20 CSR 400-7.030 - Mandatory Provisions- All Contracts
PURPOSE: This rule sets forth the provisions which must be present in an evidence of coverage. This rule is promulgated pursuant to sections 354.430 and 354.485, RSMo.
(1) All group and
individual contracts and all evidences of coverage must contain in substance
the following provisions, or provisions which in the opinion of the director of
insurance are more favorable to the enrollee or at least as favorable to the
enrollee and more favorable to the contract holder: name, address and telephone
number of the administrative offices of the health maintenance organization
(HMO) must appear on the face page; the face page is the first page that
contains any written material; and if in booklet form, the first page inside
the cover is the face page.
(2)
Benefits. A description of all health care services available to an enrollee
under the health care plan, including any copayments or other charges for which
the member may be responsible.
(3)
Cancellation. A statement that the HMO must give the group contract holder, in
the case of group coverage, or the enrollee, in the case of individual
coverage, at least thirty-one (31) days' prior notice of any cancellation or
termination except termination for nonpayment of premium. In the case of group
coverage, the HMO may not terminate the contract prior to the first anniversary
date except for nonpayment of the required premium or the failure to meet
continued underwriting standards.
(4) Claim Filing Procedure. A provision
setting forth the procedure for filing claims, including:
(A) How, when and where to obtain claim
forms, if required; and
(B) The
requirements for providing proper notice of claim and proof of loss. Failure to
furnish the notice or proof within the time required shall not invalidate or
reduce any claim, if it was not reasonably possible to give notice or proof
within this time.
(5)
Definitions. A provision defining any words in the evidence of coverage which
have other than the usual meaning.
(6) Effective Date. A statement of the
effective date requirements for various classes of enrollees.
(7) Eligibility. A statement of the
eligibility requirements for coverage including:
(A) The condition under which dependent
enrollees may be added to those originally covered;
(B) Any limiting age for enrollees and
dependents, including effects of Medicare eligibility; and
(C) A clear statement regarding the coverage
of newborn children. All evidences of coverage which provide coverage for a
family member of the enrollee, as to this family member's coverage, also shall
provide that the benefits applicable for children also shall be applicable with
respect to a newly born child of the enrollee from the moment of birth. The
coverage for newly born children shall consist of coverage of injury or
sickness including the necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities. The HMO may require that the
enrollee notify the HMO during the initial thirty-one (31) days after the birth
of the child and pay any additional premium required to provide coverage for
the newborn child from the date of birth.
(8) Emergency Services. A description of how
to obtain services in an emergency situation, including:
(A) Any requirements that the HMO be
contacted before the enrollee obtains care; and
(B) What to do in case of a life-threatening
emergency.
(9)
Out-of-Area Benefits and Services. The contract and evidence of coverage shall
contain a specific description of benefits and services available out of the
service area. Medically necessary emergency benefits must be available when the
enrollee is temporarily outside the service area and-
(A) Medically necessary health services are
immediately required;
(B) The
condition for which the services are required could not have been
foreseen;
(C) The enrollee's
medical condition does not permit his/her return to the service area for
treatment;
(D) The reason for being
outside the service area must be for some purpose other than the receipt of
treatment for a medically-related condition;
(E) The HMO may require notification from or
on behalf of the enrollee as soon as possible; and
(F) Services received by the enrollee outside
the service area will be covered until the enrollee's medical condition permits
travel or transport to the HMO's service area.
(10) Entire Contract, Amendments. A provision
stating that the contract and any attachments constitute the entire contract
between the parties and that, to be valid, any change in the contract must be
approved by an officer of the HMO and attached to the affected contract and
that no insurance producer or representative has the authority to change the
contract or waive any of the provisions.
(11) Exclusions and Limitations. A provision
setting forth any exclusions and limitations on health care services.
(12) Time Limit on Certain Defenses. A
provision that, in the absence of fraud, all statements made by an enrollee are
considered representations and not warranties and that no statement voids the
coverage or reduces the benefits after the coverage has been in force for two
(2) years from its effective date, unless the statement was material to the
risk assumed and contained in a written application. A copy of the written
application or enrollment form must have been furnished to the enrollee if the
terms of the application or enrollment form are to be applied.
(13) Schedule of Rates. A provision that
discloses the HMO's right to change the rates charged and indicates the amount
of prior notice which must be given.
(14) Service Area. A map or clear description
of the service area indicating major primary and emergency care delivery
sites.
(15) Termination Due to
Attaining Limiting Age.
(A) Medicare. A
provision describing the effect of becoming eligible for Medicare on the part
of an enrollee or dependent.
(B)
Handicapped Child. A provision that a child's attainment of a limiting age does
not operate to terminate coverage of the child while that child is incapable of
self-sustaining employment due to mental or physical handicap and chiefly
dependent upon the enrollee for support and maintenance. The enrollee may be
required to furnish proof of incapacity and dependency within thirty-one (31)
days before the child's attainment of the limiting age and subsequently, as
required, but not more frequently than annually following the child's
attainment of the limiting age.
(16) Where to Obtain Services. A statement
explaining where and in what manner information is available as to how services
may be obtained.
(17) Every HMO
that has a plan which will affect the choice of physician, hospital or other
health care provider, such as by refusing to cover services rendered by a
provider not affiliated with the HMO, shall set forth conspicuously the
following statement, or other wording which has been approved by the director
to the same effect, on the following materials when given to current and
prospective enrollees: certificates and evidences of coverage, member
handbooks, provider directories and any materials which make a direct offer to
an individual prospective enrollee to become a member of the HMO.
NOTICE
THIS HMO MAY HAVE RESTRICTIONS REGARDING WHICH PHYSICIANS OR OTHER HEALTH CARE PROVIDERS AN HMO MEMBER MAY USE. PLEASE CONSULT YOUR MEMBER HANDBOOK OR PROVIDER DIRECTORY FOR MORE DETAILS. IF YOU HAVE ANY ADDITIONAL QUESTIONS, PLEASE WRITE OR CALL US AT:
____________________________________
(HMO's Name)
____________________________________
(HMO's Address)
____________________________________
(HMO's Telephone Number)
(A) The HMO shall not be required to place
such a statement in materials that constitute or represent supplemental benefit
riders, copayment schedules or marketing or promotional material including, but
not limited to, posters or print or media advertisements, which are not
directed to specific individual enrollees but which may be directed toward a
group(s) of enrollees.
(B) Every
HMO shall include such a statement at the time promotional and descriptive
materials, disclosure forms and certificates and evidences of coverage are
issued or revised for distribution, but in no case later than the effective
date of section (17) of this rule (January 1, 1994).
Notes
*Original authority: 354.430, RSMo 1983, amended 1997; 354.485, RSMo 1983; and 374.045, RSMo 1967, amended 1993, 1995.
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