Chapter 376 Life, Health and Accident Insurance

376.1528 - Rulemaking authority.

Steven Groce, Attorney Advertisement

The director under the provisions of section 374.045 may promulgate rules to administer and interpret the provisions of sections 376.1500 to 376.1532.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.995 - Limited mandate health insurance policies defined — certain sections not to apply to limited mandate health insurance policies, exceptions — requirements to sell or issue — certain law to apply.

1.This section shall be known as the "Limited Mandate Health Insurance Act".

2.Limited mandate health insurance policies and contracts shall mean those policies and contracts of health insurance as defined in section 376.960 and which cover individuals and their families (but not including any Medicare supplement policy or contract) and groups sponsored by an employer who employs fifty or fewer persons.

3.No law requiring the coverage of a particular health care service or benefit, or requiring the reimbursement, utilization or inclusion of a specific category of licensed health care practitioner, shall apply to limited mandate health insurance policies and contracts, except the following provisions:

(1)Subsection 1 of section 354.095, to the extent that it regulates maternity benefits;

(2)Section 375.995;

(3)Section 376.406;

(4)Section 376.428;

(5)Section 376.782;

(6)Section 376.816;

(7)Section 376.1210;

(8)Section 376.1215; and

(9)Section 376.1219.

4.In order for an insurer as defined in section 376.960 to be eligible to market, sell or issue limited mandate health insurance, the insurer shall:

(1)Restrict its marketing and sales efforts to only those persons or groups as defined in subsection 2 of this section which currently do not have health insurance coverage or to those persons or employers which certify in writing to the insurer that they will terminate the coverage they currently have at the time they would otherwise renew coverage because of cost;

(2)Fully and clearly disclose to the person or group to whom the limited mandate health insurance policy or contract is to be issued that the reason coverage for this product is less expensive than other coverage is because the policy or contract does not contain coverages or health professional payment mechanisms that are required by subsection 3 of this section;

(3)Clearly disclose in all sales, promotional and advertising material related thereto that the product is a limited mandate health insurance policy or contract.

5.The provisions of section 376.441 shall not apply to any group which replaces its current coverage with a limited mandate health insurance policy or contract if the benefit to be extended is one for services which are not covered by the replacing policy or contract.

6.Notwithstanding any other provision of this section to the contrary, the provisions of paragraph (b) of subdivision (11) of section 375.936 shall apply to limited mandate health insurance policies with respect to physician services covered under such policies, which can be provided by persons licensed pursuant to section 332.181.

(L. 1990 H.B. 998 § 15, A.L. 1992 S.B. 796, A.L. 1996 H.B. 904, et al. merged with H.B. 1069, A.L. 1997 H.B. 600 & 388)

376.699 - Person insured by group policy entitled to individual life policy, notice requirements.

If any individual insured under a group life insurance policy hereafter delivered in this state becomes entitled under the terms of such policy to have an individual policy of life insurance issued without evidence of insurability, subject to the making of an application and paying the first premium within the period specified in such policy, and if such individual is not given notice of the existence of such right at least fifteen days prior to the expiration date of such period, then, in such event, the individual shall have an additional period within which to exercise such right.Nothing contained herein shall be construed to continue any insurance beyond the period provided in such policy.The additional period provided in this section shall expire fifteen days after the individual is given the notice of his rights regarding an individual policy, but in no event shall such additional period extend beyond sixty days after the expiration date of the period provided in such policy.Written notice presented to the individual or mailed by the policyholder to the last known address of the individual, or mailed by the insurer to the last known address of the individual as furnished by the policyholder, shall constitute notice for the purpose of this section.

(L. 1982 H.B. 1546 § 5)

376.423 - Health insurance, claims for chiropractic services denial, qualified chiropractor to review, qualifications — investigation by department, when.

1.Beginning January 1, 1993, any consultant retained by any insurance company, health services corporation and any self-insured group arrangement to the extent not preempted by federal law, to review claims, under any policy of accident and sickness insurance or membership contract, denied in whole or in part for services rendered by a chiropractor shall:

(1)Be licensed and practicing as a chiropractor in the state of Missouri, and, if the claim is made from a metropolitan statistical area in Missouri as that term is defined by the United States Bureau of the Census, then he shall be practicing as a chiropractor in any such metropolitan statistical area in Missouri; or be licensed and practicing as a chiropractor in the state in which the claim is reviewed;

(2)Obtain a certificate from the board of chiropractic examiners, which shall indicate that the licensee has complied with the provisions of this section and has met the minimum standards contained in this section.The application for a certificate shall be on a form provided by the board;

(3)Provide to the board of chiropractic examiners, in addition to the other information required to be provided on the application, certification that the licensee has either:

(a)Successfully completed at least one hundred hours of postgraduate training in insurance claims consulting, which training was presented by a college of chiropractic having status with the council on chiropractic education; or

(b)Successfully completed at least one hundred hours training in insurance claims consulting in the course of study approved by the board of chiropractic examiners; and

(4)Have received at least one-half of his earned income from the clinical practice of chiropractic.The term "clinical practice of chiropractic" shall not include the review of claims regulated by this section nor any of the paperwork which is or becomes part of the review nor any of the income from examining a person whose claim is being reviewed.

2.The compensation of such consultant shall not be based on a percentage of the amount by which a claim is reduced for payment.

3.Upon receipt of a complaint from the insured or the chiropractor alleging an adverse chiropractic review determination, the director of the department of insurance, financial institutions and professional registration shall investigate to determine whether the insurance company or health services corporation has engaged in an unfair claims settlement practice under the provisions of subdivision (10) of section 375.936 or a violation of this section.The department of insurance, financial institutions and professional registration shall promulgate rules to enforce the provisions of this subsection.

4.Any licensee who shall advertise or announce to the public in any communication or solicitation that he engages in or provides insurance claims consulting in any aspect without having first complied with this section shall be deemed to have engaged in false, misleading or deceptive advertising.

5.It shall be unlawful for any person who is licensed under the provisions of chapter 331 to accept employment as a consultant to review health care claims for services rendered by any chiropractor unless he meets the qualifications and conditions of subsection 1 of this section.The provisions of this subsection shall be enforced by the board of chiropractic examiners, which administers the provisions of chapter 331.Violations of this section shall constitute grounds for disciplinary action pursuant to section 331.060.

6.The board of chiropractic examiners may by rule establish and enforce the conditions under which it will issue certificates of compliance.

7.The board of chiropractic examiners is authorized, pursuant to section 331.070, to set fees to cover the cost and expense of administering this section.

(L. 1990 H.B. 1739 § 13, A.L. 1992 S.B. 698, A.L. 1993 S.B. 52, A.L. 1997 H.B. 335)

376.2030 - Definitions.

As used in sections 376.2030 to 376.2036, the following terms mean:

(1)"Health benefit plan", the same meaning as such term is defined in section 376.1350;

(2)"Health care provider", the same meaning as such term is defined in section 376.1350;

(3)"Health carrier", the same meaning as such term is defined in section 376.1350;

(4)"Step therapy override exception determination", a determination as to whether a step therapy protocol should apply in a particular situation, or whether the step therapy protocol should be overridden in favor of immediate coverage of the health care provider's preferred prescription drug.This determination is based on a review of the patient's health care provider's request for an override, along with supporting rationale and documentation;

(5)"Step therapy override exception request", a written request from the patient's health care provider for the step therapy protocol to be overridden in favor of immediate coverage of the health care provider's preferred prescription drug.The manner and form of the written request shall be disclosed to the patient and the health care provider as described in subsection 1 of section 376.2034;

(6)"Step therapy protocol", a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular patient are to be prescribed and covered by a health carrier or health benefit plan;

(7)"Utilization review organization", an entity that conducts utilization review other than an insurer or health carrier performing utilization review for its own health benefit plans.

(L. 2016 H.B. 2029)

376.1575 - Definitions

As used in sections 376.1575 to 376.1580*, the following terms shall mean:

(1)"Completed application", a practitioner's application to a health carrier that seeks the health carrier's authorization for the practitioner to provide patient care services as a member of the health carrier's network and does not omit any information which is clearly required by the application form and the accompanying instructions;

(2)"Credentialing", a health carrier's process of assessing and validating the qualifications of a practitioner to provide patient care services and act as a member of the health carrier's provider network;

(3)"Health carrier", the same meaning as such term is defined in section 376.1350;

(4)"Practitioner":

(a)A physician or physician assistant eligible to provide treatment services under chapter 334;

(b)A pharmacist eligible to provide services under chapter 338;

(c)A dentist eligible to provide services under chapter 332;

(d)A chiropractor eligible to provide services under chapter 331;

(e)An optometrist eligible to provide services under chapter 336;

(f)A podiatrist eligible to provide services under chapter 330;

(g)A psychologist or licensed clinical social worker eligible to provide services under chapter 337; or

(h)An advanced practice nurse eligible to provide services under chapter 335.

(L. 2013 S.B. 262)

Effective 1-01-14

*Section 376.1580 does not exist.

376.2034 - Restriction on step therapy protocol, patient to have access to override exception determination — procedure.

1.If coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization via a step therapy protocol, a patient, through his or her health care provider, shall have access to a clear, convenient, and readily accessible process to request a step therapy override exception determination.A health carrier, health benefit plan, or utilization review organization may use its existing medical exceptions process to satisfy this requirement.The process shall be disclosed to the patient and health care provider, which shall include the necessary documentation needed to process such request and be made available on the health carrier plan or health benefit plan website.

2.A step therapy override exception determination shall be granted if the patient has tried the step therapy required prescription drugs while under his or her current or previous health insurance or health benefit plan, and such prescription drugs were discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event.Pharmacy drug samples shall not be considered trial and failure of a preferred prescription drug in lieu of trying the step therapy required prescription drug.

3.The health carrier, health benefit plan, or utilization review organization may request relevant documentation from the patient or provider to support the override exception request.

4.Upon the granting of a step therapy override exception request, the health carrier, health benefit plan, or utilization review organization shall authorize dispensation of and coverage for the prescription drug prescribed by the patient's treating health care provider, provided such drug is a covered drug under such policy or contract.

5.This section shall not be construed to prevent:

(1)A health carrier, health benefit plan, or utilization review organization from requiring a patient to try a generic equivalent or other brand name drug prior to providing coverage for the requested prescription drug; or

(2)A health care provider from prescribing a prescription drug he or she determines is medically appropriate.

(L. 2016 H.B. 2029)

376.1075 - Definitions.

As used in sections 376.1075 to 376.1095, the following terms mean:

(1)"Administrator", "third-party administrator" or "TPA", a person who directly or indirectly solicits or effects coverage of, underwrites, collects charges or premiums from, or adjusts or settles claims on residents of this state, or residents of another state from offices in this state, in connection with life or health insurance coverage, annuities, or workers' compensation except any of the following:

(a)An employer on behalf of its employees or the employees of one or more subsidiary or affiliated corporations of such employer;

(b)A union on behalf of its members;

(c)An insurance company which is either licensed in this state pursuant to the requirements of this chapter or chapter 379;

(d)An insurer authorized to do insurance business in another state pursuant to similar laws, with respect to a policy lawfully issued and delivered in a state other than this state, when engaged in transacting the business of insurance as defined by this chapter and chapter 379;

(e)A health service corporation, health maintenance organization or prepaid dental plan operating pursuant to the requirements of chapter 354, when engaged in its duties of providing health care or dental services and indemnifying its members;

(f)A life or health agent or broker licensed in this state, whose activities are limited exclusively to the sale of insurance;

(g)A creditor on behalf of its debtors with respect to insurance covering a debt between the creditor and its debtors;

(h)A trust, its trustees, agents and employees acting thereunder, established in conformity with 29 U.S.C. 186;

(i)A trust exempt from taxation under Section 501(a) of the Internal Revenue Code, its trustees, and employees acting thereunder;

(j)A custodian, its agents and employees acting pursuant to a custodian account which meets the requirements of Section 401(f) of the Internal Revenue Code;

(k)A bank, credit union or other financial institution which is subject to supervision or examination by federal or state banking authorities;

(l)A credit card issuing company which advances for and collects premiums or charges from its credit card holders who have authorized it to do so, provided such company does not adjust or settle claims;

(m)A person who adjusts or settles claims in the normal course of his or her practice or employment as an attorney at law, and who does not collect charges or premiums in connection with life or health insurance coverage or annuities;

(n)An adjuster whose activities are limited to adjustment of claims and who is either licensed by this state or working on behalf of a licensed workers' compensation insurer;

(o)A person licensed as an insurance agent in this state, whose activities are limited exclusively to the activities of a managing general agent;

(2)"Affiliate" or "affiliated", any entity or person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, a specified entity or person;

(3)"Control", as defined in chapter 382;

(4)"Director", the director of the department of insurance, financial institutions and professional registration;

(5)"Insurance" or "insurance coverage", any coverage offered or provided by an insurer;

(6)"Insurer", any person undertaking to provide life or health insurance coverage, annuities or workers' compensation coverage in this state.For the purposes of sections 376.1075 to 376.1095, insurer includes a licensed insurance company, a prepaid hospital or medical care plan, a health maintenance organization, a multiple employer self-insured health plan, a self-insured multiple employer welfare arrangement, or any other person providing a plan of insurance subject to state insurance regulation.Insurer does not include a bona fide employee benefit plan established by an employer or an employee organization, or both, for which the insurance laws of this state are preempted pursuant to the Employee Retirement Income Security Act of 1974;

(7)"Underwrites" or "underwriting" means, but is not limited to, the acceptance of employer or individual applications for coverage of individuals in accordance with the written rules of the insurer, the overall planning and coordinating of an insurance program, and the ability to procure bonds and excess insurance.

(L. 1993 H.B. 709 § 41, A.L. 1998 H.B. 1601, et al. merged with S.B. 852 & 913)

Effective 8-28-98 (H.B. 1601, et al.); 1-01-99 (S.B. 852 & 913)

376.427 - Assignment of benefits made by insured to provider — payment, how made — exceptions — all claims to be paid, when — out-of-network services, how paid.

1.As used in this section, the following terms mean:

(1)"Health benefit plan", as such term is defined in section 376.1350;

(2)"Health care services", medical, surgical, dental, podiatric, pharmaceutical, chiropractic, licensed ambulance service, and optometric services;

(3)"Health carrier" or "carrier", as such term is defined in section 376.1350;

(4)"Insured", any person entitled to benefits under a contract of accident and sickness insurance, or medical-payment insurance issued as a supplement to liability insurance but not including any other coverages contained in a liability or a workers' compensation policy, issued by an insurer;

(5)"Insurer", any person, reciprocal exchange, interinsurer, fraternal benefit society, health services corporation, self-insured group arrangement to the extent not prohibited by federal law, or any other legal entity engaged in the business of insurance;

(6)"Provider", a physician, hospital, dentist, podiatrist, chiropractor, pharmacy, licensed ambulance service, or optometrist, licensed by this state.

2.Upon receipt of an assignment of benefits made by the insured to a provider, the insurer shall issue the instrument of payment for a claim for payment for health care services in the name of the provider.All claims shall be paid within thirty days of the receipt by the insurer of all documents reasonably needed to determine the claim.

3.Nothing in this section shall preclude an insurer from voluntarily issuing an instrument of payment in the single name of the provider.

4.Except as provided in subsection 5 of this section, this section shall not require any insurer, health services corporation, health maintenance corporation or preferred provider organization which directly contracts with certain members of a class of providers for the delivery of health care services to issue payment as provided pursuant to this section to those members of the class which do not have a contract with the insurer.

5.When a patient's health benefit plan does not include or require payment to out-of-network providers for all or most covered services, which would otherwise be covered if the patient received such services from a provider in the carrier's network, including but not limited to health maintenance organization plans, as such term is defined in section 354.400, or a health benefit plan offered by a carrier consistent with subdivision (19) of section 376.426, payment for all services shall be made directly to the providers when the health carrier has authorized such services to be received from a provider outside the carrier's network.

(L. 1990 H.B. 1739 § 14, A.L. 1992 S.B. 698, A.L. 2018 S.B. 982)

376.1092 - Certificate of authority, required, application, contents, fee — refusal to issue, when — renewal — bond, required when.

1.No person shall act as, or offer to act as, or hold himself out to be an administrator in this state without a valid certificate of authority as an administrator issued by the director.

2.Applicants to be an administrator shall make an application to the director upon a form to be furnished by the director.The application shall include or be accompanied by the following information and documents:

(1)All basic organizational documents of the administrator, including, but not limited to, any articles of incorporation, articles of association, partnership agreement, trade name certificate, trust agreement, shareholder agreement and other applicable documents and all amendments to such documents;

(2)The bylaws, rules, regulations or similar documents regulating the internal affairs of the administrator;

(3)The names, addresses, official positions and professional qualifications of the individuals who are responsible for the conduct of affairs of the administrator, including all members of the board of directors, board of trustees, executive committee or other governing board or committee; the principal officers in the case of a corporation or the partners or members in the case of a partnership or association; shareholders holding directly or indirectly ten percent or more of the voting securities of the administrator; and any other person who exercises control or influence over the affairs of the administrator;

(4)Annual financial statements or reports for the two most recent years which prove that the applicant is solvent and such information as the director may require in order to review the current financial condition of the applicant;

(5)A statement describing the business plan including information on staffing levels and activities proposed in this state and nationwide.The plan shall provide details setting forth the administrator's capability for providing a sufficient number of experienced and qualified personnel in the areas of claims processing, record keeping and underwriting;

(6)If the applicant will be managing the solicitation of new or renewal business, proof that it employs or has contracted with an agent licensed by this state for solicitation and taking of applications.Any applicant which intends to directly solicit insurance contracts or to otherwise act as an insurance agent must provide proof that it has a license as an insurance agent or agency, or as an insurance agent and agency, as applicable, in this state;

(7)An application fee of one thousand dollars;

(8)Such other pertinent information as may be required by the director.

3.The applicant shall make available for inspection by the director copies of all contracts with insurers or other persons using the services of the administrator.

4.The director may refuse to issue a certificate of authority if the director determines that the administrator or any individual responsible for the conduct of affairs of the administrator as described in subdivision (3) of subsection 2 of this section is not competent, trustworthy, financially responsible or of good personal and business reputation, has had an insurance or an administrator license denied or revoked for cause by any state or been subject to any form of criminal, civil or administrative action by any federal or state court or agency resulting* in some form of discipline or sanction.

5.Such certificate shall be renewable annually on the first day of July of each calendar year following the calendar year in which the certificate of registration was originally issued, upon application by the administrator and upon payment of the renewal fee of two hundred fifty dollars, provided that the director of the department of insurance, financial institutions and professional registration is satisfied that none of the facts specified in sections 376.1075 to 376.1095 as grounds for revoking a certificate of registration exist, and any bond required by sections 376.1075 to 376.1095 is in force.Failure to hold such a certificate shall subject the administrator to an administrative penalty of not more than fifty thousand dollars.

6.An administrator shall immediately notify the director of any material change in its ownership, control, or other fact or circumstance affecting its qualification for a certificate of authority in this state.

7.Every administrator, except as hereinafter provided, shall file with the director a surety bond in the amount and form as prescribed by the director.Such bond shall be obtained from an insurance company licensed or approved to do business in the state of Missouri.Any affiliate or subsidiary of an insurance company licensed in this state shall not be required to file such a bond so long as the director is satisfied with the financial condition of such insurance company.

(L. 1993 H.B. 709 § 51)

*Word "result" appears in original rolls.

376.891 - Definitions.

As used in sections 376.891 to 376.894, the following terms mean:

(1)"Certificate holder", a person who receives health care benefits or services pursuant to a policy, contract or plan;

(2)"Plan administrator":

(a)The person designated as the plan administrator by the instrument under which the contract or plan is operated; or

(b)If no plan administrator is designated, the plan sponsor;

(3)"Policy, contract or plan", a group insurance policy providing health care coverage on an expense incurred basis, a group service or indemnity contract issued by a not-for-profit health services corporation, a health maintenance organization plan or a self-insured group health benefit plan of any type or description.

(L. 1993 H.B. 564 § 11)

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

1.Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2003, shall include coverage for their members for the cost for human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A, B, and DR antigens for utilization in bone marrow transplantation.The testing must be performed in a facility which is accredited by the American Association of Blood Banks or its successors, and is licensed under the Clinical Laboratory Improvement Act, 42 U.S.C. Section 263a, as amended, and is accredited by the American Association of Blood Banks or its successors, the College of American Pathologists, the American Society for Histocompatibility and Immunogenetics (ASHI) or any other national accrediting body with requirements that are substantially equivalent to or more stringent than those of the College of American Pathologists.At the time of testing, the person being tested must complete and sign an informed consent form which also authorizes the results of the test to be used for participation in the National Marrow Donor Program.The health benefit plan may limit each enrollee to one such testing per lifetime to be reimbursed at a cost of no greater than seventy-five dollars by the health carrier or health benefit plan.

2.For the purposes of this section, "health carrier" and "health benefit plan" shall have the same meaning as defined in section 376.1350.

3.The health care service required by this section shall not be subject to any greater deductible or co-payment than other similar health care services provided by the health benefit plan.

4.The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months' or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

(L. 2002 S.B. 1026)

*376.1199 - Coverage for certain obstetrical/gynecological services — exclusion of contraceptive coverage permitted, when — rulemaking authority.

1.Each health carrier or health benefit plan that offers or issues health benefit plans providing obstetrical/gynecological benefits and pharmaceutical coverage, which are delivered, issued for delivery, continued or renewed in this state on or after January 1, 2002, shall:

(1)Notwithstanding the provisions of subsection 4 of section 354.618, provide enrollees with direct access to the services of a participating obstetrician, participating gynecologist or participating obstetrician/gynecologist of her choice within the provider network for covered services.The services covered by this subdivision shall be limited to those services defined by the published recommendations of the accreditation council for graduate medical education for training an obstetrician, gynecologist or obstetrician/gynecologist, including but not limited to diagnosis, treatment and referral for such services.A health carrier shall not impose additional co-payments, coinsurance or deductibles upon any enrollee who seeks or receives health care services pursuant to this subdivision, unless similar additional co-payments, coinsurance or deductibles are imposed for other types of health care services received within the provider network.Nothing in this subsection shall be construed to require a health carrier to perform, induce, pay for, reimburse, guarantee, arrange, provide any resources for or refer a patient for an abortion, as defined in section 188.015, other than a spontaneous abortion or to prevent the death of the female upon whom the abortion is performed, or to supersede or conflict with section 376.805; and

(2)Notify enrollees annually of cancer screenings covered by the enrollees' health benefit plan and the current American Cancer Society guidelines for all cancer screenings or notify enrollees at intervals consistent with current American Cancer Society guidelines of cancer screenings which are covered by the enrollees' health benefit plans.The notice shall be delivered by mail unless the enrollee and health carrier have agreed on another method of notification; and

(3)Include coverage for services related to diagnosis, treatment and appropriate management of osteoporosis when such services are provided by a person licensed to practice medicine and surgery in this state, for individuals with a condition or medical history for which bone mass measurement is medically indicated for such individual.In determining whether testing or treatment is medically appropriate, due consideration shall be given to peer-reviewed medical literature.A policy, provision, contract, plan or agreement may apply to such services the same deductibles, coinsurance and other limitations as apply to other covered services; and

(4)If the health benefit plan also provides coverage for pharmaceutical benefits, provide coverage for contraceptives either at no charge or at the same level of deductible, coinsurance or co-payment as any other covered drug.

No such deductible, coinsurance or co-payment shall be greater than any drug on the health benefit plan's formulary.As used in this section, "contraceptive" shall include all prescription drugs and devices approved by the federal Food and Drug Administration for use as a contraceptive, but shall exclude all drugs and devices that are intended to induce an abortion, as defined in section 188.015, which shall be subject to section 376.805.Nothing in this subdivision shall be construed to exclude coverage for prescription contraceptive drugs or devices ordered by a health care provider with prescriptive authority for reasons other than contraceptive or abortion purposes.

2.For the purposes of this section, "health carrier" and "health benefit plan" shall have the same meaning as defined in section 376.1350.

3.The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

4.Notwithstanding the provisions of subdivision (4) of subsection 1 of this section to the contrary:

(1)Any health carrier shall offer and issue to any person or entity purchasing a health benefit plan, a health benefit plan that excludes coverage for contraceptives if the use or provision of such contraceptives is contrary to the moral, ethical or religious beliefs or tenets of such person or entity;

(2)Upon request of an enrollee who is a member of a group health benefit plan and who states that the use or provision of contraceptives is contrary to his or her moral, ethical or religious beliefs, any health carrier shall issue to or on behalf of such enrollee a policy form that excludes coverage for contraceptives.Any administrative costs to a group health benefit plan associated with such exclusion of coverage not offset by the decreased costs of providing coverage shall be borne by the group policyholder or group plan holder;

(3)Any health carrier which is owned, operated or controlled in substantial part by an entity that is operated pursuant to moral, ethical or religious tenets that are contrary to the use or provision of contraceptives shall be exempt from the provisions of subdivision (4) of subsection 1 of this section.For purposes of this subsection, if new premiums are charged for a contract, plan or policy, it shall be determined to be a new contract, plan or policy.

5.Except for a health carrier that is exempted from providing coverage for contraceptives pursuant to this section, a health carrier shall allow enrollees in a health benefit plan that excludes coverage for contraceptives pursuant to subsection 4 of this section to purchase a health benefit plan that includes coverage for contraceptives.

6.Any health benefit plan issued pursuant to subsection 1 of this section shall provide clear and conspicuous written notice on the enrollment form or any accompanying materials to the enrollment form and the group health benefit plan application and contract:

(1)Whether coverage for contraceptives is or is not included;

(2)That an enrollee who is a member of a group health benefit plan with coverage for contraceptives has the right to exclude coverage for contraceptives if such coverage is contrary to his or her moral, ethical or religious beliefs;

(3)That an enrollee who is a member of a group health benefit plan without coverage for contraceptives has the right to purchase coverage for contraceptives;

(4)Whether an optional rider for elective abortions has been purchased by the group contract holder pursuant to section 376.805; and

(5)That an enrollee who is a member of a group health plan with coverage for elective abortions has the right to exclude and not pay for coverage for elective abortions if such coverage is contrary to his or her moral, ethical, or religious beliefs.

For purposes of this subsection, if new premiums are charged for a contract, plan, or policy, it shall be determined to be a new contract, plan, or policy.

7.Health carriers shall not disclose to the person or entity who purchased the health benefit plan the names of enrollees who exclude coverage for contraceptives in the health benefit plan or who purchase a health benefit plan that includes coverage for contraceptives.Health carriers and the person or entity who purchased the health benefit plan shall not discriminate against an enrollee because the enrollee excluded coverage for contraceptives in the health benefit plan or purchased a health benefit plan that includes coverage for contraceptives.

8.The departments of health and senior services and insurance, financial institutions and professional registration may promulgate rules necessary to implement the provisions of this section.No rule or portion of a rule promulgated pursuant to this section shall become effective unless it has been promulgated pursuant to chapter 536.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2001, shall be invalid and void.

(L. 2001 H.B. 762 merged with S.B. 266, A.L. 2012 S.B. 749)

*Effective 10-12-12, see § 21.250.S.B. 749 was vetoed on July 12, 2012.The veto was overridden on September 12, 2012.

(2013) Subsections 1(4), 4, 5, 6(1), 6(2), and 6(3) of sectionare pre-empted by the federal Affordable Care Act and its implementing regulations.Missouri Insurance Coalition v. Huff, 947 F.Supp.2d 1014 (E.D.Mo.).

376.1375 - Registry of grievances maintained, procedures — definitions.

1.A health carrier shall maintain a written register of all grievances in a manner consistent with the requirements for maintaining complaint records pursuant to section 354.445.The grievance register shall contain the total number, type, nature and result of all grievances and such other information as may be prescribed by the director.A health carrier shall furnish the director with any records regarding a grievance upon request.

2.All grievances shall be date stamped when received by the health carrier.The date shall be legible and easily identified.

3.Upon receipt of any inquiry from the department of insurance, financial institutions and professional registration regarding a grievance, a health carrier shall mail to the department an adequate response to the inquiry within twenty days from the date the department mails the inquiry.An envelope's postmark shall determine the date of mailing.When the requested response is not produced by the health carrier within twenty days, this nonproduction shall be deemed a violation of law, unless the person can demonstrate that there is reasonable justification for that delay.As used in this section:

(1)"Inquiry", each and every question or request for information submitted in writing to a health carrier by the department concerning a grievance;

(2)"Adequate response", a written response answering each inquiry with reasonable specificity.A health carrier's acknowledgment of the department's inquiry is not an adequate response.

(L. 1997 H.B. 335)

376.1020 - Plan to maintain principal place of business in Missouri, exception.

Each multiple employer self-insured health plan shall have and maintain its principal place of business in this state or shall appoint the director of the department of insurance, financial institutions and professional registration as its agent for service of process, and shall thereby make available to the department complete records of its assets, transactions, and affairs with such methods and systems as are customary for, or suitable to, the kind or kinds of business transacted.The director or his representative shall inspect these records at least every three years.The information from these records shall be furnished to the director or his representatives on demand and the original books or records shall be open to examination by the director or his representatives when demanded.Examinations shall be conducted pursuant to sections 374.160, 374.162, 374.190, 374.202 to 374.207 and 374.220.

(L. 1993 H.B. 709 § 30)

376.1524 - Advertising and marketing materials, approval in writing required.

1.All advertisements, marketing materials, brochures and discount cards used by marketers shall be approved in writing for such use by the discount medical plan organization.

2.The discount medical plan organization shall have an executed written agreement with a marketer prior to the marketer's marketing, promoting, selling, or distributing the discount medical plan.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.391 - Co-payments for chiropractic services, cap.

A health benefit plan or health carrier, as defined in section 376.1350, including but not limited to preferred provider organizations, independent physicians associations, third-party administrators, or any entity that contracts with licensed health care providers shall not impose any co-payment that exceeds fifty percent of the total cost of providing any single chiropractic service to its enrollees.

(L. 2009 H.B. 577)

*376.379 - Medication synchronization services, offer of coverage required.

1.A health carrier or managed care plan offering a health benefit plan in this state that provides prescription drug coverage shall offer, as part of the plan, medication synchronization services developed by the health carrier or managed care plan that allow for the alignment of refill dates for an enrollee's prescription drugs that are covered benefits.

2.Under its medication synchronization services, a health carrier or managed care plan shall:

(1)Not charge an amount in excess of the otherwise applicable co-payment amount under the health benefit plan for dispensing a prescription drug in a quantity that is less than the prescribed amount if:

(a)The pharmacy dispenses the prescription drug in accordance with the medication synchronization services offered under the health benefit plan; and

(b)A participating provider dispenses the prescription drug; and

(2)Provide a full dispensing fee to the pharmacy that dispenses the prescription drug to the covered person.

3.For purposes of this section, the terms "health carrier", "managed care plan", "health benefit plan", "enrollee", and "participating provider" shall have the same meanings given to such terms under section 376.1350.

(L. 2016 S.B. 608 merged with S.B. 865 & 866)

Effective 8-28-16 (S.B. 865 & 866); *10-14-16 (S.B. 608), see § 21.250

*S.B. 608 was vetoed July 5, 2016.The veto was overridden on September 14, 2016.

376.291 - Applicability and inapplicability.

Sections 376.291 to 376.307 shall apply only to investments and investment practices of domestic insurers organized under the provisions of this chapter.Sections 376.291 to 376.307 shall not apply to separate accounts of an insurer except to the extent that the provisions of section 376.309 so provide.

(L. 2007 S.B. 66)

376.1220 - Insurance coverage for newborn hearing screenings mandated.

1.Each policy issued by an entity offering individual and group health insurance which provides coverage on an expense-incurred basis, individual or group health service, or indemnity contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group health arrangements to the extent not preempted by federal law, and all health care plans provided by managed health care delivery entities of any type or description that are delivered, issued for delivery, continued or renewed in this state shall provide coverage for newborn hearing screening, necessary rescreening, audiological assessment and follow-up, and initial amplification.

2.The health care service required by this section shall not be subject to any greater deductible or co-payment than other similar health care services provided by the policy, contract or plan.

3.This section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

4.Coverage for newborn hearing screening and any necessary rescreening and audiological assessment shall be provided to newborns eligible for medical assistance pursuant to section 208.151, and the children's health program pursuant to sections 208.631 to 208.660, with payment for the newborn hearing screening required in section 191.925, and any necessary rescreening, audiological assessment and follow-up, and amplification as described in section 191.928.

(L. 1999 H.B. 401 § 376.685)

CROSS REFERENCE:

Rulemaking authority, 191.937

376.695 - Extension of policy to insure for loss due to death of spouse or dependent children, requirements, limitations.

Except for a policy issued under subdivision (2) of section 376.691, a group life insurance policy may be extended to insure the employees or members against loss due to the death of their spouses and dependent children, or any class or classes of such spouses or dependent children, subject to the following provisions:

(1)The premium for the insurance shall be paid either from funds contributed by the employer, union, association, or other person to whom the policy has been issued, or from funds contributed by the covered persons, or from both.Except as provided in subdivision (2) of this section, a policy on which no part of the premium for the spouse's and dependent child's coverage is to be derived from funds contributed by the covered persons must insure all eligible employees or members with respect to their spouses and dependent children, or any class or classes of such employees or members, except those who reject such coverage in writing;

(2)An insurer may exclude or limit the coverage on any spouse or dependent child as to whom evidence of individual insurability is not satisfactory to the insurer.

(L. 1982 H.B. 1546 § 3, A.L. 1985 H.B. 623)

376.823 - Prohibition on kickbacks not applicable for rebates for certain chronic illnesses.

Section 191.905 shall not apply to programs established by pharmaceutical companies for the purposes of providing a partial rebate of private health insurance co-payments and coinsurance to patients with multiple sclerosis or other chronic, potentially disabling, or life-threatening conditions who have been prescribed disease-managing medicines for which there are no generic equivalents.

(L. 2005 H.B. 56)

376.676 - Regulation of the valuation of life insurance policies — may adopt NAIC model regulation.

The department of insurance, financial institutions and professional registration shall promulgate regulations governing the valuation of life insurance policies.The department of insurance, financial institutions and professional registration may adopt the "Valuation of Life Insurance Policies Model Regulation" adopted by the National Association of Insurance Commissioners.

(L. 2000 H.B. 1739)

376.691 - Group life policies, eligible groups authorized for issue — premiums, how paid.

Except as provided in section 376.693, no policy of group life insurance shall be delivered in this state unless it is one of the following:

(1)A policy issued to an employer, or to the trustees of a fund established by an employer, which employer or trustees shall be deemed the policyholder, to insure employees of the employer for the benefit of persons other than the employer, subject to the following requirements:

(a)The employees eligible for insurance under the policy shall be all of the employees of the employer, or all of any class or classes of such employees.The policy may provide that the term "employees" shall include the employees of one or more subsidiary corporations, and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships, or partnerships if the business of the employer and of such affiliated corporations, proprietorships, or partnerships is under common control.The policy may also provide that the term "employees" shall include the individual proprietor or partners if the employer is an individual proprietorship or partnership.The policy may also provide that the term "employees" shall include retired employees and directors of a corporate employer.A policy issued to insure the employees of a public body may provide that the term "employees" shall include elected or appointed officials;

(b)The premium for the policy shall be paid either from the employer's funds or from funds contributed by the insured employees, or from both.Except as provided in paragraph (c) of this subdivision, a policy on which no part of the premium is to be derived from funds contributed by the insured employees must insure all eligible employees, except those who reject such coverage in writing; and

(c)An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer;

(2)A policy issued to a creditor, its parent holding company, or to a trustee or agent designated by two or more creditors, which creditor, holding company, affiliate, trustee, or agent shall be deemed the policyholder, to insure debtors of the creditor, or creditors, subject to the following requirements:

(a)The debtors eligible for insurance under the policy shall be all of the debtors of the creditor, or creditors, or all of any class or classes of such debtors.The policy may provide that the term "debtors" shall include:

a.Borrowers of money or purchasers or lessees of goods, services, or property for which payment is arranged through a credit transaction;

b.The debtors of one or more subsidiary corporations; and

c.The debtors of one or more affiliated corporations, proprietorships, or partnerships if the business of the policyholder and of such affiliated corporations, proprietorships, or partnerships is under common control;

(b)The premium for the policy shall be paid either from the creditor's funds or from charges collected from the insured debtors, or from both.Except as provided in paragraph (c) of this subdivision, a policy on which no part of the premium is to be derived from the funds contributed by insured debtors specifically for their insurance must insure all eligible debtors;

(c)An insurer may exclude any debtors as to whom evidence of individual insurability is not satisfactory to the insurer;

(d)The amount of the insurance on the life of any debtor shall at no time exceed the scheduled amount of indebtedness to the creditor;

(e)The insurance may be payable to the creditor or any successor to the right, title, and interest of the creditor.Such payment shall reduce or extinguish the unpaid indebtedness of the debtor to the extent of such payment.Any excess insurance above the scheduled amount shall be payable to the second beneficiary; if there is no second beneficiary, the insured's estate;

(f)Notwithstanding the provisions of the above paragraphs of this subdivision, insurance on agricultural credit transaction commitments may be written up to the amount of the loan commitment on a nondecreasing or level term plan.Insurance on educational credit transaction commitments may be written up to the amount of the loan commitment less the amount of any repayments made on the loan.Insurance on residential real estate secured credit transaction commitments may be written up to the amount of the loan commitment;

(3)A policy issued to a labor union or similar employee organization, which shall be deemed to be the policyholder, to insure members of such union or organization for the benefit of persons other than the union or organization or any of its officials, representatives, or agents, subject to the following requirements:

(a)The members eligible for insurance under the policy shall be all of the members of the union or organization, or all of any class or classes of such members;

(b)The premium for the policy shall be paid either from funds of the union or organization or from funds contributed by the insured members specifically for their insurance, or from both.Except as provided in this subdivision, a policy on which no part of the premium is to be derived from funds contributed by the insured members specifically for their insurance must insure all eligible members, except those who reject such coverage in writing;

(c)An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer;

(4)A policy issued to a trust or to the trustee of a fund established by two or more employers, or by one or more labor unions or similar employee organizations, or by one or more employers and one or more labor unions or similar employee organizations, which trust or trustee shall be deemed the policyholder, to insure employees of the employers or members of the unions or organizations for the benefit of persons other than the employers or the unions or organizations, subject to the following requirements:

(a)The persons eligible for insurance shall be all of the employees of the employers or all of the members of the unions or organizations, or all of any class or classes of such employees or members.The policy may provide that the term "employees" shall include retired employees, the individual proprietor or partners if an employer is an individual proprietorship or a partnership, and directors of a corporate employer.The policy may also provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with such trusteeship;

(b)The premium for the policy shall be paid from funds contributed by the employer or employers of the insured persons or by the union or unions or similar employee organizations, or by both, or from funds contributed by the insured persons or from both the insured persons and the employer or union or similar employee organization.Except as provided in paragraph (c) of this subdivision, a policy on which no part of the premium is to be derived from funds contributed by the insured persons specifically for their insurance must insure all eligible persons, except those who reject such coverage in writing;

(c)An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer;

(5)A policy issued to an association or to a trust or trustee of a fund established, created, or maintained for the benefit of members of one or more associations.The association or associations shall have at the outset a minimum of one hundred persons or there shall be a minimum of one hundred employees or* employer members of the association, shall have been organized and maintained in good faith for purposes other than that of obtaining insurance, shall have been in active existence for at least two years prior to obtaining a policy of group life insurance, and shall have a constitution and bylaws which provide that:the association shall hold regular meetings not less than annually to further purposes of its members; except for credit unions, the association shall collect dues or solicit contributions from members; and the members shall have voting privileges and representation on the governing board and committees.The policy shall be subject to the following requirements:

(a)The policy may insure members of such association, employees of such association, or employees of members of such association, or any combination thereof, or all of any class or classes of such members or employees, for the benefit of persons other than the employee's employer;

(b)The premium for the policy shall be paid from funds contributed by the association or by employer members, or by both, or from funds contributed by the covered persons, or from both the covered persons and the association or employer members;

(c)Except as provided in paragraph (d) of this subdivision, a policy on which no part of the premium is to be derived from funds contributed by the covered persons specifically for the insurance must insure all eligible persons, except those who reject such coverage in writing;

(d)An insurer may exclude or limit the coverage of any person as to whom evidence of individual insurability is not satisfactory to the insurer;

(6)A policy issued to a credit union or to a trustee or agent designated by two or more credit unions, which credit union, trustee or agent shall be deemed the policyholder, to insure members of such credit union for the benefit of persons other than the credit union, trustee, agent, or any of their officials, subject to the following requirements:

(a)The members eligible for insurance shall be all of the members of the credit union, or all of any class or classes of such members;

(b)The premium for the policy shall be paid by the policyholder from the credit union's funds and, except as provided in paragraph (c) of this subdivision, must insure all eligible members;

(c)An insurer may exclude or limit the coverage on any member as to whom evidence of individual insurability is not satisfactory to the insurer.

(L. 1982 H.B. 1546 § 1, A.L. 1987 H.B. 510)

*Word "of" appears in original rolls.

376.1224 - Definitions — insurance coverage required — limitations on coverage — maximum benefit amount, adjustments — reimbursements, how made — applicability to plans — waiver, when — report.

1.For purposes of this section, the following terms shall mean:

(1)"Applied behavior analysis", the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior;

(2)"Autism service provider":

(a)Any person, entity, or group that provides diagnostic or treatment services for autism spectrum disorders who is licensed or certified by the state of Missouri; or

(b)Any person who is licensed under chapter 337 as a board-certified behavior analyst by the behavior analyst certification board or licensed under chapter 337 as an assistant board-certified behavior analyst;

(3)"Autism spectrum disorders", a neurobiological disorder, an illness of the nervous system, which includes Autistic Disorder, Asperger's Disorder, Pervasive Developmental Disorder Not Otherwise Specified, Rett's Disorder, and Childhood Disintegrative Disorder, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association;

(4)"Diagnosis of autism spectrum disorders", medically necessary assessments, evaluations, or tests in order to diagnose whether an individual has an autism spectrum disorder;

(5)"Habilitative or rehabilitative care", professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop the functioning of an individual;

(6)"Health benefit plan", shall have the same meaning ascribed to it as in section 376.1350;

(7)"Health carrier", shall have the same meaning ascribed to it as in section 376.1350;

(8)"Line therapist", an individual who provides supervision of an individual diagnosed with an autism diagnosis and other neurodevelopmental disorders pursuant to the prescribed treatment plan, and implements specific behavioral interventions as outlined in the behavior plan under the direct supervision of a licensed behavior analyst;

(9)"Pharmacy care", medications used to address symptoms of an autism spectrum disorder prescribed by a licensed physician, and any health-related services deemed medically necessary to determine the need or effectiveness of the medications only to the extent that such medications are included in the insured's health benefit plan;

(10)"Psychiatric care", direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices;

(11)"Psychological care", direct or consultative servicesprovided by a psychologist licensed in the state in which the psychologist practices;

(12)"Therapeutic care", services provided by licensed speech therapists, occupational therapists, or physical therapists;

(13)"Treatment for autism spectrum disorders", care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist, including equipment medically necessary for such care, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, including, but not limited to:

(a)Psychiatric care;

(b)Psychological care;

(c)Habilitative or rehabilitative care, including applied behavior analysis therapy;

(d)Therapeutic care;

(e)Pharmacy care.

2.All group health benefit plans that are delivered, issued for delivery, continued, or renewed on or after January 1, 2011, if written inside the state of Missouri, or written outside the state of Missouri but insuring Missouri residents, shall provide coverage for the diagnosis and treatment of autism spectrum disorders to the extent that such diagnosis and treatment is not already covered by the health benefit plan.

3.With regards to a health benefit plan, a health carrier shall not deny or refuse to issue coverage on, refuse to contract with, or refuse to renew or refuse to reissue or otherwise terminate or restrict coverage on an individual or their dependent because the individual is diagnosed with autism spectrum disorder.

4.(1)Coverage provided under this section is limited to medically necessary treatment that is ordered by the insured's treating licensed physician or licensed psychologist, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, in accordance with a treatment plan.

(2)The treatment plan, upon request by the health benefit plan or health carrier, shall include all elements necessary for the health benefit plan or health carrier to pay claims.Such elements include, but are not limited to, a diagnosis, proposed treatment by type, frequency and duration of treatment, and goals.

(3)Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, a health carrier shall have the right to review the treatment plan not more than once every six months unless the health carrier and the individual's treating physician or psychologist agree that a more frequent review is necessary.Any such agreement regarding the right to review a treatment plan more frequently shall only apply to a particular individual being treated for an autism spectrum disorder and shall not apply to all individuals being treated for autism spectrum disorders by a physician or psychologist.The cost of obtaining any review or treatment plan shall be borne by the health benefit plan or health carrier, as applicable.

5.Coverage provided under this section for applied behavior analysis shall be subject to a maximum benefit of forty thousand dollars per calendar year for individuals through eighteen years of age.Such maximum benefit limit may be exceeded, upon prior approval by the health benefit plan, if the provision of applied behavior analysis services beyond the maximum limit is medically necessary for such individual.Payments made by a health carrier on behalf of a covered individual for any care, treatment, intervention, service or item, the provision of which was for the treatment of a health condition unrelated to the covered individual's autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.Any coverage required under this section, other than the coverage for applied behavior analysis, shall not be subject to the age and dollar limitations described in this subsection.

6.The maximum benefit limitation for applied behavior analysis described in subsection 5 of this section shall be adjusted by the health carrier at least triennially for inflation to reflect the aggregate increase in the general price level as measured by the Consumer Price Index for All Urban Consumers for the United States, or its successor index, as defined and officially published by the United States Department of Labor, or its successor agency.Beginning January 1, 2012, and annually thereafter, the current value of the maximum benefit limitation for applied behavior analysis coverage adjusted for inflation in accordance with this subsection shall be calculated by the director of the department of insurance, financial institutions and professional registration.The director shall furnish the calculated value to the secretary of state, who shall publish such value in the Missouri Register as soon after each January first as practicable, but it shall otherwise be exempt from the provisions of section 536.021.

7.Subject to the provisions set forth in subdivision (3) of subsection 4 of this section, coverage provided under this section shall not be subject to any limits on the number of visits an individual may make to an autism service provider, except that the maximum total benefit for applied behavior analysis set forth in subsection 5 of this section shall apply to this subsection.

8.This section shall not be construed as limiting benefits which are otherwise available to an individual under a health benefit plan.The health care coverage required by this section shall not be subject to any greater deductible, coinsurance, or co-payment than other physical health care services provided by a health benefit plan.Coverage of services may be subject to other general exclusions and limitations of the contract or benefit plan, not in conflict with the provisions of this section, such as coordination of benefits, exclusions for services provided by family or household members, and utilization review of health care services, including review of medical necessity and care management; however, coverage for treatment under this section shall not be denied on the basis that it is educational or habilitative in nature.

9.To the extent any payments or reimbursements are being made for applied behavior analysis, such payments or reimbursements shall be made to either:

(1)The autism service provider, as defined in this section; or

(2)The entity or group for whom such supervising person, who is certified as a board-certified behavior analyst by the Behavior Analyst Certification Board, works or is associated.

Such payments or reimbursements under this subsection to an autism service provider or a board-certified behavior analyst shall include payments or reimbursements for services provided by a line therapist under the supervision of such provider or behavior analyst if such services provided by the line therapist are included in the treatment plan and are deemed medically necessary.

10.Notwithstanding any other provision of law to the contrary, health carriers shall not be held liable for the actions of line therapists in the performance of their duties.

11.The provisions of this section shall apply to any health care plans issued to employees and their dependents under the Missouri consolidated health care plan established pursuant to chapter 103 that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011.The terms "employees" and "health care plans" shall have the same meaning ascribed to them in section 103.003.

12.The provisions of this section shall also apply to the following types of plans that are established, extended, modified, or renewed on or after January 1, 2011:

(1)All self-insured governmental plans, as that term is defined in 29 U.S.C. Section 1002(32);

(2)All self-insured group arrangements, to the extent not preempted by federal law;

(3)All plans provided through a multiple employer welfare arrangement, or plans provided through another benefit arrangement, to the extent permitted by the Employee Retirement Income Security Act of 1974, or any waiver or exception to that act provided under federal law or regulation; and

(4)All self-insured school district health plans.

13.The provisions of this section shall not automatically apply to an individually underwritten health benefit plan, but shall be offered as an option to any such plan.

14.The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy.

15.Any health carrier or other entity subject to the provisions of this section shall not be required to provide reimbursement for the applied behavior analysis delivered to a person insured by such health carrier or other entity to the extent such health carrier or other entity is billed for such services by any Part C early intervention program or any school district for applied behavior analysis rendered to the person covered by such health carrier or other entity.This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education plan, or an individualized service plan.This section shall not be construed as affecting any obligation to provide reimbursement pursuant to section 376.1218.

16.The provisions of sections 376.383, 376.384, and 376.1350 to 376.1399 shall apply to this section.

17.The director of the department of insurance, financial institutions and professional registration shall grant a small employer with a group health plan, as that term is defined in section 379.930, a waiver from the provisions of this section if the small employer demonstrates to the director by actual claims experience over any consecutive twelve-month period that compliance with this section has increased the cost of the health insurance policy by an amount of two and a half percent or greater over the period of a calendar year in premium costs to the small employer.

18.The provisions of this section shall not apply to the Mo HealthNet program as described in chapter 208.

19.(1)By February 1, 2012, and every February first thereafter, the department of insurance, financial institutions and professional registration shall submit a report to the general assembly regarding the implementation of the coverage required under this section.The report shall include, but shall not be limited to, the following:

(a)The total number of insureds diagnosed with autism spectrum disorder;

(b)The total cost of all claims paid out in the immediately preceding calendar year for coverage required by this section;

(c)The cost of such coverage per insured per month; and

(d)The average cost per insured for coverage of applied behavior analysis;

(2)All health carriers and health benefit plans subject to the provisions of this section shall provide the department with the data requested by the department for inclusion in the annual report.

(L. 2010 H.B. 1311 & 1341)

376.295 - Additional prohibited acts — authorized actions.

1.(1)Except as provided in subsection 2 of this section, an insurer shall not without written approval of the director, directly or indirectly:

(a)Make a loan to or other investment in an officer or director of the insurer or a person in which the officer has any direct or indirect financial interest;

(b)Make a guarantee for the benefit of or in favor of an officer or director of the insurer or a person in which the officer or director has any direct or indirect financial interest; or

(c)Enter into an agreement for the purchase or sale of property from or to an officer or director of the insurer or a person in which the officer or director has any direct or indirect financial interest.

(2)For purposes of this section, an officer or director shall not be deemed to have a financial interest by reason of an interest that is held directly or indirectly through the ownership of equity interests representing less than two percent of all outstanding equity interest issued by a person that is a party to the transaction or solely by reason of that individual's position as a director or officer of a person that is a party to the transaction.

(3)This subsection shall not permit an investment that is prohibited by section 376.294.

(4)This subsection shall not apply to a transaction between an insurer and any of its subsidiaries or affiliates that is entered into in compliance with chapter 382, other than a transaction between an insurer and its officer or director.

2.An insurer may, without the prior written approval of the director make:

(1)Policy loans in accordance with the terms of the policy or contract and section 376.306;

(2)Advances to officers or directors for expenses reasonably expected to be incurred in the ordinary course of the insurer's business or guarantees associated with credit or charge cards issued or credit extended for the purpose of financing these expenses;

(3)Loans secured by the principal residence of an existing or new officer of the insurer made in connection with the officer's relocation at the insurer's request if the loans comply with the requirements of section 376.302 and the terms and conditions otherwise are the same as those generally available from unaffiliated third parties;

(4)Loans and advances to officers or directors made in compliance with state or federal law specifically related to the loans and advances by a regulated noninsurance subsidiary or affiliate of the insurer in the ordinary course of business and on terms no more favorable than available to other customers of the entity; and

(5)Secured loans to an existing or new officer of the insurer made in connection with the officer's relocation at the insurer's request, if the loans:

(a)Do not have a term exceeding two years;

(b)Are required to finance mortgage loans outstanding at the same time on the prior and new residences of the officer;

(c)Do not exceed an amount equal to the equity of the officer in the prior residence;

(d)Are required to be fully repaid upon the earlier of the end of the two-year period or the sale of the prior residence.

(L. 2007 S.B. 66)

376.395 - Definitions for group health conversion policy requirements.

As used in sections 376.395 to 376.404 the following terms shall mean:

(1)"Group policy", a group health insurance policy issued by an insurance company and a group contract issued by a health service corporation, a health maintenance organization or a similar corporation or organization;

(2)"Group policyholder", the entity purchasing the group policy from the insurer;

(3)"Individual policy" or "converted policy", an individual health insurance policy issued by an insurance company or an individual health services contract issued by a health service corporation, a health maintenance organization or a similar corporation or organization;

(4)"Insurer", the entity issuing a group policy or an individual or converted policy;

(5)"Medicare", Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded;

(6)"Premium", any premium or other consideration payable for coverage under a group or individual policy.

(L. 1981 S.B. 58 § 1)

Effective 1-01-83

376.791 - Portion of section 376.777 not applicable to individual health insurance coverage.

1.The provisions of subdivisions (4) and (5) of subsection 2 of section 376.777 shall not apply to any individual health insurance coverage.The term "individual health insurance coverage" shall have the meaning assigned to it in section 376.450.

2.The director shall promulgate rules and regulations to implement and administer the provisions of this section prior to January 1, 2016.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2015, shall be invalid and void.

(L. 2015 H.B. 709)

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

1.This section applies to the hospital and medical expense provisions of an accident or sickness insurance policy.

2.If a policy provides that coverage of a dependent child terminates upon attainment of the limiting age for dependent children specified in the policy, such policy so long as it remains in force shall be deemed to provide that attainment of such limiting age does not operate to terminate the hospital and medical coverage of such child while the child is and continues to be both incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the policyholder for support and maintenance.Proof of such incapacity and dependency must be furnished to the insurer by the policyholder at least thirty-one days after the child's attainment of the limiting age.The insurer may require at reasonable intervals during the two years following the child's attainment of the limiting age subsequent proof of the child's disability and dependency.After such two-year period, the insurer may require subsequent proof not more than once each year.

3.If a policy provides that coverage of a dependent child terminates upon attainment of the limiting age for dependent children specified in the policy, such policy, so long as it remains in force until the dependent child attains the limiting age, shall remain in force at the option of the policyholder.The policyholder's election for continued coverage under this section shall be furnished by the policyholder to the insurer within thirty-one days after the child's attainment of the limiting age.As used in this subsection, a dependent child is a person who:

(1)Is a resident of this state;

(2)Is unmarried and no more than twenty-five years of age; and

(3)Not provided coverage as a named subscriber, insured, enrollee, or covered person under any group or individual health benefit plan, or entitled to benefits under Title XVIII of the Social Security Act, P.L. 89-97, 42 U.S.C. Section 1395, et seq.

4.This section applies only to policies delivered or issued for delivery in this state more than one hundred twenty days after October 13, 1967.

(L. 1967 p. 577, A.L. 2007 H.B. 818)

Effective 1-01-08

376.1124 - Rescinding of a long-term care policy, permitted when — grounds for contesting — no field issuance, when.

1.For a policy or certificate that has been in force less than six months, an insurer may rescind a long-term care insurance policy or certificate, or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage.

2.For a policy or certificate that has been in force for at least six months but less than two years, an insurer may rescind a long-term care insurance policy or certificate, or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance of coverage and which pertains to the conditions for which benefits are sought.

3.After a policy or certificate has been in force for two years, such policy or certificate is not contestable upon the grounds of misrepresentation alone.Such policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.

4.No long-term care insurance policy or certificate shall be field issued based on medical or health status.For purposes of this subsection, "field issued" means a policy or certificate issued by an agent or third-party administrator pursuant to the underwriting authority granted to the agent or third-party administrator by an insurer.

5.If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments shall not be recovered by the insurer if such policy or certificate is rescinded.

6.In the event of the death of the insured, this section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care.In this situation, the remaining death benefits under these such policies shall be governed by the contestability provisions otherwise applicable in the policy to life insurance benefits.In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care.

(L. 2002 H.B. 1568 merged with S.B. 1009)

376.1520 - Notice of changes.

Each discount medical plan organization required to be registered pursuant to this section shall provide the director at least thirty days' advance notice of any change in the discount medical plan organization's name, address, principal business address, or mailing address.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.989 - No liability, criminal or civil, for participation in pool by members.

Neither the participation in the pool as members, the establishment of rates, forms or procedures, nor any other joint or collective action required or permitted by the provisions of sections 376.960 to 376.989 shall be the basis of any legal action, criminal or civil liability or penalty against the pool, the pool administrator, the board or any of its members, or pool employees, contractors, or consultants, or any of its members.

(L. 1990 H.B. 998 § 7, A.L. 2007 H.B. 818)

Effective 1-01-08

376.562 - Charitable, benevolent, educational and religious organizations may be beneficiary or owner of policy, life insurance, when — fraud or coercion, exception.

It shall be lawful for any charitable, benevolent, educational or religious institution qualified pursuant to section 501(c)(3) of the Internal Revenue Code, as amended, to solicit, procure and enforce, in the absence of any fraud or coercion, the payment of proceeds of:

(1)An assignment or designation as beneficiary, a gift or assignment of an interest in life insurance in the life of a donor or assignor; or

(2)An ownership of an interest in life insurance on the life of an insured if the charitable, benevolent, educational or religious institution has obtained the consent of the person whose life is being insured, as required by section 376.531.

(L. 1992 H.B. 1574 § 376.560, A.L. 1997 H.B. 622)

376.1130 - Rulemaking authority.

1.The director shall promulgate reasonable rules to promote premium adequacy and to provide alternatives for the policyholder in the event of substantial rate increases, and to establish minimum standards for marketing practices, agent testing, penalties, and reporting practices for long-term care insurance.

2.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in sections 376.1121 to 376.1130 shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2002, shall be invalid and void.

(L. 2002 H.B. 1568 merged with S.B. 1009)

376.1030 - Agreement of employer to pay benefits, requirements, form — copy filed with director — no excuse from liability.

1.A multiple employer self-insured health plan shall require each employer, as a condition of participation in the plan, to execute an agreement by which the employer agrees personally to pay all claims for benefits covered under the plan which are incurred by his or its covered employees and their covered dependents, but which the plan or its stop-loss insurer has failed to pay.Such agreements shall be made on forms prescribed by the director and shall extend to all unpaid claims for benefits incurred by the employer's employees and their dependents during the time such employees and dependents were covered under the plan.

2.A clear and legible copy of each agreement executed by each participating employer shall be filed with the director by the plan as part of its application for a license.No license shall be issued unless copies of such agreements are filed.With respect to an employer who joins the plan after a license has been issued, the plan shall file a copy of the agreement executed by the employer within ten days after the employer joins the plan.

3.Neither failure of an employer to execute an agreement, nor failure of the plan to require such execution, shall excuse the employer from liability for unpaid claims incurred by covered employees and dependents.An employer shall be deemed to have notice of the requirements of this section, and upon joining the plan, the employer shall be deemed to have agreed to liability for unpaid claims of his covered employees and their dependents in the same manner as if an agreement had been executed.

(L. 1993 H.B. 709 § 34)

376.889 - Violations, penalty.

1.If the director determines that a person has engaged, is engaging in, or has taken a substantial step toward engaging in an act, practice or course of business constituting a violation of sections 376.850 to 376.890 or a rule adopted or order issued pursuant thereto, or that a person has materially aided or is materially aiding an act, practice, omission, or course of business constituting a violation of sections 376.850 to 376.890 or a rule adopted or order issued pursuant thereto, the director may issue such administrative orders as authorized under section 374.046. A violation of any of these sections is a level two violation under section 374.049.

2.If the director believes that a person has engaged, is engaging in, or has taken a substantial step toward engaging in an act, practice or course of business constituting a violation of sections 376.850 to 376.890 or a rule adopted or order issued pursuant thereto, or that a person has materially aided or is materially aiding an act, practice, omission, or course of business constituting a violation of sections 376.850 to 376.890 or a rule adopted or order issued pursuant thereto, the director may maintain a civil action for relief authorized under section 374.048. A violation of any of these sections is a level two violation under section 374.049.

(L. 1989 H.B. 615 & 563, A.L. 1992 H.B. 1574, A.L. 2007 S.B. 66)

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

1.Every policy issued by a health carrier, as defined in section 376.1350, shall provide coverage for chiropractic care delivered by a licensed chiropractor acting within the scope of his or her practice as defined in chapter 331.The coverage shall include initial diagnosis and clinically appropriate and medically necessary services and supplies required to treat the diagnosed disorder, subject to the terms and conditions of the policy.The coverage may be limited to chiropractors within the health carrier's network, and nothing in this section shall be construed to require a health carrier to contract with a chiropractor not in the carrier's network nor shall a carrier be required to reimburse for services rendered by a nonnetwork chiropractor unless prior approval has been obtained from the carrier by the enrollee.An enrollee may access chiropractic care within the network for a total of twenty-six chiropractic physician office visits per policy period, but may be required to provide the health carrier with notice prior to any additional visit as a condition of coverage.A health carrier may require prior authorization or notification before any follow-up diagnostic tests are ordered by a chiropractor or for any office visits for treatment in excess of twenty-six in any policy period.The certificate of coverage for any health benefit plan issued by a health carrier shall clearly state the availability of chiropractic coverage under the policy and any limitations, conditions, and exclusions.

2.A health benefit plan shall provide coverage for treatment of a chiropractic care condition and shall not establish any rate, term, or condition that places a greater financial burden on an insured for access to treatment for a chiropractic care condition than for access to treatment for another physical health condition.

3.The provisions of this section shall not apply to any health plan or contract that is individually underwritten.

4.The provisions of this section shall not apply to benefits provided under the Medicaid program.

5.The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months' or less duration, or any other similar supplemental policy.

(L. 2003 H.B. 121 §§ 376.1230 and 376.1231)

376.685 - Optometrists, health insurance plans not to limit fees charged unless reimbursed by plan — requirements — definitions.

1.No agreement between a health carrier or other insurer that writes vision insurance and an optometrist for the provision of vision services on a preferred or in-network basis to plan members or insurance subscribers in connection with coverage under a stand-alone vision plan, medical plan, health benefit plan, or health insurance policy shall require that an optometrist provide optometric or ophthalmic services or materials at a fee limited or set by the plan or health carrier unless the services or materials are reimbursed as covered services under the contract.

2.No provider shall charge more for services or materials that are not covered under a health benefit or vision plan than his or her usual and customary rate for those services or materials.

3.Reimbursement paid by the health benefit or vision plan for covered services or materials shall be reasonable and shall not provide nominal reimbursement in order to claim that services or materials are covered services.No health carrier shall provide de minimis reimbursement or coverage in an effort to avoid the requirements of this section.

4.No vision care insurance policy or vision care discount plan that provides covered services for materials shall have the effect, directly or indirectly, of limiting the choice of sources and suppliers of materials by a patient of a vision care provider.

5.Notwithstanding any other provisions in this section, nothing shall prohibit an optometrist from contractually opting in to an optometric services discount plan sponsored by a stand-alone vision plan, medical plan, health benefit plan, or health insurance policy.

6.For the purposes of this section, the following terms shall mean:

(1)"Covered services", optometric or ophthalmic services or materials for which reimbursement from the health benefit or vision plan is provided for by an enrollee's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, alternative benefit payments, or frequency limitations;

(2)"Health benefit plan", the same meaning as such term is defined in section 376.1350;

(3)"Health carrier", the same meaning as such term is defined in section 376.1350;

(4)"Materials", includes, but is not limited to, lenses, frames, devices containing lenses, prisms, lens treatment and coatings, contact lenses, orthoptics, vision training devices, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa;

(5)"Optometric services", any services within the scope of optometric practice under chapter 336;

(6)"Vision plan", any policy, contract of insurance, or discount plan issued by a health carrier, health benefit plan, or company which provides coverage or a discount for optometric or ophthalmic services or materials.

(L. 2016 H.B. 1682)

376.785 - What does not constitute waiver of defenses.

The acknowledgment by an insurer of the receipt of notice given under any policy covered by sections 376.770 to 376.800, or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.

(L. 1959 H.B. 252 § 7)

376.381 - Health insurance products, department duties.

Notwithstanding any other provision of law to the contrary, the department of insurance, financial institutions and professional registration shall exercise its authority and responsibility over health insurance product form filings, consumer complaints, and investigations into compliance with state law, regardless as to how a health insurance product may be sold or marketed in this state or to residents of this state.

(L. 2013 S.B. 262 § 1)

Effective 7-12-13

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

1.Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a health services corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements, to the extent not preempted by federal law, and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed in this state on or after January 1, 1998, shall offer coverage for all physician-prescribed medically appropriate and necessary equipment, supplies and self-management training used in the management and treatment of diabetes.Coverage shall include persons with gestational, type I or type II diabetes.

2.Health care services required by this section shall not be subject to any greater deductible or co-payment than any other health care service provided by the policy, contract or plan.

3.No entity enumerated in subsection 1 of this section may reduce or eliminate coverage due to the requirements of this section.

4.Nothing in this section shall apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, or other limited benefit health insurance policies.

(L. 1997 S.B. 24)

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

1.All group health insurance policies providing coverage on an expense-incurred basis, all group service or indemnity contracts issued by a not-for-profit health service corporation, all self-insured group health benefit plans of any type or description, and all such health plans or policies that are individually underwritten or provide for such coverage for specific individuals and the members of their families as nongroup policies, which provide for hospital treatment, shall offer coverage for the necessary care and treatment of 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.All Missouri group contracts issued or renewed on or after December 31, 1984, shall be subject to this section.Notwithstanding any construction or relationship of interdependent contracts or plans affecting coverage and payment of reimbursement prerequisites under the policy or contract, coverage required by this section shall be included in the policy or contract and payment provided as for other coverage in the same policy or contract.

2.The offer of benefits under subsection 1 of this section shall be in writing and may be rejected by the individual or group policyholder.

3.Nothing in this section shall prohibit the insurance company or not-for-profit health service corporation from including any coverage for loss or impairment of speech, language or hearing as standard coverage in their policies or contracts, but same shall not contain terms contrary to this section.

4.The phrase "loss or impairment of speech or hearing" shall include those communicative disorders generally treated by a speech pathologist, audiologist or speech/language pathologist licensed by the state board of healing arts or certified by the American Speech-Language and Hearing Association (ASHA), or both, and which fall within the scope of his or her license or certification.

5.Any provision in a health insurance policy contrary to or in conflict with the provisions of this section shall, to the extent of the conflict, be void, but such invalidity shall not offset the validity of the other provisions of such policy.

6.The department of insurance, financial institutions and professional registration may issue rules necessary to carry out the provisions of this section.No rule or portion of a rule promulgated under the authority of this section shall become effective unless it has been promulgated pursuant to the provisions of section 536.024.

(L. 1984 S.B. 522 § 1, A.L. 1995 S.B. 3)

376.1369 - Certification of compliance, when.

A health carrier shall annually provide a written certification to the director that the utilization review program of the health carrier or its designee complies with all applicable state and federal laws establishing confidentiality and reporting requirements.

(L. 1997 H.B. 335)

376.1530 - Denial and refusal to issue registrations, when.

1.The director may deny a registration to an applicant or refuse to renew, suspend, or revoke the registration of a registrant if the applicant or registrant, or an officer, director, or employee of the applicant or registrant:

(1)Makes a material misstatement or misrepresentation in an application for registration;

(2)Fraudulently or deceptively obtains or attempts to obtain a registration for the applicant or registrant or for another;

(3)Has advertised, merchandised or attempted to merchandise its services in such a manner as to misrepresent its services or capacity for service or has engaged in deceptive, misleading or unfair practices with respect to advertising or merchandising;

(4)In connection with the advertisement, offer, sale or administration of a health care discount program, makes any untrue statement of material fact, conceals any material fact, uses any deception or commits fraud or engages in any dishonest activity;

(5)Is not fulfilling its obligations as a discount medical plan organization;

(6)Does not have the minimum net worth as required by sections 376.1500 to 376.1532; or

(7)Violates any provision of sections 376.1500 to 376.1532, or any law or regulation of this state relating to insurance or the provision of medical care.

2.If the director has cause to believe that grounds for the suspension or revocation of a registration exist, the director shall notify the discount medical plan organization in writing, specifically stating the grounds for suspension or revocation, and shall provide opportunity for a hearing on the matter before the director.

3.When the registration of a discount medical plan organization is surrendered or revoked, such organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs transacted under the registration.The organization may not engage in any further advertising, solicitation, collecting of fees, or renewal of contracts.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.1361 - Documented clinical review criteria used in a utilization program — medical director qualifications — compensation of utilization review services.

1.A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy.A health carrier may develop its own clinical review criteria, or it may purchase or license clinical review criteria from qualified vendors.A health carrier shall make available its clinical review criteria upon request by either the director of the department of health and senior services or the director of the department of insurance, financial institutions and professional registration.

2.Any medical director who administers the utilization review program or oversees the review decisions shall be a qualified health care professional licensed in the state of Missouri.A licensed clinical peer shall evaluate the clinical appropriateness of adverse determinations.

3.A health carrier shall issue utilization review decisions in a timely manner pursuant to the requirements of sections 376.1363, 376.1365 and 376.1367.A health carrier shall obtain all information required to make a utilization review decision, including pertinent clinical information.A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria consistently.

4.A health carrier's data systems shall be sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively.

5.If a health carrier delegates any utilization review activities to a utilization review organization, the health carrier shall maintain adequate oversight, which shall include:

(1)A written description of the utilization review organization's activities and responsibilities, including reporting requirements;

(2)Evidence of formal approval of the utilization review organization program by the health carrier; and

(3)A process by which the health carrier evaluates the performance of the utilization review organization.

6.The health carrier shall coordinate the utilization review program with other medical management activities conducted by the carrier, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for accessing member satisfaction and risk management.

7.A health carrier shall provide enrollees and participating providers with timely access to its review staff by a toll-free number.

8.When conducting utilization review, the health carrier shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency and duration of services.

9.Compensation to persons providing utilization review services for a health carrier shall not contain direct or indirect incentives for such persons to make medically inappropriate review decisions.Compensation to any such persons may not be directly or indirectly based on the quantity or type of adverse determinations rendered.

10.A health carrier shall permit enrollees or a provider on behalf of an enrollee to appeal for the coverage of medically necessary pharmaceutical prescriptions and durable medical equipment as part of the health carriers' utilization review process.

11.(1)This subsection shall apply to:

(a)Any health benefit plan that is issued, amended, delivered or renewed on or after January 1, 1998, and provides coverage for drugs; or

(b)Any person making a determination regarding payment or reimbursement for a prescription drug pursuant to such plan.

(2)A health benefit plan that provides coverage for drugs shall provide coverage for any drug prescribed to treat an indication so long as the drug has been approved by the FDA for at least one indication, if the drug is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature and deemed medically appropriate.

(3)This section shall not be construed to require coverage for a drug when the FDA has determined its use to be contraindicated for treatment of the current indication.

(4)A drug use that is covered pursuant to subsection 1 of this section shall not be denied coverage based on a "medical necessity" requirement except for a reason that is unrelated to the legal status of the drug use.

(5)Any drug or service furnished in a research trial, if the sponsor of the research trial furnishes such drug or service without charge to any participant in the research trial, shall not be subject to coverage pursuant to subsection 1 of this section.

(6)Nothing in this section shall require payment for nonformulary drugs, except that the state may exclude or otherwise restrict coverage of a covered outpatient drug from Medicaid programs as specified in the Social Security Act, Section 1927(d)(1)(B).

12.A carrier shall issue a confirmation number to an enrollee when the health carrier, acting through a participating provider or other authorized representative, authorizes the provision of health care services.

13.If an authorized representative of a health carrier authorizes the provision of health care services, the health carrier shall not subsequently retract its authorization after the health care services have been provided, or reduce payment for an item or service furnished in reliance on approval, unless

(1)Such authorization is based on a material misrepresentation or omission about the treated person's health condition or the cause of the health condition; or

(2)The health benefit plan terminates before the health care services are provided; or

(3)The covered person's coverage under the health benefit plan terminates before the health care services are provided.

(L. 1997 H.B. 335)

376.962 - Plan of operation to be submitted by board — effective when — failure to submit, director's duty to develop rules — plan content — amendments, procedure.

