Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.24 - Group Coordination of Benefits › Rule 6.6.2403 - DEFINITIONS

Current through Register Vol. 13, July 5, 2024
As used in these rules, these words and terms have the
				  following meanings, unless the context clearly indicates otherwise:
(1) "Allowable expense," except as set forth
				in (a) through (g), or where a statute requires a different definition, means
				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:
(a) 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 may
				not be subject to the deductible as described in Section 223(c)(2)(C) of the
				Internal Revenue Code of 1986;
(b)
				an expense or a portion of an expense that is not covered by any of the plans
				is not an allowable expense;
(c)
				any expense that a provider by law or in accordance with a contractual
				agreement is prohibited from charging a covered person is not an allowable
				expense; and
(d) the following are
				examples of expenses that are not allowable expenses:
(i) If a 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 is not an allowable expense, unless one of the
				plans provides coverage for private hospital room expenses;
(ii) if a person is covered by two 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;
(iii) if a person is
				covered by two 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; and
(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 shall be 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 shall be the allowable expense used by the
				secondary plan to determine its benefits.
(e) The definition of "allowable expense" may
				exclude certain types of coverage or benefits such as dental care, vision care,
				prescription drug, or hearing aids. A plan that limits the application of COB
				to certain coverages or benefits may limit the definition of allowable expense
				in its contract to expenses that are similar to the expenses that it provides.
				When COB is restricted to specific coverages or benefits in a contract, the
				definition of allowable expense shall include similar expenses to which COB
				applies;
(f) when a plan provides
				benefits in the form of services, the reasonable cash value of each service
				will be considered an allowable expense and a benefit paid; and
(g) the amount of the reduction may be
				excluded from allowable expense when a covered person's benefits are reduced
				under a primary plan:
(i) because the covered
				person does not comply with the plan provisions concerning second surgical
				opinions or precertification of admissions or services; or
(ii) because the covered person has a lower
				benefit because the covered
person did not use a preferred provider.