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Section: 354.0442 Disclosure information to enrollees required, when. RSMO 354.442


Published: 2015

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Missouri Revised Statutes













Chapter 354

Health Services Corporations--Health Maintenance Organizations--Prepaid Dental Plans

←354.441

Section 354.442.1

354.443→

August 28, 2015

Disclosure information to enrollees required, when.

354.442. 1. Each enrollee, and upon request each prospective

enrollee prior to enrollment, shall be supplied with written disclosure

information. In the event of any inconsistency between any separate

written disclosure statement and the enrollee contract or evidence of

coverage, the terms of the enrollee contract or evidence of coverage shall

be controlling. The information to be disclosed in writing shall include

at a minimum the following:



(1) A description of coverage provisions, health care benefits,

benefit maximums, including benefit limitations;



(2) A description of any exclusions of coverage, including the

definition of medical necessity used in determining whether benefits will

be covered;



(3) A description of all prior authorization or other requirements

for treatments and services;



(4) A description of utilization review policies and procedures used

by the health maintenance organization, including:



(a) The circumstances under which utilization review shall be

undertaken;



(b) The toll-free telephone number of the utilization review agent;



(c) The time frames under which utilization review decisions shall be

made for prospective, retrospective and concurrent decisions;



(d) The right to reconsideration;



(e) The right to an appeal, including the expedited and standard

appeals processes and the time frames for such appeals;



(f) The right to designate a representative;



(g) A notice that all denials of claims shall be made by qualified

clinical personnel and that all notices of denial shall include information

about the basis of the decision; and



(h) Further appeal rights, if any;



(5) An explanation of an enrollee's financial responsibility for

payment of premiums, coinsurance, co-payments, deductibles and any other

charge, annual limits on an enrollee's financial responsibility, caps on

payments for covered services and financial responsibility for noncovered

health care procedures, treatments or services provided within the health

maintenance organization;



(6) An explanation of an enrollee's financial responsibility for

payment when services are provided by a health care provider who is not

part of the health maintenance organization's network or by any provider

without required authorization, or when a procedure, treatment or service

is not a covered health care benefit;



(7) A description of the grievance procedures to be used to resolve

disputes between a health maintenance organization and an enrollee,

including:



(a) The right to file a grievance regarding any dispute between an

enrollee and a health maintenance organization;



(b) The right to file a grievance when the dispute is about referrals

or covered benefits;



(c) The toll-free telephone number which enrollees may use to file a

grievance;



(d) The department of insurance, financial institutions and

professional registration's toll-free consumer complaint hotline number;



(e) The time frames and circumstances for expedited and standard

grievances;



(f) The right to appeal a grievance determination and the procedures

for filing such an appeal;



(g) The time frames and circumstances for expedited and standard

appeals;



(h) The right to designate a representative;



(i) A notice that all disputes involving clinical decisions shall be

made by qualified clinical personnel; and



(j) All notices of determination shall include information about the

basis of the decision and further appeal rights, if any;



(8) A description of a procedure for providing care and coverage

twenty-four hours a day, seven days a week, for emergency services. Such

description shall include the definition of emergency services and

emergency medical condition, notice that emergency services are not subject

to prior approval, and shall describe the enrollee's financial and other

responsibilities regarding obtaining such services, including when such

services are received outside the health maintenance organization's service

area;



(9) A description of procedures for enrollees to select and access

the health maintenance organization's primary and specialty care providers,

including notice of how to determine whether a participating provider is

accepting new patients;



(10) A description of the procedures for changing primary and

specialty care providers within the health maintenance organization;



(11) Notice that an enrollee may obtain a referral for covered

services to a health care provider outside of the health maintenance

organization's network or panel when the health maintenance organization

does not have a health care provider with appropriate training and

experience in the network or panel to meet the particular health care needs

of the enrollee and the procedure by which the enrollee may obtain such

referral;



(12) A description of the mechanisms by which enrollees may

participate in the development of the policies of the health maintenance

organization;



(13) Notice of all appropriate mailing addresses and telephone

numbers to be utilized by enrollees seeking information or authorization;



(14) Listings by specialty, which may be in separate documents that

are updated annually, of the names, addresses and telephone numbers of all

participating providers, including facilities, and in addition in the case

of physicians, board certification; and



(15) The director of the department of insurance, financial

institutions and professional registration shall develop a standard

credentialing form which shall be used by all health carriers when

credentialing health care professionals in a managed care plan. If the

health carrier demonstrates a need for additional information, the director

of the department of insurance, financial institutions and professional

registration may approve a supplement to the standard credentialing form.

