reglab/statecodes huggingface dataset:
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 4 - Basic Medical Benefits › Section 2220.16 - Basic Miscellaneous Hospital Services Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Except to the extent provided otherwise in Section
						2220.20, a benefit covering
						miscellaneous hospital services (other than a benefit described in Sections
						2220.19 and
						2220.22) shall be deemed not
						sufficient to be of real economic value to the insured if.
(a) When the benefit specifies a blanket
					 amount for miscellaneous hospital services for unnamed items, such blanket
					 amount is less than five times the largest daily hospital benefit of the
					 policy; or
(b) When the benefit
					 specifies a blanket amount for miscellaneous hospital services for a number of
					 named items, such blanket amount is less than five times the largest daily
					 hospital benefit of the policy, or the items named are less than six in number;
					 or
(c) When the benefit specifies a
					 separate limiting amount per separate item named, the amount per item is less
					 than $15.00 and the aggregate limiting amount for all such items is less than
					 $150 or the items named are less than seven in number and the amounts are not
					 reasonably related; or
(d) Less
					 than six of such items if separately named are of a reasonably normal frequency
					 or occurrence; and
(e) It does not
					 provide benefits under either (a) or (b) or (c) above for diagnostic X-rays,
					 laboratory tests and electrocardiograms on an in-patient basis and also on an
					 out-patient basis for preadmission hospital testing when the procedures are
					 performed within 72 hours of admission to the hospital.
A policy or rider which contains the benefits of this
						section and Section
						2220.15 may be subject to a
						combined deductible not in excess of $100.00, except that if the miscellaneous
						hospital service benefits are not less than ten times the daily hospital
						benefit, the combined deductible may be not in excess of $150.00. This section
						shall not prohibit a miscellaneous hospital services benefit which, in the
						opinion of the Commissioner is not less than the actuarial equivalent of one of
						the specified benefits in this section.
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 4 - Basic Medical Benefits › Section 2220.17 - Basic Hospital Benefits Expressed as Increases of Loss-of-Time Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A benefit expressed as an increase of a loss-of-time
						benefit (Section
						2220.11) during hospital
						confinement shall be deemed not sufficient to be of real economic value to the
						insured if:
(a) The increase in the
					 loss-of-time benefit is less than either the lesser of the basic loss-of-time
					 amount required under Section
					 2220.11 or, if expressed
					 otherwise, if it is less than $300.00 per month, or if the benefit is payable
					 for less than two months duration; except
(b) In the case of industrial insurance, if
					 the increase in the loss-of-time benefit is less than either the lesser of the
					 basic loss-of-time amount required under Section
					 2220.11 or, if expressed
					 otherwise, it is less than $150 per month, or if the benefit is payable for
					 less than one month duration.
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 4 - Basic Medical Benefits › Section 2220.18 - Basic Private Duty Nurse Benefit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A policy which provides a benefit for in hospital or out
						of hospital private duty nursing by either a licensed registered nurse (R.N.)
						or a licensed vocational nurse (L.V.N.) shall be deemed not sufficient to be of
						real economic value to an insured if:
(a) The amount of the daily private duty
					 nursing benefit is less than $18.00 per shift for not less than one shift per
					 day for a licensed registered nurse or $12.00 per shift for not less than one
					 shift per day for a licensed vocational nurse; or
(b) The maximum period of time for which the
					 benefit is payable is less than 10 days.
A policy which provides a nurse benefit for professional
						nurse home calls-by either a registered nurse or a vocational nurse shall be
						deemed not to be of real economic value to the insured unless the benefit
						equals not less than 25 percent of the benefit provided under Subsections (a)
						and (b) of this section and is not subject to elimination periods of more than
						the first three home calls for a sickness benefit and not more than the first
						three home calls for an accident benefit. A "home call" for the purpose of this
						section means a personal home visit during any one twenty-four hour
						period.
