Ins 3.40(4)(d)(d) When COB is restricted in its use to a specific coverage in a contract, for example, major medical or dental, the definition of allowable expense shall include the corresponding expenses or services to which COB applies.

Ins 3.40(5)(a)(a) A claim determination period may not be less than 12 months and usually is a calendar year, but a Plan may use some other period of time that fits the coverage of the group contract. A person may be covered by a Plan during a portion of a claim determination period if that person’s coverage starts or ends during that claim determination period.

Ins 3.40(5)(b)(b) As each claim is submitted, each Plan shall determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. However, that determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.

Ins 3.40(6)(a)(a) The definition of Plan in the group contract shall state the types of coverage which shall be considered in applying the COB provision of that contract. The right to include a type of coverage is limited by the rest of this subsection.

Ins 3.40(6)(b)(b) The definition of Plan shown in the model COB provision in APPENDIX A is an example of what may be used. Any definition that satisfies sub. (3) (i) and this subsection may be used.

Ins 3.40(6)(c)(c) Notwithstanding the fact that this section uses the term “Plan,” a group contract may instead use “Program” or some other term.

Ins 3.40(6)(d)(d) “Plan” shall not include individual or family insurance or subscriber contracts or individual or family coverage through health maintenance organizations (HMOs), limited service health organizations (LSHOs), or any other prepayment, group practice or individual practice plan except as provided in pars. (e) and (f).

Ins 3.40(6)(e)(e) “Plan” may include: group insurance and group subscriber contracts; uninsured arrangements of group or group-type coverage; group or group-type coverage through HMOs, LSHOs and other prepayment, group practice and individual practice plans; and group-type contracts.

Ins 3.40(6)(f)(f) “Plan” may include the medical benefits coverage in group, group-type, and individual automobile “no-fault” contracts; but, as to the traditional automobile “fault” contracts, only the medical benefits written on a group or group-type basis may be included.

Ins 3.40(6)(g)(g) If “Plan” includes Medicare or other governmental benefits, that part of the definition of “Plan” may be limited to the hospital, medical and surgical benefits of the governmental program. However, “Plan” shall not include a state plan under Medicaid (Title XIX, Grants to State for Medical Assistance Programs, of the United States Social Security Act as amended from time to time) and shall not include a law or plan whose benefits, by law, are excess to those of any private insurance plan or other non-government plan.

Ins 3.40(6)(h)(h) “Plan” shall not include group or group-type hospital indemnity benefits of $100 per day or less but may include the amount by which group or group-type hospital indemnity benefits exceed $100 per day.

Ins 3.40(6)(i)(i) “Plan” shall not include school accident-type coverages that cover grammar, high school, and college students for accidents only, including athletic injuries, either on a 24-hour basis or on a “to and from school” basis.

Ins 3.40(6)(j)(j) Each contract or other arrangement for coverage is a separate Plan. If an arrangement has 2 parts and COB rules apply only to one of the 2, each of the parts is a separate Plan.

Ins 3.40(7)(a)(a) The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another plan covering the person.

Ins 3.40(7)(b)(b) There may be more than one Primary Plan. A Plan is a Primary Plan if either subd. 1. or 2. is true:

Ins 3.40(7)(b)1.1. The Plan either has no order of benefit determination rules, or it has rules that differ from sub. (11).

Ins 3.40(7)(b)2.2. All plans that cover the person are complying plans and, under sub. (11), the Plan determines its benefits first.

Ins 3.40(7)(c)(c) When there are more than 2 plans covering the person, This Plan may be a Primary Plan as to one or more other Plans and may be a Secondary Plan as to a different Plan or Plans.

Ins 3.40(7)(d)(d) If a person is covered by more than one Secondary Plan, the order of benefit determination rules of this section decide the order in which the benefits are determined in relation to each other. The benefits of each Secondary Plan may take into consideration the benefits of the Primary Plan or Plans and the benefits of any other Plan which, under the rules of this section, has its benefits determined before those of that Secondary Plan.

Ins 3.40(8)(a)(a) This coordination of benefits (COB) provision applies to This Plan when an employee or the employee’s covered dependent has health care coverage under more than one Plan.

Ins 3.40(8)(b)(b) If this COB provision applies, the order of benefit determination rules shall be looked at first. Those rules determine whether the benefits of This Plan are determined before or after those of another Plan.

Ins 3.40(8)(c)(c) The benefits of This Plan shall not be reduced when, under the order of benefit determination rules, This Plan is primary and determines its benefits before another Plan.

Ins 3.40(8)(d)(d) The benefits of This Plan may be reduced when, under the order of benefit determination rules, another Plan determines its benefits first.

Ins 3.40(9)(a)(a) APPENDIX A shall be considered authorized clauses pursuant to s. 631.23, Stats., for use in policy forms subject to this section and shall only be changed as provided in this section.