Title XXIV — BUSINESS AND FINANCIAL INSTITUTIONS

376.1253. Second opinion, right of newly diagnosed cancer patients, attending physician to inform — insurance coverage for such second opinions required, when. — 1. Each physician attending any patient with a newly diagnosed cancer shall inform the patient that the patient has th…

376.1257. Orally administered anticancer medications, plan to provide coverage no less favorable than IV or injected medications — definitions — requirements — effective date. — 1. As used in this section the following terms shall mean: (1) "Anticancer medications", medications u…

376.1275. Coverage for human leukocyte antigen testing for bone marrow transplantation required, when — exceptions. — 1. Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this s…

376.1290. Coverage for lead testing. — 1. Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a health services corporation, individual and group se…

376.130. To furnish certificate of deposit, when. — When the corporators have fully complied with the requirements of the preceding sections, and the laws of this state governing the organization of private corporations, and said corporation has deposited with the director of the…

376.1300. Reorganization of a domestic mutual life insurance company, authority. — A domestic mutual life insurance company organized and operating pursuant to this chapter may reorganize by forming a mutual life insurance holding company as described in section 376.1309 or by me…

376.1305. Formation of holding company, application — shareholder approval. — 1. A mutual life insurance company proposing to reorganize pursuant to sections 376.1300 to 376.1322 shall form a mutual life insurance holding company, which may hereafter be referred to as a mutual ho…

376.1307. Issuance of shares. — All of the shares, if any are issued, of the capital stock of the reorganized life insurance company shall be issued to the mutual holding company, which shall at all times own a majority of the voting shares of the capital stock of the reorganized…

376.1309. Member's interest — nontransference of membership — immunity from liability — assessments, not imposed — security, membership interest. — 1. The membership interest of the policyholders of a reorganized life insurance company shall become membership interests in the mut…

376.1312. Nonapplicability of certain provisions of insurance holding companies law. — Sections 382.040, 382.060, and 382.095 shall not apply to a reorganization or merger pursuant to the provisions of sections 376.1300 to 376.1322. ­­-------- (L. 1996 S.B. 759)

376.1315. Incorporation of mutual holding company, authority, approval. — Notwithstanding any provision of this chapter to the contrary, a mutual holding company organized pursuant to section 376.1300 shall be incorporated pursuant to this chapter. The articles of incorporation a…

376.1318. Powers of mutual holding company, engaging in business of insurance, no authority, affiliation and merger agreements. — A mutual holding company shall have the same powers granted to domestic insurance companies pursuant to chapter 382 relating to insurance holding comp…

376.1322. Mutual holding company subject to supervision of director, dissolution or liquidation — demutualization. — 1. A mutual holding company is subject to the supervision of the director of the department of commerce and insurance in the same manner as an insurer subject to t…

376.1345. Method of reimbursement not to require fee, discount, or remuneration — notification requirements — electronic funds transfer, when — overpayment, procedure — violation, penalty. — 1. As used in this section, unless the context clearly indicates otherwise, terms shall h…

376.1350. Definitions. — For purposes of sections 376.1350 to 376.1390*, the following terms mean: (1) "Adverse determination", a determination by a health carrier or a utilization review entity that an admission, availability of care, continued stay or other health care service …

376.1353. Utilization review activities monitored. — A health carrier shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of sections 376.1350 to 376.1390 and applicable r…

376.1356. Utilization review entity monitored, when. — Whenever a health carrier contracts to have a utilization review entity perform the utilization review functions required by sections 376.1350 to 376.1390* or applicable rules and regulations, the health carrier shall be resp…

376.1359. Written utilization program implemented, filed with the director. — 1. A health carrier that conducts utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated, for covered services prov…

376.1361. Documented clinical review criteria used in a utilization program — medical director qualifications — compensation of utilization review services. — 1. A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence a…

376.1363. Utilization review decisions, procedures. — 1. A health carrier shall maintain written procedures for making utilization review decisions and for notifying enrollees and providers acting on behalf of enrollees of its decisions. For purposes of this section, "enrollee" i…

376.1364. Unique confirmation number required, prior authorization review — secure electronic transmission for prior authorizations — single cover page, contents. — 1. Any utilization review entity performing prior authorization review shall provide a unique confirmation number t…

376.1365. Reconsideration of an adverse determination, when. — 1. In a case involving an initial determination or a concurrent review determination, a health carrier shall give the provider rendering the service an opportunity to request on behalf of the enrollee a reconsideratio…

376.1367. Emergency services benefit determination, coverage required, when. — When conducting utilization review or making a benefit determination for emergency services: (1) A health carrier shall cover emergency services necessary to screen and stabilize an enrollee, as determ…

376.1369. Certification of compliance, when. — A health carrier shall annually provide a written certification to the director that the utilization review program of the health carrier or its designee complies with all applicable state and federal laws establishing confidentialit…

376.1372. Certification and member handbook to include utilization review procedures — website or provider portal, prior authorization requirements available on. — 1. In the certificate of coverage and the member handbook provided to enrollees, a health carrier shall include a cl…

376.1375. Registry of grievances maintained, procedures — definitions. — 1. A health carrier shall maintain a written register of all grievances in a manner consistent with the requirements for maintaining complaint records pursuant to section 354.445. The grievance register shal…

