Minnesota Administrative Rules

2740.9964 EQUIVALENT POINTS FOR BASIC AND MAJOR MEDICAL HEALTH PLANS; NOT TO BE USED FOR MEDICARE SUPPLEMENT PLANS.

Subpart 1.

Hospital room and board.

Maximum Days	Room & Board
31	327
70	347
120	351
365	359
Unlimited	363

A.

Room and board is defined to include a semiprivate room, or charges for a private room if prescribed as medically necessary by a physician. If the policy does not pay the additional charges for a private room, then deduct three points from hospital room and board.

B.

If the policy pays the private room charge even though not medically necessary, then add ten points if average charge per day is four percent greater than the average semiprivate room and board charge.

C.

If the policy pays the hospital room and board charge up to a maximum daily benefit which is less than the average semiprivate room and board charge in the area, then multiply the points for the semiprivate room and board at the indicated maximum days by the ratio of the scheduled amount to the ASP value in the area for the year.

Subp. 2.

Hospital extras.

Hospital extras such as hospital services, special hospital services, ancillary services, and hospital therapeutics.

	Anesthesia**
Maximum Amount*	Included	Not Included
$ 500	130	130
1,000	217	216
2,000	317	312
5,000	413	401
10,000	454	433
15,000	469	444
Unlimited	480	451

*Before entering this table, divide the maximum amount in the policy by the ASP factor for the year.

**Anesthesia does not include the administration of anesthesia.

This is for miscellaneous hospital services and includes the cost for inpatient hospital care, the cost for outpatient hospital treatment and the excess cost of intensive care unit or coronary care unit over the average semiprivate room and board.

Subp. 3.

Surgery.

	Administration of Anesthesia
Limit	Included	Not Included
Prevailing Fee with Assistant Surgeon	243	206
Prevailing Fee without Assistant Surgeon	244	187

If the policy pays the reasonable and customary charges up to a maximum in a schedule, then multiply the points for the prevailing fee by the ratio of the value of the schedule used in the policy to the SURG value for the year.

Subp. 4.

Home and office physician care.

	First Visit Accident
Annual Maximum*	First Visit Sickness	Third Visit Sickness
$ 200	111	63
500	141	72
1,000	165	93
Unlimited	215	118

*Before entering this table, divide the annual maximum in the policy by SURG factor for the year.

Subp. 5.

In-hospital physician care.

Maximum Number of Visits	Prevailing Fee
31	46
70	49
120	49
365	50
Unlimited	51

A.

This benefit pays the reasonable and customary charge to the physician (other than the surgeon, assistant surgeon, or anesthetist) while confined in the hospital for medical or surgical reasons.

B.

If the policy pays the greater of this benefit or the surgical benefit, then reduce these points by 30 percent.

C.

A number of policies pay a limited amount per visit (limited to one visit per day) which is less than or equal to the cost for a routine follow-up visit in the hospital. If it is equal to the cost for a routine follow-up visit (assumed to be $24.20*/day in 1984), then deduct 14 points from the above points. If it is less than that, then use a proportional part of the points determined as if the maximum was equal to the cost for a routine follow-up visit.

*Multiply the indicated value by the SURG factor for the year.

Subp. 6.

Maternity.

A.

complications only:

limited to some specified list	20
any complications	25

B.

full maternity (including complications):

Maximum Limit	Deductible	Flat Maternity	Obstetrics	Hospital Maternity
$ 300	None	-	23	28
600	None	49	44	55
1,000	None	81	59	80
2,000	None	149	-	-
Unlimited	None	173	63	110

*Before entering this table, divide maximum limit in the policy by the ASP factor for the year.

Subp. 7.

X-rays and laboratory tests (out of hospital).

Maximum*	Scheduled (Any Scheduled)	Unscheduled
$100	56	70
200	67	89
500	74	101
Unlimited	77	105

*Before entering this table, divide the maximum in the policy by the ASP factor for the year.

Subp. 8.

Prescription drugs and medicine (out of hospital).

Deductible* Per Prescription
$4.00	69
2.00	86
None	100

*Before entering this table, divide the deductible per prescription by the SURG factor for the year.

Subp. 9.

