Title 58 — INSURANCE

Terms used in this chapter mean: (1) "Birthday," refers only to a month and day in a calendar year and does not include the year in which the person was born; (2) "Claim," a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of: (a) Servi…

For the purposes of this chapter, the term, allowable expense, means any health care expense, including coinsurance or copayments and without reduction for any applicable deductible, that is covered in full or in part by any of the plans covering the person. If a plan is advised …

The following are examples of expenses that are not allowable expenses: (1) If a person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the private room is not an allowable expense, unless one of the plans provide…

For the purposes of this chapter, the term, allowable expense, may exclude certain types of coverage or benefits such as dental care, vision care, prescription drugs, or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definit…

For the purposes of this chapter, the term, plan, means a form of coverage with which coordination is allowed. Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are con…

For the purposes of this chapter, the term, plan, includes: (1) Group and nongroup insurance contracts and subscriber contracts; (2) Uninsured arrangements of group or group-type coverage; (3) Group and nongroup coverage through closed panel plans; (4) Group-type contracts; (5) T…

For the purposes of this chapter, the term, plan, does not include: (1) Hospital indemnity coverage benefits or other fixed indemnity coverage; (2) Accident only coverage; (3) Specified disease or specified accident coverage; (4) Limited benefit health coverage; (5) School accide…

Sections 58-18A-53 to 58-18A-83 , inclusive, apply to all plans that are issued on or after January 1, 2007. Source: SL 2006, ch 259 , § 8.

The director shall promulgate rules pursuant to chapter 1-26 to carry out the provisions of §§ 58-18A-53 to 58-18A-83 , inclusive. In promulgating any rules, the director shall give great weight to any national standards that may exist for the coordination of benefits for plans. …

No COB provision may be used that permits a plan to reduce its benefits on the basis that: (1) Another plan exists and the covered person did not enroll in that plan; (2) A person is or could have been covered under another plan, except with respect to Part B of Medicare; or (3) …

No plan may contain a provision that its benefits are always excess or always secondary except in accordance with the rules permitted by §§ 58-18A-53 to 58-18A-83 , inclusive. No plan is required to coordinate benefits provided that it pays benefits as a primary plan; but if the …

Under the terms of a closed panel plan, no benefits are payable if the covered person does not use the services of a closed panel provider. No COB occurs if a covered person is enrolled in two or more closed panel plans and obtains services from a provider in one of the closed pa…

No plan may use a COB provision, or any other provision, that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of a plan as provided by §§ 58-18A-53 to 58-18A-83 , inclusive. Source: SL 2006, ch 259 , § 13.

If a person is covered by two or more plans, the provisions for determining the order of benefit payments are as follows: (1) The primary plan shall pay or provide its benefits as if any secondary plan did not exist; (2) If the primary plan is a closed panel plan and the secondar…

A plan may take into consideration the benefits paid or provided by another plan only if, under the provisions of §§ 58-18A-53 to 58-18A-83 , inclusive, it is secondary to that other plan. Source: SL 2006, ch 259 , § 15.

Order of benefits determined under §§ 58-18A-69 to

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. However, if the person is a medicare beneficiary, and…

Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows: (1) For a dependent child whose parents are married or are living together, whether or not they have ever been married: (a) The plan of the parent …

The plan that covers a person as an active employee that is, 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-of…

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 …

If the preceding provisions in §§ 58-18A-69 to 58-18A-72 , inclusive, 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 pl…

If the preceding provisions of §§ 58-18A-69 to 58-18A-73 , inclusive, do not determine the order of benefits, the allowable expenses shall be shared equally between the plans. Source: SL 2006, ch 259 , § 22.

In determining the amount to be paid by the secondary plan on a claim, if the plan wishes 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 a…

A secondary plan that provides benefits in the form of services may recover the reasonable cash value of the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the primary plan…

A plan with order of benefit determination provisions that comply with §§ 58-18A-53 to 58-18A-83 , inclusive, may coordinate its benefits with a plan that is excess or always secondary or that uses order of benefit determination provisions that are inconsistent with those contain…

If the noncomplying plan reduces its benefits so that the covered person receives less in benefits than the covered person would have received had the complying plan paid or provided its benefits as the secondary plan and the noncomplying plan paid or provided its benefits as the…

COB differs from subrogation. Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other. Source: SL 2006, ch 259 , § 27.

If the plans cannot agree on the order of benefits within thirty 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. Howev…

A contract that provides health care benefits and that was issued before July 1, 2006, shall be brought into compliance with §§ 58-18A-53 to 58-18A-83 , inclusive, by the later of: (1) The next anniversary date or renewal date of the contract; (2) Twelve months following July 1, …

Sections 58-18A-53 to 58-18A-83 , inclusive, do not affect an action or proceeding commenced before July 1, 2006. Source: SL 2006, ch 259 , § 30.

Sections 58-18A-53 to 58-18A-83 , inclusive, do not impair or affect any duty or act done, offense committed or right accruing, accrued or acquired or liability, penalty, forfeiture or punishment incurred prior to the date on or after July 1, 2007, but the same may be employed, a…