SB 847 Modifies provisions relating to health care
Sponsor: Schaaf
LR Number: 5245L.02I Fiscal Note not available
Committee: Veterans' Affairs and Health
Last Action: 2/27/2014 - Second Read and Referred S Veterans' Affairs and Health Committee Journal Page: S436
Title: Calendar Position:
Effective Date: August 28, 2014

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Current Bill Summary


SB 847 - This act amends provisions relating to the provision of health care.

STATE LEGAL EXPENSE FUND-MO HEALTHNET PILOT PROJECT PROVIDERS (SECTION 105.711)

This act includes under the State Legal Expense Fund certain licensed physicians under contract to provide medical care to participants in the MO HealthNet pilot project created under this act in Section 208.188. Under such circumstances, the aggregate of payments from the State Legal Expense Fund shall be limited to a maximum of 500 thousand dollars for all claims arising out of and judgments based upon the same act or acts alleged in a single cause and shall not exceed 500 thousand dollars for any one claimant. Liability or malpractice insurance obtained and maintained in force by or on behalf of any licensed physician shall not be considered available to pay that portion of a judgment or claim for which the fund is liable under this provision.

SCHOLARSHIP AND LOANS FOR RURAL PHYSICIANS (SECTION 173.228)

This act creates within the Department of Higher Education the "Board of Medical Scholarship Awards", for the purpose of awarding scholarships and loans to provide for current and prospective medical students in the University of Missouri School of Medicine or any other accredited or provisionally accredited school of medicine in this state. The recipients of loan awards shall enter into a valid agreement with the Board to practice the profession of medicine in those areas and localities of Missouri as may be determined by the Board for a number of years to be stipulated in the agreement. There is also established the Board of Medical Scholarship Awards Fund.

The act specifies the makeup and duties of the Board, including promulgating rules for implementing and administering the provisions of scholarship programs. Any recipient who fails for any reason to continue his or her medical education may, at the discretion of the Board, be required to repay all loan amounts immediately with simple interest of 8 percent annually from the date of his or her departure or removal from medical school.

The attorney general, upon request of the Board, shall institute proceedings in the name of the state for the purpose of recovering any amount due the state under this act. Any moneys recovered under this act from loan recipients or paid by recipients to the board shall be retained by the board for funding of future scholarships.

PRICE TRANSPARENCY (SECTION 191.875)

By January 1, 2015,this act requires all health care providers and insurers to provide cost estimates prior to the provision of such services, if feasible, but in no event later than 3 business days after such request. These provisions shall not apply to emergency health care services.

REPORTING OF PRICES FOR MOST COMMON PROCEDURES (SECTIONS 197.170 & 197.173)

This act requires hospitals and ambulatory surgical centers to submit to the Department of Health and Senior Services prices for 140 of the most common procedures, including 100 of the most common procedures in hospital inpatient settings as well as 20 of the most common surgery and 20 of the most common imaging procedures conducted in both outpatient hospital and ambulatory surgical settings.

The Department shall provide such information on its internet website in a manner that is easily understood by the public. Information for each hospital shall be listed separately and hospitals shall be listed in groups by category as determined by the Department through the promulgation of rules. Information for each hospital outpatient Department and each ambulatory surgical center shall also be listed separately.

The information regarding hospital inpatient procedures shall be submitted beginning with the quarter ending June 30, 2015, and quarterly thereafter. The information regarding outpatient surgical and imaging procedures shall be submitted beginning with the quarter ending September 30, 2015, and quarterly thereafter.

These provisions are identical to SB 684 (2014).

CERTIFICATE OF NEED (SECTIONS 197.300 TO 197.367)

This act amends the certificate of need (CON) law as follows:

(1) Limits the radius area for "affected persons" to a 5 mile radius of proposed new development as well as when consideration shall be given to the facilities located within the 5 mile radius when determining if a CON shall be issued;

(2) Provides that a certificate of need shall not be required for a proposed project which creates ten or more new full-time jobs;

(3) Raises the expenditure minimum for falling under CON review for capital expenditures to one million dollars and for major medical equipment to 2 million dollars;

(4) Requires all testimony and other evidence taken during the hearings to be under oath and subject to penalty of perjury;

(5) Changes the procedures and evidentiary standard at the certificate of need hearing;

(6) Prohibits all ex parte communications between members of the committee and any interested party or witness regarding the subject matter of the hearing at any time prior to, during, or after the hearing and

(7) Modifies the membership and requirements for Missouri Health Facilities Review Committee for the Certificate of Need Program.

These provisions are identical to SB 10 (2011 Special); SB 640 (2012) and substantially similar to HB 2355 (2008).

