HCS/SB 575 - This act modifies provisions relating to reimbursement of health care services. TELEHEALTH (Sections 191.1145, 208.670, 208.671, 208.673, 208.675, and 208.677) This act repeals existing provisions of law relating to MO HealthNet telehealth, including provisions relating to MO HealthNet reimbursement for asynchronous store-and-forward technology, MO HealthNet telehealth rules promulgation, originating sites, and the Telehealth Services Advisory Committee. This act requires the Department of Social Services to reimburse health care providers for telehealth services if such providers can ensure that the services are rendered with the same standard of care that would be provided in person. The Department shall not restrict the originating site through rule or payment as long as the provider can ensure the services meet the requisite standard of care. No payment for telehealth services shall depend on a minimum distance requirement between the originating and distant sites. Reimbursement for asynchronous store-and-forward may be capped at the reimbursement rate for services provided in person. Prior to the provision of telehealth services provided in a school, the parent or guardian of a child shall provide the necessary authorization. Additionally, this act specifies that a health carrier shall not be prohibited from reimbursing non-clinical staff for services provided through telehealth if otherwise allowable by law. These provisions are identical to SS#3/SCS/HCS/HB 1617 (2018), and to provisions in CCS/HCS/SB 951 (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 SS/SB 982 (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 SS/SB 982 (2018), and similar to provisions in HCS/HB 2225 (2018) and SCS/SB 928 (2018). UNANTICIPATED OUT-OF-NETWORK CARE (Section 376.690) This act requires health care professionals to send any claim for charges incurred for unanticipated out-of-network 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 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. Bills may be settled prior to commencement of the arbitration, bills from similar circumstances may be combined in a single arbitration, and no health care professional 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 shall take effect on January 1, 2019. These provisions are similar to provisions in SS/SB 982 (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 the act when conducting a market conduct examination. These provisions are identical to provisions in SS/SB 982 (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 pay statute. 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 SS/SB 982 (2018), SCS/SB 928 (2018), HCS/HB 2225 (2018), and HB 2463 (2018). ERIC VANDER WEERD HA 1 - MODIFIES PROVISIONS RELATING TO UNANTICIPATED OUT-OF-NETWORK CARE