reglab/statecodes huggingface dataset:
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.500 - Conferences called by director as to suspected or potential violations.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 2007
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 maintenance organization and to the representatives, or other persons who appear to be involved in such suspected violation, to arrange a conference with the alleged violators, or potential violators, or their authorized representatives, for the purpose of attempting to ascertain the facts relating to such suspected or potential violation, and, in the event it appears that any violation has occurred or is about to occur, to arrive at an adequate and effective means of correcting or preventing such violation. Proceedings under this subsection shall not be governed by any formal procedural requirements, and may be conducted in such manner as the director may deem appropriate under the circumstances.
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(L. 1983 H.B. 127, A.L. 2007 S.B. 66)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.505 - Laws regulating insurance or health service corporations not to apply, exceptions.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 under sections 354.400 to 354.636 unless made specifically applicable by statute. This provision shall not apply to an insurer or health services corporation licensed and regulated pursuant to the insurance laws of the health services corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to sections 354.400 to 354.636.
2. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its duly authorized representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
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(L. 1983 H.B. 127, A.L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.510 - Public documents, all filings and required reports.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 2007
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.
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(L. 1983 H.B. 127, A.L. 2007 S.B. 66)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.515 - Confidential information, diagnosis, treatment, health of enrollees or applicants, exceptions.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 maintenance organization shall be held in confidence and shall not be disclosed to any person except as follows:
(1) To the extent that it may be necessary to carry out the purposes of sections 354.400 to 354.636;
(2) Upon the express consent of the enrollee or applicant;
(3) Pursuant to statute or court order for the production of evidence or the discovery thereof;
(4) In the event of a claim or litigation between such person and the health maintenance organization wherein such data or information is pertinent. A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnishes such information to the health maintenance organization is entitled to claim, but no such claim or privilege against disclosure may be made against the director by such health maintenance organization.
2. Every health maintenance organization shall establish and maintain procedures to ensure that all mental health records of enrollees remain confidential. Such procedures and any subsequent amendments thereto shall be filed annually with the director.
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(L. 1983 H.B. 127, A.L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.520 - Mergers, consolidations, control of organization, requirements.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1983
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 health maintenance organization, nor enter into any other agreement which if, after the consummation thereof, that person would, directly or indirectly, or by conversion or by exercise of any right to acquire, be in control of the health maintenance organization. No person may enter into an agreement to merge or consolidate with, or to otherwise acquire control of a health maintenance organization, unless, at the time any offer, request, or invitation is made, or any agreement is entered into, or prior to the acquisition of the securities if no offer or agreement is involved, the person has filed with the director, and has sent to the health maintenance organization, information required by chapter 382, and the offer, request, invitation, agreement, or acquisition has been approved by the director. Such approval by the director shall be governed by the provisions of chapter 382.
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(L. 1983 H.B. 127)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.525 - Health provision collective bargaining agreements or contracts — charge for coverage, how determined.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1983
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 prevailing collective bargaining agreement, or other contract, for the provision of health benefits to its employees; provided, that the employer or benefits fund shall pay to the health maintenance organization chosen by each employee or member an amount equal to the lesser of (a) the amount paid on behalf of its other employees or members for health benefits; or (b) the health maintenance organization's charge for coverage approved by the director pursuant to section 354.435.
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(L. 1983 H.B. 127)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.530 - Severability clause.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 2007
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 remaining sections, terms, and provisions shall be and remain in full force and effect.
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(L. 1983 H.B. 127, A.L. 2007 S.B. 66)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.536 - Continuation of dependent child coverage, when — dependent child defined.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 01 Jan 2008, see footnote
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 the child is and continues to be both incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the enrollee for support and maintenance. Proof of such incapacity and dependency must be furnished to the health maintenance organization by the enrollee at least thirty-one days after the child's attainment of the limiting age. The health maintenance organization may require at reasonable intervals during the two years following the child's attainment of the limiting age subsequent proof of the child's disability and dependency. After such two-year period, the health maintenance organization may require subsequent proof not more than once each year.
