Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 3 - Regulation 32-Coordination of Benefits › Section XIII-303 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. As used in this regulation, these words and terms have the
				  following meanings, unless the context clearly indicates otherwise.
Allowable Expense
- a health care service or
				  expense including deductibles, coinsurance, or copayments that are covered in
				  full or in part by any of the plans covering the person, except as set forth
				  below or where a statute requires a different definition. This means that an
				  expense or service or a portion of an expense or service that is not covered by
				  any of the plans is not an allowable expense.
a. The following are examples of expenses or services that
				  are and are not an allowable expense.
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 routinely provides coverage for private hospital rooms), is not an
				  allowable expense.
ii. If a person is covered by two or more plans that compute
				  their benefit payments on the basis of usual and customary fees, any amount in
				  excess of the highest of the usual and customary fee 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.
iv. If a person is covered by one plan that calculates its
				  benefits or services on the basis of usual and customary fees 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.
b. 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 expenses
				  in its contract to services or expenses that are similar to the services or
				  expenses that it provides. When COB is restricted to specific coverages or
				  benefits in a contract, the definition of
allowable expense
shall include similar services or expenses to which COB applies.
c. 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.
d. 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 pre-certification of
				  admissions or services; or
ii. because the covered person has a lower benefit because he
				  or she did not use a preferred provider.
e. If the primary plan is a closed panel plan and the
				  secondary plan is not a closed panel plan, the secondary plan shall pay or
				  provide benefits as if it were primary when a covered person uses a nonpanel
				  provider, except for emergency services or authorized referrals that are paid
				  or provided by the primary plan.
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.
g. The amount of the reduction may be excluded from allowable
				  expense when a covered persons 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.
Birthday
-refers only to month and day in a calendar year and
				  does not include the year in which the individual is born.
Claim
-a request that benefits of a plan be provided or paid.
				  The benefits claimed may be in the form of:
a. services (including supplies);
b. payment for all or a portion of the expenses
				  incurred;
c. a combination of Subparagraphs a and b of this Paragraph;
				  or
d. an indemnification.
Claim Determination Period
or
Plan
				  Year
-a period of not less than 12 consecutive months over which
				  allowable expenses shall be compared with total benefits payable in the absence
				  of COB to determine whether overinsurance exists and how much each plan will
				  pay or provide.
a. The claim determination period is usually a calendar year,
				  but a plan may use some other period of time that fits the coverage of the
				  group or individual contract. A person is covered by a plan during a portion of
				  a claim determination period if that person's coverage starts or ends during
				  the claim determination period.
b. As each claim is submitted, each plan determines its
				  liability and pays or provides benefits based upon allowable expenses incurred
				  to that point in the claim determination period. That determination is subject
				  to adjustment as later allowable expenses are incurred in the same claim
				  determination period.
Closed Panel Plan
- a plan that provides
				  health benefits to covered persons primarily in the form of services through a
				  panel of providers that have contracted with or are employed by the plan, and
				  that excludes benefits for services provided by other providers, except in
				  cases of emergency or referral by a panel member.
Consolidated Omnibus Budget Reconciliation Act of
				  1985
or
COBRA
-coverage provided under a right of
				  continuation pursuant to federal law.
Coordination of Benefits
or
COB
-a provision establishing an order in which plans pay their
				  claims, and permitting secondary plans to reduce their benefits so that the
				  combined benefits of all plans do not exceed total allowable expenses.
Custodial Parent
-
a. the parent awarded custody of a child by a court decree;
				  or
b. in the absence of a court decree, the parent with whom the
				  child resides more than one half of the calendar year without regard to any
				  temporary visitation.
Group-Type Contract
-a contract that is not
				  available to the general public and is obtained and maintained only because of
				  membership in or a connection with a particular organization or group,
				  including blanket coverage. Group type contract does not include an
				  individually underwritten and issued guaranteed renewable policy even if the
				  policy is purchased through payroll deduction at a premium savings to the
				  insured since the insured would have the right to maintain or renew the policy
				  independently of continued employment with the employer.
High-Deductible Health Plan
-the meaning
				  given the term under section 223 of the
Internal Revenue Code
of 1986, as amended by the Medicare Prescription Drug, Improvement and
				  Modernization Act of 2003.
Hospital Indemnity Benefits
-benefits not
				  related to expenses incurred. Hospital indemnity benefits does not include
				  reimbursement-type benefits even if they are designed or administered to give
				  the insured the right to elect indemnity-type benefits at the time of
				  claim.
Plan
-a form of coverage with which
				  coordination is allowed. Separate parts of a plan for members of a group that
				  are provided through alternative contracts that are intended to be part of a
				  coordinated package of benefits are considered one plan and there is no COB
				  among the separate parts of the plan. If a plan coordinates benefits, its
				  contract shall state the types of coverage that will be considered in applying
				  the COB provision of that contract. Whether the contract uses the term "plan"
				  or some other term such as "program," the contractual definition may be no
				  broader than the definition of "plan" in this subsection. The definition of
				  "plan" in the model COB provision in Appendix A of §321 of this Chapter is an
				  example.
a. Plan includes:
i. group and nongroup insurance contracts and subscriber
				  contracts;
ii. uninsured arrangements of group or group-type
				  coverage;
iii. group and nongroup coverage through closed panel
				  plans;
iv group-type contracts;
v. the medical care components of long-term care contracts,
				  such as skilled nursing care;
vi. the medical benefits coverage in automobile "no fault"
				  and traditional automobile "fault" type contracts;
vii. Medicare or other governmental benefits, as permitted by
				  law, except as provided in Subparagraph b of this Paragraph. That part of the
				  definition of plan may be limited to the hospital, medical and surgical
				  benefits of the governmental program; and
viii. group and nongroup insurance contracts and subscriber
				  contracts that pay or reimburse for the cost of dental care.
b. Plan does not include:
i. hospital indemnity coverage benefits or other fixed
				  indemnity coverage;
ii. accident only coverage;
iii. specified disease or specified accident coverage;
iv. limited benefit health coverage as defined in
				  R.S.
				  22:47(2)(c);
v. school accident-type coverages that cover students for
				  accidents only, including athletic injuries, either on a 24-hour basis or on a
				  "to and from school" basis;
vi. benefits provided in long-term care insurance policies
				  for non-medical services, for example, personal care, adult day care, homemaker
				  services, assistance with activities of daily living, respite care and
				  custodial care or for contracts that pay a fixed daily benefit without regard
				  to expenses incurred or the receipt of services;
vii. Medicare supplement policies;
viii. a state plan under Medicaid; or
ix. a governmental plan, which, by law, provides benefits
				  that are in excess of those of any private insurance plan or other
				  non-governmental plan.
Policyholder
or
Subscriber
-the primary insured named in a nongroup insurance
				  policy.
Primary Plan
-a plan whose benefits for a
				  persons health care coverage must be determined without taking the existence of
				  any other plan into consideration. A plan is a primary plan if:
a. the plan either has no order of benefit determination
				  rules, or its rules differ from those permitted by this regulation; or
b. all plans that cover the person use the order of benefit
				  determination rules required by this regulation, and under those rules the plan
				  determines its benefits first. Provider-a health care professional or health
				  care facility. Secondary Plan-a plan that is not a primary plan.
AUTHORITY NOTE:
				  Promulgated in accordance with R.S. 22:3.2014.