Illinois Administrative Code › Title 50 - INSURANCE › Part 2009 - COORDINATION OF BENEFITS › Section 2009.60 - Miscellaneous Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 Reasonable Cash Values of Services
A secondary plan that 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 subsection shall be interpreted to require a plan to reimburse
				a covered person in cash for the value of services provided by a plan that
				provides benefits in the form of services.
b) Excess and Other Nonconforming Provisions
1) Some plans have order of benefit
			 determination standards not consistent with this Part that 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 Part pursuant to
			 Section
			 2009.20.
2) A plan with order of benefit determination
			 standards that comply with this Part (complying plan) may coordinate its
			 benefits with a plan that is "excess" or "always secondary" or that uses order
			 of benefit determination standards that are inconsistent with those contained
			 in this Part (noncomplying plan) on the following basis:
A) If the complying plan is the primary plan,
			 it shall pay or provide its benefits on a primary basis;
B) 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, the payment shall be the limit of the
			 complying plan's liability;
C) If
			 the noncomplying plan does not provide the information needed by the complying
			 plan to determine its benefits within 60 days 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 that assumption
			 whenever information becomes available as to the actual benefits of the
			 noncomplying plan; and
D) 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 in subsection
			 (d), the complying plan shall advance to or on behalf of the employee,
			 subscriber or member an amount equal to the 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 the advance, the complying plan shall be subrogated to all
			 rights of the employee, subscriber or member against the noncomplying plan. The
			 advance by the complying plan shall also be without prejudice to any claim it
			 may have against the noncomplying plan in the absence of subrogation.