Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3209.Certificates of coverage,contracts and other marketingdocuments, contents, form, filing;continuation and conversion requirements; enrollee not liable to provider foramount owed; application of 40-2209 and40-2215.(a) All forms of group and individual certificates ofcoverage and contracts issued by theorganization to enrollees or other marketing documents purporting to describethe organization'shealth care services shall contain as a minimum:
(1) A complete description of the health care services and other benefits towhich theenrollee is entitled;
(2) The locations of all facilities, the hours of operation and the serviceswhich are providedin each facility in the case of individual practice associations or medicalstaff and group practices,and, in all other cases, a list of providers by specialty with a list ofaddresses and telephone numbers;
(3) the financial responsibilities of the enrollee and the amount of anydeductible, copaymentor coinsurance required;
(4) all exclusions and limitations on services or any other benefits to beprovided includingany deductible or copayment feature and all restrictions relating topre-existing conditions;
(5) all criteria by which an enrollee may be disenrolled ordenied reenrollment;
(6) service priorities in case of epidemic, or other emergency conditionsaffecting demand for medical services;
(7) in the case of a health maintenance organization, a provision that anenrollee or a covered dependent of an enrollee whose coverage under a healthmaintenance organization group contract has been terminated for any reason butwho remains in the service area and who has been continuously covered by thehealth maintenance organization or under any group policy providing similarbenefits which it replaces for at least three months immediately prior totermination shall be entitled to obtain a converted contract or have suchcoverage continued under the group contract for a period of 18 months followingwhich such enrollee or dependent shall beentitled to obtain a converted contract in accordance with the provisions ofthis section. The employer shall give theemployee and such employee'sdependents reasonable notice of the right to continuation of coverage. Theterminated employee shall pay the insurance carrier thepremium for the continuation ofcoverage andsuch premium shall be the same as that applicable to members or employeesremaining in the group. The converted contract shall provide coverage at leastequal to the conversion coverage options generally available from insurers ormutual nonprofit hospital and medical service corporations in the service areaat the applicable premium cost. The group enrollee or enrollees shall be solelyresponsible for paying the premiums for the alternative coverage. The frequencyof premium payment shall be the frequency customarily required by the healthmaintenance organization, mutual nonprofit hospital and medical servicecorporation or insurer for the policy form and plan selected, except that theinsurer, mutual nonprofit hospital and medical service corporation or healthmaintenance organization shall require premium payments at least quarterly. Thecoverage shall be available to all enrollees of any group without medicalunderwriting. The requirement imposed by this subsection shall not apply to acontract which provides benefits for specific diseases or for accidentalinjuries only, nor shall it apply to any employee or member or such employee'sor member's covered dependents when:
(A) Such person was terminated for cause as permitted by the group contractapproved by the commissioner;
(B) any discontinued group coverage was replaced by similar groupcoverage within 31 days; or
(C) the employee or member is or could be covered by any other insured ornoninsuredarrangement which provides expense incurred hospital, surgical or medicalcoverage and benefitsfor individuals in a group under which the person was not covered prior to suchtermination. Writtenapplication for the converted contract shall be made and the first premium paidnot later than 31 daysafter termination of the group coverage or receipt of notice of conversionrights from the healthmaintenance organization, whichever is later, and shall become effective theday following thetermination of coverage under the group contract. The health maintenanceorganization shall give the employee or member and such employee's or member'scovered dependents reasonable notice of the right to convert at least oncewithin 30 days of termination of coverage under the group contract. The groupcontract and certificates may include provisions necessary to identify orobtain identification of persons and notification of events that would activatethe notice requirements and conversion rights created by this section but suchrequirements and rights shall not be invalidated by failure of persons otherthan the employee or member entitled to conversion to comply with any suchprovisions. In addition, the converted contract shall be subject to theprovisions contained in paragraphs (2), (4), (5), (6), (7), (8), (9), (13),(14), (15), (16), (17) and (19) of subsection (j) ofK.S.A. 40-2209, and amendments thereto;
(8) (A) group contracts shall contain a provision extending payment of suchbenefits until discharged or for a period not less than 31 days following theexpiration date of the contract, whichever is earlier, for covered enrolleesand dependents confined in a hospital on the date oftermination;
(B) a provision that coverage under any subsequent replacement contract thatis intended to afford continuous coverage will commence immediately followingexpiration of any prior contract with respect to covered services not providedpursuant to subparagraph (8)(A); and
(9) an individual contract shall provide for a 10-day period for the enrolleeto examine and return the contract and have the premium refunded, but ifservices were received by the enrollee during the 10-day period, and theenrollee returns the contract to receive a refund of the premium paid, theenrollee must pay for such services.
