Missouri Senate

House Committee Substitute

ESTABLISHING PHYSICIAN/PATIENT RELATIONSHIP- Under current law, prior to prescribing a drug or other treatment through the internet, the physician must establish a physician-patient relationship. Under this act, this relationship shall include obtaining medical history and performing a physical examination of the patient, whether in person or via telehealth (Section 334.108).

HMOS AND DEDUCTIBLE PLANS - 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. The act specifically provides that HMOs shall have the power to offer as an option one or more health benefit plans which contain deductibles, coinsurance, coinsurance differentials, or variable copayments. These types of health benefit plans must be combined with any health savings accounts as described under federal law. The total out-of-pocket expenses under the plan shall not exceed the annual contribution limits for health savings accounts and the health savings account must be sufficiently funded so that reimbursement for qualified medical expenses is made to a health care provider within 30 days of the submission of a claim (Sections 354.410, 354.415 and 354.430). These provisions are also contained in SB 403 (2013).

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). These provisions are also contained in SB 403 (2013).

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 if the health carrier files the amendment form within 30 days of the request of the department (Sections 376.405 and 376.777). These provisions are also contained in SB 403 (2013).

MISSOURI HEALTH INSURANCE POOL -TRANSITION TO FEDERAL HEALTH INSURANCE EXCHANGE - Under the terms of this act, the board of directors and employees of the Missouri Health Insurance Pool are authorized to provide assistance and resources to any department, agency, public official, employee or agent of the federal government for the purpose of transitioning pool enrollees to coverage outside of the pool on or before January 1, 2014. This authority does not authorize the pool to establish a state-based exchange (Section 376.961).

Under the act, the board must submit amendments to the pool's plan of operation as are necessary to ensure a reasonable transition period to allow for the termination of issuance of policies by the pool. The plan of operation amendments shall address the transition of pool enrollees to alternative health insurance coverage as it is available January 1, 2014. The plan of operation shall also address procedures for finalizing the financial matters of the pool, including assessments, claims expenses, and other matters (section 376.962).

Under the terms of the act, the Missouri Health Insurance Pool shall not issue new health insurance policies on or after January 1, 2014 (Section 376.964). Coverage under the Missouri Health Insurance Pool shall expire on January 1, 2014 (Section 376.966).

Under the act, the board shall invite all insurers and third-party administrators to submit bids to serve as the administering insurer or third-party administrator for the pool. The board shall make its selection prior to January 1, 2014. Beginning January 1, 2014, the administering insurer or third-party administrator shall submit to the board and the director a detailed plan outlining the winding down of operations of the pool (Sections 376.968 and 376.970)

Assessments under the pool shall continue until all claims have been paid. Any assessments remaining shall be deposited in the state general revenue fund (Section 376.973).

ACTUARIAL ANALYSIS OF CERTAIN HEALTH INSURANCE MANDATES - Under this act, the Oversight Division of the Joint Committee on Legislative Research must conduct an actuarial analysis of the cost impact to consumers, health insurers, and other private and public payers if a state mandate was enacted to provide health benefit plan coverages for:

(1) Orally administered anticancer medications charged at the same out-of-pocket cost as intravenously administered or injected cancer medications;

(2) Diagnosis and treatment of certain eating disorders that include residential treatment and access to psychiatric and medical treatments.

Under the terms of the act, the division director must submit a report of the actuarial findings to the Speaker of the House of Representatives, President Pro Tem of the Senate, and the chair of the House Special Committee on Health Insurance and the Senate Small Business, Insurance and Industry Committee by December 31, 2013. The actuarial analysis shall assume that the mandated coverage will not be subject to any greater deductible or copayment than other health care services provided under a health benefit plan and will not apply to a supplemental insurance policy. The cost for each actuarial analysis cannot exceed $30,000 and the division may utilize any actuary contracted to perform services for the Missouri Consolidated Health Care Plan to perform the analysis required under the act. The provisions regarding the actuarial analysis expire December 31, 2013 (Section 376.1192). This portion of the act is similar to SB 161 (2013).

