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| Home > Statutes > Usa Arizona |
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USA Statutes : arizona
Title : Insurance
Chapter : ACCOUNTABLE HEALTH PLANS
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20-2301 Definitions; late enrollee coverage
A. In this chapter, unless the context otherwise requires:
1. "Accountable health plan" means an entity that offers, issues or otherwise
provides a health benefits plan and is approved by the director as an accountable health
plan pursuant to section 20-2303.
2. "Affiliation period" means a period of two months, or three months for late
enrollees, that under the terms of the health benefits plan offered by a health care
services organization must expire before the health benefits plan becomes effective and
in which the health care services organization is not required to provide health care
services or benefits and cannot charge the participant or beneficiary a premium for any
coverage during the period.
3. "Base premium rate" means, for each rating period, the lowest premium rate that
could have been charged under a rating system by the accountable health plan to small
employers for health benefits plans involving the same or similar coverage, family size
and composition, and geographic area.
4. "Basic health benefit plan" means a plan that is developed by a committee
established by the legislature and that is adopted by the director.
5. "Bona fide association" means, for a health benefits plan issued by an
accountable health plan, an association that meets the requirements of section 20-2324.
6. "COBRA continuation provision" means:
(a) Section 4980B, except subsection (f)(1) as it relates to pediatric vaccines, of
the internal revenue code of 1986.
(b) Title I, subtitle B, part 6, except section 609, of the employee retirement
income security act of 1974 (P.L. 93-406; 88 Stat. 829; 29 United States Code sections
1001 through 1461).
(c) Title XXII of the public health service act.
(d) Any similar provision of the law of this state or any other state.
7. "Creditable coverage" means coverage solely for an individual, other than
limited benefits coverage, under any of the following:
(a) An employee welfare benefit plan that provides medical care to employees or the
employees' dependents directly or through insurance, reimbursement or otherwise pursuant
to the employee retirement income security act of 1974.
(b) A church plan as defined in the employee retirement income security act of
1974.
(c) A health benefits plan issued by an accountable health plan as defined in
section 20-2301.
(d) Part A or part B of title XVIII of the social security act.
(e) Title XIX of the social security act, other than coverage consisting solely of
benefits under section 1928.
(f) Title 10, chapter 55 of the United States Code.
(g) A medical care program of the Indian health service or of a tribal
organization.
(h) A health benefits risk pool operated by any state of the United States.
(i) A health plan offered pursuant to title 5, chapter 89 of the United States
Code.
(j) A public health plan as defined by federal law.
(k) A health benefit plan pursuant to section 5(e) of the peace corps act (P.L.
87-293; 75 Stat. 612; 22 United States Code sections 2501 through 2523).
(l) A policy or contract, including short-term limited duration insurance, issued
on an individual basis by an insurer, a health care services organization, a hospital
service corporation, a medical service corporation or a hospital, medical, dental and
optometric service corporation or made available to persons defined as eligible under
section 36-2901, paragraph 6, subdivisions (b), (c), (d) and (e).
(m) A policy or contract issued by a health care insurer or an accountable health
plan to a member of a bona fide association.
8. "Demographic characteristics" means objective factors an insurer considers in
determining premium rates. Demographic characteristics do not include health
status-related factors, industry or duration of coverage since issue.
9. "Different policy forms" means variations between policy forms offered by a
health care insurer, including policy forms that have different cost sharing arrangements
or different riders.
10. "Genetic information" means information about genes, gene products and inherited
characteristics that may derive from the individual or a family member, including
information regarding carrier status and information derived from laboratory tests that
identify mutations in specific genes or chromosomes, physical medical examinations,
family histories and direct analysis of genes or chromosomes.
11. "Health benefits plan" means a hospital and medical service corporation policy
or certificate, a health care services organization contract, a multiple employer welfare
arrangement or any other arrangement under which health services or health benefits are
provided to two or more individuals. Health benefits plan does not include the following:
(a) Accident only, dental only, vision only, disability income only or long-term
care only insurance, fixed or hospital indemnity coverage, limited benefit coverage,
specified disease coverage, credit coverage or Taft-Hartley trusts.
(b) Coverage that is issued as a supplement to liability insurance.
(c) Medicare supplemental insurance.
(d) Workers' compensation insurance.
(e) Automobile medical payment insurance.
12. "Health status-related factor" means any factor in relation to the health of the
individual or a dependent of the individual enrolled or to be enrolled in an accountable
health plan including:
(a) Health status.
(b) Medical condition, including physical and mental illness.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions arising out of acts of domestic
violence as defined in section 20-448.
(h) The existence of a physical or mental disability.
13. "Higher level of coverage" means a health benefits plan offered by an
accountable health plan for which the actuarial value of the benefits under the coverage
is at least fifteen per cent more than the actuarial value of the health benefits plan
offered by the accountable health plan as a lower level of coverage in this state but not
more than one hundred twenty per cent of a policy form weighted average.
14. "Index rate" means, as to a rating period, the arithmetic average of the
applicable base premium rate and the highest premium rate that could have been charged
under a rating system by the accountable health plan to small employers for a health
benefits plan involving the same or similar coverage, family size and composition, and
geographic area.
15. "Late enrollee" means an employee or dependent who requests enrollment in a
health benefits plan after the initial enrollment period that is provided under the terms
of the health benefits plan if the initial enrollment period is at least thirty-one days.
An employee or dependent shall not be considered a late enrollee if:
(a) The person:
(i) At the time of the initial enrollment period was covered under a public or
private health insurance policy or any other health benefits plan.
(ii) Lost coverage under a public or private health insurance policy or any other
health benefits plan due to the employee's termination of employment or eligibility, the
reduction in the number of hours of employment, the termination of the other plan's
coverage, the death of the spouse, legal separation or divorce or the termination of
employer contributions toward the coverage.
(iii) Requests enrollment within thirty-one days after the termination of
creditable coverage that is provided under a public or private health insurance or other
health benefits plan.
(iv) Requests enrollment within thirty-one days after the date of marriage.
(b) The person is employed by an employer that offers multiple health benefits
plans and the person elects a different plan during an open enrollment period.
(c) A court orders that coverage be provided for a spouse or minor child under a
covered employee's health benefits plan and the person requests enrollment within
thirty-one days after the court order is issued.
(d) The person becomes a dependent of a covered person through marriage, birth,
adoption or placement for adoption and requests enrollment no later than thirty-one days
after becoming a dependent.
16. "Lower level of coverage" means a health benefits plan offered by an accountable
health plan for which the actuarial value of the benefits under the health benefits plan
is at least eighty-five per cent but not more than one hundred per cent of the policy
form weighted average.
17. "Network plan" means a health benefits plan provided by an accountable health
plan under which the financing and delivery of health benefits are provided, in whole or
in part, through a defined set of providers under contract with the accountable health
plan in accordance with the determination made by the director pursuant to section
20-1053 regarding the geographic or service area in which an accountable health plan may
operate.
18. "Participating provider" means a professional or institutional health care
provider that is employed by or has a written contract with an accountable health plan.
