Utah Admin. Code R590-131-4 - Coordination of Benefits Contract Provisions

(1) A COB provision may not be used that permits a plan to reduce the plan benefits on the basis that an enrollee is eligible to enroll in another plan and the enrollee did not enroll in that plan.

(2)

(a) Under the terms of a closed panel plan, benefits are not payable if the enrollee does not use the services of a closed panel plan's providers.

(b) In most instances, COB does not occur if an enrollee is enrolled in two or more closed panel plans and obtains services from a provider in only one of the closed panel plans because the other closed panel plan, the one whose providers were not used, has no liability.

(c)

(i) COB may occur when an enrollee receives emergency services that are covered by both plans.

(ii) The secondary plan shall use Section R590-131-7 to determine the amount it shall pay for the benefit.

(3) A plan may not use a COB or other provision that reduces the plan's benefits for non-conforming benefits.

(4) A coordinated package is one plan and there is no COB among the multiple plans or separate parts of a plan.

(5) If a plan coordinates benefits, the plan shall state the type of coverage that will be considered in applying the COB provision.

(6) Whether a plan uses the term "plan" or some other term such as "program," the definition may not be broader than the definition of "plan."

Notes

Utah Admin. Code R590-131-4

Amended by Utah State Bulletin Number 2020-15, effective 7/22/2020 Amended by Utah State Bulletin Number 2022-17, effective 8/22/2022