CurrentColorado Rocky Mountain Health PlansPolicy ADMINISTRATIVE 149.15

Succeeding Carrier for Inpatient Admissions

Governs responsibility for inpatient coverage when a member changes carriers while confined in an inpatient facility; applies to Oxford Commercial plan membership (excluding self-funded plans) and relevant state-regulated products.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySucceeding Carrier for Inpatient Admissions

Policy CodePolicy ADMINISTRATIVE 149.15

Change TypeRevised definition (Total Disability for NY plans)

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionDetermine which carrier (Prior or Succeeding) is responsible for the remainder of an inpatient stay when a member's coverage changes while Totally Disabled.

SourceLink

POLICY UPDATE CHANGES

Revised definition of 'Total Disability or Totally Disabled' for all New York plans.

Oxford CommercialLines of Business affected (excludes Self-Funded)

Disabling conditionScope of Extended Benefits

12 monthsMaximum elapsed time

NY, CT, NJStates/products specified

Extended Benefits and Coverage Responsibility

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Extended Benefits carrier responsibility and termination

Rules determining which carrier is responsible for completing an inpatient stay and conditions that terminate Extended Benefits.

ALL of the following

ONE of
- If Oxford is the Prior Carrier: Oxford is responsible for the remainder of the inpatient stay unless the Member was covered under an Oxford New York insurance product (Classic, Access, Direct, Metro) and there is a Succeeding Carrier (Members cannot elect to stay with the Prior Carrier in this instance). Note: this does not apply to New York HMO products.
- If the Member elects coverage under the Succeeding Carrier, the Succeeding Carrier is responsible for the remainder of the inpatient stay.
- If the Member was covered under a Self‑Funded plan that does not contain an Extended Benefits provision, the Self‑Funded plan is not required to continue Extended Benefits and Oxford is not responsible.
ALSO CONSIDER
- If Oxford is the Succeeding Carrier (Member's coverage with Oxford begins while Member is inpatient): the remainder of the inpatient stay is the Prior Carrier's responsibility unless the Prior Carrier is an insurer in New York (not an HMO) — insurers are not required to provide Extended Benefits in that instance and Members cannot elect to stay with the Prior Carrier — or the Member has elected coverage under the Succeeding Carrier, or the Member was covered under a Self‑Funded plan without Extended Benefits.
- If Oxford is both Prior and Succeeding Carrier (plans differ despite same carrier), the rules above apply consistently to determine responsibility.

Coverage scope: Coverage under Extended Benefits is limited to Covered Services used to treat the disabling condition; only the Totally Disabled Member is covered under this provision for NY, CT, and NJ Large Group products; no premium is required for those large‑group products.

NJ Small Group special rules

For NJ Small groups the Subscriber must elect Extended Coverage and pay the entire premium; dependents can be added to the Extended Coverage.

Termination of Extended Benefits — coverage ends on the date any of the following occur

The Member is no longer defined as Totally Disabled.
The benefit being used has been exhausted.
Twelve (12) months have elapsed from the date on which the Extended Benefits began.
The Member becomes eligible for coverage under another group policy or Medicare where allowed by federal law (for groups with fewer than 100 employees) — applies to New York and NJ Large Group where noted.

Regulatory References and Maximum Duration

Regulatory referencesmixed

11 NYCRR 52.17	11 NYCRR 52.17.
11 NYCRR 52.18	11 NYCRR 52.18.
C.G.S.A. § 38a-546-6	C.G.S.A. § 38a-546-6 Continuation of benefits under group health policies.
C.G.S.A. 38a-546	C.G.S.A. 38a-546.
CT ADC 38a-546-5	CT ADC 38a-546-5.
Department of Health and Human Services Program Memorandum: Insurance Commissioners and Insurance Issues Transmittal No. 00-04	Department of Health and Human Services and the Health Care Financing Administration; Program Memorandum: Insurance Commissioners and Insurance Issues Transmittal No. 00-04.
N.J.A.C. 11:2-13.5	N.J.A.C. 11:2-13.5.
N.J.A.C. 11:2-13.6	N.J.A.C. 11:2-13.6 Replacement carrier coverage.
N.J.A.C. 8:38-17.4	N.J.A.C. 8:38-17.4.
N.J.S.A. 17B:26-3	N.J.S.A. 17B:26-3.

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inv-03: Maximum duration — Extended Benefits termination criteria

Maximum elapsed timeExtended Benefits end after 12 months have elapsed from the date on which the Extended Benefits began.

Other termination triggersCoverage also ends when the member is no longer Totally Disabled or the benefit being used has been exhausted.

Eligibility-based terminationCoverage ends if the member becomes eligible for another group policy or Medicare where allowed by law (applies to certain small groups).

Determining Carrier Responsibility — Actions for Providers

Prior Authorization

Determine Prior vs Succeeding carrier responsibility for inpatient Extended Benefits

When a member’s coverage changes while they are Totally Disabled and confined as an inpatient, determine whether the Prior Carrier or the Succeeding Carrier is responsible for the remainder of the inpatient stay using the specific exceptions listed below. Responsibility defaults to Oxford as the Prior Carrier if the member was Oxford-covered on the date of admission, except when: the member was covered under an Oxford New York insurance product and there is a succeeding carrier (members cannot elect to remain with the Prior Carrier in this instance; does not apply to New York HMOs); the member elects coverage under the Succeeding Carrier; or the prior coverage was a self‑funded plan without an Extended Benefits provision. Conversely, if coverage with Oxford begins while the member is an inpatient, the remainder of the stay is the Prior Carrier’s responsibility unless the Prior Carrier is a New York insurer (not an HMO), the member elects the Succeeding Carrier, or the prior coverage was self‑funded without Extended Benefits.

Verify whether the member was Totally Disabled and inpatient at the time prior coverage terminated or new coverage began.
Check if the prior plan was a New York insurance product (Classic, Access, Direct, Metro) — if so and a succeeding carrier exists, the succeeding carrier (not the prior) may be responsible and member election to remain with the prior carrier is not permitted (excludes NY HMOs).
Confirm whether the member elected coverage under the succeeding carrier; if elected, the succeeding carrier assumes responsibility.
Confirm whether the prior coverage was a self‑funded plan that lacks an Extended Benefits provision; if so, Oxford may not be required to cover the remainder of the stay.

Key Definitions

inv-05: Prior Carrier / Succeeding Carrier / Total Disability — Definitions

Prior CarrierThe carrier that provided coverage on the date the Member was admitted.

Succeeding CarrierThe carrier that begins coverage for a new Member and such Member is in an inpatient facility on the date coverage becomes effective for that Member.

Total Disability / Totally DisabledDefinitions vary by product/state: For CT and NJ large plans, inability to perform substantial duties of regular employment (dependents inability to perform normal activities); for NJ small plans, inability to perform any duty of occupation and not engaged in wage work (must be under practitioner care); for all NY plans, prevented from engaging in any work or other gainful activity (minors: prevented from substantially all normal activities).

inv-06: Member Eligibility — Eligibility requirements and NJ small group notes

Eligibility at loss of coverageMember must lose coverage while Totally Disabled (coverage ended or agreement ended) to be eligible for Extended Benefits.

NJ Small Group subscriber ruleFor NJ small groups, an employee/subscriber must have been covered for at least three months prior to the date coverage ends; subscriber must pay premium to continue coverage for the subscriber (dependents may be added).

Applicability exclusionsThe Extended Benefits requirement does not apply to Self‑Funded plans unless the plan elects to provide the benefit.