All forms and supplements shall meet all requirements as defined by the

National Committee of Quality Assurance.



2. Each health maintenance organization shall, upon request of an

enrollee or prospective enrollee, provide the following:



(1) A list of the names, business addresses and official positions of

the membership of the board of directors, officers, controlling persons,

owners or partners of the health maintenance organization;



(2) A copy of the most recent annual certified financial statement of

the health maintenance organization, including a balance sheet and summary

of receipts and disbursements prepared by a certified public accountant;



(3) A copy of the most recent individual, direct pay enrollee

contracts;



(4) Information relating to consumer complaints compiled annually by

the department of insurance, financial institutions and professional

registration;



(5) The procedures for protecting the confidentiality of medical

records and other enrollee information;



(6) An opportunity to inspect drug formularies used by such health

maintenance organization and any financial interest in a pharmacy provider

utilized by such organization. The health maintenance organization shall

also disclose the process by which an enrollee or his representative may

seek to have an excluded drug covered as a benefit;



(7) A written description of the organizational arrangements and

ongoing procedures of the health maintenance organization's quality

assurance program;



(8) A description of the procedures followed by the health

maintenance organization in making decisions about the experimental or

investigational nature of individual drugs, medical devices or treatments

in clinical trials;



(9) Individual health practitioner affiliations with participating

hospitals, if any;



(10) Upon written request, written clinical review criteria relating

to conditions or diseases and, where appropriate, other clinical

information which the organization may consider in its utilization review.

The health maintenance organization may include with the information a

description of how such information will be used in the utilization review

process;



(11) The written application procedures and minimum qualification

requirements for health care providers to be considered by the health

maintenance organization;



(12) A description of the procedures followed by the health

maintenance organization in making decisions about which drugs to include

in the health maintenance organization's drug formulary.



3. Nothing in this section shall prevent a health maintenance

organization from changing or updating the materials that are made

available to enrollees.



4. The information to be provided under subsections 1 and 2 of this

section may be provided online unless a paper copy is requested by the

enrollee. A request by the enrollee may include written, oral or

electronic means. Such requested paper copy shall be provided to the

enrollee within fifteen business days.



(L. 1997 H.B. 335, A.L. 2010 S.B. 583)





1997



1997



354.442. 1. Each enrollee, and upon request each prospective enrollee

prior to enrollment, shall be supplied with written disclosure information.

In the event of any inconsistency between any separate written disclosure

statement and the enrollee contract or evidence of coverage, the terms of the

enrollee contract or evidence of coverage shall be controlling. The

information to be disclosed in writing shall include at a minimum the

following:



(1) A description of coverage provisions, health care benefits, benefit

maximums, including benefit limitations;



(2) A description of any exclusions of coverage, including the

definition of medical necessity used in determining whether benefits will be

covered;



(3) A description of all prior authorization or other requirements for

treatments and services;



(4) A description of utilization review policies and procedures used by

the health maintenance organization, including:



(a) The circumstances under which utilization review shall be

undertaken;



(b) The toll-free telephone number of the utilization review agent;



(c) The time frames under which utilization review decisions shall be

made for prospective, retrospective and concurrent decisions;



(d) The right to reconsideration;



(e) The right to an appeal, including the expedited and standard appeals

processes and the time frames for such appeals;



(f) The right to designate a representative;



(g) A notice that all denials of claims shall be made by qualified

clinical personnel and that all notices of denial shall include information

about the basis of the decision; and



(h) Further appeal rights, if any;



(5) An explanation of an enrollee's financial responsibility for payment

of premiums, coinsurance, co-payments, deductibles and any other charge,

annual limits on an enrollee's financial responsibility, caps on payments for

covered services and financial responsibility for noncovered health care

procedures, treatments or services provided within the health maintenance

organization;



(6) An explanation of an enrollee's financial responsibility for payment

when services are provided by a health care provider who is not part of the

health maintenance organization's network or by any provider without required

authorization, or when a procedure, treatment or service is not a covered

health care benefit;



