28 CA ADC § 1300.63.2
28 CCR s 1300.63.2
Cal. Admin. Code tit. 28, s 1300.63.2
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 1300.63.2. 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."
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Sections 1345, 1360, 1363 and 1368, Health and Safety Code.
HISTORY
1. New section filed 8-12-82; effective thirtieth day thereafter (Register
82,
No. 33).
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, CaliforniaCode of Regulations (Register 2000, No.
29).
28 CA ADC s 1300.63.2
END OF DOCUMENT
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