan.
II Definitions.
(A) “Allowable Expense" means a 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. 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 unless the patient's stay in a private hospital room is medically necessary either in terms of generally accepted medical practice or as specifically defined in the Plan. When a Plan provides benefits in the form of services, the reasonable cash value of each service rendered shall be considered both an Allowable Expense and a benefit paid.
(B) “Claim Determination Period" means a calendar year. However, it does not include any part of a year during which a person has no coverage under This Plan or any part of a year before the date this COB provision or a similar provision takes effect.
(C) “Plan" means any of the following which provides benefits or services for, or because of, medical or dental care or treatment:
(i) Group insurance or group-type coverage, whether insured or uninsured, that includes continuous 24-hour coverage. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident-type coverage.
(ii) Coverage under a governmental plan or coverage that is required or provided by law. This does not include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act as amended from time to time). It also does not include any plan whose benefits, by law, are excess to those of any private insurance program or other non-governmental program. Each contract or other arrangement for coverage under (i) or (ii) is a separate Plan. If an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate Plan.
(D) “Primary Plan"/“Secondary Plan." The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another Plan covering the person.
When This Plan is a Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other Plan's benefits.
When This Plan is a Primary Plan, its benefits are determined before those of the other Plan and without considering the other Plan's benefits.
When there are more than two 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.
(E) “This Plan" means the part of the group contract that provides benefits for health care expenses.
(III) Order of benefit determination rules.
(A) General. When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan which has its benefits determined after those of the other Plan, unless:
(i) the other Plan has rules coordinating its benefits with those of This Plan; and
(ii) both those rules and This Plan's rules described in subparagraph (B) require that This Plan's benefits be determined before those of the other Plan.
(B) Rules. This plan determines its order of benefits using the first of the following rules which applies:
(i) Non-dependent/Dependent. The benefits of the Plan which covers the person as an employee, member or subscriber are determined before those of the Plan which covers the person as a dependent of an employee, member or subscriber.
(ii) Dependent Child/Parents Not Separated or Divorced. Except as stated in subparagraph (B) (iii), 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 the calendar year are determined before those of the Plan of the parent whose birthday falls later in that calendar 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.
However, if the other Plan does not have the rule described in 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.
(iii) Dependent Child/Separated or Divorced Parents. If two 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 the custody of the child; and
c. finally, the Plan of the parent not having custody of the child.
Also, 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 of those terms, benefits for the dependent child shall be determined according to (III) (B) (ii).
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 that Plan are determined first. This paragraph 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.
(iv) Active/Inactive Employee. The benefits of a Plan which covers a person as an employee who is neither laid off nor 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 (iv) is ignored.
Ins 3.40 Note
Note:
If a dependent is a Medicare beneficiary and if, under the Social Security Act of 1965 as amended, Medicare is secondary to the plan covering the person as a dependent of an active employee, the federal Medicare regulations shall supersede this paragraph (iv).
(v) Continuation coverage.
a. 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:
i. First, the benefits of a plan covering the person as an employee, member or subscriber or as a dependent of an employee, member or subscriber.
ii. Second, the benefits under the continuation coverage.
b. If the other plan does not have the rule described in subparagraph a., and if, as a result, the plans do not agree on the order of benefits, this paragraph (v) is ignored.
(vi) Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the benefits of the Plan which covered an employee, member or subscriber longer are determined before those of the Plan which covered that person for the shorter time.
(IV) Effect on the benefits of this plan.
(A) When This Section Applies. This Section (IV) applies when, in accordance with Section (III) Order of Benefit Determination Rules, This Plan is a Secondary Plan as to one or more other Plans. In that event the benefits of This Plan may be reduced under this section. Such other Plan or Plans are referred to as “the other Plans" in (B).
(B) Reduction in This Plan's Benefits. The benefits of This Plan will be reduced when the sum of the following exceeds the Allowable Expenses in a Claim Determination Period:
(i) the benefits that would be payable for the Allowable Expenses under This Plan in the absence of this COB provision; and
(ii) 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. Under this provision, the benefits of This Plan will be reduced so that they and the benefits payable under the other Plans do not total more than those Allowable Expenses.
When the benefits of This Plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of This Plan.
Ins 3.40 Note
Note:
The last paragraph may be omitted if the Plan provides only one benefit or may be altered to suit the coverage provided.
