West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Section 114-28-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
The following words and terms, when used in this rule shall have
				  the following meanings unless the context clearly indicates otherwise:
2.1. Allowable Expenses.
2.1.a. "Allowable Expense" means the necessary,
				reasonable and customary item of expense for health care when the item of expense is
				covered at least in part under any of the plans involved, except where a statute
				requires a different definition, including coinsurance or copayments and without
				reduction for any applicable deductible.
2.1.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, as amended, 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, as amended.
2.1.c. An expense or a portion of an expense that
				is not covered by any of the plans is not an allowable expense.
2.1.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.
2.1.e. The
				following are examples of expenses that are not allowable expenses:
2.1.e.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;
2.1.e.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 reimbursement amount for
				a specified benefit is not an allowable expense;
2.1.e.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;
2.1.e.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 it 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.
2.1.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 Coordination of Benefits (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.
2.1.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.
2.1.h. The amount of the reduction may be excluded
				from allowable expense when a covered person's benefits are reduced under a primary
				plan:
2.1.h.1. Because the covered person does not
				comply with the plan provisions concerning second surgical opinions or
				precertification of admissions or services; or
2.1.h.2. Because the covered person has a lower
				benefit because the covered person did not use a preferred provider.