19. "Policy form weighted average" means the average actuarial value of the benefits
provided by all health benefits plans issued by either the accountable health plan or, if
the data are available, by all accountable health plans in the group market in this state
during the previous calendar year, weighted by the enrollment for all coverage forms.
20. "Preexisting condition" means a condition, regardless of the cause of the
condition, for which medical advice, diagnosis, care or treatment was recommended or
received within not more than six months before the date of the enrollment of the
individual under a health benefits plan issued by an accountable health plan. A genetic
condition is not a preexisting condition in the absence of a diagnosis of the condition
related to the genetic information and shall not result in a preexisting condition
limitation or preexisting condition exclusion.
21. "Preexisting condition limitation" or "preexisting condition exclusion" means a
limitation or exclusion of benefits for a preexisting condition under a health benefits
plan offered by an accountable health plan.
22. "Small employer" means an employer who employs at least two but not more than
fifty eligible employees on a typical business day during any one calendar year.
23. "Taft-Hartley trust" means a jointly-managed trust, as allowed by 29 United
States Code sections 141 through 187, that contains a plan of benefits for employees and
that is negotiated in a collective bargaining agreement governing the wages, hours and
working conditions of the employees, as allowed by 29 United States Code section 157.
24. "Waiting period" means the period that must pass before a potential participant
or beneficiary in a health benefits plan offered by an accountable health plan is
eligible to be covered for benefits as determined by the individual's employer.
B. Coverage for a late enrollee begins on the date the person becomes a dependent if
a request for enrollment is received within thirty-one days after the person becomes a
dependent.
20-2302 Scope of article
A. This article applies to any health benefits plan that provides coverage to
eligible employees or dependents in this state and that is issued by an accountable
health plan if:
1. Any portion of the premium or benefits is paid by or on behalf of the employer.
2. The eligible employee or dependent is reimbursed by or on behalf of the employer
for any portion of the premium.
3. The health benefits plan is treated by the employer or any of the eligible
employees or dependents as part of a plan or program for the purposes of section 106, 162
or 220 of the internal revenue code.
B. This article applies to a health benefits plan that qualifies as a group health
plan under section 2791(a)(1) of the health insurance portability and accountability act
of 1996 (P.L. 104-191; 110 Stat. 1936).
C. This article does not apply to any policy that is issued on an individual basis.
20-2303 Approval as accountable health plan; definition
An entity may offer, issue or otherwise provide a health benefits plan only if the
entity is authorized to transact insurance in this state and is approved as an
accountable health plan by the director based on a determination that the entity meets
the applicable requirements of this chapter.
20-2304 Availability of insurance; premium tax exemption
A. Beginning on July 1, 1997, as a condition of doing business in this state each
accountable health plan shall offer at least one health benefits plan on a guaranteed
issuance basis to small employers as required by this section. All small employers
qualify for this guaranteed offer of coverage. The accountable health plan shall provide
a health benefits plan to each small employer without regard to health status-related
factors if the small employer agrees to make the premium payments and to satisfy any
other reasonable provisions of the plan that are not inconsistent with this chapter.
B. If an accountable health plan offers more than one health benefits plan to small
employers, the accountable health plan shall offer a choice of all health benefits plans
that the accountable health plan offers to small employers and shall accept any small
employer that applies for any of those plans.
C. In addition to the requirements prescribed in section 20-2323, for any offering
of any health benefits plan to a small employer, as part of the accountable health plan's
solicitation and sales materials, an accountable health plan shall make a reasonable
disclosure to the employer of the availability of the information described in this
subsection and, on request of the employer, shall provide that information to the
employer. The accountable health plan shall provide information concerning the following:
1. Provisions of coverage relating to the following, if applicable:
(a) The accountable health plan's right to change premium rates and the factors
that may affect changes in premium rates.
(b) Renewability of coverage.
(c) Any preexisting condition exclusion.
(d) Any affiliation period applied by a health care services organization.
(e) The geographic areas served by health care services organizations.
2. The benefits and premiums available under all health benefits plans for which
the employer is qualified.
D. The accountable health plan shall describe the information required by
subsection C of this section in language that is understandable by the average small
employer and with a level of detail that is sufficient to reasonably inform a small
employer of the employer's rights and obligations under the health benefits plan. This
requirement is satisfied if the accountable health plan provides each of the following
for each product the accountable health plan offers:
1. An outline of coverage that describes the benefits in summary form.
2. The rate or rating schedule that applies to the product, preexisting condition
exclusion or affiliation period.
3. The minimum employer contribution and group participation rules that apply to
any particular type of coverage.
4. In the case of a network plan, a map or listing of the areas served.
E. An accountable health plan is not required to disclose any information that is
proprietary and protected trade secret information under applicable law.
F. An accountable health plan that issues a health benefits plan through a network
plan may limit the employers that may apply for any health benefits plan offered by the
accountable health plan to those eligible individuals who live, work, or reside in the
service area for the network plan of the accountable health plan.
G. On approval of the director, an accountable health plan may refuse to enroll a
qualified small employer in a health benefits plan or in a geographic area served by the
plan if the accountable health plan demonstrates that its financial or administrative
capacity to serve previously enrolled groups and individuals would be impaired. An
accountable health plan that refuses to enroll a qualified small employer may not enroll
an employer of the same or larger size until the earlier of:
1. The date on which the director determines that the accountable health plan has
the capacity to enroll a qualified small employer.
2. The date on which the accountable health plan enrolls a qualified small
employer.
H. An accountable health plan that offers coverage to a qualified small employer
shall offer coverage to all of the eligible employees of the qualified small employer and
their eligible dependents.
I. An accountable health plan may request health screening and underwriting
information on prospective enrollees to evaluate the risks associated with a qualified
small employer who applies for coverage. The accountable health plan may use this
information for the purposes of setting premiums, evaluating plan offerings and making
reinsurance decisions. An accountable health plan shall not use this information to deny
coverage to a qualified small employer or to an eligible employee or to an eligible
dependent, except a late enrollee who attempts to enroll outside an open enrollment
period.
J. Notwithstanding the requirements of section 20-224, subsection B and sections
20-837, 20-1010 and 20-1060, beginning July 1, 1996, accountable health plans shall pay a
premium tax of one per cent of the net premiums received for health benefits plans issued
to small employers. Beginning July 1, 1997, accountable health plans are exempt from the
premium taxes that are required by this subsection, section 20-224, subsection B and
sections 20-837, 20-1010 and 20-1060, for the net premiums received for health benefits
plans issued to small employers. Each accountable health plan shall notify the small
employers to whom it provides coverage of the reductions in the premium tax as specified
in this subsection.
K. The director may use independent contractor examiners pursuant to sections
20-148 and 20-159 to review the higher level of coverage and lower level of coverage
health benefits plans offered by an accountable health plan insurer in compliance with
this section. All examination and examination related expenses shall be borne by the
insurer and shall be paid by the insurance examiners' revolving fund pursuant to section
20-159.