FEE CAPPING OF DENTAL SERVICES - This act prohibits a contract between a health carrier and a dentist from requiring the dentist to provide dental services to an insured at a fee established by the health carrier if the dental services are not covered under the plan. This portion of the act is similar to SB 281 (2013), HB 346 (2013) and HB 1050 (2012)(Section 376.1226).

PRESCRIPTION EYE DROPS - This act requires a health carrier that offers or issues plans which are issued or renewed on or after January 1, 2014, that provide coverage for prescription eye drops, to provide coverage for refilling the eye drop prescription prior to the last day of the insured's dosage period without regard to a restriction for an early refill as long as the prescribing health care provider authorizes the early refill and the health carrier or health benefit plan is notified. The coverage must not be subject to any greater deductible or co-payment than other similar health care services provided by the health plan. The act exempts certain supplemental insurance policies from its provisions. This portion of the act terminates on January 1, 2017. This portion of the act is similar to SB 147 (2013), SB 622 (2012) and HB 1081 (2012) (Section 376.1237).

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). This portion of the act may also be found in SB 403 (2013).

CREDENTIALING OF HEALTH CARE PRACTITIONERS - This act outlines the requirements for a health carrier to credential a health care practitioner within 90 days of receiving a completed application and to pay the practitioner for treatment services pending approval. "Credentialing" is defined as a health carrier's process of assessing and validating the qualifications of a practitioner to provide patient care services and act as a member of the health carrier's provider network. "Completed application" is defined as a practitioner's application to a health carrier that seeks such authorization for the practitioner to provide patient care services as a member of the health carrier's network and does not omit any information which is clearly required by the application form or the accompanying instructions.

The ninety-day deadline established in this act shall not apply if the application or subsequent verification of information indicates that the practitioner has:

(1) A history of behavioral disorders or other impairments affecting the practitioner's ability to practice, including but not limited to substance abuse;

(2) Disciplinary actions against the practitioner's license to practice imposed by any state or territory or foreign jurisdiction;

(3) Had the practitioner's hospital admitting or surgical privileges or other organizational credentials or authority to practice revoked, restricted, or suspended based on the practitioner's clinical performance; or

(4) A judgment or judicial award against the practitioner arising from a medical malpractice liability lawsuit.

The Department of Insurance, Financial Institutions and Professional Registration shall establish a mechanism for reporting alleged violations of this act to the Department.

This act is substantially similar to SB 742 and HB 1490 (2012)(Sections 376.1575 and 376.1578).

TELEHEALTH HEALTH INSURANCE COVERAGE - Under this act, health carriers issuing or renewing health benefit plans on or after January 1, 2014, shall not deny coverage for a health care service on the basis that the service was provided through telehealth if the same service would be covered when delivered in person.

Under the act, a health carrier may not exclude an otherwise covered health care service from coverage solely because the service is provided through telehealth rather than face-to-face consultation or contact between a health care provider and a patient. Subject to approval by the health carrier, health care services may be provided by telehealth providers without any prior face-to-face consultation or contact between a health care provider and a patient.

The act does not requires a health carrier to reimburse a telehealth provider or a consulting provider for technological fees or costs for the provision of telhealth services. However, a health carrier must reimburse an telehealth provider for the diagnosis, consultation, or treatment of an insured delivered through telehealth on the same basis that the health carrier covers the service when it is delivered in person.

Under the act, a health care service provided through telehealth services shall not be subject to any greater deductible, copayment, or coinsurance amount than would be applicable if the same health care service was provided through face-to-face diagnosis, consultation, or treatment.

The act allows health carriers to undertake utilization review to determine the appropriateness of telehealth as a means of delivering a health care service. Utilization review determinations, however, must be made in the same manner as those regarding the same service when it is delivered in person.

The act allows a health carrier or health benefit plan to limit coverage for health care services that are provided through telehealth to health care providers that are in a network approved by the plan or the health carrier.

The provisions of the act do not apply to certain types of supplemental insurance policies such as accident-only policies or Medicare supplement policies.

The telehealth mandate portion of the act has an effective date of January 1, 2014 (Section 376.1900 and Section B).

STEPHEN WITTE