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Colorado Administrative Code
Department 700 - Department of Regulatory AgenciesDivision 702 - Division of InsuranceRule 3 CCR 702-4 - LIFE, ACCIDENT AND HEALTHSection 3 CCR 702-4 Series 4-6 - LIFE, ACCIDENT AND HEALTH, Series 4-6 Group Health Insurance, Small Group Health Plans
Regulation Regulation 4-6-2 - GROUP COORDINATION OF BENEFITS
Section 3 CCR 702-4-6-2-4 - Definitions

3 Colo. Code Regs. § 702-4-6-2-4

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Current through Register Vol. 47, No. 16, August 25, 2024
Section 3 CCR 702-4-6-2-4 - Definitions
A. "Allowable expense" means, for the purposes of this regulation, a health care service or expense including deductibles, coinsurance and/or copayments, that is covered in full or in part by any of the plans covering the person, except as set forth below or where a statute requires a different definition. This means that an expense or service or a portion of an expense or service that is not covered by any of the plans is not an allowable expense.
1. 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 26 U.S.C. § 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 26 U.S.C. § 223(c)(2)(C) of the Internal Revenue Code of 1986.
2. 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.
3. The following are examples of expenses or services that are not an allowable expense:
a. If a covered 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, unless the patient's stay in the private hospital room is medically necessary in terms of generally accepted medical practice or one of the plans routinely provides coverage for private hospital rooms or the hospital does not have a semi-private room.
b. 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.
c. 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.
d. 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 the specific negotiated fee or payment amount that is different than the primary plan's plan 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.
4. The definition of "allowable expense" may exclude certain types of coverage or benefits such as dental care, vision care, prescription drugs or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definition of allowable expenses in its contract to services or expenses that are similar to the services or expenses that it provides. When COB is restricted to specific coverages or benefits in a contract, the definition of "allowable expense" shall include similar services or expenses to which COB applies.
5. 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.
6. The amount of the reduction may be excluded from allowable expense when a covered person's benefits are reduced under a primary plan:
a. Because the covered person does not comply with the plan provisions concerning second surgical opinions or precertification of admissions or services unless a reduction is prohibited by § 10-16-704(14) C.R.S.; or
b. Because the covered person has a lower benefit because the covered person did not use a preferred provider.
7. If the primary plan is a closed panel plan with no out-of-network benefits and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were primary when no benefits are available from the primary plan because the covered person uses a non-panel provider, except for emergency services that are paid or provided by the primary plan.
8. If the two plans are closed panel plans:
a. The two plans will coordinate benefits for services that are covered services for both plans, including emergency services, authorized referrals, or services from providers that are participating in both plans.
b. COB does not occur if there is no covered benefit from either plan. This may occur in various circumstances including if the enrollee did not go to either plan's closed panel of providers, unless there is a covered benefit (i.e. medical emergency, authorized out-of-network referral, etc.).
c. If the enrollee obtains services that are covered benefits of the primary plan, the secondary carrier plan shall coordinate benefits only to the extent that there are benefits or reserves available.
d. If the service is not a covered benefit of the primary plan but the service is a covered benefit of the secondary plan (e.g.) the covered person went to a provider who does not participate with the primary plan and the service is not due to a medical emergency or the covered person went to a provider who does not participate with the primary plan and the service is not due to a medical emergency), the secondary plan will pay benefits as though it is primary.
B. "Birthday" means, for the purposes of this regulation, the month and day in a calendar year and does not include the year in which the individual was born.
C. "Catastrophic plan" shall have the same meaning as found at § 10-16-102(10), C.R.S.
D. "Claim" means, for the purposes of this regulation, a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of:
1. Services (including supplies);
2. Payment for all or a portion of the expenses incurred;
3. A combination of Paragraphs 4.D.1 and 4.D.2., or
4. An indemnification.
E. "Claim determination period" means, for the purposes of this regulation, a period of not less than twelve (12) consecutive months, over which allowable expenses shall be compared with total benefits payable in the absence of COB, to determine whether overinsurance exists and how much each plan will pay or provide.
1. The claim determination period is usually a calendar year, but a plan may use some other period of time that fits the coverage of the group contract. A person is covered by a plan during a portion of a claim determination period if that person's coverage starts or ends during the claim determination period.
2. As each claim is submitted, each plan determines its liability and pays or provides benefits based upon allowable expenses incurred to that point in the claim determination period. That determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.
F. "Closed panel plan" means, for the purposes of this regulation, a health maintenance organization (HMO), exclusive provider organization (EPO), preferred provider organization (PPO) or other plan that provides health benefits to covered persons primarily in the form of services through a panel of providers that have contracted with either directly or indirectly or are employed by the plan, and that limits or excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel provider.
