Title XXIII — CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS

354.462. Enrollee, grounds for disenrollment. — An enrollee may not be disenrolled nor denied renewal except for the failure to pay the charge for such coverage, for fraudulent misuse of the system, for abusive conduct, for failure to establish a proper patient-physician relation…

354.464. Names not authorized for use, exceptions. — No health maintenance organization, unless licensed as an insurer, may use in its name, contracts, or literature any of the words "insurance", "casualty", "surety", "mutual", or any other words descriptive of the insurance, cas…

354.465. Examinations by division, when — costs, how paid. — 1. The director, or any duly appointed representative, may make an examination of the affairs of any health maintenance organization as often as he deems it necessary for the protection of the interests of the people of…

354.470. Suspension or revocation, when — effect. — 1. The director may suspend, revoke or place conditions or restrictions on any certificate of authority issued to a health maintenance organization pursuant to sections 354.400 to 354.636 if the director finds that any of the fo…

354.475. Insurance companies or health service company may organize and operate a health maintenance organization. — 1. An insurance company licensed in this state, or a health services corporation authorized to do business in this state, may directly or through a subsidiary or a…

354.480. Rehabilitation, liquidation, or conservation, grounds, procedure — enrollee's priorities — claims, priority. — 1. Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation …

354.485. Rules and regulations authorized. — The director may promulgate such reasonable rules and regulations in accordance with chapter 536 as are necessary or proper to carry out the provisions of sections 354.400 to 354.636. ­­-------- (L. 1983 H.B. 127, A.L. 2007 S.B. 66)

354.490. Certificate of authority, denial, suspension or revocation, grounds — procedure. — 1. When the director has cause to believe that grounds for the denial of an application for a certificate of authority exist, that grounds for the suspension or revocation of a certificate…

354.495. Fees to be paid to director. — Every health maintenance organization subject to sections 354.400 to 354.636 shall pay to the director the fees specified in section 374.230. ­­-------- (L. 1983 H.B. 127, A.L. 2007 S.B. 66, A.L. 2018 S.B. 982) Effective 1-01-19

354.500. Conferences called by director as to suspected or potential violations. — If the director shall for any reason have cause to believe that any violation of sections 354.400 to 354.636 has occurred or is about to occur, the director may give notice to the health maintenanc…

354.505. Laws regulating insurance or health service corporations not to apply, exceptions. — 1. Provisions of the insurance law and provisions of health services corporation laws shall not be applicable to any health maintenance organization granted a certificate of authority un…

354.510. Public documents, all filings and required reports. — Unless otherwise provided, all applications, filings, and reports required under sections 354.400 to 354.636 shall be treated as public documents. ­­-------- (L. 1983 H.B. 127, A.L. 2007 S.B. 66)

354.515. Confidential information, diagnosis, treatment, health of enrollees or applicants, exceptions. — 1. Any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant obtained from such person, or from any provider, by any health maint…

354.520. Mergers, consolidations, control of organization, requirements. — No person may take a tender for, or a request or invitation for tenders of, or enter into an agreement to exchange securities for, or acquire in the open market or otherwise, any voting security of a healt…

354.525. Health provision collective bargaining agreements or contracts — charge for coverage, how determined. — No employer in this state shall be required to pay more for health benefits as a result of the application of this section than would otherwise be required by any prev…

354.530. Severability clause. — If any section, term, or provision of sections 354.400 to 354.636 shall be adjudged invalid for any reason, such judgment shall not affect, impair, or invalidate any other section, term, or provision of sections 354.400 to 354.636, but the remainin…

354.535. Pharmacist, emergency situation, may take an assignment of enrollee's right to reimbursement — health maintenance organizations shall only contract with entities licensed by the board of pharmacy — requirements for drug prescriptions, exceptions. — 1. If a pharmacy, oper…

354.536. Continuation of dependent child coverage, when — dependent child defined. — 1. If a health maintenance organization plan provides that coverage of a dependent child terminates upon attainment of the limiting age for dependent children, such coverage shall continue while …

354.540. Health maintenance organization of bordering states may be admitted to do business — procedure. — A health maintenance organization approved and regulated under the laws of another bordering state may be admitted to do business in this state by satisfying the director th…

354.545. Exempt plans and companies. — The provisions of sections 354.400 to 354.636 shall not apply to any labor organization's health plan providing services established and maintained solely for its members and their dependents, and facilities of not-for-profit corporations in…

354.546. Second medical opinion to be allowed by health maintenance organizations, procedure, costs. — 1. A health maintenance organization shall allow enrollees to seek a second medical opinion or consultation from the health maintenance organization's choice of other primary ca…

354.550. Laws not applicable to community health companies. — The provisions of sections 354.400 to 354.636 shall not apply to community health corporations as defined by Public Law 94-63 so long as such corporations limit their activities to those described in Public Law 94-63. …

354.551. Health maintenance organizations may offer point of service (POS) riders, when. — 1. Missouri licensed health maintenance organizations shall be permitted to offer point of service riders (POS) to their approved health plan products, without being required to obtain a se…

354.552. Community-based health maintenance organizations, requirements. — 1. A community-based health maintenance organization shall have available and accessible a sufficient number and type of physicians, specialists, and other providers as needed to: (1) Provide the benefits …

