0691S.06F

To repeal sections 135.095, 197.285, 198.530, 354.535, 354.603, 354.606, 354.618, 376.383, 376.406, 376.406, 376.893, 376.1350, 376.1361, 376.1367, 376.1400, 376.1403 and 379.930, RSMo 2000, relating to the regulation of managed care, and to enact in lieu thereof thirty-four new sections relating to the same subject, with an emergency clause for certain sections.

Section A. Sections 135.095, 197.285, 198.530, 354.535, 354.603, 354.606, 354.618, 376.383, 376.406, 376.406, 376.893, 376.1350, 376.1361, 376.1367, 376.1400, 376.1403 and 379.930, RSMo 2000, are repealed and thirty-four new sections enacted in lieu thereof, to be known as sections 135.095, 197.285, 198.530, 354.535, 354.603, 354.604, 354.606, 354.618, 376.383, 376.384, 376.396, 376.406, 376.419, 376.893, 376.895, 376.1350, 376.1361, 376.1367, 376.1405, 376.1406, 376.1408, 379.930, 660.700, 660.703, 660.706, 660.709, 660.712, 660.715, 660.718, 660.721, 660.724, 660.727, 660.729 and 1, to read as follows:

135.095. For all tax years beginning on or after January 1, 1999, but before January 1, 2005, a [resident individual] claimant who has attained sixty-five years of age on or before the last day of the tax year shall be allowed, for the purpose of offsetting the cost of legend drugs, a maximum credit against the tax otherwise due pursuant to chapter 143, RSMo, not including sections 143.191 to 143.265, RSMo, of two hundred dollars. For the purpose of this section, a "claimant" is defined as a person or persons claiming a credit under sections 135.005. If two claimants are eligible to file a joint federal income tax return and reside at the same address at any time during the taxable year, then the credit may only be allowed if claimed on a combined Missouri income tax return or a combined claim return reporting their combined incomes and property taxes. A claimant shall not be allowed a credit unless the claimant or spouse has attained the age of sixty-five on or before the last day of the calendar year and the claimant or spouse was a resident of Missouri for the entire year during which the credit is claimed. A claimant must apply for his or her own credit. [An individual] A claimant shall be entitled to the maximum credit allowed by this section if the [individual] claimant has [a Missouri adjusted gross income] an income as defined in section 135.010 of fifteen thousand dollars or less; provided that, no [individual who receives full reimbursement for the cost of legend drugs from Medicare or Medicaid, or] claimant who meets the income criteria for Medicaid eligibility, or has coverage for pharmaceutical benefits through a health benefit plan as defined in section 376.1350, RSMo, including a Medicare supplement or Medicare + Choice plan, or through a self-funded employee benefit plan shall qualify for the credit allowed pursuant to this section unless a claimant's pharmaceutical expenses exceed the claimant's coverage, in which case, a claimant may qualify for a credit for the additional expenses, up to two hundred dollars. No claimant who is a resident of a local, state or federally funded facility shall qualify for the credit allowed pursuant to this section. If [an individual's Missouri adjusted gross income] a claimant's income as defined in section 135.010 is greater than fifteen thousand dollars, such [individual] claimant shall be entitled to a credit equal to the greater of zero or the maximum credit allowed by this section reduced by two dollars for every hundred dollars such [individual's] claimant's income exceeds fifteen thousand dollars. The credit shall be claimed as prescribed by the director of the department of revenue, however, the claim must be accompanied by proof of a claimant's pharmaceutical expenses, as provided by the claimant's pharmacist. Such proof of expense must include the claimant's name, a list of each legend drug filled by the pharmacist for the calendar year during which the credit is claimed, and the cost of such legend drugs less any insurance coverage or reimbursement. Such credit shall be considered an overpayment of tax and shall be refundable even if the amount of the credit exceeds [an individual's] a claimant's tax liability. A credit may not be claimed pursuant to this section for any tax year ending after December 31, 2001, or any tax year during which the Missouri pharmaceutical assistance program is in full operation, whichever is later.

197.285. 1. Hospitals and ambulatory surgical centers shall establish and implement a written policy adopted by each hospital and ambulatory surgical center relating to the protections for employees who disclose information pursuant to subsection 2 of this section. This policy shall include a time frame for completion of investigations related to complaints, not to exceed thirty days, and a method for notifying the complainant of the disposition of the investigation. This policy shall be submitted to the department of health to verify implementation. At a minimum, such policy shall include the following provisions:

(1) No supervisor or individual with authority to hire or fire in a hospital or ambulatory surgical center shall prohibit employees from disclosing information pursuant to subsection 2 of this section;

(2) No supervisor or individual with authority to hire or fire in a hospital or ambulatory surgical center shall use or threaten to use his or her supervisory authority to knowingly discriminate against, dismiss, penalize or in any way retaliate against or harass an employee because the employee in good faith reported or disclosed any information pursuant to subsection 2 of this section, or in any way attempt to dissuade, prevent or interfere with an employee who wishes to report or disclose such information;

(3) Establish a program to identify a compliance officer who is a designated person responsible for administering the reporting and investigation process and an alternate person should the primary designee be implicated in the report.

2. This section shall apply to information disclosed or reported in good faith by an employee concerning:

(1) Alleged facility mismanagement or fraudulent activity;

(2) Alleged violations of applicable federal or state laws or administrative rules concerning patient care, patient safety or facility safety; or

(3) The ability of employees to successfully perform their assigned duties.

All information disclosed, collected and maintained pursuant to this subsection and pursuant to the written policy requirements of this section shall be accessible to the department of health at all times and shall be reviewed by the department of health at least annually. Complainants shall be notified of the department of health's access to such information and of the complainant's right to [appeal to the department of health] notify the department of health of any information concerning alleged violations of applicable federal or state laws or administrative rules concerning patient care, patient safety or facility safety.

3. Prior to any disclosure to individuals or agencies other than the department of health, employees wishing to make a disclosure pursuant to the provisions of this section shall first report to the individual or individuals designated by the hospital or ambulatory surgical center pursuant to subsection 1 of this section.

4. If the compliance officer, compliance committee or management official discovers credible evidence of misconduct from any source and, after a reasonable inquiry, has reason to believe that the misconduct may violate criminal, civil or administrative law, then the hospital or ambulatory surgical center shall report the existence of misconduct to the appropriate governmental authority within a reasonable period, but not more than seven days after determining that there is credible evidence of a violation.

5. Reports made to the department of health shall be subject to the provisions of section 197.477, provided that the restrictions of section 197.477 shall not be construed to limit the employee's ability to subpoena from the original source the information reported to the department pursuant to this section.

6. Each written policy shall allow employees making a report who wish to remain anonymous to do so, and shall include safeguards to protect the confidentiality of the employee making the report, the confidentiality of patients and the integrity of data, information and medical records.

7. Each hospital and ambulatory surgical center shall, within forty-eight hours of the receipt of a report, notify the employee that his or her report has been received and is being reviewed.

[8. The enactment of this section shall become effective January 1, 2001.]

198.530. 1. If an enrollee in a managed care organization is also a resident in a long-term care facility licensed pursuant to chapter 198, or a continuing care retirement community, as defined in section 197.305, RSMo, such enrollee's managed care organization shall provide the enrollee with the option of receiving the covered service in the long-term care facility which serves as the enrollee's primary residence. For purposes of this section, "managed care organization" means any [organization that offers any health plan certified] entity licensed by the department of [health] insurance that offers any health plans designed to provide incentives to medical care providers to manage the cost and use of care associated with claims, including, but not limited to, a health maintenance organization [and preferred provider organization], insurance company and health services corporation. The resident enrollee's managed care organization shall reimburse the resident facility for those services which would otherwise be covered by the managed care organization if the following conditions apply:

(1) The facility is willing and able to provide the services to the resident; and

(2) The facility and those health care professionals delivering services to residents pursuant to this section meet the licensing and training standards as prescribed by law; and

(3) The facility is certified through Medicare; and

(4) The facility and those health care professionals delivering services to residents pursuant to this section agree to abide by the terms and conditions of the health carrier's contracts with similar providers, abide by patient protection standards and requirements imposed by state or federal law for plan enrollees and meet the quality standards established by the health carrier for similar providers.

