California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.5 - Standards for Determining Conformity of Individual Disability Policies with the Provisions of Paragraph (7) of Subdivision (b) of Section 10291.5 of the Insurance Code › Subarticle 6 - Major Medical Expense Benefits › Section 2220.25 - Major Medical Expense Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A policy, or rider, shall be deemed to provide major
						medical expense benefits and shall be deemed to be of real economic value and
						not subject to Section
						2220.15 through
						2220.24 if:
(a) The aggregate maximum benefit is not less
					 than $10,000 per covered person.
(b) The coinsurance percentage applicable to
					 expenses covered under Items (f), (g), (h), (i) and (j) below is not more than
					 25 percent, and the coinsurance percentage applicable to Item (k) and any other
					 covered expense not referred to in this section is not more than 50
					 percent.
(c) The deductible amount
					 (other than as specified below in this section) is not more than 10 percent of
					 the maximum benefit.
(d) The
					 maximum benefit period for an "each cause" type of policy (where a separate
					 deductible is required for different sicknesses and accidents) is not less than
					 18 months and the maximum benefit period for an "all cause" type of policy
					 (where separate deductibles are not required for different sicknesses or
					 accidents) is not less than the number of days remaining in the calendar or
					 policy year after the deductible has been met.
(e) The period allowed to satisfy the
					 deductible is not less than 90 days if the deductible is $500 or less, or is
					 not less than 90 plus an additional 30 days for each additional $500, or
					 fraction thereof, of deductible.
(f) Hospital room and board expenses are
					 covered, prior to application of the coinsurance percentage, for not less than
					 $50.00 daily (or in lieu thereof the cost of a semi-private room rate in the
					 area where the insured resides), and is not less than either the cost or double
					 the daily amount during confinement in the hospital's intensive care unit for
					 up to 10 days.
(g) Miscellaneous
					 hospital services are covered, prior to application of the coinsurance
					 percentage, for an aggregate maximum of not less than $1,500.
(h) Surgical fees are covered, prior to
					 application of the coinsurance percentage, to a maximum of not less than $750
					 for the most severe operation in accordance with a surgical schedule which
					 otherwise meets the requirements of Section
					 2220.21; and anesthesia services
					 are covered, prior to application of the coinsurance percentage, for a maximum
					 of not less than 15 percent of the covered surgical fees, or, alternatively, if
					 the surgical schedule is based on a California Relative Value Schedule, not
					 less than the amount provided therein for anesthesia services at the same unit
					 value as used for the surgical schedule.
(i) Doctors visits are covered, in or out of
					 the hospital, with minimum dollar amounts per visit, prior to application of
					 the coinsurance percentage, equal to not less than $8.00 per visit, covering
					 not less than one visit per day and for an aggregate maximum of such covered
					 charges of not less than $500.
(j)
					 Out-of-hospital diagnostic X-rays and tests are covered, prior to application
					 of the coinsurance percentage, for an aggregate maximum of not less than
					 $500.
(k) Not fewer than three of
					 the following additional benefits are covered, prior to application of the
					 coinsurance percentage, for an aggregate maximum of not less than $1,000:
(1) In-hospital private duty registered nurse
					 services.
(2) Convalescent nursing
					 home care.
(3) Diagnosis and
					 treatment by a radiologist or physiotherapist.
(4) Rental of special medical equipment, as
					 defined by the insurer in the policy.
(5) Artificial limbs or eyes; casts, splints,
					 trusses or braces.
(6) Treatment
					 for functional nervous disorders, and mental and emotional disorders.
(7) Out-of-hospital prescription drugs and
					 medications.
The deductible amount may be expressed as either:
(1) a fixed dollar amount; or
(2) the higher of a fixed dollar amount of
					 basic deductible or the policy's covered charges paid by medical expense
					 insurance; or
(3) not more than $500
					 plus the policy covered charges paid by other medical expense insurance.
Notwithstanding the terminology of either this section,
						or any other section of this Article, this section shall not be interpreted in
						any manner which is or would be inconsistent with the provisions of any
						applicable section of the Insurance Code. A benefit under this section shall
						not be of real economic value to an insured person if any coinsurance
						percentage factor of the policy is applied as a reduction in benefits prior to
						application of any deductible.
If a policy, or rider, provides a fixed benefit (a
						benefit not subject to a coinsurance percentage) for any of the medical
						expenses referred to in (f), (h) or (i) above, a fixed benefit of 75 percent of
						the minimum covered charge specified in (f), (h) or (i) shall be acceptable;
						and, if coinsurance percentages of less than 25 percent are applicable, a lower
						covered charge will be acceptable if at least as much as 75 percent of the
						minimum covered charge specified in (f), (h) or (i).