PURPOSE: This rule sets forth enrollee protection provisions. This rule is promulgated pursuant to section 354.485, RSMo.

1. (1) Providers who provide health care services to health maintenance organization (HMO)-covered enrollees pursuant to a provider contract between themselves and the HMO, under no circumstances (including, but not limited to, nonpayment by an HMO for medical services rendered to an enrollee by a provider, insolvency of an HMO or an HMO’s breach of any term or condition of its FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION

agreement with a provider), shall bill, charge, collect a deposit, seek compensation, remuneration or reimbursement from or have any recourse against an enrollee or person acting on behalf of an enrollee for fees, charges or expenses relating to medical services which the HMO is obligated to provide and pay for under the terms of the enrollee’s subscriber agreement with the HMO. (2) In order to ensure compliance with this provision, no contract between an HMO and provider will be valid or enforceable by the provider unless the contract specifically establishes an independent contractor relationship between the HMO and the provider and further provides that under no circumstances (including, but not limited to, those sets of circumstances previously described) shall the provider bill, charge or in any way seek to hold an enrollee legally liable for the payment of any fees which are the legal obligation of the HMO as provided in this rule.

1. (3) The contract must further provide that the provision referred to in this rule will survive the termination of the provider’s agreement with the HMO regardless of the cause of the termination and that the terms are applicable to, and binding upon, all individuals with whom a provider may subcontract to provide services to HMO enrollees. Nothing in this provision, however, shall in any way affect or limit a provider’s right or obligation to collect from enrollees copayments, deductibles or fees assessed for noncovered services in accordance with the agreement governing the enrollee’s enrollment with the HMO.

AUTHORITY: section 354.485, RSMo 1986.* This rule was previously filed as 4 CSR 190- 15.160. Original rule filed Nov. 2, 1987, effective April 11, 1988.

*Original authority: 354.485, RSMo 1983.