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 4 - Basic Medical Benefits › Section 2220.19 - Basic Accident Emergency Treatment Benefit

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A separate basic accident emergency treatment benefit
						shall be deemed not sufficient to be of real economic value to the insured
						if:
(a) The amount of the benefit is
					 less than one day of the loss-of-time benefit (without application of any
					 elimination period) but in no event less than $10.00 when an emergency accident
					 treatment benefit is provided on other than an expense incurred basis in a
					 loss-of-time policy; or
(b) The
					 benefit is payable on an expense incurred basis, and the amount is less than
					 $25.00; or
(c) The benefit is
					 payable, irrespective of the expense incurred, in other than a loss-of-time
					 policy, and the amount payable is less than $10.00.
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 4 - Basic Medical Benefits › Section 2220.20 - Basic Blanket Medical Expense Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A benefit providing basic blanket coverage (coverage
						without inside dollar limits for specific items) for basic medical expenses
						shall not be subject to the provisions of Sections
						2220.15,
						2220.16 and
						2220.17 but shall be deemed not
						sufficient to be of real economic value to the insured if.
(a) When an accident benefit, its limit is
					 less than $1,000 or the expenses for which it is payable are limited to those
					 incurred within a period of less than six months following each separate
					 accident; or
(b) When a sickness
					 benefit, other than a benefit described in Section
					 2220.24, is limited to a
					 specifically named sickness, its limit is less than $1,000 or the expenses for
					 which it is payable are limited to those incurred within a period of less than
					 six months following the commencement of any one period of sickness;
					 or
(c) Payments for the expenses of
					 each separate accident or period of sickness are subject to a deductible amount
					 in excess of ten percent of the maximum benefit.
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 4 - Basic Medical Benefits › Section 2220.21 - Basic Scheduled Surgical Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A basic surgical benefit in which surgical operations are
						listed by name or description with a limiting amount on each item shall be
						deemed not sufficient to be of real economic value to the insured if the amount
						provided for the most severe operation is less than $300.00 and the amounts
						provided for other operations are not reasonably related to such maximum amount
						and if it fails to contain a proviso that any operation not named and not
						otherwise excluded will be paid for in an amount which shall be objectively
						determined by the company on the basis of the gravity and severity of the
						unnamed operation as compared to analogously named
						operations.
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 4 - Basic Medical Benefits › Section 2220.22 - Basic Pregnancy or Maternity Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A separate benefit for pregnancy, childbirth or
						miscarriage, when expressed as a specified dollar amount shall be deemed not
						sufficient to be of real economic value to the insured if its amount is less
						than $75.00 for normal delivery and $50.00 for miscarriage during the first
						policy year and less than $150.00 for normal delivery and $75.00 for
						miscarriage during subsequent policy years.
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 4 - Basic Medical Benefits › Section 2220.23 - Basic Medical Service Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A benefit for expenses incurred for professional calls of
						doctors, covering home, office and hospital calls or one or more of such types
						of calls, shall be deemed not sufficient to be of real economic value to the
						insured if:
(a) More than the first
					 three home calls, the first three hospital calls, or the first three office
					 calls as the case may be, (counting as a call for such purpose at least one
					 such call actually made during any one twenty-four hour period), are eliminated
					 from the benefit; or
(b) The
					 benefit limits payment for call made and otherwise compensable to fewer than
					 one per twenty-four hour period; or
(c) The amount payable per compensable call
					 is less than $6.00 per home call and less than $6.00 per office or hospital
					 call; or
(d) Compensation provided
					 for expenses of covered calls (whether resulting from each separate accident or
					 sickness or occurring in each separate policy year) is limited:
(1) To a number less than 30 where the limit
					 of such coverage is expressed in terms of number of calls, or
(2) To an amount less than $180.00 where the
					 limit of such coverage is expressed in terms of a stated amount.
This section does not prohibit a provision which provides
						that physician's calls are not covered for a period after a surgical procedure
						is performed if the policy form provides a surgical benefit for the surgical
						procedure performed.