20-2307 Eligibility; annual open enrollment period
A. Except as otherwise provided in this section or section 20-2308 or 20-2309, an
accountable health plan may not exclude from coverage any employee or a spouse or a
dependent child of the employee if the person meets the eligibility requirements
established by the employer.
B. Subsection A of this section does not apply to a period in which an employee is
excluded from coverage under the health benefits plan pursuant to an employer requirement
that imposes a minimum period of service before the employee and the employee's
dependents are eligible for coverage.
C. An accountable health plan may deny enrollment to employees or family members of
an employer if the employees or family members are located outside the service area of
the accountable health plan and if the denial is applied uniformly without regard to
health status-related factors or insurability.
D. An accountable health plan that provides an annual open enrollment period of at
least thirty-one days may deny enrollment to a late enrollee until the next annual open
enrollment period or may require acceptable evidence of insurability.
20-2308 Portability
A newborn child, adopted child or child placed for adoption is an eligible
individual if the child was timely enrolled and otherwise would have met the definition
of an eligible individual as prescribed in section 20-1379 other than the required period
of creditable coverage and the child is-not subject to any preexisting condition
exclusion or limitation if the child has been continuously covered under health insurance
coverage or a health benefits plan offered by an accountable health plan since birth,
adoption or placement for adoption.
20-2309 Renewability
A. At least sixty days before the date of expiration of a health benefits plan, an
accountable health plan that provides a health benefits plan shall provide for written
notice to the employer of the terms for renewal of the plan. The notice shall include an
explanation of the extent to which any increase in premiums is due to actual or expected
claims experience of the individuals covered under the employer's health benefits plan
contract.
B. An accountable health plan may refuse to renew or may terminate a health
benefits plan only if:
1. The employer fails to pay premiums or contributions in accordance with the terms
of the health benefits plan of the accountable health plan or the accountable health plan
does not receive premium payments in a timely manner.
2. The employer committed an act or practice that constitutes fraud or made an
intentional misrepresentation of material fact under the terms of the health benefits
plan.
3. The employer has failed to comply with a material plan provision relating to
individual or employer participation rules as prescribed in subsection C of this section.
4. The accountable health plan has ceased to offer coverage in the group market
pursuant to this section.
5. In the case of an accountable health plan that offers a health benefits plan
through a network plan in this state, there is no longer any enrollee in connection with
the accountable health plan who lives, resides or works in the service area of the
accountable health plan or in the area served by the network plan for which the
accountable health plan is authorized to do business and the accountable health plan
would deny enrollment pursuant to section 20-2304, subsection G.
6. In the case of an accountable health plan that offers a health benefits plan in
the group market only through one or more bona fide associations, the membership of an
employer in the association has ceased but only if that coverage is terminated uniformly
without regard to any health status-related factor or any covered individual.
C. An accountable health plan may require that a minimum percentage of employees
who are not covered under a spouse's or parent's employer's health benefits plan be
enrolled in a plan if the percentage is applied uniformly to all plans that are offered
to employers of comparable size.
D. An accountable health plan is not required to renew a health benefits plan with
respect to an employer or individual if the accountable health plan:
1. Elects not to renew all of its health benefits plans that are issued to
employers or individuals in this state.
2. Provides notice to the director at least five business days before the
accountable health plan gives notice to each employer or individual covered under a
health benefits plan of the intention to discontinue offering any health benefits plans
in this state.
3. Provides notice of termination to each employer or individual covered under a
plan at least one hundred eighty days before the expiration date of the plan. If the
accountable health plan terminates coverage, the accountable health plan may not issue a
health benefits plan to an employer in this state during the five year period beginning
on the termination date of the last plan that was not renewed.
E. If an accountable health plan decides to discontinue offering a particular
health benefits plan offered in the group market, the accountable health plan may
discontinue that coverage only if the accountable health plan:
1. Provides notice to the director at least five business days before the
accountable health plan gives notice to each employer or individual covered under that
health benefits plan of the intention to discontinue offering that health benefits plan
in this state.
2. Provides notice to each employer or individual covered under that health
benefits plan at least ninety days before the date of the discontinuation of that
coverage.
3. Offers to each employer whose coverage is discontinued pursuant to this
subsection the option to purchase all other health benefits plans currently offered by
the accountable health plan for employers in the group market uniformly without regard to
any health status-related factor of any employee or a spouse or a dependent of the
employee enrolled or individuals who may become eligible for that coverage.
20-2310 Discrimination prohibited; preexisting conditions
A. Except as provided in subsection B of this section, a health benefits plan may
not deny, limit or condition the coverage or benefits based on a person's health
status-related factors or a lack of evidence of insurability.
B. A health benefits plan shall not exclude coverage for preexisting conditions,
except that:
1. A health benefits plan may exclude coverage for preexisting conditions for a
period of not more than twelve months or, in the case of a late enrollee, eighteen
months. The exclusion of coverage does not apply to services that are furnished to
newborns who were otherwise covered from the time of their birth or to persons who
satisfy the portability requirements under section 20-2308.
2. The accountable health plan shall reduce the period of any applicable
preexisting condition exclusion by the aggregate of the periods of creditable coverage
that apply to the individual.
C. A health benefits plan shall not include an affiliation period in a policy
unless the affiliation period satisfies the requirements prescribed in 45 Code of Federal
Regulations section 146.119(b).
D. On request of a health benefits plan, a person who provides coverage during a
period of continuous coverage with respect to a covered individual shall promptly
disclose the coverage provided to the covered individual, the period of the coverage and
the benefits provided under the coverage.
E. The accountable health plan shall calculate creditable coverage according to the
following rules:
1. The accountable health plan shall give an individual credit for each day the
individual was covered by creditable coverage.
2. The accountable health plan shall not count a period of creditable coverage for
an individual enrolled in a health benefits plan if after the period of coverage and
before the enrollment date there were sixty-three consecutive days during which the
individual was not covered under any creditable coverage.
3. The accountable health plan shall give credit in the calculation of creditable
coverage for any period that an individual is in a waiting period or an affiliation
period for any health coverage.
4. The accountable health plan shall not count a period of creditable coverage with
respect to enrollment of an individual if, after the most recent period of creditable
coverage and before the enrollment date, sixty-three consecutive days lapse during all of
which the individual was not covered under any creditable coverage. The accountable
health plan shall not include in the determination of the period of continuous coverage
described in this section any period that an individual is in a waiting period for health
insurance coverage offered by a health care insurer, is in a waiting period for benefits
under a health benefits plan offered by an accountable health plan or is in an
affiliation period.
5. In determining the extent to which an individual has satisfied any portion of
any applicable preexisting condition period the accountable health plan shall count a
period of creditable coverage without regard to the specific benefits covered during that
period.
6. An accountable health plan shall not impose any preexisting condition exclusion
in the case of an individual who is covered under creditable coverage thirty-one days
after the individual's date of birth.
7. An accountable health plan shall not impose any preexisting condition exclusion
in the case of a child who is adopted or placed for adoption before age eighteen and who
is covered under creditable coverage thirty-one days after the adoption or placement for
adoption.
