20-1076. Health care plans; disclosure form; enrollee notification

A. Each health care services organization that offers a health care plan to the public shall provide disclosure forms as required by this section. The disclosure form shall be in a form prescribed by the director and shall include the following:

1. A separate roster of plan primary care physicians who are licensed pursuant to title 32, chapter 13, 17 or 29, including the physician's degree and practice specialty, the year first licensed to practice medicine and, if different, the year initially licensed to practice in Arizona.

2. In concise and specific terms:

(a) The full premium cost of the plan.

(b) Any copayment, coinsurance or deductible requirements that an enrollee or the enrollee's family may incur in obtaining coverage under the plan and any reservation by the plan to change premiums.

(c) The health care benefits to which an enrollee would be entitled. The disclosure shall state where and in what manner an enrollee may obtain services, including the procedures for selecting or changing primary care physicians and the locations of hospitals and outpatient treatment centers that are under contract with the health care services organization.

3. Any limitations of the services, kinds of service, benefits and exclusions that apply to the plan. A description of limitations shall include:

(a) Procedures for emergency room, nighttime or weekend visits and referrals to specialist physicians.

(b) Whether services received outside the plan are covered and in what manner they are covered.

(c) Procedures an enrollee must follow, if any, to obtain prior authorization for services.

(d) The circumstances under which prior authorization is required for emergency medical care and a statement as to whether and where the plan provides twenty-four hour emergency services.

(e) The circumstances under which the plan may retroactively deny coverage for emergency medical treatment and nonemergency medical treatment that had prior authorization under the plan's written policies.

(f) A statement regarding whether or not plan providers must comply with any specified numbers, targeted averages or maximum durations of patient visits. If any of these are required of plan providers, the disclosure shall state the specific requirements.

(g) The procedures to be followed by an enrollee for consulting a physician other than the primary care physician, and whether the enrollee's physician, the plan's medical director or a committee must first authorize the referral.

(h) The necessity of repeating prior authorization if the specialist care is continuing.

(i) Whether a point of service option is available, and if so, how it is structured.

4. Grievance procedures for claim or treatment denials, dissatisfaction with care and access to care issues.

5. Subject to section 20-1057.02, a response to whether a plan physician is restricted to prescribing drugs from a plan list or plan formulary and the extent to which an enrollee will be reimbursed for costs of a drug that is not on a plan list or plan formulary.

6. A response to whether plan provider compensation programs include any incentives or penalties that are intended to encourage plan providers to withhold services or minimize or avoid referrals to specialists. If these types of incentives or penalties are included, the health care services organization shall provide a concise description of them. The health care services organization may also include, in a separate section, a concise explanation or justification for the use of these incentives or penalties.

7. A description of the health care services organization's continuity of care policies pursuant to section 20-1057.04.

8. A statement that the disclosure form is a summary only, and that the plan evidence of coverage should be consulted to determine governing contractual provisions.

B. A health care services organization shall not disseminate a completed disclosure form until the form is submitted to the director. For purposes of this section, a health care services organization is not required to submit to the director its separate roster of plan physicians or any roster updates.

C. On request, a health care services organization shall provide the information required under subsection A of this section to all employers who are considering participating in a health care plan that is offered by the health care services organization or to an employer that is considering renewal of a plan that is provided by the health care services organization.

D. An employer shall provide to its eligible employees the disclosures required under subsection A of this section no later than the initiation of any open enrollment period or at least ten days before any employee enrollment deadline that is not associated with an open enrollment period.

E. An employer shall not execute a contract with a health care services organization until the employer receives the information required under subsection A of this section.

F. Nothing in this section provides any private right or cause of action to or on behalf of any enrollee, prospective enrollee, employer or other person, whether a resident or nonresident of this state. This section provides solely an administrative remedy to the director of the department of insurance for any violation of this section or any related rule.

G. Unless preempted under federal law or unless federal law imposes greater requirements than this section, this section applies to a provider sponsored health care services organization.