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 5 - Dread Disease Benefits › Section 2220.24 - Dread Disease Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A sickness benefit which is limited to a delineated or
						defined field of sickness coverage (such as poliomyelitis, cancer or a
						specifically named or described disease) shall be deemed not sufficient to be
						of real economic value to the insured if:
(a) Its maximum limit is less than $10,000,
					 or if the expenses for which it is payable are limited to those incurred for
					 treatment necessitated by each such sickness within a period of less than three
					 years following the commencement of medical treatment for such sickness, or if
					 the benefits are subject to scheduled inside dollar limits and such limits do
					 not meet the minimum requirements of Section
					 2220.25; or
(b) In lieu of the minimum benefits specified
					 in paragraph (a) above, a policy or rider limited to cancer provides minimum
					 benefits not less than the following: $50 a day for the first 12 days of
					 hospitalization without any elimination period, deductible or coinsurance
					 factor and also $30 a day for each day of continuous hospitalization thereafter
					 with no limit on the number of days of hospitalization; X-ray, radium and
					 cobalt therapy up to a total of $1,500; attending physician's charges in
					 hospital (other than the operating surgeon) of $7.50 per day up to a total of
					 $500; surgical charges in accordance with the 1964 California Relative Value
					 Schedule; anesthetist services either up to $100 for an operation other than
					 for a skin cancer operation for which the anesthetist fee shall be not less
					 than $30 for an operation or in an amount consistent with the amount provided
					 by the 1964 California Relative Value Schedule; nursing expenses of $24 per
					 shift for not less than one shift per day up to a total of $750; blood
					 transfusions and plasma up to a total of $500; prescribed drugs and medicines
					 up to a total of $250; and an overall aggregate limit on all benefits of not
					 less than $10,000.
1. Change
						without regulatory effect adopting subarticle 5 heading and removing subject
						heading filed 7-14-2021 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2021, No. 29). Filing deadline specified in Government
						Code section
						11349.3(a)
						extended 60 calendar days pursuant to Executive Order
						N-40-20.
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 7 - Catastrophic Medical Expense Benefits › Section 2220.26 - Catastrophic Medical Expense Benefits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A policy, or rider, shall be deemed to provide
						catastrophic major medical expense benefits, and shall be deemed of real
						economic value and not subject to Sections
						2220.15 through
						2220.24, if it would otherwise
						qualify as providing major medical expense benefits under Section
						2220.25 and (1) has an aggregate
						maximum benefit of not less than $25,000 per covered person, and (2) includes
						benefits for all of the items listed in Section
						2220.25 (k) (1) through
						(k) (6) for an aggregate maximum of not less
						than $5,000.
1. Change
						without regulatory effect adopting subarticle 7 heading and removing subject
						heading filed 7-14-2021 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2021, No. 29). Filing deadline specified in Government
						Code section
						11349.3(a)
						extended 60 calendar days pursuant to Executive Order
						N-40-20.
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 7 - Catastrophic Medical Expense Benefits › Section 2220.27 - Deductibles and Coinsurance Prohibited Unless Specifically Permissible

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Except to the extent specifically provided otherwise in
						Sections 2220.7 through
						2220.30, deductables and
						coinsurance percentage factors are prohibited by this Article unless the
						benefits provided are of real economic value and the use of other coinsurance
						percentage factors and deductibles are approved by the Commissioner in
						accordance with the procedure provided under Section
						2220.7. The Commissioner shall
						consider under the provision of Section
						2220.7 other deductibles and
						coinsurance percentage factors for basic hospital, medical and surgical
						coverages provided that the benefits, in the opinion of the Commissioner, are
						not less than the actuarial equivalent for a covered person of the minimum
						benefits specified in this Article for the same type of
						benefit.
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 7 - Catastrophic Medical Expense Benefits › Section 2220.28 - Recurrent Confinements and Recurrent Disabilities

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A policy may contain provisions relating to recurrent
						confinements or recurrent disabilities, provided however, a recurrent
						confinement provision or a recurrent disability provision shall be deemed not
						sufficient to be of real economic value to the insured if in applying any two
						or more periods of confinement or disability the periods of confinement or
						disability must be separated by more than 6 months.