F. An accountable health plan shall provide the certificate of creditable coverage
described in subsection G of this section without charge for creditable coverage
occurring after June 30, 1996 if the individual:
1. Ceases to be covered under a health benefits plan offered by an accountable
health plan or otherwise becomes covered under a COBRA continuation provision. An
individual who is covered by a health benefits plan that is offered by an accountable
health plan, that is terminated or not renewed at the choice of the employer and where
the replacement of the health benefits plan is without a break in coverage is not
entitled to receive the certification prescribed in this paragraph but is instead
entitled to receive the certifications prescribed in paragraphs 2 and 3 of this
subsection.
2. Who was covered under a COBRA continuation provision ceases to be covered under
the COBRA continuation provision.
3. Requests certification from the accountable health plan within twenty-four
months after the coverage under a health benefits plan offered by an accountable health
plan ceases.
G. The certificate of creditable coverage provided by an accountable health plan is
a written certification of:
1. The period of creditable coverage of the individual under the accountable health
plan and any applicable coverage under a COBRA continuation provision.
2. Any applicable waiting period or affiliation period imposed on an individual for
any coverage under the accountable health plan.
H. Any accountable health plan that issues health benefits plans in this state, as
applicable, shall issue and accept a written certificate of creditable coverage of the
individual that contains at least the following information:
1. The date that the certificate is issued.
2. The name of the individual or dependent for whom the certificate applies and any
other information that is necessary to allow the issuer providing the coverage specified
in the certificate to identify the individual, including the individual's identification
number under the policy and the name of the policyholder if the certificate is for or
includes a dependent.
3. The name, address and telephone number of the issuer providing the certificate.
4. The telephone number to call for further information regarding the certificate.
5. One of the following:
(a) A statement that the individual has at least eighteen months of creditable
coverage. For purposes of this subdivision, eighteen months means five hundred forty-six
days.
(b) Both the date that the individual first sought coverage, as evidenced by a
substantially complete application, and the date that creditable coverage began.
6. The date creditable coverage ended, unless the certificate indicates that
creditable coverage is continuing from the date of the certificate.
7. The consumer assistance telephone number for the department.
8. The following statement in at least fourteen point type:
Important notice!
Keep this certificate with your important personal records to protect your
rights under the health insurance portability and accountability act of 1996
("HIPAA"). This certificate is proof of your prior health insurance coverage.
You may need to show this certificate to have a guaranteed right to buy new
health insurance ("Guaranteed issue"). This certificate may also help you
avoid waiting periods or exclusions for preexisting conditions. Under HIPAA,
these rights are guaranteed only for a very short time period. After your
group coverage ends, you must apply for new coverage within 63 days to be
protected by HIPAA. If you have questions, call the ARIZONA department of
insurance.
I. An accountable health plan may provide any certification pursuant to subsection
F, paragraph 1 of this section at the same time the accountable health plan sends the
notice required by the applicable COBRA continuation provision.
J. An accountable health plan has satisfied the certification requirement under
this section if the accountable health plan offering the health benefits plan provides
the prescribed certificate in accordance with this section within thirty days after the
event that triggered the issuance of the certification.
K. If an accountable health plan imposes a waiting period for coverage of
preexisting conditions, within a reasonable period of time after receiving an
individual's proof of creditable coverage and not later than the date by which the
individual must select an insurance plan, the accountable health plan shall give the
individual written disclosure of the accountable health plan's determination regarding
any preexisting condition exclusion period that applies to that individual. The
disclosure shall include all of the following information:
1. The period of creditable coverage allowed toward the waiting period for coverage
of preexisting conditions.
2. The basis for the accountable health plan's determination and the source and
substance of any information on which the accountable health plan has relied.
3. A statement of any right the individual may have to present additional evidence
of creditable coverage and to appeal the accountable health plan's determination,
including an explanation of any procedures for submission and appeal.
L. Periods of creditable coverage for an individual are established by presentation
of the written certifications described in this section and section 20-1379. In addition
to written certification of the period of creditable coverage as described in this
section, individuals may establish creditable coverage through the presentation of
documents or other means. In order to make a determination that is based on the relevant
facts and circumstances of the amount of creditable coverage that an individual has, an
accountable health plan shall take into account all information that the plan obtains or
that is presented to the plan on behalf of the individual.
M. The department may enforce and monitor the issuance and delivery of the notices
and certificates by accountable health plans and insurers as required by this section,
the health insurance portability and accountability act of 1996 (P.L. 104-191; 110 Stat.
1936) and any federal regulations adopted to implement the health insurance portability
and accountability act of 1996.
20-2311 Premium rates and rating practices
A. The premium rate that an accountable health plan charges during a rating period
for a health benefits plan issued to a small employer shall not vary by more than sixty
per cent from the index rate for health benefits plans involving the same or similar
coverage, family size and composition, and geographic area.
B. In establishing premium rates for health benefits plans offered to small
employers:
1. An accountable health plan making adjustments with respect to demographic
characteristics shall apply those adjustments consistently across all small employers.
2. An accountable health plan may not use a geographic area that is smaller than a
county or smaller than an area that includes all areas in which the first three digits of
the zip code are identical, whichever is smaller.
C. The percentage increase in the premium rate that is charged to a small employer
for a new rating period may not exceed the sum of the following:
1. The percentage change in the base premium rate.
2. Fifteen percentage points.
3. Any adjustment due to a change in coverage, family size or composition,
geographic area or demographic characteristics.
D. At the time an accountable health plan offers a health benefits plan to a small
employer, the accountable health plan shall fully disclose to the employer all of the
following:
1. Rating practices for small employer health benefits plans, including rating
practices for different populations and benefit designs.
2. The extent to which premium rates for the small employer are established or
adjusted based on the actual or expected variation in claims costs or health condition of
the employees of the small employer and their dependents.
3. The accountable health plan's right to change premium rates, the extent to which
premiums can be modified and the factors that affect changes in premium rates.
E. Each accountable health plan shall file annually with the director a written
statement by a member of the American academy of actuaries or another individual
acceptable to the director certifying that based on an examination by the individual,
including a review of the appropriate records and of the actuarial assumptions of the
accountable health plan and methods used by the accountable health plan in establishing
premium rates for small employer health benefits plans:
1. The accountable health plan is in compliance with the applicable provisions of
this article.
2. The rating methods are actuarially sound.
F. Each accountable health plan shall retain a copy of the statement required by
subsection E for examination at its principal place of business.
20-2313 Marketing practices
A. An accountable health plan or its insurance producer shall not:
1. Discourage an employer from filing an application for a health benefits plan
because of the health status-related factors, industry, occupation or geographic location
of the employer.
2. Encourage or direct an employer to seek a health benefits plan from another
insurer because of the health status-related factors, industry, occupation or geographic
location of the employer.
B. This section does not prohibit an accountable health plan from providing
information regarding the geographic service area of the accountable health plan.
C. Notwithstanding any law to the contrary, an accountable health plan may market
health benefits plans to groups of small employers from the same or different industries
that elect to pool their risks on a voluntary basis.
