Miscellaneous Provisions

Section 2009 Section 2009.60  Miscellaneous Provisions a)         Reasonable Cash Values of Services A secondary plan that provides benefits in the form of services may recover the reasonable cash value of providing the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the primary plan. Nothing in this subsection shall be interpreted to require a plan to reimburse a covered person in cash for the value of services provided by a plan that provides benefits in the form of services. b)         Excess and Other Nonconforming Provisions 1)         Some plans have order of benefit determination standards not consistent with this Part that declare that the plan's coverage is "excess" to all others or "always secondary".  This occurs because certain plans may not be subject to insurance regulation, or because some group contracts have not yet been conformed with this Part pursuant to Section 2009.20. 2)         A plan with order of benefit determination standards that comply with this Part (complying plan) may coordinate its benefits with a plan that is "excess" or "always secondary" or that uses order of benefit determination standards that are inconsistent with those contained in this Part (noncomplying plan) on the following basis: A)        If the complying plan is the primary plan, it shall pay or provide its benefits on a primary basis; B)        If the complying plan is the secondary plan, it shall, nevertheless, pay or provide its benefits first, but the amount of the benefits payable shall be determined as if the complying plan were the secondary plan.  In such a situation, the payment shall be the limit of the complying plan's liability; C)        If the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within 60 days after it is requested to do so, the complying plan shall assume that the benefits of the noncomplying plan are identical to its own and shall pay its benefits accordingly.  However, the complying plan must adjust any payments it makes based on that assumption whenever information becomes available as to the actual benefits of the noncomplying plan; and D)        If the noncomplying plan reduces its benefits so that the employee, subscriber or member receives less in benefits than he or she would have received had the complying plan paid or provided its benefits as the secondary plan and the noncomplying plan paid or provided its benefits as the primary plan, and governing state law allows the right of subrogation set forth in subsection (d), the complying plan shall advance to or on behalf of the employee, subscriber or member an amount equal to the difference. However, in no event shall the complying plan advance more than the complying plan would have paid had it been the primary plan less any amount it previously paid.  In consideration of the advance, the complying plan shall be subrogated to all rights of the employee, subscriber or member against the noncomplying plan.  The advance by the complying plan shall also be without prejudice to any claim it may have against the noncomplying plan in the absence of subrogation. c)         Allowable Expense.  Terms such as "usual and customary", "usual and prevailing", "maximum allowable fee", "eligible expense", or "reasonable and customary" may be substituted for the term "necessary, reasonable and customary".  Terms such as "medical care" or "dental care" may be substituted for "health care" to describe the coverages to which the COB provisions apply. d)         Subrogation.  The COB concept clearly differs from that of traditional subrogation.  Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other.