Section 21.86.070. Evidence of coverage; charges for health care services.

   (a) An enrollee residing in this state is entitled to evidence of coverage.  If an enrollee obtains coverage from an insurance policy or from a subscriber contract issued by a hospital or medical service corporation, whether by option or otherwise, the insurer or hospital or medical service corporation shall issue the evidence of coverage; otherwise, the health maintenance organization shall issue the evidence of coverage.  Each subsequent change in coverage must be evidenced in a separate document issued to the enrollee.
   (b) Except as provided in (d) of this section, evidence of coverage, or an amendment or endorsement to coverage, may not be issued or delivered to a person in this state until a copy of the form of the evidence of coverage, amendment, or endorsement has been filed with and approved by the director. A filing shall be made not less than 30 days before the intended date of delivery or issuance.  The form of evidence of coverage, amendment, or endorsement is considered approved 30 days after it was filed, unless it is affirmatively approved or disapproved by an order of the director before the expiration of the 30-day period.  If the form of evidence of coverage, amendment, or endorsement is disapproved, the director's order must specify the reasons for disapproval.  A hearing shall be granted to a person aggrieved by either an approval or disapproval under this subsection if a written request is made by that person to the director.  The hearing shall be granted within 30 days after the receipt of the written request.
   (c) An evidence of coverage
        (1) may not contain a provision or statement that is unjust, unfair, inequitable, misleading, deceptive, or encourages misrepresentation, or that is untrue, misleading, or prohibited under AS 21.86.150; and
        (2) must contain a clear and concise 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;
             (B) limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including a 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;
             (E) the health maintenance organization's method for resolving enrollee complaints; and
             (F) guidelines explaining when treatment may be denied.
   (d) If a form of the evidence of coverage, or an amendment or endorsement to it, is subject to the jurisdiction of the director under AS 21.42.120 and 21.42.130, or under AS 21.87.180, the filing requirements of (b) of this section do not apply.  If a form of evidence of coverage, or an amendment or endorsement to it, is subject to AS 21.42.120 and 21.42.130, or to AS 21.87.180, those applicable provisions, as well as (c) of this section, apply to the content of the form of evidence of coverage, amendment, or endorsement.
   (e) A schedule of charges for enrollee coverage for health care services, or an amendment or endorsement to it, may not be used until a copy of the schedule has been filed with and approved by the director. A filing shall be made not less than 30 days before its proposed use. The schedule of charges, amendment, or endorsement is considered approved 30 days after it was filed unless it was affirmatively approved or disapproved by an order of the director before the expiration of the 30-day period.  If a schedule of charges, amendment, or endorsement is disapproved, the director's order must specify the reasons for disapproval.  A hearing shall be granted to a person aggrieved by either an approval or disapproval under this subsection if a written request is made by that person to the director.  The hearing shall be granted within 30 days after receipt of the written request.
   (f) A schedule of charges, or an amendment or endorsement to it, shall be established according to sound actuarial principles for various categories of enrollees, but charges applicable to an enrollee may not be individually determined based on that enrollee's health status.  The charges may not be excessive, inadequate, nor unfairly discriminatory.  Certification by an actuary who is a member in good standing of the American Academy of Actuaries or another person who is considered qualified by the director, as to the appropriateness of the application of the charges, based on reasonable assumptions, must accompany each filing under (e) of this section, along with adequate supporting information.
   (g) The director may require that additional relevant material considered necessary by the director be submitted in order to determine the acceptability of a filing made under either (b) or (e) of this section.

Authorities

21.86.190;21.86.310

Notes

Implemented As

3 AAC 31.200
3 AAC 31.205
3 AAC 31.210
3 AAC 31.215
3 AAC 31.217
3 AAC 31.221
3 AAC 31.250
3 AAC 31.299

References

3 AAC 31.200
3 AAC 31.215
3 AAC 31.217
AS 21.86.190 Suspension or revocation of certificate of authority.
AS 21.86.310 Dual choice.

History

(Sec. 1 ch 95 SLA 1990; am Sec. 3 ch 60 SLA 1998)