(b) No health maintenance organization or medicare provider organizationauthorized under this act shall contract with any provider under provisionswhich require enrollees to guarantee payment, other than copayments anddeductibles, to such provider in the event of nonpayment by the healthmaintenance organization or medicare provider organization for any serviceswhich have been performed under contracts between such enrollees and the healthmaintenance organization or medicare provider organization. Further, anycontract between a health maintenance organization or medicare providerorganization and a provider shall provide that if the health maintenanceorganization or medicare provider organization fails to pay for covered healthcare services as set forth in the contract between the health maintenanceorganization or medicare provider organization and its enrollee, the enrolleeor covered dependents shall not be liable to any provider for any amounts owedby the health maintenance organization or medicare provider organization. Ifthere is no written contract between the health maintenance organization ormedicare provider organization and the provider or if the written contractfails to include the above provision, the enrollee and dependents are notliable to any provider for any amounts owed by the health maintenanceorganization or medicare provider organization. Any action by a provider tocollect or attempt to collect from a subscriber or enrollee any sum owed by thehealth maintenance organization to a provider shall be deemed to be anunconscionable act within the meaning of K.S.A.50-627 and amendments thereto.
(c) No group or individual certificate of coverage or contract form oramendment to an approved certificate of coverage or contract form shall beissued unless it is filed with the commissioner. Such contract form oramendment shall become effective within 30 days of such filing unless thecommissioner finds that such contract form or amendment does not comply withthe requirements of this section.
(d) Every contract shall include a clear and understandable description ofthe health maintenance organization's or medicare provider organization'smethod for resolving enrollee grievances.
(e) The provisions of subsections (A), (B), (C), (D) and (E) of K.S.A.40-2209 and 40-2215 and amendments thereto shall apply to all contracts issuedunder this section, and the provisions of such sections shall apply to healthmaintenance organizations.
(f) In lieu of any of the requirements of subsection (a), the commissionermay accept certificates of coverage issued by a medicare provider organizationin conformity with requirements imposed by any appropriate federal regulatoryagency.
Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3209.Certificates of coverage,contracts and other marketingdocuments, contents, form, filing;continuation and conversion requirements; enrollee not liable to provider foramount owed; application of 40-2209 and40-2215.(a) All forms of group and individual certificates ofcoverage and contracts issued by theorganization to enrollees or other marketing documents purporting to describethe organization'shealth care services shall contain as a minimum:
(1) A complete description of the health care services and other benefits towhich theenrollee is entitled;
(2) The locations of all facilities, the hours of operation and the serviceswhich are providedin each facility in the case of individual practice associations or medicalstaff and group practices,and, in all other cases, a list of providers by specialty with a list ofaddresses and telephone numbers;
(3) the financial responsibilities of the enrollee and the amount of anydeductible, copaymentor coinsurance required;
(4) all exclusions and limitations on services or any other benefits to beprovided includingany deductible or copayment feature and all restrictions relating topre-existing conditions;
(5) all criteria by which an enrollee may be disenrolled ordenied reenrollment;
(6) service priorities in case of epidemic, or other emergency conditionsaffecting demand for medical services;
(7) in the case of a health maintenance organization, a provision that anenrollee or a covered dependent of an enrollee whose coverage under a healthmaintenance organization group contract has been terminated for any reason butwho remains in the service area and who has been continuously covered by thehealth maintenance organization or under any group policy providing similarbenefits which it replaces for at least three months immediately prior totermination shall be entitled to obtain a converted contract or have suchcoverage continued under the group contract for a period of 18 months followingwhich such enrollee or dependent shall beentitled to obtain a converted contract in accordance with the provisions ofthis section. The employer shall give theemployee and such employee'sdependents reasonable notice of the right to continuation of coverage. Theterminated employee shall pay the insurance carrier thepremium for the continuation ofcoverage andsuch premium shall be the same as that applicable to members or employeesremaining in the group. The converted contract shall provide coverage at leastequal