SB 566 - This act changes the laws regarding the health care market and services in Missouri and establishes the Insure Missouri Plan in the MO HealthNet Division within the Department of Social Services. TRANSPARENCY OF HEALTH CARE SERVICES (Sections 191.1020 to 191.1028) This act requires health care providers and insurers, upon request, to provide patients with the information necessary to compare cost data for an ordered or planned service. These provisions do not apply to health care services delivered on an emergency basis, requests regarding services to be performed as part of ongoing inpatient care, or services represented by certain codes published by the American Medical Association. By January 1, 2016, the Department of Insurance, Financial Institutions, and Professional Registration is required to provide on its web site the Medicare fee schedule, by code and provider, for all Missouri Medicare providers and, for each Missouri hospital, the Medicare diagnosis-related group payment for each code. Compliance with this section will not be considered a violation of any provider contract provisions with a health carrier that prohibit disclosure of the provider's fee schedule with a health carrier to third parties. Criteria is established for insurers to use in programs that publicly assess and compare quality and cost efficiency of health care data. A provider cannot decline to enter into a provider contract with an insurer solely because the insurer uses quality and cost efficiency of health care data programs. A person who sells or distributes health care quality and cost efficiency data in a comparative format to the public is required to identify the source used to confirm the validity of the data and its analysis as an objective indicator of health care quality. This provision does not apply to articles or research studies that are published in peer-reviewed academic journals. The Department of Health and Senior Services is required to investigate complaints of alleged violations and is authorized to impose a penalty of up to $1,000. Alleged violations by health insurers will be investigated and enforced by the Department of Insurance, Financial Institutions, and Professional Registration. MISSOURI HEALTH FACILITIES REVIEW COMMITTEE (Sections 197.310 and 197.330) This act changes the membership of the Missouri Health Facilities Review Committee for the Certificate of Need Program to: (1) One member who is professionally qualified in health insurance plan sales and administration; (2) One member who has professionally qualified experience in commercial development, financing, and lending; (3) Two members with a doctorate of philosophy in economics; (4) Two members who are professionally qualified as medical doctors or doctors of osteopathy, but who are not employees of a hospital or consultants to a hospital; (5) Two members who are professionally experienced in hospital administration, but are not employed by a hospital or as consultants to a hospital; and (6) One member who is a registered nurse, but who is not an employee of a hospital or a consultant to a hospital. All members will be appointed by the Governor with the advice and consent of the Senate and serve a four-year term. No more than five members can be from the same political party. For all hearings held by the committee, the act: (1) Requires all testimony and other evidence taken during the hearings to be under oath and subject to the penalty of perjury; (2) Specifies that the committee can, upon a majority vote of the committee, subpoena witnesses and require the attendance of witnesses, the giving of testimony, and the production of records; (3) 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; (4) Requires any party opposing the issuance of a certificate of need to show by clear and convincing evidence that the need does not exist or that the new facility will cause a substantial and continuing loss of medical services within the affected region or community; (5) Specifies that all committee hearings will be governed by rules adopted by the committee but not be bound by the technical rules of evidence; and (6) Authorizes the committee, upon a majority vote, to assess the costs of court reporting transcription or the issuance of subpoenas to one or both of the involved parties. STANDARDIZED INSURANCE APPLICATIONS (Section 374.184) The Director of the Department of Insurance, Financial Institutions, and Professional Registration must establish by rule uniform insurance application forms to be used by all insurers. MISSOURI HEALTH INSURANCE POOL (Sections 376.960, 376.962,376.966, 376.981, 376.983, 376.985, 376.986, and 376.991) This act: (1) Requires all health insurers to notify an insured person when he or she has exhausted 85% of his or her total lifetime health insurance benefits and the person's eligibility for and the methods of applying for coverage under the pool. Notification must be repeated when an insured has exhausted 100% of his or her total lifetime health insurance benefits; (2) Requires the pool to offer stop-loss coverage for any insurer in the private individual health insurance market to cover claim liability for an insured person who becomes uninsurable or an uninsurable dependent and to establish a two-year pilot program that offers small group stop-loss coverage to stabilize small group premiums when risks associated with specific individuals under a small group policy would result in increased premiums for the entire group. The MHIP board is required to submit a