Nebraska Statutes 44-32,129. Group and individual contracts; required provisions
Every group and individual contract holder shall be entitled to a group or individual contract. The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, or deceptive or which encourage misrepresentation as described by section 44-1525. The contract shall contain a clear statement of the following:
Terms Used In Nebraska Statutes 44-32,129
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: shall mean an individual who is covered by a health maintenance organization and shall include both subscribers and dependents of subscribers. See Nebraska Statutes 44-3299
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Extension of benefits: shall mean the continuation of coverage under a particular benefit provided under a contract following termination with respect to an enrollee who is totally disabled on the date of termination. See Nebraska Statutes 44-32,101
- Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. Source: Federal Reserve
- Grievance: shall mean a written complaint submitted in accordance with the health maintenance organization's formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization relative to the enrollee. See Nebraska Statutes 44-32,102
- Group contract: shall mean a contract for health care services which by its terms limits eligibility to members of a specified group. See Nebraska Statutes 44-32,103
- Health maintenance organization: shall mean any person who undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis except for enrollee responsibility for copayments or deductibles. See Nebraska Statutes 44-32,105
- Individual contract: shall mean a contract for health care services issued to and covering an individual. See Nebraska Statutes 44-32,107
- State: when applied to different states of the United States shall be construed to extend to and include the District of Columbia and the several territories organized by Congress. See Nebraska Statutes 49-801
(1) Name and address of the health maintenance organization;
(2) Eligibility requirements;
(3) Benefits and services within the service area;
(4) Emergency care benefits and services;
(5) Out-of-area benefits and services, if any;
(6) Copayments, deductibles, or other out-of-pocket expenses;
(7) Limitations and exclusions;
(8) Enrollee termination;
(9) Enrollee reinstatement, if any;
(10) Claims procedures;
(11) Enrollee grievance procedures;
(12) Continuation of coverage;
(13) Conversion;
(14) Extension of benefits, if any;
(15) Coordination of benefits, if applicable;
(16) Subrogation, if any;
(17) Description of the service area;
(18) Entire contract provision;
(19) Term of coverage;
(20) Cancellation of group or individual contract holder;
(21) Renewal;
(22) Reinstatement of group or individual contract holder, if any;
(23) Grace period; and
(24) Conformity with state law.
An evidence of coverage may be filed as part of the group contract to describe the provisions required in subdivisions (1) through (17) of this section.