Section 376.450

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS

Chapter 376

Effective - 01 Jan 2008, 2 histories, see footnote   

  376.450.  Citation of law — definitions (Missouri HIPAA). — 1.  Sections 376.450 to 376.454 shall be known and may be cited as the "Missouri Health Insurance Portability and Accountability Act".  Notwithstanding any other provision of law to the contrary, health insurance coverage offered in connection with the small group market, the large group market and the individual market shall comply with the provisions of sections 376.450 to 376.453 and, in the case of the small group market, the provisions of sections 379.930 to 379.952.  As used in sections 376.450 to 376.453, the following terms mean:

  (1)  "Affiliation period", a period which, under the terms of the coverage offered by a health maintenance organization, must expire before the coverage becomes effective.  The organization is not required to provide health care services or benefits during such period and no premium shall be charged to the participant or beneficiary for any coverage during the period;

  (2)  "Beneficiary", the same meaning given such term under Section 3(8) of the Employee Retirement Income Security Act of 1974 and Public Law 104-191;

  (3)  "Bona fide association", an association which:

  (a)  Has been actively in existence for at least five years;

  (b)  Has been formed and maintained in good faith for purposes other than obtaining insurance;

  (c)  Does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee);

  (d)  Makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to such members (or individuals eligible for coverage through a member); and

  (e)  Does not make health insurance coverage offered through the association available other than in connection with a member of the association; and

  (f)  Meets all other requirements for an association set forth in subdivision (5) of subsection 1 of section 376.421 that are not inconsistent with this subdivision;

  (4)  "COBRA continuation provision":

  (a)  Section 4980B of the Internal Revenue Code (26 U.S.C. 4980B), as amended, other than subsection (f)(1) of such section as it relates to pediatric vaccines;

  (b)  Title I, Subtitle B, Part 6, excluding Section 609, of the Employee Retirement Income Security Act of 1974; or

  (c)  Title XXII of the Public Health Service Act, 42 U.S.C. 300dd, et seq.;

  (5)  "Creditable coverage", with respect to an individual:

  (a)  Coverage of the individual under any of the following:

  a.  A group health plan;

  b.  Health insurance coverage;

  c.  Part A or Part B of Title XVIII of the Social Security Act;

  d.  Title XIX of the Social Security Act, other than coverage consisting solely of benefits under Section 1928 of such act;

  e.  Chapter 55 of Title 10, United States Code;

  f.  A medical care program of the Indian Health Service or of a tribal organization;

  g.  A state health benefits risk pool;

  h.  A health plan offered under Title 5, Chapter 89, of the United States Code;

  i.  A public health plan as defined in federal regulations authorized by Section 2701(c)(1)(I) of the Public Health Services Act, as amended by Public Law 104-191;

  j.  A health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. 2504(3));

  (b)  Creditable coverage does not include coverage consisting solely of excepted benefits;

  (6)  "Department", the Missouri department of commerce and insurance;

  (7)  "Director", the director of the Missouri department of commerce and insurance;

  (8)  "Enrollment date", with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for such enrollment;

  (9)  "Excepted benefits":

  (a)  Coverage only for accident (including accidental death and dismemberment) insurance;

  (b)  Coverage only for disability income insurance;

  (c)  Coverage issued as a supplement to liability insurance;

  (d)  Liability insurance, including general liability insurance and automobile liability insurance;

  (e)  Workers' compensation or similar insurance;

  (f)  Automobile medical payment insurance;

  (g)  Credit-only insurance;

  (h)  Coverage for on-site medical clinics;

  (i)  Other similar insurance coverage, as approved by the director, under which benefits for medical care are secondary or incidental to other insurance benefits;

  (j)  If provided under a separate policy, certificate or contract of insurance, any of the following:

  a.  Limited scope dental or vision benefits;

  b.  Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof;

  c.  Other similar limited benefits as specified by the director;

  (k)  If provided under a separate policy, certificate or contract of insurance, any of the following:

  a.  Coverage only for a specified disease or illness;

  b.  Hospital indemnity or other fixed indemnity insurance;

  (l)  If offered as a separate policy, certificate, or contract of insurance, any of the following:

  a.  Medicare supplemental coverage (as defined under Section 1882(g)(1) of the Social Security Act);

  b.  Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code;

  c.  Similar supplemental coverage provided to coverage under a group health plan;

