20 CSR 400-7.095 - HMO Access Plans
(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 4007.010 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
hospitalization/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 perinatologists 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.
(2) Requirements for
Filing Access Plans.
(A) Annual filing-By
March 1 of each year, an HMO must file an access plan for each managed care
plan it was offering in this state on January 1 of that same year. An HMO may
file separate access plans for each managed care plan it offers, or it may file
a consolidated access plan incorporating information for multiple managed care
plans that it offers, so long as the information submitted with the
consolidated access plan clearly identifies the managed care plan or plans to
which it applies. The access plan must contain the following information for
each managed care plan to which it applies:
1.
Pursuant to section 354.603.2(1), RSMo, either:
A. Information regarding the participating
providers in each managed care plan's network and the enrollees covered by each
managed care plan in a format to be determined by the department including, but
not limited to, the following:
(I) The name,
address where medical care is provided, zip code, professional license number
or other unique identifier as assigned by the appropriate licensing or
oversight agency, and specialty, degree or type of each provider;
(II) Whether or not the provider is a closed
practice provider, as defined in subsection (1)(C) of this regulation, above;
and
(III) The number of enrollees
by either work or residence zip code in each managed care plan to which the
access plan applies;
B.
Proof of accreditation identifying the accredited entity and an affidavit in
the form contained in Exhibit B, which is included herein, certifying that the
managed care plan to which the affidavit applies has met one (1) or more of the
following standards:
(I) The managed care plan
is a Medicare+Choice (M+C) or successor coordinated care plan operated by the
HMO pursuant to a contract with the federal Centers for Medicare and Medicaid
Services;
(II) The managed care
plan is accredited by the National Committee for Quality Assurance (NCQA), or
successor organization, at a level of "accredited" or better, and such
accreditation is in effect at the time the access plan is filed;
(III) The managed care plan's network is
accredited by the Joint Commission on the Accreditation of Healthcare
Organizations (JCAHO), or successor organization, at a level of "accredited" or
better, and such accreditation is in effect at the time the access plan is
filed.The presence of any Type I recommendations for standards
related to access to care shall prevent JCAHO accreditation from fulfilling the
requirements of this part. The department shall annually review current JCAHO
requirements and identify the specific JCAHO standards that address access to
care. The department will annually notify all HMOs of those JCAHO standards
that address access to care;
(IV)
The managed care plan is accredited by the utilization review accreditation
commission (URAC), or successor organization, at a level of full URAC Health
Plan accreditation, and such accreditation is in effect at the time the access
plan is filed; or
(V) The managed
care plan or its network is accredited by any other nationally recognized
managed care accrediting organization, similar to those above, that is approved
by the department prior to the filing of the access plan, and such
accreditation is in effect at the time the access plan is filed. Requests for
approval of another nationally recognized managed care accrediting organization
must be submitted to the department no later than October 15 of the year prior
to the year the access plan is filed;
C. If the managed care plan's service area
has expanded beyond that which was in effect at the time the current
accreditation was awarded, then the department may request additional data on
that service area expansion pursuant to the provisions of (2)(A)1.A.,
above.
2. Pursuant to
section 354.603.2(2) through (8), RSMo, a written description with any relevant
supporting documentation addressing each of the requirements set forth in that
statute.
