Missouri Code of State Regulations
Title 20 - DEPARTMENT OF COMMERCE AND INSURANCE
Division 400 - Life, Annuities and Health
Chapter 2 - Accident and Health Insurance in General
Section 20 CSR 400-2.065 - Actual Payment as Basis for Policy or Plan Calculations
Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule effectuates or aids in the interpretation of the following sections: 354.085 and 354.430(1), RSMo relating to certain policy forms that contain provisions which are deceptive, ambiguous, misleading, unfair, unjust, or inequitable; 354.350 and 375.445, RSMo regarding the carrying out of contracts in good faith; 354.410.1(2) and 354.430.3(2), RSMo pertaining to reasonable requirements for copayments; 354.085, 376.405 and 376.777, RSMo regarding whether policy forms contain such words, phraseology, conditions and provisions which are specific, certain and reasonably adequate to meet the needed requirements for the protection of those insured; and 354.410.1(9), RSMo relating to operating contrary to the public interest.
(1) Definitions. As used in this rule-
(2) Expense Participation. Under any health plan which provides for expense participation, whether in the form of coinsurance, copayments, a deductible or otherwise, such that the expense participation is to be computed as a percentage of, or as a function of the health service provider's charge(s) for a health service(s), the charge used in such computation shall always and solely be no greater than the actual payment(s) made to the health service provider.
(3) Benefit Caps. Under any health plan which establishes benefit maximums or caps, such benefit maximums or caps shall always and solely be determined using a basis that is no greater than the actual payment(s) made to the health service provider.
(4) No Limitation. Nothing in this rule limits a health insurer's right to pay some or all of an insured's expense participation share of any charge for health services, or to exceed an insured's benefit maximum or cap.
(5) Insurer-Provider Contract. This rule addresses the basis for calculating expense participation and benefit maximums or caps, and in no way affects the relationship or negotiations between health insurers and health services providers.
*Original authority: 354.085, RSMo 1973, amended 1983, 2000; 354.120, RSMo 1973, amended 1983, 1993, 1995; 354.485, RSMo 1983, amended 2007; 374.045, RSMo 1967, amended 1993, 1995; and 376.405, RSMo 1959, amended 1984.