230 R.I. Code R. 230-RICR-20-30-1.10

Current through December 3, 2024

Section 230-RICR-20-30-1.10 - Group Anti-Duplication Provision

A. If a group health benefit contract contains a provision restricting benefit payments on account of the benefit paid by another plan, such provision shall be at least as favorable to the insured as the following:

1. Provision for Co-Ordination Between This Contract and Other Benefits

a. Benefits Subject to This Program

(1) All of the benefits provided under this contract are subject to this provision.

(2) (Note: When contract provides both integrated Major Medical Expense Benefits and the underlying Basic Benefits, but provision applies to Major Medical only, use the following alternate wording: Only the Major Medical Expense Benefits under this contract are subject to this provision).

b. Definitions

(1) (Note: Include here the definition of a Plan, that is, the benefits, including those provided by this contract, that are to be co-ordinated. The following definition is illustrative only, except that "plan" may not be defined to include individual health benefit contracts. If government programs are excluded, language substantially equivalent to that at (iv) must be used.)

(AA) "Plan" means any plan providing benefits or services for or by reason of medical or dental care or treatment, which benefits or services are provided by:

(i) group, blanket or franchise insurance coverage,

(ii) Blue Cross, Blue Shield, group practice, individual practice and other prepayment coverage,

(iii) any coverage under labor-management trusteed plans, union welfare plans, employer organization plans, or employee benefit organization plans, and

(iv) any coverage under governmental programs, and any coverage required or provided by any statute; except that "plan" shall not include benefits provided under R.I. Gen. Laws §§ 42-62-5, 6, 7 and 8.

(BB) The term "plan" shall be construed separately with respect to each contract or other arrangement for benefits or services and separately with respect to that portion of any such contract or other arrangement which reserves the right to take the benefits or services of other Plans into consideration in determining its benefits and that portion which does not.

(2) "This Plan" means that portion of this contract which provides the benefits that are subject to this provision.

(3) "Allowable Expense" means any necessary, reasonable, and customary item of expense at least a portion of which is covered under at least one the Plans covering the person for whom claim is made.

(AA) When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be deemed to be both an Allowable Expense and a benefit paid.

(4) "Claim Determination Period" means (Note: Insert here an appropriate period of time such as, "calendar year" or "Benefit Period as defined elsewhere in this contract.")

c. Effective on Benefits

(1) This provision shall apply in determining the benefits as to a person covered under this Plan for any Claim Determination Period if, for the Allowable Expenses incurred as to such person during such period, the sum of

(AA) the benefits that would be payable under this Plan in the absence of this provision, and

(BB) the benefits that would be payable under all other Plans in the absence therein of provision of similar purpose to this provision would exceed such Allowable Expenses.

(2) As to any Claim Determination Period with respect to which this provision is applicable, the benefits that would be payable under this Plan in the absence of this provision for the Allowable Expenses incurred as to such person during such Claim Determination Period shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all other Plans except as provided in § 1.10(A)(1)(c)(3) of this Part, shall not exceed the total of such Allowable Expenses. Benefits payable under another Plan include the benefits that would have been payable had claim been duly made therefor.

(3) If:

(AA) another Plan which is involved in § 1.10(A)(1)(c)(2) of this Part and which contains a provision co-ordinating its benefits with those of this Plan would, according to its rules, determine its benefits after the benefits of this Plan have been determined, and

(BB) the rules set forth in § 1.10(A)(1)(c)(4) of this Part would require this Plan to determine its benefits before such other Plan which the benefits of such other Plan will be ignored for the purposes of determining the benefits under this Plan.

(4) For the purposes of item § 1.10(A)(1)(c)(3) of this Part, the rules establishing the order of benefit determination are:

(AA) The benefits of Plan which cover the person on whose expenses claim is based other than as a dependent shall be determined before the benefits of a Plan which covers such person as a dependent;

(BB) Dependent Child/Parents Not separated or Divorced. Except as stated in § 1.10(A)(1)(c) ((4))((BB))((iii)) of this Part below, when this Plan and another Plan cover the same child as a dependent of different persons, called "parents":

(i) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later in that year; but

(ii) if both parents have the same birthday, the benefits of the Plan which covered the parent longer are determined before those of the Plan which covered the other parent for a shorter period of time.

(iii) However, if the other Plan does not have the rule described in § 1.10(A)(1)(c) ((4))((BB))((i)) of this Part immediately above but instead has a rule based upon the gender of the parents, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of benefits.

(CC) Dependent Child/Separated or Divorced Parents, If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order;

(i) first, the Plan of the parent with custody of the child;

(ii) then, the Plan of the spouse of the parent with the custody of the child; and

(iii) finally, the plan of the parent not having custody of the child.

(iv) However, 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 the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period of plan year during which any benefits are actually paid or provided before the entity has that actual knowledge

(DD) Active/Inactive Employee. 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) are 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 rule, and if, as a result, the Plans do not agree on the order of benefits, this rule § 1.10(A)(1)(c) ((4))((DD)) of this Part is ignored.

(EE) When rules § 1.10(A)(1)(c) ((4))(AA) and (BB) of this Part do not establish an order of benefits determination, the benefits of a Plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefit of a Plan which has covered such person the shorter period of time.

(FF) This amendment is effective immediately. However, it shall apply to all claims incurred on or after January 1, 1988.

(5) (Note: This item (5) may be omitted if the Plan provides only one benefit. The wording shown is illustrative.)

(AA) When this provision operates to reduce the total amount of benefits otherwise payable as to a person covered under this Plan during any Claim Determination period, each benefit that would be payable in the absence of this provision shall be reduced proportionately, and such reduced amount shall be charges against any applicable benefit limit of this Plan.

d. Right to Receive and Release Necessary Information

(1) For the purpose of determining the applicability of and implementing the terms of this provision of this Plan or any provision of similar purpose of any other Plan, the insurer may, without the consent of or notice to any person, release to or obtain from any other insurance company or other organization or person any information, with respect to any person, which the insurer deems to be necessary for such purposes. Any person claiming benefits under this Plan shall furnish to the insurer such information as may be necessary to implement this provision.

e. Facility of Payment

(1) Whenever payment which should have been made under this Plan is accordance with this provision have been made under any other Plans, the insurer shall have the right, exercisable alone and in its sole discretion, to pay over to any organizations making such other payments any amounts it shall determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be deemed to be benefits paid under this Plan and, to the extent of such payments, the insurer shall be fully discharged form liability under this Plan.

f. Right of Recovery

(1) Whenever payments have been made by the insurer with respect to Allowable Expenses in a total amount, in excess of the maximum amount or payment necessary at that time to satisfy the intent of this provision, the insurer shall have the right to recover such payments, to the extent of such excess, from among one or more of the following, as the insurer shall determine: any persons to or for or with respect to whom such payments were made, any other insurers, any other organizations.

230 R.I. Code R. 230-RICR-20-30-1.10