376.450. Citation of law--definitions (MISSOURI HIPAA).
Citation of law--definitions (MISSOURI HIPAA).
376.450. 1. Sections 376.450 to 376.454 shall be known and may becited as the "Missouri Health Insurance Portability and AccountabilityAct". Notwithstanding any other provision of law to the contrary, healthinsurance coverage offered in connection with the small group market, thelarge group market and the individual market shall comply with theprovisions of sections 376.450 to 376.453 and, in the case of the smallgroup market, the provisions of sections 379.930 to 379.952, RSMo. As usedin sections 376.450 to 376.453, the following terms mean:
(1) "Affiliation period", a period which, under the terms of thecoverage offered by a health maintenance organization, must expire beforethe coverage becomes effective. The organization is not required toprovide health care services or benefits during such period and no premiumshall be charged to the participant or beneficiary for any coverage duringthe period;
(2) "Beneficiary", the same meaning given such term under Section3(8) of the Employee Retirement Income Security Act of 1974 and Public Law104-191;
(3) "Bona fide association", an association which:
(a) Has been actively in existence for at least five years;
(b) Has been formed and maintained in good faith for purposes otherthan obtaining insurance;
(c) Does not condition membership in the association on any healthstatus-related factor relating to an individual (including an employee ofan employer or a dependent of an employee);
(d) Makes health insurance coverage offered through the associationavailable to all members regardless of any health status-related factorrelating to such members (or individuals eligible for coverage through amember); and
(e) Does not make health insurance coverage offered through theassociation available other than in connection with a member of theassociation; and
(f) Meets all other requirements for an association set forth insubdivision (5) of subsection 1 of section 376.421 that are notinconsistent with this subdivision;
(4) "COBRA continuation provision":
(a) Section 4980B of the Internal Revenue Code (26 U.S.C. 4980B), asamended, other than subsection (f)(1) of such section as it relates topediatric vaccines;
(b) Title I, Subtitle B, Part 6, excluding Section 609, of theEmployee Retirement Income Security Act of 1974; or
(c) Title XXII of the Public Health Service Act, 42 U.S.C. 300dd, etseq.;
(5) "Creditable coverage", with respect to an individual:
(a) Coverage of the individual under any of the following:
a. A group health plan;
b. Health insurance coverage;
c. Part A or Part B of Title XVIII of the Social Security Act;
d. Title XIX of the Social Security Act, other than coverageconsisting solely of benefits under Section 1928 of such act;
e. Chapter 55 of Title 10, United States Code;
f. A medical care program of the Indian Health Service or of a tribalorganization;
g. A state health benefits risk pool;
h. A health plan offered under Title 5, Chapter 89, of the UnitedStates Code;
i. A public health plan as defined in federal regulations authorizedby Section 2701(c)(1)(I) of the Public Health Services Act, as amended byPublic Law 104-191;
j. A health benefit plan under Section 5(e) of the Peace Corps Act(22 U.S.C. 2504(3));
(b) Creditable coverage does not include coverage consisting solelyof excepted benefits;
(6) "Department", the Missouri department of insurance, financialinstitutions and professional registration;
(7) "Director", the director of the Missouri department of insurance,financial institutions and professional registration;
(8) "Enrollment date", with respect to an individual covered under agroup health plan or health insurance coverage, the date of enrollment ofthe individual in the plan or coverage or, if earlier, the first day of thewaiting period for such enrollment;
(9) "Excepted benefits":
(a) Coverage only for accident (including accidental death anddismemberment) insurance;
(b) Coverage only for disability income insurance;
(c) Coverage issued as a supplement to liability insurance;
(d) Liability insurance, including general liability insurance andautomobile liability insurance;
(e) Workers' compensation or similar insurance;
(f) Automobile medical payment insurance;
(g) Credit-only insurance;
(h) Coverage for on-site medical clinics;
(i) Other similar insurance coverage, as approved by the director,under which benefits for medical care are secondary or incidental to otherinsurance benefits;
(j) If provided under a separate policy, certificate or contract ofinsurance, any of the following:
a. Limited scope dental or vision benefits;
b. Benefits for long-term care, nursing home care, home health care,community-based care, or any combination thereof;
c. Other similar limited benefits as specified by the director;
(k) If provided under a separate policy, certificate or contract ofinsurance, any of the following:
a. Coverage only for a specified disease or illness;
b. Hospital indemnity or other fixed indemnity insurance;
(l) If offered as a separate policy, certificate, or contract ofinsurance, any of the following:
a. Medicare supplemental coverage (as defined under Section1882(g)(1) of the Social Security Act);
b. Coverage supplemental to the coverage provided under Chapter 55 ofTitle 10, United States Code;
c. Similar supplemental coverage provided to coverage under a grouphealth plan;
(10) "Group health insurance coverage", health insurance coverageoffered in connection with a group health plan;
(11) "Group health plan", an employee welfare benefit plan as definedin Section 3(1) of the Employee Retirement Income Security Act of 1974 andPublic Law 104-191 to the extent that the plan provides medical care, asdefined in this section, and including any item or service paid for asmedical care to an employee or the employee's dependent, as defined underthe terms of the plan, directly or through insurance, reimbursement orotherwise, but not including excepted benefits;
