(a) A health maintenance organization or a representative of a health maintenance organization may not cause or knowingly permit a person to provide, on behalf of the health maintenance organization, health care services that the person is not licensed to provide.
(b) A health maintenance organization, or a representative of a health maintenance organization, may not cause or knowingly permit the use of advertising that is untrue or misleading, solicitation that is untrue or misleading, or a form of evidence of coverage that is deceptive. For purposes of this chapter,
(1) a statement or item of information is considered to be untrue if it does not conform to fact in any respect that is or might be significant to an enrollee of, or person considering enrollment with, a health maintenance organization;
(2) a statement or item of information is considered to be misleading, whether or not it is untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information might be understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating a benefit or advantage or the absence of an exclusion, limitation, or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health maintenance organization if the benefit or advantage or absence of limitation, exclusion, or disadvantage does not exist;
(3) an evidence of coverage is considered to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as to language, might cause a reasonable person, not possessing special knowledge regarding health maintenance organizations or an evidence of coverage, to expect benefits, services, charges, or other advantages that the evidence of coverage does not provide or that the health maintenance organization issuing the evidence of coverage does not regularly make available for an enrollee covered under the evidence of coverage.
(c) AS 21.36 applies to health maintenance organizations and to an evidence of coverage except to the extent that the director determines that the nature of health maintenance organizations and the evidence of coverage renders that chapter clearly inappropriate.
(d) A health maintenance organization may not cancel or refuse to review an enrollee, except for
(1) reasons stated in the organization's regulations applicable to all enrollees;
(2) failure to pay the charge for the enrollee's coverage; or
(3) other reasons adopted by the director by regulation.
(e) Unless it is licensed as an insurer, a health maintenance organization may not refer to itself as an insurer or use a name deceptively similar to the name or description of an insurance or surety corporation doing business in the state.
(f) A person may not use the phrase "health maintenance organization" or "HMO" in the course of the person's operations unless the person possesses a valid certificate of authority issued under this chapter.
(g) A health maintenance organization that offers, renews, issues for delivery, or delivers in this state a health care insurance plan in the group market that does not impose a preexisting condition exclusion with respect to a particular coverage option under the plan may impose an affiliation period for that coverage option only if the affiliation period
(1) is applied uniformly without regard to a health status factor;
(2) does not exceed two months for new enrollees and three months for late enrollees;
(3) begins on the enrollment date; and
(4) runs concurrently with any waiting period under the plan.
(h) A health maintenance organization may use a method other than a preexisting condition exclusion or an affiliation period to lessen the risk of adverse selection only with prior written approval of the director.
(i) A health maintenance organization, including a health maintenance organization operating a managed care plan, or a representative of a health maintenance organization may not cause, request, or knowingly permit
(1) the imposition of limits regarding
(A) criticism by a health care provider of health care services provided by the health maintenance organization; or
(B) written or oral communications between a health care provider and an enrollee regarding health care services;
(2) the employment of a health care provider to be terminated unless the provider receives written notice of the cause for the termination before being terminated;
(3) denial of health care coverage for an enrollee unless the enrollee has been examined by at least two physicians; or
(4) financial incentives to be given or offered to a provider for denying or delaying health care services.
(j) A utilization review decision to deny, reduce, or terminate a health care benefit or to deny payment for a health care service because that service is not medically necessary may only be made by a health care provider trained in that specialty or subspecialty and licensed to practice in this state after consultation with the covered person's health care provider.
Section: Previous 21.86.087 21.86.090 21.86.100 21.86.110 21.86.120 21.86.130 21.86.140 21.86.150 21.86.160 21.86.170 21.86.180 21.86.190 21.86.200 21.86.210 21.86.220 NextLast modified: November 15, 2016