3. Pursuant to section
354.603.2(9), RSMo, the following information:
A. For all managed care plans, information
demonstrating that:
(I) Emergency medical
services-A written triage, treatment and transfer protocol for all ambulance
services and hospitals is in place. The protocol shall address post-emergency
situations when members have received emergency care from a non-participating
provider;
(II) Home health
providers-Home health providers are contracted to serve enrollees in each
county where enrollment is reported. A home health provider need not be
physically located or headquartered in each county. However, there must be at
least one (1) home health provider under contract to serve enrollees in each
county if the need arises; and
(III) Administrative measures are in place
which ensure enrollees timely access to appointments with the medical providers
listed in Exhibit A, based on the following guidelines:
(a) Routine care, without symptoms-within
thirty (30) days from the time the enrollee contacts the provider;
(b) Routine care, with symptoms-within five
(5) business days from the time the enrollee contacts the provider;
(c) Urgent care for illnesses/injuries which
require care immediately, but which do not constitute emergencies as defined by
section 354.600, RSMo -within
twenty-four (24) hours from the time the enrollee contacts the
provider;
(d) Emergency care-a
provider or emergency care facility shall be available twenty-four (24) hours
per day, seven (7) days per week for enrollees who require emergency care as
defined by section 354.600, RSMo;
(e) Obstetrical care-within one (1) week for
enrollees in the first or second trimester of pregnancy; within three (3) days
for enrollees in the third trimester. Emergency obstetrical care is subject to
the same standards as emergency care, except that an obstetrician must be
available twenty-four (24) hours per day, seven (7) days per week for enrollees
who require emergency obstetrical care; and
(f) Mental health care-Telephone access to a
licensed therapist shall be available twenty-four (24) hours per day, seven (7)
days per week.
B. For all managed care plans, a section
demonstrating that the entire network is available to all enrollees of a
managed care plan, including reference to contracts or evidences of coverage
that clearly state the entire network is available and describing any network
management practices that affect enrollees' access to all participating
providers;
C. For employer specific
networks, a section demonstrating that the group contract holder agreed in
writing to the different or reduced network. An employer specific network is
subject to the standards in this rule;
D. For all managed care plans, a listing of
the product names used to market those plans;
E. For all managed care plans, written
policies and procedures to assure that, with regard to providers not addressed
in Exhibit A of this regulation, access to providers is reasonable. For
otherwise covered services, the policies and procedures must show that the HMO
will provide out-of-network access at no greater cost to the enrollee than for
access to in-network providers if access to in-network providers cannot be
assured without unreasonable delay; and
F. Any other information the department may
require.
(B)
Updates to annual filing-An HMO must file an updated access plan for a managed
care plan if, at any time between the time annual access plan filings are due,
one (1) of the following occurs:
1. If an
affidavit was submitted for a managed care plan pursuant to the provisions of
(2)(A)1.B., above, and the accreditation specified in the affidavit is no
longer in effect, the HMO must file, within thirty (30) days of the date such
accreditation is no longer in effect, or such longer period of time as the
department determines is reasonable, either:
A. Network and enrollee information for the
managed care plan as required by the provisions of (2)(A)1.A., above;
or
B. If the accreditation has been
replaced by alternative acceptable accreditation, an affidavit as required by
the provisions of (2)(A)1.B., above.
2. If changes in the network or in the number
or location of enrollees cause an accredited managed care plan not to meet any
of the distance standards set forth in Exhibit A, the HMO must file, within
thirty (30) days of such changes, updated network and enrollee information as
required.
3. If network and
enrollee information was submitted for a managed care plan pursuant to the
provisions of (2)(A)1.A., above, and changes in the network or number of
enrollees may cause the managed care plan not to meet any of the distance
standards set forth in Exhibit A, the HMO must file, within thirty (30) days of
such changes, updated network and enrollee information as required by the
provisions of (2)(A)1.A., above.
(C) Prior to offering a new managed care
plan-If at any time between the time annual access plan filings are due an HMO
proposes to begin offering a new managed care plan in this state, the HMO must
file an access plan for the new managed care plan prior to offering the new
managed care plan, including a managed care plan with an employer specific
network.
(D) Waiver for the filing
of the annual access plan-
1. An HMO may
request a waiver of the filing of the annual access plan for a managed care
plan if it certifies to the department that:
A. The HMO has notified enrollees of the
managed care plan and producers with whom the HMO does business that the
managed care plan is no longer being marketed, and the HMO has ceased writing
any new contracts for the managed care plan; and
B. The HMO has informed enrollees of the
managed care plan that they may access any provider at no greater cost than if
that provider was a participating provider in the event the managed care plan
cannot provide access to providers as required under this rule.
