Mo. Code Regs. tit. 20 § 400-7.095
Current through Register Vol. 49, No. 23, December 2, 2024
Section 20 CSR 400-7.095 - HMO Access PlansPURPOSE: This rule clarifies the information required to be submitted as part of an access plan for a health maintenance organization's managed care plans pursuant to section 354.603, RSMo Supp. 2001, and the process for approval or disapproval of the access plans filed.
(1) Definitions. (A) Access plan-The plan required to be filed with the department pursuant to section 354.603, RSMo, and in accordance with the requirements of this regulation.(B) Categories of counties- 1. Urban access counties-Counties with a population of two hundred thousand (200,000) or more persons.2. Basic access counties-Counties with a population between fifty thousand (50,000) persons and one hundred ninety-nine thousand, nine hundred ninety-nine (199,999) persons.3. Rural access counties-Counties with a population of fewer than fifty thousand (50,000) persons.4. Population figures shall be based on census data as reported in the latest edition of the Official Manual of the State of Missouri.(C) Closed practice provider-A health care provider who does not accept new or additional patients from the health maintenance organization (HMO) that is reporting the provider as part of the managed care plan's network.(D) Department-The Missouri Department of Commerce and Insurance.(E) Distance standard-The travel distance standards set forth in Exhibit A, which is included herein. Each distance standard represents the maximum number of miles an enrollee may be required to travel in order to access participating providers of the managed care plan. The standards set forth in Exhibit A shall be used to evaluate enrollee access in each county of an HMO's current service area.(F) Employer specific network-A network created for a specific employer group that differs from the networks of all other managed care plans customarily offered by the HMO in either the identity or number of providers included within the network. An employer specific network constitutes a different or reduced network for the purposes of section 354.603.1(4), RSMo, and is a distinct managed care plan for access plan filing purposes.(G) Enrollee access rate-The percentage of a managed care plan's enrollees living or working within a county who are able to access a participating provider within the travel distance standards set forth in Exhibit A.(H) Health benefit plan-A policy, contract, certificate or agreement entered into, offered or issued by an HMO to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, and identified by the form number or numbers used by the HMO when the health benefit plan was filed for approval pursuant to 20 CSR 400-7.010 and 20 CSR 400-8.200.(I) Hospitals- 1. Basic-Hospitals that meet any of the following criteria:A. Licensed or state owned hospitals that designate themselves as general medical surgical hospitals in the Department of Health and Senior Services licensure survey and which offer general medical surgical care to all ages of the general population;B. Hospitals located in an adjacent state, appropriately licensed or owned by that state, and offering general medical surgical care to all ages of the general population; orC. Children's hospitals, except that children's hospitals shall not be included in the calculation of the basic hospital enrollee access rate.2. Secondary-Basic hospitals reporting on the most recent available Department of Health and Senior Services licensure survey or other available sources of information that are appropriate and verifiable that the following services are available at the reporting hospital: A. At least one (1) functioning operating room;B. Obstetrics services except that hospitals delivering babies only on an emergency basis shall not be include in the calculation of the secondary hospital enrollee access rate; andC. Intensive care services.(J) Managed Care Plan-A health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use an identified set of health care providers managed, owned, under contract with or employed by the HMO. A managed care plan is a type of health benefit plan. For purposes of this rule, a managed care plan consists of a health benefit plan and a network. If an HMO offers managed care plans where the health benefit plan, the network or both differ, the HMO is offering more than one (1) managed care plan. For example:1. If the HMO offers the same health benefit plan with two (2) different networks, the HMO is offering two (2) managed care plans.2. If the HMO offers two (2) different health benefit plans with the same network, the HMO is offering two (2) managed care plans.3. If the HMO offers two (2) different health benefit plans each with a different network, the HMO is offering two (2) managed care plans.