Health plans - Missouri

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.

Missouri laws include the following provisions:

• Plans must allow freedom of choice in the selection of any duly licensed physician, surgeon, optometrist, chiropractor, dentist, psychologist, pharmacist, pharmacy, or podiatrist. §375.936
• If the plan provides coverage on an expense-incurred basis, must cover physician-prescribed medically appropriate and necessary equipment, supplies, and self-management training used in the management and treatment of diabetes. §376.385
• If the plan provides coverage for family members, it must cover newly born children of participants from the moment of birth, including congenital defects and birth abnormalities. §376.406
• Children who are incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the policyholder for support and maintenance, must remain covered regardless of age. §376.426, §376.776
• Plans must cover clinical trials for the prevention, early detection, or treatment of cancer. §376.429
• Plans must offer optional coverage for loss or impairment of speech or hearing subject to the same durational limits, dollar limits, deductibles, and coinsurance factors as other covered services in such policies or contracts. §376.781
• If the plan covers family members, it must offer child health supervision services, from the moment of birth through 12 years old. §376.801
• The plan must cover adopted children of participants or enrollees on the same basis as other dependents. §376.816
• The plan cannot deny enrollment of a child on the grounds that the child was born out of wedlock, is not claimed as a dependent on the parent's federal income tax return, or does not reside with the parent or in the insurer's service area. §376.820
• Plans must cover immunizations of a child from birth to five years old, without deductible or co-payment limits. §376.1215
• Plans must cover formula and low protein modified food products for phenylketonuria or any inherited disease of amino and organic acids for those less than six years of age. §376.1219
• Plans must cover newborn hearing screening, necessary rescreening, audiological assessment and follow-up, and initial amplification. §376.1220
• Plans must cover the administration of general anesthesia and hospital charges for dental care provided to children under the age of five, severely disabled persons, or persons who have a medical or behavioral condition which requires hospitalization or general anesthesia when dental care is provided. §376.1225
• Plans must cover chiropractic care, subject to the terms and conditions of the policy. The coverage may be limited to chiropractors within the health carrier's network. §376.1230
• Plans must cover prostrate and colorectal cancer exams. §376.1250
• Plans must cover a second opinion rendered by a specialist in that specific cancer diagnosis area when a patient with a newly diagnosed cancer is referred to such specialist by his or her attending physician. §376.1253
• Plans must cover human leukocyte antigen testing for use in bone marrow transplantation. §376.1275
• Plans must offer optional coverage for testing for lead poisoning.§376.1290
• Plans must cover mental health conditions with the same financial burden as physical health conditions. §376.1550
• Plans must not deny or alter coverage to any previously covered individual who has been diagnosed as having HIV infection or any HIV-related condition during the previous policy or contract period only because of such diagnosis. §191.671
• Effective August 28, 2005, employers may provide or contract for health insurance benefits at a reduced premium rate, or (effective August 28, 2006) at a reduced deductible for employees who do not smoke or use tobacco products. §290.145
• Effective August 28, 2006, insurers may offer a policy to an employer that charges a reduced premium rate or deductible for employees who do not smoke or use tobacco products. (§376.421) (See SB 567)

State

Contact

Missouri Department of Insurance

Regulations

Missouri Revised Statutes

Title XVII Labor and Industrial Relations

Chapter 290 – Wages, Hours, and Dismissal Rights

§290.145Discrimination, refusal to hire or discharge employee for alcohol or tobacco use not during working hours, prohibited, exception--not cause for legal actions.

Title XXIV Business and Financial Institutions

Chapter 375- Laws Applicable to All Insurance Companies

§375.936 Unfair practices defined.

Chapter 376 – Life, Health, and Accident Insurance

§376.385 Diabetes—insurance coverage for equipment, supplies and self-management training.

§376.406 Newborn child to be covered under health policies, extent of coverage—notification of birth, when, effect of—definitions.

§376.421 Group health insurance, authorized categories.

§376.426 Group health policies, required provisions.

§376.429 Coverage for certain clinical trials for prevention, early detection and treatment of cancer, restrictions—definitions—exclusions.

§376.776 Hospital and medical expense provisions extended for certain handicapped and dependent children past normal coverage age.

§376.781 Speech and hearing disorders, companies to offer coverage, when—rules, procedure.

§376.801 Coverage for child health supervision services required—definitions—permitted limitations on benefits.

§376.816 Adopted children to be provided health care coverage on the same basis as other dependents—effective from date of birth or on placement--placement defined.

§376.820 Insurers may not deny coverage of child because of marital status of parents, residence or income tax dependency claim.

§376.1215 Immunizations, mandated coverage, exceptions, rulemaking.

§376.1219 PKU formula and low protein modified food products covered by insurance, when—exceptions.

§376.1220 Insurance coverage for newborn hearing screenings mandated.

§376.1225 Mandated coverage for general anesthesia and hospital charges for dental care, when--prior authorization required, when—exceptions.

§376.1230 Chiropractic care coverage, rates, terms, conditions, limits, and exclusions.

§376.1250 Cancer screening, health insurance coverage required, when, types.

§376.1253 Second opinion, right of newly diagnosed cancer patients, attending physician to inform—insurance coverage for such second opinions required, when.

§376.1275 Coverage for human leukocyte antigen testing for bone marrow transplantation required, when—exceptions.

§376.1290 Coverage for lead testing.

§376.1550 Mental health coverage, requirements—definitions—exclusions.

Chapter 191 - Health and Welfare

Chapter 191

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)