Mo. Code Regs. Ann. tit. 20, § 400-7.095
PURPOSE: 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.
(B) Categories of counties—
with a population of two hundred thousand (200,000) or more persons.
a population between fifty thousand (50,000) persons and one hundred ninety-nine thousand, nine hundred ninety-nine (199,999) persons.
a population of fewer than fifty thousand (50,000) persons.
census data as reported in the latest edition of the Official Manual of the State of Missouri.
(H) Hospitals—
vices, dietary services, emergency services, medical records, nursing services, pathology and medical laboratory services, pharmaceutical services, radiology services, social work services and an inpatient care unit.
facilities listed under “Basic,” plus one (1) or more operating rooms, obstetrics unit, and intensive care unit.
(I) 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:
benefit plan with two (2) different networks, the HMO is offering two (2) managed care plans.
health benefit plans with the same network, the HMO is offering two (2) managed care plans.
health benefit plans each with a different network, the HMO is offering two (2) managed care plans.
(L) 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:
not go for covered services, with or without a referral from a primary care provider, are not participating providers;
the event that an enrollee has a point-of-service benefit level, or other option attached to the HMO level of benefits, are not participating providers for purposes of complying with this rule; and
services to an enrolled person in an isolated instance for purposes of treating a medical need that cannot otherwise be met within the network is not a participating provider.
(P) Tertiary services—
secondary hospital with a Level I or Level II trauma unit according to the most recent Hospital Profiles. A trauma unit that is designated as pediatric only by the Bureau of Emergency Medical Services does not satisfy the requirements of this rule.
hospital offering a neonatal intensive care unit according to the most recent Hospital Profiles.
hospital with active perinatologists on staff and offering perinatal items according to the most recent Hospital Profiles.
hospital with active board certified oncologists on staff, according to the most recent Hospital Profiles, and offering all cancer ser- 20 CSR 400-7
vices listed in the most recent Hospital Profiles.
hospital with active cardiovascular disease physicians on staff and offering a cardiac catheterization lab and adult cardiac catheterizations according to the most recent Hospital Profiles.
tal with active cardiovascular disease physicians on staff and offering open heart surgery according to the most recent Hospital Profiles.
pital with active pediatricians and pediatric specialists on staff and offering staffed pediatric beds according to the most recent Hospital Profiles.
(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:
RSMo, either:
pating 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 of Insurance including, but not limited to, the following:
cal 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;
a closed practice provider, as defined in subsection (1)(C) of this regulation, above; and
either work or residence zip code in each managed care plan to which the access plan applies; or
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:
Medicare+Choice coordinated care plan operated by the HMO pursuant to a contract with the federal Centers for Medicare and Medicaid Services;
accredited by the National Committee for Quality Assurance (NCQA) at a level of “accredited” or better, and such accreditation is in effect at the time the access plan is filed;
work is accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) at a level of “accreditation without type I recommendations” or better, and such accreditation is in effect at the time the access plan is filed;
accredited by the American Accreditation Healthcare Commission (URAC) at a level of full URAC Health Plan accreditation, and such accreditation is in effect at the time the access plan is filed; or
network is accredited by any other nationally recognized managed care accrediting organization, similar to those above, that is approved by the Department of Insurance 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.
through (8), RSMo, a written description with any relevant supporting documentation addressing each of the requirements set forth in the statute.
RSMo, the following information:
mation demonstrating that:
written triage, treatment and transfer protocol for all ambulance services and hospitals is in place;
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 arose; and
place which ensure enrollees timely access to appointments with the medical providers listed in Exhibit A, based on the following guidelines:
toms—within thirty (30) days from the time the enrollee contacts the provider;
toms—within one (1) week or five (5) business days from the time the enrollee contacts the provider;
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;
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;
(24) hours per day, seven (7) days per week for enrollees who require emergency obstetrical care; and
phone access to a licensed therapist shall be available twenty-four (24) hours per day, seven (7) days per week.
tion 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;
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;
ing of the product names used to market those plans; and
may require.