Radioactive therapy (out of hospital).

Scheduled (Any Schedule)	10
Unscheduled	15

Subp. 10.

Nursing or convalescent home care (within 14 days of hospital confinement of at least three days).

Maximum Days
120 or More	16
Less than 120	0

Subp. 11.

Home health care agency services.

Maximum Visits/Year
180 or More	8
Less than 180	0

Subp. 12.

Miscellaneous.

A.

physical therapy (out of hospital), 10;

B.

oxygen (out of hospital), 4;

C.

prostheses (out of hospital), 5;

D.

durable medical equipment rental or purchase (out of hospital), 5;

E.

second opinion surgery, 2;

F.

home care nursing (in hospital only), 2; and

G.

ambulance, 3.

Subp. 13.

Hospital room and board in full to indicated limit (basic and comprehensive major medical plans).

Add these points to the points in subpart 1 if the maximum hospital room and board is the semiprivate room and board. If it is less than the semiprivate room and board, make an appropriate adjustment.

	Plan Deductible*		Limit*
Plan	On All Benefits	$1,000	$2,000	$5,000	Unlimited
Comprehensive	$ 0 - 300	58	60	66	79
Comprehensive	301 - 600	61	63	69	82
Comprehensive	601 - 900	66	68	74	87
Comprehensive	901 - 1200	74	76	82	95

*Before entering the table, divide the deductible and the "in full limit" by the ASP factor for the year.

A.

The above table assumes that the policyholder pays 20 percent after the deductible. If the policyholder pays a different percentage, multiply the above points by the ratio of the percentage being paid by the insured to 20 percent.

B.

This benefit assumes that hospital room and board will be paid at 100 percent and that the deductible will not be applied to it. The deductible will be applied to the other covered expenses. After the limit is attained, any remaining deductible will not be applied but the coinsurance will be applied, to the hospital room and board benefits.

Subp. 14.

All hospital charges in full to indicated limit (basic and comprehensive major medical plans).

Add these points to the total points in subparts 1 and 2 if the maximum hospital room and board is the semiprivate room and board. If it is less than the semiprivate room and board, make an appropriate adjustment.

	Plan Deductible*		Limit*
Plan	On All Benefits	$1,000	$2,000	$5,000	Unlimited
Comprehensive	$ 0 - 300	70	110	121	177
Comprehensive	301 - 600	171	151	162	218
Comprehensive	601 - 900	198	238	249	305
Comprehensive	901 - 1200	343	383	394	450

*Before entering the table, divide the deductible and the "in full limit" by the ASP factor for the year.

A.

The above table assumes that the insured pays 20 percent of the costs after the deductible and that the number of points before the deductible and coinsurance is 1800. If the percentage being paid by the insured is not 20 percent, multiply the above points by the ratio of the percentage being paid by the insured to 20 percent.

B.

This benefit assumes that the hospital room and board and hospital services will be paid at 100 percent and that the deductible will not be applied to them. The deductible will be applied to the other covered expenses. After the limit is attained, any remaining deductible will not be applied but the coinsurance will be applied, to either hospital room and board or hospital services benefits.

Subp. 15.

Major medical maximum (comprehensive and superimposed plans).

Maximum*	Add (+) or Subtract (-)
$ 100,000	-27
250,000	-12
500,000	- 7
1,000,000	- 2

*Before entering the table, divide the maximum in the policy by the COMP factor for the year.

The smallest maximum in a qualified plan is $250,000. The $100,000 maximum as provided must be used in future years to help determine the reduction for a $250,000 plan.

Subp. 16.

Coinsurance and deductibles (comprehensive major medical plans).

A.

This table assumes that the point values for all medical services and supplies are approximately 1800 points before deduction for the maximum on total benefits. If the total points are significantly greater or smaller, then the point values must be adjusted.

Deductible*	Deducted Points
$ 0	0
50	85
100	170
150	245
200	310
500	622
1,000	820

*Before entering this table, divide the deductible in the policy by the COMP factor for the year.

B.

To determine the deduction for the coinsurance, subtract the points deducted for the deductible from the total point value for the benefits and then multiply the result by the coinsurance percentage.

Subp. 17.