G. "Consolidated Omnibus Budget Reconciliation Act of 1985" or "COBRA" means, for the purposes of this regulation, coverage provided under a right of continuation pursuant to federal law.
H. "Coordination of benefits" or "COB" means, for the purposes of this regulation, a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses.
I. "Custodial parent" means, for the purposes of this regulation, the parent awarded sole custody of a child by a court decree. In the absence of a court decree, the parent with whom the child resides more than half the calendar year without regard to any temporary visitation.
J. "Group-type contract" means, for the purposes of this regulation, a contract that is not available to the general public and is obtained and maintained only because of membership in or a connection with a particular organization or group, including blanket coverage. "Group type contract" does not include an individually underwritten and issued guaranteed renewable policy even if the policy is purchased through payroll deduction at a premium savings to the insured since the insured would have the right to maintain or renew the policy independently of continued employment with the employer.
K. "Health benefit plan" shall have the same meaning as found at § 10-16-102(32), C.R.S.
L. "High-deductible health plan" has the meaning given the term under 26 U.S.C. § 223 of the Internal Revenue Code of 1986, as amended by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.
M. "Hospital indemnity benefits" means, for the purposes of this regulation, benefits not related to expenses incurred. The term does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.
N. "Limited benefit plan" means, for the purposes of this regulation, any type of health coverage that is not provided by a health benefit plan, as defined in § 10-16-102(32)(a), C.R.S.
O. "Plan" means, for the purposes of this regulation, a form of coverage with which coordination is allowed or required. Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are considered one plan and there is no COB among the separate parts of the plan.
1. If a plan coordinates benefits, its contract shall state the types of coverage that will be considered in applying the COB provision of that contract.
2 The definition shown in the model COB provision in Appendix A is an example of how a plan may be defined, but any definition that satisfies this subsection may be used.
3. This regulation uses the term "plan." However, a contract may use "program" or some other term that meets the definition of a plan.
4. "Plan" includes:
a. Group insurance contracts and group subscriber contracts;
b. Uninsured arrangements of group or group-type coverage;
c. Group coverage through closed panel plans;
d. Group-type contracts;
e. The medical care components of group long-term care contracts, such as skilled nursing care;
f. The medical benefits coverage in group, group-type and individual automobile "no fault" and traditional automobile "fault" type contracts;
g. Medicare or other governmental benefits, as permitted by law, except as provided in Section 4.O.4.h. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program; and
h. Group insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care.
5. "Plan" shall not include:
a. Hospital indemnity coverage benefit other than fixed indemnity coverage;
b. Accident only coverage;
c. Specified disease or specified accident coverage;
d. Limited benefit plans, as defined in Section 4.N.;
e. School accident-type coverages that cover students for accidents only, including athletic injuries, either on a twenty-four-hour basis or on a "to and from school" basis;
f. Benefits provided in group long-term care insurance policies for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services;
g. Medicare supplement policies;
h. A state plan under Medicaid; or
i. A governmental plan which, by law, provides benefits in excess of those of any private insurance plan or other non-governmental plan.
P. "Primary plan" means, for the purposes of this regulation, a plan whose benefits for a person's health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if either of the following is true:
1. The plan either has no order-of-benefit determination rules, or its rules differ from those permitted by this regulation; or
2. All plans that cover the person use the order-of-benefit determination rules required by this regulation, and under those rules the plan determines its benefits first.
Q. "Secondary plan" means, for the purposes of this regulation, a plan that is not a primary plan.
R. "This plan" in a COB provision means the part of the group contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the group contract providing health care benefits is separate from "this plan." A group contract may apply one COB provision to certain of its benefits (such as dental benefits), coordinating only with similar benefits, and may apply another COB provision to coordinate with other benefits.

