20-2323. Disclosure of information
A. Each accountable health plan that offers a health benefits plan to the public
shall provide disclosure forms as required by this section. The disclosure form shall be
in a form that is prescribed by the director and that includes all of the following:
1. A separate roster of the plan's primary care physicians who are licensed
pursuant to title 32, chapter 13, 17 or 29, and registered nurse practitioners who are
licensed pursuant to title 32, chapter 15, including the physician's or registered nurse
practitioner's degree and practice specialty, the year initially licensed to practice
and, if different, the year initially licensed to practice in this state.
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.
(d) Where and in what manner an enrollee may obtain services, including the
procedures for selecting or changing primary care physicians and registered nurse
practitioners and the locations of hospitals and outpatient treatment centers that are
under contract with the accountable health plan.
3. Any limitations of the services, kinds of services, benefits and exclusions that
apply to the plan including:
(a) Procedures for emergency room, nighttime or weekend visits and referrals to
specialist physicians and registered nurse practitioners.
(b) Whether services received outside of the plan are covered and in what manner
they are covered.
(c) The circumstances under which prior authorization is required for emergency
health care and a statement as to whether and where the plan provides twenty-four hour
emergency services.
(d) The circumstances under which the plan may retroactively deny coverage for
emergency health related treatment and nonemergency health related treatment that had
prior authorization under the plan's written policies.
(e) A statement regarding whether the plan's providers must comply with any
specified numbers, targeted averages or maximum durations of patient visits and the
specific requirements of each.
(f) The procedures that the enrollee must follow to consult with a physician or a
registered nurse practitioner other than the enrollee's primary care physician or
registered nurse practitioner and whether the enrollee's primary care physician or
registered nurse practitioner, the plan's medical director or a committee must first
authorize the referral.
(g) Whether it is necessary to repeat prior authorization if the specialist care is
continuing.
(h) Whether a point of service option is available and how it is structured.
4. Grievance procedures for claim or treatment denials, creditable coverage
determinations, dissatisfaction with care and access to care issues.
5. Subject to section 20-2326, a statement as to whether a plan physician or
registered nurse practitioner 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 statement as 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 specialist physicians, and if these types of
incentives or penalties are included, a concise description of and, at the option of the
accountable health plan, justification for each of them.
7. A statement that the disclosure form is a summary only and that the enrollee
should consult the plan's evidence of coverage to determine any governing contractual
provision.
B. An accountable health plan shall not disseminate a completed disclosure form
until the form is submitted to the director. This section does not require an accountable
health plan to submit to the director its separate roster of plan physicians and
registered nurse practitioners or any roster updates.
C. On request, an accountable health plan shall provide the information required
under subsection A of this section to all employers who are considering participating in
a health benefits plan that is offered by the accountable health plan or to an employer
that is considering renewal of a health benefits plan that is provided by an accountable
health plan.
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 an accountable health plan 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.
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