Current through August 31, 2023
01.
Minimum
Covered Benefits. (3-31-22)
a. Daily
hospital room and board expenses subject only to limitations based on average
daily cost of the semiprivate room rate in the area where the insured resides;
(3-31-22)
b. Miscellaneous hospital
services; (3-31-22)
c. Surgical
services; (3-31-22)
d. Anesthesia
services; (3-31-22)
e. In-hospital
medical services; and (3-31-22)
f.
Out-of-hospital care, consisting of physicians' services rendered on an
ambulatory basis where coverage is not provided elsewhere in the policy for
diagnosis and treatment of sickness or injury, diagnostic x-ray, laboratory
services, radiation therapy, and hemodialysis ordered by a physician.
(3-31-22)
02.
Minimum Additional Benefits. A separate premium corresponding to
additional benefits offered through a rider is to be filed and actuarially
justified. A policy is to provide not fewer than three (3) of the following
additional benefits: (3-31-22)
a. In-hospital
private duty registered nurse services; (3-31-22)
b. Convalescent nursing home care;
(3-31-22)
c. Diagnosis and
treatment by a radiologist or physiotherapist; (3-31-22)
d. Rental of special medical equipment, as
defined by the insurer in the policy; (3-31-22)
e. Artificial limbs or eyes, casts, splints,
trusses or braces; (3-31-22)
f.
Treatment for functional nervous disorders, and mental and emotional disorders;
or (3-31-22)
g. Out-of-hospital
prescription drugs and medications. (3-31-22)
03.
Enhanced Short-term Plans Covered
Benefits. The following covered benefits and limitations are to be
provided consistent with the Benchmark Medical Plan, including: (3-31-22)
a. Ambulatory (outpatient) patient services;
(3-31-22)
b. Emergency services;
(3-31-22)
c. Hospitalization;
(3-31-22)
d. Maternity and newborn
care; (3-31-22)
e. Mental health
and substance use disorder services, including behavioral health treatment;
(3-31-22)
f. Prescription drugs;
(3-31-22)
g. Rehabilitative and
habilitative services and devices; (3-31-22)
h. Laboratory services; and
(3-31-22)
i. Preventive and
wellness services and chronic disease management. (3-31-22)
04.
Prescription Drug Formulary.
If a prescription drug coverage formulary is applied, the applicable formulary
drug list is to: (3-31-22)
a. Include at
least one drug in every United States Pharmacopeia (USP) category and class;
(3-31-22)
b. Cover a range of drugs
across a broad distribution of therapeutic categories and classes and
recommended drug treatment regimens that treat all covered disease states, and
does not discourage enrollment by any group of enrollees; and
(3-31-22)
c. Provide appropriate
access to drugs included in broadly accepted treatment guidelines and
indicative of then-current general best practices.
(3-31-22)
05.
Cost
Sharing. (3-31-22)
a. Except for
out-of-network benefits offered as part of a managed care plan, a coinsurance
percentage is not to exceed fifty percent (50%) of covered charges. A
coinsurance percentage for out-of-network benefits offered as part of a managed
care plan is not to exceed sixty percent (60%) of covered charges.
(3-31-22)
b. The maximum
out-of-pocket is to be stated in the policy and in aggregate is not to exceed
four percent (4%) of the aggregate annual limit under the policy for each
covered person. All deductibles, copayments, coinsurance and any other
cost-sharing are applicable to the maximum out-of-pocket. Within the aggregate
maximum, the policy may include separate out-of-pocket limits applicable to
particular services. (3-31-22)
c.
The annual limit is no less than one million dollars ($1,000,000) for each
covered person. (3-31-22)
d.
Enhanced short-term plans are to provide coverage for and not impose any cost
sharing requirements for preventive and wellness services consistent with QHP
requirements. (3-31-22)
06.
Applicability of Mental Health
Parity. Enhanced short-term plans are to meet the requirements of
Section 2726 of the
Public Health Service Act (Mental Health Parity and Addiction Equity Act) in
the same manner and extent as QHPs. (3-31-22)
07.
Benefit Requirements. The
minimum benefits imposed by Subsections
030.01,
030.02, and
030.03 may be subject to all
applicable deductibles, coinsurance and general policy exceptions and
limitations. Except as disallowed by Subsections
030.03,
030.05, and
030.06, a policy may also have
special or internal limitations for nursing facilities, transplants,
experimental treatments, services covered under Subsection
030.02, and other special or
internal limitations authorized by the Director. Except as authorized by this
Subsection through the application of special or internal limitations, a policy
will cover, after any deductibles or coinsurance provisions are met, the usual,
customary and reasonable charges, as determined consistently by the carrier and
as subject to prior written approval by the Director or another rate agreed to
between the insurer and provider, for covered services up to the annual limit.
(3-31-22)
