Missouri Revised Statutes
Chapter 354
Health Services Corporations--Health Maintenance Organizations--Prepaid Dental Plans
←354.380
Section 354.400.1
354.405→
August 28, 2015
Definitions.
354.400. As used in sections 354.400 to 354.636, the following terms
shall mean:
(1) "Basic health care services", health care services which an enrolled
population might reasonably require in order to be maintained in good health,
including, as a minimum, emergency care, inpatient hospital and physician
care, and outpatient medical services;
(2) "Community-based health maintenance organization", a health
maintenance organization which:
(a) Is wholly owned and operated by hospitals, hospital systems,
physicians, or other health care providers or a combination thereof who
provide health care treatment services in the service area described in the
application for a certificate of authority from the director;
(b) Is operated to provide a means for such health care providers to
market their services directly to consumers in the service area of the health
maintenance organization;
(c) Is governed by a board of directors that exercises fiduciary
responsibility over the operations of the health maintenance organization and
of which a majority of the directors consist of equal numbers of the
following:
a. Physicians licensed pursuant to chapter 334;
b. Purchasers of health care services who live in the health maintenance
organization's service area;
c. Enrollees of the health maintenance organization elected by the
enrollees of such organization; and
d. Hospital executives, if a hospital is involved in the corporate
ownership of the health maintenance organization;
(d) Provides for utilization review, as defined in section 374.500,
under the auspices of a physician medical director who practices medicine in
the service area of the health maintenance organization, using review
standards developed in consultation with physicians who treat the health
maintenance organization's enrollees;
(e) Is actively involved in attempting to improve performance on
indicators of health status in the community or communities in which the
health maintenance organization is operating, including the health status of
those not enrolled in the health maintenance organization;
(f) Is accountable to the public for the cost, quality and access of
health care treatment services and for the effect such services have on the
health of the community or communities in which the health maintenance
organization is operating on a whole;
(g) Establishes an advisory group or groups comprised of enrollees and
representatives of community interests in the service area to make
recommendations to the health maintenance organization regarding the policies
and procedures of the health maintenance organization;
(h) Enrolls fewer than fifty thousand covered lives;
(3) "Covered benefit" or "benefit", a health care service to which an
enrollee is entitled under the terms of a health benefit plan;
(4) "Director", the director of the department of insurance, financial
institutions and professional registration;
(5) "Emergency medical condition", the sudden and, at the time,
unexpected onset of a health condition that manifests itself by symptoms of
sufficient severity that would lead a prudent lay person, possessing an
average knowledge of health and medicine, to believe that immediate medical
care is required, which may include, but shall not be limited to:
(a) Placing the person's health in significant jeopardy;
(b) Serious impairment to a bodily function;
(c) Serious dysfunction of any bodily organ or part;
(d) Inadequately controlled pain; or
(e) With respect to a pregnant woman who is having contractions:
a. That there is inadequate time to effect a safe transfer to another
hospital before delivery; or
b. That transfer to another hospital may pose a threat to the health or
safety of the woman or unborn child;
(6) "Emergency services", health care items and services furnished or
required to screen and stabilize an emergency medical condition, which may
include, but shall not be limited to, health care services that are provided
in a licensed hospital's emergency facility by an appropriate provider;
(7) "Enrollee", a policyholder, subscriber, covered person or other
individual participating in a health benefit plan;
(8) "Evidence of coverage", any certificate, agreement, or contract
issued to an enrollee setting out the coverage to which the enrollee is
entitled;
(9) "Health care services", any services included in the furnishing to
any individual of medical or dental care or hospitalization, or incident to
the furnishing of such care or hospitalization, as well as the furnishing to
any person of any and all other services for the purpose of preventing,
alleviating, curing, or healing human illness, injury, or physical disability;
(10) "Health maintenance organization", any person which undertakes to
provide or arrange for basic and supplemental health care services to
enrollees on a prepaid basis, or which meets the requirements of Section 1301
of the United States Public Health Service Act;
(11) "Health maintenance organization plan", any arrangement whereby any
person undertakes to provide, arrange for, pay for, or reimburse any part of
the cost of any health care services and at least part of such arrangement
consists of providing and assuring the availability of basic health care
services to enrollees, as distinguished from mere indemnification against the
