SECOND REGULAR SESSION
HOUSE BILL NO. 1816
96TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE WHITE.
5927L.02I D. ADAM CRUMBLISS, Chief Clerk
To amend chapter 376, RSMo, by adding thereto two new sections relating to health insurance providers.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto two new sections, to be known as sections 376.393 and 376.1425, to read as follows:
376.393. 1. As used in this section, the following terms shall mean:
(1) "Health carrier", the same meaning as such term is defined in section 376.1350;
(2) "Provider", the same meaning as such term is defined in section 376.1350, and in addition, licensed pharmacies and home health agencies.
2. Each health carrier shall provide each contracted provider with access to the health carrier's standard fee schedule, specific to the provider's geographic area, through a secure website. Such fee schedule shall reflect the current payment rates for all goods and services pertinent to the provider's practice or business, defined by procedure codes, diagnosis related groups, or defined by another payment mechanism, and all contracted providers in such geographic area shall be paid for the goods and services provided at such rates, unless different rates have been specifically agreed upon contractually with an individual provider, or at rates under subsection 3 of this section for providers contracted under such subsection. In no case shall the standard fee schedule include a rate for a specific good or service that is less than the lowest rate individually contracted for by the providers of such good or service in the applicable geographic area if all the providers in such area, excluding those contracted under subsection 3 of this section, have individually contracted to be paid at different rates for such good or service.
3. No health carrier, or any of its subsidiaries, networks, contractors, or subcontractors, shall refuse to contract with any Missouri provider who is located within the geographic coverage area of a health benefit plan and who is willing to meet the terms and conditions for provider participation established for such health benefit plan, including the MO HealthNet and Medicare programs, if such provider is willing, as a term of such contract, to be paid at rates equal to ninety-nine percent of the standard rates provided under subsection 2 of this section.
376.1425. 1. Every health care provider, as defined in section 376.1350, making a referral of a patient to a medical facility for health care services shall fully inform the patient of every medical facility within a health carrier's or health benefit plan's provider network which the health care provider has privileges to provide the services for which the patient is being referred and which are medically appropriate for the provision of such services.
2. If a patient is not insured, the health care provider shall fully inform the patient of every medical facility which the health care provider has privileges to provide the services for which the patient is being referred and which are medically appropriate for the provision of such services.
3. In accordance with the options provided to a patient under subsections 1 and 2 of this section, a health care provider shall provide the heath care services at the medical facility of a patient's choosing.
4. No referral by a provider or selection of facility by a patient shall be required or otherwise restricted by health carrier or health benefit plan, as defined in section 376.1350, if the medical facility referred to and selected by a patient is in the provider network and is medically appropriate for the health care service to be provided. No health carrier or health benefit plan shall discriminate between all medically appropriate facilities regarding benefit coverage or reimbursement for provider services for the same health care service.
5. Any health care provider, health carrier, or health benefit plan shall be subject to licensure sanction for failure to comply with the provisions of this section.