SB 642 - This act requires all health carriers of at least 50,000 people to expend at least 90% of their total annual Missouri-associated revenues on health care services in any given calendar year (non-health expenditures must not exceed 10% of their Missouri-associated revenue). This percentage is known as the Missouri care share under the act. The act also requires health carriers of at 25,000 persons but less than 50,000 persons to expend at least 85% of their total annual Missouri-associated revenues on health care services in any given calendar year.
The act requires health carriers to report submit an annual report to the director of the Department of Insurance, Financial Institutions and Professional Registration. The health carrier shall report its total revenues, Missouri-associated revenue, total premiums, Missouri premiums, total health expenditures, Missouri-associated health expenditures, total non-health expenditures, care share, and Missouri care share.
The director shall publish annually the care share and the Missouri care share of each health carrier doing business in the state of Missouri. All written materials used for advertising and marketing health benefit plans to prospective insured persons or groups shall include a statement of the health carrier's care share and its Missouri care share.
Under the terms of the act, any health carrier that fails to comply with the act shall refund to the persons insured by it a percentage of its Missouri-associated revenues equal to the Missouri care share required by the act for the calendar year less the Missouri care share actually expended for the calendar year. An insurer that reports a shortfall in its Missouri care share may pay the refund by reducing the total premiums payable by its insureds or enrollees for the calendar year in which the shortfall is reported by an amount equal to the total shortfall.
The act requires the director to audit the books and records of a random sample of 10% of health carriers that have more than 25,000 persons insured under health benefit plans. The director may appoint an independent auditor to conduct the audit and shall assess each health carrier a fee to pay the reasonable costs of such audit.