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6.6.2403    DEFINITIONS

(1) (a) A "plan" is a form of coverage with which coordination is allowed. The definition of plan in the group contract must state the types of coverage which will be considered in applying the COB provision of that contract. The right to include a type of coverage is limited by subsection(1) of ARM 6.6.2403.

(b) A group contract that includes a COB provision may use any definition of "plan" that is consistent with the definition of "plan" in these rules.

(c) These rules use the term "plan". However, a group contract may, instead, use "program" or some other term.

(d) Except as provided in subsections (e) and (f) below, "plan" does not mean individual or family:

(i) insurance contracts;

(ii) subscriber contracts;

(iii) coverage through health maintenance organizations (HMOs) ; or

(iv) coverage under other prepayment, group practice, and individual practice plans.

(e) "Plan" means:

(i) group insurance and group subscriber contracts;

(ii) uninsured arrangements of group or group-type coverage;

(iii) group or group-type coverage through HMOs and other prepayment, group practice, and individual practice plans; and

(iv) group-type contracts. Group-type contracts are contracts that are not available to the general public and may be obtained and maintained only because of membership in or connection with a particular organization or group. Group-type contracts may be included in the definition of plan, at the option of the insurer, the health service corporation, or the service provider and its contract-client, whether or not uninsured arrangements or individual contract forms are used and regardless of how the group-type coverage is designated (for example, "franchise" or "blanket") . The use of payroll deductions by the employee, subscriber, or member to pay for the coverage does not, of itself, make an individual contract part of a group-type plan. This description of group-type contracts is not intended to include individually underwritten and issued, guaranteed renewable policies that may be purchased through payroll deduction at a premium savings to the insured.

(f) "Plan" may mean the medical benefits coverage in group and group-type automobile contracts.

(g) "Plan" may mean medicare or other governmental benefits. That part of the definition of "plan" may be limited to the hospital, medical, and surgical benefits of the governmental program. However, "plan" may not mean a state plan under medicaid or a plan established by law if by law its benefits are excess to those of any private insurance plan or other non-governmental plan.

(h) "Plan":

(i) may not be construed to mean group or group-type hospital indemnity benefits of $100 per day or less; but

(ii) may be construed to mean the amount by which group or group-type hospital indemnity benefits exceed $100 per day. "Hospital indemnity benefits" are those benefits not related to expenses incurred. The term does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.

(i) "Plan" may not mean blanket accident-type only coverages or school accident-type coverages that cover grammar, high school, and college students for accidents only, including athletic injuries, either on a 24-hour basis or on a "to and from school" basis.

(2) (a) "This plan", in a COB provision, means the part of the group contract providing the health care benefits to which the COB provision applies and which may be reduced on account of the benefits of other plans. Any other part of the group contract providing health care benefits is separate from this plan.

(b) A group contract may apply one COB provision to certain of its benefits (such as dental benefits) , coordinating only with like benefits, and may apply other separate COB provisions to coordinate other benefits.

(3) "Primary plan" means a plan under which benefits for a person's health care coverage must be determined without taking the existence of any other plan into consideration. There may be more than one primary plan (for example, two plans that do not have order of benefit determination rules) . A plan is a primary plan if either:

(a) the plan has no order of benefit determination rules, or it has rules that differ from those permitted by these rules; or

(b) all plans that cover the person use the order of benefit determination rules required by these rules and under those rules the plan determines its benefits first.

(4) "Secondary plan" means a plan that is not a primary plan. If a person is covered by more than one secondary plan, the order of benefit determination rules of these rules decide the order in which their benefits are determined in relation to each other. The benefits of each secondary plan may take into consideration the benefits of the primary plan or plans and the benefits of any other plan that, under these rules, has its benefits determined before those of that secondary plan.

(5) (a) "Allowable expense" means a necessary, reasonable, and customary item of expense for health care, if the item of expense is covered at least in part under any of the plans involved, unless a statute requires a different definition. However, items of expense under coverages such as dental care, vision care, prescription drug, or hearing aid programs may be excluded from the definition of allowable expense. A plan that provides benefits only for any such items of expense may limit its definition of allowable expenses to like items of expense.

(b) If a plan provides benefits in the form of services, the reasonable cash value of each service is considered as both an allowable expense and benefit paid.

(c) The difference between the cost of a private hospital room and the cost of a semiprivate hospital room is not considered an allowable expense under the above definition unless the patient's stay in a private hospital room is medically necessary in terms of generally accepted medical practice.

(d) If COB is restricted in its use to specific coverage in a contract (for example, major medical or dental) , the definition of "allowable expense" must include the corresponding expenses or services to which COB applies.

(6) "Claim" means a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of:

(a) services (including supplies) ;

(b) payment for all or a portion of the expenses incurred;

(c) a combination of (a) and (b) above; or

(d) an indemnification.

(7) "Claim determination period" means:

(a) The period of time, which must not be less than 12 consecutive months, over which allowable expenses are compared with total benefits payable in the absence of COB to determine:

(i) whether overinsurance exists; and

(ii) how much each plan will pay or provide. The claim determination period usually is a calendar year, but a plan may use some other period of time that fits the coverage of the group contract. A person may be covered by a plan during a portion of a claim determination period if that person's coverage starts or ends during the claim determination period.

(b) As each claim is submitted, each plan must determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. But that determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.

History: Sec. 33-1-313 MCA; IMP, Sec. 33-15-304(3), 33-18-201(6), and 33-22-502(2) MCA; NEW, 1987 MAR p. 1766, Eff. 10/16/87.

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