(1) of the following occurs:
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 either:
for the managed care plan as required by the provisions of (2)(A)1.A., above; or
replaced by alternative acceptable accreditation, an affidavit as required by the provisions of (2)(A)1.B., above.
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.
(D) Waiver for the filing of the annual access plan—
filing of the annual access plan for a managed care plan if it certifies to the department that:
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; and
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.
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:
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:
ed at one (1) hospital, or among multiple hospitals; and
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:
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;
tion 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 credentialing 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;
tion 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;
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 section, 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
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.
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:
managed care plan being a Medicare+Choice plan will only apply to the specific managed care plan that is a Medicare+Choice 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;
aged care plan being accredited by the NCQA 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 20 CSR 400-7
indicating they are otherwise accredited pursuant to the provisions of (2)(B)1.B., above;
managed care plan’s network being accredited by the JCAHO 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;
managed care plan being accredited by URAC 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;
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.
(4) Approval or Disapproval of Access Plans.
which network and enrollee information is submitted pursuant to the provisions of (2)(A)1.A. above, the department will:
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;
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 will 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; or
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:
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; or
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:
remove any HMO’s obligations to provide adequate access to care as expressed in this regulation or in Exhibit A. 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:
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; and
(2)(A)3.A.(III), above, 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 for timely access to appointments;
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.
(A) If a managed care plan’s access plan has been disapproved pursuant to (4)(A)3., above, it is subject to the following:
on probationary status by the department for a period not to exceed ninety (90) days to allow the HMO time to bring the managed care plan’s distance standard rate across the entire network up to ninety percent (90%) and/or submit satisfactory information pursuant to (2)(A)2. and 3., above. 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;
tion 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.
(B) If the managed care plan’s access plan has been disapproved pursuant to (4)(B)2., above, it is subject to the following:
on probationary status for a period not to exceed ninety (90) days to allow the HMO time to remedy any problems with the affidavit submitted pursuant to (2)(A)1.B., above, and/or submit satisfactory information pursuant to (2)(A)2. and 3., above. 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;
tion 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.
| Outpatient-Geriatric | 15 | 30 | 60 |
|---|---|---|---|
| Inpatient/Intensive Treatment-Adult | 25 | 50 | 100 |
| Inpatient/Intensive Treatment-Child/Adolescent | 25 | 50 | 100 |
| Inpatient/Intensive Treatment-Geriatric | 38 | 75 | 100 |
| Inpatient/Intensive Treatment-Alcohol/Chemical Dependency | 38 | 75 | 100 |
| Ancillary Services | |||
| Physical Therapy | 30 | 30 | 30 |
| Occupational Therapy | 30 | 30 | 30 |
| Speech Therapy | 50 | 50 | 50 |
| Audiology | 50 | 50 | 50 |
| Pharmacy | |||
| Pharmacy | 10 | 20 | 30 |
| Secondary Hospital | 50 | 50 | 50 |
|---|---|---|---|
| Tertiary Services | |||
| Level I or Level II trauma unit | 100 | 100 | 100 |
| Neonatal intensive care unit | 100 | 100 | 100 |
| Perinatology services | 100 | 100 | 100 |
