Disclosure information to enrollees required, when.
354.442. 1. Each enrollee, and upon request each prospective enrolleeprior to enrollment, shall be supplied with written disclosure information.In the event of any inconsistency between any separate written disclosurestatement and the enrollee contract or evidence of coverage, the terms of theenrollee contract or evidence of coverage shall be controlling. Theinformation to be disclosed in writing shall include at a minimum thefollowing:
(1) A description of coverage provisions, health care benefits, benefitmaximums, including benefit limitations;
(2) A description of any exclusions of coverage, including thedefinition of medical necessity used in determining whether benefits will becovered;
(3) A description of all prior authorization or other requirements fortreatments and services;
(4) A description of utilization review policies and procedures used bythe health maintenance organization, including:
(a) The circumstances under which utilization review shall beundertaken;
(b) The toll-free telephone number of the utilization review agent;
(c) The time frames under which utilization review decisions shall bemade for prospective, retrospective and concurrent decisions;
(d) The right to reconsideration;
(e) The right to an appeal, including the expedited and standard appealsprocesses and the time frames for such appeals;
(f) The right to designate a representative;
(g) A notice that all denials of claims shall be made by qualifiedclinical personnel and that all notices of denial shall include informationabout the basis of the decision; and
(h) Further appeal rights, if any;
(5) An explanation of an enrollee's financial responsibility for paymentof premiums, coinsurance, co-payments, deductibles and any other charge,annual limits on an enrollee's financial responsibility, caps on payments forcovered services and financial responsibility for noncovered health careprocedures, treatments or services provided within the health maintenanceorganization;
(6) An explanation of an enrollee's financial responsibility for paymentwhen services are provided by a health care provider who is not part of thehealth maintenance organization's network or by any provider without requiredauthorization, or when a procedure, treatment or service is not a coveredhealth care benefit;
(7) A description of the grievance procedures to be used to resolvedisputes between a health maintenance organization and an enrollee, including:
(a) The right to file a grievance regarding any dispute between anenrollee and a health maintenance organization;
(b) The right to file a grievance when the dispute is about referrals orcovered benefits;
(c) The toll-free telephone number which enrollees may use to file agrievance;
(d) The department of insurance, financial institutions and professionalregistration's toll-free consumer complaint hot line number;
(e) The time frames and circumstances for expedited and standardgrievances;
(f) The right to appeal a grievance determination and the procedures forfiling such an appeal;
(g) The time frames and circumstances for expedited and standardappeals;
(h) The right to designate a representative;
(i) A notice that all disputes involving clinical decisions shall bemade by qualified clinical personnel; and
(j) All notices of determination shall include information about thebasis of the decision and further appeal rights, if any;
(8) A description of a procedure for providing care and coveragetwenty-four hours a day, seven days a week, for emergency services. Suchdescription shall include the definition of emergency services and emergencymedical condition, notice that emergency services are not subject to priorapproval, and shall describe the enrollee's financial and otherresponsibilities regarding obtaining such services, including when suchservices are received outside the health maintenance organization's servicearea;
(9) A description of procedures for enrollees to select and access thehealth maintenance organization's primary and specialty care providers,including notice of how to determine whether a participating provider isaccepting new patients;
(10) A description of the procedures for changing primary and specialtycare providers within the health maintenance organization;
(11) Notice that an enrollee may obtain a referral for covered servicesto a health care provider outside of the health maintenance organization'snetwork or panel when the health maintenance organization does not have ahealth care provider with appropriate training and experience in the networkor panel to meet the particular health care needs of the enrollee and theprocedure by which the enrollee may obtain such referral;
(12) A description of the mechanisms by which enrollees may participatein the development of the policies of the health maintenance organization;
(13) Notice of all appropriate mailing addresses and telephone numbersto be utilized by enrollees seeking information or authorization;
(14) A listing by specialty, which may be in a separate document that isupdated annually, of the names, addresses and telephone numbers of allparticipating providers, including facilities, and in addition in the case ofphysicians, board certification; and
(15) The director of the department of insurance, financial institutionsand professional registration shall develop a standard credentialing formwhich shall be used by all health carriers when credentialing health careprofessionals in a managed care plan. If the health carrier demonstrates aneed for additional information, the director of the department of insurance,financial institutions and professional registration may approve a supplementto the standard credentialing form. All forms and supplements shall meet allrequirements as defined by the National Committee of Quality Assurance.
