Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.14 - COORDINATION OF BENEFITS › Section 18.04.14.010 - DEFINITIONS

Current through August 31, 2023
As used in this chapter, these words and terms have the
				following meanings, unless the context clearly indicates otherwise:
				(3-31-22)
01.
Allowable
			 Expense
. Any health care expense including coinsurance or copayments,
			 and without reduction for any applicable deductible that is covered in full or
			 in part by any of the plans covering the person. If a plan is advised by a
			 covered person that all plans covering the person are high-deductible health
			 plans and the person intends to contribute to a health savings account
			 established in accordance with Section
			 223 of the Internal Revenue Code of
			 1986, the primary high-deductible health plan's deductible is not an allowable
			 expense, except for any health care expense incurred that will not be subject
			 to the deductible as described in Section
			 223(c) (2) (C)  of
			 the Internal Revenue Code of 1986. An expense that a provider by law or in
			 accordance with contractual agreement is banned from charging a covered person
			 is not an allowable expense. An expense or a portion of an expense that is not
			 covered by any of the plans is not an allowable expense. (3-31-22)
a. The following are examples of expenses or
			 services that are not an allowable expense: (3-31-22)
i. If a covered person is confined in a
			 private hospital room, the difference between the cost of a semi private room
			 in the hospital and the private room (unless the patient's stay in the private
			 hospital room is medically necessary in terms of generally accepted medical
			 practice, or one of the plans provides coverage for private hospital rooms) is
			 not an allowable expense. (3-31-22)
ii. If a person is covered by two (2) or more
			 plans that compute their benefit payments on the basis of usual and customary
			 fees, or relative value schedule reimbursement or other similar reimbursement
			 methodology, any amount charged by the provider in excess of the highest
			 reimbursement amount for a specified benefit is not an allowable expense.
			 (3-31-22)
iii. If a person is
			 covered by two (2) or more plans that provide benefits or services on the basis
			 of negotiated fees, any amount in excess of the highest of the negotiated fees
			 is not an allowable expense. (3-31-22)
iv. If a person is covered by one plan that
			 calculates its benefits or services on the basis of usual and customary fees or
			 relative value schedule reimbursement or other similar reimbursement
			 methodology and another plan that provides its benefits or services on the
			 basis of negotiated fees, the primary plan's payment arrangement is the
			 allowable expense for all plans. However, if the provider has contracted with
			 the secondary plan to provide the benefit or service for a specific negotiated
			 fee or payment amount that is different than the primary plan's payment
			 arrangement and if the provider's contract permits, that negotiated fee or
			 payment is the allowable expense used by the secondary plan to determine its
			 benefits. (3-31-22)