20-1051. Definitions In this article, unless the context otherwise requires: 1. " Enrollee" means an individual who has been enrolled in a health care plan. 2. " Evidence of coverage" means any certificate, agreement or contract issued to an enrollee and setting out the coverage to which the enrollee is entitled. 3. " Genetic information" […]
20-1052. Establishment of health care services organizations A. A person shall not establish or operate a health care services organization in this state, or sell or offer to sell, or solicit offers to purchase, or receive advance or periodic consideration in conjunction with a health care plan without obtaining and maintaining a certificate of authority […]
20-1052.01. Establishment of provider sponsored health care services organizations; rules; limitations A. No person shall establish or operate a provider sponsored health care services organization in this state, or sell or offer to sell, or solicit offers to purchase, or receive advance or periodic consideration in conjunction with a health care plan without obtaining and […]
20-1053. Application for certificate of authority A. An application for a certificate of authority to operate as a health care services organization shall be filed with the director in a form prescribed by the director, shall be verified by an officer or authorized representative of the applicant and shall set forth, or be accompanied by, […]
20-1054. Issuance of certificate of authority A. Issuance of a certificate of authority shall be granted within the time prescribed in section 20-216 by the director if the director is satisfied that the following conditions are met: 1. The persons responsible for conducting the affairs of the health care services organization are competent and are […]
20-1055. Deposit requirement A. A health care services organization at all times shall maintain on deposit with the state treasurer through the director’s office cash, or securities eligible for the investment of capital funds of domestic insurers under this title, or other financial security approved by the director in an amount of not less than […]
20-1057. Evidence of coverage by health care services organizations; renewability; definitions A. Every enrollee in a health care plan shall be issued an evidence of coverage by the responsible health care services organization. B. Any contract, except accidental death and dismemberment, applied for that provides family coverage shall also provide, as to such coverage of […]
20-1057.01. Standing referrals to network health care professionals; definition A. A health care services organization shall establish a procedure by which an enrollee may apply for a standing referral to a network health care professional. The health care services organization shall provide an enrollee with a standing referral if all of the following conditions are […]
20-1057.02. Prescription drug formulary; definitions A. A health care services organization with a prescription drug benefit that uses a drug formulary as a component of the evidence of coverage shall provide to its enrollees notice in the evidence of coverage regarding the applicable drug formulary. The health care services organization shall write the notice so […]
20-1057.03. Chiropractic care; definitions A. Every health care services organization shall provide coverage for chiropractic services provided by network chiropractic providers pursuant to this section. B. A health care services organization is not required to provide coverage for chiropractic services obtained from a provider who is not a member of the health care services organization’s […]
20-1057.04. Continuity of care; definition A. A health care services organization shall allow any new enrollee whose health care provider is not a member of the provider network, on written request of the enrollee to the health care services organization, to continue an active course of treatment with that health care provider during a transitional […]
20-1057.05. Medical supplies Any health care services organization that provides coverage for medical supplies shall provide coverage for those medical supplies through one or more participating vendors who are reasonably accessible to enrollees as determined by the department in terms of hours of service and areas of coverage within the geographic service area of the […]
20-1057.06. Prior authorization A health care services organization shall not request information from a health care professional that does not apply to the medical condition at issue for the purposes of determining whether to approve or deny a prior authorization request.
20-1057.07. Health care services organizations; clinical trials; cancer; definitions A. A health care services organization is not obligated to pay any costs, other than covered patient costs, that are directly associated with a cancer clinical trial that is offered in this state and in which the enrollee participates voluntarily. A cancer clinical trial is a […]
20-1057.08. Prescription contraceptive drugs and devices; definition A. If a health care services organization issues evidence of coverage that provides coverage for: 1. Prescription drugs, the evidence of coverage shall provide coverage for any prescribed drug or device that is approved by the United States food and drug administration for use as a contraceptive. A […]
20-1057.09. Health care services organizations; varying copayments and deductibles allowed A. Except as provided in sections 20-1379 and 20-2304, a health care services organization may offer one or more health care plans that contain a choice of deductibles, coinsurance, copayments, out-of-pocket and any other cost sharing levels. Plans offered under this section shall clearly disclose […]
20-1057.10. Eosinophilic gastrointestinal disorder; formula A. Any contract or evidence of coverage that is offered by a health care services organization and that contains a prescription drug benefit shall cover amino acid-based formula that is ordered by a physician or a registered nurse practitioner if: 1. The enrollee has been diagnosed with an eosinophilic gastrointestinal […]
20-1057.11. Health care services organizations; autism spectrum disorder; coverage; exceptions; definitions A. A health care services organization shall not: 1. Exclude or deny coverage for a treatment or impose dollar limits, deductibles and coinsurance provisions based solely on the diagnosis of autism spectrum disorder. For the purposes of this paragraph, " treatment" includes diagnosis, assessment […]
20-1057.12. Contracts; dentists; covered services; definition A. A contract, entered into or renewed on or after January 1, 2011, between a health care services organization and a dentist who is licensed to practice in this state shall not require the dentist to provide services to an individual covered under an evidence of coverage based on […]
20-1057.13. Telehealth; coverage of health care services; definition A. An evidence of coverage issued, delivered or renewed by a health care services organization in this state must provide coverage for health care services that are provided through telehealth if the health care service would be covered were it provided through an in-person encounter between the […]