2. The managed care organization shall reimburse the resident facility at a rate of reimbursement not less than the Medicare allowable rate pursuant to Medicare rules and regulations.

3. The services in subsection 1 of this section shall include, but are not limited to, skilled nursing care, rehabilitative and other therapy services, and postacute care, as needed. Nothing in this section shall limit the managed care organization from utilizing contracted providers to deliver the services in the enrollee's resident facility.

4. A resident facility shall not prohibit a health carrier's participating providers from providing covered benefits to an enrollee in the resident facility. A resident facility or health care professional shall not impose any charges on an enrollee for any service that is ancillary to, a component of, or in support of the services provided under this section when the services are provided by a health carrier's participating provider, or otherwise create a disincentive for the use of the health carrier's participating providers. Any violation of the requirements of this subsection by the resident facility shall be considered abuse or neglect of the resident enrollee.

354.535. 1. If a pharmacy, operated by or contracted with by a health [maintenance organization] carrier, is closed or is unable to provide health care services to an enrollee in an emergency, a pharmacist may take an assignment of such enrollee's right to reimbursement, if the policy or contract provides for such reimbursement, for those goods or services provided to an enrollee of a health [maintenance organization] carrier. No health [maintenance organization] carrier shall refuse to pay the pharmacist any payment due the enrollee under the terms of the policy or contract.

2. No health [maintenance organization] carrier, conducting business in the state of Missouri, shall contract with a pharmacy, pharmacy distributor or wholesale drug distributor, nonresident or otherwise, unless such pharmacy or distributor has been granted a permit or license from the Missouri board of pharmacy to operate in this state.

3. Every health [maintenance organization] carrier shall apply the same coinsurance, co-payment and deductible factors to all drug prescriptions filled by a pharmacy provider who participates in the health [maintenance organization's] carrier's network if the provider meets the contract's explicit product cost determination. If any such contract is rejected by any pharmacy provider, the health [maintenance organization] carrier may offer other contracts necessary to comply with any network adequacy provisions of this act. However, nothing in this section shall be construed to prohibit the health [maintenance organization] carrier from applying different coinsurance, co-payment and deductible factors between generic and brand name drugs.

4. Health [maintenance organizations] carriers shall not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription, unless such limit is applied uniformly to all pharmacy providers in the health [maintenance organization's] carrier's network.

5. Health [maintenance organizations] carriers shall not insist or mandate any physician or other licensed health care practitioner to change an enrollee's maintenance drug unless the provider and enrollee agree to such change. For the purposes of this provision, a maintenance drug shall mean a drug prescribed by a practitioner who is licensed to prescribe drugs, used to treat a medical condition for a period greater than thirty days. Violations of this provision shall be subject to the penalties provided in section 354.444. Notwithstanding other provisions of law to the contrary, health [maintenance organizations] carriers that change an enrollee's maintenance drug without the consent of the provider and enrollee shall be liable for any damages resulting from such change. Nothing in this subsection, however, shall apply to the dispensing of generically equivalent products for prescribed brand name maintenance drugs as set forth in section 338.056, RSMo.

354.603. 1. A health carrier shall maintain a network that is sufficient in number and types of [providers] health care professionals to assure that all services to enrollees shall be accessible without unreasonable delay. In the case of emergency services, enrollees shall have access twenty-four hours per day, seven days per week. The health carrier's medical director shall be responsible for the sufficiency and supervision of the health carrier's network. Sufficiency shall be determined by the director in accordance with the requirements of this section and by reference to any reasonable criteria, including but not limited to, provider-enrollee ratios by specialty, primary care provider-enrollee ratios, geographic accessibility, reasonable distance accessibility criteria for pharmacy and other services, waiting times for appointments with participating [providers] health care professionals, hours of operation, and the volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care.

(1) In any case where the health carrier has an insufficient number or type of participating [providers] health care professionals to provide a covered benefit, the health carrier shall ensure that the enrollee obtains the covered benefit at no greater cost than if the benefit was obtained from a participating [provider] health care professional, or shall make other arrangements acceptable to the director.

(2) The health carrier shall establish and maintain adequate arrangements to ensure reasonable proximity of participating [providers] health care professional, including local pharmacists, to the business or personal residence of enrollees. In determining whether a health carrier has complied with this provision, the director shall give due consideration to the relative availability of health care [providers] professionals in the service area under, especially rural areas, consideration.

(3) A health carrier shall monitor, on an ongoing basis, the ability, clinical capacity[, financial capability] and legal authority of its [providers] health care professionals to furnish all contracted benefits to enrollees. The provisions of this subdivision shall not be construed to require any health care professional to submit copies of such health care professional's income tax returns to a health carrier. A health carrier may require a health care professional to obtain audited financial statements if such health care professional received ten percent or more of the total medical expenditures made by the health carrier.

(4) A health carrier shall make its entire network available to all enrollees unless a contract holder has agreed in writing to a different or reduced network.

2. [Beginning July 1, 1998,] A health carrier shall file with the director, in a manner and form defined by rule of the department of insurance, an access plan meeting the requirements of sections 354.600 to 354.636 for each of the managed care plans that the health carrier offers in this state. The health carrier may request the director to deem sections of the access plan as proprietary or competitive information that shall not be made public. For the purposes of this section, information is proprietary or competitive if revealing the information will cause the health carrier's competitors to obtain valuable business information. The health carrier shall provide such plans, absent any information deemed by the director to be proprietary, to any interested party upon request. The health carrier shall prepare an access plan prior to offering a new managed care plan, and shall update an existing access plan whenever it makes any change as defined by the director to an existing managed care plan. The director shall approve or disapprove the access plan, or any subsequent alterations to the access plan, within sixty days of filing. The access plan shall describe or contain at a minimum the following:

(1) The health carrier's network;

(2) The health carrier's procedures for making referrals within and outside its network;

(3) The health carrier's process for monitoring and assuring on an ongoing basis the sufficiency of the network to meet the health care needs of enrollees of the managed care plan;

(4) The health carrier's methods for assessing the health care needs of enrollees and their satisfaction with services;

(5) The health carrier's method of informing enrollees of the plan's services and features, including but not limited to, the plan's grievance procedures, its process for choosing and changing [providers] health care professionals, and its procedures for providing and approving emergency and specialty care;

(6) The health carrier's system for ensuring the coordination and continuity of care for enrollees referred to specialty physicians, for enrollees using ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning;

(7) The health carrier's process for enabling enrollees to change primary care professionals;

(8) The health carrier's proposed plan for providing continuity of care in the event of contract termination between the health carrier and any of its participating [providers] health care professionals, in the event of a reduction in service area or in the event of the health carrier's insolvency or other inability to continue operations. The description shall explain how enrollees shall be notified of the contract termination, reduction in service area or the health carrier's insolvency or other modification or cessation of operations, and transferred to other [providers] health care professionals in a timely manner; and

(9) Any other information required by the director to determine compliance with the provisions of sections 354.600 to 354.636.

354.604. The provisions of subdivision (3) of subsection 1 of section 354.603 shall not be construed to require any provider to submit copies of such provider's income tax returns to a health carrier. A health carrier may require a provider to obtain audited financial statements if such provider received ten percent or more of the total medical expenditures made by the health carrier.

354.606. 1. A health carrier shall establish a mechanism by which the participating provider shall be notified on an ongoing basis of the specific covered health services for which the provider shall be responsible, including any limitations or conditions on services.

2. Every contract between a health carrier and a participating provider shall set forth a hold harmless provision specifying protection for enrollees. This requirement shall be met by including a provision substantially similar to the following:

"Provider agrees that in no event, including but not limited to nonpayment by the health carrier or intermediary, insolvency of the health carrier or intermediary, or breach of this agreement, shall the provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against an enrollee or a person, other than the health carrier or intermediary, acting on behalf of the enrollee for services provided pursuant to this agreement. This agreement shall not prohibit the provider from collecting coinsurance, deductibles or co-payments, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to enrollees. This agreement shall not prohibit a provider, except for a health care professional who is employed full time on the staff of a health carrier and has agreed to provide service exclusively to that health carrier's enrollees and no others, and an enrollee from agreeing to continue services solely at the expense of the enrollee, as long as the provider has clearly informed the enrollee that the health carrier may not cover or continue to cover a specific service or services. Except as provided herein, this agreement does not prohibit the provider from pursuing any available legal remedy; including, but not limited to, collecting from any insurance carrier providing coverage to a covered person."

