354.618. Open referral health plans offered, when--definitions--obstetrician/ gynecologist services to be offered, when--eye care providers, discrimination against, prohibited--exemptions.

MISSOURI STATUTES AND CODES

354.618. Open referral health plans offered, when--definitions--obstetrician/ gynecologist services to be offered, when--eye care providers, discrimination against, prohibited--exemptions.

Open referral health plans offered, when--definitions--obstetrician/gynecologist services to be offered, when--eye care providers,discrimination against, prohibited--exemptions.

354.618. 1. A health carrier shall be required to offer as anadditional health plan, an open referral health plan whenever it markets agatekeeper group plan as an exclusive or full replacement health plan offeringto a group contract holder:

(1) In the case of group health plans offered to employers of fifty orfewer employees, the decision to accept or reject the additional open referralplan offering shall be made by the group contract holder. For health plansmarketed to employers of over fifty employees, the decision to accept orreject shall be made by the employee;

(2) Contracts currently in existence shall offer the additional openreferral health plan at the next annual renewal after August 28, 1997;however, multiyear group contracts need not comply until the expiration oftheir current multiyear term unless the group contract holder elects to complybefore that time;

(3) If an employer provides more than one health plan to its employeesand at least one is an open referral plan, then all health benefit plansoffered by such employer shall be exempt from the requirements of thissection.

2. For the purposes of this act, the following terms shall mean:

(1) "Open referral plan", a plan in which the enrollee is allowed toobtain treatment for covered benefits without a referral from a primary carephysician from any person licensed to provide such treatment;

(2) "Gatekeeper group plan", a plan in which the enrollee is required toobtain a referral from a primary care professional in order to accessspecialty care.

3. Any health benefit plan provided pursuant to the Medicaid programshall be exempt from the requirements of this section.

4. A health carrier shall have a procedure by which a female enrolleemay seek the health care services of an obstetrician/gynecologist at leastonce a year without first obtaining prior approval from the enrollee's primarycare provider if the benefits are covered under the enrollee's health benefitplan, and the obstetrician/gynecologist is a member of the health carrier'snetwork. In no event shall a health carrier be required to permit an enrolleeto have health care services delivered by a nonparticipatingobstetrician/gynecologist. An obstetrician/gynecologist who delivers healthcare services directly to an enrollee shall report such visit and health careservices provided to the enrollee's primary care provider. A health carriermay require an enrollee to obtain a referral from the primary care physician,if such enrollee requires more than one annual visit with anobstetrician/gynecologist.

5. Except for good cause, a health carrier shall be prohibited eitherdirectly, or indirectly through intermediaries, from discriminating betweeneye care providers when selecting among providers of health services forenrollment in the network and when referring enrollees for health servicesprovided within the scope of those professional licenses and when reimbursingamounts for covered services among persons duly licensed to provide suchservices. For the purposes of this section, an eye care provider may beeither an optometrist licensed pursuant to chapter 336, RSMo, or a physicianwho specializes in opthamologic medicine, licensed pursuant to chapter 334,RSMo.

6. Nothing contained in this section shall be construed as to require ahealth carrier to pay for health care services not provided for in the termsof a health benefit plan.

7. Any health carrier, which is sponsored by a federally qualifiedhealth center and is presently in existence and which has been in existencefor less than three years shall be exempt from this section for a period notto exceed two years from August 28, 1997.

8. A health carrier shall not be required to offer the direct accessrider for a group contract holder's health benefit plan if the health benefitplan is being provided pursuant to the terms of a collective bargainingagreement with a labor union, in accordance with federal law and the laborunion has declined such option on behalf of its members.

9. Nothing in this act shall be construed to preempt the employer'sright to select the health care provider pursuant to section 287.140, RSMo, ina case where an employee incurs a work-related injury covered by theprovisions of chapter 287, RSMo.

10. Nothing contained in this act shall apply to certified managed careorganizations while providing medical treatment to injured employees entitledto receive health benefits under chapter 287, RSMo, pursuant to contractualarrangements with employers, or their insurers, under section 287.135, RSMo.