| (a) Disclosure of complaint system. An EPP policy or
certificate must contain the Complaints and Appeals Process found
in this subchapter. This information must include a clear and understandable
description of the issuer's methods for resolving complaints. An issuer
must provide any subsequent changes to the complaint system to insureds,
which it may include in a separate document issued to the insured.
(b) Medically necessary covered services. If medically
necessary covered services are not available through exclusive providers,
the issuer, on the request of an exclusive provider, must allow referral
within a reasonable period to a non-network health care provider and
must fully reimburse the non-network health care provider at the usual
and customary or an agreed rate. The policy must provide for a review
by a health care provider of the same specialty or a similar specialty
as the type of health care provider to whom a referral is requested
before the issuer may deny a referral.
(c) Schedule of premiums. An issuer must file the schedule
of premium rates and formula or method for calculating the schedule
of premium rates for covered health care services along with supporting
documentation with the commissioner before it is used in conjunction
with any EPP. The issuer must establish the formula or method in accordance
with accepted actuarial principles and must produce premium rates
that are not excessive, inadequate, or unfairly discriminatory, as
well as premium rates that are reasonable with respect to benefits.
An issuer may not alter the premium rates resulting from the application
of the formula or method for an individual insured based on the status
of that insured's health.
(1) An issuer must accompany each schedule of premium
rates and formula or method for calculating the schedule of premium
rates with the certification of a qualified actuary that, based on
reasonable assumptions, the formula is appropriate to produce premium
rates that are not excessive, inadequate, or unfairly discriminatory.
An actuary is considered qualified if he or she:
(A) is a member of the American Academy of Actuaries;
or
(B) is a Fellow of the Society of Actuaries.
(2) An issuer must accompany each formula or method
for calculating the schedule of premium rates with adequate detail
including assumptions to justify that the premium rates produced by
the formula or method are not excessive, inadequate, or unfairly discriminatory.
(3) If the formula or method for calculating the schedule
of premium rates and the resulting rates are to be continued beyond
a one-year period, the issuer must file with the commissioner, no
later than the anniversary of the effective date of the original filing,
an actuarial statement stating that the issuer has applied the previously
filed formula or method consistently, and that the rates charged have
proven and are expected to continue to be adequate, not excessive,
nor unfairly discriminatory. The issuer must include with this filing
a reconciliation of actual benefits to a schedule of premium rates.
(4) To the extent that an entity contracting with the
insured predetermines the schedule of premium rates, the issuer must
submit the information described in this subsection and demonstrate
that the issuer is able to provide the services for the contracted
rates.
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