18 Del. Admin. Code § 1307-5.0

Current through Register Vol. 28, No. 3, September 1, 2024

Section 1307-5.0 - Rules for Coordination of Benefits

5.1 The general order of benefits is as follows:

5.1.1 The Primary Plan must pay or provide its benefits as if the Secondary Plan or Plans did not exist. A Plan that does not include a coordination of benefits provision may not take the benefits of another Plan as defined in section 3.0 into account when it determines its benefits. There is one exception: a contract holder's coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder.

5.1.2 A Secondary Plan may take the benefits of another plan into account only when, under these rules, it is Secondary to that other plan.

5.1.3 The benefits of the plan which covers the person as an employee, member or subscriber (that is, other than a dependent) are determined before those of the plan which covers the person as a dependent.

5.2 The rules for the order of benefits for a dependent child when the parents are not separated or divorced are as follows:

5.2.1 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;

5.2.2 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;

5.2.3 The word "birthday" refers only to month and day in a calendar year, not the year in which the person was born;

5.2.4 A group contract which includes COB and which is issued or renewed, or which has an anniversary date on or after sixty days after the effective date of this subchapter shall include the substance of the provision in sections 5.2.1, 5.2.2, and 5.2.3 above. Until that provision becomes effective, the group contract may instead contain wording such as: "Except as stated in section 5.1.3, the benefits of a plan which covers the person as a dependent of a female."

5.2.5 If the other plan does not have the rule described in sections 5.2.1, 5.2.2, and 5.2.3 above but instead has a rule based upon the gender of the parent; and if, as a result, the plans do not agree on the order of benefits, the rule based upon the gender of the parent will determine the order of benefits.

5.3 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:

5.3.1 First, the plan of the parent with custody of the child;

5.3.2 Then, the plan of the spouse of the parent with the custody of the child; and

5.3.3 Finally, the plan of the parent not having custody of the child.

5.3.4 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. The plan of the other parent shall be the Secondary Plan. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge.

5.3.5 Upon request by either parent of a dependent child, a carrier subject to this Section 5.3 shall immediately issue an insurance card or, if it does not issue such cards to its policy holders, equivalent proof of applicable insurance for the dependent child to the parent making such request.

5.3.6 If benefits are not assigned and would be paid to an individual other than the provider, the carrier shall issue the benefits to the parent who sought the treatment for the dependent child.

5.4 The benefits of a plan that 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 is ignored.

5.5 If none of the above rules determines the order of benefits, the benefits of the plan which covered an employee, member or subscriber longer are determined before those of the plan which covered that person for the shorter term.

5.5.1 To determine the length of time a person has been covered under a plan, two plans shall be treated as one if the claimant was eligible under the second within twenty-four hours after the first ended.

5.5.2 The start of a new plan does not include:

5.5.2.1 a change in the amount of scope of a plan's benefits;

5.5.2.2 a change in the entity which pays, provides or administers the plan's benefits; or

5.5.2.3 a change from one type of plan to another (such as, from a single employer plan to that of a multiple employer plan).

5.5.3 The claimant's length of time covered under a plan is measured from the claimant's first date of coverage under that plan. If that date is not readily available, the date the claimant first became a member of the group shall be used as the date from which to determine the length of time the claimant's coverage under the present plan has been in force.

18 Del. Admin. Code § 1307-5.0

10 DE Reg. 1828 (06/01/07)