Connecticut Administrative Code › Title 38a - Insurance Department › 480 - Coordination of Benefits › Section 38a-480-3 - Definitions

Current through July 10, 2024
(a)
Plan
.
(1) A "Plan" is 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 subsection
			 38a-480-3(a).
(2) The definition shown in the COB Provision
			 in Section
			 38a-480-4
			 is an example of what may be used. Any definition that satisfies this
			 subsection
			 38a-480-3(a)
			 may be used.
(3) This regulation
			 uses the term "Plan." However, a group contract may, instead, use "Program" or
			 some other term.
(4) "Plan" shall
			 not include individual or family:
(A)
			 insurance contracts;
(B) subscriber
			 contracts;
(C) coverage through
			 Health Maintenance Organizations (HMOs); or
(D) coverage under other prepayment, group
			 practice and individual practice plan; except as provided in (5) and (6)
			 below.
(5) "Plan" may
			 include:
(A) group insurance and group
			 subscriber contracts;
(B) uninsured
			 arrangements of group or group-type coverage;
(C) group or group-type coverage through HMOs
			 and other prepayment, group practice and individual practice plans;
			 and
(D) group-type contracts.
Group type contracts are contracts which are not available to
				the general public and can 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 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 employee,
				subscriber or member to pay for the coverage is not sufficient, of itself, to
				make an individual contract part of a group-type plan.
(6) "Plan" may include the medical
			 benefits coverage in group, group-type, and individual automobile "no-fault"
			 and traditional automobile "fault" type contracts.
(7) "Plan" may include 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, and shall not
			 include a law or plan when, by law, its benefits are excess to those of any
			 private insurance plan or other non-governmental plan.
(8) "Plan":
(A) shall not be construed to include group
			 or group-type hospital indemnity benefits of $30 per day or less; but
(B) may be construed to include the amount by
			 which group or group-type hospital indemnity benefits exceed $30 per day.
"Hospital indemnity benefits" are those 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.
(9) "Plan" shall not include student accident
			 or student accident and health coverages for which the student or parent pays
			 the entire premium.
(10) "Plan"
			 shall not include:
(A) group contracts issued
			 by or reinsured through the Health Reinsurance Association; or
(B) subscriber contracts issued by a residual
			 market mechanism established by hospital and medical service corporations and
			 providing comprehensive health care coverage as provided in Chapter 700a of
			 Connecticut General Statutes.