Ala. Admin. Code r. 482-1-079-.04
Enrollee contracts mean the certificate or contract provided to the enrollee which describes the health care services provided and the amount to be charged. Individual or family contracts must contain the entire agreement between the HMO and the enrollees, including but not limited to: date of contract; rate to be charged; mode of payment (monthly, quarterly, etc. with provision for change of mode); grace period for late payment; co-payment features, if any; renewal conditions; services to be furnished; names and addresses of clinics or other facilities at which services are available (which may be listed in a separate addendum that is updated at least every six months); factors pertaining to pre-existing conditions; limitations; exclusions and exceptions, such as waiting periods, specific conditions not covered and limitations on length of stay and all other qualifying or limiting features; provisions pertaining to amount and kind of reimbursement made if illness or accident happens outside of geographic area and explanation of this coverage; provisions for adding new family members; and any other factor necessary for complete understanding of the coverages and exclusions of the contract.
Group master contracts must contain complete information as above, but a certificate may be issued to the individual enrollee who is a member of the group showing the salient features of the plan along with a descriptive pamphlet or brochure to fully explain the coverage if it is first filed with the Commissioner. However, the group master contract shall be available for review by any enrollee or member during regular business hours in the Alabama office of the HMO.
Provisions relating to grievances must be included in all contracts or certificates.
All contracts must be clear and legible. All limitations, exclusions and exceptions (except co-payment provisions) must be grouped together in separate sections with captions in bold-face type and shall be printed with at least the same prominence as provisions which describe the benefits.
Author: Commissioner of Insurance
Ala. Admin. Code r. 482-1-079-.04
Statutory Authority:Code of Ala. 1975, §§ 27-2-17, 27-21A-19.