94-05: Basic and Standard Health Benefit Plans
From: Jay Angoff, Director
Re: Basic and Standard Health Benefit Plans
Date: July 21, 1994
I am providing each carrier that has advised us of its desire to be a small employer carrier in Missouri a diskette containing the Standard and Basic plans. These plans are required to be offered to each small employer to which you market group health coverage subject to the Missouri Small Employer Health Insurance Availability Act (the Act), sections 379.930 through 379.952, RSMo. Pursuant to section 379.940.1(4), RSMo, these plans shall be offered to each small employer applying for coverage on or after November 21, 1994.
The Health Benefit Plan Committee established in the Act has developed The Basic and Standard plans to provide indemnity, preferred provider organization or health maintenance organization coverage. A benefit outline is included for each of these plans showing the coverage, benefits, and cost sharing levels. These forms include a small employer agreement, a certificate, a benefit schedule, and a standard plan amendment for each coverage type.
The policy, as defined in the certificates, is composed of a Small Employer Agreement, a Policyholder's Application, any individual employee applications or enrollment forms and a copy of the certificate. A separate master Policy form is not required.
The language of these plans should be general enough to be usable by most carriers; however individual carriers may provide greater clarity of their specific administrative procedures such as case management, prior authorization or claims procedures, provided none of these provisions are more restrictive than those of the Basic or Standard plans. In addition, carriers may choose not to impose pre-existing condition limitations.
Small employer carriers may receive expedited approval of their standard and basic plans by filing a completed transmittal document and $50 filing fee for each policy. This filing must be accompanied by an authorized officer's certification that the plans are equal to the plans developed by the benefit plan committee. The letter should also provide a discussion of any modifications to reflect carrier specific administrative procedures. It is not necessary to file the plans themselves because the Benefit Plan Committee received approval of the basic and standard plans on May 25, 1994.
Each carrier should develop the standard and basic plan benefit schedules on their own systems.
Director of Insurance
INSTRUCTIONS FOR ACCESS OF FILES ON DISKETTE
The enclosed Bulletin from Jay Angoff, the Director of the Missouri Department of Insurance, states the reason for the diskette and that its purpose is to provide easy access to small employer carriers doing business in the State of Missouri. This page is intended to provide instructions as to the formatting of the diskette, how to access the files, the contents of the file, and a telephone number to call for possible assistance.
The diskette was produced in the WordPerfect 5.1 Version program. Some paging modifications were required so at the same time the printer was assigned to a LaserJet II, since it is easier to switch from a II to a LaserJet III than vice versa. If you wish to print the files and you have a LaserJet III, it is necessary to switch the records through the Print screen (Shift F7) by selecting the LaserJet III printer option. If you do not have one of these two types of printers, additional paging modifications may be necessary. If you do not have the WordPerfect 5.1 Version program, you can call the number below and a "hard copy" of the specific documents desired will be mailed to you.
2. File Contents
Since we realize that not all carriers offer, or wish to offer, all three types of plans -- Indemnity, PPO, and HMO -- you may want to only use and access specific files. Below is a listing of the files on the diskette and what each one is:
- BODYCERT.HMO The Small Employer Agreement and the Certificate of Coverage for the Basic HMO Plan.
- BODYCERT.IND The Small Employer Agreement and the Certificate of Coverage for the Basic Indemnity Plan.
- BODYCERT.PPO The Small Employer Agreement and the Certificate of Coverage for the Basic PPO Plan. NOTE: The carrier will add to these documents their own Policyholder's Application and any individual employee applications or enrollment forms they require to create the policy.
- BODYHMO.STD The required Amendment when added to the Basic HMO Plan creates the Standard HMO Plan.
- BODYIND.STD The required Amendment when added to the Basic Indemnity Plan creates the Standard Indemnity Plan.
- BODYPPO.STD The required Amendment when added to the Basic PPO Plan creates the Standard PPO Plan.
- BODYSCH1.PPO The Schedule of Benefits for the Basic PPO Plan.
- BODYSCH2.PPO The Schedule of Benefits for the Standard PPO Plan.
- BODYSCH3.IND The Schedule of Benefits for the Basic Indemnity Plan.
- BODYSCH4.IND The Schedule of Benefits for the Standard Indemnity Plan.
- BODYSCH5.HMO The Schedule of Benefits for the Basic HMO Plan.
- BODYSCH6.HMO The Schedule of Benefits for the Standard HMO Plan.
If you have any questions regarding the diskette or require a "hard copy" of any of the documents, you may call Cameron Ahrens, the Project Manager to the Board of Directors of the Missouri Small Employer Reinsurance Program, at (816) 461-5454, extension 24.