210 Neb. Admin. Code, ch. 44, § 008 - Benefits

008.01A Except as indicated elsewhere in this rule, when an insured person incurs an expense for a covered service or supply, the pool will cover 80% of the usual, normal charges in excess of the deductible. The Preferred Provider Organization Plan may reduce the coverage of the charges to 70% if an insured person does not obtain a covered service or supply from a contracted medical provider with the pool. Benefits are limited to;

(a) one million dollars during the lifetime of the insured; and

(b) expense incurred after the deductible has been satisfied.

008.01B The following are exceptions to the general benefit payable under subsection 008.01:

008.01B(1) Hospital confinement preauthorization is required and when expenses are incurred for days of hospital confinement which are not preauthorized in accordance with the requirement of the policy:

008.01B(2) Benefits for these expenses will not exceed 75% of the expense incurred in excess of the deductible for all covered expenses;

008.01B(3) Those expenses will not be used to satisfy the maximum out-of-pocket expense amount described in section 009;

008.01B(4) The 75% limitation will be applied regardless of whether the individual has previously satisfied the maximum out-of-pocket expense amount.

008.01C Expenses for hospital preadmission testing will be paid at 100% of the usual customary and reasonable charges subject to the following limitations:

008.01C(1) The insured person must be admitted to the hospital as an inpatient within seven days after the pre-admission testing for the same condition for which the test was performed. If not, benefits will be considered at 80% of covered services after the deductible.

008.01C(2) If the tests are duplicated on an inpatient basis, benefits for the original and duplicate test will be considered at 80% of covered services after the deductible.

008.01D Where home health care expenses have been incurred and such care is received in lieu of hospitalization, furnished under a planned program by an agency licensed to provide home health care, and ordered and directed by your physician, the pool will pay benefits for forty (40) visits per year and shall be paid at 80% of the expense incurred.

008.01E Expenses incurred by the insured person who enrolls, participates and completes a Diabetes Patient Education Program will be paid at 90%. The deductible will not apply, but the following limitations are applicable:

008.01E(1) The maximum amount payable is $500 during the insureds lifetime.

008.01E(2) The person taking the program must be the insured.

008.01E(3) The person that has diabetes must be the insured person.

008.01E(4) Charges in excess of the $500 maximum will not be used to satisfy the deductible or maximum out-of-pocket expense amount.

008.01E(5) What constitutes Diabetes Patient Education Program will be defined in the policy.

008.01F The pool shall, subject to approval by the Director of Insurance, provide benefits for a prescription drug plan. The Board may implement co-payments for said prescription drugs as they deem necessary.

008.01G Where an insured receives an organ transplant, from a Preferred Transplant Center, the benefits payable for covered services and supplies will be the maximum provided as stated in the insurance contract. Where an insured receives an organ transplant from a non-approved provider, the maximum benefits payable for covered services and supplies will be limited to $100,000. No benefits are payable unless prior certification has been granted by the medical review board determining an organ transplant to be medically necessary.

008.01H Benefits for Mental Diseases or Disorders, Alcoholism or Drug, Dependency will be paid at 50% (after the deductible) of the covered expense up to a maximum of $25,000 during the lifetime of the insured. The Preferred Provider Organization Plan may reduce coverage to 40% if an insured person does not obtain services from a medical provider that has contracted with the pool. Out-of-Pocket expenses for such treatment will not be used to satisfy the Maximum Out-of-Pocket Expense Amount described in section 9.

008.01I Expenses will be paid for mammographic screening as required by Neb.Rev.Stat. § 44-785.

008.01J Childhood immunizations for children from birth to six years of age including vaccinations for measles, mumps, rubella, poliomyelitis, diphtheria, pertussis, tetanus, haemophilus influenzae type B.

008.01K Coverage for a newly born child of the insured, from the moment of birth, for a period of 31 days.

008.01L Coverage of hospital outpatient rehabilitation services for cardiac or pulmonary rehabilitation as medically necessary.

008.01M Coverage for up to 60 inpatient days per calendar year for covered services for physical rehabilitation, as defined in the policy.

Notes

210 Neb. Admin. Code, ch. 44, § 008