3. Every contract between a health carrier and a participating provider shall set forth that in the event of a health carrier's or intermediary's insolvency or other cessation of operations, covered services to enrollees shall continue through the period for which a premium has been paid to the health carrier on behalf of the enrollee or until the enrollee's discharge from an inpatient facility, whichever time is greater.

4. The contract provisions satisfying the requirements of subsections 2 and 3 of this section shall:

(1) Be construed in favor of the enrollee;

(2) Survive the termination of the contract regardless of the reason for termination, including the insolvency of the health carrier; and

(3) Supersede any oral or written contrary agreement between a provider and an enrollee or the representative of an enrollee if the contrary agreement is inconsistent with the hold harmless and continuation of covered services provisions required by subsections 2 and 3 of this section.

5. In no event shall a participating provider collect or attempt to collect from an enrollee any money owed to the provider by the health carrier nor shall a participating provider collect or attempt to collect from an enrollee any money in excess of the coinsurance, co-payments or deductibles. Failure of a health carrier to make timely payment of an amount owed to a provider in accordance with the provider's contract shall constitute an unfair claims settlement practice subject to sections 375.1000 to 375.1018, RSMo.

6. (1) A health carrier shall develop selection standards for participating primary care professionals and each participating health care professional specialty. Such standards shall be in writing and used in determining the selection of health care professionals by the health carrier, its intermediaries and any provider networks with which it contracts. Selection criteria shall not be established in a manner that will:

(a) Allow a health carrier to avoid a high-risk population by excluding a provider because such provider is located in a geographic area that contains a population presenting a risk of higher than average claims, losses or health services utilization; or

(b) Exclude a provider because such provider treats or specializes in treating a population presenting a risk of higher than average claims, losses or health services utilization.

(2) Paragraphs (a) and (b) of subdivision (1) of this subsection shall not be construed to prohibit a health carrier from declining to select a provider who fails to meet the other legitimate selection criteria of the health carrier developed in compliance with sections 354.600 to 354.636.

(3) The provisions of sections 354.600 to 354.636 shall not require a health carrier, its intermediaries or the provider networks with which it contracts, to employ specific providers or types of providers, or to contract with or retain more providers or types of providers than are necessary to maintain an adequate network.

7. A health carrier shall file its selection standards for participating providers with the director. A health carrier shall also file any subsequent changes to its selection standards with the director. The selection standards shall be made available to licensed health care providers.

8. A health carrier shall notify a participating provider of the provider's responsibilities with respect to the health carrier's applicable administrative policies and programs, including but not limited to payment terms, utilization review, quality assessment and improvement programs, credentialing, grievance procedures, data reporting requirements, confidentiality requirements and any applicable federal or state programs.

9. No contract between a health carrier and a provider for the delivery of health care service, entered into or renewed after August 28, 2001, shall require the mandatory use of a hospitalist. For purposes of this subsection, "hospitalist" means a physician who becomes a physician of record at a hospital for a patient of a participating provider and who may return the care of the patient to that participating provider at the end of hospitalization.

[9.] 10. A health carrier shall not offer an inducement under the managed care plan to a provider to provide less than medically necessary services to an enrollee.

[10.] 11. A health carrier shall not prohibit a participating provider from advocating in good faith on behalf of enrollees within the utilization review or grievance processes established by the health carrier or a person contracting with the health carrier.

[11.] 12. A health carrier shall require a provider to make health records available to appropriate state and federal authorities involved in assessing the quality of care but shall not disclose individual identities, or investigating the grievances or complaints of enrollees, and to comply with the applicable state and federal laws related to the confidentiality of medical or health records.

[12.] 13. The rights and responsibilities of a provider under a contract between a health carrier and a participating provider shall not be assigned or delegated by the provider without the prior written consent of the health carrier.

[13.] 14. A health carrier shall be responsible for ensuring that a participating provider furnishes covered benefits to all enrollees without regard to the enrollee's enrollment in the plan as a private purchaser of the plan or as a participant in a publicly financed program of health care service.

[14.] 15. A health carrier shall notify the participating providers of their obligations, if any, to collect applicable coinsurance, co-payments or deductibles from enrollees pursuant to the evidence of coverage, or of the providers' obligations, if any, to notify enrollees of their personal financial obligations for noncovered services.

[15.] 16. A health carrier shall not penalize a provider because the provider, in good faith, reports to state or federal authorities any act or practice by the health carrier that may jeopardize patient health or welfare.

[16.] 17. A health carrier shall establish a mechanism by which a participating provider may determine in a timely manner whether a person is covered by the carrier.

[17.] 18. A health carrier shall not discriminate between health care professionals when selecting such professionals for enrollment in the network or when referring enrollees for health care services to be provided by such health care professional who is acting within the scope of his professional license.

[18.] 19. A health carrier shall establish procedures for resolution of administrative, payment or other disputes between providers and the health carrier.

[19.] 20. A contract between a health carrier and a provider shall not contain definitions or other provisions that conflict with the definitions or provisions contained in the managed care plan or sections 354.600 to 354.636.

354.618. 1. A health carrier shall be required to offer as an additional health plan, an open referral health plan whenever it markets a gatekeeper group plan as an exclusive or full replacement health plan offering to a group contract holder:

(1) In the case of group health plans offered to employers of fifty or fewer employees, the decision to accept or reject the additional open referral plan offering shall be made by the group contract holder. For health plans marketed to employers of over fifty employees, the decision to accept or reject shall be made by the employee;

(2) Contracts currently in existence shall offer the additional open referral health plan at the next annual renewal after August 28, 1997; however, multiyear group contracts need not comply until the expiration of their current multiyear term unless the group contract holder elects to comply before that time;

(3) If an employer provides more than one health plan to its employees and at least one is an open referral plan, then all health benefit plans offered by such employer shall be exempt from the requirements of this section.

2. For the purposes of this [act] section, the following terms shall mean:

(1) "Open referral plan", a plan in which the enrollee is allowed to obtain treatment for covered benefits without a referral from a primary care physician from any person licensed to provide such treatment;

(2) "Gatekeeper group plan", a plan in which the enrollee is required to obtain a referral from a primary care professional in order to access specialty care.

3. Any health benefit plan provided pursuant to the Medicaid program shall be exempt from the requirements of this section.

4. [A health carrier shall have a procedure by which a female enrollee may seek the health care services of an obstetrician/gynecologist at least once a year without first obtaining prior approval from the enrollee's primary care provider if the benefits are covered under the enrollee's health benefit plan, and the obstetrician/gynecologist is a member of the health carrier's network.] Each health carrier or health benefit plan that offers or issues health benefit plans providing obstetrical/gynecological benefits which are delivered, issued for delivery, continued or renewed in this state on or after January 1, 2002, shall provide enrollees with direct access to the services of a participating obstetrician, participating gynecologist or participating obstetrician/gynecologist of her choice within the provider network for covered services. The services covered by this subsection shall be limited to those services defined by the published recommendations of the accreditation council for graduate medical education for training an obstetrician, gynecologist or obstetrician/gynecologist, including but not limited to diagnosis, treatment and referral for such services. A health carrier shall not impose additional co-payments, coinsurance, or deductibles upon any enrollee who seeks or receives health care services pursuant to this subsection, unless similar additional co-payments, coinsurance, or deductibles are imposed for other types of health care services received within the provider network. Nothing in this subsection shall be construed to conflict with section 376.805, RSMo. In no event shall a health carrier be required to permit an enrollee to have health care services delivered by a nonparticipating obstetrician/gynecologist. An obstetrician/gynecologist who delivers health care services directly to an enrollee shall report such visit and health care services provided to the enrollee's primary care provider. [A health carrier may require an enrollee to obtain a referral from the primary care physician, if such enrollee requires more than one annual visit with an obstetrician/gynecologist.]

