354.552. Community-based health maintenance organizations, requirements. - Missouri Statutes

Community-based health maintenance organizations, requirements.

354.552. 1. A community-based health maintenance organization shallhave available and accessible a sufficient number and type of physicians,specialists, and other providers as needed to:

(1) Provide the benefits covered by the plan;

(2) Meet the medical needs of the health plan's enrolled population;

(3) Provide members with a reasonable choice of primary carephysicians and specialty physicians.

2. If a community-based health maintenance organization does notemploy or contract with a physician with the expertise necessary to providemedically necessary care covered by the health plan, then the healthmaintenance organization shall arrange for a referral to a physician withthe necessary expertise and ensure that the members obtain the coveredbenefit at no greater cost to the member than if the benefit were obtainedfrom participating physicians.

3. A community-based health maintenance organization's physicians,physician specialists and facilities shall be reasonably available.Primary health care services shall be in reasonable proximity to a member'spersonal residence or business, with due consideration given to theavailability of physicians within the community-based health maintenanceorganization's service area. This provision shall not preclude acommunity-based health maintenance organization from arranging for theprovision of member care outside the service area for a higher level ofskill or specialty care than is available within the service area.

(L. 1997 H.B. 335 § 1)