20-1057

20-1057. Evidence of coverage by health care
services organizations; renewability; definitions

A. Every enrollee in a health care plan shall be issued an evidence of coverage by
the responsible health care services organization.

B. Any contract, except accidental death and dismemberment, applied for that
provides family coverage shall also provide, as to such coverage of family members, that
the benefits applicable for children shall be payable with respect to a newly born child
of the enrollee from the instant of such child's birth, to a child adopted by the
enrollee, regardless of the age at which the child was adopted, and to a child who has
been placed for adoption with the enrollee and for whom the application and approval
procedures for adoption pursuant to section 8-105 or 8-108 have been completed to the
same extent that such coverage applies to other members of the family. The coverage for
newly born or adopted children or children placed for adoption shall include coverage of
injury or sickness including necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities. If payment of a specific premium is required
to provide coverage for a child, the contract may require that notification of birth,
adoption or adoption placement of the child and payment of the required premium must be
furnished to the insurer within thirty-one days after the date of birth, adoption or
adoption placement in order to have the coverage continue beyond the thirty-one day
period.

C. Any contract, except accidental death and dismemberment, that provides coverage
for psychiatric, drug abuse or alcoholism services shall require the health care services
organization to provide reimbursement for such services in accordance with the terms of
the contract without regard to whether the covered services are rendered in a psychiatric
special hospital or general hospital.

D. No evidence of coverage or amendment to the coverage shall be issued or
delivered to any person in this state until a copy of the form of the evidence of
coverage or amendment to the coverage has been filed with and approved by the director.

E. An evidence of coverage shall contain a clear and complete statement if a
contract, or a reasonably complete summary if a certificate of contract, of:

1. The health care services and the insurance or other benefits, if any, to which
the enrollee is entitled under the health care plan.

2. Any limitations of the services, kind of services, benefits or kind of benefits
to be provided, including any deductible or copayment feature.

3. Where and in what manner information is available as to how services may be
obtained.

4. The enrollee's obligation, if any, respecting charges for the health care plan.

F. An evidence of coverage shall not contain provisions or statements that are
unjust, unfair, inequitable, misleading or deceptive, that encourage misrepresentation or
that are untrue.

G. The director shall approve any form of evidence of coverage if the requirements
of subsections E and F of this section are met. It is unlawful to issue such form until
approved. If the director does not disapprove any such form within forty-five days after
the filing of the form, it is deemed approved. If the director disapproves a form of
evidence of coverage, the director shall notify the health care services organization.
In the notice, the director shall specify the reasons for the director's disapproval.
The director shall grant a hearing on such disapproval within fifteen days after a
request for a hearing in writing is received from the health care services organization.

H. A health care services organization shall not cancel or refuse to renew an
enrollee's evidence of coverage that was issued on a group basis without giving notice of
the cancellation or nonrenewal to the enrollee and, on request of the director, to the
department of insurance. A notice by the organization to the enrollee of cancellation or
nonrenewal of the enrollee's evidence of coverage shall be mailed to the enrollee at
least sixty days before the effective date of such cancellation or nonrenewal. The notice
shall include or be accompanied by a statement in writing of the reasons as stated in the
contract for such action by the organization. Failure of the organization to comply with
this subsection shall invalidate any cancellation or nonrenewal except a cancellation or
nonrenewal for nonpayment of premium, for fraud or misrepresentation in the application
or other enrollment documents or for loss of eligibility as defined in the evidence of
coverage. A health care services organization shall not cancel an enrollee's evidence of
coverage issued on a group basis because of the enrollee's or dependent's age, except for
loss of eligibility as defined in the evidence of coverage, sex, health status-related
factor, national origin or frequency of utilization of health care services of the
enrollee. An evidence of coverage issued on a group basis shall clearly delineate all
terms under which the health care services organization may cancel or refuse to renew an
evidence of coverage for an enrollee or dependent. Nothing in this subsection prohibits
the cancellation or nonrenewal of a health benefits plan contract issued on a group basis
for any of the reasons allowed in section 20-2309. A health care services organization
may cancel or nonrenew an evidence of coverage issued to an individual on a nongroup
basis only for the reasons allowed by subsection N of this section.

