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C.__Eligibility may not be extended to an enrollee unless | | the evidence of coverage demonstrates that the enrollee has | | had coverage under a primary health care policy or other | | approved health insurance policy within 180 days before the | | date the enrollee applies for eligibility under the plan. |
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| | | 2.__Plan benefits.__As provided in this subsection, the plan | | must provide coverage to enrollees through one standard | | benefit plan. Benefits for covered health care services may | | not be provided to an enrollee until the enrollee has reached | | the maximum amount payable for coverage under that enrollee's | | primary health care policy.__Covered health care services must | | be provided if those services are medically necessary or | | appropriate for the prevention, diagnosis or treatment of, or | | maintenance or rehabilitation following, injury, disability or | | disease.__Covered health care must include all services and | | providers for which coverage is mandated under this Title.__ | | After consultation with the bureau, the agency shall adopt | | rules regarding the standard benefit design for the plan. This | | subsection does not preclude supplementary benefit insurance | | for services that are not medically necessary. |
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| | | 3.__Delivery of health care services.__This subsection | | governs the delivery of covered health care services. |
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| | | A.__Covered health care services must be provided to | | enrollees by participating providers who are located | | within the State and who are chosen by the enrollees. |
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| | | B.__The plan must pay for health care services provided to | | an enrollee while the enrollee is temporarily outside the | | State.__The maximum period of time an enrollee may be | | covered and receive services while out-of-state is 90 days | | per year.__An enrollee may qualify to begin services | | outside the State but, in order to receive continued | | treatment, may be required to receive treatment within the | | State. |
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| | | C.__A participating provider may not charge enrollees or | | 3rd parties for covered health care services in excess of | | the amount reimbursed to that provider by the plan. |
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| | | D.__A participating provider may not refuse to provide | | services to an enrollee on the basis of health status, | | medical condition, previous insurance status, race, color, | | creed, age, national origin, citizenship status, gender, | | sexual orientation, disability or marital status. |
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| | | 4. Participating carriers; contracts.__The plan may contract | | with one or more participating carriers to provide coverage to |
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