report to the General Assembly by January 1, 2018, regarding the pilot program and any recommendations to expand the program statewide; (3) Allows the MHIP board to establish a premium subsidy program for low-income individuals; (4) Requires the pool, beginning July 1, 2015, to offer at least two plans that meet the criteria of the federal Centers for Medicare and Medicaid for uninsurable individuals eligible under the Insure Missouri Program; (5) Establishes premium rates for health insurance coverage through the pool;(6) Specifies that any licensed insurance agent or broker who sells a health insurance policy offered under the pool to an eligible individual will receive a commission for the sale at an amount to be set by the board; and (7) Eliminates insurer assessments under the pool and distributes premium taxes currently collected from insurers offering health-related insurance products to the pool beginning January 1, 2016. INSURE MISSOURI PROGRAM (Section 376.991) This act: (1) Establishes the Insure Missouri Program within the Department of Social Services to provide health care coverage to low-income working Missourians; (2) Requires the department to apply to the United States Department of Health and Human Services for a waiver and/or a Medicaid state plan amendment to develop and implement the program and to submit the proposed application to the Joint Committee on MO HealthNet for its review, recommendations, and approval; (3) Specifies that the program is not an entitlement program. The maximum enrollment of program participants is dependent on the moneys appropriated by the General Assembly, and eligibility for the program can be phased in incrementally based on appropriations; (4) Requires the department to establish certain specified standards for consumer protection; (5) Requires the program to pay 100% of the premium costs for participants, except for any participant whose health care account balance exceeds the annual required contribution amount. The amount in excess of the annual required amount will go toward payment of the participant's premium costs under the program; (6) Specifies eligibility requirements for program participants and requires them to be subject to approval by the United States Department of Health and Human Services; (7) Specifies covered, medically necessary services and that the program can include incentives designed to promote and encourage healthy lifestyles; (8) Establishes a health care account for each eligible individual into which payments for his or her participation can be made by the individual, an employer, the state, or any philanthropic or charitable contributor. The account will be used to pay the individual's deductible under the program; (9) Specifies that an individual's participation in the program does not begin until the participant makes an initial payment of at least one-twelfth of the annual required payment; (10) Specifies that a participant's annual required payment is the lesser of $1,000 less any payments under the Mo HealthNet Program, the Children's Health Insurance Program, and the federal Medicare Program or a certain percentage of his or her household income; (11) Requires the state to contribute the difference to the participant's account if his or her account does not have sufficient funds to pay any deductible or co-payments; (12) Specifies that a participant will be terminated from participation in the plan if his or her required payment is not made within 90 days after the required date. Written notice must be given before a participant can be terminated from the plan; (13) Specifies that approved participants are eligible for a 12-month period but must file a renewal application to remain in the program; (14) Specifies that an eligible individual who participates in the program without a break in service and has an income exceeding the current income limit for participation, set by appropriations, at the time of renewal will be eligible for transitional participation in the program. Transitional participation will terminate when the individual's income exceeds 225% of the federal poverty level; (15) Requires any moneys remaining in the health care account to be used to reduce the participant's payments for the subsequent program period if the individual renews his or her participation. The division must refund any amount remaining in the health care account, less any outstanding individual obligations under the program, to a participant who is no longer eligible, has not renewed participation, or is terminated from the program; (16) Specifies how health insurance coverage will be obtained for approved program participants; (17) Prohibits the deductible for any qualified plan under the program from exceeding $2,500; (18) Specifies that any licensed insurance agent or broker who sells a health insurance policy offered under the MHIP to an individual eligible for the program will receive a commission in an amount set by the Department of Social Services; and (19) Requires the department, in consultation and coordination with the Department of Insurance, Financial Institutions, and Professional Registration and the MHIP board of directors, to ensure that eligible participants are able to obtain health insurance coverage through licensed insurance agents and brokers. This act contains an emergency clause placing certain sections into effect on July 1, 2015 and an effective date for other sections on January 1, 2016. This act is substantially similar to HB 2413, et al. (2008). SARAH HASKINS