(1) All insurers offering a health benefit plan in this state that requires an enrollee to designate a participating primary care physician shall:
(a) Permit the enrollee to change participating primary care physicians at will, except that the enrollee may be restricted to making changes no more frequently than two times in any 12-month period and may be limited to designating only those participating primary care physicians accepting new patients.
(b) Have available for employer purchasers of group health plans a point-of-service benefit plan providing for payment for the services of a provider on a fee-for-service or discounted fee-for-service basis with reasonable access to a broad array of licensed providers in the insurer’s geographic service area. Any higher premium for the point-of-service benefit plan may not exceed true actuarial cost, including administrative costs, to the insurer.
(2) A health maintenance organization that is exempt from federal income tax under Internal Revenue Code section 501(c)(3) or (4) shall not be required to offer a point-of-service benefit plan as required by subsection (1)(b) of this section if offering such a plan could result in loss of federal tax-exempt status. Until such time as the federal government establishes guidelines for health maintenance organizations exempt from federal income tax that offer point-of-service benefit plans, such a health maintenance organization shall not be required to offer a point-of-service benefit plan if:
(a) Enrollment in Internal Revenue Code section 501(m) coverages exceeds five percent of its business; or
(b) Revenue from Internal Revenue Code section 501(m) coverages exceeds five percent of its revenue.
(3) A health maintenance organization that is federally qualified under 42 U.S.C. 300e et seq. shall not be required to offer a point-of-service benefit plan in a manner or to an extent that is inconsistent with federal law and regulation. [1995 c.672 §4; 1997 c.343 §1; 1999 c.987 §19]
Section: Previous 743.801 743.802 743.803 743.804 743.805 743.806 743.807 743.808 743.809 743.810 743.811 743.812 743.813 743.814 743.815 NextLast modified: August 7, 2008