State Law

Missouri Statutes-Title XXIII-Chapter 354-Health Services Corps/HMOs/Prepaid Dental Plans–Community-Based HMOs

08/09/2023 Missouri Section 354.552

Community-based health maintenance organizations, requirements

Network Adequacy

1. A community-based health maintenance organization shall have 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 care physicians and specialty physicians.

2. If a community-based health maintenance organization does not employ or contract with a physician with the expertise necessary to provide medically necessary care covered by the health plan, then the health maintenance organization shall arrange for a referral to a physician with the necessary expertise and ensure that the members obtain the covered benefit at no greater cost to the member than if the benefit were obtained from 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’s personal residence or business, with due consideration given to the availability of physicians within the community-based health maintenance organization’s service area. This provision shall not preclude a community-based health maintenance organization from arranging for the provision of member care outside the service area for a higher level of skill or specialty care than is available within the service area.