420-A:9 Contracts With Subscribers. –
Every contract between a health service corporation and a subscriber shall be in writing, a copy of which shall be furnished to the subscriber and shall contain the following provisions:
I. A statement of the amount payable to the health service corporation by the subscriber and the manner in which such amount is payable.
II. A statement of the nature and extent of the benefits to be provided, and, if any benefits are to be limited or excepted, an enumeration of such limitations or exceptions shall be printed with the same prominence as the statement of the benefits conferred.
III. A statement that a maternity benefits rider will be made available at the subscriber's request, if maternity care is not covered under the contract. Nothing in this paragraph shall be construed to apply to supplemental health insurance and disability insurance policies.
IV. A statement of the terms and conditions upon which the contract may be cancelled or otherwise terminated at the option of either party.
V. A statement that the contract includes the endorsements thereon and attached papers, if any, and that it comprises the entire contract.
VI. A provision that no statement by the subscriber in the application for a contract shall void the contract or be used in any legal proceeding thereunder unless such application or an exact copy is included or attached to the contract.
VII. A statement of the period of grace which will be allowed the subscriber for making any payment due under the contract. Such period shall be not less than 10 days.
VIII. Notwithstanding any provision of any policy of insurance issued under the provisions of this section, whenever such policy provides for reimbursement for any service which may be legally performed by a person licensed as an advanced practice registered nurse, reimbursement under such policy shall not be denied when such service is rendered by a person so licensed.
IX. No health service corporation shall, when issuing or renewing a policy or contract of insurance or any certificate under such policy or contract covered by this chapter, deny coverage or limit coverage to any resident of this state on the basis of health risk or condition except that a waiting period consistent with insurance department rules may be imposed for pre-existing medical conditions. If a health service corporation accepts an application for group coverage, such acceptance shall be subject to the following:
(a) If the group has coverage in effect through another plan, the health service corporation shall accept all persons covered under the existing plan. If the group does not have coverage in effect through another plan, the health service corporation shall accept all persons for which the group seeks coverage.
(b) Once a group policy has been issued, any person becoming eligible for coverage shall become covered by enrolling within 31 days after becoming eligible. Any person so enrolling shall not be required to submit evidence of insurability based on medical conditions. If a person does not enroll at this time, such person is a late enrollee.
(c) Once a group policy has been issued, the health service corporation shall provide the group with an annual open enrollment period for late enrollees. During the open enrollment period, any late enrollee shall be permitted to enroll without submitting any evidence of insurability based on medical conditions. For late enrollees only, the pre-existing condition provisions shall apply for 18 months from the date of enrollment.
X. An insurer issuing policies of group insurance shall allocate the costs associated with maternity and childbirth over both males and females covered by its entire block of business in this state. In cases in which, because of the amount written in the state, allocation to an entire block of business needs to occur, the carrier may apply for a waiver from the commissioner.
XI. A statement allowing subscribers with Medicare supplement insurance benefits a period of at least one year after the incurral of a covered expense within which the subscriber shall furnish any proof of loss required by the insurer. Failure to furnish such proof within such time shall not invalidate or reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and such proof was furnished as soon as was reasonably possible.
XII. A provision that such contract shall be signed by the president and secretary before it shall become effective.
XIII. A statement that all benefits payable shall be paid to the participating providers except those in reimbursement of payments made by the subscriber to a non-participating provider and for which the corporation was liable at the time of payment.
Source. 1997, 190:1. 2009, 54:5, eff. July 21, 2009.