1.The board of directors on behalf of the pool shall submit to the director a plan of operation for the pool and any amendments thereto necessary or suitable to assure the fair, reasonable and equitable administration of the pool.After notice and hearing, the director shall approve the plan of operation, provided it is determined to be suitable to assure the fair, reasonable and equitable administration of the pool, and it provides for the sharing of pool gains or losses on an equitable proportionate basis.The plan of operation shall become effective upon approval in writing by the director consistent with the date on which the coverage under sections 376.960 to 376.989 becomes available.If the pool fails to submit a suitable plan of operation within one hundred eighty days after the appointment of the board of directors, or at any time thereafter fails to submit suitable amendments to the plan, the director shall, after notice and hearing, adopt and promulgate such reasonable rules as are necessary or advisable to effectuate the provisions of this section.Such rules shall continue in force until modified by the director or superseded by a plan submitted by the pool and approved by the director.

2.In its plan, the board of directors of the pool shall:

(1)Establish procedures for the handling and accounting of assets and moneys of the pool;

(2)Select an administering insurer or third-party administrator in accordance with section 376.968;

(3)Establish procedures for filling vacancies on the board of directors; and

(4)Establish procedures for the collection of assessments from all members to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made.The level of payments shall be established by the board pursuant to the provisions of section 376.973.Assessment shall occur at the end of each calendar year and shall be due and payable within thirty days of receipt of the assessment notice.

3.On or before September 1, 2013, the board shall submit the amendments to the plan of operation as are necessary or suitable to ensure a reasonable transition period to allow for the termination of issuance of policies by the pool.

4.The amendments to the plan of operation submitted by the board shall include all of the requirements outlined in subsection 2 of this section and shall address the transition of individuals covered under the pool to alternative health insurance coverage as it is available after January 1, 2014.The plan of operation shall also address procedures for finalizing the financial matters of the pool, including assessments, claims expenses, and other matters identified in subsection 2 of this section.

5.The director shall review the plan of operation submitted under subsection 3 of this section and shall promulgate rules to effectuate the transitional plan of operation.Such rules shall be effective no later than October 1, 2013.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2013, shall be invalid and void.

(L. 1990 H.B. 998 § 2 subsecs. 4, 5, A.L. 2013 S.B. 262)

376.733 - Assignment of rights to association by persons receiving benefits, when — subrogation rights.

1.Any person receiving benefits under sections 376.715 to 376.758 shall be deemed to have assigned the rights under, and any causes of action against any person for losses arising under, resulting from, or otherwise relating to, the covered policy or contract to the association to the extent of the benefits received because of the provisions of sections 376.715 to 376.758, whether the benefits are payments of or on account of contractual obligations, continuation of coverage or provision of substitute or alternative policies, contracts, or coverages.The association may require an assignment to it of such rights and cause of action by any enrollee, payee, policy or contract owner, beneficiary, insured or annuitant as a condition precedent to the receipt of any right or benefits conferred by sections 376.715 to 376.758 upon such person.

2.The subrogation rights of the association under this section have the same priority against the assets of the impaired or insolvent insurer as that possessed by the person entitled to receive benefits under sections 376.715 to 376.758.

3.In addition to subsections 1 and 2 of this section, the association shall have all common law rights of subrogation and any other equitable or legal remedy which would have been available to the impaired or insolvent insurer or owner, beneficiary, enrollee, or payee of a policy or contract with respect to such policy or contracts, including, without limitation in the case of a structured settlement annuity, any rights of the owner, beneficiary, or payee of the annuity, to the extent of benefits received under sections 376.715 to 376.758, against a person, originally or by succession, responsible for the losses arising from the personal injury relating to the annuity or payment thereof, excepting any such person responsible solely by reason of serving as an assignee in respect of a qualified assignment under Section 130 of the Internal Revenue Code of 1986, as amended.

(L. 1988 S.B. 430 § 13, A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

376.1186 - State-based health benefit exchanges prohibited without statutory authority — executive order to establish prohibited — state agency restrictions — taxpayer standing — definitions.

1.No state-based health benefit exchange may be established, created, or operated within this state in order to implement Section 1311 of the federal health care act, 42 U.S.C. Section 18031, or any other provision of the federal health care act that relates to the creation and operation of a state-based health benefit exchange, unless the authority to create or operate such an exchange is enacted into law through:

(1)A bill as prescribed by Article III of the Missouri Constitution;

(2)An initiative petition as prescribed by Article III, Section 50 of the Missouri Constitution; or

(3)A referendum as prescribed by Article III, Section 52(a) of the Missouri Constitution.

2.In no case shall the authority for establishing, administering, or operating a state-based health benefit exchange in Missouri be based upon an executive order issued by the governor of Missouri.

3.No department, agency, instrumentality or political subdivision of the state of Missouri shall establish any program, promulgate any rule, policy, guideline or plan or change any program, rule, policy or guideline to implement, establish, create, administer or otherwise operate a state-based health benefit exchange described in the federal health care act unless such department, agency, instrumentality or political subdivision has received statutory authority to do so in a manner consistent with subsection 1 of this section.No department, agency, instrumentality or political subdivision of the state of Missouri shall act as an eligible entity as described in Section 1311(f)(3)(B) of the federal health care act to perform one or more of the responsibilities of a state-based health benefit exchange unless authorized by statute or a regulation validly promulgated pursuant to such statute.

4.No department, agency, instrumentality, or political subdivision of this state shall apply for, accept or expend federal moneys related to the creation, implementation or operation of a state-based health benefit exchange or a federally facilitated health benefit exchange unless such acceptance or expenditure is authorized by statute or an appropriations bill.

5.No department, agency, instrumentality, political subdivision, public officer or employee of this state shall enter into any agreement or any obligation to establish, administer, or operate a federally facilitated health benefit exchange described in Section 1321(c)(1) of the federal health care act unless such department, agency, instrumentality, political subdivision, public officer or employee of this state has received statutory authority to enter into such agreements or obligations.No department, agency, instrumentality, political subdivision, public officer or employee of this state shall provide assistance or resources of any kind to any department, agency, public official, employee or agent of the federal government related to the creation or operation of a federally facilitated health benefit exchange unless such assistance or resources are authorized by state statute or a regulation promulgated thereto or such assistance or resources are specifically required by federal law.

6.Any taxpayer of this state or any member of the general assembly shall have standing to bring suit against the state of Missouri or any official, department, division, agency, or political subdivision of this state which is in violation of this section in any court with jurisdiction to enforce the provisions of this section.The court shall award attorney's fees, court costs, and all reasonable expenses incurred by the taxpayer or member of the general assembly if the court finds that the provisions of this section have been violated.Such attorney's fees, court costs, and reasonable expenses shall be paid from funds appropriated to the department, division, agency, or any political subdivision of this state determined to have violated, in whole or in part, the provisions of this section.In no case shall the award of attorney's fees, court costs, or reasonable expenses be paid from the legal defense fund, nor shall any department, division, agency, or political subdivision of this state request, or be granted, additional appropriations in order to satisfy an award made under this section.

7.As used in this section, the term "federal health care act" shall mean the federal Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and any amendments thereto, or regulations or guidance issued under such federal acts.

8.As used in this section, the term "state-based health benefit exchange" means a governmental agency or nonprofit entity established by the state of Missouri and not the federal government that meets the applicable requirements of Section 1311 of the federal health care act and regulations promulgated thereto and makes qualified health care plans available to qualified individuals and qualified employers.The term "state-based health benefit exchange" includes regional or other interstate exchanges and subsidiary exchanges as described in Section 1311(f)(1) and (2) of the federal health care act.The term "federally facilitated health benefit exchange" means a health benefit exchange established and operated by the Secretary of Health and Human Services under Section 1321(c)(1) of the federal health care act, either directly or through agreement with a not-for-profit entity.

(L. 2012 S.B 464 Adopted by Referendum, Proposition E, November 6, 2012)

376.789 - Definition of actual charge and actual fee.

1.(1)This section applies to an individual or a group specified disease insurance policy issued to any person that contains the terms "actual charge" or "actual fee" without containing an express definition of the term.

(2)"Actual charge" or "actual fee" when used in an individual specified disease insurance policy in connection with the benefits payable for services rendered by a health care provider or other designated person or entity means the amount the health care provider or other designated person or entity:

(a)Agrees to accept under a network or other participation agreement with the health insurer, third-party administrator, or other third-party payor, or other person, including the insured, as payment in full for the treatment, goods, or services provided to the insured; or

(b)Agrees, or as obligated by operation of law, to accept as payment in full for the treatment, goods, or services provided to the insured under a provider, participation, or supplier agreement under Medicare, Medicaid, or any other government-administered health care program where the insured is covered or reimbursed by this program.

(3)"Payment in full" includes the actual charge or actual fee that was actually paid for the health care provider's treatment, goods, or services on behalf of the insured by Medicare, Medicaid, any other government-administered health care program, any other health insurer, thirty-party administrator, or other third-party payor and, where applicable, any remaining portion of the actual charge or actual fee that was applied or assessed against the insured by Medicare, Medicaid, any other government-administered health care program, any other health insurer, third-party administrator, or other third-party payor for the applicable deductions, coinsurance requirements, or co-pay requirements.

(4)If paragraphs (a) and (b) of subdivision (2) of this subsection apply, the actual charge or actual fee shall be the lesser of the amounts determined under such paragraphs.

2.Notwithstanding any other provision of law, after August 28, 2009, an insurer or issuer of an individual or group specified disease insurance policy shall not pay a claim of benefit under the applicable policy in an amount in excess of the actual charge or actual fee as defined in this section.

(L. 2009 H.B. 481)

376.433 - Self-insurance plans for health care, public entities — subject to Medicaid rights, obligations, and remedies.

1.Any public entity which provides, furnishes, or pays for hospital, medical, surgical, or other health care services under a plan of self-insurance to an employee or to any other person covered under the public entity's plan of self-insurance shall have the same rights and obligations, and be subject to the same remedies, as the department of social services has with Medicaid, as provided in section 208.215.

2.As used in this section, the term "public entity" shall have the same meaning ascribed to it in section 107.170.

3.This section shall not apply to limited benefit supplemental health insurance policies paid for entirely by an employee of the public entity.

(L. 2004 H.B. 1233)

376.1065 - Official notification communications, contracting entity requirements.

1.As used in this section, the following terms shall mean:

(1)"Contracting entity", any health carrier, as such term is defined in section 376.1350, subject to the jurisdiction of the department engaged in the act of contracting with providers for the delivery of dental services, or the selling or assigning of dental network plans to other entities under the jurisdiction of the department;

(2)"Department", the department of insurance, financial institutions and professional registration;

(3)"Official notification", written communication by a provider or participating provider to a contracting entity describing such provider's or participating provider's change in contact information or participation status with the contracting entity;

(4)"Participating provider", a provider who has an agreement with a contracting entity to provide dental services with an expectation of receiving payment, other than coinsurance, co-payments, or deductibles, directly or indirectly from such contracting entity;

(5)"Provider", any person licensed under chapter 332.

2.A contracting entity shall, upon official notification, make changes contained in the official notification to their electronic provider material and their next edition of paper material made available to plan members or other potential plan members.

3.The department, when determining the result of a market conduct examination under sections 374.202 to 374.207, shall consider violations of this section by a contracting entity.

(L. 2018 S.B. 982)

376.1082 - Records maintained by administrator for insurer — director may examine records — records owned by insurer, transfer allowed, when.

1.Every administrator shall maintain and make available to the insurer complete books and records of all transactions performed on behalf of the insurer.The books and records shall be maintained in accordance with prudent standards of insurance record keeping and shall be maintained for a period of not less than five years from the date of their creation.

2.The director shall have access to books and records maintained by an administrator for the purposes of examination, audit and inspection.Any trade secrets contained in such books and records, including the identity and addresses of policyholders and certificate holders, shall be kept confidential, except that the director may use such information in any proceeding instituted against the administrator.Examinations shall be conducted pursuant to sections 374.160, 374.162, 374.190, 374.202 to 374.207 and 374.220.

3.The insurer shall own the records generated by the administrator pertaining to the insurer; however, the administrator shall retain the right to continuing access to books and records to permit the administrator to fulfill all of its contractual obligations to insured parties, claimants, and the insurer.

4.In the event the insurer and the administrator cancel their agreement, notwithstanding the provisions of subsection 1 of this section, the administrator may, by written agreement with the insurer, transfer all records to a new administrator rather than retain them for five years.In such cases, the new administrator shall acknowledge, in writing, that he is responsible for retaining the records of the prior administrator as required in subsection 1 of this section.

(L. 1993 H.B. 709 § 44)

376.966 - No employee to lose coverage by enrolling in pool — eligibility for pool coverage, ineligibility — medical underwriting considerations, notification required, when — expiration date.

1.No employee shall involuntarily lose his or her group coverage by decision of his or her employer on the grounds that such employee may subsequently enroll in the pool.The department shall have authority to promulgate rules and regulations to enforce this subsection.

2.Prior to January 1, 2014, the following individual persons shall be eligible for coverage under the pool if they are and continue to be residents of this state:

(1)An individual person who provides evidence of the following:

(a)A notice of rejection or refusal to issue substantially similar health insurance for health reasons by at least two insurers; or

(b)A refusal by an insurer to issue health insurance except at a rate exceeding the plan rate for substantially similar health insurance;

(2)A federally defined eligible individual who has not experienced a significant break in coverage;

(3)A trade act eligible individual;

(4)Each resident dependent of a person who is eligible for plan coverage;

(5)Any person, regardless of age, that can be claimed as a dependent of a trade act eligible individual on such trade act eligible individual's tax filing;

(6)Any person whose health insurance coverage is involuntarily terminated for any reason other than nonpayment of premium or fraud, and who is not otherwise ineligible under subdivision (4) of subsection 3 of this section.If application for pool coverage is made not later than sixty-three days after the involuntary termination, the effective date of the coverage shall be the date of termination of the previous coverage;

(7)Any person whose premiums for health insurance coverage have increased above the rate established by the board under paragraph (a) of subdivision (1) of subsection 3 of this section;

(8)Any person currently insured who would have qualified as a federally defined eligible individual or a trade act eligible individual between the effective date of the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 and the effective date of this act.

3.The following individual persons shall not be eligible for coverage under the pool:

(1)Persons who have, on the date of issue of coverage by the pool, or obtain coverage under health insurance or an insurance arrangement substantially similar to or more comprehensive than a plan policy, or would be eligible to have coverage if the person elected to obtain it, except that:

(a)This exclusion shall not apply to a person who has such coverage but whose premiums have increased to one hundred fifty percent to two hundred percent of rates established by the board as applicable for individual standard risks;

(b)A person may maintain other coverage for the period of time the person is satisfying any preexisting condition waiting period under a pool policy; and

(c)A person may maintain plan coverage for the period of time the person is satisfying a preexisting condition waiting period under another health insurance policy intended to replace the pool policy;

(2)Any person who is at the time of pool application receiving health care benefits under section 208.151;

(3)Any person having terminated coverage in the pool unless twelve months have elapsed since such termination, unless such person is a federally defined eligible individual;

(4)Any person on whose behalf the pool has paid out one million dollars in benefits;

(5)Inmates or residents of public institutions, unless such person is a federally defined eligible individual, and persons eligible for public programs;

(6)Any person whose medical condition which precludes other insurance coverage is directly due to alcohol or drug abuse or self-inflicted injury, unless such person is a federally defined eligible individual or a trade act eligible individual;

(7)Any person who is eligible for Medicare coverage.

4.Any person who ceases to meet the eligibility requirements of this section may be terminated at the end of such person's policy period.

5.If an insurer issues one or more of the following or takes any other action based wholly or partially on medical underwriting considerations which is likely to render any person eligible for pool coverage, the insurer shall notify all persons affected of the existence of the pool, as well as the eligibility requirements and methods of applying for pool coverage:

(1)A notice of rejection or cancellation of coverage;

(2)A notice of reduction or limitation of coverage, including restrictive riders, if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.

6.Coverage under the pool shall expire on January 1, 2014.

(L. 1990 H.B. 998 § 3, A.L. 2007 H.B. 818, A.L. 2009 H.B. 218, A.L. 2013 S.B. 262)

376.1365 - Reconsideration of an adverse determination, when.

1.In a case involving an initial determination or a concurrent review determination, a health carrier shall give the provider rendering the service an opportunity to request on behalf of the enrollee a reconsideration of an adverse determination by the reviewer making the adverse determination.

2.The reconsideration shall occur within one working day of the receipt of the request and shall be conducted between the provider rendering the service and the reviewer who made the adverse determination or a clinical peer designated by the reviewer if the reviewer who made the adverse determination is not available within one working day.

3.If the reconsideration process does not resolve the difference of opinion, the adverse determination may be appealed by the enrollee or the provider on behalf of the enrollee.Reconsideration is not a prerequisite to a standard appeal or an expedited appeal of an adverse determination.

(L. 1997 H.B. 335)

376.1382 - First- and second-level grievance review for managed care plans, first-level procedures.

1.A health carrier that offers managed care plans shall establish a first-level and second-level grievance review process for its managed care plans.A grievance may be submitted by an enrollee, an enrollee's representative or a provider acting on behalf of an enrollee.

2.Upon receipt of a request for first-level grievance review, a health carrier shall:

(1)Acknowledge receipt in writing of the grievance within ten working days;

(2)Conduct a complete investigation of the grievance within twenty working days after receipt of a grievance, unless the investigation cannot be completed within this time.If the investigation cannot be completed within twenty working days after receipt of a grievance, the enrollee shall be notified in writing on or before the twentieth working day and the investigation shall be completed within thirty working days thereafter.The notice shall set forth with specificity the reasons for which additional time is needed for the investigation;

(3)Within five working days after the investigation is completed, have someone not involved in the circumstances giving rise to the grievance or its investigation decide upon the appropriate resolution of the grievance and notify the enrollee in writing of the health carrier's decision regarding the grievance and of the right to file an appeal for a second-level review.The notice shall explain the resolution of the grievance and the right to appeal in terms which are clear and specific;

(4)Within fifteen working days after the investigation is completed, notify the person who submitted the grievance of the carrier's resolution of said grievance.

(L. 1997 H.B. 335)

376.737 - Deferment of assessment, how, when — maximum assessment — refund of, when — members may increase premiums to cover assessments.

1.The association may abate or defer, in whole or in part, the assessment of a member insurer if, in the opinion of the board, payment of the assessment would endanger the ability of the member insurer to fulfill its contractual obligations.In the event an assessment against a member insurer is abated, or deferred in whole or in part, the amount by which such assessment is abated or deferred may be assessed against the other member insurers in a manner consistent with the basis for assessments set forth in this section.Once the conditions that caused a deferral have been removed or rectified, the member insurer shall pay all assessments that were deferred under a repayment plan approved by the association.

2.(1)Subject to the provisions of subdivision (2) of this subsection, the total of all assessments upon a member insurer for each account shall not in any one calendar year exceed two percent of such insurer's average annual premiums received in this state on the policies and contracts covered by the account during the three calendar years preceding the year in which the member insurer became an impaired or insolvent insurer.If the maximum assessment, together with the other assets of the association in any account, does not provide in any one year in the account an amount sufficient to carry out the responsibilities of the association, the necessary additional funds shall be assessed as soon thereafter as permitted by sections 376.715 to 376.758.

(2)If two or more assessments are made in one calendar year with respect to member insurers that become impaired or insolvent in different calendar years, the average annual premiums for purposes of the aggregate assessment percentage limitation referenced in subdivision (1) of this subsection shall be equal and limited to the higher of the three-year average annual premiums for the applicable account as calculated under this section.

3.The board may provide in the plan of operation a method of allocating funds among claims, whether relating to one or more impaired or insolvent insurers, when the maximum assessment will be insufficient to cover anticipated claims.

4.The board may, by an equitable method as established in the plan of operation, refund to member insurers, in proportion to the contribution of each member insurer to that account, the amount by which the assets of the account exceed the amount the board finds is necessary to carry out during the coming year the obligations of the association with regard to that account, including assets accruing from assignment, subrogation net realized gains and income from investments.A reasonable amount may be retained in any account to provide funds for the continuing expenses of the association and for future losses.

5.It shall be proper for any member insurer, in determining its premium rates and policy owner dividends as to any kind of insurance or health maintenance organization business within the scope of sections 376.715 to 376.758, to consider the amount reasonably necessary to meet its assessment obligations under the provisions of sections 376.715 to 376.758.

(L. 1988 S.B. 430 §§ 17, 18, 19, A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

376.881 - Policy certificate front page to contain notice of right to return and receive premium refund.

Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason.Any refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.

(L. 1989 H.B. 615 & 563, A.L. 1992 H.B. 1574)

Effective 7-06-92

376.1210 - Maternity benefits, minimum hospital stays, exceptions — notice of benefits, contents — attending physician defined — rulemaking.

1.Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law, and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed in this state on or after January 1, 1997, and providing for maternity benefits, shall provide coverage for a minimum of forty-eight hours of inpatient care following a vaginal delivery and a minimum of ninety-six hours of inpatient care following a cesarean section for a mother and her newly born child in a hospital as defined in section 197.020 or any other health care facility licensed to provide obstetrical care under the provisions of chapter 197.

2.Notwithstanding the provisions of subsection 1 of this section, any entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law, and all managed health care delivery entities of any type or description that are delivered, issued for delivery, continued or renewed in this state on or after January 1, 1997, and providing for maternity benefits, may authorize a shorter length of hospital stay for services related to maternity and newborn care if:

(1)A shorter hospital stay meets with the approval of the attending physician after consulting with the mother.The physician's approval to discharge shall be made in accordance with the most current version of the "Guidelines for Perinatal Care" prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, or similar guidelines prepared by another nationally recognized medical organization; and

(2)The entity providing the individual or group health insurance policy provides coverage for post-discharge care to the mother and her newborn.

3.Post-discharge care shall consist of a minimum of two visits at least one of which shall be in the home, in accordance with accepted maternal and neonatal physical assessments, by a registered professional nurse with experience in maternal and child health nursing or a physician.The location and schedule of the post-discharge visits shall be determined by the attending physician.Services provided by the registered professional nurse or physician shall include, but not be limited to, physical assessment of the newborn and mother, parent education, assistance and training in breast or bottle feeding, education and services for complete childhood immunizations, the performance of any necessary and appropriate clinical tests and submission of a metabolic specimen satisfactory to the state laboratory.Such services shall be in accordance with the medical criteria outlined in the most current version of the "Guidelines for Perinatal Care" prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, or similar guidelines prepared by another nationally recognized medical organization.Any abnormality, in the condition of the mother or the child, observed by the nurse shall be reported to the attending physician as medically appropriate.

4.For the purposes of this section, "attending physician" shall include the attending obstetrician, pediatrician, or other physician attending the mother or newly born child.

5.Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description shall provide notice to policyholders, insured persons and participants regarding the coverage required by this section.Such notice shall be in writing and prominently positioned in the policy, certificate of coverage or summary plan description.

6.Such health care service shall not be subject to any greater deductible or co-payment than other similar health care services provided by the policy, contract or plan.

7.No insurer may provide financial disincentives to, or deselect, terminate the services of, require additional documentation from, require additional utilization review, or reduce payments to, or otherwise penalize the attending physician in retaliation solely for ordering care consistent with the provisions of this section.

8.The department of insurance, financial institutions and professional registration shall adopt rules and regulations to implement and enforce the provisions of this section.No rule or portion of a rule promulgated pursuant to this section shall become effective unless it has been promulgated pursuant to the provisions of section 536.024.

(L. 1996 H.B. 1069)

376.742 - Director, powers and duties.

1.In addition to the duties and powers enumerated elsewhere in sections 376.715 to 376.758, the director shall:

(1)Upon request of the board of directors, provide the association with a statement of the premiums in this and any other appropriate states for each member insurer;

(2)When an impairment is declared and the amount of the impairment is determined, serve a demand upon the impaired insurer to make good the impairment within a reasonable time.Notice to the impaired insurer shall constitute notice to its shareholders, if any.The failure of the impaired insurer to promptly comply with such demand shall not excuse the association from the performance of its powers and duties under the provisions of sections 376.715 to 376.758;

(3)In any liquidation or rehabilitation proceeding involving a domestic insurer, be appointed as the liquidator or rehabilitator.

2.The director may suspend or revoke, after notice and hearing, the certificate of authority to transact business in this state of any member insurer which fails to pay an assessment when due or fails to comply with the plan of operation.As an alternative the director may levy a forfeiture on any member insurer which fails to pay an assessment when due.Such forfeiture shall not exceed five percent of the unpaid assessment per month, but no forfeiture shall be less than one hundred dollars per month.

3.Any action of the board of directors or the association may be appealed to the director by any member insurer if such appeal is taken within sixty days of the action being appealed.If a member company is appealing an assessment, the amount assessed shall be paid to the association and available to meet association obligations during the pendency of an appeal.If the appeal on the assessment is upheld, the amount paid in error or excess shall be returned to the member company.Any final action or order of the director shall be subject to judicial review in a court of competent jurisdiction.

4.The liquidator, rehabilitator, or conservator of any impaired insurer may notify all interested persons of the effect of sections 376.715 to 376.758.

5.To aid in the detection and prevention of member insurer insolvencies or impairments, the director shall:

(1)Notify the commissioners of all the other states, territories of the United States and the District of Columbia when he takes any of the following actions against a member insurer:

(a)Revocation of license;

(b)Suspension of license; or

(c)Makes any formal order that such member insurer restricts its premium writing, obtain additional contributions to surplus, withdraw from the state, reinsure all or any part of its business, or increase capital, surplus, or any other account for the security of policy owners, contract owners, certificate holders, or creditors.

Such notice shall be mailed to all commissions within thirty days following the action taken or the date on which such action occurs;

(2)Report to the board of directors when he has taken any of the actions set forth in subdivision (1) of this subsection or has received a report from any other commissioner indicating that any such action has been taken in another state.Such report to the board of directors shall contain all significant details of the action taken or the report received from another commissioner;

(3)Report to the board of directors when he has reasonable cause to believe from any examination, whether completed or in process, of any member company that such company may be an impaired or insolvent insurer;

(4)Furnish to the board of directors the NAIC Insurer Regulatory Information Service (IRIS) ratios and listings of companies not included in the ratios developed by the National Association of Insurance Commissioners, and the board may use the information contained therein in carrying out its duties and responsibilities under this section.Such report and the information contained therein shall be kept confidential by the board of directors until such time as made public by the director or other lawful authority.

6.The director may seek the advice and recommendations of the board of directors concerning any matter affecting his duties and responsibilities regarding the financial condition of member insurers and health maintenance organizations seeking admission to transact insurance business in this state.

(L. 1988 S.B. 430 §§ 23, 24, A.L. 2018 H.B. 1690)

376.146 - Board of directors or trustees of mutual, membership qualifications, term of office.

1.The corporate powers of a mutual life insurance corporation shall be exercised by, and its business and affairs shall be controlled by, a board of directors or trustees composed of not less than three nor more than twenty-one natural persons who are policyholders or members of the corporation.The members of such board shall be at least eighteen years of age, and at least three members must be residents and citizens of this state.

2.In order to secure continuity of membership in its board of directors or trustees, the articles of incorporation of any mutual life insurance corporation may provide for division of the board into not more than three classes, as nearly equal in number as possible, and may fix the term of office for each class.

3.Unless such provision is made in the articles of incorporation, all directors and trustees shall be elected annually.

(L. 1957 p. 224 §§ 6, 7, A.L. 1976 S.B. 490)

376.1514 - Written agreement required, contents.

1.All providers offering medical services to members under a discount medical plan shall provide such services pursuant to a written agreement.The agreement may be entered into directly by the health care provider or by a health care provider network to which the provider belongs if the provider network has contracts with the health care provider that allow the provider network to contract on behalf of the health care provider.

2.A health care provider agreement shall provide the following:

(1)A description of the services and products to be provided at a discount;

(2)The amount or amounts of the discounts or, alternatively, a fee schedule which reflects the health care provider's discounted rates; and

(3)A provision that the health care provider will not charge members more than the discounted rates.

3.A health care provider agreement with a health care provider network shall require that the health care provider network have written agreements with its health care providers that:

(1)Contain the terms described in this subsection;

(2)Authorize the health care provider network to contract with the discount medical plan organization on behalf of the provider; and

(3)Require the network to maintain an up-to-date list of its contracted health care providers and to provide that list on a quarterly basis to the discount medical plan organization.

4.A health care provider agreement between a discount medical plan organization and an entity that contracts with a health care provider network shall require that the entity, in its contract with the health care provider network, require the health care provider network to have written agreements with its providers that comply with subsection 3 of this section.

5.The discount medical plan organization shall maintain a copy of each active health care provider agreement into which it has entered.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.2051 - Definitions.

As used in sections 376.2050 to 376.2053, the following terms mean:

(1)"Asymmetric conduct", an insurer's use of the death master file prior to January 1, 2018, in connection with searching for information regarding whether annuitants under the insurer's contracts might be deceased, but not in connection with whether the insureds or account owners under its policies or retained asset accounts might be deceased;

(2)"Contract", an annuity contract.The term contract shall not include an annuity used to fund an employment-based retirement plan or program in which the insurer does not perform the record-keeping services or the insurer is not committed by terms of the annuity contract to pay death benefits to the beneficiaries of specific plan participants;

(3)"Death master file", the United States Social Security Administration's death master file or any other database or service that is at least as comprehensive as the United States Social Security Administration's death master file for determining that a person has reportedly died;

(4)"Death master file match", a search of the death master file that results in a match of the Social Security number or the name and date of birth of an insured, annuitant, or retained asset account holder;

(5)"Policy", any policy or certificate of life insurance that provides a death benefit.The term policy shall not include:

(a)Any policy or certificate of life insurance that provides a death benefit under:

a.An employee benefit plan, subject to the Employee Retirement Income Security Act of 1974, as defined by 29 U.S.C. Section 1002(3), as periodically amended; or

b.Any federal employee benefit program;

(b)Any policy or certificate of life insurance that is used to fund a preneed funeral contract or arrangement;

(c)Any policy or certificate of credit life or accidental death insurance; or

(d)Any policy issued to a group master policyholder for which the insurer does not provide record-keeping services;

(6)"Record-keeping services", those circumstances under which the insurer has agreed with a group policy or contract customer to be responsible for obtaining, maintaining, and administering in its own or its agents' systems at least the following information about each individual insured under an insured's group insurance contract, or a line of coverage thereunder:

(a)Social Security number or name and date of birth;

(b)Beneficiary designation information;

(c)Coverage eligibility;

(d)Benefit amount; and

(e)Premium payment status;

(7)"Retained asset account", any mechanism whereby the settlement of proceeds payable under a policy or contract is accomplished by the insurer or an entity acting on behalf of the insurer depositing the proceeds into an account with check or draft writing privileges, where those proceeds are retained by the insurer or its agent, under a supplementary contract not involving annuity benefits other than death benefits.

(L. 2016 H.B. 2150)

376.1010 - Excess stop-loss coverage maintained by plan.

A multiple employer self-insured health plan shall maintain aggregate excess stop-loss coverage and individual excess stop-loss coverage provided by an insurer licensed by the state to write accident and health insurance on a direct basis.Aggregate excess stop-loss coverage shall include provisions to cover incurred, unpaid claim liability in the event of plan termination.The excess or stop-loss insurer shall bear the risk of coverage for any member employer of the plan that becomes insolvent with outstanding contributions due.In addition, the plan shall have a participating employer's fund in an amount at least equal to the point at which the excess or stop-loss insurer shall assume one hundred percent of additional liability.A plan shall submit its proposed excess or stop-loss insurance contract to the director at least thirty days prior to the proposed plan's effective date and at least thirty days subsequent to any renewal date.The director shall review the contract to determine whether it meets the standards established by sections 376.1000 to 376.1045 and respond within a thirty-day period.Any excess or stop-loss insurance plan must be noncancelable for a minimum term of two years.

(L. 1993 H.B. 709 § 26)

376.442 - Rules and regulations, procedure.

The department of insurance, financial institutions and professional registration is authorized to promulgate rules and regulations necessary to the administration or enforcement of the provisions of sections 376.431 to 376.442, pursuant to section 376.982 and chapter 536.

(L. 1985 H.B. 623, A.L. 1993 S.B. 52)

376.446 - Enrollee cost-sharing responsibilities, health carriers to provide timely information — exceptions.

1.Health carriers shall permit individuals to learn the amount of cost-sharing, including deductibles, copayments, and coinsurance, under the individual's health benefit plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider in a timely manner upon the request of the individual.At a minimum, such information shall be made available to such individual through an internet website and such other means for individuals without access to the internet.As used in this section, the terms "health carrier" and "health benefit plans" shall have the same meanings assigned to them in section 376.1350.

2.This section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, hospitalization-surgical care policy, short-term major medical policy of six months or less duration, or any other supplemental policy.

3.The provisions of subsections 1 and 2 shall become effective on January 1, 2014.

(L. 2011 S.B. 62 § 376.1190, subsecs. 1, 2, 4)

CROSS REFERENCE:

Nonseverability clause, 190.840

376.142 - Stock company may become mutual — procedure — policyholders' meeting — acquisition of stock.

1.Any domestic stock life insurance corporation, incorporated under a general law, may become a mutual life insurance corporation, and to that end may carry out a plan for the acquisition of shares of its capital stock, provided such plan

(1)Has been adopted by a vote of a majority of the directors of such corporation;

(2)Has been approved by a vote of stockholders representing a majority of the capital stock then outstanding at a meeting of stockholders called for the purpose;

(3)Has been approved by a majority of the policyholders voting at a meeting of policyholders called for the purpose, each of whom is insured in a sum of at least one thousand dollars and whose insurance shall then be in force and shall have been in force for at least one year prior to such meeting.

2.As used in this section, "policyholder" means the person insured under an individual policy of life insurance, and the person to whom any annuity or pure endowment is presently or prospectively payable by the terms of an individual annuity or pure endowment contract, except where the policy or contract declares some other person to be the owner or holder thereof, in which case such owner or policyholder shall be deemed the policyholder, and except in cases of assignment.In the case of any individual policy or contract insuring two or more persons jointly or in case the policy or contract declares two or more persons to be the owner, the persons insured or declared to be the owner are considered as one policyholder for the purposes of this section.In case any such policy or contract has been assigned by an assignment absolute on its face to an assignee other than the corporation, and such assignment has been filed at the principal office of the corporation at least thirty days prior to the date of the meeting of the policyholders, then such assignee shall be deemed a policyholder.Except as provided in this section, an assignee of a policy or contract shall not be deemed a policyholder.The reference in subdivision (3) of subsection 1 to insurance in the amount of one thousand dollars or more is deemed to include any annuity contract, the commuted value of which is one thousand dollars or more on the date of said meeting, and any pure endowment contract for the principal sum of one thousand dollars or more.

3.Notice of the meeting of policyholders shall be given by mailing such notice from the home office of the corporation at least thirty days prior to such meeting in a sealed envelope, postage prepaid, addressed to such policyholders at their last known post-office addresses, provided that personal delivery of such written notice to any policyholder evidenced by written receipt therefor may be substituted for mailing the same.The meeting shall be otherwise provided for and conducted in such manner as is provided in the mutualization plan, provided that policyholders may vote in person, by proxy, or by mail, and that all votes shall be cast by ballot on a uniform ballot furnished by the corporation.The director of the department of insurance, financial institutions and professional registration shall supervise and direct the method and procedure of said meeting and shall appoint an adequate number of inspectors to conduct the voting at said meeting who may determine all questions concerning the verification of the ballots, the ascertainment of the validity of such ballots, the qualifications of the voters, and the canvass of the vote, and who shall certify to the director and to the corporation the result of such proceedings, which shall be supervised by said inspectors in accordance with such rules and regulations as are prescribed by the director.All necessary expenses incurred by the director shall be paid by the corporation, as certified to by him.

4.Such plan may provide for the acquisition of the shares of the capital stock of the corporation, the price at which it is proposed to acquire the same, and the method of acquisition and mode of payment therefor, whether immediate or deferred.Before such a plan can be carried out, it must be submitted to the director of the department of insurance, financial institutions and professional registration and must be approved by him in writing; provided that every payment for the acquisition of any shares of the capital stock of such corporation, the purchase price of which is not fixed by such plan, shall be subject to the approval of the director, and provided that neither such plan, nor any such payment, shall be approved by the director unless at the time of such approvals, respectively, the corporation, after deducting the aggregate sum appropriated by such plan for the acquisition of any part or all of its capital stock, and, in the case of any payment not fixed by such plan and subject to separate approval by the director, after deducting also the amount of such payment, shall be possessed of assets sufficient to maintain its deposit made previously with the director, and such assets shall be not less than the entire liabilities of the corporation, including the net values of its outstanding contracts computed according to the standard adopted by the corporation under sections 376.010 to 376.670 and including all funds, contingent reserves, and surplus, except for such surplus as has been appropriated or paid under such plan.

(L. 1957 p. 224 § 1)

376.1510 - Prohibited acts.

A discount medical plan organization shall not:

(1)Use in its advertisements, marketing material, brochures, and discount cards the terms "health plan", "coverage", "co-pay", "co-payments", "preexisting conditions", "guaranteed issue", "premium", "PPO", "preferred provider organization", or other terms in a manner that could reasonably mislead a person to believe that the discount medical plan is health insurance;

(2)Except for hospital services, have restrictions on free access to plan providers including waiting periods and notification periods;

(3)Pay providers any fees for medical services;

(4)Collect or accept money from a member for payment to a provider for specific medical services furnished or to be furnished to the member, unless the organization is licensed by the director to act as an administrator; or

(5)Except as otherwise provided in sections 376.1500 to 376.1532, as a disclaimer of any relationship between discount medical plan benefits and insurance, or as a description of an insurance product connected with a discount medical plan, use in its advertisements, marketing material, brochures, and discount cards the term "insurance".

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.2008 - Consultation with licensed insurance producer, navigator to advise, when.

Upon contact with a person who acknowledges having existing health insurance coverage obtained through an insurance producer, a navigator shall advise the person to consult with a licensed insurance producer regarding coverage in the private market.

(L. 2013 S.B. 262)

Effective 7-12-13

(2016) Provision requiring state navigators to refer certain persons to consult with licensed insurance producers was preempted by the federal Patient Protection and Affordable Care Act.St. Louis Effort for AIDS v. Huff, 170 F.Supp.3d 1219 (W.D.Mo.).

376.746 - Records of association meetings to be kept — association deemed creditor of insolvent or impaired insured.

1.Nothing in sections 376.715 to 376.758 shall be construed to reduce the liability for unpaid assessments of the insureds of an impaired or insolvent insurer operating under a plan with assessment liability.

2.Records shall be kept of all negotiations and meetings in which the association or its representatives are involved to discuss the activities of the association in carrying out its powers and duties under the provisions of sections 376.715 to 376.758.Records of such negotiations or meetings shall be made public only upon the termination of a liquidation, rehabilitation, or conservation proceeding involving the impaired or insolvent insurer, upon the termination of the impairment or insolvency of the insurer, or upon the order of a court of competent jurisdiction.Nothing in this subsection shall limit the duty of the association to render a report of its activities under subsection 1 of section 376.750.

3.For the purpose of carrying out its obligations under the provisions of sections 376.715 to 376.758, the association is deemed to be a creditor of the impaired or insolvent insurer to the extent of assets attributable to covered policies reduced by any amounts to which the association is entitled as subrogee under the provisions of sections 376.715 to 376.758.Assets of the impaired or insolvent insurer attributable to covered policies shall be used to continue all covered policies and pay all contractual obligations of the impaired or insolvent insurer as required by sections 376.715 to 376.758.Assets attributable to covered policies or contracts, as used in this subsection, are that proportion of the assets which the reserves that should have been established for such policies or contracts bear to the reserves that should have been established for all policies of insurance or health benefit plans written by the impaired or insolvent insurer.

(L. 1988 S.B. 430 § 27, A.L. 2018 H.B. 1690)

376.2000 - Citation of law — definitions.

1.Sections 376.2000 to 376.2014 shall be known and may be cited as the "Health Insurance Marketplace Innovation Act of 2013".

2.As used in sections 376.2000 to 376.2014, the following terms mean:

(1)"Department", the department of insurance, financial institutions and professional registration;

(2)"Director", the director of the department of insurance, financial institutions and professional registration;

(3)"Exchange", any health benefit exchange established or operating in this state, including any exchange established or operated by the United States Department of Health and Human Services;

(4)"Navigator", a person that, for compensation, provides information or services in connection with eligibility, enrollment, or program specifications of any health benefit exchange operating in this state, including any person that is selected to perform the activities and duties identified in 42 U.S.C. 18031(i) in this state, any person who receives funds from the United States Department of Health and Human Services to perform any of the activities and duties identified in 42 U.S.C. 18031(i), or any other person certified by the United States Department of Health and Human Services, or a health benefit exchange operating in this state, to perform such defined or related duties irrespective of whether such person is identified as a navigator, certified application counselor, in-person assister, or other title.A "navigator" does not include any not-for-profit entity disseminating to a general audience public health information.

(L. 2013 S.B. 262)

Effective 7-12-13

376.1518 - Net worth to be maintained, amount.

1.Each discount medical plan organization registered pursuant to sections* 376.1500 to 376.1532 shall at all times maintain a net worth of at least one hundred fifty thousand dollars.

2.The director may not allow a registration unless the discount medical plan organization has a net worth of at least one hundred fifty thousand dollars.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

*Word "sections" appears twice in original rolls of S.B. 66, 2007.

376.1118 - Benefits funded by a life insurance death benefit acceleration, reports to policyholder required, content.

Any time a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder.Such report shall include:

(1)Any long-term care benefits paid out during the month;

(2)An explanation of any changes in the policy, such as death benefits or cash values, due to long-term care benefits being paid out; and

(3)The amount of long-term care benefits existing or remaining.

(L. 1990 S.B. 765 § 7)

Transferred 2002; formerly 376.958

376.717 - Coverages provided, persons covered — coverage not provided, when — maximum benefits allowable.

1.Sections 376.715 to 376.758 shall provide coverage for the policies and contracts specified in subsection 2 of this section:

(1)To persons who, regardless of where they reside, except for nonresident certificate holders under group policies or contracts, are the beneficiaries, assignees or payees, including health care providers rendering services covered under health insurance policies or certificates, of the persons covered under subdivision (2) of this subsection; and

(2)To persons who are owners of, certificate holders, or enrollees under such policies or contracts, other than structured settlement annuities, who:

(a)Are residents of this state; or

(b)Are not residents, but only under all of the following conditions:

a.The member insurers which issued such policies or contracts are domiciled in this state;

b.The persons are not eligible for coverage by an association in any other state due to the fact that the insurer or health maintenance organization was not licensed in such state at the time specified in such state's guaranty association law; and

c.The states in which the persons reside have associations similar to the association created by sections 376.715 to 376.758;

(3)For structured settlement annuities specified in subsection 2 of this section, subdivisions (1) and (2) of subsection 1 of this section shall not apply, and sections 376.715 to 376.758 shall, except as provided in subdivisions (4) and (5) of this subsection, provide coverage to a person who is a payee under a structured settlement annuity, or beneficiary of a payee if the payee is deceased, if the payee:

(a)Is a resident, regardless of where the contract owner resides; or

(b)Is not a resident, but only under both of the following conditions:

a.(i)The contract owner of the structured settlement annuity is a resident; or

(ii)The contract owner of the structure settlement annuity is not a resident, but:

i.The insurer that issued the structured settlement annuity is domiciled in this state; and

ii.The state in which the contract owner resides has an association similar to the association created under sections 376.715 to 376.758; and

b.Neither the payee or beneficiary nor the contract owner is eligible for coverage by the association of the state in which the payee or contract owner resides;

(4)Sections 376.715 to 376.758 shall not provide to a person who is a payee or beneficiary of a contract owner resident of this state, if the payee or beneficiary is afforded any coverage by such an association of another state;

(5)Sections 376.715 to 376.758 are intended to provide coverage to a person who is a resident of this state and, in special circumstances, to a nonresident.In order to avoid duplicate coverage, if a person who would otherwise receive coverage under sections 376.715 to 376.758 is provided coverage under the laws of any other state, the person shall not be provided coverage under sections 376.715 to 376.758.In determining the application of the provisions of this subdivision in situations where a person could be covered by such an association of more than one state, whether as an owner, payee, enrollee, beneficiary, or assignee, sections 376.715 to 376.758 shall be construed in conjunction with the other state's laws to result in coverage by only one association.

2.Sections 376.715 to 376.758 shall provide coverage to the persons specified in subsection 1 of this section for policies or contracts of direct, nongroup life insurance, health insurance, which for the purposes of sections 376.715 to 376.758 includes health maintenance organizations' subscriber contracts and certificates, or annuities and supplemental contracts to any such policies or contracts, and for certificates under direct group policies and contracts, except as limited by the provisions of sections 376.715 to 376.758.Annuity contracts and certificates under group annuity contracts include allocated funding agreements, structured settlement annuities, and any immediate or deferred annuity contracts.

3.Except as otherwise provided in paragraph (c) of subdivision (3) of this subsection, sections 376.715 to 376.758 shall not provide coverage for:

(1)Any portion of a policy or contract not guaranteed by the member insurer, or under which the risk is borne by the policy or contract holder;

(2)Any policy or contract of reinsurance, unless assumption certificates have been issued;

(3)Any portion of a policy or contract to the extent that the rate of interest on which it is based, or the interest rate, crediting rate, or similar factor determined by use of an index or other external reference stated in the policy or contract employed in calculating returns or changes in value:

(a)Averaged over the period of four years prior to the date on which the association becomes obligated with respect to such policy or contract, exceeds the rate of interest determined by subtracting three percentage points from Moody's Corporate Bond Yield Average averaged for that same four-year period or for such lesser period if the policy or contract was issued less than four years before the association became obligated;

(b)On and after the date on which the association becomes obligated with respect to such policy or contract exceeds the rate of interest determined by subtracting three percentage points from Moody's Corporate Bond Yield Average as most recently available; and

(c)The exclusion from coverage referenced in this subdivision shall not apply to any portion of a policy or contract, including a rider, that provides long-term care or any other health insurance benefits;

(4)Any portion of a policy or contract issued to a plan or program of an employer, association or other person to provide life, health, or annuity benefits to its employees or members to the extent that such plan or program is self-funded or uninsured, including but not limited to benefits payable by an employer, association or other person under:

(a)A multiple employer welfare arrangement as defined in 29 U.S.C. Section 1144, as amended;

(b)A minimum premium group insurance plan;

(c)A stop-loss group insurance plan; or

(d)An administrative services only contract;

(5)Any portion of a policy or contract to the extent that it provides dividends or experience rating credits, voting rights, or provides that any fees or allowances be paid to any person, including the policy or contract holder, in connection with the service to or administration of such policy or contract;

(6)Any policy or contract issued in this state by a member insurer at a time when it was not licensed or did not have a certificate of authority to issue such policy or contract in this state;

(7)A portion of a policy or contract to the extent that the assessments required by section 376.735 with respect to the policy or contract are preempted by federal or state law;

(8)An obligation that does not arise under the express written terms of the policy or contract issued by the member insurer to the enrollee, certificate holder, contract owner, or policy owner, including without limitation:

(a)Claims based on marketing materials;

(b)Claims based on side letters, riders, or other documents that were issued by the member insurer without meeting applicable policy or contract form filing or approval requirements;

(c)Misrepresentations of or regarding policy or contract benefits;

(d)Extra-contractual claims;

(e)A claim for penalties or consequential or incidental damages;

(9)A contractual agreement that establishes the member insurer's obligations to provide a book value accounting guaranty for defined contribution benefit plan participants by reference to a portfolio of assets that is owned by the benefit plan or its trustee, which in each case is not an affiliate of the member insurer;

(10)An unallocated annuity contract;

(11)A portion of a policy or contract to the extent it provides for interest or other changes in value to be determined by the use of an index or other external reference stated in the policy or contract, but which have not been credited to the policy or contract, or as to which the policy or contract owner's rights are subject to forfeiture, as of the date the member insurer becomes an impaired or insolvent insurer under sections 376.715 to 376.758, whichever is earlier.If a policy's or contract's interest or changes in value are credited less frequently than annually, for purposes of determining the value that have been credited and are not subject to forfeiture under this subdivision, the interest or change in value determined by using the procedures defined in the policy or contract will be credited as if the contractual date of crediting interest or changing values was the date of impairment or insolvency, whichever is earlier, and will not be subject to forfeiture;

(12)A policy or contract providing any hospital, medical, prescription drug or other health care benefit under Part C or Part D of Subchapter XVIII, Chapter 7 of Title 42 of the United States Code, Medicare Parts C & D, Subchapter XIX, Chapter 7 of Title 42 of the United States Code, Medicaid, or any regulations issued thereunder.

4.The benefits for which the association may become liable, with regard to a member insurer that was first placed under an order of rehabilitation or under an order of liquidation if no order of rehabilitation was entered prior to August 28, 2013, shall in no event exceed the lesser of:

(1)The contractual obligations for which the member insurer is liable or would have been liable if it were not an impaired or insolvent insurer; or

(2)With respect to any one life, regardless of the number of policies or contracts:

(a)Three hundred thousand dollars in life insurance death benefits, but not more than one hundred thousand dollars in net cash surrender and net cash withdrawal values for life insurance;

(b)One hundred thousand dollars in health insurance benefits, including any net cash surrender and net cash withdrawal values;

(c)One hundred thousand dollars in the present value of annuity benefits, including net cash surrender and net cash withdrawal values.

Provided, however, that in no event shall the association be liable to expend more than three hundred thousand dollars in the aggregate with respect to any one life under paragraphs (a), (b), and (c) of this subdivision.

5.Except as otherwise provided in subdivision (2) of this subsection, the benefits for which the association may become liable with regard to a member insurer that was first placed under an order of rehabilitation or under an order of liquidation if no order of rehabilitation was entered on or after August 28, 2013, shall in no event exceed the lesser of:

(1)The contractual obligations for which the insurer is liable or would have been liable if it were not an impaired or insolvent insurer; or

(2)(a)With respect to any one life, regardless of the number of policies or contracts:

a.Three hundred thousand dollars in life insurance death benefits, but not more than one hundred thousand dollars in net cash surrender and net cash withdrawal values for life insurance;

b.For health insurance benefits:

(i)One hundred thousand dollars of coverages other than disability income insurance, health benefit plans, or long-term care insurance, including any net cash surrender and net cash withdrawal values;

(ii)Three hundred thousand dollars for disability income insurance and three hundred thousand dollars for long-term care insurance;

(iii)Five hundred thousand dollars for health benefit plans;

c.Two hundred fifty thousand dollars in the present value of annuity benefits, including net cash surrender and net cash withdrawal values; or

(b)With respect to each payee of a structured settlement annuity, or beneficiary or beneficiaries of the payee if deceased, two hundred fifty thousand dollars in present value annuity benefits, in the aggregate, including net cash surrender and net cash withdrawal values, if any;

(c)Except that, in no event shall the association be obligated to cover more than:

a.An aggregate of three hundred thousand dollars in benefits with respect to any one life under paragraphs (a) and (b) of this subdivision, except with respect to benefits for health benefit plans under item (iii) of subparagraph b. of paragraph (a) of this subdivision, in which case the aggregate liability of the association shall not exceed five hundred thousand dollars with respect to any one individual; or

b.With respect to one owner of multiple nongroup policies of life insurance, whether the policy owner is an individual, firm, corporation, or other person, and whether the persons insured are officers, managers, employees, or other persons, more than five million dollars in benefits, regardless of the number of policies and contracts held by the owner.

6.The limitations set forth in subsections 4 and 5 of this section are limitations on the benefits for which the association is obligated before taking into account either its subrogation and assignment rights or the extent to which such benefits could be provided out of the assets of the impaired or insolvent insurer attributable to covered policies.The costs of the association's obligations under sections 376.715 to 376.758 may be met by the use of assets attributable to covered policies or reimbursed to the association under its subrogation and assignment rights.

7.For the purposes of sections 376.715 to 376.758, benefits provided by a long-term care rider to a life insurance policy or annuity contract shall be considered the same type of benefits as the basic life insurance policy or annuity contract to which it relates.

(L. 1988 S.B. 430 § 3, A.L. 2010 S.B. 583, A.L. 2013 S.B. 59, A.L. 2018 H.B. 1690)

376.1045 - Injunctive relief, director may seek, when — procedures.

The director may, in addition to any other remedy or sanction authorized under the insurance laws of this state, seek injunctive relief against any unauthorized insurer under section 375.786 or any unauthorized multiple employer self-insured health plan under sections 376.1000 to 376.1045. Pursuant to such injunctive relief, the court may order such unauthorized insurer or plan to pay money sufficient to pay for the outstanding claims of residents of this state against such insurer or plan and for the adjustment of such claims and the administration of such claims and adjustment.The money shall be payable to any fund established by the director for the purposes of this section.Such fund shall be controlled and administered by the director and his appointees, subject to the supervision of the court.The director and his appointees shall be subject to judicial immunity for any acts or omissions within the scope of establishing, controlling or administering such fund.

(L. 1993 H.B. 709 § 40)

376.1218 - Insurance coverage for children enrolled in the Part C early intervention system (First Steps).

1.Any health carrier or health benefit plan that offers or issues health benefit plans, other than Medicaid health benefit plans, which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2006, shall provide coverage for early intervention services described in this section that are delivered by early intervention specialists who are health care professionals licensed by the state of Missouri and acting within the scope of their professions for children from birth to age three identified by the Part C early intervention system as eligible for services under Part C of the Individuals with Disabilities Education Act, 20 U.S.C. Section 1431, et seq.Such coverage shall be limited to three thousand dollars for each covered child per policy per calendar year, with a maximum of nine thousand dollars per child.

2.As used in this section, "health carrier" and "health benefit plan" shall have the same meaning as such terms are defined in section 376.1350.

3.In the event that any health benefit plan is found not to be required to provide coverage under subsection 1 of this section because of preemption by a federal law, including but not limited to the act commonly known as ERISA contained in Title 29 of the United States Code, or in the event that subsection 1 of this section is found to be unconstitutional, then the lead agency shall be responsible for payment and provision of any benefit provided under this section.

4.For purposes of this section, "early intervention services" means medically necessary speech and language therapy, occupational therapy, physical therapy, and assistive technology devices for children from birth to age three who are identified by the Part C early intervention system as eligible for services under Part C of the Individuals with Disabilities Education Act, 20 U.S.C. Section 1431, et seq.Early intervention services shall include services under an active individualized family service plan that enhance functional ability without effecting a cure.An individualized family service plan is a written plan for providing early intervention services to an eligible child and the child's family that is adopted in accordance with 20 U.S.C. Section 1436.The Part C early intervention system, on behalf of its contracted regional Part C early intervention system centers and providers, shall be considered the rendering provider of services for purposes of this section.

5.No payment made for specified early intervention services shall be applied by the health carrier or health benefit plan against any maximum lifetime aggregate specified in the policy or health benefit plan if the carrier opts to satisfy its obligations under this section under subdivision (2) of subsection 7 of this section.A health benefit plan shall be billed at the applicable Medicaid rate at the time the covered benefit is delivered, and the health benefit plan shall pay the Part C early intervention system at such rate for benefits covered by this section.Services under the Part C early intervention system shall be delivered as prescribed by the individualized family service plan and an electronic claim filed in accordance with the carrier's or plan's standard format.Beginning January 1, 2007, such claims' payments shall be made in accordance with the provisions of sections 376.383 and 376.384.

6.The health care service required by this section shall not be subject to any greater deductible, co-payment, or coinsurance than other similar health care services provided by the health benefit plan.

7.(1)Subject to the provisions of this section, payments made during a calendar year by a health carrier or group of carriers affiliated by or under common ownership or control to the Part C early intervention system for services provided to children covered by the Part C early intervention system shall not exceed one-half of one percent of the direct written premium for health benefit plans as reported to the department of insurance, financial institutions and professional registration on the health carrier's most recently filed annual financial statement.

(2)In lieu of reimbursing claims under this section, a carrier or group of carriers affiliated by or under common ownership or control may, on behalf of all of the carrier's or carriers' health benefit plan or plans providing coverage under this section, directly pay the Part C early intervention system by January thirty-first of the calendar year an amount equal to one-half of one percent of the direct written premium for health benefit plans as reported to the department of insurance, financial institutions and professional registration on the health carrier's most recently filed annual financial statement, or five hundred thousand dollars, whichever is less, and such payment shall constitute full and complete satisfaction of the health benefit plan's obligation for the calendar year.Nothing in this subsection shall require a health carrier or health benefit plan providing coverage under this section to amend or modify any provision of an existing policy or plan relating to the payment or reimbursement of claims by the health carrier or health benefit plan.

8.This section shall not apply to a supplemental insurance policy, including a life care contract, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, hospitalization-surgical care policy, policy that is individually underwritten or provides such coverage for specific individuals and members of their families, long-term care policy, or short-term major medical policies of six months or less duration.

9.Except for health carriers or health benefit plans making payments under subdivision (2) of subsection 7 of this section, the department of insurance, financial institutions and professional registration shall collect data related to the number of children receiving private insurance coverage under this section and the total amount of moneys paid on behalf of such children by private health carriers or health benefit plans.The department shall report to the general assembly regarding the department's findings no later than January 30, 2007, and annually thereafter.

10.Notwithstanding the provisions of section 23.253 to the contrary, the provisions of this section shall not sunset.

(L. 2005 S.B. 500, A.L. 2007 S.B. 112)

376.1318 - Powers of mutual holding company, engaging in business of insurance, no authority, affiliation and merger agreements.

A mutual holding company shall have the same powers granted to domestic insurance companies pursuant to chapter 382 relating to insurance holding company systems, and shall be subject to the requirements and provisions of such chapter and shall have all the powers granted to corporations organized pursuant to chapter 351.Neither the mutual holding company nor any stock holding company created pursuant to sections 376.1300 to 376.1322 shall be an insurer or shall have the authority to engage in the business of insurance.A mutual holding company may enter into an affiliation agreement or a merger agreement either at the time of reorganization, or at some later time with the approval of the director, with any mutual life insurance company authorized to do business in this state.Any such merger agreement may authorize participating policyholders of the mutual life insurance company to become members of the mutual holding company.Any such affiliation agreement or merger agreement is subject to the insurance laws of this state relating to such transactions entered into by a domestic mutual life insurance company.

(L. 1996 S.B. 759)

376.2004 - Application procedure.

1.An individual applying for a navigator license shall make application to the department on a form developed by the director and declare under penalty of refusal, suspension, or revocation of the license that the statements made in the application are true, correct, and complete to the best of the individual's knowledge and belief.Before approving the application, the director shall find that the individual:

(1)Is eighteen years of age or older;

(2)Resides in this state or maintains his or her principal place of business in the state;

(3)Is not disqualified for having committed any act that would be grounds for refusal to issue, renew, suspend, or revoke an insurance producer license under section 375.141;

(4)Has successfully passed the written examination prescribed by the director;

(5)When applicable, has the written consent of the director under 18 U.S.C. 1033 or any successor statute regulating crimes by or affecting persons engaged in the business of insurance whose activities affect interstate commerce;

(6)Has identified the entity with which he or she is affiliated and supervised; and

(7)Has paid the fees prescribed by the director.

2.An entity that acts as a navigator, supervises the activities of individual navigators, or receives funding to perform such activities shall obtain a navigator entity license.An entity applying for an entity navigator license shall make application on a form containing the information prescribed by the director.

3.The director may require any documents deemed necessary to verify the information contained in an application submitted in accordance with subsections 1 and 2 of this section.

4.Entities licensed as navigators shall, in a manner prescribed by the director, provide a list of all individual navigators that are employed by or in any manner affiliated with the navigator entity and shall report any changes in employment or affiliation within twenty days of such change.

5.Prior to any exchange becoming operational in this state, the director shall prescribe initial training, continuing education, and written examination standards and requirements for navigators.

(L. 2013 S.B. 262)

376.403 - Benefit levels — group coverage may be provided in lieu of converted policy — delivery outside state, form.

1.If the benefit levels required in subdivision (9) of subsection 1 of section 376.397 exceed the benefit levels provided under the group policy, the converted policy may offer benefits which are substantially similar to those provided under the group policy in lieu of those required in subdivision (9) of subsection 1 of section 376.397.

2.The insurer may elect to provide group insurance coverage in lieu of the issuance of an individual converted policy.

3.A converted policy which is delivered outside this state may be on a form which could be delivered in such other jurisdiction as a converted policy had the group policy been issued in that jurisdiction.

(L. 1981 S.B. 58 § 4)

Effective 1-01-83

376.2010 - Sanction of license, when — restitution required, when — examination and investigation of records.

1.The director may place on probation, suspend, revoke, or refuse to issue, renew, or reinstate a navigator license or may levy a fine not to exceed one thousand dollars for each violation, or any combination of actions, for any one or more of the causes listed in section 375.141, 375.936 or for other good cause.In the event that the action by the director is not to renew or to deny an application for a license, the director shall notify the applicant or licensee in writing and shall advise the applicant or licensee of the reason for the denial or nonrenewal.Appeal of the nonrenewal or denial of the application for a navigator license shall be made under the provisions of chapter 621.

2.In addition to imposing the penalties authorized by subsection 1 of this section, the director may require that restitution be made to any person who has suffered financial injury because of a violation of this section.

3.The director shall have the power to examine and investigate the business affairs and records of any navigator to determine whether the individual or entity has engaged or is engaging in any violation of this section.

4.The navigator license held by an entity may be suspended or revoked, renewal or reinstatement thereof may be refused, or a fine may be levied, with or without a suspension, revocation, or refusal to renew a license, if the director finds that an individual licensee's violation was known or should have been known by the employing or supervising entity and the violation was not reported to the director and no corrective action was undertaken on a timely basis.

(L. 2013 S.B. 262)

Effective 7-12-13

376.1508 - Processing fee — cancellation of membership, effect of.

1.A discount medical plan organization may charge a reasonable one-time processing fee and a periodic charge as long as the fee is disclosed to the applicant.

2.If the member cancels the membership within the first thirty days after receipt of the discount card and other membership materials, the member shall receive a reimbursement of all periodic charges paid.The return of all periodic charges shall be made within thirty days of the date of the cancellation.If all of the periodic charges have not been paid within thirty days, interest shall be assessed and paid on the proceeds at a rate of the treasury bill rate of the preceding calendar year, plus two percentage points.

3.The right of cancellation shall be set out in the written membership materials on the first page, in ten-point type or larger.

4.If a discount medical plan organization cancels a membership for any reason other than nonpayment of charges by the member, the discount medical plan organization shall make a pro rata reimbursement of all periodic charges to the member.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.307 - Limits on acquisition of certain investments.

1.Solely for the purpose of acquiring investments that exceed the quantitative limitations of sections 376.297 to 376.304, an insurer may acquire under this subsection an investment, or engage in investment practices described in section 376.303, but an insurer shall not acquire an investment, or engage in investment practices described in section 376.303, under this subsection if as a result of and after giving effect to the transaction:

(1)The aggregate amount of investments then held by an insurer under this subsection would exceed three percent of its admitted assets; or

(2)The aggregate amount of investments as to one limitation in sections 376.297 to 376.304 then held by the insurer under this subsection would exceed one percent of its admitted assets.

2.In addition to the authority provided in subsection 1 of this section, an insurer may acquire under this subsection an investment of any kind, or engage in investment practices described in section 376.303 that are not specifically prohibited by this chapter without regard to the categories, conditions, standards, or other limitations of sections 376.297 to 376.304, if as a result of and after giving effect to the transaction the aggregate amount of investments then held under this subsection would not exceed the lesser of:

(1)Ten percent of its admitted assets; or

(2)Seventy-five percent of its capital and surplus.

An insurer shall not acquire any investment, or engage in any investment practice under this subsection, if as a result of and after giving effect to the transaction the aggregate amount of all investments in any one person then held by the insurer under this subsection would exceed three percent of its admitted assets.

3.In addition to the investments acquired under subsections 1 and 2 of this section, an insurer may acquire under this subsection an investment of any kind, or engage in investment practices described in section 376.303 that are not specifically prohibited by this chapter without regard to any limitations of sections 376.297 to 376.304, if:

(1)The director grants prior approval;

(2)The insurer demonstrates that its investments are being made in a prudent manner and that the additional amounts will be invested in a prudent manner; and

(3)As a result of and after giving effect to the transaction, the aggregate amount of investments then held by the insurer under this subsection does not exceed the greater of:

(a)Twenty-five percent of its capital and surplus; or

(b)One hundred percent of its capital and surplus less ten percent of its admitted assets.

4.Under this section, an insurer shall not acquire or engage in an investment practice prohibited under section 376.294 or acquire or engage in an investment that is a derivative transaction.

(L. 1961 p. 175 § 1, A.L. 1982 S.B. 726, A.L. 2002 H.B. 1518 merged with S.B. 1009, A.L. 2007 S.B. 66, A.L. 2012 H.B. 1112)

376.1800 - Definitions — medical retainer agreements not insurance — agreement requirements — use of health savings accounts for fees.

1.As used in this section, the following terms shall mean:

(1)"Medical retainer agreement", a contract between a physician and an individual patient or such individual patient's legal representative in which the physician agrees to provide certain health care services described in the agreement to the individual patient for an agreed-upon fee and period of time;

(2)"Physician", a physician licensed under chapter 334.Physician includes an individual physician or a group of physicians.

2.A medical retainer agreement is not insurance and is not subject to this chapter.Entering into a medical retainer agreement is not the business of insurance and is not subject to this chapter.

3.A physician or agent of a physician is not required to obtain a certificate of authority or license under this section to market, sell, or offer to sell a medical retainer agreement.

4.To be considered a medical retainer agreement for the purposes of this section, the agreement shall meet all of the following requirements:

(1)Be in writing;

(2)Be signed by the physician or agent of the physician and the individual patient or such individual patient's legal representative;

(3)Allow either party to terminate the agreement on written notice to the other party;

(4)Describe the specific health care services that are included in the agreement;

(5)Specify the fee for the agreement;

(6)Specify the period of time under the agreement; and

(7)Prominently state in writing that the agreement is not health insurance.

5.(1)For any patient who enters into a medical retainer agreement under this section and who has established a health savings account (HSA) in compliance with 26 U.S.C. Section 223, or who has a flexible spending arrangement (FSA) or health reimbursement arrangement (HRA), fees under the patient's medical retainer agreement may be paid from such health savings account or reimbursed through such flexible spending arrangement or health reimbursement arrangement, subject to any federal or state laws regarding qualified expenditures from a health savings account, or reimbursement through a flexible spending arrangement or a health reimbursement arrangement.

(2)The employer of any patient described in subdivision (1) of this subsection may:

(a)Make contributions to such patient's health savings account, flexible spending arrangement, or health reimbursement arrangement to cover all or any portion of the agreed-upon fees under the patient's medical retainer agreement, subject to any federal or state restrictions on contributions made by an employer to a health savings account, or reimbursement through a flexible spending arrangement, or health reimbursement arrangement; or

(b)Pay the agreed-upon fees directly to the physician under the medical retainer agreement.

6.Nothing in this section shall be construed as prohibiting, limiting, or otherwise restricting a physician in a collaborative practice arrangement from entering into a medical retainer agreement under this section.

(L. 2015 H.B. 769)

376.303 - Lending and repurchase, permitted when.

An insurer may enter into securities lending, repurchase, reverse repurchase, and dollar-roll transactions with business entities subject to the following requirements:

(1)The insurer's board of directors shall adopt a written plan that is consistent with the requirements of the written plan under subdivision (1) of subsection 2 of section 376.293 that specifies guidelines and objectives to be followed, such as:

(a)A description of how cash received will be invested or used for general corporate purposes of the insurer;

(b)Operational procedures to manage interest rate risk, counterparty default risk, the conditions under which proceeds from reverse repurchase transactions may be used in the ordinary course of business, and use of acceptable collateral in a manner that reflects the liquidity needs of the transaction; and

(c)The extent to which the insurer may engage in these transactions;

(2)The insurer shall enter into a written agreement for all transactions authorized in this section other than dollar-roll transactions.The written agreement shall require that each transaction terminate no more than one year from its inception or upon the earlier demand of the insurer.The agreement shall be with the business entity counterparty and the agreement may be with an agent acting on behalf of the insurer if the agent is a qualified business entity and if the agreement:

(a)Requires the agent to enter into separate agreements with each counterparty that are consistent with the requirements of this section; and

(b)Prohibits securities lending transactions under the agreement with the agent or its affiliates;

(3)Cash received in a transaction under this section shall be invested in accordance with this chapter and in a manner that recognizes the liquidity needs of the transaction or used by the insurer for its general corporate purpose.So long as the transaction remains outstanding, the insurer, its agent, or custodian shall maintain as to acceptable collateral received in a transaction under this section either physically or through the book entry systems of the Federal Reserve, Depository Trust Company, Participants Trust Company, or other securities depositories approved by the director:

(a)Possession of the acceptable collateral;

(b)A perfected security interest in the acceptable collateral; or

(c)In the case of a jurisdiction outside of the United States, title to or rights of a secured creditor to the acceptable collateral;

(4)The limitations of sections 376.297 and 376.304 shall not apply to the business entity counterparty exposure created by transactions under this section.For purposes of calculations made to determine compliance with this subsection, no effect will be given to the insurer's future obligation to resell securities in the case of a repurchase transaction or to repurchase securities in the case of a reverse repurchase transaction.An insurer shall not enter into a transaction under this section if as a result of and after giving effect to the transaction:

(a)The aggregate amount of securities then loaned, sold to, or purchased from any one business entity counterparty under this section would exceed five percent of its admitted assets.In calculating the amount sold to or repurchased from a business entity counterparty under repurchase or reverse repurchase transactions, effect may be given to netting provisions under a master written agreement; or

(b)The aggregate amount of all securities then loaned, sold to, or purchased from all business entities under this section would exceed forty percent of its admitted assets;

(5)In a dollar-roll transaction, the insurer shall receive cash in an amount at least equal to the market value of the securities transferred by the insurer in the transaction as of the transaction date.

(L. 1955 p. 271 § 1, A.L. 1967 p. 516, A.L. 1971 H.B. 331, A.L. 1985 H.B. 589, A.L. 2007 S.B. 66)

376.1900 - Definitions — reimbursement for telehealth services, when.

1.As used in this section, the following terms shall mean:

(1)"Electronic visit", or "e-visit", an online electronic medical evaluation and management service completed using a secured web-based or similar electronic-based communications network for a single patient encounter.An electronic visit shall be initiated by a patient or by the guardian of a patient with the health care provider, be completed using a federal Health Insurance Portability and Accountability Act (HIPAA)-compliant online connection, and include a permanent record of the electronic visit;

(2)"Health benefit plan" shall have the same meaning ascribed to it in section 376.1350;

(3)"Health care provider" shall have the same meaning ascribed to it in section 376.1350;

(4)"Health care service", a service for the diagnosis, prevention, treatment, cure or relief of a physical or mental health condition, illness, injury or disease;

(5)"Health carrier" shall have the same meaning ascribed to it in section 376.1350;

(6)"Telehealth" shall have the same meaning ascribed to it in section 208.670.

2.Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2014, shall not deny coverage for a health care service on the basis that the health care service is provided through telehealth if the same service would be covered if provided through face-to-face diagnosis, consultation, or treatment.

3.A health carrier may not exclude an otherwise covered health care service from coverage solely because the service is provided through telehealth rather than face-to-face consultation or contact between a health care provider and a patient.

4.A health carrier shall not be required to reimburse a telehealth provider or a consulting provider for site origination fees or costs for the provision of telehealth services; however, subject to correct coding, a health carrier shall reimburse a health care provider for the diagnosis, consultation, or treatment of an insured or enrollee when the health care service is delivered through telehealth on the same basis that the health carrier covers the service when it is delivered in person.

5.A health care service provided through telehealth shall not be subject to any greater deductible, co-payment, or coinsurance amount than would be applicable if the same health care service was provided through face-to-face diagnosis, consultation, or treatment.

6.A health carrier shall not impose upon any person receiving benefits under this section any co-payment, coinsurance, or deductible amount, or any policy year, calendar year, lifetime, or other durational benefit limitation or maximum for benefits or services that is not equally imposed upon all terms and services covered under the policy, contract, or health benefit plan.