5. Except for good cause, a health carrier shall be prohibited either directly, or indirectly through intermediaries, from discriminating between eye care providers when selecting among providers of health services for enrollment in the network and when referring enrollees for health services provided within the scope of those professional licenses and when reimbursing amounts for covered services among persons duly licensed to provide such services. For the purposes of this section, an eye care provider may be either an optometrist licensed pursuant to chapter 336, RSMo, or a physician who specializes in [opthamologic] ophthalmologic medicine, licensed pursuant to chapter 334, RSMo.

6. Nothing contained in this section shall be construed as to require a health carrier to pay for health care services not provided for in the terms of a health benefit plan.

7. Any health carrier, which is sponsored by a federally qualified health center and is presently in existence and which has been in existence for less than three years shall be exempt from this section for a period not to exceed two years from August 28, 1997.

8. A health carrier shall not be required to offer the direct access rider for a group contract holder's health benefit plan if the health benefit plan is being provided pursuant to the terms of a collective bargaining agreement with a labor union, in accordance with federal law and the labor union has declined such option on behalf of its members.

9. Nothing in this [act] section shall be construed to preempt the employer's right to select the health care provider pursuant to section 287.140, RSMo, in a case where an employee incurs a work-related injury covered by the provisions of chapter 287, RSMo.

10. Nothing contained in this [act] section shall apply to certified managed care organizations while providing medical treatment to injured employees entitled to receive health benefits [under] pursuant to the provisions of chapter 287, RSMo, pursuant to contractual arrangements with employers, or their insurers, [under] pursuant to section 287.135, RSMo.

376.383. 1. To the extent consistent with the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001, et seq., this section shall apply to any health [insurer] carrier as defined in section [376.806, any nonprofit health service plan and any health maintenance organization] 376.1350.

2. Within [forty-five] thirty days after receipt of a claim by a health carrier or a third party contracted with said health carrier to receive or process the claim for reimbursement [from a person entitled to reimbursement] for a health care service provided in this state as defined in section 376.1350, a health [insurer, nonprofit health service plan or health maintenance organization] carrier shall pay the claim in accordance with this section or send a notice of receipt and status of the claim that states:

(1) That the [insurer, nonprofit health service plan or health maintenance organization] health carrier refuses to reimburse all or part of the claim and the reason for the refusal; or

(2) That a request for additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary[.] to process the entire claim for payment. The health carrier must acknowledge receipt to the health care professional or entity that submitted the claim of all the requested additional information or pay the claim. Acknowledgment may be through electronic means.

3. Within forty-five days after receipt of a claim by a health carrier or a third party contracted with said health carrier to receive or process the claim for reimbursement for a health care service provided in this state as defined in section 376.1350, a health carrier shall pay the claim in accordance with this section or send a notice of receipt and status of the claim that states:

(1) That the health carrier refuses to reimburse all or part of the claim and the reason for refusal; or

(2) That a final request for additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary to process the entire claim for payment. The health carrier must acknowledge receipt to the health care professional or entity that submitted the claim of the requested additional information within five working days.

[3.] 4. If [an insurer, nonprofit health service plan or health maintenance organization] a health carrier fails to comply with subsection 2 or 3 of this section, the [insurer, nonprofit health service plan or health maintenance organization] health carrier shall pay interest on the amount of the claim that remains unpaid forty-five days after the claim is [filed] received by the health carrier or a third party contracted with said health carrier to receive or process the claim at the monthly rate of one percent. The interest paid pursuant to this subsection shall be included in any late reimbursement without the necessity for the person that filed the original claim to make an additional claim for that interest. A carrier may combine interest payments and make payment once the aggregated amount reaches five dollars.

5. All claims shall be deemed complete claims upon receipt until such time as it is determined that additional information is required in order to pay the claim. If additional information is requested pursuant to subsection 2 or 3 of this section, the claim shall again be deemed complete upon receipt of all additional information requested. For the purpose of calculating the number of days pursuant to this section, the counting of days shall begin on the day the claim is received by the health carrier or a third party contracted with said health carrier to receive or process the claim. The counting of days shall be suspended the day following the day the health care professional receives a request for additional information pursuant to this section and the counting of days shall resume again once all the additional information requested is received by the health carrier or a third party contracted with said health carrier to receive or process the claim. All requests for additional information may be made electronically.

[4.] 6. Within [ten] sixty days after the day on which [all additional information is received] a claim is received by [an insurer, nonprofit health service plan or health maintenance organization] a health carrier or a third party contracted with said health carrier to receive or process the claim, [it] said health carrier shall pay the claim in accordance with this section or send a written notice that:

(1) States refusal to reimburse the claim or any part of the claim; and

(2) Specifies each reason for denial.

[An insurer, nonprofit health service plan or health maintenance organization that fails to comply with this subsection shall pay interest on any amount of the claim that remains unpaid at the monthly rate of one percent.]

7. The failure of the health care professional to provide and the health carrier to receive all requested information pursuant to subsection 2 or 3 of this section by the one hundred twentieth day after the initial receipt of the original claim may be a proper ground for denying all or part of the claim.

8. A health carrier that fails to pay or deny a claim pursuant to the requirements of this section shall pay, in addition to interest, a penalty prescribed by this subsection. Beginning January 1, 2002, for a claim received by a health carrier or a third party contracted with said health carrier to receive or process the claim which is not paid or denied as required by this section, a penalty shall accrue in the amount of forty dollars per day for each day all or part of the claim, interest in excess of five dollars, or penalty remains unpaid. If such claim and interest are paid in their entirety prior to day sixty, then no penalty shall accrue.

9. The penalties prescribed by this section shall cease to accrue if, within thirty days after penalties begin to accrue, the health care professional fails to notify the health carrier that all or part of the claim, interest or penalty remains unpaid. Such notification shall reference the claim or claims in question.

[5. A provider who is paid interest under this section shall pay the proportionate amount of said interest to the enrollee or insured to the extent and for the time period that the enrollee or insured had paid for the services and for which reimbursement was due to the insured or enrollee.

6.] 10. This section shall become effective [April 1, 1999] January 1, 2002.

11. Nothing in this section shall apply to workers' compensation claims filed pursuant to chapter 287, RSMo.

376.384. 1. For purposes of this section, "health care professional" means the same as such term is defined in section 376.1350 and "health carrier" means the same as such term is defined in section 376.1350. Any health carrier shall:

(1) Permit health care professionals to file a claim for reimbursement for a health care service provided in this state as defined in section 376.1350 for a period of up to one hundred eighty days from the date of service;

(2) Not request a refund or offset against a claim more than one hundred eighty days after a carrier has paid a claim except in cases of fraud or material misrepresentation by the health care professional;

(3) The health carrier shall, upon request, provide any contracted health care professional with a fee schedule with the carrier's reimbursement rates for no less than thirty procedure codes for the most commonly performed services for which the health care professional is contracted to provide;

(4) Issue within one working day a confirmation of receipt of an electronically filed claim by a health care professional or entity that submitted the claim, unless the claim is paid during such time.

2. On or after January 1, 2003, all claims submitted electronically for reimbursement for a health care service provided in this state shall be submitted in a uniform format utilizing standard medical code sets. The uniform format and the standard medical code sets shall be promulgated by the department of insurance through rules consistent with but no more stringent than the federal administrative simplification standards adopted pursuant to the Health Insurance Portability and Accountability Act of 1996. Any claim submitted in a nonelectronic format after January 1, 2002, shall not be subject to the provisions of subsection 8 of section 376.383; however, interest shall accrue on claims filed in a nonelectronic format that are not paid or denied in accordance with section 376.383. A health carrier shall provide electronic filing after January 1, 2002.

3. Nothing in this section shall apply to workers' compensation claims filed pursuant to chapter 287, RSMo.

376.396. 1. Upon written request and no less than once each policy year, every insurer issuing a group policy in this state shall provide the group policyholder with an annual written report. Such report shall be written in a manner which protects the confidentiality of all employees of the group policyholder and shall be consistent with federal law or shall be no more stringent than federal law.

