HCS HB 497 -- TRANSPARENCY OF HEALTH CARE INFORMATION, MISSOURI
HEALTH INSURANCE POOL, AND PATIENT PRIVACY AND SAFETY

SPONSOR:  Wilson, 130 (Ervin)

COMMITTEE ACTION:  Voted "do pass" by the Special Committee on
Health Insurance by a vote of 8 to 4.

This substitute changes the laws regarding transparency of health
care information, Missouri Health Insurance Pool, and patient
privacy and safety.

PRIVACY OF HEALTH CARE INFORMATION

The substitute establishes the Missouri Patient Privacy Act which
prohibits the disclosure of patient-specific health information
to any employer, public or private payer, or employee or agent of
a state department or agency without the written consent of the
patient and health care provider.  Health information may be
disclosed to a health insurer, employer, state employee or agent
of the Missouri Consolidated Health Care Plan, the Department of
Health and Senior Services, or the MO HealthNet Division within
the Department of Social Services in connection with the
employee's official duties including oversight of state health
problems, tracking infectious diseases, administering state
wellness initiatives and programs, and researching state medical
trends.  The substitute does not prohibit disclosure of personal
health information consistent with federal law and does not
require health care providers to obscure or remove the
information when disclosing it.

TRANSPARENCY OF HEALTH CARE INFORMATION

Programs of insurers that publicly assess and compare the quality
and cost efficiency of health care providers must conform to
specified criteria for the transparency of health care
information.

Any person who sells or distributes comparative health care
quality and cost-efficiency data for public disclosure must
identify the measuring technique used to validate and analyze the
data, except for articles or research studies published in
peer-reviewed academic journals that do not receive funding from
a health care insurer or state or local government.  Individuals
violating this provision will be investigated by the Department
of Health and Senior Services and may be subject to a penalty of
up to $1,000.  Health insurers violating this provision will be
investigated by the Department of Insurance, Financial
Institutions and Professional Registration and subject to the
department's enforcement powers of the state's insurance laws.

PATIENT SAFETY

Beginning January 1, 2010, hospitals must report all serious
health care incidents resulting in serious adverse events to a
federally designated patient safety organization no later than
one business day following the discovery of the incident.  The
report must describe the immediate actions taken to minimize
patient risk and the prevention measures carried out.  The
hospital will have 45 days after the incident was discovered to
submit a root cause analysis report and prevention plan to the
organization, with or without the technical assistance of the
organization.  If the organization finds any of the reports
provided by the hospital to be insufficient, the hospital will
have two attempts to make corrections.  If permitted by the
federal Patient Safety and Quality Improvement Act of 2005, the
Department of Health and Senior Services will assist hospitals
with three or more insufficient reports and accept reports from a
hospital that does not submit serious adverse events to an
organization.  All hospitals must establish policies to notify a
patient within one business day after the hospital is aware of an
occurrence of a serious adverse event in health care.  Notifying
the patient will not be considered acknowledgment or admission of
hospital liability for the serious adverse event.  After
receiving a complete root cause analysis report and prevention
plan from a hospital, an organization must assess the information
and report back to the hospital with its findings and
recommendations for preventing future incidents.

By April 30 of every year, the department must publish to the
public a report indicating the number of serious adverse events
for the previous year by category of reportable incident and rate
per patient encounter by region and by category of reportable
incident, and by facility region.  Hospitals must report
incidents of serious adverse events on a quarterly basis to the
department.

Patient safety organization meetings with individuals related to
an incident must keep discussions limited to the course of
carrying out the business of the organization.  Proceedings and
records of an organization cannot be used in civil action against
a health care provider, and providers furnishing services to an
organization cannot be liable for civil damages as a result of
findings based on the provider's services.

An organization can disclose non-identifying information
regarding the number and type of patient safety incidents that
occur, but documents and any communication created by a health
care provider must be kept confidential by the organization.

Beginning January 1, 2010, hospitals that report an incident of a
serious adverse event cannot charge for or bill individuals or
insurers for services related to the incident.  If an insurer
denies a claim because of lack of coverage for services that
resulted from an incident of a serious adverse event, the health
care provider or facility involved cannot bill the patient for
the uncovered services.

MISSOURI HEALTH INSURANCE POOL

A Missouri resident who has exhausted his or her maximum benefits
from his or her health insurer or can only obtain health
insurance from a carrier at a rate that is more expensive than
the pool's eligibility rates will be eligible for coverage under
the pool.  Currently, after December 31, 2009, a person who has
health insurance coverage through an insurer and has experienced
a premium rate increase of 300% or more of the individual
standard rates established by the MHIP Board is eligible to
obtain coverage through the pool.  The substitute removes this
provision.

