WILLIAM DONALD SCHAEFER, Governor                                Ch. 9

(IV) MEDICARE SUPPLEMENT POLICIES;

(V) LONG-TERM CARE INSURANCE;

(VI) DISABILITY INCOME INSURANCE;

(VII) COVERAGE ISSUED AS A SUPPLEMENT TO LIABILITY
INSURANCE;

(VIII) WORKERS' COMPENSATION OR SIMILAR INSURANCE;

(IX) DISEASE SPECIFIC INSURANCE; OR

(X) AUTOMOBILE MEDICAL PAYMENT INSURANCE.

(E)     "PREEXISTING CONDITION" MEANS:

(1) A CONDITION THAT WOULD CAUSE AN ORDINARILY PRUDENT
PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR TREATMENT; OR

(2) A CONDITION FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR
TREATMENT WAS RECOMMENDED OR RECEIVED DURING A SPECIFIED PERIOD
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF THIS COVERAGE.

(F)      "PREEXISTING CONDITION PROVISION" MEANS A PROVISION IN A
HEALTH BENEFIT PLAN THAT DENIES, EXCLUDES, OR LIMITS BENEFITS FOR AN
ENROLLEE FOR EXPENSES OR SERVICES RELATED TO A PREEXISTING CONDITION.

699.

(A) IN ADDITION TO ANY OTHER REQUIREMENTS UNDER THIS ARTICLE, A
CARRIER THAT OFFERS A HEALTH BENEFIT PLAN IN THIS STATE SHALL:

(1) HAVE DEMONSTRATED THE CAPACITY TO ADMINISTER THE
HEALTH BENEFIT PLAN, INCLUDING ADEQUATE NUMBERS AND TYPES OF
ADMINISTRATIVE STAFF;

(2)      HAVE THE ABILITY, EXPERIENCE, AND STRUCTURE TO ENSURE THE
DELIVERY OF THE APPROPRIATE LEVEL AND TYPE OF HEALTH CARE SERVICE;

(3) HAVE THE ABILITY AND PROCEDURES TO MONITOR AND
EVALUATE THE QUALITY AND COST EFFECTIVENESS OF CARE;

(4)      HAVE THE ABILITY TO ENSURE THAT ENROLLEES HAVE ADEQUATE
ACCESS TO PROVIDERS OF HEALTH CARE, INCLUDING GEOGRAPHIC AVAILABILITY
AND ADEQUATE NUMBERS AND TYPES;

(5) HAVE THE ABILITY AND PROCEDURES TO MONITOR ACCESS
INCLUDING APPOINTMENT WAITING TIMES;

(6) HAVE A SATISFACTORY GRIEVANCE PROCEDURE AND ABILITY TO
RESPOND TO ENROLLEES' CALLS, QUESTIONS, AND COMPLAINTS; AND

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