North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-08 - Group Insurance › Chapter 45-08-01.2 - Coordination of Benefits Regulation › Appendix B

Current through Supplement No. 393, July, 2024
CONSUMER EXPLANATORY BOOKLET
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 state's 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 spouse's 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 individual's 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 child's 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 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 amount called for in our contract or the amount called for in the
				  contract of the primary plan, whichever is higher. 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 may reduce our payment by any amount so that, when combined with
				  the amount paid by the primary plan, the total benefits paid do not exceed the
				  total allowable expense for your claim. We will credit any amount we would have
				  paid in the absence of your other health care coverage toward our own plan
				  deductible.
* If the primary plan covers similar kinds of health care
				  expenses, but allows expenses that we do not cover, we may pay for those
				  expenses.
* 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 precertification, as
				  required by that plan, we will not pay the amount of the reduction, because it
				  is not an allowable expense.
Questions About Coordination of Benefits?
Contact Your State Insurance Department