97-05: Implementation Dates for HB 335

* This bulletin was repealed by 08-05

RESCINDED AND INOPERATIVE

To:           All Heath Maintenance Organizations, Managed Care Plans, and Utilization Review Agents

From:      Jay Angoff

Re:          Implementation Dates for HB 335

Date:       August 25, 1997

Earlier this year, the Missouri General Assembly passed, and Governor Carnahan signed into law HB 335, affecting Health Maintenance Organizations, managed care plans, and utilization review services, among other things. Listed below are effective dates for various provisions of HB 335, along with implementation notes which may be of interest. Citations to the bill and page numbers of the bill are included for your convenience.

The Department of Insurance (DOI) and the Department of Health are in the process of promulgating regulations pursuant to HB 335. Between the effective date of provisions of HB 335 and the effective date of regulations promulgated pursuant to HB335, health carriers are responsible for compliance with the statute without the benefit of regulations interpreting the statute. The DOI will evaluate compliance with HB 335 based on a carrier's good faith effort to conform to the requirements of the law.

Please note, not all provisions of the law are specifically enumerated below. This does not relieve a carrier's responsibility for complying with those provisions not specifically enumerated.

  • Community Based HMOs: Sections 1-10
    • Definition of CBHMO: § 354.400 (2): p 3
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
    • Network Adequacy for CBHMOs: Section 1: p 59-60
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
    • Standing Referrals for CBHMOs: Section 2: p 60
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
    • Marketing Materials for CBHMOs: Section 4: p 60-1
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
    • Gag Rule for CBHMOs: Section 5: p 61
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
    • Payment Arrangements of CBHMOs: Section 6: p 61-2
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
    • CBHMO Grievance Procedures: Section 7: p 62
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
    • CBHMO Utilization Review: Section 8: p 62
      • Effective Date: 8/28/97
      • Affected Parties: Community Based HMOs
  • Network Adequacy
    • Adequate Network Necessary for C.O.A.: § 354.405.3 (13) p 7-8
      • Effective Date: 8/28/97
      • Affected Parties: HMOs
    • Sufficient Network Required: § 354.603.1 p 21-22
      • Effective Date: 8/28/97
      • Affected Parties: HMOs
    • Access Plans (& changes thereto) to be Filed: § 354.603.2 p 22-23
      • Effective Date: beginning on 7/1/98
      • Affected Parties: HMOs
      • Notes: This does not affect current filing requirements for service area expansions.
    • Standing and Out-of-Network Referrals: § 354.615 p 29-30
      • Effective Date: 8/28/97
      • Affected Parties: HMOs
  • Evidence of Coverage to include Toll Free Numbers: § 354.430.3 (e) p 11-12
    • Effective Date: For Health Benefit Plans issued, continued or renewed on or after 8/28/97.
    • Affected Parties: Insurers/Health Services Corporations/HMO's
    • Notes: The toll free number is: 800-726-7390
  • Gag Rule: § 354.441 p 12
    • Effective Date: For Provider Contracts entered into, continued or renewed on or after 8/28/97.
    • Affected Parties: HMOs, medical group/staff model, independent practice associations/other entities
  • Provider May Advocate on Behalf of Patient: § 354.606.10 p 25
    • Effective Date: For Provider Contracts entered into, continued or renewed on or after 1/1/98.
    • Affected Parties: HMOs
    • Notes: See also 354.606.15, 354.609.5, 376.1350.10 and 376.1361.10.
  • Written Disclosures: § 354.442 p 12-15
    • Effective Date: 8/28/97
    • Affected Parties: HMOs
    • Notes: A mailing to each current enrollee to provide them with this information on or about 8/28/97 will be required. However, information previously provided to enrollees need not be sent again during the current policy period. Additional information may be sent in supplemental mailings such as quarterly newsletters, as long as mailings are sent within a reasonable time after August 28. A single mailing to a household with more than one enrollee will be sufficient.
  • Standardized Credentialling: § 354.442.1 (15) p 14
    • Effective Date: 8/28/97
    • Parties Affected: HMOs
    • Notes: The DOI is in the processing of developing a standardized credentialling format in the rulemaking process.
