Missouri Code of State Regulations › Title 20 - DEPARTMENT OF COMMERCE AND INSURANCE › Division 400 - Life, Annuities and Health › Chapter 2 - Accident and Health Insurance in General › Section 20 CSR 400-2.065 - Actual Payment as Basis for Policy or Plan Calculations

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule effectuates or aids in the
				  interpretation of the following sections: 354.085 and 354.430(1), RSMo relating
				  to certain policy forms that contain provisions which are deceptive, ambiguous,
				  misleading, unfair, unjust, or inequitable; 354.350 and 375.445, RSMo regarding
				  the carrying out of contracts in good faith; 354.410.1(2) and 354.430.3(2),
				  RSMo pertaining to reasonable requirements for copayments; 354.085, 376.405 and
				  376.777, RSMo regarding whether policy forms contain such words, phraseology,
				  conditions and provisions which are specific, certain and reasonably adequate
				  to meet the needed requirements for the protection of those insured; and
				  354.410.1(9), RSMo relating to operating contrary to the public
				  interest.
(1) Definitions. As
				used in this rule-
(A) "Actual payment," the
				real total dollar amount actually paid or to be paid in fact, by a health
				insurer, or by the health insurer and the insured when the insured is
				responsible for some part of the cost, to a health services provider for a
				health service(s) pursuant to a health plan. Annual adjustments in amounts paid
				to providers which are based on referral rates, quality or cost effectiveness
				measurements, or other similar contractual provisions may be excluded from the
				calculation of actual payments, at the option of the health insurer.
(B) "Expense participation," a financial
				contribution that the insured is required by the health plan to pay for a
				health service(s). "Expense participation" includes, but is not limited to,
				these forms of expense participation: deductibles, copayments, coinsurance, and
				additional charges by the health insurer that are caused by a failure to follow
				the utilization management or other requirements of the health plan;
(C) "Health insurer," any person, fraternal
				benefit society, and any other legal entity engaged in the business of
				insurance, including producers, adjusters, public adjusters and third-party
				administrators. "Health insurer" shall also mean health services corporations,
				health maintenance corporations, prepaid limited health care service plans,
				optometric and other similar health service plans, preferred provider plans,
				managed care plans, point-of-service plans, and multiple employer self-insured
				health plans. For the purpose of this rule, these foregoing entities are deemed
				to be engaged in the business of insurance. "Health insurer" shall also include
				all companies organized, incorporated or doing business under the provisions of
				Chapters 374, 375, 376, 378, 379, RSMo; provided that only persons or entities
				which offer, issue, manage or administer a health plan shall be deemed to be a
				"health insurer;"
(D) "Health
				plan," any insurance contract, policy or certificate, or any contract, plan or
				arrangement, which provides for the payment of a health service provider's
				charges for health services provided to insured. "Health plan" does not include
				any policy of workers compensation insurance or the medical payments portion of
				any automobile, homeowners or other property and casualty insurance
				policy;
(E) "Health services," any
				service or product for which provision for benefits has been made under a
				health plan, including but not limited to, the health care and services
				provided by hospitals, or other health care institutions, organizations,
				associations or groups, and by doctors of medicine, osteopathy, chiropractic,
				psychiatry, optometry, and podiatry, and shall also include nursing services,
				preventative health care services, health screening, prenatal care, medical
				appliances, equipment and supplies, drugs, medicines, ambulance services,
				mental health services, supplemental services, and other therapeutic services
				and supplies, and laboratory analysis, physical examinations, the rendering of
				assistance to physicians, and services for drugs and alcohol abuse,
				physiotherapy, anesthesiology, and anesthesia;
(F) "Health services provider," any person or
				entity providing health services;
(G) "Insured," any individual covered by a
				health plan; and
(H) "Person," any
				natural or artificial entity, or aggregate of such entitles, including, but not
				limited to, individuals, partnerships, associations, trusts or
				corporations.