Section 3.3072 - Minimum Standards for Basic Medical-Surgical Expense Coverage(a) "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: (1) surgical services: (A) in amounts not less than those provided on a fee schedule based on the relative values contained in the 1969 California Relative Value Schedule or other acceptable value scale of surgical procedures, up to a maximum of at least $500 for any on e procedure; or(B) not less than 80% of the usual, customary and reasonable charges. Surgical schedules shall include a provision stipulating coverage for procedures not specifically listed in the schedules and not otherwise excluded by the policy, and benefits therefore shall be consistent with the benefits for comparable procedures;(2) anesthetic services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician (or his or her assistant) performing the surgical services: (A) in an amount not less than 80% of the usual, customary and reasonable charges; or(B) 15% of the "surgical services" benefit;(3) in-hospital medical services, consisting of attending 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:(A) 80% of the usual, customary and reasonable charges; or(B) $5.00 per call, one call per day, for at least 21 such calls during "one period of confinement";(4) if obstetrical-surgical benefits are included within the scope of policy coverage then the benefits for each covered pregnancy for obstetrical-surgical expenses incurred shall be based upon the relative value scale of surgical procedures referred to in paragraph (1) of this section.(b) Basic medical-surgical expense coverage must be guaranteed renewable in accordance with § 3.3020 of this title (relating to Policy Definition of Guaranteed Renewable and Limited Guarantee of Renewability) and § 3.3038 of this title (relating to Mandatory Guaranteed Renewability Provisions for Individual Hospital, Medical or Surgical Coverage; Exceptions) of this subchapter, unless such insurance constitutes short-term limited duration coverage, as defined in § 3.3002(b)(18) of this title (relating to Definitions).28 Tex. Admin. Code § 3.3072
The provisions of this §3.3072 adopted to be effective January 26, 1977, 2 TexReg 159; amended to be effective January 2, 1978, 2 TexReg 4943; amended to be effective December 22, 1997, 22 TexReg 12503.