Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
Subchapter S - MINIMUM STANDARDS AND BENEFITS AND READABILITY FOR INDIVIDUAL ACCIDENT AND HEALTH INSURANCE POLICIES
Section 3.3074 - Minimum Standards for Major Medical Expense Coverage
Universal Citation: 28 TX Admin Code § 3.3074
Current through Reg. 50, No. 13; March 28, 2025
(a) "Major Medical Expense Coverage" is an accident and sickness insurance policy which provides hospital, medical, and surgical expense coverage as follows:
(1) an
aggregate maximum of not less than $10,000;
(2) a co-payment by the covered person, shall
not exceed 20% of covered charges in policies providing aggregate maximum
benefits of $10,000 and 25% in all other policies;
(3) a deductible stated on a basis of one or
more of the following:
(A) per
person;
(B) per family;
(C) per illness;
(D) per benefit period; or
(4) policies which contain a
variable deductible provision, i.e., a provision which in addition to a stated
basic or minimum deductible amount chosen by the policyholder, includes a
deductible amount to the extent of any other medical and hospital expense
benefits available to the policyholder under any other policy, if any, shall
conform to the following criteria:
(A) the
right of renewal shall be no more limited than the applicable minimum standards
for renewability set forth in §
3.3020 of this title (relating to
Policy Definition of Guaranteed Renewable and Limited Guarantee of
Renewability);
(B) the policy
provides for an increase in the maximum amount of benefits in a sum of at least
$3.00 for each $1.00 of other medical expense benefits used as part of the
deductible.
(5) benefits
shall be provided under major medical expense coverage for each covered person
for at least:
(A) daily hospital room and
board expenses, prior to application of the co-payment percentage, for not less
than $50 daily (or in lieu thereof the average daily cost of semi-private room
rate in the area where the insured is confined) for a period of not less than
31 days during continuous hospital confinement;
(B) miscellaneous hospital services, prior to
application of the co-payment percentage, for an aggregate maximum of not less
than $1500 or 15 times the daily room and board rate if specified in dollar
amounts;
(C) surgical fees, 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
reasonably related to such maximum amount;
(D) anesthesia services, prior to application
of the co-payment percentage, for a maximum of not less than 15% 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 for the surgical schedule;
(E) doctor visits, in or out of the hospital,
with minimum dollar amounts per visit, prior to application of the co-payment
percentage, equal to not less than $10 per visit, covering at least one visit
per day and for an aggregate maximum of such covered charges of not less than
$600;
(F) out-of-hospital
diagnostic x-ray and tests, prior to application of the co-payment percentage,
for an aggregate maximum of such covered charges of not less than
$600;
(G) no fewer than three of
the following additional benefits, prior to application of the co-payment
percentage, for an aggregate maximum of such covered of not less than $1,000:
(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;
(vii) out-of-hospital prescription drugs and
medications;
(6) if hospital confinement maternity
benefits are included within the scope of policy coverage then the amount of
the minimum benefits for each covered pregnancy, prior to application of the
co-payment percentage, shall be the actual expenses incurred according to the
policy terms up to an amount that is equal to 10 times the minimum daily
hospital room and board benefit.
(b) Major medical expense coverage must be guaranteed renewable in accordance with § 3.3020 of this title (relating to Policy Definition of Guaranteed Renewable and Limited Guarantee of Renewability) and § 3.3038 of this title (relating to Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical or Surgical Coverage; Exceptions) of this subchapter, unless such insurance constitutes short-term limited duration coverage, as defined in § 3.3002(b)(18) of this title (relating to Definitions).
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