Minn. R. agency 120, ch. 2742, pt. 2742.0200
For the purposes of parts 2742.0100 to 2742.0400, the terms in this part have the meanings given them.
"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 coordination of benefits provision of that contract. The right to include a type of coverage is limited by the rest of this subpart.
The definition in part 2742.0300 is an example of what may be used. Any definition that satisfies this subpart may be used.
Parts 2742.0100 to 2742.0400 use the term "plan." However, a group contract may, instead, use "program" or some other term.
The term "plan" does not include individual or family:
"Plan" includes: group insurance and group subscriber contracts; uninsured arrangements of group or group-type coverage; group or group-type coverage through health maintenance organizations and other prepayment, group practice, and individual practice plans; and group-type contracts.
Group-type contracts are contracts which are not available to the general public and can be obtained and maintained only because of membership in or connection with a particular organization or group. Group-type contracts answering this description may be included in the definition of plan, at the option of the insurer 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 is not sufficient, of itself, to 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.
"Plan" may include the medical benefits coverage in group, group-type, and individual automobile "no-fault" and traditional automobile "fault" type contracts.
"Plan" may include 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" shall not include a state plan under Medicaid, and shall not include a law or plan when, by law, its benefits are excess to those of any private insurance plan or other nongovernmental plan.
The term "plan" shall not be construed to include group or group-type hospital indemnity benefits of $100 per day or less, but may be construed to include the amount by which group or group-type hospital indemnity benefits exceed $100 per day.
"Plan" shall not include school accident-type coverages. These 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.
"Hospital indemnity benefits" are those 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.
In a coordination of benefits provision, this term refers to the part of the group contract providing the health care benefits to which the coordination of benefits 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."
A group contract may apply one coordination of benefits provision to certain of its benefits (such as dental benefits), coordinating only with like benefits, and may apply other separate coordination of benefits provisions to coordinate other benefits.
A primary plan is one whose benefits for a person's health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if either item A or B is true.
There may be more than one primary plan (for example, two plans which have no order of benefit determination rules).
A secondary plan is one which is not a primary plan. If a person is covered by more than one secondary plan, the order of benefit determination rules of parts 2742.0100 to 2742.0400 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 which, under parts 2742.0100 to 2742.0400, has its benefits determined before those of that secondary plan.
"Allowable expense" is the necessary, reasonable, and customary item of expense for health care, when the item of expense is covered at least in part under any of the plans involved, except where a statute requires a different definition. However, items of expense under coverages such as dental care, vision care, prescription drugs, or hearing aid programs may be excluded from the definition of allowable expense. A plan which provides benefits only for any items of expense may limit its definition of allowable expenses to like items of expense.
When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid.
When coordination of benefits is restricted in its use to a 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 coordination of benefits applies.
"Claim" means a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of services, (including supplies); payment for all or a portion of the expenses incurred; a combination of services and payment for expenses incurred; or an indemnification.
"Claim determination period" means a 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 coordination of benefits, to determine whether overinsurance exists; and how much each plan will pay or provide. Claim determination period does not mean the period of time in which a plan may take to pay.
A 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 that claim determination period.
As each claim is submitted, each plan is to determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. A determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.
Minn. R. agency 120, ch. 2742, pt. 2742.0200
Statutory Authority: MS s 45.023; 72A.19