  (10)  "Group health insurance coverage", health insurance coverage offered in connection with a group health plan;

  (11)  "Group health plan", an employee welfare benefit plan as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 and Public Law 104-191 to the extent that the plan provides medical care, as defined in this section, and including any item or service paid for as medical care to an employee or the employee's dependent, as defined under the terms of the plan, directly or through insurance, reimbursement or otherwise, but not including excepted benefits;

  (12)  "Health insurance coverage", or "health benefit plan" as defined in section 376.1350 and benefits consisting of medical care, including items and services paid for as medical care, that are provided directly, through insurance, reimbursement, or otherwise under a policy, certificate, membership contract, or health services agreement offered by a health insurance issuer, but not including excepted benefits;

  (13)  "Health insurance issuer", "issuer", or "insurer", an insurance company, health services corporation, fraternal benefit society, health maintenance organization, multiple employer welfare arrangement specifically authorized to operate in the state of Missouri, or any other entity providing a plan of health insurance or health benefits subject to state insurance regulation;

  (14)  "Individual health insurance coverage", health insurance coverage offered to individuals in the individual market, not including excepted benefits or short-term limited duration insurance;

  (15)  "Individual market", the market for health insurance coverage offered to individuals other than in connection with a group health plan;

  (16)  "Large employer", in connection with a group health plan, with respect to a calendar year and a plan year, an employer who employed an average of at least fifty-one employees on business days during the preceding calendar year and who employs at least two employees on the first day of the plan year;

  (17)  "Large group market", the health insurance market under which individuals obtain health insurance coverage directly or through any arrangement on behalf of themselves and their dependents through a group health plan maintained by a large employer;

  (18)  "Late enrollee", a participant who enrolls in a group health plan other than during the first period in which the individual is eligible to enroll under the plan, or a special enrollment period under subsection 6 of this section;

  (19)  "Medical care", amounts paid for:

  (a)  The diagnosis, cure, mitigation, treatment, or prevention of disease or amounts paid for the purpose of affecting any structure or function of the body;

  (b)  Transportation primarily for and essential to medical care referred to in paragraph (a) of this subdivision; or

  (c)  Insurance covering medical care referred to in paragraphs (a) and (b) of this subdivision;

  (20)  "Network plan", health insurance coverage offered by a health insurance issuer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the issuer;

  (21)  "Participant", the same meaning given such term under Section 3(7) of the Employer Retirement Income Security Act of 1974 and Public Law 104-191;

  (22)  "Plan sponsor", the same meaning given such term under Section 3(16)(B) of the Employee Retirement Income Security Act of 1974;

  (23)  "Preexisting condition exclusion", with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.  Genetic information shall not be treated as a preexisting condition in the absence of a diagnosis of the condition related to such information;

  (24)  "Public Law 104-191", the federal Health Insurance Portability and Accountability Act of 1996;

  (25)  "Small group market", the health insurance market under which individuals obtain health insurance coverage directly or through an arrangement, on behalf of themselves and their dependents, through a group health plan maintained by a small employer as defined in section 379.930;

  (26)  "Waiting period", with respect to a group health plan and an individual who is a potential participant or beneficiary in a group health plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the group health plan.

  2.  A health insurance issuer offering group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:

  (1)  Such exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date;

  (2)  Such exclusion extends for a period of not more than twelve months, or eighteen months in the case of a late enrollee, after the enrollment date; and

  (3)  The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the participant as of the enrollment date.

  3.  For the purposes of applying subdivision (3) of subsection 2 of this section:

  (1)  A period of creditable coverage shall not be counted, with respect to enrollment of an individual under group health insurance coverage, if, after such period and before the enrollment date, there was a sixty-three day period during all of which the individual was not covered under any creditable coverage;

  (2)  Any period of time that an individual is in a waiting period for coverage under group health insurance coverage, or is in an affiliation period, shall not be taken into account in determining whether a sixty-three day break under subdivision (1) of this subsection has occurred;

  (3)  Except as provided in subdivision (4) of this subsection, a health insurance issuer offering group health insurance coverage shall count a period of creditable coverage without regard to the specific benefits included in the coverage;

  (4)  (a)  A health insurance issuer offering group health insurance coverage may elect to apply the provisions of subdivision (3) of subsection 2 of this section based on coverage within any category of benefits within each of several classes or categories of benefits specified in regulations implementing Public Law 104-191, rather than as provided under subdivision (3) of this subsection.  Such election shall be made on a uniform basis for all participants and beneficiaries.  Under such election a health insurance issuer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within the class or category.

