Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 755 - HEALTH INSURANCE CLASSIFICATIONS, DISCLOSURE, AND MINIMUM STANDARDS
Section 031-755-6 - Minimum Standards for Health Insurance Benefits

Universal Citation: 02 ME Code Rules ยง 031-755-6

Current through 2024-38, September 18, 2024

The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. An individual health insurance policy or group health insurance policy or certificate shall not be delivered or issued for delivery in this state unless it meets the required minimum standards for the specified categories or the Superintendent finds that the policies or certificates are approvable as supplemental health insurance and the outline of coverage complies with the outline of coverage in Section 7(M) of this rule.

The heading of the cover letter of any form filing subject to this rule shall state the category of coverage set forth in 24-A M.R.S.A. §2694 that the form is intended to be in.

This section shall not preclude the issuance of any policy or contract combining two or more categories set forth in 24-A M.R.S.A. §2694.

The requirements set forth in this section are in addition to any other applicable requirements as specified in Section 3(D).

A. General Rules

(1) A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" individual health insurance policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. In addition, the policy shall provide that in the event of the insured's death, the spouse of the insured, if covered under the policy, shall become the insured.

(2)
(a) The terms "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" shall not be used without further explanatory language in accordance with the disclosure requirements of Section 7A(4).

(b) The terms "noncancellable" or "noncancellable and guaranteed renewable" may be used only in an individual health insurance policy that the insured has the right to continue in force by the timely payment of premiums set forth in the policy at least until the age of 65 or until eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force.

(c) An individual health insurance policy that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness must provide that the insured has the right to continue the policy in force at least to age 60. The policy must further provide that if the insured is actively and regularly employed at age 60, the insured has the right to continue the policy in force at least until the earlier of the date the insured ceases to be actively and regularly employed or the insured's normal retirement age under social security. If the insured is ineligible for social security benefits, age 65 may be substituted for the insured's normal retirement age under social security.

(d) A policy that is subject to the renewal requirements of 24-A M.R.S.A. §2850-B and that permits the insurer to nonrenew for any reason other than nonpayment of premiums must be labeled "guaranteed renewable with limited exceptions."

(e) Except as provided in subparagraph (c) and (d) above, the term "guaranteed renewable" may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums at least until the age of 65 or until eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates on a class basis.

(3) In an individual health insurance policy covering both husband and wife, the age of the younger spouse shall be used as the basis for meeting the age and durational requirements of the definitions of "noncancellable" or "guaranteed renewable." However, this requirement shall not prevent termination of coverage of the older spouse upon attainment of the stated age so long as the policy may be continued in force as to the younger spouse to the age or for the policy duration period specified in the policy.

(4) When accidental death and dismemberment coverage is part of the individual health insurance coverage offered under the contract, the insured shall have the option to include all insureds under the coverage and not just the principal insured.

(5) If a policy contains a status-type military service exclusion or a provision that suspends coverage during military service, the policy shall provide, upon written requestof the payer, for refund of unearned premiums as applicable to the person on a pro rata basisbeginning with the first day of military service. The policy must also provide for coverage to resume without penalty to the owner upon receipt of a written request within 30 days of the end of military service.

(6) In individual health insurance policies, coverage shall continue for a dependent child who is incapable of self-sustaining employment due to mental retardation or physical handicap on the date that the child's coverage would otherwise terminate under the policy due to the attainment of a specified age for children and who is chiefly dependent on the insured for support and maintenance.

(7) A policy may contain a provision relating to recurrent disabilities, but a provision relating to recurrent disabilities shall not specify that a recurrent disability be separated by a period greater than six months.

(8) Accidental death and dismemberment benefits shall be payable if the loss occurs within 90 days from the date of the accident, irrespective of total disability. Disability coverage for loss due to an accident that occurs while the policy is in force may impose a time limit not to exceed 30 days on the time between the accidental event and commencement of the loss, but the limit must be waived if there is a clear cause and effect relationship between the accident and the subsequent loss.

(9) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.

(10) If a continuous loss commences while a policy or certificate providing disability income benefits is in force, termination of the policy will not relieve the insurer of liability for that loss. The continuous total disability of the insured may be a condition for the extension of benefits beyond the period the policy was in force, limited to the duration of the benefit period, if any, or payment of the maximum benefits.

(11) A policy providing coverage for fractures or dislocations may not provide benefits only for "full or complete" fractures or dislocations.

(12) All individual policies providing medical expense reimbursement benefits that are not subject to the grievance procedure requirements of Bureau of Insurance Rule Chapter 850 must contain a notice of the review and arbitration rights specified in 24-A M.R.S.A. §2747.