7.Nothing in this section shall preclude a health carrier from undertaking utilization review to determine the appropriateness of telehealth as a means of delivering a health care service, provided that the determinations shall be made in the same manner as those regarding the same service when it is delivered in person.

8.A health carrier or health benefit plan may limit coverage for health care services that are provided through telehealth to health care providers that are in a network approved by the plan or the health carrier.

9.Nothing in this section shall be construed to require a health care provider to be physically present with a patient where the patient is located unless the health care provider who is providing health care services by means of telehealth determines that the presence of a health care provider is necessary.

10.The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months' or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

(L. 2013 H.B. 986 merged with S.B. 262)

Effective 1-01-14

376.2014 - Applicability — severability — rulemaking authority.

1.The requirements of sections 379.930 to 379.952 and chapters 375, 376, 407 and any related rules shall apply to navigators.The activities and duties of a navigator shall be deemed to constitute transacting the business of insurance.

2.If any provision of sections 376.2000 to 376.2014 or its application to any person or circumstance is held invalid by a court of competent jurisdiction or by federal law, the invalidity does not affect other provisions or applications of sections 376.2000 to 376.2014 that can be given effect without the invalid provision or application.The provisions of sections 376.2000 to 376.2014 are severable, and the valid provisions or applications shall remain in full force and effect.

3.The director may promulgate rules and regulations to implement and administer the provisions of sections 376.2000 to 376.2014.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in sections 376.2000 to 376.2014 shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.Sections 376.2000 to 376.2014 and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2013, shall be invalid and void.

(L. 2013 S.B. 262)

Effective 7-12-13

376.407 - Advance practice nurse, claims for service to be reimbursed, when.

Any health insurer, as defined in section 376.806, nonprofit health service plan or health maintenance organization shall reimburse a claim for services provided by an advance practice nurse, as defined in section 335.016, if such services are within the scope of practice of such nurse.

(L. 1998 H.B. 1302 § 9)

376.1300 - Reorganization of a domestic mutual life insurance company, authority.

A domestic mutual life insurance company organized and operating pursuant to this chapter may reorganize by forming a mutual life insurance holding company as described in section 376.1309 or by merging its policyholders' memberships into such a mutual life insurance holding company.The reorganized life insurance company shall continue its corporate existence, either at the time of the reorganization or at some later time, as a stock life insurance company or as a mutual life insurance company.The authority granted such companies pursuant to sections 376.1300 to 376.1322 shall be in addition to any powers granted pursuant to chapter 382.

(L. 1996 S.B. 759)

376.752 - Member insurer's deposit with director, exemption from, amount.

Any member insurer organized under the provisions of sections 376.010 to 376.670, or under any general or special laws of this state and transacting business of the character designated in section 376.010, shall be exempt from the provisions of section 376.170, relating to the amount required to be deposited with the director equal to the net value of all policies and annuity contracts; provided, however, that the extent of such exemption shall be eighty percent of such net value in the calendar year during which this act shall become effective, increasing by five percent for each succeeding calendar year until such exemption shall be equal to one hundred percent of such net value.

(L. 1988 S.B. 430 § 33)

376.1200 - Certain policies to offer coverage for treatment of breast cancer — limitation on deductible, lifetime maximum benefit — administration of benefits — application, effect.

1.Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a health services corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed in this state on or after January 1, 1996, shall offer coverage for the treatment of breast cancer by dose-intensive chemotherapy/autologous bone marrow transplants or stem cell transplants when performed pursuant to nationally accepted peer review protocols utilized by breast cancer treatment centers experienced in dose-intensive chemotherapy/autologous bone marrow transplants or stem cell transplants.The offer of benefits under this section shall be in writing and must be accepted in writing by the individual or group policyholder or contract holder.

2.Such health care service shall not be subject to any greater deductible or co-payment than any other health care service provided by the policy, contract or plan, except that the policy, contract or plan may contain a provision imposing a lifetime benefit maximum of not less than one hundred thousand dollars, for dose-intensive chemotherapy/autologous bone marrow transplants or stem cell transplants for breast cancer treatment.

3.Benefits may be administered for such health care service through a managed care program of exclusive and/or preferred contractual arrangements with one or more providers rendering such health care service.These contractual arrangements may provide that the provider shall hold the patient harmless for the cost of rendering such health care service if it is subsequently found by the entity authorized to resolve disputes that:

(1)Such care did not qualify under the protocols established for the providing of care for such health care service;

(2)Such care was not medically appropriate; or

(3)The provider otherwise failed to comply with the utilization management or other managed care provision agreed to in any contract between the entity and the provider.

4.The provisions of this section shall not apply to short-term travel, accident-only, limited or specified disease policies, or to short-term nonrenewable policies of not more than seven months duration.

5.Nothing in this section shall prohibit an entity from including all or part of such health care services as standard coverage in its policies, contracts or plans.

(L. 1995 S.B. 27)

376.1000 - Multiple employer self-insured health plan, defined.

1.As used in sections 376.1000 to 376.1045, a "multiple employer self-insured health plan" is any plan or arrangement which is not fully insured and which is either:

(1)Offered by a staff or employee leasing company; or

(2)Established or maintained for the purpose of offering or providing health, dental or short-term disability benefits to employees of two or more employers.

2.A plan or arrangement is considered fully insured only if an insurer licensed to transact business in this state retains the ultimate responsibility for all benefits payable by a contract or policy of insurance.

(L. 1993 H.B. 709 § 22)

376.452 - Large group market, renewal or continuation of coverage required — nonrenewal or discontinuation permitted, when — conditions for discontinuation.

1.Except as provided in this section, if a health insurance issuer offers health insurance coverage in the large group market in connection with a group health plan, the health insurance issuer shall renew or continue the coverage in force at the option of the plan sponsor.

2.A health insurance issuer may nonrenew or discontinue health insurance coverage offered in connection with a group health plan in the large group market if:

(1)The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or if the health insurance issuer has not received timely premium payments;

(2)The plan sponsor has performed an act or practice that constitutes fraud or has made an intentional misrepresentation of material fact under the terms of the coverage;

(3)The plan sponsor has failed to comply with the health insurance issuer's minimum participation requirements;

(4)The plan sponsor has failed to comply with the health insurance issuer's employer contribution requirements;

(5)The health insurance issuer is ceasing to offer coverage in the large group market in accordance with subsection 3 of this section;

(6)In the case of a health insurance issuer that offers health insurance coverage in the large group market through a network plan, there is no longer any enrollee under the group health plan who lives, resides, or works in the service area of the health insurance issuer or in the area for which the issuer is authorized to do business;

(7)In the case of health insurance coverage that is made available in the large group market only through one or more bona fide associations, the membership of an employer in the bona fide association ceases, but only if coverage is terminated under this subdivision uniformly without regard to any health status-related factor of any covered individual.

3.A health insurance issuer shall not discontinue offering a particular type of group health insurance coverage offered in the large group market unless:

(1)The issuer provides notice to each plan sponsor, participant and beneficiary provided coverage of this type in the large group market of the discontinuation at least ninety days prior to the date of the discontinuation of the coverage;

(2)The issuer offers to each plan sponsor being provided coverage of this type in the large group market the option to purchase any other health insurance coverage currently being offered by the health insurance issuer to a group health plan in the large group market; and

(3)The issuer acts uniformly without regard to the claims experience of those plan sponsors or any health status-related factor of any participant or beneficiary covered or new participant or beneficiary who may become eligible for such coverage.

4.(1)A health insurance issuer shall not discontinue offering all health insurance coverage in the large group market unless:

(a)The issuer provides notice of discontinuation to the director and to each plan sponsor, participant and beneficiary covered at least one hundred eighty days prior to the date of the discontinuation of coverage; and

(b)All health insurance issued or delivered for issuance in Missouri in the large group market is discontinued and coverage under such health insurance is not renewed.

(2)In the case of a discontinuation under this subsection, the health insurance issuer shall not provide for the issuance of any health insurance coverage in the large group market for a period of five years beginning on the date of the discontinuation of the last health insurance coverage not renewed.

5.At the time of coverage renewal, a health insurance issuer may modify the health insurance coverage for a product offered to a group health plan in the large group market.For purposes of this subsection, renewal shall be deemed to occur not more often than annually on the anniversary of the effective date of the group health plan's health insurance coverage unless a longer term is specified in the policy or contract.

6.In the case of health insurance coverage that is made available by a health insurance issuer only through one or more bona fide associations, a reference to plan sponsor in this section is deemed, with respect to coverage provided to an employer member of the association, to include a reference to such employer.

(L. 2007 H.B. 818)

Effective 1-01-08

376.1504 - Registration requirements — term of registration — renewal.

1.To register as a discount medical plan organization, an applicant shall:

(1)File with the director an application on a form approved and adopted by the director; and

(2)Pay to the director an application fee of two hundred fifty dollars.

2.A registration is valid for a one-year term and expires one year following the registration date unless it is renewed as provided in this section.

3.Before it expires, a registrant may renew the registration for an additional one-year term if the registrant:

(1)Otherwise is qualified to receive a registration;

(2)Files with the director a renewal application on a form approved and adopted by the director; and

(3)Pays a renewal fee of two hundred fifty dollars.

4.All amounts collected as registration or renewal fees shall be deposited into the insurance dedicated fund.

5.Nothing in this subsection shall require a provider who provides discounts to his or her own patients to obtain and maintain a registration as a discount medical plan organization.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.1100 - Law, how cited — definitions.

1.Sections 376.1100 to 376.1130 may be known and cited as the "Long-term Care Insurance Act".

2.As used in sections 376.1100 to 376.1130, unless the context requires otherwise, the following terms mean:

(1)"Applicant":

(a)In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits; and

(b)In the case of a group long-term care insurance policy, the proposed certificate holder;

(2)"Certificate", any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this state;

(3)"Director", the director of the department of insurance, financial institutions and professional registration of this state;

(4)"Group long-term care insurance", a long-term care insurance policy which is delivered or issued for delivery in this state and issued to:

(a)One or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof, of the labor organization; or

(b)Any professional, trade or occupational association for its members or former or retired members, or combination thereof, if such association;

a.Is composed of individuals all of whom are or were actively engaged in the same profession, trade or occupation; and

b.Has been maintained in good faith for purposes other than obtaining insurance; or

(c)An association or a trust or the trustee of a fund established, created or maintained for the benefit of members of one or more associations.Prior to advertising, marketing or offering such policy within this state, the association or associations, or the insurer of the association or associations, shall file evidence with the director that the association or associations have at the outset a minimum of one hundred persons and have been organized and maintained in good faith for purposes other than that of obtaining insurance; have been in active existence for at least one year; and have a constitution and bylaws which provide that:

a.The association or associations hold regular meetings not less than annually to further purposes of the members;

b.Except for credit unions, the association or associations collect dues or solicit contributions from members; and

c.The members have voting privileges and representation on the governing board and committees.

Thirty days after such filing the association or associations shall be deemed to satisfy such organizational requirements, unless the director makes a finding that the association or associations do not satisfy those organizational requirements;

(d)A group other than as described in paragraph (a), (b) or (c) of subdivision (4) of this subsection, subject to a finding by the director that:

a.The issuance of the group policy is not contrary to the best interest of the public;

b.The issuance of the group policy would result in economies of acquisition or administration; and

c.The benefits are reasonable in relation to the premiums charged;

(5)"Long-term care insurance", any insurance policy or rider advertised, marketed, offered or designed to provide coverage for not less than twelve consecutive months for each covered person on an expense-incurred, indemnity, prepaid or other basis; for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance of personal care services, provided in a setting other than an acute care unit of a hospital.Such term includes group and individual annuities and life insurance policies or riders which provide directly or which supplement long-term care insurance.Such term also includes a policy or rider which provides for payment of benefits based upon cognitive impairment or the loss of functional capacity.Long-term care insurance also includes qualified long-term care insurance contracts.Long-term care insurance may be issued by insurers; fraternal benefit societies; health services corporations; prepaid health plans; health maintenance organizations, or any similar organization to the extent they are otherwise authorized to issue life or health insurance.Long-term care insurance shall not include any insurance policy which is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage.With respect or regard to life insurance, long-term care insurance does not include life insurance policies that accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement, and that provide the option of a lump sum payment for those benefits and neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care.Notwithstanding any other provision of sections 376.1100 to 376.1130 to the contrary, any product advertised, marketed, or offered as long-term care insurance shall be subject to the provisions of sections 376.1100 to 376.1130;

(6)"Policy", any policy, subscriber agreement, rider or endorsement delivered or issued for delivery in this state by an insurer; fraternal benefit society; health services corporation; prepaid health plan, health maintenance organization, or any similar organization;

(7)"Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract", the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract that satisfies the requirements of Section 7702B(b) and (e) of the Internal Revenue Code of 1986, as amended."Qualified long-term care insurance contract" also includes an individual or group insurance contract that meets the requirements of Section 7702B(b) of the Internal Revenue Code of 1986, as amended, as follows:

(a)The only insurance protection provided under the contract is coverage of qualified long-term care services.A contract shall not fail to satisfy the requirements of this paragraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate;

(b)The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act, as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount.The requirements of this paragraph do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor.A contract shall not fail to satisfy the requirements of this paragraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate;

(c)The contract is guaranteed renewable within the meaning of Section 7702B(b)(1)(C) of the Internal Revenue Code of 1986, as amended;

(d)The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in paragraph (e) of this subdivision;

(e)All refunds of premiums and all policyholder dividends or similar amounts under the contract are to be applied as a reduction in future premiums or to increase future benefits; except that a refund on the event of death of the insured or a complete surrender or cancellation of the contract shall not exceed the aggregate premiums paid under the contract; and

(f)The contract meets the consumer protection provisions set forth in Section 7702B(g) of the Internal Revenue Code of 1986, as amended.

(L. 1990 S.B. 765 §§ 1, 2, A.L. 2002 H.B. 1568 merged with S.B. 1009)

Transferred 2002; formerly 376.951

376.1500 - Definitions.

As used in sections 376.1500 to 376.1532, the following words or phrases mean:

(1)"Director", the director of the department of insurance, financial institutions and professional registration;

(2)"Discount card", a card or any other purchasing mechanism or device, which is not insurance, that purports to offer discounts or access to discounts in health-related purchases from health care providers;

(3)"Discount medical plan", a business arrangement or contract in which a person, in exchange for fees, dues, charges, or other consideration, provides access for plan members to providers of medical services and the right to receive medical services from those providers at a discount.The term does not include any product regulated as an insurance product, group health service product or membership in a health maintenance organization in this state or discounts provided by an insurer, group health service, or health maintenance organizations where those discounts are provided at no cost to the insured or member and are offered due to coverage with a licensed insurer, group health service, or health maintenance organization.The term does not include an arrangement where the discounts or prices are sold, rented or otherwise provided to another licensed carrier or to a self-insured or self-funded employer sponsored plan or Taft-Hartley trust;

(4)"Discount medical plan organization", means a person or an entity that, in exchange for fees, dues, charges or other consideration, provides access for plan members to providers of medical services and the right to receive medical services from those providers at a discount.It is the person or organization that contracts with providers, provider networks or other discount medical plan organizations to offer access to medical services at a discount and determines the charge to plan members;

(5)"Health care provider", any person or entity licensed by this state to provide health care services including, but not limited to physicians, hospitals, home health agencies, pharmacies, and dentists;

(6)"Health care provider network", an entity which directly contracts with physicians and hospitals and has contractual rights to negotiate on behalf of those health care providers with a discount medical plan organization to provide medical services to members of the discount medical plan organization;

(7)"Marketer", a person or entity who markets, promotes, sells or distributes a discount medical plan, including a private label entity that places its name on and markets or distributes a discount medical plan but does not operate a discount medical plan;

(8)"Medical services", any care, service or treatment of illness or dysfunction of, or injury to, the human body including, but not limited to, physician care, inpatient care, hospital surgical services, emergency services, ambulance services, dental care services, vision care services, mental health services, substance abuse services, chiropractic services, podiatric care services, laboratory services, and medical equipment and supplies.The term does not include pharmaceutical supplies or prescriptions;

(9)"Member", any person who pays fees, dues, charges, or other consideration for the right to receive the purported benefits of a discount medical plan; and

(10)"Person", an individual, corporation, business trust, estate, trust, partnership, association, joint venture, limited liability company, or any other government or commercial entity.

(L. 2007 H.B. 818 and L. 2007 S.B. 66, A.L. 2011 H.B. 315)

376.1359 - Written utilization program implemented, filed with the director.

1.A health carrier that conducts utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated, for covered services provided.The program document shall describe information as required by the director.

2.A health carrier shall file an annual report of its utilization review program activities with the director.

(L. 1997 H.B. 335)

376.1400 - Explanation of benefits, standardized information used, contents, when.

1.Every health insurance carrier offering policies of insurance in this state shall use standardized information for the explanation of benefits given to the health care provider whenever a claim is paid or denied.As used in this section, the term "health insurance carrier" shall have the meaning given to "health carrier" in section 376.1350.Nothing in this section shall apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, short-term major medical policies of six months or less duration, other limited benefit health insurance policies.

2.The standardized information shall contain the following:

(1)The name of the insured;

(2)The insured's identification number;

(3)The date of service;

(4)Amount of charge;

(5)Explanation for any denial;

(6)The amount paid;

(7)The patient's full name;

(8)The name and address of the insurer; and

(9)The phone number to contact for questions on explanation of benefits.

3.All health insurance carriers shall use the standard explanation of benefits information after January 1, 2002.

(L. 1999 H.B. 191)

376.807 - Policies not to reduce or deny benefits to persons eligible for medical assistance — deemed primary contract.

1.No contract of medical expense insurance, delivered or issued for delivery, amended or renewed in this state after August 13, 1988, by a self-insured or self-funded plan, prepaid health plan, health maintenance organization plan, health services corporation plan or insurance company licensed to issue policies in this state, shall contain any provision denying or reducing benefits because services are rendered to an insured or dependent who is eligible for or receiving medical assistance pursuant to chapter 208.

2.All such contracts shall be deemed to be the primary coverage of an insured or dependent who is eligible for or receiving medical assistance pursuant to chapter 208.

(L. 1988 S.B. 430 § 38)

376.756 - Summary document, association to prepare, contents — policy not covered by guaranty association to contain notice, form determined by director.

1.The association shall prepare a summary document describing the general purposes and current limitations of the act and complying with subsection 2 of this section.This document should be submitted to the director for approval.Sixty days after receiving such approval, no insurer may deliver a policy or contract described in subsection 2 of section 376.717 to a policy owner, contract holder, certificate holder, or enrollee unless the document is delivered to the policy or contract holder prior to or at the time of delivery of the policy or contract except if subsection 3 of this section applies.The document should also be available upon request by a policyholder, contract owner, certificate holder, or enrollee.The distribution, delivery, or contents or interpretation of this document shall not mean that either the policy or the contract or the policy owner, contract owner, certificate holder, or enrollee thereof would be covered in the event of the impairment or insolvency of a member insurer.The description document shall be revised by the association as amendments to the act may require.Failure to receive this document does not give the policyholder, contract holder, certificate holder, enrollee, or insured any greater rights than those stated in sections 376.715 to 376.758.

2.The document prepared under subsection 1 of this section shall contain a clear and conspicuous disclaimer on its face.The director shall promulgate a rule establishing the form and content of the disclaimer.The disclaimer shall:

(1)State the name and address of the life and health insurance guaranty association and department of insurance, financial institutions and professional registration;

(2)Prominently warn the policy owner, contract owner, certificate holder, or enrollee that the Missouri life and health insurance guaranty association may not cover the policy or contract or, if coverage is available, it will be subject to substantial limitations, exclusions and conditioned on continued residence in the state;

(3)State that the member insurer and its agents are prohibited by law from using the existence of the life and health insurance guaranty association for the purpose of sales, solicitation or inducement to purchase any form of insurance or health maintenance organization coverage;

(4)Emphasize that the policy owner, contract owner, certificate holder, or enrollee should not rely on coverage under the Missouri life and health insurance guaranty association when selecting an insurer or health maintenance organization;

(5)Provide other information as directed by the director.

3.No insurer or agent may deliver a policy or contract described in subsection 2 of section 376.717 and excluded under subsection 3 of section 376.717 from coverage under the provisions of sections 376.715 to 376.758 unless the insurer or agent, prior to or at the time of delivery, gives the policy or contract holder a separate written notice which clearly and conspicuously discloses that the policy or contract is not covered by the Missouri life and health insurance guaranty association.The director shall by rule specify the form and content of the notice.

(L. 1988 S.B. 430 § 36, A.L. 2018 H.B. 1690)

376.1209 - Mastectomy — mandatory insurance coverage for prosthetic devices and reconstructive surgery — no time limit to be imposed.

1.Each entity offering individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law, and all managed health care delivery entities of any type or description, that provide coverage for the surgical procedure known as a mastectomy, and which are delivered, issued for delivery, continued or renewed in this state on or after January 1, 1998, shall provide coverage for prosthetic devices or reconstructive surgery necessary to restore symmetry as recommended by the oncologist or primary care physician for the patient incident to the mastectomy.Coverage for prosthetic devices and reconstructive surgery shall be subject to the same deductible and coinsurance conditions applied to the mastectomy and all other terms and conditions applicable to other benefits with the exception that no time limit shall be imposed on an individual for the receipt of prosthetic devices or reconstructive surgery and if such individual changes his or her insurer, then the new policy subject to the federal Women's Health and Cancer Rights Act (Sections 901-903 of P.L. 105-277), as amended, shall provide coverage consistent with the federal Women's Health and Cancer Rights Act (Sections 901-903 of P.L. 105-277), as amended, and any regulations promulgated pursuant to such act.

2.As used in this section, the term "mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a physician licensed pursuant to chapter 334.

3.The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy or long-term care policy.

(L. 1997 H.B. 129, A.L. 2001 H.B. 762)

376.1450 - Enrollee's right to receive documents and materials in printed or electronic form, when.

An enrollee, as defined in section 376.1350, may receive documents and materials from a managed care entity in printed or electronic form so long as such documents and materials are readily accessible in printed form upon request.A request by the enrollee may include written, oral, or electronic means.Such requested printed form shall be provided to the enrollee within fifteen business days.For purposes of this section, "managed care entity" includes, but is not limited to, a health maintenance organization, preferred provider organization, point of service organization and any other managed health care delivery entity of any type or description.

(L. 2002 H.B. 1473, A.L. 2010 S.B. 583)

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

1.All health benefit plans which provide coverage for a family member of an enrollee shall, as to such family member's coverage, also provide that the health benefits applicable for children shall be payable with respect to a newly born child of the enrollee from the moment of birth.

2.The coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

3.If payment of a specific premium or subscription fee is required to provide coverage for a child, the health benefit plan may require that notification of birth of a newly born child and payment of the required premium or fees must be furnished to the health carrier within thirty-one days after the date of birth in order to have the coverage continue beyond such thirty-one-day period.If an application or other form of enrollment is required in order to continue coverage beyond the thirty-one-day period after the date of birth and the enrollee has notified the health carrier of the birth, either orally or in writing, the health carrier shall, upon notification, provide the enrollee with all forms and instructions necessary to enroll the newly born child and shall allow the enrollee an additional ten days from the date the forms and instructions are provided in which to enroll the newly born child.

4.The requirements of this section shall apply to all health benefit plans delivered or issued for delivery in this state on or after August 28, 2001.

5.For the purposes of this section, any review, renewal, extension, or continuation of any health benefit plan or of any of the terms, premiums, or subscriptions of the health benefit plan shall constitute a new delivery or issuance for delivery of the health benefit plan.

6.As used in this section, the terms "health benefit plan", "health carrier", and "enrollee" shall have the same meaning as defined in section 376.1350.

(L. 1974 H.B. 1487 §§ 1 to 4, A.L. 1983 S.B. 333, A.L. 2001 H.B. 328 & 88)

(1990) Statute preempted by ERISA.When employer's medical plan is self-insured, it is not subject to the requirement of automatic coverage for newborn children under health insurance plans which provide coverage for family member of the insured.(Mo. App.) St. Louis Children's Hospital v. Commerce Bancshares, Inc., No. 56423, Eastern District, May 9, 1990.

(1991)Language in statute mandating coverage for newborn child borne by a family member where policy provided coverage for family member is sufficiently broad to require mandatory health insurance coverage of a newborn child borne by the insured herself.Kelly v. Pan-American Life Insurance Co., 765 F.Supp. 1406 (W.D. Mo.).

376.1309 - Member's interest — nontransference of membership — immunity from liability — assessments, not imposed — security, membership interest.

1.The membership interest of the policyholders of a reorganized life insurance company shall become membership interests in the mutual holding company.Policyholders of the reorganized life insurance company shall be members of the mutual holding company in accordance with the articles of incorporation and bylaws of the mutual holding company and the applicable provisions of this chapter relating to mutual life insurance companies.

2.No member of a mutual holding company may transfer membership in the holding company or any right arising from such membership.

3.A member of a mutual holding company is not, as a member, personally liable for the acts, debts, liabilities or obligations of the company.

4.No assessments of any kind may be imposed upon the members of a mutual holding company by the directors or members, or because of any liability of any company owned or controlled by the mutual holding company or because of any act, debt or liability of the mutual holding company itself.

5.A membership interest in a domestic mutual holding company shall not constitute a security under the laws of this state.

(L. 1996 S.B. 759)

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

1.Notwithstanding any other provision of law to the contrary, each health carrier that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2005, shall provide coverage for a mental health condition, as defined in this section, and shall comply with the following provisions:

(1)A health benefit plan shall provide coverage for treatment of a mental health condition and shall not establish any rate, term, or condition that places a greater financial burden on an insured for access to treatment for a mental health condition than for access to treatment for a physical health condition.Any deductible or out-of-pocket limits required by a health carrier or health benefit plan shall be comprehensive for coverage of all health conditions, whether mental or physical;

(2)The coverages set forth is this subsection:

(a)May be administered pursuant to a managed care program established by the health carrier; and

(b)May deliver covered services through a system of contractual arrangements with one or more providers, hospitals, nonresidential or residential treatment programs, or other mental health service delivery entities certified by the department of mental health, or accredited by a nationally recognized organization, or licensed by the state of Missouri;

(3)A health benefit plan that does not otherwise provide for management of care under the plan or that does not provide for the same degree of management of care for all health conditions may provide coverage for treatment of mental health conditions through a managed care organization; provided that the managed care organization is in compliance with rules adopted by the department of insurance, financial institutions and professional registration that assure that the system for delivery of treatment for mental health conditions does not diminish or negate the purpose of this section.The rules adopted by the director shall assure that:

(a)Timely and appropriate access to care is available;

(b)The quantity, location, and specialty distribution of health care providers is adequate; and

(c)Administrative or clinical protocols do not serve to reduce access to medically necessary treatment for any insured;

(4)Coverage for treatment for chemical dependency shall comply with sections 376.779, 376.810 to 376.814, and 376.825 to 376.836* and for the purposes of this subdivision the term "health insurance policy" as used in sections 376.779, 376.810 to 376.814, and 376.825 to 376.836*, the term "health insurance policy" shall include group coverage.

2.As used in this section, the following terms mean:

(1)"Chemical dependency", the psychological or physiological dependence upon and abuse of drugs, including alcohol, characterized by drug tolerance or withdrawal and impairment of social or occupational role functioning or both;

(2)"Health benefit plan", the same meaning as such term is defined in section 376.1350;

(3)"Health carrier", the same meaning as such term is defined in section 376.1350;

(4)"Mental health condition", any condition or disorder defined by categories listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders;

(5)"Managed care organization", any financing mechanism or system that manages care delivery for its members or subscribers, including health maintenance organizations and any other similar health care delivery system or organization;

(6)"Rate, term, or condition", any lifetime or annual payment limits, deductibles, co-payments, coinsurance, and other cost-sharing requirements, out-of-pocket limits, visit limits, and any other financial component of a health benefit plan that affects the insured.

3.This section shall not apply to a health plan or policy that is individually underwritten or provides such coverage for specific individuals and members of their families pursuant to section 376.779, sections 376.810 to 376.814, and sections 376.825 to 376.836*, a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, hospitalization-surgical care policy, short-term major medical policies of six months or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

4.Notwithstanding any other provision of law to the contrary, all health insurance policies that cover state employees, including the Missouri consolidated health care plan, shall include coverage for mental illness.Multiyear group policies need not comply until the expiration of their current multiyear term unless the policyholder elects to comply before that time.

5.The provisions of this section shall not be violated if the insurer decides to apply different limits or exclude entirely from coverage the following:

(1)Marital, family, educational, or training services unless medically necessary and clinically appropriate;

(2)Services rendered or billed by a school or halfway house;

(3)Care that is custodial in nature;

(4)Services and supplies that are not immediately nor clinically appropriate; or

(5)Treatments that are considered experimental.

6.The director shall grant a policyholder a waiver from the provisions of this section if the policyholder demonstrates to the director by actual experience over any consecutive twenty-four-month period that compliance with this section has increased the cost of the health insurance policy by an amount that results in a two percent increase in premium costs to the policyholder.The director shall promulgate rules establishing a procedure and appropriate standards for making such a demonstration.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2004, shall be invalid and void.

(L. 2004 H.B. 855, A.L. 2018 S.B. 718 merged with S.B. 951)

*Sections 376.825 to 376.836 were repealed by H.B. 1298 Revision, 2014.

376.1109 - Policies, content requirements, provisions prohibited — rules authorized — cancellation, refund required.

1.The director may adopt regulations that include standards for full and fair disclosure setting forth the manner, content and required disclosures for the sale of long-term care insurance policies, terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, continuation or conversion, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, recurrent conditions and definitions of terms.Regulations adopted pursuant to sections 376.1100 to 376.1130 shall be in accordance with the provisions of chapter 536.

2.No long-term care insurance policy may:

(1)Be cancelled, nonrenewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder; or

(2)Contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or

(3)Provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than for lower levels of care.

3.No long-term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in paragraph (a) of subdivision (4) of subsection 2 of section 376.1100:

(1)Shall use a definition of preexisting condition which is more restrictive than the following:"Preexisting condition" means a condition for which medical advice or treatment was recommended by, or received from, a provider of health care services, within six months preceding the effective date of coverage of an insured person;

(2)May exclude coverage for a loss or confinement which is the result of a preexisting condition unless such loss or confinement begins within six months following the effective date of coverage of an insured person.

4.The director may extend the limitation periods set forth in subdivisions (1) and (2) of subsection 3 of this section as to specific age group categories in specific policy forms upon findings that the extension is in the best interest of the public.

5.The definition of preexisting condition provided in subsection 3 of this section does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that insurer's established underwriting standards.Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in subdivision (2) of subsection 3 of this section expires.No long-term care insurance policy or certificate may exclude or use waivers or riders of any kind to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subdivision (2) of subsection 3 of this section.

6.No long-term care insurance policy may be delivered or issued for delivery in this state if such policy:

(1)Conditions eligibility for any benefits on a prior hospitalization requirement; or

(2)Conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care; or

(3)Conditions eligibility for any benefits other than waiver of premium, post-confinement, post-acute care or recuperative benefits on a prior institutionalization requirement.

7.A long-term care insurance policy containing post-confinement, post-acute care or recuperative benefits shall clearly label in a separate paragraph of the policy or certificate entitled "Limitations or Conditions on Eligibility for Benefits" such limitations or conditions, including any required number of days of confinement.

8.A long-term care insurance policy or rider which conditions eligibility of noninstitutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than thirty days.

9.No long-term care insurance policy or rider which provides benefits only following institutionalization shall condition such benefits upon admission to a facility for the same or related conditions within a period of less than thirty days after discharge from the institution.

10.The director may adopt regulations establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term care insurance policies is contained in the regulation.

11.Long-term care insurance applicants shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason.Long-term care insurance policies and certificates shall have a notice prominently printed on the first page or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, other than a certificate issued pursuant to a policy issued to a group defined in paragraph (a) of subdivision (4) of subsection 2 of section 376.1100, the applicant is not satisfied for any reason.This subsection shall also apply to denials of applications and any refund must be made within thirty days of the return or denial.

12.(1)If a long-term care insurance policy issued, delivered, or renewed in this state on or after January 1, 2011, is cancelled for any reason, the insurer shall refund the unearned portion of any premium paid beyond the month in which the cancellation is effective.Any refund shall be returned to the policyholder within twenty days from the date the insurer receives notice of the cancellation.Long-term care insurance policies and certificates shall have a notice prominently printed on the first page or attached thereto stating in substance that the applicant shall be entitled to a refund of the unearned premium if the policy is cancelled for any reason.

(2)The policyholder may notify the insurer of cancellation of such long-term care insurance policy at any time by sending written or electronic notification.

(L. 1990 S.B. 765 § 5, A.L. 2002 H.B. 1568 merged with S.B. 1009, A.L. 2010 S.B. 583)

Transferred 2002; formerly 376.955

376.1750 - Health care sharing ministry, provisions not to apply to — ministry not engaging in the business of insurance, when — health care sharing ministry defined.

1.The provisions of this chapter relating to health insurance, health maintenance organizations, health benefit plans, group health services, and health carriers shall not apply to a health care sharing ministry.A health care sharing ministry which, through its publication to members or subscribers, solicits funds for the payment of medical expenses of other subscribers or members, shall not be considered to be engaging in the business of insurance for purposes of this chapter or any provision of Title XXIV and shall not be subject to the jurisdiction of the director if the requirements of subsection 2 of this section are met.

2.As used in this section, a "health care sharing ministry" is a faith-based nonprofit organization tax exempt under the Internal Revenue Code that:

(1)Limits its membership to those who are of a similar faith;

(2)Acts as an organizational clearinghouse for information between members or subscribers who have financial, physical, or medical needs and members or subscribers with the present ability to assist those with present financial or medical needs;

(3)Provides for the financial or medical needs of a member or subscriber through gifts directly from one member or subscriber to another.The requirements of this subdivision can be satisfied by a trust established solely for the benefit of members or subscribers, which trust is audited annually by an independent auditing firm;

(4)Provides amounts that members or subscribers may give with no assumption of risk or promise to pay either among the members or subscribers or between the members or subscribers and such organization;

(5)Provides a written monthly statement to all members or subscribers, listing the total dollar amount of qualified needs submitted to such organization, as well as the amount actually published or assigned to members or subscribers for voluntary payment; and

(6)Provides the following written disclaimer on or accompanying all promotional or informational documents distributed by or on behalf of the organization, including applications, and guideline materials:

"NOTICE

This publication is not an insurance company nor is it offered through an insurance company.Whether anyone chooses to assist you with your medical bills will be totally voluntary, as no other subscriber or member will be compelled to contribute toward your medical bills.As such, this publication should never be considered to be insurance.Whether you receive any payments for medical expenses and whether or not this publication continues to operate, you are always personally responsible for the payment of your own medical bills.".

(L. 2007 H.B. 818)

376.302 - Mortgage interests, may be acquired, when — other real estate interests.

1.(1)Subject to the limitations of section 376.297, an insurer may acquire directly or indirectly through limited partnership interests and general partnership interests not otherwise prohibited by subsection 4 of section 376.294, joint ventures, stock of an investment subsidiary or membership interests in a limited liability company, trust certificates, or other similar instruments or obligations secured by mortgages on real estate situated within a domestic jurisdiction, but a mortgage loan which is secured by other than a first lien shall not be acquired under this subdivision unless the insurer is the holder of the first lien.The obligations held by the insurer and any obligations with an equal lien priority shall not at the time of acquisition of the obligation exceed:

(a)Ninety percent of the fair market value of the real estate if the mortgage loan is secured by a purchase money mortgage or like security received by the insurer upon disposition of the real estate;

(b)Eighty percent of the fair market value of the real estate if the mortgage requires immediate scheduled payment in periodic installments of principal and interest and has an amortization period of thirty years or less and periodic payments not less than annually.Each periodic payment shall be sufficient to assure that at all times:

a.The outstanding principal balance of the mortgage loan is not greater than the outstanding principal balance that would be outstanding under a mortgage loan with the same original principal balance and interest rate; and

b.There are equal payments of principal and interest with the same frequency over the same amortization period.

Mortgage loans permitted under this subsection are permitted notwithstanding the fact that they provide for a payment of the principal balance prior to the end of the period of the amortization of the loan.For residential mortgage loans, the eighty percent limitation may be increased to ninety-seven percent if acceptable private mortgage insurance has been obtained; or

(c)Seventy-five percent of the fair market value of the real estate for mortgage loans that do not meet the requirements of paragraph (a) or (b) of this subdivision.

(2)For purposes of subdivision (1) of this subsection, the amount of an obligation required to be included in the calculation of the loan-to-value ratio may be reduced to the extent the obligation is insured by the Federal Housing Administration or guaranteed by the Administrator of Veterans' Affairs, or their successor.

(3)Subject to the limitations of section 376.297, an insurer may acquire directly or indirectly through limited partnership interests and general partnership interests not otherwise prohibited by subsection 4 of section 376.294, joint ventures, stock of an investment subsidiary or membership interests in a limited liability company, trust certificates, or other similar instruments or obligations secured by a second mortgage on real estate situated within a domestic jurisdiction other than as authorized in subdivision (1) of this subsection.The obligation held by the insurer shall be the sole second lien priority obligation and shall not at the time of acquisition of the obligation exceed seventy percent of the amount by which the fair market value of the real estate exceeds the amount outstanding under the first mortgage.

(4)A mortgage loan that is held by an insurer under subdivision (6) of subsection 1 of section 376.293 or acquired under this section and is restructured in a manner that meets the requirements of a restructured mortgage loan in accordance with the NAIC Accounting Practices and Procedures Manual or its successor publication shall continue to qualify as a mortgage loan.

(5)Subject to the limitations of section 376.297, credit lease transactions that do not qualify for investment under section 376.298 with the following characteristics shall be exempt from the provisions of subdivision (1) of this subsection:

(a)The loan amortizes over the initial fixed lease term at least in an amount sufficient so that the loan balance at the end of the lease term does not exceed the original appraised value of the real estate;

(b)The lease payments cover or exceed the total debt service over the life of the loan;

(c)A tenant or its affiliated entity whose rated credit instruments have a SVO "1" or "2" designation or a comparable rating from a nationally recognized statistical rating organization recognized by the SVO has a full faith and credit obligation to make the lease payments;

(d)The insurer holds or is the beneficial holder of a first lien mortgage on the real estate;

(e)The expenses of the real estate are passed through to the tenant, excluding exterior structural, parking and heating, ventilation and air conditioning replacement expenses, unless annual escrow contributions from cash flows derived from the lease payments cover the expense shortfall; and

(f)There is a perfected assignment of the rents due under the lease to or for the benefit of the insurer.

2.(1)An insurer may acquire, manage, and dispose of real estate situated in a domestic jurisdiction directly or indirectly through limited partnership interests and general partnership interests not otherwise prohibited by subsection 4 of section 376.294, joint ventures, stock of an investment subsidiary or membership interests in a limited liability company, trust certificates, or other similar instruments.The real estate shall be income producing or intended for improvement or development for investment purposes under an existing program in which case the real estate shall be deemed to be income producing.

(2)The real estate may be subject to mortgages, liens, or other encumbrances, and the amount of which shall, to the extent that the obligations secured by the mortgages, liens, or encumbrances are without recourse to the insurer, be deducted from the amount of the investment of the insurer in the real estate for purposes of determining compliance with subdivisions (2) and (3) of subsection 4 of this section.

3.An insurer may acquire, manage, and dispose of real estate for the convenient accommodation of the insurer's (which may include its affiliates) business operations, including home office, branch office, and field office operations.Such real estate acquired may:

(1)Include excess space for rent to others if the excess space at its fair market value would otherwise be a permitted investment under subsection 2 of this section and is so qualified by the insurer; or

(2)Be subject to one or more mortgage, lien, or other encumbrance, and the amount of which shall, to the extent that the obligations secured by the mortgages, liens, or encumbrances are without recourse to the insurer, be deducted from the amount of the investment of the insurer in the real estate for purposes of determining compliance with subsection 4 of this section.

For purposes of this subsection, business operations shall not include that portion of real estate used for the direct provision of health care services by an accident and health insurer for its insureds.An insurer may acquire real estate used for these purposes under subsection 2 of this section.

4.An insurer may not acquire an investment:

(1)Under subsection 1 of this section, if as a result of, and after giving effect to the investment, the aggregate amount of all investments then held by the insurer under subsection 1 of this section would not exceed:

(a)One percent of its admitted assets in mortgage loans covering any one secured location;

(b)One-fourth of one percent of its admitted assets in construction loans covering any one secured location; or

(c)Two percent of its admitted assets in construction loans in the aggregate;

(2)Under subsection 2 of this section if as a result of and after giving effect to the investment and any outstanding guarantees made by the insurer in connection with the investment the aggregate amount of investments then held by the insurer under subsection 2 of this section plus the guarantees then outstanding would exceed:

(a)One percent of its admitted assets in one parcel or group of contiguous parcels of real estate, except that this limitation shall not apply to that portion of real estate used for the direct provision of health care services by an accident and health insurer for its insureds, such as hospitals, medical clinics, medical professional buildings, or other health facilities for the purposes of providing health services; or

(b)Fifteen percent of its admitted assets in the aggregate but not more than five percent of its admitted assets in real estate to be improved or developed;

(3)Under subsection 1 or 2 of this section if as a result of and after giving effect to the investment and any guarantees made by the insurer in connection with the investment the aggregate amount of all investments then held by the insurer under subsections 1 and 2 of this section plus the guarantees then outstanding would exceed forty-five percent of its admitted assets.However, an insurer may exceed this limitation by no more than thirty percent of its admitted assets if:

(a)This increased amount is invested only in residential mortgage loans;

(b)The insurer has no more than ten percent of its admitted assets invested in mortgage loans other than residential mortgage loans;

(c)The loan-to-value ratio of each residential mortgage loan does not exceed sixty percent at the time the mortgage loan is qualified under this increased authority and the fair market value is supported by an appraisal no more than two years old prepared by an independent appraiser;

(d)A single mortgage loan qualified under this increased authority does not exceed one-half of one percent of its admitted assets;

(e)The insurer files with the director and receives approval from the director for a plan that is designed to result in a portfolio of residential mortgage loans that is geographically diversified; and

(f)The insurer agrees to file annually with the director records that demonstrate that its portfolio of residential mortgage loans is geographically diversified in accordance with the plan.

The limitations of section 376.297 shall not apply to an insurer's acquisition of real estate under subsection 3 of this section.An insurer shall not acquire real estate under subsection 3 of this section if as a result of and after giving effect to the acquisition the aggregate amount of real estate then held by the insurer under subsection 3 of this section would exceed ten percent of its admitted assets.With the permission of the director, additional amounts of real estate may be acquired under subsection 3 of this section.

(L. 2007 S.B. 66)

376.706 - Delivery of guide and summary required, when.

1.The insurer shall provide, to all prospective purchasers, a buyer's guide and a policy summary prior to accepting the applicant's initial premium or premium deposit, unless the policy for which application is made contains an unconditional refund provision of at least ten days or unless the policy summary contains such an unconditional refund offer, in which event the buyer's guide and policy summary must be delivered with the policy or prior to delivery of the policy.

2.The insurer shall provide a buyer's guide and a policy summary to any prospective purchaser upon request.

3.In the case of policies whose equivalent level death benefit does not exceed five thousand dollars, the requirement for providing a policy summary will be satisfied by delivery of a written statement containing the information described in section 376.704(7), items (b), (c), (d), (e)b., (e)c., (f), (g), (j) and (k).

(L. 1979 H.B. 508 § 4)

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

1.All individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed on or after August 28, 1999, and providing coverage to any resident of this state shall provide benefits or coverage for:

(1)A pelvic examination and pap smear for any nonsymptomatic woman covered under such policy or contract, in accordance with the current American Cancer Society guidelines;

(2)A prostate examination and laboratory tests for cancer for any nonsymptomatic man covered under such policy or contract, in accordance with the current American Cancer Society guidelines; and

(3)A colorectal cancer examination and laboratory tests for cancer for any nonsymptomatic person covered under such policy or contract, in accordance with the current American Cancer Society guidelines.

2.Coverage and benefits related to the examinations and tests as required by this section shall be at least as favorable and subject to the same dollar limits, deductible, and co-payments as other covered benefits or services.

3.Nothing in this act shall apply to accident-only, hospital indemnity, Medicare supplement, long-term care, or other limited benefit health insurance policies.

4.The provisions of this section shall not apply to short-term major medical policies of six months or less duration.

5.The attending physician shall advise the patient of the advantages, disadvantages, and risks, including cancer, associated with breast implantation prior to such operation.

6.Nothing in this section shall alter, impair or otherwise affect claims, rights or remedies available pursuant to law.

(L. 1999 H.B. 191 § 1, A.L. 2011 H.B. 388)

376.1350 - Definitions.

For purposes of sections 376.1350 to 376.1390*, the following terms mean:

(1)"Adverse determination", a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the payment for the requested service is therefore denied, reduced or terminated;

(2)"Ambulatory review", utilization review of health care services performed or provided in an outpatient setting;

(3)"Case management", a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions;

(4)"Certification", a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness;

(5)"Clinical peer", a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review;

(6)"Clinical review criteria", the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the necessity and appropriateness of health care services;

(7)"Concurrent review", utilization review conducted during a patient's hospital stay or course of treatment;

(8)"Covered benefit" or "benefit", a health care service that an enrollee is entitled under the terms of a health benefit plan;

(9)"Director", the director of the department of insurance, financial institutions and professional registration;

(10)"Discharge planning", the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility;

(11)"Drug", any substance prescribed by a licensed health care provider acting within the scope of the provider's license and that is intended for use in the diagnosis, mitigation, treatment or prevention of disease.The term includes only those substances that are approved by the FDA for at least one indication;

(12)"Emergency medical condition", the sudden and, at the time, unexpected onset of a health condition that manifests itself by symptoms of sufficient severity, regardless of the final diagnosis that is given, that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that immediate medical care is required, which may include, but shall not be limited to:

(a)Placing the person's health in significant jeopardy;

(b)Serious impairment to a bodily function;

(c)Serious dysfunction of any bodily organ or part;

(d)Inadequately controlled pain; or

(e)With respect to a pregnant woman who is having contractions:

a.That there is inadequate time to effect a safe transfer to another hospital before delivery; or

b.That transfer to another hospital may pose a threat to the health or safety of the woman or unborn child;

(13)"Emergency service", a health care item or service furnished or required to evaluate and treat an emergency medical condition, which may include, but shall not be limited to, health care services that are provided in a licensed hospital's emergency facility by an appropriate provider;

(14)"Enrollee", a policyholder, subscriber, covered person or other individual participating in a health benefit plan;

(15)"FDA", the federal Food and Drug Administration;

(16)"Facility", an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings;

(17)"Grievance", a written complaint submitted by or on behalf of an enrollee regarding the:

(a)Availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

(b)Claims payment, handling or reimbursement for health care services; or

(c)Matters pertaining to the contractual relationship between an enrollee and a health carrier;

(18)"Health benefit plan", a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services; except that, health benefit plan shall not include any coverage pursuant to liability insurance policy, workers' compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy;

(19)"Health care professional", a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services consistent with state law;

(20)"Health care provider" or "provider", a health care professional or a facility;

(21)"Health care service", a service for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease;

(22)"Health carrier", an entity subject to the insurance laws and regulations of this state that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or health services; except that such plan shall not include any coverage pursuant to a liability insurance policy, workers' compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy;

(23)"Health indemnity plan", a health benefit plan that is not a managed care plan;

(24)"Managed care plan", a health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use, health care providers managed, owned, under contract with or employed by the health carrier;

(25)"Participating provider", a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the health carrier;

(26)"Peer-reviewed medical literature", a published scientific study in a journal or other publication in which original manuscripts have been published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts, and that has been determined by the International Committee of Medical Journal Editors to have met the uniform requirements for manuscripts submitted to biomedical journals or is published in a journal specified by the United States Department of Health and Human Services pursuant to Section 1861(t)(2)(B) of the Social Security Act, as amended, as acceptable peer-reviewed medical literature.Peer-reviewed medical literature shall not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier;

(27)"Person", an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing;

(28)"Prospective review", utilization review conducted prior to an admission or a course of treatment;

(29)"Retrospective review", utilization review of medical necessity that is conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment;

(30)"Second opinion", an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health service to assess the clinical necessity and appropriateness of the initial proposed health service;

(31)"Stabilize", with respect to an emergency medical condition, that no material deterioration of the condition is likely to result or occur before an individual may be transferred;

(32)"Standard reference compendia":

(a)The American Hospital Formulary Service-Drug Information; or

(b)The United States Pharmacopoeia-Drug Information;

(33)"Utilization review", a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings.Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review.Utilization review shall not include elective requests for clarification of coverage;

(34)"Utilization review organization", a utilization review agent as defined in section 374.500.

(L. 1997 H.B. 335, A.L. 2002 H.B. 1468 merged with H.B. 1473, A.L. 2018 S.B. 982)

*Section 376.1390 does not exist.

376.702 - Application of law — exceptions.

1.Except as hereafter exempted, sections 376.700 to 376.714 shall apply to any solicitation, negotiation or procurement of life insurance occurring within this state.Sections 376.700 to 376.714 shall apply to every issuer of life insurance contracts including fraternal benefit societies.

2.Unless otherwise specifically included, the provisions of sections 376.700 to 376.714 shall not apply to:

(1)Annuities;

(2)Credit life insurance;

(3)Group life insurance;

(4)Life insurance policies issued in connection with pension and welfare plans as defined by and which are subject to the federal Employee Retirement Income Security Act of 1974 (ERISA); or

(5)Variable life insurance under which the death benefits and cash values vary in accordance with unit values of investments held in a separate account.

(L. 1979 H.B. 508 § 2)

376.306 - Cash surrender value, life insurer may lend to policyholder, when.

A life insurer may lend to a policyholder on the security of the cash surrender value of the policyholder's policy a sum not to exceed the legal reserve that the insurer is required to maintain on the policy.

(L. 2007 S.B. 66)

376.502 - Life insurers not to discriminate based on lawful travel destinations — violations, penalty.

1.No life insurance company doing business within this state shall deny or refuse to accept an application for life insurance, refuse to renew, cancel, restrict, or otherwise terminate a policy of life insurance, or charge a different rate for the same life insurance coverage, based upon the applicant's or insured's past or future lawful travel destinations.Nothing in this section shall prohibit a life insurance company from denying an application for life insurance, or restricting or charging a different premium or rate for coverage under such a policy based on a specific travel destination where the denial, restriction, or rate differential is based upon sound actuarial principles or is related to actual or reasonably anticipated experience.

2.A violation of the provisions of this section shall be unfair trade practice as defined by sections 375.930 to 375.948 and shall be governed by and subject to all of the provisions and penalties provided by such sections.

3.The provisions of this section shall apply to any life insurance policy issued or renewed on or after August 28, 2009.

(L. 2009 H.B. 577 merged with S.B. 126)

376.2011 - Violations, administrative orders, civil actions — penalty.

1.If the director determines that a person has engaged, is engaging, or has taken a substantial step toward engaging in an act, practice, omission, or course of business constituting a violation of sections 376.2000 to 376.2014 or a rule adopted or order issued pursuant thereto, or a person has materially aided or is materially aiding an act, practice, omission, or course of business constituting a violation in sections 376.2000 to 376.2014 or a rule adopted or order issued pursuant thereto, the director may issue such administrative orders as authorized under section 374.046.

2.If the director believes that a person has engaged, is engaging, or has taken a substantial step toward engaging in an act, practice, omission, or course of business constituting a violation of sections 376.2000 to 376.2014 or a rule adopted or order issued pursuant thereto, or that a person has materially aided or is materially aiding an act, practice, omission, or course of business constituting a violation in sections 376.2000 to 376.2014 or a rule adopted or order issued pursuant thereto, the director may maintain a civil action for relief authorized under section 374.048.

3.A violation of sections 376.2000 to 376.2014 is a level two violation under section 374.049.

(L. 2013 S.B. 262)

Effective 7-12-13

376.1305 - Formation of holding company, application — shareholder approval.

1.A mutual life insurance company proposing to reorganize pursuant to sections 376.1300 to 376.1322 shall form a mutual life insurance holding company, which may hereafter be referred to as a mutual holding company, and shall file an application with the director of the department of insurance, financial institutions and professional registration which shall contain such insurer's plan of reorganization.The director shall review the application, and may retain such consultants as may be reasonably necessary, at the expense of the applicant; conduct an adequate review to assure that policyholders' interests are protected and may conduct a public hearing.The director shall approve the formation of the mutual holding company and the plan of reorganization if the director finds that the plan is fair and equitable to the policyholders.The director may condition such approval on adoption of modifications to the plan if the director finds such modifications are necessary for the protection of the policyholders' interests.

2.No mutual life insurance company may reorganize pursuant to sections 376.1300 to 376.1322 unless the reorganization plan is approved by a majority of the policyholders voting in person or by proxy at a special meeting called for that purpose.Any group of at least one hundred policyholders having a right to vote at such special meeting shall be entitled at their own expense to have the secretary of the company mail informational materials to all policyholders provided that such materials and the cost thereof are presented to the secretary at least forty-five days before the special meeting.

(L. 1996 S.B. 759)

376.806 - Refund of health insurance unearned premium on notice of death of insured — refunded to whom — definitions — exception — failure to notify within one year.

1.As used in this section, the following terms mean:

(1)"Health insurance contract", any one of the following when providing coverage to a resident of this state:

(a)Individual insurance policies providing coverage on an expense incurred basis;

(b)Individual indemnity type contracts issued by a health services corporation;

(c)Any individual contract issued by a health maintenance organization;

(d)Any self-insured health benefit plan, except to the extent preempted by federal law;

(e)Group health insurance in which the insured pays the full premium directly to the insurer, health services corporation or health maintenance corporation;

(2)"Health insurer", any entity issuing a health insurance contract.

2.A health insurer shall refund promptly any premium which it did not earn, upon notification of the death of any person covered under the health insurer's health insurance contract.The health insurer shall earn only that part of the premiums paid on behalf of the decedent which the period of coverage during which the decedent was alive bears to the whole period for which premiums were paid.

3.The refund of premiums shall be made directly to:

(1)The decedent's spouse at the time of the decedent's death;

(2)The primary insured person under the health insurance contract, if the decedent was not married at the time of death and was covered under the health insurance contract as a dependent;

(3)The decedent's estate, if neither subdivision (1) nor (2) of this subsection is applicable.

4.This section does not apply if the notification of the death of an insured person is given to the health insurer more than one year after the death of the decedent.

(L. 1991 H.B. 561 § 1)

376.1005 - Application for certificate of authority, form — fee — policy or other evidence of coverage provided to employees, form.

1.Application for a certificate of authority shall be made on forms prescribed by the director of the department of insurance, financial institutions and professional registration.No multiple employer self-insured health plan may hold or obtain a certificate of authority unless it had not less than two hundred fifty covered employees during the preceding calendar quarter.

2.Not later than March first of each year, every multiple employer self-insured health plan shall pay to the director a license fee equal to two percent of the Missouri claims paid by the plan during the immediately preceding calendar year.All the funds collected by the director shall be deposited in the Missouri department of insurance, financial institutions and professional registration dedicated fund.

3.Within forty-five days from the date coverage commences, the plan shall issue to each covered employee a policy, contract, certificate, summary plan description or other evidence of the benefits and coverages provided.This evidence of the benefits and coverages provided shall contain in boldfaced print in a conspicuous location, the following statement:

"The benefits and coverages described herein are provided through a trust fund established and funded by a group of employers.The benefits and coverages are not fully insured by an insurer licensed to do business in the state of Missouri and are therefore not protected by the Missouri Life and Health Guaranty Association".

(L. 1993 H.B. 709 § 24)

376.453 - Premium — only cafeteria plans required, when.

1.An employer that provides health insurance coverage for which any portion of the premium is payable by the employer shall not provide such coverage unless the employer has established a premium-only cafeteria plan as permitted under federal law, 26 U.S.C. Section 125.The provisions of this subsection shall not apply to employers who offer health insurance through any self-insured or self-funded group health benefit plan of any type or description.

2.Nothing in this section shall prohibit or otherwise restrict an employer's ability to either provide a group health benefit plan or create a premium-only cafeteria plan with defined contributions and in which the employee purchases the policy.

(L. 2007 H.B. 818)

Effective 1-01-08

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.

1.No health carrier or health benefit plan that offers or issues health benefit plans, other than Medicaid health benefit plans, shall deliver, issue for delivery, continue, or renew a health benefit plan to a Missouri resident on or after January 1, 2011, unless the health benefit plan covers adopted children of the insured, subscriber or enrollee on the same basis as other dependents.

2.The coverage required by subsection 1 of this section is effective:

(1)From the date of birth if a petition for adoption is filed within thirty days of the birth of such child; or

(2)From the date of placement for the purpose of adoption if a petition for adoption is filed within thirty days of placement of such child.

Such coverage shall continue unless the placement is disrupted prior to legal adoption and the child is removed from placement.Coverage shall include the necessary care and treatment of medical conditions existing prior to the date of placement.

3.As used in this section, the following terms shall mean:

(1)"Health benefit plan", the same meaning as such term is defined in section 376.1350;

(2)"Health carrier", the same meaning as such term is defined in section 376.1350;

(3)"Placement", in the physical custody of the adoptive parent.

(L. 1991 S.B. 352 § 8, A.L. 1998 S.B. 674, A.L. 2010 S.B. 583)

376.1215 - Immunizations, mandated coverage, exceptions, rulemaking.

1.All individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a health services corporation, individual and group service contracts issued by a health maintenance organization and all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description shall provide coverage for immunizations of a child from birth to five years of age as provided by department of health and senior services regulations.

2.Such coverage shall not be subject to any deductible or co-payment limits.

3.The contract issued by a health maintenance organization may provide that the benefits required pursuant to this section shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization, except that the health maintenance organization shall, as a condition of participation, comply with the immunization requirements of state or federally funded health programs.

4.This section shall not apply to supplemental insurance policies, including life care contracts, accident-only policies, specified disease policies, hospital policies providing a fixed daily benefit only, Medicare supplement policies, long-term care policies, coverage issued as a supplement to liability insurance, short-term major medical policies of six months or less duration and other supplemental policies as determined by the department of insurance, financial institutions and professional registration.

5.The department of health and senior services shall promulgate rules and regulations to determine which immunizations shall be covered by policies, plans or contracts described in this section.No rule or portion of a rule promulgated under the authority of this section shall become effective unless it has been promulgated pursuant to the provisions of section 536.024.

6.No health care provider shall charge more than one hundred percent of the reasonable and customary charges for providing any immunization.

(L. 1996 H.B. 904, et al. § 1)

376.1315 - Incorporation of mutual holding company, authority, approval.

Notwithstanding any provision of this chapter to the contrary, a mutual holding company organized pursuant to section 376.1300 shall be incorporated pursuant to this chapter.The articles of incorporation and any amendments to such articles of the mutual holding company shall be subject to approval of the director of the department of insurance, financial institutions and professional registration and the attorney general in the same manner as those of a mutual life insurance company.

(L. 1996 S.B. 759)

376.747 - Distribution of member insurer assets upon liquidation, priority of association.

1.Prior to the termination of any liquidation, rehabilitation, or conservation proceeding, the court may take into consideration the contributions of the respective parties, including the association, the shareholders, contract owners, certificate holders, enrollees, and policy owners of the insolvent insurer, and any other party with a bona fide interest, in making an equitable distribution of the ownership rights of such insolvent insurer.In such a determination consideration shall be given to the welfare of the policy owners, contract owners, certificate holders, enrollees, and policyholders of the continuing or successor member insurer.

2.No distribution to stockholders, if any, of an impaired or insolvent insurer shall be made until and unless the total amount of valid claims of the association with interest thereon for funds expended in carrying out its powers and duties under the provisions of sections 376.715 to 376.758 with respect to such member insurer have been fully recovered by the association.

(L. 1988 S.B. 430 § 28, A.L. 2018 H.B. 1690)

376.143 - Stock company may acquire its own shares to be held in trust for mutual — appointment, powers and duties of trustees.

1.If a domestic stock life insurance corporation determines to become a mutual life insurance corporation, it may, in carrying out any plan to that end under section 376.142, acquire any shares of its own stock by gift, bequest, or purchase.Until all of such shares are acquired, any shares so acquired, or acquired pursuant to section 376.144, shall be acquired in trust for the corporation as provided in subsection 2, and shall be assigned and transferred on the books of the corporation to not less than three nor more than five trustees.Such shares shall be held by them in trust and be voted by such trustees at all corporate meetings at which stockholders have the right to vote, until all of the capital stock of such corporation is acquired, at which time the entire capital stock shall be retired and cancelled and the corporation shall become, thereupon, a mutual life insurance corporation without capital stock.

2.The trustees provided for in subsection 1 shall be appointed and vacancies shall be filled by the director of the department of insurance, financial institutions and professional registration.Such trustees shall be qualified directors of the corporation at the time of such appointment and shall continue as such trustees until the purpose of the trust is accomplished or abandoned, unless they are removed for cause by the director.Said trustees shall file with the director a verified acceptance of their appointment and a declaration that they will faithfully discharge their duties as trustees.Such trustees shall give and file with the director bonds in such an amount as under the circumstances the director deems proper, with sureties thereon approved by the director.All dividends and other sums received by said trustees on the shares of stock held by them shall be immediately repaid to said corporation.The necessary expenses of executing the trust shall be paid by the corporation.All shares held by such trustees are considered as admitted assets of such corporation at their par value.

3.Neither the retirement of the corporation's capital stock nor the amendment of its articles of incorporation shall affect existing suits, rights, or contracts of such corporation.The deposit of securities made by such corporation, pursuant to sections 376.010 to 376.670, shall be retained by the director in trust for the benefit and security of all of the members and policyholders of such corporation.

(L. 1957 p. 224 §§ 2, 4)

376.1115 - Coverage outline to be delivered to applicants, when, content.

1.An outline of coverage shall be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means which prominently direct the attention of the recipient to the document and its purpose.The director shall prescribe a standard format, including style, arrangement and overall appearance, and the content of an outline of coverage.In the case of agent solicitations, an agent shall deliver the outline of coverage prior to the presentation of an application or enrollment form.In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with any application or enrollment form.In the case of a policy issued to a group defined in section 376.1100, an outline of coverage shall not be required to be delivered; provided that the information described in subdivisions (1) to (6) of subsection 2 of this section is contained in other materials relating to enrollment.Upon request, such other materials shall be made available to the director.

2.The outline of coverage shall include:

(1)A description of the principal benefits and coverage provided in the policy;

(2)A statement of the principal exclusions, reductions, and limitations contained in the policy;

(3)A statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change the premium.Continuation or conversion provisions of group coverage shall be specifically described;

(4)A statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions;

(5)A description of the terms under which the policy or certificate may be returned and premium refunded;

(6)A brief description of the relationship of cost of care and benefits; and

(7)A statement that discloses to the policyholder or certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.

3.A certificate issued pursuant to a group long-term care insurance policy which policy is delivered or issued for delivery in this state shall include:

(1)A description of the principal benefits and coverage provided in the policy;

(2)A statement of the principal exclusions, reductions and limitations contained in the policy; and

(3)A statement that the group master policy determines governing contractual provisions.

4.If an application for a long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later than thirty days after the date of approval.

5.At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy which provides long-term care benefits within the policy or by rider.In the case of direct response solicitations, the insurer shall deliver the policy summary upon the applicant's request, but regardless of request shall make such delivery no later than at the time of policy delivery.In addition to complying with all applicable requirements, the summary shall also include:

(1)An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;

(2)An illustration of the amount of benefits, the length of benefit, and the guaranteed lifetime benefits, if any, for each covered person;

(3)Any exclusions, reductions and limitations on benefits of long-term care;

(4)A statement that any long-term care inflation protection option that may be required by the laws of this state is not available under the policy; and

(5)If applicable to the policy type, the summary shall also include:

(a)A disclosure of the effects of exercising other rights under the policy;

(b)A disclosure of guarantees related to long-term care costs of insurance charges;

(c)Current and projected maximum lifetime benefits; and

(d)The provisions of the policy summary listed in paragraphs (a) to (c) of this subdivision may be incorporated into a basic illustration required to be delivered in accordance with sections 375.1509 or into the life insurance policy summary required to be delivered in accordance with section 376.706.

(L. 1990 S.B. 765 § 6 subsecs. 2 to 5, A.L. 2002 H.B. 1568 merged with S.B. 1009)

Transferred 2002; formerly 376.957

376.1015 - Department not to grant approval, when.

The department shall not grant or renew approval as to any plan if the department determines:

(1)Any trustee is incompetent or untrustworthy;

(2)That any trustee has been found guilty of, or has pled guilty or no contest to a felony, a crime involving moral turpitude, or a crime punishable by imprisonment of one year or more under the law of any state, territory, or country, whether or not a judgment of conviction has been entered;

(3)That any trustee has had any type of insurance license revoked, suspended, or disciplined in this or any other state; or

(4)That the business operations of the plan are or have been marked, to the detriment of the employers participating in the plan, of persons receiving benefits from the plan, or of creditors or the public, by the improper manipulation of assets, accounts, or specific or aggregate excess incurrence or by bad faith or if the number of covered employees in* any calendar quarter is found to be less than two hundred fifty.

(L. 1993 H.B. 709 § 28)

*Word "in" does not appear in original rolls.

376.147 - Meetings of board of mutual, notice — executive committee of board, powers.

1.Meetings of the board of directors or trustees of any mutual life insurance corporation shall be upon such notice as the articles of agreement prescribe.Attendance of a director or trustee at any meeting constitutes a waiver of notice of such meeting, except when a director or trustee attends the meeting for the express purpose of objecting to the transaction of any business because the meeting is not lawfully called or convened.The notice or waiver of notice need not specify the business to be transacted at, nor the purpose of, any regular or special meeting of the board of directors or trustees.

2.If the articles of agreement of any mutual life insurance corporation so provide, the board of directors or trustees, by a resolution adopted by a majority of the whole board, may designate three or more of its number to constitute an executive committee, which committee shall, to the extent provided in the resolution or in the articles of agreement, have and exercise, during the interim between the meetings of the board, all of the authority of the board in the management of the corporation.

3.The designation of such committee shall not relieve the board, or any member thereof, of any responsibility imposed by law.

(L. 1957 p. 224 §§ 8, 9)

376.2050 - Citation of act.

Sections 376.2050 to 376.2053 shall be known and may be cited as the "Unclaimed Life Insurance Benefits Act".

(L. 2016 H.B. 2150)

376.743 - Board of directors, powers.

1.The board of directors may, upon majority vote, make reports and recommendations to the director upon any matter germane to the solvency, liquidation, rehabilitation or conservation of any member insurer or germane to the solvency of any insurer or health maintenance organization seeking to do business in this state.Such reports and recommendations shall not be considered public documents.

2.The board of directors shall, upon majority vote, notify the director of any information indicating any member insurer may be an impaired or insolvent insurer.The board of directors may, upon majority vote, make recommendations to the director for the detection and prevention of member insurer insolvencies.

(L. 1988 S.B. 430 § 25, A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

*376.1516 - Written membership materials, required contents — forms to be submitted to director.

1.Each benefit under the discount medical plan shall be included in the written membership materials between the discount medical plan organization and the member.The written membership materials shall also include a statement notifying the members of their right to cancel under section 376.1508, and such materials shall also list all of the disclosures required by section 376.1512.

2.Upon request by the director, any forms used by a discount medical plan organization, including written membership materials, shall be submitted to the director.

(L. 2007 S.B. 66)

*This section was enacted by H.B. 818 and S.B. 66 during the First Regular Session of the 94th General Assembly, 2007.Due to possible conflict, both versions of this section are printed here.

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

1.Each policy issued by an entity offering individual and group health insurance which provides coverage on an expense-incurred basis, individual and group health service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group health arrangements to the extent not preempted by federal law, and all health care plans provided by managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed in this state on or after September 1, 1997, shall provide coverage for formula and low protein modified food products recommended by a physician for the treatment of a patient with phenylketonuria or any inherited disease of amino and organic acids who is covered under the policy, contract, or plan and who is less than six years of age.

2.For purposes of this section, "low protein modified food products" means foods that are specifically formulated to have less than one gram of protein per serving and are intended to be used under the direction of a physician for the dietary treatment of any inherited metabolic disease.Low protein modified food products do not include foods that are naturally low in protein.

3.The coverage required by this section may be subject to the same deductible for similar health care services provided by the policy, contract, or plan as well as a reasonable coinsurance or co-payment on the part of the insured, which shall not be greater than fifty percent of the cost of the formula and food products, and may be subject to an annual benefit maximum of not less than five thousand dollars per covered child.Nothing in this section shall prohibit a carrier from using individual case management or from contracting with vendors of the formula and food products.

4.This section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

(L. 1997 H.B. 600 & 388, A.L. 2002 S.B. 1026)

376.712 - Effective date.

Sections 376.700 to 376.714 shall apply to all solicitations of life insurance which commence on or after January 1, 1980.

(L. 1979 H.B. 508 § 7)

376.1040 - Plan not to be offered to general public — marketing restrictions.

No multiple employer self-insured health plan shall be offered or advertised to the public generally.No plan shall be sold, solicited, or marketed by persons or entities defined in section 375.012 or sections 376.1075 to 376.1095.

(L. 1993 H.B. 709 § 38)

376.580 - Misrepresentation.

No misrepresentation made in obtaining or securing a policy of insurance on the life or lives of any person or persons, citizens of this state, shall be deemed material, or render the policy void, unless the matter misrepresented shall have actually contributed to the contingency or event on which the policy is to become due and payable, and whether it so contributed in any case shall be a question for the jury.

(RSMo 1939 § 5843)

Prior revisions: 1929 § 5732; 1919 § 6142; 1909 § 6937

(1955) Where accident and health policy contained no sound health provision, no provision making insured's answers in the application warranties, nor any provision conditioning the policy on the truth of such answers, material misrepresentations must have been knowingly and fraudulently made before they will avoid the policy. Dixon v. Business Men's Assurance Co., 365 Mo. 580, 285 S.W.2d 619.

(1959) This section held inapplicable to determine whether action on insurance policy where fraud and deceit in the procurement thereof was asserted as a defense was triable in equity or by jury in federal court. Curry v. Pyramid Life Insurance Co., 271 F.2d 1.

(1961) Evidence as to misrepresentation of the health of the insured examined and held sufficient to create an issue for the jury. Winger v. General American Life Ins. Co. (Mo.), 345 S.W.2d 170.

(1961) Evidence held sufficient to present jury question as to whether misrepresentation was as to illness causing death.Pyramid Life Ins. Co. v. Curry, 291 F.2d 411.

(1963) Requirement in policy that policy holder be in "good health" at time of payment of first premium would bar recovery when insured was suffering from cancer at time of such payment whether insured knew of such disease or not. Security Life Insurance Company v. Jackson, 318 F.2d 846.

(1966) This section applies whether the misrepresentations are fraudulent or innocent and makes these misrepresentations immaterial unless the matter misrepresented actually contributed to the happening of the event on which payment under the policy of insurance depends. Bohm v. Fidelity and Casualty Co. of New York (A.), 399 S.W.2d 450.

376.480 - Domestic companies may assume risks of foreign companies — duties of director.

Whenever any life insurance company incorporated under the laws of this state assumes the risks, in whole or in part, of any life insurance company incorporated under the laws of any other state or the Dominion of Canada or any province thereof a deposit of any part of its capital stock, surplus, legal reserve or other funds on the policies so assumed, the director of the department of insurance, financial institutions and professional registration is hereby authorized, in his discretion, to receive from such official such deposit pertaining to the policies so assumed or the capital stock, surplus, legal reserve or other funds assigned by such foreign company to such domestic company, and during the time that any such official of any other state or the Dominion of Canada or any province thereof retains or holds possession and custody of such deposit after their assignment to such domestic company, such director may treat such deposits so held by the officials of such other state or the Dominion of Canada or any province thereof the same as if they had been received by and were in the custody of such director, and may, in his discretion, register the policies so assumed and may or may not, during such time, require such domestic company to make or maintain with such department of insurance, financial institutions and professional registration any additional deposit on account thereof; provided, that when any of the capital stock, surplus, legal reserve or other funds of any such foreign company is legally invested in securities not authorized by the laws of this state, such securities shall be sold and disposed of within five years as the director may direct, and such domestic company shall not hold such securities or carry same as part of its capital stock, surplus, legal reserve or other funds for a longer period unless it shall procure a certificate from such director that its interests will suffer materially by the forced sale thereof.