2. A request to waive the filing
of the annual access plan for a managed care plan must be received by the
department no later than January 15 of the year in which an access plan would
otherwise be required.
(3) Evaluation of Access Plans.
(A) For the information submitted pursuant to
section 354.603.2(1), RSMo, the information will be evaluated as follows:
1. If information regarding a managed care
plan's network and enrollees is submitted, the department will calculate the
enrollee access rate for each type of provider in each county in the HMO's
approved service area to determine if the average enrollee access rate for each
county and the average enrollee access rate for all counties is greater than or
equal to ninety percent (90%). In calculating the enrollee access rate for a
managed care plan, the department will give consideration to the following:
A. Tertiary services may be contracted at one
(1) hospital, or among multiple hospitals; and
B. With the department's approval, a managed
care plan's network may receive an exception for one (1) or more of the
distance standards set forth in Exhibit A under the following circumstances:
(I) Quality of care exception-An exception
may be granted if the managed care plan's access plan is designed to
significantly enhance the quality of care to enrollees, demonstrates that it
does in fact enhance the quality of care, and imposes no greater cost on
enrollees than would be incurred if they had access to contracted,
participating providers as otherwise required under this rule;
(II) Noncompetitive market exception for PCPs
and pharmacies-In the event an HMO can demonstrate to the department that there
is not a competitive market among PCPs and/or pharmacies who meet the HMO's
credentialing standards, and who are qualified within the scope of their
professional license to provide appropriate care and services to enrollees, the
department may grant an exception for the managed care plan's network that
doubles the distance standard indicated in Exhibit A for PCPs or
pharmacies;
(III) Noncompetitive
market exception for other provider types-If no provider (exclusive of PCPs and
pharmacies) of the appropriate type provides services to enrollees of a managed
care plan in a county within the distance standards indicated in Exhibit A, an
exception may be granted if the HMO can demonstrate that no fewer than ninety
percent (90%) of the population of that county (or, at the HMO's discretion,
ninety percent (90%) of the enrollees residing or working in the county) have
access to a participating provider of the appropriate type, which provider is
located no more than twenty-five (25) miles further than the provider closest
to that county;
(IV) Staff or
Independent Practice Association (IPA) Model exception-An exception may be
granted for those health care services provided to enrollees of the managed
care plan if substantially all of those services are provided by the HMO to its
enrollees through qualified full-time employees of the HMO or qualified
full-time employees of a medical group that does not provide substantial health
care services other than on behalf of such HMO. In order to qualify for the
exception provided for in this part, an HMO must demonstrate that all or
substantially all of the type of health care services in question are provided
by full-time employees, that enrollees have adequate access to such health care
services as described in the provisions of (2)(A)3.A., above, and that the
contract holder was made aware of the circumstances under which such services
were to be provided prior to the decision to contract with the HMO for that
managed care plan; or
(V) Use of
physician extenders-If there is insufficient availability of physicians of the
appropriate type providing services to enrollees of a managed care plan in a
county within the distance standards indicated in Exhibit A, an exception may
be granted for the use of physician extenders. The HMO must demonstrate that
enrollees residing or working in the county may access a participating provider
who may be either a physician or an advanced practice nurse rendering care
under a collaborative agreement pursuant to
4 CSR
200-4.200, and in accordance with the provider
contracts and health benefit plans of the HMO. An exception may be granted for
other types of physician extenders in addition to advanced practice nurses if
information is submitted justifying, to the satisfaction of the department,
that the other types of physician extenders are able to provide the appropriate
services within the scope of their license, and in accordance with the provider
contracts and health benefit plans of the HMO.
