§ 26-34-117 — Prohibited practices

(a) No health maintenance organization, or representative
thereof, shall cause or knowingly permit the use of advertising
which is untrue or misleading, solicitation which is untrue or
misleading or any form of evidence of coverage which is
deceptive. For purposes of this chapter:
(i) A statement or item of information is:
(A) Untrue if it does not conform to fact in any
respect which is or may be significant to an enrollee of or
person considering enrollment with a health maintenance
organization;
(B) Misleading, whether or not it may be
literally untrue, if, in the total context in which the
statement is made or the item of information is communicated,
the statement or item of information may be reasonably
understood by a reasonable person, not possessing special
knowledge regarding health care coverage, as indicating any
benefit or advantage or the absence of any exclusion, limitation
or disadvantage of possible significance to an enrollee of, or
person considering enrollment in a health maintenance
organization if the benefit or advantage or absence of
limitation, exclusion or disadvantage does not in fact exist.
(ii) An evidence of coverage is deceptive if the
evidence of coverage taken as a whole, and with consideration
given to typography and format, as well as language, is such as
to cause a reasonable person, not possessing special knowledge
regarding health maintenance organizations and evidences of
coverage therefor, to expect benefits, services, premiums or
other advantages which the evidence of coverage does not provide
or which the health maintenance organization issuing the
evidence of coverage does not regularly make available for
enrollees covered under the evidence of coverage.
(b) Chapter 13 of this code applies to health maintenance
organizations and evidences of coverage except to the extent
that the commissioner determines that the nature of health
maintenance organizations and evidences of coverage render that
chapter, or any section thereof, clearly inappropriate.
(c) A health maintenance organization shall not cancel or
refuse to review an enrollee, except for reasons stated in the
organization's rules applicable to all enrollees or for the
failure to pay the premiums for coverage, or for any other
reasons the commissioner may specify by rule and regulation.
(d) No health maintenance organization unless licensed as
an insurer shall refer to itself as an insurer or use a name
deceptively similar to the name or description of any insurance
or surety corporation doing business in the state.
(e) Any person not in possession of a valid certificate of
authority issued pursuant to this chapter shall not use the
phrase "health maintenance organization" or "HMO" in the course
of operation.
(f) A health care maintenance organization shall not
refuse to contract with or compensate for covered services an
otherwise eligible health care provider solely because that
provider has in good faith communicated with one (1) or more of
his current, former or prospective patients regarding the
provisions, terms or requirements of the organization's products
as they related to the needs of that provider's patients.
(g) A health care maintenance organization shall not
prohibit or restrict any health care provider from disclosing to
any subscriber, enrollee or member any medically appropriate
health care information the provider deems appropriate regarding
the:
(i) Nature of treatment, risks or alternatives;
(ii) Decision of any plan to authorize or deny
services;
(iii) Process used to authorize or deny health care
services or benefits.