(1) Every health maintenance organization shall annually provide to its enrollees:
The most recent annual statement of financial condition including a balance sheetand summary of receipts and disbursements;
A description of the organizational structure and operation of the health care plan anda summary of any material changes since the issuance of the last report;
A description of services and information as to where and how to secure them; and
A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints.
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.
(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:
That a limited health benefit plan may impose a limit on the total maximum benefitamount 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;
The specific amount of the annual total maximum benefit amount and the annualtotal maximum amount for particular health care services covered by the limited health benefit plan; and
That once the enrollee receives the total maximum amount of benefits under thelimited 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-ofpocket 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.
The health maintenance organization shall ensure that the information required bythis subsection (3) is prominently displayed, in bold-faced font in at least fourteen-point type, on any materials provided to enrollees.
(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, the Colorado Indigent Care 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.
Source: L. 92: Entire article R&RE, p. 1700, § 1, effective July 1; (2) added, p. 1789, §
1, effective January 1, 1993. L. 2002: (2) amended, p. 1295, § 10, effective January 1, 2003. L. 2009: (3) added, (HB 09-1143), ch. 114, p. 481, § 3, effective August 5.
Editor's note: (1) This section is similar to former § 10-17-110 as it existed prior to 1992.
(2) Subsection (2) of this section was numbered as § 10-17-110 (2) in Senate Bill 92-104 but was renumbered on revision and harmonized with this section since article 17 was repealed and the substantive provisions of § 10-17-110 were moved to this section.
Cross references: For the legislative declaration contained in the 2009 act adding subsection (3), see section 1 of chapter 114, Session Laws of Colorado 2009.