2. If an affidavit is submitted, the
department will review it to make sure that it meets all the requirements of
Exhibit B. If the access plan is a consolidated access plan including
information for more than one (1) managed care plan, the department will also
review the affidavit for the following:
A. An
affidavit that relies upon a managed care plan being an M+C or successor
coordinated care plan will only apply to the specific managed care plan that is
such a plan. All other managed care plans included in the access plan must be
accompanied by either network information pursuant to the provisions of
(2)(A)1.A., above, or an affidavit indicating they are otherwise accredited
pursuant to the provisions of (2)(B)1.B., above;
B. An affidavit that relies upon a managed
care plan being accredited by the NCQA, or successor organization, will only
apply to the specific managed care plan included with the accreditation. All
other managed care plans included in the access plan must be accompanied by
either network information pursuant to the provisions of (2)(A)1.A., above, or
an affidavit indicating they are otherwise accredited pursuant to the
provisions of (2)(B)1.B., above;
C.
An affidavit that relies upon a managed care plan's network being accredited by
the JCAHO, or successor organization, will only apply to that portion of the
managed care plan's network that is included within the accreditation. For the
remainder of the network, either network information pursuant to the provisions
of (2)(A)1.A., above, or an affidavit indicating the remaining network is
otherwise accredited pursuant to the provisions of (2)(B)1.B., above, must be
submitted. All other managed care plans included in the access plan must be
accompanied by either network information pursuant to the provisions of
(2)(A)1.A., above, or an affidavit indicating they are otherwise accredited
pursuant to the provisions of (2)(B)1.B., above;
D. An affidavit that relies upon a managed
care plan being accredited by URAC, or successor organization, will only apply
to the specific managed care plan included with the accreditation. All other
managed care plans included in the access plan must be accompanied by either
network information pursuant to the provisions of (2)(A)1.A., above, or an
affidavit indicating they are otherwise accredited pursuant to the provisions
of (2)(B)1.B., above;
E. An
affidavit that relies upon a managed care plan being accredited by any other
nationally recognized managed care accrediting organization, similar to those
above, will only apply to the specific managed care plan included with the
accreditation. All other managed care plans included in the access plan must be
accompanied by either network information pursuant to the provisions of
(2)(A)1.A., above, or an affidavit indicating they are otherwise accredited
pursuant to the provisions of (2)(B)1.B., above.
(B) For information submitted pursuant to
sections 354.603.2(2) through (9), RSMo, the department will evaluate the
information to determine whether it is sufficient to meet the requirements of
sections 354.600 to
354.636, RSMo, for each managed
care plan to which the access plan applies.
(4) Approval or Disapproval of Access Plans.
(A) For a managed care plan for which network
and enrollee information is submitted pursuant to the provisions of (2)(A)1.A.
above, the department will:
1. Approve the
access plan or portion of a consolidated access plan that applies to that
managed care plan when the enrollee access rate across the entire network (all
counties, all provider types) for that managed care plan is ninety percent
(90%) or better, and the average enrollee access rate in each county in an
HMO's approved service area for that managed care plan is ninety percent (90%)
or better, and the information submitted pursuant to the provisions of (2)(A)2.
and 3., above, is satisfactory;
2.
Conditionally approve the access plan or portion of a consolidated access plan
that applies to that managed care plan when the enrollee access rate across the
entire network (all counties, all provider types) for that managed care plan is
ninety percent (90%) or better, but the average enrollee access rate in any
county for that managed care plan is less than ninety percent (90%), and the
information submitted pursuant to the provisions of (2)(A)2. and 3., above, is
satisfactory. If an access plan or portion of an access plan is conditionally
approved, the department may require the HMO to present an action plan for
increasing the enrollee access rate for that managed care plan's network to
ninety percent (90%) or better in those counties where this standard is not
met; or
3. Disapprove the access
plan or portion of a consolidated access plan that applies to that managed care
plan when the enrollee access rate across the entire network (all counties, all
provider types) for that managed care plan is less than ninety percent (90%)
and/or the information submitted pursuant to the provisions of (2)(A)2. and 3.,
above, is unsatisfactory. Disapproval of the access plan or portion of the
access plan will subject the HMO and its managed care plan to the enforcement
mechanisms described in section (5), below, of this regulation.