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 8 - Insurance Issued to Persons Eligible for Benefits Under Medicare › Section 2220.29 - Hospital Indemnity Policies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A daily hospital benefit, provided on other than an
						expense incurred basis and issued to a person eligible for benefits under
						Medicare, shall be deemed not sufficient to be of real economic value to the
						person insured if:
(a) It provides a
					 daily hospital benefit of less than $15, payable for less than 60 days, or if
					 it is a hospital benefit for mental disorders, and the period of time the
					 benefit is payable than 30 days; or
(b) The elimination period, if any, exceeds
					 one day for sickness benefits and one day for accident benefits; or
(c) The benefits is subject to any waiting
					 period other than a waiting period for condition specified in Section
					 2220.10(b);
					 or
(d) It excludes coverages or
					 provides reduced benefits for exceptions, limitations or reductions other than
					 those specified in Section
					 2220.8; or
(e) It contains a pre-existing condition
					 provision other than as specified in Section
					 2220.52(a).
A hospital indemnity policy conforming to this Section
						may not be labeled or described as a Medicare Supplement
						Policy.
1.
						Amendment filed 4-5-78; effective thirtieth day thereafter (Register 78, No.
						14).
2. Amendment of subsection (e) filed 3-31-83; effective
						thirtieth day thereafter (Register 83, No. 14).
3. Change without
						regulatory effect adopting subarticle 8 heading and removing subject heading
						filed 7-14-2021 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2021, No. 29). Filing deadline specified in Government
						Code section
						11349.3(a)
						extended 60 calendar days pursuant to Executive Order
						N-40-20.0.52
Note: Authority cited: Section
						  10291.5(c),
						  Insurance Code. Reference: Section
						  10291.5(b)
						  (7), Insurance
						  Code.
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 8 - Insurance Issued to Persons Eligible for Benefits Under Medicare › Section 2220.30 - Medicare Supplement Expense Policies. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Amendment filed 4-5-78; effective thirtieth day thereafter (Register 78, No.
						14).
2. Repealer filed 3-31-83; effective thirtieth day thereafter
						(Register 83, No. 14).
Note: Authority cited: Section
						  10291.5
						  (c), Insurance Code. Reference: Section
						  10291.5 (b)
						  (7), Insurance
						  Code.
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 8 - Insurance Issued to Persons Eligible for Benefits Under Medicare › Section 2220.31 - Prior Inconsistent Regulations and Bulletins Superseded

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This regulation supersedes all prior regulations and
						bulletins of this Department to the extent that such prior regulations and
						bulletins are inconsistent with this regulation.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.50 - Purpose and Scope

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This Article establishes minimum benefit and policy
					 provision standards for Medicare supplement coverages which are equal to or
					 exceed those applied in the voluntary certification of such coverages by the
					 United States Secretary of Health and Human Services pursuant to
					 Public Law
					 96-265.
It shall apply to all individual and group Medicare
					 supplement insurance policies and non-profit hospital service plan benefit
					 agreements approved by the Commissioner after its effective date its effective
					 date. Pursuant to Insurance Code Section
					 10195, this
					 Article also applies to all certificates providing Medicare supplement coverage
					 issued to California residents pursuant to master policies delivered outside of
					 California.
1. New
					 Article 1.6 (Sections
					 2220.50 --2220.57) filed 3-31-83;
					 effective thirtieth day thereafter (Register 83, No.
					 14).