3 CCR 702-4-6-2-4

37 CR 11, June 10, 2014, effective 7/1/2014
37 CR 12, June 25, 2014, effective 7/15/2014
Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/2014
37 CR 23, December 10, 2014, effective 1/1/2015
38 CR 03, February 10, 2015, effective 3/15/2015
38 CR 06, March 25, 2015, effective 4/30/2015
38 CR 09, May 10, 2015, effective 6/1/2015
38 CR 13, July 10, 2015, effective 7/30/2015
38 CR 19, October 10, 2015, effective 11/1/2015
38 CR 21, November 10, 2015, effective 1/1/2016
38 CR 23, December 10, 2015, effective 1/1/2016
39 CR 01, January 10, 2016, effective 2/1/2016
39 CR 05, March 10, 2016, effective 4/1/2016
39 CR 08, April 25, 2016, effective 5/15/2016
39 CR 19, October 10, 2016, effective 11/1/2016
39 CR 20, October 25, 2016, effective 1/1/2017
39 CR 22, November 25, 2016, effective 1/1/2017
39 CR 23, December 10, 2016, effective 1/1/2017
39 CR 23, December 25, 2016, effective 1/1/2017
40 CR 03, February 10, 2017, effective 3/15/2017
40 CR 09, May 10, 2017, effective 6/1/2017
40 CR 15, August 10, 2017, effective 9/1/2017
40 CR 17, September 10, 2017, effective 10/1/2017
40 CR 21, November 10, 2017, effective 12/1/2017
41 CR 04, February 25, 2018, effective 4/1/2018
41 CR 05, March 10, 2018, effective 6/1/2018
41 CR 08, April 25, 2018, effective 6/1/2018
41 CR 09, May 10, 2018, effective 6/1/2018
41 CR 11, June 10, 2018, effective 7/1/2018
41 CR 15, August 10, 2018, effective 9/1/2018
41 CR 17, September 10, 2018, effective 10/1/2018
41 CR 18, September 25, 2018, effective 10/15/2018
41 CR 21, November 10, 2018, effective 12/1/2018
41 CR 23, December 10, 2018, effective 1/1/2019
42 CR 01, January 10, 2019, effective 2/1/2019
41 CR 19, October 10, 2018, effective 3/1/2019
42 CR 03, February 10, 2019, effective 4/1/2019
42 CR 04, February 25, 2019, effective 4/1/2019
42 CR 06, March 25, 2019, effective 6/1/2019
42 CR 08, April 10, 2019, effective 6/1/2019
42 CR 15, August 10, 2019, effective 9/1/2019
42 CR 17, September 10, 2019, effective 10/1/2019
43 CR 02, January 25, 2020, effective 12/20/2019
43 CR 02, January 25, 2020, effective 12/23/2019
42 CR 23, December 10, 2019, effective 1/1/2020
43 CR 01, January 10, 2020, effective 2/1/2020
42 CR 24, December 25, 2019, effective 2/2/2020
43 CR 06, March 25, 2020, effective 4/15/2020
43 CR 10, May 25, 2020, effective 8/1/2020
43 CR 14, July 25, 2020, effective 8/15/2020
43 CR 17, September 10, 2020, effective 10/1/2020
43 CR 18, September 25, 2020, effective 11/1/2020
43 CR 22, November 25, 2020, effective 12/15/2020
43 CR 24, December 25, 2020, effective 1/15/2021
44 CR 03, February 10, 2021, effective 3/15/2021
44 CR 08, April 25, 2021, effective 5/15/2021
44 CR 09, May 10, 2021, effective 6/1/2021
44 CR 10, May 25, 2021, effective 6/14/2021
44 CR 10, May 25, 2021, effective 6/15/2021
44 CR 13, July 10, 2021, effective 8/1/2021
44 CR 15, August 10, 2021, effective 9/1/2021
44 CR 19, October 10, 2021, effective 11/1/2021
44 CR 21, November 10, 2021, effective 12/1/2021
44 CR 23, December 10, 2021, effective 12/30/2021
44 CR 21, November 10, 2021, effective 1/1/2022
44 CR 23, December 10, 2021, effective 1/15/2022
44 CR 24, December 25, 2021, effective 1/15/2022
45 CR 03, February 10, 2022, effective 3/2/2022
45 CR 08, April 25, 2022, effective 5/30/2022
45 CR 09, May 10, 2022, effective 5/30/2022
45 CR 10, May 25, 2022, effective 6/14/2022
45 CR 11, June 10, 2022, effective 6/30/2022
45 CR 11, June 10, 2022, effective 7/15/2022
45 CR 19, October 10, 2022, effective 11/1/2022
45 CR 20, October 25, 2022, effective 11/14/2022
45 CR 21, November 10, 2022, effective 11/30/2022
45 CR 24, December 25, 2022, effective 1/14/2023
46 CR 01, January 10, 2023, effective 2/14/2023
46 CR 06, March 25, 2023, effective 2/15/2023
46 CR 03, February 10, 2022, effective 3/2/2023
46 CR 04, February 25, 2023, effective 3/17/2023
46 CR 05, March 10, 2023, effective 4/15/2023
46 CR 09, May 10, 2023, effective 5/30/2023
46 CR 09, May 10, 2023, effective 6/1/2023
46 CR 10, May 25, 2023, effective 6/15/2023
46 CR 11, June 10, 2023, effective 6/30/2023