OAR 836-020-0780
Use of Model COB Contract Provision

(1)

Appendix A (Exhibit 1 to this rule) contains a model COB provision for use in contracts. The use of this model COB provision is subject to OAR 836-020-0785 (Rules for Coordination of Benefits)(1), (2) and (3).

(2)

Appendix B (Exhibit 2 to this rule) 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 set forth in the contract. Its purpose is to explain the process by which the two or more plans will pay for or provide benefits.

(3)

The COB provision contained in Appendix A and the plain language explanation in Appendix B do not have to use the specific words and format shown in Appendix A or Appendix B. Changes may be made to fit the language and style of the rest of the contract or to reflect differences among plans that provide services, that pay benefits for expenses incurred and that indemnify. No substantive changes are permitted.

(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 is eligible or could have been covered under another plan, except with respect to Part B of Medicare; 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)

A plan may not contain a provision that its benefits are “always excess” or “always secondary” except in accordance with the rules permitted by OAR 836-020-0770 (Authority, Purpose and Effective Date of OAR 836-020-0770 to 836-020-0806) to 836-020-0806 (Effective Date for Existing Contracts).

(6)

Under the terms of a closed panel plan, benefits are not payable if the covered person does not use the services of a closed panel provider. In most instances, COB does not occur if a covered person is enrolled in two or more closed panel plans and obtains services from a provider in one of the closed panel plans because the other closed panel plan (the one whose providers were not used) has no liability. However, COB may occur during the plan year when the covered person receives emergency services that would have been covered by both plans. Then the secondary plan shall use OAR 836-020-0790 to determine the amount it should pay for the benefit.

(7)

A plan may not 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 in OAR 836-020-0775 (Definitions).
[ED. NOTE: Appendices referenced are available from the agency.]

Source: Rule 836-020-0780 — Use of Model COB Contract Provision, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-020-0780.

836–020–0200
Purpose and Authority 836–020–0205
Applicability 836–020–0210
Definitions 836–020–0215
Method of Disclosure of Required Information 836–020–0220
Form and Content of Advertisements 836–020–0225
Advertisements of Benefits Payable, Losses Covered, or Premiums Payable 836–020–0230
Necessity for Disclosing Policy Provisions Relating to Renewal, Cancellation, and Termination 836–020–0235
Testimonials or Endorsements by Third Parties 836–020–0240
Use of Statistics 836–020–0245
Identification of Plan or Number of Policies 836–020–0250
Disparaging Comparisons and Statements 836–020–0255
Licensed Jurisdictions and Status of Insurer 836–020–0260
Identity of Insurer and Policy 836–020–0265
Group or Quasi-Group Implication 836–020–0270
Introductory, Initial, or Special Offers 836–020–0275
Statements About an Insurer 836–020–0280
Enforcement Procedures 836–020–0285
Prior Approval 836–020–0290
Severability 836–020–0295
Effective Date 836–020–0300
Statutory Authority 836–020–0305
Disclosure 836–020–0770
Authority, Purpose and Effective Date of OAR 836-020-0770
to 836-020-0806 836–020–0775
Definitions 836–020–0780
Use of Model COB Contract Provision 836–020–0785
Rules for Coordination of Benefits 836–020–0791
Procedure to be Followed by Secondary Plan to Calculate Benefits and Pay a Claim 836–020–0796
Notice to Covered Persons 836–020–0801
Miscellaneous Provisions 836–020–0806
Effective Date for Existing Contracts
Last Updated

Jun. 8, 2021

Rule 836-020-0780’s source at or​.us