§ 24-A §4207-A — Point-of-service products

1.
Product design; mandatory requirements.
A point-of-service product, filed and approved for use subject to the requirements of section 4207, subsection 4, at a minimum must:
2.
Product design; optional provisions.
A point-of-service product may:
3.
Product limitations and exclusions.
A health maintenance organization is subject to the following requirements as to its point-of-service product.
4.
Plan requirements.
A health maintenance organization may not issue a point-of-service product until it has filed and has had approved by the superintendent a plan to comply with this section, including, in addition to any other requirements of this section, group contracts, subscriber contracts and other materials used by enrollees.
5.
Claims processing.
Explanation of benefits given to an enrollee of a point-of-service plan must contain an explanation of coverage for self-referral health care services that is adequate to permit an enrollee to determine claims liability under the plan.
5-A.
Assignment of benefits.
All point-of-service contracts and certificates must contain a provision permitting the insured to assign any benefits provided for medical or dental care on an expense-incurred basis to the provider of the care. An assignment of benefits under this subsection does not affect or limit the payment of benefits otherwise payable under the contract or certificate.
6.
Disclosure.
All marketing materials, subscriber contracts, member handbooks or other material used by enrollees must contain a clear and concise explanation of point-of-service health care services. The explanation must include:

Legislative History

PL 1991, c. 709, §5 (NEW). PL 1997, c. 604, §E4 (AMD). PL 1999, c. 21, §4 (AMD).