2. Each health maintenance organization shall, upon request of anenrollee or prospective enrollee, provide the following:
(1) A list of the names, business addresses and official positions ofthe membership of the board of directors, officers, controlling persons,owners or partners of the health maintenance organization;
(2) A copy of the most recent annual certified financial statement ofthe health maintenance organization, including a balance sheet and summary ofreceipts and disbursements prepared by a certified public accountant;
(3) A copy of the most recent individual, direct pay enrollee contracts;
(4) Information relating to consumer complaints compiled annually by thedepartment of insurance, financial institutions and professional registration;
(5) The procedures for protecting the confidentiality of medical recordsand other enrollee information;
(6) An opportunity to inspect drug formularies used by such healthmaintenance organization and any financial interest in a pharmacy providerutilized by such organization. The health maintenance organization shall alsodisclose the process by which an enrollee or his representative may seek tohave an excluded drug covered as a benefit;
(7) A written description of the organizational arrangements and ongoingprocedures of the health maintenance organization's quality assurance program;
(8) A description of the procedures followed by the health maintenanceorganization in making decisions about the experimental or investigationalnature of individual drugs, medical devices or treatments in clinical trials;
(9) Individual health practitioner affiliations with participatinghospitals, if any;
(10) Upon written request, written clinical review criteria relating toconditions or diseases and, where appropriate, other clinical informationwhich the organization may consider in its utilization review. The healthmaintenance organization may include with the information a description of howsuch information will be used in the utilization review process;
(11) The written application procedures and minimum qualificationrequirements for health care providers to be considered by the healthmaintenance organization;
(12) A description of the procedures followed by the health maintenanceorganization in making decisions about which drugs to include in the healthmaintenance organization's drug formulary.
3. Nothing in this section shall prevent a health maintenanceorganization from changing or updating the materials that are made availableto enrollees.
Disclosure information to enrollees required, when.
354.442. 1. Each enrollee, and upon request each prospective enrolleeprior to enrollment, shall be supplied with written disclosure information.In the event of any inconsistency between any separate written disclosurestatement and the enrollee contract or evidence of coverage, the terms of theenrollee contract or evidence of coverage shall be controlling. Theinformation to be disclosed in writing shall include at a minimum thefollowing:
(1) A description of coverage provisions, health care benefits, benefitmaximums, including benefit limitations;
(2) A description of any exclusions of coverage, including thedefinition of medical necessity used in determining whether benefits will becovered;
(3) A description of all prior authorization or other requirements fortreatments and services;
(4) A description of utilization review policies and procedures used bythe health maintenance organization, including:
(a) The circumstances under which utilization review shall beundertaken;
(b) The toll-free telephone number of the utilization review agent;
(c) The time frames under which utilization review decisions shall bemade for prospective, retrospective and concurrent decisions;
(d) The right to reconsideration;
(e) The right to an appeal, including the expedited and standard appealsprocesses and the time frames for such appeals;
(f) The right to designate a representative;
(g) A notice that all denials of claims shall be made by qualifiedclinical personnel and that all notices of denial shall include informationabout the basis of the decision; and
(h) Further appeal rights, if any;
(5) An explanation of an enrollee's financial responsibility for paymentof premiums, coinsurance, co-payments, deductibles and any other charge,annual limits on an enrollee's financial responsibility, caps on payments forcovered services and financial responsibility for noncovered health careprocedures, treatments or services provided within the health maintenanceorganization;
(6) An explanation of an enrollee's financial responsibility for paymentwhen services are provided by a health care provider who is not part of thehealth maintenance organization's network or by any provider without requiredauthorization, or when a procedure, treatment or service is not a coveredhealth care benefit;
(7) A description of the grievance procedures to be used to resolvedisputes between a health maintenance organization and an enrollee, including:
(a) The right to file a grievance regarding any dispute between anenrollee and a health maintenance organization;
(b) The right to file a grievance when the dispute is about referrals orcovered benefits;
(c) The toll-free telephone number which enrollees may use to file agrievance;
(d) The department of insurance, financial institutions and professionalregistration's toll-free consumer complaint hot line number;
(e) The time frames and circumstances for expedited and standardgrievances;
(f) The right to appeal a grievance determination and the procedures forfiling such an appeal;
(g) The time frames and circumstances for expedited and standardappeals;
(h) The right to designate a representative;
(i) A notice that all disputes involving clinical decisions shall bemade by qualified clinical personnel; and
(j) All notices of determination shall include information about thebasis of the decision and further appeal rights, if any;
(8) A description of a procedure for providing care and coveragetwenty-four hours a day, seven days a week, for emergency services. Suchdescription shall include the definition of emergency services and emergencymedical condition, notice that emergency services are not subject to priorapproval, and shall describe the enrollee's financial and otherresponsibilities regarding obtaining such services, including when suchservices are received outside the health maintenance organization's servicearea;
(9) A description of procedures for enrollees to select and access thehealth maintenance organization's primary and specialty care providers,including notice of how to determine whether a participating provider isaccepting new patients;
(10) A description of the procedures for changing primary and specialtycare providers within the health maintenance organization;
(11) Notice that an enrollee may obtain a referral for covered servicesto a health care provider outside of the health maintenance organization'snetwork or panel when the health maintenance organization does not have ahealth care provider with appropriate training and experience in the networkor panel to meet the particular health care needs of the enrollee and theprocedure by which the enrollee may obtain such referral;
(12) A description of the mechanisms by which enrollees may participatein the development of the policies of the health maintenance organization;
(13) Notice of all appropriate mailing addresses and telephone numbersto be utilized by enrollees seeking information or authorization;
(14) A listing by specialty, which may be in a separate document that isupdated annually, of the names, addresses and telephone numbers of allparticipating providers, including facilities, and in addition in the case ofphysicians, board certification; and
(15) The director of the department of insurance, financial institutionsand professional registration shall develop a standard credentialing formwhich shall be used by all health carriers when credentialing health careprofessionals in a managed care plan. If the health carrier demonstrates aneed for additional information, the director of the department of insurance,financial institutions and professional registration may approve a supplementto the standard credentialing form. All forms and supplements shall meet allrequirements as defined by the National Committee of Quality Assurance.
