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-.08 - Effective Date; Existing Contracts

Current through Rules and Regulations filed through June 27, 2024
(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:
(a) The next anniversary date or renewal date
				of the group contract; or
(b) The
				expiration of any applicable collectively bargained contract pursuant to which
				it was written.
APPENDIX A
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 should be looked at first. Those rules determine whether
				  the benefits of This Plan are determined before or after those of another plan.
				  The benefits of This Plan:
(1) Shall not be reduced when, under the order of benefit
				  determination rules, This Plan determines its benefits before another plan;
				  but
(2) May be reduced when, under the order of benefits
				  determination rules, another plan determines its benefits first. The above
				  reduction is described in Section IV "Effect on the Benefits of This
				  Plan."
II. DEFINITIONS
A. "Plan" is any of these which provides benefits or services
				  for, or because of, medical or dental care or treatment:
(1) Group insurance of group-type coverage, whether insured
				  or uninsured. This includes prepayment, group practice or individual practice
				  coverage. It also includes coverage other than school accident-type
				  coverage.
(2) Coverage under a governmental plan, or coverage 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).
Each contract or other arrangement for coverage under (1) or
				  (2) is a separate plan. Also, if an arrangement has two parts and COB rules
				  apply only to one of the two, each of the parts is a separate plan.
B. "This Plan" is the part of the group contract that
				  provides benefits for health care expenses.
C. "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 Primary Plan, its benefits are determined
				  before those of the other plan and without considering the other plan's
				  benefits.
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 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.
D. "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 semiprivate 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 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 will be considered both an
				  Allowable Expense and a benefit paid.
When benefits are reduced under a Primary Plan because a
				  covered person does not comply with the plan provisions, the amount of such
				  reduction will not be considered an Allowable Expense. Examples of such
				  provisions are those related to second surgical opinions, precertification of
				  admissions or services, and preferred provider arrangements.
E. "Claims 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.
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:
(1) The other plan has rules coordinating its benefits with
				  those of This Plan; and
(2) Both those rules and This Plan's rules, in Subsection B
				  below, 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:
(1) Non-dependent/Dependent. The benefits of the plan which
				  covers the person as an employee, member, or subscriber (that is, other than as
				  a dependent) are determined before those of the plan which covers the person as
				  a dependent.
(2) Dependent Child/Parents not Separated or Divorced. Except
				  as stated in Paragraph B.
(3) below, 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 one 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) immediately above, 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 will determine the order of benefits.
(3) Dependent Child/Separated or Divorced. 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.
(c) Finally, the plan of the parent not having custody of the
				  child.
However, if the specific terms of a court decree state that
				  one of the parents is responsible for the health care expense 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. The plan of the other parent shall be the Secondary Plan. 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.
(4) Joint Custody. If the specific terms of a court decree
				  state that the parents shall share joint custody, without stating that one of
				  the parents is responsible for the health care expenses of the child, the plans
				  covering the child shall follow the order of benefit determination rules
				  outlined in Paragraph III B.(2).
(5) 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 (5) is ignored.
(6) 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 term.
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 immediately below.
B. Reduction in this Plan's Benefits. The benefits of This
				  Plan will be reduced when the sum of:
(1) The benefits that would be payable for the Allowable
				  Expense under This Plan in the absence of this COB provision; and
(2) 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; exceeds those
				  Allowable Expenses in a Claim Determination Period. In that case, 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.
V. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION
Certain facts are needed to apply these COB rules. [Insurer]
				  has the right to decide which facts it needs. It may get needed facts from or
				  give them to any other organization or person. [Insurer] need not tell, or get
				  the consent of, any person to do this. Each person claiming benefits under This
				  Plan must give [insurer] any facts it needs to pay the claim.
VI. FACILITY OF PAYMENT
A payment made under Another plan may include an amount which
				  should have been paid under This Plan. If it does, [insurer] 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. [Insurer] will not
				  have to pay that amount against. 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.
VII. RIGHT OF RECOVERY
If the amount of the payments made by [in surer] is more than
				  it should have paid under this 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.
The "amount of the payments made" includes the reasonable
				  cash value of any benefits provided in the form of services.