N.H. Admin. Code § Ins 1904.05 - Rules for Coordination of Benefits
When a person is covered by 2 or more plans:
(a) The rules for determining the order of
benefit payments are as follows:
(1) The
primary plan shall 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 rule, 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 rule; and
(4)
If a person is covered by more than one secondary plan, the order of benefit
determination rules of this rule 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 the rules of this rule, has its
benefits determined before those of that secondary plan.
(b) Except as provided in paragraph (2)
below:
(1) A plan that does not contain order
of benefit determination provisions that are consistent with this rule is
always the primary plan unless the provisions of both plans, regardless of the
provisions of this paragraph, state that the complying plan is primary;
and
(2) 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. Examples of
these types of situations are major medical coverages that are superimposed
over base plan hospital and surgical benefits, and insurance type coverages
that are written in connection with a closed panel plan to provide
out-of-network benefits.
(c) A plan may take into consideration the
benefits paid or provided by another plan only when, under the rules of this
rule, it is secondary to that other plan.
(d) Order of Benefit Determination. Each plan
determines its order of benefits using the first of the following rules that
applies:
(1) Non-Dependent or Dependent.
a. Subject to subparagraph b. of this
paragraph, the plan that covers the person other than as a dependent, for
example as an employee, member, subscriber, policyholder or retiree, is the
primary plan and the plan that covers the person as a dependent is the
secondary plan.
b. If 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). Then the order of benefits is reversed so that the plan covering the
person as an employee, member, subscriber, policyholder or retiree is the
secondary plan and the other plan covering the person as a dependent is the
primary plan.
(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 ever 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 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 a 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
responsibility has no health care coverage for the dependent child's health
care expenses, but that parent's spouse does, that parent's spouse's plan is
the primary plan. This item shall not apply with respect to any plan year
during which benefits are paid or provided before the entity has actual
knowledge of the court decree provision;
2. If a court decree states that both parents
are responsible for the dependent child's health care expenses or health care
coverage, the provisions of subparagraph a. of this paragraph shall determine
the order of benefits;
3. If a
court 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 dependent child, the provisions of subparagraph a. of this
paragraph 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:
(i) The plan covering the custodial
parent;
(ii) The plan covering the
custodial parent's spouse;
(iii)
The plan covering the non-custodial parent; and then
(iv) The plan covering the non-custodial
parent's spouse; and
c. For a dependent child covered under more
than one plan of individuals who are not the parents of the child, the order of
benefits shall be determined, as applicable, under subparagraph a. or b. of
this paragraph as if those individuals were parents of the child.
(3) Active Employee or Retired or
Laid-Off Employee.
a. The plan that covers a
person as an active employee that is, an employee who is neither laid off nor
retired or as a dependent of an active employee is the primary plan. The plan
covering that same person as a retired or laid-off employee or as a dependent
of a retired or laid-off employee is the secondary plan.
b. If the other plan does not have this rule,
and as a result, the plans do not agree on the order of benefits, this rule is
ignored; and
c. This rule does not
apply if the rule in paragraph (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 other 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; and
c. This rule does not apply if the rule in
paragraph (1) can determine the order of benefits.
(5) Longer or Short 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 successive plans shall be treated as one if
the covered person was eligible under the second plan within 24 hours after
coverage under 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 a multiple employer plan; and
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; and
(6) If none of the preceding rules determines
the order of benefits, the allowable expenses shall be shared equally between
the plans.
Notes
#3164, eff 12-24-85; ss by #4287, eff 7-1-87; ss by #5656, eff 7-1-93; ss by #7017, INTERIM, eff 7-1-99, EXPIRED: 10-29-99
New. #8402, eff 8-1-05; ss by #10371, eff 8-1-13
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