3 Colo. Code Regs. § 702-4-6-2-6
Current through Register Vol. 47, No. 16, August 25, 2024
Section 3 CCR 702-4-6-2-6 - Rules for Coordination of BenefitsA. When a person is covered by two (2) or more plans, the rules for determining the order-of-benefit payments are as follows:1. The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist.2. If the primary plan is a closed panel plan, and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were the primary plan when a covered person uses a non-panel provider, except for emergency services or authorized referrals that are paid or provided by the primary plan.3. When multiple contracts providing coordinated coverage are treated as a single plan under this regulation, this section applies only to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the plan, the carrier designated as primary within the plan shall be responsible for the plan's compliance with this regulation.4. If a person is covered by more than one secondary plan, the order-of-benefit determination rules of this regulation decide the order in which secondary plan benefits are determined in relation to each other. Each secondary plan shall take into consideration the benefits of the primary plan or plans and the benefits of any other plan, which, under the rules of this regulation, has its benefits determined before those of that secondary plan.5. Under the terms of a closed panel plan, benefits are not payable if the covered person does not use the services of a closed panel provider, with the exceptions of medical emergencies and if there are allowable benefits available. In most instances, COB does not occur if a covered person is enrolled in two (2) or more closed panel plans and obtains services from a provider in one of the closed panel plans because the other closed panel plan (the one whose providers were not used) has no liability. However, COB may occur during the claim determination period when the covered person receives emergency services that would have been covered by both plans.B. Except as provided in Section 6.A.2., a plan that does not contain order-of-benefit determination provisions that are consistent with this regulation will always be the primary plan, unless the provisions of both plans, regardless of the provisions of this subsection, state that the plan is primary. Coverage that is obtained by virtue of being members in a group, and designed to supplement part of the basic package of benefits, may provide supplementary coverage that shall be in excess of any other parts of the plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverage that are written in connection with closed panel plan to provide out-of-network benefits.
C. A plan may consider the benefits paid or provided by another plan only when it is secondary to that other plan.D. Order-of-Benefit Determination Each plan determines the order-of-benefits using the first of the following rules that apply:
1. Non-Dependent or Dependent a. Subject to section 6.D.1.b., the plan that covers the person other than as a dependent, for example as an employee, member, subscriber or retiree, is primary and the plan that covers the person as a dependent is secondary.b. The order of benefits is changed, making the plan covering the person as a dependent primary, Medicare secondary, and the plan covering the person as other than a dependent (e.g. a retired employee) last when the person is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is: (1) Secondary to the plan covering the person as a dependent; and(2) Primary to the plan covering the person as other than a dependent (e.g. a retired employee).c. Secondary for the first thirty (30) months for treatment of End Stage Renal Disease (ESRD) for group plan members after the Medicare mandated waiting period is met.d. Primary after the thirty (30) month coordination period for the treatment of ESRD is exhausted for group plan members.2. Dependent Child Covered Under More Than One Plan Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order-of-benefits as follows:
a. For a dependent child whose parents are married or are living together, whether or not they have been married:(1) The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or(2) If both parents have the same birthday, the plan that has covered the parent the longest is the primary plan.b. For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married: (1) If the court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage, and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with financial responsibility has no health care coverage for the dependent child's health care, but that parent's spouse does, the spouse's plan is primary. This item shall not apply with respect to a plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;(2) If the court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of Section 6.D.2.a. shall determine the order-of-benefits;(3) If the divorce decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the depend child, the provisions of Section 6.D.2.a. shall determine the order-of-benefits; or(4) If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order-of-benefits for the child are as follows: (a) The plan of the custodial parent;(b) The plan of the spouse of the custodial parent;(c) The plan of the noncustodial parent; and then(d) The plan of the spouse of the noncustodial parent.c. For a dependent child covered under more than one plan of individuals who are not parents of the child, the order-of-benefits shall be determined, as applicable, under Section 6.D.2.a. or b. as if those individuals were the parents of the child.d. For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the rule in Section 6.D.5. applies. In the event the dependent child's coverage under the spouse's plan began on the same date as the dependent child's coverage under either or both parents' plans, the order-of-benefits shall be determined by applying the birthday rule in Section 6.D.2.a. to the dependent child's parent(s) and the dependent's spouse.
