State RegulationsMA specificDifficulty 2/5
A Massachusetts insured is covered under her own employer's health plan and also as a dependent under her spouse's plan. Which rule governs how the two plans coordinate payment for her claims?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Massachusetts coordination-of-benefits rules, found in 211 CMR 38.01 to 38.08, require group health plans to determine the order in which multiple coverages pay — using settled rules for employee-versus-dependent coverage and similar situations — and cap the combined payment so the insured recovers no more than the actual expenses. The regulations exist to prevent double recovery while ensuring the claim is paid promptly by the properly primary plan.
Why the other options are wrong
- A) Automatic half-and-half payment is not the Massachusetts method; 211 CMR 38.01 to 38.08 establish a defined order of benefit determination instead.
- B) The insured's per-claim choice does not control; the coordination regulations fix the order by rule.
- C) The secondary plan's obligation is not suspended until the primary's maximum is exhausted; coordination addresses the order and the total payable, which cannot exceed actual expenses.
Memory hook
Two plans, one order of payment — 211 CMR 38 keeps the total at actual expenses.