211 CMR 38.04 - Rules for Coordination of Benefits

Current through Register 1466, April 1, 2022

(1) When a person is covered by two or more Plans, 211 CMR 38.04 determines the order of benefit payments:
(a) The Primary Plan must pay or provide its benefits as if the Secondary Plan or Plans did not exist.
(b) 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 the services of a health care provider that is not within the Primary Plan's Closed Panel provider network, except for emergency services or authorized referrals that are paid or provided by the Primary Plan.
(c) If the Primary Plan is not a Closed Panel Plan and the Secondary Plan is a Closed Panel Plan, and the covered person uses the services of a health care provider that is not within the Secondary Plan's provider network, then the Secondary Plan is not required to pay or provide benefits, except for emergency services or authorized referrals that are paid or provided by the Primary Plan.
(d) When multiple contracts providing coordinated coverage are treated as a single Plan under 211 CMR 38.00, 211 CMR 38.04 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 211 CMR 38.00.
(e) If a person is covered by more than one Secondary Plan, the order of benefit determination rules of 211 CMR 38.00 decide the order in which Secondary Plans 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 211 CMR 38.00, has its benefits determined before those of that Secondary Plan.
(2)
(a) Except as otherwise provided in 211 CMR 38.00, a Plan that does not contain order of benefit determination provisions that are consistent with 211 CMR 38.00 is always the Primary Plan unless the provisions of both Plans, regardless of the provisions of 211 CMR 38.04(2)(a), state that the complying Plan is primary.
(b) Coverage that is obtained by virtue of membership in a group and designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the Plan provided by the contract holder.
(3) A Plan may take the benefits paid or provided by another Plan into account only when, under 211 CMR 38.00, it is secondary to that other Plan.

Notes

211 CMR 38.04
Amended by Mass Register Issue 1323, eff. 10/7/2016. Amended by Mass Register Issue 1325, eff. 10/7/2016.

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