28 CA ADC § 1300.63.1
28 CCR s 1300.63.1
Cal. Admin. Code tit. 28, s 1300.63.1
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 5. ADVERTISING AND DISCLOSURE
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.63.1. Evidence of Coverage.
(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 an evidence of coverage or a
copy of the plan contract, which shall conform to the requirements of this
section. The Director may permit the evidence of coverage and the
disclosure form prescribed by Section 1300.63 to be presented in a single
document if the purposes of each are fulfilled.
(b) Except as may be otherwise permitted by the Director, the evidence of
coverage shall conform to the requirements of subsection (a) of Section
1300.63 and the following requirements:
(1) It shall be clearly entitled "Evidence of Coverage."
(2) The portions of the text specifying (1) limitations, exclusions,
exceptions and reductions; (2) rights of cancellation; (3) restrictions on
renewal or reinstatement; (4) rights of the health plan to change
benefits; (5) subsequent providers; and (6) liability of members in the
event of nonpayment by the health plan, shall be in type not less than 2
points larger than the text relating to other provisions and in no event
less than 12 point type.
(3) It shall be divided into sections, each of which shall have a title
identifying the nature of the information contained therein.
(4) The evidence of coverage 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 evidence of coverage 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) The definitions for the words contained therein that have meanings
other than those attributed to them by the public in general usage.
(3) The manner in which the member can determine who is or may be entitled
to benefits.
(4) The time and date or occurrence upon which coverage takes effect
including a specification of any applicable waiting periods.
(5) The time and date or occurrence upon which coverage will terminate.
(6) 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.
(7) The conditions for and any restrictions upon the member's right to
renewal or reinstatement.
(8) 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.
(9) A complete statement of all benefits and coverages and the related
limitations, exclusions, exceptions, reductions, copayments, and
deductibles.
(10) A statement of any restriction on assignment of sums payable to the
member by the health plan.
(11) 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.
(12) Any procedures required to be followed by the member in the event any
dispute arises under the contract, including any requirement for
arbitration.
(13) 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.
(14) 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.
(15) A statement to the effect that in the event the health plan fails to
pay a noncontracting provider, the member may be liable to the
noncontracting provider for the cost of the services.
(16) An appropriate statement to fulfill the requirement of Section
1300.69(i)(1), unless the plan undertakes to mail such information
annually.
(17) A statement which shall be set forth in boldface type not less than 2
points larger than the type required by subsection (b)(2): "This evidence
of coverage constitutes only a summary of the health plan. The health plan
contract must be consulted to determine the exact terms and conditions of
coverage."
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Sections 1345, 1360 and 1363, Health and Safety Code.
HISTORY
1. Amendment of subsection (c)(16) filed 6-2-78; effective thirtieth day
thereafter (Register 78, No. 22).
2. Amendment of subsection (c) filed 1-12-83; effective thirtieth day
thereafter (Register 83, No. 3).
3. Change without regulatory effect amending subsections (a), (b) and
(c)(6)
filed 7-18-2000 pursuant to
section 100, title 1, California Code ofRegulations (Register 2000, No.
29).
28 CA ADC s 1300.63.1
END OF DOCUMENT
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