Merritt Personal Lines Manual: Enrollment

The HMO must provide the insured with evidence of coverage within 60 days of enrollment.

Evidence of coverage is equivalent to a Certificate of Insurance for standard insurance policies.

The evidence of coverage should include the insured's coverages and benefits (including the required co-payments), benefit limits, exclusions and specified conversion privileges. It should also include:

• the name, address and telephone number of the HMO;
• the effective date and term of coverage;
• a list of providers and a description of the service area;
• terms and conditions for termination;
• a complaint system;
• a 31-day grace period for premium payment provision;
• a coordination of benefits provision;
• incontestability clause; and
• a provision on eligibility requirements for membership in the HMO.

Other provisions may also be found in the evidence of coverage, but those outlined above must be included.

HMO benefits are not limited to treatment resulting from illness or injury, but include preventative measures like routine physical examinations and programs for quitting smoking, losing weight and managing blood pressure. HMO members pay a set fee, usually on a monthly basis, which entitles them to a broad definition of "necessary health care."

HMOs provide a wide range of health care services. These required services are referred to as basic health care services. And any services or benefits provided by the HMO in excess of the basic services are referred to as supplemental health care services. The HMO must provide the insured with a list of the basic services that are covered under the plan. The following is an example:

• Inpatient hospital and physician services for at least 90 days per calendar year for treatment of injury and illness or injury;
• If inpatient treatment is for mental, emotional or nervous disorders - including alcohol and drug rehabilitation treatment - services may be limited to 30 days per calendar year.
• Treatment for alcohol and drug rehabilitation and treatment may be restricted to a 90-day lifetime limit.
• Outpatient medical services when prescribed by a physician and rendered in a non-hospital health care facility (i.e. physician's office, member's home, etc.) including diagnostic services, treatment services, short-term physical therapy and rehabilitation services, laboratory and x-ray services and outpatient surgery;
• Preventative health services, including well child care from birth, eye and ear examinations for children under age 18 and periodic health evaluations and immunizations;
• In- and out-of-area emergency services, including medically necessary ambulance services, available on an inpatient or an outpatient basis 24 hours per day, seven days per week.
• Supplemental health care services may take the form of additional coverages over and above those provided as basic or additional amounts of the basic benefits already provided.