Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 39 - COORDINATION OF BENEFITS REGULATION › Section 210-39-003 - Definitions

Current through June 17, 2024
As used in this regulation, these words and terms have the
				  following meanings, unless the context clearly indicates otherwise:
003.01(A) "Allowable expense," except as set
				forth below 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.
003.01(B) 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.
003.01(C) An expense or a
				portion of an expense that is not covered by any of the plans is not an
				allowable expense.
003.01(D) 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.
003.01(E) The following
				are examples of expenses that are not allowable expenses:
003.01(E)(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.
003.01(E)(ii) If a person is covered by two
				(2) 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.
003.01(E)(iii) If a person
				is covered by two (2) 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.
003.01(E)(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.