Section R590-131-8 - Miscellaneous Provisions(1) Reasonable Cash Value of Services.(a) A secondary plan that provides a benefit in the form of a service may recover the reasonable cash value of providing the service from the primary plan, if the service is covered by the primary plan and has not been paid or provided by the primary plan.(b) Nothing in this Subsection may be interpreted to require a plan to reimburse an enrollee the cash value of a service provided by a plan that provides a benefit in the form of a service.(2) Excess and Other Provisions.(a) Except as provided in Subsection (2)(b), a conforming plan may not contain a provision that the plan benefits are excess or always secondary to any other plan or policy.(b) A b lanket accident-only plan may contain a provision that its benefits are excess or always secondary to any other plan.(3) Non-conforming Plan. (a) A conforming plan may coordinate benefits with a non-conforming plan.(i) If the conforming plan is the primary plan, it shall pay or provide its benefits as the primary plan;(ii) If the conforming plan is the secondary plan, it shall pay or provide its benefits as the secondary plan, and the payment shall be the limit of the conforming plan's liability.(iii) If the non-conforming plan does not provide the information needed by the conforming plan to determine its benefits within a reasonable time after it is requested to do so, the conforming plan shall assume that the benefits of the non-conforming plan are identical to its own and shall pay its benefits accordingly.(iv) If the conforming plan receives information as to the actual benefits of the non-conforming plan, it may adjust any payments in compliance with Subsection 31A-26-301.6(14)(a)(ii).(b)(i) If a non-conforming plan reduces its benefits so that the enrollee receives less in benefits than the enrollee would have received had the conforming plan paid or provided its benefits as the secondary plan, and the non-conforming plan paid or provided its benefits as the primary plan, then the conforming plan shall advance to the enrollee, or on behalf of the enrollee, an amount equal to the difference.(ii) In no event shall the conforming plan advance more than the conforming plan would have paid had it been the primary plan, less any amount it had previously paid.(iii) In consideration of an advance, the conforming plan shall be subrogated to all rights of the covered person against the non-conforming plan in the absence of subrogation. (iv) An advance by the conforming plan shall be without prejudice to any claim it may have against a non-conforming plan in the absence of subrogation. (4) Subrogation. COB differs from subrogation. Provisions for either COB or subrogation may be included in a contract without compelling the inclusion or exclusion of the other.
(5) Right To Receive and Release Needed Information. (a) An insurer may obtain or give needed information to another person without obtaining consent from an enrollee. (b) To facilitate cooperation with insurers, guidelines for medical privacy issues are provided under Rule R590-206, Privacy of Consumer Financial and Health Information Rule, and Gramm-Leach-Bliley Act of 1999, 15 U.S.C. 6801 et. seq.(c) Each enrollee claiming benefits under a plan shall give the insurer any information necessary to pay the claim.(6) Right of Recovery.(a) If an insurer is paid more than required under this rule, subject to Section 31A-26-301.6, the insurer may recover the overpayment from one or more of the following: (iv) another organization.(b) The insurer is responsible for adjustments between insurers and providers. (7) Notice to Enrollee. The explanation of benefits provided to an enrollee shall include, "If you are covered by more than one health benefit plan, you should file all your claims with each plan."(8) If covered benefits are due to a loss under Section 31A-22-306, an accident and health insurer may exclude benefits covered by personal injury protection described in Subsection 31A-22-307(1)(a), up to :(a) the personal injury protection benefit provided by motor vehicle insurance; or(b) if motor vehicle insurance is not in effect, the minimum amount provided in Subsection 31A-22-307(1)(a).(9) Facility of Payment. (a) If a plan pays an amount that should have been paid under an insurer's plan, the insurer may pay that amount to the other plan.(b) The amount the insurer pays to the other plan is treated as a benefit paid under the plan and the insurer will not have to pay that amount again.Utah Admin. Code R590-131-8
Amended by Utah State Bulletin Number 2020-15, effective 7/22/2020Amended by Utah State Bulletin Number 2022-17, effective 8/22/2022