2. For group policyholders classified as small groups and subject to the small group underwriting regulations, the insurer shall provide a written report that includes:

(1) Medical and administrative costs (expressed as per member per month amounts) of the small group class to which the group policyholder is assigned for the most recent premium year;

(2) Group specific medical costs for the most recent premium year;

(3) The insurer's trend factor used to estimate the costs in the premium year being quoted; and

(4) The pricing tier (expressed as a percentage of the insurer's best new business premium rate for this class of business) used to compute the group policyholder's premium.

3. For group policyholders not subject to small group underwriting regulations, the insurer shall provide a written report that includes:

(1) Group specific medical costs for the most recent premium year;

(2) The insurer's trend factor used to estimate those costs in the premium year being quoted;

(3) The insurer's book rate for the group adjusted for the age and sex;

(4) The underwriting mark-up or mark-down to the book rate based upon the medical risk experience of the group; and

(5) The provision for administrative costs, expressed as a percentage of premium used in developing the premium quote.

4. Group specific medical costs shall be reported on a fully incurred basis, and shall at a minimum provide separate totals for inpatient, outpatient, physician and pharmacy costs.

5. Any group policyholder may waive receipt of the written report, or agree to delivery of the written report separate from an initial or renewal premium quote either in writing or by electronic message.

376.406. 1. All [individual and group health insurance policies providing coverage on an expense incurred basis, individual and group service or indemnity type contracts issued by a nonprofit corporation, and all self-insured group health benefit plans, of any type or description,] health benefit plans, as defined in section 376.1350, which provide coverage for a family member of [the insured or subscriber] an enrollee shall, as to such family member's coverage, also provide that the health [insurance] benefits applicable for children shall be payable with respect to a newly born child of the [insured or subscriber] enrollee from the moment of birth.

2. The coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.

3. If payment of a specific premium or subscription fee is required to provide coverage for a child, the [policy or contract] health benefit plan may require that notification of birth of a newly born child and payment of the required premium or fees must be furnished to the [insurer or nonprofit service or indemnity corporation] health carrier within thirty-one days after the date of birth in order to have the coverage continue beyond such thirty-one day period. If an application or other form of enrollment is required in order to continue coverage beyond the thirty-one-day period after the date of birth and the enrollee has notified the health carrier of the birth, either orally or in writing, the health carrier shall, upon notification, provide the enrollee with all forms and instructions necessary to enroll the newly born child and shall allow the enrollee an additional ten days from the date the forms and instructions are provided in which to enroll the newly born child.

4. The requirements of this section shall apply to all [insurance policies and subscriber contracts] health benefit plans delivered or issued for delivery in this state [more than one hundred twenty days after August 13, 1974] on or after August 28, 2001.

5. For the purposes of this section, any review, renewal, extension, or continuation of any [plan, policy, or contract] health benefit plan or of any of the terms, premiums, or subscriptions of the [plan, policy, or contract] health benefit plan shall constitute a new delivery or issuance for delivery of the [plan, policy or contract] health benefit plan.

6. As used in this section, the terms "health benefit plan", "health carrier" and "enrollee" shall have the same meaning as defined in section 376.1350.

376.419. 1. As used in this section, the term "hold harmless clause" means a contractual arrangement whereby a health care provider assumes the sole liability inherent in the provision of health care services, thereby relieving an insurer from such liability except that nothing in this section shall be construed to apply to any clause in the contract prohibiting providers from balance billing the enrollee or his or her family for any amount in excess of the amount provided for in the contract between the provider and the carrier. For purposes of this section, "health care provider" or "provider" means a health care professional or facility.

2. Except to the extent preempted by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001, et seq., this section shall apply to any health carrier, as defined in section 376.1350.

3. Any contract between a health care provider and a health carrier entered into after the effective date of this section shall include a clause that states that each party shall be responsible for any and all claims, liabilities, damages or judgments which may arise as a result of its own negligence or intentional wrongdoing. Each party signatory to the contract shall hold harmless and indemnify the other party against any claims, liabilities, damages or judgments which may be asserted against, imposed upon or incurred by the other party as a result of the first party's negligence or intentional wrongdoing.

376.893. 1. Within sixty days of legal separation or the entry of a decree of dissolution of marriage or prior to the expiration of a thirty-six month federal Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation period covering a legally separated or divorced spouse, if such spouse has elected and maintained such COBRA coverage, a legally separated or divorced spouse eligible for continued coverage [under] pursuant to section 376.892 who seeks such coverage shall give the plan administrator written notice of the legal separation or dissolution. The notice shall include the mailing address of the legally separated or divorced spouse.

2. Within thirty days of the death of a certificate holder whose surviving spouse is eligible for continued coverage [under] pursuant to section 376.892 or prior to the expiration of a thirty-six month federal Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation period covering such surviving spouse, if such spouse has elected and maintained such COBRA coverage, the group policyholder shall give the plan administrator written notice of the death and of the mailing address of the surviving spouse.

3. Within fourteen days of receipt of notice [under] pursuant to subsection 1 or 2 of this section, the plan administrator shall notify the legally separated, divorced or surviving spouse that the policy may be continued. The notice shall be mailed to the mailing address provided to the plan administrator and shall include:

(1) A form for election to continue the coverage;

(2) A statement of the amount of periodic premiums to be charged for the continuation of coverage and of the method and place of payment; [and]

(3) Instructions for returning the election form by mail within sixty days after the date of mailing of the notice by the plan administrator; and

(4) Notice that if insurance is continued the insurer is required to provide both parents of a covered child with coverage information upon request regardless of whether the parent is the primary policyholder pursuant to section 376.895.

4. Failure of the legally separated, divorced or surviving spouse to exercise the election in accordance with subsection 3 of this section shall terminate the right to continuation of benefits.

5. If a plan administrator was properly notified pursuant to the provisions of subsection 1 or 2 of this section and fails to notify the legally separated, divorced or surviving spouse as required by subsection 3 of this section, such spouse's coverage shall continue in effect, and such spouse's obligation to make any premium payment for continuation coverage [under] pursuant to sections 376.891 to 376.894 shall be postponed for the period of time beginning on the date the spouse's coverage would otherwise terminate and ending thirty-one days after the date the plan administrator provides the required notice. Failure or delay by a plan administrator in providing the notice required by this section shall not reduce, eliminate or postpone the plan sponsor's obligation to pay premiums on behalf of such legally separated, divorced or surviving spouse to the plan administrator during such period.

6. The provisions of sections 376.891 to 376.894 apply only to employers with twenty or more employees and any policy, contract or plan with twenty or more certificate holders.

376.895. Any health carrier, as defined in section 376.1350, providing coverage for a child with parents who are legally separated or divorced shall provide upon request coverage information regarding such child to both parents regardless of whether the inquiring parent is the primary policyholder.

376.1350. For purposes of sections 376.1350 to 376.1390, the following terms mean:

(1) "Adverse determination", a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the payment for the requested service is therefore denied, reduced or terminated;

(2) "Ambulatory review", utilization review of health care services performed or provided in an outpatient setting;

(3) "Case management", a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions;

(4) "Certification" or "certifies", a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness, and that the service is a covered benefit under the plan;

(5) "Clinical peer", a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review;

(6) "Clinical review criteria", the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the necessity and appropriateness of health care services;

(7) "Concurrent review", utilization review conducted during a patient's hospital stay or course of treatment;

(8) "Covered benefit" or "benefit", a health care service that an enrollee is entitled under the terms of a health benefit plan;

(9) "Director", the director of the department of insurance;

(10) "Discharge planning", the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility;

(11) "Drug", any substance prescribed by a licensed health care provider acting within the scope of the provider's license and that is intended for use in the diagnosis, mitigation, treatment or prevention of disease. The term includes only those substances that are approved by the FDA for at least one indication;

(12) "Emergency medical condition", the sudden and, at the time, unexpected onset of a health condition that manifests itself by symptoms of sufficient severity that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that immediate medical care is required, which may include, but shall not be limited to:

(a) Placing the person's health in significant jeopardy;

(b) Serious impairment to a bodily function;

(c) Serious dysfunction of any bodily organ or part;

(d) Inadequately controlled pain; or

(e) With respect to a pregnant woman who is having contractions:

a. That there is inadequate time to effect a safe transfer to another hospital before delivery; or

b. That transfer to another hospital may pose a threat to the health or safety of the woman or unborn child;