20-1076. Health care plans; disclosure form; enrollee notification

A. Each health care services organization that offers a health care plan to the public shall provide disclosure forms as required by this section. The disclosure form shall be in a form prescribed by the director and shall include the following:

1. A separate roster of plan primary care physicians who are licensed pursuant to title 32, chapter 13, 17 or 29, including the physician's degree and practice specialty, the year first licensed to practice medicine and, if different, the year initially licensed to practice in Arizona.

2. In concise and specific terms:

(a) The full premium cost of the plan.

(b) Any copayment, coinsurance or deductible requirements that an enrollee or the enrollee's family may incur in obtaining coverage under the plan and any reservation by the plan to change premiums.

(c) The health care benefits to which an enrollee would be entitled. The disclosure shall state where and in what manner an enrollee may obtain services, including the procedures for selecting or changing primary care physicians and the locations of hospitals and outpatient treatment centers that are under contract with the health care services organization.

3. Any limitations of the services, kinds of service, benefits and exclusions that apply to the plan. A description of limitations shall include:

(a) Procedures for emergency room, nighttime or weekend visits and referrals to specialist physicians.

(b) Whether services received outside the plan are covered and in what manner they are covered.

(c) Procedures an enrollee must follow, if any, to obtain prior authorization for services.

(d) The circumstances under which prior authorization is required for emergency medical care and a statement as to whether and where the plan provides twenty-four hour emergency services.

(e) The circumstances under which the plan may retroactively deny coverage for emergency medical treatment and nonemergency medical treatment that had prior authorization under the plan's written policies.

(f) A statement regarding whether or not plan providers must comply with any specified numbers, targeted averages or maximum durations of patient visits. If any of these are required of plan providers, the disclosure shall state the specific requirements.

(g) The procedures to be followed by an enrollee for consulting a physician other than the primary care physician, and whether the enrollee's physician, the plan's medical director or a committee must first authorize the referral.

(h) The necessity of repeating prior authorization if the specialist care is continuing.

(i) Whether a point of service option is available, and if so, how it is structured.

4. Grievance procedures for claim or treatment denials, dissatisfaction with care and access to care issues.

5. Subject to section 20-1057.02, a response to whether a plan physician is restricted to prescribing drugs from a plan list or plan formulary and the extent to which an enrollee will be reimbursed for costs of a drug that is not on a plan list or plan formulary.

6. A response to whether plan provider compensation programs include any incentives or penalties that are intended to encourage plan providers to withhold services or minimize or avoid referrals to specialists. If these types of incentives or penalties are included, the health care services organization shall provide a concise description of them. The health care services organization may also include, in a separate section, a concise explanation or justification for the use of these incentives or penalties.

7. A description of the health care services organization's continuity of care policies pursuant to section 20-1057.04.

8. A statement that the disclosure form is a summary only, and that the plan evidence of coverage should be consulted to determine governing contractual provisions.

B. A health care services organization shall not disseminate a completed disclosure form until the form is submitted to the director. For purposes of this section, a health care services organization is not required to submit to the director its separate roster of plan physicians or any roster updates.

C. On request, a health care services organization shall provide the information required under subsection A of this section to all employers who are considering participating in a health care plan that is offered by the health care services organization or to an employer that is considering renewal of a plan that is provided by the health care services organization.

D. An employer shall provide to its eligible employees the disclosures required under subsection A of this section no later than the initiation of any open enrollment period or at least ten days before any employee enrollment deadline that is not associated with an open enrollment period.

E. An employer shall not execute a contract with a health care services organization until the employer receives the information required under subsection A of this section.

F. Nothing in this section provides any private right or cause of action to or on behalf of any enrollee, prospective enrollee, employer or other person, whether a resident or nonresident of this state. This section provides solely an administrative remedy to the director of the department of insurance for any violation of this section or any related rule.

G. Unless preempted under federal law or unless federal law imposes greater requirements than this section, this section applies to a provider sponsored health care services organization.