2. If a health maintenance organization plan provides that coverage of a dependent child terminates upon attainment of the limiting age for dependent children, such plan, so long as it remains in force, until the dependent child attains the limiting age, shall remain in force at the option of the enrollee. The enrollee's election for continued coverage under this section shall be furnished to the health maintenance organization within thirty-one days after the child's attainment of the limiting age. As used in this subsection, a dependent child is a person who is:
(1) Unmarried and no more than twenty-five years of age; and
(2) A resident of this state; and
(3) Not provided coverage as a named subscriber, insured, enrollee, or covered person under any group or individual health benefit plan, or entitled to benefits under Title XVIII of the Social Security Act, P.L. 89-97, 42 U.S.C. Section 1395, et seq.
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(L. 2007 H.B. 818)
Effective 1-01-08
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.540 - Health maintenance organization of bordering states may be admitted to do business — procedure.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 2007
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 that it is fully and legally organized under the laws of its state, and that it complies with all requirements for health maintenance organizations organized within Missouri. The director may waive or modify the provisions of sections 354.400 to 354.636 if he determines that the same are not appropriate or necessary to a particular health maintenance organization of another state.
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(L. 1983 H.B. 127, A.L. 2007 S.B. 66)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.545 - Exempt plans and companies.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 2007
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 existence on October 1, 1980, subject either to the provisions and regulations of Section 302 of the Labor-Management Relations Act, 29 U.S.C. 186 or the Labor-Management Reporting and Disclosure Act, 29 U.S.C. 401-538.
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(L. 1983 H.B. 127, A.L. 2007 S.B. 66)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.546 - Second medical opinion to be allowed by health maintenance organizations, procedure, costs.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1998
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 care physicians and specialty physicians at no additional cost to the enrollee beyond what the enrollee would otherwise pay for an initial medical opinion or consultation.
2. If an enrollee chooses to seek a second medical opinion, and if the health maintenance organization does not employ or contract with another physician with the expertise necessary to provide a second medical opinion, then the health maintenance organization shall arrange for a referral to a physician with the necessary expertise to provide a second opinion or consultation and ensure that the enrollee obtains the covered benefit at no greater cost to the enrollee than if the benefit were obtained from participating physicians.
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(L. 1998 S.B. 754)
CROSS REFERENCE:
Second medical opinions covered, when, 354.207
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.550 - Laws not applicable to community health companies.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 2007
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.
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(L. 1983 H.B. 127, A.L. 2007 S.B. 66)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.551 - Health maintenance organizations may offer point of service (POS) riders, when.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 separate license as a health insurer pursuant to chapter 376, so long as medical and hospital expenses incurred under the POS rider do
*
not exceed ten percent of total medical and hospital expenses incurred for all health plan products sold.
2. Health maintenance organizations which have been licensed for at least one calendar year, who choose to insure the POS rider, shall maintain a net worth of the greater of:
(1) One million two hundred thousand dollars; or
(2) Two percent of total premium revenue for the immediately preceding twelve months plus fifty percent of uncovered liabilities as reported in the immediately preceding calendar quarter.
3. Health maintenance organizations which have been licensed for less than one calendar year, who choose to insure the POS rider, shall maintain a net worth of the greater of:
(1) One million two hundred thousand dollars; or
(2) Ten percent of the yearly average of the three-year annual premium plus fifty percent of its average annual uncovered liabilities as projected in its application for a certificate of authority.
4. The department of commerce and insurance may modify the net worth requirements for a health maintenance organization which has been licensed for less than one calendar year if its actual results deviate materially from its projections. In addition to any other deposit required of a licensed health maintenance organization pursuant to section 354.410, any health maintenance organization which chooses to issue a POS rider shall deposit an additional six hundred thousand dollars
**
with the director of the department of commerce and insurance. Any health maintenance organization which issues a POS rider whose medical and hospital expenses incurred under the POS rider exceed
***
ten percent of total medical and hospital expenses incurred for all health plan products sold shall either cease insuring new POS riders until it comes into compliance with the ten percent limitation of this section or meet the minimum net worth requirements and all other statutory and regulatory requirements of a Missouri domestic life insurance company.
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(L. 1997 H.B. 335 § 11)
*Word "does" appears in original rolls.
**Word "dollars" does not appear in original rolls.
***Word "exceeds" appears in original rolls.
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.552 - Community-based health maintenance organizations, requirements.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 covered by the plan;
(2) Meet the medical needs of the health plan's enrolled population;
(3) Provide members with a reasonable choice of primary care physicians and specialty physicians.
2. If a community-based health maintenance organization does not employ or contract with a physician with the expertise necessary to provide medically necessary care covered by the health plan, then the health maintenance organization shall arrange for a referral to a physician with the necessary expertise and ensure that the members obtain the covered benefit at no greater cost to the member than if the benefit were obtained from participating physicians.
