Current through Register Vol. 41, No. 3, September 23, 2024
A. An enrollee shall receive an evidence of
coverage under a health care plan provided by a health maintenance organization
established or operating in this Commonwealth, including any amendments to it.
The evidence of coverage shall be delivered or issued for delivery within a
reasonable period of time after enrollment, but not more than 60 days from the
later of the effective date of coverage or the date on which the health
maintenance organization is notified of enrollment. An identification card
shall be delivered or issued for delivery within 15 days from the later of the
effective date of coverage or the date on which the health maintenance
organization is notified of enrollment.
B. An evidence of coverage delivered or
issued for delivery shall contain the following:
1. The name, address, and telephone number of
the health maintenance organization;
2. The health care services and other
benefits to which the enrollee is entitled under the health care
plan;
3. Exclusions or limitations
on the services, kind of services, benefits, or kind of benefits to be
provided, including any cost sharing features;
4. Where and in what manner information is
available as to how services may be obtained;
5. The effective date and the term of
coverage;
6. The total amount of
payment for health care services and any indemnity or service benefits that the
enrollee is obligated to pay with respect to individual contracts, or an
indication whether the plan is contributory or noncontributory for group
certificates;
7. A description of
the health maintenance organization's method of resolving enrollee complaints,
including a description of any arbitration procedure if complaints may be
resolved through a specified arbitration agreement;
8. A list of providers and a description of
the service area that shall be provided with the evidence of coverage if the
information is not given at the time of enrollment;
9. The right of an enrollee to continue group
coverage, including the terms and conditions under which coverage may be
continued;
10. The terms and
conditions under which coverage may be terminated or rescinded;
11. Coordination of benefits provisions, if
applicable;
12. Assignment of
benefits restrictions in the contract;
13. The health maintenance organization's
procedure for filing claims, including any requirements for notifying the
health maintenance organization of a claim and requirements for filing proof of
loss;
14. The health maintenance
organization's enrollment and eligibility requirements, including the
conditions under which dependents may be added and any limiting age for
dependents covered under an individual or group contract;
15.
A provision that the contract or evidence of coverage and any amendments to it
constitutes the entire contractual agreement between the parties involved and
that no portion of the charter, bylaws, or other document of the health
maintenance organization shall constitute part of the contract unless it is set
forth in full in the contract;
16. Except for an
evidence of coverage that does not provide for the periodic payment of premium
or for the payment of any premium, a provision that the contract holder is
entitled to a grace period of not less than 31 days for the payment of any
premium due except the first premium. The provision shall also state that
during the grace period the coverage shall continue in force unless the
contract holder has given the health maintenance organization written notice of
discontinuance in accordance with the terms of the contract and in advance of
the date of discontinuance. The contract may provide that the contract holder
shall be liable to the health maintenance organization for the payment of a pro
rata premium for the time the contract was in force during the grace period;
and
17. Terms and conditions related to the designation of
a primary care health care professional.
C. A copy of the evidence of coverage shall
be delivered to each enrollee and may be delivered electronically in accordance
with the Uniform Electronic Transactions Act (§ 59.1-479 et seq. of the
Code of Virginia).
Statutory Authority: §§ 12.1-13 and 38.2-223 of
the Code of Virginia.
