Service Area Expansion

PURPOSE: This rule sets forth the information to be provided to the director by a health maintenance organization seeking to expand its service area. This rule is promulgated pursuant to sections 354.430 and 354.485, RSMo. (1) For a contiguous service area expansion request to be approved, the health maintenance organization (HMO) must provide the director with the following information in support of the request: (A) If prior action of the HMO’s board is required, minutes of the board meeting at which expansion was authorized and any related amendments to the basic organization document or bylaws; (B) A map of the new service area showing locations of primary care physicians, hospitals and emergency care facilities; (C) Any pro forma contracts or agreements with physicians and other providers in the new area; and (D) A list of all physicians and other providers who have agreed to provide services in the new area. (2) If the new area is not contiguous with the previously approved area, the following additional information must be provided: (A) A brief narrative description of the administrative arrangements and other pertinent information; (B) Biographical data sheets for the management staff assigned to the new area; (C) Enrollee participation plan for the new area; (D) Marketing information about the new area, including demographic material, enrollment projections for the period from the beginning of operations until operations in the new service area have produced a net income for twelve (12) consecutive months and proposed advertising and sales materials; (E) Evidence of coverage to be used in the new area; (F) Rates to be charged and appropriate actuarial certifications; (G) Copies of leases, loans and contracts to be used in the proposed new area; and (H) Sources of financing and financial projections for the period from the beginning of operations until operations in the new area will have produced a net income for twelve (12) consecutive months. (3) The HMO shall provide other information as the director may consider necessary to adequately describe the proposal. AUTHORITY: section 354.485, RSMo 1986.* This rule was previously filed as 4 CSR 19015.170. Original rule filed Nov. 2, 1987, effective April 11, 1988. *Original authority: 354.485, RSMo 1983.