ECONOMIC CREDENTIALING (SECTION 197.710)

This act prohibits a hospital from requiring a physician to agree to make patient referrals to the hospital-affiliated facility as a condition of receiving medical staff membership or medical staff privileges at the hospital. This act also prohibits a hospital from refusing to grant medical staff membership or privileges or participatory status in the hospital because the physician or his or her partner, associate, employee, or family member provides medical or health care services at, has ownership interest in, or has a leadership position on the medical staff of another hospital, hospital system, or health care facility. Nor shall such physician be refused such privileges because he or she leases or offers for lease medical office, clinical, or other medical facility space in close proximity to or within the same geographic service area of such hospital.

The Department of Health and Senior Services may impose administration sanctions or otherwise sanction the license of a hospital in any case in which the department finds that there has been a substantial failure to comply with the requirements of this action.

This provision is substantially similar to SB 529 (2012).

MO HEALTHNET ASSET LIMITS RAISED (SECTION 208.010)

This act modifies the amount of cash, securities or other total non-exempt assets an aged or disabled participant is allowed to retain in order to qualify for MO HealthNet benefits from less than $1,000 to $2,000 for a single person and from $2,000 to $4,000 for a married couple.

This provision is identical to SB 739 (2014) and substantially similar to SB 582 (2014).

MO HEALTHNET PATIENT-CENTERED CARE ACT/HEALTH SAVINGS ACCOUNTS (SECTION 208.187)

Beginning July 1, 2015, or upon termination of any current contracted health plans in the pilot project areas and subject to federal approval, the MO HealthNet Division shall establish a pilot project which transfers current MO HealthNet recipients in the pilot project areas to an approved health plan arrangement wherein recipients may purchase health services through individual health savings accounts.

The pilot project shall be supported by a health management and population analytics system that tracks and monitors health outcomes in traditionally challenging populations, such as mothers at risk for premature births, frequent utilizers of emergency departments, and those suffering from chronic pain conditions. The system shall implement clinically based predictive models and interventions to improve the care coordination for the targeted populations within the pilot area.

Under the pilot project, the eligible government assistance amount shall be determined annually based on a survey of the commercial health market in this state and establishing the average cost of an approved health plan arrangement which is composed of direct primary care services and a high-deductible insurance plan. Such average cost shall be the government assistance amount. The act specifies the parameters for the health savings accounts.

Beginning July 1, 2017, unless the provisions of this act are repealed by an act of the General Assembly, the pilot project described in this act shall automatically be implemented on a statewide basis for all MO HealthNet recipients who are eligible to receive MO HealthNet benefits under this pilot project in accordance with federal law and state plan amendments and waivers.

MO HEALTHNET PILOT PROJECT-EBT FOR HEALTH SERVICES (SECTION 208.188)

Beginning July 1, 2015, subject to appropriations and subject to receipt of federal approval, the MO HealthNet Division shall establish a pilot project which implements an electronic benefit transfer (EBT) payment system for receipt of MO HealthNet services by participating recipients. The provisions of this act shall not apply to aged, blind, and disabled recipients. Such system shall:

(1) Allow participating recipients to receive MO HealthNet services from providers selected by the recipients through direct pay to the provider, a health insurance plan, managed care plan, health services plan, or any other available health care product providing benefits and payment for services in an approved health plan arrangement;

(2) Require the use of electronic benefit transfer (EBT) cards issued to participating recipients to pay for MO HealthNet services;

(3) Require recipients to receive an annual examination within six months of enrollment;

(4) Provide educational opportunities for recipients relating to budgeting, planning, and appropriate use of health care options;

(5) Provide incentives for recipients to seek health care services as needed, while retaining a portion of any savings achieved from efficient use of their EBT cards;

(6) Provide additional moneys to recipients for health savings accounts, payment of health insurance premiums, and other health-related costs to recipients not covered under the MO HealthNet program;

(7) Provide reimbursement of any willing providers licensed in this sate and eligible to provide services under the terms of the pilot project at a rate of one hundred percent of the Medicare reimbursement rate for the same or similar services provided; and

(8) Provide demographic and cost efficiency information to determine feasibility of statewide implementation of the EBT payment system.

The act specifies how the balance of the health savings account and amount in the EBT card will be apportioned.

The MO HealthNet Division shall establish a minimum of 3, but not more than 6, pilot project areas in this state which shall include at least 10 percent of the total MO HealthNet recipient population, excluding the aged, blind, and disabled population, in the first 2 years of the pilot project. In the third year of the pilot project, the Division may increase the total number of pilot project areas to not more than 10 and shall increase the number of participants to at least 20 percent of the total MO HealthNet recipient population, excluding the aged, blind, and disabled population. If the pilot project is automatically implemented on a statewide basis, the EBT payment system shall apply to every MO HealthNet recipient, excluding the aged, blind, and disabled population.

