Missouri Senate

Introduced

Health care providers are required to disclose, to the best of their ability, the allowed amount or the charge for a non-emergency admission, procedure, or service within 2 days of a prospective patient's request. If a health care provider can not provide a specific amount in advance due to an inability to predict the specific treatment or diagnostic code, the provider shall disclose what information is known for the estimated amount and inform the prospective patient that the estimate is incomplete and that the patient may obtain an updated estimate once additional information is determined. At an insured prospective patient's request, a health care provider shall, to the best of its ability, provide the patient with sufficient information for the patient to receive from his or her health carrier an estimate of out-of-pocket costs. Health care providers may assist prospective patients in obtaining this estimate from the health carrier.

Health carriers shall establish a web-accessible interactive mechanism enabling enrollees to obtain information on the payments made by the carrier to health care providers for health care services. The mechanism must allow enrollees to compare the cost of a particular health care service between in-network providers.

This act provides that health carriers shall, within 2 days of an enrollee's request, provide a good faith estimate of the allowed amount and the out-of-pocket cost of a non-emergency admission, procedure, or service that is a medically-necessary covered benefit from an in-network provider. Health carriers shall notify enrollees that the provided information is an estimate that may vary because of unforeseen circumstances arising out of the proposed non-emergency admission, procedure, or service.

Health carriers shall develop and implement a program providing incentives for enrollees electing to receive covered shoppable health care services from a provider charging less than the average price that carrier pays for that shoppable health care service. This act also provides methodologies for calculating the incentive and the average price, and provides that the incentive shall be provided to the enrollee as a cash payment.

This act requires health carriers to make incentive programs available as a component of all health plans offered in this state, and to provide eligible enrollees with annual notice of the program at enrollment or renewal. Health carriers are required to file a description of the incentive program with the Director of the Department of Insurance, Financial Institutions, and Professional Registration ("DIFP"), who may review the filing to determine compliance with this act. Filings and supporting documentation are confidential until the filing has been reviewed.

Health carriers must apply shared savings incentive payments to enrollees' member cost sharing the same way for out-of-network providers as the health plan specifies for in-network providers, and the act provides that shared savings incentive payments are not administrative expenses of the carrier for rate development or rate filing purposes.

This act requires health carriers to annually file with the Director of DIFP information from the most recent calendar year on the total number of incentive payments made, the use of shoppable health care services by category, the total payments made to enrollees, the average size of incentive payments made by service, the total savings achieved below average price by service, and the total number and percentage of the carrier's enrollees that participated in such transactions. This act requires the Director of DIFP to submit an aggregate report of this data to the legislative committees having jurisdiction over health insurance matters.

This act has an effective date of February 28, 2018.

ERIC VANDER WEERD