18 Del. Admin. Code § 1304-7.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1304-7.0 - Accidents and Sickness Minimum Standards for Benefits

7.1 The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. No individual policy of health insurance or nonprofit hospital, medical or dental service corporation contract shall be delivered or issued for delivery in this state which does not meet the required minimum standards for the specified categories unless the Commissioner finds that such policies or contracts are approvable as Limited Benefit Health insurance and the Outline of Coverage complies with the appropriate outline in section 8.11 of this regulation.

Nothing in this section shall preclude the issuance of any policy or contract combining two or more categories of coverage set forth in 18 Del.C. § 3604 (a) and (b).

7.2 General Rules

7.2.1 A "noncancellable," "guaranteed renewable," or "noncancellable and guaranteed renewable" policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. Such policies shall provide that in the event of the insured's death the spouse of the insured, if covered under the policy, shall become the insured.

7.2.2 The terms "noncancellable," "guaranteed renewable," and "noncancellable and guaranteed renewable" shall not be used without further explanatory language in accordance with the disclosure requirements of section 8.1. The terms "noncancellable" or "noncancellable and guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums set forth in the policy until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force: Provided, however, any accident and health or accident only policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness may provide that the insured has the right to continue the policy only to age sixty (60) if, at age sixty (60), the insured has the right to continue the policy in force at least to age sixty-five (65) while actively or regularly employed. Except as provided above, the term "guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates by classes: Provided, however, any accident and health or accident only policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness may provide that the insured has the right to continue the policy only to age sixty (60) if, at age sixty (60), the insured has the right to continue the policy in force at least to age sixty-five (65) while actively and regularly employed.

7.2.3 In a family policy covering both husband and wife the age of the younger spouse must be used as the basis for meeting the age and durational requirements of the definitions of "noncancellable" or "guaranteed renewable." However, the requirement shall not prevent termination of coverage of the older spouse upon attainment of the stated age limit (e.g., age 65) so long as the policy may be continued in force as to the younger spouse to the age or for the durational period as specified in said definition.

7.2.4 When accidental death and dismemberment coverage is part of the insurance coverage offered under the contract, the insured shall have the option to include all insureds under such coverage and not just the principal insured.

7.2.5 If a policy contains a status type military service exclusion or a provision which suspends coverage during military service, the policy shall provide, upon receipt of written request, for refund of premiums as applicable to such person on a pro rata basis.

7.2.6 In the event the insurer cancels or refuses to renew, policies providing pregnancy benefits shall provide for an extension of benefits as to pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy remained in force. The extension of such benefits shall be conditioned upon continuation of premium payments.

7.2.7 Policies providing convalescent or extended care benefits following hospitalization shall not condition such benefits upon admission to the convalescent or extended care facility within a period of less than fourteen (14) days after discharge from the hospital.

7.2.8 Family coverage shall continue for any dependent child who is incapable of self-sustaining employment due to mental retardation or physical handicap on the date that such child's coverage would otherwise terminate under the policy due to the attainment of a specified age limit for children and is chiefly dependent on the insured for support and maintenance. The policy may require that within 31 days of such date the company receive due proof of such incapacity in order for the insured to elect to continue the policy in force with respect to such child, or that a separate converted policy be issued.

7.2.9 Any policy providing coverage for the recipient in a transplant operation shall also provide reimbursement of any medical expenses of a live donor to the extent that benefits remain and are available under the recipient's policy, after benefits for the recipient's own expenses have been paid. The extension of such benefits to the donor may be conditioned upon the absence of other coverage available to the donor.

7.2.10 A policy may contain a provision relating to recurrent disabilities; provided however, that no such provision shall specify that a recurrent disability be separated by a period greater than six (6) months.

7.2.11 Accidental death and dismemberment benefits shall be payable if the loss occurs within ninety (90) days from the date of the accident, irrespective of total disability. Disability income benefits, if provided, shall not require the loss to commence less than thirty (30) days after the date of accident, nor shall any policy which the insurer cancels or refuses to renew require that it be in force at the time disability commences if the accident occurred while the policy was in force.

7.2.12 Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.

7.2.13 Any accident only policy providing benefits which vary according to type of accidental cause shall prominently set forth in the outline of coverage the circumstances under which benefits are payable which are lesser than the maximum amount payable under the policy.

