A. Insurers other than non-profit hospital,
medical, and health care service organizations.
(1) Hospital Surgical Expense Benefits. If
the group insurance policy from which conversion is made insures the employee
or member, with or without dependent coverage, for basic hospital and/or
surgical expense insurance; the covered individuals shall be entitled to obtain
a converted policy, or at the insurer's option a group certificate, providing
coverage on an expense incurred basis under plans meeting the following
requirements:
PLAN A
(a) hospital
room and board daily expense benefits in a dollar amount approximating or equal
to the average semi-private rate charged in metropolitan areas of this State,
as determined by the Superintendent, for a period of seventy days per hospital
confinement,
(b) miscellaneous
hospital expense benefits, in the amount of ten times the room and board daily
expense benefit, per hospital confinement, and
(c) surgical expense benefits according to a
surgical schedule consistent with those customarily offered by the insurer
under group or individual health insurance policies and providing a maximum
benefit of eight hundred dollars; or
PLAN B
(a) hospital
room and board daily expense benefits in a dollar amount equal to 75 percent of
the dollar amount determined in Plan A, for a period of seventy days per
hospital confinement,
(b)
miscellaneous hospital expense benefits, in the amount of ten times the
hospital room and board daily expense benefits, per hospital confinement,
and
(c) surgical expense benefits
according to a surgical schedule consistent with those customarily offered by
the insurer under group or individual health insurance policies and providing a
maximum benefit of six hundred dollars; or
PLAN C
(a) hospital
room and board daily expense benefits in a dollar amount equal to 50 percent of
the dollar amount determined for Plan A, for a period of seventy days per
hospital confinement.
(b)
miscellaneous hospital expense benefits, in the amount of ten times the
hospital room and board daily expense benefit, per hospital confinement,
and
(c) surgical expense benefits
according to a surgical schedule consistent with those customarily offered by
the insurer under group or individual health insurance policies and providing a
maximum benefit of four hundred dollars.
The insurer must offer all three of these plans. The
individual may choose any one of the three. The average semi-private rate
referred to in Plan A, Subparagraph a, originally determined to be $200 in
Bureau Rules Chapter 280 effective October 18, 1982, shall continue to be $200
until July 1, 1988.
Effective July 1, 1988, this amount will increase to $240.
Any insurer needing to file new forms or rates in order to comply with this
change, must submit the filing on or before April 1, 1988. Any insurer
intending to use previously approved forms and rates to comply with this
change, must file a statement, specifying the forms and rates to be used, by
April 1, 1988.
The average semi-private rate referred to in Plan A,
Subparagraph a, may be redetermined by the Superintendent from time to time, as
to converted policies issued subsequent to such redetermination, but not more
often than once in three years. The dollar amounts in Plan A, B, and C shall be
rounded upward to the nearest multiple of ten dollars ($10).
For the purpose of determining the hospital room and board
daily expense benefits and the miscellaneous hospital expense benefits under
Plans A, B, and C, the policy or certificate may define recurrent hospital
confinements resulting from the same cause to be one continuous period of
confinement if the confinements are separated by a period of less than 180
days. If recurrent hospital confinements do not result from the same cause or
are separated by a period of 180 days or more, the subsequent confinement shall
be considered to be a separate confinement for the purpose of determining the
benefits payable under the policy or certificate.
(2) Major Medical
Benefits. If the group insurance policy from which conversion is made insures
the employee or member, with or without dependent coverage, for major medical
expense insurance; the covered individuals shall be entitled to obtain a
converted policy, or at the insurer's option a group certificate, providing
major medical coverage under a plan meeting the following requirements:
(a) A Maximum benefit at least equal to
either, at the option of the insurer, (i) or (ii) below:
(i) The smaller of the following amounts:
(A) The maximum benefit provided under the
group policy; or
(B) A maximum
payment of $250,000 per covered person for all covered medical expenses
incurred during the covered person's lifetime.
(ii) The smaller of the following amounts:
(A) The maximum benefit provided under the
group policy; or
(B) A maximum
payment of $250,000 for each unrelated injury or sickness.
(b) Payment of benefits at the
rate of 80 percent of covered medical expenses which are in excess of the
deductible, until 20 percent of such expenses in a benefit period reaches
$1,000, after which benefits will be paid at the rate of 100 percent during the
remainder of such benefit period. If the group policy from which conversion is
made provided benefits for the outpatient treatment of mental illness at a
level exceeding 50 percent of covered expenses, the converted policy need not
provide benefits in excess of 50 percent of covered expenses.
(c) A deductible for each benefit period
which, at the option of the insurer, shall be (i) the sum of the benefits
deductible and $100, or (ii) the corresponding deductible in the group policy
from which conversion is made. The term "benefits deductible," as used herein,
means the value of any benefits provided on an expense incurred basis with
respect to covered medical expenses by: any other hospital, surgical, or
medical insurance policy; any hospital or medical service subscriber contract;
any medical practice or other prepayment plan; any other plan or program
whether on an insured or uninsured basis; or any requirements of state or
federal law; and, if pursuant to Subparagraph (f) below the converted policy
provides both basic hospital or surgical coverage and major medical coverage,
the value of such basic benefits. If the maximum benefit is determined by (a)
(ii) above, the insurer may require that the deductible be satisfied during a
period of not less than three months, if the deductible is $100 or less; and
not less than six months if the deductible exceeds $100.
(d) The benefit period shall be a calendar
year when the maximum benefit is determined by (a) (i) above or twenty-four
months when the maximum benefit is determined by (a) (ii) above.
(e) The term "covered medical expenses" as
used above shall include at least, in the case of hospital room and board
charges, the lesser of the dollar amount in Plan A or the average semi-private
room and board rate for the hospital in which the individual is confined and
twice these amounts for charges in an intensive care unit. Any surgical
schedule shall be consistent with those customarily offered by the insurer
under group or individual health insurance policies and must provide at least a
$1,200 maximum benefit.
(f) If the
group insurance policy from which conversion is made provides the employee or
member with basic hospital and/or surgical expense insurance as well as major
medical expense insurance, then the benefits outlined in paragraphs 1 and 2
above may be offered under one policy or certificate. However, the three basic
plans outlined in Section
3(A)
(1) above must also be offered as
alternatives.
(g) The policy or
certificate shall contain no exclusions other than those contained in the group
policy from which conversion is made. However, if the group policy covered
dental and/or vision services, these services need not be covered by the
conversion policy or certificate.
