Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 39 - COORDINATION OF BENEFITS REGULATION › Section 210-39-006 - Rules for Coordination of Benefits

Current through June 17, 2024
When a person is covered by two (2) or more plans, the rules
				  for determining the order of benefit payments are as follows:
006.01(A) The primary plan shall pay or
				provide its benefits as if the secondary plan or plans did not exist.
006.01(B) 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 the primary plan when a
				covered person uses a non-panel provider, except for emergency services or
				authorized referrals that are paid or provided by the primary plan.
006.01(C) When multiple contracts providing
				coordinated coverage are treated as a single plan under this regulation, this
				section applies only to the plan as a whole, and coordination among the
				component contracts is governed by the terms of the contracts. If more than one
				carrier pays or provides benefits under the plan, the carrier designated as
				primary within the plan shall be responsible for the plan's compliance with
				this regulation.
006.01(D) If a
				person is covered by more than one secondary plan, the order of benefit
				determination rules of this regulation decide the order in which secondary
				plans benefits are determined in relation to each other. Each secondary plan
				shall take into consideration the benefits of the primary plan or plans and the
				benefits of any other plan, which, under the rules of this regulation, has its
				benefits determined before those of that secondary plan.
006.02(A) Except as provided in Paragraph
				006.02(B), a plan
				that does not contain order of benefit determination provisions that are
				consistent with this regulation is always the primary plan unless the
				provisions of both plans, regardless of the provisions of this paragraph, state
				that the complying plan is primary.
006.02(B) Coverage that is obtained by virtue
				of membership in a group and designed to supplement a part of a basic package
				of benefits may provide that the supplementary coverage shall be excess to any
				other parts of the plan provided by the contract holder. Examples of these
				types of situations are major medical coverages that are superimposed over base
				plan hospital and surgical benefits, and insurance type coverages that are
				written in connection with a closed panel plan to provide out-of-network
				benefits.
006.03 A plan may take
				into consideration the benefits paid or provided by another plan only when,
				under the rules of this regulation, it is secondary to that other
				plan.
006.04 Order of Benefit
				Determination
Each plan determines its order of benefits using the first of
				  the following rules that applies:
006.04(A) Non-Dependent or Dependent
006.04(A)(i) Subject to Subparagraphs
				006.04(A)(ii)(a)
				through
				006.04(A)(ii)(b)
				of this paragraph, the plan that covers the person other than as a dependent,
				for example as an employee, member, subscriber, policyholder or retiree, is the
				primary plan and the plan that covers the person as a dependent is the
				secondary plan.
006.04(A)(ii)(a)
				If the person is a Medicare beneficiary, and, as a result of the provisions of
				Title XVIII of the Social Security Act and implementing regulations, Medicare
				is:
006.04(A)(ii)(a)(1) Secondary to the plan
				covering the person as a dependent; and
006.04(A)(ii)(a)(2) Primary to the plan
				covering the person as other than a dependent (e.g. a retired employee),
006.04(A)(ii)(b) Then
				the order of benefits is reversed so that the plan covering the person as an
				employee, member, subscriber, policyholder or retiree is the secondary plan and
				the other plan covering the person as a dependent is the primary
				plan.