376.1378. Grievances and certificate of compliance filed with the director, when. — 1. A copy of the grievance procedures, including all forms used to process a grievance, shall be filed with the director. Any subsequent material modifications to the documents also shall be filed…

376.1382. First- and second-level grievance review for managed care plans, first-level procedures. — 1. A health carrier that offers managed care plans shall establish a first-level and second-level grievance review process for its managed care plans. A grievance may be submitted…

376.1385. Second-level review procedures. — 1. Upon receipt of a request for second-level review, a health carrier shall submit the grievance to a grievance advisory panel consisting of: (1) Other enrollees; and (2) Representatives of the health carrier that were not involved in …

376.1387. Appeals of grievances determined by the director. — 1. The director shall resolve any grievance regarding an adverse determination as to covered services appealed by an enrollee or health carrier or plan sponsor through any means not specifically prohibited by law but i…

376.1389. Expedited grievance review procedure. — 1. A health carrier shall establish written procedures for the expedited review of a grievance involving a situation where the time frame of the standard grievance procedures set forth in sections 376.1382 and 376.1385 would serio…

376.1399. Rules, effective, when — rules invalid and void, when. — Any rule or portion of a rule promulgated pursuant to this act shall become effective only as provided pursuant to chapter 536, including, but not limited to, section 536.028, if applicable, after August 28, 1997.…

376.1400. Explanation of benefits, standardized information used, contents, when. — 1. Every health insurance carrier offering policies of insurance in this state shall use standardized information for the explanation of benefits given to the health care provider whenever a claim…

376.1403. Referrals, standardized information used, content, when. — 1. Every health care provider and health carrier that conducts business in this state shall use standardized information for referrals. As used in this section, the terms "health care provider" and "health carri…

376.142. Stock company may become mutual — procedure — policyholders' meeting — acquisition of stock. — 1. Any domestic stock life insurance corporation, incorporated under a general law, may become a mutual life insurance corporation, and to that end may carry out a plan for the…

376.143. Stock company may acquire its own shares to be held in trust for mutual — appointment, powers and duties of trustees. — 1. If a domestic stock life insurance corporation determines to become a mutual life insurance corporation, it may, in carrying out any plan to that en…

376.144. Acquisition of shares of dissenting stockholders, procedure — abandonment of mutualization. — 1. If a stockholder of any domestic stock life insurance corporation planning to become a mutual life insurance corporation under section 376.142 files with the corporation prio…

376.145. Officers of stock company to continue as officers of mutual. — When a domestic stock life insurance corporation has become converted into a mutual life insurance corporation, the officers and directors or trustees of the original corporation shall remain as the officers …

376.1450. Enrollee's right to receive documents and materials in printed or electronic form, when. — An enrollee, as defined in section 376.1350, may receive documents and materials from a managed care entity in printed or electronic form so long as such documents and materials a…

376.146. Board of directors or trustees of mutual, membership qualifications, term of office. — 1. The corporate powers of a mutual life insurance corporation shall be exercised by, and its business and affairs shall be controlled by, a board of directors or trustees composed of …

376.147. Meetings of board of mutual, notice — executive committee of board, powers. — 1. Meetings of the board of directors or trustees of any mutual life insurance corporation shall be upon such notice as the articles of agreement prescribe. Attendance of a director or trustee …

376.148. Policyholders are members of mutual — voting rights — directors may alter articles — additional assessments prohibited. — 1. The articles of agreement of any mutual life insurance corporation shall provide that each policyholder of the corporation shall be a member of th…

376.150. Stock and mutual companies — content of charter. — When such corporators propose to form a stock and mutual company for the purposes designated in section 376.010, the charter comprised in the declaration named in section 376.050 shall set forth all the particulars menti…

376.1500. Definitions. — As used in sections 376.1500 to 376.1532, the following words or phrases mean: (1) "Director", the director of the department of commerce and insurance; (2) "Discount card", a card or any other purchasing mechanism or device, which is not insurance, that …

376.1502. Requirements for transaction of business. — 1. It is unlawful to transact business in this state as a discount medical plan organization, unless the organization is a corporation, limited liability corporation, partnership, limited liability partnership or other legal e…

376.1504. Registration requirements — term of registration — renewal. — 1. To register as a discount medical plan organization, an applicant shall: (1) File with the director an application on a form approved and adopted by the director; and (2) Pay to the director an application…

376.1506. Violations, penalty. — 1. If the director has a reason to believe that the discount medical plan organization is not complying with the requirements of sections 376.1500 to 376.1532, the director may examine or investigate the business and affairs of any discount medica…

376.1508. Processing fee — cancellation of membership, effect of. — 1. A discount medical plan organization may charge a reasonable one-time processing fee and a periodic charge as long as the fee is disclosed to the applicant. 2. If the member cancels the membership within the f…

376.1510. Prohibited acts. — A discount medical plan organization shall not: (1) Use in its advertisements, marketing material, brochures, and discount cards the terms "health plan", "coverage", "co-pay", "co-payments", "preexisting conditions", "guaranteed issue", "premium", "PP…

376.1512. Required disclosures. — 1. The following disclosures, to be printed in bold and in not less than twelve-point type, shall be made in writing to any prospective member and shall appear on the first page or first content page of any advertisements, marketing materials or …