PURPOSE: This rule describes the evidence the department will require of a health maintenance organization to prove the health maintenance organization meets the criteria set out in sections 354.400(2)(d), 354.400(2)(e) and 354.400(2)(f), RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997), to be designated as a community-based health maintenance organization and other information which the department may take into account in determining whether or not a health maintenance organization meets the aforementioned criteria.

1. (1) In order to evidence that a health maintenance organization has met the requirements of sections 354.400(2)(d), 354.400(2)(e) and 354.400(2)(f), RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997), to be designated as a community-based health maintenance organization, a health maintenance organization must file with the department a Community Benefits Mission Statement adopted by resolution of its board of directors (or trustees) containing a board-approved Community Benefits Plan (Plan) which shall be available to the public and which—

   1. (A) Demonstrates the health maintenance organization’s active and ongoing involvement in attempting to improve performance on indicators of health status in the communities it serves, including the health status of those not enrolled in the health maintenance organization; and
   2. (B) Demonstrates its accountability to the public for the cost of, quality of, and access to health care treatment services and for the effect such services have on the health of the community or communities served by the health maintenance organization.

2. (2) The Plan shall, at a minimum—

   1. (A) Identify health care indicators in the communities served by the health maintenance organization and rate each community served by the health maintenance organization as to each indicator;
   2. (B) Describe the means by which the health maintenance organization will be actively involved in attempting to improve performance on the identified indicators of health status in the community or communities in which the health maintenance organization is operating, including the health status of those not enrolled in the health maintenance organization;
   3. (C) Describe the means by which the health maintenance organization will be accountable for the cost, quality, and access to health care treatment services and for the effect such services have on the health of the communities served by the health maintenance organization. Community-based health maintenance organizations shall at a minimum be required to hold an annual public hearing at which time they will seek public comment on their proposed budget for the coming year. The proposed budget should be made publicly available at least ten (10) days prior to the hearing. This budget should include, but not be limited to, a description of the community-based health maintenance organization’s cost of providing health care services on a per-member, per-month basis for the past year and their projections for the coming year including their proposed premium structure. The information disclosed in the proposed budget should be of sufficient detail to help the public understand the components of health care costs in their proposed premium, which components are changing most rapidly, and what proportion of cost each component comprises. The public hearing should allow for ample time for public comment as well as a requirement on the part of the community-based health maintenance organization to publicly respond to the input that it received at the public hearing;
   4. (D) Set out a timetable for the development and implementation of the Plan;
   5. (E) Identify the members of the governing body and the senior management of the health maintenance organization responsible for the oversight, development, and implementation of the Plan;
   6. (F) Identify the resources to be allocated to the Plan;
   7. (G) Identify the administrative mechanisms for the Plan’s regular evaluation; and
   8. (H) Establish an advisory group comprised of enrollees and representatives of community interests to make recommendations to the health maintenance organization regarding the policies and procedures of the health maintenance organization.

3. (3) The department will utilize public resources and participation, including, but not limited to, plans or written comments from Community Health Resource Team programs established through the Department of Health in evaluating whether or not Plans submitted prove the submitting health maintenance organization meets the criteria of sections 354.400(2)(d), 354.400(2)(e) and 354.400(2)(f), RSMo, H.B. 335 (First Regular Session of the 89th General Assembly 1997), for designation as a community-based health maintenance organization. The department will also consider priorities set by the health maintenance organization to improve community performance on the indicators of health status it identified in the Plan, including, but not limited to, those which concern—

   1. (A) Promoting and marketing products to attract segments of the population of the communities which have not historically been served by the health maintenance organization;
   2. (B) Avoiding marketing and advertising practices designed to discourage older, poorer, and less healthy persons from applying for membership;
   3. (C) Allowing direct enrollment for nongroup coverage;
   4. (D) Promoting translator and telecommunications device for the deaf (TDD) services at all key points of patient contact;
   5. (E) Providing subsidized coverage to those who are uninsured and unable to pay for health care services; and
   6. (F) Providing assistance to consumers in obtaining and maintaining health care coverage, at least for limited periods of time at reduced rates.
4. (4) Any information which a communitybased health maintenance organization deems to be proprietary, shall be handled in accordance with 20 CSR 10-2.400.
5. (5) A community-based health maintenance organization which has a grievance procedure established which is in compliance with Health Care Financing Administration guidelines for grievance procedures for Medicare recipients, may use that procedure for non- Medicare enrollees, provided that such enrollees may appeal an adverse determination to the Missouri Department of Insurance grievance procedure as set out in 20 CSR 100-5.020 Grievance Review Procedures, and the enrollee is notified of that procedure in a manner consistent with 20 CSR 100-5.010 Notice Requirements of an Adverse Determination.

AUTHORITY: section 354.485, RSMo 1994.* Original rule filed Nov. 3, 1997, effective June 30, 1998.

*Original authority 1983.