(K) Mental health facilities- 1. Inpatient mental health treatment facility-A. A hospital offering staffed psychiatric or alcohol/chemical dependency beds and having psychiatrists on staff based on the most recent available Department of Health and Senior Services licensure survey; orB. A facility recognized by the federal Substance Abuse and Mental Health Service Administration as a psychiatric hospital, a general hospital with a psychiatric unit; orC. An inpatient substance abuse hospital, or an inpatient facility identified through other available sources of information that are appropriate and verifiable.2. Ambulatory mental health treatment provider-A. A hospital outpatient psychiatric or alcohol/chemical dependency service identified in the most recent available Department of Health and Senior Services licensure survey; orB. A provider recognized by the Missouri Department of Mental Health as a community psychiatric rehabilitation center, a community psychiatric rehabilitation program, a community psychiatric rehabilitation day program, an outpatient program, an access crisis intervention program, an off-site day habilitation program, an on-site day habilitation program, a day program, a supported employment program, an alcohol or drug treatment and rehabilitation program, an alcohol or drug abuse prevention program; orC. A provider recognized by the federal Substance Abuse and Mental Health Service Administration as a multi-setting mental health organization, a partial hospitaliza-tion/day treatment provider or an outpatient clinic; orD. A nonresidential, non-inpatient provider of mental health related services identified through other available sources of information that are appropriate and verifiable.3. Residential mental health treatment provider-A. A provider recognized by the Missouri Department of Mental Health as a group home, a residential care facility, a semi-independent living arrangement, an intermediate care facility, a residential center, a residential habilitation provider, a supported living arrangement, a family living arrangement; orB. A provider recognized by the federal Substance Abuse and Mental Health Service Administration as a residential substance abuse provider, a community residential organization, a residential treatment center for children; orC. A provider of mental health services in residential settings identified through other available sources of information that are appropriate and verifiable.(L) Network-The group of participating providers providing services to a managed care plan or pursuant to a health benefit plan established by an HMO. The meaning of the term network is further clarified for purposes of this rule as such: A network is one (1) component of a managed care plan. A network is the identified set of health care providers managed, owned, under contract with or employed by the HMO, either directly or indirectly, for purposes of rendering medical services to all enrollees of a managed care plan.(M) Offer-An HMO is offering a managed care plan when it is presenting that managed care plan for sale in Missouri.(N) Participating provider-A provider who, under a contract with the HMO or with the HMO's contractors or subcontractors, has agreed to provide health care services to all enrollees of a managed care plan with an expectation of receiving payment directly or indirectly from the HMO. The following types of providers are not participating providers:1. Providers to which an enrollee may not go for covered services, with or without a referral from a primary care provider;2. Providers that are only available in the event that an enrollee has a point-of-service benefit level, or other option attached to the HMO level of benefits; and3. A provider that has agreed to render services to an enrolled person in an isolated instance for purposes of treating a medical need that cannot otherwise be met within the network.(O) Pharmacy-Any pharmacy, drug store, chemical store or apothecary shop possessing a valid and current permit issued by the State of Missouri Board of Pharmacy and doing business for the purposes of compounding, dispensing and retailing any drug, medicine, chemical or poison to be used for filling a physician's prescription.(P) Primary care provider (PCP)-A participating health care professional designated by the HMO to supervise, coordinate, or provide initial care or continuing care to an enrollee, and who may be required by the HMO to initiate a referral for specialty care and maintain supervision of health care services rendered to the enrollee. A PCP may be a professional who practices general medicine, family medicine, general internal medicine or general pediatrics. A PCP may be a professional who practices obstetrics and/or gynecology, in accordance with the provider contracts and health benefit plans of the HMO.(Q) Specialist-A licensed health care professional whose area of specialization is in an area other than general medicine, family medicine or general internal medicine. A professional whose area of specialization is pediatrics, obstetrics and/or gynecology may be either a PCP or a specialist within the meaning of this rule.