General Policies and Procedures

Coordination of Benefits (COB)

Yale Health coverage is subject to coordination of benefits (COB) provisions. Yale Health follows the National Association of Insurance Commissioners’ (NAIC) Coordination of Benefits Guidelines. Coordination of benefits is the term applied to the standard process used to determine the order in which benefit plans should pay for covered services when a member is covered by more than one benefit plan.

Coordination of benefits works by using one benefit plan to cover some of the expenses not fully covered by another plan. For example, if you have other coverage that covers less than 100% of the fee for a service and you may be entitled to benefits from Yale Health, COB entitles you to receive coverage from that source to supplement the amount Yale Health covers, if services are consistent and compliant with the other plan guidelines, up to 100% of expenses.

Coordination of benefits also entitles Yale Health to receive payment from other benefit plans for some services rendered by Yale Health. If you have other coverage when you first enroll in Yale Health, or if the coverage changes while you are enrolled, (e.g. Medicare Disability, other insurance) you are required to notify Yale Health. Failure to disclose this information may affect the terms of your coverage or result in the denial of claims. The following rules determine which plan provides benefits first:

1. The plan covering the person as a subscriber provides benefits first
2. Dependent children are covered first under the plan of the parent whose birthday is earlier in the calendar year
3. If the parents are divorced or separated, the order below is followed
   1. the plan of the parent with custody
   2. the plan of the spouse of the parent with custody
   3. the plan of the parent without custody
   4. the plan of the spouse of the parent without custody

If a court decree establishes responsibility for the child’s healthcare, the plan of the parent with that responsibility provides benefits first. If none of these rules apply, the plan that has covered the member for the longer period of time will provide benefits first.

Yale Health General Consent to Treatment

In order to receive care from Yale Health, your consent to treatment is required. By presenting to the Yale Health Center for care, you implicitly consent to and/or acknowledge the following:

1. you consent to treatment as a patient of Yale Health for the purpose of receiving medical care and treatment and/or diagnostic procedures as determined to be necessary or advisable in your care;
2. you consent to admission to the Yale Health Infirmary when indicated by your medical condition;
3. you acknowledge that Yale Health may use telehealth tools in your care including, but not limited to, video visits, e-consults with specialists, and audio and/or video monitoring in acute and inpatient departments;
4. you acknowledge that as part of your medical care and treatment, you may be tested for HIV and this testing is voluntary; and you will notify your Yale Health care provider if you do not agree to HIV testing;
5. you acknowledge that photographic images, videotaped images or other images may be made of you for purposes of medical documentation or education as Yale Health deems appropriate, and that the use or release of such images will be in accordance with Yale Health's Notice of Privacy Practices;
6. you acknowledge that discussion of the risk, benefits and alternatives to each procedure or test is available to you so you can make informed decisions about your care;
7. you acknowledge that you have an obligation to disclose any other insurance information to Yale Health as part of Coordination of Benefits (COB) provisions and failure to do so may impact your coverage, care, and/or financial responsibility for services;
8. you acknowledge that you have a financial responsibility for care and services rendered to you when ineligible for coverage;
9. you acknowledge that the terms of your Yale Health coverage may include copays, deductibles, coinsurance percentages, or late cancellation and no-show fees, and payment of applicable amounts is your responsibility.

Subrogation (Third-Party Liability)

Third-Party Liability

A member or enrolled dependent may receive compensation for an illness or injury for which another party is liable to pay damages. In these cases, that party has the primary payment responsibility and Yale Health has the legal right to be reimbursed for services covered or provided by Yale Health. If a Yale Health member brings legal action or otherwise makes a claim against a third party allegedly responsible for their condition, that Yale Health member agrees to:

1. Notify the Yale Health Billing Department as soon as possible and to keep the Billing Department informed at all times of subsequent developments.
2. Reimburse Yale Health for its costs and services out of any resulting settlement to the full extent permitted by law.
3. Cooperate in protecting the interests of Yale Health under this provision and execute and deliver to Yale Health or its nominees any and all documents (e.g., accident reports) requested by Yale Health that may be necessary to effectuate and protect its rights.

