Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-48 - GROUP COORDINATION OF BENEFITS › Rule 120-2-48-.07 - Miscellaneous Provisions

Current through Rules and Regulations filed through June 27, 2024
(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 Provisions.
(a) Some
				plans have order of benefit determination rules not consistent with this
				Regulation which declare that the plan's coverage is "excess" to all others, or
				"always secondary." This occurs because certain plans may not be subject to
				insurance regulation, or because some group contracts have not yet been
				conformed with this Regulation pursuant to Rule
				120-2-48-.02.
(b) A plan with order of benefit
				determination rules which comply with this Regulation (Complying Plan) may
				coordinate its benefits with a plan which is "excess" or "always secondary" or
				which uses order of benefit determination rules which are inconsistent with
				those contained in this Regulation (Noncomplying Plan) on the following basis:
1. If the Complying Plan is the Primary Plan,
				it shall pay or provide its benefits on a primary basis;
2. If the Complying Plan is the Secondary
				Plan, it shall, nevertheless, 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, such payment shall be the limit of the
				Complying Plan's liability; and
3.
				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 must adjust any payments it makes
				based on such assumption whenever information becomes available as to the
				actual benefits of the Noncomplying Plan.
(c) 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, and governing State law allows the right of
				subrogation set forth below, then the complying Plan shall advance to or on
				behalf of the employee, subscriber or member an amount equal to such
				difference. However, 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.
(d) Allowable
				Expenses. 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.
(e) Subrogation.
				The COB concept clearly differs from that of subrogation. Provisions for one
				may be included in health care benefits contracts without compelling the
				inclusion or exclusion of the other.