  (b)  In the case of an election with respect to health insurance coverage offered by a health insurance issuer in the small or large group market under this subdivision, the health insurance issuer shall prominently state in any disclosure statements concerning the coverage, and prominently state to each employer at the time of the offer or sale of the coverage, that the issuer has made such election, and include in such statements a description of the effect of this election;

  (5)  Periods of creditable coverage with respect to an individual may be established through presentation of certifications and other means as specified in Public Law 104-191 and regulations pursuant thereto.

  4.  A health insurance issuer offering group health insurance coverage shall not apply any preexisting condition exclusion in the following circumstances:

  (1)  Subject to subdivision (4) of this subsection, a health insurance issuer offering group health insurance coverage shall not impose any preexisting condition exclusion in the case of an individual who, as of the last day of the thirty-one-day period beginning with the date of birth, is covered under creditable coverage;

  (2)  Subject to subdivision (4) of this subsection, a health insurance issuer offering group health insurance coverage shall not impose any preexisting condition exclusion in the case of a child who is adopted or placed for adoption before attaining eighteen years of age and who, as of the last day of the thirty-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage.  The previous sentence shall not apply to coverage before the date of such adoption or placement for adoption;

  (3)  A health insurance issuer offering group health insurance coverage shall not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition;

  (4)  Subdivisions (1) and (2) of this subsection shall no longer apply to an individual after the end of the first sixty-three-day period during all of which the individual was not covered under any creditable coverage.

  5.  A health insurance issuer offering group health insurance coverage shall provide a certification of creditable coverage as required by Public Law 104-191 and regulations pursuant thereto.

  6.  A health insurance issuer offering group health insurance coverage shall provide for special enrollment periods in the following circumstances:

  (1)  A health insurance issuer offering group health insurance in connection with a group health plan shall permit an employee or a dependent of an employee who is eligible but not enrolled for coverage under the terms of the plan to enroll for coverage if:

  (a)  The employee or dependent was covered under a group health plan or had health insurance coverage at the time that coverage was previously offered to the employee or dependent;

  (b)  The employee stated in writing at the time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or health insurance issuer required the statement at the time and provided the employee with notice of the requirement and the consequences of the requirement at the time;

  (c)  The employee's or dependent's coverage described in paragraph (a) of this subdivision was:

  a.  Under a COBRA continuation provision and was exhausted; or

  b.  Not under a COBRA continuation provision and was terminated as a result of loss of eligibility for the coverage or because employer contributions toward the cost of coverage were terminated; and

  (d)  Under the terms of the group health plan, the employee requests the enrollment not later than thirty days after the date of exhaustion of coverage described in subparagraph a.  of paragraph (c) of this subdivision or termination of coverage or employer contributions described in subparagraph b.  of paragraph (c) of this subdivision;

  (2)  (a)  A group health plan shall provide for a dependent special enrollment period described in paragraph (b) of this subdivision during which an employee who is eligible but not enrolled and a dependent may be enrolled under the group health plan and, in the case of the birth or adoption of a child, the spouse of the employee may be enrolled as a dependent if the spouse is otherwise eligible for coverage.

  (b)  A dependent special enrollment period under this subdivision is a period of not less than thirty days that begins on the date of the marriage or adoption or placement for adoption, or the period provided for enrollment in section 376.406 in the case of a birth;

  (3)  The coverage becomes effective:

  (a)  In the case of marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received;

  (b)  In the case of a dependent's birth, as of the date of birth; or

  (c)  In the case of a dependent's adoption or placement for adoption, the date of the adoption or placement for adoption.

  7.  In the case of group health insurance coverage offered by a health maintenance organization, the plan may provide for an affiliation period with respect to coverage through the organization only if:

  (1)  No preexisting condition exclusion is imposed with respect to coverage through the organization;

  (2)  The period is applied uniformly without regard to any health status-related factors;

  (3)  Such period does not exceed two months, or three months in the case of a late enrollee;

  (4)  Such period begins on the enrollment date; and

  (5)  Such period runs concurrently with any waiting period.

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(L. 2007 H.B. 818)

Effective 1-01-08