W. Va. Code R. § 114-28-3

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-28-3 - Model COB Contract Provision

3.1. Appendix A contains a model COB provision for use in contracts. That use is subject to the provisions of subsections 3.2, 3.3 and 3.4 of this section and to the provisions of Section 5 of this rule.

3.2. Appendix B is a plain language description of the COB process that explains to the covered person how health plans will implement coordination of benefits. It is not intended to replace or change the provisions that are set forth in the contract. Its purpose is to explain the process by which the two (2) or more plans will pay for or provide benefits.

3.3. The COB provision contained in Appendix A and the plain language explanation in Appendix B do not have to use the specific words and format shown in Appendix A or Appendix B. Changes may be made to fit the language and style of the rest of the group contract or to reflect the difference among plans which provide services, which pay benefits for expenses incurred, and which indemnify. No other substantive changes are allowed.

3.4. A COB provision may not be used that permits a plan to reduce its benefits on the basis that:

3.4.a. Another plan exists and the covered person did not enroll in that plan;

3.4.b. A person is or could have been covered under another plan, except with respect to Part B of Medicare; or

3.4.c. A person has elected an option under another plan providing a lower level of benefits than another option which could have been elected.

3.5. No plan may contain a provision that its benefits are "always excess" or "always secondary" except in accordance with this rule.

3.6. Under the terms of a closed panel plan, benefits are not payable if the covered person does not use the services of a closed panel provider. In most instances, COB does not occur if a covered person is enrolled in two (2) or more closed panel plans and obtains services from a provider in one of the closed panel plans because the other closed panel plan (the one whose providers were not used) has no liability. However, COB may occur during the plan year when the covered person receives emergency services that would have been covered by both plans. Then the secondary plan shall use the provisions of section 7 of this rule to determine the amount it should pay for the benefit.

3.7. No plan may use a COB provision, or any other provision that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of plan under subdivision c, subsection 2.11 of this rule.

W. Va. Code R. § 114-28-3