Note: Authority cited: Sections
						10291.5
						(c) and
						10195,
						Insurance Code. Reference: Sections
						10195 and
						10291.5(b)
						(7), Insurance
						Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.51 - Definition

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
"Medicare Supplement Coverage" is accident and sickness
					 insurance which is designed primarily to supplement Medicare, or is advertised,
					 marketed, or otherwise purported to be a supplement to Medicare and which meets
					 the requirements of the following rules and standards applicable to any such
					 insurance sold to a person eligible for Medicare by reason of age. It includes
					 any individual, family, selected group ("franchise") or group disability
					 insurance policy (and certificate) issued in this state, any certificate
					 delivered in this state pursuant to a group master policy issued in another
					 state, and any individual, family or group benefit agreement issued by a
					 non-profit hospital service plan. It excludes group policies issued to one or
					 more employers or labor organizations, or to the trustees of a fund established
					 by one or more employers or labor organizations, or combinations thereof, for
					 employees or former employees, or combinations thereof, for employees or former
					 employees, or combinations thereof, of the labor organization. It also excludes
					 individual policies or contracts issued pursuant to a conversion privilege in a
					 policy or contract of group or individual insurance when the group or
					 individual policy contract includes provisions which are inconsistent with the
					 requirements of this Article.
Note: Authority cited: Section
						10291.5(c),
						Insurance Code. Reference: Sections
						10195 and
						10291.5 (b)
						(7), Insurance
						Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.53 - Minimum Benefit Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Medicare Supplement Coverages shall provide at least the
					 following benefits to an insured person:
(a) Coverage of Part A Medicare eligible
				  expenses 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
				  inpatient 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.
Note: Authority cited: Section
						10291.5(c),
						Insurance Code. Reference: Sections
						10195 and
						10291.5 (b)
						(7), Insurance
						Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.54 - Requirements for Replacement of Medicare Supplement Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Application
				  forms shall include a question designed to elicit information as to whether the
				  insurance to be issued is intended to replace any other accident and sickness
				  insurance presently in force. A supplementary application or other form to be
				  signed by the applicant containing such a question may be used.
(b) Upon determining that a sale will involve
				  replacement, an insurer, other than a direct response insurer, or its agent
				  shall furnish the applicant, prior to issuance or delivery of the policy, the
				  notice described in (c) below. One (1) copy of such notice shall be retained by
				  the applicant and an additional copy signed by the applicant shall be retained
				  by the insurer. A direct response insurer shall deliver to the applicant upon
				  issuance of the policy, the notice described in (d) below.
(c) The notice required by (b) above for an
				  insurer, than a direct response insurer, shall provide, in substantially the
				  following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
					 SICKNESS INSURANCE
According to (your application) (information you have
					 furnished), you intend to lapse or otherwise terminate existing accident and
					 sickness insurance and replace it with a policy to be issued by (insert Company
					 Name) Insurance Company. For your own information and protection, you should be
					 aware of and seriously consider certain factors which may affect the insurance
					 protection available to you under the new policy.
[1] Health conditions which you may presently
				  have (pre-existing conditions) may not be immediately or fully covered under
				  the new policy. This could result in denial or delay of a claim for benefits
				  under the new policy, whereas a similar claim might have been payable under
				  your present policy. Drafting Notes:
[a]
				  Subsection [1] may be modified if pre-existing conditions are covered under the
				  new policy.
[b] The term "Medicare
				  Supplement Insurance" may be used in lieu of "Accident and Sickness
				  Insurance."
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.55 - Informational Brochure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Insurers issuing policies which provide hospital or medical
					 expense coverage on an expense incurred or indemnity basis, other than
					 incidentally, to a person eligible for Medicare by reason of age, shall provide
					 to the policyholder, a copy of the
Guide to Health Insurance for People
					 with Medicare,
developed jointly by the National Association of
					 Insurance Commissioners and the Health Care Financing Administration. Delivery
					 of the Guide shall be made whether or not the policy qualifies as "Medicare
					 Supplement Coverage" in accordance with Section
					 2220.51. Except in the case of a
					 direct response insurer, delivery of the Guide shall be made at the time of
					 application, and acknowledgment of receipt of certification of delivery of the
					 Guide shall be provided to the insurer. Direct response insurers shall deliver
					 the Guide upon request, but not later than at the time the policy is
					 delivered.
Note: Authority cited: Section
						10195(h),
						Insurance Code. Reference: Section
						10195(h),
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.56 - Loss Ratios

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Policies to supplement Medicare shall develop loss ratios
					 as follows: individual policies 60%, group policies 75%, subject to appropriate
					 standards set forth in Article 1.9, Subchapter 2 of this
					 Title.
