Current through Vol. 42, No. 13, March 17, 2025
(a)
Minimum standards. The
following minimum standards for benefits are prescribed for categories of
coverage noted in the following subsections. No individual policy or accident
and sickness insurance shall be delivered or issued for delivery in this site
which does not meet the required minimum standards for the specified categories
unless the Commissioner finds that such policies or contracts are approvable as
Limited Benefit Health insurance and the Outline of Coverage complied with the
appropriate outline in 365:10-5-5(j). Nothing in this section shall preclude
the issuance of any policy or contract combining two or more categories of
coverage.
(b)
General
rules.
(1) A "noncancellable",
"guaranteed renewable", or "noncancellable and guaranteed renewable" 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 non-payment of premium. 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) 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
365:10-5-6(a)(1).
The terms "noncancellable" or "noncancellable and guaranteed renewable" may be
used only in a policy which the insured has the right to continue in force by
the timely payment of premiums set forth in the policy until the age of
sixty-five (65) or to eligibility for medicare, during which period the insurer
has no right to make unilaterally any change in a provision of the policy while
the policy is in force; provided, however, any accident and health or accident
and health only policy which provides for periodic payments, weekly or monthly,
for a specified period during the continuance of disability resulting from
accident or sickness, may provide that the insured has the right to continue
the policy only to age sixty (60) if, at age sixty (60), the insured has the
right to continue the policy in force at least to age sixty-five (65) while
actively or regularly employed. Except as provided above, the term "guaranteed
renewable" may be used only in a policy which the insured has the right to
continue in force by the timely payment of premiums until the age of sixty-five
(65) or to 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
by classes. Provided however, any accident and health or accident only policy
which provides for periodic payments, weekly or monthly, for a specified period
during the continuance of disability resulting from accident or sickness may
provide that the insured has the right to continue the policy only to age sixty
(60) if, at age sixty (60), the insured has the right to continue the policy in
force at least to age sixty-five (65) while actively and regularly
employed.
(3) In a family policy
covering both husband and wife the age of the younger spouse must be used as
the basis for meeting the age and duration 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 limit (e.g., age 65) so long as the policy may be continued in force
as to the younger spouse to the age or for the duration period as specified in
said definition.
(4) When accident
health and dismemberment coverage is part of the insurance coverage offered
under the contract, the insured shall have the option to include all insureds
under such coverage and not just the principal insured.
(5) If a policy contains a status type
military service exclusion or a provision which suspends coverage during
military service, the policy shall provide, upon receipt of written request,
for refund of premiums as applicable to such person on a pro rata
basis.
(6) In the event the insurer
cancels or refuses to renew, policies providing pregnancy benefits shall
provide for an extension of benefits as to pregnancy commencing while the
policy is in force and for which benefits would have been payable had the
policy remained in force.
(7)
Policies providing convalescent or extended care benefits following
hospitalization shall not condition such benefits upon admission to the
convalescent or extended care facility within a period of less than fourteen
(14) days after discharge from the hospital.
(8) Family coverage shall continue for any
dependent child who is incapable of self sustaining employment due to mental
retardation or physical handicap on the date that such child's coverage would
otherwise terminate under the policy due to the attainment of a specified age
limit for children, if the child is chiefly dependent on the insured for
support and maintenance. The policy may require that within 31 days of such
date the company receive due proof of such incapacity in order for the insured
to elect to continue the policy in force with respect to such child, or that a
separate converted policy be issued at the option of the insured or
policyholder.
(9) Any policy
providing coverage for the recipient in a transplant operation shall also
provide reimbursement of any medical expense of a live donor to the extent that
benefits remain and are available under the recipient's policy, after benefits
for the recipient's own expenses have been paid.
(10) A policy may contain a provision
relating to recurrent disabilities, provided however, that no such provision
shall specify that a recurrent disability be separated in a period greater than
six (6) months.
(11) Accidental
death and dismemberment benefits shall be payable if the loss occurs within
ninety (90) days from the date of the accident, irrespective of total
disability. Disability income benefits, if provided, shall not require the loss
to commence less than thirty (30) days after the date of accident, nor shall
any policy which the insurer cancels or refuses to renew require that it be in
force at the time disability commences if the accident occurred while the
policy was in force.
(12) Specific
dismemberment benefits shall not be in lieu of other benefits unless the
specific benefit equals or exceeds the other benefits.
(13) Any accident only policy providing
benefits which vary according to the type of accidental cause shall prominently
set forth in the outline of coverage the circumstances under which benefits are
payable which are less than the maximum amount payable under the
policy.
(14) Termination of the
policy shall be without prejudice to any continuous loss which commenced while
the policy was in force, but the extension of benefits beyond the period the
policy was in force may be predicated upon the continuous total disability of
the insured, limited to the duration of the policy benefit period, if any, of
payment of the maximum benefits.
(15) Any policy which does not meet the
prescribed minimum standards stated in this section which in the opinion of the
Department, is either experimental in nature or is demonstrated to be of a type
of coverage that will fulfill a reasonable need of the person or persons
insured, may be approved only as to categories prescribed by the
Department.