(R) Tertiary services-Hospitals that offer the following types of services are required in every HMO network and will be identified through hospital responses to the most recent available annual Department of Health and Senior Services licensing survey or other available sources of information that are appropriate and verifiable: 1. Level I or Level II trauma hospital- a hospital as designated by the Department Health and Senior Services. A trauma unit that is designated as pediatric only does not satisfy the requirements of this rule.2. Neonatal intensive care services-a hospital or children's hospital or secondary hospital offering neonatal intensive care services and at least one (1) functioning operating room.3. Perinatology services-a secondary hospital with active board certified perinatol-ogists on staff and a level II or III obstetrical unit.4. Comprehensive cancer services-any hospital with active board certified oncologists on staff and providing all cancer treatment services listed in the annual licensing survey, and at least one (1) functioning operating room.5. Comprehensive cardiac services-any hospital with active board certified cardiovascular disease physicians on staff, at least one (1) functioning operating room and providing all interventional cardiac services and open heart surgery.6. Pediatric subspecialty care-a hospital or children's hospital or secondary hospital with active board certified pediatricians and pediatric specialists on staff, at least one (1) functioning operating room and providing intensive care services, neonatal intensive care services or pediatric intensive care services. (2) Requirements for Filing Access Plans. (A) Annual filing-By March 1 of each year, an HMO must file an access plan for each managed care plan it was offering in this state on January 1 of that same year. An HMO may file separate access plans for each managed care plan it offers, or it may file a consolidated access plan incorporating information for multiple managed care plans that it offers, so long as the information submitted with the consolidated access plan clearly identifies the managed care plan or plans to which it applies. The access plan must contain the following information for each managed care plan to which it applies: 1. Pursuant to section 354.603.2(1), RSMo, either: A. Information regarding the participating providers in each managed care plan's network and the enrollees covered by each managed care plan in a format to be determined by the department including, but not limited to, the following: (I) The name, address where medical care is provided, zip code, professional license number or other unique identifier as assigned by the appropriate licensing or oversight agency, and specialty, degree or type of each provider;(II) Whether or not the provider is a closed practice provider, as defined in subsection (1)(C) of this regulation, above; and(III) The number of enrollees by either work or residence zip code in each managed care plan to which the access plan applies;B. Proof of accreditation identifying the accredited entity and an affidavit in the form contained in Exhibit B, which is included herein, certifying that the managed care plan to which the affidavit applies has met one (1) or more of the following standards:(I) The managed care plan is a Medicare+Choice (M+C) or successor coordinated care plan operated by the HMO pursuant to a contract with the federal Centers for Medicare and Medicaid Services;(II) The managed care plan is accredited by the National Committee for Quality Assurance (NCQA), or successor organization, at a level of "accredited" or better, and such accreditation is in effect at the time the access plan is filed;(III) The managed care plan's network is accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), or successor organization, at a level of "accredited" or better, and such accreditation is in effect at the time the access plan is filed. The presence of any Type I recommendations for standards related to access to care shall prevent JCAHO accreditation from fulfilling the requirements of this part. The department shall annually review current JCAHO requirements and identify the specific JCAHO standards that address access to care. The department will annually notify all HMOs of those JCAHO standards that address access to care;(IV) The managed care plan is accredited by the utilization review accreditation commission (URAC), or successor organization, at a level of full URAC Health Plan accreditation, and such accreditation is in effect at the time the access plan is filed; or(V) The managed care plan or its network is accredited by any other nationally recognized managed care accrediting organization, similar to those above, that is approved by the department prior to the filing of the access plan, and such accreditation is in effect at the time the access plan is filed. Requests for approval of another nationally recognized managed care accrediting organization must be submitted to the department no later than October 15 of the year prior to the year the access plan is filed;C. If the managed care plan's service area has expanded beyond that which was in effect at the time the current accreditation was awarded, then the department may request additional data on that service area expansion pursuant to the provisions of (2)(A)1.A., above.2. Pursuant to section 354.603.2(2) through (8), RSMo, a written description with any relevant supporting documentation addressing each of the requirements set forth in that