18 Del. Admin. Code § 1308-16.0

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

Section 1308-16.0 - Effective date

This regulation shall become effective on January 4, 1993, to correspond with the effective date of 18 Del.C. Ch. 72, under which authority Regulation 1308 (Formerly Regulation 72) is promulgated. The public welfare requires the promulgation of this regulation with less than 30 days' notice, and therefore, under the emergency provisions of 29 Del.C. § 10123, this regulation may become effective less than 30 days from signature.

APPENDIX A -- PLAN ONE
BASIC INDEMNITY BENEFIT PLAN
BENEFIT		BASIC INDEMNITY
Physician Services:
Prescribed Periodic Screening		Covered in full
The following primary care outpatient services are covered at the co-insurance amount after $150 of services have been provided without co-insurance or deductible application:
Prenatal & postnatal office visits		First $150 paid, then 70%/30%
Primary care visits		First $150 paid, then 70%/30%
Surgery (outpatient)		First $150 paid, then 70%/30%
Diagnostic Lab (physician's office)		First $150 paid, then 70%/30%
Inpatient visits		Covered in full after paying (Medical/surgical) deductible. Maximum 30 days per calendar year.
Outpatient surgery		Covered after deductible
Ambulatory Surgicenters		(facility charge)
Hospital Services		(No deductible)
Inpatient		70%/30%. Maximum 30 day
(Semi-private rate) per calendar year
Emergency Room		$50 co-pay per visit (waived if admitted)
Outpatient Services
Diagnostic X-ray, Diagnostic Lab		Covered after deductible
Chemotherapy, Radiation therapy, Physical therapy		Covered after deductible; limit 20 visits per calendar year. Condition must be subject to significant improvement.
Mental Health		Inpatient: 70%/30% Maximum $500
		Outpatient: $50 max per visit; five visit maximum. Ambulance 70%/30% (emergency only)
Home Health Care		In place of hospitalization, 30 days, 70%/30%
Outpatient Prescription drugs		Not covered
Substance abuse, allergy tests, allergy treatment, Other Conditions:		$250 deductible, two person maximum
		Coinsurance limit $3000, two person maximum
		Uut-of-pocket maximum $3250, two person maximum
		Coinsurance: carrier pays 70%, patient pays 30%, up to out-of-pocket maximum, then carrier pays 100% per calendar year
		$50,000 maximum benefit per member per calendar year. All limits are calendar year limits. All hospital inpatient benefits are paid at the prevailing semi-private rate. Physician benefits paid at the providers' usual and customary charge.
		Pre-admission testing required for non-emergency admissions.
		Pre-certification required for all non-emergency admissions.

APPENDIX A -- PLAN TWO
STANDARD INDEMNITY BENEFIT PLAN
BENEFITS		STANDARD INDEMNITY
Physician Services
Prescribed periodic screening		Covered in full
THE FOLLOWING PRIMARY CARE OUTPATIENT SERVICES ARE COVERED AT THE COINSURANCE AMOUNT AFTER $150 OF SERVICES HAVE BEEN PROVIDED WITHOUT CO-INSURANCE OR DEDUCTIBLE APPLICATION:
Prenatal & postnatal office visits		First $150 paid, then 80%/20%
Primary care visits		First $150 paid, then 80%/20%
Office visit to referral provider		First $150 paid, then 80%/20%
Surgery (outpatient)		First $150 paid, then 80%/20%
Diagnostic Lab (Phys. office)		First $150 paid, then 80%/20%
Inpatient visits		Covered in full after (Medical/surgical) deductible met. Maximum 30 days per calendar year.
Outpatient surgery		Covered after deductible Ambulatory Surgicenters (facility charges)
Hospital Services		(No deductible)
Inpatient (semi-private room)		80%/20%; maximum 30 days per calendar year.
Emergency Room		$50 co-pay/visit (waived if admitted)
Outpatient Services
THE FOLLOWING SERVICES ARE COVERED AT THE CO-INSURANCE AMOUNT AFTER THE DEDUCTIBLE:
Diagnostic X-ray, Diagnostic lab		Covered after deductible
chemotherapy, radiation therapy Physical therapy		Covered after deductible; limit 20 visits per calendar year. Condition must be subject to significant improvement.
Mental health		Inpatient 80%/20%; max $5000. Outpatient $50 max per visit, 20 visit max per cal. year.
Ambulance (emergency only)		80%/20%
Home health care		In place of hospitalization: 30 days, 80%/20%
Outpatient Prescription drugs		Co-pay the greater of $5 or 25% of the drug cost, to a max of $500 per calendar year.
Substance Abuse		Covered as mental health benefit
Allergy tests		Covered as phys. office visit
Allergy treatment		Covered as phys. office visit
Other Conditions:		$150 deductible, two person maximum
		Coinsurance limit: $2500, two person maximum
		Out-of-pocket maximum: $2650, two person maximum
		Coinsurance: carrier pays 80%, patient pays 20%, up to out-of-pocket, then carrier pays 100% per calendar year
		All limits are calendar year limits; except mental health
		Lifetime maximum - $1,000,000
		Mental health lifetime maximum - $20,000
		All hospital inpatient benefits paid at the prevailing semi-private rate
		Physician benefits paid at the providers' usual and customary charge
		Pre-admission testing required for non-emergency admissions
		Pre-certification required for all non-emergency admissions