(16) Nothing in this
regulation shall preclude the issuance of any policy or outline of coverage
that combines two or more of the categories of coverage enumerated in (c)
through (i) of this paragraph.
(c)
Basic hospital expense
coverage. "Basic Hospital Expense Coverage" is a policy of accident and
sickness insurance which provides coverage for a period of not less than
thirty-one (31) days during any continuous hospital confinement for each person
insured under the policy, for expense incurred for 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 semi-private room accommodations; or
(2) miscellaneous hospital services for
expenses incurred for the charges made by the hospital for services and
supplies which 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 $1,000.00 or ten times the daily
hospital room and board benefits;
(3) hospital outpatient servies consisting
of:
(A) hospital services on the day surgery
is performed, and
(B) hospital
services rendered within 72 hours after accidental injury, in an amount not
less than $50.00, and
(C) X-ray and
laboratory tests to the extent that benefits for such services would have been
provided to an extent not less than $100.00 if rendered to an in-patient of the
hospital;
(4) benefits
provided under (1) and (2) of this section, may be provided subject to a
combined deductible amount not in excess of $100.00.
(d)
Basic medical-surgical expense
coverage. "Basic Medical-Surgical Expense Coverage" is a policy of
accident and sickness insurance which provides coverage for each person insured
under the policy for the expenses incurred for the necessary services rendered
in 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 the State of New
York certified surgical fee schedule, or the 1964 California Relative Value
Schedule or other acceptable relative value scale or surgical procedures, up to
a maximum of at least $500.00 for any one procedure; or
(B) not less than 80% of the reasonable
charges.
(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 his assistant) performing the surgical
services:
(A) in an amount not less than 80%
of the reasonable charges; or
(B)
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 80% of the reasonable charges; or $5.00
per day for not less than twenty-one (21) days during one period of
confinement.
(e)
Hospital confinement indemnity coverage. "Hospital Confinement
Indemnity Coverage" is a policy of accident and sickness insurance which
provides daily benefits for hospital confinement on an indemnity basis in an
amount not less that $30.00 per day and not less than thirty-one (31) days
during any one period of confinement for each person insured under the
policy.
(f)
Major medical
expense coverage. "Major Medical Expense Coverage" is an accident and
sickness insurance policy which provides hospital, medical and surgical expense
coverage, to an aggregate maximum of not less than $10,000.00; co-payment by
the covered person not to exceed 25% of covered charges, a deductible stated on
a per person, per family, per illness, per benefit period, or per year basis,
or a combination of such basis not to exceed 5% of the aggregate maximum limit
under the policy, unless the policy is written to complement "other health
plans" as defined in
365:10-5-3, in
which case such deductible may be increased by the amount of the benefits
provided by such "other health plans". However, if the covered person is
insured by two or more policies containing such a non-duplication of benefits
feature, only the policy which has covered the person for the longest time may
apply such non-duplication provision. To be classified as "major Medical
Expense Coverage", a policy must provide for each covered person for at least:
(1) Daily hospital room and board expense,
prior to application of the co-payment percentage, for not less than $50.00
daily (or in lieu thereof the average daily cost of semiprivate room rate in
the area where the insured resides) for a period of not less than 31 days
during continuous hospital confinement;
(2) miscellaneous hospital services, prior to
application of the co-payment percentage, for an aggregate maximum of not less
than $1,500 or 15 times the daily room and board rate if specified in dollar
amounts;
(3) surgical services,
prior to application of co-payment percentage to a maximum of not less than
$600 for the most severe operation with the amounts provided for other
operations related to such maximum amount;
(4) anesthesia services prior to application
of the co-payment percentage, for a maximum of not less than 15 percent of the
covered surgical fees or, alternatively, if the surgical schedule is based on
relative values, not less than the amount provided therein for anesthesia
services at the same unit value as used to the surgical schedule;
(5) in hospital medical services, prior to
application of the co-payment percentage, as defined in
365:10-5-3(c)
of this subsection.
(6) Out of
hospital care prior to application of the co-payment percentage 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, and diagnostic X-ray, laboratory services, radiation therapy, and
hemodialysis ordered by a physician; and
(7) no fewer than three of the following
additional benefits, prior to application of the co-payment percentage, for a
aggregate maximum of such covered charges of not less than $1,000:
(A) In hospital private duty graduate
registered nurse services.
(B)
Convalescent nursing home care.
(C)
Diagnosis and treatment by a radiologist or physiotherapist.
(D) Rental of special medical equipment, as
defined by the insurer in the policy.
(E) Artificial limbs or eyes, casts, splints,
trusses or braces.
(F) Treatment
for functional nervous disorders, and mental emotional disorders.
(G) Out-of-hospital prescription drugs and
medications.
(g)
Disability income protection
coverage. "Disability tincome protection coverage" is a policy which
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 thereof which:
(1) Provides
that periodic payments which are payable at ages after 62 and reduced solely on
the basis of age are at least 50% of amounts payable immediately prior to
62.