statute.3. Pursuant to section 354.603.2(9), RSMo, the following information: A. For all managed care plans, information demonstrating that:(I) Emergency medical services-A written triage, treatment and transfer protocol for all ambulance services and hospitals is in place. The protocol shall address post-emergency situations when members have received emergency care from a non-participating provider;(II) Home health providers-Home health providers are contracted to serve enrollees in each county where enrollment is reported. A home health provider need not be physically located or headquartered in each county. However, there must be at least one (1) home health provider under contract to serve enrollees in each county if the need arises; and(III) Administrative measures are in place which ensure enrollees timely access to appointments with the medical providers listed in Exhibit A, based on the following guidelines: (a) Routine care, without symptoms-within thirty (30) days from the time the enrollee contacts the provider;(b) Routine care, with symptoms-within five (5) business days from the time the enrollee contacts the provider;(c) Urgent care for illnesses/injuries which require care immediately, but which do not constitute emergencies as defined by section 354.600, RSMo -within twenty-four (24) hours from the time the enrollee contacts the provider;(d) Emergency care-a provider or emergency care facility shall be available twenty-four (24) hours per day, seven (7) days per week for enrollees who require emergency care as defined by section 354.600, RSMo;(e) Obstetrical care-within one (1) week for enrollees in the first or second trimester of pregnancy; within three (3) days for enrollees in the third trimester. Emergency obstetrical care is subject to the same standards as emergency care, except that an obstetrician must be available twenty-four (24) hours per day, seven (7) days per week for enrollees who require emergency obstetrical care; and(f) Mental health care-Telephone access to a licensed therapist shall be available twenty-four (24) hours per day, seven (7) days per week.B. For all managed care plans, a section demonstrating that the entire network is available to all enrollees of a managed care plan, including reference to contracts or evidences of coverage that clearly state the entire network is available and describing any network management practices that affect enrollees' access to all participating providers;C. For employer specific networks, a section demonstrating that the group contract holder agreed in writing to the different or reduced network. An employer specific network is subject to the standards in this rule;D. For all managed care plans, a listing of the product names used to market those plans;E. For all managed care plans, written policies and procedures to assure that, with regard to providers not addressed in Exhibit A of this regulation, access to providers is reasonable. For otherwise covered services, the policies and procedures must show that the HMO will provide out-of-network access at no greater cost to the enrollee than for access to in-network providers if access to in-network providers cannot be assured without unreasonable delay; and F. Any other information the department may require.(B) Updates to annual filing-An HMO must file an updated access plan for a managed care plan if, at any time between the time annual access plan filings are due, one (1) of the following occurs:1. If an affidavit was submitted for a managed care plan pursuant to the provisions of (2)(A)1.B., above, and the accreditation specified in the affidavit is no longer in effect, the HMO must file, within thirty (30) days of the date such accreditation is no longer in effect, or such longer period of time as the department determines is reasonable, either: A. Network and enrollee information for the managed care plan as required by the provisions of (2)(A)1.A., above; orB. If the accreditation has been replaced by alternative acceptable accreditation, an affidavit as required by the provisions of (2)(A)1.B., above.2. If changes in the network or in the number or location of enrollees cause an accredited managed care plan not to meet any of the distance standards set forth in Exhibit A, the HMO must file, within thirty (30) days of such changes, updated network and enrollee information as required.3. If network and enrollee information was submitted for a managed care plan pursuant to the provisions of (2)(A)1.A., above, and changes in the network or number of enrollees may cause the managed care plan not to meet any of the distance standards set forth in Exhibit A, the HMO must file, within thirty (30) days of such changes, updated network and enrollee information as required by the provisions of (2)(A)1.A., above.(C) Prior to offering a new managed care plan-If at any time between the time annual access plan filings are due an HMO proposes to begin offering a new managed care plan in this state, the HMO must file an access plan for the new managed care plan prior to offering the new managed care plan, including a managed care plan with an employer specific network.