Note: Authority cited: Section
						10195(e),
						Insurance Code. Reference: Section
						10193(a), Section
						10195(e),
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.57 - Severability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
If any Section or portion of a Section of this Article or
					 the applicability thereof to any person or circumstance, is held invalid by a
					 court, the remainder of this Article, or the applicability of such provision to
					 other persons or circumstances, shall not be affected
					 thereby.
Note: Authority cited: Section
						10291.5(c),
						Insurance Code. Reference: Sections
						10195 and
						10291.5(b)(7),
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.6 - Medicare Supplement Coverage › Section 2220.58 - Annual Premium Rates and Loss Ratio Experience Filing Requirements for Medicare Supplement Insurance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  This regulation applies to all insurers who offer Medicare Supplement
				  Insurance, including pre-standardized Medicare Supplement Insurance plans,
				  standardized Medicare Supplement Insurance plans, and Medicare SELECT plans,
				  whether to individuals or groups.
(b) Annual premium rates and loss ratio
				  experience filings must be made regardless of Medicare changes, an insurer's
				  prior year loss ratio experience, future marketing plans, or whether new
				  premium rates are being requested.
(c) Insurers offering Medicare Supplement
				  Insurance must include the following in their annual filings with the
				  Commissioner of Insurance:
(1)
Premium
				  Rate Schedules
. Submit premium rate schedules for each individual
				  policy or group certificate. Indicate all special rating factors used for
				  California, such as a zip code rating factor. Indicate whether a premium rate
				  change is requested and, if so, the percentage change.
(2)
Policy Forms
. Submit
				  specimens of each individual Medicare Supplement Insurance individual policy or
				  group certificate and outlines of coverage for each plan, if revised, new, or
				  not included in a filing for a previous year.
(3)
Loss Ratio Experience
				  Exhibits
. Provide complete loss ratio information for each Medicare
				  Supplement Insurance plan since the inception of that plan. For rate filings
				  made in anticipation of Medicare benefit changes, include at least nine months'
				  of loss ratio experience (unless the plan has not been marketed for at least
				  nine months, in which case, submit loss ratio experience information for the
				  period the plan was marketed). First quarter filings must include the entire
				  previous year's loss ratio experience. Such information for plans covering
				  fewer than 100 California residents may be combined if the coverages are
				  similar. Re-state the loss ratio information for the previous year, adjusted
				  for run-off accruals to date. Include the number of California residents
				  covered by the plan.
(4)
Projected Loss Ratio Experience
. Provide projected loss ratio
				  experience for at least five years into the future, reflecting that projected
				  experience both with and without any requested premium rate increase.
(5)
NAIC Medicare Supplement
				  Experience Exhibit
. Provide a National Association of Insurance
				  Commissioners (NAIC) Experience Exhibit for each individual policy form or
				  group certificate which covers 100 or more California residents.
(6)
Actuarial Memorandum
.
				  Submit an actuarial memorandum for each Medicare Supplement Insurance plan in
				  accordance with subsection (d).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.7 - Transitional Requirements for the Conversion of Medicare Supplement Insurance Benefits and Premiums to Conform to Repeal of Medicare Catastrophic Coverage Act [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer of
				  article 1.7 (sections
				  2221-2221.10) by operation of
				  Government Code section
				  11346.1(g)
				  filed 1-22-91 (Register 91, No. 19).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.8 - Medicare Supplement Insurance-Compliance with Section 4081 of the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer of
				  article 1.8 (sections
				  2221.50-2221.51) by operation of
				  Government Code section
				  11346.1(g)
				  (Register 90, No. 6).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.9 - Standards for Determining Whether Benefits of an Individual Hospital, Medical or Surgical Policy Are Unreasonable in Relation to the Premium Charged Pursuant to Subdivision (c) of Section 10293 › Section 2222.10 - Applicability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This article is adopted pursuant to and in implementation
					 of Section
					 10293(a)
					 of the Insurance Code, is applicable to individual disability policies
					 providing hospital, medical or surgical insurance coverages, as defined in
					 Section 2222.11 herein, and mass-marketed
					 policies as defined in Insurance Code section
					 10293(c)(1),
					 that are either (1) delivered or issued for delivery to any person in this
					 State on or after July 1, 2007, or (2) delivered or issued for delivery to any
					 person in this State on or after July 1, 1962 and subject to any rate revision
					 effective on or after July 1, 2007, and relates to standards by which the
					 Insurance Commissioner shall withdraw approval of policy forms the benefits of
					 which are unreasonable in relation to the premiums charged.
