State RegulationsNY specificDifficulty 2/5
An employee in Manhattan is covered by two group health plans. The primary plan has already paid its full benefit on his claim. Under the coordination of benefits rules of Reg 62, how does the secondary plan determine its payment?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under Reg 62 (11 NYCRR Part 52 (Reg 62)), once the primary plan has paid, the secondary plan coordinates payment by applying its own benefits to the remaining allowable expense, so that the combined payments of both plans do not exceed the total covered expense. The secondary plan must take into account what the primary paid before calculating its own obligation, which prevents overinsurance while still leaving the insured fully protected.
Why the other options are wrong
- A) Double recovery of the same expense is exactly what coordination of benefits forbids; the secondary plan must account for the primary payment.
- C) The secondary plan does not automatically deny the claim; it must process the claim and pay any remaining covered balance.
- D) Nothing in Reg 62 requires premium refunds or cancellation of duplicate coverage; coordination adjusts claim payments only.
Memory hook
Secondary pays the leftover, never the whole: consider what primary already paid.