(RSMo 1939 § 6034)

Prior revision: 1929 § 5923

376.1035 - Chapter 376 applicable to plan.

The provisions of this chapter relating to group health and group accident insurance, including policy approval provisions, shall apply to all multiple employer self-insured health plans licensed to do business in this state.

(L. 1993 H.B. 709 § 36)

376.680 - Assignment of incidents of ownership, group life policy, effect of.

Subject to the terms of the policy relating to assignment of incidents of ownership thereunder, a person whose life is insured under a policy of group life insurance may assign any or all incidents of ownership granted him under such policy, including but not limited to any right to designate a beneficiary, to have an individual policy issued to him, and to pay premiums.Any assignment by the insured, made either before or after September 28, 1971, shall be valid for the purpose of vesting in the assignee in accordance with any provisions included therein as to the time at which it is to be effective, all of such incidents of ownership so assigned, but without prejudice to the insurer on account of any payment it may make or individual policy it may issue without notice of the assignment.

(L. 1971 S.B. 125 § 1)

376.384 - Reimbursement of claims, duties of health carriers — claims submitted in electronic format, when — compliance monitored by department — complaint procedures developed — standard medical code sets required, when — rulemaking authority.

1.All health carriers shall:

(1)Permit nonparticipating health care providers to file a claim for reimbursement for a health care service provided in this state as defined in section 376.1350 for a period of up to one year from the date of service;

(2)Permit participating health care providers to file a claim for reimbursement for a health care service provided in this state for a period of up to six months from the date of service, unless the contract between the health carrier and health care provider specifies a different standard;

(3)Not request a refund or offset against a claim more than twelve months after a health carrier has paid a claim except in cases of fraud or misrepresentation by the health care provider;

(4)Issue within one working day a confirmation of receipt of an electronically filed claim.

2.On or after January 1, 2003, all claims for reimbursement for a health care service provided in this shall be submitted in an electronic format consistent with federal administrative simplification standards adopted pursuant to the Health Insurance Portability and Accountability Act of 1996.Any claim submitted by a health care provider after January 1, 2003, in a nonelectronic format shall not be subject to the provisions of section 376.383.Any health carrier shall provide readily accessible electronic filing after this date to health care providers.

3.On or after January 1, 2002, the director of the department of insurance, financial institutions and professional registration shall monitor health carrier compliance with the provisions of this section and section 376.383.Examinations, which may be based upon statistical samplings, to determine compliance may be conducted by the department or the director may contract with a qualified private entity.Compliance shall be defined as properly processing and paying ninety-five percent of all claims received in a given calendar year in accordance with the provisions of this section and section 376.383.The director may assess an administrative penalty in addition to the penalties outlined in section 376.383 of up to twenty-five dollars per claim for the percentage of claims found to be in noncompliance, but not to exceed an annual aggregate penalty of two hundred fifty thousand dollars, for any health carrier deemed to be not in* compliance with this section and section 376.383.Any penalty assessed pursuant to this subsection shall be assessed in addition to penalties provided for pursuant to sections 375.942 and 375.1012.

4.If the director finds that health carriers are failing to make interest payments to health care professionals authorized by section 376.383, the director is authorized to order such health carriers to remit such interest payments.The director is also authorized to assess a monetary penalty, payable to the state of Missouri, in a sum not to exceed twenty-five percent of the unpaid interest payment against health carriers.

5.A health carrier may request a waiver of the requirements of this section and section 376.383 if the basis for the request is an act of God or other good cause as determined by the director.

6.The director shall develop a method by which health care providers may submit complaints to the department identifying violations of this section and section 376.383 by a health carrier.The director shall consider such complaints when determining whether to examine a health carrier's compliance.Prior to filing a complaint with the department, health care providers who believe that a health carrier has not paid a claim in accordance with this section and section 376.383 shall first contact the health carrier to determine the status of the claim to ensure that sufficient documentation supporting the claim has been provided and to determine whether the claim is considered to be complete.Complaints to the department regarding the payment of claims by a health carrier should contain information such as:

(1)The health care provider's name, address, and daytime phone number;

(2)The health carrier's name;

(3)The dates of service and the dates the claims were filed with the health carrier;

(4)Relevant correspondence between the health care provider and the health carrier, including requests from the health carrier for additional information; and

(5)Additional information which the health care provider believes would be of assistance in the department's review.

7.On or after January 1, 2003, all claims submitted electronically for reimbursement for a health care service provided in this state shall be submitted in a uniform format utilizing standard medical code sets.The uniform format and the standard medical code sets shall be promulgated by the department of insurance, financial institutions and professional registration through rules consistent with but no more stringent than the federal administrative simplification standards adopted pursuant to the Health Insurance Portability and Accountability Act of 1996.

8.The department shall have authority to promulgate rules for the implementation of section 376.383 and this section.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and if applicable, sections 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date or to disapprove and annul a rule subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2001, shall be invalid and void.

(L. 2001 H.B. 328 & 88)

Effective 1-01-02

*Word "it" appears in original rolls.

376.780 - Limits on provisions, effect of conflict of policy with law.

1.Other policy provisions.No policy provision which is not subject to section 376.777 shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to sections 376.770 to 376.800.

2.Policy conflicting with sections 376.770 to 376.800.A policy delivered or issued for delivery to any person in this state in violation of sections 376.770 to 376.800 shall be held valid but shall be construed as provided in sections 376.770 to 376.800. When any provision in a policy subject to sections 376.770 to 376.800 is in conflict with any provision of sections 376.770 to 376.800, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of sections 376.770 to 376.800.

(L. 1959 H.B. 252 § 5)

376.380 - Legal minimum standards for valuation — interest rates — valuation manual, operative date, effect of — reserves required.

1.The legal minimum standard for valuation of policies and contracts and the reserves to be maintained thereon shall be as follows:

(1)For those policies and contracts issued prior to the operative date provided in subsection 20 of section 376.670:

(a)Except as otherwise provided in subdivision (3) of this subsection, the legal minimum standard for valuation of policies of life insurance or annuity contracts issued prior to April 13, 1934, shall be the Actuaries' or Combined Experience Table of Mortality, with interest at the rate of five percent per annum for group annuity contracts and four percent per annum for all other policies and contracts; and for policies of life insurance and annuity contracts issued on and after April 13, 1934, such minimum standard shall be the American Experience Table of Mortality with interest at the rate of five percent per annum for group annuity contracts and three and one-half percent per annum for all other policies and contracts;

(b)The director may vary the legal minimum standards of interest and mortality for annuity contracts and in particular cases of invalid or substandard lives and other extra hazards, and shall have the right and authority to designate the legal minimum standard for valuation of total and permanent disability benefits and additional accidental death benefits;

(c)Policies issued by companies doing business in this state may provide for not more than one year preliminary term insurance by incorporating in the provisions thereof, specifying the premium consideration to be received, a clause plainly showing that the first year's insurance under such policies is term insurance, purchased by the whole or a part of the premium to be received during the first policy year and shall be valued accordingly; provided, that if the premium charged for term insurance under a limited payment life preliminary term policy providing for the payment of all premiums thereon in less than twenty years from the date of the policy, or under an endowment preliminary term policy, exceeds that charged for life insurance twenty payment life preliminary term policies of the same company, the reserve thereon at the end of any year, including the first, shall not be less than the reserve on a twenty payment life preliminary term policy issued in the same year and at the same age, together with an amount which shall be equivalent to the accumulation of a net level premium sufficient to provide for a pure endowment at the end of the premium payment period equal to the difference between the value at the end of such period of such twenty payment life preliminary term policy and the full reserve at such time of such a limited payment life or endowment policy.The premium payment period is the period during which premiums are concurrently payable under such twenty payment life preliminary term policy and such limited payment life or endowment policy;

(d)Reserves for all such policies and contracts may be calculated, at the option of the company, according to any standards which produce greater aggregate reserves for all such policies and contracts than the minimum reserves required by this subdivision.In the case of policy obligations of an insolvent life insurance company assumed or reinsured in bulk by an insurance company upon a basis requiring a separate accounting of the business and assets of such insolvent company and an application of any part of the earnings therefrom upon obligations which are not implicit in the original terms of the policies or contracts assumed or reinsured, the director, in order to protect all policyholders of the reinsuring company, including the holders of all policies so assumed or reinsured, and to safeguard the future solvency of such reinsuring company, shall have the right and authority to designate standards of valuation for such reinsured policies and contracts which will produce greater aggregate reserves for all such policies and contracts than the minimum reserves required by this subdivision or the terms and provisions of the policies and contracts so assumed or reinsured, and, in such event, such reinsuring company shall not, thereafter, adopt any lower standards of valuation without the approval of the director.

(2)For those policies and contracts issued on or after the operative date provided in subsection 20 of section 376.670:

(a)Except as otherwise provided in subdivision (3) of this subsection and subsection 2 of this section, the minimum standard for the valuation of all such policies and contracts shall be the commissioners reserve valuation methods defined in paragraphs (b), (c), (d), (e), and (h) of this subdivision, three and one-half percent interest on all such policies and contracts except those contracts specified in subparagraph c.of this paragraph which consist of single premium annuity contracts and in subparagraph d. of this paragraph which consists of group annuity contracts where the interest rate shall be five percent, and except policies and contracts, other than annuity and pure endowment contracts, issued on or after September 28, 1975, where the interest rate shall be four percent interest for such policies issued prior to September 28, 1979, and four and one-half percent interest for such policies issued on or after September 28, 1979, and the following tables:

a.For all ordinary policies of life insurance issued prior to the operative date provided in subsection 12 of section 376.670 on the standard basis, excluding any disability and accidental death benefits in such policies, the Commissioners 1941 Standard Ordinary Mortality Table, and for such policies issued on or after the operative date provided in subsection 12 of section 376.670, and prior to the operative date of subsection 14 of section 376.670, the Commissioners 1958 Standard Ordinary Mortality Table; provided that for any category of such policies issued on or after September 28, 1979, on female risks all modified net premiums and present values referred to in this section may be calculated according to an age not more than six years younger than the actual age of the insured; and for such policies issued on or after the operative date of subsection 14 of section 376.670:

(i)The Commissioners 1980 Standard Ordinary Mortality Table; or

(ii)At the election of the company for any one or more specified plans of life insurance, the Commissioners 1980 Standard Ordinary Mortality Table with Ten-Year Select Mortality Factors; or

(iii)Any ordinary mortality table, adopted after 1980 by the NAIC, that is approved by regulation promulgated by the director for use in determining the minimum standard of valuation for such policies;

b.For all industrial life insurance policies issued on the standard basis, excluding any disability and accidental death benefits in such policies, the 1941 Standard Industrial Mortality Table for such policies issued prior to the operative date of subsection 13 of section 376.670 and for such policies issued on or after such operative date, the Commissioners 1961 Standard Industrial Mortality Table or any industrial mortality table, adopted after 1980 by the NAIC, that is approved by regulation promulgated by the director for use in determining the minimum standard of valuation for such policies;

c.For individual annuity and pure endowment contracts, excluding any disability and accidental death benefits in such policies, the 1937 Standard Annuity Mortality Table or, at the option of the company, the Annuity Mortality Table for 1949, Ultimate, or any modification of either of these tables approved by the director;

d.For group annuity and pure endowment contracts, excluding any disability and accidental death benefits in such policies, the Group Annuity Mortality Table for 1951, any modification of such table approved by the director, or, at the option of the company, any of the tables or modifications of tables specified for individual annuity and pure endowment contracts;

e.For total and permanent disability benefits in or supplementary to ordinary policies or contracts, for policies or contracts issued on or after January 1, 1966, the tables of period two disablement rates and the 1930 to 1950 termination rates of the 1952 disability study of the Society of Actuaries, with due regard to the type of benefit or any tables of disablement rates and termination rates, adopted after 1980 by the NAIC, that are approved by regulation promulgated by the director for use in determining the minimum standard of valuation for such policies; for policies or contracts issued on or after January 1, 1961, and prior to January 1, 1966, either such tables or at the option of the company, the Class (3) Disability Table (1926); and for policies issued prior to January 1, 1961, the Class (3) Disability Table (1926).Any such table shall, for active lives, be combined with a mortality table permitted for calculating the reserves for life insurance policies;

f.For accidental death benefits in or supplementary to policies issued on or after January 1, 1966, the 1959 Accidental Death Benefits Table or any accidental death benefits table, adopted after 1980 by the NAIC, that is approved by regulation promulgated by the director for use in determining the minimum standard of valuation for such policies; for policies issued on or after January 1, 1961, and prior to January 1, 1966, either such table or, at the option of the company, the Inter-Company Double Indemnity Mortality Table; and for policies issued prior to January 1, 1961, the Inter-Company Double Indemnity Mortality Table.Either table shall be combined with a mortality table permitted for calculating the reserves for life insurance policies;

g.For group life insurance, life insurance issued on the substandard basis and other special benefits, such tables as may be approved by the director;

(b)Except as otherwise provided in paragraphs (d), (e), and (h) of this subdivision, reserves according to the commissioners reserve valuation method, for the life insurance and endowment benefits of policies providing for a uniform amount of insurance and requiring the payment of uniform premiums shall be the excess, if any, of the present value, at the date of valuation, of such future guaranteed benefits provided for by such policies, over the then present value of any future modified net premiums therefor.The modified net premiums for any such policy shall be such uniform percentage of the respective contract premiums for such benefits that the present value, at the date of issue of the policy, of all such modified net premiums shall be equal to the sum of the then present value of such benefits provided for by the policy and the excess of a. over b., as follows:

a.A net level annual premium equal to the present value, at the date of issue, of such benefits provided for after the first policy year, divided by the present value, at the date of issue, of an annuity of one per annum payable on the first and each subsequent anniversary of such policy on which a premium falls due; provided, however, that such net level annual premium shall not exceed the net level annual premium on the nineteen year premium whole life plan for insurance of the same amount at an age one year higher than the age at issue of such policy;

b.A net one year term premium for such benefit provided for in the first policy year; provided, that for any life insurance policy issued on or after January 1, 1986, for which the contract premium in the first policy year exceeds that of the second year and for which no comparable additional benefit is provided in the first year for such excess and which provides an endowment benefit or a cash surrender value or a combination thereof in an amount greater than such excess premium, the reserve according to the commissioners reserve valuation method as of any policy anniversary occurring on or before the assumed ending date defined herein as the first policy anniversary on which the sum of any endowment benefit and any cash surrender value then available is greater than such excess premium shall, except as otherwise provided in paragraph (h) of this subdivision, be the greater of the reserve as of such policy anniversary calculated as described in paragraph (b) of this subdivision and the reserve as of such policy anniversary calculated as described in paragraph (b) of this subdivision, but with:

(i)The value defined in subparagraph a. of paragraph (b) of this subdivision being reduced by fifteen percent of the amount of such excess first year premium;

(ii)All present values of benefits and premiums being determined without reference to premiums or benefits provided for by the policy after the assumed ending date;

(iii)The policy being assumed to mature on such date as an endowment; and

(iv)The cash surrender value provided on such date being considered as an endowment benefit.

In making the above comparison the mortality and interest bases stated in paragraph (a) of this subdivision and subsection 2 of this section shall be used;

(c)Reserves according to the commissioners reserve valuation method for:

a.Life insurance policies providing for a varying amount of insurance or requiring the payment of varying premiums;

b.Group annuity and pure endowment contracts purchased under a retirement plan or plan of deferred compensation, established or maintained by an employer (including a partnership or sole proprietorship) or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under Section 408 of the Internal Revenue Code, as now or hereafter amended;

c.Disability and accidental death benefits in all policies and contracts; and

d.All other benefits, except life insurance and endowment benefits in life insurance policies and benefits provided by all other annuity and pure endowment contracts, shall be calculated by a method consistent with the principles of paragraph (b) of this subdivision;

(d)Paragraph (e) of this subdivision shall apply to all annuity and pure endowment contracts other than group annuity and pure endowment contracts purchased under a retirement plan or plan of deferred compensation, established or maintained by an employer (including a partnership or sole proprietorship), or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under Section 408 of the Internal Revenue Code, as now or hereafter amended;

(e)Reserves according to the commissioners annuity reserve method for benefits under annuity or pure endowment contracts, excluding any disability and accidental death benefits in such contracts, shall be the greatest of the respective excesses of the present values, at the date of valuation, of the future guaranteed benefits, including guaranteed nonforfeiture benefits, provided for by such contracts at the end of each respective contract year, over the present value, at the date of valuation, of any future valuation considerations derived from future gross considerations, required by the terms of such contract, that become payable prior to the end of such respective contract year.The future guaranteed benefits shall be determined by using the mortality table, if any, and the interest rate, or rates, specified in such contracts for determining guaranteed benefits.The valuation considerations are the portions of the respective gross considerations applied under the terms of such contracts to determine nonforfeiture values;

(f)In no event shall a company's aggregate reserves for all life insurance policies, excluding disability and accidental death benefits, be less than the aggregate reserves calculated in accordance with the method set forth in paragraphs (b), (c), (d), (e), (h) and (i) of this subdivision and the mortality table or tables and rate or rates of interest used in calculating nonforfeiture benefits for such policies;

(g)In no event shall the aggregate reserves for all policies, contracts and benefits be less than the aggregate reserves determined by the qualified actuary to be necessary to render the opinion required by subsections 4 and 5 of this section;

(h)If in any contract year the gross premium charged by any life insurance company on any policy or contract is less than the valuation net premium for the policy or contract calculated by the method used in calculating the reserve thereon but using the minimum valuation standards of mortality and rate of interest, the minimum reserve required for such policy or contract shall be the greater of either the reserve calculated according to the mortality table, rate of interest, and method actually used for such policy or contract, or the reserve calculated by the method actually used for such policy or contract but using the minimum valuation standards of mortality and rate of interest and replacing the valuation net premium by the actual gross premium in each contract year for which the valuation net premium exceeds the actual gross premium.The minimum valuation standards of mortality and rate of interest referred to in this section are those standards stated in paragraph (a) of this subdivision and subsection 2 of this section; provided, that for any life insurance policy issued on or after January 1, 1986, for which the gross premium in the first policy year exceeds that of the second year and for which no comparable additional benefit is provided in the first year for such excess and which provides an endowment benefit or a cash surrender value or a combination thereof in an amount greater than such excess premium, the foregoing provisions of this paragraph shall be applied as if the method actually used in calculating the reserve for such policy were the method described in paragraph (b) of this subdivision.The minimum reserve at each policy anniversary of such a policy shall be the greater of the minimum reserve calculated in accordance with paragraphs (b) and (c) of this subdivision and the minimum reserve calculated in accordance with this paragraph;

(i)In the case of any plan of life insurance which provides for future premium determination, the amounts of which are to be determined by the insurance company based on then estimates of future experience, or in the case of any plan of life insurance or annuity which is of such a nature that the minimum reserves cannot be determined by the methods described in paragraphs (b) to (e) of this subdivision, and paragraph (h) of this subdivision, the reserves which are held under any such plan must:

a.Be appropriate in relation to the benefits and the pattern of premiums for that plan; and

b.Be computed by a method which is consistent with the principles of this section as determined by regulations promulgated by the director.

(3)Except as provided in subsection 2 of this section, the minimum standard for the valuation of all individual annuity and pure endowment contracts issued on or after the operative date of this subdivision, as defined herein, and for all annuities and pure endowments purchased on or after such operative date under group annuity and pure endowment contracts, shall be the commissioners reserve valuation methods defined in paragraphs (b), (c), (d), and (e) of subdivision (2) of this subsection, and the following tables and interest rates:

(a)For individual annuity and pure endowment contracts issued prior to September 28, 1979, excluding any disability and accidental death benefits in such contracts, the 1971 Individual Annuity Mortality Table, or any modification of this table approved by the director, and six percent interest for single premium immediate annuity contracts, and four percent interest for all other individual annuity and pure endowment contracts;

(b)For individual single premium immediate annuity contracts issued on or after September 28, 1979, excluding any disability and accidental death benefits in such contracts, the 1971 Individual Annuity Mortality Table, or any individual annuity mortality table adopted after 1980 by the NAIC, that is approved by regulation promulgated by the director for use in determining the minimum standard of valuation for such contracts, or any modification of these tables approved by the director, and seven and one-half percent interest;

(c)For individual annuity and pure endowment contracts issued on or after September 28, 1979, other than single premium immediate annuity contracts, excluding any disability and accidental death benefits in such contracts, the 1971 Individual Annuity Mortality Table, or any individual annuity mortality table adopted after 1980 by the NAIC, that is approved by regulation promulgated by the director for use in determining the minimum standard of valuation for such contracts, or any modification of these tables approved by the director, and five and one-half percent interest for single premium deferred annuity and pure endowment contracts and four and one-half percent interest for all other such individual annuity and pure endowment contracts;

(d)For all annuities and pure endowments purchased prior to September 28, 1979, under group annuity and pure endowment contracts, excluding any disability and accidental death benefits purchased under such contracts, the 1971 Group Annuity Mortality Table, or any modification of this table approved by the director, and six percent interest;

(e)For all annuities and pure endowments purchased on or after September 28, 1979, under group annuity and pure endowment contracts, excluding any disability and accidental death benefits purchased under such contracts, the 1971 Group Annuity Mortality Table, or any group annuity mortality table adopted after 1980 by the NAIC, that is approved by regulation promulgated by the director for use in determining the minimum standard of valuation for such annuities and pure endowments, or any modification of these tables approved by the director, and seven and one-half percent interest;

(f)On and after September 28, 1975, any company may file with the director a written notice of its election to comply with the provisions of this subdivision after a specified date before January 1, 1980, which shall be the operative date of this subdivision for such company, provided a company may elect a different operative date for individual annuity and pure endowment contracts from that elected for group annuity and pure endowment contracts.If a company makes no such election, the operative date of this subdivision for such company shall be January 1, 1980.

2.(1)The calendar year statutory valuation interest rates as defined in this subsection shall be the interest rates used in determining the minimum standard for the valuation of:

(a)All life insurance policies issued in a particular calendar year, on or after the operative date of subsection 14 of section 376.670;

(b)All individual annuity and pure endowment contracts issued in a particular calendar year on or after January 1, 1983;

(c)All annuities and pure endowment contracts purchased in a particular calendar year on or after January 1, 1983, under group annuity and pure endowment contracts; and

(d)The net increase, if any, in a particular calendar year after January 1, 1983, in amounts held under guaranteed interest contracts.

(2)The calendar year statutory valuation interest rates, I, shall be determined as follows and the results rounded to the nearer one-quarter of one percent:

(a)For life insurance:

I =.03 + W (R1 -.03) + W/2 (R2 -.09);

(b)For single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and from guaranteed interest contracts with cash settlement options:

I =.03 + W (R -.03), where R1 is the lesser of R and .09; R2 is the greater of R and .09; R is the reference interest rate defined in this subsection; and W is the weighting factor defined in this subsection;

(c)For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on an issue year basis, except as stated in paragraph (b) of this subdivision, the formula for life insurance stated in paragraph (a) of this subdivision shall apply to annuities and guaranteed interest contracts with guarantee durations in excess of ten years and the formula for single premium immediate annuities stated in paragraph (b) of this subdivision shall apply to annuities and guaranteed interest contracts with guarantee durations of ten years or less;

(d)For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the formula for single premium immediate annuities stated in paragraph (b) of this subdivision shall apply;

(e)For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a change in fund basis, the formula for single premium immediate annuities stated in paragraph (b) of this subdivision shall apply.If the calendar year statutory valuation interest rate for any life insurance policies issued in any calendar year determined without reference to this sentence differs from the corresponding actual rate for similar policies issued in the immediately preceding calendar year by less than one-half of one percent, the calendar year statutory valuation interest rate for such life insurance policies shall be equal to the corresponding actual rate for the immediately preceding calendar year.For purposes of applying the immediately preceding sentence, the calendar year statutory valuation interest rate for life insurance policies issued in a calendar year shall be determined for 1980 (using the reference interest rate defined for 1979) and shall be determined for each subsequent calendar year regardless of when subsection 14 of section 376.670 becomes operative.

(3)The weighting factors referred to in the formulas stated in subdivision (2) of this subsection are given in the following tables:

(a)Weighting factors for life insurance:

GuaranteeWeighting
DurationFactors
(Years)
10 or less.50
More than 10, but not more than 20.45
More than 20.35

For life insurance, the guarantee duration is the maximum number of years the life insurance can remain in force on a basis guaranteed in the policy or under options to convert to plans of life insurance with premium rates or nonforfeiture values or both which are guaranteed in the original policy;

(b)Weighting factor for single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and guaranteed interest contracts with cash settlement options:.80;

(c)Weighting factors for other annuities and for guaranteed interest contracts, except as stated in paragraph (b) of this subdivision, shall be as specified in subparagraphs a., b., and c. of this paragraph, according to the rules and definitions in subparagraphs d., e., and f. of this paragraph:

a.For annuities and guaranteed interest contracts valued on an issue year basis:

GuaranteeWeighting Factor
Durationfor Plan Type
(Years)ABC
5 or less:.80.60.50
More than 5, but not more than 10:.75.60.50
More than 10, but not more than 20:.65.50.45
More than 20:.45.35.35

;

b.For annuities and guaranteed interest contracts valued on a change in fund basis, the factors shown in subparagraph a. of this paragraph increased by:

Plan Type
ABC
.15.25.05

;

c.For annuities and guaranteed interest contracts valued on an issue year basis (other than those with no cash settlement options) which do not guarantee interest on considerations received more than one year after issue or purchase and for annuities and guaranteed interest contracts valued on a change in fund basis which do not guarantee interest rates on considerations received more than twelve months beyond the valuation date, the factors shown in subparagraph a. of this paragraph or derived in subparagraph b. of this paragraph increased by:

Plan Type
ABC
.05.05.05

;

d.For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, the guarantee duration is the number of years for which the contract guarantees interest rates in excess of the calendar year statutory valuation interest rate for life insurance policies with guarantee duration in excess of twenty years.For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the guarantee duration is the number of years from the date of issue or date of purchase to the date annuity benefits are scheduled to commence;

e.Plan type as used in subparagraphs a., b., and c. of this paragraph is defined as follows:

Plan Type A:At any time policyholder may withdraw funds only with an adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurance company, or without such adjustment but in installments over five years or more, or as an immediate life annuity, or no withdrawal permitted;

Plan Type B:Before expiration of the interest rate guarantee, policyholder may withdraw funds only with an adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurance company, or without such adjustment but in installments over five years or more, or no withdrawal permitted.At the end of interest rate guarantee, funds may be withdrawn without such adjustment in a single sum or installments over fewer than five years;

Plan Type C:Policyholder may withdraw funds before expiration of interest rate guarantee in a single sum or installments over fewer than five years either without adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurance company, or subject only to a fixed surrender charge stipulated in the contract as a percentage of the fund;

f.A company may elect to value guaranteed interest contracts with cash settlement options and annuities with cash settlement options on either an issue year basis or on a change in fund basis.Guaranteed interest contracts with no cash settlement options and other annuities with no cash settlement options must be valued on an issue year basis.As used in this subsection an issue year basis of valuation refers to a valuation basis under which the interest rate used to determine the minimum valuation standard for the entire duration of the annuity or guaranteed interest contract is the calendar year valuation interest rate for the year of issue or year of purchase of the annuity or guaranteed interest contract, and the change in fund basis of valuation refers to a valuation basis under which the interest rate used to determine the minimum valuation standard applicable to each change in the fund held under the annuity or guaranteed interest contract is the calendar year valuation interest rate for the year of the change in the fund.

(4)The "reference interest rate" referred to in subdivision (2) of this subsection shall be defined as follows:

(a)For all life insurance, the lesser of the average over a period of thirty-six months and the average over a period of twelve months, ending on June thirtieth of the calendar year next preceding the year of issue, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.;

(b)For single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, the average over a period of twelve months, ending on June thirtieth of the calendar year of issue or purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.;

(c)For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a year of issue basis, except as stated in paragraph (b) of this subdivision, with guarantee duration in excess of ten years, the lesser of the average over a period of thirty-six months and the average over a period of twelve months, ending on June thirtieth of the calendar year of issue or purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.;

(d)For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a year of issue basis, except as stated in paragraph (b) of this subdivision, with guarantee duration of ten years or less, the average over a period of twelve months, ending on June thirtieth of the calendar year of issue or purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.;

(e)For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the average over a period of twelve months, ending on June thirtieth of the calendar year of issue or purchase, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.;

(f)For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a change in fund basis, except as stated in paragraph (b) of this subdivision, the average over a period of twelve months, ending on June thirtieth of the calendar year of the change in the fund, of the Monthly Average of the Composite Yield on Seasoned Corporate Bonds, as published by Moody's Investors Service, Inc.

(5)In the event that the Monthly Average of the Composite Yield on Seasoned Corporate Bonds is no longer published by Moody's Investors Service, Inc., or in the event that the NAIC determines that the Monthly Average of the Composite Yield on Seasoned Corporate Bonds as published by Moody's Investors Service, Inc., is no longer appropriate for the determination of the reference interest rate, then an alternative method for determination of the reference interest rate, which is adopted by the NAIC and approved by regulation promulgated by the director, may be substituted.

3.For accident and health insurance contracts issued on or after the operative date of the valuation manual, the standard prescribed in the valuation manual is the minimum standard of valuation required under subsection 2 of section 376.370.For disability, accident and sickness, and accident and health insurance contracts issued on or after the operative date provided in subsection 20 of section 376.670 and prior to the operative date of the valuation manual, the minimum standard of valuation is the standard adopted by the director by regulation.

4.(1)This subsection shall apply to actuarial opinions of reserves prior to the date of the valuation manual.

(2)Every life insurance company doing business in this state shall annually submit the opinion of a qualified actuary as to whether the reserves and related actuarial items held in support of the policies and contracts specified by the director by regulation are computed appropriately, are based on assumptions which satisfy contractual provisions, are consistent with prior reported amounts and comply with applicable laws of this state.The director by regulation shall define the specifics of this opinion and add any other items deemed to be necessary to its scope.

(3)(a)Every life insurance company, except as exempted by or pursuant to regulation, shall also annually include in the opinion required by subdivision (2) of this subsection, an opinion of the same qualified actuary as to whether the reserves and related actuarial items held in support of the policies and contracts specified by the director by regulation, when considered in light of the assets held by the company with respect to the reserves and related actuarial items, including but not limited to the investment earnings on the assets and the considerations anticipated to be received and retained under the policies and contracts, make adequate provision for the company's obligations under the policies and contracts, including but not limited to the benefits under and expenses associated with the policies and contracts.

(b)The director may provide by regulation for a transition period for establishing any higher reserves which the qualified actuary may deem necessary in order to render the opinion required by this subsection.

(4)Each opinion required by subdivision (3) of this subsection shall be governed by the following provisions:

(a)A memorandum, in form and substance acceptable to the director as specified by regulation, shall be prepared to support each actuarial opinion; and

(b)If the insurance company fails to provide a supporting memorandum at the request of the director within a period specified by regulation or the director determines that the supporting memorandum provided by the insurance company fails to meet the standards prescribed by the regulations or is otherwise unacceptable to the director, the director may engage a qualified actuary at the expense of the company to review the opinion and the basis for the opinion and prepare such supporting memorandum as is required by the director.

(5)Every opinion required by this subsection shall be governed by the following provisions:

(a)The opinion shall be submitted with the annual statement reflecting the valuation of such reserve liabilities for each year ending on or after December 31, 1993;

(b)The opinion shall apply to all business in force including individual and group health insurance plans, in form and substance acceptable to the director as specified by regulation;

(c)The opinion shall be based on standards adopted from time to time by the Actuarial Standards Board and on such additional standards as the director may by regulation prescribe;

(d)In the case of an opinion required to be submitted by a foreign or alien company, the director may accept the opinion filed by that company with the insurance supervisory official of another state if the director determines that the opinion reasonably meets the requirements applicable to a company domiciled in this state;

(e)For the purposes of this section, "qualified actuary" means a member in good standing of the American Academy of Actuaries who meets the requirements set forth in such regulations;

(f)Except in cases of fraud or willful misconduct, the qualified actuary shall not be liable for damages to any person, other than the insurance company and the director, for any act, error, omission, decision or conduct with respect to the actuary's opinion;

(g)Disciplinary action by the director against the company or the qualified actuary shall be defined in regulations by the director; and

(h)Any memorandum in support of the opinion, and any other material provided by the company to the director in connection therewith, shall be kept confidential by the director and shall not be made public and shall not be subject to subpoena, other than for the purpose of defending an action seeking damages from any person by reason of any action required by this section or by regulations promulgated hereunder; except that the memorandum or other material may otherwise be released by the director:

a.With the written consent of the company; or

b.To the American Academy of Actuaries upon request stating that the memorandum or other material is required for the purpose of professional disciplinary proceedings and setting forth procedures satisfactory to the director for preserving the confidentiality of the memorandum or other material.

Once any portion of the confidential memorandum is cited by the company in its marketing or is cited before any governmental agency other than a state insurance department or is released by the company to the news media, all portions of the confidential memorandum shall be no longer confidential.

5.(1)This subsection shall apply to actuarial opinions of reserves after the operative date of the valuation manual.

(2)Every company with outstanding life insurance contracts, accident and health insurance contracts, or deposit-type contracts in Missouri and subject to regulation by the director shall annually submit the opinion of the appointed actuary as to whether the reserves and related actuarial items held in support of the policies and contracts are computed appropriately, are based on assumptions that satisfy contractual provisions, are consistent with prior reported amounts, and comply with applicable Missouri law.The valuation manual shall prescribe the specifics of such opinion, including any items deemed to be necessary to its scope.

(3)Every company with outstanding life insurance contracts, accident and health insurance contracts, or deposit-type contracts in Missouri and subject to regulation by the director, except as exempted in the valuation manual, shall also annually include in the opinion required under subdivision (2) of this subsection an opinion of the same appointed actuary as to whether the reserves and related actuarial items held in support of the policies and contracts specified in the valuation manual, when considered in light of the assets held by the company with respect to the reserves and related actuarial items including, but not limited to, the investment earnings on the assets and the considerations anticipated to be received and retained under the policies and contracts, make adequate provision for the company's obligations under the policies and contracts including, but not limited to, benefits under and expenses associated with the policies and contracts.

(4)Each opinion required by subdivision (3) of this subsection shall be governed by the following provisions:

(a)A memorandum, in form and substance as specified in the valuation manual and acceptable to the director, shall be prepared to support each actuarial opinion; and

(b)If the insurance company fails to provide a supporting memorandum at the request of the director within a period specified in the valuation manual or the director determines that the supporting memorandum provided by the insurance company fails to meet the standards prescribed by the valuation manual or is otherwise unacceptable to the director, the director may engage a qualified actuary at the expense of the company to review the opinion and the basis for the opinion and prepare the supporting memorandum required by the director.

(5)Every opinion required by this subsection shall be governed by the following:

(a)The opinion shall be in form and substance as specified in the valuation manual and acceptable to the director;

(b)The opinion shall be submitted with the annual statement reflecting the valuation of such reserve liabilities for each year ending on or after the operative date of the valuation manual;

(c)The opinion shall apply to all policies and contracts subject to subdivision (3) of this subsection, plus other actuarial liabilities as may be specified in the valuation manual;

(d)The opinion shall be based on standards adopted from time to time by the Actuarial Standards Board or its successor, and on such additional standards as may be prescribed in the valuation manual;

(e)In the case of an opinion required to be submitted by a foreign or alien company, the director may accept the opinion filed by such company with the insurance supervisory official of another state if the director determines that the opinion reasonably meets the requirements applicable to a company domiciled in Missouri;

(f)Except in cases of fraud or willful misconduct, the appointed actuary shall not be liable for damages to any person, other than the insurance company and the director, for any act, error, omission, decision, or conduct with respect to the appointed actuary's opinion; and

(g)Disciplinary action by the director against the company or the appointed actuary shall be defined in regulations by the director.

6.(1)For policies issued on or after the operative date of the valuation manual, the standard prescribed in the valuation manual is the minimum standard of valuation required under subsection 2 of section 376.370, except as provided under subdivision (5) or (7) of this subsection.

(2)The operative date of the valuation manual is January first of the first calendar year following the first July first as of which all of the following have occurred:

(a)The valuation manual has been adopted by the NAIC by an affirmative vote of at least forty-two members or three-fourths of the members voting, whichever is greater;

(b)The standard valuation law as amended by the NAIC in 2009 or legislation including substantially similar terms and provisions has been enacted by states representing greater than seventy-five percent of the direct premiums written as reported in the following annual statements submitted for 2008:life, accident, and health annual statements; health annual statements; or fraternal annual statements;

(c)The standard valuation law as amended by the NAIC in 2009 or legislation including substantially similar terms and provisions has been enacted by at least forty-two of the following fifty-five jurisdictions: the fifty states of the United States, American Samoa, the American Virgin Islands, the District of Columbia, Guam, and Puerto Rico; and

(d)The valuation manual becomes effective under an order of the director.

(3)Unless a change in the valuation manual specifies a later effective date, changes to the valuation manual shall be effective on January first following the date when all of the following have occurred:

(a)The change to the valuation manual has been adopted by the NAIC by an affirmative vote representing:

a.At least three-fourths of the members of the NAIC voting, but not less than a majority of the total membership; and

b.Members of the NAIC representing jurisdictions totaling greater than seventy-five percent of the direct premiums written as reported in the following annual statements most recently available prior to the vote in subparagraph a. of this paragraph:life, accident, and health annual statements; health annual statements; or fraternal annual statements;

(b)The valuation manual becomes effective under an order of the director.

(4)The valuation manual shall specify all of the following:

(a)Minimum valuation standards for and definitions of the policies or contracts subject to subsection 2 of section 376.370.Such minimum standards shall be:

a.The commissioners reserve valuation method for life insurance contracts, other than annuity contracts, subject to subsection 2 of section 376.370;

b.The commissioners annuity reserve valuation method for annuity contracts subject to subsection 2 of section 376.370; and

c.Minimum reserves for all other policies and contracts subject to subsection 2 of section 376.370;

(b)Which policies or contracts or types of policies or contracts are subject to the requirements of a principle-based valuation under subdivision (1) of subsection 7 of this section and the minimum valuation standards consistent with such requirements;

(c)For policies and contracts subject to principle-based valuation under subsection 7 of this section:

a.Requirements for the format of reports to the director under paragraph (c) of subdivision (2) of subsection 7 of this section and which shall include information necessary to determine if the valuation is appropriate and in compliance with sections 376.365 to 376.380;

b.Assumptions which shall be prescribed for risks over which the company does not have significant control or influence;

c.Procedures for corporate governance and oversight of the actuarial function, and a process for appropriate waiver or modification of such procedures;

(d)For policies not subject to a principle-based valuation under subsection 7 of this section, the minimum valuation standard shall either:

a.Be consistent with the minimum standard of valuation prior to the operative date of the valuation manual; or

b.Develop reserves that quantify the benefits and guarantees, and the funding, associated with the contracts and their risks at a level of conservatism that reflects conditions that include unfavorable events that have a reasonable probability of occurring;

(e)Other requirements including, but not limited to, those relating to reserve methods, models for measuring risk, generation of economic scenarios, assumptions, margins, use of company experience, risk measurement, disclosure, certifications, reports, actuarial opinions and memorandums, transition rules, and internal controls; and

(f)The data and form of the data required under subsection 8 of this section, to whom the data shall be submitted, and may specify other requirements, including data analyses and reporting of analyses.

(5)In the absence of a specific valuation requirement or if a specific valuation requirement in the valuation manual is not, in the opinion of the director, in compliance with sections 376.365 to 376.380, the company shall, with respect to such requirements, comply with minimum valuation standards prescribed by the director by regulation.

(6)The director may engage a qualified actuary, at the expense of the company, to perform an actuarial examination of the company and opine on the appropriateness of any reserve assumption or method used by the company, or to review and opine on a company's compliance with any requirement set forth in sections 376.365 to 376.380.The director may rely upon the opinion regarding provisions contained in sections 376.365 to 376.380 of a qualified actuary engaged by the director of another state, district, or territory of the United States.As used in this subdivision, engage includes employment and contracting.

(7)The director may require a company to change any assumption or method that in the opinion of the director is necessary in order to comply with the requirements of the valuation manual or sections 376.365 to 376.380, and the company shall adjust the reserves as required by the director.The director may take other disciplinary action as permitted under chapter 354 and chapters 374 to 385.

7.(1)A company shall establish reserves using a principle-based valuation that meets the following conditions for policies or contracts as specified in the valuation manual:

(a)Quantify the benefits and guarantees, and the funding, associated with the contracts and their risks at a level of conservatism that reflects conditions that include unfavorable events that have a reasonable probability of occurring during the lifetime of the contracts.For policies or contracts with significant tail risk, the company's valuation shall reflect conditions appropriately adverse to quantify the tail risk;

(b)Incorporate assumptions, risk analysis methods, and financial models and management techniques that are consistent with, but not necessarily identical to, those utilized within the company's overall risk assessment process, while recognizing potential differences in financial reporting structures and any prescribed assumptions or methods;

(c)Incorporate assumptions that are derived in one of the following manners:

a.The assumption is prescribed in the valuation manual; or

b.For assumptions that are not prescribed, the assumption shall:

(i)Be established utilizing the company's available experience to the extent it is relevant and statistically credible; or

(ii)To the extent that company data is not available, relevant, or statistically credible, be established utilizing other relevant statistically credible experience;

(d)Provide margins for uncertainty, including adverse deviation and estimation error, such that the greater the uncertainty the larger the margin and resulting reserve.

(2)A company using a principle-based valuation for one or more policies or contracts subject to this section as specified in the valuation manual shall:

(a)Establish procedures for corporate governance and oversight of the actuarial valuation function consistent with those described in the valuation manual;

(b)Provide to the director an annual certification of the effectiveness of the internal controls with respect to the principle-based valuation.Such controls shall be designed to ensure that all material risks inherent in the liabilities and associated assets subject to such valuation are included in the valuation and that valuations are made in accordance with the valuation manual.The certification shall be based on the controls in place as of the end of the preceding calendar year;

(c)Develop, and file with the director upon request, a principle-based valuation report that complies with standards prescribed in the valuation manual.

(3)A principle-based valuation may include a prescribed formulaic reserve component.

8.For policies in force on or after the operative date of the valuation manual, a company shall submit mortality, morbidity, policyholder behavior, or expense experience and other data as prescribed in the valuation manual.

9.(1)For purposes of this subsection, "confidential information" means:

(a)Amemorandum in support of an opinion submitted under subsection 4 or 5 of this section and any other documents, materials, and other information including, but not limited to, all working papers and copies thereof created, produced, or obtained by or disclosed to the director or any other person in connection with such memorandum;

(b)All documents, materials, and other information including, but not limited to, all working papers and copies thereof created, produced, or obtained by or disclosed to the director or any other person in the course of an examination made under subdivision (6) of subsection 6 of this section; provided, however, that if an examination report or other material prepared in connection with an examination made under section 374.205 is not held as private and confidential information under section 374.205, an examination report or other material prepared in connection with an examination made under subdivision (6) of subsection 6 of this section shall not be confidential information to the same extent as if such examination report or other material had been prepared under section 374.205;

(c)Any reports, documents, materials, and other information developed by a company in support of or in connection with an annual certification by the company under paragraph (b) of subdivision (2) of subsection 7 of this section evaluating the effectiveness of the company's internal controls with respect to a principle-based valuation and any other documents, materials, and other information including, but not limited to, all working papers and copies thereof created, produced, or obtained by or disclosed to the director or any other person in connection with such reports, documents, material, and other information;

(d)Any principle-based valuation report developed under paragraph (c) of subdivision (2) of subsection 7 of this section and any other documents, materials, and other information including, but not limited to, all working papers and copies thereof created, produced, or obtained by or disclosed to the director or any other person in connection with such report; and

(e)Any documents, materials, data, and other information submitted by a company under subsection 8 of this section (collectively, "experience data" ) and any other documents, materials, data, and other information including, but not limited to, all working papers and copies thereof created or produced in connection with such experience data, in each case that include any potentially company-identifying or personally identifiable information, that is provided to or obtained by the director (together with any "experience data", the "experience materials" ) and any other documents, materials, data, and other information including, but not limited to, all working papers and copies thereof created, produced, or obtained by or disclosed to the director or any other person in connection with such experience materials.

(2)(a)Except as provided in this subsection, a company's confidential information is confidential by law and privileged, and shall not be subject to chapter 610, shall not be subject to subpoena, and shall not be subject to discovery or admissible in evidence in any private civil action; provided, however, that the director is authorized to use the confidential information in the furtherance of any regulatory or legal action brought against the company as a part of the director's official duties.

(b)Neither the director nor any person who received confidential information while acting under the authority of the director shall be permitted or required to testify in any private civil action concerning any confidential information.

(c)In order to assist in the performance of the director's duties, the director may share confidential information with:

a.Other state, federal, and international regulatory agencies and with the NAIC and its affiliates and subsidiaries; and

b.In the case of confidential information specified in paragraphs (a) and (d) of subdivision (1) of this subsection only, the Actuarial Board for Counseling and Discipline or its successor upon request stating that the confidential information is required for the purpose of professional disciplinary proceedings and with state, federal, and international law enforcement officials.

(d)The sharing of confidential information detailed in paragraph (c) of this subdivision shall be contingent on such recipient agreeing and having the legal authority to agree to maintain the confidentiality and privileged status of such documents, materials, data, and other information in the same manner and to the same extent as required for the director.

(e)The director may receive documents, materials, data, and other information, including otherwise confidential and privileged documents, materials, data, or information, from the NAIC and its affiliates and subsidiaries, from regulatory or law enforcement officials of other foreign or domestic jurisdictions, and from the Actuarial Board for Counseling and Discipline or its successor and shall maintain as confidential or privileged any document, material, data, or other information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material, or other information.

(f)The director may enter into agreements governing sharing and use of information consistent with this subdivision.

(g)No waiver of any applicable privilege or claim of confidentiality in the confidential information shall occur as a result of disclosure to the director under this section or as a result of sharing as authorized in paragraph (c) of this subdivision.

(h)A privilege established under the law of any state or jurisdiction that is substantially similar to the privilege established under this subdivision shall be available and enforced in any proceeding in, and in any court of, Missouri.

(i)In this subsection, regulatory agency, law enforcement agency, and the NAIC include, but are not limited to, their employees, agents, consultants and contractors.

(3)Notwithstanding subdivision (2) of this subsection, any confidential information specified in paragraphs (a) and (d) of subdivision (1) of this subsection:

(a)May be subject to subpoena for the purpose of defending an action seeking damages from the appointed actuary submitting the related memorandum in support of an opinion submitted under subsection 4 or 5 of this section or principle-based valuation report developed under paragraph (c) of subdivision (2) of subsection 7 of this section by reason of an action required by sections 376.365 to 376.380 or by regulations promulgated hereunder;

(b)May otherwise be released by the director with the written consent of the company; and

(c)Once any portion of a memorandum in support of an opinion submitted under subsection 4 or 5 of this section or a principle-based valuation report developed under paragraph (c) of subdivision (2) of subsection 7 of this section is cited by the company in its marketing, or is publicly volunteered to or before a governmental agency other than a state insurance department, or is released by the company to the news media, all portions of such memorandum or report shall no longer be confidential.

10.The director may exempt specific product forms or product lines of a domestic company that is licensed and doing business only in Missouri from the requirements of subsection 6 of this section provided:

(1)The director has issued an exemption in writing to the company and has not subsequently revoked the exemption in writing; and

(2)The company computes reserves using assumptions and methods used prior to the operative date of the valuation manual in addition to any requirements established by the director and promulgated by regulation.

For any company granted an exemption under this section, subsection 3 of section 376.370 and subsections 1 to 5 of this section shall be applicable.With respect to any company applying this exemption, any reference to subsection 6 of this section found in subsection 3 of section 376.370 and subsections 1 to 5 of this section shall not be applicable.

11.(1)A company that has less than three hundred million dollars of ordinary life premium and that is licensed and doing business in Missouri and that is subject to the requirements of subsections 6 and 7 of this section may hold reserves based on the mortality tables and interest rates defined by the valuation manual for net premium reserves and using the methodology defined in the provisions of paragraphs (b) through (i) of subdivision (2) of subsection 1 of this section and subsection 3 of section 376.370 as they apply to ordinary life insurance in lieu of the reserves required by subsections 6 and 7 of this section, provided that:

(a)If the company is a member of a group of life insurers, the group has combined ordinary life premiums of less than six hundred million dollars;

(b)The company reported total adjusted capital of at least four hundred fifty percent of authorized control level risk-based capital in the risk-based capital report for the prior calendar year;

(c)The appointed actuary has provided an unqualified opinion on the reserves in accordance with subsections 4 and 5 of this section for the prior calendar year;

(d)The company has provided a certification by a qualified actuary that any universal life policy with a secondary guarantee issued after the operative date of the valuation manual meets the definition of a nonmaterial secondary guarantee universal life product as defined in the valuation manual.

(2)For purposes of subdivision (1) of this subsection, ordinary life premiums are measured as direct premium plus reinsurance assumed from an unaffiliated company, as reported in the prior calendar year annual statement.

(3)A domestic company meeting all of the above conditions may file a statement prior to July first with the director certifying that these conditions are met for the current calendar year based on premiums and other values from the prior calendar year financial statements.The director may reject such statement prior to September first and require a company to comply with the valuation manual requirements for life insurance reserves.

(RSMo 1939 § 5831, A.L. 1943 p. 596, A.L. 1947 V. I p. 335, A.L. 1959 H.B. 268, A.L. 1961 p. 177, A.L. 1965 p. 577, A.L. 1971 H.B. 506, A.L. 1975 S.B. 116, A.L. 1979 S.B. 325, A.L. 1982 S.B. 469, A.L. 1993 H.B. 709, A.L. 2015 S.B. 164)

Prior revisions: 1929 § 5720; 1919 § 6131; 1909 § 6925

(1959) Where company intended to convert a term life insurance policy to ordinary life insurance and did accept premiums for fifteen weeks after expiration of the term, the contract would be treated as an ordinary life policy and its reserves accumulated accordingly. Richardson v. Life Ins. Co.of Missouri (A.), 330 S.W.2d 267.

376.280 - Capital necessary to do business — how invested.

1.No joint stock or stock and mutual company formed under the provisions of sections 376.010 to 376.670, or the laws of this state, for any purpose mentioned in section 376.010, shall commence to do business or issue policies unless upon an actual capital of at least six hundred thousand dollars and a surplus of at least six hundred thousand dollars, nor shall any such company commence to do any business unless the full amount of capital stock and surplus named in its charter or articles of association has been paid in and invested in such securities and in accordance with all the provisions as is provided for in sections 376.291 to 376.307, or as the same may be subsequently amended.

2.In order to continue writing new business, any stock company organized under the provisions of sections 376.010 to 376.670, or the laws of this state, for any purpose mentioned in section 376.010, shall maintain an actual capital and surplus in the amount required to commence business.

3.Any other provision of this section notwithstanding, a joint stock or stock and mutual company licensed to do business in this state on August 13, 1982, may renew its license for business specified therein until December 31, 1984, by maintaining in lieu of the capital and surplus requirements an actual capital and surplus of at least nine hundred thousand dollars.

4.No mutual company formed under the provisions of sections 376.010 to 376.670, or of the laws of this state, shall commence or continue to do any business mentioned in section 376.010 until agreement, in writing, with such company shall have been entered into by not less than one hundred persons for assurance upon their own lives, or the lives of other persons for their benefit, nor until it shall have received premiums on the same in cash, to an aggregate amount of not less than six hundred thousand dollars and in addition shall have a surplus of six hundred thousand dollars; provided further, that nothing herein contained shall be so construed as to prohibit any such company from complying with the provisions of sections 362.180 to 362.195.

5.Any other provision of this section notwithstanding, a mutual company licensed to do business in this state on August 13, 1982, may renew its license for business specified therein until December 31, 1984, by maintaining in lieu of the surplus requirement paid-in premiums in an aggregate amount of not less than nine hundred thousand dollars.

6.Violation of any of the provisions of this section by any insurer is grounds for the revocation of its certificate of authority by the director.

(RSMo 1939 § 5826, A.L. 1963 p. 485, A.L. 1977 S.B. 368, A.L. 1982 S.B. 729, A.L. 2007 S.B. 66)

Prior revisions: 1929 § 5715; 1919 § 6126; 1909 § 6920

376.080 - Director to examine, when.

Upon being notified that the capital stock named in the charter has been subscribed, and two hundred thousand dollars thereof paid in, the director shall make an examination, or cause one to be made by some disinterested person specially appointed by him for that purpose, and if it shall be found by himself, or if the person so appointed shall certify, under oath, that the provisions of section 376.280 have been complied with by said company, as far as applicable thereto, which certificate, when made, shall set forth the particulars of such compliance, then the director shall so certify, and the corporators or officers of such company shall be required to certify, under oath, to the person making such examination, that the money, notes, stocks, bonds, mortgages and deeds of trust exhibited to him are the bona fide property of said company.

(RSMo 1939 § 5806, A.L. 1967 p. 516)

Prior revisions: 1929 § 5696; 1919 § 6107; 1909 § 6901

376.180 - Certificates as to registration and reserves on policy — policies exempt, exceptions.

1.After making the deposits mentioned in section 376.170, the company shall issue its policies of insurance or annuity bonds and each policy may have set out in the body thereof the following:"This policy is registered and the net reserves secured by a pledge of bonds, deeds of trust on real estate and other securities deposited with the department of insurance, financial institutions and professional registration of Missouri as required by section 376.170, RSMo."

2.The company under the supervision of the director shall prepare and keep a permanent register thereof.

3.The provisions of this section pertaining to the registration of policies shall not apply to policies issued on the industrial or prudential plans except when such policies exceed one thousand dollars in amount, nor shall the provisions of this section apply to term policies of seven years or less and in amounts of ten thousand dollars or less, or to policies of group insurance or group annuity; except that nothing contained herein shall be deemed to prevent any policy from being registered hereunder, if the company issuing the policy shall so desire.

(RSMo 1939 § 5816, A.L. 1951 p. 274, A.L. 1953 p. 241, A.L. 1961 p. 170, A.L. 1963 p. 491, A.L. 1967 p. 516, A.L. 1969 S.B. 63)

Prior revisions: 1929 § 5705; 1919 § 6116; 1909 § 6910

376.980 - Pool member exempt from taxation of financial institution, may be allowed to offset against sales or use tax, when — excess of assessment over sales or use tax payable in any one year a credit in succeeding years until excess is exhausted.

Each pool member exempt from chapter 148 shall be allowed to offset against any sales or use tax on purchases due, paid, or payable in the calendar year in which such assessments are made.Further, such assessment, for any fiscal year, shall not exceed one percent of nongroup premium income, exclusive of Medicare supplement programs, received in the previous year.If the assessment exceeds the part of any sales tax or use tax due or payable in such year, the excess shall be a credit or offset carried forward against the part of any sales tax or use tax due or payable in succeeding years until the excess is exhausted.The director of revenue, in consultation with the board, shall promulgate and enforce reasonable rules and regulations and prescribe forms for the administration and enforcement of this law.

(L. 1990 H.B. 998 § 5 subsec. 5 subdiv. (2))

Effective 1-01-91

376.436 - Discontinuance notice by carrier, contents — notice forms furnished by carrier for distribution to policyholders.

1.Any notice of discontinuance so given by the carrier shall include a request to the group policyholder or other entity involved to notify employees covered under the policy or contract of the date as of which the group policy or contract will discontinue and to advise that unless otherwise provided in the policy or contract, the carrier shall not be liable for claims for losses incurred after such date.Such notice of discontinuance shall also advise, in any instance in which the plan involves employee contributions, that if the policyholder or other entity continues to collect contributions for the coverage beyond the date of discontinuance, the policyholder or other entity may be held solely liable for the benefits with respect to which the contributions have been collected.

2.The carrier will prepare and furnish to the policyholder or other entity at the same time a supply of a notice form to be distributed to the employees or members concerned indicating such discontinuance and the effective date thereof, and urging the employees or members to refer to their certificates or contracts in order to determine what rights, if any, are available to them upon such discontinuance.

(L. 1985 H.B. 623, A.L. 1999 H.B. 903)

376.1083 - Advertising restrictions for administrator.

An administrator may use only such advertising pertaining to the business underwritten by an insurer as has been approved in writing by the insurer in advance of its use.

(L. 1993 H.B. 709 § 45)

376.1060 - Access to dental services not to be sold, assigned, or granted access without express authorization — definitions — requirements.

1.As used in this section, the following terms shall mean:

(1)"Contracting entity", any person or entity that is engaged in the act of contracting with providers for the delivery of dental services or the selling or assigning of dental network plans to other health care entities;

(2)"Identify", providing in writing, by email or otherwise, to the participating provider the name, address, and telephone number, to the extent possible, for any third party to which the contracting entity has granted access to the health care services of the participating provider;

(3)"Network plan", health insurance coverage offered by a health insurance issuer under which the financing and delivery of dental services are provided in whole or in part through a defined set of participating providers under contract with the health insurance issuer;

(4)"Participating provider", a provider who, under a contract with a contracting entity, has agreed to provide dental services with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the contracting entity;

(5)"Provider", any person licensed under section 332.071.

2.A contracting entity shall not sell, assign, or otherwise grant access to the dental services of a participating provider under a health care contract unless expressly authorized by the health care contract.The health care contract shall specifically provide that one purpose of the contract is the selling, assigning, or giving the contracting entity rights to the services of the participating provider, including network plans.

3.Upon entering a contract with a participating provider and upon request by a participating provider, a contracting entity shall properly identify any third party that has been granted access to the dental services of the participating provider.

4.A contracting entity that sells, assigns, or otherwise grants access to the dental services of a participating provider shall maintain an internet website or a toll-free telephone number through which the participating provider may obtain information which identifies the insurance carrier to be used to reimburse the participating provider for the covered dental services.

5.A contracting entity that sells, assigns, or otherwise grants access to a participating provider's dental services shall ensure that an explanation of benefits or remittance advice furnished to the participating provider that delivers dental services under the health care contract identifies the contractual source of any applicable discount.

6.All third parties that have contracted with a contracting entity to purchase, be assigned, or otherwise be granted access to the participating provider's discounted rate shall comply with the participating provider's contract, including all requirements to encourage access to the participating provider, and pay the participating provider pursuant to the rates of payment and methodology set forth in that contract, unless otherwise agreed to by a participating provider.

7.A contracting entity is deemed in compliance with this section when the insured's identification card provides information which identifies the insurance carrier to be used to reimburse the participating provider for the covered dental services.

(L. 2014 S.B. 884)

376.1087 - Commissions not to be contingent on savings in payment of claims — may be based on premiums collected.

1.An administrator shall not enter into any agreement or understanding with an insurer in which the effect is to make the amount of the administrator's commissions, fees or charges contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer's obligations.This provision shall not prohibit an administrator from receiving performance based compensation for providing hospital or other auditing services.

2.This section shall not prevent the compensation of an administrator from being based on premiums or charges collected or the number of claims paid or processed.

(L. 1993 H.B. 709 § 48)

376.432 - Group-type basis, defined.

As used in sections 376.431 to 376.442, the term "group-type basis" means a benefit plan, other than salary budget plans utilizing individual insurance policies or contracts, which meets the following conditions:

(1)Coverage is provided through insurance policies or contracts to classes of employees or members defined in terms of conditions pertaining to employment or membership;

(2)The coverage is not available to the general public and can be obtained and maintained only because of the covered person's membership in or connection with the particular organization or group;

(3)There are arrangements for bulk payment of premiums or subscription charges to the insurer or health services corporation; and

(4)There is sponsorship of the plan by the employer, union or association.

(L. 1985 H.B. 623, A.L. 1999 H.B. 903)

376.984 - Abatement or deferring all or part of assessment of member, when — amount abated or deferred may be assessed against other members — deficiency liability.

The board may abate or defer, in whole or in part, the assessment of a member if, in the opinion of the board, payment of the assessment would endanger the ability of the member to fulfill its contractual obligations.In the event an assessment against a member is abated or deferred in whole or in part, the amount by which such assessment is abated or deferred may be assessed against the other members in a manner consistent with the basis for assessment set forth in subsections 1, 2, and 3 of section 376.973.The member receiving such abatement or deferment shall remain liable to the pool for the deficiency for four years.

(L. 1990 H.B. 998 § 5 subsec. 6)

Effective 1-01-91

376.732 - Director to have association's powers and duties, when — association may appear in court, when.

1.If the association fails to act within a reasonable period of time when authorized to do so, the director shall have the powers and duties of the association under sections 376.715 to 376.758 with respect to the insolvent insurers.

2.The association may render assistance and advice to the director, upon his request, concerning rehabilitation, payment of claims, continuance of coverage, or the performance of other contractual obligations of any impaired or insolvent insurer.

3.The association shall have standing to appear or intervene before any court or agency in this state with jurisdiction over an impaired or insolvent insurer concerning which the association is or may become obligated under sections 376.715 to 376.758, or with jurisdiction over any person or property against which the association may have rights through subrogation or otherwise.Such standing shall extend to all matters germane to the powers and duties of the association, including, but not limited to, proposals for reinsuring, modifying or guaranteeing the policies or contracts of the impaired or insolvent insurer and the determination of the policies or contracts and contractual obligations.The association shall have the right to appear or intervene before a court or agency in another state with jurisdiction over an impaired or insolvent insurer for which the association is or may become obligated or with jurisdiction over any person or property against whom the association may have rights through subrogation or otherwise.

(L. 1988 S.B. 430 § 12, A.L. 2010 S.B. 583)

376.1387 - Appeals of grievances determined by the director.

1.The director shall resolve any grievance regarding an adverse determination as to covered services appealed by an enrollee or health carrier or plan sponsor through any means not specifically prohibited by law but if the grievance is unresolved by the director then it shall be resolved by referral of such grievance to an independent review organization.The director shall establish the qualifications for such review organizations(s) and shall seek the services of such organization(s) by competitive bid pursuant to chapter 34.The director shall enter into contracts with such organization(s) as deemed necessary to conduct the adverse determination appeals process set forth in this section.Any request for an adverse determination appeal shall be assigned on a rotational basis.The organization's decision as to the resolution of the grievance shall be based upon a review of the written record before it.The grievance and resolution of such grievance shall not be considered a contested case within the meaning of section 536.010, but the resolution of such grievance by the panel shall be considered a final agency decision within the director's discretion, binding upon the enrollee and health carrier, and subject to judicial review if:

(1)Action for such review is filed within thirty days of the final agency decision; and

(2)Judicial review is limited to the record before the director; and

(3)The enrollee and health carrier are deemed real parties in interest; and

(4)The scope of judicial review extends only to a determination of whether the action of the director is unconstitutional, unlawful, unreasonable, arbitrary, or capricious or involves an abuse of discretion or is in excess of the statutory authority or jurisdiction of the director.

2.Nothing in this section is intended to restrict the director's authority to investigate and resolve any complaint against a health carrier that does not constitute a grievance within the meaning of section 376.1350.

3.Any grievance involving coverage provided pursuant to a Medicaid program, however, shall be resolved in accordance with the rules and procedures established for the Medicaid program.

(L. 1997 H.B. 335)

376.884 - Advertisement to be reviewed by director.

Every issuer of Medicare supplement insurance policies or certificates in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio or television medium to the director for review or approval by the director to the extent it may be required under state law.

(L. 1989 H.B. 615 & 563, A.L. 1992 H.B. 1574)

Effective 7-06-92

376.726 - Nonpayment of premiums, effect of.

1.Nonpayment of premiums within thirty-one days after the date required under the terms of any guaranteed, assumed, alternative or reissued policy or contract or substitute coverage shall terminate the association's obligations under such policy, contract, or coverage under sections 376.715 to 376.758 with respect to such policy, contract, or coverage, except with respect to any claims incurred or any net cash surrender value which may be due in accordance with the provisions of sections 376.715 to 376.758.

2.Premiums due for coverage after entry of an order of liquidation of an insolvent insurer shall belong to and be payable at the direction of the association, and the association shall be liable for unearned premiums due to policy or contract owners arising after the entry of such order.

(L. 1988 S.B. 430 § 9, A.L. 2018 H.B. 1690)

376.890 - Invalidity of any section regulating Medicare supplement not to affect others.

If any provision of sections 376.850 to 376.890 or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of sections 376.850 to 376.890 and the application of such provision to other persons or circumstances shall not be affected thereby.

(L. 1981 S.B. 347 § 8, A.L. 1989 H.B. 615 & 563)

376.298 - Acquisition of rate credit instruments, when.

1.Subject to the limitations of subsection 6 of this section and subsection 2 of section 376.297, an insurer may acquire rated credit instruments issued, assumed, guaranteed or issued by:

(1)The United States; or

(2)A government-sponsored enterprise of the United States if the instruments of the government-sponsored enterprise are assumed, guaranteed, or insured by the United States or are otherwise backed or supported by the full faith and credit clause of the United States.

2.Subject to the limitations of subsection 6* of this section and subsection 2 of section 376.297, an insurer may acquire rated credit instruments issued, assumed, guaranteed, or insured by:

(1)Canada; or

(2)A government-sponsored enterprise of Canada if the instruments of the government-sponsored enterprise are assumed, guaranteed, or insured by Canada or are otherwise backed or supported by the full faith and credit clause of Canada.

An insurer shall not acquire an instrument under this subsection if as a result of and after giving effect to the investment the aggregate amount of investments then held by the insurer under this subsection would exceed forty percent of its admitted assets.

3.Subject to the limitations of subsection 6 of this section and subsection 2 of section 376.297, an insurer may acquire rated credit instruments excluding asset-backed securities:

(1)Issued by a government money market mutual fund, a class one money market mutual fund, or a class one bond mutual fund;

(2)Issued, assumed, guaranteed, or insured by a government-sponsored enterprise of the United States other than those eligible under subsection 1 of this section;

(3)Issued, assumed, guaranteed, or insured by a state if the instruments are general obligations of the state; or

(4)Issued by a multilateral development bank.

An insurer shall not acquire an instrument of any one fund, any one enterprise or entity, or any one state under this subsection if as a result of and after giving effect to the investment the aggregate amount of investments then held by the insurer in any one fund, enterprise, entity, or state under this subsection would exceed ten percent of its admitted assets.

4.Subject to the limitations of subsection 6 of this section and section 376.297, an insurer may acquire preferred stocks that are not foreign investments and that meet the requirement of rated credit instruments if as a result of and after giving effect to the investment:

(1)The aggregate amount of preferred stocks then held by the insurer under this subsection does not exceed twenty percent of its admitted assets; and

(2)The aggregate amount of preferred stocks then held by the insurer under this subsection which are not sinking fund stocks or rated "P1" or "P2" by the SVO does not exceed ten percent of its admitted assets.

5.Subject to the limitations of subsection 6 of this section and section 376.297, in addition to those investments eligible under subsections 1 to 4 of this section, an insurer may acquire rated credit instruments that are not foreign investments.

6.An insurer shall not acquire special rated credit instruments under this section if as a result of and after giving effect to the investment the aggregate amount of special rated credit instruments then held by the insurer would exceed five percent of its admitted assets.The director may by rule under section 376.305 identify certain special rated credit instruments that will be exempt from the limitation imposed by this subsection.

(L. 2007 S.B. 66)

*Words "subdivision (6)" appear in original rolls.

376.426 - Group health policies, required provisions.

No policy of group health insurance shall be delivered in this state unless it contains in substance the following provisions, or provisions which in the opinion of the director of the department of insurance, financial institutions and professional registration are more favorable to the persons insured or at least as favorable to the persons insured and more favorable to the policyholder; except that:provisions in subdivisions (5), (7), (12), (15), and (16) of this section shall not apply to policies insuring debtors; standard provisions required for individual health insurance policies shall not apply to group health insurance policies; and if any provision of this section is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the director, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy:

(1)A provision that the policyholder is entitled to a grace period of thirty-one days for the payment of any premium due except the first, during which grace period the policy shall continue in force, unless the policyholder shall have given the insurer written notice of discontinuance in advance of the date of discontinuance and in accordance with the terms of the policy.The policy may provide that the policyholder shall be liable to the insurer for the payment of a pro rata premium for the time the policy was in force during such grace period;

(2)A provision that the validity of the policy shall not be contested, except for nonpayment of premiums, after it has been in force for two years from its date of issue, and that no statement made by any person covered under the policy relating to insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of two years during such person's lifetime nor unless it is contained in a written instrument signed by the person making such statement; except that, no such provision shall preclude the assertion at any time of defenses based upon the person's ineligibility for coverage under the policy or upon other provisions in the policy;

(3)A provision that a copy of the application, if any, of the policyholder shall be attached to the policy when issued, that all statements made by the policyholder or by the persons insured shall be deemed representations and not warranties and that no statement made by any person insured shall be used in any contest unless a copy of the instrument containing the statement is or has been furnished to such person or, in the event of the death or incapacity of the insured person, to the individual's beneficiary or personal representative;

(4)A provision setting forth the conditions, if any, under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of the individual's coverage;

(5)A provision specifying the additional exclusions or limitations, if any, applicable under the policy with respect to a disease or physical condition of a person, not otherwise excluded from the person's coverage by name or specific description effective on the date of the person's loss, which existed prior to the effective date of the person's coverage under the policy.Any such exclusion or limitation may only apply to a disease or physical condition for which medical advice or treatment was received by the person during the twelve months prior to the effective date of the person's coverage.In no event shall such exclusion or limitation apply to loss incurred or disability commencing after the earlier of:

(a)The end of a continuous period of twelve months commencing on or after the effective date of the person's coverage during all of which the person has received no medical advice or treatment in connection with such disease or physical condition; or

(b)The end of the two-year period commencing on the effective date of the person's coverage;

(6)If the premiums or benefits vary by age, there shall be a provision specifying an equitable adjustment of premiums or of benefits, or both, to be made in the event the age of the covered person has been misstated, such provision to contain a clear statement of the method of adjustment to be used;

(7)A provision that the insurer shall issue to the policyholder, for delivery to each person insured, a certificate setting forth a statement as to the insurance protection to which that person is entitled, to whom the insurance benefits are payable, and a statement as to any family member's or dependent's coverage;

(8)A provision that written notice of claim must be given to the insurer within twenty days after the occurrence or commencement of any loss covered by the policy.Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible;

(9)A provision that the insurer shall furnish to the person making claim, or to the policyholder for delivery to such person, such forms as are usually furnished by it for filing proof of loss.If such forms are not furnished before the expiration of fifteen days after the insurer receives notice of any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting, within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character, and extent of the loss for which claim is made;

(10)A provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within ninety days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within ninety days after the date of such loss.Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it was not reasonably possible to furnish such proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required;

(11)A provision that all benefits payable under the policy other than benefits for loss of time shall be payable not more than thirty days after receipt of proof and that, subject to due proof of loss, all accrued benefits payable under the policy for loss of time shall be paid not less frequently than monthly during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period shall be paid as soon as possible after receipt of such proof;

(12)A provision that benefits for accidental loss of life of a person insured shall be payable to the beneficiary designated by the person insured or, if the policy contains conditions pertaining to family status, the beneficiary may be the family member specified by the policy terms.In either case, payment of these benefits is subject to the provisions of the policy in the event no such designated or specified beneficiary is living at the death of the person insured.All other benefits of the policy shall be payable to the person insured.The policy may also provide that if any benefit is payable to the estate of a person, or to a person who is a minor or otherwise not competent to give a valid release, the insurer may pay such benefit, up to an amount not exceeding two thousand dollars, to any relative by blood or connection by marriage of such person who is deemed by the insurer to be equitably entitled thereto;

(13)A provision that the insurer shall have the right and opportunity, at the insurer's own expense, to examine the person of the individual for whom claim is made when and so often as it may reasonably require during the pendency of the claim under the policy and also the right and opportunity, at the insurer's own expense, to make an autopsy in case of death where it is not prohibited by law;

(14)A provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration of sixty days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all unless brought within three years from the expiration of the time within which proof of loss is required by the policy;

(15)A provision specifying the conditions under which the policy may be terminated.Such provision shall state that except for nonpayment of the required premium or the failure to meet continued underwriting standards, the insurer may not terminate the policy prior to the first anniversary date of the effective date of the policy as specified therein, and a notice of any intention to terminate the policy by the insurer must be given to the policyholder at least thirty-one days prior to the effective date of the termination.Any termination by the insurer shall be without prejudice to any expenses originating prior to the effective date of termination.An expense will be considered incurred on the date the medical care or supply is received;

(16)A provision stating that if a policy provides that coverage of a dependent child terminates upon attainment of the limiting age for dependent children specified in the policy, such policy, so long as it remains in force, shall be deemed to provide that attainment of such limiting age does not operate to terminate the hospital and medical coverage of such child while the child is and continues to be both incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the certificate holder for support and maintenance.Proof of such incapacity and dependency must be furnished to the insurer by the certificate holder at least thirty-one days after the child's attainment of the limiting age.The insurer may require at reasonable intervals during the two years following the child's attainment of the limiting age subsequent proof of the child's incapacity and dependency.After such two-year period, the insurer may require subsequent proof not more than once each year.This subdivision shall apply only to policies delivered or issued for delivery in this state on or after one hundred twenty days after September 28, 1985;

(17)A provision stating that if a policy provides that coverage of a dependent child terminates upon attainment of the limiting age for dependent children specified in the policy, such policy, so long as it remains in force, until the dependent child attains the limiting age, shall remain in force at the option of the certificate holder.Eligibility for continued coverage shall be established where the dependent child is:

(a)Unmarried and no more than that twenty-five years of age; and

(b)A resident of this state; and

(c)Not provided coverage as a named subscriber, insured, enrollee, or covered person under any group or individual health benefit plan, or entitled to benefits under Title XVIII of the Social Security Act, P.L.89-97, 42 U.S.C. Section 1395, et seq.;

(18)In the case of a policy insuring debtors, a provision that the insurer shall furnish to the policyholder for delivery to each debtor insured under the policy a certificate of insurance describing the coverage and specifying that the benefits payable shall first be applied to reduce or extinguish the indebtedness;

*(19)Notwithstanding any other provision of law to the contrary, a health carrier, as defined in section 376.1350, may offer a health benefit plan that is a managed care plan that requires all health care services to be delivered by a participating provider in the health carrier's network, except for emergency services, as defined in section 376.1350, and the services described in subsection 4 of section 376.811.Such a provision shall be disclosed in clear, conspicuous, and understandable language in the enrollment application and in the policy form.Whenever a health carrier offers a health benefit plan pursuant to this subdivision to a group contract holder as an exclusive or full replacement health benefit plan the health carrier shall offer at least one additional health benefit plan option that includes an out-of-network benefit.The decision to accept or reject the offer of the option of a health benefit plan that includes an out-of-network benefit shall be made by the enrollee and not the group contract holder;

*(20)A provision stating that a health benefit plan issued pursuant to subdivision (19) of this section shall have in place a procedure by which an enrollee may obtain a referral to a nonparticipating provider when the enrollee is diagnosed with a life-threatening condition or disabling degenerative disease.

