Current through Register Vol. 51, No. 19, September 20, 2024
A. Except as provided in §B of this regulation, if the group policy from which conversion is made provided coverage for basic hospital, medical, or surgical expense insurance, the insured person at the insured person's option shall be entitled to obtain a converted policy under any one of Plans A, B, or C, which are described in §C of this regulation.
B. If the group policy provided hospital benefits based on the full cost of a semiprivate room, the carrier, at its option, may offer the insured person only Plan A, and if the group policy provided hospital benefits on a basis other than the full cost of a semiprivate room, the carrier, at its option, may offer the insured person only Plans B and C.
C. Plans A-C provide the following minimum benefits:
(1) A Plan A policy shall provide as minimum the following benefits or similar benefits which are substantially actuarially equivalent:
(a) All semiprivate room and board and miscellaneous hospital charges for a 70-day maximum duration, and
(b) Surgical-medical expense benefits according to a schedule consistent with those customarily offered by the carrier under group insurance policies and providing a maximum benefit of $7,000;
(2) A Plan B policy shall provide as minimum the following benefits or similar benefits which are substantially actuarially equivalent:
(a) Hospital room and board benefits in a maximum amount of $700 daily for a 70-day maximum duration;
(b) Miscellaneous hospital expense benefits in a maximum amount of $7,000; and
(c) Surgical-medical expense benefits according to a schedule consistent with those customarily offered by the carrier under group policies and providing a maximum benefit of $7,000;
(3) A Plan C policy shall provide as minimum the following benefits or similar benefits which are substantially actuarially equivalent:
(a) Hospital room and board benefits in a maximum amount of $350 daily for a 70-day maximum duration;
(b) Miscellaneous hospital expense benefits in a maximum amount of $3,500; and
(c) Surgical-medical expense benefits according to a schedule consistent with those customarily offered by the carrier under group policies and providing a maximum benefit of $3,500.
D. If the group policy from which conversion is made provided coverage for major medical or catastrophe expense benefits, the insured person shall be entitled to obtain a converted policy meeting the following minimum specifications subject to the deductible and the limitation of §§E and F of this regulation, or similar benefits which are substantially actuarially equivalent:
(1) Hospital room and board benefits in an amount not less than 75 percent of the charges for semiprivate room accommodations;
(2) Miscellaneous hospital expense benefits for the charges made by the hospital for services and supplies which are customarily furnished by the hospital and provided for use during a period of hospital confinement, in an amount not less than 75 percent of the charges incurred subject to a maximum of $7,000;
(3) Surgical expense benefits not less than 75 percent of the scheduled benefits customarily offered by the carrier under its group policy with a maximum of $7,000;
(4) Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician, or the physician's assistant, performing the surgical services, in an amount not less than 75 percent of the reasonable charges;
(5) Medical expense benefits for the diagnosis and treatment of sickness or injury, in an amount not less than 75 percent of the reasonable charges; and
(6) Seventy-five percent of reasonable charges for diagnostic X-ray, laboratory services, radiation therapy, prosthetic appliances, and rental of durable medical equipment required for therapeutic use.
E. Major medical or catastrophe coverage benefits may be subject to a deductible equal to the benefits provided under any basic hospital-medical-surgical policy or other plan of health benefits covering the insured person plus a cash deductible of $800.
F. A major medical or catastrophe converted policy may be subject to an aggregate maximum benefit limit per person of $350,000.
G. Benefit Periods and Benefit Limits.
(1) The converted policy may use a definition of benefit period similar to that contained in the group policy from which conversion is made or may use a calendar year benefit period.
(2) The converted policy may contain a benefit limit for each benefit period.
(3) The benefit limit need not be greater than the limit for each benefit period which was available under the group policy, or $87,500, if less.
H. The benefits required under §§C and D of this regulation may be combined in a comprehensive policy which affords benefits at least as favorable as those required under §§C and D of this regulation, when both are applicable.