(13) A short-term nonrenewable policy shall be classified in one of the categories specified in Subsections B through I, K, or L based on its benefits.

(14) For a Sickness first manifested before the policy effective date, that was fraudulently not disclosed or fraudulently misrepresented in answer to a question in an application for coverage, an insurer may void or contest the policy or deny a claim at any time.

B. Basic Hospital Expense Coverage

"Basic hospital expense coverage" is a policy of health insurance that provides coverage, for a period of not less than 31 days during any one period of confinement for each person insured under the policy, for expense incurred for medically necessary treatment and services rendered as a result of accident or sickness for at least the following:

(1) Daily hospital room and board in an amount not less than the lesser of:
(a) 80% of the charges for semiprivate room accommodations or

(b) $500 per day;

(2) Miscellaneous hospital services for expenses incurred for the charges made by the hospital for services and supplies that are customarily rendered by the hospital and provided for use only during any one period of confinement in an amount not less than either 80% of the charges incurred up to at least $5,000 or ten times the daily hospital room and board benefits; and

(3) Hospital outpatient services consisting of:
(a) Hospital services on the day surgery is performed,

(b) Hospital services rendered within 72 hours after injury, in an amount not less than $1,000; and

(c) X-ray and laboratory tests in an amount not less than $500.

(4) Benefits provided under this subsection may be provided subject to a combined deductible amount not in excess of $500.

C. Basic Medical-Surgical Expense Coverage

"Basic medical-surgical expense coverage" is a policy of health insurance that provides coverage for each person insured under the policy for the expenses incurred for the medically necessary services rendered by a physician for treatment of an injury or sickness for at least the following:

(1) Surgical services:
(a) In amounts not less than those provided on a fee schedule based on the relative values contained in a fee schedule up to a maximum of at least $5,000 for one procedure; or

(b) Not less than 80% of the usual, customary and reasonable charges, as determined consistent with § 7(A)(7); or

(c) Not less than 80% of a maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions.

(2) Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical service rendered by a physician other than the physician (or the physician assistant) performing the surgical services:
(a) In an amount not less than 80% of the usual, customary and reasonable charges, as determined consistent with § 7(A)(7); or

(b) Not less than 80% of a maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions.; or

(c) 15% of the surgical service benefit.

(3) In-hospital medical services, consisting of physician services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical care is required, in an amount not less than:
(a) 80% of the usual, customary and reasonable charges, as determined consistent with § 7(A)(7); or

(b) 80% of a maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions; or

(c) $100 per day for not less than 21 days during one period of confinement.

D. Basic Hospital/Medical-Surgical Expense Coverage

"Basic hospital/medical-surgical expense coverage" is a combined coverage and must meet the requirements of both Subsections B and C.

E. Hospital Confinement Indemnity Coverage

(1) "Hospital confinement indemnity coverage" is a policy of health insurance that provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $50 per day and not less than 31 days during any one period of confinement for each person insured under the policy.

(2) Coverage shall not be excluded due to a preexisting condition for a period greater than 12 months following the effective date of coverage of an insured person unless the preexisting condition is specifically and expressly excluded.

(3) Except as permitted under 24-A M.R.S.A. §2723, benefits shall be paid regardless of other coverage.

F. Major Medical Expense Coverage

(1) "Major medical expense coverage" is a health insurance policy that provides coverage for medically necessary hospital, medical, and surgical expenses, subject to a lifetime maximum of not less than $1,000,000 per covered person, a coinsurance percentage not to exceed 50% of covered charges, provided that the coinsurance out-of-pocket maximum per covered person after any deductibles shall not exceed $10,000 per year, and a deductible stated on a per person, per family, per illness, per benefit period, or per year basis, or a combination of these bases not to exceed 5% of the lifetime maximum limit under the policy for each covered person, for at least:
(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;

(b) Miscellaneous hospital services;

(c) Surgical services;

(d) Anesthesia services;

(e) In-hospital medical services;

(f) Out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis for diagnosis and treatment of sickness or injury, diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and

(g) Diagnosis and treatment by a radiologist or physiotherapist;

(h) Treatment for functional nervous disorders and mental and emotional disorders; and

(i) Out-of-hospital prescription drugs and medications. Cost sharing for the drug benefit shall not exceed 50% on average. If there is a separate maximum for this benefit, it shall be at least $1,500 per year.

(2) If the policy is written to complement underlying basic hospital expense and basic medical-surgical expense coverage, the deductible may be increased by the amount of the benefits provided by the underlying coverage.