1. New
					 Article 1.9 (Sections
					 2222.10 through
					 2222.19) filed 12-12-62; effective
					 thirtieth day thereafter (Register 62, No. 25).
2. Amendment filed
					 5-6-77 as procedural and organizational; effective upon filing (Register 77,
					 No. 19).
3. Amendment of section and NOTE filed 12-29-2006;
					 operative 3-29-2007 pursuant to Insurance Code section
					 10293(a)
					 (Register 2006, No. 52).
Note: Authority cited: Section
						10293,
						Insurance Code. Reference: Section
						10293(a),
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.9 - Standards for Determining Whether Benefits of an Individual Hospital, Medical or Surgical Policy Are Unreasonable in Relation to the Premium Charged Pursuant to Subdivision (c) of Section 10293 › Section 2222.11 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The term
				  "hospital, medical or surgical policy" as used in this article means any
				  disability insurance contract (whether composed solely of a policy or of a
				  policy and one or more riders, endorsements, or amendments attached thereto)
				  designed, constructed, advertised or sold as having as its dominant purpose the
				  provision of benefits contingent upon the rendition of hospital, medical or
				  surgical services. This definition includes a "mass-marketed policy," as
				  described in Insurance Code section
				  10293. This
				  definition also includes a policy of "health insurance" as described in
				  Insurance Code section
				  106(b),
				  but does not include supplemental policies of individual health insurance that
				  provide coverage for vision care expenses only, dental care expenses only, or
				  short-term limited duration health insurance with coverage durations of 6
				  months or less.
For purposes of this article, the phrase "dominant purpose"
					 means any disability insurance contract (whether composed solely of a policy,
					 or of a policy and one or more riders, endorsements, or amendments attached
					 thereto) upon which at least 50 percent of the initial premium or of any
					 renewal premium is or may be, under the underwriting rules or practices of the
					 insurer, allocated or apportioned or should reasonably be allocated or
					 apportioned to the hospital, medical or surgical benefits provided therein. In
					 case of a "hospital, medical or surgical policy" which contains, in addition to
					 benefits contingent upon the rendition of hospital, medical or surgical
					 services, other benefits which are not subject to this article, the insurer may
					 segregate the earned premiums and the incurred losses for those benefits which
					 are subject to the provision of this article, and the commissioner may require
					 such segregation if substantial benefits not subject to this article are
					 provided. If there is no such segregation, the experience of the policy will be
					 considered as a unit. This definition shall not be construed to include:
(1) policies which provide a benefit
				  expressed as an increase of a loss of time benefit during hospital confinement,
				  which is not advertised or sold as a hospital benefit, or
(2) a single premium nonrenewable
				  transportation ticket policy having as its dominant feature the protection of
				  the insured from a transportation hazard.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.9 - Standards for Determining Whether Benefits of an Individual Hospital, Medical or Surgical Policy Are Unreasonable in Relation to the Premium Charged Pursuant to Subdivision (c) of Section 10293 › Section 2222.12 - Standards of Reasonability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The authority of the commissioner under Insurance Code
					 Section
					 10293 being
					 to withdraw approval of policy forms the benefits of which are not reasonable
					 in relation to the premium charged, whether the approval of any form of an
					 insurer should be withdrawn pursuant to said section shall be determined by an
					 analysis of actual loss experience, giving due consideration to all factors
					 relevant to the determination of how the past loss experience may be used to
					 reasonably indicate the average loss experience which should develop. Some of
					 such factors which will be considered by the commissioner are hereinafter in
					 this article set forth, but their listing does not preclude an insurer from
					 urging any other factors which it considers relevant to the issue
					 involved.
