Ill. Admin. Code tit. 80 § 2210.530

Current through Register Vol. 48, No. 52, December 27, 2024

Section 2210.530 - Coordination of Benefits

a) If a Member or Dependent is entitled to receive primary benefits through a group medical, dental, or vision plan other than the Program, the benefits payable by the Program may be reduced to the extent that the total payment provided by all plans does not exceed the total allowable expense incurred for the service.

b) The Program shall coordinate benefits with the following types of coverage:

1) Any group insurance plan;

2) Medicare;

3) Any Veterans' Administration plan; and

4) A motor vehicle plan required by law which provides medical or dental payments, in whole or in part, without regard to fault.

c) The Program will not coordinate benefits with the following types of coverage:

1) Private individual insurance plans;

2) Any student insurance policy;

3) Medicaid, or any other State-sponsored insurance program; and

4) TRICARE.

d) Members and Dependents must notify the Agency of enrollment in Medicare insurance benefits.

e) Members and Dependents shall promptly report to the Agency any changes to other insurance coverage.

f) Order of Benefit Determination.

1) The Program shall coordinate benefits with other available insurance in accordance with model regulations issued by the National Association of Insurance Commissioners (available at https://content.naic.org/sites/default/files/model-law-120.pdf). Coordination of benefits with Medicare shall be in accordance with Medicare Secondary Payer guidelines issued by the federal Centers for Medicare & Medicaid Services (available at https://www.medicare.gov/sites/default/files/2021-10/02179-Medicare-and-other-health-benefits-your-guide-to-who-pays-first.pdf).

2) The Agency shall provide notice of the methodology for coordination of benefits through incorporation into the Benefits Handbook available to Members.

Ill. Admin. Code tit. 80, § 2210.530

Added at 47 Ill. Reg. 5329, effective 4/3/2023