2005 Idaho Code - 41-3915 — HEALTH CARE CONTRACTS

                                  TITLE  41
                                  INSURANCE
                                  CHAPTER 39
                             MANAGED CARE REFORM
    41-3915.  HEALTH CARE CONTRACTS. (1) All health care contracts or other
marketing documents describing health care services offered by any managed
care organization shall contain:
    (a)  A complete description of the health care services and other benefits
    to which the member is entitled;
    (b)  A description of the accessibility and availability of services,
    including a list of the providers participating in the managed care plan
    and of the providers who are accepting new patients, the addresses of
    primary care physicians and participating hospitals, and the specialty of
    each physician and category of the other participating providers. The
    information required by this subsection (1)(b) may be contained in a
    separate document and incorporated in the contract by reference and shall
    be amended from time to time as necessary to provide members with the most
    current information;
    (c)  Any predetermined and prepaid rate of payment for health care
    services and for other benefits, if any, and any services or benefits for
    which the member is obliged to pay, including member responsibility for
    deductibles, copayments, and coinsurance;
    (d)  All exclusions and limitations on services or other benefits
    including all restrictions relating to preexisting conditions;
    (e)  A statement as to whether the plan includes a limited formulary of
    medications and a statement that the formulary will be made available to
    any member on request;
    (f)  All criteria by which a member may be terminated or denied
    reenrollment;
    (g)  Service priorities in case of epidemic, or other emergency conditions
    affecting demand for health care services;
    (h)  A statement that members shall not, under any circumstances, be
    liable, assessable or in any way subject to payment for the debts,
    liabilities, insolvency, impairment or any other financial obligations of
    the managed care organization;
    (i)  Grievance procedures;
    (j)  Procedures for notifying enrollees of any change in benefits; and
    (k)  A description of all prior authorization review procedures for health
    care services.
    (2)  In addition to the requirements of subsection (1) of this section, an
organization offering a general managed care plan shall:
    (a)  Establish procedures for members to select or change primary care
    providers;
    (b)  Establish procedures to notify members of the termination of their
    primary care provider and the manner in which the managed care
    organization will assist members in transferring to another participating
    primary care provider;
    (c)  Establish referral procedures for specialty care and procedures for
    after-hours, out-of-network, out-of-area and emergency care;
    (d)  Allow members direct access to network obstetricians and
    gynecologists for maternity care, annual visits, and follow-up
    gynecological care for conditions diagnosed during maternity care or
    annual visits;
    (e)  Allow family practice and general practice physicians, general
    internists, pediatricians, obstetricians, and gynecologists to be included
    in the general managed care plan's listing of primary care providers.
    (3)  No managed care organization shall cancel the enrollment of a member
or refuse to transfer a member from a group to an individual basis for reasons
relating to age, sex, race, religion, occupation, or health status. However,
nothing contained herein shall prevent termination of a member who has
violated any published policies of the organization, which have been approved
by the director.
    (4)  No managed care organization shall contract with any provider under
provisions which require a member to guarantee payment, other than specified
copayments, deductibles and coinsurance to such provider in the event of
nonpayment by the managed care organization for any services rendered under
contract directly or indirectly between the member and the managed care
organization.
    (5)  No health care provider shall require a member to make additional
payments for covered services under a health care contract, other than
specified deductibles, copayments, or coinsurance once a provider has agreed
in writing to accept the managed care organization's reimbursement rate to
provide a covered service.
    (6)  The rates charged by any managed care organization to its members
shall not be excessive, inadequate, or unfairly discriminatory. The director
may define by rule what constitutes excessive, inadequate or unfairly
discriminatory rates and may require a description of the actuarial
assumptions and analysis upon which such rates are based as well as whatever
other information, available to the managed care organization, he deems
necessary to determine that a rate or proposed rate meets the requirements of
this subsection. If experience rating is a common health insurance practice in
the area served by the managed care organization, it shall have the right to
experience-rate its own contracts.
    (7)  No such contract form or amendment to an approved contract form shall
be issued unless it has been filed with the director. The contract form or
amendment  shall become effective thirty (30) days after such filing unless
specifically disapproved by the director. Any such disapproval shall be based
on the requirements of section 41-3905, Idaho Code, or subsection (1), (2),
(4), (5) or (6) of this section.
    (8)  The director shall disapprove any contract which, with amendments,
does not constitute the entire contractual obligation between the parties
involved. No portion of the charter, bylaws, or other constituent document of
the managed care organization shall constitute part of such a contract unless
set forth in full therein or incorporated by reference as authorized in this
section.