§ 10-16-406 — Evidence of coverage - rules

(1) Every enrollee residing in this
state is entitled to evidence of coverage under a health-care plan. If the enrollee
obtains coverage under a health-care plan through an insurance policy or a
contract issued by a nonprofit hospital, medical-surgical, and health service
corporation, whether by option or otherwise, the insurer or the nonprofit hospital,
medical-surgical, and health service corporation shall issue the evidence of
coverage. Otherwise, the health maintenance organization shall issue the evidence
of coverage.

(2) (a) The commissioner may establish, by rule, the required elements of an
evidence of coverage, which must:

(I) Not contain any provisions or statements that are unjust, unfair,
inequitable, misleading, or deceptive; encourage misrepresentation; or are untrue,
misleading, or deceptive as defined in section 10-16-413 (1); and

(II) Contain a clear and complete statement, if a contract, or a reasonably
complete summary, if a certificate, of:

(A) The health-care services and the insurance or other benefits, if any, to
which the enrollee is entitled under the health-care plan, including the ability to
obtain a second opinion for proposed treatment by the health-care provider, if the
health benefit plan provides such coverage;

(B) Any limitations on the services, kind of services, benefits, or kind of
benefits to be provided, including any deductible or copayment feature;

(C) Where and in what manner information is available as to how services
may be obtained;

(D) The total amount of payment for health-care services and the indemnity
or service benefits, if any, that the enrollee is obligated to pay with respect to
individual contracts, or an indication whether the plan is contributory or
noncontributory with respect to group certificates;

(E) A clear and understandable description of the health maintenance
organization's method for resolving enrollee complaints.

(b) The carrier may evidence a subsequent change in coverage in a separate
document issued to the enrollee.

(c) A copy of the form of the evidence of coverage to be used in this state,
and any amendment to the form, is subject to the filing and approval requirements
of section 10-16-107.2.

Legislative History

Source: L. 92: Entire article R&RE, p. 1700, � 1, effective July 1. L. 2013: Entire section amended with relocations, (HB 13-1266), ch. 217, p. 980, � 33, effective May 13.