D.C. Mun. Regs. tit. 26, r. 26-A3504
Each enrollee shall be entitled to receive an individual contract, evidence of coverage, or other description of covered services in a form that has been approved by the Commissioner. Each group contract holder shall be entitled to receive a group contract as approved by the Commissioner. Group contracts, individual contracts and evidences of coverage shall be delivered or issued for delivery to enrollees or group contract holders within a reasonable time after enrollment, but not more than fifteen (15) days from the later of the effective date of coverage or the date on which the HMO is notified of enrollment.
The group or individual contract and evidence of coverage shall contain the name, address and telephone number of the HMO, and where and in what manner information is available as to how services may be obtained. A telephone number within the service area for calls, without charge to members, to the HMO's administrative office shall be made available and disseminated to enrollees to adequately provide telephone access for enrollee services, problems or questions.
An HMO must provide a method by which the enrollee may contact the HMO, at no cost to the enrollee. This may be done through the use of toll-free or collect telephone calls. The enrollee must be informed of the method by notice in the handbook, newsletter, or flyer. The group or individual contract or evidence of coverage may indicate the manner in which the number will be disseminated rather than list the number itself.
The group or individual contract and evidence of coverage shall contain eligibility requirements indicating the conditions that must be met to enroll as a enrollee or eligible dependent, the limiting age for enrollees and eligible dependents including the effects of Medicare eligibility, and a clear statement regarding coverage of newborn children.
The group or individual contract and evidence of coverage shall contain a specific description of benefits and services available for emergencies twenty-four (24) hours a day, seven (7) days a week, including disclosure of any restrictions on emergency care services. No group or individual contract or evidence of coverage shall limit the coverage of emergency services within the service area to affiliated providers only.
The group or individual contract and evidence of coverage shall contain a description of any limitations or exclusions on the services, kind of services, benefits, or kind of benefits, including any limitations or exclusions due to preexisting conditions, waiting periods or an enrollee's refusal of treatment.
No HMO shall cancel or terminate coverage of services provided an enrollee under an HMO group or individual contract except for one or more of the following reasons:
Coverage shall not be cancelled or terminated on the basis of the status of the enrollee's health or because the enrollee has exercised his or her rights under the HMO's grievance procedure by registering a grievance against the HMO.
No HMO shall cancel, fail to continue, or terminate an enrollee's coverage for services provided under an HMO group or individual contract without giving the enrollee at least fifteen (15) days written notice of such termination. Notice will be considered given on the date of mailing or, if not mailed, on the date of delivery. This notice shall include the reason. If this action is due to nonpayment of premium, the grace period required in subsections 3504.28 through 3504.30 shall apply.
No HMO shall terminate coverage of a dependent child upon attainment of the limiting age stated in the contract if the child is and continues to be both:
Proof of such incapacity and dependency shall be furnished to the HMO by the enrollee within thirty-one (31) days of the child's attainment of the limiting age and subsequently as reasonably required by the HMO.
If an HMO permits reinstatement of an enrollee's coverage, the group or individual contract and evidence of coverage must include any terms and conditions concerning reinstatement. The contract and evidence of coverage may state that all reinstatements are at the option of the HMO and that the HMO is not obligated to reinstate any terminated coverage.
The group contract or individual contract and evidence of coverage shall contain procedures for filing claims that include:
A group contract and evidence of coverage shall contain a conversion provision which provides that each enrollee has the right to convert coverage to an individual HMO contract in the following circumstances:
To obtain the conversion contract, an enrollee shall submit a written application and the applicable premium payment to the HMO within thirty-one (31) days after the date the enrollee's eligibility for coverage terminates.
A conversion contract shall not be required to be made available if:
The conversion contract shall provide basic health care services to its enrollees as a minimum.
The conversion contract shall begin coverage of the enrollee formerly covered under the group contract on the date of termination from such group contract.
Coverage shall be provided without requiring evidence of insurability and shall not impose any preexisting condition limitations or exclusions as described in subsections 3513.1 through 3513.3 other than those remaining unexpired under the contract from which conversion is exercised. Any probationary or waiting period set forth in the conversion contract shall be deemed to commence on the effective date of the enrollee's coverage under the prior group contract.
If an HMO does not issue individual or conversion contracts, the HMO may use a non-cancelable group contract to provide coverage for enrollees who are eligible for conversion coverage.
The group or individual contract and evidence of coverage may contain a provision for coordination of benefits that shall be consistent with that applicable to other carriers in the jurisdiction. Any provisions or rules for coordination of benefits established by an HMO shall not relieve an HMO of its duty to provide or arrange for a covered health care service to any enrollee where the enrollee is entitled to coverage under any other contract, policy or plan, including coverage provided under government programs. The HMO shall be required to provide covered health care services first and then, at its option, seek coordination of benefits.
The group or individual contract and evidence of coverage shall not contain any provisions concerning subrogation for injuries caused by third parties unless the wording has been approved by the Commissioner.
The group or individual contract shall contain a statement that the contract, all applications and any amendments thereto shall constitute the entire agreement between the parties. No portion of the charter, bylaws or other document of the HMO shall be part of such a contract unless set forth in full in the contract or attached thereto. However, the evidence of coverage may be attached to and made a part of the group contract.
The group or individual contract and evidence of coverage shall state the time and date or the occurrence upon which coverage takes effect, including any applicable waiting periods, or describe how the time and date or occurrence upon which coverage takes effect is determined. The contract and evidence of coverage shall also state the time and date or the occurrence upon which coverage will terminate.
The group or individual contract shall contain the conditions upon which cancellation or termination may be effected by the HMO, the group contract holder, or the enrollee.
The group or individual contract and evidence of coverage shall contain the conditions for, and any restrictions upon, the enrollee's right to renewal.
If an HMO permits reinstatement of a group or individual, the contract and evidence of coverage must include any terms and conditions concerning reinstatement. The contract and evidence of coverage may state that all reinstatements are at the option of the HMO and that the HMO is not obligated to reinstate any terminated contract.
The group or individual contract shall provide for a grace period of not less than thirty (30) days for the payment of any premium except the first, during which time the coverage shall remain in effect if payment is made during the grace period. The evidence of coverage shall include notice that a grace period exists under the group contract and that coverage continues in force during the grace period.
During the grace period the following shall occur:
During the grace period, if the premium is not paid and coverage is terminated in accordance with the provisions of the contract, then the contract holder shall be liable for services rendered on a fee for service basis under the usual terms of the contract.
If the premium is not paid during the grace period, coverage shall be terminated per the terms of the contract. Following the effective date of such termination, the HMO shall deliver written notice thereof to the contract holder.
An individual contract shall contain a provision stating that a person who has entered into an individual contract with a health maintenance organization shall be permitted to return the contract within ten (10) days of receiving it and to receive a refund of the premium paid if the person is not satisfied with the contract for any reason. If the contract is returned to the HMO or to the agent through whom it was purchased, it is considered void from the beginning. However, if services are rendered or claims are paid for such person by the HMO during the ten (10) -day examination period and the person returns the contract to receive a refund of the premium paid, the person shall be required to pay for such services.
D.C. Mun. Regs. tit. 26, r. 26-A3504