20-2318 Mandatory coverage prohibited
Notwithstanding any law to the contrary, the basic health benefit plan is not
subject to the requirements of section 20-461, subsection A, paragraph 16 and subsection
B, section 20-826, subsections C, D, E, F, H, I, J and K, sections 20-841, 20-841.01 and
20-841.02, section 20-1051, paragraph 4, section 20-1057, subsections B, C, I, J, K, L
and M, section 20-1402, subsection A, paragraphs 2, 4, 5, 6, 7 and 8, section 20-1404,
subsections E, F, G, H, I and J and sections 20-1406, 20-1406.01, 20-1406.02 and 20-1408.
20-2320 Exchange of information
A. By January 1, 1995, but no sooner than twelve months after approval of a form by
the American national standards institute, an accountable health plan shall receive
twenty-five per cent of its claim submissions from providers by electronic means in a
form approved by the American national standards institute. By January 1, 1997, but no
sooner than thirty-six months after approval of a form by the American national standards
institute, an accountable health plan shall receive fifty per cent of its claim
submissions by electronic means.
B. By January 1, 1995, but no sooner than twelve months after approval of a form by
the American national standards institute, an accountable health plan shall remit
twenty-five per cent of its claim payments to providers by electronic means in a form
approved by the American national standards institute. By January 1, 1997, but no sooner
than thirty-six months after approval of a form by the American national standards
institute, an accountable health plan shall remit fifty per cent of its claim payments by
electronic means.
C. By January 1, 1995, but no sooner than twelve months after approval of a form by
the American national standards institute, an accountable health plan shall conduct
twenty-five per cent of its eligibility verification transactions with providers by
electronic means in a form approved by the American national standards institute. By
January 1, 1997, but no sooner than thirty-six months after approval of a form by the
American national standards institute, an accountable health plan shall conduct fifty per
cent of its eligibility verifications by electronic means.
D. The percentage requirements under this section shall be determined based on the
numerical volume rather than on the monetary volume of claims.
20-2321 Maternity benefits; adoption; coverage
A. A contract that is issued to an enrollee pursuant to this article and that
provides coverage for maternity benefits shall also provide that the maternity benefits
apply to the costs of the birth of a child who is legally adopted by the enrollee if all
of the following are true:
1. The child is adopted within one year of birth.
2. The enrollee is legally obligated to pay the costs of birth.
3. All preexisting conditions and other limitations have been met and all
deductibles and copayments have been paid by the enrollee.
4. The enrollee has notified the insurer of the enrollee's acceptability to adopt
children pursuant to section 8-105 within sixty days after this approval or within sixty
days after a change in insurance policies, plans or companies.
B. The coverage prescribed by subsection A of this section is excess to any other
coverage the natural mother may have for maternity benefits except coverage made
available to persons pursuant to title 36, chapter 29 but not including coverage made
available to persons defined as eligible under section 36-2901, paragraph 6, subdivisions
(b), (c), (d) and (e).
C. If other coverage exists the agency, attorney or individual arranging the
adoption shall make arrangements for the insurance to pay those costs that may be covered
under that policy and shall advise the adopting parent in writing of the existence and
extent of the coverage without disclosing any confidential information such as the
identity of the natural parent.
D. The enrollee adopting parents shall notify their accountable health plan of the
existence and extent of the other coverage.
E. An accountable health plan is not required to pay any costs in excess of the
amounts it would have been obligated to pay to its hospitals and providers if the natural
mother and child had received the maternity and newborn care directly from or through
that accountable health plan.
F. Beginning January 1, 1998, any contract that provides maternity benefits shall
not restrict benefits for any hospital length of stay in connection with childbirth for
the mother or the newborn child to less than forty-eight hours following a normal vaginal
delivery or ninety-six hours following a cesarean section. The contract shall not
require the provider to obtain authorization from the accountable health plan for
prescribing the minimum length of stay required by this subsection. The contract may
provide that an attending provider in consultation with the mother may discharge the
mother or the newborn child before the expiration of the minimum length of stay required
by this subsection. The accountable health plan shall not:
1. Deny the mother or the newborn child eligibility or continued eligibility to
enroll or to renew coverage under the terms of the contract solely for the purpose of
avoiding the requirements of this subsection.
2. Provide monetary payments or rebates to mothers to encourage those mothers to
accept less than the minimum protections available pursuant to this subsection.
3. Penalize or otherwise reduce or limit the reimbursement of an attending provider
because that provider provided care to any insured under the contract in accordance with
this subsection.
4. Provide monetary or other incentives to an attending provider to induce that
provider to provide care to an insured under the contract in a manner that is
inconsistent with this subsection.
5. Except as described in subsection G of this section, restrict benefits for any
portion of a period within the minimum length of stay in a manner that is less favorable
than the benefits provided for any preceding portion of that stay.
G. Nothing in subsection F of this section:
1. Requires a mother to give birth in a hospital or to stay in the hospital for a
fixed period of time following the birth of the child.
2. Prevents an accountable health plan from imposing deductibles, coinsurance or
other cost sharing in relation to benefits for hospital lengths of stay in connection
with childbirth for a mother or a newborn child under the contract, except that any
coinsurance or other cost sharing for any portion of a period within a hospital length of
stay required pursuant to subsection F of this section shall not be greater than the
coinsurance or cost sharing for any preceding portion of that stay.
3. Prevents an accountable health plan from negotiating the level and type of
reimbursement with a provider for care provided in accordance with subsection F of this
section.
H. An accountable health plan shall not impose any preexisting condition exclusions
or limitations relating to pregnancy as a preexisting condition.
20-2322 Mental health services and benefits; definitions
A. Beginning on January 1, 1998, any health benefits plan that is offered by an
accountable health plan and that provides services or health benefits that include mental
health services or mental health benefits shall comply with this section.
B. If the health benefits plan does not include an aggregate lifetime limit on
substantially all health services or health benefits that are not related to mental
health services or mental health benefits, the health benefits plan shall not impose any
aggregate lifetime limit on mental health services or mental health benefits. If the
health benefits plan includes an aggregate lifetime limit on substantially all health
services or health benefits that are not related to mental health services or mental
health benefits, the health benefits plan shall either:
1. Apply the applicable lifetime limit to both the health services or health
benefits that are not related to mental health services or mental health benefits and to
the mental health services or mental health benefits.
2. Not include an aggregate lifetime limit on mental health services or mental
health benefits that is less than the applicable lifetime limit for health services or
health benefits that are not related to mental health services or mental health benefits.
C. If the health benefits plan does not include an aggregate annual limit on
substantially all health services or health benefits that are not related to mental
health services or mental health benefits, the health benefits plan shall not impose any
aggregate annual limit on mental health services or mental health benefits. If the
health benefits plan includes an aggregate annual limit on substantially all health
services or health benefits that are not related to mental health services or mental
health benefits, the health benefits plan shall either:
1. Apply the applicable annual limit to both the health services or health benefits
that are not related to mental health services or mental health benefits and to the
mental health services or mental health benefits.
