About Mandates, Offers and Required Provisions
A mandate must be included in the applicable type of health insurance coverage. The person buying the insurance cannot choose to leave it out.
An offer must be offered when the applicable type of health insurance is sold, but can be declined by the person buying the insurance.
A Required Provision is a regulatory/administrative requirement similar to a mandate. The person buying insurance cannot choose to leave it out.
Health Insurance Mandates in Missouri
| 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 treatment if confined to a hospital or in a residential or nonresidential facility. 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 |
| Early refill of prescription eye drops | 376.1237 RSMo | Plans providing coverage for prescription eye drops shall provide coverage for refilling an eye drop prescription early. Sunsets 1/1/2020. | 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 |
| HIV mandate | 20 CSR 400-2.110 | All forms shall cover HIV infection, including AIDS and ARC, as they would any other serious medical condition | 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 |
| Oral chemotherapy | 376.1257 | Any health benefit plan that provides coverage and benefits for cancer treatment shall provide coverage of prescribed orally administered anticancer medications on a basis no less favorable than intravenously administered or injected anticancer medications | 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 RSMo 376.893 RSMo 376.894 RSMo | Following COBRA | Required Provision |
| Telehealth | 367.1900 RSMo | Telehealth services must be covered same as in person services | Mandate |
| Therapy Cost Sharing - Physical and Occupational | 376.1235 RSMo | Copay or co-insurance for each PT or OT date of service that requires a prescription not to exceed primary care office visit copay or co-insurance | 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 |