Missouri Senate

Introduced

Health carriers are required to develop and implement a program that provides financial incentives to enrollees in a health plan who choose to receive comparable health care services from providers that charge less than the average amount paid by that carrier to in-network providers for that service.

This incentive program must be a component of all health plans offered by the carrier in this state, and carriers shall annually provide a description of the program and notice to enrollees about its availability. Incentive payments made by a health carrier shall not be considered an administrative expense for purposes of rate development or rate filing.

Prior to offering the program to any enrollee, a health carrier shall file a description of the program that may be reviewed by the Director of the Department of Insurance, Financial Institutions, and Professional Registration for compliance with this act. A health carrier shall also file an annual statement of the number of incentive payments made, the use of comparable health care services by category, the total payments made to enrollees, the average amount of payments made by service, the total savings achieved below the average amount paid in-network, and the total number and percentage of a health carrier's enrollees that participated in the program. The Director shall submit an aggregate report for all carriers to the legislative committees having jurisdiction over health insurance matters.

A health carrier shall establish on its publicly accessible website an interactive mechanism for the enrollee to request information about payments made to in-network providers for comparable health care services. The mechanism shall allow enrollees to compare covered costs, out-of-pocket costs, and the average amounts paid to providers under the enrollees health plan. The out-of-pocket estimate shall be a good faith estimate based on the information available at the time the request is made. This act shall not prohibit carriers from imposing costs for unforeseen services. Health carriers may contract with third-party vendor to satisfy these requirements.

For enrollees receiving a covered health care service from an out-of-network provider at a price that is the same or less than the average price an enrollee's carrier pays in-network, carriers shall, upon request by the enrollee, apply the payments made by the enrollee for that service toward the enrollee's deductible and out-of-pocket maximum as if provided by an in-network provider.

In-network health care providers are required to disclose within 2 working days of a request, to the best of their ability, sufficient information for the enrollee to receive a cost estimate of the proposed non-emergency admission, procedure, or service from their carrier. 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. Out-of-network providers shall disclose within 2 working days of a request the amount that will be charged, including any facility fees.

Health care providers shall post in a visible area notification of the ability for patients to obtain sufficient information to allow a health carrier to assist the patient in comparing costs. This notice shall inform patients of their right to obtain services from providers without a recommendation or referral, and that seeking lower-cost providers may result in the patient receiving an incentive payment. It shall also notify patients that their carrier is required to provide cost estimates upon request.

This act requires the board of trustees for the Missouri Consolidated Health Care Plan to conduct an analysis of the cost effectiveness of these incentive programs, and to implement any program found to be cost effective. The board shall communicate the rationale for its decision to the relevant legislative committees in writing.

The provisions of this act are effective on January 1, 2019.

This act is similar to HB 1659 (2018), SB 245 (2017), HB 123 (2017), and HB 125 (2017).

ERIC VANDER WEERD