§ 23-99-405. Mastectomies
(a) Every health benefit plan providing mastectomy benefits and issued or renewed after July 16, 2003, shall conform with the requirements of the Women’s Health and Cancer Rights Act of 1998, 42 U.S.C. §§ 300gg-6 and 300gg-52, as it existed on January 1, 2003. (b) To the extent the requirements of this section do not […]
§ 23-99-406. Obstetrical and gynecological services
(a) In order to ensure that healthcare benefits are safely and appropriately delivered to women, insurers which require the selection or assignment of a primary care physician shall allow each covered person who is a woman to select a participating obstetrician/gynecologist in addition to her primary care physician. (b) If the woman chooses to make […]
§ 23-99-407. “Gag clause” prohibition
No participating provider may be prohibited, restricted, or penalized in any way from disclosing to any covered person any healthcare information that the participating provider deems appropriate regarding the nature of treatment, risks, or alternatives thereto, the availability of alternate therapies, consultations, or tests, the decision of utilization reviewers or similar persons to authorize or […]
§ 23-99-408. Continuity of care
(a) When healthcare insurers use participating providers, the healthcare insurers shall develop procedures to provide for the continuity of care of their covered persons. At a minimum, the procedures shall: (1) Ensure that when a new patient is enrolled in a health benefit plan and is being treated by a nonparticipating provider for a current […]
§ 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.