(a) Benefits provided by a
				  hospital, medical or surgical policy shall be deemed to be reasonable in
				  relation to premiums if both of the criteria in subdivisions (1) and (2),
				  below, are satisfied:
(1)
(A) the lifetime anticipated loss ratio is
				  not less than 70%, and
(B) in the
				  case of a rate revision, the anticipated loss ratio over the future period for
				  which the revised rates are computed to provide coverage is also not less than
				  70%, or, if the insurer chooses to include disease management expenses in
				  determining compliance with these standards,
(C) the sum of the lifetime anticipated loss
				  ratio and the lifetime anticipated disease management ratio is not less than
				  70%, and
(D) in the case of a rate
				  revision, the sum of the anticipated loss ratio over the future period for
				  which the revised rates are computed to provide coverage and the anticipated
				  disease management ratio over the future period for which revised rates are
				  computed to provide coverage is also not less than 70%,
				  and;
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.9 - Standards for Determining Whether Benefits of an Individual Hospital, Medical or Surgical Policy Are Unreasonable in Relation to the Premium Charged Pursuant to Subdivision (c) of Section 10293 › Section 2222.13 - Preliminary Screening Procedure. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. Repealer
					 filed 12-29-2006; operative 3-29-2007 pursuant to Insurance Code section
					 10293(a)
					 (Register 2006, No. 52).
Note: Authority cited: Section
						10293,
						Insurance Code. Reference: Section
						10293(a),
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.9 - Standards for Determining Whether Benefits of an Individual Hospital, Medical or Surgical Policy Are Unreasonable in Relation to the Premium Charged Pursuant to Subdivision (c) of Section 10293 › Section 2222.14 - Credibility Factors

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The commissioner may consider the use of credibility
					 factors consistent with sound actuarial principles in the review of experience
					 to recognize deviations from the loss ratio standard that may be due to chance
					 variation.
1. Repealer
					 of section and new section and NOTE filed 12-29-2006; operative 3-29-2007
					 pursuant to Insurance Code section
					 10293(a)
					 (Register 2006, No. 52).
Note: Authority cited: Section
						10293,
						Insurance Code. Reference: Section
						10293(a),
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.9 - Standards for Determining Whether Benefits of an Individual Hospital, Medical or Surgical Policy Are Unreasonable in Relation to the Premium Charged Pursuant to Subdivision (c) of Section 10293 › Section 2222.15 - Communication to Insurer

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prior to taking any action under Section
					 2222.17, the commissioner will
					 communicate with the insurer in writing, identifying those policies for which
					 any preliminary review does not establish an inference that the benefits
					 provided therein are reasonable in relation to the premium charged. Such
					 communication shall be deemed confidential, and shall advise the insurer that
					 it should inform the commissioner as to any factors applicable to the
					 consideration of the policy under review which it considers relevant to the
					 reasonableness of the relationship of benefits to premiums. The insurer may,
					 from time to time, submit supplementary material which it deems to be relevant
					 to the study of the loss ratios generated by a specific policy; and the
					 commissioner may request such additional information as the commissioner may
					 deem necessary to complete the commissioner's consideration of such
					 policy.
1. Amendment
					 of section and new NOTE filed 12-29-2006; operative 3-29-2007 pursuant to
					 Insurance Code section
					 10293(a)
					 (Register 2006, No. 52).
2. Change without regulatory effect
					 amending section filed 7-14-2021 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2021, No. 29). Filing deadline specified in Government
					 Code section
					 11349.3(a)
					 extended 60 calendar days pursuant to Executive Order
					 N-40-20.
Note: Authority cited: Section
						10293,
						Insurance Code. Reference: Section
						10293(a),
						Insurance Code.