Some examples of Subrogation include motor vehicle and personal injury accidents.

Workers’ Compensation

In cases of work-related injury or illness, members may be entitled to coverage under Workers’ Compensation, employer’s liability insurance, or occupational disease law. If it is determined that you are eligible for coverage through these sources for services provided by Yale Health, Yale Health is entitled to be reimbursed for those services. Yale Health will pay only for that portion of services covered under a Yale Health plan not covered by an approved Workers’ Compensation, employer’s liability insurance, or occupational disease law claim. If it is determined that you are not eligible for coverage through these sources for services covered by Yale Health, Yale Health will cover those services according to the What the Plan Covers section of the Member Booklet.

Please note, however, that if you receive care outside of Yale Health or the Yale Health network that is not covered by Yale Health for a work-related injury or illness and your claims through Workers’ Compensation, employer’s liability insurance, or occupational disease law are denied, Yale Health will not cover those claims and you will be billed directly by the provider.

If you become eligible for coverage under Workers’ Compensation, employer’s liability insurance, or occupational disease law, Yale Health is entitled to:

1. charge the entity obligated under such law(s) for services rendered at Yale Health
2. charge the member for services covered by Yale Health to the extent that the member has been paid for the same services under such law(s) or insurance
3. reduce any sum Yale Health owes the member by the amount that the member has been paid for the services under such law(s) or insurance
4. withdraw payment from a provider or facility equal to the amount Yale Health has paid for services rendered to the member

If you are a Yale employee and are injured on the job or become ill because of your job, report this to your supervisor as soon as your condition permits. If you seek care at Yale Health, obtain a health service appointment and report form(s) from your department supervisor and provide this information to Yale Health staff at the time of your initial evaluation and any subsequent appointments. For Yale employees, Yale Health will provide medical treatment upon a member’s request and bill Workers’ Compensation for these services. For non-Yale employees, Yale Health will provide medical treatment and bill the responsible insurance carrier or employer directly upon receipt of an attending physician’s claim form assigning payment to Yale Health. Failure to provide this or any other necessary documents required to effectuate and protect the rights of Yale Health will result in direct billing to the patient.

Miscellaneous Provisions

1. Members are subject to all the rules and regulations of Yale Health. They must receive care from a Yale Health network provider or such care must be arranged by a Yale Health provider and approved in advance by the Yale Health  Authorizations Department.
2. The member and each enrolled dependent agree that any provider, hospital, referral agency, or agent that has made a diagnosis or provided treatment for an ailment may furnish to Yale Health all information and records, to the extent permitted by law, relating to said diagnosis or treatment. Members further agree that Yale Health may send all such information and records to Yale Health or network providers and/or to medical or financial audit firms with whom Yale Health contracts.
3. The coverage and rights described in this Booklet are personal to the member and enrolled dependents and cannot be assigned or transferred.
4. In the event of a major disaster, epidemic, or circumstances not reasonably within the control of Yale Health, Yale Health shall provide services insofar as practical, according to its best judgment, within the limits of its facilities and staff. In this event, Yale Health shall have no liability for delay or failure to provide or arrange for services on account of such events.
5. Members or applicants for membership shall complete and submit to such enrollment forms, medical review questionnaires, or other forms or statements as Yale Health may reasonably request. Members or applicants warrant that the information contained therein shall be true, correct, and complete, and all rights to services are subject to that condition.
6. Yale Health may adopt reasonable policies, procedures, rules, and interpretations to promote the orderly and efficient administration of the policies and coverage plans described in this Booklet.
7. The Yale Health membership card issued to each member is for identification purposes only and does not in and of itself confer any rights to any of the services described in this Booklet.
8. The headings of various sections of this Booklet are inserted for convenience and do not (expressly or implicitly) limit, define, or extend the specific terms of the designated section.
9. If Yale determines that you, your spouse, civil union partner, or dependent child is ineligible, you will be billed for all services rendered or claims paid by Yale Health on behalf of the ineligible individual, and premiums paid will not be refunded.

