Effective - 28 Aug 1997
354.609. Termination of a contract, procedure. — 1. A health carrier and a participating provider shall provide at least sixty days written notice to each other before terminating the contract without cause. The written notice shall include an explanation of why the contract is being terminated. The health carrier shall provide written notice within thirty working days of receipt or issuance of a notice of termination to all enrollees who are patients seen on a regular basis by the provider whose contract is terminating, irrespective of whether the termination was for or without cause. Where a contract termination involves a primary care professional, all enrollees who are patients of such professional shall be notified. Within fifteen working days of the date that the provider either gives or receives notice of termination, the provider shall supply the health carrier with a list of those patients of the provider that are covered by a plan of the health carrier.
2. (1) A health carrier shall not terminate a contract with a health care professional unless the health carrier provides to the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing as hereinafter provided. This subsection shall not apply in cases involving imminent harm to patients, a determination of fraud, or a final disciplinary action by a state licensing board or other governmental agency.
(2) The notice of the proposed contract termination provided by the health carrier to the health care professional shall include:
(a) The reasons for the proposed action;
(b) Notice that the health care professional has the right to request a hearing or review, at the professional's discretion, before a panel appointed by the health carrier;
(c) A time limit of not less than thirty days within which a health care professional may request a hearing; and
(d) A time limit for a hearing date which shall be held within thirty days after the date of receipt of a request for a hearing.
(3) The hearing panel shall be comprised of at least three persons appointed by the health carrier. At least one person on such panel shall be a clinical peer in the same discipline and the same or similar specialty as the health care professional under review. The hearing panel may consist of more than three persons, provided however that the number of clinical peers on such panel shall constitute one-third or more of the total membership of the panel.
(4) The hearing panel shall render a decision on the proposed action within fifteen days after a hearing. Such decision shall include reinstatement of the health care professional by the health carrier, provisional reinstatement subject to conditions set forth by the health carrier or termination of the health care professional. Such decision shall be provided in writing to the health care professional.
(5) A decision by the hearing panel to terminate a health care professional shall be effective not less than thirty days after the receipt by the health care professional of the hearing panel's decision.
(6) In no event shall termination be effective earlier than sixty days from the receipt of the notice of termination.
3. Either party to a contract may exercise a right of nonrenewal at the expiration of the contract period set forth therein or upon sixty days' notice to the other party; provided, however, that any nonrenewal shall not constitute a termination for purposes of this section.
4. A health carrier shall develop and implement policies and procedures to ensure that a health care professional is regularly informed of information maintained by the health carrier to evaluate the performance or practice of the health care professional. The health carrier shall consult with health care professionals in developing methodologies to collect and analyze health care professional profiling data. The health carrier shall provide any such information and profiling data and analysis to the health care professionals. Such information, data or analysis shall be provided on a periodic basis appropriate to the nature and amount of data and the volume and scope of services provided. Any profiling data used to evaluate the performance or practice of a health care professional shall be measured against stated criteria and an appropriate group of health care professionals using similar treatment modalities serving a comparable patient population. Upon presentation of such information or data, each health care professional shall be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the health care professional's profile and to work cooperatively with the health carrier to improve performance.
5. No health carrier shall terminate a contract or employment solely or in part because a health care provider in good faith:
(1) Advocates on behalf of an enrollee;
(2) Files a complaint against the health carrier;
(3) Appeals a decision of the health carrier;
(4) Provides information or files a report with the department of commerce and insurance; or
(5) Requests a hearing or review pursuant to this section.
6. A health carrier shall give a provider at least thirty days to review a managed care contract.
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(L. 1997 H.B. 335)
Structure Missouri Revised Statutes
Title XXIII - Corporations, Associations and Partnerships
Chapter 354 - Health Services Corporations — Health Maintenance Organizations — Prepaid Dental Plans
Section 354.010 - Definitions.
Section 354.015 - Health services corporations, laws applicable to — exceptions.
Section 354.020 - Preexisting health services corporation to amend articles, effect of.
Section 354.025 - Corporate purposes and authority.
Section 354.030 - For-profit corporations excluded from act.
Section 354.035 - Procedure for organization of corporation.
Section 354.040 - Articles of incorporation, required information and contents.
Section 354.045 - Issuance of certificate, effect of.
Section 354.050 - General powers of corporation.
Section 354.055 - Certificate of authority required — expiration of, extended how.
Section 354.060 - Director to issue certificate, when.
Section 354.065 - Articles of incorporation, how amended — copy to director, when.
Section 354.070 - Certificate of authority automatically extended, when.
Section 354.075 - Capital required to do business.
Section 354.080 - Reserves required, how computed.
Section 354.090 - Health services corporation contracts, purposes, parties to.
Section 354.095 - Limitation of membership and benefits — certain benefits to be provided, when.
Section 354.105 - Annual report required, contents of.
Section 354.120 - Rules and regulations by director authorized — procedure, review.
Section 354.130 - Exemption from certain taxes, exceptions.
