N.J. Admin. Code § 11:4-28.6

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:4-28.6 - Rules for coordination of benefits

(a) The general order of benefit determination shall be as follows:

1. The primary plan shall pay or provide its benefits as if the secondary plan or plans did not exist.

2. A secondary plan shall take the benefits of another plan into account only when, under this subchapter, it is secondary to that other plan.

3. The benefits of the plan which covers the person as an employee, member, subscriber or retiree (that is, other than as a dependent) shall be determined before those of the plan which covers the person as a dependent.

(b) The rules for the order of benefits for a dependent child when the parents are not separated or divorced are as follows:

1. The benefits of the plan of the parent whose birthday falls earlier in a year shall be determined before those of the plan of the parent whose birthday falls later in that year.

2. If both parents have the same birthday, the benefits of the plan which covered the parent longer shall be determined before those of the plan which covered the other parent for a shorter period of time.

3. The word "birthday" refers only to month and day in a calendar year and not the year in which the person was born.

4. If the other plan does not follow the rules described in (b)1, 2 and 3 above, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule based upon the gender of the parent shall determine the order of benefits.

(c) If two or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child shall be determined according to the provisions of this subsection:

1. The plan of the parent with custody of the child shall have its benefits determined first;

2. The plan of the spouse of the parent with the custody of the child shall have its benefits determined next;

3. The plan of the parent not having custody of the child shall have its benefits determined last.

4. If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and if the plan of that parent is a secondary plan, and further, if the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, then the benefits of that plan shall be determined first. The plan of the other parent shall be considered the secondary plan. This paragraph shall not apply to any claim determination period or plan year during which any benefits are actually paid or provided before the entity that has actual knowledge.

(d) The benefits of a plan which covers a person as an employee who is neither laid-off nor retired (or as that employee's dependent) shall be determined before those of a plan which covers that person as a laid-off or retired employee (or as that employee's dependent). If the other plan does not have this particular provision, and if, as a result, the plans do not agree on the order of benefits, this subsection shall be ignored.

(e) When a person provided coverage under a right of continuation pursuant to Federal or State law also is covered under another plan, the plan covering the person as an employee, member, subscriber or retiree (or as that person's dependent) is primary and the continuation coverage is secondary unless the other plan does not contain a provision allowing it to apply this rule and as a result the plans do not agree on the order of benefits.

(f) If none of the provisions of (c) and (d) above determines the order of benefits, the benefits of the plan which covered an employee, member or subscriber longer shall be determined before those of the plan which covered that person for the shorter term.

1. To determine the time a person has been covered under a plan, successive plans of a given group shall be treated as one if the claimant was eligible under the second plan within 24 hours after the first plan ended.

2. The start of a new plan shall not include:

i. A change in the amount or scope of a plan's benefits;

ii. A change in the entity which pays, provides or administers the plan's benefits; and

iii. A change from one plan to another (such as, from a single employer plan to that of a multiple employer plan).

3. The claimant's time covered under a plan shall be measured from the claimant's initial date of coverage under that plan. If that date is not readily available, the date the claimant first became a member of the group shall be used as the date from which to determine the time of the claimant's coverage under the present plan.

N.J. Admin. Code § 11:4-28.6

Amended by R.2002 d.106, effective 4/1/2002 (operative January 1, 2003).
See: 33 New Jersey Register 2578(a), 34 New Jersey Register 1440(a).
In (a)3, inserted "or retiree" following "subscriber"; added a new (e) and recodified former (e) as (f).