33-22-1521. Association plan -- minimum benefits. A plan of health coverage must be certified as an association plan if it otherwise meets the requirements of Title 33, chapters 15, 22 (excepting 33-22-701 through 33-22-705), and 30, and other laws of this state, whether or not the policy is issued in this state, and meets or exceeds the following minimum standards:
(1) (a) The minimum benefits for an insured must, subject to the other provisions of this section, be equal to at least 50% of the covered expenses required by this section in excess of an annual deductible that does not exceed $1,000 per person. The coverage must include a limitation of $5,000 per person on the total annual out-of-pocket expenses for services covered under this section. Coverage must be subject to a maximum lifetime benefit, but the maximums may not be less than $100,000.
(b) One association plan must be offered with coverage for 80% of the covered expenses provided in this section in excess of an annual deductible that does not exceed $1,000 per person. This association plan must provide a maximum lifetime benefit of at least $2 million.
(c) Covered expenses for plans under subsection (1)(a) and (1)(b) must be paid as specified in provider contracts or, in the absence of a provider contract, at the prevailing charge in the state where the service is provided.
(d) The board may authorize other association plans, including managed care plans as defined in 33-36-103.
(2) Covered expenses for plans offered under subsections (1)(a) and (1)(b) must be for the following medically necessary services and articles when prescribed by a physician or other licensed health care professional and when designated in the contract:
(a) hospital services;
(b) professional services for the diagnosis or treatment of injuries, illness, or conditions, other than dental;
(c) use of radium or other radioactive materials;
(d) oxygen;
(e) anesthetics;
(f) diagnostic x-rays and laboratory tests, except as specifically provided in subsection (3);
(g) services of a physical therapist;
(h) transportation provided by licensed ambulance service to the nearest facility qualified to treat the condition;
(i) oral surgery for the gums and tissues of the mouth when not performed in connection with the extraction or repair of teeth or in connection with TMJ;
(j) rental or purchase of durable medical equipment, which must be reimbursed after the deductible has been met at the rate of 50%, up to a maximum of $1,000;
(k) prosthetics, other than dental;
(l) services of a licensed home health agency, up to a maximum of 180 visits per year;
(m) drugs requiring a physician's prescription that are approved for use in human beings in the manner prescribed by the United States food and drug administration, covered at 50% of the expense, up to an annual maximum of $2,000;
(n) medically necessary, nonexperimental transplants of the kidney, pancreas, heart, heart/lung, lungs, liver, cornea, and high-dose chemotherapy bone marrow transplantation, limited to a lifetime maximum of $150,000, with an additional benefit not to exceed $10,000 for expenses associated with the donor;
(o) pregnancy, including complications of pregnancy;
(p) newborn infant coverage, as required by 33-22-301;
(q) sterilization;
(r) immunizations;
(s) outpatient rehabilitation therapy;
(t) foot care for diabetics;
(u) services of a convalescent home, as an alternative to hospital services, limited to a maximum of 60 days per year;
(v) travel, other than transportation by a licensed ambulance service, to the nearest facility qualified to treat the patient's medical condition when approved in advance by the insurer; and
(w) coverage for severe mental illness as required in 33-22-706.
(3) (a) Covered expenses for the services or articles specified in this section do not include:
(i) home and office calls, except as specifically provided in subsection (2);
(ii) rental or purchase of durable medical equipment, except as specifically provided in subsection (2);
(iii) the first $20 of diagnostic x-ray and laboratory charges in each 14-day period;
(iv) oral surgery, except as specifically provided in subsection (2);
(v) that part of a charge for services or articles that exceeds the prevailing charge in the state where the service is provided; or
(vi) care that is primarily for custodial or domiciliary purposes that would not qualify as eligible services under medicare.
(b) Covered expenses for the services or articles specified in this section do not include charges for:
(i) care or for any injury or disease arising out of an injury in the course of employment and subject to a workers' compensation or similar law, for which benefits are payable under another policy of disability insurance or medicare;
(ii) treatment for cosmetic purposes other than surgery for the repair or treatment of an injury or congenital bodily defect to restore normal bodily functions;
(iii) travel other than transportation provided by a licensed ambulance service to the nearest facility qualified to treat the condition, except as provided by subsection (2);
(iv) confinement in a private room to the extent that the charge exceeds the facility's charge for its most common semiprivate room, unless the private room is prescribed as medically necessary by a physician;
(v) services or articles that are not within the scope of authorized practice of the facility or individual rendering the services or articles;
(vi) room and board for a nonemergency admission on Friday or Saturday;
(vii) routine well baby care;
(viii) complications to a newborn, unless no other source of coverage is available;
(ix) reversal of sterilization;
(x) abortion, unless the life of the mother would be endangered if the fetus were carried to term;
(xi) weight modification or modification of the body to improve the mental or emotional well-being of an insured;
(xii) artificial insemination or treatment for infertility; or
(xiii) breast augmentation or reduction.
History: En. Sec. 6, Ch. 595, L. 1985; amd. Sec. 31, Ch. 798, L. 1991; amd. Sec. 11, Ch. 357, L. 1995; amd. Sec. 152, Ch. 42, L. 1997; amd. Sec. 7, Ch. 173, L. 1999; amd. Sec. 4, Ch. 367, L. 2001; amd. Sec. 4, Ch. 133, L. 2011.
