20-1342

20-1342. Scope and format of policy;
definitions

A. A policy of disability insurance shall not be delivered or issued for delivery
to any person in this state unless it otherwise complies with this title and complies
with the following:

1. The entire money and other considerations shall be expressed in the policy.

2. The time when the insurance takes effect and terminates shall be expressed in
the policy.

3. It shall purport to insure only one person, except that a policy may insure,
originally or by subsequent amendment, on the application of the policyholder or the
policyholder's spouse, any two or more eligible members of that family, including
husband, wife, dependent children or any children under a specified age that does not
exceed nineteen years and any other person dependent upon the policyholder. Any policy,
except accidental death and dismemberment, applied for that provides family coverage
shall, as to such coverage of family members, shall also provide that the benefits
applicable for children shall be payable with respect to a newly born child of the
insured from the instant of such child's birth, to a child adopted by the insured,
regardless of the age at which the child was adopted, and to a child who has been placed
for adoption with the insured and for whom the application and approval procedures for
adoption pursuant to section 8-105 or 8-108 have been completed to the same extent that
such coverage applies to other members of the family. The coverage for newly born or
adopted children or children placed for adoption shall include coverage of injury or
sickness including necessary care and treatment of medically diagnosed congenital defects
and birth abnormalities. If payment of a specific premium is required to provide coverage
for a child, the policy may require that notification of birth, adoption or adoption
placement of the child and payment of the required premium must be furnished to the
insurer within thirty-one days after the date of birth, adoption or adoption placement in
order to have the coverage continue beyond the thirty-one day period.

4. The style, arrangement and overall appearance of the policy shall give no undue
prominence to any portion of the text, and every printed portion of the text of the
policy and of any endorsements or attached papers shall be plainly printed in light-faced
type of a style in general use, the size of which shall be uniform and not less than ten
point with a lower case unspaced alphabet length of not less than one hundred and twenty
point. "Text" shall include all printed matter except the name and address of the
insurer, name or title of the policy, the brief description, if any, and captions and
subcaptions.

5. The exceptions and reductions of indemnity shall be set forth in the policy and,
other than those contained in sections 20-1345 through 20-1368, shall be printed and, at
the insurer's option, either included with the benefit provision to which they apply or
under an appropriate caption such as "exceptions", or "exceptions and reductions", except
that if an exception or reduction specifically applies only to a particular benefit of
the policy, a statement of such exception or reduction shall be included with the benefit
provision to which it applies.

6. Each such form, including riders and endorsements, shall be identified by a form
number in the lower left-hand corner of the first page.

7. The policy shall contain no provision purporting to make any portion of the
charter, rules, constitution or bylaws of the insurer a part of the policy unless such
portion is set forth in full in the policy, except in the case of the incorporation of,
or reference to, a statement of rates or classification of risks, or short-rate table
filed with the director.

8. Each contract shall be so written that the corporation shall pay benefits:

(a) For performance of any surgical service that is covered by the terms of such
contract, regardless of the place of service.

(b) For any home health services that are performed by a licensed home health
agency and that a physician has prescribed in lieu of hospital services, as defined by
the director, providing the hospital services would have been covered.

(c) For any diagnostic service that a physician has performed outside a hospital in
lieu of inpatient service, providing the inpatient service would have been covered.

(d) For any service performed in a hospital's outpatient department or in a
freestanding surgical facility, providing such service would have been covered if
performed as an inpatient service.

9. A disability insurance policy that provides coverage for the surgical expense of
a mastectomy shall also provide coverage incidental to the patient's covered mastectomy
for the expense of reconstructive surgery of the breast on which the mastectomy was
performed, surgery and reconstruction of the other breast to produce a symmetrical
appearance, prostheses, treatment of physical complications for all stages of the
mastectomy, including lymphedemas, and at least two external postoperative prostheses
subject to all of the terms and conditions of the policy.

10. A contract, except a supplemental contract covering a specified disease or other
limited benefits, that provides coverage for surgical services for a mastectomy shall
also provide coverage for mammography screening performed on dedicated equipment for
diagnostic purposes on referral by a patient's physician, subject to all of the terms and
conditions of the policy and according to the following guidelines:

(a) A baseline mammogram for a woman from age thirty-five to thirty-nine.

(b) A mammogram for a woman from age forty to forty-nine every two years or more
frequently based on the recommendation of the woman's physician.

11. Any contract that is issued to the insured and that provides coverage for
maternity benefits shall also provide that the maternity benefits apply to the costs of
the birth of any child legally adopted by the insured if all the following are true:

(a) The child is adopted within one year of birth.

(b) The insured is legally obligated to pay the costs of birth.

