SB 0856 Makes various changes to the managed care statutes
LR Number:3821L.05F Fiscal Note:3821-05
Committee:Aging, Families and Mental Health
Last Action:05/12/00 - In Conference Journal page:
Title:HS HCS SB 856
Effective Date:August 28, 2000
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Current Bill Summary

CCS/HS/HCS/SB 856 - This act makes several changes to the managed care statutes.

SECTION 198.530 - This act makes a technical drafting change. Clarifies that a managed care organization is to be certified by the Department of Insurance rather than the Department of Health.

SECTION 354.603 - This act clarifies that Section 354.603, RSMo, does not require providers to submit copies of their income tax returns to a health carrier. The entity may require a provider to obtain audited financial statements if the provider receives 10% or more of the total medical expenditures made by the health carrier.

SECTION 354.618 - Provides for direct access to a participating obstetrician or gynecologist within the provider network. A health carrier shall not impose additional copayments or deductibles for accessing such health service unless they are imposed on other types of health care services received within the network.

SECTION 376.383 - This act specifies that the "prompt pay" provisions of Section 376.383 apply after a health carrier receives a claim for a health care service provided in this state. The current statute applies when a carrier receives a claim from a person entitled to reimbursement. The carrier is also required to provide, within 45 days of receiving the claim, a complete description of all additional information that is necessary to process the entire claim. A carrier may combine interest payment and make payment once the aggregate amount reaches five dollars.

This act allows a person who has filed a claim for reimbursement for a health care service to file a civil action against a carrier for violations of the "prompt pay" provisions of Section 376.383. If the court finds a violation of this section, it shall award the plaintiff $50 per day beginning ten days following the date interest began to accrue in addition to the claimed reimbursement and interest.

SECTION 376.384 - This act requires health carriers, when processing claims, to permit providers to file confirmation numbers of authorized services and claims for reimbursement in the same format, to allow providers to file claims for reimbursement for a period of at least one year following the provision of a health care service, to issue within 24 hours an electronic confirmation of receiving a claim for reimbursement, and to accept all medical codes and modifiers used by the Health Care Financing Administration. Requires carriers to accept reimbursement claims electronically and requires the Department of Insurance to promulgate rules regarding the format of such forms.

This act requires health carriers to furnish providers with a current fee schedule for reimbursement amounts of covered services for which the health carrier is contracted to provide. This act also prohibits carriers from requesting a refund against a claim more than 12 months after a carrier has paid the claim except in cases of fraud or misrepresentation by the provider. This act requires health carriers to provide Internet access to a current provider directory. This act requires health carriers to inform enrollees of any denial of health care coverage. The explanation must be in plain language that is easy for a layperson to understand.

Effective July 1, 2001, this act requires health carrier to issue each enrollee a card which includes a telephone number for the plan, prescription drug information, and a brief description of the enrollee's plan. A card must be reissued if there is a change in coverage that impacts the information on the card.

SECTION 376.406 - This act requires health carriers to provide, upon proper notification, an enrollee with the forms and instructions necessary to enroll a newly born child if an application is required in order to continue coverage beyond the thirty-one day period after the child's birth. The health carrier shall allow the enrollee an additional 10 days from the date the forms are provided in which to enroll the newly born child.

SECTION 376.419 - This act prohibits "hold harmless" clauses that require a health care provider to assume the sole liability of the provision of health care services. Any contract between a health care provider and a health carrier shall include a clause which states that each party will be responsible for its own negligence or intentional wrongdoing. Each party to the contract shall hold harmless and indemnify the other party against claims as a result of the party's own negligence or intentional wrongdoing.

SECTIONS 376.893 & 376.895 - This act requires insurers, upon request, to provide both parents of a covered child with coverage information regardless of whether the parent is the primary policyholder.

SECTION 375.1350 - This act adds prescription medication to the definition of health care service, modifies the definition of certification to include a determination that the health care service is a covered benefit under the plan.

SECTION 376.1361 - This act requires health carriers to notify the dispensing pharmacist, prescribing physician, and enrollee when a nonformulary drug is authorized for a limited period of time. This act allows a health carrier to retract a prior authorization of a health care service if the enrollee's coverage under the plan has exceeded the enrollee's lifetime or annual benefits limit.

SECTION 376.1367 - This act requires a health carrier to provide authorization for emergency services within 45 minutes.

SECTIONS 376.1405 - 376.1498 - This act requires health carriers to use, after January 1, 2003, standardized forms for referrals and the explanation of benefits. The Department of Insurance must establish a task force by January 1, 2002, to develop the standardized forms. This act requires health carriers to make formulary information to participating pharmacists through the Internet or other electronic means. These provisions are preempted if the federal government develops its own standardized forms for use.

SECTION 1 - This act requires all managed care organizations to allow enrolles the right to select long-term care facilities which have the same religious orientation as demonstrated by the enrollee. If a religiously appropriate facility is not within the managed care organization's provider network, it shall provide the enrollee the option to receive care from an out-of- network long-term-care facility. In order to receive care from an out-of-network long-term-care facility, the facility must be willing to provide its services to the resident; the facility and its health care professionals must meet all licensing and training standards prescribed by law; the facility must be certified through Medicare; and the facility must agree to abide by the terms and conditions of the managed care organization's contract with similar providers. The managed care organization shall reimburse the facility at a rate consistent with the carrier's contract with the Health Care Financing Administration for long-term care services.