(3) The minimum benefits required by Section 6(F)(1) may be subject to all applicable deductibles, coinsurance, and general policy exceptions and limitations. A major medical expense policy may also have special or internal limitations for prescription drugs, nursing facilities, intensive care facilities, mental health treatment, alcohol or substance abuse treatment, transplants, experimental treatments, mandated benefits required by law, and other such special or internal limitations as are authorized or approved by the Superintendent. Except as authorized by this subsection through the application of special or internal limitations, a major medical expense policy must be designed to cover, after any deductibles or coinsurance provisions are met:
(a) The usual, customary, and reasonable charges, as determined consistent with § 7(A)(7); or

(b) A maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions; or

(c) Another rate agreed to between the insurer and provider, for covered services up to the lifetime policy maximum.

G. Basic Medical Expense Coverage

(1) "Basic medical expense coverage" is a health insurance policy that provides coverage for medically necessary hospital, medical, and surgical expenses, subject to a lifetime maximum of not less than $250,000 per covered person, a coinsurance percentage not to exceed 50% of covered charges, provided that the coinsurance out-of-pocket maximum after any deductibles shall not exceed $25,000 per covered person per year, and a deductible stated on a per person, per family, per illness, per benefit period, or per year basis, or a combination of these bases not to exceed 10% of the lifetime maximum limit under the policy for each covered person, for at least:
(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 or such other rate agreed to between the insurer and provider for a maximum period of not less than 31 days during any one period of confinement;

(b) Miscellaneous hospital services;

(c) Surgical services;

(d) Anesthesia services;

(e) In-hospital medical services;

(f) Out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis for diagnosis and treatment of sickness or injury, diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and

(g) Not fewer than three (3) of the following additional benefits:
(i) In-hospital private duty registered nurse services;

(ii) Convalescent nursing home care;

(iii) Diagnosis and treatment by a radiologist or physiotherapist;

(iv) Rental of special medical equipment, as defined by the insurer in the policy;

(v) Artificial limbs or eyes, casts, splints, trusses, or braces;

(vi) Treatment for functional nervous disorders and mental and emotional disorders; or

(vii) Out-of-hospital prescription drugs and medications.

(2) If the policy is written to complement underlying basic hospital expense and basic medical-surgical expense coverage, the deductible may be increased by the amount of the benefits provided by the underlying coverage.

(3) The minimum benefits required by 6G(1) may be subject to all applicable deductibles, coinsurance, and general policy exceptions and limitations. A basic medical expense policy may also have special or internal limitations for prescription drugs, nursing facilities, intensive care facilities, mental health treatment, alcohol or substance abuse treatment, transplants, experimental treatments, mandated benefits required by law, and those services covered under 6G(1)(g) and other such special or internal limitations as are authorized or approved by the Superintendent. Except as authorized by this subsection through the application of special or internal limitations, a basic medical expense policy must be designed to cover, after any deductibles or coinsurance provisions are met:
(a) The usual, customary, and reasonable charges, as determined consistently by the carrier and as subject to approval by the Superintendent; or

(b) A maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions; or

(c) Another rate agreed to between the insurer and provider, for covered services up to the lifetime policy maximum.

H. Individual Disability Income Protection Coverage

"Individual disability income protection coverage" provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination of them. The requirements of this subsection do not apply to policies providing business buy-out coverage.

(1) Policies shall not contain an elimination period greater than:
(a) 90 days in the case of a coverage providing a benefit of one year or less;

(b) 180 days in the case of coverage providing a benefit of more than one year but not greater than two (2) years; or

(c) 730 days in all other cases during the continuance of disability resulting from sickness or injury;

(2) The maximum benefit period shall be at least three months except a maximum benefit period of one month is permitted for normal pregnancy and normal childbirth or for miscarriage.

(3) No reduction in benefits shall be put into effect because of an increase in Social Security or similar benefits during a benefit period.

(4) An insurer may condition total disability benefits on care by a physician other than the insured or a member of the insured's immediate family.

I. Accident Only Coverage

"Accident only coverage" is a policy that provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under the policy shall be at least $2,000 and a single dismemberment amount shall be at least $1,000.

J. Specified Disease Coverage

(1) "Specified disease coverage" pays benefits based on diagnosis and/or treatment of a specifically named disease or diseases. A specified disease policy must meet the following rules and one of the following sets of minimum standards for benefits:
(a) Insurance covering cancer only or cancer in conjunction with other conditions or diseases must meet the standards of Paragraph (4), (5) or (6) of this subsection.

(b) Insurance covering only specified diseases other than cancer must meet the standards of Paragraph (3) or (6) of this subsection.

(2) General Rules

The following rules shall apply to specified disease coverages in addition to all other rules imposed by this Rule. In cases of conflict between the following and other rules, the following rules shall govern.

