Sec. 21.07.020. Required contract provisions for health care insurance policy.
A health care insurance policy must contain a provision
(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 42 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.
Sec. 21.51.120. Payment of claims.
(a) A health insurance policy delivered or issued for delivery must contain the following provisions:
(1) indemnity for loss of life shall be paid according to the beneficiary designation and payment provisions contained in the policy that are effective at the time of payment; if a beneficiary has not been designated, indemnity shall be paid to the estate of the insured; accrued indemnities unpaid at the insured's death shall be paid to either the beneficiary or the estate, at the option of the insurer; all other indemnities shall be paid to the insured;
(2) the insurer may, and upon written request of the insured shall, pay indemnities for hospital, nursing, medical, dental, or surgical services directly to the provider of the services; an insurer who pays indemnities to an insured, after the insured has given the insurer written notice in the proof of loss statement of an election of direct payment of indemnities to the provider of the services, shall also pay indemnities to the provider of the services; this paragraph does not require that services be provided by a particular hospital or person;
(3) a covered person may revoke an election of direct payment of indemnities made under this subsection by giving written notice of the revocation to the insurer and to the provider of the services; the written notice of revocation given to the insurer must certify that the covered person has given written notice of revocation to the provider of the services; revocation of an election of direct payment is not effective until the notice of revocation is received by the insurer and the provider of the services;
(4) the right of the insured to request payment of indemnities for hospital, nursing, medical, dental, or surgical services directly to the provider of the services or to another person may be transferred to a person who is not the insured by a qualified domestic relations order; rights under the qualified domestic relations order do not take effect until the order is received by the insurer; in this paragraph, “qualified domestic relations order” means an order or judgment in a divorce or dissolution action under AS 25.24 that designates a person to determine to whom indemnities for a named beneficiary should be paid under a health insurance policy.
(b) A health insurance policy delivered or issued for delivery may, at the option of the insurer, require that an indemnity in an amount not to exceed $1,000 that is payable to the estate of the insured, an insured or beneficiary who is a minor, or an insured who is not competent to give a valid release, be paid to a relative by blood or marriage, or a beneficiary that the insured determines is equitably entitled to the payment. A good faith payment by the insurer under this subsection fully discharges the insurer to the extent of the payment.
(c) This section does not apply to payments made under a provider contract that holds the covered person harmless from charges for services except copayments, coinsurance, and deductibles.
Sources: Sec. 21.07.020, Sec. 21.51.120