I. A health care plan that provides coverage for surgical services for a mastectomy
shall also provide coverage incidental to the patient's covered mastectomy for surgical
services for reconstruction of the breast on which the mastectomy was performed, surgery
and reconstruction of the other breast to produce a symmetrical appearance, prostheses,
treatment of physical complications for all stages of the mastectomy, including
lymphedemas, and at least two external postoperative prostheses subject to all of the
terms and conditions of the policy.

J. A contract that provides coverage for surgical services for a mastectomy shall
also provide coverage for mammography screening performed on dedicated equipment for
diagnostic purposes on referral by a patient's physician, subject to all of the terms and
conditions of the policy and according to the following guidelines:

1. A baseline mammogram for a woman from age thirty-five to thirty-nine.

2. A mammogram for a woman from age forty to forty-nine every two years or more
frequently based on the recommendation of the woman's physician.

3. A mammogram every year for a woman fifty years of age and over.

K. Any contract that is issued to the enrollee and that provides coverage for
maternity benefits shall also provide that the maternity benefits apply to the costs of
the birth of any child legally adopted by the enrollee if all the following are true:

1. The child is adopted within one year of birth.

2. The enrollee is legally obligated to pay the costs of birth.

3. All preexisting conditions and other limitations have been met and all
deductibles and copayments have been paid by the enrollee.

4. The enrollee has notified the insurer of the enrollee's acceptability to adopt
children pursuant to section 8-105 within sixty days after such approval or within sixty
days after a change in insurance policies, plans or companies.

L. The coverage prescribed by subsection K of this section is excess to any other
coverage the natural mother may have for maternity benefits except coverage made
available to persons pursuant to title 36, chapter 29 but not including coverage made
available to persons defined as eligible under section 36-2901, paragraph 6, subdivisions
(b), (c), (d) and (e). If such other coverage exists the agency, attorney or individual
arranging the adoption shall make arrangements for the insurance to pay those costs that
may be covered under that policy and shall advise the adopting parent in writing of the
existence and extent of the coverage without disclosing any confidential information such
as the identity of the natural parent. The enrollee adopting parents shall notify their
health care services organization of the existence and extent of the other coverage. A
health care services organization is not required to pay any costs in excess of the
amounts it would have been obligated to pay to its hospitals and providers if the natural
mother and child had received the maternity and newborn care directly from or through
that health care services organization.

M. Each health care services organization shall offer membership to the following
in a conversion plan that provides the basic health care benefits required by the
director:

1. Each enrollee including the enrollee's enrolled dependents leaving a group.

2. Each enrollee and the enrollee's dependents who would otherwise cease to be
eligible for membership because of the age of the enrollee or the enrollee's dependents
or the death or the dissolution of marriage of an enrollee.

N. A health care services organization shall not cancel or nonrenew an evidence of
coverage issued to an individual on a nongroup basis, including a conversion plan, except
for any of the following reasons and in compliance with the notice and disclosure
requirements contained in subsection H of this section:

1. The individual has failed to pay premiums or contributions in accordance with
the terms of the evidence of coverage or the health care services organization has not
received premium payments in a timely manner.

2. The individual has performed an act or practice that constitutes fraud or the
individual made an intentional misrepresentation of material fact under the terms of the
evidence of coverage.

3. The health care services organization has ceased to offer coverage to
individuals that is consistent with the requirements of sections 20-1379 and 20-1380.

4. If the health care services organization offers a health care plan in this state
through a network plan, the individual no longer resides, lives or works in the service
area served by the network plan or in an area for which the health care services
organization is authorized to transact business but only if the coverage is terminated
uniformly without regard to any health status-related factor of the covered individual.

