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23-76-112. Evidence of coverage and charges for healthcare services.
Arkansas Code — all titles (historical 2020) · legal_authorities
23-76-112. Evidence of coverage and charges for healthcare services.
(a)(1)(A) Every enrollee residing in this state is entitled to evidence of coverage under a healthcare plan.
(B) If the enrollee obtains coverage under a healthcare plan through an insurance policy or a contract issued by a hospital and medical service corporation, whether by option or otherwise, the insurer or the hospital and medical service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.
(2) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment thereto, has been filed with and approved by the Insurance Commissioner.
(3) An evidence of coverage shall contain:
(A) No provisions or statements that:
(i) Are unjust, unfair, inequitable, misleading, or deceptive;
(ii) Encourage misrepresentation; or
(iii) Are untrue, misleading, or deceptive as defined in § 23-76-119; and
(B) A clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:
(i) The healthcare services and the insurance or other benefits, if any, to which the enrollee is entitled under the healthcare plan;
(ii) Any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;
(iii) Where and in what manner information is available as to how services may be obtained;
(iv) The total amount of payment for healthcare services and the indemnity or service benefits, if any, that the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncont
Source: Arkansas Code — historical release 78 (November 6, 2020) · 23-76-112
Stored review status: Historical 2020-11-06 source release; later amendments not reconciled; machine-extracted, not independently legally reviewed; source heading status: text_in_historical_source. A text match is a research starting point; applicability is not established.
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Stable record: arkansas_code:legal_authorities:23-76-112
Source file: gov.ar.code.title.23.odt
Pages: Not recorded – Not recorded
Passage SHA-256: 4bbee544cdb42401cac1cf7f02e032066371549c2537e99f79e1cf72a95eff8d
Source location: content.xml paragraph 43720
Stored source content
23-76-112. Evidence of coverage and charges for healthcare services.
(a)(1)(A) Every enrollee residing in this state is entitled to evidence of coverage under a healthcare plan.
(B) If the enrollee obtains coverage under a healthcare plan through an insurance policy or a contract issued by a hospital and medical service corporation, whether by option or otherwise, the insurer or the hospital and medical service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.
(2) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment thereto, has been filed with and approved by the Insurance Commissioner.
(3) An evidence of coverage shall contain:
(A) No provisions or statements that:
(i) Are unjust, unfair, inequitable, misleading, or deceptive;
(ii) Encourage misrepresentation; or
(iii) Are untrue, misleading, or deceptive as defined in § 23-76-119; and
(B) A clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:
(i) The healthcare services and the insurance or other benefits, if any, to which the enrollee is entitled under the healthcare plan;
(ii) Any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;
(iii) Where and in what manner information is available as to how services may be obtained;
(iv) The total amount of payment for healthcare services and the indemnity or service benefits, if any, that the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncontributory with respect to group certificates; and
(v) A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints. Any subsequent change may be evidenced in a separate document issued to the enrollee.
(4) A copy of the form of the evidence of coverage to be used in this state, and any amendment thereto, shall be subject to the filing and approval requirements of subdivision (a)(2) of this section unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or hospital or medical service corporations in which event the filing and approval provisions of the laws shall apply. However, to the extent that the provisions do not apply, the requirements in subdivision (a)(3) of this section shall be applicable.
(b)(1) No schedule of charges for enrollee coverage for healthcare services, or amendment thereto, may be used in conjunction with any healthcare plan until either a copy of the schedule or the methodology for determining charges has been filed with and approved by the commissioner.
(2)(A) Either a specific schedule of charges or a methodology for determining charges shall be established in accordance with the actuarial principles for various categories of enrollees, provided that charges applicable to an individual enrollee in a group contract shall not be individually determined based on the status of the enrollee's health. However, the charges shall not be excessive, inadequate, or unfairly discriminatory.
(B) A certification by a qualified actuary, to the appropriateness of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.
(c)(1)(A) Within a reasonable period, the commissioner shall approve any form if the requirements of subsection (a) of this section are met and any schedule of charges or methodology for determining charges if the requirements of subsection (b) of this section are met.