(a) Policies covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified disease coverage under this section.

(b) Any policy issued pursuant to this section that conditions payment upon pathological diagnosis of a covered disease shall also provide that if the pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted instead.

(c) Notwithstanding any other provision of this rule, specified disease policies shall provide benefits, with the exception of any lump-sum benefit based on diagnosis of a specified disease, 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.

(d) Individual specified disease coverage shall be guaranteed renewable or noncancellable.

(e) A specified disease policy may contain a waiting or probationary period of no more than 30 days following the issue or reinstatement date of the policy or certificate.

(f) An application or enrollment form for specified disease coverage shall contain a statement above the signature of the applicant or enrollee that a person to be covered is not covered also by any Title XIX program (Medicaid). The statement may be combined with any other statement for which the insurer may require the applicant's or enrollee's signature.

(g) 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.

(h) Except as permitted under 24-A M.R.S.A. §§2722 and 2723, benefits for specified disease coverage shall be paid regardless of other coverage.

(i) After the effective date of the coverage (or applicable waiting period, if any) benefits based on care or confinement shall begin 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.

(j) Policies providing expense benefits shall not use the term "actual" when the policy pays up to only a limited amount of expenses. Instead, the policy should use language that does not have the misleading or deceptive effect of the phrase "actual charges."

(k) "Preexisting condition" shall not be defined more broadly 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."

(l) Coverage for specified diseases will not be excluded due to a preexisting condition for a period greater than six (6) months following the effective date of coverage of an insured person.

(m) Hospice Care.
(i) "Hospicecare" means services provided on a 24-hours-a-day, 7-days-a-week basis to a person who is terminally ill and that person's family. "Hospice care" includes, but is not limited to, physician services, nursing care, respite care, medical and social work services, counseling services, nutritional counseling, pain and symptom management, medical supplies and durable medical equipment, occupational, physical or speech therapies, volunteer services, home health care services, and bereavement services.

(ii) Hospice care is an optional benefit. However, if a specified disease insurance product offers coverage for hospice care, it shall meet the following minimum standards:
(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 12 months or less;

(II) A fixed-sum payment of at least $50 per day; and

(III) A lifetime maximum benefit limit of at least $20,000.

(3) Expense-incurred non-cancer coverages must provide the minimum benefits specified in either subparagraph (a) or subparagraph (b):
(a) Coverage for each insured person for a specifically named disease (or diseases) with a deductible amount not in excess of $250 and an overall aggregate benefit limit of no less than $10,000 and a benefit period of not less than two years. The policy may provide coverage for any expenses necessarily incurred in the treatment of the disease but must cover at least the following incurred expenses:
(i) Hospital room and board and any other hospital furnished medical services or supplies;

(ii) Treatment by a legally qualified physician or surgeon;

(iii) Private duty services of a registered nurse;

(iv) X-ray, radium, and other therapy procedures used in diagnosis and treatment;

(v) Professional ambulance for local service to or from a local hospital;

(vi) Blood transfusions, including expense incurred for blood donors;

(vii) Drugs and medicines prescribed by a physician;

(viii) The rental of an iron lung or similar mechanical apparatus;

(ix) Braces, crutches, and wheel chairs as are deemed necessary by the attending physician for the treatment of the disease; and

(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.

(b) 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 $25,000 payable at the rate of not less than $50 a day while confined in a hospital and a benefit period of not less than 500 days.

(4) A policy that provides coverage for cancer-only coverage or in combination with one or more other specified diseases on an expense incurred basis shall cover at least the usual, customary, and reasonable charges, as determined consistent with § 7(A)(7) or a maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions, for the following services and supplies for the care and treatment of cancer. The policy may provide for a deductible amount not in excess of $250 for each insured person, an overall aggregate benefit limit of not less than $10,000 for each insured person, and a benefit period of not less than three years. With the exception of subparagraphs (c) and (f), services and supplies provided on an outpatient basis may be subject to copayment by the insured person not to exceed 20% of covered charges. The requirements of this paragraph apply unless the Superintendent approves different minimum benefits based on a determination that the minimum benefits provided by the insurer are in the interest of the consumer.
(a) Treatment by, or under the direction of, a legally qualified physician or surgeon;

(b) X-ray, radium chemotherapy and other therapy procedures used in diagnosis and treatment;

(c) Hospital room and board and any other hospital furnished medical services or supplies;

(d) Blood transfusions and their administration, including expense incurred for blood donors;

(e) Drugs and medicines prescribed by a physician;

(f) Professional ambulance for local service to or from a local hospital;

(g) Private duty services of a registered nurse provided in a hospital;

