SS/SCS/HS/HCS/HB 121 - This act modifies provisions in the law relating to managed care chiropractic services.

New language in section 354.085 holds that whenever a health service corporation or a health maintenance organization submits a policy form to the Director of Insurance, and the Director does not disapprove the form within 45 days (up from 30 days), the form is deemed approved and is not subject to disapproval for 12 months. If during the 12-month period the Director determines that any provision of the policy is contrary to statute, the Director shall notify the health service corporation or HMO of the specific provision that is contrary to statute and may request that it file an amendment within 30 days to modify the provision so that it conforms with the statute.

Upon approval of the amendment by the Director, the health services corporation or HMO shall issue a copy of the amendment to each individual or entity in which the deemed policy form was previously issued. The health services corporation or HMO may issue the conforming amendment to the group contract holder so that it can distribute the amendment to its members or by including a copy of the amendment in the health services corporation's next scheduled mailing to its members. Such amendment have the force and effect as if the amendment was in the original filing or policy (Sections 354.085 and 354.405). (These provisions are contained within SB 452).

A managed care plan's network is deemed adequate if the managed care plan is:

(1) A Medicare + Choice coordinated care plan offered by the health carrier pursuant to a contract with the federal centers for medicare and medicaid services;

(2) A managed care plan that has been accredited by National Committee for Quality Assurance (NCQA), and such accreditation is in effect at the time the access plan is filed;

(3) The managed care plan's network has been accredited by the Joint Commission on the Accreditation of Health Organizations for network adequacy. If the accreditation applies only to a portion of the managed care plan's network, only the accredited portion will be deemed adequate; or

(4) A managed care plan that has been accredited by the Utilization Review Accreditation Commission, and such accreditation is in effect at the time the access plan is filed (Section 354.603)(This provision is contained within SB 459).

A new Section 376.1230 requires health carriers to provide coverage for chiropractic care delivered by licensed chiropractors. The coverage will include initial diagnosis and clinically appropriate and medically necessary services and supplies required to treat a diagnosed disorder. The coverage may be limited to chiropractors within the health carrier's network. Health carriers are not required to contract with a chiropractor outside the health carrier's network nor are carriers required to reimburse for services provided by a non- network chiropractor, unless prior approval has been obtained from the health carrier by the enrollee.

Enrollees may access chiropractic care within the health carrier's network for a total of 26 chiropractic office visits per policy period and may be required to provide the health carrier with notice prior to any additional visits as a condition of coverage. Health carriers may require prior authorization or notification before any follow-up diagnostic tests are ordered by a chiropractor or for any office visits for treatments in excess of 26 office visits in a policy period. Certificates of coverage for any health benefit plan are required to state the availability of chiropractic coverage under the policy and any exclusions, limitations, or conditions of coverage. The mandated chiropractic insurance coverage provided by Sections 376.1230 and 376.1231 does not extend to benefits provided under the any health plan or contract that is individually underwritten, the Medicaid program and other specified insurance policies (This provision is similar to SB 444).

A new Section 376.1231 prohibits health carriers from establishing rates, terms, and conditions of coverage for enrollees which cause a greater financial burden than for enrollees who access treatment for other physical conditions (This provision is similar to SB 444).

The act re-codifies Section 430.225, pertaining to liens of hospitals, health practitioners, and health care providers.
LORIE TOWE