PURPOSE: This rule states that an health maintenance organization may require copayments of its enrollees as a condition for the receipt of health care services. This rule is promulgated pursuant to sections 354.430 and 354.485, RSMo.

A health maintenance organization (HMO) may require copayments of its enrollees as a condition of the receipt of specific health care services. An HMO may not impose copayment charges that exceed fifty percent (50%) of the total cost of providing any single service to its enrollees, nor in the aggregate more than twenty percent (20%) of the total cost of providing all basic health services. An HMO may not impose copayment charges for basic health care services on any enrollee in any calendar year after the copayments made by the enrollee in that calendar year for basic health care services total two hundred percent (200%) of the total annual premium which is required to be paid by, or on behalf of, that enrollee and shall be stated as a dollar amount in the group contracts. Copayments shall be the only allowable charge, other than premiums, assessed to enrollees for basic and supplemental health care services. Single service copayment amounts shall be disclosed either as a percentage or as a stated dollar amount in the evidence of coverage. For group contracts the copayment amount may be changed only on the anniversary date of the group contract except by mutual agreement of the parties to the contract.

AUTHORITY: sections 354.430 and 354.485, RSMo 1986.* This rule was previously filed as 4 CSR 190-15.190. Original rule filed Nov. 2, 1987, effective April 11, 1988. Amended: Filed Aug. 16, 1989, effective Dec. 15, 1989. *Original authority: 354.430, RSMo 1983 and 354.485, RSMo, 1983.