Free Medical Plans Study Guide
Missouri Accident & Health exam — Medical Plans.
The national Medical Plans guide covers major medical design, managed care, HSAs and the ACA. This guide covers Missouri's mandated benefits, dependent rules and managed care grievance law in RSMo chapter 376 and HMO advertising rules in chapter 354.
Newborns, adopted and disabled children
- Newborns are covered from the moment of birth, including congenital defects and birth abnormalities. A plan may require notice and premium within 31 days to continue coverage past that point (376.406).
- Adopted children are covered from birth if the adoption petition is filed within 30 days of birth, or from placement if filed within 30 days of placement. Conditions existing before placement are covered (376.816).
- Disabled children: coverage continues while the child can't support himself or herself and depends on the policyholder. Proof is due within 31 days of reaching the limiting age. Later proof may be required at reasonable intervals for two years, then no more than yearly (376.776).
- Dependent continuation: the policyholder may continue coverage for a dependent child who is no more than 25, electing within 31 days of the child reaching the limiting age (376.776.3; 354.536 for HMOs).
Mandated benefits (examples tested)
| Benefit | Missouri rule |
|---|---|
| Mental health parity | No rate, term or condition may make mental health care costlier to access than physical health care. Deductibles and out-of-pocket limits must be combined (376.1550). |
| Mammograms | A baseline for women 35–39 and annually at 40+, with no referral required (376.782) |
| Child immunizations | Birth to age 5, with no deductible or copay (376.1215) |
| Maternity stays | At least 48 hours after vaginal delivery and 96 hours after a cesarean, plus at least 2 post-discharge visits, one at home (376.1210) |
| Chiropractic | Up to 26 office visits per policy period before notice or prior authorization may be required (376.1230). Copays no more than 50% of the service cost (376.391). |
| PT and OT | Cost sharing no greater than a primary care office visit (376.1235) |
| Telehealth | Can't be denied, or carry higher cost sharing, when the service would be covered face to face (376.1900) |
| Oral cancer drugs | Covered no less favorably than IV or injected anticancer drugs (376.1257) |
| Autism | Coverage can't be denied or restricted because of an autism or developmental disability diagnosis (376.1224) |
| PKU and amino acid disorders | Formula coverage for children under 6. Coinsurance no more than 50%, and an annual maximum of at least $5,000 (376.1219) |
| Cancer clinical trials | Routine patient care costs in phase II, III or IV trials (376.429) |
| Cancer screenings | Per current American Cancer Society guidelines (376.1250) |
| Dental anesthesia | For children under 5, the severely disabled, or those whose condition needs hospitalization or general anesthesia (376.1225) |
Some coverages only have to be offered:
- Diabetes coverage, including gestational, type I and type II (376.385).
- Coverage under 376.781, which may be rejected in writing.
- Treatments under 376.1200, which has a lifetime maximum of at least $100,000. The offer must be accepted in writing.
Formulary changes: at least 30 days' notice before deleting a drug, other than for a generic substitution, from the formulary for enrollees taking it (376.392).
Managed care grievances (376.1378–376.1389)
| Step | Deadline |
|---|---|
| Acknowledge a grievance | 10 working days |
| Complete the investigation | 20 working days, extendable by 30 working days with written reasons |
| Expedited decision | Oral notice within 72 hours, with written confirmation within 3 working days |
- Grievance panels include other enrollees and carrier staff who weren't involved.
- Grievances the Director doesn't resolve go to an independent review organization. Its decision is final.
- Enrollees must be told they can contact the Director's office, with a toll-free number.
- Electronic claims: receipt is acknowledged electronically within 48 hours (376.383).
Renewability and advertising
- Individual health coverage renews at the individual's option. It may be nonrenewed only for listed reasons, such as nonpayment, fraud, market exit or moving out of the service area (376.454).
- HMO advertising and solicitation may not be untrue or misleading (354.460).
- Advertising files are kept 4 years (20 CSR 400-5.700).
Common exam traps
- Newborns are covered at birth, with notice and premium due within 31 days.
- Adoption coverage starts at birth if the petition is filed within 30 days.
- Mammograms: baseline at 35–39, then yearly at 40+, with no referral.
- Maternity: 48 / 96 hours.
- Child immunizations to age 5 carry no cost sharing.
- Grievances: acknowledge in 10, resolve in 20 working days. Expedited decisions in 72 hours.
Practice Medical Plans questions All Accident & Health topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