5. If the health care services organization offers health coverage in this state in
the individual market only through one or more bona fide associations, the membership of
the individual in the association has ceased but only if that coverage is terminated
uniformly without regard to any health status-related factor of any covered individual.

O. A conversion plan may be modified if the modification complies with the notice
and disclosure provisions for cancellation and nonrenewal under subsection H of this
section. A modification of a conversion plan that has already been issued shall not
result in the effective elimination of any benefit originally included in the conversion
plan.

P. Any person who is a United States armed forces reservist, who is ordered to
active military duty on or after August 22, 1990 and who was enrolled in a health care
plan shall have the right to reinstate such coverage upon release from active military
duty subject to the following conditions:

1. The reservist shall make written application to the health plan within ninety
days of discharge from active military duty or within one year of hospitalization
continuing after discharge. Coverage shall be effective upon receipt of the application
by the health plan.

2. The health plan may exclude from such coverage any health or physical condition
arising during and occurring as a direct result of active military duty.

Q. The director shall adopt emergency rules that are applicable to persons who are
leaving active service in the armed forces of the United States and returning to civilian
status consistent with subsection P of this section and that include:

1. Conditions of eligibility.

2. Coverage of dependents.

3. Preexisting conditions.

4. Termination of insurance.

5. Probationary periods.

6. Limitations.

7. Exceptions.

8. Reductions.

9. Elimination periods.

10. Requirements for replacement.

11. Any other conditions of evidences of coverage.

R. Any contract that provides maternity benefits shall not restrict benefits for
any hospital length of stay in connection with childbirth for the mother or the newborn
child to less than forty-eight hours following a normal vaginal delivery or ninety-six
hours following a cesarean section. The contract shall not require the provider to obtain
authorization from the health care services organization for prescribing the minimum
length of stay required by this subsection. The contract may provide that an attending
provider in consultation with the mother may discharge the mother or the newborn child
before the expiration of the minimum length of stay required by this subsection. The
health care services organization shall not:

1. Deny the mother or the newborn child eligibility or continued eligibility to
enroll or to renew coverage under the terms of the contract solely for the purpose of
avoiding the requirements of this subsection.

2. Provide monetary payments or rebates to mothers to encourage those mothers to
accept less than the minimum protections available pursuant to this subsection.

3. Penalize or otherwise reduce or limit the reimbursement of an attending provider
because that provider provided care to any insured under the contract in accordance with
this subsection.

4. Provide monetary or other incentives to an attending provider to induce that
provider to provide care to an insured under the contract in a manner that is
inconsistent with this subsection.

5. Except as described in subsection S of this section, restrict benefits for any
portion of a period within the minimum length of stay in a manner that is less favorable
than the benefits provided for any preceding portion of that stay.

S. Nothing in subsection R of this section:

1. Requires a mother to give birth in a hospital or to stay in the hospital for a
fixed period of time following the birth of the child.

2. Prevents a health care services organization from imposing deductibles,
coinsurance or other cost sharing in relation to benefits for hospital lengths of stay in
connection with childbirth for a mother or a newborn child under the contract, except
that any coinsurance or other cost sharing for any portion of a period within a hospital
length of stay required pursuant to subsection R of this section shall not be greater
than the coinsurance or cost sharing for any preceding portion of that stay.

3. Prevents a health care services organization from negotiating the level and type
of reimbursement with a provider for care provided in accordance with subsection R of
this section.

T. Any contract or evidence of coverage that provides coverage for diabetes shall
also provide coverage for equipment and supplies that are medically necessary and that
are prescribed by a health care provider including:

1. Blood glucose monitors.

2. Blood glucose monitors for the legally blind.

3. Test strips for glucose monitors and visual reading and urine testing strips.

4. Insulin preparations and glucagon.

5. Insulin cartridges.

6. Drawing up devices and monitors for the visually impaired.

7. Injection aids.

8. Insulin cartridges for the legally blind.

9. Syringes and lancets including automatic lancing devices.

10. Prescribed oral agents for controlling blood sugar that are included on the plan
formulary.

11. To the extent coverage is required under medicare, podiatric appliances for
prevention of complications associated with diabetes.

