20-1076

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.