Health insurance mandates in Missouri

*What's the difference between a mandate, an offer and a required provision?

Coverage Citation Summary Type of Requirement*
Adopted children 376.816 RSMo Provision identifying the effective dates of coverage for adoptive children Mandate
Alcoholism 376.779 RSMo 30 days inpatient treatment for alcoholism - applicable if the benefits outlined under 376.811 are not automatically included or are rejected Mandate
Antigen Testing 376.1275 RSMo Antigen testing - Bone marrow transplantation Mandate
Appeal, right to 376.1361.10 RSMo Right to appeal for coverage of drugs & durable medical equip. Mandate
Autism - Applied Behavior Analysis 376.1224 RSMo $40K+ coverage of ABA therapy, adjusted triennially for inflation - must be offered to each individual on individually underwritten group coverage. Mandate
Cancer Diagnosis- 2nd Opinion 376.1253 RSMo Patient has the right to a referral for a second opinion. Mandate
Cancer Screenings 376.1250 RSMo Pelvic exam, prostate exam, colorectal exam, etc. Mandate
Chemical dependency & mental illness, definitions 376.810 RSMo Definitions: chemical dependency & mental illness Mandate
Chemical dependency and mental illness benefits 376.811 RSMo Minimum standards for coverage offered for chemical dependency and mental illness Offer
Chemotherapy 376.1200 RSMo Chemotherapy/Bone Marrow Transplants Offer
Child Coverage: Discrimination Prohibited 376.820 RSMo Prohibited discrimination of child enrollment Mandate
Child Health Supervision 376.801 RSMo Applies to Group only Offer
Childhood immunizations 376.1215 RSMo Childhood immunizations with no deductible, coinsurance or co-payment Mandate
Chiropractic Care 376.1230 RSMo Shall provide chiropractic care, as defined in chapter 331, RSMo, as part of basic health care services for covered conditions. Does not apply to individually underwritten coverage. (Some groups may be individually underwritten such as Association or Discretionary groups) Mandate
Clinical Trials 376.429 RSMo Shall provide coverage for routine patient care costs incurred from phase II, III or IV clinical trials Mandate
Continuation of coverage 376.428 RSMo Continuation for terminated member - group Required Provision
Conversion - group 376.397 RSMo Conversion upon termination of eligibility - group Required Provision
Diabetes 376.385 RSMo Coverage for all physician-prescribed equipment, supplies and self-management training. Offer
Drug Cancellation Notification 376.392 RSMo Carriers are required to notify enrollees 30 days prior to cancellation of a specific Rx. Mandate
Drug Co-pay 376.386 RSMo 1 co-pay for multi dosage, where applicable Mandate
Elements of coverage required 20 CSR 400-2.060(3) Elements of coverage required Reference
Emergency services determination 376.1367 RSMo UR or benefit determination for emergencies Mandate
Expedited review 376.1389 RSMo Procedure for an expedited review Mandate
Extension of Benefits - group 376.438 RSMo Provision for extension of benefits in the event of total disability at the date of any termination Required Provision
First Steps 376.1218 RSMo For children enrolled in the Part C early intervention system. Mandate
Free Look 20 CSR 400-2.010 10 day free look period for all individual and discretionary group policy forms Required Provision
Grievance procedures 376.1382 RSMo Guidelines for 1st level grievance procedure identified Mandate
Grievance procedures in evidence of coverage (EOC) 376.1378 RSMo Includes statement that enrollee can contact MDI at anytime Mandate
Grievance: second level review 376.1385 RSMo Guidelines for 2nd level grievance Mandate
Hospital Dental procedure 376.1225 RSMo Coverage for general anesthesia, hospital charges for dental care Mandate
Lead poisoning testing 376.1290 RSMo Coverage for testing pregnant women for lead poisoning and for all testing for lead poisoning authorized by sections 701.340 to 701.349, RSMo, or by rule of the department of health and senior services promulgated pursuant to sections 701.340 to 701.349, RSMo. Offer
Mammography 376.782 RSMo Minimum requirements Mandate
Mastectomy, reconstructive surgery after 376.1209 RSMo Coverage for reconstructive surgery & prosthetic devices following mastectomy Mandate
Maternity 376.1210 RSMo 48/96 hour inpatient, post-discharge, etc. Mandate
Mental Health Parity 376.1550 RSMo No longer allows a time limit for in-patient requirement as found in 376.811.2(3). Applies to group policies with mental health coverage. Does not apply to individually underwritten coverage. (Some groups may be individually underwritten such as Association or Discretionary groups) Mandate
Newborn coverage 376.406 RSMo Moment of birth to 31 days. Mandate
Newborn Hearing Screening 376.1220 RSMo Coverage for Newborn hearing screening, necessary re-screening, follow-up. Mandate
OB/GYN, direct access 376.1199 RSMo Direct access OB/GYN, Osteoporosis, Contraceptives Mandate
PKU testing and formula 376.1219 RSMo Coverage for the treatment of phenylketonuria Mandate
Prosthetics 376.1232 RSMo Shall offer coverage for prosthetic devices and services, including original and replacement devices, as prescribed by a physician acting within the scope of his or her practice. Offer
Public Hospitals 376.778 RSMo Payment to public hospitals Required Provision
Speech & Hearing 376.781 RSMo Coverage for the necessary care and treatment of loss or impairment of speech or hearing. Offer
Spousal continuation - group 376.891 RSMo
376.892 RMSo
376.893 RSMo
376.894 RMSo
Following COBRA Required Provision
Utilization Review Determinations 376.1363 RSMo Notification requirements for UR determinations Mandate
Utilization Review procedures 376.1372 RSMo UR procedures in EOC Mandate
Utilization review, definitions 376.1350 RSMo Definitions UR Reference