Cal. Code Regs. Tit. 28, § 1300.63.2 - Combined Evidence of Coverage and Disclosure Form
Notwithstanding Sections 1300.63 and 1300.63.1 of these rules, a plan may combine the evidence of coverage and disclosure form into a single document if such plan complies with each of the following requirements:
(a) Each plan shall furnish to each
individual subscriber, and make available to group contract holders for
dissemination to all persons eligible under the group contract, either a single
document consisting of a combined evidence of coverage and disclosure form or a
copy of the plan contract, which shall conform to the requirements of this
section.
(b) Except as may be
otherwise permitted by the Director, the combined evidence of coverage and
disclosure form shall conform to the following requirements:
(1) It shall be clearly entitled "Combined
Evidence of Coverage and Disclosure Form."
(2) The text shall be printed in at least ten
point block type. Titles and captions shall be in at least twelve point to
fifteen point boldface type.
(3) It
shall be written in clear, concise, easily understood language.
(4) It should relate to one form of plan
contract; however, combined evidence of coverage and 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.
(5) It shall be presented
in an easily readable format.
(6)
The combined evidence of coverage and disclosure form when taken as a whole,
with consideration being given to format, typography and language, must
constitute a fair disclosure of the provisions of the health
plan.
(c) The combined
evidence of coverage and disclosure form shall contain at a minimum the
following information:
(1) The name of the
health plan, the principal address from which it conducts its business and its
telephone number.
(2) A statement
that the specimen of the plan contract will be furnished on request.
(3) The definitions for the words contained
therein that have meanings other than those attributed to them by the public in
general usage.
(4) The manner in
which the member can determine who is or may be entitled to benefits, except
that a member under group coverage may be referred to the group contract holder
for such information.
(5) The time
and date or occurrence upon which coverage takes effect including a
specification of any applicable waiting periods.
(6) The time and date or occurrence upon
which coverage will terminate.
(7)
The conditions upon which cancellation may be effected by the health plan or by
the member, and a statement that a subscriber or enrollee who alleges that an
enrollment or subscription has been cancelled or not renewed because of the
enrollee's or subscriber's health status or requirements for health care
services may request a review of cancellation by the Director.
(8) The conditions for and any restrictions
upon the member's right to renewal or reinstatement.
(9) The caption "Prepayment 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.
(10) The
amount of the periodic payment to be made by the member, the time by which the
payment must be made, and the address at or to which the payment shall be made,
except that a member under group coverage may be referred to the group contract
holder for information regarding any sums to be withheld from the member's
salary or to be paid by the member to the employer or group contract
holder.
(11) A complete statement
of all benefits and coverages and the related limitations, exclusions,
exceptions, reductions, copayments, and deductibles.
(12) The caption "Other Charges," followed by
a description of each copayment, coinsurance, or deductible requirement that
may be incurred by the member or the member's family in obtaining coverage
under the plan.
(13) A statement of
any restriction on assignment of sums payable to the member by the health
plan.
(14) The exact procedure for
obtaining benefits including the procedure for filing claims. The procedure for
filing claims must state the time by which the claim must be filed, the form in
which it is to be filed, and the address at or to which it shall be delivered
or mailed.
(15) Any procedures
required to be followed by the member in the event any dispute arises under the
contract, including any requirement for arbitration.
(16) The address and telephone number
designated by the health plan to which complaints from members are to be
directed, and a description of the plan's grievance procedure.
(17) The caption "Choice of Physicians and
Providers," followed by 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.
(18) A statement to the
effect that, by statute, every contract between the health plan and a provider
shall provide that in the event the health plan fails to pay the provider, the
member shall not be liable to the provider for any sums owed by the health
plan.
(19) A statement to the
effect that in the event the health plan fails to pay noncontracting providers,
the member may be liable to the noncontracting provider for the cost of
services.
(20) 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.
(21) 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, as appropriate, including any
reservation by the plan of any right to change premiums or other plan contract
provisions.
(22) The caption
"Facilities," followed by a statement of the principal facilities available
under the plan contract, including their location and description of the
services provided. The hours of availability of both emergency and
non-emergency 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 the
provider facilities defined in subsection (i)(2) of Section
1300.45 of these rules may be
obtained, in lieu of listing such provider facilities.
(23) 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.
(24) 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.
(25) Any
appropriate statement to fulfill the requirement of Section
1300.69(i)(1) of
these rules, unless the plan undertakes to mail such information
annually.
(26) In the event that
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 combined evidence of coverage and disclosure form
may be required by the Director to disclose such facts.
(27) A statement which shall be set forth in
boldface type not less than two points larger than the type required by
subsection (b)(2): "This combined evidence of coverage and disclosure form
constitutes only a summary of the health plan. The health plan contract must be
consulted to determine the exact terms and conditions of
coverage."
Notes
2. Change without regulatory effect amending subsections (b), (c)(7), (c)(22) and (c)(26) 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: Sections 1345, 1360, 1363 and 1368, Health and Safety Code.
2. Change without regulatory effect amending subsections (b), (c)(7), (c)(22) and (c)(26) filed 7-18-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 29).
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