SECOND REGULAR SESSION
93RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES KRAUS (Sponsor), YATES, JOHNSON (47), WILSON (130) AND AVERY (Co-sponsors).
Read 1st time February 15, 2006 and copies ordered printed.
STEPHEN S. DAVIS, Chief Clerk
AN ACT
To repeal section 354.430, RSMo, and to enact in lieu thereof one new section relating to evidence of coverage under a policy issued by a health maintenance organization.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Section 354.430, RSMo, is repealed and one new section enacted in lieu thereof, to be known as section 354.430, to read as follows:
354.430. 1. Every enrollee residing in this state is entitled to evidence of coverage. If the enrollee obtains coverage through an insurance policy or a contract issued by a health services corporation, whether by option or otherwise, the insurer or the health services corporation shall issue the evidence of coverage. Otherwise the health maintenance organization shall issue the evidence of coverage.
2. No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment thereto, has been filed with the director.
3. An evidence of coverage shall contain:
(1) No provisions or statements which are unjust, unfair, inequitable, misleading, or deceptive, or which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in subsection 1 of section 354.460; and
(2) A clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of:
(a) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled;
(b) Any limitations on the services, kind of services, benefits or kinds of benefits to be provided, including any deductible or co-payment feature, or coinsurance or other cost-sharing feature, which feature shall be as requested by the group sponsor or, in the case of individual coverage, the individual certificate holder;
(c) Where and in what manner information is available as to how services may be obtained;
(d) The total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts; and
(e) A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints, including the health maintenance organization's toll-free customer service number and the department of insurance's consumer complaint hot line number.
4. Any subsequent change in an evidence of coverage may be made in a separate document issued to the enrollee.
5. A copy of the form of the evidence of coverage to be used in this state, and any amendment thereto, shall be subject to the filing of subsection 2 of this section unless it is subject to the jurisdiction of the director under the laws governing health insurance or health services corporations, in which event the filing provisions of those laws shall apply.
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