Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.038 - SPECIFIED DISEASE COVERAGE

Current through August 31, 2023
01.
Minimum
			 Standards for Benefits
. The following minimum standards apply to
			 specified disease coverage: (3-31-22)
a.
			 Coverage for cancer only or cancer in conjunction with other conditions or
			 diseases needs to meet the standards of Paragraphs 01.e., 01.f., or 01.g. of
			 this section. (3-31-22)
b. Coverage
			 for specified diseases other than cancer meets the standards of Paragraphs
			 01.c., 01.d., or 01.g. of this section. (3-31-22)
c. Non-cancer Coverages with Deductible.
			 Coverage for each insured person for a specifically named disease (or diseases)
			 with a deductible amount not in excess of two hundred fifty dollars ($250) and
			 an overall aggregate benefit limit of not less than ten thousand dollars
			 ($10,000) and a benefit period of not less than two (2) years for at least the
			 following incurred expenses: (3-31-22)
i.
			 Hospital room and board and any other hospital furnished medical services or
			 supplies; (3-31-22)
ii. Treatment
			 by a legally qualified physician or surgeon; (3-31-22)
iii. Private duty services of a registered
			 nurse (R.N.); (3-31-22)
iv. X-ray,
			 radium and other therapy procedures used in diagnosis and treatment;
			 (3-31-22)
v. Professional ambulance
			 for local service to or from a local hospital; (3-31-22)
vi. Blood transfusions, including expense
			 incurred for blood donors; (3-31-22)
vii. Drugs and medicines prescribed by a
			 physician; (3-31-22)
viii. The
			 rental of an iron lung or similar mechanical apparatus; (3-31-22)
ix. Braces, crutches, and wheel chairs deemed
			 necessary by the attending physician for the treatment of the disease;
			 (3-31-22)
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
			 (3-31-22)
xi. May include coverage
			 of any other expenses necessarily incurred in the treatment of the disease.
			 (3-31-22)
d. Non-cancer
			 Coverages without Deductible. Coverage for each insured person for a
			 specifically named disease (or diseases) with no deductible amount, and an
			 overall aggregate benefit limit of not less than twenty five thousand dollars
			 ($25,000) payable at the rate of not less than fifty dollars ($50) a day while
			 confined in a hospital and a benefit period of not less than five hundred (500)
			 days. (3-31-22)
e. Cancer-only or
			 Combination Expense Policies. Coverage for each insured person for cancer-only
			 coverage or in combination with one (1) or more other specified diseases on an
			 expense incurred basis for services, supplies, care, and treatment of cancer,
			 in amounts not in excess of the usual and customary charges, with a deductible
			 amount not in excess of two hundred fifty dollars ($250), and an overall
			 aggregate benefit limit of not less than ten thousand dollars ($10,000) and a
			 benefit period of not less than three (3) years for at least the following
			 minimum provisions: (3-31-22)
i. Treatment by,
			 or under the direction of, a legally qualified physician or surgeon;
			 (3-31-22)
ii. X-ray, radium,
			 chemotherapy and other therapy procedures used in diagnosis and treatment;
			 (3-31-22)
iii. Hospital room and
			 board and any other hospital furnished medical services or supplies;
			 (3-31-22)
iv. Blood transfusions
			 and their administration, including expense incurred for blood donors;
			 (3-31-22)
v. Drugs and medicines
			 prescribed by a physician; (3-31-22)
vi. Professional ambulance for local service
			 to or from a local hospital; (3-31-22)
vii. Private duty services of a registered
			 nurse provided in a hospital; (3-31-22)
viii. Braces, crutches, and wheelchairs
			 deemed necessary by the attending physician for the treatment of the disease;
			 (3-31-22)
ix. 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
			 (3-31-22)
x. Home health care that
			 is necessary care and treatment provided at the insured person's residence by a
			 home health care agency or by others under arrangements made with a home health
			 care agency. The program of treatment will be prescribed in writing by the
			 insured person's attending physician, who will approve the program prior to its
			 start. The physician certifies that hospital confinement would be otherwise
			 necessary. Home health care includes, but is not limited to: (3-31-22)
(1) Part-time or intermittent skilled nursing
			 services provided by a registered nurse or a licensed practical nurse;
			 (3-31-22)
(2) Part-time or
			 intermittent home health aide services that provide supportive services in the
			 home under the supervision of a registered nurse or a physical, speech, or
			 hearing occupational therapists; (3-31-22)
(3) Physical, occupational, or speech and
			 hearing therapy; (3-31-22)
(4)
			 Medical supplies, drugs, and medicines prescribed by a physician and related
			 pharmaceutical services, and laboratory services to the extent the charges or
			 costs would have been covered if the insured person had remained in the
			 hospital; (3-31-22)
xi.
