Rule 20:06:39:27 Requirements for basic plan -- Schedule of benefits.
20:06:39:27. Requirements for basic plan -- Schedule of
benefits. The schedule of benefits for the basic plan are
(1) A deductible per person of at least $1,000
but nor more than $5,000. Carriers must offer at least the $1,000 and the $5,000
(2) An emergency room deductible of $50 for each
emergency room visit unless the person is subsequently
admitted as an inpatient. The emergency room deductible applies toward meeting
the out-of-pocket maximum;
(3) A coinsurance maximum of $4,000 per person.
The percentage of coinsurance is 40 percent of the eligible charges for covered
services received from participating or nonparticipating providers; and
(4) A lifetime benefits maximum of:
(a) $1,000,000 per person;
(b) $250,000 for the treatment of AID/HIV;
(c) 90 days of inpatient treatment for
(d) 50 percent of covered charges up to a
$10,000 maximum for the outpatient treatment of alcoholism and chemical
dependency. There is a $50 maximum fee for each outpatient visit; and
(e) $10,000 for the
inpatient treatment of chemical dependency, excluding the treatment of
All of the limits in (4)(b) to
(4)(e), inclusive, in this section may apply toward meeting the $1,000,000
lifetime maximum per person.
Source: 27 SDR
69, effective January 15, 2001.
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