Missouri Code of State Regulations
Division 400 - Life, Annuities and Health
Chapter 7 - Health Maintenance Organizations
Section 20 CSR 400-7.040 - Additional Mandatory Provisions-Group Contracts and Evidences of Coverage

Current through Register Vol. 48, No. 18, September 15, 2023

PURPOSE: This rule sets forth provisions which must be included in group contracts and evidences of coverage in addition to the provisions set forth in 20 CSR 400-7.030. This rule is promulgated pursuant to sections 354.430 and 354.485, RSMo.

(1) Group contracts and evidences of coverage must contain in substance the following provision(s) which, in the opinion of the director of insurance, are more favorable to the enrollee or at least as favorable to the enrollee and more favorable to the contract holder in addition to those set out in 20 CSR 400-7.030.

(2) Evidence of Coverage. Provisions that the group contract holder must be provided with evidence of coverage to be delivered to each enrollee, that the evidence of coverage is a part of the group contract as if fully incorporated in the contract; and that any direct conflict between the group contract and the evidence of coverage will be resolved according to the terms which are most favorable to the enrollee. Note: This section does not apply if the same form is used for both the group contract and the evidence of coverage.

(3) New Employees. A provision specifying the conditions under which new enrollees may be added to those originally covered, including the terms under which coverage will be effective.

(4) Grace Period. A provision for a grace period of at least thirty-one (31) days for the payment of any premium falling due after the first premium, during which time the coverage remains in effect. Coverage may be terminated at the end of the grace period and, if services are rendered during the grace period, the group will be responsible for either the premium due or the value of services received.

AUTHORITY: sections 354.430 and 354.485, RSMo 1986.* This rule was previously filed as 4 CSR 190-15.110. Original rule filed Nov. 2, 1987, effective April 11 , 1988.

*Original authority: 354.430, RSMo 1983, and 354.485, RSMo 1983.

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