3. A community-based health maintenance organization's physicians, physician specialists and facilities shall be reasonably available. Primary health care services shall be in reasonable proximity to a member's personal residence or business, with due consideration given to the availability of physicians within the community-based health maintenance organization's service area. This provision shall not preclude a community-based health maintenance organization from arranging for the provision of member care outside the service area for a higher level of skill or specialty care than is available within the service area.
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(L. 1997 H.B. 335 § 1)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.554 - Standing referrals for certain members of community-based health maintenance organizations, when.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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, disabling condition requiring a regimen of specialized medical treatment lasting for six months or more to receive a standing referral for specialty care case management by a physician or specialty care center with expertise in treating the condition. Under such specialty care case management, the provider shall coordinate primary and specialty care for the enrollee under a treatment plan approved by the health maintenance organization in consultation with the enrollee's primary care provider and the specialist physician or specialty care center.
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(L. 1997 H.B. 335 § 2)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.556 - Trustees, vacancies, elections.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 filled for the unexpired term in the same manner as the office was previously filled, except that the board of trustees may appoint a qualified person to fill the vacancy in the office of an elected enrollee until the next regular election at which time an enrollee of the community-based health maintenance organization shall be elected for the unexpired term.
3. The elections of the enrollee members of the board of trustees shall be arranged for, managed and conducted by the board of trustees of the community-based health maintenance organization.
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(L. 1997 H.B. 335 § 3)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.558 - Materials provided to prospective purchasers.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 contractual agreement to provide services under the plan of coverage. It shall be a violation of the unfair trade practices act for a community-based health maintenance organization to falsely list that a provider has a contractual agreement to provide services under its plan of coverage;
(2) Information to describe how the community-based health maintenance organization will use utilization management to promote efficiency in the delivery of services in accordance with the terms of the contract for coverage. This information shall explain how the community-based health maintenance organization will encourage the use of treatment options that produce the most cost-effective results. The format and content of the descriptive information disclosed under this subdivision shall be approved by the department of commerce and insurance and shall include information regarding covered benefits available under the plan;
(3) Disclosure of grievance procedures established in accordance with regulations promulgated by the department of commerce and insurance for community-based health maintenance organizations. Included in this information shall be notification of how and when to contact the health plan and the department of commerce and insurance regarding a grievance; and
(4) Notice of the availability of coverage as described in section 354.554.
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(L. 1997 H.B. 335 § 4)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.559 - Disclosure to members, restrictions and prohibitions.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 nature of treatment, risks or alternatives thereto, the availability of other therapy, consultation or test, the decision of any plan to authorize or deny services, or to process the plan or any person to authorize or deny services, or to process the plan or any person contracting with the plan uses or proposes to use, to authorize or deny health care services or benefits. Any such prohibition or restriction contained in a contract with a provider entered into after August 28, 1997, shall be void and unenforceable. The standards used to determine if a community-based health maintenance organization has prohibited or restricted a provider's disclosure in violation of this section shall be those established by federal regulation of the Health Care Financing Administration for use in regulating managed care plans serving Medicare enrollees.
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(L. 1997 H.B. 335 § 5)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.560 - Payment arrangements, department to adopt rules — disclosure of financial arrangements — confidentiality.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 organizations which use payment withholding arrangements that place a physician at substantial financial risk. The standards for determining substantial financial risk and determining which payment arrangements are subject to rules shall be the same as provided for health maintenance organizations and competitive medical plans contracting with the Medicare program, as provided in 42 CFR 417.479, or its successor regulation.
2. The department of commerce and insurance may require that community-based health maintenance organizations disclose to the department financial arrangements or contractual provisions that place a physician at substantial financial risk. Such financial arrangements and contractual provisions which constitute substantial financial risk for the physician shall be reviewed by the department and shall be deemed approved if not disapproved by the director of the department within thirty days from the date that they are filed with the department.
3. The department of commerce and insurance shall promulgate rules governing the confidentiality of proprietary information disclosed to the department pursuant to this section. Proprietary information disclosed pursuant to this section shall not be construed to be a public record as defined in chapter 610.
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(L. 1997 H.B. 335 § 6)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.562 - Grievance procedures, rulemaking authority.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 not less or more stringent than federal regulations governing grievance procedures promulgated by the Health Care Financing Administration of the United States Department of Health and Human Services for Medicare enrollees in managed care plans.
