Coordination WAC A governmental plan, which, by law, provides benefits that are in of Benefits excess of those of any private insurance plan or other (Cont’d) nongovernmental plan; Definition of WAC Automobile insurance policies required by statute to provide “Plan” for medical benefits; purposes of WAC Benefits provided as part of a direct agreement with a direct COB patient-provider primary care practice as defined at section 3, (Cont’d) chapter 267, Laws of 2007. WAC If a person has met the requirements for coverage under the primary Contract 284-51-200(7) plan, a closed panel plan in secondary position must pay benefits as Description of if the covered person had met the requirements of the closed panel COB plan. COB may occur during the claim determination period even where there are no savings in the closed panel plan. WAC "Closed panel plan" means a plan that provides benefits in the form 284-51-195(5) of services primarily through providers employed by the plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member. WAC The definition of “allowable expense” should be clear that when coordinating benefits, any secondary plans must pay an amount which, together with the payment made by the primary plan, cannot be less than the allowable expense the secondary plan would have paid if it was primary. A secondary plan must not be required to pay an amount in excess of its maximum benefit plus accrued savings. Rules for WAC Contract may not contain any provisions that are inconsistent with or Coordination 284-51-205(1)(a) less favorable than COB rules: of Benefits The primary plan must provide benefits as if the secondary plan did not exist. A plan may only take into consideration benefits provided by another plan when it is secondary to that other plan.
Coordination of Benefits (Cont’d) WAC A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other nongovernmental plan; Definition of “Plan” for purposes of COB (Cont’d) WAC Automobile insurance policies required by statute to provide medical benefits; WAC Benefits provided as part of a direct agreement with a direct patient-provider primary care practice as defined at section 3, chapter 267, Laws of 2007. Contract Description of COB WAC 284-51-200(7) If a person has met the requirements for coverage under the primary plan, a closed panel plan in secondary position must pay benefits as if the covered person had met the requirements of the closed panel plan. COB may occur during the claim determination period even where there are no savings in the closed panel plan. WAC 284-51-195(5) "Closed panel plan" means a plan that provides benefits in the form of services primarily through providers employed by the plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member. WAC The definition of “allowable expense” should be clear that when coordinating benefits, any secondary plans must pay an amount which, together with the payment made by the primary plan, cannot be less than the allowable expense the secondary plan would have paid if it was primary. A secondary plan must not be required to pay an amount in excess of its maximum benefit plus accrued savings. Rules for Coordination of Benefits WAC 284-51-205(1)(a) Contract may not contain any provisions that are inconsistent with or less favorable than COB rules: The primary plan must provide benefits as if the secondary plan did not exist. A plan may only take into consideration benefits provided by another plan when it is secondary to that other plan.
cl-forms-19-hcsc-sg-analyst-checklist.docx