(d) The insured has notified the insurer of the insured's acceptability to adopt
children pursuant to section 8-105, within sixty days after such approval or within sixty
days after a change in insurance policies, plans or companies.

12. The coverage prescribed by paragraph 11 of this subsection is excess to any
other coverage the natural mother may have for maternity benefits except coverage made
available to persons pursuant to title 36, chapter 29, but not including coverage made
available to persons defined as eligible under section 36-2901, paragraph 6, subdivisions
(b), (c), (d) and (e). If such other coverage exists the agency, attorney or individual
arranging the adoption shall make arrangements for the insurance to pay those costs that
may be covered under that policy and shall advise the adopting parent in writing of the
existence and extent of the coverage without disclosing any confidential information such
as the identity of the natural parent. The insured adopting parents shall notify their
insurer of the existence and extent of the other coverage.

B. Any contract that provides maternity benefits shall not restrict benefits for
any hospital length of stay in connection with childbirth for the mother or the newborn
child to less than forty-eight hours following a normal vaginal delivery or ninety-six
hours following a cesarean section. The contract shall not require the provider to obtain
authorization from the insurer for prescribing the minimum length of stay required by
this subsection. The contract may provide that an attending provider in consultation
with the mother may discharge the mother or the newborn child before the expiration of
the minimum length of stay required by this subsection. The insurer shall not:

1. Deny the mother or the newborn child eligibility or continued eligibility to
enroll or to renew coverage under the terms of the contract solely for the purpose of
avoiding the requirements of this subsection.

2. Provide monetary payments or rebates to mothers to encourage those mothers to
accept less than the minimum protections available pursuant to this subsection.

3. Penalize or otherwise reduce or limit the reimbursement of an attending provider
because that provider provided care to any insured under the contract in accordance with
this subsection.

4. Provide monetary or other incentives to an attending provider to induce that
provider to provide care to an insured under the contract in a manner that is
inconsistent with this subsection.

5. Except as described in subsection C of this section, restrict benefits for any
portion of a period within the minimum length of stay in a manner that is less favorable
than the benefits provided for any preceding portion of that stay.

C. Nothing in subsection B of this section:

1. Requires a mother to give birth in a hospital or to stay in the hospital for a
fixed period of time following the birth of the child.

2. Prevents an insurer from imposing deductibles, coinsurance or other cost sharing
in relation to benefits for hospital lengths of stay in connection with childbirth for a
mother or a newborn child under the contract, except that any coinsurance or other cost
sharing for any portion of a period within a hospital length of stay required pursuant to
subsection B of this section shall not be greater than the coinsurance or cost sharing
for any preceding portion of that stay.

3. Prevents an insurer from negotiating the level and type of reimbursement with a
provider for care provided in accordance with subsection B of this section.

D. Any contract that provides coverage for diabetes shall also provide coverage for
equipment and supplies that are medically necessary and that are prescribed by a health
care provider including:

1. Blood glucose monitors.

2. Blood glucose monitors for the legally blind.

3. Test strips for glucose monitors and visual reading and urine testing strips.

4. Insulin preparations and glucagon.

5. Insulin cartridges.

6. Drawing up devices and monitors for the visually impaired.

7. Injection aids.

8. Insulin cartridges for the legally blind.

9. Syringes and lancets including automatic lancing devices.

10. Prescribed oral agents for controlling blood sugar that are included on the plan
formulary.

11. To the extent coverage is required under medicare, podiatric appliances for
prevention of complications associated with diabetes.

12. Any other device, medication, equipment or supply for which coverage is required
under medicare from and after January 1, 1999. The coverage required in this paragraph
is effective six months after the coverage is required under medicare.

E. Nothing in subsection D of this section:

1. Prohibits a disability insurer from imposing deductibles, coinsurance or other
cost sharing in relation to benefits for equipment or supplies for the treatment of
diabetes.

2. Requires a policy to provide an insured with outpatient benefits if the policy
does not cover outpatient benefits.

F. Any contract that provides coverage for prescription drugs shall not limit or
exclude coverage for any prescription drug prescribed for the treatment of cancer on the
basis that the prescription drug has not been approved by the United States food and drug
administration for the treatment of the specific type of cancer for which the
prescription drug has been prescribed, if the prescription drug has been recognized as
safe and effective for treatment of that specific type of cancer in one or more of the
standard medical reference compendia prescribed in subsection G of this section or
medical literature that meets the criteria prescribed in subsection G of this section.
The coverage required under this subsection includes covered medically necessary services
associated with the administration of the prescription drug. This subsection does not:

1. Require coverage of any prescription drug used in the treatment of a type of
cancer if the United States food and drug administration has determined that the
prescription drug is contraindicated for that type of cancer.

