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WAC 284-51-200

Use of model COB contract provision.

(1) WAC 284-51-255, Appendix A contains a model COB provision for use in contracts. The use of this model COB provision is subject to the provisions of subsections (2), (3), and (4) of this section and to the provisions of this chapter.
(2) WAC 284-51-260, Appendix B is a plain language description of the COB process that explains to the covered person how health plans will implement coordination of benefits. It is not intended to replace or change the provisions that are in the contract. Its purpose is to explain the process to be used by two or more plans to pay for or provide benefits as allowed by the provisions of this chapter.
(3) Issuers need not use the specific words and format provided in WAC 284-51-255 and the plain language explanation in WAC 284-51-260. Editing changes may be made by the issuer to fit the language and style of the rest of its contract or to reflect differences among plans that provide services, that pay benefits for expenses incurred and that indemnify. Modifications may be made provided they do not conflict with the requirements of this chapter.
(4) A COB provision may not be used that permits a plan to reduce its benefits on the basis that:
(a) Another plan exists and the covered person did not enroll in that plan;
(b) A person could have been covered under another plan; or
(c) A person has elected an option under another plan providing a lower level of benefits than another option that could have been elected.
(5) No plan may contain a provision that its benefits are "always excess" or "always secondary" except under the rules permitted in this chapter.
(6) 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 plan as defined in this chapter.
(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. Further, coordination of benefits may occur during the claim determination period even where there are no savings in the closed panel plan.
[Statutory Authority: RCW 48.20.60 [48.20.060], 48.21.200, 48.44.050, and 48.46.200. WSR 07-13-008 (Matter No. R 2005-07), ยง 284-51-200, filed 6/8/07, effective 7/9/07.]
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