Ala. Admin. Code r. 420-5-6-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-6-.09 - Enrollee Documents

(1) An enrollee contract is the document which is to be issued to employers, unions, trustees, or other organizations and individuals. Every health maintenance organization shall offer at least one contract to all enrollees which shall include:

(a) Definitions;

(b) Eligibility for enrollment; At a minimum:

1. Enrollees must work or live in the health maintenance organization service area to be eligible for group coverage.

2. Enrollees must live in the health maintenance organization service area to be eligible for individual coverage.

(c) Health care services to be provided;

(d) Where and in what manner the health care services may be obtained including explanation of primary care physician role;

(e) Provisions for adding new family members;

(f) Benefits for newborn children;

(g) Provisions relating to termination or cancellation;

(h) Limitations, exceptions, or exclusions;

(i) Provisions relating to preexisting conditions, if applicable;

(j) Provisions relating to coordination of benefits;

(k) Provisions relating to subrogation;

(l) Any applicable arbitration provisions;

(m) Conversion privileges, if applicable;

(n) Complaint procedures;

(o) Any applicable copayments;

(p) Emergency services and out-of-area coverage;

(q) Referral services;

(r) The names of contracted specialty physicians, the names and addresses of all contracted OB/GYN providers, the names and addresses of contracted primary care providers, hospitals, and ancillary providers are to be furnished as a supplement to contracts; and

(s) Any other factors necessary for complete understanding of what is covered and what is excluded and such information required by the Alabama Department of Insurance.

Author: Department of Public Health

Ala. Admin. Code r. 420-5-6-.09

Filed September 1, 1982. Repealed and New Rule adopted in lieu thereof: Filed March 31, 1987. Amended: Filed January 20, 1999; effective February 24, 1999.

Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.