2. Not include any aggregate annual limit on mental health services or mental
health benefits that is less than the applicable annual limit for health services or
health benefits that are not related to mental health services or mental health benefits.
D. Except as provided in subsections A, B and C, this section does not prevent an
accountable health plan that offers a health benefits plan that provides mental health
services or mental health benefits from imposing terms and conditions, including cost
sharing, limits on the number of visits or days of coverage or requirements relating to
medical necessity in relation to the amount, duration or scope of coverage for mental
health services or mental health benefits under the health benefits plan. Nothing in
this section requires an accountable health plan to:
1. Offer a health benefits plan that provides mental health services or mental
health benefits.
2. Comply with this section in connection with any health benefits plan offered to
a small employer.
3. Comply with this section if that compliance under the health benefits plan
offered by the accountable health plan would result in an increase in the cost to the
health benefits plan of at least one per cent.
E. The requirements of this section apply separately to each health benefits plan
offered by an accountable health plan and shall be consistent with title VII of the
health insurance portability and accountability act of 1996 (P.L. 104-204; 110 Stat.
2944) and 45 Code of Federal Regulations part 146.
F. Mental health services or mental health benefits do not include benefits for the
treatment of substance abuse or chemical dependency.
G. For the purposes of this section:
1. "Aggregate annual limit" means a dollar limitation on the total amount that may
be paid in a twelve month period for benefits or services under a health benefits plan
for an individual who is covered under a health benefits plan.
2. "Aggregate lifetime limit" means a dollar limitation on the total amount that
may be paid for benefits or services under a health benefits plan for an individual who
is covered under a health benefits plan.
20-2323 Disclosure of information
A. Each accountable health plan that offers a health benefits plan to the public
shall provide disclosure forms as required by this section. The disclosure form shall be
in a form that is prescribed by the director and that includes all of the following:
1. A separate roster of the plan's primary care physicians who are licensed
pursuant to title 32, chapter 13, 17 or 29, including the physician's degree and practice
specialty, the year initially licensed to practice medicine and, if different, the year
initially licensed to practice medicine in this state.
2. In concise and specific terms:
(a) The full premium cost of the plan.
(b) Any copayment, coinsurance or deductible requirements that an enrollee or the
enrollee's family may incur in obtaining coverage under the plan and any reservation by
the plan to change premiums.
(c) The health care benefits to which an enrollee would be entitled.
(d) Where and in what manner an enrollee may obtain services, including the
procedures for selecting or changing primary care physicians and the locations of
hospitals and outpatient treatment centers that are under contract with the accountable
health plan.
3. Any limitations of the services, kinds of services, benefits and exclusions that
apply to the plan including:
(a) Procedures for emergency room, nighttime or weekend visits and referrals to
specialist physicians.
(b) Whether services received outside of the plan are covered and in what manner
they are covered.
(c) The circumstances under which prior authorization is required for emergency
medical care and a statement as to whether and where the plan provides twenty-four hour
emergency services.
(d) The circumstances under which the plan may retroactively deny coverage for
emergency medical treatment and nonemergency medical treatment that had prior
authorization under the plan's written policies.
(e) A statement regarding whether the plan's providers must comply with any
specified numbers, targeted averages or maximum durations of patient visits and the
specific requirements of each.
(f) The procedures that the enrollee must follow to consult with a physician other
than the enrollee's primary care physician and whether the enrollee's primary care
physician, the plan's medical director or a committee must first authorize the referral.
(g) Whether it is necessary to repeat prior authorization if the specialist care is
continuing.
(h) Whether a point of service option is available and how it is structured.
4. Grievance procedures for claim or treatment denials, creditable coverage
determinations, dissatisfaction with care and access to care issues.
5. Subject to section 20-2326, a statement as to whether a plan physician is
restricted to prescribing drugs from a plan list or plan formulary and the extent to
which an enrollee will be reimbursed for costs of a drug that is not on a plan list or
plan formulary.
6. A statement as to whether plan provider compensation programs include any
incentives or penalties that are intended to encourage plan providers to withhold
services or minimize or avoid referrals to specialist physicians, and if these types of
incentives or penalties are included, a concise description of and, at the option of the
accountable health plan, justification for each of them.
7. A statement that the disclosure form is a summary only and that the enrollee
should consult the plan's evidence of coverage to determine any governing contractual
provision.
B. An accountable health plan shall not disseminate a completed disclosure form
until the form is submitted to the director. This section does not require an accountable
health plan to submit to the director its separate roster of plan physicians or any
roster updates.
C. On request, an accountable health plan shall provide the information required
under subsection A of this section to all employers who are considering participating in
a health benefits plan that is offered by the accountable health plan or to an employer
that is considering renewal of a health benefits plan that is provided by an accountable
health plan.
D. An employer shall provide to its eligible employees the disclosures required
under subsection A of this section no later than the initiation of any open enrollment
period or at least ten days before any employee enrollment deadline that is not
associated with an open enrollment period.
E. An employer shall not execute a contract with an accountable health plan until
the employer receives the information required under subsection A of this section.
F. Nothing in this section provides any private right or cause of action to or on
behalf of any enrollee, prospective enrollee, employer or other person, whether a
resident or nonresident of this state. This section provides solely an administrative
remedy to the director of the department of insurance for any violation of this section
or any related rule.
20-2324 Bona fide associations; definition
A. On or before January 1 of each year, every association that qualifies as a bona
fide association shall file a statement with the director that certifies that the
association:
1. Has been in active existence for at least five years.
2. Has been formed and maintained in good faith for purposes other than obtaining
insurance and does not condition membership in the association on the purchase of
insurance that is sponsored by the association.
3. Has a constitution and bylaws.
4. Insures at least twenty-five members, employees or employees of members of the
association for the benefit of persons other than the association or its officers or
trustees.
5. Does not condition membership in the association on any health status-related
factor relating to an individual, including an employee of an employer or a dependent of
an employee, and clearly states this in all membership and application materials.
6. Makes health benefits plans offered through the association available to all
members regardless of any health status-related factor relating to any member of the
association or individual eligible for coverage through a member and clearly states this
in all membership and application materials.
7. Does not make health benefits plans offered through the association available
other than in connection with a member of the association and clearly states this in all
membership and application materials.
B. The requirements of section 20-2304, subsection A shall not apply to health
benefits plans offered by an accountable health plan if the accountable health plan makes
this coverage available in the small group market only through one or more bona fide
associations.
C. As used in this section, the term "employees" shall be deemed to include retired
employees.
20-2325 Diabetes; equipment; supplies
A. Any health benefits plan that is offered by an accountable health plan and that
provides coverage for diabetes shall also provide coverage for equipment and supplies
that are medically necessary and that are prescribed by a health care provider,
including:
1. Blood glucose monitors.
2. Blood glucose monitors for the legally blind.
3. Test strips for glucose monitors and visual reading and urine testing strips.
4. Insulin preparations and glucagon.
5. Insulin cartridges.
6. Drawing up devices and monitors for the visually impaired.
7. Injection aids.
8. Insulin cartridges for the legally blind.
9. Syringes and lancets including automatic lancing devices.
10. Prescribed oral agents for controlling blood sugar that are included on the plan
formulary.