(13) "Emergency service", a health care item or service furnished or required to evaluate and treat an emergency medical condition, which may include, but shall not be limited to, health care services that are provided in a licensed hospital's emergency facility by an appropriate provider;

(14) "Enrollee", a policyholder, subscriber, covered person or other individual participating in a health benefit plan;

(15) "FDA", the federal Food and Drug Administration;

(16) "Facility", an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings;

(17) "Grievance", a written complaint submitted by or on behalf of an enrollee regarding the:

(a) Availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

(b) Claims payment, handling or reimbursement for health care services; or

(c) Matters pertaining to the contractual relationship between an enrollee and a health carrier;

(18) "Health benefit plan", a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services;

(19) "Health care professional", a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services consistent with state law;

(20) "Health care provider" or "provider", a health care professional or a facility;

(21) "Health care service", a service or prescription medication for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease;

(22) "Health carrier", an entity subject to the insurance laws and regulations of this state that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or health services;

(23) "Health indemnity plan", a health benefit plan that is not a managed care plan;

(24) "Managed care plan", a health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use, health care providers managed, owned, under contract with or employed by the health carrier;

(25) "Participating provider", a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the health carrier;

(26) "Peer-reviewed medical literature", a published scientific study in a journal or other publication in which original manuscripts have been published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts, and that has been determined by the International Committee of Medical Journal Editors to have met the uniform requirements for manuscripts submitted to biomedical journals or is published in a journal specified by the United States Department of Health and Human Services pursuant to section 1861(t)(2)(B) of the Social Security Act, as amended, as acceptable peer-reviewed medical literature. Peer-reviewed medical literature shall not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier;

(27) "Person", an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing;

(28) "Prospective review", utilization review conducted prior to an admission or a course of treatment;

(29) "Retrospective review", utilization review of medical necessity that is conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment;

(30) "Second opinion", an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health service to assess the clinical necessity and appropriateness of the initial proposed health service;

(31) "Stabilize", with respect to an emergency medical condition, that no material deterioration of the condition is likely to result or occur before an individual may be transferred;

(32) "Standard reference compendia":

(a) The American Hospital Formulary Service-Drug Information; or

(b) The United States Pharmacopoeia-Drug Information;

(33) "Utilization review", a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review. Utilization review shall not include elective requests for clarification of coverage;

(34) "Utilization review organization", a utilization review agent as defined in section 374.500, RSMo.

376.1361. 1. A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier may develop its own clinical review criteria, or it may purchase or license clinical review criteria from qualified vendors. A health carrier shall make available its clinical review criteria upon request by either the director of the department of health or the director of the department of insurance.

2. Any medical director who administers the utilization review program or oversees the review decisions shall be a qualified health care professional licensed in the state of Missouri. A licensed clinical peer shall evaluate the clinical appropriateness of adverse determinations.

3. A health carrier shall issue utilization review decisions in a timely manner pursuant to the requirements of sections 376.1363, 376.1365 and 376.1367. A health carrier shall obtain all information required to make a utilization review decision, including pertinent clinical information. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria consistently.

4. A health carrier's data systems shall be sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively.

5. If a health carrier delegates any utilization review activities to a utilization review organization, the health carrier shall maintain adequate oversight, which shall include:

(1) A written description of the utilization review organization's activities and responsibilities, including reporting requirements;

(2) Evidence of formal approval of the utilization review organization program by the health carrier; and

(3) A process by which the health carrier evaluates the performance of the utilization review organization.

6. The health carrier shall coordinate the utilization review program with other medical management activities conducted by the carrier, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for accessing member satisfaction and risk management.

7. A health carrier shall provide enrollees and participating providers with timely access to its review staff by a toll-free number.

8. When conducting utilization review, the health carrier shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency and duration of services.

9. Compensation to persons providing utilization review services for a health carrier shall not contain direct or indirect incentives for such persons to make medically inappropriate review decisions. Compensation to any such persons may not be directly or indirectly based on the quantity or type of adverse determinations rendered.

10. A health carrier shall permit enrollees or a provider on behalf of an enrollee to appeal for the coverage of medically necessary pharmaceutical prescriptions and durable medical equipment as part of the health carriers' utilization review process.

11. (1) This subsection shall apply to:

(a) Any health benefit plan that is issued, amended, delivered or renewed on or after January 1, 1998, and provides coverage for drugs; or

(b) Any person making a determination regarding payment or reimbursement for a prescription drug pursuant to such plan.

(2) A health benefit plan that provides coverage for drugs shall provide coverage for any drug prescribed to treat an indication so long as the drug has been approved by the FDA for at least one indication, if the drug is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature and deemed medically appropriate.

(3) This section shall not be construed to require coverage for a drug when the FDA has determined its use to be contraindicated for treatment of the current indication.

(4) A drug use that is covered pursuant to subsection 1 of this section shall not be denied coverage based on a "medical necessity" requirement except for a reason that is unrelated to the legal status of the drug use.

(5) Any drug or service furnished in a research trial, if the sponsor of the research trial furnishes such drug or service without charge to any participant in the research trial, shall not be subject to coverage pursuant to subsection 1 of this section.

(6) Nothing in this section shall require payment for nonformulary drugs, except that the state may exclude or otherwise restrict coverage of a covered outpatient drug from Medicaid programs as specified in the Social Security Act, Section 1927(d)(1)(B).

(7) Every health carrier shall notify the prescribing physician and enrollee when a nonformulary drug is authorized with conditions, such as an authorization for a limited period of time.

12. A carrier shall issue a confirmation number to an enrollee when the health carrier, acting through a participating provider or other authorized representative, [authorizes] certifies the provision of health care services.

13. If an authorized representative of a health carrier [authorizes] certifies the provision of health care services, the health carrier shall not subsequently retract its [authorization] certification after the health care services have been provided, or reduce payment for an item or service furnished in reliance on [approval] such certification, unless:

(1) Such [authorization] certification is based on a material misrepresentation or omission about the treated person's health condition or the cause of the health condition; or

(2) The health benefit plan terminates before the health care services are provided; [or]

(3) The covered person's coverage under the health benefit plan terminates before the health care services are provided; or

(4) The covered person's coverage under the health benefit plan has exceeded such person's annual or lifetime benefits limit.

376.1367. When conducting utilization review or making a benefit determination for emergency services:

(1) A health carrier shall cover emergency services necessary to screen and stabilize an enrollee and shall not require prior authorization of such services;

(2) Coverage of emergency services shall be subject to applicable co-payments, coinsurance and deductibles;

(3) When an enrollee receives an emergency service that requires immediate post evaluation or post stabilization services, a health carrier shall provide [an authorization] a certification decision within [sixty] forty-five minutes of receiving a request; if the [authorization] certification decision is not made within [thirty] forty-five minutes, such services shall be deemed approved.

376.1405. 1. Every health insurance carrier offering policies of insurance in this state shall use a standardized form for the explanation of benefits given to the health care provider whenever a claim is paid or denied. As used in this section, the term "health insurance carrier" shall have the meaning given to "health carrier" in section 376.1350. Nothing in this section shall apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care or other limited benefit health insurance policies.

2. The standardized form developed by the task force as established in section 376.1408 shall contain the following:

(1) The name of the insured;

(2) The insured's identification number;

(3) The date of service;

(4) Amount of charge;

(5) Explanation for any denial;

(6) The amount paid and any balance due;

(7) The procedure code;

(8) The patient's full name; and

(9) The phone number and name of whom to contact for questions on explanation of benefits.

3. All health insurance carriers shall use the standard explanation of benefits form after January 1, 2004.

4. Every health carrier shall after January 1, 2004, make formulary information available to participating pharmacies through the Internet or other electronic means. The department of insurance shall develop rules to implement the requirements of this subsection and to protect the proprietary rights of the health carrier.

5. The provisions of this section shall be preempted if a federal regulating entity develops a standardized form for the explanation of benefits which is applicable to all health carriers as defined in section 376.1350.

376.1406. 1. Every health care provider and health carrier that conducts business in this state shall use a standardized form for referrals. The standardized referral form shall be used in lieu of any specific referral form developed by a health carrier for the referral process. As used in this section, the terms "health care provider" and "health carrier" shall have the meaning given to them in section 376.1350.

