Pursuant to s.
632.897(4) (b), Stats., the following plans of
conversion coverage are established.
(1)PLAN 1-BASIC COVERAGE. Plan 1 basic
coverage consists of the following:
(a)
Hospital room and board daily expense benefits in a maximum dollar amount
approximating the average semi-private rate charged in the major metropolitan
area of this state, for a maximum duration of 70 days per calendar
year;
(b) Miscellaneous in-hospital
expenses, including anesthesia services, up to a maximum amount of 20 times the
hospital room and board daily expense benefits per calendar year; and
(c) In-hospital and out-of-hospital surgical
expenses payable on a usual, customary and reasonable basis up to a maximum
benefit of $2,000 a calendar year.
(2)PLAN 2-MAJOR MEDICAL EXPENSE COVERAGE.
Plan 2 major medical expense coverage shall consist of benefits for hospital,
surgical and medical expenses incurred either in or out of a hospital of the
following:
(a) A lifetime maximum benefit of
$75,000.
(b) Payment of benefits at
the rate of 80% of covered hospital, medical, and surgical expenses which are
in excess of the deductible, until 20% of such expenses in a benefit period
reaches $1,000, after which benefits shall be paid at 100% for the remainder of
the benefit period; provided, however, benefits for outpatient treatment of
mental illness, if covered by the policy, may be limited as provided in par.
(g), and surgical expenses shall be covered at a usual, customary and
reasonable level.
(c) A deductible
for each benefit period of $500 except that the deductible shall be $1,000 for
each benefit period for a policy insuring members of a family. All covered
expenses of any insured family member may be applied to satisfy the
deductible.
(d) A "benefit period"
shall be defined as a calendar year.
(e) Payment for all services covered under
the contract by any licensed health care professional qualified to provide the
services; except payment for psychologists' services may be conditioned upon
referral or supervision by a physician.
(f) Payment of benefits for maternity,
subject to the limitations in pars. (a), (b), and (c), if maternity was covered
under the prior policy.
(g)
Benefits for outpatient treatment of mental illness, if provided by the policy,
may be limited to either of the following coverages at the option of the
insurer:
1. At least 50% of usual, customary
and reasonable expenses which are in excess of the policy deductible, subject
to the policy lifetime maximum.
2.
The minimum benefits for group policies described in s.
632.89(2) (d), Stats.
(3)PLAN 3-MAJOR MEDICAL EXPENSE COVERAGE.
Plan 3 major medical expense coverage shall consist of benefits for hospital,
surgical and medical expenses incurred either in or out of a hospital of the
following:
(Same as Plan 2 except that maximum benefit is $100,000 and
deductible is $1,000 for an individual and $2,000 for a
family.)
