Coordination of Benefits Model Regulation

What this document is

Coordination of Benefits Model Regulation is a naic model law published by National Association of Insurance Commissioners (NAIC). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• NAIC Model #120: Section 6 (Rules for Coordination of Benefits)

  “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.”

• NAIC Model #120: Section 3 (Definitions)

  “M. “Primary plan” means a plan whose benefits for a person’s health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if: (1) The plan either has no order of benefit determination rules, or its rules differ from those...”

• NAIC Model #120: Section 6D(2)(c) (Dependent Child Covered by Individuals Who Are Not the Parents)

  “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.”

• NAIC Coordination of Benefits Model Regulation, Appendix A, Order of Benefit Determination Rules, Section D(2)(b)(i), notice of a court decree

  “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. This rule applies to plan years commencing after the Plan is given notice of the court decree;”

• NAIC Model NAIC 120: Appendix A, Definitions D (Allowable Expense)

  “Allowable expense is a health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by any Plan covering the person.”

• NAIC Model NAIC 120: Appendix A, Order of Benefit Determination Rules D(1) (Non-Dependent or Dependent; Medicare)

  “if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a dependent; and primary to the Plan covering the person as other than a dependent (e.g. a retired employee); then the order of benefits between the two Plans is...”

• NAIC Coordination of Benefits Model Regulation, Appendix A § D(5), amounts excluded from allowable expense

  “The amount of any benefit reduction by the Primary plan because a covered person has failed to comply with the Plan provisions is not an Allowable expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions, and preferred provider arrangements.”

• NAIC Coordination of Benefits Model Regulation, Appendix A, Order of Benefit Determination Rules, Section D(2)(a), birthday rule for a dependent child

  “Unless there is a court decree stating otherwise, when a dependent child is covered by more than one Plan the order of benefits is determined as follows: (a) For a dependent child whose parents are married or are living together, whether or not they have ever been married: • The Plan of the parent...”

• NAIC Coordination of Benefits Model Regulation § 3B, definition of birthday

  ““Birthday” refers only to month and day in a calendar year and does not include the year in which the individual is born.”

• NAIC Coordination of Benefits Model Regulation § 6D(2)(a)(i)-(ii), birthday rule for a dependent child

  “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 the parent longest is the primary plan.”

• NAIC Coordination of Benefits Model Regulation § 6D(2)(b)(iv), order of benefits when no court decree allocates responsibility

  “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: (I) The plan covering the custodial parent; (II) The plan covering the custodial parent’s spouse; (III) The plan covering the...”

• NAIC Coordination of Benefits Model Regulation § 7, procedure to be followed by secondary plan to calculate benefits and pay a claim

  “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...”

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