HCS HB 2413, 2355, 2394 & 2398 -- TRANSFORMATION OF THE HEALTH
CARE MARKET
SPONSOR: Schaaf
COMMITTEE ACTION: Voted "do pass" by the Special Committee on
Healthcare Transformation by a vote of 6 to 2.
This substitute changes the laws regarding the health care market
and services in Missouri and establishes the Insure Missouri Plan
in the MO HealthNet Division within the Department of Social
Services.
TRANSPARENCY OF HEALTH CARE SERVICES
The substitute requires health care providers and insurers, upon
request, to provide patients with the information necessary to
compare cost data for an ordered or planned service. These
provisions do not apply to health care services delivered on an
emergency basis, requests regarding services to be performed as
part of ongoing inpatient care, or services represented by
certain codes published by the American Medical Association. By
January 1, 2009, the Department of Insurance, Financial
Institutions, and Professional Registration is required to
provide on its web site the Medicare fee schedule, by code and
provider, for all Missouri Medicare providers and, for each
Missouri hospital, the Medicare diagnosis-related group payment
for each code. Compliance with this section will not be
considered a violation of any provider contract provisions with a
health carrier that prohibit disclosure of the provider's fee
schedule with a health carrier to third parties.
Criteria is established for insurers to use in programs that
publicly assess and compare quality and cost efficiency of health
care data. A provider cannot decline to enter into a provider
contract with an insurer solely because the insurer uses quality
and cost efficiency of health care data programs.
A person who sells or distributes health care quality and cost
efficiency data in a comparative format to the public is required
to identify the source used to confirm the validity of the data
and its analysis as an objective indicator of health care
quality. This provision does not apply to articles or research
studies that are published in peer-reviewed academic journals.
The Department of Health and Senior Services is required to
investigate complaints of alleged violations and is authorized to
impose a penalty of up to $1,000.
Alleged violations by health insurers will be investigated and
enforced by the Department of Insurance, Financial Institutions,
and Professional Registration.
MISSOURI HEALTH FACILITIES REVIEW COMMITTEE
Currently, the Missouri Health Facilities Review Committee for
the Certificate of Need Program is composed of two members of the
Senate, two members of the House of Representatives, and five
members appointed by the Governor. The substitute changes the
membership of the committee to:
(1) One member who is professionally qualified in health
insurance plan sales and administration;
(2) One member who has professionally qualified experience in
commercial development, financing, and lending;
(3) Two members with a doctorate of philosophy in economics;
(4) Two members who are professionally qualified as medical
doctors or doctors of osteopathy, but who are not employees of a
hospital or consultants to a hospital;
(5) Two members who are professionally experienced in hospital
administration, but are not employed by a hospital or as
consultants to a hospital; and
(6) One member who is a registered nurse, but who is not an
employee of a hospital or a consultant to a hospital.
All members will be appointed by the Governor with the advice and
consent of the Senate and serve a four-year term. No more than
five members can be from the same political party.
For all hearings held by the committee, the substitute:
(1) Requires all testimony and other evidence taken during the
hearings to be under oath and subject to the penalty of perjury;
(2) Specifies that the committee can, upon a majority vote of
the committee, subpoena witnesses and require the attendance of
witnesses, the giving of testimony, and the production of
records;
(3) Prohibits all ex parte communications between members of the
committee and any interested party or witness regarding the
subject matter of the hearing at any time prior to, during, or
after the hearing;
(4) Requires any party opposing the issuance of a certificate of
need to show by clear and convincing evidence that the need does
not exist or that the new facility will cause a substantial and
continuing loss of medical services within the affected region or
community;
(5) Specifies that all committee hearings will be governed by
rules adopted by the committee but not be bound by the technical
rules of evidence; and
(6) Authorizes the committee, upon a majority vote, to assess
the costs of court reporting transcription or the issuance of
subpoenas to one or both of the involved parties.
The substitute removes the $1,000 fee that currently is required
when filing a certificate of need application.
STANDARDIZED INSURANCE APPLICATIONS
The Director of the Department of Insurance, Financial
Institutions, and Professional Registration must establish by
rule uniform insurance application forms to be used by all
insurers.
MISSOURI HEALTH INSURANCE POOL
The substitute:
(1) Increases the lifetime benefit cap for an individual covered
under the Missouri Health Insurance Pool (MHIP) from $1 million
to $2 million;
(2) Requires all health insurers to notify an insured person
when he or she has exhausted 95% of his or her total lifetime
health insurance benefits and the person's eligibility for and
the methods of applying for coverage under the pool.
