Required contract provisions for health care insurance policy
See text below in bold:
A health care insurance policy must contain a provision
Retroactive Denial
(1) that preauthorization for a covered medical procedure on the basis of medical necessity may not be retroactively denied unless the preauthorization is based on materially incomplete or inaccurate information provided by or on behalf of the provider;
(2) for emergency services that meet the requirements under 2 U.S.C. 300gg-19a(b) if any coverage is provided for treatment of an emergency medical condition;
(3) that covered medical care services be reasonably available in the community in which a covered person resides or that, if referrals are required by the policy, adequate referrals outside the community be available if the medical care service is not available in the community;
(4) that discloses covered benefits, optional supplemental benefits, and benefits relating to and restrictions on nonparticipating provider services;
(5) describing a mechanism for assignment of benefits for health care providers and payment of benefits;
(6) describing the availability of prescription medications or a formulary guide, and whether medications not listed are excluded; if a formulary guide is made available, the guide must be updated annually; and
(7) describing available translation or interpreter services, including audiotape or braille information.