  • Disclosure of Financial Arrangements: § 354.443 p 15-16
    • Effective Date: 8/28/97
    • Parties Affected: HMOs
    • Notes: This information should be disclosed to the DOI on 8/28/97, and any new financial arrangements entered into after 8/28/97 should be disclosed to the DOI when they are entered into.
  • HMOs May be Considered to be Practicing Medicine: § 354.505.1 p 18 (lines 17-19)
    • Effective Date: 8/28/97
    • Parties Affected: HMOs
    • Notes: Makes HMOs subject to Med Mal Claims; See also § 538.205 (p 58-9), concerning definition of Health care provider" in tort actions based on improper health care.
  • Confidentiality of Mental Health Records: § 354.515.2 p 19
    • Effective Date: 8/28/97
    • Parties Affected: HMOs
  • Pharmacy Issues: § 354.535
    • Missouri Licensed Pharmacies Only: § 354.535.2 p 19
      • Effective Date: For Provider Contracts entered into, continued or renewed on or after 8/28/97.
      • Parties Affected: HMOs
    • Same Coinsurance, Copay, & Deductible for All Pharmacies: § 354.535.3 p 19
      • Effective Date: For Provider Contracts and Health Benefit Plans issued, entered into, continued or renewed on or after 8/28/97.
      • Parties Affected: HMOs
    • Uniform Limits on Quantity of Drugs: § 354.535.4 p 19
      • Effective Date: For Provider Contracts and Health Benefit Plans issued, entered into, continued or renewed on or after 8/28/97.
      • Parties Affected: HMOs
    • Maintenance Drugs: § 354.535.5 & 6 p 19-20
      • Effective Date: For Provider Contracts and Health Benefit Plans issued, entered into, continued or renewed on or after 8/28/97.
      • Parties Affected: HMOs
  • Definitions (including Emergency Medical Condition): § 354.600 p 20-21
    • Effective Date: 8/28/97
    • Parties Affected: N/A
    • Notes: Definition of "Emergency Medical Condition" also at 354.400 (5), p 4.--not identical, but probably no substantive difference and at § 376.1350, p 42-3.
  • Hold Harmless Agreement: § 354.606 p 23-4
    • Effective Date: For Provider Contracts entered into, continued or renewed on or after 1/1/98.
    • Parties Affected: HMOs
  • Credentialling: § 354.606.6 - .8 p 24-5
    • Effective Date: 8/28/97.
    • Parties Affected: HMOs, Participating Providers
  • Prohibition on Inducements to Provide Less than Medically Necessary Services: 354.606.9 p 25
    • Effective Date: For Provider Contracts entered into, continued or renewed on or after 1/1/98.
    • Parties Affected: HMOs
    • Notes: See also, 354.443, & 376.1361.9
  • Discrimination Against Medicaid Patients Prohibited: § 354.606.13 p 26
    • Effective Date: For Provider Contracts entered into, continued or renewed on or after 1/1/98.
    • Parties Affected: HMOs
  • Provider Non-Discrimination
    • Providers Acting Within the Scope of Their License: § 354.606.17 p 26
      • Effective Date: 8/28/97.
      • Parties Affected: HMOs
    • Eye Care Providers: § 354.618.5 p 31
      • Effective Date: 8/28/97.
      • Parties Affected: HMOs
  • Contract Termination: § 354.609 p 26-28
    • Effective Date: For Provider Contracts entered into, continued or renewed on or after 1/1/98.
    • Parties Affected: HMOs/Participating Providers
  • Provider to Continue Care When Medically Necessary: § 354.612 p 28-9
    • Effective Date: For Provider Contracts entered into, continued or renewed on or after 1/1/98.
    • Parties Affected: Health Carriers & Providers
  • Open Referral Plan Requirement: § 354.618 p 30-2
    • Effective Date: For Health Benefit Plans issued, continued or renewed on or after 8/28/97. Health Benefit Plan Contracts currently in existence do not have to comply until the next annual renewal period or (for multi year contracts) when the contract expires.
    • Parties Affected: Health Carriers: HMOs sponsored by FQHCs exempt for 2 years; Medicaid and labor-negotiated plans are not covered by requirements.
    • Notes: For group health plans offered to employers with 50 or fewer employees, the offer must be made to the contract holder; for groups of over 50, the offer must be made to each employee.
  • Ob/Gyn Visits: § 354.618.4 p 31
    • Effective Date: For Health Benefit Plans issued, continued or renewed on or after 8/28/97.
    • Parties Affected: HMOs
  • Filing of Provider Contract Forms: § 354.624 p 32-3
    • Effective Date: 8/28/97.
    • Parties Affected: HMOs
    • Notes: It is necessary to file this information under current law (§§ 354.410.1(3)(d) and (4), and 20 CSR 400-8.200), and so should already have been filed with the DOI, as well as any changes to such forms.
