Additional Mandatory Provisions—Individual Contracts and Evidences of Coverage

PURPOSE: This rule sets forth provisions which must be included in individual contracts and evidences of coverage in addition to the provisions set forth in 20 CSR 4007.030. This rule is promulgated pursuant to sections 354.430 and 354.485, RSMo. (1) Individual contracts and evidences of coverage must contain in substance the following provision(s) which, in the opinion of the director of insurance, are at least as or more favorable to the enrollee, in addition to those set out in 20 CSR 400-7.030. (2) Reinstatement. A provision that clearly sets forth the requirements for reinstatement and discloses how reinstatement changes or affects the rights and coverages originally provided. New evidence on insurability may be required. (3) Ten (10) Days to Examine Agreement. A provision stating that the enrollee to whom the evidence of coverage is issued shall be permitted to return the evidence of coverage within ten (10) days of receiving it and have the premium paid refunded to them if, after examination of the agreement, the enrollee is not satisfied with it for any reason. If the enrollee, pursuant to provision, returns the evidence of coverage to the issuing health maintenance organization (HMO) or to the insurance producer or representative through whom it was purchased, it is considered void from the beginning and the parties are in the same position as if no evidence of coverage had been issued. If services are rendered or claims paid by the HMO during the ten (10) days, the person shall not be permitted to return the contract and receive a refund of the premium paid. (4) Original Premium. The original premium for coverage must be stated in the evidence of coverage or in the application. (5) Grace Period. A provision for a grace period of at least ten (10) days, for payment of any premium falling due after the first premium, during which time the coverage remains in effect. If payment is not received within ten (10) days, coverage may be cancelled after the tenth day. The terminated enrollee will be responsible for the cost of services received during the grace period if this requirement is disclosed in the evidence of coverage. AUTHORITY: sections 354.430, 354.485 and 374.045, RSMo 2000.* This rule was previously filed as 4 CSR 190-15.100. Original rule filed Nov. 2, 1987, effective April 11, 1988. Amended: Filed July 12, 2002, efective Jan. 30, 2003. *Original authority: 354.430, RSMo 1983, amended 1997; 354.485, RSMo 1983; and 374.045, RSMo 1967, amended 1993, 1995.