(1)Every health maintenance
organization shall annually provide to its enrollees:
(a)The most recent annual statement of financial condition including a
balance sheet and summary of receipts and disbursements;
(b)A description of the organizational structure and operation of the health
care plan and a summary of any material changes since the issuance of the last
report;
(c)A description of services and information as to where and how to secure
them; and
(d)A clear and understandable description of the health maintenance
organization's method for resolving enrollee complaints.
(2)Every health maintenance organization shall clearly state in its
brochures, contracts, policy manuals, and printed materials distributed to enrollees
that such enrollees shall have the option of
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(1) Every health maintenance
organization shall annually provide to its enrollees:
(a) The most recent annual statement of financial condition including a
balance sheet and summary of receipts and disbursements;
(b) A description of the organizational structure and operation of the health
care plan and a summary of any material changes since the issuance of the last
report;
(c) A description of services and information as to where and how to secure
them; and
(d) A clear and understandable description of the health maintenance
organization's method for resolving enrollee complaints.
(2) Every health maintenance organization shall clearly state in its
brochures, contracts, policy manuals, and printed materials distributed to enrollees
that such enrollees shall have the option of calling the local prehospital emergency
medical service system by dialing the emergency telephone access number 9-1-1 or
its local equivalent whenever an enrollee is confronted with a life or limb
threatening emergency. For the purposes of this section, a life or limb threatening
emergency means any event that a prudent lay person would believe threatens his
or her life or limb in such a manner that a need for immediate medical care is
created to prevent death or serious impairment of health. No enrollee shall in any
way be discouraged from using the local prehospital emergency medical service
system, the 9-1-1 telephone number, or the local equivalent, or be denied coverage
for medical and transportation expenses incurred as a result of such use in a life or
limb threatening emergency.
(3) (a) A health maintenance organization that offers basic health-care
services to enrollees through a limited health benefit plan pursuant to section 10-16-403 (1)(h) shall clearly state in its brochures, contracts, policy manuals, and
printed materials distributed to enrollees the following information:
(I) That a limited health benefit plan may impose a limit on the total
maximum benefit amount available to the enrollee on an annual basis and on the
total maximum benefit amounts available for particular health-care services
provided during a given year;
(II) The specific amount of the annual total maximum benefit amount and the
annual total maximum amount for particular health-care services covered by the
limited health benefit plan; and
(III) That once the enrollee receives the total maximum amount of benefits
under the limited health benefit plan in any given year, or receives the total
maximum amount of benefits for a particular health-care service in a given year, the
enrollee is responsible for paying out-of-pocket for the costs of any health-care
services provided to the enrollee during that year that exceed the total annual
maximum benefit amount or the total maximum benefit amount for a particular
health-care service, as applicable.
(b) The health maintenance organization shall ensure that the information
required by this subsection (3) is prominently displayed, in bold-faced font in at
least fourteen-point type, on any materials provided to enrollees.
(c) (I) Each enrollee who participates in a limited health benefit plan shall
sign the following statement of understanding indicating his or her understanding
of the limitations of the plan:
STATEMENT OF UNDERSTANDING
I, ______________, understand that I am enrolling in a limited health
benefit plan that contains a total maximum annual amount of benefits available to
me and my covered dependents each plan year for basic health care services. The
total maximum annual benefit amount is ____.
I understand that once I receive the total maximum amount of benefits
under the limited health benefit plan in a plan year, I am fully responsible for
paying out-of-pocket for the costs or charges for any health care services I or my
covered dependents receive during the remaining portion of the plan year.
I understand that I may exhaust my total annual maximum benefit amount
while I am or a covered dependent is undergoing treatment for an illness or injury
and that I will be responsible for paying the costs of treatment provided after I
have exhausted my benefits under the limited health benefit plan.
I understand that if I exhaust my total annual maximum benefit amount in a
plan year, I or my covered dependent may or may not be eligible for the state
Medicaid program or other public programs and that it is solely my choice and
responsibility to investigate my options and eligibility for participation in any
public program.
Signature of Enrollee Date
(II) The health maintenance organization shall retain the original, signed
statement of understanding, shall provide a copy to the enrollee, and shall make
the statement available to the commissioner upon request.