354.554. Standing referrals for certain members of community-based health maintenance organizations, when. — Each community-based health maintenance organization shall offer coverage that allows an enrollee who suffers from a life-threatening condition or a degenerative, disablin…

354.556. Trustees, vacancies, elections. — 1. The terms of office of the trustees elected by the enrollees of the community-based health maintenance organization shall begin immediately upon their election. 2. If a vacancy occurs in the office of a trustee, the vacancy shall be f…

354.558. Materials provided to prospective purchasers. — A community-based health maintenance organization shall provide each prospective purchaser of its services with the following marketing materials prior to enrollment: (1) A list of the health care providers who have a contr…

354.559. Disclosure to members, restrictions and prohibitions. — No community-based health maintenance organization shall prohibit or restrict any provider from disclosing to any subscriber, enrollee or member any information that such provider deems appropriate regarding the nat…

354.560. Payment arrangements, department to adopt rules — disclosure of financial arrangements — confidentiality. — 1. The director of the department of commerce and insurance shall adopt rules governing the use of payment arrangements by community-based health maintenance organ…

354.562. Grievance procedures, rulemaking authority. — The director of the department of commerce and insurance shall promulgate rules governing grievance procedures for enrollees of a community-based health maintenance organization. Such regulations shall be consistent with and …

354.563. Medicare rules to apply to community-based health maintenance organizations, when. — If the Health Care Financing Administration of the United States Department of Health and Human Services promulgates regulations governing the practice of utilization review in health ma…

354.565. Community-based health maintenance organization designation given, when — revocation. — The director of the department of commerce and insurance shall designate those health maintenance organizations which meet the criteria established in subdivision (3) of section 354.4…

354.567. Community-based health maintenance organizations subject to other laws regarding health maintenance organizations. — Community-based health maintenance organizations shall be subject to the same provisions of law as other health maintenance organizations to the extent th…

354.570. Rulemaking — procedure. — No rule or portion of a rule promulgated pursuant to sections 192.068, 354.603, 376.423, 376.1353, 376.1356, 376.1378, 376.1387, * 354.560, 354.562 and 354.563 shall become effective unless it has been promulgated in accordance with the provisio…

354.600. Definitions. — For purposes of sections 354.600 to 354.636 the following terms shall mean: (1) "Facility", an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surg…

354.603. Sufficiency of health carrier network, requirements, criteria — access plan filed with the department, when. — 1. A health carrier shall maintain a network that is sufficient in number and types of providers to assure that all services to enrollees shall be accessible wi…

354.606. Providers notified of specific covered services, when — hold harmless provision — cessation of operations procedure — selection standards for health care professionals, filing with the department. — 1. A health carrier shall establish a mechanism by which the participati…

354.609. Termination of a contract, procedure. — 1. A health carrier and a participating provider shall provide at least sixty days written notice to each other before terminating the contract without cause. The written notice shall include an explanation of why the contract is b…

354.612. Continuation of care after provider termination, when. — 1. Contracts between health plans and providers shall include a provision for the continuation of care to enrollees for a period of up to ninety days by a provider who terminates or is terminated from a network whe…

354.615. Referrals to appropriate providers, when. — 1. If a health carrier determines that it does not have a health care provider with appropriate training and experience in its panel or network to meet the particular health care needs of an enrollee, the health carrier shall m…

354.618. Open referral health plans offered, when — definitions — obstetrician/ gynecologist services to be offered, when — eye care providers, discrimination against, prohibited — exemptions. — 1. A health carrier shall be required to offer as an additional health plan, an open …

354.621. Intermediary and participating provider requirements. — 1. Intermediaries and participating providers with whom they contract shall comply with all the applicable requirements of sections 354.600 to 354.636. 2. A health carrier's statutory responsibility to monitor the o…

354.624. Proposed provider contract forms filed with the director — contracts maintained at place of business, available for review, when. — 1. A health carrier shall file with the director all contract forms proposed for use with its participating providers and intermediaries. T…

354.627. Liability of a health carrier, when. — 1. The executing of a contract by a health carrier shall not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, or of its responsibility for compliance with the law o…

354.636. Contract requirements after January 1, 1998. — All provider and intermediary contracts delivered, issued for delivery, continued or renewed on or after January 1, 1998, shall comply with sections 354.600 to 354.636 unless otherwise provided by sections 354.600 to 354.636…

354.650. Definitions. — As used in sections 354.650 to 354.658, the following terms mean: (1) "Department", the department of health and senior services; (2) "Essential community provider", an individual physician, licensed pursuant to the provisions of chapter 334, who meets the…

354.652. Designation as essential community provider, procedure, qualifications. — Any physician seeking a designation as an essential community provider shall: (1) Apply to the director of the department; (2) Document to the department that at least forty percent of the physicia…

354.654. Department of health and senior services, duties — rulemaking authority. — 1. The department of health and senior services shall issue a letter of designation as an essential community provider to any physician who makes a written request and application to the departmen…

354.656. Inclusion of essential community providers in health care network, exceptions. — 1. Any health care insurer offering or marketing a group policy, plan or contract for health care services in an area designated pursuant to subdivision (4) or (5) of section 354.650 shall a…

354.658. Designation nontransferable, site specific — annual affidavit required — notice of certain changes, required when. — 1. The designation of essential community provider shall not be transferable to another physician, health care provider or entity. 2. The designation of e…