Missouri Code of State Regulations › Title 20 - DEPARTMENT OF COMMERCE AND INSURANCE › Division 400 - Life, Annuities and Health › Chapter 7 - Health Maintenance Organizations › Section 20 CSR 400-7.095 - HMO Access Plans

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule clarifies the information required
				  to be submitted as part of an access plan for a health maintenance
				  organization's managed care plans pursuant to section
				  354.603,
				  RSMo Supp. 2001, and the process for approval or disapproval of the access
				  plans filed.
(1) Definitions.
(A) Access plan-The plan required to be filed
				with the department pursuant to section
				354.603,
				RSMo, and in accordance with the requirements of this regulation.
(B) Categories of counties-
1. Urban access counties-Counties with a
				population of two hundred thousand (200,000) or more persons.
2. Basic access counties-Counties with a
				population between fifty thousand (50,000) persons and one hundred ninety-nine
				thousand, nine hundred ninety-nine (199,999) persons.
3. Rural access counties-Counties with a
				population of fewer than fifty thousand (50,000) persons.
4. Population figures shall be based on
				census data as reported in the latest edition of the
Official Manual of
				the State of Missouri
.
(C) Closed practice provider-A health care
				provider who does not accept new or additional patients from the health
				maintenance organization (HMO) that is reporting the provider as part of the
				managed care plan's network.
(D)
				Department-The Missouri Department of Commerce and Insurance.
(E) Distance standard-The travel distance
				standards set forth in Exhibit A, which is included herein. Each distance
				standard represents the maximum number of miles an enrollee may be required to
				travel in order to access participating providers of the managed care plan. The
				standards set forth in Exhibit A shall be used to evaluate enrollee access in
				each county of an HMO's current service area.
(F) Employer specific network-A network
				created for a specific employer group that differs from the networks of all
				other managed care plans customarily offered by the HMO in either the identity
				or number of providers included within the network. An employer specific
				network constitutes a different or reduced network for the purposes of section
				354.603.1(4), RSMo, and is a distinct managed care plan for access plan filing
				purposes.
(G) Enrollee access
				rate-The percentage of a managed care plan's enrollees living or working within
				a county who are able to access a participating provider within the travel
				distance standards set forth in Exhibit A.
(H) Health benefit plan-A policy, contract,
				certificate or agreement entered into, offered or issued by an HMO to provide,
				deliver, arrange for, pay for or reimburse any of the costs of health care
				services, and identified by the form number or numbers used by the HMO when the
				health benefit plan was filed for approval pursuant to
				20 CSR
				400-7.010 and
				20 CSR
				400-8.200.
(I) Hospitals-
1. Basic-Hospitals that meet any of the
				following criteria:
A. Licensed or state owned
				hospitals that designate themselves as general medical surgical hospitals in
				the Department of Health and Senior Services licensure survey and which offer
				general medical surgical care to all ages of the general population;
B. Hospitals located in an adjacent state,
				appropriately licensed or owned by that state, and offering general medical
				surgical care to all ages of the general population; or
C. Children's hospitals, except that
				children's hospitals shall not be included in the calculation of the basic
				hospital enrollee access rate.
2. Secondary-Basic hospitals reporting on the
				most recent available Department of Health and Senior Services licensure survey
				or other available sources of information that are appropriate and verifiable
				that the following services are available at the reporting hospital:
A. At least one (1) functioning operating
				room;
B. Obstetrics services except
				that hospitals delivering babies only on an emergency basis shall not be
				include in the calculation of the secondary hospital enrollee access rate;
				and
C. Intensive care
				services.
(J)
				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 an identified set of health care providers managed, owned, under contract
				with or employed by the HMO. A managed care plan is a type of health benefit
				plan. For purposes of this rule, a managed care plan consists of a health
				benefit plan and a network. If an HMO offers managed care plans where the
				health benefit plan, the network or both differ, the HMO is offering more than
				one (1) managed care plan. For example:
1. If
				the HMO offers the same health benefit plan with two (2) different networks,
				the HMO is offering two (2) managed care plans.
2. If the HMO offers two (2) different health
				benefit plans with the same network, the HMO is offering two (2) managed care
				plans.
3. If the HMO offers two (2)
				different health benefit plans each with a different network, the HMO is
				offering two (2) managed care plans.
(K) Mental health facilities-
1. Inpatient mental health treatment
				facility-
A. A hospital offering staffed
				psychiatric or alcohol/chemical dependency beds and having psychiatrists on
				staff based on the most recent available Department of Health and Senior
				Services licensure survey; or
B. A
				facility recognized by the federal Substance Abuse and Mental Health Service
				Administration as a psychiatric hospital, a general hospital with a psychiatric
				unit; or
C. An inpatient substance
				abuse hospital, or an inpatient facility identified through other available
				sources of information that are appropriate and verifiable.