12. Any other device, medication, equipment or supply for which coverage is required
under medicare from and after January 1, 1999. The coverage required in this paragraph
is effective six months after the coverage is required under medicare.

U. Nothing in subsection T of this section:

1. Entitles a member or enrollee of a health care services organization to
equipment or supplies for the treatment of diabetes that are not medically necessary as
determined by the health care services organization medical director or the medical
director's designee.

2. Provides coverage for diabetic supplies obtained by a member or enrollee of a
health care services organization without a prescription unless otherwise permitted
pursuant to the terms of the health care plan.

3. Prohibits a health care services organization from imposing deductibles,
coinsurance or other cost sharing in relation to benefits for equipment or supplies for
the treatment of diabetes.

V. Any contract or evidence of coverage that provides coverage for prescription
drugs shall not limit or exclude coverage for any prescription drug prescribed for the
treatment of cancer on the basis that the prescription drug has not been approved by the
United States food and drug administration for the treatment of the specific type of
cancer for which the prescription drug has been prescribed, if the prescription drug has
been recognized as safe and effective for treatment of that specific type of cancer in
one or more of the standard medical reference compendia prescribed in subsection W of
this section or medical literature that meets the criteria prescribed in subsection W of
this section. The coverage required under this subsection includes covered medically
necessary services associated with the administration of the prescription drug. This
subsection does not:

1. Require coverage of any prescription drug used in the treatment of a type of
cancer if the United States food and drug administration has determined that the
prescription drug is contraindicated for that type of cancer.

2. Require coverage for any experimental prescription drug that is not approved for
any indication by the United States food and drug administration.

3. Alter any law with regard to provisions that limit the coverage of prescription
drugs that have not been approved by the United States food and drug administration.

4. Notwithstanding section 20-1057.02, require reimbursement or coverage for any
prescription drug that is not included in the drug formulary or list of covered
prescription drugs specified in the contract or evidence of coverage.

5. Notwithstanding section 20-1057.02, prohibit a contract or evidence of coverage
from limiting or excluding coverage of a prescription drug, if the decision to limit or
exclude coverage of the prescription drug is not based primarily on the coverage of
prescription drugs required by this section.

6. Prohibit the use of deductibles, coinsurance, copayments or other cost sharing
in relation to drug benefits and related medical benefits offered.

W. For the purposes of subsection V of this section:

1. The acceptable standard medical reference compendia are the following:

(a) The American hospital formulary service drug information, a publication of the
American society of health system pharmacists.

(b) The national comprehensive cancer network drugs and biologics compendium.

(d) Elsevier gold standard's clinical pharmacology compendium.

(e) Other authoritative compendia as identified by the secretary of the United
States department of health and human services.

2. Medical literature may be accepted if all of the following apply:

(a) At least two articles from major peer reviewed professional medical journals
have recognized, based on scientific or medical criteria, the drug's safety and
effectiveness for treatment of the indication for which the drug has been prescribed.

(b) No article from a major peer reviewed professional medical journal has
concluded, based on scientific or medical criteria, that the drug is unsafe or
ineffective or that the drug's safety and effectiveness cannot be determined for the
treatment of the indication for which the drug has been prescribed.

(c) The literature meets the uniform requirements for manuscripts submitted to
biomedical journals established by the international committee of medical journal editors
or is published in a journal specified by the United States department of health and
human services as acceptable peer reviewed medical literature pursuant to section
186(t)(2)(B) of the social security act (42 United States Code section 1395x(t)(2)(B)).