| Comprehensive cancer services | 100 | 100 | 100 |
| Cardiac catheterization | 100 | 100 | 100 |
| Cardiac surgery | 100 | 100 | 100 |
| Pediatric subspecialty care | 100 | 100 | 100 |
| Mental Health Facilities | |||
| Outpatient-Adult | 15 | 30 | 60 |
| Outpatient-Child/Adolescent | 15 | 30 | 60 |
| Otolaryngology | 25 | 50 | 100 |
|---|---|---|---|
| Pediatric | 25 | 50 | 100 |
| Pulmonary Disease | 25 | 50 | 100 |
| Rheumatology | 25 | 50 | 100 |
| Urology | 25 | 50 | 100 |
| General surgery | 15 | 30 | 60 |
| Psychiatrist-Adult/General | 15 | 30 | 60 |
| Psychiatrist-Child/Adolescent | 15 | 30 | 60 |
| Psychologists/Other Therapists | 10 | 20 | 40 |
| Chiropractor | 15 | 30 | 60 |
| Hospitals | |||
| Basic Hospital | 30 | 30 | 30 |
| Physical Medicine/Rehab | 25 | 50 | 100 |
|---|---|---|---|
| Podiatry | 25 | 50 | 100 |
| Vision Care/Primary Eye Care | 15 | 30 | 60 |
| Allergy | 25 | 50 | 100 |
| Cardiology | 25 | 50 | 100 |
| Endocrinology | 25 | 50 | 100 |
| Gastroenterology | 25 | 50 | 100 |
| Hematology/Oncology | 25 | 50 | 100 |
| Infectious Disease | 25 | 50 | 100 |
| Nephrology | 25 | 50 | 100 |
| Ophthalmology | 25 | 50 | 100 |
| Orthopedics | 25 | 50 | 100 |
| Exhibit A | |||
|---|---|---|---|
| Distance Standards | |||
| Provider/Service Type | |||
| Urban County | Basic County | Rural County | |
| Physicians | |||
| PCPs | 10 | 20 | 30 |
| Obstetrics/Gynecology | 15 | 30 | 60 |
| Neurology | 25 | 50 | 100 |
| Dermatology | 25 | 50 | 100 |
Exhibit B
State of ______________
County of _____________
_____________________________________________________________________________, first being duly sworn, on his/her oath states:
He/she is the _____________________________________________of _________________________________________________________, (Insert Title of Individual) a(n) ____________________________________________________ corporation, and as such officer is duly authorized to make this affidavit (Insert State of Incorporation) on behalf of said corporation;
The managed care plan to which this affidavit applies is known by the product name(s): ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________; (Insert Product Name(s) used by the HMO for this Managed Care Plan; if none, so state)
The form number(s) of the health benefit plan for this managed care plan are: ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________;
This managed care plan meets the following criteria: (insert an “X” in one or more of the following, as applicable.)
____ The managed care plan is a Medicare+Choice coordinated care plan offered pursuant to a contract with the federal Centers for Medicare and Medicaid Services, and the contract is currently in effect;
____ The managed care plan is accredited by the National Committee for Quality Assurance (NCQA) at a level of “accredited” or better, and the accreditation is currently in effect;
____ All/some (circle one) of the managed care plan’s network is accredited by the Joint Commission on the Accreditation of Health Organizations (JCAHO) at a level of “accreditation without type I recommendations” or better, and the accreditation is currently in effect. (If “some” is circled, additional information for that portion of the Network not covered by the JCAHO accreditation must be submitted pursuant to 20 CSR 400-7.095(2)(A)1.A. or B.)
____ The managed care plan is accredited by the American Accreditation Healthcare Commission (URAC) for full URAC Health Plan accreditation, and the accreditation is currently in effect;
____ The managed care plan or its network is accredited by _______________________________, this accreditation was approved by the department prior to the date of this affidavit, and this accreditation is currently in effect.
Subscribed and sworn to before me this ______________________ day of _________________________________, 20__________.
My commission expires _____________________, 20___. AFFIDAVIT PURSUANT TO 20 CSR 400-7.095(2)(A)1.B.
) ) ss. )
(Insert Name)
(Insert Name of HMO)
(Insert Form Numbers as Filed for Approval with the Department of Insurance)
______________________________________________________ (Signature of Affiant Corporate Officer)
______________________________________________________ Notary Public
AUTHORITY: sections 354.405, 354.615 and 374.045, RSMo 2000; and 354.603, RSMo Supp. 2001. Original rule filed Nov. 3, 1997, effective May 30, 1998. Rescinded and readopted: Filed Oct. 1, 2002, effective April 30, 2003.
*Original authority: 354.405, RSMo 1983, amended 1997; 354.603, RSMo 1997. amended 2001; 354.615, RSMo 1997; and 374.045, RSMo 1967.