95-01: New Mandated Benefit and Required Offer of Coverage
* This bulletin was repealed by 08-05
RESCINDED AND INOPERATIVE
From: Jay Angoff, Director
Re: New Mandated Benefit and Required Offer of Coverage
Date: September 18, 1995
Senate Bill 27 was passed in Missouri's last legislative session and signed into law by Governor Mel Carnahan. This law expands the mandated mammography benefits required by statute section 376.782 RSMo and requires the offer of coverage for certain breast cancer treatments as set forth in statute section 376.1200 RSMo. The new language added to section 376.782 RSMo and the text of 376.1200 RSMo appear below.
Your company must receive approval of forms to accommodate these laws. Offer and acceptance forms, insert pages and amendments will be given expedited review by this department to assist you with compliance. Please follow standard filing procedures. The filing fee for filings made solely to comply with this law is $50.00.
Section 376.782.2(4) RSMo was added to section 376.782 RSMo. Subdivision (4) mandates additional coverage as follows:
(4) A mammogram for any woman, upon the recommendation of a physician, where such woman, her mother or her sister has a prior history of breast cancer.
Section 376.1200 reads as follows:
- Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a health services corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed in this state on or after January 1, 1996, shall offer coverage for the treatment of breast cancer by dose-intensive chemotherapy/autologous bone marrow transplants or stem cell transplants when performed pursuant to nationally accepted peer review protocols utilized by breast cancer treatment centers experienced in dose-intensive chemotherapy/autologous bone marrow transplants or stem cell transplants. The offer of benefits under this section shall be in writing and must be accepted in writing by the individual or group policyholder or contract holder.
- Such health care service shall not be subject to any greater deductible or copayment than any other health care service provided by the policy, contract or plan, except that the policy, contract or plan may contain a provision imposing a lifetime benefit maximum of not less than one hundred thousand dollars, for dose-intensive chemotherapy/autologous bone marrow transplants or stem cell transplants for breast cancer treatment.
- Benefits may be administered for such health care service through a managed care program
of exclusive and/or preferred contractual arrangements with one or more providers
rendering such health care service. These contractual arrangements may provide that the
provider shall hold the patient harmless for the cost of rendering such health care
service if it is subsequently found by the entity authorized to resolve disputes that:
- Such care did not qualify under the protocols established for the providing of care for such health care service;
- Such care was not medically appropriate; or
- The provider otherwise failed to comply with the utilization management or other managed care provision agreed to in any contract between the entity and the provider.
- The provisions of this section shall not apply to short-term travel, accident-only, limited or specified disease policies, or to short-term nonrenewable policies of not more than seven months duration.
- Nothing in this section shall prohibit an entity from including all or part of such care services as standard coverage in its policies, contracts or plans.
By use of the term "continued" in section 376.1200.1 RSMo, the statute requires that insurers offer all policyholders this coverage effective January 1, 1996. The statute requires that an offer be made, and therefore precludes exclusion of policyholders based on medical underwriting or any other method.