§ 42-62-10 - Qualified health program.
SECTION 42-62-10
§ 42-62-10 Qualified health program.– (a) Upon application by an insurer for certification of a health insurance planor plans as a qualified program for the purpose of this chapter, the directorof the department of business regulation, after consultation with the directorof the department of human services, shall make a determination within ninety(90) days as to whether the applicant's plan or plans are qualified, and shallpublish in the major newspapers of the state on a semi-annual basis thereaftera notice that this plan or plans are qualified.
(b) A program may be certified for a period of two (2) years,if, at least:
(1) It meets the minimum standards of this chapter;
(2) Its insurer meets the duties established by this chapterand the laws of the state;
(3) It provides coverage for diagnostic, curative, andrehabilitative health services for illness and for injuries for the subscriberand his or her dependents, which the director of the department of humanservices, after consultation with the appropriate departmental health advisorycouncils, has recommended as being in the public interest;
(4) It provides benefits, which are approximately equal inscope and in actuarial value to the benefits described in subsection (c).
(c) Any plan or combination of plans which provide thefollowing benefits or their actuarial equivalent may be deemed to be aqualified program for the purposes of the operation of this chapter:
(1) Hospital services. (i) One hundred twenty (120)days of inpatient care in short-term general hospitals, or forty-five (45) daysin a specialized hospital, including the full cost of a semi-private roomaccommodation; meals and dietary services; general nursing care, and intensivecare; use of the operating room; drugs and medications used in the hospital;medical and surgical supplies; diagnostic tests including laboratoryexaminations, pulmonary function, basal metabolism, electroencephalograms andelectrocardiograms, insulin and shock therapy; diagnostic and therapeuticx-ray, radio-therapy and radioisotopic services; inhalation and oxygen therapy;blood derivatives, plasma, and charges for administration, typing, andcross-matching (but not charges for whole blood); physical therapy,occupational therapy, speech and hearing therapy.
(ii) Coverage of all necessary services as defined insubdivision (c)(1)(i) for the inpatient maternity cares.
(iii) The full cost of outpatient care from a hospital, if itis for an accidental injury occurring not more than seventy-two (72) hoursafter a poisoning or traumatic accident, and the use of an operating room foran operation involving: (A) a cutting procedure; (B) use of general anesthesia;or (C) reduction of a fracture or dislocation.
(iv) The full cost of outpatient radiological servicesincluding diagnostic X-ray, radiotherapy, and diagnostic and therapeuticradioisotopic services.
(2) Physicians' services. Physicians' usual andcustomary charges for the following services:
(i) Surgical services, consisting of operative and cuttingprocedures, including routine pre-operative and post-operative care, providedin a hospital, hospital outpatient department, physician's office, or thepatient's home.
(ii) Services of an assisting physician in connection with anoperative procedure when the nature of that procedure is such that an assistingphysician is medically necessary.
(iii) Services of a physician-anesthetist if anesthesia isadministered by a physician other than the surgeon or assisting surgeon.
(iv) Diagnostic services as listed below, whether performedin a physician's office, approved and licensed medical laboratory, or in ahospital, when required for the diagnosis of any condition due to illness orinjury:
(A) Diagnostic X-ray and radioisotopic examinations;
(B) Electroencephalograms, basal metabolism tests, andelectrocardiograms;
(C) Laboratory tests, including pathological examinations;
(D) Radiation treatments by X-ray, radium, external radiationor radioactive isotopes.
(v) Physicians' visits to care for a bed patient in ashort-term general hospital up to one hundred twenty (120) days per period ofillness, or for forty-five (45) days per period of illness in specializedhospitals, except for routine pre-operative and post-operative physicalexaminations.
(vi) Consultation services, where medically necessary in theopinion of the attending physician, at one consultation per specialty perperiod of illness.
(vii) Obstetrical delivery services, including pre-natal andpost-natal care, after the first fifty dollars ($50.00) of charges, which shallbe the liability of the patient.
(viii) Newborn baby care, when the examination and care isprovided by the physician other than the physician making the delivery oradministering anesthesia related to delivery.
(ix) Emergency accident services performed by a physicianwithin seventy-two (72) hours of a traumatic or poisoning accident are coveredin full.
(3) Major medical coverage. To supplement theprotection provided by subdivisions (c)(1) and (c)(2), the following additionalcoverages may be required as a condition for a program being certified asqualified:
(i) It provides up to ten thousand dollars ($10,000) incoverage for the payment of eligible health services;
(ii) It provides coverage for at least eighty percent (80%)of the usual and customary charges, or costs, as applicable, of health servicesdescribed in subdivisions (c)(1) and (c)(2) after an insured or subscriber haspaid an annual deductible of one hundred dollars ($100) per person to two (2)one hundred dollars ($100) deductibles per family for covered services.
(iii) The covered service provided under subdivision(C)(3)(ii) shall include:
(A) Physicians' services, including home and office visits;
(B) Professional ambulance services locally to or from ahospital for inpatients, or to a hospital accident room following an accident;
(C) Drugs and medications which by law require a writtenprescription;
(D) Rental or purchase, whichever costs less, of wheelchairsand other durable equipment used for medical treatment exclusively;
(E) Out-of-hospital speech therapy and physical therapy;
(F) Multiphasic screening and other diagnostic screeningexaminations;
(G) Orthopedic braces, prosthetic appliances, such asartificial limbs and eyes, including replacement, repair or adjustment;
(H) Visiting nurse services by a registered nurse or licensedpractical nurse when ordered by an attending physician and when medicallynecessary, up to maximum charges of seven hundred fifty dollars ($750) per year;
(I) Services for diagnosis and treatment of mental andnervous disorders; provided, however, that an insured shall be required to makea fifty percent (50%) co-payment, and that the payment of the insurer shall inno event exceed one thousand dollars ($1,000) in a case involving outpatientpsychiatric treatment.
(d) Any plan or combination of plans which provides benefitsto persons over the age of sixty-five (65) years may be deemed to be aqualified supplemental program for the purposes of this chapter if that plan orcombination of plans is designed to supplement Medicare and provide thefollowing coverage:
(1) The full cost of the hospital deductible and co-paymentof Part A of Medicare, 42 U.S.C. §§ 1395c – 1395i-2, as amendedannually by actions of the secretary of the United States Department of Healthand Human Services;
(2) The full cost of the physicians' deductible andco-payment amounts of Part B of Medicare, 42 U.S.C. § 1395j et seq.;
(3) Payments of amounts equivalent to Parts A and B ofMedicare for services rendered outside the United States;
(4) Hospital outpatient treatment for accidents and medicalemergencies; and
(5) X-ray and other diagnostic tests in the hospital'soutpatient department and in the doctor's office.