La. Admin. Code tit. 37 § XIII-305

Current through Register Vol. 50, No. 5, May 20, 2024

Section XIII-305 - Use of Model COB Contract Provision

A. Appendix A and Appendix B contain model COB provisions that shall be used in group and individual contracts or subscriber agreements. That use is subject to the provisions of Subsections B, C, and D of this Section and to the provisions of §307.

B. Appendix B is a plain language description of the COB process that explains to the covered person how insurers will implement coordination of benefits. It is not intended to replace or change the provisions that are set forth in the contract. Its purpose is to explain the process by which the two (or more) plans will pay for or provide benefits, how the benefit reserve is accrued and how the covered person may use the benefit reserve.

C. The COB provision contained in Appendix A and the plain language explanation in Appendix B do not have to use the specific words and format shown in §321, Appendix A, or §323, Appendix B. Changes may be made to fit the language and style of the rest of the group contract or to reflect differences among plans that provide services, that pay benefits for expenses incurred and that indemnify. No substantive changes are permitted.

D. 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;

2. a person is or could have been covered under another plan, except with respect to part B of Medicare; or

3. a person has elected an option under another plan providing a lower level of benefits than another option that could have been elected.

E. No plan may contain a provision that its benefits are "always excess" or "always secondary," except in accord with the rules permitted by this regulation.

F. 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 is enrolled in two 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 or plan year when the covered person receives emergency services that would have been covered by both plans. Then the secondary plan shall use the benefit reserve to pay any unpaid allowable expense.

G. A simple statement advising consumers that they can request a copy in either paper form or electronic form of Appendix C, that provides an explanation for secondary plans on the purpose and use of the benefit reserve and how secondary plans calculate claims, shall be added in the coordination of benefit section or provision found in group and individual policies.

La. Admin. Code tit. 37, § XIII-305

Promulgated by the Department of Insurance, Office of the Commissioner, LR 17:67 (January 1991), amended LR 20:52 (January 1994), LR 23:415 (April 1997), Amended LR 421097 (7/1/2016), Amended LR 4464 (1/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:3.2014.