Any willing provider eligible to provide services under the terms of the pilot project shall be reimbursed for services provided to pilot project recipients at a rate of one hundred percent of the Medicare reimbursement rate for the same or similar services provided.

The Division shall submit annual reports to the General Assembly. Beginning July 1, 2018, unless the provisions of this act are repealed by an act of the General Assembly, the pilot project described in this action shall automatically be implemented on a statewide basis for all MO HealthNet recipients.

MO HEALTHNET CLAIMS UTILIZATION DATA (SECTION 208.440)

This act requires each MO HealthNet managed care organization to provide to the MO HealthNet division all utilization, access, and spending data for the cost of care to each MO HealthNet participant covered under the organization. Such data shall be in the form of all payments made to health care providers for services rendered to MO HealthNet participants and shall also identify claim-specific data for each patient service or procedure. The Department of Social Services may require additional information through the promulgation of rules to meet the requirements of this act.

This provision is identical to SB 334 (2011).

PRESCRIPTION COPAYS (SECTIONS 334.735 AND 354.535)

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 were contained in SB 674 (2012); SB 122 (2011) and HB 1495 (2010).

COLLABORATIVE PRACTICE ARRANGEMENTS WITH PHYSICIAN ASSISTANTS, ADVANCED PRACTICE REGISTERED NURSES AND NEWLY CREATED ASSISTANT PHYSICIANS TO SERVE RURAL OR UNDERSERVED AREAS (SECTIONS 334.035, 334.036, 334.104; 334.735)

This act allows certain medical school graduates to obtain a temporary assistant physician license in order to enter into "assistant physician collaborative practice arrangements" with a physician. An assistant physician collaborative practice arrangement shall limit the assistant physician to providing only primary care services and only in medically underserved rural or urban areas of this state. An "assistant physician", is defined as any medical school graduate who has passed the prescribed medical examinations and who has not entered into postgraduate residency training prescribed by rule of the State Board of Registration for the Healing Arts. The act prescribes the other requirements to be licensed as an assistant physician and specifies certain practices an assistant physician cannot perform.

The collaborating physician is responsible at all times for the oversight of the activities of, and accepts responsibility for, primary care services rendered by the assistant physician. A licensed assistant physician shall enter into an assistant physician collaborative practice arrangement within six months of his or her initial licensure and shall not have more than a six-month time period between collaborative practice arrangements during his or her licensure period.

The State Board of Registration for the Healing Arts shall promulgate one set of rules applicable to all three licensure categories; physician assistants, advance practice registered nurses and the newly created assistant physicians, and shall not promulgate separate rules applicable to only one licensure category.

ANY WILLING PROVIDER (SECTIONS 376.393 & 376.1425)

Under this act, each health carrier shall provide each contracted provider with access to the health carrier's standard fee schedule, specific to the provider's geographic area, through a secure website. Such fee schedule shall reflect the current payment rates for all goods and services pertinent to the provider's practice or business, defined by procedure codes, diagnosis related groups, or defined by another payment mechanism, and all contracted providers in such geographic area shall be paid for the goods and services provided at such rates, unless different rates have been specifically agreed upon contractually with an individual provider. In no case shall the standard fee schedule include a rate for a specific good or service that is less than the lowest rate individually contracted for by the providers of such good or service in the applicable geographic area if all the providers in such area have individually contracted to be paid at different rates for such good or service.

Under the act, no health carrier shall refuse to contract with any Missouri provider who is located within the geographic coverage area of a health benefit plan and who is willing to meet the terms and conditions for provider participation established for such health benefit plan if the provider is willing, as a term of such contract, to be paid at rates equal to 99% of the standard rates established pursuant to this act. Section 376.393

Every health care provider who refers a patient to a medical facility for health care services shall fully inform the patient fo every medical facility within the health carrier's or health benefit plan's provider network at which the provider has privileges to provide the services for which the patient is being referred and which are medically appropriate.

If the medical facility referred to and selected by a patient is in the provider network and is medically appropriate for the health care service to be provided, no referral by a provider or selection of a facility by a patient can be required otherwise restricted by the health carrier or plan. A health carrier or plan cannot discriminate between medically appropriate facilities within the provider network regarding benefit coverage or reimbursement for provider services for the same health care service.

A health care provider, health carrier, or health benefit plan shall be subject to licensure sanction for failure to comply with the provisions of this act.

These provisions are substantially similar to provisions in HB 1145 (2014) and SB 519 (2012).

