SB 0197 Certification of health care plans
Committee:CORRLR Number:L0301.01P
Last Action:04/25/95 - Hearing Conducted H Insurance Committee
Effective Date:August 28, 1995
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Current Bill Summary

SB 197 -This act requires the Director of the Department of Insurance to certify all managed health care plans in the state. "Managed care plans" are those plans operated by a managed care entity that provides for the financing and delivery of health care services to persons enrolled in such plans through: (1) arrangements with selected providers to furnish health care services; (2) explicit standards for the selection of participating providers; and (3) financial incentives for persons to use the participating providers.

"Managed care entities" which had previously been defined to included "insurance companies, hospitals or medical service plans, health maintenance organization, an employer or employee organization or a managed care contractor that operated a managed care plan" has been expanded to include "provider groups". But restricted from including those organizations which do not provide actual medical services but which operate service oriented businesses on behalf of medical clients.


The Director of the Department of Insurance shall establish standards for the certification of qualified managed care plans in accordance with this act. The standards require (1) detailed and comparable information to be given to prospective enrollees; (2) demonstration that a plan has adequate access to physicians; (3) sufficient financial reserves; (4) physician participation in the plan policy; and (5) objective credentialing of physicians within the plan.


A provider denied access to a plan or denied renewal to a plan must be given the reasons why. However, a decision to deny or renew an application is not subject to an appeal.

If a provider is to be terminated from a "managed care plan" that provider should be given notice to such action and allowed an opportunity to discuss the decision and to enter and complete a corrective action plan to stay in the plan.

Any provider applying for credentials in a managed care plan shall disclose, as a part of his application, all direct or indirect ownership or investments or any arrangements from which he receives payments for referral that the provider, provider's employer or immediate family member of such provider has or shall have in any health care services, including medical testing, pharmaceutical, medical equipment, therapy or treatment services which might be used by the managed care plan.


This bill would not allow Missouri's antitrust laws to be used to forbid the existence or operation of any not for profit medical association created for the purpose of mutual help or forbid its members to participate in activities directed solely to the distribution of information regarding fees charged for services relating to the practice of medicine or surgery. TOM MORTON/CHERYL GRAZIER