Current through Supplement No. 394, October, 2024
1.
Description of providers.
a. A
health maintenance organization shall provide its subscribers with a list of
the names and locations of all of its providers no later than the time of
enrollment or the time the group or individual contract and evidence of
coverage are issued and upon reenrollment. If a provider is no longer
affiliated with a health maintenance organization, the health maintenance
organization shall provide notice of such change to its affected subscribers
within thirty days. Subject to the approval of the commissioner, a health
maintenance organization may provide its subscribers with a list of providers
or provider groups for a segment of the service area. However, a list of all
providers must be made available to subscribers upon request.
b. Any list of providers must contain a
notice regarding the availability of the listed primary care physicians. Such
notice must be in not less than twelve-point type and be placed in a prominent
place on the list of providers. The notice must contain the following or
similar language:
Enrolling in [name of health maintenance organization] does
not guarantee services by a particular provider on this list. If you wish to
receive care from specific providers listed, you should contact those providers
to be sure that they are accepting additional patients for [name of health
maintenance organization].
2.
Description of the services area.
A health maintenance organization shall provide its subscribers with a
description of its service area no later than the time of enrollment or the
time the group or individual contract and evidence of coverage is issued and
upon request thereafter. If the description of the service area is changed, the
health maintenance organization shall provide at such time a new description of
the service area to its subscribers.
3.
Copayments and deductibles. A
health maintenance organization may require copayments or deductibles of
enrollees as a condition for the receipt of specific health care services.
Copayments for basic health care services must be shown in the group or
individual contract and evidence of coverage as a specified dollar amount.
Copayments and deductibles must be the only allowable charge, other than
premiums, assessed to subscribers for basic, supplemental, and nonbasic health
care services.
4.
Grievance
procedure.
a. A grievance procedure
must be established and maintained by a health maintenance organization to
provide reasonable procedures for the prompt and effective resolution of
written grievances.
b. A health
maintenance organization shall provide grievance forms to be given to enrollees
who wish to register written grievances. Such forms must include the address
and telephone number to which grievances must be directed and must also specify
any required time limits imposed by the health maintenance organization.
c. The grievance procedure must
provide for written acknowledgment of grievances and grievances to be resolved
or to have a final determination of the grievance by the health maintenance
organization within a reasonable period of time, but not more than ninety days
from the date the grievance is received. This period may be extended in the
event of a delay in obtaining the documents or records necessary for the
resolution of the grievance, or by the mutual written agreement of the health
maintenance organization and the enrollee.
d. Prior to the resolution of a grievance
filed by a subscriber or enrollee, coverage may not be terminated for any
reason which is the subject of the written grievance, except if the health
maintenance organization has, in good faith, made a reasonable effort to
resolve the written grievance through its grievance procedure and coverage is
being terminated as provided for in subsection 8 of section
45-06-07-04.
e. If enrollee's grievances may be resolved
through a specified arbitration agreement, the enrollee must be advised in
writing of the enrollee's rights and duties under the agreement at the time the
grievance is registered. Any such agreement must be accompanied by a statement
setting forth in writing the terms and conditions of binding arbitration. Any
health maintenance organization that makes such binding arbitration a condition
of enrollment must fully disclose this requirement to its enrollees in the
group or individual contract and evidence of coverage.
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC
26.1-18.1