PLAN EXCLUSIONS

(Applicable to both Basic and Standard Indemnity Benefit Plans):

There are no benefits available for the following services, supplies or charges:

1. Which are not medically necessary.

2. Which are determined to be experimental or investigational in nature; including any service, supply, procedure or treatment directly related to an experimental or investigational treatment.

3. For any condition, disease, illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provisions of any legislation of any government unit. This exclusion applies whether or not the member claims the benefits or compensation.

4. To the extent benefits are provided by any governmental unit except as required by federal law for treatment of veterans in Veterans Administration or armed forces facilities for non-service-related medical conditions.

5. For any illness or injury suffered as a result of any act of war or while in the military service.

6. For which the member would have no legal obligation to pay in the absence of this or similar coverage.

7. Received from any dental or medial department maintained by or on behalf of an employer, labor union, trust or similar person or group

8. Surgery and any related services intended solely to improve appearance, but not to restore bodily function or to correct deformity resulting from disease, trauma, congenital or developmental anomalies.

9. Incurred prior to the member's effective date.

10. Incurred after the member's termination date.

11. For telephone consultations, charges for failing to keep an appointment, charges for completion of forms or charges for medical information.

12. For inpatient visits primarily for diagnostic studies.

13. For whole blood, blood components and blood derivatives which are not classified as drugs.

14. For custodial, domiciliary care or rest cures.

15. For reverse sterilization.

16. For dental work or treatment which includes hospital or professional care when performed in conjunction with: - an operation or treatment for the fitting or wearing of dentures - orthodontic care of treatment for malocclusion - operations on or treatment of or to the teeth or supporting tissues of the teeth except for removal of malignant tumors and cysts.

17. For treatment of weak, strained or flat feet, including orthopedic shoes or other supportive devices, or for the cutting, removal or treatment of corns, calluses or nails, other than with corrective surgery, or for the metabolic or peripheral vascular disease.

18. For eye glasses or contact lenses and the vision examination for prescribing or fitting of eye glasses or contact lenses, except for aphakic patients; and soft lenses or scleral shells intended for use and when used for the treatment of disease or injury.

19. For hearing aids and supplies, tinnitus maskers, or examinations for the prescription or fitting of hearing aids.

20. For radial keratotomy, myopic keratomileusis and any surgery which involves corneal tissue for the purpose of altering, modifying or correcting myopia, hyperopia or stigmatic error.

21. For inpatient admissions which are primarily for physical therapy.

22. For any treatment leading to or in conjunction with transsexualism, sex changes or modification, including but not limited to surgery.

23. For treatment of sexual dysfunction not related to organic disease.

24. For conditions related to autistic disease of childhood, hyperkinetic syndromes, learning disabilities, behavioral problems, mental retardation, or for inpatient confinement for environmental change.

