SS/SB 982 - This act modifies provisions relating to payments for health care services.
PAYMENTS MADE BY INSURANCE COMPANIES (Sections 354.150, 354.495, 374.115, 374.150, and 374.230)
This act creates a unified fee structure for filing fees paid by health services corporations and health maintenance organizations.
Additionally, the act specifies that fees paid under the insurance laws of this state shall be collected and deposited into the Insurance Dedicated Fund by the Director of the Department of Insurance, Financial Institutions, and Professional Registration rather than by the Director of the Department of Revenue, and eliminates a provision specifying that $500,000 from the fund shall be transferred annually to general revenue.
The act adjusts fees for companies filing insurance documents, and enacts fees for filing an own risk and solvency assessment (ORSA) summary report and for insurance holding company filings. The act eliminates fees charged for affixing the seal of the office of the Director of the Department of Insurance, Financial Institutions, and Professional Registration, and for accepting service of process upon the company.
This act also eliminates the requirement that insurance examiners appointed by the Director be compensated according to the applicable levels established by the National Association of Insurance Commissioners.
These provisions become effective January 1, 2019.
These provisions are identical to provisions in HCS/SS/SB 597 (2018), and are substantially similar to provisions in SCS/HCS/HBs 2337 & 2272 (2018), and to SCS/SB 962 (2018).
ACCREDITATION OF MANAGED CARE PLANS (Section 354.603)
This act provides that the Director of the Department of Insurance, Financial Institutions and Professional Registration shall determine that a managed care plan's network is adequate if the managed care plan is being offered by a health carrier accredited by the Accreditation Association for Ambulatory Health Care.
This provision is identical to a provision in HCS/SB 575 (2018), and to SB 194 (2017), HB 1185 (2017), SB 778 (2016), and SB 153 (2015).
DIRECT PAYMENT FOR AUTHORIZED SERVICES (Section 376.427)
This act provides that when a health benefit plan does not provide for payment to out-of-network providers for all or most services that are covered if provided in-network, including HMO plans and exclusive provider organization (EPO) plans, payment for all services shall be made directly to the health care providers when the health carrier has authorized for such services to be received from an out-of-network provider.
This provision is identical to a provision in HCS/SB 575 (2018), and similar to provisions in HCS/HB 2225 (2018) and SCS/SB 928 (2018).
UNANTICIPATED OUT-OF-NETWORK CARE (Section 376.690)
Within 180 days of providing unanticipated out-of-network care, health care professionals may send any claim for charges incurred for the care to the patient's health carrier in the format specified in the act. Within 45 processing days of receiving the claim, the carrier shall offer to pay the professional a reasonable reimbursement. If the professional participates in one or more of the carrier's networks, the offer shall be the amount from the network with the highest reimbursement.
If the professional declines the carrier's initial offer, the carrier and professional shall have 60 days from the initial offer to negotiate in good faith. If the carrier and professional do not agree to a reimbursement within 60 days, the dispute shall be resolved through an arbitration process as specified in the act. To initiate arbitration, either party must provide written notice indicating certain information to the Director of the Department of Insurance, Financial Institutions, and Professional Registration within 120 days of the end of the negotiation period. Claims may be settled prior to commencement of the arbitration, claims from similar circumstances may be combined in a single arbitration, and no health care professional that directly bills a health carrier for unanticipated medical care under the act shall send a bill to the patient for any difference in the billed charge and the reimbursement rate. The act specifies that patients' cost-sharing requirements shall be based on the payment amount determined under the act, requires health carriers to disclose cost-sharing requirements within 45 processing days of receiving a claim, and provides that the in-network deductible and out-of-pocket maximum cost-sharing requirements shall apply to the claim for unanticipated out-of-network care.
The Director of the Department of Insurance, Financial Institutions, and Professional Registration shall ensure access to an arbitration process as described in the act. Arbitration costs shall be split equally between, and shall be billed directly to, the professional and the carrier. At the conclusion of the process, the arbitrator shall issue a final decision that shall be binding on the parties. The arbitrator shall provide copies of the final decision to the Director. The arbitrator shall determine a dollar amount due that is between 120% of the Medicare allowed amount and the 70th percentile of the usual and customary rate for the unanticipated out-of-network care, as determined by benchmarks from independent nonprofit organizations not affiliated with insurance carriers or provider organizations.
The act specifies factors to be considered by the arbitrator, and specifies that the enrollee shall not be required to participate in the arbitration process. The health carrier and health care professional shall execute a nondisclosure agreement prior to the arbitration.
These provisions are similar to provisions in HCS/SB 575 (2018) and SCS/SB 928 (2018), and to SB 1057 (2018).
DENTAL SERVICE PROVIDERS (Section 376.1065)
This act requires any health carrier engaged in the act of contracting with providers for the delivery of dental services, or in the act of selling or assigning dental network plans, to update their electronic and paper provider materials made available to plan members or other potential plan members upon receiving written notice of changes by providers.
The Department of Insurance, Financial Institutions, and Professional Registration shall consider violations of this provision when conducting a market conduct examination.
These provisions are identical to provisions in HCS/SB 575 (2018), and similar to SB 852 (2018).
EMERGENCY MEDICAL CONDITIONS (Sections 376.1350 and 376.1367)
This act specifies that whether an ailment is considered an "emergency medical condition" depends on the person having sufficiently severe symptoms, regardless of what final diagnosis is given.
This act specifies that necessity of emergency services to screen and stabilize a patient shall be determined by the treating health care provider.
Before a health carrier denies payment for an emergency service based on the lack of an emergency medical condition, it shall review the enrollee's medical records regarding the emergency condition at issue. If a health carrier requests records for a potential denial, the provider shall submit the record to the carrier within 45 processing days or the claim shall be subject to the prompt payment insurance law. The carrier's review of the records shall be completed by a board certified physician licensed to practice in the state.
The act increases, from 30 minutes to 60 minutes, the amount of time health carriers have to provide authorization decisions for immediate post evaluation or post stabilization services before the services are deemed approved.
When a patient's health benefit plan does not provide for payment to out-of-network healthcare providers for emergency services, including but not limited to HMO and EPO plans, payment for all emergency services necessary to screen and stabilize the enrollee shall be paid directly to the health care provider by the health carrier. Any service authorized by the health carrier for the enrollee once the enrollee is stabilized shall also be paid by the health carrier directly to the provider.
These provisions are similar to provisions in HCS/SB 575 (2018), SCS/SB 928 (2018), HCS/HB 2225 (2018), and HB 2463 (2018).
PORTABLE ELECTRONICS INSURANCE (Section 379.1545)
This act specifies that agreements to receive notice and correspondence regarding portable electronics insurance shall be determined in accordance with the Uniform Electronic Transactions Act.
This provision is identical to SB 914 (2018) and HB 1972 (2018), and to provisions in SCS/HCS/HBs 2337 & 2272 (2018).
ERIC VANDER WEERD