Missouri Regulatory Attachment Form

MISSOURI REGULATORY ATTACHMENT
As set forth in Sections [9.5 and 9.15/8.5 and 8.15 for Facility Agreement] of the Agreement, the Parties agree to abide by the terms of the Agreement, and also agree to abide by the additional requirements applicable to the provision of services to Covered Persons enrolled in commercial (e.g., not Medicare Advantage) managed care plans in Missouri are set forth in this Exhibit. This Exhibit 3 amends the Agreement to comply with legislative and regulatory requirements of the State of Missouri (e.g. Mo. Rev. Stat. § 354.400 et seq. (the “HMO Act”) and Title 20, Division 400 of the Missouri Code of Regs.) regarding provider contracts with providers rendering health care services in the State of Missouri. To the extent that such laws and regulations are applicable but not preempted by applicable federal law, the provisions of this Exhibit shall apply and, to the extent of a conflict with a provision in the Agreement and this Exhibit, this Exhibit shall control. For purposes of this Exhibit, the term “Covered Person” means an individual who is eligible under a plan insured and/or administered by Plan, and the term “Covered Services” means services that are covered under any such plan. References to [[Provider/Facility]/Facility] herein means the [Provider/Facility] listed on the signature page of the Agreement to which this Exhibit relates.

1. T o the

   extent

   that

   Covered

   Services

   are

   rendered

   by [Provider/Facility]

   to Covered

   Persons

   enrolled

   in a health

   maintenance

   or ganization (“HMO”)

   plan,

   the

   following

   provisions

   are

   hereby

   added

   to
   the

   Agreement

   to the extent

   required

   by law

   applicable

   to [Provider/Facility]:

   a. Plan shall not restrict or prohibit [Provider/Facility] from disclosing to a Covered Person information that [Provider/Facility] deems appropriate regarding the nature of treatment, risks or alternatives thereto, availability of other therapy, the decision of Plan to authorize or deny services, or the process that Plan uses to authorize or deny health care services. [Mo. Rev. Stat. § 354.441] b. [Provider/Facility] agrees that in no event, including but not limited to nonpayment by Plan, insolvency of Plan, or breach of this Agreement, shall [Provider/Facility] bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Covered Person, other Plan, acting on behalf of the Covered Person for Covered Services provided pursuant to this Agreement. This Agreement shall not prohibit [Provider/Facility] from collecting Copayments, as specifically provided in the evidence of coverage, or fees for non Covered Services delivered on a fee-for-service basis to Covered Persons. This Agreement shall not prohibit [Provider/Facility] (except for a health care professional who is employed full time on the staff of Plan and has agreed to provide service exclusively to Plan’s Covered Persons and no others) and a Covered Person from agreeing to continue services solely at the expense of the Covered Person, as long as [Provider/Facility] has clearly informed the Covered person that Plan may not cover or continue to cover a specific service or services. Except as provided herein, this Agreement does not prohibit [Provider/Facility] from pursuing any available legal remedy; including, but not limited to, collecting from any insurance carrier providing Covered Services to a Covered Person. [Mo. Rev. Stat. § 354.606.2] c. In the event of Plan’s insolvency or cessation of operations, Covered Services to Covered Persons shall continue through the period for which a premium has been paid to Plan on behalf of the Covered Person until Covered Person’s discharge from an inpatient facility, whichever time is greater. [Mo. Rev. Stat. § 354.606.3]

d. The foregoing Sections 1(b) and 1(c) of this Exhibit shall: (i) be construed in favor of a Covered Person; (ii) survive the termination of this Agreement regardless of the reason for termination, including the insolvency of Plan and (iii) supersede any oral or written agreement between [Provider/Facility] and a Covered Person if the contrary agreement is inconsistent with Sections 1(b) and 1(c) of this Exhibit. [Mo. Rev. Stat. § 354.606.4] e. Plan shall ensure that [Provider/Facility] furnishes Covered Services to Covered Persons without regard to Covered Person’s enrollment in Plan as a private purchaser of Plan or as a participant in a publicly financed program of health care service. [Mo. Rev. Stat. § 354.606.14] f. Either Party may terminate the Agreement without cause following the provision of sixty (60) days’ advance written notice to the other Party. The written notice shall include an explanation of why the contract is being terminated. Plan shall provide written notice within thirty (30) business days of issuance or receipt of a notice of termination to all Covered Persons who are seen on a regular basis by [Provider/Facility] or Participating [Provider/Facility] whose contract is terminating, irrespective of whether the termination was for or without cause. When the termination involves a Primary Care [Provider/Facility], all Covered Persons of such Primary Care [Provider/Facility] shall be notified. Within fifteen (15) business days of the date [Provider/Facility] gives or receives notice of termination [Provider/Facility] shall supply Plan with a list of those Covered Persons that are covered by Plan. [Mo. Rev. Stat. § 354.609.1] g. Upon termination of a Participating [Provider/Facility], continued care for Covered Persons shall be provided for a period up to ninety (90) days by [Provider/Facility] where continuation of care is medically necessary and in accordance with the dictates of medical prudence, including circumstances such as disability, pregnancy or life threatening illness. Covered Person shall not be liable to the [Provider/Facility] for amounts owed for Covered Services other than Copayments specified in the benefit Plan. If [Provider/Facility] is authorized to continue treating a Covered Person following termination, Plan shall have an obligation to pay [Provider/Facility] at the previously contracted rate for Covered Services provided to the Covered Person. [Mo. Rev. Stat. § 354.612] h. Notwithstanding legitimate and medically based referral patterns, neither Party shall act in a manner that unreasonably restricts a Covered Person’s access to the entire network, unless Plan has a written agreement with the Covered Person to a reduced network, and has requested an exception for a reduced network. [Mo. Rev. Stat. § 354.603.1(4)]