25. For services or supplies for or related to fertility testing, treatment of infertility and conception by artificial means, including but not limited to: artificial insemination, in vitro fertilization, ovum or embryo placement or transfer, gamete intra-fallopian tube transfer, or cryogenic or other preservation techniques in such or similar procedures.

26. For travel whether or not recommended by a physician.

27. For complications or side effects arising from services, procedures or treatments excluded by this policy.

28. For private duty nursing.

29. For skilled nursing facility, unless specifically provided for in this contract.

30. For home health care, unless specifically provided for in this contract.

31. For durable medical equipment, unless specifically provided for in this contract.

32. For prescription drugs, unless specifically provided for in this contract.

33. For the care and treatment of an injury due to the commission of, or an intent to commit, an assault or a felony or an injury or illness incurred while engaging in an illegal act or occupation.

34. For wigs.

35. For weekend admission charges, except for emergencies or maternity.

36. For speech therapy except to restore speech abilities which were lost due to an injury or illness.

37. For treatment of Temporomandibular Joint Dysfunction (TMJ) and Craniomandibular Pain Syndrome (CPS).

APPENDIX B -- PLAN ONE
BASIC HMO BENEFIT PLAN
BENEFITS		BASIC HMO BENEFITS
All care must be provided by or authorized by the primary care physician
Physician services
Prescribed Periodic Screening		Covered in full
Prenatal & postnatal office visits		$10 copay per visit
Primary care visits		$10 copay per visit
Office visit to referral provider		$20 copay per visit
Surgical care in physicians office		$50 copay per procedure
Inpatient visits Medical/surgical		Same as referral office visits
Outpatient surgery		$100 copay per procedure
Hospital Services
Inpatient (Semi private rate)		$250 per day days 1-5 balance paid at 100%
Emergency Room		$100 copay/visit (waived if admitted)
Outpatient services
Outpatient non-surgical care		Covered in full (including lab and xray)
Mental Health		$250 per day
- Inpatient		3 days per calendar year
- Outpatient		$20 copay per visit 5 visit per calendar year
Ambulance		$25 copay (emergency only)
Home Health Care, Outpatient		Not covered
Prescription drugs, Substance Abuse, Maternity Care		Same as all other illness
Other conditions;		No deductible
		Maximum out of pocket limit 200% of annual premium
		all limits are calendar year limits
		All hospital inpatient benefits paid at the prevailing semi-private rate
		Physician benefits paid at the providers usual and customary charge
		Pre-admission testing required for non-emergency admissions
		Pre-certification required for all non-emergency admissions
		All Managed care utilization controls apply

APPENDIX B -- PLAN TWO
STANDARD HMO BENEFIT PLAN
BENEFITS		STANDARD HMO BENEFITS
All care must be provided by or authorized by the primary care physician
Physician services
Prescribed Periodic Screening		Covered in full
Prenatal & postnatal office visits		$10 copay per visit
Primary care visits		$10 copay per visit
Office visit to referral provider		$10 copay per visit
Surgical care in physicians office		$25 copay per procedure
Inpatient visits Medical/surgical		Same as referral office visits
Outpatient surgery		$50 copay per procedure
Hospital Services
Inpatient (Semi private rate)		$100 per day days 1-5 balance paid at 100%
Emergency Room		$50 copay/visit (waived if admitted)
Outpatient services
Outpatient non-surgical care		Covered in full (including lab and xray)
Mental Health		$100 per day
-Inpatient		10 days per calendar year
-Outpatient		$10 copay per visit 20 visit per calendar year
Ambulance		$25 copay (emergency only)
Home Health Care		$10 copay per visit
Outpatient prescription drugs		The greater of $5 copay or 25% of the cost of the drug
Substance Abuse		Not covered
Maternity Care		Same as all other illness
Other conditions;		No deductible
		Maximum out of pocket limit 200% of annual premium
		all limits are calendar year limits
		All hospital inpatient benefits paid at the prevailing semi-private rate
		Physician benefits paid at the providers usual and customary charge
		Pre-admission testing required for non-emergency admissions
		Pre-certification required for all non-emergency admissions
		All Managed care utilization controls apply

