PURPOSE: This rule specifies when a health maintenance organization may disenroll an enrollee for nonpayment of a copayment when his/her premium has been paid. This rule is promulgated pursuant to section 354.485, RSMo and implements section 354.462, RSMo.

1. (1) Definitions.

   1. (A) Copayment means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid.
   2. (B) Copayment maximum means the total amount of copayments an enrollee is obligated to pay during the calendar year as defined by the contract.
   3. (C) Disenrollment means a health maintenance organization’s (HMO) termination of an enrollee’s eligibility for service.
   4. (D) Enrollee means an individual who is properly enrolled in an HMO.
2. (2) Disenrollment. An enrollee for whom premium has been paid may not be disenrolled nor denied renewal for nonpayment of a copayment except when the HMO or provider to whom the copayment is due has initiated collection efforts within sixty (60) days after the HMO is notified that copayment is due. The enrollee also must receive written notice from the HMO stating the disenrollment will occur unless arrangements for payment of the copayment are made within ten (10) working days after receipt of the notice.
3. (3) Refunds. An HMO shall refund any premium payment, net of copayments due, made to cover the period after disenrollment.
4. (4) Copayment Notification. Upon request, an HMO shall inform an enrollee if s/he has reached his/her copayment maximum.
5. (5) Discipline. The director of the Department of Insurance may institute disciplinary action for a violation of this rule in accordance with the provision of section 354.500, RSMo and any other applicable law.

AUTHORITY: sections 354.462 and 354.485, RSMo 1986.* Original rule filed April 14, 1992, effective Feb. 26, 1993.

*Original authority: 354.462, RSMo 1983 and 354.485, RSMo 1983.