Section R590-131-6 - Determining Order of Benefits The order of benefits for each plan is determined using the first rule that applies in this section.
(1) Non-dependent or Dependent Rule. The plan covering an enrollee as a non-dependent, such as an employee, member, policyholder, or retiree, is the primary plan and the plan covering the enrollee as a dependent is the secondary plan.
(2) Child Covered Under More Than One Plan Rule. A plan covering a child shall determine the order of benefits as follows, unless there is a court order stating otherwise.
(a) For a child whose parents are married or whose parents are living together if they have never been married: (i) the plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or(ii) if both parents have the same birthday, the plan that has covered the parent the longest is the primary plan.(b) For a child whose parents are divorced, legally separated, or are not living together if they have never been married:(i)(A) if a court order states that one of the parents is responsible for the child's health care expenses or health care coverage, the responsible parent's plan is the primary plan; or(B) if the parent responsible for the child's health care expenses or health care coverage does not have health care coverage for the child, but the responsible parent's spouse has health care coverage for the child, the responsible parent's spouse's plan is the primary plan;(ii) if a court order states that both parents are responsible for the child's health care expenses or health care coverage, Subsection (2)(a) applies;(iii) if a court order states that the parents have joint custody without stating that one parent has responsibility for the health care expenses or health care coverage of the child, Subsection (2)(a) applies; and(iv) if no court order allocates responsibility for the child's health care expenses or health care coverage, the order of benefits for the child is: (A) the plan covering the custodial parent;(B) the plan covering the custodial parent's spouse;(C) the plan covering the non-custodial parent; and then(D) the plan covering the non-custodial parent's spouse. (c) If a plan provides coverage for a child through an individual who is not a parent of the child, the order of benefits is determined under Subsections (2)(a) and (2)(b) as if the individual is the child's parent.(3) Active, Retired, or Laid-Off Employee Rule. (a)(i) A plan covering an active employee who is not laid-off, retired, or a dependent of an active employee, is the primary plan .(ii) A plan covering a retired employee or a laid-off employee, or a dependent of a retired employee or laid-off employee, is the secondary plan. (b) Subsection (3) does not apply if: (i) the other plan does not have an active, retired, or laid-off rule and the plans do not agree on the order of benefits; or (ii) Subsection (1) determines the order of benefits.(4) Continuation of Coverage Rule. (a) If an enrollee is covered under a continuation of coverage law and another plan, the plan under a continuation of coverage law is the secondary plan. (b) Subsection (4)(a) does not apply if: (i) the other plan does not have a continuation of coverage rule and the plans do not agree on the order of benefits; or(ii) Subsection (1) determines the order of benefits.(5) Longer or Shorter Length of Coverage Rule.(a) If Subsections (1) through (4) do not determine the order of benefits;(i) the plan covering an enrollee for the longest time period is the primary plan; and(ii) the plan covering an enrollee for the shortest time period is the secondary plan.(b)(i) To determine the length of time an enrollee is covered under a plan, two successive plans are treated as one if the enrollee was eligible under the second plan within 24 hours after coverage under the first plan ended.(ii) The start of a new plan does not include:(A) a change in the amount or scope of a plan's benefits;(B) a change in the entity that pays, provides, or administers the plan's benefits; or(C) a change from one type of plan to another, such as from a single employer plan to a multiple employer plan.(iii)(A) The time an enrollee is covered under a plan is measured from the enrollee's first date of coverage under that plan. (B) If the date in Subsection (5)(b)(iii)(A) is not readily available, the date the enrollee first became a member of the group will determine the length of time the enrollee is covered under a plan.(6) If Subsections (1) through (5) cannot determine the primary plan, the plans shall equally share the allowable expense.(7)(a) If the plans cannot agree on the order of benefits within 30 calendar days after the plans have received the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities following payment.(b) A plan is not required to pay more than it would have paid as a primary plan.Utah Admin. Code R590-131-6
Amended by Utah State Bulletin Number 2020-15, effective 7/22/2020Amended by Utah State Bulletin Number 2022-17, effective 8/22/2022