(2) Contains an elimination
period no greater than:
(A) Ninety (90) days
in the case of a coverage providing a benefit of one (1) year or
less;
(B) One hundred and eighty
(180) days in the case of coverage providing a benefit of more than one year
but not greater than two years;
(C)
Three hundred and sixty-five (365) days in all other cases during the
continuance of disability resulting from sickness or injury.
(3) Has a maximum period of time
for which it is payable during disability of at least six (6) months, except in
the case of a policy covering disability arising out of pregnancy, childbirth,
or miscarriage, in which case the period for such disability may be one (1)
month. No reduction in benefits shall be put into effect because of an increase
in Social Security or similar benefits during a benefit period. 365:10-5-5(g)
does not apply to these policies providing business buy out coverage.
(h)
Accident only
coverage. "Accident only coverage" is a policy of accident insurance
which provides coverage, singularly or in combination, for death,
dismemberment, disability, or hospital and medical care caused by accident.
Accidental death and double dismemberment amounts under such a policy shall be
at least $1,000.00 and a single dismemberment amount shall be at least
$500.00.
(i)
Specified
disease and specified accident coverage.
(1) "Specified Disease Coverage" is a policy
which meets one of the following definitions:
(A) A policy which provides coverage for each
person insured under the policy for a specifically named disease (or diseases)
with a deductible amount not in excess of $250.00 and an overall aggregate
benefit limit of not less than $5,000.00 and a benefit period of not less than
two (2) years for 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;
(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;
and
(xi) May include coverage of
any other expenses necessarily incurred in the treatment of the
disease.
(B) A policy
which provides coverage for each person insured under the policy 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.
(2) "Specified Accident Coverage" is an
accident insurance policy which 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 with a benefit
amount not less than $1,000.00 for accidental death, $1,000.00 for double
dismemberment and $500.00 for single dismemberment.
(j)
Medicare supplement
coverage. "Medicare Supplement Coverage" is a policy of accident and
sickness insurance which is designed primarily to supplement Medicare, or is
advertised, marketed, or otherwise proposed to be a supplement to Medicare and
which meets the requirements of the following rules and standards applicable to
any such policy sold to a person eligible for Medicare by reason of age:
(1) The following shall be applicable to
"Medicare Supplement Coverage" and shall be in addition to other requirements
of this regulation. These are minimum standards and do not preclude the
inclusion of additional benefits in such coverage:
(A) Notwithstanding
365:10-5-3(6),
365:10-5-4(c) and
(g), pre-existing condition limitations shall
not exclude coverage for more than six months after the effective date of
coverage under the policy for a condition for which medical advice was given or
treatment was recommended by or received from a physician within six (6) months
before the effective date of the coverage;
(B) The term "Medicare benefit period" shall
mean the unit of time used in the Medicare program to measure use of services
and availability of benefits under Part A Medicare hospital
insurance;
(C) The term "Medicare
eligible expenses" shall mean health care expenses of the kinds covered by
Medicare to the extent recognized as reasonable by Medicare. Payment of
benefits by insurers for Medicare eligible expenses may be conditioned upon the
same or less restrictive payment conditions, including determinations of
medical necessity as are applicable to Medicare claims;
(D) Coverage, when issued, shall not be
subject to any exclusions, limitations, or reductions (other than as permitted
in this section and other applicable laws and regulations) which are
inconsistent with the exclusions, limitations or reductions permissible under
Medicare, other than a provision that coverage is not provided for any expenses
to the extent of any benefit available to the insured person under
Medicare;
(E) Coverage shall not
indemnify against losses resulting from sickness on a different basis than
losses resulting from accidents; and
(F) Coverage shall provide that benefits
designed to cover cost sharing amounts under Medicare will be changed
automatically to coincide with any changes in the applicable Medicare
deductible amount and co-payment percentage factors. Premiums may be changed to
correspond with such changes.
(2) Minimum Benefit Provisions, Medicare
Supplement Coverages shall provide at least the following benefits to an
insured person:
(A) Coverage of Part A
Medicare eligible for hospitalization to the extent not covered by Medicare
from the 61st day through the 90th day in any Medicare Benefit
period;
(B) Coverage of Part A
Medicare eligible expenses incurred as daily hospital charges during use of
Medicare's lifetime hospital inpatient reserve days;
(C) Upon exhaustion of all Medicare hospital
impatient coverage, including the lifetime reserve days coverage of 90% of all
Medicare Part A Eligible expenses for hospitalization not covered by Medicare,
subject to a lifetime maximum benefit of an additional 365 days.
(D) Coverage of 20% of the amount of Medicare
eligible expenses under Part B, regardless of hospital confinement, subject to
a maximum calendar year out-of-pocket deductible of $200 of such expenses and
to a maximum benefit of at least $5000 per calendar year.
(k)
Limited Benefit Health
Insurance Coverage. "Limited Benefit Health Insurance Coverage" is any
policy or contract which provides benefits that are less than the minimum
standards for benefits required under (c), (d), (e), (f), (h), (i), and (j) of
this paragraph. Such policies or contracts may be delivered or issued for
delivery in this state only if the outline coverage required by
365:10-5-6(h)
is completed and delivered by
365:10-5-6(b).