Notification must be repeated when an insured has exhausted 100%
of his or her total lifetime health insurance benefits;
(3) Reduces the pre-existing condition waiting period from 12
months to six months;
(4) Requires the pool to offer stop-loss coverage for any
insurer in the private individual health insurance market to
cover claim liability for an insured person who becomes
uninsurable or an uninsurable dependent and to establish a
two-year pilot program that offers small group stop-loss coverage
to stabilize small group premiums when risks associated with
specific individuals under a small group policy would result in
increased premiums for the entire group. The MHIP board is
required to submit a report to the General Assembly by January 1,
2011, regarding the pilot program and any recommendations to
expand the program statewide;
(5) Allows the MHIP board to establish a premium subsidy program
for low-income individuals;
(6) Requires the pool, beginning July 1, 2008, to offer at least
one plan that meets the criteria of the federal Centers for
Medicare and Medicaid for uninsurable individuals eligible under
the Insure Missouri Program;
(7) Establishes premium rates for health insurance coverage
through the pool. For individuals with incomes of less than 300%
of the federal poverty level, the premium will be equal to the
standard risk rate. For individuals with incomes of 300% or more
of the federal poverty level, the premium will be a sliding scale
rate based on his or her income of between 100% and 125% of the
standard risk rate;
(8) Specifies that any licensed insurance agent or broker who
sells a health insurance policy offered under the pool to an
eligible individual will receive a commission for the sale at an
amount to be set by the board; and
(9) Eliminates insurer assessments under the pool and
distributes premium taxes currently collected from insurers
offering health-related insurance products to the pool beginning
January 1, 2009.
INSURE MISSOURI PROGRAM
The substitute:
(1) Establishes the Insure Missouri Program within the
Department of Social Services to provide health care coverage to
low-income working Missourians;
(2) Requires the department to apply to the United States
Department of Health and Human Services for a waiver and/or a
Medicaid state plan amendment to develop and implement the
program and to submit the proposed application to the Joint
Committee on MO HealthNet for its review, recommendations, and
approval;
(3) Specifies that the program is not an entitlement program.
The maximum enrollment of program participants is dependent on
the moneys appropriated by the General Assembly, and eligibility
for the program can be phased in incrementally based on
appropriations;
(4) Requires the department to establish certain specified
standards for consumer protection;
(5) Requires the program to pay 100% of the premium costs for
participants, except for any participant whose health care
account balance exceeds the annual required contribution amount.
The amount in excess of the annual required amount will go toward
payment of the participant's premium costs under the program;
(6) Specifies eligibility requirements for program participants
and requires them to be subject to approval by the United States
Department of Health and Human Services;
(7) Specifies covered, medically necessary services and that the
program can include incentives designed to promote and encourage
healthy lifestyles;
(8) Establishes a health care account for each eligible
individual into which payments for his or her participation can
be made by the individual, an employer, the state, or any
philanthropic or charitable contributor. The account will be
used to pay the individual's deductible under the program;
(9) Specifies that an individual's participation in the program
does not begin until the participant makes an initial payment of
at least one-twelfth of the annual required payment;
(10) Specifies that a participant's annual required payment is
the lesser of $1,000 less any payments under the Mo HealthNet
Program, the Children's Health Insurance Program, and the federal
Medicare Program or a certain percentage of his or her household
income;
(11) Requires the state to contribute the difference to the
participant's account if his or her account does not have
sufficient funds to pay any deductible or co-payments;
(12) Specifies that a participant will be terminated from
participation in the plan if his or her required payment is not
made within 90 days after the required date. Written notice must
be given before a participant can be terminated from the plan;
(13) Specifies that approved participants are eligible for a
12-month period but must file a renewal application to remain in
the program;
(14) Specifies that an eligible individual who participates in
the program without a break in service and has an income
exceeding the current income limit for participation, set by
appropriations, at the time of renewal will be eligible for
transitional participation in the program. Transitional
participation will terminate when the individual's income exceeds
225% of the federal poverty level;
(15) Requires any moneys remaining in the health care account to
be used to reduce the participant's payments for the subsequent
program period if the individual renews his or her participation.
