Coordination of Benefits determination period. Required Provisions: “Facility of Payment” “Right of Recovery” “Notice to Covered Persons” WAC 284-51-220 WAC 284-51-225 WAC 284-51-235 If the plan provides for COB, does it contain provisions substantially as follows? "If payments that should have been made under this plan are made by another plan, the issuer has the right, at its discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision. To the extent of such payments, the issuer is fully discharged from liability under this plan." "The issuer has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this provision. The issuer may recover excess payment from any person, other issuer or plan that has received payment. A plan must include the following statement in the enrollee contract or booklet provided to covered persons: "If you are covered by more than one health benefit plan, and you do not know which is your primary plan, you or your provider should contact any one of the health plans to verify which plan is primary. The health plan you contact is responsible for working with the other plan to determine which is primary and will let you know within thirty calendar days. CAUTION: All health plans have timely claim filing requirements. If you or your provider fail to submit your claim to a secondary health plan within that plan's claim filing time limit, the plan can deny the claim. If you experience delays in the processing of your claim by the primary health plan, you or your provider will need to submit your claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. To delays in claims processing, if you are covered by more than one plan you should promptly report to your providers and plans any changes in your coverage."
Coordination of Benefits (Cont’d) Cost-Sharing Protections (Grandfathered and plans) Cost-Sharing Protections (Grandfathered and plans) (Cont’d) Lifetime and annual dollar limits on dollar value of EHB 42 USC 45 CFR 147.126(a) 45 CFR § 147.126(c) 42 USC §300gg-11(b) 45 CFR §147.126 (b)(1) 45 CFR §147.126(a)(2)(ii) Issuer and plan may not establish any lifetime or annual on the dollar amount of essential health benefits for any individual. The term “essential health benefits” means essential health benefits under section 1302(b) of the Patient Protection and Affordable Care Act and applicable regulations. Per CMS Bulletin: DOL, Treasury, and HHS will consider a large group plan, or a grandfathered group health plan, to have used a permissible definition of EHB if the definition is one that is authorized by the Secretary of HHS (including any available benchmark option, supplemented as needed to ensure coverage of all ten statutory categories). The definition must be used consistently by the issuer. Exception: May place lifetime or annual limits on the dollar amount of specific covered benefits that are not essential health benefits. Note: Restriction on lifetime or annual limits does not apply to FSAs, MSAs, or HSAs. In the case of HRAs that are integrated with other group health plan coverage that complies, the fact that benefits under the HRA itself are limited is not a violation. Resource: (Q10) Maximum 42 USC §18022(c) 45 CFR § 156.130(a)(2) Plan must comply with annual limit on cost-sharing (e.g., deductible, copayment, coinsurance) with respect to the essential health benefits. This single MOOP must apply to all essential health benefits under the plan (e.g., medical, prescription drug, and mental health benefits). Plans design may include separate OOP limits for different categories of benefits, provide that the combined amount does not exceed the single combined limit. Exceptions: trial Grandfathered Grandfathered
Unfair and Discriminatory Practices (Cont’d) More favorable treatment of individuals with adverse health factors permitted 45 CFR §146.121 (g) Issuer may establish more favorable rules for individuals with an adverse health factor, such as disability, than for individuals without the adverse health factor.