2. Each health maintenance organization shall, upon request of anenrollee or prospective enrollee, provide the following:
(1) A list of the names, business addresses and official positions ofthe membership of the board of directors, officers, controlling persons,owners or partners of the health maintenance organization;
(2) A copy of the most recent annual certified financial statement ofthe health maintenance organization, including a balance sheet and summary ofreceipts and disbursements prepared by a certified public accountant;
(3) A copy of the most recent individual, direct pay enrollee contracts;
(4) Information relating to consumer complaints compiled annually by thedepartment of insurance, financial institutions and professional registration;
(5) The procedures for protecting the confidentiality of medical recordsand other enrollee information;
(6) An opportunity to inspect drug formularies used by such healthmaintenance organization and any financial interest in a pharmacy providerutilized by such organization. The health maintenance organization shall alsodisclose the process by which an enrollee or his representative may seek tohave an excluded drug covered as a benefit;
(7) A written description of the organizational arrangements and ongoingprocedures of the health maintenance organization's quality assurance program;
(8) A description of the procedures followed by the health maintenanceorganization in making decisions about the experimental or investigationalnature of individual drugs, medical devices or treatments in clinical trials;
(9) Individual health practitioner affiliations with participatinghospitals, if any;
(10) Upon written request, written clinical review criteria relating toconditions or diseases and, where appropriate, other clinical informationwhich the organization may consider in its utilization review. The healthmaintenance organization may include with the information a description of howsuch information will be used in the utilization review process;
(11) The written application procedures and minimum qualificationrequirements for health care providers to be considered by the healthmaintenance organization;
(12) A description of the procedures followed by the health maintenanceorganization in making decisions about which drugs to include in the healthmaintenance organization's drug formulary.
3. Nothing in this section shall prevent a health maintenanceorganization from changing or updating the materials that are made availableto enrollees.
Disclosure information to enrollees required, when.
354.442. 1. Each enrollee, and upon request each prospective enrolleeprior to enrollment, shall be supplied with written disclosure information.In the event of any inconsistency between any separate written disclosurestatement and the enrollee contract or evidence of coverage, the terms of theenrollee contract or evidence of coverage shall be controlling. Theinformation to be disclosed in writing shall include at a minimum thefollowing:
(1) A description of coverage provisions, health care benefits, benefitmaximums, including benefit limitations;
(2) A description of any exclusions of coverage, including thedefinition of medical necessity used in determining whether benefits will becovered;
(3) A description of all prior authorization or other requirements fortreatments and services;
(4) A description of utilization review policies and procedures used bythe health maintenance organization, including:
(a) The circumstances under which utilization review shall beundertaken;
(b) The toll-free telephone number of the utilization review agent;
(c) The time frames under which utilization review decisions shall bemade for prospective, retrospective and concurrent decisions;
(d) The right to reconsideration;
(e) The right to an appeal, including the expedited and standard appealsprocesses and the time frames for such appeals;
(f) The right to designate a representative;
(g) A notice that all denials of claims shall be made by qualifiedclinical personnel and that all notices of denial shall include informationabout the basis of the decision; and
(h) Further appeal rights, if any;
(5) An explanation of an enrollee's financial responsibility for paymentof premiums, coinsurance, co-payments, deductibles and any other charge,annual limits on an enrollee's financial responsibility, caps on payments forcovered services and financial responsibility for noncovered health careprocedures, treatments or services provided within the health maintenanceorganization;
(6) An explanation of an enrollee's financial responsibility for paymentwhen services are provided by a health care provider who is not part of thehealth maintenance organization's network or by any provider without requiredauthorization, or when a procedure, treatment or service is not a coveredhealth care benefit;
(7) A description of the grievance procedures to be used to resolvedisputes between a health maintenance organization and an enrollee, including:
(a) The right to file a grievance regarding any dispute between anenrollee and a health maintenance organization;
(b) The right to file a grievance when the dispute is about referrals orcovered benefits;
(c) The toll-free telephone number which enrollees may use to file agrievance;
(d) The department of insurance, financial institutions and professionalregistration's toll-free consumer complaint hot line number;
