Current through Register Vol. 35, No. 18, September 24, 2024
A specified disease plan is subject to these additional
requirements.
A.
General
requirements
(1) A plan covering a
single specified disease or combination of specified diseases shall not be sold
or offered for sale other than as a specified disease plan.
(2) A specified disease plan that conditions
payment upon a pathological diagnosis shall also provide that if the
pathological diagnosis is not medically feasible, a clinical diagnosis will be
accepted.
(3) A specified disease
plan shall pay a lump-sum upon medical diagnosis of the specified disease, or
for any form or variation of a specified disease that is covered by the
plan.
(4) An individual specified
disease plan shall be guaranteed renewable.
(5) A specified disease plan shall not be
sold to a person covered by any Title XIX program (Medicaid, Centennial Care or
any similar name). An individual specified disease plan shall contain a
statement above the signature line of an individual applicant or covered person
attesting that the person seeking to be covered for a specified disease is not
covered by Medicaid. The statement may not be combined with any other statement
for which the carrier may require the applicant or covered person's signature.
For group plans, the carrier shall provide a notice in any enrollment materials
of the above prohibition of sale of a specified disease plan to persons covered
by Title XIX programs.
(6) Any
benefit that is conditioned on repeated care for a specified disease shall
begin with the first day of care even if the diagnosis is made at some later
date.
(7) A specified disease plan
shall provide benefits only on a fixed indemnity basis.
(8) A specified disease plan may offer other
fixed indemnity benefits in compliance with 13.10.34.12.
B.
Minimum benefits The
following minimum benefits standards apply to all specified disease coverages:
(1) No less than an aggregate amount of
$5,000 per triggering diagnosis. The OSI may approve product filings that allow
a lower aggregate amount for a variant or subtype of a covered specified
disease that requires minimally invasive treatment or are non-life-threatening.
OSI may also approve plan designs for more extensive coverage for
dependents.
(2) Dollar benefit
limits shall be offered for sale only in even increments of $1,000 unless for
dependent extended coverage riders, in which case this extended coverage may be
offered for sale only in even increments of $500.
(3) 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 variant or subtype of the
disease, unless lower aggregate amounts have otherwise been approved under
Paragraph (1) of this subsection.
C.
Reductions in benefits. A
specified disease plan shall not eliminate or reduce benefits based on the
occurrence of specified events or attaining a certain age.
D.
Overinsurance No carrier or
producer shall offer or sell a specified disease plan, or combination of such
plans, that apply to more than eight specified diseases. Except for group
specified disease plans offered by an employer, no carrier or producer shall
sell a specified disease plan if that would result in the customer having
coverage for more than eight specified diseases under plans issued by different
carriers. Except for group specified disease plans offered by an employer, a
specified disease plan application shall inquire whether a prospective insured
has other specified disease coverage, and about the number and type of diseases
covered by a prospective insured's other coverage, if any. A specified disease
plan may provide benefits for all medically diagnosed and commonly recognized
forms or variations of each specified disease or illness without having each
variation count against the eight disease limit. A carrier shall not sell to an
individual a specified disease plan if such coverage would result in the
individual being covered by more than one specified disease plan for the same
specified disease.