Section 354.140 - Dissolution, liquidation or rehabilitation of corporation, procedure for.
Section 354.145 - Appeal from director's actions or decisions, how taken.
Section 354.150 - Fees — waiver, when.
Section 354.155 - Disclaimer as to nonhealth services corporations.
Section 354.165 - Certain organizations exempt.
Section 354.175 - Wage continuation plans by employer exempt.
Section 354.180 - Administrative order, director to issue, when.
Section 354.190 - Examinations, procedures.
Section 354.195 - Records of examination, duty to keep.
Section 354.200 - Examinations, false testimony, penalty.
Section 354.205 - Examinations — costs, how paid.
Section 354.210 - Director may seek relief, when.
Section 354.215 - Examiner's sick leave to apply to health services corporations.
Section 354.220 - Director may bring suit to recover fees or sums.
Section 354.230 - License required for enrollment representative.
Section 354.235 - Enrollment representative — license issued when, qualifications.
Section 354.240 - Nonresident may be licensed — examination waived, when.
Section 354.265 - Nonrenewable temporary license issued, when.
Section 354.275 - Violations by enrollment representatives, penalties.
Section 354.300 - Certificate of authority suspended or revoked, when.
Section 354.305 - Corporation advertising assets also to show liabilities — penalties.
Section 354.330 - Public official failing to perform duties as to investment violations, penalty.
Section 354.335 - Damages allowed if corporation without reasonable cause refuses to pay.
Section 354.350 - Fraudulent or bad faith conduct — investigation by division — hearing, procedure.
Section 354.357 - Receivership, grounds, procedure.
Section 354.362 - Newborn child coverage required — notice of birth, when, effect.
Section 354.380 - Certain provisions of insurance law to be applicable.
Section 354.400 - Definitions.
Section 354.407 - PACE projects not deemed health maintenance organizations, when.
Section 354.415 - Powers of organization.
Section 354.420 - Advisory panels to afford enrollees participation in policy decisions.
Section 354.425 - Bonding of officers who disburse or invest funds — bond requirements.
Section 354.435 - Annual reports filed with director, when — content — forms.
Section 354.440 - Information to be available to enrollees.
Section 354.441 - Disclosures to subscribers shall not be prohibited or restricted.
Section 354.442 - Disclosure information to enrollees required, when.
Section 354.444 - Administrative orders for violations — voluntary forfeitures, civil actions.
Section 354.445 - Complaints by enrollees, organization to establish system.
Section 354.450 - Investments authorized.
Section 354.455 - Deposit required, how made.
Section 354.462 - Enrollee, grounds for disenrollment.
Section 354.464 - Names not authorized for use, exceptions.
Section 354.465 - Examinations by division, when — costs, how paid.
Section 354.470 - Suspension or revocation, when — effect.
Section 354.485 - Rules and regulations authorized.
Section 354.490 - Certificate of authority, denial, suspension or revocation, grounds — procedure.
Section 354.495 - Fees to be paid to director.
Section 354.500 - Conferences called by director as to suspected or potential violations.
Section 354.505 - Laws regulating insurance or health service corporations not to apply, exceptions.
Section 354.510 - Public documents, all filings and required reports.
Section 354.520 - Mergers, consolidations, control of organization, requirements.
Section 354.530 - Severability clause.
Section 354.536 - Continuation of dependent child coverage, when — dependent child defined.
Section 354.545 - Exempt plans and companies.
Section 354.550 - Laws not applicable to community health companies.
Section 354.551 - Health maintenance organizations may offer point of service (POS) riders, when.
Section 354.552 - Community-based health maintenance organizations, requirements.
Section 354.556 - Trustees, vacancies, elections.
Section 354.558 - Materials provided to prospective purchasers.
Section 354.559 - Disclosure to members, restrictions and prohibitions.
Section 354.562 - Grievance procedures, rulemaking authority.
Section 354.563 - Medicare rules to apply to community-based health maintenance organizations, when.
Section 354.570 - Rulemaking — procedure.
Section 354.600 - Definitions.
Section 354.609 - Termination of a contract, procedure.
Section 354.612 - Continuation of care after provider termination, when.
Section 354.615 - Referrals to appropriate providers, when.
Section 354.621 - Intermediary and participating provider requirements.
Section 354.627 - Liability of a health carrier, when.
Section 354.636 - Contract requirements after January 1, 1998.
Section 354.650 - Definitions.
Section 354.652 - Designation as essential community provider, procedure, qualifications.
Section 354.654 - Department of health and senior services, duties — rulemaking authority.
Section 354.656 - Inclusion of essential community providers in health care network, exceptions.
Section 354.700 - Definitions.
Section 354.704 - Application for certificate of authority, content.
Section 354.705 - Certificate of authority granted, when.
Section 354.717 - Director, powers — financial examinations, when, by whom made and paid.
Section 354.720 - Annual report, required, content.
Section 354.721 - Agents, registration required — rules and regulations authorized.
Section 354.723 - Rulemaking authorized.
Section 354.725 - Exclusion, labor organization's health plans.