Ins 3.40(11)(b)5m.a.a. First, the benefits of a Plan covering the person as an employee, member or subscriber or as a dependent of an employee, member or subscriber.
Ins 3.40(11)(b)5m.b.b. Second, the benefits under the continuation coverage.
Ins 3.40(11)(b)5s.5s. If the other Plan does not have the rule described in subd. 5m. and if, as a result, the Plans do not agree on the order of benefits, this subdivision is ignored.
Ins 3.40(11)(b)6.6. ‘Longer or shorter length of coverage.’ If none of the above rules determines the order of benefits, the benefits of the Plan which covered an employee, member or subscriber longer are determined before those of the Plan which covered that person for the shorter time.
Ins 3.40(11)(b)6m.6m. To determine the length of time a person has been covered under a Plan, 2 Plans shall be treated as one if the claimant was eligible under the second within 24 hours after the first ended. Thus, the start of a new Plan does not include:
Ins 3.40(11)(b)6m.a.a. A change in the amount or scope of a Plan’s benefits;
Ins 3.40(11)(b)6m.b.b. A change in the entity which pays, provides or administers the Plan’s benefits; or
Ins 3.40(11)(b)6m.c.c. A change from one type of Plan to another, such as, from a single employer plan to that of a multiple employer plan.
Ins 3.40(11)(b)6s.6s. The claimant’s length of time covered under a Plan is measured from the claimant’s first date of coverage under that Plan. If that date is not readily available, the date the claimant first became a member of the group shall be used as the date from which to determine the length of time the claimant’s coverage under the present Plan has been in force.
Ins 3.40(11)(c)(c) If a dependent is a Medicare beneficiary and if, under the Social Security Act of 1965 as amended, Medicare is secondary to the Plan covering the person as a dependent of an active employee, the federal Medicare regulations shall supersede this subsection.
Ins 3.40(12)(12)Payment as a secondary plan.
Ins 3.40(12)(a)(a) In accordance with order of benefit determination rules under sub. (11), when This Plan is a secondary Plan as to one or more other Plans, the benefits of This Plan may be reduced as provided in par. (b). The other Plan or Plans are referred to as “the other Plans” in par. (b).
Ins 3.40(12)(b)(b)
Ins 3.40(12)(b)1.1. The benefits of This Plan shall be reduced when the sum of the following exceeds the allowable expenses in a claim determination period:
Ins 3.40(12)(b)1.a.a. The benefits that would be payable for the allowable expenses under This Plan in the absence of this COB provision, and
Ins 3.40(12)(b)1.b.b. The benefits that would be payable for the allowable expenses under the other Plans, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made.
Ins 3.40(12)(b)2.2. If subd. 1. applies, the benefits of This Plan will be reduced so that they and the benefits payable under the other Plans do not equal more than the total allowable expenses. When the benefits of This Plan are reduced as described, each benefit is reduced in proportion and is then charged against any applicable benefit limit of This Plan.
Ins 3.40(12)(c)(c) If the benefits of This Plan are reduced under par. (b), a Secondary Plan may reduce its benefits so that the total benefits paid or provided by all Plans during a claim determination period are not more than the total allowable expenses. The amount by which the Secondary Plan’s benefits are reduced shall be used by the Secondary Plan to pay allowable expenses not otherwise paid, which were incurred during the claim determination period by the person for whom the claim is made. As each claim is submitted, the Secondary Plan determines its obligation to pay for allowable expenses based on all claims which were submitted up to that point in time during the claim determination period.
Ins 3.40(14)(14)Right to receive and release needed information. An insurer has the right to decide the facts it needs to apply the COB rules. It may get needed facts from or give them to any other organization or person without the consent of the insured but only as needed to apply the provisions of this section. This subsection does not relieve the insurer of the requirements of s. 146.82, Stats. Each person claiming benefits under This Plan shall give the insurer any facts it needs to pay the claim.
Ins 3.40(15)(15)Facility of payment. A payment made under another Plan may include an amount which should have been paid under This Plan. If it does, the insurer responsible for payment may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. The insurer will not have to pay that amount again. The term “payment made” includes providing benefits in the form of services, in which case “payment made” means reasonable cash value of the benefits provided in the form of services.
Ins 3.40(16)(16)Right of recovery. If the amount of the payments made by the insurer responsible for payment, including the reasonable cash value of any benefits provided in the form of services, is more than it should have paid under a COB provision, it may recover the excess from one or more of:
Ins 3.40(16)(a)(a) The persons it has paid or for whom it has paid;
Ins 3.40(16)(b)(b) Insurance companies; or
Ins 3.40(16)(c)(c) Other organizations.
Ins 3.40(17)(17)Reasonable cash value of services. A Secondary Plan which provides benefits in the form of services may recover the reasonable cash value of providing the services from the Primary Plan, to the extent that benefits for the services are covered by the Primary Plan and have not already been paid or provided by the Primary Plan. Nothing in this provision shall be interpreted to require a Plan to reimburse a covered person in cash for the value of services provided by a Plan which provides benefits in the form of services.
Ins 3.40(18)(18)Coordination with noncomplying plans. Except for expenses covered by worker’s compensation, employer’s liability insurance, Medicare, medical assistance, or traditional automobile “fault” contracts, a Complying Plan may coordinate its benefits with a Noncomplying Plan that may not be subject to insurance regulation on the following basis:
Ins 3.40(18)(a)(a) If the Complying Plan is the Primary Plan, it shall pay or provide its benefits on a primary basis.
Ins 3.40(18)(b)(b) If the Complying Plan is the Secondary Plan, it shall pay or provide its benefits first, but the amount of the benefits payable shall be determined as if the Complying Plan were the Secondary Plan. In such a situation, the payment shall be the limit of the Complying Plan’s liability.
Ins 3.40(18)(c)(c) If the Noncomplying Plan does not provide the information needed by the Complying Plan to determine its benefits within a reasonable time after it is requested to do so, the Complying Plan shall assume that the benefits of the Noncomplying Plan are identical to its own and shall pay its benefits accordingly. However, the Complying Plan shall adjust any payments it makes based on such assumption whenever information becomes available as to the actual benefits of the Noncomplying Plan.