7.2.14 Termination of the policy shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits.

7.3 Basic Hospital Expense Coverage

7.3.1 "Basic Hospital Expense Coverage" is a policy of accident and sickness insurance which provides coverage for a period of not less than thirty-one (31) days during any continuous hospital confinement for each person insured under the policy, for expense incurred for medically necessary treatment and services rendered as a result of accident or sickness for at least the following:

7.3.1.1 daily hospital room and board in an amount not less than the lesser of (a) 80% of the charges for semi-private room accommodations or (b) $30.00 per day;

7.3.1.2 miscellaneous hospital services for expenses incurred for the charges made by the hospital for services and supplies which are customarily rendered by the hospital and provided for use only during any one period of confinement in an amount not less than either 80% of the charges incurred up to at least $1,000.00 or ten times the daily hospital room and board benefits; and

7.3.1.3 hospital outpatient services consisting of (a) hospital services on the day surgery is performed, and (b) hospital services rendered within 72 hours after accidental injury, in an amount not less than $50.00, and (c) X-ray and laboratory tests to the extent that benefit for such services would have been provided to an extent not less than $100.00 if rendered to an in-patient of the hospital.

7.3.1.4 benefits provided under s sections 7.3.1.1 and 7.3.1.2 above, may be provided subject to a combined deductible amount not in excess of the greater of:

7.3.1.4.1 $100.00; or

7.3.1.4.2 the value of one day's hospital room.

7.4 Basic Medical-Surgical Expense Coverage

7.4.1 "Basic Medical-Surgical Expense Coverage" is a policy of accident and sickness insurance which provides coverage for each person insured under the policy for the expenses incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the following:

7.4.1.1 Surgical services:

7.4.1.1.1 in amounts not less than those provided on a fee schedule based on the relative values contained in the state of New York certified surgical fee schedule, or the 1964 California Relative Value Schedule or other acceptable relative value scale or surgical procedures, up to a maximum of at least $500.00 for any one procedure; or

7.4.1.1.2 not less than 80% of the reasonable charges.

7.4.1.2 Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical service rendered by a physician other than the physician (or his assistant) performing the surgical services;

7.4.1.2.1 in an amount not less than 80% of the reasonable charges; or

7.4.1.2.2 15% of the surgical service benefit.

7.4.1.2.3 In-hospital medical services, consisting of physician services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical care is required, in an amount not less than 80% of the reasonable charges; or $5.00 per day for not less than twenty-one (21) days during one period of confinement.

7.5 Hospital Confinement Indemnity Coverage

7.5.1 "Hospital Confinement Indemnity Coverage" is a policy of accident and sickness insurance which provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $30.00 per day and not less than thirty-one (31) days during any one period of confinement for each person insured under the policy.

7.6 Major Medical Expense Coverage

7.6.1 "Major medical expense coverage" is an accident and sickness insurance policy which provides hospital, medical and surgical expense coverage, to an aggregate maximum of not less than $10,000.00; co-payment by the covered person not to exceed 25% of covered charges; a deductible started on a per person, per family, per illness, per benefit period, or per year basis, or a combination of such bases not to exceed 5% of the aggregate maximum limit under the policy, unless the policy is written to complement underlying hospital and medical insurance in which case such deductible may be increased by the amount of the benefits provided by such underlying insurance, for each covered person for at least:

7.6.1.1 Daily hospital room and board expenses, prior to application of the co-payment percentage, for not less than $50.00 daily (or in lieu thereof the average daily cost of semi-private room rate in the area where the insured resides) for a period of not less than 31 days during continuous hospital confinement;

7.6.1.2 miscellaneous hospital services, prior to application of the co-payment percentage, for an aggregate maximum of not less than $1,500.00 or 15 times the daily room and board rate if specified in dollar amounts;

7.6.1.3 surgical services, prior to application of co-payment percentage to a maximum of not less than $600.00 for the most severe operation with the amounts provided for other operations reasonably related to such maximum amount;

7.6.1.4 anesthesia services prior to application of the co-payment percentage, for a maximum of not less than 15 percent 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;

7.6.1.5 in-hospital medical services, prior to application of the co-payment percentage, as defined in section 7.4.1.2.3;