Combined dental and health insurance deductible (comprehensive major medical plans).

Deductible*	Added Points
$ 50	75
100	60
150	43
200	38
500	35
1,000	15

*Before entering this table, divide the deductible in the policy by the COMP factor for the year.

Subp. 18.

Coordination and nonduplication of benefits (all plans).

A.

The following percentage of points after deduction for deductible and coinsurance must be subtracted if the policy coordinates benefits with other plans and its pricing assumes that a number of insured will have other policies in force.

(1)

with other health plans, 4.0 percent;

(2)

with no fault, 2.5 percent;

(3)

with both subitems (1) and (2), 6.5 percent; and

(4)

with neither, 0.

B.

The percentage must be applied to the total points after deduction for deductible and coinsurance.

Subp. 19.

Limit on "out-of-pocket" expenses (maximum copayment and deductible per benefit year) -- comprehensive and superimposed major medical plans.

Maximum Claim when Out-of-Pocket is reached*		Points
$ 500		236
1,000		196
2,000		158
3,000		130
4,000		110
11,000		45
13,000		36
14,400		30

*Before entering this table, divide the maximum claim when out-of-pocket limit by the COMP factor for the year.

A.

The above table assumes that the insured pays 20 percent of the costs after the deductible and that the number of points before the deductible and coinsurance is about 1800. If the percentage of claims being paid by the insured is other than 20 percent, multiply the number of points above by the ratio of the coinsurance being paid by the insured to 20 percent.

B.

The above table assumes that the amounts paid by the policyholder for deductible and coinsurance are included in determining the out-of-pocket limitation.

Subp. 20.

Well baby care.

Deductible*	Points
$ 0	17
150	8
500	2
1,000	0

*Before entering this table, multiply the deductible in the policy by the COMP factor for the year.

The above benefit assumes that the deductible and coinsurance are applied to the costs of the newborn.

Subp. 21.

Emergency and supplemental accident (basic plans only).

Maximum*		Emergency	Supplemental
$ 50		10	--
100		15	20
300		--	30
500		--	35
1,000		--	40
Unlimited		20	--

*Before entering this table, divide the maximum in the policy by the SURG factor for the year.

Subp. 22.

Student dependents.

Student Extension Beyond Age 19
None	0
To age 21	2
To age 23	4
To age 25	5

Subp. 23.

Superimposed major medical plans; over basic health plans with less than 500 points.

A.

Calculate point value of a comprehensive major medical plan by using deductible* $200 greater than actual.

B.

Add basic health plan points.

*Before entering the table, divide the deductible in the policy by the COMP factor for the year before adding $200. Do not make any further adjustments to the deductible.

Subp. 24.

Superimposed major medical plans; 80/20 coinsurance; over basic health plans with 500-799 points.

			Calendar Year Plan			Two year benefit period plan
Deductible*			Individual	2 x family		Individual	2 x family
a.	Corridor
$	100		740	780		745	765
	200		665	705		680	700
	300		615	655		630	650
	500		543	582		558	578
	1,000		385	425		400	420
b.	Integrated
$	1,000		615	635		650	670
	2,000		515	525		535	545

Note: Points assume major medical contains Minnesota qualified plan number 3 benefits. Adjust for benefits not included and for variation in coinsurance.

*Before entering this table, divide the deductible in the policy by the COMP factor for the year.

Subp. 25.

Superimposed major medical plans; 80/20 coinsurance; over basic health plans with 800 or more points.

Add to Basic Plan Points
			Calendar Year Plan			Two year benefit period plan
Deductible*			Individual	2 x family		Individual	2 x family
a.	Corridor
$	100		515	545		525	535
	200		445	475		455	465
	300		405	435		415	425
	500		339	369		349	359
	1,000		215	245		225	235
b.	Integrated
$	1,000		505	525		530	550
	2,000		405	415		420	430

Note: Points assume major medical contains Minnesota qualified plan number 3 benefits. Adjust for benefits not included and for variation in coinsurance.

*Before entering this table, divide the deductible in the policy by the COMP factor for the year.

Statutory Authority:

MS s 62E.09

History:

10 SR 474; L 2014 c 291 art 9 s 5

Published Electronically:

August 12, 2014