State RegulationsNY specificDifficulty 2/5
Maria is covered as an employee under her own employer's group health plan in Albany, and she is also covered as a dependent under her husband's group health plan. Under New York's coordination of benefits rules, which plan is primary for Maria's claim?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under Reg 62 (11 NYCRR Part 52 (Reg 62)), New York's order-of-benefits rules provide that a plan covering a person as an employee, member, or subscriber is primary over a plan covering the same person as a dependent. Because Maria is covered in her own right as an employee, her own employer's plan must pay first, and her husband's plan pays any remaining covered balance as secondary.
Why the other options are wrong
- B) Dependent coverage is secondary to coverage the person holds in her own right as an employee or member; the dependent plan pays the leftover balance.
- C) Premium size has nothing to do with the order of benefits; the determination rests on the basis of coverage, not on its cost.
- D) Equal splitting ignores the order-of-benefits rules; the secondary plan processes the claim only after the primary plan has paid.
Memory hook
Your own job plan pays first; riding on a spouse's plan pays second.