(D) Waiver for the filing of the annual access plan- 1. An HMO may request a waiver of the filing of the annual access plan for a managed care plan if it certifies to the department that: A. The HMO has notified enrollees of the managed care plan and producers with whom the HMO does business that the managed care plan is no longer being marketed, and the HMO has ceased writing any new contracts for the managed care plan; andB. The HMO has informed enrollees of the managed care plan that they may access any provider at no greater cost than if that provider was a participating provider in the event the managed care plan cannot provide access to providers as required under this rule.2. A request to waive the filing of the annual access plan for a managed care plan must be received by the department no later than January 15 of the year in which an access plan would otherwise be required.(3) Evaluation of Access Plans. (A) For the information submitted pursuant to section 354.603.2(1), RSMo, the information will be evaluated as follows: 1. If information regarding a managed care plan's network and enrollees is submitted, the department will calculate the enrollee access rate for each type of provider in each county in the HMO's approved service area to determine if the average enrollee access rate for each county and the average enrollee access rate for all counties is greater than or equal to ninety percent (90%). In calculating the enrollee access rate for a managed care plan, the department will give consideration to the following: A. Tertiary services may be contracted at one (1) hospital, or among multiple hospitals; andB. With the department's approval, a managed care plan's network may receive an exception for one (1) or more of the distance standards set forth in Exhibit A under the following circumstances: (I) Quality of care exception-An exception may be granted if the managed care plan's access plan is designed to significantly enhance the quality of care to enrollees, demonstrates that it does in fact enhance the quality of care, and imposes no greater cost on enrollees than would be incurred if they had access to contracted, participating providers as otherwise required under this rule;(II) Noncompetitive market exception for PCPs and pharmacies-In the event an HMO can demonstrate to the department that there is not a competitive market among PCPs and/or pharmacies who meet the HMO's cre-dentialing standards, and who are qualified within the scope of their professional license to provide appropriate care and services to enrollees, the department may grant an exception for the managed care plan's network that doubles the distance standard indicated in Exhibit A for PCPs or pharmacies;(III) Noncompetitive market exception for other provider types-If no provider (exclusive of PCPs and pharmacies) of the appropriate type provides services to enrollees of a managed care plan in a county within the distance standards indicated in Exhibit A, an exception may be granted if the HMO can demonstrate that no fewer than ninety percent (90%) of the population of that county (or, at the HMO's discretion, ninety percent (90%) of the enrollees residing or working in the county) have access to a participating provider of the appropriate type, which provider is located no more than twenty-five (25) miles further than the provider closest to that county;(IV) Staff or Independent Practice Association (IPA) Model exception-An exception may be granted for those health care services provided to enrollees of the managed care plan if substantially all of those services are provided by the HMO to its enrollees through qualified full-time employees of the HMO or qualified full-time employees of a medical group that does not provide substantial health care services other than on behalf of such HMO. In order to qualify for the exception provided for in this part, an HMO must demonstrate that all or substantially all of the type of health care services in question are provided by full-time employees, that enrollees have adequate access to such health care services as described in the provisions of (2)(A)3.A., above, and that the contract holder was made aware of the circumstances under which such services were to be provided prior to the decision to contract with the HMO for that managed care plan; or(V) Use of physician extenders-If there is insufficient availability of physicians of the appropriate type providing services to enrollees of a managed care plan in a county within the distance standards indicated in Exhibit A, an exception may be granted for the use of physician extenders. The HMO must demonstrate that enrollees residing or working in the county may access a participating provider who may be either a physician or an advanced practice nurse rendering care under a collaborative agreement pursuant to 4 CSR 200-4.200, and in accordance with the provider contracts and health benefit plans of the HMO. An exception may be granted for other types of physician extenders in addition to advanced practice nurses if information is submitted justifying, to the satisfaction of the department, that the other types of physician extenders are able to provide the appropriate