Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 2 - Coordination of Benefits (formerly Insurance Regulation 48) (230-RICR-20-30-2) › Section 230-RICR-20-30-2.3 - Definitions

Current through June 14, 2024
A. The following words and terms, when used
				  in this Part, shall have the following meanings unless the context clearly
				  indicates otherwise.
1. "Allowable expense"
a. "Allowable expense" except as set forth
				  below or where a statute requires a different definition, means any health care
				  expense, including coinsurance or co-payments and without reduction for any
				  applicable deductible, that is covered in full or in part by any of the plans
				  covering the person.
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.
c.
				  An expense or a portion of an expense that is not covered by any of the plans
				  is not an allowable expense
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
e. The following are examples of expenses
				  that are not allowable expenses:
(1) 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.
(2) 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 of the negotiated fees is not an allowable
				  expense
(3) 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.
(4) 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.
f. 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 expense in
				  its contract to expenses that are similar to the expenses that it provides.
				  When COB is restricted to specific coverages or benefits in a contract, the
				  definition of allowable expense shall include similar expenses to which COB
				  applies
g. 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.
h. The amount of the reduction may be
				  excluded from allowable expense when a covered person's benefits are reduced
				  under a primary plan:
(1) Because the covered
				  person does not comply with the plan provisions concerning second surgical
				  opinions or precertification of admissions or services: or
(2) Because the covered person has a lower
				  benefit because the covered person did not use a preferred provider.