Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part V - Disclosure and Prohibitions › Section 14VAC5-211-210 - Evidence of coverage requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. An enrollee shall receive an evidence of
				  coverage under a health care plan provided by a health maintenance organization
				  established or operating in this Commonwealth, including any amendments to it.
				  The evidence of coverage shall be delivered or issued for delivery within a
				  reasonable period of time after enrollment, but not more than 60 days from the
				  later of the effective date of coverage or the date on which the health
				  maintenance organization is notified of enrollment. An identification card
				  shall be delivered or issued for delivery within 15 days from the later of the
				  effective date of coverage or the date on which the health maintenance
				  organization is notified of enrollment.
B. An evidence of coverage delivered or
				  issued for delivery shall contain the following:
1. The name, address, and telephone number of
				  the health maintenance organization;
2. The health care services and other
				  benefits to which the enrollee is entitled under the health care
				  plan;
3. Exclusions or limitations
				  on the services, kind of services, benefits, or kind of benefits to be
				  provided, including any cost sharing features;
4. Where and in what manner information is
				  available as to how services may be obtained;
5. The effective date and the term of
				  coverage;
6. The total amount of
				  payment for health care services and any indemnity or service benefits that the
				  enrollee is obligated to pay with respect to individual contracts, or an
				  indication whether the plan is contributory or noncontributory for group
				  certificates;
7. A description of
				  the health maintenance organization's method of resolving enrollee complaints,
				  including a description of any arbitration procedure if complaints may be
				  resolved through a specified arbitration agreement;
8. A list of providers and a description of
				  the service area that shall be provided with the evidence of coverage if the
				  information is not given at the time of enrollment;
9. The right of an enrollee to continue group
				  coverage, including the terms and conditions under which coverage may be
				  continued;
10. The terms and
				  conditions under which coverage may be terminated or rescinded;
11. Coordination of benefits provisions, if
				  applicable;
12. Assignment of
				  benefits restrictions in the contract;
13. The health maintenance organization's
				  procedure for filing claims, including any requirements for notifying the
				  health maintenance organization of a claim and requirements for filing proof of
				  loss;
14. The health maintenance
				  organization's enrollment and eligibility requirements, including the
				  conditions under which dependents may be added and any limiting age for
				  dependents covered under an individual or group contract;
15.
				  A provision that the contract or evidence of coverage and any amendments to it
				  constitutes the entire contractual agreement between the parties involved and
				  that no portion of the charter, bylaws, or other document of the health
				  maintenance organization shall constitute part of the contract unless it is set
				  forth in full in the contract;
16. Except for an
				  evidence of coverage that does not provide for the periodic payment of premium
				  or for the payment of any premium, a provision that the contract holder is
				  entitled to a grace period of not less than 31 days for the payment of any
				  premium due except the first premium. The provision shall also state that
				  during the grace period the coverage shall continue in force unless the
				  contract holder has given the health maintenance organization written notice of
				  discontinuance in accordance with the terms of the contract and in advance of
				  the date of discontinuance. The contract may provide that the contract holder
				  shall be liable to the health maintenance organization for the payment of a pro
				  rata premium for the time the contract was in force during the grace period;
				  and
17. Terms and conditions related to the designation of
				  a primary care health care professional.