  • Utilization Review: (UR)
  • "Utilization Review" definition & application: § 374.500 - 510 p 33-6
    • Effective Date: 8/28/97: § 374.510.6 requires that all utilization review agents certified before 9/1/97 must meet requirements of §§ 376.1350 - 1390 by 1/1/98 or certification is invalid.
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agent.
  • Definitions: § 376.1350 p 41-5
    • Effective Date: 8/28/97
    • Notes: Definition of "Emergency Medical Condition" also at 354.400 (5), p 4.--not identical, but probably no substantive difference and at § 354.600, p 21-2.
  • Monitoring UR Activities: § 376.1353 - 1356 p 45
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Written Review Program: § 376.1359 p 45
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
      (c) Notes: Annual report should be filed 3/1/98, but written review program should be implemented 8/28/97.
  • Clinical Review Criteria Required in UR Program: § 376.1361.1 p 45
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents.
  • Medical Director to Have Missouri License: § 376.1361.2 p 45
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents.
  • UR Toll Free Number: § 376.1361.7 p 46
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Compensation Not Based on Incentives: § 376.1361.9 p 46
    • Effective Date: Utilization review contracts entered into, continued, or renewed on or after 8/28/97.
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Coverage for FDA Approved Drugs Required: § 376.1350.11 p 46-7
    • Effective Date: Health Benefit Plans issued, amended, delivered, or renewed on or after 1/1/98.
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Confirmation Numbers: § 376.1361.12 p 47
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Retraction of Authority Prohibited: § 376.1361.13 p 47
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Decision Notification Time Lines: § 376.1363 p 47-9
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Emergency Services Decisions: § 376.1367 p 49
    • Effective Date: For (1) & (2): Health benefit plans issued, continued, or renewed on or after 8/28/97. For (3) 8/28/97.
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Certification of UR Compliance: § 376.1369 p 49
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • UR Procedures in Handbook: § 376.1372 p 49-50
    • Effective Date: For health benefit plans issued, continued, or renewed on or after 8/28/97.
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • UR Toll Free Number on Membership Cards: § 376.1372.3 p 50
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
    • Notes: Number must be on any membership cards printed after 8/28/97.
  • Mental Illness Benefits
    • Definitions, Including Expanded Definition of "Licensed Professional", and Recognized Mental Illness": § 376.810 p 38-9
      • Effective Date: 8/28/97
    • Minimum Coverage and Offer Standards: § 376.811.2 p 40
      • Effective Date: For health benefit plans issued, continued, or renewed on or after 8/28/97.
      • Parties Affected: Insurance Companies/Health Services Corporations/HMO's
  • Grievance Procedures: § 376.1375 - 1389
  • Written Register of Grievances: § 376.1375.1 p 50
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Adequate Response to DOI W/I 20 Days: § 376.1375.3 p 50
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Grievance Procedure/DOI Toll Free Number in Handbook: § 376.1378 p 50-1
    • Effective Date: For health benefit plans issued, continued, or renewed on or after 8/28/97.
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
    • Notes: Toll Free Number is: 800-726-7390
  • Standards for First Level Grievance Review: § 376.1382.2 p 51
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Standards for Second Level Grievance Review: § 376.1385 p 51-2
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • DOI Grievance Review/Independent Review Organization: § 376.1387 p 52
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • Standards for Expedited Review: § 376.1389 p 53
    • Effective Date: 8/28/97
    • Parties Affected: Health Carrier broadly defined: includes: indemnity companies, HMOs, nonprofit hospital and health services corporations and any other entity providing a plan of health insurance, as well as Utilization Review Agents
  • POS Rider Without Separate License: Section 11 p 62
    • Effective Date: 8/28/97
    • Parties Affected: Licensed HMO's
  • Peer Review Evaluations Exempt from Discovery: § 537.035 p 56-7
    • Effective Date: 8/28/97
    • Parties Affected: HMOs