An individual who has had prior creditable coverage with a group,
governmental, or church plan and is not eligible for certain
Social Security or Title XIX benefits; does not have other health
insurance coverage; and has exhausted continuation of coverage
through COBRA will be eligible for coverage under the pool.

All health insurers must notify an insured when he or she has
exhausted 85% of his or her total lifetime health insurance
benefits and of 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, and the insurer must also
notify the pool with the name and address of the affected person.

The board is required to offer health benefit plans that are in
the best interest of the individuals covered under the pool
including, but not limited to, coverage for dental, vision, and
limited mandate plans or other flexible benefit plans and can
establish a premium rate load to allow enrollees to buy down
creditable coverage.  An individual's premium rate for the pool
must be based on the individual's family size.  The substitute
removes the lower limit requirement for pool coverage for
applicants.  Pool coverage rates cannot exceed 125% of those
applicable to individual standard risks for individuals who have
had prior creditable coverage with a group, governmental, or
church plan; are not eligible for certain Social Security or
Title XIX benefits; do not have other health insurance coverage;
and have exhausted continuation of coverage through COBRA.  Pool
coverage rates cannot exceed 125% of rates applicable to
individual standard risks for all others covered in the pool.

The pool must establish a premium assistance program, subject to
appropriations, for individuals with incomes less than the pool's
eligibility limit or who jointly contribute to their premium with
their employer.  The premium assistance will be based on a
sliding income scale, capped at 300% of the federal poverty
level, established by the pool along with any cost-sharing
requirements, such as deductibles, co-payments, and co-insurance.
Any federal or grant funds received for the purpose of premium
assistance must be used through the premium assistance program
established by the pool.

When implementing the provisions regarding the coverage for pool
enrollees and provider payments, the board is required to make
sure that the special needs of Missouri's Tier I Safety Net
providers are not disproportionately impacted by its rules.

Insurance agents and brokers selling or renewing pool policies
will receive a 5% commission.

HEALTH CARRIER NOTIFICATION REQUIREMENTS

The substitute requires all health carriers to notify their
enrollees in writing or electronically or by phone when a health
care provider changes from an in-network provider to an
out-of-network provider.  Carriers must notify enrollees at least
30 business days prior to the effective date, or as soon as
possible, of the status change and must have a written procedure
that ensures continuity of care for enrollees when network status
changes occur including notification and transfers to other
in-network providers.  If a provider changes its network status,
the carrier must provide enrollees with continuation of care for
up to 90 days when medically necessary and medically prudent.  If
continuation of care is needed or if the carrier fails to notify
an enrollee 30 days prior to any network status change, the
enrollee can continue to receive services at in-network costs
from the provider who changed to out-of-network status and the
enrollee will not be liable for any charges in excess of
in-network rates and costs.  If the in-network provider who
changed network status is authorized to provide continuation of
care to an enrollee, the carrier must reimburse the provider at
in-network rates.

FISCAL NOTE:  Estimated Cost on General Revenue Fund of Unknown
but Greater than $304,166 in FY 2010, Unknown but Greater than
$325,000 in FY 2011, and Unknown but Greater than $325,000 in FY
2012.  No impact on Other State Funds in FY 2010, FY 2011, and FY
2012.

PROPONENTS:  Supporters say that because of the third-party payor
system, the way in which we consume health care services is
unlike any other services that we consume, meaning that consumers
do not seek the best bargain.  Obtaining cost and quality health
care data is difficult to do.  Health care is not rationed on the
basis for price; thus, providers do not compete on price or even
quality.  Utilization, technology, and competency are the drivers
of health care costs.  Transparency is one thing that we can do
at the state level to help Missouri citizens make more informed
decisions regarding their health care.

Testifying for the bill were Representative Ervin; Anthem Blue
Cross Blue Shield of Missouri; Monsanto Company; Ron Laudel,
Carpenters' Health and Welfare Trust Fund of St. Louis; Jim
Denning, Discover Vision Center; Mary Jo Feldstein, Business
Health Coalition; Associated Industries of Missouri; and Ford
Motor Company.

OPPONENTS:  Those who oppose the bill say that we need to
standardize quality measures which the bill does, but it needs
additional provisions in order to implement correctly within the
industry.  There has to be more separation between regulators and
patient safety organizations.  The bill does not tell providers
the guidelines of how to implement the provisions.  The insurers
must have uniformity in reporting instead of many individual
reports.

Testifying against the bill were BJC Health Care Systems;
Washington University; Missouri Association of Osteopathic
Physicians and Surgeons; Missouri Hospital Association; Missouri
State Medical Association; and Missouri Academy of Family
Physicians.

Missouri House of Representatives
95th General Assembly, 1st Regular Session
Last Updated November 17, 2009 at 9:25 am