Summary of the Introduced Version of the Bill

HB 1816 -- Health Insurance Providers

Sponsor: White

This bill requires a health carrier to provide each contracted

health care provider including a licensed pharmacy and home

health agency Internet access to the carrier’s standard fee

schedule, specific to the provider’s geographic area, that

reflects the current payment rates for all goods and services.

All contracted providers in the geographic area must be paid at

those rates with specified exceptions. The fee schedule cannot

include a rate for a specific good or service that is less than

the lowest contracted rate for a specific good or service in a

geographic area if all of the providers in the area have

different individually contracted rates. A health carrier cannot

refuse to contract with any Missouri provider who is located

within the geographic coverage area of the health benefit plan

and is willing to meet the terms and conditions for participation

in the health benefit plan if the provider is willing to be paid

a reimbursement rate equal to 99% of the specified standard

rates.

Every health care provider who refers a patient to a medical

facility for health care services must fully inform the patient

of every medical facility within the health carrier’s or health

benefit plan’s provider network which the provider has privileges

to provide the services for which the patient is being referred

and which are medically appropriate. A health care provider must

fully inform an uninsured patient of every medical facility which

the provider has privileges to provide the services for which the

patient is being referred and which are medically appropriate. A

health care provider must provide the health care services at the

medical facility of the patient’s choosing.

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 referral by a provider or

selection of a facility by a patient can be required or otherwise

be restricted by the health carrier or plan. A carrier or plan

cannot discriminate between all medically appropriate facilities

regarding benefit coverage or reimbursement for provider services

for the same health care service.

A health care provider, health carrier, or health benefit plan

will be subject to licensure sanction for failure to comply with

the provisions of the bill.

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