11. To the extent coverage is required under medicare, podiatric appliances for
prevention of complications associated with diabetes.
12. Any other device, medication, equipment or supply for which coverage is required
under medicare from and after January 1, 1999. The coverage required in this paragraph
is effective six months after the coverage is required under medicare.
B. Nothing in subsection A of this section:
1. Entitles a member or enrollee of an accountable health plan to equipment or
supplies for the treatment of diabetes that are not medically necessary as determined by
the accountable health plan's medical director or the medical director's designee.
2. Provides coverage for diabetic supplies obtained by a member or enrollee of an
accountable health plan without a prescription unless otherwise permitted pursuant to the
terms of the health benefits plan.
3. Prohibits an accountable health plan from imposing deductibles, coinsurance or
other cost sharing in relation to benefits for equipment or supplies for the treatment of
diabetes.
20-2326 Drugs; cancer treatment; definitions
A. Any health benefits plan that is offered by an accountable health plan and that
provides coverage for prescription drugs shall not limit or exclude coverage for any
prescription drug prescribed for the treatment of cancer on the basis that the
prescription drug has not been approved by the United States food and drug administration
for the treatment of the specific type of cancer for which the prescription drug has been
prescribed, if the prescription drug has been recognized as safe and effective for
treatment of that specific type of cancer in one or more of the standard medical
reference compendia prescribed in subsection B or medical literature that meets the
criteria prescribed in subsection B. The coverage required under this subsection includes
covered medically necessary services associated with the administration of the
prescription drug. This subsection does not:
1. Require coverage of any prescription drug used in the treatment of a type of
cancer if the United States food and drug administration has determined that the
prescription drug is contraindicated for that type of cancer.
2. Require coverage for any experimental prescription drug that is not approved for
any indication by the United States food and drug administration.
3. Alter any law with regard to provisions that limit the coverage of prescription
drugs that have not been approved by the United States food and drug administration.
4. Require reimbursement or coverage for any prescription drug that is not included
in the drug formulary or list of covered prescription drugs specified in the health
benefits plan.
5. Prohibit a health benefits plan from limiting or excluding coverage of a
prescription drug, if the decision to limit or exclude coverage of the prescription drug
is not based primarily on the coverage of prescription drugs required by this section.
6. Prohibit the use of deductibles, coinsurance, copayments or other cost sharing
in relation to drug benefits and related medical benefits offered.
B. For the purposes of subsection A:
1. The acceptable standard medical reference compendia are the following:
(a) The American medical association drug evaluations, a publication of the
American medical association.
(b) The American hospital formulary service drug information, a publication of the
American society of health system pharmacists.
(c) Drug information for the health care provider, a publication of the United
States pharmacopoeia convention.
2. Medical literature may be accepted if all of the following apply:
(a) At least two articles from major peer reviewed professional medical journals
have recognized, based on scientific or medical criteria, the drug's safety and
effectiveness for treatment of the indication for which the drug has been prescribed.
(b) No article from a major peer reviewed professional medical journal has
concluded, based on scientific or medical criteria, that the drug is unsafe or
ineffective or that the drug's safety and effectiveness cannot be determined for the
treatment of the indication for which the drug has been prescribed.
(c) The literature meets the uniform requirements for manuscripts submitted to
biomedical journals established by the international committee of medical journal editors
or is published in a journal specified by the United States department of health and
human services as acceptable peer reviewed medical literature pursuant to section
186(t)(2)(B) of the social security act (42 United States Code section 1395x(t)(2)(B)).
20-2327 Metabolic disorders; medical foods; definitions
A. Any health benefits plan offered by an accountable health plan that contains a
prescription drug benefit shall provide coverage of medical foods to treat inherited
metabolic disorders as provided by this section.
B. The metabolic disorders triggering medical foods coverage under this section
shall:
1. Be part of the newborn screening program prescribed in section 36-694.
2. Involve amino acid, carbohydrate or fat metabolism.
3. Have medically standard methods of diagnosis, treatment and monitoring including
quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA
confirmation in tissues.
4. Require specially processed or treated medical foods that are generally
available only under the supervision and direction of a physician who is licensed
pursuant to title 32, chapter 13 or 17, that must be consumed throughout life and without
which the person may suffer serious mental or physical impairment.
C. Medical foods eligible for coverage under this section shall be prescribed or
ordered under the supervision of a physician licensed pursuant to title 32, chapter 13 or
17 as medically necessary for the therapeutic treatment of an inherited metabolic
disease.
D. An accountable health plan shall cover at least fifty per cent of the cost of
medical foods prescribed to treat inherited metabolic disorders and covered pursuant to
this section. A corporation may limit the maximum annual benefit for medical foods under
this section to five thousand dollars which applies to the cost of all prescribed
modified low protein foods and metabolic formula.
E. For the purposes of this section:
1. "Inherited metabolic disorder" means a disease caused by an inherited
abnormality of body chemistry and includes a disease tested under the newborn screening
program prescribed in section 36-694.
2. "Medical foods" means modified low protein foods and metabolic formula.
3. "Metabolic formula" means foods that are all of the following:
(a) Formulated to be consumed or administered enterally under the supervision of a
physician who is licensed pursuant to title 32, chapter 13 or 17.
(b) Processed or formulated to be deficient in one or more of the nutrients present
in typical foodstuffs.
(c) Administered for the medical and nutritional management of a person who has
limited capacity to metabolize foodstuffs or certain nutrients contained in the
foodstuffs or who has other specific nutrient requirements as established by medical
evaluation.
(d) Essential to a person's optimal growth, health and metabolic homeostasis.
4. "Modified low protein foods" means foods that are all of the following:
(a) Formulated to be consumed or administered enterally under the supervision of a
physician who is licensed pursuant to title 32, chapter 13 or 17.
(b) Processed or formulated to contain less than one gram of protein per unit of
serving, but does not include a natural food that is naturally low in protein.
(c) Administered for the medical and nutritional management of a person who has
limited capacity to metabolize foodstuffs or certain nutrients contained in the
foodstuffs or who has other specific nutrient requirements as established by medical
evaluation.
(d) Essential to a person's optimal growth, health and metabolic homeostasis.
20-2328 Accountable health plans; clinical trials; cancer; definitions
A. An accountable health plan is not obligated to pay any costs, other than covered
patient costs, that are directly associated with a cancer clinical trial that is offered
in this state and in which the enrollee participates voluntarily. A cancer clinical trial
is a course of treatment in which all of the following apply:
1. The treatment is part of a scientific study of a new therapy or intervention
that is being conducted at an institution in this state, that is for the treatment,
palliation or prevention of cancer in humans and in which the scientific study includes
all of the following:
(a) Specific goals.
(b) A rationale and background for the study.
(c) Criteria for patient selection.
(d) Specific directions for administering the therapy and monitoring patients.
(e) A definition of quantitative measures for determining treatment response.
(f) Methods for documenting and treating adverse reactions.