cost of such services, on a prepaid basis through insurance or otherwise, and
as distinguished from the mere provision of service benefits under health
service corporation programs;
(12) "Individual practice association", a partnership, corporation,
association, or other legal entity which delivers or arranges for the
delivery of health care services and which has entered into a services
arrangement with persons who are licensed to practice medicine, osteopathy,
dentistry, chiropractic, pharmacy, podiatry, optometry, or any other health
profession and a majority of whom are licensed to practice medicine or
osteopathy. Such an arrangement shall provide:
(a) That such persons shall provide their professional services in
accordance with a compensation arrangement established by the entity; and
(b) To the extent feasible for the sharing by such persons of medical
and other records, equipment, and professional, technical, and administrative
staff;
(13) "Medical group/staff model", a partnership, association, or other
group:
(a) Which is composed of health professionals licensed to practice
medicine or osteopathy and of such other licensed health professionals
(including dentists, chiropractors, pharmacists, optometrists, and
podiatrists) as are necessary for the provisions of health services for which
the group is responsible;
(b) A majority of the members of which are licensed to practice medicine
or osteopathy; and
(c) The members of which (i) as their principal professional activity
over fifty percent individually and as a group responsibility engaged in the
coordinated practice of their profession for a health maintenance
organization; (ii) pool their income from practice as members of the group and
distribute it among themselves according to a prearranged salary or drawing
account or other plan, or are salaried employees of the health maintenance
organization; (iii) share medical and other records and substantial portions
of major equipment and of professional, technical, and administrative staff;
(iv) establish an arrangement whereby an enrollee's enrollment status is not
known to the member of the group who provides health services to the enrollee;
(14) "Person", any partnership, association, or corporation;
(15) "Provider", any physician, hospital, or other person which is
licensed or otherwise authorized in this state to furnish health care
services;
(16) "Uncovered expenditures", the costs of health care services that are
covered by a health maintenance organization, but that are not guaranteed,
insured, or assumed by a person or organization other than the health
maintenance organization, or those costs which a provider has not agreed to
forgive enrollees if the provider is not paid by the health maintenance
organization.
(L. 1983 H.B. 127, A.L. 1997 H.B. 335, A.L. 2007 S.B. 66)
1997
1997
354.400. As used in sections 354.400 to 354.535, the following terms
shall mean:
(1) "Basic health care services", health care services which an
enrolled population might reasonably require in order to be maintained in
good health, including, as a minimum, emergency care, inpatient hospital
and physician care, and outpatient medical services;
(2) "Community-based health maintenance organization", a health
maintenance organization which:
(a) Is wholly owned and operated by hospitals, hospital systems,
physicians, or other health care providers or a combination thereof who
provide health care treatment services in the service area described in the
application for a certificate of authority from the department of
insurance;
(b) Is operated to provide a means for such health care providers to
market their services directly to consumers in the service area of the
health maintenance organization;
(c) Is governed by a board of directors that exercises fiduciary
responsibility over the operations of the health maintenance organization
and of which a majority of the directors consist of equal numbers of the
following:
a. Physicians licensed pursuant to chapter 334, RSMo;
b. Purchasers of health care services who live in the health
maintenance organization's service area;
c. Enrollees of the health maintenance organization elected by the
enrollees of such organization; and
d. Hospital executives, if a hospital is involved in the corporate
ownership of the health maintenance organization;
(d) Provides for utilization review, as defined in section 374.500,
RSMo, under the auspices of a physician medical director who practices
medicine in the service area of the health maintenance organization, using
review standards developed in consultation with physicians who treat the
health maintenance organization's enrollees;
(e) Is actively involved in attempting to improve performance on
indicators of health status in the community or communities in which the
health maintenance organization is operating, including the health status
of those not enrolled in the health maintenance organization;
(f) Is accountable to the public for the cost, quality and access of
health care treatment services and for the effect such services have on the
health of the community or communities in which the health maintenance
organization is operating on a whole;
(g) Establishes an advisory group or groups comprised of enrollees
and representatives of community interests in the service area to make
recommendations to the health maintenance organization regarding the
policies and procedures of the health maintenance organization;
