2740.9954 Worksheet For Other Than Medicare Supplement Plans


Published: 2015

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2740.9954 WORKSHEET FOR OTHER THAN MEDICARE SUPPLEMENT PLANS.

Comprehensive Health Insurance
Test for Actuarial Equivalence
Other than Medicare Supplement Plans



Major Medical


Subparts of part 2740.9964
Benefit
Basic
Superimposed
Comprehensive


1.
Hospital room and board





2.
Hospital extras





3.
Surgery





4.
Physician care; home, office





5.
Physician care; hospital





6.
Maternity





7.
Diagnostic X-ray and lab





8.
Drugs and medicine





9.
Radioactive therapy





10.
Nursing/convalescent facility





11.
Home health care





12.
Physical therapy





12.
Oxygen





12.
Prostheses





12.
Durable medical equipment





12.
Second opinion surgery





12.
Home care nursing





12.
Ambulance





13.
Hospital room and board in full





14.
All hospital expenses in full





15.
Major medical maximums





Subtotal reasonable and customary medical services





16.
Deductible





16.
Coinsurance





Subtotal net of deductible and coinsurance





17.
Adjust (Comb. medical/dental deductible)





18.
COB/No-Fault





19.
Limit on "out-of-pocket" expenses





20.
Well baby care





21.
Emergency and supplemental accident





22.
Student dependents





23.-25.
Superimposed major medical





Grand Total





Combined Basic and Superimposed

XXX
XXX


Equivalent to Minnesota qualified plan number _____ nonqualified ______


Date
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By
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