40-2124.Same; deductible and copayment provisions;maximum lifetime benefit; preexisting conditions exclusion; reduction of planbenefits for duplicate coverage; recovery of benefits paid for noncoveredexpenses.(a)Coverage under the plan shall be subject to both deductible and coinsuranceprovisions set by theboard. The plan shall offer to currentparticipants and new enrolleesno fewer than four choices of deductible and copayment options. Coverage shallcontain acoinsurance provision for each service covered by the plan, and such copaymentrequirement shallnot be subject to a stop-loss provision. Such coverage may provide for apercentage or dollar amountof coinsurance reduction at specific thresholds of copayment expenditures bythe insured.
(b) Coverage under the plan shall be subject to a maximum lifetime benefit of$2,000,000 per covered individual.
(c) Coverage under the plan shall exclude charges or expenses incurredduring the first 90 days following the effective date of coverage as to anycondition: (1) Which manifested itself during the six-month period immediatelyprior to the application for coverage in such manner as would cause anordinarily prudent person to seek diagnosis, care or treatment; or (2) forwhich medical advice, care or treatment was recommended or received in thesix-month period immediately prior to the application for coverage. Insucceeding years of operation of the plan, coverage of preexisting conditionsmay be excluded as determined by the board, except that no such exclusion shallexceed 180 calendar days, and no exclusion shall be applied to a federallydefined eligible individual provided that application for coverage is made notlater than 63 days following the applicant's most recent prior creditablecoverage. For any individual who is eligible for the credit for healthinsurance costs under section 35 of the internal revenue code of 1986, thepreexisting conditions limitation will not apply whenever such individual hasmaintained creditable health insurance coverage for an aggregate period ofthree months, not counting any period prior to a 63 day break in coverage, asof the date on which such individual seeks to enroll in coverage provided bythis act.
(d) (1) Benefits otherwise payable under plan coverage shall be reduced byall amounts paid or payable through any other health insurance, or insurancearrangement, and by all hospital and medical expense benefits paid or payableunder any workers compensation coverage, automobile medical payment orliability insurance whether provided on the basis of fault or nonfault, and byany hospital or medical benefits paid or payable under or provided pursuant toany state or federal law or program.
(2) The association shall have a cause of action against an eligible personfor the recovery of the amount of benefits paid which are not covered expenses.Benefits due from the plan may be reduced or refused as a set-off against anyamount recoverable under this section.
40-2124.Same; deductible and copayment provisions;maximum lifetime benefit; preexisting conditions exclusion; reduction of planbenefits for duplicate coverage; recovery of benefits paid for noncoveredexpenses.(a)Coverage under the plan shall be subject to both deductible and coinsuranceprovisions set by theboard. The plan shall offer to currentparticipants and new enrolleesno fewer than four choices of deductible and copayment options. Coverage shallcontain acoinsurance provision for each service covered by the plan, and such copaymentrequirement shallnot be subject to a stop-loss provision. Such coverage may provide for apercentage or dollar amountof coinsurance reduction at specific thresholds of copayment expenditures bythe insured.
(b) Coverage under the plan shall be subject to a maximum lifetime benefit of$2,000,000 per covered individual.
(c) Coverage under the plan shall exclude charges or expenses incurredduring the first 90 days following the effective date of coverage as to anycondition: (1) Which manifested itself during the six-month period immediatelyprior to the application for coverage in such manner as would cause anordinarily prudent person to seek diagnosis, care or treatment; or (2) forwhich medical advice, care or treatment was recommended or received in thesix-month period immediately prior to the application for coverage. Insucceeding years of operation of the plan, coverage of preexisting conditionsmay be excluded as determined by the board, except that no such exclusion shallexceed 180 calendar days, and no exclusion shall be applied to a federallydefined eligible individual provided that application for coverage is made notlater than 63 days following the applicant's most recent prior creditablecoverage. For any individual who is eligible for the credit for healthinsurance costs under section 35 of the internal revenue code of 1986, thepreexisting conditions limitation will not apply whenever such individual hasmaintained creditable health insurance coverage for an aggregate period ofthree months, not counting any period prior to a 63 day break in coverage, asof the date on which such individual seeks to enroll in coverage provided bythis act.
(d) (1) Benefits otherwise payable under plan coverage shall be reduced byall amounts paid or payable through any other health insurance, or insurancearrangement, and by all hospital and medical expense benefits paid or payableunder any workers compensation coverage, automobile medical payment orliability insurance whether provided on the basis of fault or nonfault, and byany hospital or medical benefits paid or payable under or provided pursuant toany state or federal law or program.
(2) The association shall have a cause of action against an eligible personfor the recovery of the amount of benefits paid which are not covered expenses.Benefits due from the plan may be reduced or refused as a set-off against anyamount recoverable under this section.
40-2124.Same; deductible and copayment provisions;maximum lifetime benefit; preexisting conditions exclusion; reduction of planbenefits for duplicate coverage; recovery of benefits paid for noncoveredexpenses.(a)Coverage under the plan shall be subject to both deductible and coinsuranceprovisions set by theboard. The plan shall offer to currentparticipants and new enrolleesno fewer than four choices of deductible and copayment options. Coverage shallcontain acoinsurance provision for each service covered by the plan, and such copaymentrequirement shallnot be subject to a stop-loss provision. Such coverage may provide for apercentage or dollar amountof coinsurance reduction at specific thresholds of copayment expenditures bythe insured.
(b) Coverage under the plan shall be subject to a maximum lifetime benefit of$2,000,000 per covered individual.
(c) Coverage under the plan shall exclude charges or expenses incurredduring the first 90 days following the effective date of coverage as to anycondition: (1) Which manifested itself during the six-month period immediatelyprior to the application for coverage in such manner as would cause anordinarily prudent person to seek diagnosis, care or treatment; or (2) forwhich medical advice, care or treatment was recommended or received in thesix-month period immediately prior to the application for coverage. Insucceeding years of operation of the plan, coverage of preexisting conditionsmay be excluded as determined by the board, except that no such exclusion shallexceed 180 calendar days, and no exclusion shall be applied to a federallydefined eligible individual provided that application for coverage is made notlater than 63 days following the applicant's most recent prior creditablecoverage. For any individual who is eligible for the credit for healthinsurance costs under section 35 of the internal revenue code of 1986, thepreexisting conditions limitation will not apply whenever such individual hasmaintained creditable health insurance coverage for an aggregate period ofthree months, not counting any period prior to a 63 day break in coverage, asof the date on which such individual seeks to enroll in coverage provided bythis act.
(d) (1) Benefits otherwise payable under plan coverage shall be reduced byall amounts paid or payable through any other health insurance, or insurancearrangement, and by all hospital and medical expense benefits paid or payableunder any workers compensation coverage, automobile medical payment orliability insurance whether provided on the basis of fault or nonfault, and byany hospital or medical benefits paid or payable under or provided pursuant toany state or federal law or program.
(2) The association shall have a cause of action against an eligible personfor the recovery of the amount of benefits paid which are not covered expenses.Benefits due from the plan may be reduced or refused as a set-off against anyamount recoverable under this section.
