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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