			 Therapy, including physical, speech, hearing, and occupational therapy;
			 (3-31-22)
xii. Special equipment
			 including hospital bed, toilette, pulleys, wheelchairs, aspirator, chux,
			 oxygen, surgical dressings, rubber shields, colostomy, and ileostomy
			 appliances; (3-31-22)
xiii.
			 Prosthetic devices including wigs and artificial breasts; (3-31-22)
xiv. Nursing home care for non-custodial
			 services; and (3-31-22)
xv.
			 Reconstructive surgery when deemed necessary by the attending physician.
			 (3-31-22)
f. Per Diem
			 Cancer Coverages. Cancer coverages on a per diem indemnity basis includes:
			 (3-31-22)
i. A fixed-sum payment of at least
			 one hundred dollars ($100) for each day of hospital confinement for at least
			 three hundred sixty-five (365) days; (3-31-22)
ii. A fixed-sum payment equal to one-half
			 (1/2) the hospital inpatient benefit for each day of hospital or nonhospital
			 outpatient surgery, chemotherapy and radiation therapy, for at least three
			 hundred sixty-five (365) days of treatment; and (3-31-22)
iii. A fixed-sum payment of at least fifty
			 dollars ($50) per day for blood and plasma, which includes their administration
			 whether received as an inpatient or outpatient for at least three hundred
			 sixty-five (365) days of treatment. (3-31-22)
g. Lump Sum Indemnity Coverage. Lump sum
			 indemnity coverage for any specified disease will be payable as a fixed,
			 one-time payment made within thirty (30) days of submission to the insurer of
			 proof of diagnosis of the specified disease. (3-31-22)
i. Dollar benefits may only be in increments
			 of one thousand dollars ($1,000). (3-31-22)
ii. Where coverage is advertised or otherwise
			 represented to offer generic coverage of a disease or diseases, the same dollar
			 amounts will be payable regardless of the particular subtype of the disease
			 with one exception. In the case of clearly identifiable subtypes with
			 significantly lower treatments costs, lesser amounts may be payable so long as
			 the policy or certificate clearly differentiates that subtype and its benefits.
			 (3-31-22)
h. Hospice
			 Care. Hospice care is optional and does not cover non-terminally ill patients.
			 If offered, it will provide: (3-31-22)
i.
			 Eligibility for payment of benefits when the attending physician of the insured
			 provides a written statement that the insured person has a life expectancy of
			 six (6) months or less; (3-31-22)
ii. A fixed-sum payment of at least fifty
			 dollars ($50) per day; and (3-31-22)
iii. A lifetime maximum benefit limit of at
			 least ten thousand dollars ($10,000). (3-31-22)
i. Nursing Home Care. Benefits for skilled
			 nursing home confinement or the receipt of home health care are optional. If
			 offered, it will provide: (3-31-22)
i. A
			 fixed-sum payment equal to one-fourth (1/4) the hospital in-patient benefit for
			 each day of skilled nursing home confinement for at least one hundred (100)
			 days, but no more restrictive than under Medicare; (3-31-22)
ii. A fixed-sum payment equal to one-fourth
			 (1/4) the hospital in-patient benefit for each day of home health care for at
			 least one hundred (100) days, but no more restrictive than under Medicare; and
			 (3-31-22)
iii. Benefit payments
			 begin with the first day of care or confinement after the effective date of
			 coverage if the care or confinement is for a covered disease even though the
			 diagnosis of a covered disease is made at some later date (but not retroactive
			 more than thirty (30) days from the date of diagnosis) if the initial care or
			 confinement was for diagnosis or treatment of the covered disease.
			 (3-31-22)