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(L. 1997 H.B. 335 § 7)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.563 - Medicare rules to apply to community-based health maintenance organizations, when.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 maintenance organizations serving enrollees in the Medicare program, the director of the department of commerce and insurance may issue rules to apply those standards to community-based health maintenance organizations as defined in subdivision (3) of section 354.400.
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(L. 1997 H.B. 335 § 8)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.565 - Community-based health maintenance organization designation given, when — revocation.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 354.400 as community-based health maintenance organizations. After a community-based health maintenance organization has been so designated for two years, the director may revoke such designation at any time thereafter upon finding that the health maintenance organization has ceased to meet the established criteria for community-based health maintenance organizations.
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(L. 1997 H.B. 335 § 9)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.567 - Community-based health maintenance organizations subject to other laws regarding health maintenance organizations.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 they are not inconsistent with the provisions of sections 354.552 to 354.567.
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(L. 1997 H.B. 335 § 10)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.570 - Rulemaking — procedure.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 provisions of chapter 536.
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(L. 1997 H.B. 335 § 14)
*Section number "376.1390" appears in original rolls, but was not enacted by H.B. 335, 1997.
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.600 - Definitions.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 2007
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 surgical or treatment centers, skilled nursing facilities, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings;
(2)
"Health benefit plan"
, a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;
(3)
"Health care professional"
, a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services;
(4)
"Health care provider"
or
"provider"
, a health care professional or a facility;
(5)
"Health carrier"
, a health maintenance organization established pursuant to sections 354.400 to 354.636;
(6)
"Health indemnity plan"
, a health benefit plan that is not a managed care plan;
(7)
"Intermediary"
, a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network;
(8)
"Managed care plan"
, a health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use health care providers managed, owned, under contract with or employed by the health carrier;
(9)
"Network"
, the group of participating providers providing services to a managed care plan;
(10)
"Participating provider"
, a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the health carrier;
(11)
"Primary care professional"
or
"primary care provider"
, a participating health care professional designated by the health carrier to supervise, coordinate or provide initial care or continuing care to an enrollee, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the enrollee.
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(L. 1997 H.B. 335, A.L. 2007 S.B. 66)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.612 - Continuation of care after provider termination, when.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 where the continuation of care is medically necessary and in accordance with the dictates of medical prudence, including circumstances such as disability, pregnancy, or life-threatening illness.
2. Such provision for the continuation of care shall guarantee that the enrollee shall not be liable to the provider for any amounts owed for medical care other than deductibles or co-payment amounts specified in the certificate of coverage or other contract between the enrollee and the health plan.
3. In the event the terminated provider is authorized to continue treating the enrollee pursuant to this section, the health plan shall have an obligation to pay the terminated provider at the previously contracted rate for services provided to the enrollee.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.621 - Intermediary and participating provider requirements.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 offering of covered benefits to enrollees shall not be delegated or assigned to the intermediary.
3. If applicable, an intermediary shall transmit utilization documentation and claims paid documentation to the health carrier. The carrier shall monitor the timeliness and appropriateness of payments made to providers and health care services received by enrollees.
4. If applicable, an intermediary shall maintain the books, records, financial information and documentation of services provided to enrollees at its principal place of business in the state and preserve them for five years in a manner that facilitates regulatory review.
5. An intermediary shall allow a health carrier or the director access to the intermediary's books, records, financial information and any documentation of services provided to enrollees, as necessary to determine compliance with sections 354.600 to 354.636.
6. A health carrier shall have the right, in the event of the intermediary's insolvency, to require the assignment to the health carrier of the provisions of a provider's contract addressing the provider's obligation to furnish covered services.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.624 - Proposed provider contract forms filed with the director — contracts maintained at place of business, available for review, when.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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. The forms shall not contain any information on compensation terms, rates or other payments by the carrier to participating providers or intermediaries and shall contain information on any term involving risk-sharing arrangements between the parties.
2. The health carrier shall maintain provider and intermediary contracts at its principal place of business in the state, or the health carrier shall have access to all contracts and provide copies to facilitate regulatory review upon twenty days' prior written notice from the director or at the time of any examination.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.627 - Liability of a health carrier, when.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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 or applicable regulations.
2. All contracts shall be in writing and may be subject to review by the department of commerce and insurance.
3. All contracts shall comply with applicable requirements of the law and applicable regulations.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.636 - Contract requirements after January 1, 1998.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1997
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.