(h) Braces, crutches, and wheelchairs deemed necessary by the attending physician for the treatment of the disease;

(i) 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;

(j)
(i) Home health care, which 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 policy may require that the program of treatment be prescribed in writing by the insured person's attending physician and that the physician approve the program prior to its start. The policy also may require that the physician certify that confinement in a hospital or a skilled nursing facility would be otherwise required. A "home health care agency" is an entity that (1) is an agency approved under Medicare, (2) is licensed to provide home health care under applicable state law, or (3) meets all of the following requirements:
(I) It is primarily engaged in providing home health care services;

(II) Its policies are established by a group of professional personnel (including at least one physician and one registered nurse);

(III) It is available to provide the care needed in the home seven days a week and has telephone answering service available 24 hours per day;

(IV) It provides, either directly or through contract, the services of a coordinator responsible for case discovery and planning and for assuring that the covered person receives the services ordered by the physician;

(V) It has under contract the services of a physician-advisor licensed by the State or a physician; and

(VI) It maintains clinical records on all patients.

(ii) Home health care includes, but is not limited to:
(I) Part-time or intermittent skilled nursing services provided by a registered nurse or a licensed practical nurse;

(II) 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;

(III) Physical, occupational or speech and hearing therapy; and

(IV) 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.

(k) Physical, speech, hearing and occupational therapy;

(l) Special equipment including hospital bed, toilette, pulleys, wheelchairs, aspirator, chux, oxygen, surgical dressings, rubber shields, and colostomy and eleostomy appliances;

(m) Prosthetic devices including wigs and artificial breasts;

(n) Nursing home care for noncustodial services; and

(o) Reconstructive surgery when deemed necessary by the attending physician.

(p) Policies that offer transportation and lodging benefits for an insured person may not condition those benefits on hospitalization.

(5) The requirements of this paragraph apply unless the Superintendent approves different minimum benefits based on a determination that the minimum benefits provided by the insurer are in the interest of the consumer.
(a) The following minimum benefits standards apply to cancer coverages written on a per diem indemnity basis. These coverages shall offer insured persons:
(i) A fixed-sum payment of at least $100 for each day of hospital confinement for at least 365 days;

(ii) A fixed-sum payment equal to one half the hospital inpatient benefit for each day of hospital or nonhospital outpatient surgery, chemotherapy, and radiation therapy, for at least 365 days of treatment; and

(iii) A fixed-sum payment of at least $50 per day for blood and plasma, which includes their administration whether received as an inpatient or outpatient for at least 365 days of treatment.

(b) Benefits tied to confinement in a skilled nursing home or to receipt of home health care are optional. If a policy offers these benefits, the benefits must be as follows:
(i) A fixed-sum payment equal to one-fourth the hospital in-patient benefit for each day of skilled nursing home confinement for at least 100 days.

(ii) A fixed-sum payment equal to one-fourth the hospital in-patient benefit for each day of home health care for at least 100 days.

(iii) Benefit payments shall 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 if the initial care or confinement was for diagnosis or treatment of the covered disease.

(iv) Notwithstanding any other provision of this rule, any restriction or limitation applied to the benefits in (b)(i) and (b)(ii) whether by definition or otherwise, shall be no more restrictive than those under Medicare.

(6) The following minimum benefits standards apply to lump-sum indemnity coverage of any specified disease:
(a) These coverages must pay indemnity benefits on behalf of insured persons of a specifically named disease or diseases. The benefits are payable as a fixed, one-time payment made within 30 days of submission to the insurer of proof of diagnosis of the specified disease.

(b) Where coverage is advertised or otherwise represented to offer generic coverage of a disease or diseases, the same dollar amounts shall 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 clearly differentiates that subtype and its benefits.

K. Specified Accident Coverage

"Specified accident coverage" is a policy that provides coverage for a specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment combined. The benefit amount shall not be less than $2,000 for accidental death, $2,000 for double dismemberment, and $1,000 for single dismemberment.

L. Supplemental Health Coverage

"Supplemental health coverage" is a policy or contract, other than a policy or contract covering only a specified disease or diseases, that provides benefits that are less than the minimum standards for benefits required under Subsections B, C, D, E, F, G, I and K. These policies or contracts may be delivered or issued for delivery in this state only if the outline of coverage required by Section 7(M) of this rule is completed and delivered as required by Section 7(B) of this rule and the policy or certificate is clearly labeled as a supplemental policy or certificate as required by Section 7(A)(17). A policy covering a single specified disease or combination of diseases shall meet the requirements of Section 6(J) and shall not be offered for sale as a "limited" or "supplemental" coverage.

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