Cal. Code Regs. Tit. 28, § 1300.63 - Disclosure Form
(a) The
disclosure form required under subdivision (a) of Section
1363 of the Act shall conform to
the following requirements.
(1) The text shall
be printed in at least 10-point block type. Titles and captions shall be in at
least 12-point to 15-point bold face type.
(2) It shall be written in clear, concise,
easily understood language.
(3) It
should relate to one form of plan contract; however, disclosure forms offering
alternative plans or options will be permitted if presented in a manner which
clearly identifies the alternatives and their effect upon the
contract.
(4) It shall be presented
in an easily readable format.
(b) The disclosure form shall be arranged and
captioned in the following manner, except as may otherwise be permitted by the
Director.
(1) The name of the plan and, if
necessary, a designation of the plan contract described in the form.
(2) The title of the form (e.g., "disclosure
form," "summary of contract provisions").
(3) A statement in at least 10-point bold
face type to the effect that the disclosure form is a summary only and that the
plan contract itself should be consulted to determine the governing contractual
provisions.
(4) A statement to the
effect that a specimen copy of the plan contract will be furnished on
request.
(5) The caption "Principal
Benefits and Coverages," followed by a description of such benefits and
coverages.
(6) The caption
"Principal Exclusions and Limitations on Benefits," followed by a description
of the principal exclusions, exceptions, reductions and limitations that apply,
and arranged in a uniform manner with the preceding section of the
form.
(7) The caption "Prepayments
Fees" followed by a statement of the methods by which such premium may be paid;
the full premium charge of the plan; and a statement of the authority to change
the fees during the term of the contract.
(8) The caption "Other Charges," followed by
a description of each co-payment, co-insurance, or deductible requirement that
may be incurred by the member or the member's family in obtaining coverage
under the plan.
(9) The caption
"Choice of Physicians and Providers," followed by a description of the nature,
extent and circumstances under which choice is permitted. This section shall
include, if applicable, a subcaption "Liability of Subscriber or Enrollee for
Payment" followed by a description of the financial liability which is, or may
be, incurred by the subscriber, enrollee or a third party by reason of the
exercise of such choice.
(10) If
applicable, the caption "Reimbursement Provisions," followed by a description
of the circumstances under which reimbursements are made under the plan
contract, the extent of reimbursement, and the method of claim for
reimbursement.
(11) The caption
"Facilities," followed by a statement of the principal facilities available
under the plan contract, including their location and a description of the
services, provided. The hours of availability of both emergency and
nonemergency services should be indicated, either specifically or by general
description. However, if the Director approves in advance, a plan may provide a
telephone number from which information as to the identity and location of
provider facilities defined in subsection (i)(2) of Section
1300.45 may be obtained, in lieu
of listing such provider facilities.
(12) The caption "Renewal Provisions,"
followed by a statement of the terms under which the plan contract may be
renewed by the group or the plan member, including any reservation by the plan
of any right to change premiums or other plan contract provisions.
(13) In the case of group contracts, the
caption "Individual Continuation of Benefits," followed by a statement of the
terms and conditions under which subscribers and enrollees may remain in the
plan, as provided pursuant to Subdivision (g) of Section
1373 of the Act.
(14) The caption "Termination of Benefits,"
followed by a statement of the terms and conditions for cancellation or
termination of benefits, including a statement as to when benefits shall cease
in the event of nonpayment of the prepaid or periodic charge and the effect of
nonpayment upon a member who is hospitalized or undergoing treatment for an
ongoing condition.
(c) In
the event the receipt of benefits or reimbursements to subscribers or enrollees
under the plan contract is subject to significant delays, based upon the
current experience of the plan, the disclosure form may be required by the
Director to disclose such facts.
Notes
2. Change without regulatory effect amending subsections (b), (b)(11) and (c) filed 7-18-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 29).
Note: Authority cited: Section 1344, Health and Safety Code. Reference: Section 1363, Health and Safety Code.
2. Change without regulatory effect amending subsections (b), (b)(11) and (c) filed 7-18-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 29).
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