Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule describes timely and appropriate
access to mental health care, adequate distribution of the quantity, location
and specialty of mental health care providers, and administrative and clinical
protocols that protect access to medically necessary mental health treatment
for any insured. This rule is promulgated pursuant to section
376.1550,
RSMo.
(1) Definitions.
(A) "Administrative protocols" include, but
are not limited to, a provider network, referral requirements, prior
authorization requirements, and utilization review.
(B) "Clinical protocols" include, but are not
limited to, visit limitations, length-of-stay limitations, formularies,
step-therapy requirements, and drug quantity limitations.
(C) Categories of counties-
1. Urban counties-Counties with a population
of two hundred thousand (200,000) or more persons;
2. Basic counties-Counties with a population
between fifty thousand (50,000) persons and one hundred ninety-nine thousand
nine hundred ninety-nine (199,999) persons;
3. Rural counties-Counties with a population
of fewer than fifty thousand (50,000) persons; and
4. Population figures shall be based on
census data as reported in the latest edition of the Official Manual
State of Missouri.
(D) "Director" means the director of the
Department of Commerce and Insurance.
(E) "Health benefit plan" has the same
meaning as stated at section
376.1350,
RSMo.
(F) "Health carrier" has the
same meaning as stated at section
376.1350,
RSMo.
(G) "HMO" means health
maintenance organizations licensed pursuant to Chapter 354, RSMo.
(H) "Insured" means any person entitled to
benefits under a health benefit plan.
(I) "Insurer" means a health carrier that is
not an HMO.
(J) "Mental health
condition" means any condition or disorder defined by the most recent edition
of the Diagnostic and Statistical Manual of Mental Disorders
except for chemical dependency.
(K)
"Provider" means any professional or institution which is licensed or otherwise
authorized in this or any other state to furnish health care
services.
(L) "Utilization review"
has the same meaning as stated at section
376.1350,
RSMo.
(2) Applicability.
(A) This rule shall apply to all health
benefit plans, except for the types of health benefit plans covered under
subsection (2)(C) of this rule.
(B)
This rule shall apply to managed care organizations providing mental health
benefits under a health benefit plan that does not otherwise provide for
management of care under the plan or that does not provide for the same degree
of management of care for all health conditions.
(C) This rule shall not apply to:
1. Health benefit plans issued by an
HMO;
2. Health benefit plans issued
by insurers that provide for the same degree of management of care under the
plan for all health conditions;
3.
Individual health benefit plans, including those that cover
dependents;
4. Individually
underwritten group health benefit plans;
5. Supplemental insurance policies, including
life care contracts, accident-only policies, specified disease policies,
hospital policies providing a fixed daily benefit only, Medicare supplement
policies, long-term care policies, hospitalization-surgical care policies, or
short-term major medical policies of six (6) months or less duration;
and
6. Any other supplemental
policy as determined by the director.
(3) Timely Access to Care-Appointments with
or admissions to medical providers must be available no later than as follows:
(A) For routine care, without symptoms-
within thirty (30) days from the time the enrollee contacts the
provider;
(B) For routine care,
with symptoms- within five (5) business days from the time the insured contacts
the provider;
(C) For urgent care
for situations which require immediate care, but which do not constitute
emergencies as defined by section
376.1350, RSMo-within
twenty-four (24) hours from the time the insured contacts the
provider;
(D) For emergency care-an
appropriate mental health provider or emergency care facility shall be
available twenty-four (24) hours per day, seven (7) days per week for people
who require emergency care as defined by section
376.1350, RSMo;
and
(E) For telephone access-a
licensed mental health care professional shall be available twenty-four (24)
hours per day, seven (7) days per week.
(4) Adequate Quantity of Health Care
Providers-A system for delivery of treatment for mental health conditions shall
have sufficient quantities of mental health care providers to meet the timely
access requirements stated in section (3) of this rule.
(5) Appropriate Access to Care and Adequate
Location and Distribution of Health Care Providers.
(A) A health benefit plan or managed care
organization may establish a system for delivery of treatment for mental health
conditions that includes utilization review. Such system shall comply with the
provisions of sections
376.1350 to
376.1389,
RSMo.
(B) If a provider network
lacks an appropriate provider or it cannot assure access to medically necessary
care without unreasonable delay, then coverage of mental health treatment
outside the network shall place no greater cost upon the insured than if the
treatment were delivered inside the network.
(C) For purposes of subsection (5)(B) of this
rule, an appropriate provider is one that is reasonably suited to provide
treatment that reflects the insured's age, diagnosis, anticipated length of
treatment, and any other relevant factors.
(6) Administrative and Clinical Protocols.
(A) Administrative and clinical protocols
applied by an insurer, either directly or indirectly through a managed care
organization shall:
1. Be clearly and
completely stated in written or electronic materials distributed to any insured
or prospective insured, except that merely posting the information on a website
shall not by itself meet this requirement;
2. Be clearly and completely stated in
written or electronic materials distributed to any provider responsible for
providing treatment to an insured; and
3. Be available for review by the director
within thirty (30) days of the director making a request to review
protocols.
(B)
Administrative and clinical protocols applied by an insurer, either directly or
indirectly through a managed care organization, shall not serve to reduce
access to medically necessary treatment for any insured.
(7) Filings with the Director. On October 15
of each year, all insurers shall file with the director a certification of
compliance with the provisions of this rule and section
376.1550,
RSMo, for all health benefit plans. The certification shall be in a format
prescribed by the director, and shall contain, at a minimum, the following
information:
(A) The legal name and National
Association of Insurance Commissioners (NAIC) number of the insurer;
(B) The number of insureds covered by health
benefit plans that the insurer believes to be subject to this rule, if
any;
(C) If applicable, a statement
of the reasons an insurer believes none of its health benefit plans are subject
to this rule, referencing the exceptions listed in paragraphs (2)(C)1. through
(2)(C)6. of this rule;
(D) The
insurer's certification of compliance with all the applicable provisions of
this rule, unless subsection (7)(C) applies; and
(E) If the insurer provides coverage of
mental health benefits through a managed care organization, the name, address
and contact information of that organization.
*Original authority: 376.1550, RSMo
2004.