PLAN EXCLUSIONS

(Applicable to both Basic and Standard HMO Benefit Plans):

There are no benefits available for the following services, supplies or charges;

**All services must be provided by or authorized by the patients primary care physician.

1. Which are not medically necessary

2. Which are determined to be experimental or investigational in nature; including any service, supply, procedure or treatment directly related to an experimental or investigational treatment

3. For any condition, disease, illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provisions of any legislation or any governmental unit. This exclusion applies whether or not the member claims the benefits or compensation

4. To the extant benefits are provided by any governmental unit except as required by federal law for treatment of veterans in Veterans Administration or armed forces facilities for non- service related medical conditions.

5. For any illness or injury suffered as a result of any act of war or while in military service

6. For which the member would have no legal obligation to pay in the absence of this or similar coverage.

7. Received from any dental or medical department maintained by or on behalf of an employer, labor union, trust or similar person or group.

8. Surgery and any related services intended solely to improve appearance, but not to restore bodily function or to correct deformity resulting from disease, trauma, congenital or developmental anomalies

9. Incurred prior to the members effective date

10. Incurred after the members termination date

11. For telephone consultations, charges for failing to keep an appointment, charges for completion of forms or charges for medical information

12. For inpatient visits primarily for diagnostic studies

13. For whole blood, blood components and blood derivatives which are not classified as drugs

14. For custodial, domiciliary care or rest cures

15. For reverse sterilization

16. For dental work or treatment which includes hospital or professional care when performed in conjunction with; - an operation or treatment for the fitting or wearing of dentures - Orthodontic care of treatment for malocclusion - operations on or treatment of or to the teeth or supporting tissues of the teeth except for; . removal of malignant tumors and cysts

17. For treatment of weak, strained or flat feet, including orthopedic shoes or other supportive devices, or for the cutting, removal or treatment of corns, calluses or nails, other than with corrective surgery, or for metabolic or peripheral vascular disease

18. For eye glasses or contact lenses and the vision examination for prescribing or fitting of eye glasses or contact lenses; except for aphakic patients and soft lenses or scleral shells intended for use and when used for the treatment of disease or injury

19. For hearing aids and supplies, tinnitus maskers, or examinations for the prescription or fitting of hearing aids

20. For radial keratotomy, myopic keratomileusis and any surgery which involves corneal tissue for the purpose of altering, modifying or correcting myopia, hyperopia or stigmatic error

21. For inpatient admissions which are primarily for physical therapy

22. For any treatment leading to or in conjunction with transsexualism, sex changes or modification, including but not limited to surgery

23. For treatment of sexual dysfunction not related to organic disease

24. For conditions related to autistic disease of childhood, hyperkinetic syndromes, learning disabilities, behavioral problems, mental retardation, or for inpatient confinement for environmental change

25. For services or supplies for or related to fertility testing, treatment of infertility and conception by artificial means, including but not limited to; artificial insemination, in vitro fertilization, ovum or embryo placement or transfer, gamete intra-fallopian tube transfer, or cryogenic or other preservation techniques in such or similar procedures

26. For travel whether or not recommended by a physician

27. For complications or side effects arising from services, procedures or treatments excluded by this policy

28. For private duty nursing

29. For skilled nursing facility, unless specifically provided for in this contract

30. For home health care, unless specifically provided for in this contract

31. For Durable Medical equipment, unless specifically provided for in this contract

32. For Prescription drugs, unless specifically provided for in this contract

33. For the care or treatment of an injury due to the commission of, or an intent to commit, an assault or a felony or an injury or illness incurred while engaging in an illegal act or occupation

34. For wigs

35. For weekend admission charges, except for emergencies or maternity

36. For speech therapy except to restore speech abilities which were lost due to injury or illness

37. For the treatment of Temporomandibular Joint Dysfunction (TMJ) and Craniomandibular Pain Syndrome (CPS).

18 Del. Admin. Code § 1308-16.0