Current through Register Vol. 35, No. 18, September 24, 2024
A. Each health care insurer through its
managed health care plan (MHCP) shall implement written policies and procedures
regarding the rights of covered persons and implementation of such
rights.
B. At the time of
enrollment, each health care insurer through its MHCP shall provide each
subscriber, and upon request, a covered person, or a covered person's
representative, in compliance with state or federal law, with a summary of
benefits and exclusions, premium information and provider listing, along with
information on how to access or obtain the evidence of coverage. Basic consumer
information, including the phone number of the managed health care bureau,
shall be included on a newly issued covered person's health insurance card, or
on a separate wallet-sized card, to include the phone number and website of the
managed health care bureau, issued simultaneously with the newly issued health
insurance card.
C. The evidence of
coverage shall include a complete statement that a covered person shall have
the right, at a minimum:
(1) to available and
accessible services when medically necessary, and in an HMO, as determined by
the primary care or treating physician in consultation with the MHCP, 24 hours
per day, 7 days per week for urgent or emergency care services, and for other
health care services as defined by the contract or the evidence of
coverage;
(2) to be treated with
courtesy and consideration, and with respect for the covered person's dignity
and need for privacy;
(3) to be
provided with information concerning the health care insurer's policies and
procedures regarding products, services, providers, appeals procedures and
other information about the MHCP and the benefits provided;
(4) in an HMO, to choose a primary care
practitioner within the limits of the covered benefits, plan network, and as
provided by this rule, including the right to refuse care of specific health
care professionals;
(5) to receive
from the covered person's physician(s) or provider, in terms that the covered
person understands, an explanation of his or her complete medical condition,
recommended treatment, risk(s) of the treatment, expected results and
reasonable medical alternatives, irrespective of the health care insurers or
MHCP's position on treatment options; if the covered person is not capable of
understanding the information, the explanation shall be provided to his or her
next of kin, guardian, agent or surrogate, if available, and documented in the
covered person's medical record;
(6) to all the rights afforded by law, rule,
or regulation as a patient in a licensed health care facility, including the
right to refuse medication and treatment after possible consequences of this
decision have been explained in language the covered person
understands;
(7) to prompt
notification, as required in this rule, of termination or changes in benefits,
services or provider network;
(8)
to file a complaint or appeal with the health care insurer or the
superintendent and to receive an answer to those complaints in accordance with
existing law;
(9) to privacy of
medical and financial records maintained by the health care insurer and its
health care providers, in accordance with existing law;
(10) to know upon request of any financial
arrangements or provisions between the health care insurer and its providers
which may restrict referral or treatment options or limit the services offered
to covered persons;
(11) to
adequate access to qualified health professionals for the treatment of covered
benefits near where the covered person lives or works within the service area
of the MHCP;
(12) in an HMO, and to
the extent available and applicable to the MHCP, to affordable health care,
with limits on out-of-pocket expenses, including the right to seek care from a
non-participating provider, and an explanation of a covered person's financial
responsibility when services are provided by a non-participating provider, or
provided without required preauthorization;
(13) in a MHCP that provides benefits for
out-of-network coverage, to an approved example of the financial responsibility
incurred by a covered person when going out-of-network; inclusion of the entire
"billing examples" provided by the superintendent available on the division's
website at the time of the filing of the plan will be deemed satisfaction of
this requirement; any substitution for, or changes to, the division's "billing
examples" requires written approval by the superintendent;
(14) to detailed information about coverage,
maximum benefits, and exclusions of specific conditions, ailments or disorders,
including restricted prescription benefits, and all requirements that a covered
person must follow for prior authorization and utilization review;
(15) to a complete explanation of why care is
denied, an opportunity to appeal the decision to the health care insurer's
internal review, the right to a secondary appeal, and the right to request the
superintendent's assistance.
D. The health care insurer shall establish
and implement written policies and procedures regarding the responsibilities of
covered persons. A complete statement of these responsibilities shall be
included in the evidence of coverage.
