Actual Payment as Basis for Policy or Plan Calculations

PURPOSE: This rule effectuates or aids in the interpretation of the following sections: 354.085 and 354.430(1), RSMo relating to certain policy forms that contain provisions which are deceptive, ambiguous, misleading, unfair, unjust, or inequitable; 354.350 and 375.445, RSMo regarding the carrying out of contracts in good faith; 354.410.1(2) and 354.430.3(2), RSMo pertaining to reasonable requirements for copayments; 354.085, 376.405 and 376.777, RSMo regarding whether policy forms contain such words, phraseology, conditions and provisions which are specific, certain and reasonably adequate to meet the needed requirements for the protection of those insured; and 354.410.1(9), RSMo relating to operating contrary to the public interest. (1) Definitions. As used in this rule— (A) “Actual payment,” the real total dollar amount actually paid or to be paid in fact, by a health insurer, or by the health insurer and the insured when the insured is responsible for some part of the cost, to a health services provider for a health service(s) pursuant to a health plan. Annual adjustments in amounts paid to providers which are based on referral rates, quality or cost effectiveness measurements, or other similar contractual provisions may be excluded from the calculation of actual payments, at the option of the health insurer. (B) “Expense participation,” a financial contribution that the insured is required by the health plan to pay for a health service(s). “Expense participation” includes, but is not limited to, these forms of expense participation: deductibles, copayments, coinsurance, and additional charges by the health insurer that are caused by a failure to follow the utilization management or other requirements of the health plan; (C) “Health insurer,” any person, fraternal benefit society, and any other legal entity engaged in the business of insurance, including producers, adjusters, public adjusters and thirdparty administrators. “Health insurer” shall also mean health services corporations, health maintenance corporations, prepaid limited health care service plans, optometric and other similar health service plans, preferred provider plans, managed care plans, point-of-service plans, and multiple employer self-insured health plans. For the purpose of this rule, these foregoing entities are deemed to be engaged in the business of insurance. “Health insurer” shall also include all companies organized, incorporated or doing business AND INSURANCE under the provisions of Chapters 374, 375, 376, 378, 379, RSMo; provided that only persons or entities which offer, issue, manage or administer a health plan shall be deemed to be a “health insurer;” (D) “Health plan,” any insurance contract, policy or certificate, or any contract, plan or arrangement, which provides for the payment of a health service provider’s charges for health services provided to insured. “Health plan” does not include any policy of workers compensation insurance or the medical payments portion of any automobile, homeowners or other property and casualty insurance policy; (E) “Health services,” any service or product for which provision for benefits has been made under a health plan, including but not limited to, the health care and services provided by hospitals, or other health care institutions, organizations, associations or groups, and by doctors of medicine, osteopathy, chiropractic, psychiatry, optometry, and podiatry, and shall also include nursing services, preventative health care services, health screening, prenatal care, medical appliances, equipment and supplies, drugs, medicines, ambulance services, mental health services, supplemental services, and other therapeutic services and supplies, and laboratory analysis, physical examinations, the rendering of assistance to physicians, and services for drugs and alcohol abuse, physiotherapy, anesthesiology, and anesthesia; (F) “Health services provider,” any person or entity providing health services; (G) “Insured,” any individual covered by a health plan; and (H) “Person,” any natural or artificial entity, or aggregate of such entitles, including, but not limited to, individuals, partnerships, associations, trusts or corporations. (2) Expense Participation. Under any health plan which provides for expense participation, whether in the form of coinsurance, copayments, a deductible or otherwise, such that the expense participation is to be computed as a percentage of, or as a function of the health service provider’s charge(s) for a health service(s), the charge used in such computation shall always and solely be no greater than the actual payment(s) made to the health service provider. (3) Benefit Caps. Under any health plan which establishes benefit maximums or caps, such benefit maximums or caps shall always and solely be determined using a basis that is no greater than the actual payment(s) made to the health service provider. (4) No Limitation. Nothing in this rule limits a health insurer’s right to pay some or all of an insured’s expense participation share of any charge for health services, or to exceed an insured’s benefit maximum or cap. (5) Insurer-Provider Contract. This rule addresses the basis for calculating expense participation and benefit maximums or caps, and in no way affects the relationship or negotiations between health insurers and health services providers. AUTHORITY: sections 354.120, 374.045 and 376.405, RSMo 2000 and sections 354.085 and 354.485, RSMo Supp. 2007.* Original rule filed Nov. 1, 2007, effective July 30, 2008. *Original authority: 354.085, RSMo 1973, amended 1983, 2000; 354.120, RSMo 1973, amended 1983, 1993, 1995; 354.485, RSMo 1983, amended 2007; 374.045, RSMo 1967, amended 1993, 1995; and 376.405, RSMo 1959, amended 1984.