Section 760 IAC 1-38.1-7 - "Plan" definedAuthority: IC 27-1-3-7
Affected: IC 27-8-5-19
Sec. 7.
(a) As used in this rule, "plan" means a form of coverage with which coordination is allowed. Separate parts of a plan for members of a group that are: (1) provided through alternative contracts; and(2) intended to be part of a coordinated package of benefits; are considered one (1) plan, and there is no COB among the separate parts of the plan. If a plan coordinates benefits, the definition of plan in the group contract must state the types of coverage that will be considered in applying the coordination of benefits provision of that contract. The right to include a type of coverage is limited by subsections (b) through (d).
(b) This rule uses the term "plan". However, a group contract may instead use "program" or some other term.(c) A plan may include the following:(1) Group and nongroup insurance contracts and subscriber contracts.(2) Uninsured arrangements of group or group-type coverage.(3) Group or nongroup coverage through closed panel plans.(4) Group-type contracts.(5) The medical care components of long term care contracts, such as skilled nursing care.(6) The medical benefits coverage in: (A) automobile "no fault"; and(B) traditional automobile "fault"; type contracts.
(7) Medicare or other governmental benefits, except as provided in subsection (d)(7). That part of the definition of plan may be limited to the hospital, medical, and surgical benefits of the governmental program.(d) A plan shall not include the following: (1) Accident only coverage.(2) Specified disease or specified accident coverage.(3) Limited health benefit coverage.(4) Benefits provided in long term care insurance policies for either of the following: (A) Nonmedical services, such as the following:(iii) Homemaker services.(iv) Assistance with activities of daily living.(v) Respite care and custodial care.(B) Contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services.(5) Hospital indemnity coverage benefits or other fixed indemnity coverage.(6) School accident-type coverages covering grammar, high school, and college students for accidents only, including athletic injuries, either on a: (A) twenty-four (24) hour; or(B) "to and from school"; basis.
(7) A state plan under Medicaid or a government plan that, by law, provides benefits that are in excess of those of any:(A) private insurance plan; or(B) other nongovernmental plan.(8) Medicare supplement policies.Department of Insurance; 760 IAC 1-38.1-7; filed Feb 14, 1990, 3:30 p.m.: 13 IR 1170; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; filed Sep 15, 2006, 2:02 p.m.: 20061011-IR-760050265FRA; readopted filed Nov 21, 2012, 4:15 p.m.: 20121219-IR-760120454RFAReadopted filed Nov 13, 2018, 10:02 a.m.: 20181212-IR-760180372RFAReadopted filed 10/31/2024, 3:52 p.m.: 20241127-IR-760230814RFA