SCS/SB 403 - This act modifies several provisions of law relating to the regulation of health insurance.
HMOS AND DEDUCTIBLES -Under current law, health maintenance organizations (HMOs) are not allowed to charge deductibles for basic health care services. This act allows health maintenance organizations to charge deductibles and coinsurance for basic health care services (Sections 354.410 and 354.430).
EXCLUSIVE IN-NETWORK PLANS - Under the terms of this act, HMOs and other health carriers may offer health benefit plans that are managed care plans that require all health care services to be delivered by participating providers in the HMO's or health carrier's network. The exclusive in-network plan shall not apply to emergency services and certain mental health benefit services. An exclusive in-network plan must be disclosed in the policy form (Sections 354.603, 376.426, and 376.777).
INDIVIDUAL AND GROUP POLICY FORM APPROVAL PROCESS - This act modifies the process for approving group and individual health insurance policy forms. If a policy form is disapproved by the director, all specific reasons for noncompliance shall be stated in writing within 45 days from the date of filing. The failure of the director to take action approving or disapproving a submitted policy within 45 days (currently not to exceed 60 days) from the date of the filing, shall be deemed approval of the policy. If at any time after a policy form is approved or deemed approved, the director determines that any provision of the filing is contrary to state law, the director shall notify the health carrier of the specific provision that is contrary to state law and request that the health carrier file an amendment form that modifies the provision to conform to state law. The failure of the director to take action approving or disapproving a submitted amendment form within 45 days from the date of filing shall be deemed an approval thereof. In the event that a policy form is approved or deemed approved and is subsequently amended for state law compliance upon the department's request, the department shall not retroactively enforce the amended policy form (Sections 376.405 and 376.777).
HEALTH CARRIERS AND HIGH DEDUCTIBLE POLICIES - Under the terms of this act, any health carrier may offer as an option one or more health benefit plans which contain deductibles, coinsurance, coinsurance differentials, or variable copayments. Health benefit plans which contain deductibles may be combined with any health savings accounts (HSA) as described in federal law. However, no combination of deductibles and copayments paid for the receipt of basic health care services may exceed the annual maximum out-of-pocket expenses of a high deductible health plan as set forth in federal law. Deductibles and copayments applicable to supplemental health care services, catastrophic-only plans as defined under the Affordable Care Act, or pre-existing conditions are not subject to the annual limitations described in this portion of the act (Section 376.446).
UTILIZATION REVIEW PROCEDURE - This act updates Missouri's current utilization review procedure so that health carriers may notify health care providers of certain insurance determinations in an electronic manner. Current law only allows health carriers to notify providers by telephone (Section 376.1363).
LICENSURE OF NAVIGATORS - This act provides that no individual or entity shall perform, offer to perform, or advertise any service as a navigator in Missouri or receive navigator funding from Missouri or a health insurance exchange unless licensed as a navigator by the Department of Insurance, Financial Institutions and Professional Registration. Navigators are prohibited from engaging in activities that would require an insurance producer license. In addition, navigators are prohibited from providing advice concerning the benefits, terms, and features of a particular health plan or offering advice about which health plan is better or worse for a particular individual or employer. Navigators may not recommend or endorse a particular health plan or advise consumers about which health plan to choose or provide any information or services related to health benefit plans or other products not offered in the health insurance exchange.
The act specifies that only persons licensed as insurance producers in this state may:
(1) Sell, solicit, or negotiate health insurance;
(2) Provide advice concerning the benefits, terms, and features of a particular health plan or offer advice about which health plan is better or worse for a particular individual or employer; or
(3) Recommend a particular health plan or advise consumers about which health plan to choose.
The act delineates the process for obtaining a navigator license, including the qualifications for obtaining such a license, the payment of licensing fees, the posting of surety bonds, and other ancillary matters.
A navigation license is valid for 2 years. The act sets forth the process for renewing a navigator license. In order to renew a license, an individual licensee must comply with any training and continuing education requirements established by the director. Failure to satisfy training and continuing education requirements shall result in the expiration of the license.
Under the act, any navigator who has contact with a person who acknowledges having existing health insurance coverage obtained through an insurance producer must refer the person back to the insurance producer for information, assistance, and any other services.
The act establishes a procedure for suspending, revoking, or refusing to issue or renew a navigator license. The grounds for suspension or revocation are similar to the grounds for suspending an insurance producer license. A navigator license may also be suspended or revoked for engaging in unfair trade practices.
Under the terms of the act, each licensed navigator shall report to the director within 30 calendar days of the final disposition of the matter of any administrative action taken against him or her in another jurisdiction or by another governmental agency in this state. The act further requires, within 30 days of the initial pretrial hearing date, a navigator to report any criminal prosecution of the navigator in any jurisdiction.
The provisions pertaining to navigator licensing are severable.
The act authorizes the director to promulgate rules and regulations to implement the licensing provisions (sections 376.2000 to 376.2014).
Several provisions of this act are similar to the ones contained in the truly agreed to versio of SB 262 (2013) and in HB 701 (2013).