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 medicallyrelated 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). AUTHORITY: sections 354.430, 354.485, and 374.045, RSMo 2000.* This rule was previously filed as 4 CSR 190-15.090. Original rule filed Nov. 2, 1987, effective April 11, 1988. Amended: Filed Nov. 3, 1992, effective Jan. 1, 1994. Amended: Filed July 12, 2002, effective Jan. 30, 2003. *Original authority: 354.430, RSMo 1983, amended 1997; 354.485, RSMo 1983; and 374.045, RSMo 1967, amended 1993, 1995.