2. Require coverage for any experimental prescription drug that is not approved for
any indication by the United States food and drug administration.

3. Alter any law with regard to provisions that limit the coverage of prescription
drugs that have not been approved by the United States food and drug administration.

4. Require reimbursement or coverage for any prescription drug that is not included
in the drug formulary or list of covered prescription drugs specified in the contract.

5. Prohibit a contract from limiting or excluding coverage of a prescription drug,
if the decision to limit or exclude coverage of the prescription drug is not based
primarily on the coverage of prescription drugs required by this section.

6. Prohibit the use of deductibles, coinsurance, copayments or other cost sharing
in relation to drug benefits and related medical benefits offered.

G. For the purposes of subsection F of this section:

1. The acceptable standard medical reference compendia are the following:

(a) The American hospital formulary service drug information, a publication of the
American society of health system pharmacists.

(b) The national comprehensive cancer network drugs and biologics compendium.

(d) Elsevier gold standard's clinical pharmacology compendium.

(e) Other authoritative compendia as identified by the secretary of the United
States department of health and human services.

2. Medical literature may be accepted if all of the following apply:

(a) At least two articles from major peer reviewed professional medical journals
have recognized, based on scientific or medical criteria, the drug's safety and
effectiveness for treatment of the indication for which the drug has been prescribed.

(b) No article from a major peer reviewed professional medical journal has
concluded, based on scientific or medical criteria, that the drug is unsafe or
ineffective or that the drug's safety and effectiveness cannot be determined for the
treatment of the indication for which the drug has been prescribed.

(c) The literature meets the uniform requirements for manuscripts submitted to
biomedical journals established by the international committee of medical journal editors
or is published in a journal specified by the United States department of health and
human services as acceptable peer reviewed medical literature pursuant to section
186(t)(2)(B) of the social security act (42 United States Code section 1395x(t)(2)(B)).

H. Any contract that is offered by a disability insurer and that contains a routine
outpatient prescription drug benefit shall provide coverage of medical foods to treat
inherited metabolic disorders as provided by this section.

I. The metabolic disorders triggering medical foods coverage under this section
shall:

1. Be part of the newborn screening program prescribed in section 36-694.

2. Involve amino acid, carbohydrate or fat metabolism.

3. Have medically standard methods of diagnosis, treatment and monitoring including
quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA
confirmation in tissues.

4. Require specially processed or treated medical foods that are generally
available only under the supervision and direction of a physician who is licensed
pursuant to title 32, chapter 13 or 17 or a registered nurse practitioner who is
licensed pursuant to title 32, chapter 15, that must be consumed throughout life and
without which the person may suffer serious mental or physical impairment.

J. Medical foods eligible for coverage under this section shall be prescribed or
ordered under the supervision of a physician licensed pursuant to title 32, chapter 13 or
17 or a registered nurse practitioner who is licensed pursuant to title 32, chapter 15 as
medically necessary for the therapeutic treatment of an inherited metabolic disease.

K. An insurer shall cover at least fifty per cent of the cost of medical foods
prescribed to treat inherited metabolic disorders and covered pursuant to this section.
An insurer may limit the maximum annual benefit for medical foods under this section to
five thousand dollars, which applies to the cost of all prescribed modified low protein
foods and metabolic formula.

L. For the purposes of:

1. This section:

(a) "Inherited metabolic disorder" means a disease caused by an inherited
abnormality of body chemistry and includes a disease tested under the newborn screening
program prescribed in section 36-694.

(b) "Medical foods" means modified low protein foods and metabolic formula.

(i) Formulated to be consumed or administered enterally under the supervision of a
physician who is licensed pursuant to title 32, chapter 13 or 17 or a registered
nurse practitioner who is licensed pursuant to title 32, chapter 15.

(ii) Processed or formulated to be deficient in one or more of the nutrients
present in typical foodstuffs.

(iii) Administered for the medical and nutritional management of a person who has
limited capacity to metabolize foodstuffs or certain nutrients contained in the
foodstuffs or who has other specific nutrient requirements as established by medical
evaluation.

(iv) Essential to a person's optimal growth, health and metabolic homeostasis.

(d) "Modified low protein foods" means foods that are all of the following:

(ii) Processed or formulated to contain less than one gram of protein per unit of
serving, but does not include a natural food that is naturally low in protein.

(iv) Essential to a person's optimal growth, health and metabolic homeostasis.

2. Subsection A of this section, the term "child", for purposes of initial coverage
of an adopted child or a child placed for adoption but not for purposes of termination of
coverage of such child, means a person under the age of eighteen years.