Idaho Admin. Code r. 18.04.08.038

Current through September 2, 2024

Section 18.04.08.038 - SPECIFIED DISEASE COVERAGE

01.Minimum Standards for Benefits. The minimum standards for specified disease coverage are:

a. Coverage for cancer only or cancer in conjunction with other conditions or diseases needs to meet the standards of Paragraphs 01.e., 01.f., or 01.g. of this section.

b. Coverage for specified diseases other than cancer meets the standards of Paragraphs 01.c., 01.d., or 01.g. of this section.

c. Non-cancer Coverages with Deductible. Coverage for each insured person for a specifically named disease (or diseases) with a deductible amount not in excess of two hundred fifty dollars ($250) and an overall aggregate benefit limit of not less than ten thousand dollars ($10,000) and a benefit period of not less than two (2) years for at least the following incurred expenses:

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

ii. Treatment by a legally qualified physician or surgeon;

iii. Private duty services of a registered nurse;

iv. Medical services and supplies used in diagnosis and treatment;

v. Professional ambulance for local service to or from a local hospital;

vi. Blood transfusions, including expense incurred for blood donors;

vii. Drugs and medicines prescribed by a physician;

viii. The rental of an iron lung or similar mechanical apparatus;

ix. Durable medical equipment deemed necessary by the attending physician for the treatment of the disease;

x. 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

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

d. Non-cancer Coverages without Deductible. Coverage for each insured person for a specifically named disease (or diseases) with no deductible amount, and an overall aggregate benefit limit of not less than twenty-five thousand dollars ($25,000) payable at the rate of not less than fifty dollars ($50) a day while confined in a hospital and a benefit period of not less than five hundred (500) days.

e. Cancer-only or Combination Expense Policies. Coverage for each insured person for cancer-only coverage or in combination with one (1) or more other specified diseases on an expense incurred basis for services, supplies, care, and treatment of cancer, in amounts not in excess of the usual and customary charges, with a deductible amount not in excess of two hundred fifty dollars ($250), and an overall aggregate benefit limit of not less than ten thousand dollars ($10,000) and a benefit period of not less than three (3) years for at least the following minimum provisions:

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

ii. Medical services and supplies used in diagnosis and treatment;

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

iv. Blood transfusions and their administration, including expense incurred for blood donors;

v. Drugs and medicines prescribed by a physician;

vi. Professional ambulance for local service to or from a local hospital;

vii. Private duty services of a registered nurse provided in a hospital;

viii. Durable medical equipment deemed necessary by the attending physician for the treatment of the disease;

ix. 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

x. Home health care that is necessary care and treatment provided at the insured 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 will be prescribed in writing by the insured person's attending physician, who will approve the program prior to its start.

xi. Therapy, including physical, speech, hearing, and occupational therapy;

xii. Special equipment including hospital bed, toilette, pulleys, wheelchairs, aspirator, Chux, oxygen, surgical dressings, rubber shields, colostomy, and ileostomy appliances;

xiii. Prosthetic devices including wigs and artificial breasts;

xiv. Nursing home care for non-custodial services; and

xv. Reconstructive surgery when deemed necessary by the attending physician.

f. Per Diem Cancer Coverages. Cancer coverages on a per diem indemnity basis includes:

i. A fixed-sum payment of at least one hundred dollars ($100) for each day of hospital confinement for at least three hundred sixty-five (365) days;

ii. A fixed-sum payment equal to one-half (1/2) the hospital inpatient benefit for each day of hospital or nonhospital outpatient surgery, chemotherapy and radiation therapy, for at least three hundred sixty-five (365) days of treatment; and

iii. A fixed-sum payment of at least fifty dollars ($50) per day for blood and plasma, which includes their administration whether received as an inpatient or outpatient for at least three hundred sixty-five (365) days of treatment.

g. Lump Sum Indemnity Coverage. Lump sum indemnity coverage for any specified disease will be payable as a fixed, one-time payment made within thirty (30) days of submission to the insurer of proof of diagnosis of the specified disease.

i. Dollar benefits may only be in increments of one thousand dollars ($1,000).

