Section 760 IAC 1-38.1-11 - Model coordination of benefits provision; prohibited coordination; benefit designAuthority: IC 27-1-3-7
Affected: IC 27-8-5-19
Sec. 11.
(a) A model coordination of benefits provision for use in group contracts, contained as Appendix A to the Group Coordination of Benefits Model Regulation as adopted and amended in April 2005, by the National Association of Insurance Commissioners (NAIC) (2005 Proc. I), appearing in the NAIC Model Insurance Laws, Regulations and Guidelines, Vol. I, pages 120-14 through 120-19, is hereby adopted by reference, as if fully set out in this rule.(b) A group contract's coordination of benefits provision does not have to use the words and format shown in the model provision adopted by reference in subsection (a). Changes may be made to: (1) fit the language and style of the rest of the group contract; or(2) reflect the difference among plans that:(B) pay benefits for expenses incurred; and(C) indemnify. No substantive changes are allowed.
(c) A COB provision may not be used that permits a plan to reduce its benefits on the basis that: (1) another plan exists and the covered person did not enroll in that plan; or(2) a person: (A) is or could have been covered under another plan, except with respect to Part B of Medicare; or(B) has elected an option under another plan providing a lower level of benefits than another option that could have been elected.(d) No contract may contain a provision that its benefits are "always excess" or "always secondary" to any plan as defined in section 7 of this rule, except in compliance with this rule.(e) 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. In most instances, COB does not occur if a covered person:(1) is enrolled in two (2) or more closed panel plans; and(2) obtains services from a provider in one (1) of the closed panel plans because the other closed panel plan (the one (1) whose providers were not used) has no liability. However, COB may occur during the plan year when the covered person receives emergency services that would have been covered by both plans. The secondary plan shall use the provisions of section 17 of this rule to determine the amount to pay for the benefit.
(f) No plan may use a COB provision or any other provision that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of plan as defined by section 7 of this rule.Department of Insurance; 760 IAC 1-38.1-11; filed Feb 14, 1990, 3:30 p.m.: 13 IR 1172; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; filed Sep 15, 2006, 2:02 p.m.: 20061011-IR-760050265FRA; readopted filed Nov 21, 2012, 4:15 p.m.: 20121219-IR-760120454RFAReadopted filed Nov 13, 2018, 10:02 a.m.: 20181212-IR-760180372RFA