23 CAR § 86-301. Minimum standards — Generally

(a)(1) The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. (2) No individual policy shall be delivered or issued for delivery in this state that does not meet the required minimum standards for the specified categories unless the Insurance Commissioner finds that such policies or contracts are approvable as limited benefit health insurance and the outline of coverage complies with the appropriate outline in 23 CAR § 86-410. (3) Nothing in this section shall preclude the issuance of any policy or contract combining two (2) or more categories of coverage. (b) General rules. (1) Each policy shall contain on its face page the actual title or titles reflecting the categories contained in this subpart. (2)(A) A "noncancellable", "guaranteed renewable", or "noncancellable and guaranteed renewable" policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. (B) The policy shall provide that in the event of the insured's death, the spouse of the insured, if covered under the policy, shall become the insured. (3)(A) The terms "noncancellable", "guaranteed renewable", or "noncancellable and guaranteed renewable" shall not be used without further explanatory language in accordance with the disclosure requirements of 23 CAR § 86-401(a). (B)(i) The terms "noncancellable" or "noncancellable and guaranteed renewable" may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums set forth in the policy until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force. (ii) Provided, however, any accident and health policy that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness may provide that the insured has the right to continue the policy only to age sixty (60) if, at age sixty (60), the insured has the right to continue the policy in force at least to age sixty-five (65) while actively or regularly employed. (C)(i) Except as provided above, the term "guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates by classes. (ii) Provided, however, any accident and health policy that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness may provide that the insured has the right to continue the policy only to age sixty (60) if, at age sixty (60), the insured has the right to continue the policy in force at least to age sixty-five (65) while actively and regularly employed. (4)(A) In a family policy covering both husband and wife, the age of the younger spouse must be used as the basis for meeting the age and durational requirements of the definitions of “noncancellable” or "guaranteed renewable". (B) However, this requirement shall not prevent termination of coverage of the older spouse upon attainment of the stated age limit (e.g., age sixty-five (65)) so long as the policy may be continued in force as to the younger spouse to the age or for the durational period as specified in said contract. (5) When accidental death and dismemberment is part of the insurance coverage offered under the contract, the insured shall have the option to include all insureds under such coverage and not just the principal insured. (6) If a policy contains a status-type military service exclusion or a provision that suspends coverage during military service, the policy shall provide, upon receipt of written request, for refund of premiums as applicable to such person on a pro-rata basis. (7) In the event the insurer cancels or refuses to renew, policies providing pregnancy benefits shall provide for an extension of benefits as to pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy remained in force. (8) Policies providing convalescent or extended-care benefits following hospitalization shall not condition such benefits upon admission to the convalescent or extended-care facility within a period of less than fourteen (14) days after discharge from the hospital. (9)(A) Family coverage shall continue for any unmarried dependent child who is incapable of self-sustaining employment due to an intellectual disability or physical handicap and who is chiefly dependent on the insured for support and maintenance on the date that such child's coverage would otherwise terminate under the policy due to the attainment of a specified age limit (prior to the attainment of nineteen (19)) for children. (B) The coverage shall continue so long as the: (i) Contract remains in force; and (ii) Dependent remains in such condition. (C) Notice of such incapacity or dependency must be furnished to the insurer by the policyholder, except in no event shall this notice requirement preclude eligible dependents under this part regardless of age. (10) Any policy coverage for the recipient in a transplant operation shall also provide reimbursement of any medical expenses of a live donor to the extent that benefits remain and are available under the recipient's policy after benefits for the recipient's own expenses have been paid. (11)(A) A policy may contain a provision relating to recurrent disabilities. (B) Provided, however, that no such provision shall specify that a recurrent disability be separated by a period greater than six (6) months. (12)(A) Accidental death and dismemberment benefits shall be payable if the loss occurs within ninety (90) days from the date of the accident, irrespective of total disability. (B) However, no claim shall be denied wherein the insured with the use of extraordinary life support systems delays the loss for more than ninety (90) days from the date of the accident. (C) Disability income benefits, if provided, shall not require the loss to commence less than thirty (30) days after the date of accident, nor shall any policy that the insurer cancels or refuses to renew require that it be in force at the time disability commences if the accident occurred while the policy was in force. (13) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits. (14) Any accident-only policy providing benefits that vary according to the type of accidental cause shall prominently set forth in the outline of coverage the circumstances under which benefits are payable that are lesser than the maximum amount payable under the policy. (15) Termination of the policy shall be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period the policy was in force may be predicated upon the continuous total disability of the insured, limited to: (A) The duration of the policy benefit period, if any; or (B) Payment of the maximum benefits. (16)(A) If, to prevent overinsurance, benefits are reduced due to the presence of Medicare, then benefits may be reduced for those insureds actually covered by Medicare. (B) Benefits may not be reduced based solely on eligibility for Medicare.