(7) A description of the grievance procedures to be used to resolve

disputes between a health maintenance organization and an enrollee, including:



(a) The right to file a grievance regarding any dispute between an

enrollee and a health maintenance organization;



(b) The right to file a grievance when the dispute is about referrals or

covered benefits;



(c) The toll-free telephone number which enrollees may use to file a

grievance;



(d) The department of insurance, financial institutions and professional

registration's toll-free consumer complaint hot line number;



(e) The time frames and circumstances for expedited and standard

grievances;



(f) The right to appeal a grievance determination and the procedures for

filing such an appeal;



(g) The time frames and circumstances for expedited and standard

appeals;



(h) The right to designate a representative;



(i) A notice that all disputes involving clinical decisions shall be

made by qualified clinical personnel; and



(j) All notices of determination shall include information about the

basis of the decision and further appeal rights, if any;



(8) A description of a procedure for providing care and coverage

twenty-four hours a day, seven days a week, for emergency services. Such

description shall include the definition of emergency services and emergency

medical condition, notice that emergency services are not subject to prior

approval, and shall describe the enrollee's financial and other

responsibilities regarding obtaining such services, including when such

services are received outside the health maintenance organization's service

area;



(9) A description of procedures for enrollees to select and access the

health maintenance organization's primary and specialty care providers,

including notice of how to determine whether a participating provider is

accepting new patients;



(10) A description of the procedures for changing primary and specialty

care providers within the health maintenance organization;



(11) Notice that an enrollee may obtain a referral for covered services

to a health care provider outside of the health maintenance organization's

network or panel when the health maintenance organization does not have a

health care provider with appropriate training and experience in the network

or panel to meet the particular health care needs of the enrollee and the

procedure by which the enrollee may obtain such referral;



(12) A description of the mechanisms by which enrollees may participate

in the development of the policies of the health maintenance organization;



(13) Notice of all appropriate mailing addresses and telephone numbers

to be utilized by enrollees seeking information or authorization;



(14) A listing by specialty, which may be in a separate document that is

updated annually, of the names, addresses and telephone numbers of all

participating providers, including facilities, and in addition in the case of

physicians, board certification; and



(15) The director of the department of insurance, financial institutions

and professional registration shall develop a standard credentialing form

which shall be used by all health carriers when credentialing health care

professionals in a managed care plan. If the health carrier demonstrates a

need for additional information, the director of the department of insurance,

financial institutions and professional registration may approve a supplement

to the standard credentialing form. All forms and supplements shall meet all

requirements as defined by the National Committee of Quality Assurance.



2. Each health maintenance organization shall, upon request of an

enrollee or prospective enrollee, provide the following:



(1) A list of the names, business addresses and official positions of

the membership of the board of directors, officers, controlling persons,

owners or partners of the health maintenance organization;



(2) A copy of the most recent annual certified financial statement of

the health maintenance organization, including a balance sheet and summary of

receipts and disbursements prepared by a certified public accountant;



(3) A copy of the most recent individual, direct pay enrollee contracts;



(4) Information relating to consumer complaints compiled annually by the

department of insurance, financial institutions and professional registration;



(5) The procedures for protecting the confidentiality of medical records

and other enrollee information;



(6) An opportunity to inspect drug formularies used by such health

maintenance organization and any financial interest in a pharmacy provider

utilized by such organization. The health maintenance organization shall also

disclose the process by which an enrollee or his representative may seek to

have an excluded drug covered as a benefit;



(7) A written description of the organizational arrangements and ongoing

procedures of the health maintenance organization's quality assurance program;



(8) A description of the procedures followed by the health maintenance

organization in making decisions about the experimental or investigational

nature of individual drugs, medical devices or treatments in clinical trials;



(9) Individual health practitioner affiliations with participating

hospitals, if any;



(10) Upon written request, written clinical review criteria relating to

conditions or diseases and, where appropriate, other clinical information

which the organization may consider in its utilization review. The health

maintenance organization may include with the information a description of how

such information will be used in the utilization review process;



(11) The written application procedures and minimum qualification

requirements for health care providers to be considered by the health

maintenance organization;



(12) A description of the procedures followed by the health maintenance

organization in making decisions about which drugs to include in the health

maintenance organization's drug formulary.



3. Nothing in this section shall prevent a health maintenance

organization from changing or updating the materials that are made available

to enrollees.



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