Current through Reg. 50, No. 13; March 28, 2025
(a)
An issuer must write all policies, health benefit plan certificates,
endorsements, amendments, applications, and riders in plain language, in a
readable and understandable format, and in compliance with all applicable
requirements relating to minimum readability requirements as found in §
3.602 of this title (relating to
Plain Language Requirements).
(b)
The issuer shall provide to current or prospective insureds on request an
accurate written description of the terms and conditions of the policy to allow
current or prospective insureds to make comparisons and informed decisions
before selecting among health care plans. The written description must be in a
readable and understandable format as prescribed by the commissioner and must
include a current list of exclusive providers. The issuer's handbook may
satisfy this requirement if it is substantively similar to and achieves the
same level of disclosure as the written description prescribed by subsection
(e) of this section and it contains the current list of health care
providers.
(c) An issuer shall
furnish a current list of exclusive providers to all insureds no less
frequently than annually.
(d) No
issuer, or agent or representative of an issuer, may cause or permit the use or
distribution to prospective insureds of information which is untrue or
misleading.
(e) The written plan
description must be in a readable and understandable format that includes a
clear, complete and accurate description of paragraphs (1) - (11) of this
subsection in the following order:
(1) a
statement that the plan providing the coverage is an EPP;
(2) a toll-free number, unless exempted by
statute or rule, and address for the prospective or current group contract
holder or prospective or current enrollee to obtain additional information,
including provider information;
(3)
all covered services and benefits, including a description of the options (if
any) for prescription drug coverage, both generic and brand name;
(4) emergency care services and benefits,
including coverage for out-of-area emergency care services and information on
access to after-hours care;
(5)
out-of-area services and benefits (if any);
(6) an explanation of enrollee financial
responsibility for payment of premiums, copayments, deductibles, and any other
out-of-pocket expenses for noncovered or out-of-plan services, and an
explanation that exclusive providers have agreed to look only to the issuer and
not to its insureds for payment of covered services, except as set forth in the
description of the plan;
(7) any
limitations or exclusions, including the existence of any drug formulary
limitations;
(8) any description of
prior authorization requirements, including limitations or restrictions
thereon, and a summary of procedures to obtain approval for referrals to
providers other than primary care physicians or dentists, and other review
requirements, including preauthorization review, concurrent review, post
service review, and post payment review, and the consequences resulting from
the failure to obtain any required authorizations;
(9) provision for continuity of treatment in
the event of the termination of a primary care physician or dentist in those
instances where an insured has selected one;
(10) a summary of the complaint and appeal
procedures of the EPP, a statement of the availability of the independent
review process as applicable, and a statement that the EPP is prohibited from
retaliating against insureds because the group contract holder or insured has
filed a complaint against the EPP or appealed a decision of the EPP, and is
prohibited from retaliating against a health care provider because the health
care provider has, on behalf of an insured, reasonably filed a complaint
against the EPP or appealed a decision of the EPP; and
(11) a statement that female insureds shall
have direct access to an OB/GYN (who is an exclusive provider) for female
services.