The provisions of subdivisions (19) and (20) of this section shall expire and be null and void at the end of the calendar year following the repeal of 42 U.S.C. Section 300gg by the United States Congress or at the end of the calendar year following a finding by a court of competent jurisdiction that such section is unconstitutional or otherwise infirm.

(L. 1985 H.B. 623, A.L. 2007 H.B. 818, A.L. 2013 S.B. 262)

*Contingent expiration date

*Revisor's Note:42 U.S.C. § 300gg had not been repealed as of the date of the general republication of the Revised Statutes of Missouri in 2016.

376.1093 - Annual report filed with director, when — contents — filing fee, amount.

1.Each administrator shall file an annual report for the preceding calendar year with the director on or before March first of each year, or within such extension of time therefor as the director for good cause may grant.The report shall be in the form and contain such matters as the director prescribes and shall be verified by at least two officers of the administrator.

2.The annual report shall include the complete names and addresses of all insurers and trusts with which the administrator had an agreement during the preceding fiscal year.

3.The annual report shall identify which insurers or trusts are fully insured by an insurer licensed to transact business in this state, self-insured, or have stop-loss coverage.

4.For those insurers or trusts which are fully insured or which possess stop-loss coverage, the annual report shall identify the carrier and policy or certificate number.

5.At the time of filing its annual report, the administrator shall pay a filing fee of two hundred fifty dollars.

(L. 1993 H.B. 709 § 52)

376.398 - Application to all group policies — effective, when.

The provisions of sections 376.395 to 376.404 shall become effective January 1, 1983, and shall apply to all group policies delivered, issued for delivery or amended on or after January 1, 1983.

(L. 1981 S.B. 58 § A)

Effective 1-01-83

376.422 - Direct response solicitation and sponsoring or endorsing entity, defined — certain group or individual insurers paying compensation to policyholder or sponsoring entity to notify policyholders.

1.As used in this section, the following terms shall mean:

(1)"Direct response solicitation", a solicitation through a sponsoring or endorsing entity or through the mails, telephone, or other mass communications medium;

(2)"Sponsoring or endorsing entity", an organization which has arranged for the offering of a program of insurance in a manner which communicates that eligibility for participation in the program is dependent upon affiliation with such organization or that it endorses participation in the program.

2.With respect to a program of insurance, whether issued on an individual basis or a group basis, which would not qualify under subdivisions (1), (2), (3), (4) and (6) of subsection 1 of section 376.421, if issued on a group basis, if compensation of any kind will or may be paid to a policyholder in the case of a group policy, or a sponsoring or endorsing entity in the case of individual, blanket or franchise policies marketed by means of direct response solicitation, the insurer shall cause to be distributed to prospective insureds a written notice that compensation will or may be paid.Such notice shall be distributed whether compensation is direct or indirect and whether such compensation is paid to or retained by the policyholder or sponsoring or endorsing entity or paid to or retained by a third party at the direction of the policyholder or sponsoring or endorsing entity or any entity affiliated therewith by way of ownership, contract or employment.The notice required by this subsection shall be placed on or shall accompany any application or enrollment form provided prospective insureds.

(L. 1985 H.B. 623)

376.894 - Amount of premium, date of payment — termination of right of continuation of coverage, grounds.

If a legally separated, divorced or surviving spouse elects continuation of coverage under section 376.893:

(1)During the period of time covered by the federal Consolidated Omnibus Budget Reconciliation Act (COBRA), the monthly contribution for the premium shall not be greater than the amount that would be charged if the legally separated, divorced or surviving spouse were a current certificate holder of the group contract, policy or plan plus the amount that the group policyholder would contribute toward the premium if the legally separated, divorced or surviving spouse were a certificate holder of the group plan, plus an additional amount not to exceed two percent of the certificate holder and group plan holder contributions, for the cost of administration.Once the period of time covered by the insurance premium provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA) has expired, the monthly contribution for the premium shall not be greater than the amount that would have been charged if the legally separated, divorced or surviving spouse were a current certificate holder of the group contract, policy or plan plus the amount that the group policyholder would contribute toward the premium if the legally separated, divorced or surviving spouse were a certificate holder plus an amount not to exceed twenty-five percent of the certificate holder and group plan holder contributions.Such additional contributions shall be determined by each individual plan administrator and shall be subject to review by the Missouri department of insurance, financial institutions and professional registration;

(2)The first premium shall be paid by the legally separated, divorced or surviving spouse within forty-five days of the date of the election;

(3)The right to continuation of coverage shall terminate upon the earliest of any of the following:

(a)The failure to pay premiums when due, including any grace period allowed by the policy;

(b)The date that the group policy is terminated as to all group members except that if a different group policy is made available to group members, the legally separated, divorced or surviving spouse shall be eligible for continuation of coverage as if the original policy had not been terminated;

(c)The date on which the legally separated, divorced or surviving spouse becomes insured under any other group health plan;

(d)The date on which the legally separated, divorced or surviving spouse remarries and becomes insured under another group health plan; or

(e)The date on which the legally separated, divorced or surviving spouse attains his sixty-fifth birthday.

(L. 1993 H.B. 564 § 14)

376.973 - Administering insurer at close of fiscal year to make accounting and assessment — how calculated — excess to be held at interest for future losses or to reduce premiums — future losses, defined — assessments, continuation of.

1.Following the close of each fiscal year, the pool administrator shall determine the net premiums (premiums less administrative expense allowances), the pool expenses of administration and the incurred losses for the year, taking into account investment income and other appropriate gains and losses.Health insurance premiums and benefits paid by an insurance arrangement that are less than an amount determined by the board to justify the cost of collection shall not be considered for purposes of determining assessments.The total cost of pool operation shall be the amount by which all program expenses, including pool expenses of administration, incurred losses for the year, and other appropriate losses exceeds all program revenues, including net premiums, investment income, and other appropriate gains.

2.Each insurer's assessment shall be determined by multiplying the total cost of pool operation by a fraction, the numerator of which equals that insurer's premium and subscriber contract charges for health insurance written in the state during the preceding calendar year and the denominator of which equals the total of all premiums, subscriber contract charges written in the state and one hundred ten percent of all claims paid by insurance arrangements in the state during the preceding calendar year; provided, however, that the assessment for each health maintenance organization shall be determined through the application of an equitable formula based upon the value of services provided in the preceding calendar year.

3.Each insurance arrangement's assessment shall be determined by multiplying the total cost of pool operation calculated under subsection 1 of this section by a fraction, the numerator of which equals one hundred ten percent of the benefits paid by that insurance arrangement on behalf of insureds in this state during the preceding calendar year and the denominator of which equals the total of all premiums, subscriber contract charges and one hundred ten percent of all benefits paid by insurance arrangements made on behalf of insureds in this state during the preceding calendar year.Insurance arrangements shall report to the board claims payments made in this state on an annual basis on a form prescribed by the director.

4.If assessments exceed actual losses and administrative expenses of the pool, the excess shall be held at interest and used by the board to offset future losses or to reduce pool premiums.As used in this subsection, "future losses" include reserves for incurred but not paid claims.

5.Assessments shall continue until such a time as the executive director of the pool provides notice to the board and director that all claims have been paid.

6.Any assessment funds remaining at the time the executive director provides notice that all claims have been paid shall be deposited in the state general revenue fund.

(L. 1990 H.B. 998 § 5 subsecs. 1 to 4, A.L. 2013 S.B. 262)

376.722 - Board of directors, established, members, how selected — expense reimbursement.

1.The board of directors of the association shall consist of not less than seven nor more than eleven member insurers serving terms as established in the plan of operation.The members of the board shall be selected by member insurers subject to the approval of the director.Each class of member insurer, as defined in section 376.718, shall be represented on the board.Vacancies on the board shall be filled for the remaining period of the term by a majority vote of the remaining board members, subject to the approval of the director.In determining voting rights at the organizational meeting, each member insurer shall be entitled to one vote in person or by proxy.

2.In approving selections or in appointing members to the board, the director shall consider, among other things, whether all member insurers are fairly represented.

3.Members of the board may be reimbursed from the assets of the association for expenses incurred by them as members of the board of directors but members of the board shall not otherwise be compensated by the association for their services.

(L. 1988 S.B. 430 § 6, A.L. 2018 H.B. 1690)

376.1025 - Director may adopt rules.

The director may adopt regulations which are necessary to implement the provisions of sections 376.1000 to 376.1045 and to ensure the safe and proper operation of multiple employer self-insured health plans in this state.No rule or portion of a rule promulgated under the authority of this section shall become effective unless it has been promulgated pursuant to the provisions of section 536.024.

(L. 1993 H.B. 709 § 32, A.L. 1995 S.B. 3)

376.1378 - Grievances and certificate of compliance filed with the director, when.

1.A copy of the grievance procedures, including all forms used to process a grievance, shall be filed with the director.Any subsequent material modifications to the documents also shall be filed.In addition, a health carrier shall file annually with the director, as part of its annual report required by section 376.1375, a certificate of compliance stating that the health carrier has established and maintains, for each of its health benefit plans, grievance procedures that fully comply with the provisions of sections 376.1350 to 376.1390.The director has authority to disapprove a filing that fails to comply with sections 376.1350 to 376.1390 or applicable rules and regulations.

2.A description of the grievance procedure shall be set forth in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage provided to enrollees.

3.The grievance procedure documents shall include a statement of an enrollee's right to contact the director's office for assistance at any time.The statement shall include the toll-free telephone number and address of the department of insurance, financial institutions and professional registration.

4.No such grievance procedure shall act as a bar to any suit in a court of competent jurisdiction instituted by any such enrollee, or as a bar to any defense thereto by the health carrier.

5.In the event there is a conflict between the outcomes of the grievance procedure and any such suit, the outcome of the suit in a court of competent jurisdiction shall prevail.

(L. 1997 H.B. 335)

376.590 - Misrepresentations, false estimates and circulars prohibited — agents — notes to be held until policy delivered.

1.No life insurance company doing business in this state, and no officer, director, or agent thereof, shall issue or circulate, or cause or permit to be issued or circulated, any estimate, illustration, circular or statement of any sort misrepresenting the terms of any policy issued by it or the benefits or advantages promised thereby, or the dividends or shares of surplus to be received thereon, or shall use any name or title of any policy or class of policies misrepresenting the true nature thereof.

2.Any person who shall solicit an application for insurance upon the life of another shall, in any controversy between the assured or his beneficiary and the company issuing any policy upon such application, be regarded as the agent of the company and not the agent of the assured, nor shall any life insurance company or agent sell, discount or otherwise dispose of any note or notes taken for payment of life insurance premium or premiums, before delivering to the applicant, in person, the policy for which said note or notes shall have been given.

(RSMo 1939 § 5844)

Prior revisions: 1929 § 5733; 1919 § 6143; 1909 § 6938

376.790 - Limits on applicability of law.

Nothing in sections 376.770 to 376.800 shall apply to or affect (1) any policy of workers' compensation insurance or any policy of liability insurance with or without supplementary expense coverage therein; or (2) any policy or contract of reinsurance; or (3) any blanket or group policy of insurance; or (4) life insurance endowment or annuity contracts or contracts supplemental thereto which contain only such provisions relating to accident and sickness insurance as (a) provide additional benefits in case of death or dismemberment or loss of sight by accident, or as (b) operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant shall become totally and permanently disabled, as defined by the contract or supplemental contract.

(L. 1959 H.B. 252 § 9)

376.777 - Specifically required provisions — exemptions, when — director's powers — inapplicability of certain provisions to individual health insurance coverage.

1.Required provisions.Except as provided in subsection 3 of this section each such policy delivered or issued for delivery to any person in this state shall contain the provisions specified in this subsection in the words in which the same appear in this section; provided, however, that the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the director of the department of insurance, financial institutions and professional registration which are in each instance not less favorable in any respect to the insured or the beneficiary.Such provisions shall be preceded individually by the caption appearing in this subsection or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the director of the department of insurance, financial institutions and professional registration may approve.

(1)A provision as follows: "ENTIRE CONTRACT; CHANGES:

This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance.No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto.No agent has authority to change this policy or to waive any of its provisions".

(When under the provisions of subdivision (2) of subsection 1 of section 376.775 the effective and termination dates are stated in the premium receipt, the insurer shall insert in the first sentence of the foregoing policy provision immediately following the comma after the word "any", the following words:"and the insurer's official premium receipt when executed" ).

(2)A provision as follows: "TIME LIMIT ON CERTAIN DEFENSES:

(a)After two years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such two-year period".

(The foregoing policy provision shall not be so construed as to affect any legal requirements for avoidance of a policy or denial of a claim during such initial two-year period, nor to limit the application of subdivisions (1), (2), (3), (4) and (5) of subsection 2 of this section in the event of misstatement with respect to age or occupation or other insurance.)

(A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (1) until at least age fifty or, (2) in the case of a policy issued after age forty-four, for at least five years from its date of issue, may contain in lieu of the foregoing the following provision (from which the clause in parentheses may be omitted at the insurer's option) under the caption "UNCONTESTABLE":

"After this policy has been in force for a period of three years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become uncontestable as to the statements contained in the application).

(b)No claim for loss incurred or disability (as defined in the policy) commencing after two years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy."

(3)A provision as follows: "GRACE PERIOD:

A grace period of ______ (insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force."

(A policy which contains a cancellation provision may add, at the end of the above provision, subject to the right of the insurer to cancel in accordance with the cancellation provision hereof.A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision, "Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted" ).

(4)A provision as follows: "REINSTATEMENT:

If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer, or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application.The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date.In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement.Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than sixty days prior to the date of reinstatement".

(The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age fifty or, (2) in the case of a policy issued after age forty-four, for at least five years from its date of issue.)

(5)A provision as follows: "NOTICE OF CLAIM:

Written notice of claim must be given to the insurer within twenty days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible.Notice given by or on behalf of the insured or the beneficiary to the insured at ______ (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer".

(In a policy providing a loss-of-time benefit which may be payable for at least two years, an insurer may at its option insert the following between the first and second sentences of the above provision:

"Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he shall, at least once in every six months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity.The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision.Delay in the giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given" ).

(6)A provision as follows: "CLAIM FORMS:

The insurer upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss.

If such forms are not furnished within fifteen days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made".

(7)A provision as follows: "PROOFS OF LOSS:

Written proof of loss must be furnished to the insurer at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within ninety days after the termination of the period for which the insurer is liable and in case of claim for any other loss within ninety days after the date of such loss.Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required".

(8)A provision as follows: "TIME OF PAYMENT OF CLAIMS:

Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss.Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ______ (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof".

(9)A provision as follows: "PAYMENT OF CLAIMS:

Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment.If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured.Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate.All other indemnities will be payable to the insured".

(The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:

"If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $______ (insert an amount which shall not exceed one thousand dollars), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto.Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person" ).

(10)A provision as follows: "PHYSICAL EXAMINATIONS AND AUTOPSY:

The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law".

(11)A provision as follows: "LEGAL ACTIONS:

No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this policy.No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished".

(12)A provision as follows: "CHANGE OF BENEFICIARY:

Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to change of beneficiary or beneficiaries, or to any other changes in this policy".

(The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the insurer's option).

2.Other provisions.Except as provided in subsection 3 of this section, no such policy delivered or issued for delivery to any person in this state shall contain provisions respecting the matters set forth below unless such provisions are in the words in which the same appear in this section; provided, however, that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the director of the department of insurance, financial institutions and professional registration which is not less favorable in any respect to the insured or the beneficiary.Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in this subsection or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the director of the department of insurance, financial institutions and professional registration may approve.

(1)A provision as follows: "CHANGE OF OCCUPATION:

If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation.If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent.In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation".

(2)A provision as follows: "MISSTATEMENT OF AGE:

If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age".

(3)A provision as follows: "OTHER INSURANCE IN THIS INSURER:

If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for ______ (insert type of coverage or coverages) in excess of $______ (insert maximum limit of indemnity or indemnities) the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate, or in lieu thereof.

Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies".

(4)A provision as follows: "INSURANCE WITH OTHER INSURERS:

If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro rata portion for the amount so determined.For the purpose of applying this provision when other coverage is on a provision of service basis, the "like amount" of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage".

(If the foregoing policy provision is included in a policy which also contains the next following policy provision there shall be added to the caption of the foregoing provision the phrase "EXPENSE INCURRED BENEFITS".The insurer may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the director of the department of insurance, financial institutions and professional registration, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the director of the department of insurance, financial institutions and professional registration.In the absence of such definition such term shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employees benefit organizations.For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute whether provided by a governmental agency or otherwise shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice.In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage" ).

(5)A provision as follows: "INSURANCE WITH OTHER INSURERS:

If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro rata portion for the indemnities thus determined".

(If the foregoing policy provision is included in a policy which also contains the next preceding policy provision there shall be added to the caption of the foregoing provision the phrase "OTHER BENEFITS".The insurer may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the director of the department of insurance, financial institutions and professional registration which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the director of the department of insurance, financial institutions and professional registration.In the absence of such definition such term shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations.For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute) whether provided by a governmental agency or otherwise shall in all cases be deemed to be "other valid coverage", of which the insurer has had notice.In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage" ).

(6)A provision as follows: "RELATION OF EARNINGS TO INSURANCE:

If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of two hundred dollars or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time".

(The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age fifty or, (2) in the case of a policy issued after age forty-four, for at least five years from this date of issue.The insurer may, at its option, include in this provision a definition of "valid loss of time coverage", approved as to form by the director of the department of insurance, financial institutions and professional registration, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the director of the department of insurance, financial institutions and professional registration or any combination of such coverages.In the absence of such definition such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute), or benefits provided by union welfare plans or by employer or employee benefit organizations).

(7)A provision as follows: "UNPAID PREMIUM:

Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom".

(8)A provision as follows: "CANCELLATION:

The insurer may cancel this policy at any time by written notice delivered to the insured, or mailed to his last address as shown by the records of the insurer, stating when, not less than five days thereafter, such cancellation shall be effective; and after the policy has been continued beyond its original term the insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice.In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid.If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued.If the insurer cancels, the earned premium shall be computed pro rata.Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation".

(9)A provision as follows: "CONFORMITY WITH STATE STATUTES:Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes".

(10)A provision as follows: "ILLEGAL OCCUPATION:

The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation".

(11)A provision as follows: "INTOXICANTS AND NARCOTICS:

The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician".

3.Inapplicable or inconsistent provisions.If any provision of this section is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy the insurer, with the approval of the director of the department of insurance, financial institutions and professional registration, shall omit from such policy an inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision, in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

4.Order of certain policy provisions.The provisions which are the subject of subsections 1 and 2 of this section, or any corresponding provisions which are used in lieu thereof in accordance with such subsections, shall be printed in the consecutive order of the provisions in such subsections or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.

5.Third party ownership.The word "insured" as used in sections 376.770 to 376.800, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.

6.Requirements of other jurisdictions.

(1)Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of sections 376.770 to 376.800 and which is prescribed or required by the law of the state under which the insurer is organized.

(2)Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.

7.Approval of policies.

(1)No policy subject to sections 376.770 to 376.800 shall be delivered or issued for delivery to any person in this state unless such policy, including any rider, endorsement or other provisions, supplementary thereto, shall have been approved by the director of the department of insurance, financial institutions and professional registration.

(2)The director of the department of insurance, financial institutions and professional registration shall have authority to make such reasonable rules and regulations concerning the filing and submission of policies as are necessary, proper or advisable.Such rules and regulations shall provide, among other things, that if a policy form is disapproved, all specific reasons for nonconformance shall be stated in writing within forty-five days from the date of filing; that a hearing shall be granted upon such disapproval, if so requested; and that the failure of the director of the department of insurance, financial institutions and professional registration, to take action approving or disapproving a submitted policy form within forty-five days from the date of filing, shall be deemed an approval thereof.If at any time after a policy form is approved or deemed approved, the director determines that any provision of the filing is contrary to state law, the director shall notify the health carrier of the specific provisions that are contrary to state law and any specific statute or regulation to which the provision is contrary, and request that the health carrier file within thirty days of the notification an amendment form that modifies the provision to conform to state law.Upon approval of the amendment form by the director, the health carrier shall issue a copy of the amendment to each individual and entity to which the filing has been issued.Such amendment shall have the force and effect as if the amendment was in the original filing or policy.

(3)The director of the department of insurance, financial institutions and professional registration shall approve only those policies which are in compliance with the insurance laws of this state and which contain such words, phraseology, conditions and provisions which are specific, certain and unambiguous and reasonably adequate to meet needed requirements for the protection of those insured.The disapproval of any policy form shall be based upon the requirements of the laws of this state or of any regulation lawfully promulgated thereunder.

(4)The director of the department of insurance, financial institutions and professional registration may, by order or bulletin, exempt from the approval requirements of this section for so long as he deems proper any insurance policy, document, or form or type thereof, as specified in such order or bulletin, to which, in his opinion, this section may not practicably be applied, or the approval of which is, in his opinion, not desirable or necessary for the protection of the public.

(5)Notwithstanding any other provision of law to the contrary, a health carrier, as defined in section 376.1350, may offer a health benefit plan that is a managed care plan that requires all health care services to be delivered by a participating provider in the health carrier's network, except for emergency services, as defined in section 376.1350, and the services described in subsection 4 of section 376.811.Such a provision shall be disclosed in the policy form.

(L. 1959 H.B. 252 § 4, A.L. 1984 S.B. 592, A.L. 2013 S.B. 262)

376.677 - Life policies may be issued that have no cash surrender value prior to death — no policy loans so law regulating not applicable — requirements to issue.

1.Notwithstanding any provision of section 376.670, to the contrary, after September 28, 1987, a company may issue policies of life insurance which differ from its existing or currently filed policies only in that they do not provide for any cash surrender value prior to the death of the life insured.If a policy provides for any cash surrender value, endowment, or pure endowment prior to the death of the life insured, this exemption shall not apply.Any policy without cash surrender values, for which one or more cash surrender values would otherwise have been required, shall contain on its first page a concise, exact description set out in contrasting type at least four points larger than used in the body of that page a statement in a prominent place that such values are not provided and that no policy loans are available under the policy.The company shall provide to each prospective purchaser of such a policy a policy summary, the form of which shall be filed for approval pursuant to section 376.675, which includes the same description as the policy, similarly displayed, and which shows the premium said company charges for the same policy when cash surrender values are included.Such policy summary shall be delivered before any premium is accepted.

2.Except for the requirement of payment upon surrender, the nonforfeiture amounts for such policies shall be subject to all provisions of chapter 376, which apply to the cash surrender values of otherwise similar life insurance policies with cash surrender values.

3.The insurance laws of this state relating to policy loans shall not apply to policies which do not provide cash surrender values.

(L. 1987 H.B. 415 § 1)

376.690 - Unanticipated out-of-network care, claim procedure — limitation on amount billed to patient — external arbitration process — rulemaking authority.

1.As used in this section, the following terms shall mean:

(1)"Emergency medical condition", the same meaning given to such term in section 376.1350;

(2)"Facility", the same meaning given to such term in section 376.1350;

(3)"Health care professional", the same meaning given to such term in section 376.1350;

(4)"Health carrier", the same meaning given to such term in section 376.1350;

(5)"Unanticipated out-of-network care", health care services received by a patient in an in-network facility from an out-of-network health care professional from the time the patient presents with an emergency medical condition until the time the patient is discharged.

2.(1)Health care professionals may send any claim for charges incurred for unanticipated out-of-network care to the patient's health carrier within one hundred * eighty days of the delivery of the unanticipated out-of-network care on a U.S. Centers of Medicare and Medicaid Services Form 1500, or its successor form, or electronically using the 837 HIPAA format, or its successor.

(2)Within forty-five processing days, as defined in section** 376.383, of receiving the health care professional's claim, the health carrier shall offer to pay the health care professional a reasonable reimbursement for unanticipated out-of-network care based on the health care professional's services.If the health care professional participates in one or more of the carrier's commercial networks, the offer of reimbursement for unanticipated out-of-network care shall be the amount from the network which has the highest reimbursement.

(3)If the health care professional declines the health carrier's initial offer of reimbursement, the health carrier and health care professional shall have sixty days from the date of the initial offer of reimbursement to negotiate in good faith to attempt to determine the reimbursement for the unanticipated out-of-network care.

(4)If the health carrier and health care professional do not agree to a reimbursement amount by the end of the sixty-day negotiation period, the dispute shall be resolved through an arbitration process as specified in subsection 4 of this section.

(5)To initiate arbitration proceedings, either the health carrier or health care professional must provide written notification to the director and the other party within one hundred twenty days of the end of the negotiation period, indicating their intent to arbitrate the matter and notifying the director of the billed amount and the date and amount of the final offer by each party.A claim for unanticipated out-of-network care may be resolved between the parties at any point prior to the commencement of the arbitration proceedings.Claims may be combined for purposes of arbitration, but only to the extent the claims represent similar circumstances and services provided by the same health care professional, and the parties attempted to resolve the dispute in accordance with subdivisions (3) to*** (5) of this subsection.

(6)No health care professional who sends a claim to a health carrier under subsection 2 of this section shall send a bill to the patient for any difference between the reimbursement rate as determined under this subsection and the health care professional's billed charge.

3.(1)When unanticipated out-of-network care is provided, the health care professional who sends a claim to a health carrier under subsection 2 of this section may bill a patient for no more than the cost-sharing requirements described under this section.

(2)Cost-sharing requirements shall be based on the reimbursement amount as determined under subsection 2 of this section.

(3)The patient's health carrier shall inform the health care professional of its enrollee's cost-sharing requirements within forty-five processing days of receiving a claim from the health care professional for services provided.

(4)The in-network deductible and out-of-pocket maximum cost-sharing requirements shall apply to the claim for the unanticipated out-of-network care.

4.The director shall ensure access to an external arbitration process when a health care professional and health carrier cannot agree to a reimbursement under subdivision (3) of subsection 2 of this section.In order to ensure access, when notified of a parties' intent to arbitrate, the director shall randomly select an arbitrator for each case from the department's approved list of arbitrators or entities that provide binding arbitration.The director shall specify the criteria for an approved arbitrator or entity by rule.The costs of arbitration shall be shared equally between and will be directly billed to the health care professional and health carrier.These costs will include, but are not limited to, reasonable time necessary for the arbitrator to review materials in preparation for the arbitration, travel expenses and reasonable time following the arbitration for drafting of the final decision.

5.At the conclusion of such arbitration process, the arbitrator shall issue a final decision, which shall be binding on all parties.The arbitrator shall provide a copy of the final decision to the director.The initial request for arbitration, all correspondence and documents received by the department and the final arbitration decision shall be considered a closed record under section 374.071.However, the director may release aggregated summary data regarding the arbitration process.The decision of the arbitrator shall not be considered an agency decision nor shall it be considered a contested case within the meaning of section** 536.010.

6.The arbitrator shall determine a dollar amount due under subsection 2 of this section between one hundred twenty percent of the Medicare-allowed amount and the seventieth percentile of the usual and customary rate for the unanticipated out-of-network care, as determined by benchmarks from independent nonprofit organizations that are not affiliated with insurance carriers or provider organizations.

7.When determining a reasonable reimbursement rate, the arbitrator shall consider the following factors if the health care professional believes the payment offered for the unanticipated out-of-network care does not properly recognize:

(1)The health care professional's training, education, or experience;

(2)The nature of the service provided;

(3)The health care professional's usual charge for comparable services provided;

(4)The circumstances and complexity of the particular case, including the time and place the services were provided; and

(5)The average contracted rate for comparable services provided in the same geographic area.

8.The enrollee shall not be required to participate in the arbitration process.The health care professional and health carrier shall execute a nondisclosure agreement prior to engaging in an arbitration under this section.

9.This section shall take effect on January 1, 2019.

10.The department of insurance, financial institutions and professional registration may promulgate rules and fees as necessary to implement the provisions of this section, including but not limited to procedural requirements for arbitration.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2018, shall be invalid and void.

(L. 2018 S.B. 982)

Effective 1-01-19

*Word "and" appears here in original rolls.

**Word "section" does not appear in original rolls.

***Word "through" appears in original rolls.

376.294 - Prohibited acts.

1.An insurer shall not directly or indirectly:

(1)Invest in an obligation or security or make a guarantee for the benefit of or in favor of an officer or director of the insurer except as provided in section 376.295;

(2)Invest in an obligation or security, make a guarantee for the benefit of or in favor of, or make other investments in a business entity of which ten percent or more of the voting securities or equity interests are owned directly or indirectly by or for the benefit of one or more officers or directors in the insurer except under a transaction entered into in compliance with section 382.195 or provided in section 376.295;

(3)Engage on its own behalf or through one or more affiliates in a transaction or series of transactions designed to evade the prohibitions of section 375.345 and sections 376.291 to 376.307, or section 376.311;

(4)Invest in a partnership as a general partner, except that an insurer may make an investment as a general partner:

(a)If all other partners in the partnership are subsidiaries of the insurer or other insurance company affiliates of the insurer;

(b)For the purpose of:

a.Meeting cash calls committed to prior to August 28, 2007;

b.Completing those specific projects or activities of the partnership in which the insurer was a general partner as of August 28, 2007, that had been undertaken as of that date; or

c.Making capital improvements to property owned by the partnership on August 28, 2007, if the insurer was a general partner as of that date; or

(c)In accordance with subdivision (3) of subsection 1 of section 376.293; or

(5)Invest or lend its funds upon the security of shares of its own stock, except as authorized by other provisions of this chapter.However, no such shares shall be admitted assets of the insurer.

2.Subdivision (4) of subsection 1 of this section shall not prohibit a subsidiary or other affiliate of the insurer from becoming a general partner.

(L. 2007 S.B. 66)

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

1.All individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed on or after August 28, 1998, shall provide coverage for administration of general anesthesia and hospital charges for dental care provided to the following covered persons:

(1)A child under the age of five;

(2)A person who is severely disabled; or

(3)A person who has a medical or behavioral condition which requires hospitalization or general anesthesia when dental care is provided.

2.Each plan as described in this section must provide coverage for administration of general anesthesia and hospital or office charges for treatment rendered by a dentist, regardless of whether the services are provided in a participating hospital or surgical center or office.

3.Nothing in this section shall prevent a health carrier from requiring prior authorization for hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.

4.Nothing in this section shall apply to accident-only, dental-only plans or other specified disease, hospital indemnity, Medicare supplement or long-term care policies, or short-term major medical policies of six months or less in duration.

(L. 1998 H.B. 1302 § 8)

376.673 - Life insurance policies, regulations relative to.

1.No life insurance policy shall be issued or delivered in this state after October 13, 1967, which:

(1)By its terms expressly provides that the policyholder will participate in the distribution of earnings or surplus other than earnings or surplus attributable, by reasonable and nondiscriminatory standards, to the participating policies of the company and allocated to the policyholder on reasonable and nondiscriminatory standards; or

(2)Through sales material or oral presentations, is represented by the company or its agent to prospective policyholders as entitling the policyholder to the benefits described in subdivision (1) of this subsection; or

(3)By its terms expressly provides that the policyholder will receive some preferential or discriminatory advantage or benefit not available to persons who purchase insurance from the company at future dates or under other circumstances; or

(4)Through sales material or oral presentations is represented by the company or its agent to prospective policyholders as entitling the policyholder to the benefits described in subdivision (3) of this subsection.

2.Life insurance policies providing for the payment of a series of pure endowments maturing periodically during the premium paying period of the policy which are issued or delivered in this state after October 13, 1967, shall be subject to the following provisions:

(1)No detachable coupons or certificates or passbooks may be used.No other device may be used which tends to emphasize the periodic pure endowment benefits or which tends to create the impression that the pure endowments represent interest earnings or anything other than benefits which have been purchased by part of the policyholder's premium payments.

(2)Each pure endowment benefit must have a fixed maturity date and payment of the pure endowment benefit shall not be contingent upon the payment of any premium becoming due on or after the maturity date.

(3)The pure endowment benefits must be expressed in dollar amounts rather than as percentages of other quantities or in other ways, both in the policy itself and in the sale thereof.

(4)The pure endowment premiums shall be calculated with mortality, interest, and expense factors which are consistent with those for the basic policy premium and it shall be noted in bold type on the face of the policy that "a portion of the premium is used to pay the annual endowment".

(5)No insurance company, insurance agent, solicitor, nor insurance company representative, shall, as a competitive or twisting device, inform any policyholder or prospective policyholder that any insurance company was required to change a policy form or related material to comply with the provisions of this law.

(L. 1967 p. 516)

376.290 - Deposit and transfer of securities.

No existing company organized under any general or special law of this state, and transacting business of the character designated in section 376.010, nor any company organized under sections 376.010 to 376.670, shall commence, continue or carry on business until the company has transferred to and deposited with the director of the department of insurance, financial institutions and professional registration, for the security of its policyholders, the sum of six hundred thousand dollars in notes or bonds secured by mortgages or deeds of trust of the description mentioned in section 376.280, or bonds or treasury notes of the United States, or bonds of the state of Missouri, or funded bonds of any county or municipal township of this state, and in all cases not to be received at a rate above their par value, nor above their current market value.

(RSMo 1939 § 5828, A.L. 1967 p. 516, A.L. 1982 S.B. 729)

Prior revisions: 1929 § 5717; 1919 § 6128; 1909 § 6922

376.694 - Group life, definitions of direct response solicitation and sponsoring or endorsing entity — certain insurers required to give notice of compensation to policyholder or endorsing entity.

1.As used in this section, the following terms shall mean:

(1)"Direct response solicitation", a solicitation through a sponsoring or endorsing entity or through the mails, telephone, or other mass communications medium;

(2)"Sponsoring or endorsing entity", an organization which has arranged for the offering of a program of insurance in a manner which communicates that eligibility for participation in the program is dependent upon affiliation with such organization or that it endorses participation in the program.

2.With respect to a program of insurance, whether issued on an individual basis or a group basis, which would not qualify under subdivisions (1), (2), (3), (4) and (6) of section 376.691 if issued on a group basis, if compensation of any kind will or may be paid to a policyholder in the case of a group policy, or a sponsoring or endorsing entity in the case of individual, blanket or franchise policies marketed by means of direct response solicitation, the insurer shall cause to be distributed to prospective insureds a written notice that compensation will or may be paid.

3.Such notice shall be distributed whether compensation is direct or indirect and whether such compensation is paid to or retained by the policyholder or sponsoring or endorsing entity or paid to or retained by a third party at the direction of the policyholder or sponsoring or endorsing entity or any entity affiliated therewith by way of ownership, contract or employment.

4.The notice required by this section shall be placed on or accompany any application or enrollment form provided prospective insureds.

(L. 1985 H.B. 623)

376.1578 - Credentialing procedure, health carrier duties — violations, mechanism for reporting.

1.Within two working days after receipt of a faxed or mailed completed application, the health carrier shall send a notice of receipt to the practitioner.A health carrier shall provide access to a provider web portal that allows the practitioner to receive notice of the status of an electronically submitted application.

2.A health carrier shall assess a health care practitioner's credentialing information and make a decision as to whether to approve or deny the practitioner's credentialing application within sixty business days of the date of receipt of the completed application.The sixty-day deadline established in this section shall not apply if the application or subsequent verification of information indicates that the practitioner has:

(1)A history of behavioral disorders or other impairments affecting the practitioner's ability to practice, including but not limited to substance abuse;

(2)Licensure disciplinary actions against the practitioner's license to practice imposed by any state or territory or foreign jurisdiction;

(3)Had the practitioner's hospital admitting or surgical privileges or other organizational credentials or authority to practice revoked, restricted, or suspended based on the practitioner's clinical performance; or

(4)A judgment or judicial award against the practitioner arising from a medical malpractice liability lawsuit.

3.The department of insurance, financial institutions and professional registration shall establish a mechanism for reporting alleged violations of this section to the department.

(L. 2013 S.B. 262)

Effective 1-01-14

376.390 - Reserve liability for group insurance — how computed.

The reserve liability for group insurance written by any life insurance company doing business in this state shall be computed upon such tables and basis as may be approved by the director of the department of insurance, financial institutions and professional registration.

(RSMo 1939 § 5832, A.L. 1943 p. 596)

Prior revision: 1929 § 5721

376.773 - Definitions.

1.The word "insurer" as used in sections 376.770 to 376.800 shall mean any insurance company issuing or writing any policy of accident and sickness insurance which is subject to the provisions of sections 376.770 to 376.800.

2.The term "policy of accident and sickness insurance" as used in sections 376.770 to 376.800 includes any policy or contract of insurance against loss resulting from sickness or from bodily injury or death by accident, or both, issued or written by any insurance company authorized under the laws of the state of Missouri to transact such insurance in this state or issued by any insurance company to a resident of the state of Missouri.

3.The term "director of insurance" as used in sections 376.770 to 376.800 shall mean the director of the department of insurance, financial institutions and professional registration.

(L. 1959 H.B. 252 § 2)

376.998 - Health insurance mandate exemption for excepted benefit plans — definitions — procedure to exempt.

1.As used in this section, the following terms shall mean:

(1)"Excepted benefit plan", a policy or certificate of insurance extending the following coverages or any combination thereof:

(a)Coverage under short-term major medical policies;

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

(c)Coverage only for disability income insurance;

(d)Credit-only insurance;

(e)Other similar insurance coverage under which benefits for medical care are supplemental to other insurance benefits;

(f)Coverage only for a specified disease or illness; or

(g)Hospital indemnity or other fixed indemnity insurance;

(2)"Health benefit plan", "health care services", "health carrier", and "health care provider", the same meaning as under section 376.1350;

(3)"Health insurance mandate", a requirement under state law for a health carrier to offer or provide coverage for:

(a)A treatment by a particular type of health care provider;

(b)A certain treatment or service, including procedures, medical equipment, or drugs that are used in connection with a treatment or service; or

(c)Screening, diagnosis, or treatment of a particular disease or condition;

(4)"Notice", a requirement under Missouri law to disclose information regarding the availability of certain benefits or services under a health benefit plan.

2.Excepted benefit plans shall be exempt from any health insurance mandate enacted on or after August 28, 2016, unless the statute enacting such mandate expressly declares that it is applicable to excepted benefit plans as defined in this section.

3.Notwithstanding the provisions of any other law to the contrary, the director may, by bulletin, exempt a type of excepted benefit plan from notice or disclosure requirements required by statute for specific services that by custom are not covered by the particular type of excepted benefit plans being exempted.

4.This section shall apply to an excepted benefit plan to the extent the excepted benefit plan does not materially change coverage to provide for the reimbursement of health care services which extend beyond the types of health care services customarily provided by the specific type of excepted benefit plan or where the combination of coverages and benefits would otherwise meet the definition of a health benefit plan.

(L. 2016 S.B. 833)

376.190 - Additional deposits required.

The director shall annually cause the registered policies and annuity bonds of each company outstanding and in force to be carefully valued, and whenever the total of the actual net value of such policies and annuity bonds exceeds the market value of the securities on deposit, the company issuing such policies or annuity bonds shall immediately deposit sufficient securities of the same kind and type provided for in sections 376.291 to 376.307 to equal the net value of such policies and annuity bonds so that the market value of the securities deposited shall always be equal to the actual net value of the registered policies and annuity bonds issued by such company and still in force.

(RSMo 1939 § 5817, A.L. 1951 p. 275, A.L. 1961 p. 170, A.L. 2007 S.B. 66)

Prior revisions: 1929 § 5706; 1919 § 6117; 1909 § 6911

376.1121 - Denial of claim, long-term care insurance, duties of issuer.

If a claim under a long-term care insurance contract is denied, the issuer shall, within sixty days of the date of a written request by the policyholder or certificate holder, or a representative thereof:

(1)Provide a written explanation of the reasons for the denial; and

(2)Make available all information directly related to the denial.

(L. 2002 H.B. 1568 merged with S.B. 1009)

376.090 - To furnish certificate of deposit, when.

When the corporators have fully complied with the requirements of the preceding sections, and the laws of this state governing the organization of private corporations, and said corporation has deposited with the director of the department of insurance, financial institutions and professional registration the amount of capital required to be deposited by section 376.290, and shall have filed with the director a certified copy of the certificate of incorporation issued by the secretary of state, it shall be his duty to furnish the company a certificate of such deposit, and his certificate of authority for it to commence the business proposed in its charter, which, with the certified copies of the aforesaid declaration and certificates, on being filed and recorded in the office of the recorder of the county in which the company is to be located, shall be its authority to commence business and issue policies; and such certified copies of the declaration certificates and certificate of deposit may be used in evidence for or against said company, with the same effect as the originals.

(RSMo 1939 § 5807)

Prior revisions: 1929 § 5697; 1919 § 6108; 1909 § 6902

376.961 - Missouri health insurance pool created — members to be all health insurers in state — board of directors, members, terms, qualifications — transitioning resources.

1.There is hereby created a nonprofit entity to be known as the "Missouri Health Insurance Pool".All insurers issuing health insurance in this state and insurance arrangements providing health plan benefits in this state shall be members of the pool.

2.Beginning January 1, 2007, the board of directors shall consist of the director of the department of insurance, financial institutions and professional registration or the director's designee, and eight members appointed by the director.Of the initial eight members appointed, three shall serve a three-year term, three shall serve a two-year term, and two shall serve a one-year term.All subsequent appointments to the board shall be for three-year terms.Members of the board shall have a background and experience in health insurance plans or health maintenance organization plans, in health care finance, or as a health care provider or a member of the general public; except that, the director shall not be required to appoint members from each of the categories listed.The director may reappoint members of the board.The director shall fill vacancies on the board in the same manner as appointments are made at the expiration of a member's term and may remove any member of the board for neglect of duty, misfeasance, malfeasance, or nonfeasance in office.

3.Beginning August 28, 2007, the board of directors shall consist of fourteen members.The board shall consist of the director and the eight members described in subsection 2 of this section and shall consist of the following additional five members:

(1)One member from a hospital located in Missouri, appointed by the governor, with the advice and consent of the senate;

(2)Two members of the senate, with one member from the majority party appointed by the president pro tem of the senate and one member of the minority party appointed by the president pro tem of the senate with the concurrence of the minority floor leader of the senate; and

(3)Two members of the house of representatives, with one member from the majority party appointed by the speaker of the house of representatives and one member of the minority party appointed by the speaker of the house of representatives with the concurrence of the minority floor leader of the house of representatives.

4.The members appointed under subsection 3 of this section shall serve in an ex officio capacity.The terms of the members of the board of directors appointed under subsection 3 of this section shall expire on December 31, 2009.On such date, the membership of the board shall revert back to nine members as provided for in subsection 2 of this section.

5.Beginning on August 28, 2013, the board of directors, on behalf of the pool, the executive director, and any other employees of the pool, shall have the authority to provide assistance or resources to any department, agency, public official, employee, or agent of the federal government for the specific purpose of transitioning individuals enrolled in the pool to coverage outside of the pool beginning on or before January 1, 2014.Such authority does not extend to authorizing the pool to implement, establish, create, administer, or otherwise operate a state-based exchange.

(L. 1990 H.B. 998 § 2 subsecs. 1, 2, 3, A.L. 2006 S.B. 837, A.L. 2007 H.B. 818, A.L. 2013 S.B. 262)

376.730 - Liens, association may impose, when.

In carrying out its duties under the provisions of sections 376.715 to 376.758, the association may, subject to approval by the court:

(1)Impose permanent policy or contract liens in connection with any guarantee, assumption or reinsurance agreement, if the association finds that the amounts which can be assessed under sections 376.715 to 376.758 are less than the amounts needed to assure full and prompt performance of the association's duties under sections 376.715 to 376.758, or that the economic or financial conditions as they affect member insurers are sufficiently adverse to render the imposition of such permanent policy or contract liens, to be in the public interest;

(2)Impose temporary moratoriums or liens on payments of cash values and policy loans, or any other right to withdraw funds held in conjunction with policies or contracts, in addition to any contractual provisions for deferral of cash or policy loan value.

(L. 1988 S.B. 430 § 11)

376.986 - Pool to offer medical coverage — premiums, how established — standard risk rate, how calculated — director to approve rates — exclusions — benefits reduced by other insurance or workers' compensation — medical expense to include prayer for spiritual healing.

1.The pool shall offer major medical expense coverage to every person eligible for coverage under section 376.966.The coverage to be issued by the pool and its schedule of benefits, exclusions and other limitations, shall be established by the board with the advice and recommendations of the pool members, and such plan of pool coverage shall be submitted to the director for approval.The pool shall also offer coverage for drugs and supplies requiring a medical prescription and coverage for patient education services, to be provided at the direction of a physician, encompassing the provision of information, therapy, programs, or other services on an inpatient or outpatient basis, designed to restrict, control, or otherwise cause remission of the covered condition, illness or defect.

2.In establishing the pool coverage the board shall take into consideration the levels of health insurance provided in this state and medical economic factors as may be deemed appropriate, and shall promulgate benefit levels, deductibles, coinsurance factors, exclusions and limitations determined to be generally reflective of and commensurate with health insurance provided through a representative number of insurers in this state.

3.The pool shall establish premium rates for pool coverage as provided in subsection 4 of this section.Separate schedules of premium rates based on age, sex and geographical location may apply for individual risks.Premium rates and schedules shall be submitted to the director for approval prior to use.

4.The pool, with the assistance of the director, shall determine the standard risk rate by considering the premium rates charged by other insurers offering health insurance coverage to individuals.The standard risk rate shall be established using reasonable actuarial techniques and shall reflect anticipated experience and expenses for such coverage.Initial rates for pool coverage shall not be less than one hundred twenty-five percent of rates established as applicable for individual standard risks.Subject to the limits provided in this subsection, subsequent rates shall be established to provide fully for the expected costs of claims including recovery of prior losses, expenses of operation, investment income of claim reserves, and any other cost factors subject to the limitations described herein.In no event shall pool rates exceed the following:

(1)For federally defined eligible individuals and trade act eligible individuals, rates shall be equal to the percent of rates applicable to individual standard risks actuarially determined to be sufficient to recover the sum of the cost of benefits paid under the pool for federally defined and trade act eligible individuals plus the proportion of the pool's administrative expense applicable to federally defined and trade act eligible individuals enrolled for pool coverage, provided that such rates shall not exceed one hundred fifty percent of rates applicable to individual standard risks; and

(2)For all other individuals covered under the pool, one hundred fifty percent of rates applicable to individual standard risks.

5.Pool coverage established pursuant to this section shall provide an appropriate high and low deductible to be selected by the pool applicant.The deductibles and coinsurance factors may be adjusted annually in accordance with the medical component of the consumer price index.

6.Pool coverage shall exclude charges or expenses incurred during the first twelve months following the effective date of coverage as to any condition for which medical advice, care or treatment was recommended or received as to such condition during the six-month period immediately preceding the effective date of coverage.Such preexisting condition exclusions shall be waived to the extent to which similar exclusions, if any, have been satisfied under any prior health insurance coverage which was involuntarily terminated, if application for pool coverage is made not later than sixty-three days following such involuntary termination and, in such case, coverage in the pool shall be effective from the date on which such prior coverage was terminated.

7.No preexisting condition exclusion shall be applied to the following:

(1)A federally defined eligible individual who has not experienced a significant gap in coverage; or

(2)A trade act eligible individual who maintained creditable health insurance coverage for an aggregate period of three months prior to loss of employment and who has not experienced a significant gap in coverage since that time.

8.Benefits otherwise payable under pool coverage shall be reduced by all amounts paid or payable through any other health insurance, or insurance arrangement, and by all hospital and medical expense benefits paid or payable under any workers' compensation coverage, automobile medical payment or liability insurance whether provided on the basis of fault or nonfault, and by any hospital or medical benefits paid or payable under or provided pursuant to any state or federal law or program except Medicaid.The insurer or the pool shall have a cause of action against an eligible person for the recovery of the amount of benefits paid which are not for covered expenses.Benefits due from the pool may be reduced or refused as a setoff against any amount recoverable under this subsection.

9.Medical expenses shall include expenses for comparable benefits for those who rely solely on spiritual means through prayer for healing.

(L. 1990 H.B. 998 § 6, A.L. 2007 H.B. 818)

Effective 1-01-08

376.1385 - Second-level review procedures.

1.Upon receipt of a request for second-level review, a health carrier shall submit the grievance to a grievance advisory panel consisting of:

(1)Other enrollees;

(2)Representatives of the health carrier that were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance; and

(3)Where the grievance involves an adverse determination, a majority of persons that are appropriate clinical peers in the same or similar specialty as would typically manage the case being reviewed that were not involved in the circumstances giving rise to the grievance or in any subsequent investigation or determination of the grievance.

2.Review by the grievance advisory panel shall follow the same time frames as a first level review, except as provided for in section 376.1389 if applicable.Any decision of the grievance advisory panel shall include notice of the enrollee's or the health carrier's or plan sponsor's rights to file an appeal with the director's office of the grievance advisory panel's decision.The notice shall contain the toll-free telephone number and address of the director's office.

(L. 1997 H.B. 335)

376.630 - Life insurance policies not to be forfeited or become invalid, when.

No policies of insurance on life issued prior to the operative date of section 376.670 by any life insurance company authorized to do business in this state shall, after payment upon it of three or more annual payments, be forfeited or become void by reason of nonpayment of premiums thereon, but it shall be subject to the following rules of commutation, to wit: The net value of the policy, when the premium becomes due and is not paid, shall be computed upon the actuaries' or combined experience table of mortality with four percent interest per annum, and after deducting from three-fourths of such net value the unpaid portion of any notes given on account of past premium payments on said policy and any other indebtedness to the company secured by said policy, which notes and indebtedness shall then be cancelled, the balance shall be taken as a net single premium for temporary insurance (extended insurance).The amount of such temporary insurance shall be such as is specified in the policy, but never less than the face amount insured by the policy reduced by the unpaid portion of notes and indebtedness aforesaid; and the term for which said temporary insurance shall be in force shall be determined by the attained age of the person whose life is insured at the time of default of premium, the assumption of mortality and interest aforesaid, the amount of temporary insurance granted and the net single premium available for temporary insurance previously defined; provided, that if the original policy shall be an endowment, payable at a certain time or at death, if it should occur previously, then if the net single premium available for temporary insurance as aforesaid shall exceed the net single premium for temporary insurance granted for the remainder of the endowment term, such excess shall be considered as a net single premium for pure endowment of as much as said excess of premiums will purchase, determined by the attained age of the insured at date of default in the payment of premiums on the original policy, and the table of mortality and interest aforesaid, which amount of pure endowment shall be paid at the end of the original term of endowment if the insured shall then be alive.

(RSMo 1939 § 5852, A.L. 1943 p. 596)

Prior revisions: 1929 § 5741; 1919 § 6151; 1909 § 6946

376.886 - Regulations, requirements — rules, procedure.

Regulations adopted pursuant to sections 376.850 to 376.890 shall be subject to the provisions of section 376.982, section 536.021 and section 536.024.Any regulation adopted pursuant to sections 376.850 to 376.890 shall contain all of the provisions of the model regulation or regulations relating to Medicare supplement policies adopted by the National Association of Insurance Commissioners.

(L. 1989 H.B. 615 & 563, A.L. 1992 H.B. 1574, A.L. 1993 S.B. 52, A.L. 1996 S.B. 883)

Effective 4-26-96

376.1085 - Premiums held in fiduciary capacity, duties — financial records, duties — withdrawals from fiduciary account by agreement only, contents — payment of claims.

1.All insurance charges or premiums collected by an administrator on behalf of or for an insurer or insurers, and the return of premiums received from that insurer or insurers, shall be held by the administrator in a fiduciary capacity.Such funds shall be immediately remitted to the person or persons entitled to them or shall be deposited promptly in a fiduciary account established and maintained by the administrator in a federally or state insured financial institution.The written agreement between the administrator and the insurer shall provide for the administrator to render periodically an accounting to the insurer detailing all transactions performed by the administrator pertaining to the business underwritten by the insurer.

2.If charges or premiums deposited in a fiduciary account have been collected on behalf of or for one or more insurers, the administrator shall keep records clearly recording the deposits in and withdrawals from the account on behalf of each insurer.The administrator shall keep copies of all the records and, upon request of an insurer, shall furnish the insurer with copies of the records pertaining to such deposits and withdrawals.

3.The administrator shall not pay any claim by withdrawals from a fiduciary account in which premiums or charges are deposited.Withdrawals from such account shall be made as provided in the written agreement between the administrator and the insurer.The written agreement shall address, but not be limited to, the following:

(1)Remittance to an insurer entitled to remittance;

(2)Deposit in an account maintained in the name of the insurer;

(3)Transfer to and deposit in a claims-paying account, with claims to be paid as provided for in subsection 4 of this section;

(4)Payment to a group policyholder for remittance to the insurer entitled to such remittance;

(5)Payment to the administrator of its commissions, fees or charges; or

(6)Remittance of return premium to the person or persons entitled to such return premium.

4.All claims paid by the administrator from funds collected on behalf of or for an insurer shall be paid only on drafts or checks of, and as authorized by, the insurer.

(L. 1993 H.B. 709 § 47)

376.130 - To furnish certificate of deposit, when.

When the corporators have fully complied with the requirements of the preceding sections, and the laws of this state governing the organization of private corporations, and said corporation has deposited with the director of the department of insurance, financial institutions and professional registration the amount of notes, bonds and mortgages, or deeds of trust, required by sections 376.010 to 376.670, and shall have filed with the director a certified copy of the certificate of incorporation issued by the secretary of state, it shall be his duty to furnish the company a certificate of such deposit, and his certificate of authority for it to commence the business proposed in its charter, which, with the certified copies of the aforesaid declaration and certificates, on being filed and recorded in the office of the recorder of the county in which the company is to be located, shall be its authority to commence business and issue policies; and such certified copies of the declarations, certificates and certificate of deposit may be used in evidence, for or against said company, with the same effect as the originals.

(RSMo 1939 § 5811)

Prior revisions: 1929 § 5701; 1919 § 6112; 1909 § 6906

376.434 - Carrier liable for claims incurred during grace period, when — exceptions.

1.If a policy or contract subject to sections 376.431 to 376.442 provides for automatic discontinuance of the policy or contract after a premium or subscription charge has remained unpaid through the grace period allowed for such payment, the carrier shall be liable for valid claims for covered losses incurred prior to the end of the grace period.However, in no case shall a carrier be held liable for claims incurred during a grace period unless:

(1)Appropriate dues or premiums are received by the carrier during such grace period; or

(2)Such liability is specifically stated in the contract.

2.If the actions of the carrier after the end of the grace period indicate that it considers the policy or contract as continuing in force beyond the end of the grace period, such as by continuing to recognize claims subsequently incurred, the carrier shall be liable for valid claims for losses beginning prior to the effective date of written notice of discontinuance to the policyholder or other entity responsible for making payments or submitting subscription charges to the carrier.The effective date of discontinuance shall not be prior to midnight at the end of the third scheduled work day after the date upon which the notice is delivered.

(L. 1985 H.B. 623)

376.669 - Annuity contract requirements — paid-up annuity benefits, how calculated — cash surrender benefits, how calculated — applicable, when.

1.This section shall not apply to any reinsurance, group annuity purchased under a retirement plan, or plan of deferred compensation established or maintained by an employer (including a partnership or sole proprietorship) or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under Section 408 of the Internal Revenue Code of 1986, as amended, premium deposit fund, variable annuity, investment annuity, immediate annuity, any deferred annuity contract after annuity payments have commenced, or reversionary annuity, nor to any contract which shall be delivered outside this state through an agent or other representative of the company issuing the contract.

2.In the case of contracts issued on or after the effective date of this section as defined in subsection 11 of this section, no contract of annuity, except as stated in subsection 1 of this section, shall be delivered or issued for delivery in this state unless it contains in substance the following provisions, or corresponding provisions which in the opinion of the director are at least as favorable to the contract holder, upon cessation of payment of considerations under the contract:

(1)That upon cessation of payment of considerations under a contract, or upon the written request of the contract owner, the company shall grant a paid-up annuity benefit on a plan stipulated in the contract of such value as is specified in subsections 4, 5, 6, 7, and 9 of this section;

(2)If a contract provides for a lump sum settlement at maturity, or at any other time, that upon surrender of the contract at or prior to the commencement of any annuity payments, the company shall pay in lieu of a paid-up annuity benefit a cash surrender benefit of such amount as is specified in subsections 4, 5, 7, and 9 of this section.The company may reserve the right to defer the payment of the cash surrender benefit for a period not to exceed six months after demand therefor with surrender of the contract after making written request and receiving written approval of the director.The request shall address the necessity and equitability to all policyholders of the deferral;

(3)A statement of the mortality table, if any, and interest rates used in calculating any minimum paid-up annuity, cash surrender or death benefits that are guaranteed under the contract, together with sufficient information to determine the amounts of the benefits; and

(4)A statement that any paid-up annuity, cash surrender or death benefits that may be available under the contract are not less than the minimum benefits required by any statute of the state in which the contract is delivered and an explanation of the manner in which the benefits are altered by the existence of any additional amounts credited by the company to the contract, any indebtedness to the company on the contract or any prior withdrawals from or partial surrenders of the contract.

Notwithstanding the requirements of this subsection, a deferred annuity contract may provide that if no considerations have been received under a contract for a period of two full years and the portion of the paid-up annuity benefit at maturity on the plan stipulated in the contract arising from prior considerations paid would be less than twenty dollars monthly, the company may at its option terminate the contract by payment in cash of the then present value of the portion of the paid-up annuity benefit, calculated on the basis on the mortality table, if any, and interest rate specified in the contract for determining the paid-up annuity benefit, and by this payment shall be relieved of any further obligation under the contract.

3.The minimum values as specified in subsections 4, 5, 6, 7, and 9 of this section of any paid-up annuity, cash surrender or death benefits available under an annuity contract shall be based upon minimum nonforfeiture amounts as defined in this section.

(1)The minimum nonforfeiture amount at any time at or prior to the commencement of any annuity payments shall be equal to an accumulation up to such time at rates of interest as indicated in subdivision (3) of this subsection of the net considerations (as hereinafter defined) paid prior to such time, decreased by the sum of paragraphs (a) to (d) below:

(a)Any prior withdrawals from or partial surrenders of the contract accumulated at rates of interest as indicated in subdivision (3) of this subsection; and

(b)An annual contract charge of fifty dollars, accumulated at rates of interest as indicated in subdivision (3) of this subsection;

(c)Any premium tax paid by the company for the contract, accumulated at rates of interest as indicated in subdivision (3) of this subsection; and

(d)The amount of any indebtedness to the company on the contract, including interest due and accrued.

(2)The net considerations for a given contract year used to define the minimum nonforfeiture amount shall be an amount equal to eighty-seven and one-half percent of the gross considerations credited to the contract during that contract year.

(3)The interest rate used in determining minimum nonforfeiture amounts shall be an annual rate of interest determined as the lesser of three percent per annum and the following, which shall be specified in the contract if the interest rate will be reset:

(a)The five-year Constant Maturity Treasury Rate reported by the Federal Reserve as of a date, or average over a period, rounded to the nearest one-twentieth of one percent, specified in the contract no longer than fifteen months prior to the contract issue date or redetermination date under paragraph (d) of this subdivision;

(b)Reduced by one hundred twenty-five basis points;

(c)Where the resulting interest rate is not less than one percent; and

(d)The interest rate shall apply for an initial period and may be redetermined for additional periods.The redetermination date, basis and period, if any, shall be stated in the contract.The basis is the date or average over a specified period that produces the value of the five-year Constant Maturity Treasury Rate to be used at each redetermination date.

(4)During the period or term that a contract provides substantive participation in an equity indexed benefit, it may increase the reduction described in paragraph (b) of subdivision (3) of this subsection by up to an additional one hundred basis points to reflect the value of the equity index benefit.The present value at the contract issue date, and at each redetermination date thereafter, of the additional reduction shall not exceed the market value of the benefit.The director may require a demonstration that the present value of the additional reduction does not exceed the market value of the benefit.Lacking such a demonstration that is acceptable to the director, the director may disallow or limit the additional reduction.

(5)The director may adopt rules to implement the provisions of subdivision (4) of this subsection and to provide for further adjustments to the calculation of minimum nonforfeiture amounts for contracts that provide substantive participation in an equity index benefit and for other contracts that the director determines adjustments are justified.

4.Any paid-up annuity benefit available under a contract shall be such that its present value on the date annuity payments are to commence is at least equal to the minimum nonforfeiture amount on that date.Present value shall be computed using the mortality table, if any, and the interest rates specified in the contract for determining the minimum paid-up annuity benefits guaranteed in the contract.

5.For contracts that provide cash surrender benefits, the cash surrender benefits available prior to maturity shall not be less than the present value as of the date of surrender of that portion of the maturity value of the paid-up annuity benefit that would be provided under the contract at maturity arising from considerations paid prior to the time of cash surrender reduced by the amount appropriate to reflect any prior withdrawals from or partial surrenders of the contract, such present value being calculated on the basis of an interest rate not more than one percent higher than the interest rate specified in the contract for accumulating the net considerations to determine maturity value, decreased by the amount of any indebtedness to the company on the contract, including interest due and accrued, and increased by any existing additional amounts credited by the company to the contract.In no event shall any cash surrender benefit be less than the minimum nonforfeiture amount at that time.The death benefit under such contracts shall be at least equal to the cash surrender benefit.

6.For contracts that do not provide cash surrender benefits, the present value of any paid-up annuity benefit available as a nonforfeiture option at any time prior to maturity shall not be less than the present value of that portion of the maturity value of the paid-up annuity benefit provided under the contract arising from considerations paid prior to the time the contract is surrendered in exchange for, or changed to, a deferred paid-up annuity, such present value being calculated for the period prior to the maturity date on the basis of the interest rate specified in the contract for accumulating the net considerations to determine maturity value, and increased by any additional amounts credited by the company to the contract.For contracts that do not provide any death benefits prior to the commencement of any annuity payments, present values shall be calculated on the basis of such interest rate and the mortality table specified in the contract for determining the maturity value of the paid-up annuity benefit.However, in no event shall the present value of a paid-up annuity benefit be less than the minimum nonforfeiture amount at that time.

7.For the purpose of determining the benefits calculated under subsections 5 and 6 of this section, in the case of annuity contracts under which an election may be made to have annuity payments commence at optional maturity dates, the maturity date shall be deemed to be the latest date for which election shall be permitted by the contract, but shall not be deemed to be later than the anniversary of the contract next following the annuitant's seventieth birthday or the tenth anniversary of the contract, whichever is later.

8.A contract that does not provide cash surrender benefits or does not provide death benefits at least equal to the minimum nonforfeiture amount prior to the commencement of any annuity payments shall include a statement in a prominent place in the contract that such benefits are not provided.

9.Any paid-up annuity, cash surrender, or death benefits available at any time, other than on the contract anniversary under any contract with fixed scheduled considerations, shall be calculated with allowance for the lapse of time and the payment of any scheduled considerations beyond the beginning of the contract year in which cessation of payment of considerations under the contract occurs.

10.For a contract which provides, within the same contract by rider or supplemental contract provision, both annuity benefits and life insurance benefits that are in excess of the greater of cash surrender benefits or a return of the gross considerations with interest, the minimum nonforfeiture benefits shall be equal to the sum of the minimum nonforfeiture benefits for the annuity portion and the minimum nonforfeiture benefits, if any, for the life insurance portion computed as if each portion were a separate contract.Notwithstanding the provisions of subsections 4, 5, 6, 7, and 9 of this section, additional benefits payable in the event of total and permanent disability, as reversionary annuity or deferred reversionary annuity benefits, or as other policy benefits additional to life insurance, endowment, and annuity benefits, and considerations for all such additional benefits shall be disregarded in ascertaining the minimum nonforfeiture amounts, paid-up annuity, cash surrender, and death benefits that may be required by this section.The inclusion of such benefits shall not be required in any paid-up benefits, unless the additional benefits separately would require minimum nonforfeiture amounts, paid-up annuity, cash surrender, and death benefits.

11.Notwithstanding the provisions of section 376.671, after the effective date of this section*, a company may elect to apply the provisions of this section in lieu of section 376.671 to annuity contracts on a contract form-by-contract form basis before July 1, 2006.In all other instances, this section shall become operative with respect to annuity contracts issued by the company after July 1, 2006.

(L. 2004 H.B. 938 merged with S.B. 1188)

*Effective 6-21-04 (S.B. 1188); 8-28-04 (H.B. 938)

376.882 - Cancellation of policy, refund required — notification.

1.If a Medicare supplement policy issued, delivered, or renewed in this state on or after January 1, 2011, is cancelled for any reason, the insurer shall refund the unearned portion of any premium paid beyond the month in which the cancellation is effective.Any refund shall be returned to the policyholder within twenty days from the date the insurer receives notice of the cancellation.

2.The policyholder may notify the insurer of cancellation of such Medicare supplement policy by sending written or electronic notification.

(L. 2010 S.B. 583)

376.230 - Changing of securities on deposit.

Any company shall have the right at any time to change the securities on deposit with the director of the department of insurance, financial institutions and professional registration by substituting a like amount of the character required in the first instance and to withdraw any excess of securities; and so long as such company shall remain solvent, and the amount of its deposits as herein required are not impaired, it may collect the interest on the securities deposited as the same accrues.

(RSMo 1939 § 5821)

Prior revisions: 1929 § 5710; 1919 § 6121; 1909 § 6915

376.965 - Board members not civilly liable for performance of duties, exception.

No member of the board of directors of the Missouri health insurance pool shall be civilly liable, either jointly or separately, as a result of any act, omission or decision in performance of his duties as specifically required by sections 376.960 to 376.989.Such immunity shall not attach for any intentional or reckless act affecting the property or rights of any person.

(L. 1991 H.B. 385, et al. § 112)

376.330 - Securities may be changed.

Any company organized under the laws of this state, or doing in this state any business mentioned in section 376.010, may at any time change the securities in which its capital or any part thereof is invested, whether the same are deposited with the director of the department of insurance, financial institutions and professional registration or elsewhere, for any other securities; provided, that the amount or value of the securities required by sections 376.010 to 376.670 to be deposited with said director shall in no case be diminished or impaired.

(RSMo 1939 § 5827)

Prior revisions: 1929 § 5716; 1919 § 6127; 1909 § 6921

376.982 - Rulemaking procedure.

No rule or portion of a rule promulgated under the authority of this chapter shall become effective unless it has been promulgated pursuant to the provisions of section 536.024.

(L. 1990 H.B. 998 § 5 subsec. 5 subdiv. (2)(a)-(d), A.L. 1993 S.B. 52, A.L. 1995 S.B. 3)

376.734 - Additional powers of association.

1.In addition to any other rights and powers under sections 376.715 to 376.758, the association may:

(1)Enter into such contracts as are necessary or proper to carry out the provisions and purposes of sections 376.715 to 376.758;

(2)Sue or be sued, including taking any legal actions necessary or proper for recovery of any unpaid assessments under subsections 1 and 2 of section 376.735 and to settle claims or potential claims against it;

(3)Borrow money to effect the purposes of sections 376.715 to 376.758.Any notes or other evidence of indebtedness of the association not in default shall be legal investments for domestic member insurers and may be carried as admitted assets;

(4)Employ or retain such persons as are necessary to handle the financial transactions of the association, and to perform such other functions as become necessary or proper under sections 376.715 to 376.758;

(5)Take such legal action as may be necessary to avoid or recover payment of improper claims;

(6)Exercise, for the purposes of sections 376.715 to 376.758 and to the extent approved by the director, the powers of a domestic life insurer, health insurer, or health maintenance organization but in no case may the association issue policies or contracts other than those issued to perform its obligations under sections 376.715 to 376.758;

(7)Request information from a person seeking coverage from the association in order to aid the association in determining its obligations under sections 376.715 to 376.758 with respect to the person, and the person shall promptly comply with the request;

(8)Unless prohibited by law, in accordance with the terms and conditions of the policy or contract, file an actuarially justified rate or premium increase for any policy or contract for which it provides coverage under sections 376.715 to 376.758;

(9)Take other necessary or appropriate action to discharge its duties and obligations or to exercise its powers under sections 376.715 to 376.758; and

(10)With respect to covered policies for which the association becomes obligated after an entry of an order of liquidation or rehabilitation, elect to succeed to the rights of the insolvent insurer arising after the order of liquidation or rehabilitation under any contract of reinsurance to which the insolvent insurer was a party, to the extent that such contract provides coverage for losses occurring after the date of the order of liquidation or rehabilitation.As a condition to making this election, the association shall pay all unpaid premiums due under the contract for coverage relating to periods before and after the date of the order of liquidation or rehabilitation.

2.The board of directors of the association may exercise reasonable business judgment to determine the means by which the association is to provide the benefits of sections 376.715 to 376.758 in an economical and efficient manner.

3.Where the association has arranged for or offered to provide the benefits of sections 376.715 to 376.758 to a covered person under a plan or arrangement that fulfills the association's obligations under sections 376.715 to 376.758, the person shall not be entitled to benefits from the association in addition to or other than those provided under the plan or arrangement.

4.The association may join an organization of one or more other state associations of similar purposes, to further the purposes and administer the powers and duties of the association.

(L. 1988 S.B. 430 § 14, A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

376.1389 - Expedited grievance review procedure.

1.A health carrier shall establish written procedures for the expedited review of a grievance involving a situation where the time frame of the standard grievance procedures set forth in sections 376.1382 and 376.1385 would seriously jeopardize the life or health of an enrollee or would jeopardize the enrollee's ability to regain maximum function.A request for an expedited review may be submitted orally or in writing.However, for purposes of the grievance register requirements in section 376.1375, the request shall not be considered a grievance unless the request is submitted in writing.Expedited review procedures shall be available to an enrollee, the representative of an enrollee and to the provider acting on behalf of an enrollee.