7.6.1.6 out of hospital care prior to application of the co-payment percentage, consisting of physicians' services rendered on an ambulatory basis where coverage is not provided elsewhere in the policy for diagnosis and treatment of sickness or injury, and diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and

7.6.1.7 not fewer than three of the following additional benefits, prior to application of the co-payment percentage, for an aggregate maximum of such covered charges of not less than $1,000.00;

7.6.1.7.1 In-hospital private duty graduate registered nurse services.

7.6.1.7.2 Convalescent nursing home care as defined in section 5.1.3.1 above.

7.6.1.7.3 Diagnosis and treatment by a radiologist or physiotherapist.

7.6.1.7.4 Rental of special medical equipment, determined to be medically necessary, and which equipment is defined by the insurer in the policy.

7.6.1.7.5 Artificial limbs or eyes, casts, splints, trusses or braces.

7.6.1.7.6 Treatment for functional nervous disorders, and mental and emotional disorders.

7.6.1.7.7 Out-of-hospital prescription drugs and medications.

7.7 Disability Income Protection Coverage

7.7.1 "Disability income protection coverage" is a policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination thereof which:

7.7.1.1 Provides that periodic payments which are payable at ages after 62 and reduced solely on the basis of age are at least 50% of amounts payable immediately prior to 62.

7.7.1.2 Contains an elimination period no greater than:

7.7.1.2.1 Ninety (90) days in the case of a coverage providing a benefit of one (1) year or less;

7.7.1.2.2 One hundred and eighty (180) days in the case of coverage providing a benefit of more than one year but not greater than two (2) years, or

7.7.1.2.3 Three hundred sixty-five (365) days in all other cases during the continuance of disability resulting from sickness or injury.

7.7.1.3 Has a maximum period of time for which it is payable during disability of at least six (6) months except in the case of a policy covering disability arising out of pregnancy, childbirth, or miscarriage in which case the period for such disability may be one (1) month. No reduction in benefits shall be put into effect because of an increase in Social Security or similar benefits during a benefit period. Section 7.7 does not apply to those policies providing business buyout coverage.

7.8 Accident Only Coverage

7.8.1 "Accident only coverage" is a policy of accident insurance which provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under such a policy shall be at least $1,000.00 and a single dismemberment shall beat least $500.00.

7.9 Specified Disease and Specified Accident Coverage

7.9.1 "Specified disease coverage" pays benefits for the diagnosis and treatment of a specifically named disease or diseases. Any such Policy must meet the following general -- rules and one of the following sets of minimum standards for benefits; such insurance covering cancer -- whether cancer only or in conjunction with other conditions) or disease(s) -- must meet the standards of sections 7.9.2, 7.9.3, or 7.9.3.4; insurance covering specified disease(s) other than cancer must meet the standards of section 7.9.1, or 7.9.3.4.

7.9.1.1 General Rules

7.9.1.1.1 Except for cancer coverage provided on an expense-incurred basis, either as cancer-only coverage or in combination with one or more other specified diseases, the following rules shall apply to specified-disease coverages in addition to all other rules imposed by this regulation; in cases of conflict between the following and other rules, the following ones shall govern:

7.9.1.1.1.1 Policies covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified-disease coverage under this section.

7.9.1.1.1.2 Any policy issued pursuant to this section which conditions payment upon pathological diagnosis of a covered disease, shall also provide that if such a pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted in lieu thereof.

7.9.1.1.1.3 Notwithstanding any other provision of this regulation, specified-disease policies shall provide benefits to any covered person not only for the specified disease(s) but also for any other conditions) or disease(s), directly caused or aggravated by the specified disease(s) or the treatment of the specified disease(s).

7.9.1.1.1.4 Policies containing specified disease coverage shall be at least Guaranteed Renewable.

7.9.1.1.1.5 No policy issued pursuant to this section shall contain a waiting or probationary period greater than thirty (30) days.

7.9.1.1.1.6 Any application for specified disease coverage shall contain a statement above the signature of the applicant that no person to be covered for specified disease is also covered by any Title XIX program (Medicaid, MediCal or any similar name). Such statement may be combined with any other statement for which the insurer may require the applicant's signature.

7.9.1.1.1.7 Payments may be conditioned upon a covered person's receiving medically necessary care, given in a medically appropriate location, under a medically accepted course of diagnosis or treatment.

