Minnesota Administrative Rules

2740.9954 WORKSHEET FOR OTHER THAN MEDICARE SUPPLEMENT PLANS.

Comprehensive Health Insurance

Test for Actuarial Equivalence

Other than Medicare Supplement Plans

		Major Medical
Subparts of part 2740.9964	Benefit	Basic	Superimposed	Comprehensive
1.	Hospital room and board
2.	Hospital extras
3.	Surgery
4.	Physician care; home, office
5.	Physician care; hospital
6.	Maternity
7.	Diagnostic X-ray and lab
8.	Drugs and medicine
9.	Radioactive therapy
10.	Nursing/convalescent facility
11.	Home health care
12.	Physical therapy
12.	Oxygen
12.	Prostheses
12.	Durable medical equipment
12.	Second opinion surgery
12.	Private duty nursing
12.	Ambulance
13.	Hospital room and board in full
14.	All hospital expenses in full
15.	Major medical maximums
Subtotal reasonable and customary medical services
16.	Deductible
16.	Coinsurance
Subtotal net of deductible and coinsurance
17.	Adjust (Comb. medical/dental deductible)
18.	COB/No-Fault
19.	Limit on "out-of-pocket" expenses
20.	Well baby care
21.	Emergency and supplemental accident
22.	Student dependents
23.-25.	Superimposed major medical
Grand Total
Combined Basic and Superimposed			XXX	XXX

Equivalent to Minnesota qualified plan number _____ nonqualified ______

Date _ By _

Statutory Authority:

MS s 62E.09

History:

10 SR 474

Published Electronically:

October 8, 2007