Coordination of Benefits Coordination of Benefits (Cont’d) Disclosure of Coordination If the plan satisfies both of the following criteria, you can skip the rest of the COB section. If not, review for all COB requirements. WAC 284-51-200 Each certificate of coverage under a contract that provides for COB must contain a description of the COB provisions. Does the contract use the COB provisions in WAC 284-51-255 Appendix A? Does the contract use the model “plain language description” of COB in WAC 284-51-260, Appendix B? General General (Cont’d) WAC 284-51-200(3) Plan need not use the specific and format provided in WAC 284-51-255 and the plain language explanation in WAC Changes may be made to fit the language and style of the rest of the contract or to reflect differences among plans that provide services, that pay benefits for expenses incurred, and that indemnify, provided they do not conflict with the requirements of Chapter 284-51 WAC. WAC 284-51-200 (4) Plan cannot have a COB provision that permits it to reduce its benefits on the basis that: Another plan exists and the enrollee did not enroll in that plan; A person could have been covered under another plan; or A person have elected an option under another plan that pays a higher level of benefits than what he elected. WAC 284-51-200(5) Plan may not provide that its benefits are "always excess" or "always secondary" except as permitted in Chapter 284-51 WAC. RCW 48.21.200(1) A carrier may not administer COB in a way that reduces total benefits payable below an amount equal to 100% of total
Coordination of Benefits (Cont’d) Rules for Coordination of Benefits (Cont’d) WAC 284-51-205(4)(f) If none of the preceding rules determines the order of benefits, the allowable expenses must be shared equally between the plans.
Required Definition of Disorders” WAC 284-96-020(4)(a) The following definitions must and must be contained in the contract (not required to be verbatim): "Temporomandibular joint disorders" must include those disorders which have one or more of the following characteristics: Pain in the musculature associated with the temporomandibular joint, internal derangements of the temporomandibular joint, arthritic problems with the temporomandibular joint, or an abnormal range of motion or limitation of motion of the temporomandibular joint. Required Definition of “Medical Services” WAC "Medical Services" are those which are: Reasonable and appropriate for the treatment of a disorder of the temporomandibular joint, under all the factual circumstances of the case; and WAC Effective for the control or elimination of one or more of the following, caused by a disorder of the temporomandibular joint: Pain, infection, disease, difficulty in speaking, or difficulty in chewing or swallowing food; and WAC Recognized as effective, according to the professional standards of good medical practice; and (4)(b)(iv) Not experimental or primarily for cosmetic purposes. Required Definition of “Dental Services” WAC "Dental services" are those which are: Reasonable and appropriate for the treatment of a disorder of the temporomandibular joint, under all the factual circumstances of the case; and WAC Effective for the control or elimination of one or more of the following, caused by a disorder of the temporomandibular joint: Pain, infection, disease, difficulty in speaking, or difficulty in chewing or swallowing food; and