To repeal sections 354.430 and 354.440, RSMo 1994, relating to managed care plans, and to enact in lieu thereof two new sections relating to the same subject.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF MISSOURI,

AS FOLLOWS:

Section A. Sections 354.430 and 354.440, RSMo 1994, are repealed and two new sections enacted in lieu thereof, to be known as sections 354.430 and 354.440, to read as follows: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 exclusions, restrictions or limitations on the services, kind of services, benefits or kinds of benefits to be provided, including any deductible or copayment feature or any other potential out-of-pocket expense;

(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[.]; and

(f) Whether and how coverage decisions can be fairly and simply appealed within the corporation or organization.

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.

6. The evidence of coverage must be objective, truthful, written in consumer tested terms, and understandable at a fifth grade reading level.

354.440. 1. Every health maintenance organization shall make available to its enrollees:

(1) The most recent annual statement of financial condition, including a balance sheet and summary of receipts and disbursements;

(2) A description of the organizational structure and operation of the health care plan and a summary of any material changes since the issuance of the last report;

(3) A description of services and information as to where and how to secure them; and

(4) A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints.

2. Every health maintenance organization shall make available to its potential enrollees a concise, written statement of the following:

(1) The health care services and the insurance or other benefits available;

(2) Any exclusions, restrictions or limitations on the services, or types of services to be provided, including but not limited to:

(a) Choice of physicians and pharmacists;

(b) Referral to specialty physicians and other providers;

(c) Clinical laboratory tests;

(d) Diagnostic tests including mammography exams and screening tests for osteoporosis and prostate cancer;

(e) Dental services;

(f) Coverage of specific prescription drugs including the use of formularies and prior approval procedures;

(g) Coverage of eye care services and providers; and

(h) Mental health services and providers including psychiatrists and psychologists;

(3) The types and amounts of any deductibles, copayments and other potential out-of-pocket expenses;

(4) How and whether coverage decisions can be fairly and simply appealed; and

(5) Whether coverage may be denied because of a preexisting condition.

3. All descriptions and explanations for potential enrollees under this section must be objective, truthful, in consumer tested terms, and understandable at a fifth grade reading level.