(a) The commissioner by rule shall prescribe a disclosure form to be provided with a short-term limited-duration insurance policy and application.
(b) The disclosure form must be in an easily readable font at least 14-point in size and include:
(1) the duration of coverage;
(2) a statement:
(A) of the number of times the policy may be renewed or that the policy may not be renewed, as applicable;
(B) that the expiration of short-term coverage is not a qualifying life event that would make a person eligible for a special enrollment period; and
(C) that the policy may expire outside of the open enrollment period;
(3) to the extent the information is available, the dates of the next three open enrollment periods under the Patient Protection and Affordable Care Act (Pub. L. No. 111-148) following the date the policy expires;
(4) whether the policy contains any limitations or exclusions to preexisting conditions;
(5) the maximum dollar amount payable under the policy;
(6) the deductibles under the policy and the health care services to which the deductibles apply;
(7) whether the following health care services are covered, including:
(A) prescription drug coverage;
(B) mental health services;
(C) substance abuse treatment;
(D) maternity care;
(E) hospitalization;
(F) surgery;
(G) emergency health care; and
(H) preventive health care; and
(8) any other information the commissioner determines is important for a purchaser of a short-term limited-duration insurance policy.

(c) An insurer issuing a short-term limited-duration insurance policy shall adopt procedures in accordance with commissioner rule to obtain a signed form from the insured acknowledging receipt of the disclosure form described by this section. The rule must allow for electronic acknowledgment. The insurer shall retain an acknowledgment form until the fifth anniversary of the date the insurer receives the form, and the insurer shall make the form available to the department on request.