2. Ambulatory mental health
				treatment provider-
A. A hospital outpatient
				psychiatric or alcohol/chemical dependency service identified in the most
				recent available Department of Health and Senior Services licensure survey;
				or
B. A provider recognized by the
				Missouri Department of Mental Health as a community psychiatric rehabilitation
				center, a community psychiatric rehabilitation program, a community psychiatric
				rehabilitation day program, an outpatient program, an access crisis
				intervention program, an off-site day habilitation program, an on-site day
				habilitation program, a day program, a supported employment program, an alcohol
				or drug treatment and rehabilitation program, an alcohol or drug abuse
				prevention program; or
C. A
				provider recognized by the federal Substance Abuse and Mental Health Service
				Administration as a multi-setting mental health organization, a partial
				hospitaliza-tion/day treatment provider or an outpatient clinic; or
D. A nonresidential, non-inpatient provider
				of mental health related services identified through other available sources of
				information that are appropriate and verifiable.
3. Residential mental health treatment
				provider-
A. A provider recognized by the
				Missouri Department of Mental Health as a group home, a residential care
				facility, a semi-independent living arrangement, an intermediate care facility,
				a residential center, a residential habilitation provider, a supported living
				arrangement, a family living arrangement; or
B. A provider recognized by the federal
				Substance Abuse and Mental Health Service Administration as a residential
				substance abuse provider, a community residential organization, a residential
				treatment center for children; or
C. A provider of mental health services in
				residential settings identified through other available sources of information
				that are appropriate and verifiable.
(L) Network-The group of participating
				providers providing services to a managed care plan or pursuant to a health
				benefit plan established by an HMO. The meaning of the term network is further
				clarified for purposes of this rule as such: A network is one (1) component of
				a managed care plan. A network is the identified set of health care providers
				managed, owned, under contract with or employed by the HMO, either directly or
				indirectly, for purposes of rendering medical services to all enrollees of a
				managed care plan.
(M) Offer-An HMO
				is offering a managed care plan when it is presenting that managed care plan
				for sale in Missouri.
(N)
				Participating provider-A provider who, under a contract with the HMO or with
				the HMO's contractors or subcontractors, has agreed to provide health care
				services to all enrollees of a managed care plan with an expectation of
				receiving payment directly or indirectly from the HMO. The following types of
				providers are not participating providers:
1.
				Providers to which an enrollee may not go for covered services, with or without
				a referral from a primary care provider;
2. Providers that are only available in the
				event that an enrollee has a point-of-service benefit level, or other option
				attached to the HMO level of benefits; and
3. A provider that has agreed to render
				services to an enrolled person in an isolated instance for purposes of treating
				a medical need that cannot otherwise be met within the network.
(O) Pharmacy-Any pharmacy, drug
				store, chemical store or apothecary shop possessing a valid and current permit
				issued by the State of Missouri Board of Pharmacy and doing business for the
				purposes of compounding, dispensing and retailing any drug, medicine, chemical
				or poison to be used for filling a physician's prescription.
(P) Primary care provider (PCP)-A
				participating health care professional designated by the HMO to supervise,
				coordinate, or provide initial care or continuing care to an enrollee, and who
				may be required by the HMO to initiate a referral for specialty care and
				maintain supervision of health care services rendered to the enrollee. A PCP
				may be a professional who practices general medicine, family medicine, general
				internal medicine or general pediatrics. A PCP may be a professional who
				practices obstetrics and/or gynecology, in accordance with the provider
				contracts and health benefit plans of the HMO.
(Q) Specialist-A licensed health care
				professional whose area of specialization is in an area other than general
				medicine, family medicine or general internal medicine. A professional whose
				area of specialization is pediatrics, obstetrics and/or gynecology may be
				either a PCP or a specialist within the meaning of this rule.
(R) Tertiary services-Hospitals that offer
				the following types of services are required in every HMO network and will be
				identified through hospital responses to the most recent available annual
				Department of Health and Senior Services licensing survey or other available
				sources of information that are appropriate and verifiable:
1. Level I or Level II trauma hospital- a
				hospital as designated by the Department Health and Senior Services. A trauma
				unit that is designated as pediatric only does not satisfy the requirements of
				this rule.
2. Neonatal intensive
				care services-a hospital or children's hospital or secondary hospital offering
				neonatal intensive care services and at least one (1) functioning operating
				room.
3. Perinatology services-a
				secondary hospital with active board certified perinatol-ogists on staff and a
				level II or III obstetrical unit.
4. Comprehensive cancer services-any hospital
				with active board certified oncologists on staff and providing all cancer
				treatment services listed in the annual licensing survey, and at least one (1)
				functioning operating room.
5.
				Comprehensive cardiac services-any hospital with active board certified
				cardiovascular disease physicians on staff, at least one (1) functioning
				operating room and providing all interventional cardiac services and open heart
				surgery.
6. Pediatric subspecialty
				care-a hospital or children's hospital or secondary hospital with active board
				certified pediatricians and pediatric specialists on staff, at least one (1)
				functioning operating room and providing intensive care services, neonatal
				intensive care services or pediatric intensive care services.