Kentucky Administrative Regulations › Title 806 - PUBLIC PROTECTION CABINET - DEPARTMENT OF INSURANCE › Chapter 18 - Group and Blanket Health Insurance › Section 806 KAR 18:030 - Group health insurance coordination of benefits

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				304.17-042,
				304.17A-250(9),
				304.18-032,
				304.18-085,
				304.32-145,
				304.38-185,
				42 U.S.C.
				1395
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				304.2-110 authorizes the commissioner of the
				Department of Insurance to promulgate reasonable administrative regulations
				necessary for or as an aid to the effectuation of any provision of the Kentucky
				Insurance Code.
				KRS
				304.32-250 authorizes the commissioner to
				promulgate reasonable administrative regulations necessary for the proper
				administration of KRS 304.32.
				KRS
				304.38-150 authorizes the commissioner to
				promulgate reasonable administrative regulations necessary for the proper
				administration of KRS 304.38. This administrative regulation establishes
				guidelines for coordination of benefits by group health insurance
				contracts.
Section 1. Definitions.
(1) "Allowable expense" means a health care
			 service or expense, including deductibles, coinsurance, and copayments, that is
			 covered in full or in part by any of the plans covering the person.
(2) "Claim" means a request that benefits of
			 a plan be provided or paid, and the benefits claimed are in the form of:
(a) Services including supplies;
(b) Payment for all or a portion of the
			 expenses incurred;
(c) A
			 combination of paragraphs (a) and (b) of this subsection; or
(d) An indemnification.
(3) "Complying plan" means a plan with
			 benefit determination requirements that comply with the requirements of this
			 administrative regulation.
(4)
			 "Coordination of benefits" means 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.
(5) "Custodial parent"
			 means the parent awarded custody of a child by a court decree or with whom the
			 child resides more than one-half (1/2) of the calendar year.
(6) "Insurer" is defined by
			 KRS
			 304.17A-005(27).
(7) "Noncomplying plan" means a plan without
			 benefit determination requirements or whose benefit determination requirements
			 do not comply with the requirements of this administrative
			 regulation.
(8) "Plan":
(a) Means:
1. A form of coverage with which coordination
			 of benefits is allowed and "health benefit plans" as defined by
			 KRS
			 304.17A-005(22);
			 and
2. Sometimes includes Medicare
			 benefits pursuant to
			 42 U.S.C.
			 1395, or other governmental benefits;
			 and
(b) Does not mean:
1. The medical benefits coverage in a group,
			 group-type, and individual motor vehicle "no-fault" and traditional automobile
			 "fault" type contracts; or
2.
			 School accident-type coverages that cover elementary, high school, or college
			 students for accidents only, including athletic injuries, either on a
			 twenty-four (24) hour basis or on a "to-and-from school" basis.
(9) "Primary plan"
			 means a plan whose benefits for a person's health care coverage are determined
			 without taking the existence of any other plan into consideration if:
(a) The plan either has no order of benefit
			 determination requirements, or its requirements differ from those permitted by
			 this administrative regulation; or
(b) All plans that cover the person use the
			 order of benefit determination requirements required by this administrative
			 regulation, and under those requirements the plan determines its benefits
			 first.
(10) "Secondary
			 plan" means a plan that is not a primary plan.