Missouri SB 262 Modifies various provisions relating to health insurance 5/17/13 Truly Agreed To and Finally Passed

CCS/HCS/SS/SB 262 – This act modifies various provisions relating to health insurance.

HMOS AND DEDUCTIBLE PLANS – Under current law, health maintenance organizations (HMOs) are not allowed to charge deductibles for basic health care services. This act allows health maintenance organizations to charge deductibles and coinsurance for basic health care services. The act specifically provides that HMOs shall have the power to offer as an option one or more health benefit plans which contain deductibles, coinsurance, coinsurance differentials, or variable copayments. These types of health benefit plans must be combined with any health savings accounts as described under federal law. The total out-of-pocket expenses under the plan shall not exceed the annual contribution limits for health savings accounts and the health savings account must be sufficiently funded so that reimbursement for qualified medical expenses is made to a health care provider within 30 days of the submission of a claim (Sections 354.410, 354.415 and 354.430). These provisions are also contained in SB 403 (2013).

EXCLUSIVE IN-NETWORK PLANS – Under the terms of this act, HMOs and other health carriers may offer health benefit plans that are managed care plans that require all health care services to be delivered by participating providers in the HMO’s or health carrier’s network. The exclusive in-network plan shall not apply to emergency services and certain mental health benefit services. An exclusive in-network plan must be disclosed in the enrollment application and in the policy form. Whenever a health carrier offers a health benefit plan to a group contract holder as an exclusive or full replacement health benefit plan, the 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 out-of-network option shall be made by the enrollee and not the group contract holder. The health benefit plan 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 (Sections 376.426 and 376.777). The provisions contained in section 376.426 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 federal law is unconstitutional or otherwise infirm. These provisions are also contained in SB 403 (2013).

INDIVIDUAL AND GROUP POLICY FORM APPROVAL PROCESS – This act modifies the process for approving group and individual health insurance policy forms. If a policy form is disapproved by the director, all specific reasons for nonconformance shall be stated in writing within 45 days from the date of filing. The failure of the director to take action approving or disapproving a submitted policy form within 45 days (currently not to exceed 60 days) from the date of the filing, shall be deemed approval of the policy form. 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 must notify the health carrier of the specific provisions that are contrary to state law and request that the health carrier file, within 30 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. The amendment shall have the force and effect as if the amendment was in the original filing or policy (Sections 376.405 and 376.777). These provisions are also contained in SB 403 (2013).

MISSOURI HEALTH INSURANCE POOL – TRANSITION TO FEDERAL HEALTH INSURANCE EXCHANGE – Under the terms of this act, the board of directors and employees of the Missouri Health Insurance Pool are authorized to provide assistance and resources to any department, agency, public official, employee or agent of the federal government for the purpose of transitioning pool enrollees to coverage outside of the pool on or before January 1, 2014. This authority does not authorize the pool to establish a state-based exchange (Section 376.961).

Under the act, the board must submit amendments to the pool’s plan of operation as are necessary to ensure a reasonable transition period to allow for the termination of issuance of policies by the pool. The plan of operation amendments shall address the transition of pool enrollees to alternative health insurance coverage as it is available 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 (Section 376.962).

Under the terms of the act, the Missouri Health Insurance Pool shall not issue new health insurance policies on or after January 1, 2014 (Section 376.964). Coverage under the Missouri Health Insurance Pool shall expire on January 1, 2014 (Section 376.966).

Under the act, the board shall invite all insurers and third-party administrators to submit bids to serve as the administering insurer or third-party administrator for the pool. The board shall make its selection prior to January 1, 2014. Beginning January 1, 2014, the administering insurer or third-party administrator shall submit to the board and the director a detailed plan outlining the winding down of operations of the pool (Sections 376.968 and 376.970)

Assessments under the pool shall continue until all claims have been paid. Any assessments remaining shall be deposited in the state general revenue fund (Section 376.973).

ACTUARIAL ANALYSIS OF CERTAIN HEALTH INSURANCE MANDATES – Under this act, the Oversight Division of the Joint Committee on Legislative Research must conduct an actuarial analysis of the cost impact to consumers, health insurers, and other private and public payers if a state mandate was enacted to provide health benefit plan coverages for:

(1) Orally administered anticancer medications charged at the same out-of-pocket cost as intravenously administered or injected cancer medications;

(2) Diagnosis and treatment of certain eating disorders that include residential treatment and access to psychiatric and medical treatments.

Under the terms of the act, the division director must submit a report of the actuarial findings to the Speaker of the House of Representatives, President Pro Tem of the Senate, and the chair of the House Special Committee on Health Insurance and the Senate Small Business, Insurance and Industry Committee by December 31, 2013. The actuarial analysis shall assume that the mandated coverage will not be subject to any greater deductible or copayment than other health care services provided under a health benefit plan and will not apply to a supplemental insurance policy. The cost for each actuarial analysis cannot exceed $30,000 and the division may utilize any actuary contracted to perform services for the Missouri Consolidated Health Care Plan to perform the analysis required under the act. The provisions regarding the actuarial analysis expire December 31, 2013 (Section 376.1192). This portion of the act is similar to SB 161 (2013).

UTILIZATION REVIEW PROCEDURE – This act updates Missouri’s current utilization review procedure so that health carriers may notify health care providers of certain insurance determinations in an electronic manner. Current law only allows health carriers to notify providers by telephone (Section 376.1363). This portion of the act may also be found in SB 403 (2013).