2. The referral form developed by the task force as established in section 376.1408 shall contain the following:

(1) The name of the insured;

(2) Place of employment;

(3) The name, address and phone number of the health carrier;

(4) The identification number and group number of the insured;

(5) The type of referral;

(6) The name, address and phone number of the health care provider referring the insured;

(7) The name, address and phone number of the health care provider of whom the insured was referred;

(8) The number of visits requested and authorized; and

(9) The health carrier's authorization number.

3. All health care providers and health carriers shall use the standardized referral form after January 1, 2004.

4. The provisions of this section shall be preempted if a federal regulating entity develops a standardized form for referrals which is applicable to all health carriers as defined in section 376.1350.

376.1408. The department of insurance shall, for any forms required by sections 376.1405 and 376.1406, adopt any standardized forms adopted by the Federal Health Care Financing Administration for such purpose.

379.930. 1. Sections 379.930 to 379.952 shall be known and may be cited as the "Small Employer Health Insurance Availability Act".

2. For the purposes of sections 379.930 to 379.952, the following terms mean:

(1) "Actuarial certification" [means], a written statement by a member of the American Academy of Actuaries or other individual acceptable to the director that a small employer carrier is in compliance with the provisions of section 379.936, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the small employer carrier in establishing premium rates for applicable health benefit plans;

(2) "Affiliate" or "affiliated" [means], any entity or person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, a specified entity or person;

(3) "Agent" [means], "insurance agent" as that term is defined in section 375.012, RSMo;

(4) "Base premium rate" [means], for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under the rating system for that class of business, by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage;

(5) "Basic health benefit plan" [means], a lower cost health benefit plan developed pursuant to section 379.944;

(6) "Board" [means], the board of directors of the program established pursuant to sections 379.942 and 379.943;

(7) "Broker" [means], "broker" as that term is defined in section 375.012, RSMo;

(8) "Carrier" [means], any entity that provides health insurance or health benefits in this state. For the purposes of sections 379.930 to 379.952, carrier includes an insurance company, health services corporation, fraternal benefit society, health maintenance organization, multiple employer welfare arrangement specifically authorized to operate in the state of Missouri, or any other entity providing a plan of health insurance or health benefits subject to state insurance regulation;

(9) "Case characteristics" [means], demographic or other objective characteristics of a small employer that are considered by the small employer carrier in the determination of premium rates for the small employer, provided that claim experience, health status and duration of coverage since issue shall not be case characteristics for the purposes of sections 379.930 to 379.952;

(10) "Class of business" [means], all or a separate grouping of small employers established pursuant to section 379.934;

(11) "Committee" [means], the health benefit plan committee created pursuant to section 379.944;

(12) "Control" shall be defined in manner consistent with chapter 382, RSMo;

(13) "Dependent" [means], a spouse or an unmarried child under the age of nineteen years; an unmarried child who is a full-time student under the age of twenty-three years and who is financially dependent upon the parent; or an unmarried child of any age who is medically certified as disabled and dependent upon the parent;

(14) "Director" [means], the director of the department of insurance of this state;

(15) "Eligible employee" [means], an employee who works on a full-time basis and has a normal work week of thirty or more hours. The term includes a sole proprietor, a partner of a partnership, and an independent contractor, if the sole proprietor, partner or independent contractor is included as an employee under a health benefit plan of a small employer, but does not include an employee who works on a part-time, temporary or substitute basis. For purposes of sections 379.930 to 379.952, a person, his spouse and his minor children shall constitute only one eligible employee when they are employed by the same small employer;

(16) "Established geographic service area" [means], a geographical area, as approved by the director and based on the carrier's certificate of authority to transact insurance in this state, within which the carrier is authorized to provide coverage;

(17) "Health benefit plan" [means], any hospital or medical policy or certificate, health services corporation contract, or health maintenance organization subscriber contract. Health benefit plan does not include a policy of individual accident and sickness insurance or hospital supplemental policies having a fixed daily benefit, or accident-only, specified disease-only, credit, dental, vision, Medicare supplement, long-term care, or disability income insurance, or coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, or automobile medical payment insurance;

(18) "Index rate" [means], for each class of business as to a rating period for small employers with similar case characteristics, the arithmetic mean of the applicable base premium rate and the corresponding highest premium rate;

(19) "Late enrollee" [means], an eligible employee or dependent who requests enrollment in a health benefit plan of a small employer following the initial enrollment period for which such individual is entitled to enroll under the terms of the health benefit plan, provided that such initial enrollment period is a period of at least thirty days. However, an eligible employee or dependent shall not be considered a late enrollee if:

(a) The individual meets each of the following:

a. The individual was covered under qualifying previous coverage at the time of the initial enrollment;

b. The individual lost coverage under qualifying previous coverage as a result of termination of employment or eligibility, the involuntary termination of the qualifying previous coverage, death of a spouse or divorce;

c. The individual requests enrollment within thirty days after termination of the qualifying previous coverage;

(b) The individual is employed by an employer that offers multiple health benefit plans and the individual elects a different plan during an open enrollment period; or

(c) A court has ordered coverage be provided for a spouse or minor or dependent child under a covered employee's health benefit plan and request for enrollment is made within thirty days after issuance of the court order;

(20) "New business premium rate" [means], for each class of business as to a rating period, the lowest premium rate charged or offered, or which could have been charged or offered, by the small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage;

(21) "Plan of operation" [means], the plan of operation of the program established pursuant to sections 379.942 and 379.943;

(22) "Premium" [means], all moneys paid by a small employer and eligible employees as a condition of receiving coverage from a small employer carrier, including any fees or other contributions associated with the health benefit plan;

(23) "Producer" includes an insurance agent or broker;

(24) "Program" [means], the Missouri small employer health reinsurance program created pursuant to sections 379.942 and 379.943;

(25) "Qualifying previous coverage" and "qualifying existing coverage" [mean], benefits or coverage provided under:

(a) Medicare or Medicaid;

(b) An employer-based health insurance or health benefit arrangement that provides benefits similar to or exceeding benefits provided under the basic health benefit plan; or

(c) An individual health insurance policy (including coverage issued by a health maintenance organization, health services corporation or a fraternal benefit society) that provides benefits similar to or exceeding the benefits provided under the basic health benefit plan, provided that such policy has been in effect for a period of at least one year;

(26) "Rating period" [means], the calendar period for which premium rates established by a small employer carrier are assumed to be in effect;

(27) "Restricted network provision" [means], any provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of health care providers that have entered into a contractual arrangement with the carrier pursuant to section 354.400, RSMo, et seq. to provide health care services to covered individuals;

(28) "Small employer" [means], any person, firm, corporation, partnership or association that is actively engaged in business that, on at least fifty percent of its working days during the preceding calendar quarter, employed not less than [three] two nor more than [twenty-five] fifty eligible employees, the majority of whom were employed within this state. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of state taxation, shall be considered one employer;

(29) "Small employer carrier" [means], a carrier that offers health benefit plans covering eligible employees of one or more small employers in this state;

(30) "Standard health benefit plan" [means], a health benefit plan developed pursuant to section 379.944.

660.700. For the purposes of sections 660.700 to 660.727, the following terms mean:

(1) "Board", the board of trustees of the Missouri consolidated health care plan;

(2) "Department", the department of social services;

(3) "Fund", the Missouri pharmaceutical assistance fund created pursuant to section 660.729;

(4) "Prescription drugs", legend drugs prescribed to an individual with preference given to generic drugs unless specifically overwritten by a physician.

660.703. 1. The board shall:

(1) Conduct public hearings to accept public testimony from a wide variety of sources and perspectives regarding existing or proposed programs that:

(a) Promote public health;

(b) Improve health services for senior citizens;

(c) Reduce or prevent the use of tobacco; and

(d) Offer other information on health care in this state;

(2) Establish a process to evaluate the health needs of the senior citizens of this state and a system to rank the health problems of the senior citizens of this state, including, but not limited to, the specific health problems that are endemic to urban and rural communities;

(3) Maximize expenditures through local, state, federal and private matching contributions;

(4) Ensure that any money expended from the fund will not be used to supplant existing methods of funding that are available to public agencies;

(5) Develop policies and procedures for the administration and distribution of grants and other expenditures to nonprofit organizations, universities and community colleges. A condition of any such grant must be that not more than eight percent of the grant may be used for administrative expenses or other indirect costs. The procedures must require at least one competitive round of requests for proposals.