The division must refund any amount remaining in the health care
account, less any outstanding individual obligations under the
program, to a participant who is no longer eligible, has not
renewed participation, or is terminated from the program;
(16) Specifies how health insurance coverage will be obtained
for approved program participants;
(17) Prohibits the deductible for any qualified plan under the
program from exceeding $2,500;
(18) Specifies that any licensed insurance agent or broker who
sells a health insurance policy offered under the MHIP to an
individual eligible for the program will receive a commission in
an amount set by the Department of Social Services; and
(19) Requires the department, in consultation and coordination
with the Department of Insurance, Financial Institutions, and
Professional Registration and the MHIP board of directors, to
ensure that eligible participants are able to obtain health
insurance coverage through licensed insurance agents and brokers.
Certain provisions regarding the MHIP become effective January 1,
2009.
The substitute contains an emergency clause.
FISCAL NOTE: Estimated Cost on General Revenue Fund of Unknown
but Greater than $49,017,646 in FY 2009, Unknown but Greater than
$52,675,915 in FY 2010, and Unknown but Greater than $55,885,849
in FY 2011. Estimated Effect on Other State Funds of an income
of Unknown to a cost of Unknown but Greater than $12,293,791 in
FY 2009, an income of Unknown to a cost of Unknown but Greater
than $60,289,673 in FY 2010, and an income of Unknown to a cost
of Unknown but Greater than $106,108,982 in FY 2011.
PROPONENTS: Supporters of House Bill 2413 and House Bill 2398
say that the bills improve portability of health insurance,
eliminate the barrier of earning more money and losing health
care coverage through the transitional benefit provision, and
provide coverage to low-income working individuals.
Supporters of House Bill 2355 say that it offers commonsense
reform to the Certificate of Need Program, changing the
membership of the committee is a good reform, and the program is
antiquated.
Supporters of House Bill 2394 say that the effect of suboptimal
care is a large problem, and the bill will help health care
consumers. Consumers can realize a savings in reduced premiums
after time. The bill will also help consumers see the cost of
health care and can change behavior to seek lower cost services.
Testifying for HB 2413 and HB 2398 were Representatives Ervin and
Schaaf; Missouri Association of Homes for the Aging; United
Healthcare; Missouri Catholic Conference; and Missouri Hospital
Association.
Testifying for HB 2355 were Representative Flook; Missouri State
Medical Association; and Missouri Association of Osteopathic
Physicians and Surgeons.
Testifying for HB 2394 were Representative Ervin; United
Healthcare; Blue Cross Blue Shield of Kansas City; St. Louis Area
Business Health Coalition; Anthem Blue Cross Blue Shield; Ford
Motor Company; and Missouri Hospital Association.
OPPONENTS: Those who oppose House Bill 2413 and House Bill 2398
say that changing the membership of the Health Facilities Review
Committee can change the policy established by the committee, the
fiscal impact on the state will be negative rather than positive
as the program currently operates, and the process is shifted
from consensus to adversarial.
Those who oppose House Bill 2355 say that the burden of proof
should fall on both parties involved in the certificate of need
process, and the bill appears to pit provider against provider
when the Health Facilities Review Committee is intended to
represent the consumer.
Those who oppose House Bill 2394 say that health care providers
contract with many insurers and they don't always know which
insurer will pay for the service, data information required by
the physician and each insurer will require different data, and
there are concerns about what will happen when a patient doesn't
follow a doctor's orders and the doctor is penalized.
Testifying against HB 2413 and HB 2398 were Missouri Health Care
Association.
Testifying against HB 2355 were Missouri Hospital Association;
St. Louis Area Business Health Coalition; Ford Motor Company;
Associated Industries of Missouri; Missouri Health Facilities
Review Committee, Department of Health and Senior Services;
Missouri Health Care Association; and Hospital Corporation of
America.
Testifying against HB 2394 were Missouri State Medical
Association; Missouri Academy of Family Physicians; and Missouri
State Chiropractors Association.
OTHERS: Others testifying on House Bill 2355 say that evidence
should demonstrate that no need exists before a group is denied a
certificate of need.
Others testifying on House Bill 2394 say that there might be
problems with collecting quality data and new doctors could have
problems with quality data.
Testifying on HB 2355 was Missouri Association of Homes for the
Aging.
Testifying on HB 2394 was A.J. Delaney, MD.
Copyright (c) Missouri House of Representatives
Missouri House of Representatives
94th General Assembly, 2nd Regular Session
Last Updated October 15, 2008 at 3:12 pm