SECTION 3.3074. Minimum Standards for Major Medical Expense Coverage

(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.

(b) Major medical 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).

Source Note: The provisions of this §3.3074 adopted to be effective January 26, 1977, 2 TexReg 159; amended to be effective January 2, 1978, 3 TexReg 4943; amended to be effective December 22, 1997, 22 TexReg 12503.