to the conversion coverage options generally available from insurers ormutual nonprofit hospital and medical service corporations in the service areaat the applicable premium cost. The group enrollee or enrollees shall be solelyresponsible for paying the premiums for the alternative coverage. The frequencyof premium payment shall be the frequency customarily required by the healthmaintenance organization, mutual nonprofit hospital and medical servicecorporation or insurer for the policy form and plan selected, except that theinsurer, mutual nonprofit hospital and medical service corporation or healthmaintenance organization shall require premium payments at least quarterly. Thecoverage shall be available to all enrollees of any group without medicalunderwriting. The requirement imposed by this subsection shall not apply to acontract which provides benefits for specific diseases or for accidentalinjuries only, nor shall it apply to any employee or member or such employee'sor member's covered dependents when:
(A) Such person was terminated for cause as permitted by the group contractapproved by the commissioner;
(B) any discontinued group coverage was replaced by similar groupcoverage within 31 days; or
(C) the employee or member is or could be covered by any other insured ornoninsuredarrangement which provides expense incurred hospital, surgical or medicalcoverage and benefitsfor individuals in a group under which the person was not covered prior to suchtermination. Writtenapplication for the converted contract shall be made and the first premium paidnot later than 31 daysafter termination of the group coverage or receipt of notice of conversionrights from the healthmaintenance organization, whichever is later, and shall become effective theday following thetermination of coverage under the group contract. The health maintenanceorganization shall give the employee or member and such employee's or member'scovered dependents reasonable notice of the right to convert at least oncewithin 30 days of termination of coverage under the group contract. The groupcontract and certificates may include provisions necessary to identify orobtain identification of persons and notification of events that would activatethe notice requirements and conversion rights created by this section but suchrequirements and rights shall not be invalidated by failure of persons otherthan the employee or member entitled to conversion to comply with any suchprovisions. In addition, the converted contract shall be subject to theprovisions contained in paragraphs (2), (4), (5), (6), (7), (8), (9), (13),(14), (15), (16), (17) and (19) of subsection (j) ofK.S.A. 40-2209, and amendments thereto;
(8) (A) group contracts shall contain a provision extending payment of suchbenefits until discharged or for a period not less than 31 days following theexpiration date of the contract, whichever is earlier, for covered enrolleesand dependents confined in a hospital on the date oftermination;
(B) a provision that coverage under any subsequent replacement contract thatis intended to afford continuous coverage will commence immediately followingexpiration of any prior contract with respect to covered services not providedpursuant to subparagraph (8)(A); and
(9) an individual contract shall provide for a 10-day period for the enrolleeto examine and return the contract and have the premium refunded, but ifservices were received by the enrollee during the 10-day period, and theenrollee returns the contract to receive a refund of the premium paid, theenrollee must pay for such services.
(b) No health maintenance organization or medicare provider organizationauthorized under this act shall contract with any provider under provisionswhich require enrollees to guarantee payment, other than copayments anddeductibles, to such provider in the event of nonpayment by the healthmaintenance organization or medicare provider organization for any serviceswhich have been performed under contracts between such enrollees and the healthmaintenance organization or medicare provider organization. Further, anycontract between a health maintenance organization or medicare providerorganization and a provider shall provide that if the health maintenanceorganization or medicare provider organization fails to pay for covered healthcare services as set forth in the contract between the health maintenanceorganization or medicare provider organization and its enrollee, the enrolleeor covered dependents shall not be liable to any provider for any amounts owedby the health maintenance organization or medicare provider organization. Ifthere is no written contract between the health maintenance organization ormedicare provider organization and the provider or if the written contractfails to include the above provision, the enrollee and dependents are notliable to any provider for any amounts owed by the health maintenanceorganization or medicare provider organization. Any action by a provider tocollect or attempt to collect from a subscriber or enrollee any sum owed by thehealth maintenance organization to a provider shall be deemed to be anunconscionable act within the meaning of K.S.A.50-627 and amendments thereto.