COBRA Continuation of Coverage

The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) is a federally mandated plan that allows terminated employees and their dependents who would otherwise lose health coverage to continue that coverage for a specified period of time. With COBRA Yale employees and their dependents can continue health coverage, subject to certain conditions and payment of contributions. Continuation rights are available following a “qualifying event” that would cause an employee or family members to otherwise lose coverage. Qualifying events are listed in this section.

Continuing coverage through COBRA

When you or your covered dependents become eligible, the University will provide you with detailed information on continuing your health coverage through COBRA.

You or your dependents will need to:

• Complete and submit an application for continued health coverage, which is an election notice of your intent to continue coverage; and
• Submit your application within 60 days of the qualifying event, or within 60 days of notice of this COBRA continuation right, if later; and
• Agree to pay the required contributions.

Who qualifies for COBRA

You have 60 days from the qualifying event to elect COBRA. If you do not apply within 60 days, you will forfeit your COBRA continuation rights.

Below you will find the qualifying events and a summary of the maximum coverage periods according to COBRA requirements.

* Disability May Increase Maximum Continuation to 29 Months

If you or your covered dependents are disabled

If you or your covered dependents qualify for disability status under Title II or XVI of the Social Security Act during the 18-month continuation period, you or your covered dependents:

• Have the right to extend coverage beyond the initial 18-month maximum continuation period, and qualify for an additional 11-month period, subject to the overall COBRA conditions.
• Must notify Employee Services within 60 days of the disability determination status and before the 18-month continuation period ends.
• Must notify the employer within 30 days of any final determination that you or a covered dependent is no longer disabled.
• Are responsible for paying the contributions after the 18th month, through the 29th month.

If there are multiple qualifying events

A covered dependent could qualify for an extension of the 18- or 29-month continuation period by meeting the requirements of another qualifying event, such as divorce or death. The total continuation period, however, can never exceed 36 months.

Determining your contributions for continuation coverage

Your contributions are regulated by law, based on the following:

• For the 18- or 36-month periods, contributions may never exceed 102 percent of the plan costs.
• For the 18- through 29-month period, contributions during an extended disability period may never exceed 150 percent of the plan costs.

When you acquire a dependent during a continuation period

If through birth, adoption, or marriage, you acquire a new dependent during the continuation period, your dependent can be added to the health plan for the remainder of the continuation period if:

• They meet the definition of an eligible dependent,
• Employee Services is notified about your dependent within 30 days of eligibility, and,
• Additional contributions for continuation are paid on a timely basis.

When your COBRA continuation coverage ends

Your COBRA coverage will end when the first of the following events occurs:

• You or your covered dependents reach the maximum COBRA continuation period — the end of the 18, 29 or 36 months as applicable. (Coverage for a newly acquired dependent who has been added for the balance of a continuation period would end at the same time your continuation period ends, if they are not disabled nor eligible for an extended maximum.)
• You or your covered dependents do not pay required contributions.
• You or your covered dependents become covered under another group plan that does not restrict coverage for pre-existing conditions. If your new plan limits pre-existing condition coverage, the continuation coverage under this plan may remain in effect until the pre-existing clause ceases to apply or the maximum continuation period is reached under this plan.
• The date the University no longer offers a group health plan.
• The date you or a covered dependent becomes enrolled in benefits under Medicare. This does not apply if it is contrary to the Medicare Secondary Payer Rules or other federal law.
• You or your dependent dies.

Conversion from a group to an individual plan

You may be eligible to apply for an individual health plan without providing proof of good health:

• At the termination of employment.
• When loss of coverage under the group plan occurs, or when loss of dependent status occurs.
• At the end of the maximum health coverage continuation period.

The individual policy will not provide the same coverage as the former group plan offered by your employer. Certain benefits may not be available. You will be required to pay the associated contribution costs for the coverage. For additional conversion information, contact Employee Services.