| (a) If a covered person advises a plan that all plans
covering the person are high-deductible health plans and the person
intends to contribute to a health savings account established in accord
with §223 of the Internal Revenue Code of 1986, the primary high-deductible
plan's deductible is not an allowable expense, except for any health
care expense incurred that may not be subject to the deductible as
described in §223(c)(2)(C) of the Internal Revenue Code of 1986.
(b) An expense or a portion of an expense that is not
covered by any of the plans is not an allowable expense.
(c) Any expense that a health care provider or physician
is prohibited from charging a covered person by law or in accord with
a contractual agreement is not an allowable expense.
(d) 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 provides coverage for private hospital room expenses.
(e) If a person is covered by two or more plans that
do not have negotiated fees and that compute their benefit payments
on the basis of usual and customary fees, allowed amounts, relative
value schedule reimbursement, or other similar reimbursement methodology,
any amount charged by the health care provider or physician in excess
of the highest reimbursement amount for a specified benefit is not
an allowable expense.
(f) If a person is covered by two or more plans that
provide benefits or services based on negotiated fees, any amount
in excess of the highest of the negotiated fees is not an allowable
expense.
(g) If a person is covered by one plan that does not
have negotiated fees and that calculates its benefits or services
based on usual and customary fees, allowed amounts, relative value
schedule reimbursement, or other similar reimbursement methodology
and another plan that provides its benefits or services based on negotiated
fees, the primary plan's payment arrangement must be the allowable
expense for all plans. However, if the health care provider or physician
has contracted with the secondary plan to provide the benefit or service
for a specific negotiated fee or payment amount that is different
than the primary plan's payment arrangement and if the health care
provider's or physician's contract permits, that negotiated fee or
payment must be the allowable expense used by the secondary plan to
determine its benefits.
(h) The definition of "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
definition of "allowable expenses" in its contract to expenses that
are similar to the expenses that it provides. When COB is restricted
to specific coverages or benefits in a contract, the definition of
"allowable expense" must include similar expenses to which COB applies.
(i) When a plan provides benefits in the form of services,
the reasonable cash value of each service will be considered as both
an allowable expense and a benefit paid.
(j) The amount of the reduction of benefits under a
primary plan may be excluded from allowable expense when a covered
person's benefits are reduced under a primary plan because:
(1) the covered person does not comply with the plan
provisions concerning second surgical opinions or prior authorization
of admissions or services; or
(2) the covered person has a lower benefit because
the covered person did not use a preferred health care provider or
preferred physician.
|