3. Active Employee or Retired or Laid-Off Employee a. The plan that covers a person as an active employee, who is neither laid off nor retired, or as a dependent of an active employee, is the primary plan.b. If the secondary, or other plan, does not have this rule, and as result the plans do not agree on the order-of-benefits, this rule is ignored.c. This rule does not apply if the rule in Section 6.D.1. can determine the order-of-benefits.4. COBRA or State Continuation Coverage a. If a person whose coverage is provided pursuant to COBRA, or under a right of continuation pursuant to state or federal law is covered under another plan, the plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber, or retiree, is the primary plan and the plan covering that same person pursuant to COBRA, or under a right of continuation pursuant to state or other federal law, is the secondary plan.b. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order-of-benefits, this rule is ignored.c. This rule does not apply if the rule in Section 6.D.1. can determine the order-of-benefits.5. Longer or Shorter Length of Coverage a. If the preceding rules do not determine the order-of-benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan.b. To determine the length of time a person has been covered under a plan, two (2) successive plans shall be treated as one if the covered person was eligible under the second within twenty-four (24) hours after the first plan ended.c. The start of a new plan does not include: (1) A change in the amount or scope of a plan's benefits;(2) A change in the entity that pays, provides or administers the plan's benefits; or(3) A change from one type of plan to another, such as, from a single employer plan to that of a multiple employer plan.d. The person's length of time covered under a plan is measured from the person's first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group shall be used as the date from which to determine the length of time the person's coverage under the present plan has been in force.6. If none of the preceding rules determine the primary plan, the allowable expenses shall be shared equally between the plans.37 CR 11, June 10, 2014, effective 7/1/201437 CR 12, June 25, 2014, effective 7/15/2014Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/201437 CR 23, December 10, 2014, effective 1/1/201538 CR 03, February 10, 2015, effective 3/15/201538 CR 06, March 25, 2015, effective 4/30/201538 CR 09, May 10, 2015, effective 6/1/201538 CR 13, July 10, 2015, effective 7/30/201538 CR 19, October 10, 2015, effective 11/1/201538 CR 21, November 10, 2015, effective 1/1/201638 CR 23, December 10, 2015, effective 1/1/201639 CR 01, January 10, 2016, effective 2/1/201639 CR 05, March 10, 2016, effective 4/1/201639 CR 08, April 25, 2016, effective 5/15/201639 CR 19, October 10, 2016, effective 11/1/201639 CR 20, October 25, 2016, effective 1/1/201739 CR 22, November 25, 2016, effective 1/1/201739 CR 23, December 10, 2016, effective 1/1/201739 CR 23, December 25, 2016, effective 1/1/201740 CR 03, February 10, 2017, effective 3/15/201740 CR 09, May 10, 2017, effective 6/1/201740 CR 15, August 10, 2017, effective 9/1/201740 CR 17, September 10, 2017, effective 10/1/201740 CR 21, November 10, 2017, effective 12/1/201741 CR 04, February 25, 2018, effective 4/1/201841 CR 05, March 10, 2018, effective 6/1/201841 CR 08, April 25, 2018, effective 6/1/201841 CR 09, May 10, 2018, effective 6/1/201841 CR 11, June 10, 2018, effective 7/1/201841 CR 15, August 10, 2018, effective 9/1/201841 CR 17, September 10, 2018, effective 10/1/201841 CR 18, September 25, 2018, effective 10/15/201841 CR 21, November 10, 2018, effective 12/1/201841 CR 23, December 10, 2018, effective 1/1/201942 CR 01, January 10, 2019, effective 2/1/201941 CR 19, October 10, 2018, effective 3/1/201942 CR 03, February 10, 2019, effective 4/1/201942 CR 04, February 25, 2019, effective 4/1/201942 CR 06, March 25, 2019, effective 6/1/201942 CR 08, April 10, 2019, effective 6/1/201942 CR 15, August 10, 2019, effective 9/1/201942 CR 17, September 10, 2019, effective 10/1/201943 CR 02, January 25, 2020, effective 12/20/201943 CR 02, January 25, 2020, effective 12/23/201942 CR 23, December 10, 2019, effective 1/1/202043 CR 01, January 10, 2020, effective 2/1/202042 CR 24, December 25, 2019, effective 2/2/202043 CR 06, March 25, 2020, effective 4/15/202043 CR 10, May 25, 2020, effective 8/1/202043 CR 14, July 25, 2020, effective 8/15/202043 CR 17, September 10, 2020, effective 10/1/202043 CR 18, September 25, 2020, effective 11/1/202043 CR 22, November 25, 2020, effective 12/15/202043 CR 24, December 25, 2020, effective 1/15/202144 CR 03, February 10, 2021, effective 3/15/202144 CR 08, April 25, 2021, effective 5/15/202144 CR 09, May 10, 2021, effective 6/1/202144 CR 10, May 25, 2021, effective 6/14/202144 CR 10, May 25, 2021, effective 6/15/202144 CR 13, July 10, 2021, effective 8/1/202144 CR 15, August 10, 2021, effective 9/1/202144 CR 19, October 10, 2021, effective 11/1/202144 CR 21, November 10, 2021, effective 12/1/202144 CR 23, December 10, 2021, effective 12/30/202144 CR 21, November 10, 2021, effective 1/1/202244 CR 23, December 10, 2021, effective 1/15/202244 CR 24, December 25, 2021, effective 1/15/202245 CR 03, February 10, 2022, effective 3/2/202245 CR 08, April 25, 2022, effective 5/30/202245 CR 09, May 10, 2022, effective 5/30/202245 CR 10, May 25, 2022, effective 6/14/202245 CR 11, June 10, 2022, effective 6/30/202245 CR 11, June 10, 2022, effective 7/15/202245 CR 19, October 10, 2022, effective 11/1/202245 CR 20, October 25, 2022, effective 11/14/202245 CR 21, November 10, 2022, effective 11/30/202245 CR 24, December 25, 2022, effective 1/14/202346 CR 01, January 10, 2023, effective 2/14/202346 CR 06, March 25, 2023, effective 2/15/202346 CR 03, February 10, 2022, effective 3/2/202346 CR 04, February 25, 2023, effective 3/17/202346 CR 05, March 10, 2023, effective 4/15/202346 CR 09, May 10, 2023, effective 5/30/202346 CR 09, May 10, 2023, effective 6/1/202346 CR 10, May 25, 2023, effective 6/15/202346 CR 11, June 10, 2023, effective 6/30/2023