Idaho Administrative Code
Title IDAPA 18 - Insurance, Department of
Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE
Section 18.04.08.038 - SPECIFIED DISEASE COVERAGE
Universal Citation: ID Admin Code 18.04.08.038
Current through August 31, 2023
01. Minimum Standards for Benefits. The following minimum standards apply to specified disease coverage: (3-31-22)
a.
Coverage for cancer only or cancer in conjunction with other conditions or
diseases needs to meet the standards of Paragraphs 01.e., 01.f., or 01.g. of
this section. (3-31-22)
b. Coverage
for specified diseases other than cancer meets the standards of Paragraphs
01.c., 01.d., or 01.g. of this section. (3-31-22)
c. Non-cancer Coverages with Deductible.
Coverage for each insured person for a specifically named disease (or diseases)
with a deductible amount not in excess of two hundred fifty dollars ($250) and
an overall aggregate benefit limit of not less than ten thousand dollars
($10,000) and a benefit period of not less than two (2) years for at least the
following incurred expenses: (3-31-22)
i.
Hospital room and board and any other hospital furnished medical services or
supplies; (3-31-22)
ii. Treatment
by a legally qualified physician or surgeon; (3-31-22)
iii. Private duty services of a registered
nurse (R.N.); (3-31-22)
iv. X-ray,
radium and other therapy procedures used in diagnosis and treatment;
(3-31-22)
v. Professional ambulance
for local service to or from a local hospital; (3-31-22)
vi. Blood transfusions, including expense
incurred for blood donors; (3-31-22)
vii. Drugs and medicines prescribed by a
physician; (3-31-22)
viii. The
rental of an iron lung or similar mechanical apparatus; (3-31-22)
ix. Braces, crutches, and wheel chairs deemed
necessary by the attending physician for the treatment of the disease;
(3-31-22)
x. Emergency
transportation if in the opinion of the attending physician it is necessary to
transport the insured to another locality for treatment of the disease; and
(3-31-22)
xi. May include coverage
of any other expenses necessarily incurred in the treatment of the disease.
(3-31-22)
d. Non-cancer
Coverages without Deductible. Coverage for each insured person for a
specifically named disease (or diseases) with no deductible amount, and an
overall aggregate benefit limit of not less than twenty five thousand dollars
($25,000) payable at the rate of not less than fifty dollars ($50) a day while
confined in a hospital and a benefit period of not less than five hundred (500)
days. (3-31-22)
e. Cancer-only or
Combination Expense Policies. Coverage for each insured person for cancer-only
coverage or in combination with one (1) or more other specified diseases on an
expense incurred basis for services, supplies, care, and treatment of cancer,
in amounts not in excess of the usual and customary charges, with a deductible
amount not in excess of two hundred fifty dollars ($250), and an overall
aggregate benefit limit of not less than ten thousand dollars ($10,000) and a
benefit period of not less than three (3) years for at least the following
minimum provisions: (3-31-22)
i. Treatment by,
or under the direction of, a legally qualified physician or surgeon;
(3-31-22)
ii. X-ray, radium,
chemotherapy and other therapy procedures used in diagnosis and treatment;
(3-31-22)
iii. Hospital room and
board and any other hospital furnished medical services or supplies;
(3-31-22)
iv. Blood transfusions
and their administration, including expense incurred for blood donors;
(3-31-22)
v. Drugs and medicines
prescribed by a physician; (3-31-22)
vi. Professional ambulance for local service
to or from a local hospital; (3-31-22)
vii. Private duty services of a registered
nurse provided in a hospital; (3-31-22)
viii. Braces, crutches, and wheelchairs
deemed necessary by the attending physician for the treatment of the disease;
(3-31-22)
ix. Emergency
transportation if in the opinion of the attending physician it is necessary to
transport the insured to another locality for treatment of the disease; and
(3-31-22)
x. Home health care that
is necessary care and treatment provided at the insured person's residence by a
home health care agency or by others under arrangements made with a home health
care agency. The program of treatment will be prescribed in writing by the
insured person's attending physician, who will approve the program prior to its
start. The physician certifies that hospital confinement would be otherwise
necessary. Home health care includes, but is not limited to: (3-31-22)
(1) Part-time or intermittent skilled nursing
services provided by a registered nurse or a licensed practical nurse;
(3-31-22)
(2) Part-time or
intermittent home health aide services that provide supportive services in the
home under the supervision of a registered nurse or a physical, speech, or
hearing occupational therapists; (3-31-22)
(3) Physical, occupational, or speech and
hearing therapy; (3-31-22)
(4)
Medical supplies, drugs, and medicines prescribed by a physician and related
pharmaceutical services, and laboratory services to the extent the charges or
costs would have been covered if the insured person had remained in the
hospital; (3-31-22)
xi.
