Form M300 Mewa Coverage Requirements 760 (Page 4 of 4) in pdf

Form M300 Mewa Coverage Requirements 760 Page 4

Location in

Requirement

IDOI use

Document

(note page #)

Emergency Services: No prior authorization is required for emergency services.

Emergency service must have same cost-sharing regardless of whether they are

provided by a network provider.

(Section 2719A - PHSA/Section 10101 - PPACA)

Prohibit Rescissions: Rescission of coverage is not allowed unless the covered

individual has committed fraud or makes an intentional misrepresentation of material

fact.

By signing below, I am certifying on behalf of the above MEWA, pursuant to Ind. Code 27-1-34-9 and 760 IAC 1-68-

4, the policy form(s) submitted with this checklist meets all of the applicable requirements of Indiana law. I

understand and acknowledge, on behalf of the MEWA, that the Indiana Department of Insurance is relying on this

certification in making its determination whether to approve or disapprove this policy filing.

If any policy

provision is not in compliance with Indiana law, the Indiana Department of Insurance may take regulatory action

against the MEWA.

Signature:

Printed Name:

Title:

Date:

For IDOI Use Only

Reviewed by: _________________________________

Approve

Hold

Deny

Comments:

Form M300 Mewa Coverage Requirements 760 Page 4