§ 42-62-10. Qualified health program. (a) Upon application by an insurer for certification of a health insurance plan or plans as a qualified program for the purpose of this chapter, the director of the department of business regulation, after consultation with the director of the department of human services, shall make a determination within ninety (90) days as to whether the applicant's plan or plans are qualified, and shall publish in the major newspapers of the state on a semi-annual basis thereafter a notice that this plan or plans are qualified.

(b) A program may be certified for a period of two (2) years, if, at least:

(1) It meets the minimum standards of this chapter;

(2) Its insurer meets the duties established by this chapter and the laws of the state;

(3) It provides coverage for diagnostic, curative, and rehabilitative health services for illness and for injuries for the subscriber and his or her dependents, which the director of the department of human services, after consultation with the appropriate departmental health advisory councils, has recommended as being in the public interest;

(4) It provides benefits, which are approximately equal in scope and in actuarial value to the benefits described in subsection (c).

(c) Any plan or combination of plans which provide the following benefits or their actuarial equivalent may be deemed to be a qualified program for the purposes of the operation of this chapter:

(1) Hospital services. (i) One hundred twenty (120) days of inpatient care in short-term general hospitals, or forty-five (45) days in a specialized hospital, including the full cost of a semi-private room accommodation; meals and dietary services; general nursing care, and intensive care; use of the operating room; drugs and medications used in the hospital; medical and surgical supplies; diagnostic tests including laboratory examinations, pulmonary function, basal metabolism, electroencephalograms and electrocardiograms, insulin and shock therapy; diagnostic and therapeutic x-ray, radio-therapy and radioisotopic services; inhalation and oxygen therapy; blood derivatives, plasma, and charges for administration, typing, and cross-matching (but not charges for whole blood); physical therapy, occupational therapy, speech and hearing therapy.

(ii) Coverage of all necessary services as defined in subdivision (c)(1)(i) for the inpatient maternity cares.

(iii) The full cost of outpatient care from a hospital, if it is for an accidental injury occurring not more than seventy-two (72) hours after a poisoning or traumatic accident, and the use of an operating room for an operation involving: (A) a cutting procedure; (B) use of general anesthesia; or (C) reduction of a fracture or dislocation.

(iv) The full cost of outpatient radiological services including diagnostic X-ray, radiotherapy, and diagnostic and therapeutic radioisotopic services.

(2) Physicians' services. Physicians' usual and customary charges for the following services:

(i) Surgical services, consisting of operative and cutting procedures, including routine pre-operative and post-operative care, provided in a hospital, hospital outpatient department, physician's office, or the patient's home.

(ii) Services of an assisting physician in connection with an operative procedure when the nature of that procedure is such that an assisting physician is medically necessary.

(iii) Services of a physician-anesthetist if anesthesia is administered by a physician other than the surgeon or assisting surgeon.

(iv) Diagnostic services as listed below, whether performed in a physician's office, approved and licensed medical laboratory, or in a hospital, when required for the diagnosis of any condition due to illness or injury:

(A) Diagnostic X-ray and radioisotopic examinations;

(B) Electroencephalograms, basal metabolism tests, and electrocardiograms;

(C) Laboratory tests, including pathological examinations;

(D) Radiation treatments by X-ray, radium, external radiation or radioactive isotopes.

(v) Physicians' visits to care for a bed patient in a short-term general hospital up to one hundred twenty (120) days per period of illness, or for forty-five (45) days per period of illness in specialized hospitals, except for routine pre-operative and post-operative physical examinations.

(vi) Consultation services, where medically necessary in the opinion of the attending physician, at one consultation per specialty per period of illness.

(vii) Obstetrical delivery services, including pre-natal and post-natal care, after the first fifty dollars ($50.00) of charges, which shall be the liability of the patient.

(viii) Newborn baby care, when the examination and care is provided by the physician other than the physician making the delivery or administering anesthesia related to delivery.

(ix) Emergency accident services performed by a physician within seventy-two (72) hours of a traumatic or poisoning accident are covered in full.

(3) Major medical coverage. To supplement the protection provided by subdivisions (c)(1) and (c)(2), the following additional coverages may be required as a condition for a program being certified as qualified:

(i) It provides up to ten thousand dollars ($10,000) in coverage for the payment of eligible health services;

(ii) It provides coverage for at least eighty percent (80%) of the usual and customary charges, or costs, as applicable, of health services described in subdivisions (c)(1) and (c)(2) after an insured or subscriber has paid an annual deductible of one hundred dollars ($100) per person to two (2) one hundred dollars ($100) deductibles per family for covered services.

(iii) The covered service provided under subdivision (C)(3)(ii) shall include:

(A) Physicians' services, including home and office visits;

(B) Professional ambulance services locally to or from a hospital for inpatients, or to a hospital accident room following an accident;

(C) Drugs and medications which by law require a written prescription;

(D) Rental or purchase, whichever costs less, of wheelchairs and other durable equipment used for medical treatment exclusively;

(E) Out-of-hospital speech therapy and physical therapy;

(F) Multiphasic screening and other diagnostic screening examinations;

(G) Orthopedic braces, prosthetic appliances, such as artificial limbs and eyes, including replacement, repair or adjustment;

(H) Visiting nurse services by a registered nurse or licensed practical nurse when ordered by an attending physician and when medically necessary, up to maximum charges of seven hundred fifty dollars ($750) per year;

(I) Services for diagnosis and treatment of mental and nervous disorders; provided, however, that an insured shall be required to make a fifty percent (50%) co-payment, and that the payment of the insurer shall in no event exceed one thousand dollars ($1,000) in a case involving outpatient psychiatric treatment.

(d) Any plan or combination of plans which provides benefits to persons over the age of sixty-five (65) years may be deemed to be a qualified supplemental program for the purposes of this chapter if that plan or combination of plans is designed to supplement Medicare and provide the following coverage:

(1) The full cost of the hospital deductible and co-payment of Part A of Medicare, 42 U.S.C. §§ 1395c - 1395i-2, as amended annually by actions of the secretary of the United States Department of Health and Human Services;

(2) The full cost of the physicians' deductible and co-payment amounts of Part B of Medicare, 42 U.S.C. § 1395j et seq.;

(3) Payments of amounts equivalent to Parts A and B of Medicare for services rendered outside the United States;

(4) Hospital outpatient treatment for accidents and medical emergencies; and

(5) X-ray and other diagnostic tests in the hospital's outpatient department and in the doctor's office.

History of Section. (P.L. 1974, ch. 50, § 1; P.L. 1979, ch. 289, § 1; P.L. 1980, ch. 256, § 1; P.L. 1985, ch. 181, art. 21, § 1.)