(12) "Health insurance coverage", or "health benefit plan" as definedin section 376.1350 and benefits consisting of medical care, includingitems and services paid for as medical care, that are provided directly,through insurance, reimbursement, or otherwise under a policy, certificate,membership contract, or health services agreement offered by a healthinsurance issuer, but not including excepted benefits;
(13) "Health insurance issuer", "issuer", or "insurer", an insurancecompany, health services corporation, fraternal benefit society, healthmaintenance organization, multiple employer welfare arrangementspecifically authorized to operate in the state of Missouri, or any otherentity providing a plan of health insurance or health benefits subject tostate insurance regulation;
(14) "Individual health insurance coverage", health insurancecoverage offered to individuals in the individual market, not includingexcepted benefits or short-term limited duration insurance;
(15) "Individual market", the market for health insurance coverageoffered to individuals other than in connection with a group health plan;
(16) "Large employer", in connection with a group health plan, withrespect to a calendar year and a plan year, an employer who employed anaverage of at least fifty-one employees on business days during thepreceding calendar year and who employs at least two employees on the firstday of the plan year;
(17) "Large group market", the health insurance market under whichindividuals obtain health insurance coverage directly or through anyarrangement on behalf of themselves and their dependents through a grouphealth plan maintained by a large employer;
(18) "Late enrollee", a participant who enrolls in a group healthplan other than during the first period in which the individual is eligibleto enroll under the plan, or a special enrollment period under subsection 6of this section;
(19) "Medical care", amounts paid for:
(a) The diagnosis, cure, mitigation, treatment, or prevention ofdisease or amounts paid for the purpose of affecting any structure orfunction of the body;
(b) Transportation primarily for and essential to medical carereferred to in paragraph (a) of this subdivision; or
(c) Insurance covering medical care referred to in paragraphs (a) and(b) of this subdivision;
(20) "Network plan", health insurance coverage offered by a healthinsurance issuer under which the financing and delivery of medical care,including items and services paid for as medical care, are provided, inwhole or in part, through a defined set of providers under contract withthe issuer;
(21) "Participant", the same meaning given such term under Section3(7) of the Employer Retirement Income Security Act of 1974 and Public Law104-191;
(22) "Plan sponsor", the same meaning given such term under Section3(16)(B) of the Employee Retirement Income Security Act of 1974;
(23) "Preexisting condition exclusion", with respect to coverage, alimitation or exclusion of benefits relating to a condition based on thefact that the condition was present before the date of enrollment for suchcoverage, whether or not any medical advice, diagnosis, care, or treatmentwas recommended or received before such date. Genetic information shallnot be treated as a preexisting condition in the absence of a diagnosis ofthe condition related to such information;
(24) "Public Law 104-191", the federal Health Insurance Portabilityand Accountability Act of 1996;
(25) "Small group market", the health insurance market under whichindividuals obtain health insurance coverage directly or through anarrangement, on behalf of themselves and their dependents, through a grouphealth plan maintained by a small employer as defined in section 379.930,RSMo;
(26) "Waiting period", with respect to a group health plan and anindividual who is a potential participant or beneficiary in a group healthplan, the period that must pass with respect to the individual before theindividual is eligible to be covered for benefits under the terms of thegroup health plan.
2. A health insurance issuer offering group health insurance coveragemay, with respect to a participant or beneficiary, impose a preexistingcondition exclusion only if:
(1) Such exclusion relates to a condition, whether physical ormental, regardless of the cause of the condition, for which medical advice,diagnosis, care, or treatment was recommended or received within thesix-month period ending on the enrollment date;
(2) Such exclusion extends for a period of not more than twelvemonths, or eighteen months in the case of a late enrollee, after theenrollment date; and
(3) The period of any such preexisting condition exclusion is reducedby the aggregate of the periods of creditable coverage, if any, applicableto the participant as of the enrollment date.
3. For the purposes of applying subdivision (3) of subsection 2 ofthis section:
(1) A period of creditable coverage shall not be counted, withrespect to enrollment of an individual under group health insurancecoverage, if, after such period and before the enrollment date, there was asixty-three day period during all of which the individual was not coveredunder any creditable coverage;
(2) Any period of time that an individual is in a waiting period forcoverage under group health insurance coverage, or is in an affiliationperiod, shall not be taken into account in determining whether asixty-three day break under subdivision (1) of this subsection hasoccurred;
(3) Except as provided in subdivision (4) of this subsection, ahealth insurance issuer offering group health insurance coverage shallcount a period of creditable coverage without regard to the specificbenefits included in the coverage;
(4) (a) A health insurance issuer offering group health insurancecoverage may elect to apply the provisions of subdivision (3) of subsection2 of this section based on coverage within any category of benefits withineach of several classes or categories of benefits specified in regulationsimplementing Public Law 104-191, rather than as provided under subdivision(3) of this subsection. Such election shall be made on a uniform basis forall participants and beneficiaries. Under such election a health insuranceissuer shall count a period of creditable coverage with respect to anyclass or category of benefits if any level of benefits is covered withinthe class or category.