(c) No group or individual certificate of coverage or contract form oramendment to an approved certificate of coverage or contract form shall beissued unless it is filed with the commissioner. Such contract form oramendment shall become effective within 30 days of such filing unless thecommissioner finds that such contract form or amendment does not comply withthe requirements of this section.
(d) Every contract shall include a clear and understandable description ofthe health maintenance organization's or medicare provider organization'smethod for resolving enrollee grievances.
(e) The provisions of subsections (A), (B), (C), (D) and (E) of K.S.A.40-2209 and 40-2215 and amendments thereto shall apply to all contracts issuedunder this section, and the provisions of such sections shall apply to healthmaintenance organizations.
(f) In lieu of any of the requirements of subsection (a), the commissionermay accept certificates of coverage issued by a medicare provider organizationin conformity with requirements imposed by any appropriate federal regulatoryagency.
Article 32.--HEALTH MAINTENANCE ORGANIZATIONS AND MEDICARE PROVIDER ORGANIZATIONS
40-3209.Certificates of coverage,contracts and other marketingdocuments, contents, form, filing;continuation and conversion requirements; enrollee not liable to provider foramount owed; application of 40-2209 and40-2215.(a) All forms of group and individual certificates ofcoverage and contracts issued by theorganization to enrollees or other marketing documents purporting to describethe organization'shealth care services shall contain as a minimum:
(1) A complete description of the health care services and other benefits towhich theenrollee is entitled;
(2) The locations of all facilities, the hours of operation and the serviceswhich are providedin each facility in the case of individual practice associations or medicalstaff and group practices,and, in all other cases, a list of providers by specialty with a list ofaddresses and telephone numbers;
(3) the financial responsibilities of the enrollee and the amount of anydeductible, copaymentor coinsurance required;
(4) all exclusions and limitations on services or any other benefits to beprovided includingany deductible or copayment feature and all restrictions relating topre-existing conditions;
(5) all criteria by which an enrollee may be disenrolled ordenied reenrollment;
(6) service priorities in case of epidemic, or other emergency conditionsaffecting demand for medical services;
(7) in the case of a health maintenance organization, a provision that anenrollee or a covered dependent of an enrollee whose coverage under a healthmaintenance organization group contract has been terminated for any reason butwho remains in the service area and who has been continuously covered by thehealth maintenance organization or under any group policy providing similarbenefits which it replaces for at least three months immediately prior totermination shall be entitled to obtain a converted contract or have suchcoverage continued under the group contract for a period of 18 months followingwhich such enrollee or dependent shall beentitled to obtain a converted contract in accordance with the provisions ofthis section. The employer shall give theemployee and such employee'sdependents reasonable notice of the right to continuation of coverage. Theterminated employee shall pay the insurance carrier thepremium for the continuation ofcoverage andsuch premium shall be the same as that applicable to members or employeesremaining in the group. The converted contract shall provide coverage at leastequal to the conversion coverage options generally available from insurers ormutual nonprofit hospital and medical service corporations in the service areaat the applicable premium cost. The group enrollee or enrollees shall be solelyresponsible for paying the premiums for the alternative coverage. The frequencyof premium payment shall be the frequency customarily required by the healthmaintenance organization, mutual nonprofit hospital and medical servicecorporation or insurer for the policy form and plan selected, except that theinsurer, mutual nonprofit hospital and medical service corporation or healthmaintenance organization shall require premium payments at least quarterly. Thecoverage shall be available to all enrollees of any group without medicalunderwriting. The requirement imposed by this subsection shall not apply to acontract which provides benefits for specific diseases or for accidentalinjuries only, nor shall it apply to any employee or member or such employee'sor member's covered dependents when:
(A) Such person was terminated for cause as permitted by the group contractapproved by the commissioner;
(B) any discontinued group coverage was replaced by similar groupcoverage within 31 days; or
