§ 23-99-417. Coverage required for orthotic devices, orthotic services, prosthetic devices, and prosthetic services
(a) (1) Subject to subdivision (a)(2) of this section and subsections (b) and (c) of this section, a health benefit plan that is issued for delivery, delivered, renewed, or otherwise contracted for in this state shall provide coverage for eligible charges within limits of coverage that are no less than eighty percent (80%) of Medicare […]
§ 23-99-418. Coverage for autism spectrum disorders required — Definitions
(a) As used in this section: (1) “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications by a board-certified behavior analyst using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior; (2) […]
§ 23-99-419. Gastric pacemakers
(a) As used in this section: (1) “Gastric pacemaker” means a medical device that: (A) Uses an external programmer and implanted electrical leads to the stomach; and (B) Transmits low-frequency, high-energy electrical stimulation to the stomach to entrain and pace the gastric slow waves to treat gastroparesis; and (2) (A) “Gastroparesis” means a neuromuscular stomach […]
§ 23-99-421. Pediatric dental benefits — Definitions
(a) As used in this section: (1) “Exchange” means a health benefit exchange that offers health benefits under a health benefit plan offered by a healthcare insurer in this state through a state-based health insurance exchange or a health insurance exchange operated by the federal government under the Patient Protection and Affordable Care Act, Pub. […]
§ 23-99-409. Prescription drug formulary
When a healthcare insurer uses a formulary for prescription drugs, the insurer shall include a written procedure whereby covered persons can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the formulary when: (1) The formulary’s equivalent has been ineffective in the treatment of the covered person’s disease or […]
§ 23-99-410. Grievance procedures
(a) A healthcare insurer issuing or delivering a managed care plan shall establish for those managed care plans a grievance procedure which provides covered persons with a prompt and meaningful review on the issue of denial, in whole or in part, of a healthcare treatment or service. (b) (1) The covered person shall be provided […]
§ 23-99-411. Processing applications of providers
(a) (1) (A) Healthcare insurers shall establish mechanisms to ensure timely processing of requests for participation or renewal by providers and in making decisions that affect participation status. (B) These mechanisms shall include, at a minimum, provisions for the provider to receive a written statement of reasons for the healthcare insurer’s denial of a request […]
§ 23-99-412. Provider input
All healthcare insurers issuing or delivering managed care plans shall be required to establish a mechanism whereby participating providers provide input into the healthcare insurer’s medical policy, utilization review criteria and procedures, quality and credentialing criteria, and medical management procedures.
§ 23-99-413. Disclosure requirements
Upon request, healthcare insurers must provide the following information in a clear and understandable form to all prospective policyholders, policyholders, and covered persons. Insurers shall notify policyholders and covered persons of their right to request the information, which must include: (1) Coverage provisions, benefits, and exclusions by category of service and provider; (2) A description […]
§ 23-99-414. Rules
The Insurance Commissioner may promulgate necessary rules for carrying out this subchapter.