Kansas Administrative Regulations

Agency 40.  Insurance Department

Article 4.  Accident and Health Insurance

 

40-4-29 Same; major medical expense coverage.

 

(a) “Major medical expense coverage'' means an accident and sickness insurance policy which:

(1)  Provides hospital, medical and surgical expense coverage to an aggregate maximum of not less than $25,000;

(2)  is not subject to a co-payment by the covered person of more than 25 percent of covered charges; and

(3)  limits any deductible, stated on a per person, per family, per illness, per benefit period, or per year basis, or a combination of these bases, to five percent of the aggregate maximum limit under the policy.

(b)  If the policy is written to complement underlying hospital and medical insurance, the deductible may be increased by the amount of the benefits provided by the underlying insurance.

(c)  For each covered person, major medical expense coverage shall provide coverage for at least:

(1)  Daily hospital room and board expenses of not less than $100 daily, prior to application of the co-payment percentage and for a period of not less than 31 days during any one period of confinement;

(2)  miscellaneous hospital services, prior to application of the co-payment percentage, of an aggregate maximum of not less than $2,500 or 15 times the daily room and board rate, if specified in dollar amounts;

(3)  surgical services, prior to application of copayment percentage, of not less than $1,200 for the most severe operation, with the amounts provided for other operations reasonably related to the maximum amount;

(4)  anesthesia services, prior to application of the co-payment percentage, of not less than 15 percent of the covered surgical fees. If the surgical schedule is based on a relative value schedule, coverage for anesthesia services shall not be less than the amount provided in the policy for anesthesia services at the same unit value used for the surgical schedule;

(5)  in-hospital medical services, prior to application of the co-payment percentage, as defined in subsection (c) of K.A.R. 40-4-27;

(6)  out-of-hospital care, prior to application of the co-payment percentage, consisting of physicians' services rendered on an ambulatory basis when coverage is not provided elsewhere in the policy for diagnosis and treatment of sickness or injury, and for diagnostic x-ray and laboratory services, radiation therapy, and hemodialysis ordered by a physician; and

(7)  not fewer than three of the following additional benefits, prior to application of the copayment percentage, for an aggregate maximum of the covered charges of not less than $2,000:

(A)  In-hospital, private duty, graduate registered nurse services;

(B)  convalescent nursing home care;

(C)  diagnosis and treatment by a radiologist or physiotherapist;

(D)  rental of special medical equipment, as defined by the insurer in the policy;

(E)  artificial limbs or eyes, casts, splints, trusses or braces;

(F)  treatment for functional nervous disorders, and mental and emotional disorders; and

(G)  out-of-hospital prescription drugs and medications.

 

(Authorized by K.S.A. 40-103, 40- 2218; implementing K.S.A. 40-2218; effective Feb. 15, 1977; amended May 1, 1984; amended May 1, 1985; amended May 1, 1986.)