Therapy, including physical, speech, hearing, and occupational therapy;
(3-31-22)
xii. Special equipment
including hospital bed, toilette, pulleys, wheelchairs, aspirator, chux,
oxygen, surgical dressings, rubber shields, colostomy, and ileostomy
appliances; (3-31-22)
xiii.
Prosthetic devices including wigs and artificial breasts; (3-31-22)
xiv. Nursing home care for non-custodial
services; and (3-31-22)
xv.
Reconstructive surgery when deemed necessary by the attending physician.
(3-31-22)
f. Per Diem
Cancer Coverages. Cancer coverages on a per diem indemnity basis includes:
(3-31-22)
i. A fixed-sum payment of at least
one hundred dollars ($100) for each day of hospital confinement for at least
three hundred sixty-five (365) days; (3-31-22)
ii. A fixed-sum payment equal to one-half
(1/2) the hospital inpatient benefit for each day of hospital or nonhospital
outpatient surgery, chemotherapy and radiation therapy, for at least three
hundred sixty-five (365) days of treatment; and (3-31-22)
iii. A fixed-sum payment of at least fifty
dollars ($50) per day for blood and plasma, which includes their administration
whether received as an inpatient or outpatient for at least three hundred
sixty-five (365) days of treatment. (3-31-22)
g. Lump Sum Indemnity Coverage. Lump sum
indemnity coverage for any specified disease will be payable as a fixed,
one-time payment made within thirty (30) days of submission to the insurer of
proof of diagnosis of the specified disease. (3-31-22)
i. Dollar benefits may only be in increments
of one thousand dollars ($1,000). (3-31-22)
ii. Where coverage is advertised or otherwise
represented to offer generic coverage of a disease or diseases, the same dollar
amounts will be payable regardless of the particular subtype of the disease
with one exception. In the case of clearly identifiable subtypes with
significantly lower treatments costs, lesser amounts may be payable so long as
the policy or certificate clearly differentiates that subtype and its benefits.
(3-31-22)
h. Hospice
Care. Hospice care is optional and does not cover non-terminally ill patients.
If offered, it will provide: (3-31-22)
i.
Eligibility for payment of benefits when the attending physician of the insured
provides a written statement that the insured person has a life expectancy of
six (6) months or less; (3-31-22)
ii. A fixed-sum payment of at least fifty
dollars ($50) per day; and (3-31-22)
iii. A lifetime maximum benefit limit of at
least ten thousand dollars ($10,000). (3-31-22)
i. Nursing Home Care. Benefits for skilled
nursing home confinement or the receipt of home health care are optional. If
offered, it will provide: (3-31-22)
i. A
fixed-sum payment equal to one-fourth (1/4) the hospital in-patient benefit for
each day of skilled nursing home confinement for at least one hundred (100)
days, but no more restrictive than under Medicare; (3-31-22)
ii. A fixed-sum payment equal to one-fourth
(1/4) the hospital in-patient benefit for each day of home health care for at
least one hundred (100) days, but no more restrictive than under Medicare; and
(3-31-22)
iii. Benefit payments
begin with the first day of care or confinement after the effective date of
coverage if the care or confinement is for a covered disease even though the
diagnosis of a covered disease is made at some later date (but not retroactive
more than thirty (30) days from the date of diagnosis) if the initial care or
confinement was for diagnosis or treatment of the covered disease.
