HMO

Health Plans - Transparency In Coverage

The Patient Protection and Affordable Care Act (PPACA) requires issuers seeking certification of a health plan as a qualified health plan (QHP) to make accurate and timely disclosures of certain information to the Health Insurance Marketplace, the Secretary of Health and Human Services (HHS), and the state insurance commissioner. Certain information must also be made available to the public. Each hyperlink below includes a summary of information related to policies that may affect your health plan. The summary of information applies to individual QHP products. In the event there is a conflict between the information listed here and your Certificate of Coverage, the terms and conditions of your Certificate of Coverage will prevail. For detailed information, please refer to your Certificate of Coverage. For more details on each topic listed, please ‘click’ each link below.

Out-of-network liability and balance billing
Enrollee claims submission
Grace periods and claims pending policies during the grace period
Retroactive denials
Enrollee recoupment of overpayments
Medical necessity and prior authorization timeframes and enrollee responsibilities
Drug exceptions timeframes and enrollee responsibilities
Information on Explanations of Benefits (EOBs)
Coordination of benefits (COB)
Medical Reimbursement Form
Prescription Drug Reimbursement Form