<html> <head> <title>Rule 20:06:50:0A Model Coordination of Benefits Contract Provisions.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:50:0A"> <META NAME="Description" Content="Administrative Rules 20:06:50:0A Model Coordination of Benefits Contract Provisions."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <title>DEPARTMENT OF REVENUE AND REGULATION</title> <style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>MODEL COORDINATION OF BENEFITS CONTRACT PROVISIONS</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Chapter 20:06:50</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>APPENDIX A</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>SEE: &#167;&nbsp;20:06:50:01</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b><span style='font-weight:bold'>Source:</span></b> 32 SDR 232, effective July 10, 2006.</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>APPENDIX A</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman">&nbsp;</font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>MODEL COORDINATION OF BENEFITS CONTRACT PROVISIONS</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>COORDINATION OF THIS CONTRACT'S BENEFITS WITH OTHER BENEFITS</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one plan. Plan is defined below.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100 percent of the total allowable expense.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DEFINITIONS</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>A.&nbsp;&nbsp;A plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(1)&nbsp;&nbsp;Plan includes: group and nongroup insurance contracts, health maintenance organization (HMO) contracts, closed panel plans or other forms of group or group-type coverage (whether insured or uninsured); medical care components of long-term care contracts, such as skilled nursing care; medical benefits under group or individual automobile contracts; and Medicare or any other federal government plan, as permitted by law.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(2)&nbsp;&nbsp;Plan does not include: hospital indemnity coverage or other fixed indemnity coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; benefits for non-medical components of long-term care policies; Medicare supplement policies; Medicaid policies; or coverage under other federal governmental plans, unless permitted by law.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Each contract for coverage under (1) or (2) is a separate plan. If a plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>B.&nbsp;&nbsp;This plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>C.&nbsp;&nbsp;The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the person has health care coverage under more than one plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>When this plan is primary, it determines payment for its benefits first before those of any other plan without considering any other plan's benefits. When this plan is secondary, it determines its benefits after those of another plan and may reduce the benefits it pays so that all plan benefits do not exceed 100 percent of the total allowable expense.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>D.&nbsp;&nbsp;Allowable expense is a health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by any plan covering the person. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any plan covering the person is not an allowable expense. In addition, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an allowable expense.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The following are examples of expenses that are not allowable expenses:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(1)&nbsp;&nbsp;The difference between the cost of a semi-private hospital room and a private hospital room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(2)&nbsp;&nbsp;If a person is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology, any amount in excess of the highest reimbursement amount for a specific benefit is not an allowable expense.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(3)&nbsp;&nbsp;If a person is covered by two or more plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(4)&nbsp;&nbsp;If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology and another plan that provides its benefits or services on the basis of negotiated fees, the primary plan's payment arrangement shall be the allowable expense for all plans. However, if the provider has contracted with the secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan's payment arrangement and if the provider's contract permits, the negotiated fee or payment shall be the allowable expense used by the secondary plan to determine its benefits.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(5)&nbsp;&nbsp;The amount of any benefit reduction by the primary plan because a covered person has failed to comply with the plan provisions is not an allowable expense. Examples of these types of plan provisions include second surgical opinions, pre-certification of admissions, and preferred provider arrangements.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>E.&nbsp;&nbsp;Closed panel plan is a plan that provides health care benefits to covered persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that excludes coverage for services provided by other providers, except in cases of emergency or referral by a panel member.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>F.&nbsp;&nbsp;Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one-half of the calendar year excluding any temporary visitation.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>ORDER OF BENEFIT DETERMINATION RULES</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>When a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>A.&nbsp;&nbsp;The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>B.&nbsp;&nbsp;(1)&nbsp;&nbsp;Except as provided in paragraph (2), a plan that does not contain a coordination of benefits provision that is consistent with this regulation is always primary unless the provisions of both plans state that the complying plan is primary.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(2)&nbsp;&nbsp;Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this 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.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>C.&nbsp;&nbsp;A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits only when it is secondary to that other plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>D.