This section shall indicate the carrier responsible for liability in those instances in which one carrier’s policy or certificate replaces a plan of similar benefits of another carrier.

1. (a) After discontinuance of the policy or certificate, the prior carrier remains liable only to the extent of its accrued liabilities and extensions of benefits. The position of the prior carrier shall be the same whether the group policyholder or other entity secures replacement coverage from a new carrier, self-insures, or foregoes the provision of coverage.

2. (b) If the individual was validly covered under the prior plan on the date of discontinuance, each individual who is eligible for coverage in accordance with the succeeding carrier’s plan of benefits with respect to the class or classes of individuals eligible for coverage under the succeeding carrier’s plan shall be enrolled and covered by the succeeding carrier’s plan of benefits as follows:

   1. (1) Each person not covered under the succeeding carrier’s plan of benefits in accordance with the above shall nevertheless be covered by the succeeding carrier in accordance with the following rules if the individual was validly covered, including benefit extension, under the prior plan on the date of discontinuance and if the individual is a member of the class or classes of individuals eligible for coverage under the succeeding carrier’s plan. Any reference in the following rules to an individual who was or was not totally disabled is a reference to the individual’s status immediately prior to the date the succeeding carrier’s coverage becomes effective, and:

      1. a. The minimum level of benefits to be provided by the succeeding carrier shall be the applicable level of benefits of the prior carrier’s plan reduced by any benefits payable by the prior plan;

      2. b. Coverage shall be provided by the succeeding carrier on the earliest of the following dates:

         1. 1. The date the individual becomes eligible under the succeeding carrier’s plan as

            described in Ins 6101.05(b);

         2. 2. For each type of coverage, the date the individual’s coverage would terminate in accordance with the succeeding carrier’s plan provisions applicable to individual termination of coverage such as at termination of employment or ceasing to be an eligible dependent; or
         3. 3. In the case of an individual who was totally disabled, and in the case of a type of coverage for which Ins 6101.04 requires an extension of benefits or accrued liability, the end of any period of extension or accrued liability that is required of the prior carrier by Ins 6101.04 or, if the prior carrier’s policy, contract, or certificate is not subject to that section but would have been required of the prior carrier had the policy, contract, or certificate been subject to Ins 6101.04 at the time the prior carrier’s plan was discontinued and replaced by the succeeding carrier’s plan;

   2. (2) In the case of a preexisting conditions limitation included in the succeeding carrier’s plan, the level of benefits applicable to preexisting conditions of individuals becoming covered by the succeeding carrier’s plan in accordance with this paragraph during the period of time this limitation applies under the new plan shall be the lesser of:

      1. a. The benefits of the new plan determined without application of the preexisting conditions limitations; or
      2. b. The benefits of the prior plan;
   3. (3) The succeeding carrier, in applying any deductibles or coinsurance amounts applicable to the out-of-pocket maximum or waiting periods in its plan, shall give credit for the satisfaction or partial satisfaction of the same or similar provisions under a prior plan providing similar benefits. In the case of deductible provisions or coinsurance amounts applicable to the out-of-pocket maximums, the credit shall apply for the same or overlapping benefit periods and shall be given for expenses actually incurred and applied against the deductible or coinsurance provisions of the prior carrier’s plan during the 90 days preceding the effective date of the succeeding carrier’s plan but only to the extent these expenses are recognized under the terms of the succeeding carrier’s plan and are subject to a similar deductible or coinsurance provision; and

   4. (4) In any situation where a determination of the prior carrier’s benefit is required by the

      succeeding carrier, at the succeeding carrier’s request, the prior carrier shall furnish a statement

      of the benefits available or pertinent information sufficient to permit verification of the benefit determination or the determination itself by the succeeding carrier. For the purposes of this subparagraph, benefits of the prior plan shall be determined in accordance with all of the definitions, conditions, and covered expense provisions of the prior plan rather than those of the succeeding plan. The benefit determination shall be made as if coverage had not been replaced by the succeeding carrier.

Source. (See Revision Note #1 at chapter heading for Ins 6100) #12471, eff 1-31-18