services within the scope of their license, and in accordance with the provider contracts and health benefit plans of the HMO.2. If an affidavit is submitted, the department will review it to make sure that it meets all the requirements of Exhibit B. If the access plan is a consolidated access plan including information for more than one (1) managed care plan, the department will also review the affidavit for the following: A. An affidavit that relies upon a managed care plan being an M+C or successor coordinated care plan will only apply to the specific managed care plan that is such a plan. All other managed care plans included in the access plan must be accompanied by either network information pursuant to the provisions of (2)(A)1.A., above, or an affidavit indicating they are otherwise accredited pursuant to the provisions of (2)(B)1.B., above;B. An affidavit that relies upon a managed care plan being accredited by the NCQA, or successor organization, will only apply to the specific managed care plan included with the accreditation. All other managed care plans included in the access plan must be accompanied by either network information pursuant to the provisions of (2)(A)1.A., above, or an affidavit indicating they are otherwise accredited pursuant to the provisions of (2)(B)1.B., above;C. An affidavit that relies upon a managed care plan's network being accredited by the JCAHO, or successor organization, will only apply to that portion of the managed care plan's network that is included within the accreditation. For the remainder of the network, either network information pursuant to the provisions of (2)(A)1.A., above, or an affidavit indicating the remaining network is otherwise accredited pursuant to the provisions of (2)(B)1.B., above, must be submitted. All other managed care plans included in the access plan must be accompanied by either network information pursuant to the provisions of (2)(A)1.A., above, or an affidavit indicating they are otherwise accredited pursuant to the provisions of (2)(B)1.B., above;D. An affidavit that relies upon a managed care plan being accredited by URAC, or successor organization, will only apply to the specific managed care plan included with the accreditation. All other managed care plans included in the access plan must be accompanied by either network information pursuant to the provisions of (2)(A)1.A., above, or an affidavit indicating they are otherwise accredited pursuant to the provisions of (2)(B)1.B., above;E. An affidavit that relies upon a managed care plan being accredited by any other nationally recognized managed care accrediting organization, similar to those above, will only apply to the specific managed care plan included with the accreditation. All other managed care plans included in the access plan must be accompanied by either network information pursuant to the provisions of (2)(A)1.A., above, or an affidavit indicating they are otherwise accredited pursuant to the provisions of (2)(B)1.B., above.(B) For information submitted pursuant to sections 354.603.2(2) through (9), RSMo, the department will evaluate the information to determine whether it is sufficient to meet the requirements of sections 354.600 to 354.636, RSMo, for each managed care plan to which the access plan applies.(4) Approval or Disapproval of Access Plans. (A) For a managed care plan for which network and enrollee information is submitted pursuant to the provisions of (2)(A)1.A. above, the department will: 1. Approve the access plan or portion of a consolidated access plan that applies to that managed care plan when the enrollee access rate across the entire network (all counties, all provider types) for that managed care plan is ninety percent (90%) or better, and the average enrollee access rate in each county in an HMO's approved service area for that managed care plan is ninety percent (90%) or better, and the information submitted pursuant to the provisions of (2)(A)2. and 3., above, is satisfactory;2. Conditionally approve the access plan or portion of a consolidated access plan that applies to that managed care plan when the enrollee access rate across the entire network (all counties, all provider types) for that managed care plan is ninety percent (90%) or better, but the average enrollee access rate in any county for that managed care plan is less than ninety percent (90%), and the information submitted pursuant to the provisions of (2)(A)2. and 3., above, is satisfactory. If an access plan or portion of an access plan is conditionally approved, the department may require the HMO to present an action plan for increasing the enrollee access rate for that managed care plan's network to ninety percent (90%) or better in those counties where this standard is not met; or3. Disapprove the access plan or portion of a consolidated access plan that applies to that managed care plan when the enrollee access rate across the entire network (all counties, all provider types) for that managed care plan is less than ninety percent (90%) and/or the information submitted pursuant to the provisions of (2)(A)2. and 3., above, is unsatisfactory. Disapproval of the access plan or portion of the access plan will subject the HMO and its managed care plan to the enforcement mechanisms described in section (5), below, of this regulation.