(h) Enrolls fewer than fifty thousand covered lives;
(3) "Covered benefit" or "benefit", a health care service to which an
enrollee is entitled under the terms of a health benefit plan;
(4) "Director", the director of the department of insurance;
(5) "Emergency medical condition", the sudden and, at the time,
unexpected onset of a health condition that manifests itself by symptoms of
sufficient severity that would lead a prudent lay person, possessing an
average knowledge of health and medicine, to believe that immediate medical
care is required, which may include, but shall not be limited to:
(a) Placing the person's health in significant jeopardy;
(b) Serious impairment to a bodily function;
(c) Serious dysfunction of any bodily organ or part;
(d) Inadequately controlled pain; or
(e) With respect to a pregnant woman who is having contractions:
a. That there is inadequate time to effect a safe transfer to another
hospital before delivery; or
b. That transfer to another hospital may pose a threat to the health
or safety of the woman or unborn child;
(6) "Emergency services", health care items and services furnished or
required to screen and stabilize an emergency medical condition, which may
include, but shall not be limited to, health care services that are
provided in a licensed hospital's emergency facility by an appropriate
provider;
(7) "Enrollee", a policyholder, subscriber, covered person or other
individual participating in a health benefit plan;
(8) "Evidence of coverage", any certificate, agreement, or contract
issued to an enrollee setting out the coverage to which the enrollee is
entitled;
(9) "Health care services", any services included in the furnishing
to any individual of medical or dental care or hospitalization, or incident
to the furnishing of such care or hospitalization, as well as the
furnishing to any person of any and all other services for the purpose of
preventing, alleviating, curing, or healing human illness, injury, or
physical disability;
(10) "Health maintenance organization", any person which undertakes
to provide or arrange for basic and supplemental health care services to
enrollees on a prepaid basis, or which meets the requirements of section
1301 of the United States Public Health Service Act;
(11) "Health maintenance organization plan", any arrangement whereby
any person undertakes to provide, arrange for, pay for, or reimburse any
part of the cost of any health care services and at least part of such
arrangement consists of providing and assuring the availability of basic
health care services to enrollees, as distinguished from mere
indemnification against the cost of such services, on a prepaid basis
through insurance or otherwise, and as distinguished from the mere
provision of service benefits under health service corporation programs;
(12) "Individual practice association", a partnership, corporation,
association, or other legal entity which delivers or arranges for the
delivery of health care services and which has entered into a services
arrangement with persons who are licensed to practice medicine, osteopathy,
dentistry, chiropractic, pharmacy, podiatry, optometry, or any other health
profession and a majority of whom are licensed to practice medicine or
osteopathy. Such an arrangement shall provide:
(a) That such persons shall provide their professional services in
accordance with a compensation arrangement established by the entity; and
(b) To the extent feasible for the sharing by such persons of medical
and other records, equipment, and professional, technical, and
administrative staff;
(13) "Medical group/staff model", a partnership, association, or
other group:
(a) Which is composed of health professionals licensed to practice
medicine or osteopathy and of such other licensed health professionals
(including dentists, chiropractors, pharmacists, optometrists, and
podiatrists) as are necessary for the provisions of health services for
which the group is responsible;
(b) A majority of the members of which are licensed to practice
medicine or osteopathy; and
(c) The members of which (i) as their principal professional activity
over fifty percent individually and as a group responsibility engaged in
the coordinated practice of their profession for a health maintenance
organization; (ii) pool their income from practice as members of the group
and distribute it among themselves according to a prearranged salary or
drawing account or other plan, or are salaried employees of the health
maintenance organization; (iii) share medical and other records and
substantial portions of major equipment and of professional, technical, and
administrative staff; (iv) establish an arrangement whereby an enrollee's
enrollment status is not known to the member of the group who provides
health services to the enrollee;
(14) "Person", any partnership, association, or corporation;
(15) "Provider", any physician, hospital, or other person which is
licensed or otherwise authorized in this state to furnish health care
services;
(16) "Uncovered expenditures", the costs of health care services that
are covered by a health maintenance organization, but that are not
guaranteed, insured, or assumed by a person or organization other than the
health maintenance organization, or those costs which a provider has not
agreed to forgive enrollees if the provider is not paid by the health
maintenance organization.
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