PURPOSE: This rule sets forth the health maintenance organization’s method for enrollees to participate in matters of policy and operation. This rule is promulgated pursuant to section 354.485, RSMo and implements section 354.420, RSMo.

1. (1) Definitions.

   1. (A) Enrollee means an individual who is covered by a health maintenance organization (HMO).
   2. (B) Evidence of coverage means any certificate, agreement or contract issued to an enrollee which sets out the coverage to which the enrollee is entitled under the HMO contract which covers the enrollee.
2. (2) Enrollee Participation. Every HMO shall establish a mechanism which affords enrollees an opportunity to participate in matters of the HMO’s policy and operation. The HMO in its evidence of coverage shall clearly advise the member that a mechanism which affords enrollees an opportunity to participate in matters of the HMO’s policy and operation, and which has been approved by the Missouri Department of Commerce and Insurance, will be made available to this member upon request. At a minimum, the mechanism used must both afford enrollees an opportunity to offer appropriate suggestions to the policymaking body of the HMO and ensure that the policymaking body gives these suggestions due consideration, and either approves or disapproves them. For purposes of this section, suggestions deemed appropriate for presentation to the policymaking body shall be those selected by either an enrollee advisory committee, the composition of which is set forth in the HMO’s organizational documents or such other means as have been approved by the director.
3. (3) Discipline. The director of the Department of Commerce and Insurance may institute disciplinary action for a violation of this rule in accordance with the provisions of section 354.500, RSMo and any other applicable law.

AUTHORITY: sections 354.420 and 354.485, RSMo 1986.* Original rule filed April 14, 1992, effective Feb. 26, 1993. Non-substantive change filed Sept. 11, 2019, published Oct. 31, 2019.

*Original authority: 354.420, RSMo 1983 and 354.485, RSMo 1983.