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(L. 1997 H.B. 335)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.650 - Definitions.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1998
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 requirements set forth in section 354.652;
(3)
"Health care insurer"
, any health maintenance organization licensed in the state of Missouri;
(4)
"Health professional shortage area"
, an area designated by the Secretary of Health and Human Services as such pursuant to the guidelines established in Section 332(a)(1)(A) of the Public Service Act;
(5)
"Medically underserved area"
, an area designated by the Secretary of Health and Human Services as such pursuant to the guidelines established in Section 42 U.S.C. 254c(b)(3);
(6)
"Medically underserved population"
, eligible persons designated by the Secretary of Health and Human Services as such pursuant to the guidelines established in 42 U.S.C. 254c(b)(3);
(7)
"National committee for quality assurance"
, a private not-for-profit organization created to promote improvements in the quality of patient care provided through managed care plans. The committee's primary function is to develop and provide oversight processes, performance measurement and accreditation for health plans, and to provide information on quality to the public, consumers, purchasers, health plans and other relevant parties;
(8)
"Principal site"
, the private office of a primary care or specialist physician located within a medically underserved area or health professional shortage area in which initial patient care appointments, routine patient care examinations, routine patient treatments and patient care follow-up occur. The term "principal site" shall not include hospitals, laboratories, nursing homes, hospice centers, surgical centers and federally funded clinics.
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(L. 1998 H.B. 1302 § 1)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.652 - Designation as essential community provider, procedure, qualifications.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1998
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 physician's practice is comprised of:
(a) Medicaid or uninsured patients, or both; or
(b) A combination of paragraph (a) and Medicare or underinsured patients, or both;
(3) Serve a medically underserved area or a health professional shortage area;
(4) Serve a medically underserved population;
(5) Spend at least twenty hours per week at a principal site;
(6) Be available to a medically underserved population on evenings and weekends at a principal site;
(7) Hold hospital staff privileges with a participating network hospital of the health care insurer;
(8) Not be a direct employee of a health care insurer, a for-profit or a not-for-profit hospital or health services corporation; and
(9) Meet the following quality standards in accordance with guidelines established by the National Committee for Quality Assurance:
(a) A current valid license to practice;
(b) Clinical privileges in good standing at the hospital designated by the physician as the primary admitting facility;
(c) A valid Drug Enforcement Agency or Controlled Dangerous Substances certificate, if applicable;
(d) Graduation from medical school, and completion of a residency or board certification if applicable;
(e) Work history;
(f) Current adequate malpractice insurance according to the managed care organization's policy; and
(g) Professional liability claims history.
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(L. 1998 H.B. 1302 § 2)
2023 Missouri Revised Statutes › Title XXIII - Corporations, Associations and Partnerships › Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans › Section 354.654 - Department of health and senior services, duties — rulemaking authority.

Title XXIII CORPORATIONS, ASSOCIATIONS AND PARTNERSHIPS
Chapter 354
• Effective - 28 Aug 1998
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 department if such physician meets the qualifications of an essential community provider pursuant to the provisions of section 354.652.
2. The department shall keep the names and addresses of all essential community providers on record and shall release such information upon request.
3. The department shall promulgate rules and regulations for the administration of this section. Any rule or portion of a rule, as that term is defined in section 536.010, that is promulgated under the authority of this section, shall become effective only if the agency has fully complied with all of the requirements of chapter 536 including but not limited to, section 536.028, if applicable, after August 28, 1998. All rulemaking authority delegated prior to August 28, 1998, is of no force and effect and repealed as of August 28, 1998, however nothing in this act
*
shall be interpreted to repeal or affect the validity of any rule adopted and promulgated prior to August 28, 1998. If the provisions of section 536.028 apply, the provisions of this section are nonseverable and if any of the powers vested with the general assembly pursuant to section 536.028 to review, to delay the effective date, or to disapprove and annul a rule or portion of a rule are held unconstitutional or invalid, the purported grant of rulemaking authority and any rule so proposed and contained in the order of rulemaking shall be invalid and void, except that nothing in this act
*
shall affect the validity of any rule adopted and promulgated prior to August 28, 1998.
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(L. 1998 H.B. 1302 § 3)
*"This act" (H.B. 1302, 1998) contained numerous sections. Consult Disposition of Sections table for a definitive listing.