7.9.1.1.1.8 Except for the uniform provision regarding other insurance with this insurer, benefits for specified disease coverage shall be paid regardless of other coverage available through individual health insurance.

7.9.1.1.1.9 After the effective date of the coverage (or applicable waiting period, if any) benefits shall begin with the first day of care or confinement if such care of confinement is for a covered disease even though the diagnosis is made at some later date. The retroactive application of such coverage may not be less than ninety (90) days prior to such diagnosis.

7.9.1.2 The following minimum benefits standards apply to noncancer coverages:

7.9.1.2.1 Coverage for each person insured under the policy for a specifically named disease (or diseases) with a deductible amount not in excess of $250.00 and an overall aggregate benefit limit of no less than $5,000.00 and a benefit period of not less than two (2) years for at least the following incurred expenses:

7.9.1.2.1.1 Hospital room and board and any other hospital furnished medical services or supplies;

7.9.1.2.1.2 Treatment by a legally qualified physician or surgeon;

7.9.1.2.1.3 Private duty services of a registered nurse (R.N.);

7.9.1.2.1.4 X-ray, radium and other therapy procedures used in diagnosis and treatment;

7.9.1.2.1.5 Professional ambulance for local service to or from a local hospital;

7.9.1.2.1.6 Blood transfusions, including expense incurred for blood donors;

7.9.1.2.1.7 Drugs and medicines prescribed by a physician;

7.9.1.2.1.8 The rental of an iron lung or similar mechanical apparatus;

7.9.1.2.1.9 Brace, crutches and wheel chairs as are deemed necessary by the attending physician for the treatment of the disease;

7.9.1.2.1.10 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

7.9.1.2.1.11 May include coverage of any other expenses necessarily incurred in the treatment of the disease.

7.9.1.2.2 Coverage for each person insured under the policy for a specifically named disease (or diseases) with no deductible amount, and an overall aggregate benefit limit of not less than $25,000.00 payable at the rate of not less than $50.00 a day while confined in a hospital and a benefit period of not less than 500 days.

7.9.2 A policy which provides coverage for each person insured under the policy for cancer-only coverage or in combination with one or more other specified diseases on an expense incurred basis for services, supplies, care and treatment that are ordered or prescribed by a physician as necessary for the treatment of cancer, in amounts not in excess of the usual and customary charges, with a deductible amount not in excess of $250.00, and an overall aggregate benefit limit of not less than $10,000.00 and a benefit period of not less than three (3) years for at least the following:

7.9.2.1 Treatment by, or under the direction of, a legally qualified physician or surgeon;

7.9.2.2 X-ray, radium, chemotherapy and other therapy procedures used in diagnosis and treatment;

7.9.2.3 Hospital room and board and any other hospital furnished medical services or supplies;

7.9.2.4 Blood transfusions, and the administration thereof, including expense incurred for blood donors;

7.9.2.5 Drugs and medicines prescribed by a physician.

7.9.2.6 Professional ambulance for local service to or from a local hospital;

7.9.2.7 Private duty services of a registered nurse (R.N.) provided in a hospital; and

7.9.2.8 May include coverage of any other expenses necessarily incurred in the treatment of the disease. Provided, however, that sections 7.9.1.1.1.1, 7.9.1.1.1.2, 7.9.1.1.1.4, 7.9.1.1.1.5 and 7.9.1.1.1.6 plus at least the following shall also be included, but may be subject to co-payment by the covered person not to exceed 20% of covered charges when rendered on an outpatient basis;

7.9.2.9 Braces, crutches and wheelchairs as are deemed necessary by the attending physician for the treatment of the disease;

7.9.2.10 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

7.9.2.11 * Home health care that is necessary care and treatment provided at the covered 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 must be prescribed in writing by the covered person's attending physician, who must approve the program prior to its start. The physician must certify that hospital confinement would be otherwise required.+

7.9.2.11.1 An agency approved under Title VIII of the Social Security Act (Medicare) or

7.9.2.11.2 is licensed to provide home health care under applicable state law, or 3) meets all of the following requirements.