2.A health carrier shall notify an enrollee orally within seventy-two hours after receiving a request for an expedited review of the carrier's determination, and shall provide written confirmation of its decision covering an expedited review within three working days of providing notification of the determination.The provisions of sections 376.1350 to 376.1390 are not applicable to health indemnity plans without a managed care component as defined in 376.1350.

(L. 1997 H.B. 335)

376.930 - Insured to be furnished application for certificate and annual statement, when.

At the time of or prior to the execution of a life care contract and the transfer of any money or other property to a provider pursuant thereto, the provider shall deliver to the person with whom the life care contract is entered into a copy of the provider's application for a certificate of authority or most recent annual statement as prescribed by section 376.915, whichever is most recent.Thereafter, the provider shall annually deliver a copy of the annual statement to each resident of the facility upon request within ten days after such annual statement is filed with the department.

(L. 1981 S.B. 84 § 4, subsec. 8)

376.365 - Standard valuation law — definitions.

1.Sections 376.365 to 376.380 shall be known and may be cited as the "Standard Valuation Law".

2.As used in sections 376.365 to 376.380, the following terms shall mean and apply on or after the operative date of the valuation manual:

(1)"Accident and health insurance", contracts that incorporate morbidity risk and provide protection against economic loss resulting from accidents, sickness, or medical conditions and as may be specified in the valuation manual;

(2)"Appointed actuary", a qualified actuary who is appointed in accordance with the valuation manual to prepare the actuarial opinion required under subsection 5 of section 376.380;

(3)"Company", an entity which has written, issued, or reinsured life insurance contracts, accident and health insurance contracts, or deposit-type contracts:

(a)In Missouri and has at least one such policy in force or on claim; or

(b)In any state and is required to hold a certificate of authority to write life insurance, accident and health insurance, or deposit-type contracts in Missouri;

(4)"Deposit-type contract", a contract that does not incorporate mortality or morbidity risks and as may be specified in the valuation manual;

(5)"Life insurance", contracts that incorporate mortality risk including annuity and pure endowment contracts and as may be specified in the valuation manual;

(6)"NAIC", the National Association of Insurance Commissioners;

(7)"Operative date of the valuation manual", January first of the first calendar year that the valuation manual is effective, as described in subdivision (2) of subsection 6 of section 376.380;

(8)"Policyholder behavior", any action a policyholder, contract holder, or any other person with the right to elect options, such as a certificate holder, may take under a policy or contract subject to sections 376.365 to 376.380 including, but not limited to, lapse, withdrawal, transfer, deposit, premium payment, loan, annuitization, or benefit elections prescribed by the policy or contract but excluding events of mortality or morbidity that result in benefits prescribed in their essential aspects by the terms of the policy or contract;

(9)"Principle-based valuation", a reserve valuation that uses one or more methods or one or more assumptions determined by the insurer and is required to comply with subsection 7 of section 376.380 as specified in the valuation manual;

(10)"Qualified actuary", an individual who is qualified to sign the applicable statement of actuarial opinion in accordance with the American Academy of Actuaries qualification standards for actuaries signing such statements and who meets the requirements specified in the valuation manual;

(11)"Tail risk", a risk that occurs either if the frequency of low probability events is higher than expected under a normal probability distribution or if there are observed events of very significant size or magnitude;

(12)"Valuation manual", the manual of valuation instructions adopted by the NAIC as specified in sections 376.365 to 376.380.

(L. 2015 S.B. 164)

376.438 - Group policies, modifying or amending benefits shall provide extension of benefits in event of total disability at date of termination or discontinuance.

1.Every group policy or other contract subject to sections 376.431 to 376.442, or under which the level of benefits is hereafter altered, modified or amended, must provide a reasonable provision for extension of benefits in the event of total disability at the date of any termination or discontinuance of the group policy or contract, regardless of the reason for the termination or discontinuance, as required by the following subdivisions of this subsection:

(1)In the case of a group life plan which contains a disability benefit extension of any type, such as premium waiver extension, extended death benefit in event of total disability, or payment of income for a specified period during total disability, the discontinuance of the group policy shall not operate to terminate such extension;

(2)In the case of a group plan providing benefits for loss of time from work or specific indemnity during hospital confinement, discontinuance of the policy during a disability shall have no effect on benefits payable for that disability or confinement;

(3)In the case of health maintenance organization, hospital or medical expense coverages other than dental and maternity expense, a reasonable extension of benefits or accrued liability provision is required.Such a provision will be considered reasonable if it provides an extension of at least twelve months under health maintenance organization, major medical and comprehensive medical type coverages, and under other types of hospital or medical expense coverages provides either an extension of at least ninety days or an accrued liability for expenses incurred during a period of disability or during a period of at least ninety days starting with a specific event which occurred while coverage was in force.

2.Any applicable extension of benefits or accrued liability shall be described in any policy or contract involved as well as in insurance certificates of coverage issued to employees or members.The benefits payable during any period of extension or accrued liability may be subject to the policy's or contract's regular benefit limits.

(L. 1985 H.B. 623, A.L. 1999 H.B. 903)

376.1237 - Refills for prescription eye drops, required, when — definitions.

1.Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2014, and that provides coverage for prescription eye drops shall provide coverage for the refilling of an eye drop prescription prior to the last day of the prescribed dosage period without regard to a coverage restriction for early refill of prescription renewals as long as the prescribing health care provider authorizes such early refill, and the health carrier or the health benefit plan is notified.

2.For the purposes of this section, health carrier and health benefit plan shall have the same meaning as defined in section 376.1350.

3.The coverage required by this section shall not be subject to any greater deductible or co-payment than other similar health care services provided by the health benefit plan.

4.The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months' or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

(L. 2013 H.B. 315, A.L. 2016 H.B. 1682 merged with H.B. 1816 merged with S.B. 608 merged with S.B. 635 merged with S.B. 865 & 866 merged with S.B. 973, A.L. 2018 S.B. 718 merged with S.B. 826)

376.386 - Prescription drugs, one co-payment for dosage prescribed.

For any health carrier or health benefit plan, as defined in section 376.1350, that provides prescription drug coverage, if a prescription drug covered by a health carrier or health benefit plan is prescribed in a single dosage amount for which the particular prescription drug is not manufactured in such single dosage amount and requires dispensing the particular prescription drug in a combination of different manufactured dosage amounts, the health carrier or health benefit plan shall only impose one co-payment for the dispensing of the combination of manufactured dosages that equal the prescribed dosage for such prescription drug.Such co-payment requirement shall not apply to prescriptions in excess of a one-month supply.If technology does not permit such adjudication, the health carrier or health benefit plan shall provide reimbursement forms for the patient.

(L. 2006 S.B. 567 & 792 § 376.392)

376.782 - Mammography — low-dose screening, defined — health care policies to provide required coverage.

1.As used in this section, the term "low-dose mammography screening" means the X-ray examination of the breast using equipment specifically designed and dedicated for mammography, including the X-ray tube, filter, compression device, films, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast, and any fee charged by a radiologist or other physician for reading, interpreting or diagnosing based on such X-ray.As used in this section, the term "low-dose mammography screening" shall also include digital mammography and breast tomosynthesis.As used in this section, the term "breast tomosynthesis" shall mean a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.

2.All individual and group health insurance policies providing coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed on or after August 28, 1991, and providing coverage to any resident of this state shall provide benefits or coverage for low-dose mammography screening for any nonsymptomatic woman covered under such policy or contract which meets the minimum requirements of this section.Such benefits or coverage shall include at least the following:

(1)A baseline mammogram for women age thirty-five to thirty-nine, inclusive;

(2)A mammogram every year for women age forty and over;

(3)A mammogram for any woman, upon the recommendation of a physician, where such woman, her mother or her sister has a prior history of breast cancer.

3.Coverage and benefits related to mammography as required by this section shall be at least as favorable and subject to the same dollar limits, deductibles, and co-payments as other radiological examinations; provided, however, that on and after January 1, 2019, providers of low-dose mammography screening shall be reimbursed at rates accurately reflecting the resource costs specific to each modality, including any increased resource cost of breast tomosynthesis.

(L. 1990 S.B. 742 § 1, A.L. 1991 H.B. 385, et al., A.L. 1995 S.B. 27, A.L. 2018 H.B. 1252)

CROSS REFERENCE:

Mammography and other services also required coverage, 376.995

376.738 - Certificate of contribution, when issued.

The association shall issue to each member insurer paying an assessment under the provisions of sections 376.715 to 376.758, other than class A assessment, a certificate of contribution, in a form prescribed by the director, for the amount of the assessment so paid.All outstanding certificates shall be of equal dignity and priority without reference to amounts or dates of issue.A certificate of contribution may be shown by the member insurer in its financial statement as an asset in such form and for such amount, if any, and period of time as the director may approve.

(L. 1988 S.B. 430 § 20, A.L. 1991 H.B. 385, et al., A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

*376.2020 - Contracts prohibiting disclosure of certain payments and costs are unenforceable.

1.For purposes of this section, the following terms shall mean:

(1)"Contractual payment amount" or "payment amount", shall mean the total amount a health care provider is to be paid for providing a given health care service pursuant to a contract with a health carrier, and includes both the portions to be paid by the patient and by the health carrier.It is commonly referred to as the allowable amount;

(2)"Enrollee", shall have the same meaning ascribed to it in section 376.1350;

(3)"Health care provider", shall have the same meaning ascribed to it in section 376.1350;

(4)"Health care service", shall have the same meaning ascribed to it in section 376.1350;

(5)"Health carrier", shall have the same meaning ascribed to it in section 376.1350.

2.No provision in a contract in existence or entered into, amended, or renewed on or after August 28, 2016, between a health carrier and a health care provider shall be enforceable if such contractual provision prohibits, conditions, or in any way restricts any party to such contract from disclosing to an enrollee, or such person's parent or legal guardian, the contractual payment amount for a health care service if such payment amount is less than the health care provider's usual charge for the health care service, and if such contractual provision prevents the determination of the potential out-of-pocket cost for the health care service by the enrollee, parent, or legal guardian.

(L. 2016 S.B. 608)

*Effective 10-14-16, see § 21.250.S.B. 608 was vetoed July 5, 2016. The veto was overridden on September 14, 2016.

376.1037 - Plan subject to premium taxes.

Multiple employer self-insured health plans licensed in this state shall be subject to those taxes set out in sections 148.310 to 148.461.

(L. 1993 H.B. 709 § 37)

376.869 - Standards for policies, minimum, director to adopt.

The director shall adopt reasonable regulations to establish minimum standards for benefits, claims payment, marketing practices, compensation arrangements and reporting practices for Medicare supplement policies.

(L. 1989 H.B. 615 & 563, A.L. 1990 H.B. 1630, A.L. 1992 H.B. 1574, A.L. 1996 S.B. 883)

Effective 4-26-96

376.465 - Missouri health insurance rate transparency act — definitions — rate filing requirements, procedure — rulemaking authority.

1.This section shall be known and may be cited as the "Missouri Health Insurance Rate Transparency Act".

2.It is the intent of the Missouri general assembly that the review of health insurance rates as specified in this section is consistent with the general powers of the department as outlined under section 374.010.

3.As used in this section, the following terms mean:

(1)"Director", the director of the department of insurance, financial institutions and professional registration, or his or her designee;

(2)"Excepted health benefit plan", a health benefit plan providing the following coverage or any combination thereof:

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

(b)Coverage only for disability income insurance;

(c)Credit-only insurance;

(d)Short-term medical insurance of less than twelve months( duration; or

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

a.Dental or vision benefits;

b.Coverage only for a specified disease or illness; or

c.Hospital indemnity or other fixed indemnity insurance;

(3)"Grandfathered health benefit plan", a health benefit plan in the small group market that was issued, or a health benefit plan in the individual market that was purchased, on or before March 23, 2010;

(4)"Health benefit plan", the same meaning given to such term under section 376.1350; however, for purposes of this section, the term shall exclude plans sold in the large group market, as that term is defined under section 376.450, and shall exclude long-term care and Medicare supplement plans;

(5)"Health carrier", the same meaning given to such term under section 376.1350;

(6)"Individual market", the market for health insurance coverage offered directly to individuals and their dependents and not in connection with a group health benefit plan;

(7)"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 under section 379.930.

4.No health carrier shall deliver, issue for delivery, continue, or renew any health benefit plan until rates have been filed with the director.

5.For excepted health benefit plans, such rates shall be filed, thirty days prior to use, for informational purposes only.Rates shall not be excessive, inadequate, or unfairly discriminatory.

6.For grandfathered health benefit plans, such rates shall be filed, thirty days prior to use, for informational purposes only.

7.(1)For health benefit plans that are not grandfathered health benefit plans or excepted health benefit plans, a health carrier may use rates on the earliest of:

(a)The date the director determines the rates are reasonable;

(b)The date the health carrier notifies the director of its intent to use rates that the director has deemed unreasonable; or

(c)Sixty days after the date of filing rates with the director.

(2)The director may notify the health carrier within sixty days of the date of filing rates with the director that the health carrier has failed to provide sufficient rate filing documentation to review the proposed rates.The health carrier may, as described in this section, provide additional information to support the rate filing.

8.For health benefit plans described under subsection 7 of this section, all proposed rates and rate filing documentation shall be submitted in the form and content prescribed by rule, which is consistent with the requirements of 45 CFR 154, and shall include review standards and criteria consistent with 45 CFR 154.

9.The director shall determine by rule when rates filed under this section shall be made publicly available.Rate filing documentation and other supporting information that is a trade secret or of a proprietary nature, and has been designated as such by the health carrier, shall not be considered a public record.

10.For rates filed for health benefit plans described under subsection 7 of this section, the director shall:

(1)Provide a means by which the public can submit written comments concerning proposed rate increases;

(2)Review proposed rates and rate filing documentation;

(3)Determine that a proposed rate is an unreasonable rate if the increase is an excessive rate, an inadequate rate, an unfairly discriminatory rate, or an unjustified rate, consistent with 45 CFR 154; and

(4)Within sixty days after submission, provide a written notice to the health carrier detailing whether the proposed rates are reasonable or unreasonable.For proposed rates deemed unreasonable, the written notice shall specify deficiencies and provide detailed reasons for the director's decision that the proposed rate is excessive, inadequate, unjustified, or unfairly discriminatory.

11.Within thirty days after receiving written notice of the director's determination that the proposed rates are unreasonable, as described under subsection 10 of this section, a health carrier may amend its rates, request reconsideration based upon additional information, or implement the proposed rates.The health carrier shall notify the director of its intention no later than thirty days after its receipt of the written notice of the determination of unreasonable rates.

12.If a health carrier implements a rate that the director has determined is unreasonable under subsection 10 of this section, the department shall make such determination public, in a form and manner determined by rule.

13.For health benefit plans described under subsection 7 of this section, the director shall publish final rates on the department's website no earlier than thirty days prior to the first day of the annual open enrollment period in the individual market for the applicable calendar year.The final rate is the rate that will be implemented by the health carrier on a specified date.

14.Time frames described under this section may be extended upon mutual agreement between the director and the health carrier.

15.The director may promulgate rules to promote health insurance rate transparency including, but not limited to, prescribing the form and content of the information required to be submitted and of the standards of review that are consistent with 45 CFR 154.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly under chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2016, shall be invalid and void.

16.This section shall apply to health benefit plans that are delivered, issued for delivery, continued, or renewed on or after January 1, 2018.In order to ensure that health benefit plans comply with the provisions of this section, the director shall promulgate rules regarding the initial implementation of the provisions of this section.Such rules shall be effective no later than March 1, 2017, and, for health benefit plans described under subsection 7 of this section, shall include, but not be limited to, the form and content of the information required to be submitted and of the standards of review, consistent with 45 CFR 154.

(L. 2016 S.B. 865 & 866)

376.1399 - Rules, effective, when — rules invalid and void, when.

Any rule or portion of a rule promulgated pursuant to this act shall become effective only as provided pursuant to chapter 536, including, but not limited to, section 536.028, if applicable, after August 28, 1997. All rulemaking authority delegated prior to August 28, 1997, is of no force and effect and repealed.The provisions of this section are nonseverable and if any of the powers vested with the general assembly pursuant to section 536.028, if applicable, to review, to delay the effective date, or to disapprove and annul a rule or portion of a rule are held unconstitutional or invalid, the purported grant of rulemaking authority and any rule so proposed and contained in the order of rulemaking shall be invalid and void.

(L. 1997 H.B. 335, A.L. 1997 H.B. 600, et al., § 376.1399 and § 14, A.L. 2007 S.B. 613 Revision)

376.671 - Provisions which shall be contained in annuity contracts — inapplicability date.

1.This section shall not apply to any reinsurance, group annuity purchased under a retirement plan or plan of deferred compensation established or maintained by an employer (including a partnership or sole proprietorship) or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under Section 408 of the Internal Revenue Code, as now or hereafter amended, premium deposit fund, variable annuity, investment annuity, immediate annuity, any deferred annuity contract after annuity payments have commenced, or reversionary annuity, nor to any contract which shall be delivered outside this state through an agent or other representative of the company issuing the contract.

2.In the case of contracts issued on or after the operative date of this section as defined in subsection 11 of this section, no contract of annuity, except as stated in subsection 1 of this section, shall be delivered or issued for delivery in this state unless it contains in substance the following provisions, or corresponding provisions which in the opinion of the director are at least as favorable to the contractholder, upon cessation of payment of considerations under the contract:

(1)That upon cessation of payment of considerations under a contract, the company will grant a paid-up annuity benefit on a plan stipulated in the contract of such value as is specified in subsections 4, 5, 6, 7, and 9 of this section;

(2)If a contract provides for a lump sum settlement at maturity, or at any other time, that upon surrender of the contract at or prior to the commencement of any annuity payments, the company will pay in lieu of any paid-up annuity benefit a cash surrender benefit of such amount as is specified in subsections 4, 5, 7, and 9 of this section.The company shall reserve the right to defer the payment of such cash surrender benefit for a period of six months after demand therefor with surrender of the contract;

(3)A statement of the mortality table, if any, and interest rates used in calculating any minimum paid-up annuity, cash surrender or death benefits that are guaranteed under the contract, together with sufficient information to determine the amounts of such benefits;

(4)A statement that any paid-up annuity, cash surrender or death benefits that may be available under the contract are not less than the minimum benefits required by any statute of the state in which the contract is delivered and an explanation of the manner in which such benefits are altered by the existence of any additional amounts credited by the company to the contract, any indebtedness to the company on the contract or any prior withdrawals from or partial surrenders of the contract.Notwithstanding the requirements of this section, any deferred annuity contract may provide that if no considerations have been received under a contract for a period of two full years and the portion of the paid-up annuity benefit at maturity on the plan stipulated in the contract arising from considerations paid prior to such period would be less than twenty dollars monthly, the company may at its option terminate such contract by payment in cash of the then present value of such portion of the paid-up annuity benefit, calculated on the basis of the mortality table, if any, and interest rate specified in the contract for determining the paid-up annuity benefit, and by such payment shall be relieved of any further obligation under such contract.

3.The minimum values as specified in subsections 4, 5, 6, 7, and 9 of this section of any paid-up annuity, cash surrender or death benefits available under an annuity contract shall be based upon minimum nonforfeiture amounts as defined in this section.

(1)With respect to contracts providing for flexible considerations, the minimum nonforfeiture amount at any time at or prior to the commencement of any annuity payment shall be equal to an accumulation up to such time at a rate of interest of three percent per annum of percentages of the net considerations (as hereinafter defined) paid prior to such time, decreased by the sum of:

(a)Any prior withdrawals from or partial surrenders of the contract accumulated at a rate of interest of three percent per annum; and

(b)The amount of any indebtedness to the company on the contract, including interest due and accrued and increased by any existing additional amounts credited by the company to the contract.The net considerations for a given contract year used to define the minimum nonforfeiture amount shall be an amount not less than zero and shall be equal to the corresponding gross considerations credited to the contract during that contract year less an annual contract charge of thirty dollars and less a collection charge of one dollar and twenty-five cents per consideration credited to the contract during that contract year.The percentages of net considerations shall be sixty-five percent of the net consideration for the first contract year and eighty-seven and one-half percent of the net considerations for the second and later contract years.Notwithstanding the provisions of the preceding sentence, the percentage shall be sixty-five percent of the portion of the total net consideration for any renewal contract year which exceeds by not more than two times the sum of those portions of the net considerations in all prior contract years for which the percentage was sixty-five percent;

(2)With respect to contracts providing for fixed scheduled considerations, minimum nonforfeiture amounts shall be calculated on the assumption that considerations are paid annually in advance and shall be defined as for contracts with flexible considerations which are paid annually with two exceptions:

(a)The portion of the net consideration for the first contract year to be accumulated shall be the sum of sixty-five percent of the net consideration for the first contract year plus twenty-two and one-half percent of the excess of the net consideration for the first contract year over the lesser of the net considerations for the second and third contract years;

(b)The annual contract charge shall be the lesser of thirty dollars or ten percent of the gross annual consideration;

(3)With respect to contracts providing for a single consideration, minimum nonforfeiture amounts shall be defined as for contracts with flexible considerations except that the percentage of net consideration used to determine the minimum nonforfeiture amount shall be equal to ninety percent, and the net consideration shall be the gross consideration less a contract charge of seventy-five dollars;

(4)Notwithstanding any other provision of this subsection, for any contract issued on or after July 1, 2002, and before July 1, 2006, the interest rate at which net considerations, prior withdrawals, and partial surrenders shall be accumulated, for the purpose of determining minimum nonforfeiture amounts, shall be one and one-half percent per annum.

4.Any paid-up annuity benefit available under a contract shall be such that its present value on the date annuity payments are to commence is at least equal to the minimum nonforfeiture amount on that date.Such present value shall be computed using the mortality table, if any, and the interest rate specified in the contract for determining the minimum paid-up annuity benefits guaranteed in the contract.

5.For contracts which provide cash surrender benefits, such cash surrender benefits available prior to maturity shall not be less than the present value as of the date of surrender of that portion of the maturity value of the paid-up annuity benefit which would be provided under the contract at maturity arising from considerations paid prior to the time of cash surrender reduced by the amount appropriate to reflect any prior withdrawals from or partial surrenders of the contract, such present value being calculated on the basis of an interest rate not more than one percent higher than the interest rate specified in the contract for accumulating the net considerations to determine such maturity value, decreased by the amount of any indebtedness to the company on the contract, including interest due and accrued, and increased by any existing additional amounts credited by the company to the contract.In no event shall any cash surrender benefit be less than the minimum nonforfeiture amount at that time.The death benefit under such contracts shall be at least equal to the cash surrender benefit.

6.For contracts which do not provide cash surrender benefits, the present value of any paid-up annuity benefit available as a nonforfeiture option at any time prior to maturity shall not be less than the present value of that portion of the maturity value of the paid-up annuity benefit provided under the contract arising from considerations paid prior to the time the contract is surrendered in exchange for, or changed to, a deferred paid-up annuity, such present value being calculated for the period prior to the maturity date on the basis of the interest rate specified in the contract for accumulating the net considerations to determine such maturity value, and increased by any existing additional amounts credited by the company to the contract.For contracts which do not provide any death benefits prior to the commencement of any annuity payments, such present values shall be calculated on the basis of such interest rate and the mortality table specified in the contract for determining the maturity value of the paid-up annuity benefit.However, in no event shall the present value of a paid-up annuity benefit be less than the minimum nonforfeiture amount at that time.

7.For the purpose of determining the benefits calculated under subsections 5 and 6 of this section, in the case of annuity contracts under which an election may be made to have annuity payments commence at optional maturity date, the maturity date shall be deemed to be the latest date for which election shall be permitted by the contract, but shall not be deemed to be later than the anniversary of the contract next following the annuitant's seventieth birthday or the tenth anniversary of the contract, whichever is later.

8.Any contract which does not provide cash surrender benefits or does not provide death benefits at least equal to the minimum nonforfeiture amount prior to the commencement of any annuity payments shall include a statement in a prominent place in the contract that such benefits are not provided.

9.Any paid-up annuity, cash surrender or death benefits available at any time, other than on the contract anniversary under any contract with fixed scheduled considerations, shall be calculated with allowance for the lapse of time and the payment of any scheduled considerations beyond the beginning of the contract year in which cessation of payment of considerations under the contract occurs.

10.For any contract which provides, within the same contract by rider or supplemental contract provision, both annuity benefits and life insurance benefits that are in excess of the greater of cash surrender benefits or a return of the gross considerations with interest, the minimum nonforfeiture benefits shall be equal to the sum of the minimum nonforfeiture benefits for the annuity portion and the minimum nonforfeiture benefits, if any, for the life insurance portion computed as if each portion were a separate contract.Notwithstanding the provisions of subsections 4, 5, 6, 7, and 9 of this section, additional benefits payable in the event of total and permanent disability, as reversionary annuity or deferred reversionary annuity benefits, or as other policy benefits additional to life insurance, endowment and annuity benefits, and considerations for all such additional benefits, shall be disregarded in ascertaining the minimum nonforfeiture amounts, paid-up annuity, cash surrender and death benefits that may be required by this section.The inclusion of such additional benefits shall not be required in any paid-up benefits, unless such additional benefits separately would require minimum nonforfeiture amounts, paid-up annuity, cash surrender and death benefits.

11.After September 28, 1979, any company may file with the director a written notice of its election to comply with the provisions of this section after a specified date before September 28, 1981.After the filing of such notice, then upon such specified date, which shall be the operative date of this section for such company, this section shall become operative with respect to annuity contracts thereafter issued by such company.If a company makes no such election, the operative date of this section for such company shall be September 28, 1981.

12.The provisions of this section shall not apply to any new contract entered into after July 1, 2006.

(L. 1979 S.B. 325, A.L. 2002 H.B. 1568 merged with S.B. 1009, A.L. 2004 H.B. 938 merged with S.B. 1188, A.L. 2010 H.B. 1965)

376.292 - Definitions.

As used in sections 376.291 to 376.307, the following terms mean:

(1)"Acceptable collateral", as to securities lending repurchase and reverse repurchase transactions, any financial assets of a type for which, when taken as collateral by an insurer in such transactions, would permit the subject securities or repurchase agreements, as the case may be, to constitute admitted assets of the insurer under the relevant statutory accounting principles promulgated from time to time by the NAIC as adopted by the director;

(2)"Acceptable private mortgage insurance", insurance written by a private insurer protecting a mortgage lender against loss occasioned by a mortgage loan default and issued by a licensed mortgage insurance company with an SVO "1" designation or a rating issued by a nationally recognized statistical rating organization equivalent to an SVO "1" designation that covers losses to an eighty percent loan-to-value ratio;

(3)"Accident and health insurance", protection that provides payment of benefits for covered sickness or accidental injury, excluding credit insurance, disability insurance, accidental death and dismemberment insurance, and long-term care insurance;

(4)"Accident and health insurer", a licensed life or health insurer or health service corporation whose insurance premiums and required statutory reserves for accident and health insurance constitute at least ninety-five percent of total premium considerations or total statutory required reserves, respectively;

(5)"Admitted assets", assets permitted to be reported as admitted assets on the statutory financial statement of the insurer most recently required to be filed with the director but excluding assets of separate accounts;

(6)"Affiliate", as to any person, another person that, directly or indirectly through one or more intermediaries controls, is controlled by, or is under common control with the person;

(7)"Asset-backed security", a security or other instrument, excluding shares in a mutual fund, evidencing an interest in or the right to receive payments from, or payable from distributions on an asset, a pool of assets, or specifically divisible cash flows which are legally transferred to a trust or another special purpose bankruptcy-remote business entity on the following conditions:

(a)The trust or other business entity is established solely for the purpose of acquiring specific types of assets or rights to cash flows, issuing securities and other instruments representing an interest in or right to receive cash flows from those assets or rights, and engaging in activities required to service the assets or rights and any credit enhancement or support features held by the trust or other business entity; and

(b)The assets of the trust or other business entity consist solely of interest-bearing obligations or other contractual obligations representing the right to receive payment from the cash flow from the assets.However, the existence of credit enhancements, such as letters of credit or guarantees or support features, such as swap agreements, shall not cause a security or other instrument to be ineligible as an asset-backed security;

(8)"Business entity", a sole proprietorship, limited liability company, association, partnership, joint stock company, joint venture, mutual fund, trust, joint tendency, or other similar form of business organization, whether organized for profit or not for profit;

(9)"Capital and surplus", the sum of the capital and surplus of the insurer required to be shown on the statutory financial statement of the insurer most recently required to be filed with the director;

(10)"Cash equivalents", short-term, highly rated, and highly liquid investments or securities readily convertible to known amounts of cash without penalty and so near maturity that they present insignificant risk of change in value.Cash equivalents include government money market mutual funds and class one money market mutual funds.For purposes of this subdivision:

(a) "Short-term" means investments with a remaining term to maturity of ninety days or less; and

(b)"Highly rated" means an investment rated "P-1" by Moody's Investors Service, Inc., or "A-1" by Standard and Poor's division of The McGraw Hill Companies, Inc., or its equivalent rating by a nationally recognized statistical rating organization recognized by the SVO;

(11)"Class one bond mutual fund", a mutual fund that at all times qualifies for investment using the bond class one reserve factor under the Purpose and Procedures of the Securities Valuation Office or any successor publication;

(12)"Class one money market mutual fund", a money market mutual fund that at all times qualifies for investment using the bond class one reserve factor under the Purpose and Procedures of the Securities Valuation Office or any successor publication;

(13)"Code", this chapter and chapters 374, 375, and 382;

(14)"Commercial mortgage loan", a loan secured by a mortgage other than a residential mortgage loan;

(15)"Construction loan", a loan less than three years in term made for financing the cost of construction of a building or other improvement to real estate that is secured by the real estate;

(16)"Control", the possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract, other than a commercial contract for goods or nonmanagement service, or otherwise, unless the power is the result of an official position with or corporate office held by the person.Control shall be presumed to exist if a person, directly or indirectly, owns, controls, holds with power to vote, or holds proxies representing ten percent or more of the voting securities of another person.This presumption may be rebutted by a showing that control does not exist in fact.The director may determine after furnishing all interested persons notice and an opportunity to be heard and making specific findings of fact to support the determination that control exists in fact, notwithstanding the absence of a presumption to that effect;

(17)"Credit tenant loan", a mortgage loan which is made primarily in reliance on the credit standing of a major tenant, structured with an assignment of the rental payments to the lender with real estate pledged as collateral in the form of a first lien;

(18)"Direct" or "directly", in connection with an obligation, the designated obligor primarily liable on the instrument representing the obligation;

(19)"Dollar-roll transaction", two simultaneous transactions with different settlement dates no more than ninety-six days apart so that in the transaction with the earlier settlement date an insurer sells to a business entity, and in the other transaction the insurer is obligated to purchase, from the same business entity, substantially similar securities of the following types:

(a)Asset-backed securities issued, assumed or guaranteed by the Government National Mortgage Association, the Federal National Mortgage Association, or the Federal Home Loan Mortgage Corporation or their respective successors; and

(b)Other asset-backed securities referred to in section 106 of Title I of the Secondary Mortgage Market Enhancement Act of 1984 (15 U.S.C. 77r-1), as amended;

(20)"Domestic jurisdiction", the United States, Canada, any state, any province of Canada, or any political subdivision of the foregoing;

(21)"Equity interest", any of the following that are not rated credit instruments:

(a)Common stock;

(b)Preferred stock;

(c)Trust certificate;

(d)Equity investment in an investment company other than a money market mutual fund or a class one bond mutual fund;

(e)Investment in a common trust fund of a bank regulated by a federal or state agency;

(f)An ownership interest in mineral, oil, or gas to which the rights have been separated from the underlying fee interest in the real estate where the mineral, oil, or gas are located;

(g)Instruments which are mandatorily, or at the option of the issuer, convertible to equity;

(h)Limited partnership interests and those general partnership interests authorized under subdivision (4) of section 376.294;

(i)Member interests in limited liability companies;

(j)Warrants or other rights to acquire equity interests that are created by the person that owns or would issue the equity to be acquired; or

(k)Instruments that would be rated credit instruments except for the provisions under subdivision (47) of this section;

(22)"Foreign currency", currency other than that of a domestic jurisdiction;

(23)(a)"Foreign investment", an investment in a foreign jurisdiction or an investment in a person, real estate, or asset domiciled in a foreign jurisdiction that is substantially of the same type as those eligible for investment under this chapter other than under section 376.304.An investment shall not be deemed foreign if the issuing person, qualified primary credit source, or qualified guarantor is a domestic jurisdiction or a person domiciled in a domestic jurisdiction unless:

a.The issuing person is a shell business entity; and

b.The investment is not assumed, accepted, guaranteed, or insured or otherwise backed by a domestic jurisdiction, or a person that is not a shell business entity domiciled in a domestic jurisdiction;

(b)For purposes of this definition:

a."Shell business entity" means a business entity having no economic substance except as a vehicle for owning interests in assets issued, owned, or previously owned by a person domiciled in a foreign jurisdiction;

b."Qualified guarantor" means a guarantor against which an insurer has a direct claim for full and timely payment, evidenced by a contractual right for which an enforcement action can be brought in a domestic jurisdiction;

c."Qualified primary credit score" means the credit score to which an insurer looks for payment as to an investment and against which an insurer has a direct claim for full and timely payment evidenced by a contractual right for which an enforcement action can be brought in a domestic jurisdiction;

(24)"Foreign jurisdiction", a jurisdiction other than a domestic jurisdiction;

(25)"Government money market mutual fund", a money market mutual fund that at all times:

(a)Invests only in obligations issued, guaranteed, or insured by the federal government of the United States or collateralized repurchase agreements composed of these obligations; and

(b)Qualifies for investment without a reserve under the Purposes and Procedures of the Securities Valuation Office or any successor publication;

(26)"Government sponsored enterprise", a:

(a)Government agency; or

(b)Corporation, limited liability company, association, partnership, joint stock company, joint venture, trust, or other entity or instrumentality organized under the laws of any domestic jurisdiction to accomplish a public policy or other governmental purpose;

(27)"Guaranteed" or "insured", in connection with an obligation acquired under this chapter, the guarantor or insurer has agreed to:

(a)Perform or insure the obligation of the obligor or purchase the obligation; or

(b)Be unconditionally obligated until the obligation is repaid to maintain in the obligor a minimum net worth, fixed charge coverage, stockholders' equity or sufficient liquidity to enable the obligor to pay the obligation in full;

(28)"High-grade investment", a rated credit instruments rated "1", "2", "P1", "P2", "PSF1", or "PSF2" by the SVO;

(29)"Investment company", an investment company as defined in Section 3(a) of the Investment Company Act of 1940 (15 U.S.C. 80a-1), as amended, and a person described in Section 3(c) of that act;

(30)"Investment company series", an investment portfolio of an investment company that is organized as a series company and to which assets of the investment company have been specifically allocated;

(31)"Investment subsidiary", a subsidiary of an insurer engaged or organized to engage exclusively in the ownership and management of assets authorized as investments for the insurer if such subsidiary limits its investment in any asset so that its investments will not cause the amount of the total investment of the insurer to exceed any of the investment limitation or avoid any other provisions of this chapter applicable to the insurer.As used in this subdivision, the total investment insurer shall include:

(a)Direct investment by the insurer in an asset; and

(b)The insurer's proportionate share of an investment in an asset by an investment subsidiary of the insurer which shall be calculated by multiplying the amount of the subsidiary's investment by the percentage of the insurer's ownership interest in the subsidiary;

(32)"Investment strategy", the techniques and methods used by an insurer to meet its investment objectives, such as active bond portfolio management, passive bond portfolio management, interest rate anticipation, growth investing, and value investing;

(33)"Letter of credit", a clean, irrevocable, and unconditional letter of credit issued or confirmed by and payable and presentable at a financial institution on the list of financial institutions meeting the standards for issuing letters of credit under the Purposes and Procedures of the Securities Valuation Office or any successor publication.To constitute applicable collateral for the purposes of section 376.303, a letter of credit shall have an expiration date beyond the term of the subject transaction;

(34)"Limited liability company", a business organization, excluding partnerships and ordinary business corporations, organized or operating under the laws of the United States or any state thereof that limits the personal liability of investors to the equity investment of the investor in the business entity;

(35)"Lower grade investment", a rated credit instrument rated "4", "5", "6", "P4", "P5", "P6", "PSF4", "PSF5", or "PSF6" by the SVO;

(36)"Market value":

(a)As to cash and credit, the amounts thereof; and

(b)As to a security as of any date, the price for the security in that date obtained from a generally recognized source or the most recent quotation from a source, or to the extent no generally recognized source exists, the price for the security reasonably as determined by the insurer plus accrued but unpaid income thereon to the extent not included in the price as of that date;

(37)"Medium grade investment", a rated credit instrument rated "3", "P3", or "PSF3" by the SVO;

(38)"Money market mutual fund", a mutual fund that meets the conditions of 17 C.F.R. 270.2a-7 under the Investment Company Act of 1940 (15 U.S.C.80a-1, et seq.), as amended or renumbered;

(39)"Mortgage loan", an obligation secured by a mortgage, deed of trust, trust deed, or other consensual lien on real estate;

(40)"Multilateral development bank", an international development organization of which the United States is a member;

(41)"Mutual fund", an investment company or in the case of an investment company that is organized as a series company, an investment company series, that in either case is registered with the United States Securities and Exchange Commission under the Investment Company Act of 1940 (15 U.S.C.80a-1, et seq.), as amended;

(42)"NAIC", the National Association of Insurance Commissioners;

(43)"Obligation", a bond, note, debenture, trust certificate, including an equipment trust certificate, production payment, negotiable bank certificate of deposit, bankers' acceptance, credit tenant loan, loan secured by financing net leases, and other evidence of indebtedness for the payment of money, or participations, certificates, or other evidence of an interest in any of the foregoing, whether constituting a general obligation of the issuer or payable only out of certain revenues or certain funds pledged or otherwise dedicated for payment;

(44)"Person", an individual, a business entity, a multilateral development bank, or a government or quasigovernment body, such as a political subdivision or a government sponsored enterprise;

(45)"Preferred stock", preferred, preference, or guaranteed stock of a business entity authorized to issue the stock that has a preference in liquidation over the common stock of the business entity;

(46)"Qualified business entity", a business entity that is:

(a)An issuer of obligations or preferred stock that are rated "1" or "2" by the SVO or an issuer of obligations, preferred stock, or derivative instruments that are rated the equivalent of "1" or "2" by the SVO or the equivalent by a nationally recognized statistical rating organization recognized by the SVO;

(b)A primary dealer in the United States government securities recognized by the Federal Reserve Bank of New York; or

(c)With respect to section 376.303, an affiliate of an entity that is a qualified business entity under paragraph (a) or (b) of this subdivision whose arrangement with the insurer is guaranteed by the affiliated entity that is a qualified business entity under paragraph (a) or (b) of this subdivision;

(47)"Rated credit instrument":

(a)An obligation or other instrument which gives its holder a contractual right to receive cash or another rated credit instrument from another entity if the instrument:

a.Is rated or required to be rated by the SVO;

b.In the case of an instrument with a maturity of three hundred ninety-seven days or less, is issued, guaranteed, or insured by an entity that is rated by or another instrument of such entity is rated by the SVO or by a nationally recognized statistical rating organization recognized by the SVO;

c.In the case of an instrument with a maturity of ninety days or less, is issued, assumed, accepted, guaranteed, or insured by a qualified bank;

d.Is a share of a class one bond mutual fund; or

e.Is a share of a money market mutual fund;

(b)"Rated credit instrument" shall not mean:

a.An instrument that is mandatorily, or at the option of the issuer, convertible to an equity interest; or

b.A security that has a par value and whose terms provide that the issuer's net obligation to repay all or part of the security's par value is determined by reference to the performance of an equity, a commodity, a foreign currency, or an index of equities, commodities, foreign currencies, or combination thereof;

(48)"Real estate":

(a)Real property;

(b)Interests in real property, such as leaseholds, mineral, oil, and gas that have not been separated from the underlying fee interest;

(c)Improvements and fixtures located on or in real property; and

(d)The seller's equity in a contract providing for a deed of real estate;

As to a mortgage on a leasehold estate, real estate shall include the leasehold estate only if it has an unexpired term, including renewal options exercisable at the option of the lessee extending beyond the scheduled maturity date of the obligation that is secured by a mortgage on a leasehold estate by a period equal to at least twenty percent of the original term of the obligation or ten years, whichever is greater;

(49)"Repurchase transaction", a transaction in which an insurer purchases securities from a business entity that is obligated to repurchase the purchased securities or substantially the same securities from the insurer at a specified price within a specified period of time or on demand;

(50)"Required liabilities", total liabilities required to be reported on the statutory financial statement of the insurer most recently required to be filed with the director;

(51)"Residential mortgage loan", a loan primarily secured by a mortgage on real estate improved with a one-to-four family residence;

(52)"Reverse repurchase transaction", a transaction in which an insurer sells substantially the same securities to a business entity and is obligated to repurchase the sold securities or substantially the same securities from the business entity at a specified price within a specified period of time or upon demand;

(53)"Secured location", the contiguous real estate owned by one person;

(54)"Securities lending transaction", a transaction in which securities are loaned by an insurer to a business entity that is obligated to return the loaned securities or substantially the same securities to the insurer within a specified period of time or upon demand;

(55)"Series company", an investment company that is organized as series company, as defined in Rule 18f-2 under the Investment Company Act of 1940 (15 U.S.C. 80a-1, et seq.), as amended;

(56)"Sinking fund stock", preferred stock that:

(a)Is subject to a mandatory sinking fund or similar arrangement that will provide for the redemption or open market purchase of the entire issue over a period not longer than forty years from the date of acquisition; and

(b)Provides for mandatory sinking fund installments or open market purchases commencing not more than ten and one-half years from the date of issue with the sinking fund installments providing for the purchase or redemption on a cumulative basis commencing ten years from the date of issue of at least two and one-half percent per year of the original number of shares of that issue of preferred stock;

(57)"Special rated credit instrument", a rated credit instrument that is:

(a)Structured so that if it is held until retired by or on behalf of the issuer, its rate of return based on its purchase cost and any cash flow stream possible under the structure of the transaction may become negative due to reasons other than the credit risk associated with the issuer of the instrument; however, a rated credit instrument shall not be a special rated credit instrument under this paragraph if it is:

a.A share in a class one bond mutual fund;

b.An instrument other than an asset-backed security with payments of par value fixed as to an amount and timing or callable but in any event payable only at par value or greater and interest or dividend cash flows that are based on a fixed or variable rate determined by reference to a specified rate or index;

c.An instrument other than an asset-backed security that has a par value and is purchased at a price no greater than one hundred ten percent of par;

d.An instrument, including an asset-backed security, whose rate of return would become negative only as a result of prepayment due to casualty, condemnation, or economic obsolescence of collateral or change of law;

e.An asset-backed security that relies on collateral that meets the requirements of subparagraph b.of this paragraph and the par value of which collateral:

(i)Is not permitted to be paid sooner than one-half of the remaining term to maturity from the date of acquisition;

(ii)Is permitted to be paid prior to maturity only at a premium sufficient to provide a yield to maturity for the investment, considering the amount of prepaid and reinvestment rates at the time of early repayment, at least equal to the yield to maturity of the initial investment; or

(iii)Is permitted to be paid prior to maturity at a premium at least equal to the yield of a treasury issue of comparable remaining life; or

f.An asset-backed security that relies on cash flow from assets that are not prepayable at any time at par but is not otherwise governed by subparagraph e.of this paragraph if the asset-backed security has a par value reflecting principal payments to be received if held until retired by or on behalf of the issuer and is purchased at a price no greater than one hundred five percent of such par amount;

(b)An asset-backed security that:

a.Relies on cash flow from assets that are prepayable at par at any time;

b.Does not make payments of par that are fixed as to amount and timing; and

c.Has a negative rate of return at the time of acquisition if a prepayment threshold assumption is used with such prepayment threshold assumption defined as either:

(i)Two times the prepayment expectation reported by a recognized publicly available source as being the median of expectations contributed by broker dealers or other entities except insurers engaged in the business of selling or evaluating such securities or assets.At the insurer's election, the prepayment expectation used in this calculation shall be the prepayment expectation for pass-through securities of the Federal National Mortgage Association, the Federal Home Loan Mortgage Corporation, the Government National Mortgage Association, or for other assets of the same type of assets that underlie the asset-backed security in a gross weighted average coupon comparable to the gross weighted average coupon of the assets that underlie the asset-backed security; or

(ii)Another prepayment threshold assumption specified by the director by regulation;

(c)For purposes of paragraph (b) of this subdivision, if the asset-backed security is purchased in combination with one or more other asset-backed securities that are supported by identical underlying collateral, the insurer may calculate the rate of return for these specific combined asset-backed securities in combination.The insurer shall maintain documentation demonstrating that such securities were acquired and are continuing to be held in combination;

(58)"State", a state, territory, or possession of the United States, District of Columbia, or the Commonwealth of Puerto Rico;

(59)"Substantially the same securities", securities that meet all criteria for substantially the same securities specified in the NAIC Accounting Practices and Procedures Manual, as amended, as adopted by the director;

(60)"Subsidiary", as to any person, an affiliate controlled by such person, directly or indirectly, through one or more intermediaries;

(61)"SVO", the Securities Valuation Office of the NAIC or any successor office established by the NAIC;

(62)"Unrestricted surplus", the amount by which total admitted assets exceed one hundred and twenty-five percent of the insurer's required liabilities.

(L. 2007 S.B. 66)

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

No individual or group insurance policy providing coverage on an expense-incurred basis, no individual or group service or indemnity contract issued by a not-for-profit health services corporation, no health maintenance organization nor any self-insured group health benefit plan of any type or description shall be offered, issued or renewed in this state on or after July 1, 1994, by an insurer, including a group health plan, as defined in section 607(1) of the federal Employee Retirement Income Security Act of 1974, that denies enrollment of a child under the health coverage of the child's parent on the grounds that:

(1)The child was born out of wedlock; or

(2)The child is not claimed as a dependent on the parent's federal income tax return; or

(3)The child does not reside with the parent or in the insurer's service area.

(L. 1994 H.B. 1491 & 1134 merged with S.B. 508)

Effective 7-01-94

376.696 - Political subdivisions purchasing any insurance policies to submit to competitive bidding, when — renewal between bidding periods deemed extension.

Any other law to the contrary notwithstanding, no contract shall be entered into by the governing body of any political subdivision to purchase any insurance policy or policies unless the contract is submitted to competitive bidding at least every six years and the contract is awarded to the lowest or best bidder.The renewal of any insurance policy during any period between submissions of the contract to competitive bidding shall not constitute a separate and distinct contract for the time covered by the renewal but shall be treated only as an extension of an existing contract.

(L. 1985 H.B. 623)

376.920 - Annual statement, form, contents.

The annual statement shall be in such form as the department shall elect.The proposed provider shall include as an exhibit a copy of the proposed form of life care contract to be entered into with residents at each facility.The annual statement shall contain the following information:

(1)The name and business address of applicant;

(2)The name, address and a description of the physical property of the facility;

(3)The terms and conditions of the life care contracts to be used by the applicant, including the services to be provided to residents pursuant to the contract and the fees or charges to be paid by residents, including the method of payment of such fees or charges.The description of terms and conditions shall include:

(a)A statement of the fees that will be charged if the resident marries while at the facility, and a statement of the terms concerning the entry of a spouse to the facility and the consequences if the spouse does not meet the requirements for entry;

(b)The circumstances under which the resident will be permitted to remain in the facility in the event of possible financial difficulties of the resident;

(c)The terms and conditions under which a contract for continuing care at the facility may be cancelled by the provider or by the resident; and the conditions, if any, under which all or any portion of the entrance fee will be refunded in the event of cancellation of the contract by the provider or by the resident or in the event of the death of the resident prior to or following occupancy of a living unit;

(d)The conditions under which a living unit occupied by a resident may be made available by the facility to a different or new resident other than on the death of the original resident;

(4)If the applicant is other than an individual, such as a corporation, partnership, or trust, a statement naming the type of legal entity and listing the interest and extent of such interest of each principal in the entity.For the purposes of this section, "principal" means any person or entity having a ten percent or more financial interest or, if the legal entity is a trust, each beneficiary of the trust holding a ten percent or more beneficial interest;

(5)If the applicant is other than an individual, the names of the members of the board of directors, the trustees, or the managing partners;

(6)The estimated number of residents of the facility to be provided services by the applicant pursuant to the life care contracts;

(7)A statement of the provisions that have been made or will be made to provide reserve funding or security by the provider to enable the provider to fully perform his obligations pursuant to life care contracts, including, but not limited to, the establishment of escrow accounts, accounts in financial institutions, trusts, or reserve funds;

(8)A statement as to whether the applicant was or is affiliated with a religious, charitable, or other nonprofit organization, the extent of any affiliation and the extent to which the affiliate organization will be responsible for the financial and contract obligations of the applicant;

(9)If the applicant is a subsidiary corporation or the affiliate of another corporation, a statement identifying the parent corporation or the other affiliate corporation and the primary activities of such parent or other affiliate corporation;

(10)A description of the business experience of the applicant in the operation of similar facilities and, if the facility will be managed on a day-to-day basis by a corporation or organization other than the applicant, a description of the business experience of the manager in the operation or management of similar facilities.The description shall include the name and address of any professional service, firm, association, trust, partnership, or corporation in which such manager has, or which has in such manager, a ten percent or greater interest and which it is presently intended will or may provide goods, leases, or services to the facility of a value of five hundred dollars within any year, including a description of the goods, leases or services and the probable or anticipated cost thereof to the facility or provider or a statement that such cost cannot presently be estimated;

(11)A statement as to whether the applicant, a principal, a parent or subsidiary corporation, or an affiliate has had any injunctive or restrictive order of a court of record, or any suspension or revocation of any state or federal license or permit, arising out of or relating to business activity or health care applied against it, including without limitation actions affecting a license to operate a foster care facility, a health care institution, retirement home, or a home for the aged;

(12)A statement of any periodic rates to be initially paid by residents, the method by which such rates are determined and the manner by which the provider may adjust such rates in the future.If the facility is already in operation, or if the provider operates one or more similar facilities within this state, the statement shall include tables showing the frequency and average dollar amount of each increase in periodic rates at each such facility for the previous five years or such shorter period as the facility may have been operated by the provider;

(13)A statement of the terms and conditions under which a life care contract may be cancelled by the provider or resident, including any health and financial conditions required for a person to continue as a resident and any conditions under which all or any portion of the entrance fee will be refunded by the provider;

(14)If construction or purchase of the facility has not yet been completed, a statement of the anticipated source and application of the funds to be used in such purchase or construction, including all of the following:

(a)An estimate of the cost of purchasing or constructing and equipping the facility including such related costs as financing expense, legal expense, land costs, occupancy development costs, and all other similar costs which the provider expects to incur or become obligated for prior to the commencement of operations;

(b)An estimate of the total entrance fees to be received from residents upon completion of occupancy;

(c)A description of any mortgage loan or other long-term financing intended to be used for the financing of the facility, including the anticipated terms and costs of such financing;

(d)An estimate of any funds which are anticipated to be necessary to fund start-up losses and to assure full performance of the obligations of the provider pursuant to life care contracts including, but not limited to, any reserve fund escrow required by the division pursuant to section 376.940*;

(15)Financial statements of the applicant as of a date not more than ninety days prior to the date the annual statement is filed, which shall include a balance sheet and income statements for the three most recent fiscal years of the applicant or such shorter period of time as the applicant shall have been in existence.If applicant's fiscal year ended more than ninety days prior to the date of filing there shall also be included an income statement, which need not be certified, covering the period between the date such fiscal year ended and a date not more than ninety days prior to the date the application is filed.

(L. 1981 S.B. 84 § 4, subsec. 4)

*Words "section 8" appear in original rolls. Section 8 was codified as section 376.950, but did not contain escrow account language. Section 6, codified as 376.940, referred to escrow accounts.

376.392 - Prescription drug formularies, enrollees to be notified of changes to, when.

For any health carrier or health benefit plan, as defined in section 376.1350, that provides prescription drug coverage or contracts with a third-party for prescription drug services, the health carrier or health benefit plan shall notify enrollees presently taking a prescription drug electronically, or in writing, upon request of the enrollee, at least thirty days prior to any deletions, other than generic substitutions, in the health carrier's or health benefit plan's prescription drug formulary that affect such enrollees.

(L. 2007 H.B. 818)

Effective 1-01-08

376.775 - Matters required in policies.

1.No policy of accident and sickness insurance shall be delivered or issued for delivery to any person in this state unless:

(1)The entire money and other considerations therefor are expressed therein; and

(2)The time at which the insurance takes effect and terminates is expressed therein, except that if the policy is delivered subject to the condition that it shall take effect when the first premium is accepted by the insurer, the time at which the insurance takes effect and terminates may be expressed in the insurer's executed premium receipt which shall by reference be made a part of the policy; and

(3)It purports to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed to be the policyholder, any two or more eligible members of that family, including husband, wife, dependent children or any children under a specified age which shall not exceed nineteen years and any other person dependent upon the policyholder; and

(4)The style, arrangement and overall appearance of the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in lightfaced type of a style in general use, the size of which shall be uniform and not less than ten-point with a lowercase unspaced alphabet length not less than one hundred and twenty-point (the "text" shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description, if any, and captions and subcaptions); and

(5)The exceptions and reductions of indemnity are set forth in the policy and, except those which are set forth in section 376.777, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and

(6)Each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and

(7)It* contains no provision purporting to make any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the director of the department of insurance, financial institutions and professional registration.

2.If any policy is issued by an insurer domiciled in this state for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the director of the department of insurance, financial institutions and professional registration that any such policy is not subject to approval or disapproval by such official, the director of the department of insurance, financial institutions and professional registration may by ruling require that such policy meet the standards set forth in subsection 1 of this section and in section 376.777.

(L. 1959 H.B. 252 § 3)

*Word "if" appears in original rolls.

376.428 - Federal COBRA provisions to apply to group health insurance policies.

1.A group policy delivered or issued for delivery in this state by a health carrier or health benefit plan, as defined in section 376.1350, which insures employees or members and their eligible dependents for hospital, surgical or major medical insurance on an expense-incurred or service basis, other than for specific diseases or for accidental injuries only, shall provide that employees or members whose coverage under the group policy, which includes coverage for their eligible dependents, would otherwise terminate because of termination of employment or membership shall be entitled to continue their hospital, surgical or major medical coverage, including coverage for their eligible dependents, under that group policy in the same manner as continuation of coverage is required under the continuation of coverage provisions set forth in the federal Consolidated Omnibus Budget Reconciliation Act (COBRA), as amended.

2.The spouse of an employee or member whose coverage under the group policy would otherwise terminate due to dissolution of marriage or death of the employee or member shall have the same continuation privilege accorded under sections 376.421 to 376.442, 376.694 to 376.696, and 376.779 to the employee or member upon termination of employment or membership.

3.The right to a converted policy pursuant to sections 376.395 to 376.404 for an employee or member entitled to continuation of coverage under sections 376.421 to 376.442, 376.694 to 376.696, and 376.779 shall commence upon termination of the continued coverage provided for in sections 376.421 to 376.442, 376.694 to 376.696, and 376.779.

4.This section shall only apply to those persons who are not subject to the continuation and conversion provisions set forth in Title I, Subtitle B, Part 6 of the Employment Retirement Income Security Act of 1974 or Title XXII of the Public Health Service Act, as said acts were in effect on January 1, 1987.

(L. 1985 H.B. 623, A.L. 1987 S.B. 337, A.L. 1988 H.B. 1242 Revision, A.L. 1991 H.B. 385, et al., A.L. 2009 H.B. 231)

Effective 6-26-09

376.675 - Life insurance policies and annuity contracts to be approved — exemption, when — director's powers — judicial review of disapproval.

1.No policy of life insurance or contract of annuity shall be delivered or issued for delivery to any person in this state unless the policy or contract shall have been filed with and approved by the director of the department of insurance, financial institutions and professional registration.

2.The director of the department of insurance, financial institutions and professional registration shall have authority to make reasonable rules and regulations concerning the procedure for the filing and submission of policy or contract forms as are necessary, proper or advisable.The director shall approve or disapprove a policy or contract form within forty-five days after the filing and submission thereof.The failure of the director of the department of insurance, financial institutions and professional registration to take action approving or disapproving a submitted policy or contract form within the stipulated time shall be deemed an approval thereof until such time as the director of the department of insurance, financial institutions and professional registration shall notify the submitting company of his disapproval thereof.

3.The director of the department of insurance, financial institutions and professional registration shall approve only those forms which are in compliance with the insurance laws of this state and which contain such words, phraseology, conditions and provisions with are specific, certain and unambiguous and reasonably adequate to meet needed requirements for the protection of those insured.If any policy or contract form is disapproved, the reasons therefor shall be based upon the requirements of the laws of this state or of any regulation lawfully promulgated thereunder, and shall be stated in writing and a notification thereof shall be sent to the submitting company.The director shall accord a hearing upon a disapproval, if so requested.The disapproval of any policy or contract form by the director shall be subject to judicial review as provided in chapter 536.

4.The director of the department of insurance, financial institutions and professional registration may, by order or bulletin, exempt from the approval requirements of this section for so long as he deems proper any insurance policy, document, or form or type thereof, as specified in such order or bulletin, to which, in his opinion, this section may not practicably be applied, or the approval of which is, in his opinion, not desirable or necessary for the protection of the public.

(L. 1963 p. 497 §§ 1, 2, A.L. 1984 S.B. 592)

376.296 - Value of investments, how calculated.

The value or amount of an investment acquired or held or an investment practice engaged in under this chapter, unless otherwise specified in this code, shall be the value at which assets of an insurer are required to be reported for statutory accounting purposes as determined in accordance with procedures prescribed in published accounting and valuation standards of the NAIC, including the Purposes and Procedures of the Securities Valuation Office, the Valuation of Securities Manual, the Accounting Practices and Procedures Manual, the Annual Statement Instructions, or any successor valuation procedures officially adopted by the NAIC.

(L. 2007 S.B. 66)

376.1027 - Plan in unsound condition, powers of director.

1.If the director is of the opinion that a multiple employer self-insured health plan is in an unsound condition, that it has failed to comply with the law or any applicable regulations or orders issued by the director, or that it is in a condition which renders its proceedings hazardous to the public or to persons covered under the plan, the director may, after notice and opportunity for a hearing, revoke or suspend the license of the plan or, in lieu thereof, bring a civil action in the county which has venue of an action against the multiple employer self-insured health plan under other provisions of law.The court may impose a fine not to exceed fifty thousand dollars for each violation or ground.

2.If the director is of the opinion that any of the grounds set forth in subsection 1 of this section exist regarding a plan domiciled in this state, he may commence delinquency proceedings against the plan and supervise, rehabilitate, or liquidate such plan in accordance with the procedures set forth in sections 375.1150 to 375.1246.

(L. 1993 H.B. 709 § 33)

376.879 - Outline of coverage for fair disclosure — furnished to each applicant — format and content — rules and standards.

1.In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this state unless an outline of coverage is delivered to the applicant at the time application is made.

2.The director shall prescribe the format and content of the outline of coverage required by subsection 1 of this section.For purposes of this section, "format" means style, arrangements and overall appearance, including such items as the size, color and prominence of type and arrangement of text and captions.Such outline of coverage shall include:

(1)A description of the principal benefits and coverage provided in the policy;

(2)A statement of the renewal provisions, including any reservation by the issuer of a right to change premiums; and disclosure of the existence of any automatic renewal premium increases based on the policyholder's age;

(3)A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

3.The director may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer's ability to select the most appropriate coverage and improve the buyer's understanding of Medicare.Except in the case of direct response insurance policies, the director may require by regulation that the information brochure be provided to any prospective insureds eligible for Medicare concurrently with delivery of the outline of coverage.With respect to direct response insurance policies, the director may require by regulation that the prescribed brochure be provided upon request to any prospective insureds eligible for Medicare, but in no event later than the time of policy delivery.

4.The director may adopt regulations for captions or notice requirements, determined to be in the public interest and designed to inform prospective insureds that particular insurance coverages are not Medicare supplement coverages, for all accident and sickness insurance policies sold to persons eligible for Medicare, other than:

(1)Medicare supplement policies;

(2)Disability income policies.

5.The director may adopt reasonable regulations to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts or certificates by persons eligible for Medicare.

(L. 1989 H.B. 615 & 563, A.L. 1992 H.B. 1574, A.L. 1996 S.B. 883)

Effective 4-26-96

376.728 - Law not applicable, when.

The protection provided by sections 376.715 to 376.758 shall not apply where any guaranty protection is provided to residents of this state by the laws of the domiciliary state or jurisdiction of the impaired or insolvent insurer other than this state.

(L. 1988 S.B. 430 § 10)

376.1127 - Nonforfeiture benefit option required for long-term care insurance policies, requirements of offer — rulemaking authority.

1.Except as provided in subsection 2 of this section, a long-term care insurance policy shall not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit.The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy.If a policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that will be available for a specified period of time following a substantial increase in premium rates.

2.When a group long-term care insurance policy is issued, the offer required in subsection 1 of this section shall be made to the group policyholder; except that, if the policy is issued as a group long-term care insurance, as defined in section 376.1100, other than to a continuing care retirement community or other similar entity, the offering shall be made to each proposed certificate holder.

3.The director shall promulgate rules specifying the type or types of nonforfeiture benefits to be offered as part of long-term care insurance policies and certificates, the standards for nonforfeiture benefits, and the rules regarding contingent benefit upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse will be available and the substantial premium rate increase that triggers a contingent benefit upon lapse as described in subsection 1 of this section.

(L. 2002 H.B. 1568 merged with S.B. 1009)

376.620 - Suicide, effect on liability — refund of premiums, when.

1.Any life insurance policy, rider, endorsement, amendment, or certificate issued or delivered in this state may exclude or restrict liability under such policy, rider, endorsement, amendment, or certificate for death as the result of suicide in the event the insured, while sane or insane, dies as a result of suicide within one year from the date of the issue of such policy, rider, endorsement, amendment, or certificate.If an insured applies for additional death benefits or an increase in death benefits after initial coverage commences, the policy, rider, endorsement, amendment, or certificate may provide for an exclusion for suicide that occurs within one year after any addition or increase in death benefits only to the extent of the additional or increased death benefits.Any such exclusion or restriction shall be clearly stated in such policy, rider, endorsement, amendment, or certificate.

2.Any life insurance policy, rider, endorsement, amendment, or certificate which contains any exclusion or restriction under subsection 1 of this section shall also provide that in the event the insured dies as a result of suicide within one year from the date of issue of such policy, rider, endorsement, amendment, or certificate that the insurer shall promptly refund all premiums paid for the excluded or restricted coverage on such insured.

(RSMo 1939 § 5851, A.L. 2007 S.B. 66, A.L. 2017 H.B. 336)

Prior revisions: 1929 § 5740; 1919 § 6150; 1909 § 6945

376.1372 - Certification and member handbook to include utilization review procedures.

1.In the certificate of coverage and the member handbook provided to enrollees, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of enrollees with respect to those procedures.

2.A health carrier shall include a summary of its utilization review procedures in material intended for prospective enrollees.

3.A health carrier shall print on its membership cards a toll-free telephone number to call for utilization review decisions.

(L. 1997 H.B. 335)

376.720 - Association, created — accounts — director to supervise.

1.There is created a nonprofit legal entity to be known as the "Missouri Life and Health Insurance Guaranty Association".All member insurers shall be and remain members of the association as a condition of their authority to transact insurance or a health maintenance organization business in this state.The association shall perform its functions under the plan of operation established and approved under subsections 1 to 3 of section 376.740 and shall exercise its powers through a board of directors established pursuant to section 376.722.For purposes of administration and assessment the association shall maintain three accounts:

(1)The health account;

(2)The life insurance account;

(3)The annuity account, excluding unallocated annuity contracts.

2.The association shall come under the immediate supervision of the director and shall be subject to the applicable provisions of the insurance laws of this state.Meetings or records of the association may be opened to the public upon majority vote of the board of directors of the association.

(L. 1988 S.B. 430 § 5, A.L. 2018 H.B. 1690)

376.1095 - Rules and regulations, promulgation.

The director shall have the power to promulgate such rules and regulations as are necessary to implement the provisions of sections 376.1075 to 376.1095.No rule or portion of a rule promulgated under the authority of sections 376.1075 to 376.1095 shall become effective unless it has been promulgated pursuant to the provisions of section 536.024.

(L. 1993 H.B. 709 § 54, A.L. 1995 S.B. 3)

376.424 - Group health insurance policies may be extended to insure family members or dependents.

Except for a policy issued under subdivision (2) of subsection 1 of section 376.421, a group health insurance policy may be extended to insure the employees and members with respect to their family members or dependents, or any class or classes thereof, subject to the following:

(1)The premium for the insurance shall be paid either from funds contributed by the employer, union, association or other person to whom the policy has been issued or from funds contributed by the covered persons, or from both.Except as provided in subdivision (2) of this section, a policy on which no part of the premium for the family members' or dependents' coverage is to be derived from funds contributed by the covered persons must insure all eligible employees or members with respect to their family members or dependents, or any class or classes thereof;

(2)An insurer may exclude or limit the coverage on any family member or dependent as to whom evidence of individual insurability is not satisfactory to the insurer, subject to sections 376.406 and 376.776 in a policy insuring fewer than ten employees or members and in a policy insuring ten or more employees or members if:

(a)Application is not made within thirty-one days after the date of eligibility for insurance; or

(b)The employee or member voluntarily terminated the insurance of the family member or dependent while such family member or dependent continues to be eligible for insurance under the policy; or

(c)After the expiration of an open enrollment period during which the family member or dependent could have been enrolled for the insurance or could have been enrolled for another level of benefits under the policy.

(L. 1985 H.B. 623)

376.020 - Various companies defined.

Corporations doing the business mentioned in section 376.010, which are owned and controlled entirely by the stockholders, and in neither the management nor the profits of which the policyholders participate, shall be considered "joint stock companies"; such corporations having no capital stock, and in the management and profits of which the policyholders alone participate shall be considered "mutual companies"; and such corporations having a capital stock, but in the management or in the profits of which, or in both, the policyholders or any class or classes of policyholders are or may become entitled to participate, shall be considered "stock and mutual companies"; provided, that any association consisting of not more than one thousand five hundred citizens, residents of the state of Missouri, all living within the boundaries of not more than three counties in this state, said counties to be contiguous to each other, organized not for profit and solely for the purpose of assessing each of the members thereof upon the death of a member, the entire amount of said assessment, except ten cents paid by each member, to be given to a beneficiary or beneficiaries named by the deceased member in his or her certificate of membership, said certificate of membership to be issued by such association, shall not be construed to be a life insurance company under the laws of this state, but provided, however, no officer, trustee or other employee of such association shall receive any remuneration for any services rendered, except the secretary of such association who shall be permitted to charge each member, for his services and for the cost of collecting the assessment, not more than ten cents for each assessment levied; and provided further, that said association may if necessary assess not more than twenty-five cents per member in any one year to be used only to purchase necessary supplies, pay court costs and attorney fees; and provided further, that whenever the director of the department of insurance, financial institutions and professional registration suspects or believes that any officer, trustee or other employee of such association is in fact directly or indirectly receiving remuneration, or that the secretary of such association is collecting and receiving more than herein provided for, he may cause an examination of the books, records and other effects of such association, including its officers and employees, to be made in order to ascertain the true condition of affairs and whenever such examination is made, an assessment shall be levied on the members thereof, sufficient to pay the cost of such examination, but no such assessment shall be for more than one dollar per member; provided, that nothing herein shall be construed to apply to any corporation organized under the provisions of sections 377.010 to 377.190 or to any association having more than one thousand five hundred members.

(RSMo 1939 § 5801)

Prior revisions: 1929 § 5691; 1919 § 6102; 1909 § 6896

376.679 - Life insurance company may reinsure for risks involving aircraft, limitation.

Any domestic life insurer or reinsurer may also reinsure, by itself, or together with other insurance companies, subject to any limitations, approval or rules promulgated by the director of the department of insurance, financial institutions and professional registration, any risk arising from, related to, or incident to the manufacture, ownership or operation of aircraft.

(L. 1992 S.B. 831 §§ A, 3)

Effective 1-01-93

376.120 - Director to examine and certify, when.

Upon being notified that the proposals and agreements for assurance named in the charter have been made, and the amount of premiums therein mentioned has been received, the director shall make an examination, or cause one to be made, by some disinterested person specially appointed by him for that purpose; and if it shall be found by himself, or if the person so appointed shall certify, under oath, that agreements have been entered into with said company, and premiums received in the manner and to the amount required by section 376.280, and that the amount required to be paid to said company is held by it in money, notes or bonds, then he shall so certify; and the corporators or officers of such company shall be required to certify, under oath, to the person making such examination, that the money, notes or bonds, or other obligations exhibited to him, have been received on deposit for premiums on bona fide proposals and agreements for insurance.

(RSMo 1939 § 5810)

Prior revisions: 1929 § 5700; 1919 § 6111; 1909 § 6905

376.779 - Health insurance policies to offer coverage for treatment of alcoholism — exclusions.

1.All health plans or policies that are individually underwritten or provide for such coverage for specific individuals and the members of their families, which provide for hospital treatment, shall provide coverage, while confined in a hospital or in a residential or nonresidential facility certified by the department of mental health, for treatment of alcoholism on the same basis as coverage for any other illness, except that coverage may be limited to thirty days in any policy or contract benefit period.All Missouri individual contracts issued on or after January 1, 2005, shall be subject to this section.Coverage required by this section shall be included in the policy or contract and payment provided as for other coverage in the same policy or contract notwithstanding any construction or relationship of interdependent contracts or plans affecting coverage and payment of reimbursement prerequisites under the policy or contract.

2.Insurers, corporations or groups providing coverage may approve for payment or reimbursement vendors and programs providing services or treatment required by this section.Any vendor or person offering services or treatment subject to the provisions of this section and seeking approval for payment or reimbursement shall submit to the department of mental health a detailed description of the services or treatment program to be offered.The department of mental health shall make copies of such descriptions available to insurers, corporations or groups providing coverage under the provisions of this section.Each insurer, corporation or group providing coverage shall notify the vendor or person offering service or treatment as to its acceptance or rejection for payment or reimbursement; provided, however, payment or reimbursement shall be made for any service or treatment program certified by the department of mental health.Any notice of rejection shall contain a detailed statement of the reasons for rejection and the steps and procedures necessary for acceptance.Amended descriptions of services or treatment programs to be offered may be filed with the department of mental health.Any vendor or person rejected for approval of payment or reimbursement may modify their description and treatment program and submit copies of the amended description to the department of mental health and to the insurer, corporation or group which rejected the original description.

3.The department of mental health may issue rules necessary to carry out the provisions of this section.No rule or portion of a rule promulgated under the authority of this section shall become effective unless it has been promulgated pursuant to the provisions of section 536.024.

4.All substance abuse treatment programs in Missouri receiving funding from the Missouri department of mental health must be certified by the department.

5.This section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, hospitalization-surgical care policy, short-term major medical policy of six months or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

(L. 1977 S.B. 322 § 1, A.L. 1980 S.B. 636 & 573, A.L. 1985 H.B. 623, A.L. 1995 S.B. 3, A.L. 1999 H.B. 191, A.L. 2004 H.B. 855)

376.975 - Member's proportion of participation in pool to be determined annually — deficits to be recouped by proportioned assessment — amount of assessment to be offset against certain taxes.

Each member's proportion of participation in the pool shall be determined annually by the board based on annual statements and other reports deemed necessary by the board and filed by the member with it.Any deficit incurred by the pool shall be recouped by assessments apportioned as provided in subsections 1, 2, and 3 of section 376.973 by the board among members.The amount of assessments incurred by each member of the pool shall be allowed as an offset against certain taxes, and shall be subject to certain limitations, as follows:Each pool member subject to chapter 148 may deduct from premium taxes payable for any calendar year to the state any and all assessments paid for the same year pursuant to sections 376.960 to 376.989.All assessments, for a fiscal year, shall not exceed the net premium tax due and payable by such member in the previous year.If the assessment exceeds any premium tax due or payable in such year, the excess shall be a credit or offset carried forward against any premium tax due or payable in succeeding years until the excess is exhausted.