MOST FAVORED NATIONS CLAUSES (SECTION 376.444)

This act prohibits any agreement between a health carrier and a participating licensed health care provider from containing a provision which:

(1) Prohibits a provider from contracting with another health carrier to provide health care services at a lower price than the payment specified in the agreement;

(2) Requires the provider to accept a lower reimbursement from the carrier in the event the provider agrees to provide health care services to another health carrier at a lower price;

(3) Requires or allows the health carrier to terminate or renegotiate an existing agreement if the participating provider agrees to provide health care services to another health carrier at a lower price; or

(4) Requires the participating provider to disclose his or her reimbursement rates with other health providers.

A violation of any of these provisions will make an agreement void and unenforceable.

This provision is identical to SB 98 (2011).

PRICE TRANSPARENCY (SECTION 376.2020)

Under this act, no contract provision between a health carrier and a health care provider shall be enforceable if such provision prohibits, conditions, or in any way restricts any party to such contract from disclosing to an enrollee, patient, potential patient, or such person's parent or legal guardian, the contractual payment amount for a health care service if such payment amount is less than the health care provider's usual charge for the health care service, and if such contractual provision prevents the determination of the potential out-of-pocket cost for the health care service by the enrollee, patient, potential patient, parent or legal guardian.

This provision is identical to SB 307 (2013).

RESTRICTIVE PHYSICIAN EMPLOYMENT CONTRACTS (SECTION 431.205)

This act provides that any employment contract between a physician and a nonprofit entity restricting the right of a physician to practice medicine in any geographic area for any period of time after the termination of a partnership, employment or professional relationship as described in the act shall be void and unenforceable with respect to such restriction.

This provision is substantially similar to SB 214 (2011).

CONTINGENT FEE ARRANGEMENTS (SECTIONS 484.400 TO 484.430)

This act provides that a fiduciary relationship commences when a claimant consults a contingent fee attorney to seek professional services. Contingent fee agreements for the representation of parties with claims shall also include alternate hourly rate fees. If a contingent fee attorney has not entered into a written agreement with a claimant at the time of retention setting forth the attorney's hourly rate, a reasonable hourly rate is payable, subject to certain limitations specified under this act.

This act specifies that at any time after retention, a contingent fee attorney pursuing a claim shall send a demand for compensation by certified mail to an allegedly responsible party and further delineates how such demand shall be made.

A fee received by or contracted for by a contingent fee attorney that exceeds ten percent of any settlement or judgment received by his or her client after reasonable expenses have been deducted is unreasonable and excessive if the attorney has sent a timely demand for compensation but has omitted information of a material nature that is required by this act which he or she had in his or her possession or which was readily available to him or her at the time of filing. This act also specifies the terms and relationship under these contingent fees with respect to settlement offers.

It shall be a violation of this act for an attorney retained after the claimant has received a pre-retention offer to enter into an agreement with a claimant to receive a contingent fee based upon or payable from the proceeds of the pre-retention offer, provided that the pre-retention offer remains in effect or is renewed until the time has elapsed for issuing a response containing a settlement offer.

Under this act, an attorney entering into a fee agreement that would effectively result in payment of a percentage of a pre-retention offer to a claimant has charged an unreasonable and excessive fee. Also, an attorney who contracts with a claimant for a reasonable hourly rate or a reasonable fixed fee, or who is paid such a fee for advising a claimant regarding the fairness of the pre-retention offer, has charged a presumptively reasonable fee.

TORT REFORM, ATTORNEY'S FEES AND WITNESS FEES (SECTION 538.220)

This act provides that in any action against a health care provider for damages for personal injury or death arising out of the rendering of or the failure to render health care services:

(1) If the case is settled prior to trial, attorneys' fees shall be limited to the attorney's regular hourly rate of compensation; and

(2) If the case proceeds to trial, the prevailing party shall recover all expert witness fees and costs incurred by such prevailing party.

ACCOUNTABILITY SYSTEM (SECTION 1)

The state shall establish and maintain an accountability system utilizing health information technology. Such system shall:

(1) Have the ability to interoperate to collect and aggregate data from disparate systems. Such disparate systems shall include, but not be limited to electronic medical records, claims and eligibility databases, state-managed registries such as public health and immunizations registries, and health information organizations;

(2) Provide a quarterly analysis of each of the state managed care organizations to ensure such organizations are meeting required metrics, goals, and quality measurements as defined in the managed care contract such as costs of managed care services as compared to fee-for-service providers, and to provide the state with needed data for future contract negotiations and incentive management;

(3) Meet all state health privacy laws and federal Health Insurance Portability and Accountability Act (HIPAA) requirements; and

(4) Meet federal data security requirements.

MO HEALTHNET OVERSIGHT COMMITTEE REPEALED (SECTION 208.955)

This act repeals the MO HealthNet Oversight Committee.

ADRIANE CROUSE