Wyo. Code R. 044-0002-10
General Agency, Board or Commission Rules
Chapter 10: Coordination of Benefits
Effective Date: 09/13/2023 to Current
Rule Type: Current Rules & Regulations
Reference Number: 044.0002.10.09132023
(a) These regulations are promulgated pursuant to W.S. §§ 26-2-110, 26-18-121, and 26-19-101, et seq.
(a) "Plan" means any plan providing benefits or services for or on account of medical or dental care or treatment.
(i) "Plan" includes:
(E) Medicare or other governmental benefits, as permitted by law, except as provided in Paragraph (ii)(H) of this Subsection. That part of the definition of plan may be limited to the hospital, medical, and surgical benefits of the governmental program; and
(F) Group and non-group insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care.
(ii) "Plan" does not include:
(E) School accident-type coverages that cover students for accidents only, including athletic injuries, either on a twenty-four-hour basis or on a "to and from school" basis;
(F) Benefits provided in long-term care insurance policies for non-medical services; for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services;
(G) Medicare supplement policies;
(H) A state plan under Medicaid; or
(I) A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan.
(b) The term 'Plan' shall be construed separately with respect to each policy, contract, or other arrangement for benefits or services and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the right to take the benefits or services of other plans into consideration in determining its benefits and that portion which does not.
(c) The definition of a 'Plan' within the Coordination of Benefits provision of a group contract shall enumerate the types of coverage which the insurer may consider in determining whether overinsurance exists with respect to a specific claim. Such definition:
(i) Shall not include individual or family policies, or individual or family subscriber contracts, except as provided in this Subsection.
(ii) May include all group policies or group subscriber contracts as well as such group-type contracts as are not available to the general public and can be obtained and maintained only because of the covered person's membership in or connection with a particular organization or group. Such group-type contracts may be included in the definition, at the option of the insurer, whether or not individual policy forms are utilized and whether the group-type coverage is designated as 'franchise' or 'blanket' or in some other fashion.
(iii) Shall not include group or group-type hospital indemnity benefits written on a non-expense incurred basis unless they are characterized as reimbursement type benefits and are designed or administered so as to give the insured the right to elect indemnity type benefits, in lieu of such reimbursement type benefits, at the time of claim.
(iv) School accident type coverages written on either an individual, group, blanket, or franchise basis shall not be taken into consideration in coordination of benefits.
(v) If 'Medicare' or similar governmental benefits are included in the definition of a 'Plan,' such benefits shall be considered without expanding any of the definitions of this provision beyond the hospital, medical, and surgical benefits as may be provided by the governmental program.
(vi) A plan may not coordinate or design benefits so that the benefits payable are altered solely on the basis that:
(A) another plan exists; or
(B) the claimant is or could have been covered under another plan; or
(C) the claimant has elected an option under another plan providing a lower level of benefits than another option for which the claimant was eligible.
(vii) Shall not include any policy providing coverage for a specified disease.
(d) 'Allowable Expense' means any necessary, reasonable and customary item of expense at least a portion of which is covered under at least one of the plans covering the person for whom claim is made.
(e) When a plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered shall be deemed to be both an allowable expense and a benefit paid.
Section 3. Order of Benefit Determination. Each plan determines its order of benefits using the first of the following rules that applies:
(a) Non-Dependent or Dependent
(i) Subject to Subparagraph (A) of this paragraph, the plan that covers the person other than as a dependent, for example as an employee, member, subscriber, policyholder or retiree, is the primary plan and the plan that covers the person as a dependent is the secondary plan.
(A) If the person is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is:
(I) Secondary to the plan covering the person as a dependent; and
(II) Primary to the plan covering the person as other than a dependent (e.g. a retired employee),
(B) Then the order of benefits is reversed so that the plan covering the person as an employee, member, subscriber, policyholder or retiree is the secondary plan and the other plan covering the person as a dependent is the primary plan.
(b) Dependent Child Covered Under More Than One Plan
(i) Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:
(A) For a dependent child whose parents are married or are living together, whether or not they have ever 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 a parent longest is the primary plan.
(B) For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:
(I) If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no health care coverage for the dependent child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the primary plan. This item shall not apply with respect to any plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;
(II) If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of Subparagraph (A) of this paragraph shall determine the order of benefits;
(III) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of Subparagraph (A) of this paragraph shall determine the order of benefits; or
(IV) If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows:
(1.) The plan covering the custodial parent; (2.) The plan covering the custodial parent's spouse; (3.) The plan covering the non-custodial parent; and (4.) The plan covering the non-custodial parent's
then
spouse.
(C) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under Subparagraph (A) or (B) of this paragraph as if those individuals were parents of the child.
(D) For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the rule in subsection (e) applies.
(E) In the event the dependent child's coverage under the spouse's plan began on the same date as the dependent child's coverage under either or both parents' plans, the order of benefits shall be determined by applying the birthday rule in Subparagraph (A) of this paragraph to the dependent child's parent(s) and the dependent's spouse.
(i) The plan that covers a person as an active employee – meaning an employee who is neither laid off nor retired or as a dependent of an active employee – is the primary plan. The plan covering that same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee is the secondary plan.
(ii) If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored.
(iii) This rule does not apply if the rule in Subsection (a) of this Section can determine the order of benefits.
(i) If a person whose coverage is provided pursuant to COBRA or under a right of continuation pursuant to state or other federal law is covered under another plan, the plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber or retiree is the primary plan and the plan covering that same person pursuant to COBRA or under a right of continuation pursuant to state or other federal law is the secondary plan.
(ii) If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.
(iii) This rule does not apply if the rule in Subsection (a) of this Section can determine the order of benefits.
(i) If the preceding rules do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan.
(ii) To determine the length of time a person has been covered under a plan, two successive plans shall be treated as one if the covered person was eligible under the second plan within twenty-four (24) hours after coverage under the first plan ended.
(iii) 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.
(iv) The person’s length of time covered under a plan is measured from the person’s first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group shall be used as the date from which to determine the length of time the person’s coverage under the present plan has been in force.
(f) If none of the preceding rules determines the order of benefits, the allowable expenses shall be shared equally between the plans.
(g) If none of the preceding rules determines the order of benefits, the allowable expenses shall be shared equally between the plans. If the plans cannot agree on the order of benefits within forty-five (45) calendar days after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities following payment, except that no plan shall be required to pay more than it would have paid had it been the primary plan.
In determining the amount to be paid by the secondary plan on a claim, should the plan wish to coordinate benefits, the secondary plan shall calculate the benefits it would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed 100 percent of the total allowable expense for that claim. In addition, the secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.
Whenever payments for allowable expenses have been made by an insurer in excess of the maximum amount required by its contract requirements, the insurer shall have the right to recover excess payments as the insurer shall determine from among: any person to whom payments were made, any other insurers, or any other organizations. Coordination of Benefits differs from subrogation. Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other.
A plan shall, in its explanation of benefits provided to covered persons, include the following language: 'If you are covered by more than one health benefit plan, you should file all your claims with each plan.'
This regulation shall become effective upon filing with the Secretary of State. All policy and contract forms subject to this regulation which were issued prior to its effective date shall be brought into compliance with the requirements of this regulation at the next anniversary date or renewal date of the group policy or contract.