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) (7) Primary plan and secondary plan uses and limitations.

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) (8) Applicability.

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) (9) Flexibility and consistency with this section.

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.

Ins 3.40(9)(b) (b) This section permits but does not require the use of COB or “other insurance” provisions. However, if such provisions are used, they must conform with this section and substantially conform to the clauses contained in APPENDIX A. Liberalization of the prescribed language in APPENDIX A, including rearrangement of the order of the clauses, is permitted provided that the modified language is not less favorable to the insured person.

Ins 3.40(9)(c) (c) Policy language which reduces benefits because of other insurance and which is inconsistent with this section violates the criteria of s. 631.20, Stats., and shall not be used.

Ins 3.40(9)(d) (d) A Plan that includes a COB provision inconsistent with this section shall not take the benefits of another Plan into account when it determines its benefits. There is one exception: a contract holder’s coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the Plan provided by the contract holder.

Ins 3.40(9)(e) (e) A group contract’s COB provision does not have to use the words and format contained in APPENDIX A. Changes may be made to fit the language and style of the rest of the group contract or to reflect the differences among Plans which provide services, which pay benefits for expenses incurred, and which indemnify. Substantive changes are allowed only as set forth in this section.

Ins 3.40(9)(f) (f) A term such as “usual and customary,” “usual and prevailing,” or “reasonable and customary” may be substituted for the term “necessary, reasonable and customary.” Terms such as “medical care” or “dental care” may be substituted for “health care” to describe the coverages to which the COB provisions apply.

Ins 3.40(9)(g) (g) A group contract may apply one COB provision to certain of its benefits (such as dental benefits), coordinating only with like benefits, and may apply other separate COB provisions to coordinate other benefits.

Ins 3.40(10) (10) Prohibited coordination and benefit design.

Ins 3.40(10)(a) (a) A group contract shall not reduce benefits on the basis that:

Ins 3.40(10)(a)1. 1. Another Plan exists;

Ins 3.40(10)(a)2. 2. Except with respect to Part B of Medicare, that a person is or could have been covered under another Plan; or

Ins 3.40(10)(a)3. 3. A person has elected an option under another Plan providing a lower level of benefits than another option which could have been elected.

Ins 3.40(10)(b) (b) No contract shall contain a provision that its benefits are “excess” or “always secondary” to any Plan defined in sub. (3) (i), except as permitted under this section.

Ins 3.40(11) (11) Order of benefit determination rules.