2012 Arkansas Code
Title 23 - Public Utilities and Regulated Industries
Subtitle 3 - Insurance
Chapter 76 - Health Maintenance Organizations
§ 23-76-112 - Evidence of coverage and charges for health care services.

(a) (1) (A) Every enrollee residing in this state is entitled to evidence of coverage under a health care plan.

(B) If the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a hospital and medical service corporation, whether by option or otherwise, the insurer or the hospital and medical service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.

(2) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment thereto, has been filed with and approved by the Insurance Commissioner.

(3) An evidence of coverage shall contain:

(A) No provisions or statements that:

(i) Are unjust, unfair, inequitable, misleading, or deceptive;

(ii) Encourage misrepresentation; or

(iii) Are untrue, misleading, or deceptive as defined in § 23-76-119; and

(B) A clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:

(i) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled under the health care plan;

(ii) Any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;

(iii) Where and in what manner information is available as to how services may be obtained;

(iv) The total amount of payment for health care services and the indemnity or service benefits, if any, that the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncontributory with respect to group certificates; and

(v) A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints. Any subsequent change may be evidenced in a separate document issued to the enrollee.

(4) A copy of the form of the evidence of coverage to be used in this state, and any amendment thereto, shall be subject to the filing and approval requirements of subdivision (a)(2) of this section unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or hospital or medical service corporations in which event the filing and approval provisions of the laws shall apply. However, to the extent that the provisions do not apply, the requirements in subdivision (a)(3) of this section shall be applicable.

(b) (1) No schedule of charges for enrollee coverage for health care services, or amendment thereto, may be used in conjunction with any health care plan until either a copy of the schedule or the methodology for determining charges has been filed with and approved by the commissioner.

(2) (A) Either a specific schedule of charges or a methodology for determining charges shall be established in accordance with the actuarial principles for various categories of enrollees, provided that charges applicable to an individual enrollee in a group contract shall not be individually determined based on the status of the enrollee's health. However, the charges shall not be excessive, inadequate, or unfairly discriminatory.

(B) A certification by a qualified actuary, to the appropriateness of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.

(c) (1) (A) Within a reasonable period, the commissioner shall approve any form if the requirements of subsection (a) of this section are met and any schedule of charges or methodology for determining charges if the requirements of subsection (b) of this section are met.

(B) It shall be unlawful to issue the form or to use the schedule of charges or methodology for determining charges until approved.

(2) (A) (i) If the commissioner disapproves the filing, he or she shall notify the filer promptly.

(ii) In the notice, the commissioner shall specify the reasons for disapproval and the findings of fact and conclusion that support the reasons.

(B) A hearing will be granted by the commissioner within sixty (60) days after a request in writing by the person filing.

(C) If the commissioner does not disapprove any form or schedule of charges within sixty (60) days of the filing of the forms or charges, they shall be deemed approved.

(3) (A) If the commissioner disapproves any form or schedule of charges or methodology for determining charges, the commissioner's disapproval and the findings of fact and conclusions that support the commissioner's reasons shall be subject to judicial review pursuant to § 23-61-307.

(B) The review shall be upon the entire record, and the commissioner's decision shall be sustained if it is supported by the preponderance of the evidence in the record.

(d) The commissioner may require the submission of whatever relevant information he or she deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.