Missouri Senate

Perfected

SHOW-ME HEALTH COVERAGE PLAN

This act establishes the Show-Me Health Coverage plan within the Department of Social Services to provide health care coverage through the private insurance market to low-income working individuals in the state. The Department of Insurance, Financial Institutions and Professional Registration shall provide oversight of the marketing practices of the plan while the Department of Social Services shall establish standards for consumer protection for the plan. The maximum enrollment of plan participants is dependent on the moneys appropriated by the General Assembly, and the eligibility for the plan is phased in incrementally based on appropriations. The plan is subject to approval by the United States Department of Health and Human Services.

The eligibility requirements and the services to be provided by the plan are specified in the act. The act provides coverage for individuals with incomes up to 50% of the federal poverty level without regard to type of income and for custodial parents with earned income up to 100% of the federal poverty level. There are caps for income disregards for child support, a child’s old-age survivors or disability insurance (OASDI) benefit, and unemployment benefits for persons with earned income for those with earned income between 50% and 225% of the federal poverty level, subject to appropriation. The combined amount of earned and unearned income shall not exceed 100% of the federal poverty level. Custodial parents with earned income up to 100% of the federal poverty level shall be eligible for the Show-Me Health Coverage benefit package under a Medicaid State Plan Amendment rather than through a Medicaid waiver.

The plan shall also provide for qualifying individuals as specified in the act a health care home. Under the plan, a health care account is established for each individual, except for the custodial parent population under the state plan amendment, and payments for his or her participation can be made by the individual, an employer, the state, or any philanthropic of other charitable contributor. An individual's health care account shall be used to pay the individual's deductible for health care services under the plan. A participant will be terminated from participation in the plan if his or her required payment is not made within 60 days after the required date, however the participant may reapply to participate in the plan six months after termination from the plan. Approved participants are eligible for a 12-month period but must file a renewal application to remain in the plan.

Subject to federal approval, participation in the plan by custodial parents with incomes up to 50 % of the federal poverty level shall not exceed 3 years, except that coverage may be extended for individuals either participating in a program to complete a GED, or enrolling for and completing at least 12 hours of credit each semester at a higher education institution. The continuation of coverage shall not exceed five years total. Such

individuals receiving the continuation of coverage are required to sign a condition of participation agreement attesting to the fact that the individual understands the time limit for coverage under the plan.

The show-me health coverage plan shall be void and of no effect if there are no funds appropriated by Congress or if there are no disproportionate share hospital funds applied to the program.

The MO HealthNet division is required by December 28, 2009 to identify and report to the general assembly a strategy through which at least some portion of the individuals participating in this plan using the health care accounts are included in the Missouri consolidated health care plan (MCHCP) population using a health savings account model, or whether MCHCP could administer those individuals in this plan participating in the health care accounts using the current structure in place for MCHCP participants using such model. The department and the Board of Trustees of the MCHCP shall convene a working group to assist with the development of such strategy.

These provisions have a six-year sunset clause.

These provisions are similar to a portion of SS/SCS/SB 1283 (2008). SECTIONS 208.1300 TO 208.1345

MO HEALTHNET DATA TRANSPARENCY

This act requires the MO HealthNet Division, by August 28, 2010, to implement a program to make available through its Internet web site nonaggregated data on MO HealthNet participants collected under the federal Medicaid Statistical Information System to the extent such data has already been de-identified in accordance with federal HIPAA privacy requirements.

In implementing the program the Division shall ensure that the information made available is in a format that is easily accessible, useable, and understandable to the public, including individuals interested in improving the quality of care provided to individuals eligible for programs and services under the MO HealthNet program, researchers, health care providers, and individuals interested in reducing the prevalence of waste and fraud under the program.

By August 28, 2011, and annually thereafter, the director shall submit to the General Assembly and the MO HealthNet oversight committee, a report on the progress of the program, including the extent to which information made available through the program is accessed and the extent to which comments received on the program were used during the year to improve the utility of the program.

The Division shall also report to the General Assembly the feasibility of expanding the transparency program for the health care for uninsured children program (SCHIP).

This program has a six-year sunset clause. SECTION 208.192

These provisions are based on SB 549 (2009).

MO HEALTHNET-THIRD PARTY PAYER

This act modifies provisions relating to the MO HealthNet Division's authority to collect from third party payers and from workers' compensation beneficiaries.

Under this act any third party administrator, administrative service organization, health benefit plan and pharmacy benefits manager shall process and pay all properly submitted MO HealthNet subrogation claims for a period of three years from the date services were provided or rendered, regardless of any other timely filing requirement. The entity shall not deny such claims on the basis of the type or format of the claim form, failure to present proper documentation of coverage at the point of sale, or failure to obtain prior authorization. The MO HealthNet Division shall also enforce its rights within six years of a timely submission of a claim.

Payments made by the department to or on behalf of a MO HealthNet eligible individual as the result of any workers' compensation injury shall be presumed to be benefits incorrectly paid for purposes of Mo HealthNet estate recovery and shall be considered a debt due the state. Any settlement approved or judgment issued by the administrative law judge shall constitute a judgment of a court on account of benefits incorrectly paid for Mo HealthNet estate recovery purposes.

Any settlement approved or judgment issued by an administrative law judge shall require full repayment of all moneys paid by the department to or on behalf of a person eligible for public assistance as the result of any workers' compensation injury. All moneys repaid to the department shall be allocated as medical expenses in the settlement or judgment. The state shall have a right of subrogation to any funds for medical expenses owed to or received by the employee.

The employer and attorney for an injured worker who is eligible for public assistance as a result of a workers' compensation injury shall give the department of social services thirty days notice of any institution of a proceeding, settlement, or judgment. No such settlement or judgment may be approved or issued by the administrative law judge without the filing of a release from the MO HealthNet division evidencing full repayment of all moneys paid by the department to or on behalf of the worker for the injury. SECTIONS 208.215, 287.266

These provisions are based on your SB 552 (2009).

PREMATURE INFANTS

This act modifies provisions relating to premature infants.

The act requires the MO HealthNet program and the state children's health insurance program (SCHIP) to examine and improve hospital discharge and follow-up care procedures for premature infants born earlier than 37 weeks gestational age. The programs shall also urge hospitals serving infants eligible for MO HealthNet and SCHIP to report to the state the causes and incidence of all re-hospitalizations of premature infants. SECTION 191.1127

The Department of Health and Senior Services is required to prepare written educational materials containing information about possible complications, proper care and support associated with newborn infants who are born premature at earlier than 37 weeks gestational age. The act specifies the minimum information that shall be included in the publications and provides that the department shall distribute the publications to children's health providers, maternal care providers, hospitals, public health departments and medical organizations. SECTION 191.1130

ADRIANE CROUSE