HB 328 -- Managed Care Co-Sponsors: Harlan, Hanaway, Foley, Naeger, Williams, Holand, Dolan This bill makes numerous changes to the managed care statutes. In its main provisions, the bill: (1) Requires that a managed care organization be licensed by the Department of Insurance rather than certified by the Department of Health; (2) Clarifies that providers will not be required to submit copies of their income tax returns to a health carrier. The health carrier may require a provider to obtain audited financial statements if the provider receives 10% or more of the total medical expenditures made by the health carrier; (3) Allows direct access to a participating obstetrician or gynecologist in the provider network. A health carrier is prohibited from imposing surcharges, additional copayments, or deductibles for accessing the obstetrician or gynecologist unless the same are imposed on other types of health care services received in the network; (4) Specifies that the "prompt pay" provisions of Section 376.383, RSMo, apply after a health carrier receives a claim for health care services provided in the state. Current law applies when a carrier receives a claim from a person entitled to reimbursement. The carrier is also required to provide, within 45 days of receiving the claim, a complete description of all additional information necessary to process the entire claim; (5) Allows a person who has filed a claim for reimbursement for a health care service to file a civil action against a carrier for violations of the "prompt pay" provisions. If the court finds a violation, it will award the plaintiff $50 per day beginning 10 days following the date interest began to accrue in addition to the claimed reimbursement and interest; (6) Requires health carriers, when processing claims, to permit providers to file confirmation numbers of authorized services and claims for reimbursement in the same format, to allow providers to file claims for reimbursement for a period of at least one year following the provision of a health care service, to issue an electronic confirmation within 24 hours of receipt of an electronically filed claim for reimbursement, and to accept all medical codes and modifiers specified in the bill; (7) Requires carriers to accept electronically filed reimbursement claims starting January 1, 2003, and requires the Department of Insurance to promulgate rules regarding the format of such forms; (8) Requires health carriers to furnish providers with a current fee schedule for reimbursement amounts of covered services for which the health carrier is contracted to provide and prohibits carriers from requesting a refund against a claim more than 12 months after a carrier has paid the claim, except in cases of fraud or misrepresentation by the provider; (9) Requires health carriers to provide Internet access to a current provider directory; (10) Requires health carriers to inform enrollees of any denial of health care coverage. The explanation must be in plain language that is easy for a layperson to understand; (11) Effective July 1, 2002, requires health carriers to issue each enrollee a card which includes a telephone number for the plan, prescription drug information, and a brief description of the enrollee's plan; (12) Requires health carriers to provide, upon notification, an enrollee with the forms and instructions necessary to enroll a newly born child if an application is required in order to continue coverage beyond the 31-day period after the child's birth; (13) Prohibits "hold harmless" clauses that require a health care provider to assume the sole liability of the provision of health care services. Any contract between a health care provider and a health carrier will include a clause which states that each party will be responsible for its own negligence or intentional wrongdoing; (14) Requires insurers, upon request, to provide both parents of a covered child with coverage information regardless of whether the parent is the primary policyholder; (15) Adds prescription medication to the definition of the term "health care service" and modifies the definition of the term "certification" to include a determination that the health care service is a covered benefit under the plan; (16) Requires health carriers to notify the dispensing pharmacist, prescribing physician, and enrollee when a nonformulary drug is authorized with conditions; (17) Allows a health carrier to retract a prior certification of a health care service if the enrollee's coverage under the plan has exceeded the enrollee's lifetime or annual benefits limit; (18) Requires a health carrier to provide an authorization decision for emergency services within 45 minutes instead of 60 minutes; (19) Requires health carriers to use, after January 1, 2004, standardized forms for referrals and explanations of benefits. The Department of Insurance must establish a task force by January 1, 2003, to develop the standardized forms. These provisions are preempted if the federal government develops standardized forms; (20) Requires health carriers to make available formulary information to participating pharmacists via the Internet or other electronic means after January 1, 2004; (21) Requires all managed care organizations to allow enrollees the right to select long-term care facilities which have the same religious orientation as the enrollee. If a religiously appropriate facility is not in the managed care organization's provider network, it will provide the enrollee the option to receive care from an out-of-network, long-term care facility that meets specific qualifications; and (22) Repeals 2 sections prescribing standardized forms for explanation of benefits and referrals.Copyright (c) Missouri House of Representatives