Minnesota Administrative Rules

2740.9909 COMPOSITE POINT VALUES FOR QUALIFIED PLAN NUMBER THREE.

The composite point values for a qualified plan number three for 1984 are as shown herein.

Composite Point Values for Minnesota Qualified Plan Number 3
Points	Benefit
363	Hospital room and board, unlimited days, semiprivate.
480	Hospital extras (i.e., hospital services, hospital miscellaneous, hospital special services, or ancillary services) including anesthesia.
243	Surgery, including administration of anesthesia, assistant surgeon and oral surgery but no tooth repair or extractions.
215	Home and office physician care, unlimited.
51	Physician care in hospital, unlimited.
63	Obstetrics, unlimited.
110	Hospital maternity, unlimited.
105	X-rays and laboratory tests, outpatient and out of hospital.
100	Prescription drugs and medicine, outpatient and out of hospital.
15	Radioactive therapy, outpatient and out of hospital.
16	Nursing or convalescent facility.
8	Home health agency care.
10	Physical therapy.
4	Oxygen.
5	Prostheses.
5	Durable medical equipment rental or purchase.
2	Second opinion surgery.
2	Private duty nursing.
3	Ambulance.
-12	Adjustment for major medical maximum.
_ 1788	Total reasonable and customary medical services
-245	$150 deductible.
-309	20 percent coinsurance.
_ 1234	Total after deductions for deductible and coinsurance
-49	Coordination of benefits.
-31	Nonduplication with no-fault.
30	3,000 annual "out-of-pocket" expense limit.
8	Well baby care.
0	Emergency accident.
0	Supplement accident.
0	Student dependents.
_ 1192	Grand Total

Statutory Authority:

MS s 62E.09

History:

10 SR 474

Published Electronically:

October 8, 2007