2. The treatment is being provided as part of a study being conducted in a phase I,
phase II, phase III or phase IV cancer clinical trial.
3. The treatment is being provided as part of a study being conducted in accordance
with a clinical trial approved by at least one of the following:
(a) One of the national institutes of health.
(b) A national institutes of health cooperative group or center.
(c) The United States food and drug administration in the form of an
investigational new drug application.
(d) The United States department of defense.
(e) The United States department of veterans affairs.
(f) A qualified research entity that meets the criteria established by the national
institutes of health for grant eligibility.
(g) A panel of qualified recognized experts in clinical research within academic
health institutions in this state.
4. The proposed treatment or study has been reviewed and approved by an
institutional review board of an institution in this state.
5. The personnel providing the treatment or conducting the study:
(a) Are providing the treatment or conducting the study within their scope of
practice, experience and training and are capable of providing the treatment because of
their experience, training and volume of patients treated to maintain expertise.
(b) Agree to accept reimbursement as payment in full from the accountable health
plan at the rates that are established by the plan and that are not more than the level
of reimbursement applicable to other similar services provided by health care providers
with the plan's provider network.
6. There is no clearly superior, noninvestigational treatment alternative.
7. The available clinical or preclinical data provide a reasonable expectation that
the treatment will be at least as efficacious as any noninvestigational alternative.
B. Pursuant to the patient informed consent document, no party is liable for
damages associated with the treatment provided during any phase of a cancer clinical
trial.
C. Each health benefits plan delivered or issued for delivery in this state shall
provide benefits under the plan, and those benefits shall not supplant any portion of the
clinical trial that is customarily paid for by government, biotechnical, pharmaceutical
or medical device industry sources.
D. This section does not create any private right or cause of action for or on
behalf of any patient against the accountable health plan. This section provides solely
an administrative remedy to the director for any violation of this section or any related
rule.
E. Nothing in this section prohibits the accountable health plan from imposing
deductibles, coinsurance or other cost sharing measures in relation to benefits provided
pursuant to this section.
F. For the purposes of this section:
1. "Cooperative group" means a formal network of facilities that collaborates on
research projects and that has an established national institutes of health approved peer
review program operating within the group, including the national cancer institute
clinical cooperative group and the national cancer institute community clinical oncology
program.
2. "Institutional review board" means any board, committee or other group that is
both:
(a) Formally designated by an institution to approve the initiation of and to
conduct periodic review of biomedical research involving human subjects and in which the
primary purpose of such review is to assure the protection of the rights and welfare of
the human subjects and not to review a clinical trial for scientific merit.
(b) Approved by the national institutes of health office for protection from
research risks.
3. "Multiple project assurance contract" means a contract between an institution
and the United States department of health and human services that defines the
relationship of the institution to the United States department of health and human
services and that sets out the responsibilities of the institution and the procedures
that will be used by the institution to protect human subjects.
4. "Patient" means the enrollee or the enrollee's covered dependent.
5. "Patient cost" means any fee or expense that is covered under the contract and
that is for a service or treatment that would be required if the patient were receiving
usual and customary care. Patient cost does not include the cost:
(a) Of any drug or device provided in a phase I cancer clinical trial.
(b) Of any investigational drug or device.
(c) Of nonhealth services that might be required for a person to receive treatment
or intervention.
(d) Of managing the research of the clinical trial.
(e) That would not be covered under the patient's health benefits plan.
(f) Of treatment or services provided outside this state.
20-2329 Prescription contraceptive drugs and devices; definition
A. An accountable health plan that provides a health benefits plan that provides
coverage for:
1. Prescription drugs shall also provide coverage for any prescribed drug or device
that is approved by the United States food and drug administration for use as a
contraceptive. An accountable health plan may use a drug formulary, multitiered drug
formulary or list but that formulary or list shall include oral, implant and injectable
contraceptive drugs, intrauterine devices and prescription barrier methods if the
accountable health plan does not impose deductibles, coinsurance, copayments or other
cost containment measures for contraceptive drugs that are greater than the deductibles,
coinsurance, copayments or other cost containment measures for other drugs on the same
level of the formulary or list.
2. Outpatient health care services shall also provide coverage for outpatient
contraceptive services. For the purposes of this paragraph, "outpatient contraceptive
services" means consultations, examinations, procedures and medical services provided on
an outpatient basis and related to the use of United States food and drug prescription
contraceptive methods to prevent unintended pregnancies.
B. Notwithstanding subsection A, a religious employer whose religious tenets
prohibit the use of prescribed contraceptive methods may require that the accountable
health plan provide a health benefits plan without coverage for all federal food and drug
administration approved contraceptive methods. A religious employer shall submit a
written affidavit to the accountable health plan stating that it is a religious employer.
On receipt of the affidavit, the accountable health plan shall issue to the religious
employer a health benefits plan that excludes coverage of prescription contraceptive
methods. The accountable health plan shall retain the affidavit for the duration of the
health benefits plan and any renewals of the plan.
C. Before enrollment in the plan, every religious employer that invokes this
exemption shall provide prospective enrollees written notice that the religious employer
refuses to cover all federal food and drug administration approved contraceptive methods
for religious reasons.
D. Subsection B shall not exclude coverage for prescription contraceptive methods
ordered by a health care provider with prescriptive authority for medical indications
other than to prevent an unintended pregnancy. An accountable health plan may require the
enrollee to first pay for the prescription and then submit a claim to the accountable
health plan along with evidence that the prescription is for a noncontraceptive purpose.
An accountable health plan may charge an administrative fee for handling claims under
this subsection.
E. A religious employer shall not discriminate against an employee who
independently chooses to obtain insurance coverage or prescriptions for contraceptives
from another source.
F. For the purposes of this section, "religious employer" means an entity for which
all of the following apply:
1. The entity primarily employs persons who share the religious tenets of the
entity.
2. The entity serves primarily persons who share the religious tenets of the
entity.
3. The entity is a nonprofit organization as described in section 6033(a)(2)(A)i or
iii of the internal revenue code of 1986, as amended.
20-2330 Participation in healthcare group
A. An accountable health plan may contract with the ARIZONA health care cost
containment system administration to provide health care services pursuant to section
36-2912.02.
B. Financial requirements imposed pursuant to title 36, chapter 29, article 1 are
separate from the financial requirements imposed pursuant to this title.
20-2331 Accountable health plans; varying copayments and deductibles allowed
A. Except as provided in sections 20-1379 and 20-2304, an accountable health plan
may offer one or more health benefits plans that contain a choice of deductibles,
coinsurance, copayments, out-of-pocket and any other cost sharing levels. Plans offered
under this section shall clearly disclose in marketing materials, certificates of
coverage and contracts the insured's financial responsibilities. An accountable health
plan that offers such a health benefit plan shall continue to provide any mandated health
coverage that is required by this state or by federal law.
B. This section does not prohibit a health benefits plan that is intended to
qualify as a high deductible health plan as defined by 26 United States Code section
223(c)(2) from requiring the application of deductibles, copayments or coinsurance to
benefits provided under the health benefits plan.
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