354.400. Definitions.

MISSOURI STATUTES AND CODES

Definitions.

354.400. As used in sections 354.400 to 354.636, the following termsshall mean:

(1) "Basic health care services", health care services which an enrolledpopulation might reasonably require in order to be maintained in good health,including, as a minimum, emergency care, inpatient hospital and physiciancare, and outpatient medical services;

(2) "Community-based health maintenance organization", a healthmaintenance organization which:

(a) Is wholly owned and operated by hospitals, hospital systems,physicians, or other health care providers or a combination thereof whoprovide health care treatment services in the service area described in theapplication for a certificate of authority from the director;

(b) Is operated to provide a means for such health care providers tomarket their services directly to consumers in the service area of the healthmaintenance organization;

(c) Is governed by a board of directors that exercises fiduciaryresponsibility over the operations of the health maintenance organization andof which a majority of the directors consist of equal numbers of thefollowing:

a. Physicians licensed pursuant to chapter 334, RSMo;

b. Purchasers of health care services who live in the health maintenanceorganization's service area;

c. Enrollees of the health maintenance organization elected by theenrollees of such organization; and

d. Hospital executives, if a hospital is involved in the corporateownership of the health maintenance organization;

(d) Provides for utilization review, as defined in section 374.500,RSMo, under the auspices of a physician medical director who practicesmedicine in the service area of the health maintenance organization, usingreview standards developed in consultation with physicians who treat thehealth maintenance organization's enrollees;

(e) Is actively involved in attempting to improve performance onindicators of health status in the community or communities in which thehealth maintenance organization is operating, including the health status ofthose not enrolled in the health maintenance organization;

(f) Is accountable to the public for the cost, quality and access ofhealth care treatment services and for the effect such services have on thehealth of the community or communities in which the health maintenanceorganization is operating on a whole;

(g) Establishes an advisory group or groups comprised of enrollees andrepresentatives of community interests in the service area to makerecommendations to the health maintenance organization regarding the policiesand procedures of the health maintenance organization;

(h) Enrolls fewer than fifty thousand covered lives;

(3) "Covered benefit" or "benefit", a health care service to which anenrollee is entitled under the terms of a health benefit plan;

(4) "Director", the director of the department of insurance, financialinstitutions and professional registration;

(5) "Emergency medical condition", the sudden and, at the time,unexpected onset of a health condition that manifests itself by symptoms ofsufficient severity that would lead a prudent lay person, possessing anaverage knowledge of health and medicine, to believe that immediate medicalcare is required, which may include, but shall not be limited to:

(a) Placing the person's health in significant jeopardy;

(b) Serious impairment to a bodily function;

(d) Inadequately controlled pain; or

(e) With respect to a pregnant woman who is having contractions:

a. That there is inadequate time to effect a safe transfer to anotherhospital before delivery; or

b. That transfer to another hospital may pose a threat to the health orsafety of the woman or unborn child;

(6) "Emergency services", health care items and services furnished orrequired to screen and stabilize an emergency medical condition, which mayinclude, but shall not be limited to, health care services that are providedin a licensed hospital's emergency facility by an appropriate provider;

(7) "Enrollee", a policyholder, subscriber, covered person or otherindividual participating in a health benefit plan;

(8) "Evidence of coverage", any certificate, agreement, or contractissued to an enrollee setting out the coverage to which the enrollee isentitled;

(9) "Health care services", any services included in the furnishing toany individual of medical or dental care or hospitalization, or incident tothe furnishing of such care or hospitalization, as well as the furnishing toany person of any and all other services for the purpose of preventing,alleviating, curing, or healing human illness, injury, or physical disability;

(10) "Health maintenance organization", any person which undertakes toprovide or arrange for basic and supplemental health care services toenrollees on a prepaid basis, or which meets the requirements of Section 1301of the United States Public Health Service Act;

(11) "Health maintenance organization plan", any arrangement whereby anyperson undertakes to provide, arrange for, pay for, or reimburse any part ofthe cost of any health care services and at least part of such arrangementconsists of providing and assuring the availability of basic health careservices to enrollees, as distinguished from mere indemnification against thecost of such services, on a prepaid basis through insurance or otherwise, andas distinguished from the mere provision of service benefits under healthservice corporation programs;

(12) "Individual practice association", a partnership, corporation,association, or other legal entity which delivers or arranges for the deliveryof health care services and which has entered into a services arrangement withpersons who are licensed to practice medicine, osteopathy, dentistry,chiropractic, pharmacy, podiatry, optometry, or any other health professionand a majority of whom are licensed to practice medicine or osteopathy. Suchan arrangement shall provide:

(a) That such persons shall provide their professional services inaccordance with a compensation arrangement established by the entity; and

(b) To the extent feasible for the sharing by such persons of medicaland other records, equipment, and professional, technical, and administrativestaff;

(13) "Medical group/staff model", a partnership, association, or othergroup:

(a) Which is composed of health professionals licensed to practicemedicine or osteopathy and of such other licensed health professionals(including dentists, chiropractors, pharmacists, optometrists, andpodiatrists) as are necessary for the provisions of health services for whichthe group is responsible;

(b) A majority of the members of which are licensed to practice medicineor osteopathy; and

(c) The members of which (i) as their principal professional activityover fifty percent individually and as a group responsibility engaged in thecoordinated practice of their profession for a health maintenanceorganization; (ii) pool their income from practice as members of the group anddistribute it among themselves according to a prearranged salary or drawingaccount or other plan, or are salaried employees of the health maintenanceorganization; (iii) share medical and other records and substantial portionsof major equipment and of professional, technical, and administrative staff;(iv) establish an arrangement whereby an enrollee's enrollment status is notknown to the member of the group who provides health services to the enrollee;

(14) "Person", any partnership, association, or corporation;

(15) "Provider", any physician, hospital, or other person which islicensed or otherwise authorized in this state to furnish health careservices;

(16) "Uncovered expenditures", the costs of health care services thatare covered by a health maintenance organization, but that are not guaranteed,insured, or assumed by a person or organization other than the healthmaintenance organization, or those costs which a provider has not agreed toforgive enrollees if the provider is not paid by the health maintenanceorganization.