(b) In the case of an election with respect to health insurancecoverage offered by a health insurance issuer in the small or large groupmarket under this subdivision, the health insurance issuer shallprominently state in any disclosure statements concerning the coverage, andprominently state to each employer at the time of the offer or sale of thecoverage, that the issuer has made such election, and include in suchstatements a description of the effect of this election;
(5) Periods of creditable coverage with respect to an individual maybe established through presentation of certifications and other means asspecified in Public Law 104-191 and regulations pursuant thereto.
4. A health insurance issuer offering group health insurance coverageshall not apply any preexisting condition exclusion in the followingcircumstances:
(1) Subject to subdivision (4) of this subsection, a health insuranceissuer offering group health insurance coverage shall not impose anypreexisting condition exclusion in the case of an individual who, as of thelast day of the thirty-one-day period beginning with the date of birth, iscovered under creditable coverage;
(2) Subject to subdivision (4) of this subsection, a health insuranceissuer offering group health insurance coverage shall not impose anypreexisting condition exclusion in the case of a child who is adopted orplaced for adoption before attaining eighteen years of age and who, as ofthe last day of the thirty-day period beginning on the date of the adoptionor placement for adoption, is covered under creditable coverage. Theprevious sentence shall not apply to coverage before the date of suchadoption or placement for adoption;
(3) A health insurance issuer offering group health insurancecoverage shall not impose any preexisting condition exclusion relating topregnancy as a preexisting condition;
(4) Subdivisions (1) and (2) of this subsection shall no longer applyto an individual after the end of the first sixty-three-day period duringall of which the individual was not covered under any creditable coverage.
5. A health insurance issuer offering group health insurance coverageshall provide a certification of creditable coverage as required by PublicLaw 104-191 and regulations pursuant thereto.
6. A health insurance issuer offering group health insurance coverageshall provide for special enrollment periods in the followingcircumstances:
(1) A health insurance issuer offering group health insurance inconnection with a group health plan shall permit an employee or a dependentof an employee who is eligible but not enrolled for coverage under theterms of the plan to enroll for coverage if:
(a) The employee or dependent was covered under a group health planor had health insurance coverage at the time that coverage was previouslyoffered to the employee or dependent;
(b) The employee stated in writing at the time that coverage under agroup health plan or health insurance coverage was the reason for decliningenrollment, but only if the plan sponsor or health insurance issuerrequired the statement at the time and provided the employee with notice ofthe requirement and the consequences of the requirement at the time;
(c) The employee's or dependent's coverage described in paragraph (a)of this subdivision was:
a. Under a COBRA continuation provision and was exhausted; or
b. Not under a COBRA continuation provision and was terminated as aresult of loss of eligibility for the coverage or because employercontributions toward the cost of coverage were terminated; and
(d) Under the terms of the group health plan, the employee requeststhe enrollment not later than thirty days after the date of exhaustion ofcoverage described in subparagraph a. of paragraph (c) of this subdivisionor termination of coverage or employer contributions described insubparagraph b. of paragraph (c) of this subdivision;
(2) (a) A group health plan shall provide for a dependent specialenrollment period described in paragraph (b) of this subdivision duringwhich an employee who is eligible but not enrolled and a dependent may beenrolled under the group health plan and, in the case of the birth oradoption of a child, the spouse of the employee may be enrolled as adependent if the spouse is otherwise eligible for coverage.
(b) A dependent special enrollment period under this subdivision is aperiod of not less than thirty days that begins on the date of the marriageor adoption or placement for adoption, or the period provided forenrollment in section 376.406 in the case of a birth;
(3) The coverage becomes effective:
(a) In the case of marriage, not later than the first day of thefirst month beginning after the date on which the completed request forenrollment is received;
(b) In the case of a dependent's birth, as of the date of birth; or
(c) In the case of a dependent's adoption or placement for adoption,the date of the adoption or placement for adoption.
7. In the case of group health insurance coverage offered by a healthmaintenance organization, the plan may provide for an affiliation periodwith respect to coverage through the organization only if:
(1) No preexisting condition exclusion is imposed with respect tocoverage through the organization;
(2) The period is applied uniformly without regard to any healthstatus-related factors;
(3) Such period does not exceed two months, or three months in thecase of a late enrollee;
(4) Such period begins on the enrollment date; and
(5) Such period runs concurrently with any waiting period.
(L. 2007 H.B. 818)Effective 1-01-08