&nbsp;&nbsp;Each plan determines its order of benefits using the first of the following rules that apply:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(1)&nbsp;&nbsp; Non-dependent or dependent. The plan that covers the person other than as a dependent, for example as an employee, member, policyholder, subscriber, or retiree is the primary plan and the plan that covers the person as a dependent is the secondary plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the plan covering the person as a dependent, and primary to the plan covering the person as other than a dependent (e.g. a retired employee), then the order of benefits between the two plans is reversed so that the plan covering the person as an employee, member, policyholder, subscriber, or retiree is the secondary plan and the other plan is the primary plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(2)&nbsp;&nbsp;Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, when a dependent child is covered by more than one plan the order of benefits is determined as follows:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(a)&nbsp;&nbsp;For a dependent child whose parents are married or are living together, whether or not they have ever been married:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>If both parents have the same birthday, the plan that has covered the parent the longest is the primary plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(b)&nbsp;&nbsp;For a dependent child whose parents are divorced or separated or not living together, whether or not they have ever been married:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(i)&nbsp;&nbsp;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. This rule applies to plan years commencing after the plan is given notice of the court decree;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(ii)&nbsp;&nbsp;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) above shall determine the order of benefits;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(iii)&nbsp;&nbsp;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) above shall determine the order of benefits; or</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(iv)&nbsp;&nbsp;If there is no court decree allocating responsibility for the dependent child's health care expenses or health care coverage, the order of benefits for the child are as follows:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The plan covering the custodial parent;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The plan covering the spouse of the custodial parent;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The plan covering the non-custodial parent; and then</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>The plan covering the spouse of the non-custodial parent.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(c)&nbsp;&nbsp;For a dependent child covered under more than one plan of individuals who are the parents of the child, the provisions of subparagraph (a) or (b) above shall determine the order of benefits as if those individuals were the parents of the child.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(3)&nbsp;&nbsp;Active employee or retired or laid-off employee. The plan that covers a person as an active employee, that is, an employee who is neither laid off nor retired, is the primary plan. The plan covering that same person as a retired or laid-off employee is the secondary plan. The same would hold true if a person is a dependent of an active employee and that same person is a dependent of a retired or laid-off employee. 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. This rule does not apply if the rule labeled D(1) can determine the order of benefits.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(4)&nbsp;&nbsp;COBRA or state continuation coverage. If a person whose coverage is provided pursuant to COBRA or under a right of continuation provided by 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 COBRA or state or other federal continuation coverage is the secondary plan. 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. This rule does not apply if the rule labeled D(1) can determine the order of benefits.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(5)&nbsp;&nbsp;Longer or shorter length of coverage. The plan that covered the person as an employee, member, policyholder, subscriber, or retiree longer is the primary plan and the plan that covered the person the shorter period of time is the secondary plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>(6)&nbsp;&nbsp;If the preceding rules do not determine the order of benefits, the allowable expenses shall be shared equally between the plans meeting the definition of plan. In addition, this plan will not pay more than it would have paid had it been the primary plan.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>EFFECT ON THE BENEFITS OF THIS PLAN</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>A.&nbsp;&nbsp;When this plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all plans during a plan year are not more than the total allowable expenses. In determining the amount to be paid for any claim, the secondary plan will calculate the benefits it would have paid in the absence of other health care coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed the total allowable expense for that claim. In addition, the secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>B.&nbsp;&nbsp;If a covered person is enrolled in two or more closed panel plans and if, for any reason, including the provision of service by a non-panel provider, benefits are not payable by one closed panel plan, COB shall not apply between that plan and other closed panel plans.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this plan and other plans. [Organization responsibility for COB administration] may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under this plan and other plans covering the person claiming benefits. [Organization responsibility for COB administration] need not tell, or get the consent of, any person to do this. Each person claiming benefits under this plan must give [Organization responsibility for COB administration] any facts it needs to apply those rules and determine benefits payable.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>FACILITY OF PAYMENT</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>A payment made under another plan may include an amount that should have been paid under this plan. If it does, [Organization responsibility for COB administration] may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under this plan. [Organization responsibility for COB administration] will not have to pay that amount again. The term &quot;payment made&quot; includes providing benefits in the form of services, in which case &quot;payment made&quot; means the reasonable cash value of the benefits provided in the form of services.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>RIGHT OF RECOVERY</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>If the amount of the payments made by [Organization responsibility for COB administration] is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid; or any other person or organization that may be responsible for the benefits or services provided for the covered person. The &quot;amount of the payments made&quot; includes the reasonable cash value of any benefits provided in the form of services.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>