Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 3 - Regulation 32-Coordination of Benefits › Section XIII-323 - Appendix B-Consumer Explanatory Booklet Coordination of Benefits (Formerly section 319)

Current through Register Vol. 50, No. 6, June 20, 2024
A. Consumer
				Explanatory Booklet Coordination of Benefits
COORDINATION OF BENEFITS
IMPORTANT NOTICE
This is a summary of only a few of the provisions of
							 your health plan to help you understand coordination of benefits, which can be
							 very complicated. This is not a complete description of all of the coordination
							 rules and procedures, and does not change or replace the language contained in
							 your insurance contract, which determines your benefits.
Double Coverage
It is common for family members to be covered by more than
				  one health care plan. This happens, for example, when a husband and wife both
				  work and choose to have family coverage through both employers.
When you are covered by more than one health plan, state law
				  permits your insurers to follow a procedure called "coordination of benefits"
				  to determine how much each should pay when you have a claim. The goal is to
				  make sure that the combined payments of all plans do not add up to more than
				  your covered health care expenses.
Coordination of benefits (COB) is complicated, and covers a
				  wide variety of circumstances. This is only an outline of some of the most
				  common ones. If your situation is not described, read your evidence of coverage
				  or contact your state insurance department.
Primary or Secondary?
You will be asked to identify all the plans that cover
				  members of your family. We need this information to determine whether we are
				  the "primary" or "secondary" benefit payer. The primary plan always pays first
				  when you have a claim.
Any plan that does not contain your states COB rules will
				  always be primary.
When This Plan is Primary
If you or a family member are covered under another plan in
				  addition to this one, we will be primary when:
Your Own Expenses
The claim is for your own health care expenses, unless you
				  are covered by Medicare and both you and your spouse are retired.
Your Spouse's Expenses
The claim is for your spouse, who is covered by Medicare, and
				  you are not both retired.
Your Child's Expenses
The claim is for the health care expenses of your child who
				  is covered by this plan and You are married and your birthday is earlier in the
				  year than your spouses or you are living with another individual, regardless of
				  whether or not you have ever been married to that individual, and your birthday
				  is earlier than that other individuals birthday. This is known as the "birthday
				  rule";
or
You are separated or divorced and you have informed us of a
				  court decree that makes you responsible for the childs health care
				  expenses;
or
There is no court decree, but you have custody of the
				  child.
Other Situations
We will be primary when any other provisions of state or
				  federal law require us to be.
How We Pay Claims When We Are Primary
When we are the primary plan, we will pay the benefits in
				  accordance with the terms of your contract, just as if you had no other health
				  care coverage under any other plan.
How We Pay Claims When We Are Secondary
We will be secondary whenever the rules do not require us to
				  be primary.
How We Pay Claims When We Are Secondary
When we are the secondary plan, we do not pay until after the
				  primary plan has paid its benefits. We will then pay part or all of the
				  allowable expenses left unpaid, as explained below. An "allowable expense" is a
				  health care service or expense covered by one of the plans, including
				  copayments, coinsurance and deductibles.
* If there is a difference between the amount the plans
				  allow, we will base our payment on the higher amount. However, if the primary
				  plan has a contract with the provider, our combined payments will not be more
				  than the contract calls for. Health maintenance organizations (HMOs) and
				  preferred provider organizations (PPOs) usually have contracts with their
				  providers.
* We will determine our payment by subtracting the amount the
				  primary plan paid from the amount we would have paid if we had been primary. We
				  will use any savings to pay the balance of any unpaid allowable expenses
				  covered by either plan.
* If the primary plan covers similar kinds of health care
				  expenses, but allows expenses that we do not cover, we will pay for those items
				  as long as there is a balance in your benefit reserve, as explained
				  below.
* We will not pay an amount the primary plan did not cover
				  because you did not follow its rules and procedures. For example, if your plan
				  has reduced its benefit because you did not obtain pre-certification, as
				  required by that plan, we will not pay the amount of the reduction, because it
				  is not an allowable expense.
Benefit Reserve
* When we are secondary we often will pay less than we would
				  have paid if we had been primary. Each time we "save" by paying less, we will
				  put that savings into a benefit reserve. Each family member covered by this
				  plan has a separate benefit reserve. We use the benefit reserve to pay
				  allowable expenses that are covered only partially by both plans. To obtain a
				  reimbursement, you must show us what the primary plan has paid so we can
				  calculate the savings. To make sure you receive the full benefit or
				  coordination, you should submit all claims to each of your plans. Savings can
				  build up in your reserve for one year. At the end of the year any balance is
				  erased, and a fresh benefit reserve begins for each person the next year as
				  soon as there are savings on their claims.
Questions about Coordination of Benefits?
Contact Your State Insurance Department
AUTHORITY NOTE:
				  Promulgated in accordance with R.S. 22:3.2014.