An insurance company, as defined in section 26.1 -02-01, a health maintenance organization, or any other entity providing a plan of health insurance subject to state insurance regulation may not deliver, issue, execute, or renew a health insurance policy or health service contract unless that insurer makes available to persons covered under the policy or contract a plan description that discloses in writing the terms and conditions of the policy or contract. The plan description must use the plain and ordinary meaning of words so as to reasonably ensure comprehension by a layperson and must be made available to each person covered under the contract, in any manner reasonably assuring availability prior to the delivery, issuance, execution, or renewal of the policy or contract. 1. The information required to be disclosed by the insurer must include, in addition to any other disclosures required by law: a. A general description of benefits and covered services, including benefit limits and coverage exclusions and the definition of medical necessity used by the insurer in determining whether benefits will be covered; b. A general description of the insured's financial responsibility for payment of premiums, deductibles, coinsurance, and copayment amounts, including any maximum limitations on out -of-pocket expenses, any maximum limits on payments for health care services, and the maximum out -of-pocket costs for services that are provided by nonparticipating health care professionals; c. A general explanation of the extent to which benefits and services may be obtained from nonparticipating providers, including any out -of-network coverage or options; d. A general explanation of the extent to which a person covered under the policy or contract may select from among participating providers and any limitations imposed on the selection of participating health care providers; e. A general description of the insurer's use of any prescription drug formulary or any other general limits on the availability of prescription drugs; f. A general description of the procedures and any conditions for persons covered under the policy or contract to change participating primary and specialty providers; g. A general description of the procedures and any conditions for obtaining referrals; h. A general description of the procedure for providing emergency services, including an explanation of what constitutes an emergency situation and notice that emergency services are not subject to prior authorization, the procedure for obtaining emergency services and any cost-sharing applicable to emergency services, including out-of-network services, and any limitation on access to emergency services; i. A general description of any utilization review policies and procedures, including a description of any required prior authorizations or other requirements for health care services and appeal procedures; j. A general description of all complaint or grievance rights and procedures used to resolve disputes between the insurer and persons covered under the policy or contract or a health care provider, including the method for filing grievances and the timeframes and circumstances for acting on grievances and appeals; k. A general description of any methods used by the insurer for providing financial payment incentives or other payment arrangements to reimburse health care providers; l. Notice of appropriate mailing addresses and telephone numbers to be used by persons covered under the policy or contract in seeking information or authorization for treatment; m. If applicable, notice of the provisions required by section 26.1 -47-03 that ensure access to health care services in preferred provider arrangements; and n. Notice that the information described in subsection 2 is available upon request. 2. An insurer shall provide the following written information if requested by a person covered under a policy or contract: a. A description of any process for credentialing participating health care providers; b. A description of the policies and procedures established to ensure confidentiality of patient information; c. A description of the procedures followed by the insurer to make decisions about the experimental nature of individual drugs, medical devices, or treatments; d. With regard to any preferred provider arrangement or other network health plan, a list by specialty of the name and location of participating health care providers and the number, types, and geographic distribution of providers participating in the health plan; and e. Whether a specifically identified drug is included or excluded from coverage. 3. Nothing in this section may be construed as preventing an insurer from making the information under subsections 1 and 2 available to a person covered under the policy or contract through a handbook or similar publication.
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