(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:
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
Contain a clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of:
The health care services and the insurance or other benefits, if any, to which theenrollee 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;
Any limitations on the services, kind of services, benefits, or kind of benefits to beprovided, including any deductible or copayment feature;
Where and in what manner information is available as to how services may be obtained;
The total amount of payment for health care services and the indemnity or servicebenefits, 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;
A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints.
The carrier may evidence a subsequent change in coverage in a separate documentissued to the enrollee.
A copy of the form of the evidence of coverage to be used in this state, and anyamendment to the form, is subject to the filing and approval requirements of section 10-16107.2.
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.
Editor's note: (1) (a) This section is similar to former § 10-17-108 as it existed prior to 1992.
(b) Subsection (2) is similar to § 10-16-107 (3)(b), (3)(c), and (3)(d) as they existed prior to 2013.