2. The board may take such other actions as are necessary to carry out its duties.

3. The department shall request funding and propose legislation necessary to carry out the recommendations of the board.

660.706. 1. The department may enter into contracts with private health insurers to arrange for the availability, at a reasonable cost which may include copayments and deductibles, of health insurance policies that provide coverage up to a maximum of six thousand dollars to senior citizens not covered by other programs for prescription drugs and pharmaceutical services.

2. Subject to appropriations, a senior citizen who is sixty-five years of age or older, who is not eligible for Medicaid, but who may be eligible for Medicare and who purchases a health insurance policy that is made available pursuant to subsection 1 of this section may receive an annual grant from the fund to subsidize a portion of the cost of that insurance if such senior citizen has been a resident of this state for at least one year immediately preceding the date of his or her application and his or her household income, as defined pursuant to section 135.010, RSMo, is at or below eleven thousand six hundred dollars for an individual and fifteen thousand seven hundred dollars for a couple. Any person who is receiving Medicaid shall not be eligible to participate in the Missouri pharmaceutical assistance program. The program is the payer of last resort. If a senior citizen has coverage for pharmaceutical benefits through a health benefit plan as defined in section 376.1350, RSMo, including a Medicare supplement or Medicare + Choice plan, or through a self-funded employee benefit plan he or she shall not be eligible for the Missouri pharmaceutical assistance program. If a senior citizen receives a tax credit pursuant to section 135.095, RSMo, he or she shall not be eligible for the Missouri pharmaceutical assistance program. An applicant must not have had insurance with pharmaceutical coverage for six months prior to application to the Missouri pharmaceutical assistance program.

3. The amount of any subsidy granted pursuant to this section may not exceed the annual cost of insurance that provides coverage for prescription drugs and pharmaceutical services or eight hundred fifty dollars per year, whichever is less.

660.709. 1. A senior citizen who wishes to receive a subsidy pursuant to section 660.706 may file a request therefor with the department.

2. The request may be filed in such form and content, and accompanied by such proof, as the department may prescribe by rule.

3. The department may, within forty-five days after receiving a request for a subsidy, examine the request, grant or deny it, and if granted, may determine the amount of the subsidy to which the senior citizen is entitled.

4. The department may determine which senior citizens are eligible to receive a subsidy pursuant to section 660.706 and may pay the subsidy directly to an insurer with whom the department has entered into a contract pursuant to section 660.706.

660.712. Any subsidy granted pursuant to section 660.706 to a senior citizen who is not qualified for such a subsidy may be revoked by the department. If a subsidy is so revoked, the senior citizen shall make restitution to the department for any subsidy he has improperly received, and the department may take all proper actions to collect the amount of the subsidy as a debt.

660.715. 1. The department may deny any request for a subsidy received pursuant to section 660.709 to which the senior citizen is not entitled or any amount in excess of that to which the senior citizen is entitled.

2. The department may deny in total any request which it finds to have been filed with fraudulent intent. If any such request has been paid and is afterward denied, the amount of the subsidy must be repaid by the senior citizen to the department.

3. Any amounts received by the department pursuant to this section must be deposited with the state treasurer for credit to the Missouri pharmaceutical assistance fund.

660.718. Any person who is aggrieved by a decision of the department denying a request for a subsidy submitted pursuant to section 660.709 may request administrative review pursuant to chapter 621, RSMo.

660.721. The department is responsible for the administration of the provisions of sections 660.700 to 660.729 and may promulgate rules in conjunction with the department of insurance and the department of health regarding:

(1) The content and form of a request for a subsidy required to be submitted pursuant to section 660.709;

(2) Designation of the proof that must be submitted with such a request;

(3) The adoption of regulations to protect the confidentiality of information supplied by a senior citizen requesting a subsidy pursuant to section 660.709;

(4) The adoption of such other regulations as may be required to carry out the provisions of sections 660.700 to 660.729;

(5) Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2001, shall be invalid and void.

660.724. The department may contract with a third party entity to manage the Missouri pharmaceutical assistance program and may contract with a drug utilization review program to review the Missouri pharmaceutical assistance program. Both contracts may be defined by the department by rule.

660.727. No person may publish, disclose or use any personal or confidential information contained in a request for a subsidy submitted pursuant to section 660.709 except for purposes relating to the administration of sections 660.700 to 660.729.

660.729. 1. There is hereby created in the state treasury the "Missouri Pharmaceutical Assistance Fund" for the purpose of funding the Missouri pharmaceutical assistance program established pursuant to sections 660.700 to 660.729. Any moneys appropriated for the pharmaceutical tax credit which has not been encumbered by September 28, 2002, shall be transferred to the Missouri pharmaceutical assistance fund. Such moneys shall be appropriated until such time as other funding, such as grants, gifts or other appropriations, becomes available.

2. Any rule or portion of a rule, as that term is defined in section 536.010, RSMo, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536, RSMo, and, if applicable, section 536.028, RSMo. This section and chapter 536, RSMo, are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536, RSMo, to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2001, shall be invalid and void.

Section 1. 1. All managed care organizations, as defined in section 198.530, RSMo, shall allow the enrollee the right to select a long-term care facility licensed pursuant to chapter 198, RSMo, with the same religious orientation as demonstrated by the enrollee. If a religiously appropriate facility is not included in the managed care organization's provider network and one is available, the managed care organization shall provide the enrollee the option to receive care from an out-of-network long-term care facility licensed pursuant to chapter 198, RSMo, if the following conditions apply:

(1) The facility is willing and able to provide the services to the resident; and

(2) The facility and those health care professionals delivering services to residents pursuant to this section meet the licensing and training standards as prescribed by law; and

(3) The facility is certified through Medicare; and

(4) The facility and those health care professionals delivering services to residents pursuant to this section agree to abide by the terms and conditions of the managed care organization's contracts with similar providers, abide by patient protection standards and requirements imposed by state or federal law for plan enrollees and meet the quality standards established by the managed care organization for similar providers.

2. The managed care organization shall reimburse the facility at a rate of reimbursement consistent with the carrier's contract with the Health Care Financing Administration for long-term care services.

[376.1400. 1. Every health insurance carrier offering policies of insurance in this state shall use standardized information for the explanation of benefits given to the health care provider whenever a claim is paid or denied. As used in this section, the term "health insurance carrier" shall have the meaning given to "health carrier" in section 376.1350. Nothing in this section shall apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, short- term major medical policies of six months or less duration, other limited benefit health insurance policies.

2. The standardized information shall contain the following:

(1) The name of the insured;

(2) The insured's identification number;

(3) The date of service;

(4) Amount of charge;

(5) Explanation for any denial;

(6) The amount paid;

(7) The patient's full name;

(8) The name and address of the insurer; and

(9) The phone number to contact for questions on explanation of benefits.

3. All health insurance carriers shall use the standard explanation of benefits information after January 1, 2002.]

[376.1403. 1. Every health care provider and health carrier that conducts business in this state shall use standardized information for referrals. As used in this section, the terms "health care provider" and "health carrier" shall have the meaning given to such terms in section 376.1350.

2. The referral information shall contain the following:

(1) The name of the insured;

(2) The name, address and phone number of the health carrier;

(3) The identification number and group number of the insured;

(4) The type of referral;

(5) The name, address and phone number of the health care provider referring the insured;

(6) The name, address and phone number of the health care provider to whom the insured was referred to;

(7) The number of visits requested and authorized; and

(8) The health carrier's authorization number.

3. All health care providers and health carriers shall use the standardized referral information after January 1, 2002.]

Section B. Because of the need for immediate prescription drug assistance for the elderly, the enactment of sections 660.700 to 660.729 of this act is deemed necessary for the immediate preservation of the public health, welfare, peace and safety, and is hereby declared to be an emergency act within the meaning of the constitution, and the enactment of sections 660.700 to 660.729 of this act shall be in full force and effect upon its passage and approval.