(B) For a managed care plan for
which an affidavit is submitted pursuant to (2)(A)1.B. above, the department
will:
1. Approve the access plan or portion
of a consolidated access plan that applies to that managed care plan when both
the managed care plan's affidavit and the information submitted pursuant to
(2)(A)2. and 3., above, are satisfactory; or
2. Disapprove the access plan or portion of a
consolidated access plan that applies to that managed care plan when the
managed care plan's affidavit and/or the information submitted pursuant to
(2)(A)2. and 3., above, are unsatisfactory. Disapproval of the access plan or
portion of the access plan will subject the HMO and its managed care plan to
the enforcement mechanisms described in section (5), below, of this
regulation.
(C) Approval
of an access plan or portion of an access plan is subject to the following:
1. Approval of an access plan shall not
remove any HMO's obligations to provide adequate access to care as expressed in
this regulation or in section
354.603, RSMo. In any case where
a managed care plan's network has an insufficient number or type of
participating providers to provide a covered benefit, the HMO shall ensure that
the enrollee obtains the covered benefit at no greater cost than if the benefit
was obtained from a participating provider, or shall make other arrangements
acceptable to the director. This may include, but is not limited to, the
following:
A. With regard to the types of
providers listed in Exhibit A and only those types of providers, allowing an
enrollee access to a nonparticipating provider at no additional cost when no
participating provider of that same type is within the distance standard
prescribed by Exhibit A;
B. With
regard to the types of providers listed in Exhibit A, and only those types of
providers, allowing an enrollee access to a nonparticipating provider at no
additional cost when no participating provider is available to provide the
service within the time prescribed in (2)(A)3.A.(III), above, for timely access
to appointments; and
C. With regard
to medical providers not expressly stated in Exhibit A, allowing an enrollee
access to a nonparticipating provider at no additional cost when no
participating provider is available without unreasonable delay, pursuant to the
written policies and procedures of the HMO;
2. If there is no participating provider in a
managed care plan's network with the appropriate training and experience to
meet the particular health care needs of an enrollee, the HMO shall make
arrangements with an appropriate nonparticipating provider, pursuant to a
treatment plan developed in consultation with the primary care provider, the
nonparticipating provider and the enrollee or enrollee's designee, at no
additional cost to the enrollee beyond what the enrollee would otherwise pay
for services received within the network.
(5) Enforcement Process for Disapproved
Access Plans. If a managed care plan's access plan has been disapproved
pursuant to section (4), above, it is subject to the following:
(A) The managed care plan may be placed on
probationary status by the department for a period not to exceed ninety (90)
days. If information sufficient to allow the department to "approve" or
"conditionally approve" the managed care plan's access plan is submitted prior
to the expiration of the probationary period, the managed care plan will be
removed from probationary status;
(B) If the HMO fails to submit information
sufficient to allow the department to "approve" or "conditionally approve" the
managed care plan's access plan by the end of the probationary period, the
department may, after notice and hearing pursuant to sections
354.470 and
354.490, RSMo, order the HMO to
refrain from offering that managed care plan in part or all of the HMO's
service area until such time as the HMO can demonstrate to the department's
satisfaction that the managed care plan fully meets the requirements of this
rule;
(C) If all of an HMO's
managed care plans are disapproved at the time of renewal of the HMO's
certificate of authority, the department may, after notice and hearing pursuant
to section 354.490, RSMo, deny renewal of
the HMO's certificate of authority until such time as the HMO demonstrates to
the satisfaction of the department that one or more of its managed care plans
meet the requirements of this regulation.
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Notes
AUTHORITY: sections 354.615 and 374.045, RSMo 2000 and 354.405 and 354.603, RSMo Supp. 2006.* Original rule filed Nov. 3, 1997, effective May 30, 1998. Rescinded and readopted: Filed Oct. 1, 2002, effective April 30, 2003. Amended: Filed May 11, 2004, effective Dec. 30, 2004. Amended: Filed July 29, 2005, effective Feb. 28, 2006. Amended: Filed Dec. 14, 2006, effective June 30, 2007. Non-substantive change filed Sept. 11, 2019, published Oct. 31, 2019.
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