(e) The time frames and circumstances for expedited and standardgrievances;
(f) The right to appeal a grievance determination and the procedures forfiling such an appeal;
(g) The time frames and circumstances for expedited and standardappeals;
(h) The right to designate a representative;
(i) A notice that all disputes involving clinical decisions shall bemade by qualified clinical personnel; and
(j) All notices of determination shall include information about thebasis of the decision and further appeal rights, if any;
(8) A description of a procedure for providing care and coveragetwenty-four hours a day, seven days a week, for emergency services. Suchdescription shall include the definition of emergency services and emergencymedical condition, notice that emergency services are not subject to priorapproval, and shall describe the enrollee's financial and otherresponsibilities regarding obtaining such services, including when suchservices are received outside the health maintenance organization's servicearea;
(9) A description of procedures for enrollees to select and access thehealth maintenance organization's primary and specialty care providers,including notice of how to determine whether a participating provider isaccepting new patients;
(10) A description of the procedures for changing primary and specialtycare providers within the health maintenance organization;
(11) Notice that an enrollee may obtain a referral for covered servicesto a health care provider outside of the health maintenance organization'snetwork or panel when the health maintenance organization does not have ahealth care provider with appropriate training and experience in the networkor panel to meet the particular health care needs of the enrollee and theprocedure by which the enrollee may obtain such referral;
(12) A description of the mechanisms by which enrollees may participatein the development of the policies of the health maintenance organization;
(13) Notice of all appropriate mailing addresses and telephone numbersto be utilized by enrollees seeking information or authorization;
(14) A listing by specialty, which may be in a separate document that isupdated annually, of the names, addresses and telephone numbers of allparticipating providers, including facilities, and in addition in the case ofphysicians, board certification; and
(15) The director of the department of insurance, financial institutionsand professional registration shall develop a standard credentialing formwhich shall be used by all health carriers when credentialing health careprofessionals in a managed care plan. If the health carrier demonstrates aneed for additional information, the director of the department of insurance,financial institutions and professional registration may approve a supplementto the standard credentialing form. All forms and supplements shall meet allrequirements as defined by the National Committee of Quality Assurance.
2. Each health maintenance organization shall, upon request of anenrollee or prospective enrollee, provide the following:
(1) A list of the names, business addresses and official positions ofthe membership of the board of directors, officers, controlling persons,owners or partners of the health maintenance organization;
(2) A copy of the most recent annual certified financial statement ofthe health maintenance organization, including a balance sheet and summary ofreceipts and disbursements prepared by a certified public accountant;
(3) A copy of the most recent individual, direct pay enrollee contracts;
(4) Information relating to consumer complaints compiled annually by thedepartment of insurance, financial institutions and professional registration;
(5) The procedures for protecting the confidentiality of medical recordsand other enrollee information;
(6) An opportunity to inspect drug formularies used by such healthmaintenance organization and any financial interest in a pharmacy providerutilized by such organization. The health maintenance organization shall alsodisclose the process by which an enrollee or his representative may seek tohave an excluded drug covered as a benefit;
(7) A written description of the organizational arrangements and ongoingprocedures of the health maintenance organization's quality assurance program;
(8) A description of the procedures followed by the health maintenanceorganization in making decisions about the experimental or investigationalnature of individual drugs, medical devices or treatments in clinical trials;
(9) Individual health practitioner affiliations with participatinghospitals, if any;
(10) Upon written request, written clinical review criteria relating toconditions or diseases and, where appropriate, other clinical informationwhich the organization may consider in its utilization review. The healthmaintenance organization may include with the information a description of howsuch information will be used in the utilization review process;
(11) The written application procedures and minimum qualificationrequirements for health care providers to be considered by the healthmaintenance organization;
(12) A description of the procedures followed by the health maintenanceorganization in making decisions about which drugs to include in the healthmaintenance organization's drug formulary.
3. Nothing in this section shall prevent a health maintenanceorganization from changing or updating the materials that are made availableto enrollees.