7.9.2.11.2.1 It is primarily engaged in providing home health care services;

7.9.2.11.2.2 Its policies are established by a group of professional personnel (including at least one physician and one registered nurse [R.N.I);

7.9.2.11.2.3 Supervision of home health care services is provided by a physician or a registered nurse (R.N.);

7.9.2.11.2.4 It maintains clinical records on all patients; and

7.9.2.11.2.5 It has a full-time administrator.

7.9.2.11.3 Home health includes, but is not limited to:

7.9.2.11.3.1 part-time or intermittent skilled nursing services provided by a registered nurse (R.N.) or a licensed practical nurse (L.P.N.);

7.9.2.11.3.2 part-time or intermittent home health aide services which provide supportive services in the home under the supervision of a registered nurse or a physical, speech or hearing occupational therapist;

7.9.2.11.3.3 physical, occupational or speech and hearing therapy; and

7.9.2.11.3.4 medical supplies, drugs and medicines prescribed by a physician and related pharmaceutical services, and laboratory services to the extent such charges or costs would have been covered under the policy if the insured person had remained in the hospital.

7.9.2.12 Physical, speech, hearing and occupational therapy;

7.9.2.13 Special equipment including hospital bed, toilette, pulleys, wheelchairs, aspirator, chux, oxygen, surgical dressings, rubber shields, colostomy and eleostomy appliances;

7.9.2.14 Prosthetic devices including wigs and artificial breasts;

7.9.2.15 Nursing home care for noncustodial services.

7.9.3 The following minimum benefits standards apply to cancer coverages written on a per them indemnity basis. Such coverages must offer covered persons:

7.9.3.1 A fixed-sum payment of at least $100.00 for each day of hospital confinement for at least 365 days.

7.9.3.2 A fixed-sum payment equal to one-half the hospital inpatient benefit for each day of hospital or nonhospital outpatient surgery, chemo and radiation therapy, for at least 365 days of treatment, that requires the services of medical personnel or physicians.

7.9.3.3 Benefits tied to confinement in a skilled nursing home or to receipt of home health care are optional; if a policy offers these benefits, they must equal the following:

7.9.3.3.1 A fixed-sum payment equal to one-fourth the hospital inpatient benefit for each day of skilled nursing home confinement for at least 100 days.

7.9.3.3.2 A fixed-sum payment equal to one-fourth the hospital inpatient benefit for each day of home health care for at least 100 days.

7.9.3.3.3 Benefit payments shall begin with the first day of care or confinement after the effective date of coverage if such 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 30 days from the date of diagnosis) if the initial care or confinement was for diagnosis or treatment of such covered disease.

7.9.3.3.4 Notwithstanding any other provision of this regulation, any restriction or limitation applied to the benefits insections 7.9.3.3.1 and 7.9.3.3.2, whether by definition or otherwise, shall be no more restrictive than those under Medicare.

7.9.3.4 The following minimum benefits standards apply to lump-sum indemnity coverage of any specified disease(s):

7.9.3.4.1 Such coverages must pay indemnity benefits on behalf of covered persons of a specifically named disease or diseases. Such benefits are payable as a fixed, one-time payment made within 30 days of submission to the insurer of proof of diagnosis of the specified disease(s). Dollar benefits shall be offered for sale only in even increments of $1,000.00.

7.9.3.4.2 Where coverage is advertised or otherwise represented to offer generic coverage of a disease or diseases, the same dollar amounts must 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 clearly differentiates that subtype and its benefits.

7.9.3.4.2.1 "Specified Accident Coverage" is an accident insurance policy which provides coverage for a specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment, combined with a benefit amount not less than $1,000.00 for accidental death, $1,000.00 for double dismemberment and $500.00 for single dismemberment.

7.10 Limited Benefit Insurance Coverage

7.10.1 "Limited Benefit Health Insurance Coverage" is any policy or contract, other than a policy or contract covering only a specified disease or diseases, which provides benefits that are less than the minimum standards for benefits required under sections 7.3, 7.4, 7.5, 7.6, 7.7, 7.8, and 7.9. A policy covering a single specified disease or combination of diseases shall meet the requirements of section 7.9 and shall not be offered for sale as a "Limited Coverage." Such policies or contracts may be delivered or issued for delivery in this state only if the outline of coverage required by section 8.11 of this Regulation is completed and delivered as required by section 8.2 of this Regulation.

18 Del. Admin. Code § 1304-7.0