Missouri Senate

House Amendment

REIMBURSEMENT

Subject to appropriations, the Department of Social Services shall establish an equal reimbursement rate for the same or similar services rendered by physicians and optometrists

to MO HealthNet patients.

THIRD PARTY PAYERS

Under this act any third party payer, such as third party administrators, administrative service organizations, health benefit plans and pharmacy benefits managers, shall process and pay all properly submitted MO HealthNet subrogation claims using standard electronic transactions or paper claims forms for a period of three years from the date services were provided or rendered. However, such third party payers shall not:

(1) Be required to reimburse for items or services which are not covered under MO HealthNet;

(2) Deny a claim submitted by the state solely on the basis of the date of submission of the claim, 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;

(3) Be required to reimburse for items or services for which a claim was previously submitted to the third party payer by the health care provider or the participant and the claim was properly denied by the third party payer for procedural reasons, except for timely filing, type or format failure to present proper documentation of coverage at the point of sale, or failure to obtain prior authorization;

(4) Be required to reimburse for items or services which are not covered under or were not covered under the plan offered by the entity against which a claim form for subrogation has been filed.

Such third party payers shall reimburse for items or services to the extent that the entity would have been liable as if it had been properly billed at the point of sale, and the amount due is limited to what the entity would have paid as if it has been properly billed at the point of sale. The MO HealthNet Division shall also enforce its rights within six years of a timely submission of a claim.

Certified computerized MO HealthNet records shall be prima facie evidence of proof of moneys expended and the amount due the state.

This act contains provisions that are similar SB 799 (2010) and similar to SB 809 (2010) and to SB 552 (2009).

ADRIANE CROUSE

HA 1- OFFERED BY REP. ICET - REMOVES REFERENCES TO CHAPTER 208 [THE MO HEALTHNET CHAPTER] FROM THE SECTIONS RELATING TO THE IN-HOME PROVIDER TAX. IT ALSO EXTENDS THE EXPIRATION DATE FOR THE PROVIDER TAX FROM 2011 TO 2012.

HA 2- OFFERED BY REP. SATER - ADDS: (1) THE INSURANCE PREMIUM TAX EXPANSION FOR MEDICAID MANAGED CARE ORGANIZATIONS; (2) EXEMPTION FOR MO HEALTHNET FROM PAYING MEDICARE PART B DEDUCTIBLE AMOUNTS FOR HOSPITAL SERVICES; (3) REPEAL OF PUBLIC HOSPITAL EXEMPTION FROM THE HOSPITAL REIMBURSEMENT ALLOWANCE; (4) INDEPENDENT THIRD PARTY ASSESSMENT FOR HOME AND COMMUNITY-BASED SERVICES; AND (5) TELEPHONY REQUIREMENT.

THIS AMENDMENT IS IDENTICAL TO PROVISIONS IN HCS/SS/SCS/SB 1007 (2010).

HA 1 TO HA 2- OFFERED BY REP. COOPER - ADDS DIABETIC EDUCATION AND INITIAL DIABETIC MANAGEMENT TRAINING TO LIST OF COVERED MO HEALTHNET SERVICES.

THIS AMENDMENT IS IDENTICAL TO PROVISIONS IN HCS/SS/SCS/SB 1007 (2010).

HA 2 TO HA 2- OFFERED BY REP. TISHAURA JONES - REQUIRES THE DEPARTMENT OF HEALTH AND SENIOR SERVICES TO ESTABLISH TELEPHONY PILOT PROGRAMS AND REPORT TO THE GOVERNOR AND GENERAL ASSEMBLY ON THE PROGRAM. ALLOWS FOR A MINORITY REPORT IF CONSENSUS CANNOT BE REACHED. NO INTERESTED PARTY SHALL BE REQUIRED TO CONTRACT WITH ANY PARTICULAR TELEPHONY VENDOR.

THIS AMENDMENT IS SIMILAR TO PROVISIONS IN SS/SCS/SB 1007 (2010).

HA 4 TO HA 2- OFFERED BY REP. STORCH - PROVIDES THAT THE THIRD PARTY ASSESSMENT FOR HOME AND COMMUNITY-BASED SERVICES SHALL EXPIRE IN THREE YEARS.

HA 3- OFFERED BY REP. MOHLENDORP - PROHIBITS ANY CONTRACT BETWEEN A HEALTH INSURER AND A DENTIST FROM REQUIRING THE DENTIST TO PROVIDE SERVICES IN A DENTAL PLAN AT A FEE ESTABLISHED BY THE INSURER IF THE SERVICES ARE NOT COVERED IN A PLAN.

THIS AMENDMENT IS IDENTICAL TO HB 1620 (2010).

HA 4- OFFERED BY REP. NANCE - PROVIDES FOR STATE CHILDREN'S HEALTH INSURANCE [SCHIP] ENROLLMENT OUTREACH BY CHILD CARE PROVIDERS AND SCHOOLS.

THIS AMENDMENT IS IDENTICAL TO PROVISIONS IN SS/HCS 1270 (2010).