(L. 1990 H.B. 998 § 5 subsec. 5 subdiv. (1)(a))

Effective 1-01-91

376.724 - Impaired insurers, association's options, duties — insolvent insurers, association's options, duties — alternative policies, requirements.

1.If a member insurer is an impaired insurer, the association may, in its discretion, and subject to any conditions imposed by the association that do not impair the contractual obligations of the impaired insurer, that are approved by the director:

(1)Guarantee, assume, reissue, or reinsure, or cause to be guaranteed, assumed, reissued, or reinsured, any or all of the policies or contracts of the impaired insurer; or

(2)Provide such moneys, pledges, notes, loans, guarantees, or other means as are proper to effectuate subdivision (1) of this subsection and assure payment of the contractual obligations of the impaired insurer pending action under subdivision (1) of this subsection.

2.If a member insurer is an insolvent insurer, the association shall, in its discretion, either:

(1)(a)a.Guarantee, assume, reissue, or reinsure, or cause to be guaranteed, assumed, reissued, or reinsured, the policies or contracts of the insolvent insurer; or

b.Assure payment of the contractual obligations of the insolvent insurer; and

(b)Provide such moneys, pledges, loans, notes, guarantees, or other means as are reasonably necessary to discharge such duties; or

(2)Provide benefits and coverages in accordance with the following provisions:

(a)With respect to policies and contracts, assure payment of benefits that would have been payable under the policies of the insolvent insurer, for claims incurred:

a.With respect to group policies and contracts, not later than the earlier of the next renewal date under such policies or contracts or forty-five days, but in no event less than thirty days, after the date on which the association becomes obligated with respect to such policies and contracts;

b.With respect to individual policies, contracts, and annuities, not later than the earlier of the next renewal date, if any, under such policies or contracts or one year, but in no event less than thirty days, from the date on which the association becomes obligated with respect to such policies and contracts;

(b)Make diligent efforts to provide all known insureds, enrollees, or annuitants for individual policies and contracts, or group policy or contract owners with respect to group policies or contracts, thirty days' notice of the termination, under paragraph (a) of this subdivision, of the benefits provided;

(c)With respect to individual policies and contracts, make available to each known insured, annuitant, or owner if other than the insured, enrollee, or annuitant, and with respect to an individual formerly an insured, enrollee, or annuitant under a group policy or contract who is not eligible for replacement group coverage, make available substitute coverage on an individual basis in accordance with the provisions of paragraph (d) of this subdivision, if the insureds, enrollees, or annuitants had a right under law or the terminated policy, contract, or annuity to convert coverage to individual coverage or to continue an individual policy, contract, or annuity in force until a specified age or for a specified time, during which the insurer or health maintenance organization had no right unilaterally to make changes in any provision of the policy, contract, or annuity or had a right only to make changes in premium by class;

(d)a.In providing the substitute coverage required under paragraph (c) of this subdivision, the association may offer either to reissue the terminated coverage or to issue an alternative policy or contract at actuarially justified rates;

b.Alternative or reissued policies or contracts shall be offered without requiring evidence of insurability, and shall not provide for any waiting period or exclusion that would not have applied under the terminated policy or contract;

c.The association may reinsure any alternative or reissued policy or contract;

(e)a.Alternative policies or contracts adopted by the association shall be subject to the approval of the director.The association may adopt alternative policies or contracts of various types for future issuance without regard to any particular impairment or insolvency;

b.Alternative policies or contracts shall contain at least the minimum statutory provisions required in this state and provide benefits that shall not be unreasonable in relation to the premium charged.The association shall set the premium in accordance with a table of rates which it shall adopt.The premium shall reflect the amount of insurance to be provided and the age and class of risk of each insured, but shall not reflect any changes in the health of the insured after the original policy or contract was last underwritten;

c.Any alternative policy or contract issued by the association shall provide coverage of a type similar to that of the policy or contract issued by the impaired or insolvent insurer, as determined by the association;

(f)In carrying out its duties in connection with guaranteeing, assuming, reissuing, or reinsuring policies or contracts under this subsection, the association may issue substitute coverage for a policy or contract that provides an interest rate, crediting rate, or similar factor determined by use of an index or other external reference stated in the policy or contract employed in calculating returns or changes in value by issuing an alternative policy or contract in accordance with the following provisions:

a.In lieu of the index or other external reference provided for in the original policy or contract, the alternative policy or contract provides for a fixed interest rate, payment of dividends with minimum guarantees, or a different method for calculating interest or changes in value;

b.There is no requirement for evidence of insurability, waiting period, or other exclusion that would not have applied under the replaced policy or contract; and

c.The alternative policy or contract is substantially similar to the replaced policy or contract in all other terms.

(L. 1988 S.B. 430 § 7, A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

376.892 - Surviving spouse may continue coverage, when — divorced or separated spouse may continue coverage, when — services offered.

1.Any policy, contract or plan offered, issued or renewed in this state after August 28, 1993, providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, shall contain a provision that:

(1)The surviving spouse of a certificate holder may continue coverage under the policy, contract or plan, at the death of the certificate holder, with respect to the spouse and any dependent children whose coverage under the policy, contract or plan, otherwise would terminate because of the death of the certificate holder if the surviving spouse is fifty-five years of age or older at the time of the expiration of coverage provided by the federal Consolidated Omnibus Budget Reconciliation Act (COBRA); and

(2)The divorced or legally separated spouse of a certificate holder may continue coverage under the policy, contract or plan, upon dissolution of marriage with, or legal separation from, the certificate holder, with respect to the divorced or legally separated spouse and any dependent children whose coverage under the policy, contract or plan, otherwise would terminate because of the dissolution of marriage or legal separation, if the divorced or legally separated spouse is fifty-five years of age or older at the time of the expiration of coverage provided by the federal Consolidated Omnibus Budget Reconciliation Act (COBRA).

2. Continued coverage for dental, vision care or prescription drug expenses shall be offered to legally separated, divorced or surviving spouses and any dependent children eligible under subsection 1 of this section if such coverage is or was available to the certificate holder.

(L. 1993 H.B. 564 § 12)

376.220 - May use realty to secure notes and bonds.

Should any company depositing under section 376.170 become the owner of real estate for its own use and accommodations, or become temporarily seized and possessed of real estate in satisfaction of debt for which such real estate was pledged for security, such company may execute its own note for the value of such real estate, payable to the director, as trustee, and secure the said notes or bonds by duly recorded deeds of trust of said real estate; which notes or bonds thus secured may be deposited with said director as proper security, under and according to the provisions of sections 376.010 to 376.670, said value to be subject to the approval of the director of the department of insurance, financial institutions and professional registration.

(RSMo 1939 § 5820)

Prior revisions: 1929 § 5709; 1919 § 6120; 1909 § 6914

376.800 - Misrepresentation made in obtaining individual accident and health policy no defense, exception.

Anything in the law to the contrary notwithstanding, no misrepresentation made in obtaining or securing a policy of insurance covered by sections 376.770 to 376.800 shall be deemed material or render the policy void, or constitute a defense to a claim thereunder unless the matter misrepresented shall have actually contributed to the contingency or event on which any claim thereunder is to become due and payable, and whether it so contributed in any case shall be a question for the jury.

(L. 1967 p. 516 § C)

(1994)In claim for vexatious refusal to pay medical benefits against group health medical insurer, statute is preempted by Federal Employee Retirement Income Security Act (ERISA).Statute is not a statute which regulates insurance, therefore, does not come under the savings clause of ERISA preemption that expressly exempts state laws that regulate insurance.Coots v. United Employers Federation, 865 F.Supp 596 (E.D. Mo).

376.900 - Definitions.

For the purpose of sections 376.900 to 376.950 the following words and terms mean:

(1)"Care for a term of years", an agreement between a resident and a provider whereby the resident pays a fee for the right to occupy space in a designated facility, and to receive continuing care, for at least one year, but for less than the life of the resident."Care for a term of years" also refers to a contract or agreement for continuing care for an indefinite term;

(2)"Continuing care" or "care", furnishing shelter, food, and nursing care, whether the nursing care is provided in the facility or in another setting designated by the agreement for continuing care, to an individual not related by consanguinity or affinity to the provider furnishing such care.Other personal services provided shall be designated in the continuing care agreement."Continuing care" shall include only life care, care for life, or care for a term of years;

(3)"Department", the Missouri department of insurance, financial institutions and professional registration;

(4)"Entrance fee", an initial or deferred payment of a sum of money or property which assures the resident a place in a facility for a term of years or for life.An accommodation fee, endowment fee, admission fee, or other fee of similar form and application shall be considered to be an entrance fee;

(5)"Facility", a place in which it is undertaken to provide continuing care to an individual for a term of years or for life;

(6)"Life care" or "care for life", a life lease, life membership, life estate, or similar agreement between a resident and a provider by which the resident pays a fee for the right to occupy a space in a designated facility and to receive continuing care for life;

(7)"Provider", the owner or operator, whether a natural person, partnership, or other unincorporated association, however organized, or trust or corporation, of an institution, building, residence, or other place, whether operated for profit or not, which owner or operator undertakes to provide continuing care for a fixed or variable fee, or for any other remuneration of any type, whether fixed or variable, for the period of care, payable in a lump sum or lump sum and monthly maintenance charges or in installments; however, the term "provider" shall not include facilities operated, owned, or leased for operation by any fraternal or religious organization if the organization as a matter of policy limits residents to those who are members or spouses of members of the organization;

(8)"Resident" means a person who enters into a life care contract with a provider or who is designated in a life care contract to be a person provided with services, board, and lodging.

(L. 1981 S.B. 84 § 1)

376.308 - Secondary mortgage market act, not to preempt health insurer, when.

No requirement for the making of any investment or holding any asset by an insurer, health services corporation, health maintenance organization or other entity regulated by the department of insurance, financial institutions and professional registration pursuant to chapter 354 or chapters 374 to 385 shall be preempted by the provisions of section 106 of Title I of the federal Secondary Mortgage Market Act of 1984, as codified and may be amended from time to time.

(L. 1991 H.B. 385, et al. § 115)

376.1103 - Laws applicable, Medicare supplement laws not applicable — purpose — policies or riders must be in compliance.

1.The provisions of sections 376.1100 to 376.1130 shall apply to policies delivered or issued for delivery in this state on or after August 28, 2002.Sections 376.1100 to 376.1130 are not intended to supersede the obligations of entities subject to the provisions of sections 376.1100 to 376.1130 to comply with the substance of other applicable insurance laws insofar as they do not conflict with the provisions of sections 376.1100 to 376.1130, except that laws and regulations designed and intended to apply to Medicare supplement insurance policies shall not be applied to long-term care insurance.

2.The purposes of the provisions of sections 376.1100 to 376.1130 are to promote the public interest, to promote the availability of long-term care insurance policies, to protect applicants for long-term care insurance, as defined, from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to facilitate flexibility and innovation in the development of long-term care insurance coverage.

3.Any policy or rider advertised, marketed or offered as long-term care or nursing home insurance shall comply with the provisions of sections 376.1100 to 376.1130.

(L. 1990 S.B. 765 §§ 3, 8, A.L. 2002 H.B. 1568 merged with S.B. 1009)

Transferred 2002; formerly 376.952

376.451 - Standards prohibiting discrimination.

1.A health insurance issuer offering group health insurance coverage shall comply with the following standards prohibiting discrimination as to eligibility based upon health status:

(1)A health insurance issuer offering group health insurance coverage shall not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the group health plan based on any of the following health status-related factors of the individual or a dependent of the individual:

(a)Health status;

(b)Medical condition, including both physical and mental illness;

(c)Claims experience;

(d)Receipt of health care;

(e)Medical history;

(f)Genetic information;

(g)Evidence of insurability, including conditions arising out of acts of domestic violence; or

(h)Disability;

(2)This subsection does not require a health insurance issuer offering group health insurance coverage to provide particular benefits other than those provided under the terms of the group health insurance coverage, or prevent the issuer from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the group health insurance coverage;

(3)For purposes of subdivision (1) of this subsection, rules for eligibility to enroll include rules defining any applicable waiting or affiliation period for such enrollment, and rules relating to late and special enrollments.

2.A health insurance issuer offering group health insurance coverage shall comply with the following standards prohibiting discrimination as to premium contributions based upon health status:

(1)A health insurance issuer offering health insurance coverage in connection with a group health plan shall not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual enrolled in the group health plan on the basis of any health status-related factor in relation to the individual or to an individual enrolled under the plan as a dependent of the individual;

(2)Nothing in subdivision (1) of this subsection shall be construed to:

(a)Restrict the amount that any employer may be charged for coverage under a group health plan, other than as provided in sections 379.930 to 379.952, for health insurance coverage provided in the small group market; or

(b)Prevent a health insurance issuer offering group health insurance coverage from establishing premium discounts or rebates or modifying otherwise applicable co-payments or deductibles in return for adherence to programs of health promotion and disease prevention.Premium discount or rebates established under this subsection shall not be included when computing a small group rate band under section 379.936.

(L. 2007 H.B. 818)

Effective 1-01-08

376.1403 - Referrals, standardized information used, content, when.

1.Every health care provider and health carrier that conducts business in this state shall use standardized information for referrals.As used in this section, the terms "health care provider" and "health carrier" shall have the meaning given to such terms in section 376.1350.

2.The referral information shall contain the following:

(1)The name of the insured;

(2)The name, address and phone number of the health carrier;

(3)The identification number and group number of the insured;

(4)The type of referral;

(5)The name, address and phone number of the health care provider referring the insured;

(6)The name, address and phone number of the health care provider to whom the insured was referred to;

(7)The number of visits requested and authorized; and

(8)The health carrier's authorization number.

3.All health care providers and health carriers shall use the standardized referral information after January 1, 2002.

(L. 1999 H.B. 191 § 376.1406)

376.859 - Medicare supplement law applicable to what policies — policies not included.

1.Except as otherwise specifically provided, sections 376.850 to 376.890 shall apply to:

(1)All Medicare supplement policies delivered or issued for delivery in this state on or after August 28, 1992; and

(2)All certificates issued under group Medicare supplement policies, when certificates have been delivered or issued for delivery in this state.

2.Medicare supplement policies do not include a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees or a combination thereof or for members or former members, or a combination thereof, of the labor organizations.

3.The provisions of sections 376.850 to 376.890 are not intended to prohibit or apply to insurance policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons when policies are not marketed or held to be Medicare supplement policies or benefit plans.

(L. 1989 H.B. 615 & 563, A.L. 1992 H.B. 1574, A.L. 1996 S.B. 883)

Effective 4-26-96

376.1007 - Plan to file copy of bylaws, coverage and agreements with director.

At the time application for a certificate of authority is made, the multiple employer self-insured health plan shall file with the director a copy of the plan's bylaws, all schedules of benefits, and all management, administration, and trust agreements which the plan has made or proposes to make for the conduct of its business and affairs.Any proposed changes or amendments to the foregoing shall also be filed with the director at least sixty days prior to the proposed effective date.

(L. 1993 H.B. 709 § 25)

376.708 - Required presentations and statements — company to maintain file.

1.Each insurer shall maintain at its home office or principal office, a complete file containing one copy of each document authorized by the insurer for use pursuant to sections 376.700 to 376.714.Such file shall contain one copy of each authorized form for a period of three years following the date of its last authorized use.

2.An agent shall inform the prospective purchaser, prior to commencing a life insurance sales presentation, that he is acting as a life insurance agent and inform the prospective purchaser of the full name of the insurance company which he is representing to the buyer.In sales situations in which an agent is not involved, the insurer shall identify its full name.

3.Terms such as financial planner, investment advisor, financial consultant, or financial counseling shall not be used in such a way as to imply that the insurance agent is generally engaged in an advisory business in which compensation is unrelated to sales unless such is actually the case.

4.Any reference to policy dividends must include a statement that dividends are not guaranteed.

5.A system or presentation which does not recognize the time value of money through the use of appropriate interest adjustments shall not be used for comparing the cost of two or more life insurance policies.Such a system may be used for the purpose of demonstrating the cash-flow pattern of a policy if such presentation is accompanied by a statement disclosing that the presentation does not recognize that, because of interest, a dollar in the future has less value than a dollar today.

6.A presentation of benefits shall not display guaranteed and nonguaranteed benefits as a single sum unless they are shown separately in close proximity thereto.

7.A statement regarding the use of the life insurance cost indexes shall include an explanation to the effect that the indexes are useful only for the comparison of the relative costs of two or more similar policies.

8.A life insurance cost index which reflects dividends or an equivalent level annual dividend shall be accompanied by a statement that it is based on the company's current dividend scale and is not guaranteed.

9.For the purposes of sections 376.700 to 376.714, the annual premium for a basic policy or rider, for which the company reserves the right to change the premium, shall be the maximum annual premium.

(L. 1979 H.B. 508 § 5)

376.1307 - Issuance of shares.

All of the shares, if any are issued, of the capital stock of the reorganized life insurance company shall be issued to the mutual holding company, which shall at all times own a majority of the voting shares of the capital stock of the reorganized life insurance company; except that, either at the time of the reorganization, or at some later time with the approval of the director, the mutual holding company may create a stock holding company pursuant to chapter 351 for the purpose of owning all of the stock of the reorganized life insurance company, so long as the mutual holding company at all times owns a majority of the voting shares of the capital stock of the stock holding company.Any subsidiaries of the reorganized life insurance company may remain as subsidiaries of such company or become subsidiaries of the mutual or stock holding company provided that, if such subsidiaries shall become subsidiaries of a stock holding company then the reorganized life insurance company shall be reimbursed the fair market value of its holdings in such subsidiaries in the event shares of the stock holding company are or have been issued to other than the mutual holding company.

(L. 1996 S.B. 759)

376.755 - Advertising, use of guaranty association prohibited.

No person, including a member insurer, agent or affiliate of an insurer shall make, publish, disseminate, circulate, or place before the public, or cause directly or indirectly, to be made, published, disseminated, circulated or placed before the public, in any newspaper, magazine or other publication, or in the form of a notice, circular, pamphlet, letter or poster, or over any radio station or television station, or in any other way, any advertisement, announcement or statement, written or oral, which uses the existence of the insurance guaranty association of this state for the purpose of sales, solicitation, or inducement to purchase any form of insurance or other coverage covered by sections 376.715 to 376.758.If a policy exceeds the limitations of coverage under sections 376.715 to 376.758, the insurer shall prominently inscribe on an endorsement to the insurance contract the limitations of coverage provided by the guaranty association.This section shall not apply to the Missouri Life and Health Insurance Guaranty Association or any other entity which does not sell or solicit insurance or coverage by a health maintenance organization.

(L. 1988 S.B. 430 § 35, A.L. 1991 H.B. 385, et al., A.L. 2018 H.B. 1690)

376.500 - Discriminations, rebates and favors prohibited — contracts to conform to policy.

No life insurance company doing business in this state shall make or permit any distinction or discrimination in favor of individuals between insurants (the insured) of the same class and equal expectations of life in the amount or payment of premiums or rates charged for policies of life or endowment insurance, or in the dividends or other benefits payable thereon, or in any other of the terms and conditions of the contracts it makes; nor shall any such company, or agent thereof, make any contract of insurance or agreement as to such contract other than as plainly expressed in the policy issued thereon; nor shall any such company, or any officer, agent, solicitor or representative thereof, pay, allow or give, or offer to pay, allow or give, directly or indirectly, as inducement to insurance, any rebate of premium payable on the policy, or any special favor or advantage in the dividends or other benefits to accrue thereon, or any paid employment or contract for services of any kind, or any valuable consideration or inducement whatever, not specified in the policy contract of insurance; or give, sell or purchase, or offer to give, sell or purchase, as inducement to insurance or in connection therewith, any stocks, bonds or other securities of any insurance company or other corporation, association, or partnership, or any dividends or profits to accrue thereon, or anything of value whatsoever.The provisions of this section shall also apply to all companies incorporated under the provisions of sections 377.200 to 377.460.

(RSMo 1939 § 5840, A.L. 1965 p. 95)

Prior revisions: 1929 § 5729; 1919 § 6139; 1909 § 6934

376.600 - Penalty for violating section 376.590.

Any life insurance company which may violate any of the provisions of section 376.590, or which may permit any of its agents or representatives in this state to violate said provisions, shall have its certificate of authority or license to transact business in Missouri revoked by the state director of the department of insurance, financial institutions and professional registration, and shall be for a period of five years barred from the further transaction of business in this state; and any agent, solicitor or representative in this state of any such insurance company who shall violate any of the provisions of said section shall be deemed guilty of a misdemeanor, and, on conviction thereof, in any court of competent jurisdiction in this state, shall be fined not less than fifty nor more than five hundred dollars for each such offense or imprisoned in the county or city jail for not less than ten days nor more than six months, or by both such fine and imprisonment.

(RSMo 1939 § 5845)

Prior revisions: 1929 § 5734; 1919 § 6144; 1909 § 6939

376.700 - Purpose — use of additional material.

1.The purpose of sections 376.700 to 376.714 is to require insurers to deliver to purchasers of life insurance, information which will improve the buyer's ability to select the most appropriate plan of life insurance for his needs, improve the buyer's understanding of the basic features of the policy which has been purchased or which is under consideration, and improve the ability of the buyer to evaluate the relative costs of similar plans of life insurance.

2.Sections 376.700 to 376.714 do not prohibit the use of additional material which is not in violation of sections 376.700 to 376.714 or any other state law or regulation.

(L. 1979 H.B. 508 § 1)

376.304 - Acquisition of foreign investments, when.

1.Subject to the limitations of section 376.297, an insurer may acquire foreign investments or engage in investment practices with persons of or in foreign jurisdictions of substantially the same types as those that an insurer is permitted to acquire under this chapter, other than the type permitted under section 376.311 if as a result and after giving effect to the investment:

(1)The aggregate amount of foreign investments then held by the insurer under this subsection does not exceed twenty percent of the admitted assets; and

(2)The aggregate amount of foreign investments then held by the insurer under this subsection in a single foreign jurisdiction does not exceed ten percent of its admitted assets as to a foreign jurisdiction that has a sovereign debt rating of SVO "1" or three percent of its admitted assets as to any other foreign jurisdiction.

2.Subject to the limitations of section 376.297, an insurer may acquire investments or engage in investment practice denominated in foreign currencies whether or not they are foreign investments acquired under subsection 1 of this section or additional foreign currency exposure as a result of the termination or expiration of a hedging transaction with respect to investments denominated in a foreign currency if as a result of and after giving effect to the transaction:

(1)The aggregate amount of investments then held by the insurer under this subsection denominated in foreign currencies does not exceed ten percent of its admitted assets; and

(2)The aggregate amount of investments then held by the insurer under this subsection denominated in the foreign currency of a single foreign jurisdiction does not exceed ten percent of its admitted assets as to a foreign jurisdiction that has a sovereign debt rating of SVO "1" or three percent of its admitted assets as to any other foreign jurisdiction.

3.An investment shall not be considered denominated in a foreign currency if the acquiring insurer enters into one or more contracts in transactions permitted under section 375.345 in which the business entity counterparty agrees to exchange or grants to the insurer the option to exchange all payments made on the foreign currency denominated investment, or amounts equivalent to the payments that are or will be due to the insurer in accordance with the terms of such investment, for United States currency during the period the contract or contracts are in effect to insulate the insurer from loss caused by diminution of the value of payments owed to the insurer due to future changes in currency exchange rates.

4.In addition to investments permitted under subsections 1 to 3 of this section, an insurer that is authorized to do business in a foreign jurisdiction and that has an outstanding insurance, annuity, or reinsurance contract on lives or risks resident or located in that foreign jurisdiction and denominated in foreign currency of that jurisdiction may acquire investments denominated in the currency of that jurisdiction subject to the limitations of section 376.297.However, investments made under this subsection in obligations of foreign governments, their political subdivisions, and government-sponsored enterprises shall not be subject to the limitations of section 376.297 if those investments carry an SVO rating of "1" or "2".The aggregate amount of investments acquired by the insurer under this subsection shall not exceed the greater of:

(1)The amount the insurer is required by the law of the foreign jurisdiction to invest in the foreign jurisdiction; or

(2)One hundred fifteen percent of the amount of its reserves, net of reinsurance, and other obligations under the contracts on lives or risks resident or located in the foreign jurisdiction.

5.In addition to investments permitted under subsections 1 to 3 of this section, an insurer that is not authorized to do business in a foreign jurisdiction but which has outstanding insurance, annuity, or reinsurance contracts on lives or risks resident or located in that foreign jurisdiction and denominated in foreign currency of that jurisdiction may acquire foreign investments respecting that foreign jurisdiction and may acquire investments denominated in the currency of that jurisdiction, subject to the limitations of section 376.297.However, investments made under this subsection in obligations of foreign governments, their political subdivisions, and government sponsored enterprises shall not be subject to the limitations of section 376.297 if those investments carry an SVO rating of "1" or "2".The aggregate amount of investments acquired by the insurer under this subsection shall not exceed one hundred five percent of the amount of its reserves, net of reinsurance, and other obligations under the contracts on lives and risks resident or located in the foreign jurisdiction.

6.Investments acquired under this section shall be aggregated with investments of the same type made under this chapter and in a similar manner for purposes of determining compliance with the limitations, if any, contained in this chapter.Investments in obligations of foreign governments, their political subdivisions, and government sponsored enterprises of these persons, except for those exempted under subsections 4 and 5 of this section, shall be subject to the limitations of section 376.297.

(L. 2007 S.B. 66)

376.1356 - Utilization review organization monitored, when.

Whenever a health carrier contracts to have a utilization review organization or other entity perform the utilization review functions required by sections 376.1350 to 376.1390 or applicable rules and regulations, the health carrier shall be responsible for monitoring the activities of the utilization review organization or entity with which the health carrier contracts and for ensuring that the requirements of sections 376.1350 to 376.1390 and applicable rules and regulations are met.

(L. 1997 H.B. 335)

376.300 - Equity interests permitted, when.

1.Subject to the limitations of section 376.297, an insurer may acquire equity interests in business entities organized under the laws of any domestic jurisdiction.

2.An insurer shall not acquire an investment under this section if as a result of and after giving effect to the investment the aggregate amount of investments then held by the insurer under this section would exceed twenty percent of its admitted assets, or except for mutual funds, the amount of equity interests then held by the insurer that are not listed on a qualified exchange would exceed five percent of its admitted assets.

3.An insurer shall not acquire under this section any investment that the insurer may acquire under section 376.302.

4.An insurer shall not short sell equity interests unless the insurer covers the short sale by owning the equity interest or an unrestricted right to the equity interest exercisable within six months of the short sale.

(RSMo 1939 § 6032, A.L. 1943 p. 608, A.L. 1945 p. 995, A.L. 1945 p. 1004, A.L. 1949 p. 305, A.L. 1953 p. 235, A.L. 1961 p. 171, A.L. 1963 p. 492, A.L. 1973 H.B. 111, A.L. 1979 S.B. 322, A.L. 1982 S.B. 726, A.L. 1985 H.B. 823, A.L. 1995 S.B. 170, A.L. 2000 H.B. 1739, A.L. 2005 H.B. 69 merged with S.B. 131, A.L. 2007 S.B. 66)

Prior revision: 1929 § 5921

376.704 - Definitions.

For the purposes of sections 376.700 to 376.714, the following definitions shall apply:

(1)"Buyer's guide", a document which contains, and is limited to, the language contained in section 376.714 or language approved by the director of the department of insurance, financial institutions and professional registration;

(2)"Cash dividend", the current illustrated dividend which can be applied toward payment of the gross premium;

(3)"Equivalent level annual dividend", a calculation made by applying the following steps:

(a)Accumulate the annual cash dividends at five percent interest, or other interest rate approved by the director of the department of insurance, financial institutions and professional registration, compounded annually to the end of the tenth and twentieth policy years;

(b)Divide each accumulation of (a) by an interest factor that converts it into one equivalent level annual amount that, if paid at the beginning of each year, would accrue to the values in (a) over the respective periods stipulated in (a).If the period is ten years, the factor is 13.207 and if the period is twenty years, the factor is 34.719;

(c)Divide the results of (b) by the number of thousands of the equivalent level death benefit to arrive at the equivalent level annual dividend;

(4)"Equivalent level death benefit", an amount calculated as follows:

(a)Accumulate the guaranteed amount payable upon death, regardless of the cause of death, at the beginning of each policy year for ten and twenty years at five percent interest, or other interest rate approved by the director of the department of insurance, financial institutions and professional registration, compounded annually to the end of the tenth and twentieth policy years respectively;

(b)Divide each accumulation of (a) by an interest factor that converts it into one equivalent level annual amount that, if paid at the beginning of each year, would accrue to the value in (a) over the respective periods stipulated in (a).If the period is ten years, the factor is 13.207 and if the period is twenty years, the factor is 34.719.

(5)"Generic name", a short title which is descriptive of the premium and benefit patterns of a policy or a rider;

(6)"Life insurance cost indexes":

(a)"Life insurance surrender cost index", a calculation made by applying the following steps:

a.Determine the guaranteed cash surrender value, if any, available at the end of the tenth and twentieth policy years;

b.For participating policies, add the terminal dividend payable upon surrender, if any, to the accumulation of the annual cash dividends at five percent interest, or other interest rate approved by the director of the department of insurance, financial institutions and professional registration, compounded annually to the end of the period selected and add this sum to the amount determined in step a;

c.Divide the result of step b. (step a. for guaranteed-cost policies) by an interest factor that converts it into an equivalent level annual amount that, if paid at the beginning of each year, would accrue to the value in step b. (step a. for guaranteed-cost policies) over the respective periods stipulated in step a.If the period is ten years, the factor is 13.207 and if the period is twenty years, the factor is 34.719;

d.Determine the equivalent level premium by accumulating each annual premium payable for the basic policy or rider at five percent interest, or other interest rate approved by the director of the department of insurance, financial institutions and professional registration, compounded annually to the end of the period stipulated in step a.and dividing the result by the respective factors stated in step c.(This amount is the annual premium payable for a level premium plan.);

e.Subtract the result of step c. from step d.;

f.Divide the result of step e. by the number of thousands of the equivalent level death benefit to arrive at the life insurance surrender cost index;

(b)"Life insurance net payment cost index", a calculation made in the same manner as the comparable life insurance cost index except that the cash surrender value and any terminal dividend are set at zero;

(7)"Policy summary", for the purposes of sections 376.700 to 376.714, policy summary means a written statement describing the elements of the policy including but not limited to:

(a)A prominently placed title as follows:

STATEMENT OF POLICY COST AND BENEFIT INFORMATION;

(b)The name and address of the insurance agent, or, if no agent is involved, a statement of the procedure to be followed in order to receive responses to inquiries regarding the policy summary;

(c)The full name and home office or administrative office address of the company in which the life insurance policy is to be or has been written;

(d)The generic name of the basic policy and each rider;

(e)The following amounts, where applicable, for the first five policy years and representative policy years thereafter sufficient to clearly illustrate the premium and benefit patterns, including, but not necessarily limited to, the years for which life insurance cost indexes are displayed and at least one age from sixty through sixty-five or maturity whichever is earlier:

a.The annual premium for the basic policy;

b.The annual premium for each optional rider;

c.Guaranteed amount payable upon death, at the beginning of the policy year regardless of the cause of death other than suicide, or other specifically enumerated exclusions, which is provided by the basic policy and each optional rider, with benefits provided under the basic policy and each rider shown separately;

d.Total guaranteed cash surrender values at the end of the year with values shown separately for the basic policy and each rider;

e.Cash dividends payable at the end of the year with values shown separately for the basic policy and each rider (Dividends need not be displayed beyond the twentieth policy year.);

f.Guaranteed endowment amounts payable under the policy which are not included under guaranteed cash surrender values above;

(f)The effective policy loan annual percentage interest rate, if the policy contains this provision, specifying whether this rate is applied in advance or in arrears.If the policy loan interest rate is variable, the policy summary includes the maximum annual percentage rate;

(g)Life insurance cost indexes for ten and twenty years but in no case beyond the premium paying period.Separate indexes are displayed for the basic policy and for each optional term life insurance rider.Such indexes need not be included for optional riders which are limited to benefits such as accidental death benefits, disability waiver of premium, preliminary term life insurance coverage of less than twelve months and guaranteed insurability benefits nor for basic policies or optional riders covering more than one life;

(h)The equivalent level annual dividend, in the case of participating policies and participating optional term life insurance riders, under the same circumstances and for the same durations at which life insurance cost indexes are displayed;

(i)A policy summary which includes dividends shall also include a statement that dividends are based on the company's current dividend scale and are not guaranteed, in addition to a statement in close proximity to the equivalent level annual dividend as follows:An explanation of the intended use of the equivalent level annual dividend is included in the life insurance buyer's guide;

(j)A statement in close proximity to the life insurance cost indexes as follows:An explanation of the intended use of these indexes is provided in the life insurance buyer's guide;

(k)The date on which the policy summary is prepared.The policy summary must consist of a separate document.All information required to be disclosed must be set out in such a manner as to not minimize or render any portion thereof obscure.Any amounts which remain level for two or more years of the policy may be represented by a single number if it is clearly indicated what amounts are applicable for each policy year.Amounts in item (e) of this section shall be listed in total, not on a per thousand nor per unit basis.If more than one insured is covered under one policy or rider, guaranteed death benefits shall be displayed separately for each insured or for each class of insureds if death benefits do not differ within the class.Zero amounts shall be displayed as zero and shall not be displayed as a blank space.

(L. 1979 H.B. 508 § 3)

376.200 - Definition of net value.

The term "net value" of any such registered policy or annuity bond as used in sections 376.010 to 376.670 shall be the total of the various reserve values thereof as defined by section 376.370, as same now is or as same may be subsequently amended, less the reserve on the reinsurance policy covering that portion of said policies or annuity bonds reinsured in other solvent companies organized or doing business under the provisions of sections 376.010 to 376.670 and less the sum of any policy loans and liens, premium notes and net uncollected and deferred premiums; provided, that the sum of said policy loans, liens, premium notes, and net uncollected and deferred premiums shall not exceed the reserve of such registered policy or annuity bond exclusive of the reserve required for total and permanent disability benefits, additional accidental death benefits and unpaid dividends.

(RSMo 1939 § 5818)

376.404 - Specific requirement requests of policyholder may be met by alteration.

Upon written request by the group policyholder, the coverages required in section 376.397 may be changed or altered to meet the specific requirements of such group policyholder.

(L. 1981 S.B. 58 § 5)

Effective 1-01-83

376.100 - Mutual companies — contents of charter.

When such corporators propose to form a mutual company, for the purpose designated in section 376.010, the charter comprised in the declaration mentioned in section 376.050 shall set forth:

(1)The name assumed by such corporation, and by which it shall be known;

(2)The place where the principal office for the transaction of its business shall be located;

(3)The specific kind or kinds of business which it proposes to transact;

(4)The number of persons from whom proposals for assurance shall be received, the amount of premiums to be received on deposit, and the amount of cash to be paid on the same, before the company shall begin to do business and issue policies;

(5)The manner in which the corporate powers granted by sections 376.010 to 376.670 are to be exercised, showing the number of directors, which shall not be more than twenty-one nor less than nine, their powers and duties, the manner of their election, the mode of filling vacancies, and such other particulars as may be necessary to make manifest the objects and purposes of the association, and the manner in which it is to be conducted.

(RSMo 1939 § 5808, A.L. 1951 p. 273)

Prior revisions: 1929 § 5698; 1919 § 6109; 1909 § 6903

376.1042 - Marketing by agent, agency or broker violation of law.

The sale, solicitation or marketing of any plan by an agent, agency or broker shall constitute a violation of section 375.141.

(L. 1993 H.B. 709 § 39)

376.410 - Insurance companies to maintain reserves — exemptions.

Except as provided in subdivision (6) of this section, all companies organized under the laws of this state, and engaged in writing policies of accident or health insurance, or combination policies of accident and health insurance, and all other companies transacting such kinds of business in this state, shall maintain reserves thereon in accordance with the following requirements:

(1)On all such policies actually written there shall be maintained an unearned gross premium reserve which reserve may be computed on a pro rata basis or such reserve may be computed at not less than fifty percent of the gross premiums in force;

(2)On all such policies written on a noncancellable plan and under the terms of which the company is obligated to renew or continue for a stated period, or to a stated age or for life, there shall be maintained active life reserves and reserves for losses in amounts not less than such minimum standards which the director of the department of insurance, financial institutions and professional registration shall determine and prescribe after giving proper consideration to the terms and conditions of the policies involved;

(3) On all such policies other than those written on a noncancellable plan there shall be maintained reserves for losses in amounts not less than the minimum standards which the director of the department of insurance, financial institutions and professional registration shall determine and prescribe after giving proper consideration to the terms and conditions of the policies involved;

(4)In the calculation of reserves required to be maintained under this section, proper credit shall be allowed for reinsurance in other companies licensed to do business in this state;

(5)In addition to the minimum reserves mentioned above the director of the department of insurance, financial institutions and professional registration may also require such companies to maintain reserves for extraordinary losses in amounts not less than such minimum standards which the director of the department of insurance, financial institutions and professional registration shall determine and prescribe after giving proper consideration to the terms and conditions of the policies involved;

(6)This section shall not be applicable to total and permanent disability benefits, or to accidental death benefits, contained in or supplementary to life insurance policies or other contracts and for which benefits the standard of valuation is prescribed by section 376.380.

(L. 1945 p. 1000 § 6077a)

376.510 - Penalty for violation of section 376.500.

Any life insurance company or association which may violate any of the provisions of section 376.500 or which may permit any of its agents or representatives in this state to violate said provisions, shall have its certificate of authority, or license to transact business in Missouri, revoked by the state director of the department of insurance, financial institutions and professional registration, and shall be, for a period of five years, barred from the further transaction of business in this state; and any agent, solicitor or representative in this state of any such insurance company or association, who shall violate any of the provisions of section 376.500, shall be deemed guilty of a misdemeanor, and on conviction thereof, in any court of competent jurisdiction in this state, shall be fined not less than fifty nor more than five hundred dollars for each such offense, or imprisoned in the county or city jail, for not less than thirty days nor more than six months, or by both such fine and imprisonment.

(RSMo 1939 § 5841)

Prior revisions: 1929 § 5730; 1919 § 6140; 1909 § 6935

376.710 - Effect of omission.

Deliberate failure of an insurer to provide or deliver a buyer's guide, or a policy summary as provided in section 376.706 shall constitute an omission which misrepresents the benefits, advantages, conditions or terms of an insurance policy, and an agent's license may be revoked or suspended by the administrative hearing commission for such an omission.

(L. 1979 H.B. 508 § 6)

376.610 - Defense in case of suits.

In suits brought upon life policies, heretofore or hereafter issued, no defense based upon misrepresentation in obtaining or securing the same shall be valid, unless the defendant shall, at or before the trial, deposit in court for the benefit of the plaintiffs, the premiums received on such policies.

(RSMo 1939 § 5846)

Prior revisions: 1929 § 5735; 1919 § 6145; 1909 § 6940

(1952) Where plaintiff in equitable action to cancel policy on ground of misrepresentation as to health of deceased, deposited check in excess of amount of premiums paid with circuit clerk, and objection to failure to make deposit in cash was first made in motion for new trial, such failure did not preclude assertion of misrepresentation in equitable action. Reliable Ins. Co. v. Bell (A.), 246 S.W.2d 371.

(1960) This section does not apply to stipulated premium plan policies. Randall v. Western Life Ins. Co. (A.), 336 S.W.2d 125.

376.210 - Excess deposits.

Whenever the aggregate market value of the securities deposited by any company shall exceed the net reserve liability of the company on all of its registered policies and annuity bonds, the excess may be returned to the company, or, whenever the liability of such company on such policies shall cease, the director of the department of insurance, financial institutions and professional registration shall return the securities deposited.

(RSMo 1939 § 5819)

376.845 - Definitions — eating disorders, coverage for diagnosis and treatment of — limitations on coverage.

1.For the purposes of this section the following terms shall mean:

(1)"Eating disorder", pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association where diagnosed by a licensed physician, psychiatrist, psychologist, clinical social worker, licensed marital and family therapist, or professional counselor duly licensed in the state where he or she practices and acting within their applicable scope of practice in the state where he or she practices;

(2)"Health benefit plan", shall have the same meaning as such term is defined in section 376.1350; however, for purposes of this section "health benefit plan" does not include a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy;

(3)"Health carrier", shall have the same meaning as such term is defined in section 376.1350;

(4)"Medical care", health care services needed to diagnose, prevent, treat, cure, or relieve physical manifestations of an eating disorder, and shall include inpatient hospitalization, partial hospitalization, residential care, intensive outpatient treatment, follow-up outpatient care, and counseling;

(5)"Pharmacy care", medications prescribed by a licensed physician for an eating disorder and includes any health-related services deemed medically necessary to determine the need or effectiveness of the medications, but only to the extent that such medications are included in the insured's health benefit plan;

(6)"Psychiatric care" and "psychological care", direct or consultative services provided during inpatient hospitalization, partial hospitalization, residential care, intensive outpatient treatment, follow-up outpatient care, and counseling provided by a psychiatrist or psychologist licensed in the state of practice;

(7)"Therapy", medical care and behavioral interventions provided by a duly licensed physician, psychiatrist, psychologist, professional counselor, licensed clinical social worker, or family marriage therapist where said person is licensed or registered in the states where he or she practices;

(8)"Treatment of eating disorders", therapy provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or licensed marital and family therapist pursuant to the powers granted under such licensed physician's, psychiatrist's, psychologist's, professional counselor's, clinical social worker's, or licensed marital and family therapist's license in the state where he or she practices for an individual diagnosed with an eating disorder.

2.In accordance with the provisions of section 376.1550, all health benefit plans that are delivered, issued for delivery, continued or renewed on or after January 1, 2017, if written inside the state of Missouri, or written outside the state of Missouri but covering Missouri residents, shall provide coverage for the diagnosis and treatment of eating disorders as required in section 376.1550.

3.Coverage provided under this section is limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or licensed marital and family therapist pursuant to the powers granted under such licensed physician's, psychiatrist's, psychologist's, professional counselor's, clinical social worker's, or licensed marital and family therapist's license and acting within their applicable scope of coverage, in accordance with a treatment plan.

4.The treatment plan, upon request by the health benefit plan or health carrier, shall include all elements necessary for the health benefit plan or health carrier to pay claims.Such elements include, but are not limited to, a diagnosis, proposed treatment by type, frequency and duration of treatment, and goals.

5.Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract or benefit plan not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.Medical necessity determinations and care management for the treatment of eating disorders shall consider the overall medical and mental health needs of the individual with an eating disorder, shall not be based solely on weight, and shall take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association in addition to current standards based upon the medical literature generally recognized as authoritative in the medical community.

(L. 2015 S.B. 145)

376.945 - Escrow account, amount required — principal, how released, investment.

The department shall, as a condition of the issuance of a certificate of authority pursuant to section 376.935, require that the provider establish a reserve of an amount equal to at least fifty percent of any entrance fee paid by the first occupant of a living unit under a life care contract.The reserve shall be maintained by the provider on a current basis, in escrow with a bank, trust company, or other escrow agent approved by the department.Such reserve shall be amortized and earned by the provider at the rate of one percent per month on the balance of the reserve, provided, however, that at no time shall the entrance fee reserve together with all interest earned thereon total less than an amount equal to one and one-half times the percentage of the annual long-term debt principal and interest payments of the provider applicable only to living units occupied under life care contracts.Such portion of each entrance fee as is necessary to maintain the entrance fee reserve as set forth herein shall be paid to the reserve fund for the second and all subsequent occupancies of a living unit occupied under a life care contract.In addition, each provider shall establish and maintain separately for each facility, a reserve equal to not less than five percent of the facility's total outstanding balance of contractually obligated move-out refunds at the close of each fiscal year.All reserves required hereunder for move-out refunds shall be held in liquid assets consisting of federal government or other marketable securities, deposits, or accounts insured by the federal government.This section shall be applicable only to life care contracts executed for occupancy of living units constructed after September 28, 1981.

(L. 1981 S.B. 84 § 7, A.L. 1988 H.B. 1709)

376.310 - Investment of surplus and reserve funds by foreign companies.

Any life insurance company organized under the laws of another state, and admitted to do business in the state of Missouri, shall have power to invest its capital, reserve and surplus funds in the same manner, to the same extent and in the same investments as are permitted to domestic life insurance companies organized under the laws of this state; provided, that nothing herein contained shall be so construed as to prohibit any such foreign company from investing its capital, reserve and surplus funds as permitted by its charter and the laws of its domiciliary state.

(L. 1945 p. 1012 § 6032A)

376.714 - Contents and form of buyer's guide.

The life insurance buyer's guide shall consist of the following:

(1)The face page of the buyer's guide shall read as follows:

LIFE INSURANCE BUYER'S GUIDE
This guide can show you how to save money when you shop for life insurance. It helps you to:
-Decide how much life insurance you should buy,
-Decide what kind of life insurance policy you need, and
-Compare the cost of similar life insurance policies.
Prepared by the National Association of Insurance Commissioners
Reprinted by (company name)
(month and year of printing)

(2)The buyer's guide shall contain the following language at the bottom of page 2:

The National Association of Insurance Commissioners is an association of state insurance regulatory officials. This association helps the various Insurance Departments to coordinate insurance laws for the benefit of all consumers. You are urged to use this Guide in making a life insurance purchase.
This Guide Does Not Endorse Any Company or Policy.

(3)The remaining text of the Buyer's Guide shall begin on page 3 as follows:

BUYING LIFE INSURANCE
When you buy life insurance, you want a policy which fits your needs without costing too much. Your first step is to decide how much you need, how much you can afford to pay and the kind of policy you want. Then, find out what various companies charge for that kind of policy. You can find important differences in the cost of life insurance by using the life insurance cost indexes which are described in this guide. A good life insurance agent or company will be able and willing to help you with each of these shopping steps.
If you are going to make a good choice when you buy life insurance, you need to understand which kinds are available. If one kind does not seem to fit your needs, ask about the other kinds which are described in this guide. If you feel that you need more information than is given here, you may want to check with a life insurance agent or company or books on life insurance in your public library.
CHOOSING THE AMOUNT
One way to decide how much life insurance you need is to figure how much cash and income your dependents would need if you were to die. You should think of life insurance as a source of cash needed for expenses of final illnesses, paying taxes, mortgages or other debts. It can also provide income for your family's living expenses, educational costs and other future expenses. Your new policy should come as close as you can afford to making up the difference between (1) what your dependents would have if you were to die now, and (2) what they would actually need.
CHOOSING THE RIGHT KIND
All life insurance policies agree to pay an amount of money if you die. But all policies are not the same. There are three basic kinds of life insurance.
1.Term insurance
2.Whole life insurance
3.Endowment insurance
Remember, no matter how fancy the policy title or sales presentation might appear, all life insurance policies contain one or more of the three basic kinds. If you are confused about a policy that sounds complicated, ask the agent or company if it combines more than one kind of life insurance. The following is a brief description of the three basic kinds:
Term Insurance
Term insurance is death protection for a "term" of one or more years. Death benefits will be paid only if you die within that term of years. Term insurance generally provides the largest immediate death protection for your premium dollar.
Some term insurance policies are "renewable" for one or more additional terms even if your health has changed. Each time you renew the policy for a new term, premiums will be higher. You should check the premiums at older ages and the length of time the policy can be continued.
Some term insurance policies are also "convertible". This means that before the end of the conversion period, you may trade the term policy for a whole life or endowment insurance policy even if you are not in good health. Premiums for the new policy will be higher than you have been paying for the term insurance.
Whole Life Insurance
Whole life insurance gives death protection for as long as you live. The most common type is called "straight life" or "ordinary life" insurance, for which you pay the same premiums for as long as you live. These premiums can be several times higher than you would pay initially for the same amount of term insurance. But they are smaller than the premiums you would eventually pay if you were to keep renewing a term insurance policy until your later years.
Some whole life policies let you pay premiums for a shorter period such as 20 years, or until age 65. Premiums for these policies are higher than for ordinary life insurance since the premium payments are squeezed into a shorter period.
Although you pay higher premiums, to begin with, for whole life insurance than for term insurance, whole life insurance policies develop "cash values" which you may have if you stop paying premiums. You can generally either take the cash, or use it to buy some continuing insurance protection. Technically speaking, these values are called "nonforfeiture benefits". This refers to benefits you do not lose (or "forfeit") when you stop paying premiums. The amount of these benefits depends on the kind of policy you have, its size, and how long you have owned it.
A policy with cash values may also be used as collateral for a loan. If you borrow from the life insurance company, the rate of interest is shown in your policy. Any money which you owe on a policy loan would be deducted from the benefits if you were to die, or from the cash value if you were to stop paying premiums.
Endowment Insurance
An endowment insurance policy pays a sum or income to you — the policyholder — if you live to a certain age. If you were to die before then, the death benefit would be paid to your beneficiary. Premiums and cash values for endowment insurance are higher than for the same amount of whole life insurance. Thus endowment insurance gives you the least amount of death protection for your premium dollar.
FINDING A LOW COST POLICY
After you have decided which kind of life insurance fits your needs, look for a good buy. Your chances of finding a good buy are better if you use two types of index numbers that have been developed to aid in shopping for life insurance. One is called the "Surrender Cost Index" and the other is the "Net Payment Cost Index". It will be worth your time to try to understand how these indexes are used, but in any event, use them only for comparing the relative costs of similar policies. LOOK FOR POLICIES WITH LOW COST INDEX NUMBERS.
What is Cost?
"Cost" is the difference between what you pay and what you get back. If you pay a premium for life insurance and get nothing back, your cost for the death protection is the premium. If you pay a premium and get something back later on, such as a cash value, your cost is smaller than the premium.
The cost of some policies can also be reduced by dividends; these are called "participating" policies. Companies may tell you what their current dividends are, but the size of future dividends is unknown today and cannot be guaranteed. Dividends actually paid are set each year by the company.
Some policies do not pay dividends. These are called "guaranteed cost" or "nonparticipating" policies. Every feature of a guaranteed cost policy is fixed so that you know in advance what your future cost will be.
The premiums and cash values of a participating policy are guaranteed, but the dividends are not. Premiums for participating policies are typically higher than for guaranteed cost policies, but the cost to you may be higher or lower, depending on the dividends actually paid.
What Are Cost Indexes?
In order to compare the cost of policies, you need to look at:
1.Premiums
2.Cash values
3.Dividends
Cost indexes use one or more of these factors to give you a convenient way to compare relative costs of similar policies. When you compare costs, an adjustment must be made to take into account that money is paid and received at different times. It is not enough to just add up the premiums you will pay and to subtract the cash values and dividends you expect to get back. These indexes take care of the arithmetic for you. Instead of having to add, subtract, multiply and divide many numbers yourself, you just compare the index numbers which you can get from life insurance agents and companies:
1. LIFE INSURANCE SURRENDER COST INDEX — This index is useful if you consider the level of the cash values to be of primary importance to you. It helps you compare costs if at some future point in time, such as 10 or 20 years, you were to surrender the policy and take its cash value.
2. LIFE INSURANCE NET PAYMENT COST INDEX — This index is useful if your main concern is the benefits that are to be paid at your death and if the level of cash values is of secondary importance to you. It helps you compare costs at some future point in time, such as 10 or 20 years, if you continue paying premiums on your policy and do not take its cash value.
* * *
There is another number called the Equivalent Level Annual Dividend. It shows the part dividends play in determining the cost index of a participating policy. Adding a policy's Equivalent Level Annual Dividend to its cost index allows you to compare total costs of similar policies before deducting dividends. However, if you make any cost comparisons of a participating policy with a nonparticipating policy, remember that the total cost of the participating policy will be reduced by dividends, but the cost of the nonparticipating policy will not change.
How Do I Use Cost Indexes?
The most important thing to remember when using cost indexes is that a policy with a small index number is generally a better buy than a comparable policy with a larger index number. The following rules are also important:
(1)Cost comparisons should only be made between similar plans of life insurance. Similar plans are those which provide essentially the same basic benefits and require premium payments for approximately the same period of time. The closer policies are to being identical, the more reliable the cost comparison will be.
(2)Compare index numbers only for the kind of policy, for your age and for the amount you intend to buy. Since no one company offers the lowest cost for all types of insurance at all ages and for all amounts of insurance, it is important that you get the indexes for the actual policy, age and amount which you intend to buy. Just because a "shopper's guide" tells you that one company's policy is a good buy for a particular age and amount, you should not assume that all of that company's policies are equally good buys.
(3)Small differences in index numbers could be offset by other policy features, or differences in the quality of service you may expect from the company or its agent. Therefore, when you find small differences in cost indexes, your choice should be based on something other than cost.
(4)In any event, you will need other information on which to base your purchase decision. Be sure you can afford the premiums, and that you understand its cash values, dividends and death benefits. You should also make a judgment on how well the life insurance company or agent will provide service in the future, to you as a policyholder.
(5)These life insurance cost indexes apply to new policies and should not be used to determine whether you should drop a policy you have already owned for awhile, in favor of a new one. If such a replacement is suggested, you should ask for information from the company which issued the old policy before you take action.
IMPORTANT THINGS TO REMEMBER — A SUMMARY
The first decision you must make when buying a life insurance policy is choosing a policy whose benefits and premiums most closely meet your needs and ability to pay. Next, find a policy which is also a relatively good buy. If you compare Surrender Cost Indexes and Net Payment Cost Indexes of similar competing policies, your chances of finding a relatively good buy will be better than if you do not shop. REMEMBER, LOOK FOR POLICIES WITH LOWER COST INDEX NUMBERS. A good life insurance agent can help you to choose the amount of life insurance and kind of policy you want and will give you cost indexes so that you can make cost comparisons of similar policies.
Don't buy life insurance unless you intend to stick with it. A policy which is a good buy when held for 20 years can be very costly if you quit during the early years of the policy. If you surrender such a policy during the first few years, you may get little or nothing back and much of your premium may have been used for company expenses.
Read your new policy carefully, and ask the agent or company for an explanation of anything you do not understand. Whatever you decide now, it is important to review your life insurance program every few years to keep up with changes in your income and responsibilities.

(L. 1979 H.B. 508 § 8)

376.110 - To be submitted to attorney general.

Whenever the corporators have filed the declaration required by section 376.050 and also proof of the publication therein required by the affidavit of the publisher of the newspaper in which the publication was made, his foreman or clerk, with the director, the director shall submit the declaration to the attorney general of this state for examination, and if he finds it is in accordance with the provisions of sections 376.010 to 376.670, and not inconsistent with the constitution and laws of this state, and of the United States, he shall so certify and deliver it back to the director.The director shall cause the said declaration and affidavit with the certificate of the attorney general, to be recorded in a book kept for that purpose and furnish a certified copy of the same to the corporators, and also file a certified copy of the same with the secretary of state, who, upon payment to the director of revenue of the sum of seventy-five dollars, shall issue a certificate of incorporation, upon the receipt of which they become a body politic and corporate, and may proceed to organize in the manner set forth in their charter, and to open books and receive proposals and agreements for assurance and premiums for the same on deposit, and issue receipts therefor, and to keep such books open until the whole amount specified in its charter is received.It is not lawful for such company to issue policies or transact any business of any kind, except as aforesaid, until it fully complies with the requirements of sections 376.120, 376.130 and 376.290.

(RSMo 1939 § 5809, A.L. 1957 p. 212)

Prior revisions: 1929 § 5699; 1919 § 6110; 1909 § 6904

376.818 - Eligibility for Medicaid may not be considered by insurers.

No individual or group insurance policy providing coverage on an expense-incurred basis, no individual or group service or indemnity contract issued by a not-for-profit health services corporation, no health maintenance organization nor any self-insured group health benefit plan of any type or description shall be offered, issued or renewed in this state by any insurer on or after July 1, 1994, if any insurer, including a group health plan, as defined in section 607(1) of the federal Employee Retirement Income Security Act of 1974, takes into account that an individual is eligible for or is provided medical assistance under Medicaid (Title XIX) when enrolling an individual or in making payment for benefits to the individual or on the individual's behalf.

(L. 1994 H.B. 1491 & 1134 merged with S.B. 508)

Effective 7-01-94

376.010 - Who may form company — purposes.

Any number of persons, not less than thirteen, may associate and form a company for the purpose of making insurance upon the lives of individuals, and every assurance pertaining thereto or connected therewith (including, for policies issued outside of the United States of America, insurance of nonlife risks that are attached as riders to policies insuring the lives of individuals; provided that the aggregate premium assumed on an annual basis pursuant to such nonlife risks does not exceed three percent of the capital and surplus of such company as of the thirty-first day of December of the preceding year), and to grant, purchase and dispose of annuities and endowments of every kind and description whatsoever, and to provide an indemnity against death, and for weekly or other periodic indemnity for disability occasioned by accident or sickness to the person of the insured; but such accident and health insurance shall be made a separate department of the business of the life insurance company undertaking it.

(RSMo 1939 § 5800, A.L. 2012 H.B. 1112)

Prior revisions: 1929 § 5690; 1919 § 6101; 1909 § 6895

376.910 - Certificate of authority required.

No provider shall engage in the business of providing continuing care in this state without a certificate of authority therefor obtained from the department as provided in sections 376.900 to 376.950.

(L. 1981 S.B. 84 § 3)

376.810 - Definitions for policy requirements for chemical dependency.

As used in sections 376.810 to 376.814, the following terms mean:

(1)"Chemical dependency", the psychological or physiological dependence upon and abuse of drugs, including alcohol, characterized by drug tolerance or withdrawal and impairment of social or occupational role functioning or both;

(2)"Community mental health center", a legal entity certified by the department of mental health or accredited by a nationally recognized organization, through which a comprehensive array of mental health services are provided to individuals;

(3)"Day program services", a structured, intensive day or evening treatment or partial hospitalization program, certified by the department of mental health or accredited by a nationally recognized organization;

(4)"Episode", a distinct course of chemical dependency treatment separated by at least thirty days without treatment;

(5)"Health insurance policy", all health insurance policies or contracts that are individually underwritten or provide such coverage for specific individuals and members of their families, which provide for hospital treatment.For the purposes of subsection 2 of section 376.811, "health insurance policy" shall also include any individually underwritten coverage issued by a health maintenance organization.The provisions of sections 376.810 to 376.814 shall not apply to policies which provide coverage for a specified disease only, other than for mental illness or chemical dependency;

(6)"Licensed professional", a licensed physician specializing in the treatment of mental illness, a licensed psychologist, a licensed clinical social worker or a licensed professional counselor.Only prescription rights under this act shall apply to medical physicians and doctors of osteopathy;

(7)"Managed care", the determination of availability of coverage under a health insurance policy through the use of clinical standards to determine the medical necessity of an admission or treatment, and the level and type of treatment, and appropriate setting for treatment, with required authorization on a prospective, concurrent or retrospective basis, sometimes involving case management;

(8)"Medical detoxification", hospital inpatient or residential medical care to ameliorate acute medical conditions associated with chemical dependency;

(9)"Nonresidential treatment program", a program certified by the department of mental health involving structured, intensive treatment in a nonresidential setting;

(10)"Recognized mental illness", those conditions classified as "mental disorders" in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, but shall not include intellectual disability;

(11)"Residential treatment program", a program certified by the department of mental health involving residential care and structured, intensive treatment;

(12)"Social setting detoxification", a program in a supportive nonhospital setting designed to achieve detoxification, without the use of drugs or other medical intervention, to establish a plan of treatment and provide for medical referral when necessary.

(L. 1991 S.B. 352 § 7 subsec. 1, A.L. 1997 H.B. 335, A.L. 1999 H.B. 191, A.L. 2004 H.B. 855, A.L. 2014 H.B. 1064)

376.441 - Carrier contract replaced by similar benefit plan of another carrier — liability of prior carrier — succeeding carrier coverage requirements.

When one carrier's contract replaces a plan of similar benefits of another carrier, the prior carrier remains liable only to the extent of its accrued liabilities and extensions of benefits.The position of the prior carrier shall be the same whether the group policyholder or other entity secures replacement coverage from a new carrier, self-insurer, or foregoes the provision of coverage.Each person who is eligible for coverage in accordance with the succeeding carrier's plan of benefits in respect of classes eligible and activity at work and nonconfinement rules shall be covered by that carrier's plan of benefits.Each person not so covered under the succeeding carrier's plan of benefits must nevertheless be covered by the succeeding carrier in accordance with the following provisions if such individual was validly covered, including benefit extension, under the prior plan on the date of discontinuance and if such individual is a member of the class or classes of individuals eligible for coverage under the succeeding carrier's plan.Any reference in the following provisions to an individual who was or was not totally disabled is a reference to the individual's status immediately prior to the date the succeeding carrier's coverage becomes effective:

(1)The minimum level of benefits to be provided by the succeeding carrier shall be the applicable level of benefits of the prior carrier's plan reduced by any benefits payable by the prior plan;

(2)Coverage must be provided by the succeeding carrier until at least the earliest of the following dates:

(a)The date the individual becomes eligible under the succeeding carrier's plan;

(b)For each type of coverage, the date the individual's coverage would terminate in accordance with the succeeding carrier's plan provisions applicable to individual termination of coverage, such as at the termination of employment or ceasing to be eligible dependent, as the case may be; or

(c)In the case of an individual who was totally disabled, and in the case of a type of coverage for which section 376.438 requires an extension of accrued liability, the end of any period of extension or accrued liability which is required of the prior carrier by section 376.438 or, if the prior carrier's policy or contract is not subject to that section, would have been required of that carrier had its policy or contract been subject to section 376.438 at the time the prior plan was discontinued and replaced by the succeeding carrier's plan;

(3)In the case of a preexisting conditions limitation included in the succeeding carrier's plan, the level of benefits applicable to preexisting conditions of persons becoming covered by the succeeding carrier's plan during the period of time this limitation applies under the new plan shall be the lesser of:

(a)The benefits of the new plan determined without application of the preexisting conditions limitation; and

(b)The benefits of the prior plan;

(4)The succeeding carrier, in applying any deductibles or waiting periods in its plan, shall give credit for the satisfaction or partial satisfaction of the same or similar provisions under a prior plan providing similar benefits.In the case of deductible provisions, the credit shall apply for the same or overlapping benefit periods and shall be given for expenses actually incurred and applied against the deductible provisions of the prior carrier's plan during the ninety days preceding the effective date of the succeeding carrier's plan but only to the extent these expenses are recognized under the terms of the succeeding carrier's plan and are subject to a similar deductible provision.For purposes of this subdivision, the deductible provisions in insurance policies and health services corporation contracts are deemed to be similar to co-payment provisions in health maintenance organization contracts;

(5)In any situation where a determination of the prior carrier's benefit is required by the succeeding carrier, at the succeeding carrier's request the prior carrier shall furnish a statement of the benefits available or pertinent information, sufficient to permit verification of the benefit determination or the determination itself by the succeeding carrier.For the purposes of this section, benefits of the prior plan will be determined in accordance with all of the definitions, conditions and covered expense provisions of the prior plan rather than those of the succeeding plan.The benefit determination will be made as if coverage had not been replaced by the succeeding carrier.

(L. 1985 H.B. 623 § 376.440, A.L. 1999 H.B. 903)

376.145 - Officers of stock company to continue as officers of mutual.

When a domestic stock life insurance corporation has become converted into a mutual life insurance corporation, the officers and directors or trustees of the original corporation shall remain as the officers and directors or trustees of the newly converted corporation until the next annual meeting for the election of officers and directors or trustees, when their successors shall be elected in the manner provided in the articles of incorporation and articles of agreement previously adopted by said corporation.

(L. 1957 p. 224 § 5)

376.2052 - Comparison of in-force policies to death master file — violation deemed an unfair trade practice.

1.An insurer shall perform a comparison of its in-force life insurance policies, contracts, and retained asset accounts against a death master file on at least a semiannual basis by using the full death master file one time and thereafter using the death master file update files for future comparisons to identify potential matches.Nothing in this section shall limit an insurer from requesting a valid death certificate as part of any claims validation process.For those potential matches identified as a result of a death master file match, the insurer shall, within ninety days of a death master file match:

(1)Complete a good-faith effort, which shall be documented by the insurer, to confirm the death of the insured, annuitant, or retained asset account holder against other available records and information; and

(2)Use good-faith efforts to determine whether benefits are due in accordance with the applicable policy or contract and, if benefits are due in accordance with the applicable policy or contract:

(a)Use good-faith efforts, which shall be documented by the insurer, to locate the beneficiary or beneficiaries; and

(b)Provide the appropriate claims forms or instructions to each beneficiary or beneficiaries to make a claim, including the need to provide an official death certificate if applicable under the policy or contract.

2.To the extent that an insurer's records of its in-force policies, contracts, and account owners are available electronically, an insurer shall perform the comparison required by subsection 1 of this section using such electronic records.To the extent that an insurer's records of its in-force policies, contracts, and account owners are not available electronically, an insurer shall perform the comparison required by subsection 1 of this section using the records most easily accessible by the insurer.

3.In the event an insurer is unable to confirm the death of a person following a death master file match and completion of the good-faith efforts described in subsection 1 of this section, an insurer may consider such policy, contract, or retired asset account to be in force according to its terms.

4.With respect to group life insurance, the insurer is required to confirm the possible death of an insured or certificate holder only if the insurer has agreed to provide record-keeping services.

5.To the extent permitted by law, the insurer may disclose the minimum necessary personal information about the insured or beneficiary to a person whom the insurer reasonably believes may be able to assist the insurer to locate the beneficiary or a person otherwise entitled to payment of the claims proceeds.

6.An insurer or its service provider shall not charge any beneficiary or other authorized representative for any fees or costs associated with a death master file search or verification of a death master file match conducted in accordance with this section.

7.The benefits from a policy, contract, or retained asset account, plus any applicable accrued contractual interest, shall first be payable to the designated beneficiaries or owners, or in the event such beneficiaries or owners cannot be found shall escheat to the state as unclaimed property under section 447.510.

8.The director may promulgate rules and regulations as may be reasonably necessary to implement the provisions of sections 376.2050 to 376.2053.Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2016, shall be invalid and void.

9.The failure to meet any requirements of sections 376.2050 to 376.2053 with such frequency as to constitute a general business practice shall constitute an unfair trade practice under the provisions of sections 375.930 to 375.948.Nothing in sections 376.2050 to 376.2053 shall be construed to create or imply a private cause of action for a violation of sections 376.2050 to 376.2053.

10.Nothing in sections 376.2050 to 376.2053 limits an insurer from requiring compliance with the terms and conditions of the policy or contract relative to filing and payment of claims.

11.The director may exempt an insurer from the comparison required by subsection 1 of this section if the insurer demonstrates to the director's satisfaction that compliance would result in undue hardship to the insurer.

(L. 2016 H.B. 2150)

376.718 - Definitions.

As used in sections 376.715 to 376.758, the following terms shall mean:

(1)"Account", any of the accounts created under section 376.720;

(2)"Association", the Missouri life and health insurance guaranty association created under section 376.720;

(3)"Benefit plan", a specific employee, union, or association of natural persons benefit plan;

(4)"Contractual obligation", any obligation under a policy or contract or certificate under a group policy or contract, or portion thereof for which coverage is provided under the provisions of section 376.717;

(5)"Covered contract" or "covered policy", any policy or contract or portion of a policy or contract for which coverage is provided under the provisions of section 376.717;

(6)"Director", the director of the department of insurance, financial institutions and professional registration of this state;

(7)"Extra-contractual claims", includes but is not limited to claims relating to bad faith in the payment of claims, punitive or exemplary damages, or attorneys fees and costs;

(8)"Health benefit plan", any hospital or medical expense policy or certificate, health maintenance organization subscriber contract, or any other similar health contract.Health benefit plan does not include:

(a)Accident-only insurance;

(b)Credit insurance;

(c)Dental-only insurance;

(d)Vision-only insurance;

(e)Medicare supplement insurance;

(f)Benefits for long-term care, home health care, community-based care, or any combination thereof;

(g)Disability income insurance;

(h)Coverage for on-site medical clinics; or

(i)Specified disease, hospital confinement indemnity, or limited benefit health insurance if the types of coverage do not provide coordination of benefits and are provided under separate policies or certificates;

(9)"Impaired insurer", a member insurer which, after August 13, 1988, is not an insolvent insurer, and is placed under an order of rehabilitation or conservation by a court of competent jurisdiction;

(10)"Insolvent insurer", a member insurer which, after August 13, 1988, is placed under an order of liquidation by a court of competent jurisdiction with a finding of insolvency;

(11)"Member insurer", any insurer, health maintenance organization, or health services corporation licensed or which holds a certificate of authority to transact in this state any kind of insurance or health maintenance organization business for which coverage is provided under section 376.717, and includes any insurer or health maintenance organization whose license or certificate of authority in this state may have been suspended, revoked, not renewed or voluntarily withdrawn, but does not include:

(a)A fraternal benefit society;

(b)A mandatory state pooling plan;

(c)A mutual assessment company or any entity that operates on an assessment basis;

(d)An insurance exchange;

(e)An organization that issues qualified charitable gift annuities, as defined in section 352.500, and does not hold a certificate or license to transact insurance business; or

(f)Any entity similar to any of the entities listed in paragraphs (a) to (e) of this subdivision;

(12)"Moody's Corporate Bond Yield Average", the monthly average corporates as published by Moody's Investors Service, Inc., or any successor thereto;

(13)"Owner", "policyholder", "policy owner", or "contract owner", the person who is identified as the legal owner under the terms of the policy or contract or who is otherwise vested with legal title to the policy or contract through a valid assignment completed in accordance with the terms of the policy or contract and properly recorded as the owner on the books of the member insurer.Owner, contract owner, policyholder, and policy owner shall not include persons with a mere beneficial interest in a policy or contract;

(14)"Person", any individual, corporation, partnership, association or voluntary organization;

(15)"Premiums", amounts received on covered policies or contracts, less premiums, considerations and deposits returned thereon, and less dividends and experience credits thereon.The term does not include any amounts received for any policies or contracts or for the portions of any policies or contracts for which coverage is not provided under subsection 3 of section 376.717, except that assessable premium shall not be reduced on account of subdivision (3) of subsection 3 of section 376.717 relating to interest limitations and subdivision (2) of subsection 4 of section 376.717 relating to limitations with respect to any one life, any one participant, and any one policy or contract holder.Premiums shall not include:

(a)Premiums on an unallocated annuity contract; or

(b)With respect to multiple nongroup policies of life insurance owned by one owner, whether the policy or contract owner is an individual, firm, corporation, or other person, and whether the persons insured are officers, managers, employees, or other persons, premiums in excess of five million dollars with respect to such policies or contracts, regardless of the number of policies or contracts held by the owner;

(16)"Principal place of business", for a person other than a natural person, the single state in which the natural persons who establish policy for the direction, control, and coordination of the operations of the entity as a whole primarily exercise that function, determined by the association in its reasonable judgment by considering the following factors:

(a)The state in which the primary executive and administrative headquarters of the entity is located;

(b)The state in which the principal office of the chief executive officer of the entity is located;

(c)The state in which the board of directors, or similar governing person or persons, of the entity conducts the majority of its meetings;

(d)The state in which the executive or management committee of the board of directors, or similar governing person or persons, of the entity conducts the majority of its meetings; and

(e)The state from which the management of the overall operations of the entity is directed;

(17)"Receivership court", the court in the insolvent or impaired insurer's state having jurisdiction over the conservation, rehabilitation, or liquidation of the insurer;

(18)"Resident", any person who resides in this state on the date of entry of a court order that determines a member insurer to be an impaired insurer or a court order that determines a member insurer to be an insolvent insurer, whichever first occurs, and to whom a contractual obligation is owed.A person may be a resident of only one state, which in the case of a person other than a natural person shall be its principal place of business.Citizens of the United States that are either residents of foreign countries or residents of the United States' possessions, territories, or protectorates that do not have an association similar to the association created under sections 376.715 to 376.758 shall be deemed residents of the state of domicile of the member insurer that issued the policies or contracts;

(19)"State", a state, the District of Columbia, Puerto Rico, and a United States possession, territory, or protectorate;

(20)"Structure settlement annuity", an annuity purchased in order to fund periodic payments for a plaintiff or other claimant in payment for or with respect to personal injury suffered by the plaintiff or other claimant;

(21)"Supplemental contract", any written agreement entered into for the distribution of proceeds under a life, health, or annuity policy or contract;

(22)"Unallocated annuity contract", any annuity contract or group annuity certificate which is not issued to and owned by an individual, except to the extent of any annuity benefits guaranteed to an individual by an insurer under such contract or certificate.

