Managed Care Section

The Managed Care Section oversees the activities of HMOs, reviews company applications for new certificates of authority or service area changes and analyzes trends in activities of Missouri HMOs. Missouri had 23 licensed HMOs at the end of 2002. Of 115 Missouri counties, 108 are part of an HMO service area that allows the HMO to sell coverage to an employer. (The exceptions are Bollinger, Cape Girardeau, Marion, Mississippi, Scott, Shelby and Stoddard.) But every county in Missouri has some HMO enrollment. HMO penetration remains highest in the Kansas City and St. Louis areas. Few HMOs sell individual/family plans.

The Managed Care Section reviews quarterly utilization, cost and enrollment data from all active HMOs to ensure health care services are provided to Missouri enrollees. The information filed by HMOs allows Insurance to track activities such as pharmaceutical costs, enrollment demographics, utilization of basic services, per-member-per-month costs and managed care penetration in Missouri. The Managed Care Section uses this data and financial statements to publish the HMO Annual Report.

All HMOs must file annual network plans to ensure that enrollees have timely access, within reasonable traveling time, to health care providers that they must use. The access plan also must include written documentation on each HMO’s procedures in eight areas of network and plan operations. In 2002, the Managed Care Section reviewed 35 networks (some HMOs have multiple networks), and all eventually came into compliance with state standards.

Commercial, Medicare and Medicaid enrollment in HMO plans in Missouri dropped to 1.4 million in 2002, or by 4.3 percent - the third decline in four years. This drop is associated with rising premiums for HMO products, which increased 21 percent in 2001 and 14 percent in 2002, and employee preference for less restrictions on provider choice.

Comprehensive information on Missouri licensed HMOs is available in the HMO Annual Report. All information filed with the Managed Care Section is open to the public, except some data filed with the network access plans.