(B) It shall be unlawful to issue the form or to use the schedule of charges or methodology for determining charges until approved.
(2)(A)(i) If the commissioner disapproves the filing, he or she shall notify the filer promptly.
(ii) In the notice, the commissioner shall specify the reasons for disapproval and the findings of fact and conclusion that support the reasons.
(B) A hearing will be granted by the commissioner within sixty (60) days after a request in writing by the person filing.
(C) If the commissioner does not disapprove any form or schedule of charges within sixty (60) days of the filing of the forms or charges, they shall be deemed approved.
(3)(A) If the commissioner disapproves any form or schedule of charges or methodology for determining charges, the commissioner's disapproval and the findings of fact and conclusions that support the commissioner's reasons shall be subject to judicial review pursuant to § 23-61-307.
(B) The review shall be upon the entire record, and the commissioner's decision shall be sustained if it is supported by the preponderance of the evidence in the record.
(d) The commissioner may require the submission of whatever relevant information he or she deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.
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Arkansas Code — all titles (historical 2020) · legal_authorities
23-61-307. Hearing — Appeal.
(a) An appeal from the Insurance Commissioner shall be taken only from an order on hearing or with respect to a matter as to which the commissioner has refused or failed to grant or hold a hearing after demand therefor under § 23-61-303 or as to a matter as to which the commissioner has refused or failed to make his or her order on hearing as required by § 23-61-306.
(b) Any person who was a party to the hearing, or whose pecuniary interests are directly and immediately affected by the refusal or failure to grant a hearing, and who is aggrieved by the order, refusal, or failure may appeal from the order on hearing or as to any such matter within thirty (30) days after:
(1) The order on hearing has been mailed or delivered to the persons entitled to receive it;
(2) The commissioner's order denying rehearing or reargument has been so mailed or delivered;
(3) The commissioner has refused or failed to make his or her order on hearing as required under § 23-61-306; or
(4) The commissioner has refused or failed to grant or hold a hearing as required under § 23-61-303.
(c) The appeal shall be granted as a matter of right and shall be taken to the Pulaski County Circuit Court by filing written notice of appeal in the court and by filing a copy of the notice with the commissioner, except that, in appeals from the refusal, suspension, or revocation of the license of an agent, broker, solicitor, or surplus line broker, the person taking the appeal may at his or her option take the appeal to the circuit court of the county in which the person resides instead of to the Pulaski County Circuit Court.
(d) Upon filing of the notice of appeal therein, the court shall have full jurisdiction and shall determine whether the filing shall operate a
Source: Arkansas Code — historical release 78 (November 6, 2020) · 23-61-307
Stored review status: Historical 2020-11-06 source release; later amendments not reconciled; machine-extracted, not independently legally reviewed; source heading status: text_in_historical_source. The source passage cites 23-61-307. This identifies an authority to review, not proof of applicability.
Arkansas Code — all titles (historical 2020) · legal_authorities
23-76-119. Prohibited practices — Definition.
(a) No health maintenance organization, or representative thereof, may knowingly cause or knowingly permit the use of advertising that is untrue or misleading, solicitation that is untrue or misleading, or any form of evidence of coverage that is deceptive. For purposes of this chapter:
(1) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect that is or may be significant to an enrollee of, or person considering enrollment in, a healthcare plan;
(2) A statement or item of information shall be deemed to be misleading, whether or not it may be literally 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 may be reasonably understood by a reasonable person, not possessing special knowledge regarding healthcare coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a healthcare plan, if the benefit or advantage or absence of limitation, exclusion, or disadvantage does not in fact exist; and
(3) An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding healthcare plans and evidences of coverage therefor, to expect benefits, services, charges, or other advantages that the evidence of coverage does not provide or that the healthcare plan issuing the evidence of coverage does not regularly make available for enrollees covered under such e
Source: Arkansas Code — historical release 78 (November 6, 2020) · 23-76-119
Stored review status: Historical 2020-11-06 source release; later amendments not reconciled; machine-extracted, not independently legally reviewed; source heading status: text_in_historical_source. The source passage cites 23-76-119. This identifies an authority to review, not proof of applicability.