(L. 1988 S.B. 430 § 4, A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

376.1017 - Plan to establish loss reserves — plan to establish surplus account, amount.

1.A plan shall establish loss reserves for all incurred losses, both reported and unreported, and for unearned premiums.

2.A plan also shall establish a surplus account equal to the greater of the following:

(1)Three times the average paid monthly premium during the plan's most recent fund year;

(2)For plans which do not yet have one fund year's experience, three times estimated monthly premium; or

(3)Six hundred thousand dollars.

(L. 1993 H.B. 709 § 29)

376.814 - Rules and regulations authorized, department of mental health to advise department — procedure.

1.The department of insurance, financial institutions and professional registration shall promulgate rules and regulations, pursuant to section 376.982 and chapter 536, and the department of mental health shall advise the department of insurance, financial institutions and professional registration on the promulgation of said rules and regulations as they pertain to the development and implementation of all standards and guidelines for managed care as set out in sections 376.810 to 376.814, to ensure that all mental health services provided pursuant to sections 376.810 to 376.814 are provided in accordance with chapters 197, 334, 337, and section 630.655, provided however, that nothing in this act* shall prohibit department of mental health licensed or certified facilities or programs from using qualified mental health professionals or other specialty staff persons.

2.Any person who serves or served on a quality assessment and assurance committee required under 42 U.S.C. Sec. 1396r(b)(1)(B) and 42 CFR Sec.483.75(r), or as amended, shall be immune from civil liability only for acts done directly as a member of such committee so long as the acts are performed in good faith, without malice and are required by the activities of such committee as defined in 42 CFR Sec. 483.75(r).

(L. 1991 S.B. 352 § 7 subsecs. 5, 6, 7, A.L. 1993 S.B. 52)

*"This act" (S.B. 351, 1991) contained numerous sections. Consult Disposition of Sections table for a definitive listing.

376.745 - Assessments, offset against tax liability, when, how.

1.A member insurer may offset against its premium tax liability to this state an assessment described in section 376.738 to the extent of twenty percent of the amount of such assessment for each of the five calendar years following the year in which such assessment was paid.In the event a member insurer should cease doing business, all uncredited assessments may be credited against its premium tax liability for the year it ceases doing business.

2.A member insurer exempt from chapter 148 may offset against its sales or use tax liability to this state an assessment described in section 376.738 to the extent of twenty percent of the amount of such assessment for each of the five calendar years following the year in which such assessment was paid.In the event a member insurer should cease doing business, all uncredited assessments may be credited against its sales or use tax liability for the year it ceases doing business.

3.Any sums which are acquired by refund, pursuant to the provisions of section 376.738, from the association by member insurers, and which have theretofore been offset against premium taxes as provided in subsection 1 of this section or have theretofore been offset against sales or use taxes as provided in subsection 2 of this section, shall be paid by such insurers to this state in such manner as the tax authorities may require.The association shall notify the director that such refunds have been made.

(L. 1988 S.B. 430 § 26)

376.819 - MO HealthNet division to have right to payment for health care services provided.

To the extent that payment has been made by the MO HealthNet division for health care items or services furnished to a Medicaid-eligible individual, the MO HealthNet division is considered to have acquired the rights of the Medicaid-eligible individual to payment by any insurer or other party obligated to cover such health care items or services.

(L. 1994 H.B. 1491 & 1134 merged with S.B. 508, A.L. 2014 H.B. 1299 Revision)

CROSS REFERENCE:

Subrogation rights of department of social services, liens, recovery of medical expenses, 208.215

376.748 - Liquidation, recovery of distributions, when, exceptions, limitations.

1.If an order for liquidation or rehabilitation of a member insurer domiciled in this state has been entered, the receiver appointed under such order shall have a right to recover on behalf of the member insurer, from any affiliate that controlled it, the amount of distributions, other than stock dividends paid by the member insurer on its capital stock, made at any time during the five years preceding the petition for liquidation or rehabilitation subject to the limitations of subsections 2 to* 4 of this section.

2.No such distribution shall be recoverable if the member insurer shows that when paid the distribution was lawful and reasonable, and that the member insurer did not know and could not reasonably have known that the distribution might adversely affect the ability of the member insurer to fulfill its contractual obligations.

3.Any person who was an affiliate that controlled the member insurer at the time the distributions were paid shall be liable up to the amount of distributions he received.Any person who was an affiliate that controlled the member insurer at the time the distributions were declared shall be liable up to the amount of distributions he would have received if they had been paid immediately.If two or more persons are liable with respect to the same distributions, they shall be jointly and severally liable.

4.The maximum amount recoverable under this section shall be the amount needed in excess of all other available assets of the insolvent insurer to pay the contractual obligations of the insolvent insurer.

5.If any person liable under subsection 3 of this section is insolvent, all its affiliates that controlled it at the time the distribution was paid shall be jointly and severally liable for any resulting deficiency in the amount recovered from the insolvent affiliate.

(L. 1988 S.B. 430 § 29, A.L. 2018 H.B. 1690)

*Word "through" appears in original rolls.

376.2006 - Term of licensure — renewal — continuing education.

1.A navigator license shall be valid for two years.

2.A navigator may file an application for renewal of a license and pay the renewal fee as prescribed by the director.Any navigator who fails to timely file for license renewal shall be charged a late fee in an amount prescribed by the director.

3.Prior to the filing date for an application for renewal of a license, an individual licensee shall comply with any ongoing training and continuing education requirements established by the director.Such navigator shall file with the director, by a method prescribed by the director, proof of satisfactory certification of completion of the continuing education requirements.Any failure to fulfill the ongoing training and continuing education requirements shall result in the expiration of the license.

(L. 2013 S.B. 262)

Effective 7-12-13

376.311 - Investment of capital reserve and surplus of life insurance companies in investment pools — definitions — qualifications — requirements.

1.In addition to the investments permitted by other provisions of the laws, the capital reserve and surplus of all life insurance companies of whatever kind and character, organized or doing business pursuant to this chapter, may be invested in an investment pool meeting the requirements set out below, and any other provision of law relating to investments made by life insurance companies.

2.As used in this section, the following terms mean:

(1)"Business entity", a corporation, limited liability company, association, partnership, joint stock company, joint venture, mutual fund trust, or other similar form of business organization, including such an entity when organized as a not-for-profit entity;

(2)"Qualified bank", a national bank, state bank or trust company that at all times is no less than adequately capitalized as determined by the standards adopted by the United States banking regulators and that is either regulated by state banking laws or is a member of the Federal Reserve System.

3.(1)Qualified investment pools shall invest only in investments which an insurer may acquire pursuant to this chapter and other provisions of law.The insurer's proportionate interest in these investments may not exceed the applicable limits of this section and other provisions of law.

(2)An insurer shall not acquire an investment in an investment pool pursuant to this subsection if, after giving effect to the investment, the aggregate amount of investments in all investment pools then held by the insurer would exceed thirty percent of its assets.

(3)For an investment in an investment pool to be qualified pursuant to this chapter, the investment pool shall not:

(a)Acquire securities issued, assumed, guaranteed or insured by the insurer or an affiliate of the insurer;

(b)Borrow or incur any indebtedness for borrowed money, except for securities lending and reverse repurchase transactions;

(c)Lend money or other assets to participants in the pool.

(4)For an investment pool to be qualified pursuant to this chapter, the manager of the investment pool shall:

(a)Be organized pursuant to the laws of the United States or a state and designated as the pool manager in a pooling agreement;

(b)Be the insurer; an affiliated insurer; a business entity affiliated with the insurer; a qualified bank; a business entity registered pursuant to the Investment Advisors Act of 1940 (15 U.S.C. Sec. 80a-1 et seq.) as amended; or, in the case of a reciprocal insurer or interinsurance exchange, its attorney-in-fact.

(5)The pool manager, or an agent designated by the pool manager, shall compile and maintain detailed accounting records setting forth:

(a)The cash receipts and disbursements reflecting each participant's proportionate investment in the investment pool;

(b)A complete description of all underlying assets of the investment pool including amount, interest rate, maturity date (if any) and other appropriate designations; and

(c)Other records which, on a daily basis, allow third parties to verify each participant's investments in the investment pool.

(6)The pool manager shall maintain the assets of the investment pool in one or more custody accounts, in the name of or on behalf of the investment pool, under one or more custody agreements with a qualified bank.Each custody agreement shall:

(a)State and recognize the claims and rights of each participant;

(b)Acknowledge that the underlying assets of the investment pool are held solely for the benefit of each participant in proportion to the aggregate amount of its investments in the investment pool; and

(c)Contain an agreement that the underlying assets of the investment pool shall not be commingled with the general assets of the qualified bank or any other person.

(7)The pooling agreement for each investment pool shall be in writing and shall provide that:

(a)An insurer and its affiliates shall, at all times, hold one hundred percent of the interests in the investment pool;

(b)The underlying assets of the investment pool shall not be commingled with the general assets of the pool manager or any other person;

(c)The aggregate amount of each pool participant's interest in the investment pool shall be in proportion to:

a.Each participant's undivided interest in the underlying assets of the investment pool; and

b.The underlying assets of the investment pool held solely for the benefit of each participant;

(d)A participant or, in the event of the participant's insolvency, bankruptcy or receivership, its trustee, receiver, conservator or other successor-in-interest may withdraw all or any portion of its investment from the investment pool under the terms of the pooling agreement;

(e)Withdrawals may be made on demand without penalty or other assessment on any business day, but settlement of funds shall occur within a reasonable and customary period thereafter, provided:

a.In the case of publicly traded securities, settlement shall not exceed five business days; and

b.In the case of all other securities and investments, settlement shall not exceed ten business days.

Distributions pursuant to this paragraph shall be calculated in each case net of all then applicable fees and expenses of the investment pool.

(8)The pooling agreement shall provide that the pool manager shall distribute to a participant, at the discretion of the pool manager:

(a)In cash, the then fair market value of the participant's pro rata share of each underlying asset of the investment pool; or

(b)In-kind, a pro rata share of each underlying asset; or

(c)In a combination of cash and in-kind distributions, a pro rata share in each underlying asset;

(9)The pool manager shall make the records of the investment pool available for inspection by the director.

4.The pooling agreement and any other arrangements or agreements relating to an investment pool, and any amendments thereto, shall be submitted to the department of insurance, financial institutions and professional registration for prior approval pursuant to section 382.195.Individual financial transactions between the pool and its participants in the ordinary course of the investment pool's operations shall not be subject to the provisions of section 382.195. Investment activities of pools and transactions between pools and participants shall be reported annually in the registration statement required by section 382.100.

(L. 1997 H.B. 793, A.L. 2002 H.B. 1568 merged with S.B. 1009)

376.715 - Citation of law, purpose.

1.Sections 376.715 to 376.758 shall be known and may be cited as the "Missouri Life and Health Insurance Guaranty Association Act".

2.The purpose of sections 376.715 to 376.758 is to protect, subject to certain limitations, the persons specified in subsection 1 of section 376.717 against failure in the performance of contractual obligations, under life, health, and annuity policies, plans, or contracts specified in subsection 2 of section 376.717, because of the impairment or insolvency of the member insurer that issued the policies or contracts.

3.To provide this protection, an association of member insurers is created to pay benefits and to continue coverages as limited herein, and members of the association are subject to assessment to provide funds to carry out the purpose of sections 376.715 to 376.758.

(L. 1988 S.B. 430 §§ 1, 2, A.L. 2018 H.B. 1690)

376.940 - Escrow account for entrance fees required, released when.

1.As a condition for the issuance of a certificate of authority pursuant to section 376.935, the department shall require that the provider establish an escrow account with a licensed agent which provides that all of any entrance fee received by the provider prior to the date the resident is permitted to occupy his or her living unit in the facility be placed in escrow with a bank, trust company or other escrow agent approved by the department subject to the condition that such funds may be released only as follows:

(1)If the entrance fee applies to a living unit which has been previously occupied in the facility, the entrance fee shall be released to the provider at such time as the living unit becomes available for occupancy by the new resident;

(2)If the entrance fee applies to a living unit which has not previously been occupied by any resident, the entrance fee, or that portion of the entrance fee not to be held in escrow pursuant to section 376.945, shall be released to the provider at such time as the department is satisfied that all of the following conditions exist:

(a)If construction or purchase of the facility has been substantially completed, an occupancy permit covering the living unit has been issued by the local government having authority to issue such permits; or, if construction of the facility has not been substantially completed, then:

a.All governmental permits or approvals necessary prior to the commencement of construction have been obtained;

b.A maximum price contract has been entered into between the provider and a general contractor responsible for construction of the facility, and a bond covering the faithful performance of the construction contract by the general contractor and the payment of all obligations arising thereunder has been executed by a recognized surety authorized to do business in this state in favor of the provider;

c.A loan agreement has been entered into by the provider for an interim construction loan in the amount which, when combined with the amount of entrance fees then held in escrow under the provisions of this section plus the amount of funds from other sources then in the actual possession of the provider, will equal or exceed the estimated cost of constructing, equipping, and furnishing the facility, and not less than ten percent of the amount of such construction loan has been disbursed by the lender for physical construction or site preparation work completed; and

d.Orders at firm prices have been placed by the provider for not less than fifty percent in value, including installation charges if applicable, of items necessary for equipping and furnishing the facility in accordance with the description set forth in the annual statement required by sections 376.915 to 376.930.

(b)A commitment has been received by the provider for any permanent mortgage loan or other long-term financing described in the statement of anticipated source and application of funds submitted by the provider as part of its application for certificate of authority, and any conditions of the commitment prior to disbursement of funds thereunder have been substantially satisfied;

(c)Aggregate entrance fees received or receivable by the provider pursuant to binding life care contracts, plus the anticipated proceeds of any first mortgage loan or other long-term financing commitment are equal to not less than ninety percent of the aggregate cost of constructing or purchasing, equipping, and furnishing the facility plus not less than ninety percent of the funds estimated in the statement of anticipated source and application of funds submitted by the provider as part of its application for certificate of authority, to be necessary to fund start-up losses and assure full performance of the obligations of the provider pursuant to life care contracts.

2.If an entrance fee placed in an escrow account required to be established pursuant to subsection 1 of this section is not released in accordance with subsection 1 within a period of thirty-six months or such greater time as may have been specified by the provider with the consent of the department, or any extensions thereof approved by the department in writing, then such fee shall be returned by the escrow agent to whoever had made payment thereof to the provider.

3.An entrance fee held in escrow may be returned by the escrow agent to the person or persons who had made payment to the provider at any time upon receipt by the escrow agent of notice from the provider that such person is entitled to a refund of the entrance fee.

4.Nothing in this section shall be interpreted as requiring the escrow of any nonrefundable application fee, designated as such in the annual statement required by sections 376.915 to 376.930, received by the provider from a prospective resident.

5.This section shall be applicable only to life care contracts executed after September 28, 1981.

(L. 1981 S.B. 84 § 6)

376.148 - Policyholders are members of mutual — voting rights — directors may alter articles — additional assessments prohibited.

1.The articles of agreement of any mutual life insurance corporation shall provide that each policyholder of the corporation shall be a member of the corporation.

2.As used in this section, "policyholder" means the person insured under an individual policy of life insurance, and the person to whom any annuity or pure endowment is presently or prospectively payable by the terms of an individual annuity or pure endowment contract, except where the policy or contract declares some other person to be the owner or holder thereof, in which case such owner or policyholder shall be deemed the policyholder, and except in cases of assignment.In the case of any individual policy or contract insuring two or more persons jointly or in case the policy or contract declares two or more persons to be the owner, the persons insured or declared to be the owner are considered as one policyholder.In case any such policy or contract has been assigned by an assignment absolute on its face to an assignee other than the corporation and such assignment is filed at the principal office of the corporation, then such assignee shall be deemed a policyholder, but for the purpose of determining voting rights such assignment is not effective until thirty days after it has been filed with the corporation.Except as provided in this section an assignee of a policy or contract shall not be deemed a policyholder.

3.The articles of agreement shall provide that each policyholder who is insured in the sum of at least one thousand dollars, or who is the holder of an annuity which at normal date of maturity requires the payment of one hundred dollars or more annually, and whose insurance or contract of annuity is then in force and has been in force for at least one year prior to a policyholders' meeting, shall be entitled to only one vote, irrespective of the number of policies or contracts held by him or their amount.

4.The power to make, alter, amend, or repeal the articles of agreement is vested in the board of directors or trustees, unless it is reserved to the members by the articles of incorporation.

5.The articles of agreement of a mutual legal reserve life insurance corporation shall provide that such corporation shall issue no policy of life insurance or annuity contract which provides for the payment of any assessment by any policyholder or member in addition to the regular premium charged for such insurance or annuity.

(L. 1957 p. 224 § 10)

376.2002 - Navigators, license required — permitted acts — prohibited acts — exemptions.

1.No individual or entity shall perform, offer to perform, or advertise any service as a navigator in this state, or receive navigator funding from the state or an exchange unless licensed as a navigator by the department under sections 376.2000 to 376.2014.

2.A navigator may:

(1)Provide fair and impartial information and services in connection with eligibility, enrollment, and program specifications of any health benefit exchange operating in this state, including information about the costs of coverage, advance payments of premium tax credits, and cost-sharing reductions;

(2)Facilitate the selection of a qualified health plan;

(3)Initiate the enrollment process;

(4)Provide referrals to any applicable office of health insurance consumer assistance, ombudsman, or other agency for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or determination under the plan; and

(5)Use culturally and linguistically appropriate language to communicate the information authorized in this subsection.

3.Unless also properly licensed as an insurance producer in this state with authority for health under section 375.014, a navigator shall not:

(1)Sell, solicit, or negotiate health insurance;

(2)Engage in any activity that would require an insurance producer license;

(3)Provide advice concerning the benefits, terms, and features of a particular health plan or offer advice about which exchange health plan is better or worse for a particular individual or employer;

(4)Recommend or endorse a particular health plan or advise consumers about which health plan to choose; or

(5)Provide any information or services related to health benefit plans or other products not offered in the exchange.

4.The following entities or persons are exempt from the requirement to be licensed as a navigator:

(1)An entity or person licensed as an insurance producer in this state with authority for health under section 375.014;

(2)A law firm or licensed attorney in this state; and

(3)A "health care provider" as defined in section 376.1350 provided that:

(a)The health care provider does not receive any funds from the United States Department of Health and Human Services or a health exchange operating in this state to act as a navigator; and

(b)The activities or functions performed are related to advising, assisting, or counseling patients regarding private or public coverage or financial matters related to medical treatments or government assistance programs.

However, nothing in this section shall prohibit a health care provider from voluntarily becoming licensed as a navigator.

(L. 2013 S.B. 262)

Effective 7-12-13

(2016) Provisions prohibiting state navigators from providing certain information to consumers about health benefit plans are preempted by the federal Patient Protection and Affordable Care Act.St. Louis Effort for AIDS v. Huff, 170 F.Supp.3d 1219 (W.D.Mo.).

376.015 - Involuntary unemployment insurance may be issued in connection with extension of credit or certain group life insurance, requirements.

Corporations doing the business specified in section 376.010 may also make insurance to provide a periodic indemnity for involuntary unemployment when such insurance is sold in connection with an extension of credit or, to the extent such insurance is sold outside of the United States of America, group life insurance.Any company making such insurance shall comply with the provisions of section 379.400* and the regulations promulgated pursuant thereto, and shall have, in addition to any other capital requirements for such company, a fully paid capital and surplus equal to the amount required in section 379.010.Involuntary unemployment insurance may be written on either an individual or a group basis, but in no event may group involuntary insurance coverage be offered to residents of a state other than Missouri unless the regulatory official governing insurance in such state has granted prior approval.

(L. 1985 H.B. 826, A.L. 1989 H.B. 615 & 563, A.L. 2012 H.B. 1112)

*Section 379.400 was repealed by S.B. 519, 1992.

376.915 - Application for certificate, content — renewal, content, filed when — extensions, fee.

1.A provider shall file an application for a certificate of authority on a form prescribed by the department, and the application shall be accompanied by the annual statement and other matters as provided in this section.Thereafter, within ninety days of the end of its fiscal year, such provider shall file an annual statement along with an application for renewal of its certificate of authority unless such time shall be extended with the written consent of the department.If the department does not receive the required information within ninety days of the end of the provider's fiscal year, or within an approved time extension, a late fee shall be charged in an amount equal to fifty percent of the renewal fee in effect on the last preceding regular renewal date.

2.The annual statement shall be accompanied by a narrative describing any material differences between the pro forma income statements filed in response to section 376.920 as a part of the most immediately preceding application for a certificate of authority or annual statement and the actual results of operations during the fiscal year together with the revised pro forma income statements being filed as a part of the current annual statement.

3.When an applicant has more than one facility offering continuing care, a separate application for a certificate of authority shall be made for each facility.

4.The application for a certificate of authority shall be signed under oath by the chief executive officer of the applicant.

5.Copies of the escrow agreements executed with an escrow agent pursuant to sections 376.940 and 376.945 shall be recorded as exhibits to the application for a certificate of authority.

(L. 1981 S.B. 84 § 4, subsecs. 1 to 6)

376.240 - Deposits to be held in trust by director.

The securities deposited under the provisions of section 376.170 shall be legally transferred to the director of the department of insurance, financial institutions and professional registration, and so large an amount thereof as may be necessary to equal, at all times, the net value of the outstanding registered policies and annuity bonds, less such liens not exceeding such value as the company may hold against them, shall be held by him in trust for the purposes of sections 376.010 to 376.670, until the obligations of said companies, under said registered policies and annuity bonds shall, to the satisfaction of the said director, be fully liquidated, cancelled or annulled.

(RSMo 1939 § 5824)

Prior revisions: 1929 § 5713; 1919 § 6124; 1909 § 6918

376.1512 - Required disclosures.

1.The following disclosures, to be printed in bold and in not less than twelve-point type, shall be made in writing to any prospective member and shall appear on the first page or first content page of any advertisements, marketing materials or brochures relating to a discount medical plan:

(1)The plan is not insurance;

(2)The plan provides discounts with certain health care providers for medical services;

(3)The plan does not make payments directly to the providers of medical services;

(4)The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization; and

(5)The name and the location of the registered discount medical plan organization, including the current telephone number of the registered discount medical plan organization or other entity responsible for customer service for the plan, if different from the registered discount medical plan organization.

2.If the discount medical plan is sold, marketed, or solicited by telephone, the disclosures required by this section shall be made orally and provided in the initial written materials that describe the benefits under the discount medical plan provided to the prospective or new member.

3.Each discount card or any other plan identifier issued to a plan member shall state in bold and prominent type on the front face of the card that "THIS IS NOT INSURANCE".

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.144 - Acquisition of shares of dissenting stockholders, procedure — abandonment of mutualization.

1.If a stockholder of any domestic stock life insurance corporation planning to become a mutual life insurance corporation under section 376.142 files with the corporation prior to or at the meeting of the stockholders at which the plan is submitted to a vote, a written objection to such plan and does not vote in favor thereof, and such stockholder within twenty days after the plan is approved by such meeting makes written demand on the corporation for payment of the fair cash value of his shares as of the day prior to the date on which such plan is approved by the stockholders, excluding from such fair cash value any appreciation or depreciation in consequence of such mutualization, such stockholder shall be entitled to receive, within ninety days after such fair cash value is agreed upon or determined, upon surrender of his certificates representing his shares, such fair cash value thereof.Any stockholder who fails to make such objection or having objected fails to make demand within the twenty-day period shall be conclusively presumed to have consented to the plan and shall be bound by the terms thereof.

2.Any such objection and demand for the payment of the fair cash value of shares shall state the number and kind of shares held by the dissenting stockholder making the demand, and the amount which such stockholder claims is their fair cash value.

3.The right of a dissenting stockholder to be paid the fair cash value of his shares shall cease when the corporation, for any reason and in accordance with the provisions set forth in this section, abandons the plan to mutualize the corporation.

4.No demand for payment of such fair cash value may be withdrawn by the stockholder making the same unless the corporation, by its board of directors, consents to such withdrawal.

5.Within ten days after the receipt of any such demand the corporation shall inform such stockholder in writing whether it will pay the demanded amount, and, if it refuses to pay such amount, it shall offer in writing to pay another amount as such fair cash value.

6.If, within thirty days after the date of the written demand made by the dissenting stockholder, the value of such shares is agreed upon between the dissenting stockholder and the corporation and such value is approved by the director of the department of insurance, financial institutions and professional registration, payment therefor shall be made within ninety days after the date of such agreement, upon the surrender of the stockholder's certificates representing such shares.Upon payment of the agreed value the dissenting stockholder ceases to have any interest in such shares and ceases to be a stockholder in the corporation, but the shares previously held by him and upon which he has been paid such fair cash value shall be transferred to and held by the trustees appointed under subsections 2 and 3 of section 376.143 for benefit of the corporation.

7.If, within such period of thirty days, the stockholder and the corporation do not agree upon the value of the shares, the corporation, or the dissenting stockholder if he has complied with this section, may, within sixty days after the expiration of the thirty-day period, petition the circuit court of the county in which the principal office of the corporation is located, to determine the fair cash value of the shares mentioned in such demand as of the day before the vote was taken approving such plan.

8.If such petition is not filed within the sixty-day period, the fair cash value of the shares is conclusively deemed to be equal to the amount offered to the dissenting stockholder by the corporation if any such offer has been made or, if not, then an amount equal to that demanded by the dissenting stockholder.

9.The petition shall contain a brief statement of the facts and shall show the vote and action objected to and facts entitling such dissenting stockholder to the relief demanded.

10.Upon the filing of such petition, the court, on the motion of the petitioner, shall enter an order fixing a date for hearing, and requiring a notice of the filing and prayer of such petition and of the date for hearing to be given to the respondent or defendant in the manner in which a summons is required to be served or substituted service is required to be made in other cases.

11.On the day fixed for the hearing of such petition, or any adjournment thereof, the court shall determine from the petition and such evidence as is submitted by either party whether the dissenting stockholder is entitled to be paid the fair cash value of any shares, and the number of such shares, and if the court finds and orders that such stockholder is entitled to be paid the fair cash value of any number of shares, the court shall appoint three appraisers to determine the fair cash value of such number of shares as of the day before the vote objected to was taken, excluding from such fair cash value any appreciation or depreciation in consequence of the mutualization or vote of the corporation, and said court shall further instruct the appraisers respecting their duties in making such determination.

12.The appraisers shall forthwith proceed to determine said fair cash value and said appraisers, or a majority of them, shall make a report or award within ten days, unless the court increases said time, and shall file such report in the office of the clerk of the circuit court, whereupon, on the motion of either party, said report shall be submitted to the court and considered on such evidence as the court considers relevant, and if said award is found to be reasonable, and is confirmed and approved by the court, judgment shall be rendered against the corporation for the payment of the amount of the award, with interest at six percent from a date which shall be fixed in such judgment.

13.If such appraisers, or a majority of them, fail to make and file an award within ten days, or within such further time as may be fixed by the court, or the award is not confirmed by the court, it shall summarily determine the fair cash value of said number of shares and render judgment therefor.

14.Any judgment shall further provide that simultaneously with its payment the certificates evidencing the shares of stock affected shall be surrendered to the corporation and, upon the failure of the holder thereof to surrender such certificates, the judgment shall stand as a cancellation of such certificates.

15.The cost of the proceedings, including reasonable compensation to the appraisers to be fixed by the court, shall be assessed or apportioned as the court considers equitable.

16.Such a proceeding is considered as a special proceeding and shall be advanced upon the court's docket, and final orders therein may be reviewed, affirmed, modified or reversed as in other civil actions or proceedings.

17.Two or more dissenting stockholders may join as plaintiffs or be joined as defendants in any proceeding under this section, and two or more such proceedings may be consolidated.

18.A stockholder who so objects in writing and demands in writing payment of the fair cash value of any shares shall not be entitled to vote such shares or to exercise any rights respecting such shares or to receive any dividends or distributions thereon, unless the plan of mutualization is abandoned, or, with the consent of the corporation, the objection and demand are withdrawn; provided that if, prior to such abandonment, dividends are paid in money to stockholders who are of record on or after the day on which the vote was taken authorizing such mutualization, then an amount of money equal to the dividends otherwise payable upon such dissenting shares shall be paid to the holders of record thereof who would, except for their dissent, be entitled to receive such dividends, and each such payment shall be a credit upon the total amount to be paid for such shares by the corporation.All the holders of such dissenting shares of record at the time of any such abandonment, shall thereupon be restored to the status of a stockholder, and any payments made previously on such shares shall be considered as dividends thereon.

19.Any stockholder who has assented to the plan or who has been concluded by the vote of the assenting stockholders, and any stockholder who has objected and made demand in writing for the fair cash value of his shares subsequent to which an agreement has been reached fixing such fair cash value, but who fails to surrender his certificates for cancellation upon payment of the amount to which he is entitled, may be ordered to do so by a decree of the circuit court for the county in which the principal office of such corporation is located after notice and hearing in an action instituted by the corporation for that purpose, and such decree may provide that, upon the failure of the stockholder to surrender such certificates for cancellation, the decree shall stand in lieu of such surrender and cancellation.

20.At any time before there has been a vote of the policyholders approving a plan of mutualization, the corporation may abandon such plan by the same vote of the directors and of the stockholders as was required for its adoption.Upon such abandonment, the rights of any stockholders to be paid for their stock in accordance with the plan, and the rights of any dissenting stockholders to be paid the fair cash value of their stock, whether or not judgment may have been rendered therefor, shall terminate, and the corporation shall continue to conduct its business as a domestic stock life insurance corporation as though no plan of mutualization had ever been adopted.

(L. 1957 p. 224 § 3)

376.540 - Policy, to whom payable.

In case of the death of the wife before the decease of the husband, the amount of the insurance shall be payable to her heirs, for their use, and to their conservator, if under age, unless otherwise provided for and stipulated in the policy.

(RSMo 1939 § 5848, A.L. 1983 S.B. 44 & 45)

Prior revisions: 1929 § 5737; 1919 §6147; 1909 § 6942

376.1112 - Director to provide buyer's guide — content — advertising of long-term care policies to contain notice of availability of guide.

The director shall prepare a guide that explains the factors to be considered in selecting long-term care insurance and the consequences of particular clauses and exclusions.The guide shall be made available to the public and to interested organizations upon request.Any advertisement in this state relating to long-term care insurance shall include notice of availability of this guide from the director.

(L. 1990 S.B. 765 § 6 subsec. 1)

Transferred 2002; formerly 376.956

376.2053 - Exemption from requirements, when.

An insurer that has not engaged in any asymmetric conduct prior to January 1, 2018, shall not be required to comply with the requirements of sections 376.2050 to 376.2053 with respect to any policies, contracts, or retained asset accounts that are issued and delivered in this state and that are issued or entered into prior to January 1, 2018; provided, however, that an insurer, regardless of whether it has engaged in asymmetric conduct, shall comply with the requirements of sections 376.2050 to 376.2053 for all policies, annuities, or retained asset accounts that are issued and delivered in this state and that are issued or entered into on or after January 1, 2018.

(L. 2016 H.B. 2150)

376.1012 - Funds collected from employers held in trust — requirements — board of trustees, elected, duties — annual report, filed when.

Funds collected from the participating employers under multiple employer self-insured health plans shall be held in trust subject to the following requirements:

(1)A board of trustees elected by participating employers shall serve as fund managers on behalf of participants.Trustees shall be plan participants.No participating employer may be represented by more than one trustee.No trustee may represent more than one employer. A minimum of three and a maximum of seven trustees may be elected.Trustees may not receive remuneration but they may be reimbursed for actual and reasonable expenses incurred in connection with duties as trustee.A trustee may not be an agent, or broker for or an owner, officer or employee of any third-party administrator, insurance agency or insurer utilized by the plan.The trustees shall have the authority to approve applications of association members for participation in the arrangement and to contract with a licensed third-party administrator to administer the day-to-day affairs of the plan;

(2)Each trustee shall be bonded in an amount of not less than one hundred fifty thousand dollars by a licensed insurer;

(3)Investment of plan funds is subject to the same restrictions which are applicable to insurers pursuant to sections 376.291 to 376.307; provided, however, that no foreign plan shall be exempt under section 376.310 from the investment laws of this state unless such plan is subject to laws in its state of domicile which are substantially similar to sections 376.1032 to 376.1045.All investments shall be managed by a bank or other investment entity licensed to operate in Missouri;

(4)Trustees, on behalf of the plan, shall file an annual report with the director of the department of insurance, financial institutions and professional registration by March first showing the condition and affairs of the plan as of the preceding thirty-first day of December.The report shall be made on forms prescribed by the director.The report shall summarize the financial condition of the fund, itemize collections from participating employers, detail all fund expenditures and provide any additional information which the director requires.More frequent reports may be required at the discretion of the director.

(L. 1993 H.B. 709 § 27, A.L. 2007 S.B. 66)

376.640 - Paid-up policy may be demanded, when.

At any time after the payment of three or more full annual premiums, and not later than sixty days from the beginning of the extended insurance provided in section 376.630, the legal holder of any policy affected by section 376.630 may demand of the company, and the company shall issue, its paid-up policy, which, in case of an ordinary life policy, shall be for such an amount as three-fourths of the net value of the regular policy at the age and date of lapse, computed according to actuaries' or combined experience table of mortality, with interest at the rate of four percent per annum, without deduction of indebtedness on account of said policy, will purchase, applied as a net single premium upon the said table of mortality and interest rate aforesaid; and in case of a limited payment life policy, or of a continued payment endowment policy, payable at a certain time, or at death, it shall be for an amount bearing such proportion to the amount of the original policy as the number of complete annual premiums actually paid shall bear to the number of such annual premiums stipulated to be paid; provided, that from such amount the company shall have a right to deduct the net reversionary value of all indebtedness to the company on account of such policy; and provided further, that the policyholder shall, at the time of making demand for such paid-up policy, surrender the original policy, legally discharged, at the parent office of the company.

(RSMo 1939 § 5853, A.L. 1943 p. 596)

Prior revisions: 1929 § 5742; 1919 § 6152; 1909 § 6947

376.811 - Coverage required for chemical dependency by all insurance and health service corporations — minimum standards — offer of coverage may be accepted or rejected by policyholders, companies may offer as standard coverage — mental health benefits provided, when — exclusions.

1.Every insurance company and health services corporation doing business in this state shall offer in all health insurance policies benefits or coverage for chemical dependency meeting the following minimum standards:

(1)Coverage for outpatient treatment through a nonresidential treatment program, or through partial- or full-day program services, of not less than twenty-six days per policy benefit period;

(2)Coverage for residential treatment program of not less than twenty-one days per policy benefit period;

(3)Coverage for medical or social setting detoxification of not less than six days per policy benefit period;

(4)Coverage for medication-assisted treatment for substance use disorders for use in treating such patient's condition, including opioid-use and heroin-use disorders;

(5)The coverages set forth in this subsection may be subject to a separate lifetime frequency cap of not less than ten episodes of treatment, except that such separate lifetime frequency cap shall not apply to medical detoxification in a life-threatening situation as determined by the treating physician and subsequently documented within forty-eight hours of treatment to the reasonable satisfaction of the insurance company or health services corporation; and

(6)The coverages set forth in this subsection:

(a)Shall be subject to the same coinsurance, co-payment and deductible factors as apply to physical illness;

(b)May be administered pursuant to a managed care program established by the insurance company or health services corporation; and

(c)May deliver covered services through a system of contractual arrangements with one or more providers, hospitals, nonresidential or residential treatment programs, or other mental health service delivery entities certified by the department of mental health, or accredited by a nationally recognized organization, or licensed by the state of Missouri.

2.In addition to the coverages set forth in subsection 1 of this section, every insurance company, health services corporation and health maintenance organization doing business in this state shall offer in all health insurance policies, benefits or coverages for recognized mental illness, excluding chemical dependency, meeting the following minimum standards:

(1)Coverage for outpatient treatment, including treatment through partial- or full-day program services, for mental health services for a recognized mental illness rendered by a licensed professional to the same extent as any other illness;

(2)Coverage for residential treatment programs for the therapeutic care and treatment of a recognized mental illness when prescribed by a licensed professional and rendered in a psychiatric residential treatment center licensed by the department of mental health or accredited by the Joint Commission on Accreditation of Hospitals to the same extent as any other illness;

(3)Coverage for inpatient hospital treatment for a recognized mental illness to the same extent as for any other illness, not to exceed ninety days per year;

(4)The coverages set forth in this subsection shall be subject to the same coinsurance, co-payment, deductible, annual maximum and lifetime maximum factors as apply to physical illness; and

(5)The coverages set forth in this subsection may be administered pursuant to a managed care program established by the insurance company, health services corporation or health maintenance organization, and covered services may be delivered through a system of contractual arrangements with one or more providers, community mental health centers, hospitals, nonresidential or residential treatment programs, or other mental health service delivery entities certified by the department of mental health, or accredited by a nationally recognized organization, or licensed by the state of Missouri.

3.The offer required by sections 376.810 to 376.814 may be accepted or rejected by the group or individual policyholder or contract holder and, if accepted, shall fully and completely satisfy and substitute for the coverage under section 376.779.Nothing in sections 376.810 to 376.814 shall prohibit an insurance company, health services corporation or health maintenance organization from including all or part of the coverages set forth in sections 376.810 to 376.814 as standard coverage in their policies or contracts issued in this state.

4.Every insurance company, health services corporation and health maintenance organization doing business in this state shall offer in all health insurance policies mental health benefits or coverage as part of the policy or as a supplement to the policy.Such mental health benefits or coverage shall include at least two sessions per year to a licensed psychiatrist, licensed psychologist, licensed professional counselor, licensed clinical social worker, or, subject to contractual provisions, a licensed marital and family therapist, acting within the scope of such license and under the following minimum standards:

(1)Coverage and benefits in this subsection shall be for the purpose of diagnosis or assessment, but not dependent upon findings; and

(2)Coverage and benefits in this subsection shall not be subject to any conditions of preapproval, and shall be deemed reimbursable as long as the provisions of this subsection are satisfied; and

(3)Coverage and benefits in this subsection shall be subject to the same coinsurance, co-payment and deductible factors as apply to regular office visits under coverages and benefits for physical illness.

5.If the group or individual policyholder or contract holder rejects the offer required by this section, then the coverage shall be governed by the mental health and chemical dependency insurance act as provided in sections 376.825 to 376.836*.

6.This section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, hospitalization-surgical care policy, short-term major medical policy of six months or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.

(L. 1991 S.B. 352 § 7 subsecs. 2, 3, 4, A.L. 1997 H.B. 335, A.L. 1999 H.B. 191, A.L. 2004 H.B. 855, A.L. 2009 H.B. 326 merged with S.B. 296, A.L. 2018 S.B. 718 merged with S.B. 951)

*Sections 376.825 to 376.836 were repealed by H.B. 1298 Revision, 2014.

376.1312 - Nonapplicability of certain provisions of insurance holding companies law.

Sections 382.040, 382.060, and 382.095 shall not apply to a reorganization or merger pursuant to the provisions of sections 376.1300 to 376.1322.

(L. 1996 S.B. 759)

376.740 - Plan of operation, required, approval of director — provisions of plan.

1.The association shall submit a plan of operation and any amendments thereto necessary or suitable to assure the fair, reasonable, and equitable administration of the association to the director.The plan of operation and any amendments thereto shall become effective upon the director's written approval or unless he has not disapproved it within thirty days.

2.If the association fails to submit a suitable plan of operation within one hundred twenty days following the effective date, August 13, 1988, of sections 376.715 to 376.758 or if at any time thereafter the association fails to submit suitable amendments to the plan, the director shall, after notice and hearing, adopt and promulgate such reasonable rules as are necessary or advisable to effectuate the provisions of sections 376.715 to 376.758.Such rules shall continue in force until modified by the director or superseded by a plan submitted by the association and approved by him.

3.All member insurers shall comply with the plan of operation.

4.The plan of operation shall, in addition to requirements enumerated in sections 376.715 to 376.758:

(1)Establish procedures for handling the assets of the association;

(2)Establish the amount and method of reimbursing members of the board of directors;

(3)Establish regular places and times for meetings including telephone conference calls of the board of directors;

(4)Establish procedures for records to be kept of all financial transactions of the association, its agents, and the board of directors;

(5)Establish the procedures whereby selections for the board of directors will be made and submitted to the director;

(6)Establish any additional procedures for assessments which may be necessary;

(7)Contain additional provisions necessary or proper for the execution of the powers and duties of the association;

(8)Establish procedures whereby a director may be removed for cause, including in the case where a member insurer director becomes an impaired or insolvent insurer;

(9)Establish procedures for the initial handling of any appeals against the actions of the board, subject to the rights of appeal in subsection 3 of section 376.742.

5.The plan of operation may provide that any or all powers and duties of the association except those pursuant to provisions of subdivision (3) of subsection 1 of section 376.734 and section 376.735 are delegated to a corporation, association, or other organization which performs or will perform functions similar to those of this association, or its equivalent, in two or more states.Such a corporation, association, or organization shall be reimbursed for any payments made on behalf of the association and shall be paid for its performance of any function of the association.A delegation under this subsection shall take effect only with the approval of both the board of directors and the director, and may be made only to a corporation, association, or organization which extends protection not substantially less favorable and effective than that provided by sections 376.715 to 376.758.

(L. 1988 S.B. 430 §§ 21, 22, A.L. 2010 S.B. 583)

376.250 - Deposits to be kept separate.

The securities deposited under section 376.170 shall be deposited and kept in the same manner, but separate from other deposits of the company.

(RSMo 1939 § 5822)

Prior revisions: 1929 § 5711; 1919 § 6122; 1909 § 6916

376.805 - Elective abortion to be by optional rider and requires additional premium — elective abortion defined — health insurance exchanges not to offer coverage for elective abortions.

1.No health insurance contracts, plans, or policies delivered or issued for delivery in the state shall provide coverage for elective abortions except by an optional rider for which there must be paid an additional premium.For purposes of this section, an "elective abortion" means an abortion for any reason other than a spontaneous abortion or to prevent the death of the female upon whom the abortion is performed.

2.Subsection 1 of this section shall be applicable to all contracts, plans or policies of:

(1)All health insurers subject to this chapter; and

(2)All nonprofit hospital, medical, surgical, dental, and health service corporations subject to chapter 354; and

(3)All health maintenance organizations.

3.No health insurance exchange established within this state or any health insurance exchange administered by the federal government or its agencies within this state shall offer health insurance contracts, plans, or policies that provide coverage for elective abortions, nor shall any health insurance exchange operating within this state offer coverage for elective abortions through the purchase of an optional rider.

4.This section shall be applicable only to contracts, plans or policies written, issued, renewed or revised after September 28, 1983.For the purposes of this subsection, if new premiums are charged for a contract, plan or policy, it shall be determined to be a new contract, plan or policy.

(L. 1983 S.B. 222 § 1, A.L. 2010 S.B. 793)

(1992)Where statute prohibits insurance coverage for elective abortion unless coverage is provided in optional rider with separate premium, it does not impose an undue burden on a woman's abortion decision and it is rationally related to Missouri's interest in protecting the interest of citizens who object to subsidizing abortions through payment of their insurance premiums.Coe v. Melahn, 958 F.2d 223 (8th Cir.).

376.905 - Administration by department, powers, duties — fees.

The administration of sections 376.900 to 376.950 is vested in the division, which shall:

(1)Prepare and furnish all forms necessary under the provisions of sections 376.900 to 376.950 in relation to applications for certificates of authority or renewals thereof, statements, examinations, and other required reports;

(2)Collect in advance, and the applicant so served shall pay to it in advance, the following fees:

(a)At the time of filing an application for a certificate of authority, an application fee in the amount of seventy-five dollars for each facility;

(b)At the time of renewal of a certificate of authority, a renewal fee in the amount of seventy-five dollars for each year or part thereof for each facility where continuing care is provided;

(c)A late fee in an amount equal to fifty percent of the renewal fee in effect on the last preceding regular renewal date;

(3)Adopt rules, within the standards of sections 376.900 to 376.950, necessary to effect the purposes of sections 376.900 to 376.950.

(L. 1981 S.B. 84 § 2)

376.754 - Stay of proceedings, insolvent insurer, when.

All proceedings in which the insolvent insurer is a party in any court in this state shall be stayed sixty days from the date an order of liquidation, rehabilitation, or conservation is final to permit proper legal action by the association on any matters germane to its powers or duties.As to judgment under any decision, order, verdict, or finding based on default the association may apply to have such judgment set aside by the same court that made such judgment and shall be permitted to defend against such suit on the merits.

(L. 1988 S.B. 430 § 34)

376.350 - Reports to director.

1.It shall be the duty of the president or vice president and secretary or actuary, or a majority of the directors, of every life assurance company organized pursuant to sections 376.010 to 376.670 or pursuant to the laws of this state, or any such company incorporated by or organized pursuant to the laws of the United States or any other state, and doing business in this state, annually, on the first day of January, or within sixty days thereafter, to prepare under oath, and deposit in the office of the director of the department of insurance, financial institutions and professional registration, a statement made up for the year ending the thirty-first day of December next preceding, showing:

(1)The number of policies issued during the year;

(2)The amount of assurance effected thereby;

(3)The amount of premiums received during the year;

(4)The amount received for interest, and all other receipts during the year, classifying the items;

(5)The amount of losses paid during the year;

(6)The amount of losses unpaid, giving the reason for such nonpayment;

(7)The amount of expenses, classifying the items;

(8)The whole number of policies in force, specifying the description;

(9)The amount of liabilities or risks thereon, and of all other liabilities;

(10)The amount of capital stock and how invested;

(11)The amount of assets other than capital, specifying the particular sources from whence they have been derived, and the manner in which they are invested, and what amount is invested in real estate, in stocks, promissory notes and other securities, and what amount is loaned on bonds and mortgages, or deeds of trust, stocks, policies of the company and other securities, specifying the kinds and amounts;

(12)The amount of dividend declared to stockholders and policyholders, respectively, and how much remains unpaid; and

(13)A statement of any other facts or information concerning the affairs of said company which may be required by the director.

2.Notwithstanding any other provision of law to the contrary, information regarding compensation of any employee or officer contained within a statement required to be filed pursuant to this section shall not be subject to disclosure to any person other than employees of the department.

(RSMo 1939 § 5829, A.L. 2000 S.B. 896)

Prior revisions: 1929 § 5718; 1919 § 6129; 1909 § 6923

376.150 - Stock and mutual companies — content of charter.

When such corporators propose to form a stock and mutual company for the purposes designated in section 376.010, the charter comprised in the declaration named in section 376.050 shall set forth all the particulars mentioned in section 376.060 in regard to the formation of corporations on the joint stock plan; and in addition thereto it shall state

(1)The extent, if any, to which the policyholders shall participate in the election of directors and in the management of the company, and the manner in which they shall do so;

(2)The time for which it is proposed to remain a stock and mutual company, provided it be intended to limit the same, and the manner of changing into a mutual or stock company, if such change is proposed; but no such change shall be made unless by two-thirds majority of all the votes cast at a meeting held for that purpose, such meeting to be called by a special notice, stating its object; which notice shall be published for at least once a week, for four weeks, in a newspaper of general circulation, and published in the county or city where such company is located.

(RSMo 1939 § 5813)

Prior revisions: 1929 § 5702; 1919 § 6113; 1909 § 6907

376.1106 - Policies issued in other states may be issued to residents of Missouri if in compliance with Missouri regulations.

No group long-term care insurance coverage may be offered to a resident of this state under a group policy issued in another state to a group described in paragraph (d) of subdivision (4) of subsection 2 of section 376.1100, unless this state or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in this state has made a determination that such requirements have been met.

(L. 1990 S.B. 765 § 4)

Transferred 2002; formerly 376.953.

376.1502 - Requirements for transaction of business.

1.It is unlawful to transact business in this state as a discount medical plan organization, unless the organization is a corporation, limited liability corporation, partnership, limited liability partnership or other legal entity organized under the laws of this state or, if a foreign entity, authorized to transact business in this state, and is registered as a discount medical plan organization with the director or duly authorized by the director as an insurance company, licensed health maintenance organization, licensed group health service organization, or licensed third-party administrator.

2.An individual person, employee, or agent of a registered entity described in subsection 1 of this section may also transact business in this state on behalf of such entity.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66;) 1-01-08 (H.B. 818)

376.050 - Declaration of corporators.

The persons mentioned in section 376.010 shall be designated as "corporators", and such corporators, desiring to form a company for the purpose of transacting the business mentioned in said section, or any part of the same, shall file in the office of the director of the department of insurance, financial institutions and professional registration a declaration signed by each of said corporators, setting forth the place of residence of each of them, and their intention to form a corporation for the purpose of transacting the business aforesaid, which declaration shall comprise a copy of the charter proposed to be adopted by them; and they shall publish once in each week, or oftener, for at least four weeks, in a newspaper of general circulation, published in the county where such corporation is proposed to be located, a notice of the filing of such declaration, together with a copy of the same.

(RSMo 1939 § 5803)

Prior revisions: 1929 § 5693; 1919 § 6104; 1909 § 6898

376.454 - Individual market, renewal or continuation at option of individual — nonrenewal or discontinuation permitted, when — discontinuation of a type of coverage, procedure.

1.Except as provided in this section, a health insurance issuer that provides individual health insurance coverage to an individual shall renew or continue in force such coverage at the option of the individual.

2.A health insurance issuer may nonrenew or discontinue health insurance coverage of an individual in the individual market based only on one or more of the following:

(1)The individual has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the issuer has not received timely premium payments;

(2)The individual has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage;

(3)The issuer is ceasing to offer coverage in the individual market in accordance with subsection 4 of this section;

(4)In the case of a health insurance issuer that offers health insurance coverage in the market through a network plan, the individual no longer resides, lives, or works in the service area or in an area for which the issuer is authorized to do business but only if such coverage is terminated under this subdivision uniformly without regard to any health status-related factor of covered individuals;

(5)In the case of health insurance coverage that is made available in the individual market only through one or more bona fide associations, the membership of the individual in the association on the basis of which the coverage is provided ceases, but only if such coverage is terminated under this subdivision uniformly without regard to any health status-related factor of covered individuals.

3.In any case in which an issuer decides to discontinue offering a particular type of health insurance coverage offered in the individual market, coverage of such type may be discontinued by the issuer only if:

(1)The issuer provides notice to each covered individual provided coverage of this type in such market of such discontinuation at least ninety days prior to the date of the discontinuation of such coverage;

(2)The issuer offers to each individual in the individual market provided coverage of this type, the option to purchase any other individual health insurance coverage currently being offered by the issuer for individuals in such market; and

(3)In exercising the option to discontinue coverage of this type and in offering the option of coverage under subdivision (2) of this subsection, the issuer acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for such coverage.

4.(1)In any case in which a health insurance issuer elects to discontinue offering all health insurance coverage in the individual market in the state, health insurance coverage may be discontinued by the issuer only if:

(a)The issuer provides notice to the director and to each individual of such discontinuation at least one hundred eighty days prior to the date of the expiration of such coverage; and

(b)All health insurance issued or delivered for issuance in the state in such market is discontinued and coverage under such health insurance coverage in such market is not renewed.

(2)In the case of a discontinuation under subdivision (1) of this subsection, the issuer shall not provide for the issuance of any health insurance coverage in the individual market for a five-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.

5.At the time of coverage renewal, a health insurance issuer may modify the health insurance coverage for a policy form offered to individuals in the individual market so long as such modification is consistent with applicable law and effective on a uniform basis among all individuals with that policy form.For purposes of this subsection, renewal shall be deemed to occur not more often than annually on the anniversary of the effective date of the individual's health insurance coverage or as specified in the policy or contract.

6.In applying this section in the case of health insurance coverage that is made available by a health insurance issuer in the individual market to individuals only through one or more associations, a reference to an individual is deemed to include a reference to such an association of which the individual is a member.

7.An insurer shall provide a certification of creditable coverage as required by Public Law 104-191 and regulations pursuant thereto.

(L. 2007 H.B. 818)

Effective 1-01-08

376.1002 - Certificate of authority required — penalty for noncompliance — law inapplicable, when — exempt organizations.

1.It is unlawful for any multiple employer self-insured health plan to transact business in this state without a certificate of authority issued by the director of the department of insurance, financial institutions and professional registration.Any of the acts described in subsection 2 of section 375.786, effected by mail or otherwise, by or on behalf of a multiple employer self-insured health plan, constitutes the transaction of business in this state.

2.Any multiple employer self-insured health plan which transacts business in this state without the certificate of authority required by sections 376.1000 to 376.1045 is considered to be an unauthorized insurer within the meaning of section 375.786, and all remedies and penalties prescribed in section 375.786 shall be fully applicable.

3.Sections 376.1000 to 376.1045 do not apply to:

(1)Any plan or arrangement established or maintained by municipalities, counties, or other political subdivisions of the state pursuant to sections 537.620 to 537.650;

(2)Any multiple employer self-insured health plan which is not subject to the application of state insurance laws under the provisions of the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001, et seq.; or

(3)Any person or entity found by operation of the provisions of section 374.194 not to be subject to the jurisdiction of the department of insurance, financial institutions and professional registration.

4.A multiple employer self-insured health plan which was in existence prior to August 28, 1993, and which is associated with or organized or sponsored by a homogenous association exempt from taxation under 26 U.S.C.501(c)(6) and controlled by a board of directors a majority of whom are members of the association, is exempt from the requirements of sections 376.1000 to 376.1045 and the insurance laws of this state.To prove exemption from taxation under 26 U.S.C. 501(c)(6), the association shall provide to the director a certificate issued by the United States Internal Revenue Service demonstrating the association's tax exempt status.

(L. 1993 H.B. 709 § 23)

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 insurance, financial institutions and professional registration;

(7)"Director", the director of the Missouri department of insurance, financial institutions and professional registration;

(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.

(L. 2007 H.B. 818)

Effective 1-01-08

376.309 - Separate account defined — establishment of account and special voting or control rights authorized — approved investments — approval of director required.

1.As used in this section, "separate account" means an account established by an insurance company, into which any amounts paid to or held by such company under applicable contracts are credited and the assets of which, subject to the provisions of this section, may be invested in such investments as shall be authorized by a resolution adopted by such company's board of directors.The income, if any, and gains and losses, realized or unrealized, on such account shall be credited to or charged against the amounts allocated to such account without regard to other income, gains or losses of the company.If and to the extent so provided under the applicable contracts, that portion of the assets of any such separate account equal to the reserves and other contract liabilities with respect to such account shall not be chargeable with liabilities arising out of any other business the company may conduct.

2.Any domestic life insurance company may, after adoption of a resolution by its board of directors, establish one or more separate accounts, and may allocate to such account or accounts any amounts paid to or held by it which are to be applied under the terms of an individual or group contract to provide benefits payable in fixed or in variable dollar amounts or in both.

3.To the extent it deems necessary to comply with any applicable federal or state act, the company may, with respect to any separate account or any portion thereof, provide for the benefit of persons having beneficial interests therein special voting and other rights and special procedures for the conduct of the business and affairs of such separate account or portion thereof, including, without limitation, special rights and procedures relating to investment policy, investment advisory services, selection of public accountants, and selection of a committee, the members of which need not be otherwise affiliated with the company, to manage the business and affairs of such separate account or portion thereof; and the corporate charter of such company shall be deemed amended to authorize the company to do so.The provisions of this section shall not affect existing laws pertaining to the voting rights of such company's policyholders.

4.The amounts allocated to any separate account and the accumulations thereon may be invested and reinvested without regard to any requirements or limitations prescribed by the laws of this state governing the investments of life insurance companies, and the investments in such separate account or accounts shall not be taken into account in applying the investment limitations, including but not limited to quantitative restrictions, otherwise applicable to the investments of the company, except that to the extent that the company's reserve liability with regard to benefits guaranteed as to principal amount and duration, and funds guaranteed as to principal amount or stated rate of interest, is maintained in any separate account, a portion of the assets of such separate account at least equal to such reserve liability shall be, except as the director might otherwise approve, invested in accordance with the laws of this state governing the general investment account of any company.As used herein, the expression "general investment account" shall mean all of the funds, assets and investments of the company which are not allocated in a separate account.The provisions of section 376.170 relating to deposits for registered policies shall not be applicable to funds and investments allocated to separate accounts.No investment in the separate account or in the general investment account of a life insurance company shall be transferred by sale, exchange, substitution or otherwise from one account to another unless, in case of a transfer into a separate account, the transfer is made solely to establish the account or to support the operation of the contracts with respect to the separate account to which the transfer is made or unless the transfer, whether into or from a separate account, is made by a transfer of cash, or by a transfer of other assets having a readily determinable market value, provided that such transfer of other assets is approved by the director and is for assets of equivalent value.Such transfer shall be deemed approved to the extent the assets of a separate account so transferred have been paid to or are being held by the company in connection with a pension, retirement or profit-sharing plan subject to the provisions of the Internal Revenue Code, as amended, and the Employee Retirement Income Security Act of 1974, as amended.The director may withdraw such deemed approval by providing written notice to the company that its financial condition or past practices require such withdrawal.The director may approve other transfers among such accounts if the director concludes that such transfers would be equitable.

5.Unless otherwise approved by the director, assets allocated to a separate account shall be valued at their market value on the date of valuation, or if there is no readily available market, then as provided under the terms of the contract or the rules or other written agreement applicable to such separate account; provided, that the portion of the assets of such separate account at least equal to the company's reserve liability with regard to the guaranteed benefits and funds referred to in subsection 4 of this section, if any, shall be valued in accordance with the rules otherwise applicable to the company's assets.

6.The director shall have the sole and exclusive authority to regulate the issuance and authority to regulate the sale of contracts under which amounts are to be allocated to one or more separate accounts as provided herein, and to issue such reasonable rules, regulations and licensing requirements as the director shall deem necessary to carry out the purposes and provisions of this section; and the companies that issue such contracts shall not be subject to registration with the commissioner of securities.The director may, subject to the provisions of section 374.185, consult and cooperate with the commissioner of securities in investigations arising from the offer and sale of contracts regulated under this section and may request assistance from the commissioner of securities in any proceeding arising from the offer and sale of any such contracts.

7.No domestic life insurance company, and no other life insurance company admitted to transact business in this state, shall be authorized to deliver within this state any contract under which amounts are to be allocated to one or more separate accounts as provided herein until said company has satisfied the director that its condition or methods of operation in connection with the issuance of such contracts will not render its operation hazardous to the public or its policyholders in this state.In determining the qualifications of a company requesting authority to deliver such contracts within this state, the director shall consider, among other things:

(1)The history and financial condition of the company;

(2)The character, responsibility and general fitness of the officers and directors of the company; and

(3)In the case of a company other than a domestic company, whether the statutes and regulations of the jurisdiction of its incorporation provide a degree of protection to policyholders and the public which is substantially equal to that provided by this section and the rules and regulations issued thereunder.

8.An authorized life insurance company, whether domestic, foreign or alien, which issues contracts under which amounts are to be allocated to one or more separate accounts as provided herein, and which is a subsidiary of or affiliated through common management or ownership with another life insurance company authorized to do business in this state, may be deemed to have met the provisions of subsection 7 of this section if either it or the parent or affiliated company meets the requirements thereof.

9.If the contract provides for payment of benefits in variable amounts, it shall contain a statement of the essential features of the procedure to be followed by the company in determining the dollar amount of such variable benefits.Any such contract, including a group contract, and any certificate issued thereunder, shall state that such dollar amount may decrease or increase and shall contain on its first page a statement that the benefits thereunder are on a variable basis.

10.Except as otherwise provided in this section, all pertinent provisions of the insurance laws of this state shall apply to separate accounts and contracts relating thereto.

(L. 1963 p. 496 §§ 1 to 4, A.L. 1969 S.B. 42, A.L. 1983 S.B. 42, A.L. 1992 S.B. 831, A.L. 1993 H.B. 709, A.L. 2007 S.B. 66)

376.1506 - Violations, penalty.

1.If the director has a reason to believe that the discount medical plan organization is not complying with the requirements of sections 376.1500 to 376.1532, the director may examine or investigate the business and affairs of any discount medical plan organization under the authority of sections 374.190 and 374.202 to 374.207. The director may require any discount medical plan organization or applicant to produce any records, books, files, advertising and solicitation materials, or other information and may take statements under oath to determine whether the discount medical plan organization or applicant is in violation of the law.Reasonable expenses incurred in conducting any examination shall be paid by the discount medical plan organization under sections 374.202 to 374.207.

2.Failure by the discount medical plan organization to pay the expenses incurred under this subsection shall be grounds for denial or revocation of the discount medical plan organization's registration.

(L. 2007 H.B. 818 merged with S.B. 66)

Effective 8-28-07 (S.B. 66); 1-01-08 (H.B. 818)

376.750 - Financial report, submitted to director, when — tax exempt status — immunity from liability.

1.The association shall be subject to examination and regulation by the director.The board of directors shall submit to the director each year, not later than* one hundred twenty days after the association's fiscal year, a financial report in a form approved by the director and a report of its activities during the preceding fiscal year.

2.The association shall be exempt from payment of all fees and all taxes levied by this state or any of its subdivisions, except taxes levied on real property.

3.There shall be no liability on the part of and no cause of action of any nature shall arise against any member insurer or its agents or employees, the association or its agents or employees, members of the board of directors, or the director or his representatives, for any action or omission by them in the performance of their powers and duties under the provisions of sections 376.715 to 376.758.Such immunity shall extend to the participation in any organization of one or more other state associations of similar purposes and to any such organization and its agents or employees.

(L. 1988 S.B. 430 §§ 30, 31, 32)

*Word "that" appears in original rolls.

376.650 - Rules of payment on commuted policy.

If the death of the insured occur within the term of temporary insurance covered by the value of the policy as determined in section 376.630, and if no condition of the insurance other than the payment of premiums shall have been violated by the insured, the company shall be bound to pay the amount of the policy, the same as if there had been no default in the payment of premium, anything in the policy to the contrary notwithstanding; provided, however, that notice of the claim and proof of the death shall be submitted to the company in the same manner as provided by the terms of the policy within ninety days after the decease of the insured; and provided also, that the company shall have the right to deduct from the amount insured in the policy the amount compounded at six percent interest per annum of all the premiums that had been forborne at the time of the decease, including the whole of the year's premium in which the death occurs, but such premiums shall in no case exceed the ordinary life premium for the age at issue, with interest as last aforesaid.

(RSMo 1939 § 5854, A.L. 1943 p. 596)

Prior revisions: 1929 § 5743; 1919 § 6153; 1909 § 6948

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

1.This section shall be known and may be cited as the "Child Health Insurance Reform Plan".

2.As used in this section, the following terms mean:

(1)"Child health supervision services", the periodic review of a child's physical and emotional status by a physician or pursuant to a physician's supervision.A review shall include a history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests in keeping with prevailing medical standards;

(2)"Health care insurer", any entity regulated by the Missouri department of insurance, financial institutions and professional registration, including, but not limited to, insurance companies, nonprofit health services corporations, health maintenance organizations, or any self-insured plans or groups;

(3)"Health insurance policy", any group insurance policy providing coverage on an expense-incurred basis, any group service or indemnity contract issued by a not-for-profit health services corporation or any self-insured group health benefit plan of any type or description.Such phrase shall not include policies which cover only specified diseases, accidents or confinement in an intensive care unit.

3.All health insurance policies which provide coverage for a family member of the insured or subscriber shall offer coverage for child health supervision services.Such services shall include coverage from the moment of birth through the age of twelve years.Each such policy or contract shall, at a minimum, provide benefits for child health supervision services at approximately the following age intervals:birth, two months, four months, six months, nine months, twelve months, eighteen months, two years, three years, four years, five years, six years, eight years, ten years, and twelve years.A health insurance policy may provide that child health supervision services which are rendered during a periodic review shall only be covered to the extent that services are provided by or under the supervision of a single physician during the course of one visit.Benefits for such services shall be subject to the same durational limits, dollar limits, deductibles and coinsurance factors as other covered services in such health insurance policies.All Missouri health insurance policies delivered, issued for delivery, modified or renewed on or after January 1, 1990, shall be subject to this section.

4.The offer of benefits under subsection 3 of this section shall be in writing and may be rejected by the individual or group policyholder or contractholder.

5.Nothing in this section shall prohibit the health care insurer from including any or all coverage for child health supervision services as standard coverage in their policies or contracts.

(L. 1989 H.B. 795 §§ 1, 2, 3)

376.758 - Law inapplicable to insolvent insurers on effective date of law.

1.Sections 376.715 to 376.758 shall not apply to any insurer which is insolvent or unable to fulfill its contractual obligations on August 13, 1988.

2.Sections 376.715 to 376.758 shall be liberally construed to effect the purpose under subsection 2 of section 376.715 which shall constitute an aid and guide to interpretation.

3.The amendments to sections 376.715 to 376.758 which become effective on August 28, 2010, shall not apply to any member insurer that is an impaired or insolvent insurer prior to August 28, 2010.

4.The amendments to sections 376.715 to 376.758, which become effective on August 28, 2018, shall not apply to any member insurer that is an impaired or insolvent insurer prior to August 28, 2018.

(L. 1988 S.B. 430 § 37, A.L. 2010 S.B. 583, A.L. 2018 H.B. 1690)

376.405 - Group health and accident policies, approval required — exempt, when, director's powers.

1.No insurance company licensed to transact business in this state shall deliver or issue for delivery in this state any policy of group accident or group health insurance, or group accident and health insurance, including insurance against hospital, medical or surgical expenses, covering a group in this state, unless such policy form shall have been approved by the director of the department of insurance, financial institutions and professional registration of the state of Missouri.

2.The director of the department of insurance, financial institutions and professional registration shall have authority to make such reasonable rules and regulations concerning the filing and submission of such policy forms as are necessary, proper or advisable. Such rules and regulations shall provide, among other things, that if a policy form is disapproved, all specific reasons for nonconformance shall be stated in writing within forty-five days from the date of filing; that a hearing shall be granted upon such disapproval, if so requested; and that the failure of the director of the department of insurance, financial institutions and professional registration, to take action approving or disapproving a submitted policy form within forty-five days from the date of filing, shall be deemed an approval thereof.If at any time after a policy form is approved or deemed approved the director determines that any provision of the filing is contrary to state law, the director shall notify the health carrier of the specific provisions that are contrary to state law and any specific statute or regulation to which the provision is contrary, and request that the health carrier file, within thirty days of the notification, an amendment form that modifies the provision to conform to state law.Upon approval of the amendment form by the director, the health carrier shall issue a copy of the amendment to each individual and entity to which the filing has been issued.Such amendment shall have the force and effect as if the amendment was in the original filing or policy.

3.The director of the department of insurance, financial institutions and professional registration shall approve only those policy forms which are in compliance with the insurance laws of this state and which contain such words, phraseology, conditions and provisions which are specific, certain and unambiguous and reasonably adequate to meet needed requirements for the protection of those insured.The disapproval of any policy form shall be based upon the requirements of the laws of this state or of any regulation lawfully promulgated thereunder.

4.The director of the department of insurance, financial institutions and professional registration may, by order or bulletin, exempt from the approval requirements of this section for so long as he deems proper any insurance policy, document, or form or type thereof, as specified in such order or bulletin, to which, in his opinion, this section may not practicably be applied, or the approval of which is, in his opinion, not desirable or necessary for the protection of the public.

(L. 1959 H.B. 253 § 1, A.L. 1984 S.B. 592, A.L. 2013 S.B. 262)

376.1257 - Orally administered anticancer medications, plan to provide coverage no less favorable than IV or injected medications — definitions — requirements — effective date.

1.As used in this section the following terms shall mean:

(1)"Anticancer medications", medications used to kill or slow the growth of cancerous cells;

(2)"Covered person", a policyholder, subscriber, enrollee, or other individual enrolled in or insured by a health benefit plan for health insurance coverage;

(3)"Health benefit plan", shall have the same meaning as defined in section 376.1350.

2.Any health benefit plan that provides coverage and benefits for cancer treatment shall provide coverage of prescribed orally administered anticancer medications on a basis no less favorable than intravenously administered or injected anticancer medications.

3.Coverage of orally administered anticancer medication shall not be subject to any prior authorization, dollar limit, co-payment, deductible, or other out-of-pocket expense that does not apply to intravenously administered or injected anticancer medication, regardless of formulation or benefit category determination by the company administering the health benefit plan.

4.The health benefit plan shall not reclassify or increase any type of cost-sharing to the covered person for anticancer medications in order to achieve compliance with this section.Any change in health insurance coverage, which otherwise increases an out-of-pocket expense to anticancer medications, shall be applied to the majority of comparable medical or pharmaceutical benefits covered by the health benefit plan.

5.Notwithstanding the provisions of subsections 2, 3, and 4 of this section, a health benefit plan that limits the total amounts paid by a covered person through all cost-sharing requirements to no more than seventy-five dollars per thirty-day supply for any orally administered anticancer medication shall be considered in compliance with this section.On January 1, 2016, and on January first of each year thereafter, a health benefit plan may adjust such seventy-five dollar limit.The adjustment shall not exceed the Consumer Price Index for All Urban Consumers Midwest Region for that year.For purposes of this subsection "cost-sharing requirements" shall include co-payments, coinsurance, deductibles, and any other amounts paid by the covered person for that prescription.

6.For a health benefit plan that meets the definition of "high deductible health plan" as defined by 26 U.S.C. 223(c)(2), the provisions of subsection 5 of this section shall only apply after a covered person's deductible has been satisfied for the year.

7.The provisions of this section shall become effective January 1, 2015.

(L. 2014 S.B. 668)

Effective 1-01-15

376.854 - Definitions.

As used in sections 376.850 to 376.890, the following terms mean:

(1)"Applicant":

(a)In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits; and

(b)In the case of a group Medicare supplement policy, the proposed certificate holder;

(2)"Certificate", any certificate delivered or issued for delivery in this state under a group Medicare supplement policy;

(3)"Certificate form", the form on which the certificate is delivered or issued for delivery by the issuer;

(4)"Director", the director of the department of insurance, financial institutions and professional registration;

(5)"Issuer" includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state Medicare supplement policies or certificates;

(6)"Medicare", the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended;

(7)"Medicare supplement policy", a group or individual policy of insurance or a subscriber contract, other than a policy issued pursuant to a contract under section 1876 of the federal Social Security Act, 42 U.S.C.section 1395, et seq., or an issued policy under a demonstration project specified in 42 U.S.C. section 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare;

(8)"Policy form", the form on which the policy is delivered or issued for delivery by the issuer.

(L. 1989 H.B. 615 & 563, A.L. 1992 H.B. 1574, A.L. 1996 S.B. 883)

Effective 4-26-96

376.1753 - Services related to pregnancy, persons holding ministerial or tocological certification may provide.

Notwithstanding any law to the contrary, any person who holds current ministerial or tocological certification by an organization accredited by the National Organization for Competency Assurance (NOCA) may provide services as defined in 42 U.S.C. 1396r-6(b)(4)(E)(ii)(I).

(L. 2007 H.B. 818)

376.301 - Tangible personal property interests permitted, when.

1.(1)Subject to the limitations of section 376.297, an insurer may acquire tangible personal property or equity interest therein located or used wholly or in part within a domestic jurisdiction directly or indirectly through limited partnership interest and general partnership interest not otherwise prohibited by subsection 4 of section 376.294, joint ventures, stock of an investment subsidiary or membership interests in a limited liability company, trust certificates, or other similar instruments.

(2)Investments acquired under subdivision (1) of this subsection shall be eligible only if:

(a)The property is subject to a lease or other agreement with a person whose rated credit instruments in the amount of the purchase prices of the personal property the insurer could then acquire under section 376.298; and

(b)The lease or other agreement provides the insurer the right to receive rental, purchase, or other fixed payments for this use or purchase of the property and the aggregate value of the payments, together with the estimated residual value of the property at the end of its useful life and the estimated tax benefits to the insurer resulting from ownership of the property shall be adequate to return the cost of the insurer's investment in the property plus a return deemed adequate by the insurer.

2.An insurer shall compute the amount of each investment under this section on the basis of the out-of-pocket purchase price and applicable related expenses paid by the insurer for the investment, net of each borrowing made to finance the purchase price, and expenses to the extent the borrowing is without recourse to the insurer.

3.An insurer shall not acquire an investment under this section if as a result of and afte