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

h. Hospice Care. Hospice care is optional and does not cover non-terminally ill patients. If offered, it will provide:

i. Eligibility for payment of benefits when the attending physician of the insured provides a written statement that the insured person has a life expectancy of six (6) months or less;

ii. A fixed-sum payment of at least fifty dollars ($50) per day; and

iii. A lifetime maximum benefit limit of at least ten thousand dollars ($10,000).

i. Nursing Home Care. Benefits for skilled nursing home confinement or the receipt of home health care are optional. If offered, it will provide:

i. A fixed-sum payment equal to one-fourth (1/4) the hospital in-patient benefit for each day of skilled nursing home confinement for at least one hundred (100) days, but no more restrictive than under Medicare;

ii. A fixed-sum payment equal to one-fourth (1/4) the hospital in-patient benefit for each day of home health care for at least one hundred (100) days, but no more restrictive than under Medicare; and

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

02.Banned Policy or Certificate Provisions. 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 apply to specified disease coverages in addition to all other requirements imposed by this chapter. In cases of conflict the following govern:

a. Policies covering a single specified disease or combination of specified diseases are not to be sold or offered for sale other than as specified disease coverage under this Section.

b. Any policy issued pursuant to this Section that conditions payment upon pathological diagnosis of a covered disease will also provide that if the pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted instead.

c. Notwithstanding any other provision of this chapter, specified disease policies will provide benefits to any covered person not only for the specified diseases but also for any other conditions or diseases, directly caused or aggravated by the specified diseases or the treatment of the specified disease.

d. Individual accident and sickness policies containing specified disease coverage will be guaranteed renewable.

e. No policy issued pursuant to this Section contains a waiting or probationary period greater than thirty (30) days. A specified disease policy may contain a waiting or probationary period following the issue or reinstatement date of the policy or certificate in respect to a particular covered person before the coverage becomes effective as to that covered person.

f. Except for lump sum indemnity coverage, payments may be conditioned upon an insured person's receiving medically necessary care, given in a medically appropriate location, under a medically accepted course of diagnosis or treatment.

g. Benefits will be paid regardless of other coverage.

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

i. Policies providing expense benefits will not use the term "actual" when the policy only pays up to a limited amount of expenses. Instead, the term "charge" or substantially similar language should be used that does not have the misleading or deceptive effect of the phrase "actual charges."

j. Preexisting condition will not be defined to be more restrictive than: "Preexisting condition means a condition for which medical advice, diagnosis, care or treatment was recommended or received from a physician within the six (6) month period preceding the effective date of coverage of an insured person."

k. Coverage for specified diseases will not be excluded due to a preexisting condition for a period greater than twelve (12) months following the effective date of coverage of an insured person unless the preexisting condition is specifically excluded.

03.Disclosure Provisions.

a. An application or enrollment form for specified disease coverage will state above the signature of the applicant or enrollee that a person to be covered for specified disease is not also covered by any Title XIX program (Medicaid, or any similar name). The statement may be combined with any other statement for which the insurer may request the applicant's or enrollee's signature.

b. All specified disease policies and certificates will prominently state on the first page in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections: "Notice to Buyer: This is a specified disease (policy) (certificate). This (policy) (certificate) provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses. Read your (policy) (certificate) carefully with the outline of coverage."

c. Outlines of coverage delivered in connection with "Specified Disease" to persons eligible for Medicare by reason of age will state in boldface type on the first page: "THIS IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the 'Guide to Health Insurance for People with Medicare' available from the company."

d. An insurer will deliver to persons eligible for Medicare any notice prescribed under IDAPA 18.04.10, "Medicare Supplement Insurance Standards."

Idaho Admin. Code r. 18.04.08.038

Effective July 1, 2024