X. A health care services organization shall not issue or deliver any advertising
matter or sales material to any person in this state until the health care services
organization files the advertising matter or sales material with the director. This
subsection does not require a health care services organization to have the prior
approval of the director to issue or deliver the advertising matter or sales material.
If the director finds that the advertising matter or sales material, in whole or in part,
is false, deceptive or misleading, the director may issue an order disapproving the
advertising matter or sales material, directing the health care services organization to
cease and desist from issuing, circulating, displaying or using the advertising matter or
sales material within a period of time specified by the director but not less than ten
days and imposing any penalties prescribed in this title. At least five days before
issuing an order pursuant to this subsection, the director shall provide the health care
services organization with a written notice of the basis of the order to provide the
health care services organization with an opportunity to cure the alleged deficiency in
the advertising matter or sales material within a single five day period for the
particular advertising matter or sales material at issue. The health care services
organization may appeal the director's order pursuant to title 41, chapter 6, article 10.
Except as otherwise provided in this subsection, a health care services organization may
obtain a stay of the effectiveness of the order as prescribed in section 20-162. If the
director certifies in the order and provides a detailed explanation of the reasons in
support of the certification that continued use of the advertising matter or sales
material poses a threat to the health, safety or welfare of the public, the order may be
entered immediately without opportunity for cure and the effectiveness of the order is
not stayed pending the hearing on the notice of appeal but the hearing shall be promptly
instituted and determined.

Y. Any contract or evidence of coverage that is offered by a health care services
organization and that contains a prescription drug benefit shall provide coverage of
medical foods to treat inherited metabolic disorders as provided by this section.

Z. The metabolic disorders triggering medical foods coverage under this section
shall:

1. Be part of the newborn screening program prescribed in section 36-694.

2. Involve amino acid, carbohydrate or fat metabolism.

3. Have medically standard methods of diagnosis, treatment and monitoring including
quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA
confirmation in tissues.

4. Require specially processed or treated medical foods that are generally
available only under the supervision and direction of a physician who is licensed
pursuant to title 32, chapter 13 or 17 or a registered nurse practitioner who is licensed
pursuant to title 32, chapter 15, that must be consumed throughout life and without which
the person may suffer serious mental or physical impairment.

AA. Medical foods eligible for coverage under this section shall be prescribed or
ordered under the supervision of a physician licensed pursuant to title 32, chapter 13 or
17 or a registered nurse practitioner who is licensed pursuant to title 32, chapter 15 as
medically necessary for the therapeutic treatment of an inherited metabolic disease.

BB. A health care services organization shall cover at least fifty per cent of the
cost of medical foods prescribed to treat inherited metabolic disorders and covered
pursuant to this section. An organization may limit the maximum annual benefit for
medical foods under this section to five thousand dollars, which applies to the cost of
all prescribed modified low protein foods and metabolic formula.

CC. 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.

DD. For the purposes of:

1. This section:

(a) "Inherited metabolic disorder" means a disease caused by an inherited
abnormality of body chemistry and includes a disease tested under the newborn screening
program prescribed in section 36-694.

(b) "Medical foods" means modified low protein foods and metabolic formula.

(i) Formulated to be consumed or administered enterally under the supervision of a
physician who is licensed pursuant to title 32, chapter 13 or 17 or a registered nurse
practitioner who is licensed pursuant to title 32, chapter 15.

(ii) Processed or formulated to be deficient in one or more of the nutrients
present in typical foodstuffs.

(iii) Administered for the medical and nutritional management of a person who has
limited capacity to metabolize foodstuffs or certain nutrients contained in the
foodstuffs or who has other specific nutrient requirements as established by medical
evaluation.

(iv) Essential to a person's optimal growth, health and metabolic homeostasis.

(d) "Modified low protein foods" means foods that are all of the following:

(ii) Processed or formulated to contain less than one gram of protein per unit of
serving, but does not include a natural food that is naturally low in protein.

(iv) Essential to a person's optimal growth, health and metabolic homeostasis.

2. Subsection B of this section, "child", for purposes of initial coverage of an
adopted child or a child placed for adoption but not for purposes of termination of
coverage of such child, means a person under eighteen years of age.