354.430. Evidence of coverage, requirements--rights of enrollee--toll-free telephone number required.
Evidence of coverage, requirements--rights of enrollee--toll-freetelephone number required.
354.430. 1. Every enrollee residing in this state is entitled toevidence of coverage. If the enrollee obtains coverage through an insurancepolicy or a contract issued by a health services corporation, whether byoption or otherwise, the insurer or the health services corporation shallissue the evidence of coverage. Otherwise the health maintenance organizationshall issue the evidence of coverage.
2. No evidence of coverage, or amendment thereto, shall be issued ordelivered to any person in this state until a copy of the form of the evidenceof coverage, or amendment thereto, has been filed with the director.
3. An evidence of coverage shall contain:
(1) No provisions or statements which are unjust, unfair, inequitable,misleading, or deceptive, or which encourage misrepresentation, or which areuntrue, misleading, or deceptive as defined in subsection 1 of section354.460; and
(2) A clear and complete statement, if a contract, or a reasonablycomplete summary, if a certificate, of:
(a) The health care services and the insurance or other benefits, ifany, to which the enrollee is entitled;
(b) Any limitations on the services, kind of services, benefits or kindsof benefits to be provided, including any deductible or co-payment feature;
(c) Where and in what manner information is available as to how servicesmay be obtained;
(d) The total amount of payment for health care services and theindemnity or service benefits, if any, which the enrollee is obligated to paywith respect to individual contracts; and
(e) A clear and understandable description of the health maintenanceorganization's method for resolving enrollee complaints, including the healthmaintenance organization's toll-free customer service number and thedepartment of insurance, financial institutions and professionalregistration's consumer complaint hot line number.
4. Any subsequent change in an evidence of coverage may be made in aseparate document issued to the enrollee.
5. A copy of the form of the evidence of coverage to be used in thisstate, and any amendment thereto, shall be subject to the filing of subsection2 of this section unless it is subject to the jurisdiction of the directorunder the laws governing health insurance or health services corporations, inwhich event the filing provisions of those laws shall apply.
(L. 1983 H.B. 127, A.L. 1997 H.B. 335)