(C) the employee or member is or could be covered by any other insured ornoninsuredarrangement which provides expense incurred hospital, surgical or medicalcoverage and benefitsfor individuals in a group under which the person was not covered prior to suchtermination. Writtenapplication for the converted contract shall be made and the first premium paidnot later than 31 daysafter termination of the group coverage or receipt of notice of conversionrights from the healthmaintenance organization, whichever is later, and shall become effective theday following thetermination of coverage under the group contract. The health maintenanceorganization shall give the employee or member and such employee's or member'scovered dependents reasonable notice of the right to convert at least oncewithin 30 days of termination of coverage under the group contract. The groupcontract and certificates may include provisions necessary to identify orobtain identification of persons and notification of events that would activatethe notice requirements and conversion rights created by this section but suchrequirements and rights shall not be invalidated by failure of persons otherthan the employee or member entitled to conversion to comply with any suchprovisions. In addition, the converted contract shall be subject to theprovisions contained in paragraphs (2), (4), (5), (6), (7), (8), (9), (13),(14), (15), (16), (17) and (19) of subsection (j) ofK.S.A. 40-2209, and amendments thereto;
(8) (A) group contracts shall contain a provision extending payment of suchbenefits until discharged or for a period not less than 31 days following theexpiration date of the contract, whichever is earlier, for covered enrolleesand dependents confined in a hospital on the date oftermination;
(B) a provision that coverage under any subsequent replacement contract thatis intended to afford continuous coverage will commence immediately followingexpiration of any prior contract with respect to covered services not providedpursuant to subparagraph (8)(A); and
(9) an individual contract shall provide for a 10-day period for the enrolleeto examine and return the contract and have the premium refunded, but ifservices were received by the enrollee during the 10-day period, and theenrollee returns the contract to receive a refund of the premium paid, theenrollee must pay for such services.
(b) No health maintenance organization or medicare provider organizationauthorized under this act shall contract with any provider under provisionswhich require enrollees to guarantee payment, other than copayments anddeductibles, to such provider in the event of nonpayment by the healthmaintenance organization or medicare provider organization for any serviceswhich have been performed under contracts between such enrollees and the healthmaintenance organization or medicare provider organization. Further, anycontract between a health maintenance organization or medicare providerorganization and a provider shall provide that if the health maintenanceorganization or medicare provider organization fails to pay for covered healthcare services as set forth in the contract between the health maintenanceorganization or medicare provider organization and its enrollee, the enrolleeor covered dependents shall not be liable to any provider for any amounts owedby the health maintenance organization or medicare provider organization. Ifthere is no written contract between the health maintenance organization ormedicare provider organization and the provider or if the written contractfails to include the above provision, the enrollee and dependents are notliable to any provider for any amounts owed by the health maintenanceorganization or medicare provider organization. Any action by a provider tocollect or attempt to collect from a subscriber or enrollee any sum owed by thehealth maintenance organization to a provider shall be deemed to be anunconscionable act within the meaning of K.S.A.50-627 and amendments thereto.
(c) No group or individual certificate of coverage or contract form oramendment to an approved certificate of coverage or contract form shall beissued unless it is filed with the commissioner. Such contract form oramendment shall become effective within 30 days of such filing unless thecommissioner finds that such contract form or amendment does not comply withthe requirements of this section.
(d) Every contract shall include a clear and understandable description ofthe health maintenance organization's or medicare provider organization'smethod for resolving enrollee grievances.
(e) The provisions of subsections (A), (B), (C), (D) and (E) of K.S.A.40-2209 and 40-2215 and amendments thereto shall apply to all contracts issuedunder this section, and the provisions of such sections shall apply to healthmaintenance organizations.
(f) In lieu of any of the requirements of subsection (a), the commissionermay accept certificates of coverage issued by a medicare provider organizationin conformity with requirements imposed by any appropriate federal regulatoryagency.
