Missouri Senate

Senate Substitute

PRESCRIPTION DRUG PRICES - Under this act, if the co-payment applied by a HMO or health insurer exceeds the usual and customary retail price of a prescription drug, the enrollee shall only be required to pay the usual and customary retail price of the prescription drug and there will be no further charge to the enrollee or plan sponsor for the prescription (Sections 354.535 and 376.387). These provisions are contained in SCS/SB 122 (2011).

TRANSPARENCY/HEALTH CARE COST ESTIMATOR - This act establishes provisions relating to health care quality data standardization and transparency. Criteria is established for insurers to use in programs that publicly assess and compare the quality and cost efficiency of health care providers.

A health care provider shall furnish a patient without health insurance, upon request, a timely cost estimate for any elective or non-emergency health care service. Health carriers or third party benefit administrators are required, by July 1, 2012, to utilize a web-based estimating system or other mechanism, by which covered individuals, or their parents or guardians, will be able to enter, provide, or select from menus, the procedures, tests, or services the individual is considering having, and based upon the individual's benefit plan and the health carrier's internal data, receive estimates of the total cost and total out-of-pocket cost of the procedures, test, or services specific to all available contracted providers or facilities for which such estimates are requested. The provision of estimates under this act shall not be construed as violating any provider contract provisions with a health carrier that prohibits disclosure of a provider's fee schedule to third parties.

Insurers shall retain the services of a nationally recognized independent health care quality standard-setting organization to review the plan's programs for consumers that measure, report, and tier providers based on their performance. The program measures shall provide performance information that reflects consumers' health needs.

Consumers, consumer organizations, relevant providers and provider organizations shall be solicited to provide input on the program, including methods used to determine performance strata. A clearly defined process for consumers to resolve complaints and for providers to request review of their own performance results shall be established. All quality measures shall be endorsed by the National Quality Forum (NQF) and the act lists the other national organizations that shall be used for endorsement in the event that NQF measures do not exist for a particular level of measures.

A health plan shall be deemed compliant with the provisions of this act regarding the measurement of quality if it currently offers a program that has been granted or awarded certification from the National Committee for Quality Assurance (NCQA) as of January 1, 2012. Any non-accredited health plan shall offer an accredited program upon a contract renewal with a provider on or after January 1, 2013.

A person who sells or distributes health care quality and cost efficiency data in a comparative format to the public is required to identify the source used to confirm the validity of the data and its analysis as an objective indicator of health care quality. This provision does not apply to articles or research studies that are published in peer-reviewed academic journals, nonprofit community-based organizations, or by state or local governments. The Department of Health and Senior Services shall investigate complaints of alleged violations of this provision by a person or entity other than a health carrier and shall be authorized to impose a penalty not to exceed $1,000. Alleged violations by a health insurer shall be investigated by the Department of Insurance, Financial Institutions and Professional Registration. (Sections 191.1005 to 191.1011). These provisions are contained in SCS/SB 122, SB 153(2011), and HB 475 (2011).

PROVIDER TAXES - This act extends the sunsets from September 30, 2011 to September 30, 2013, for the Ground Ambulance, Nursing Facility, Medicaid Managed Care Organization, Hospital, Pharmacy, and Intermediate Care Facility for the Mentally Retarded Reimbursement Allowance Taxes (sections 190.839, 198.439, 208.437, 208.480, 338.550, and 633.401). These provisions are similar to SB 322 (2011) and identical to SB 235 (2011).

STEPHEN WITTE