CREDENTIALING OF HEALTH CARE PRACTITIONERS – This act outlines the requirements for a health carrier to credential a health care practitioner within 60 business days of receiving a completed application and to pay the practitioner for treatment services pending approval. “Credentialing” is defined as 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. “Completed application” is defined as a practitioner’s application to a health carrier that seeks such 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 or the accompanying instructions.

The sixty-day deadline established in this portion of the act 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) 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.

The Department of Insurance, Financial Institutions and Professional Registration shall establish a mechanism for reporting alleged violations of this act to the department.

This act is substantially similar to SB 742 and HB 1490 (2012)(Sections 376.1575 and 376.1578).

TELEHEALTH HEALTH INSURANCE COVERAGE – Under this act, health carriers issuing or renewing health benefit plans on or after January 1, 2014, shall not deny coverage for a health care service on the basis that the service was provided through telehealth if the same service would be covered when delivered in person.

Under the act, 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.

The act does not require a health carrier to reimburse a telehealth provider or a consulting provider for technological fees or costs for the provision of telhealth services. However, a health carrier must reimburse a telehealth provider for the diagnosis, consultation, or treatment of an insured delivered through telehealth on the same basis that the health carrier covers the service when it is delivered in person.

Under the act, a health care service provided through telehealth services shall not be subject to any greater deductible, copayment, or coinsurance amount than would be applicable if the same health care service was provided through face-to-face diagnosis, consultation, or treatment.

The act allows health carriers to undertake utilization review to determine the appropriateness of telehealth as a means of delivering a health care service. Utilization review determinations, however, must be made in the same manner as those regarding the same service when it is delivered in person.

The act allows a health carrier or health benefit plan to 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.

The provisions of the act do not apply to certain types of supplemental insurance policies such as accident-only policies or Medicare supplement policies.

The telehealth mandate portion of the act has an effective date of January 1, 2014 (Section 376.1900 and Section B).

MISSOURI ORAL CHEMOTHERAPY PARITY INTERIM COMMITTEE – This act establishes the Missouri Oral Chemotherapy Parity Interim Committee to study the disparity in patient co-payments between orally and intravenously administered chemotherapies, the reasons for the disparity, and the patient benefits in establishing co-payment parity between oral and infused chemotherapy agents. The committee must consider information on the costs or actuarial analysis associated with the delivery of patient oncology treatments. Under the act, the committee is comprised of 16 members, including 4 legislators. All members, except for the members from the General Assembly, are to be appointed by the Governor by September 1, 2013. The Department of Insurance must provide assistance to the committee. By January 1, 2014, the committee must submit a report to the Governor, Speaker of the House of Representatives, President Pro Tem of the Senate, and the appropriate legislative committees of the General Assembly regarding the results of the study and any legislative recommendations. This provision is also contained in HCS/HBs 593 & 695 (2013)(Section 338.321).

LICENSURE OF NAVIGATORS – This act provides that no individual or entity shall perform, offer to perform, or advertise any service as a navigator in Missouri or receive navigator funding from Missouri or a health insurance exchange unless licensed as a navigator by the Department of Insurance, Financial Institutions and Professional Registration.

Under the act, navigators may 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. In addition, navigators may facilitate the selection of a qualified health plan and initiate the enrollment process. Navigators may 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.

Unless properly licensed as a health insurance producer in this state, 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.

The act specifically exempts certain entities from the licensure requirements. Specifically, health insurance producers, law firms, licensed attorneys, and certain health care providers are exempt from licensure.

The act delineates the process for obtaining a navigator license, including the qualifications for obtaining such a license, the payment of licensing fees, and other ancillary matters.

A navigation license is valid for 2 years. The act sets forth the process for renewing a navigator license. In order to renew a license, an individual licensee must comply with any training and continuing education requirements established by the director. Failure to satisfy training and continuing education requirements shall result in the expiration of the license.

Under the act, any navigator who has contact with a person who acknowledges having existing health insurance coverage obtained through an insurance producer must advise the person to consult with a licensed insurance producer regarding coverage in the private market.

The act establishes a procedure for suspending, revoking, or refusing to issue or renew a navigator license. The grounds for suspension or revocation are similar to the grounds for suspending an insurance producer license. A navigator license may also be suspended or revoked for engaging in unfair trade practices.

The act allows the director to issue administrative orders and maintain civil actions against persons who are violating the navigator licensure provisions. Under the act, a violation of the navigator licensure provisions is a level 2 violation under the state insurance code.

Under the terms of the act, each licensed navigator shall report to the director within 30 calendar days of the final disposition of the matter of any administrative action taken against him or her in another jurisdiction or by another governmental agency in this state. The act further requires, within 30 days of the initial pretrial hearing date, a navigator to report any criminal prosecution of the navigator in any jurisdiction.

The provisions pertaining to navigator licensing are severable. The act authorizes the director to promulgate rules and regulations to implement the licensing provisions.

This act provides that the Department of Insurance 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 (Section 1).

The navigator provisions are subject to an emergency clause. This portion of the act is similar to the provisions contained in SB 401 and SB 403 (2013)(Sections 376.2000 to 376.2014).

ACCEPTANCE INTO CLOSED OR EXCLUSIVE HEALTH CARRIER NETWORKS – This act requires health carriers to accept any willing licensed physician into its closed or exclusive network established under the act who agrees to accept a fee schedule, payment or reimbursement rate that is 15% less than the health carrier’s standard prevailing or market fee schedule, payment or reimbursement rate for such network in the specific geography of the licensed physician’s practice. The provisions of this portion of the act shall not apply to any licensed physician who does not meet the health carrier’s selection standards and credentialing criteria or who has not entered into the health carrier’s standard participating provider agreement (Section 376.325).

STEPHEN WITTE

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