Section 88.166. Coverage for each covered person

Major Medical Expense Coverage must provide for each covered person the following:

(1) Hospital room and board expenses, prior to application of the copayment percentage, for not less than $50 daily or in lieu thereof the average daily cost of a semi-private room rate in the area where the insured resides for a period of not less than 31 days for any period of continuous hospital confinement.

(2) Miscellaneous hospital services, prior to application of the copayment percentage, for an aggregate maximum of not less than $1,500, or 15 times the daily room and board rate if specified in dollar amounts.

(3) Surgical fees, prior to application of the copayment 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.

(4) Anesthesia services, prior to application of the copayment 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.

(5) Doctor visits, in or out of the hospital, with minimum dollar amounts per visit, prior to application of the copayment percentage, equal to not less than $10 per visit, covering not less than one visit per day and for an aggregate maximum of such covered charges of not less than $600.

(6) Out-of-hospital diagnostic X-rays and tests, prior to application of the copayment percentage, for an aggregate maximum of such covered charges of not less than $600.

(7) Not fewer than three of the following additional benefits prior to application of the copayment percentage, for an aggregate maximum of such covered charges of not less than $1,000:

(i) In-hospital private duty registered nurse services.

(ii) Diagnosis and treatment by a radiologist or physiotherapist.

(iii) Rental of special medical equipment, as defined by the insurer in the policy.

(iv) Artificial limbs or eyes; casts, splints, trusses, or braces.

(v) Treatment for functional nervous disorders, and mental and emotional disorders.

(vi) Out-of-hospital prescription drugs and medications.

Notation

Cross References

This section cited in 31 Pa. Code § 88.165 (relating to major medical expense coverage); 31 Pa. Code § 88.169 (relating to specified disease and specified accident coverage); and 31 Pa. Code § 88.171 (relating to supplemental insurance coverage).