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

Current through Reg. 49, No. 28; July 12, 2024
(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.