State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_135 > GS_135-45_14

§ 135‑45.14. Coordination of benefits.

(a)        Benefits Subject toThis Provision. – All of the benefits provided under this Comprehensive MajorMedical Plan.

(b)        Definitions. –

(1)        "Plan"means any Plan providing benefits or services for or by reason of medical ordental care or treatment, which benefits or services are provided by (i) group,blanket or franchise insured or uninsured coverage, (ii) hospital servicesprepayment Plan on a group basis, medical service prepayment Plan on a groupbasis, group practice, or other prepayment coverage on a group basis, (iii) anycoverage under labor‑management trusteed plans, union welfare plans,employer organization plans, or employee benefit organization plans, and (iv)any coverage under governmental programs except Medicare, or any coveragerequired or provided by any statute, which coverage is not otherwise excludedfrom the calculation of benefits under this Plan, but the term "Plan"shall not include any individual policies.

Theterm "Plan" shall be construed separately with respect to eachpolicy, contract, or other arrangement for benefits or services and separatelywith respect to that portion of any such policy, contract, or other arrangementwhich reserves the right to take the benefits or services of other plans intoconsideration in determining its benefits and that portion which does not.

(2)        "Coveredservices" means any necessary, reasonable and customary item of expense atleast a portion of which is covered under at least one of the plans coveringthe person for whom claim is made. To the extent legally possible, it shall besynonymous with allowable expenses. When a Plan provides benefits in the formof services rather than cash payments, the reasonable cash value of eachservice rendered shall be deemed to be both an allowable expense and a benefitpaid.

(3)        "Claimdetermination period" means any period of time during which a personcovered by this Plan is eligible to receive benefits.

(c)        Effect on Benefits.–

(1)        This provision shallapply in determining the benefits as to a person covered under this Plan forany claim determination period if, for the covered services incurred as to sucha person during such claim determination period, the sum of:

a.         The benefits thatwould be payable under this Plan in the absence of this provision, and

b.         The benefits thatwould be payable under all other plans in the absence therein of provisions ofsimilar purpose of this provision would exceed the usual and customary chargesfor such covered services.

(2)        As to any claimdetermination period with respect to which this provision is applicable, thebenefits that would be payable under this Plan in the absence of this provisionfor the covered services incurred as to such person during such claimdetermination period shall be reduced to the extent necessary so that the sumof such reduced benefit and all the benefits payable for such covered servicesunder all other plans, except as provided in Item (3) immediately below, shallnot exceed the total of such covered services. Benefits payable under anotherPlan include the benefits that would have been payable had claim been duly madetherefor. In the case of another Plan which does not contain a provisioncoordinating its benefits, the benefits of such other Plan shall be determinedbefore the benefits of this Plan. A Plan without a coordination of benefitsprovision shall be deemed to be the primary carrier within the meaning of thisPlan.

(3)        If:

a.         Another Plan whichis involved in Item (2) immediately above and which contains provisionscoordinating its benefits with those of this Plan would, according to itsrules, determine its benefits after the benefits of this Plan have beendetermined, and

b.         The rules set forthin Item (4) immediately below would require this Plan to determine its benefitsbefore such other Plan, then the benefits of such other plan will be ignoredfor the purposes of determining the benefits under this Plan.

(4)        For the purposes ofItem (3) immediately above, the rules establishing the order of benefitdetermination are:

a.         The benefits of aPlan which covers the person on whose covered services claim is based otherthan as a dependent shall be determined before the benefits of a Plan whichcovers such person as a dependent;

b.         Except as stated insub‑subdivision c of this subdivision when this Plan and another Plancover the same child as a dependent of different persons called parents:

1.         the benefits of thePlan of the parent whose birthday falls earlier in the calendar year aredetermined before the benefits of the Plan of the parent whose birthday fallslater in the calendar year; but

2.         if both parents havethe same birthday, the benefits of the Plan that has covered a parent for alonger period of time are determined before those of the Plan that has coveredthe other parent for a shorter period of time; however, if the other Plan has arule based on the gender of the parent, and if as a result, the Plans do notagree on the order of benefits, the rule in the other Plan will determine theorder of benefits.

c.         If two or more Planscover a person as a dependent child of divorced or separated parents, benefitsfor the child are determined in this order:

1.         first, the Plan ofthe parent with custody of the child;

2.         second, the Plan ofthe spouse of the parent with custody of the child; and

3.         third, the Plan ofthe parent not having custody of the child.

However,if the specific terms of a court decree state that one of the parents isresponsible for the health care expenses of the child, and the entity obligatedto pay or provide the benefits of the Plan of that parent has actual knowledgeof those terms, the benefits of that Plan are determined first. This paragraphdoes not apply with respect to any claim determination period or Plan year duringwhich any benefits are actually paid or provided before the entity has actualknowledge.

d.         The benefits of aPlan that covers the person as an employee who is neither laid off nor retired(or as that employee's dependent) are determined before those of a Plan thatcovers that person as a laid‑off or retired employee (or as thatemployee's dependent). If the other Plan does not have this rule, and if, as aresult, the Plans do not agree on the order of benefits, this rule is ignored.

e.         When rules a and b immediatelyabove do not establish an order of benefit determination, the benefits of aPlan which has covered the person on whose covered services claim is based forthe longer period of time shall be determined before the benefits of a Planwhich had covered such person for the shorter period of time.

(5)        When this provisionoperates to reduce the total amount of benefits otherwise payable as to aperson covered under this Plan during any claim determination period, eachbenefit that would be payable in the absence of this provision shall be reducedproportionately, and such reduced amount shall be charged against anyapplicable benefit limit of this Plan.

(d)        MedicareParticipants' Eligibility. – In the case of employees eligible under the Planwho are also eligible for Medicare benefits, benefits under the Plan will bepaid in coordination with Medicare benefits in a manner consistent with federallaw.

(e)        Right to Receiveand Release Necessary Information. – For the purpose of determining theapplicability of and implementing the terms of this provision of this Plan orany provision of similar purpose of any other Plan, the Claims Processor may,without the consent of or notice to any person, release to or obtain from anyinsurance company or other organization or person any information, with respectto any person, which the Claims Processor deems to be necessary for suchpurposes. Any person claiming benefits under this Plan shall furnish to theClaims Processor such information as may be necessary to implement theprovision.

(f)         Facility ofPayment. – Whenever payments which should have been made under this Plan, inaccordance with this provision, have been made under any other plans, theClaims Processor shall have the right, exercisable alone and in its solediscretion, to pay over to any organizations making such other payments anyamounts it shall determine to be warranted in order to satisfy the intent ofthis provision, and amounts to be paid shall be deemed to be benefits paidunder this Plan, and, to the extent of such payments, the Claims Processorshall be fully discharged from liability under the Plan.

(g)        Right of Recovery.– Whenever payments have been made by the Claims Processor with respect tocovered services in a total amount which is, at any time, in excess of themaximum amount of payment necessary at that time to satisfy the intent of thisprovision, irrespective of to whom paid, the Claims Processor shall have theright to recover such payments, to the extent of such excess, from among one ormore of the following, as the Claims Processor shall determine: any persons toor for or with respect to whom such payments were made, any insurancecompanies, or any other organizations.  (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1983, c.922, s. 18; 1985 (Reg. Sess., 1986), c. 1020, ss. 20, 30; 1989, c. 770, s. 35;2008‑168, ss. 1(a), 3(a), (s).)