(3-31-22)
02. Banned Policy or Certificate Provisions. Except for cancer coverage provided on an expense-incurred basis, either as cancer-only coverage or in combination with one or more other specified diseases, the following rules apply to specified disease coverages in addition to all other requirements imposed by this chapter. In cases of conflict the following govern: (3-31-22)
a. Policies covering a
single specified disease or combination of specified diseases are not to be
sold or offered for sale other than as specified disease coverage under this
Section. (3-31-22)
b. Any policy
issued pursuant to this Section that conditions payment upon pathological
diagnosis of a covered disease will also provide that if the pathological
diagnosis is medically inappropriate, a clinical diagnosis will be accepted
instead. (3-31-22)
c.
Notwithstanding any other provision of this chapter, specified disease policies
will provide benefits to any covered person not only for the specified diseases
but also for any other conditions or diseases, directly caused or aggravated by
the specified diseases or the treatment of the specified disease.
(3-31-22)
d. Individual accident
and sickness policies containing specified disease coverage will be guaranteed
renewable. (3-31-22)
e. No policy
issued pursuant to this Section contains a waiting or probationary period
greater than thirty (30) days. A specified disease policy may contain a waiting
or probationary period following the issue or reinstatement date of the policy
or certificate in respect to a particular covered person before the coverage
becomes effective as to that covered person. (3-31-22)
f. Except for lump sum indemnity coverage,
payments may be conditioned upon an insured person's receiving medically
necessary care, given in a medically appropriate location, under a medically
accepted course of diagnosis or treatment. (3-31-22)
g. Benefits will be paid regardless of other
coverage. (3-31-22)
h. After the
effective date of the coverage (or applicable waiting period, if any) benefits
begins with the first day of care or confinement if the care or confinement is
for a covered disease even though the diagnosis is made at some later date. The
retroactive application of the coverage is not to be less than ninety (90) days
prior to the diagnosis. (3-31-22)
i. Policies providing expense benefits will
not use the term "actual" when the policy only pays up to a limited amount of
expenses. Instead, the term "charge" or substantially similar language should
be used that does not have the misleading or deceptive effect of the phrase
"actual charges." (3-31-22)
j.
Preexisting condition will not be defined to be more restrictive than the
following: "Preexisting condition means a condition for which medical advice,
diagnosis, care or treatment was recommended or received from a physician
within the six (6) month period preceding the effective date of coverage of an
insured person." (3-31-22)
k.
Coverage for specified diseases will not be excluded due to a preexisting
condition for a period greater than twelve (12) months following the effective
date of coverage of an insured person unless the preexisting condition is
specifically excluded. (3-31-22)
03. Disclosure Provisions. (3-31-22)
a. An application or enrollment form
for specified disease coverage will contain a statement above the signature of
the applicant or enrollee that a person to be covered for specified disease is
not also covered by any Title XIX program (Medicaid, or any similar name). The
statement may be combined with any other statement for which the insurer may
request the applicant's or enrollee's signature. (3-31-22)
b. All specified disease policies and
certificates will contain on the first page in either contrasting color or in
boldface type at least equal to the size type used for headings or captions of
sections in the policy or certificate a prominent statement as follows: "Notice
to Buyer: This is a specified disease (policy) (certificate). This (policy)
(certificate) provides limited benefits. Benefits provided are supplemental and
are not intended to cover all medical expenses. Read your (policy)
(certificate) carefully with the outline of coverage." (3-31-22)
c. Outlines of coverage delivered in
connection with "Specified Disease" to persons eligible for Medicare by reason
of age will contain the following language in boldface type on the first page
of the outline of coverage: "THIS IS NOT A MEDICARE SUPPLEMENT POLICY. If you
are eligible for Medicare, review the 'Guide to Health Insurance for People
with Medicare' available from the company." (3-31-22)
d. An insurer will deliver to persons
eligible for Medicare any notice prescribed under IDAPA 18.04.10, "Rule to
Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act."
(3-31-22)
Disclaimer: These regulations may not be the most recent version. Idaho may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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