(B) For a managed care plan for which an affidavit is submitted pursuant to (2)(A)1.B. above, the department will: 1. Approve the access plan or portion of a consolidated access plan that applies to that managed care plan when both the managed care plan's affidavit and the information submitted pursuant to (2)(A)2. and 3., above, are satisfactory; or2. Disapprove the access plan or portion of a consolidated access plan that applies to that managed care plan when the managed care plan's affidavit and/or the information submitted pursuant to (2)(A)2. and 3., above, are unsatisfactory. Disapproval of the access plan or portion of the access plan will subject the HMO and its managed care plan to the enforcement mechanisms described in section (5), below, of this regulation.(C) Approval of an access plan or portion of an access plan is subject to the following: 1. Approval of an access plan shall not remove any HMO's obligations to provide adequate access to care as expressed in this regulation or in section 354.603, RSMo. In any case where a managed care plan's network has an insufficient number or type of participating providers to provide a covered benefit, the HMO shall ensure that the enrollee obtains the covered benefit at no greater cost than if the benefit was obtained from a participating provider, or shall make other arrangements acceptable to the director. This may include, but is not limited to, the following: A. With regard to the types of providers listed in Exhibit A and only those types of providers, allowing an enrollee access to a nonparticipating provider at no additional cost when no participating provider of that same type is within the distance standard prescribed by Exhibit A;B. With regard to the types of providers listed in Exhibit A, and only those types of providers, allowing an enrollee access to a nonparticipating provider at no additional cost when no participating provider is available to provide the service within the time prescribed in (2)(A)3.A.(III), above, for timely access to appointments; andC. With regard to medical providers not expressly stated in Exhibit A, allowing an enrollee access to a nonparticipating provider at no additional cost when no participating provider is available without unreasonable delay, pursuant to the written policies and procedures of the HMO;2. If there is no participating provider in a managed care plan's network with the appropriate training and experience to meet the particular health care needs of an enrollee, the HMO shall make arrangements with an appropriate nonparticipating provider, pursuant to a treatment plan developed in consultation with the primary care provider, the nonparticipating provider and the enrollee or enrollee's designee, at no additional cost to the enrollee beyond what the enrollee would otherwise pay for services received within the network.(5) Enforcement Process for Disapproved Access Plans. If a managed care plan's access plan has been disapproved pursuant to section (4), above, it is subject to the following: (A) The managed care plan may be placed on probationary status by the department for a period not to exceed ninety (90) days. If information sufficient to allow the department to "approve" or "conditionally approve" the managed care plan's access plan is submitted prior to the expiration of the probationary period, the managed care plan will be removed from probationary status;(B) If the HMO fails to submit information sufficient to allow the department to "approve" or "conditionally approve" the managed care plan's access plan by the end of the probationary period, the department may, after notice and hearing pursuant to sections 354.470 and 354.490, RSMo, order the HMO to refrain from offering that managed care plan in part or all of the HMO's service area until such time as the HMO can demonstrate to the department's satisfaction that the managed care plan fully meets the requirements of this rule;(C) If all of an HMO's managed care plans are disapproved at the time of renewal of the HMO's certificate of authority, the department may, after notice and hearing pursuant to section 354.490, RSMo, deny renewal of the HMO's certificate of authority until such time as the HMO demonstrates to the satisfaction of the department that one or more of its managed care plans meet the requirements of this regulation. 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AUTHORITY: sections 354.615 and 374.045, RSMo 2000 and 354.405 and 354.603, RSMo Supp. 2006.* Original rule filed Nov. 3, 1997, effective May 30, 1998. Rescinded and readopted: Filed Oct. 1, 2002, effective April 30, 2003. Amended: Filed May 11, 2004, effective Dec. 30, 2004. Amended: Filed July 29, 2005, effective Feb. 28, 2006. Amended: Filed Dec. 14, 2006, effective June 30, 2007. Non-substantive change filed Sept. 11, 2019, published Oct. 31, 2019.
*Original authority: 354.405, RSMo 1983, amended 1997, 2003; 354.603, RSMo 1997, amended 2001, 2003; 354.615, RSMo 1997; and 374.045, RSMo 1967, amended 1993, 1995.