SECOND REGULAR SESSION
HOUSE BILL NO. 2513
94TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES BAKER (25) (Sponsor), GEORGE, RUCKER, LOW (39), HOLSMAN, McCLANAHAN, OXFORD, ROORDA, JOHNSON AND TALBOY (Co-sponsors).
Read 1st time March 31, 2008 and copies ordered printed.
D. ADAM CRUMBLISS, Chief Clerk
To amend chapter 208, RSMo, by adding thereto fourteen new sections relating to children's health insurance.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 208, RSMo, is amended by adding thereto fourteen new sections, to be known as sections 208.1100, 208.1103, 208.1106, 208.1109, 208.1112, 208.1115, 208.1118, 208.1121, 208.1124, 208.1127, 208.1130, 208.1133, 208.1136, and 208.1139, to read as follows:
208.1100. The general assembly finds that for the economic and social benefit of all residents of this state it is important to enable all children of this state to access affordable health insurance that offers comprehensive coverage and emphasizes preventive health care. Many children in working families, including many families whose annual family income ranges between forty and eighty thousand dollars, are uninsured. Numerous studies demonstrate that lack of insurance negatively affects health status. The general assembly further finds that access to health care is a key component for children's healthy development and successful education. The effects of lack of insurance also negatively impact those who are insured because the cost of paying for care to the uninsured is often shifted to those who have insurance in the form of higher health insurance premiums. It is therefore the intent of the Missouri general assembly to provide access to affordable health insurance to all uninsured children in Missouri.
208.1103. As used in sections 208.1100 to 208.1139, the following terms mean:
(1) "Application agent", an organization or individual, such as a licensed health care provider, school, youth service agency, employer, labor union, local chamber of commerce, community-based organization, or other organization approved by the department to assist in enrolling children in the program;
(2) "Child", any person less than nineteen years of age;
(3) "Department", the department of social services;
(4) "Medical assistance", health care benefits provided in accordance with the children's health insurance program established under sections 208.631 to 208.657;
(5) "Program", the covering ALL KIDS health insurance program;
(6) "Resident", an individual who:
(a) Is in the state for other than a temporary or transitory purpose during the taxable year; or
(b) Is domiciled in this state but is absent from the state for a temporary or transitory purpose during the taxable year.
208.1106. There is hereby created the "Covering ALL KIDS Health Insurance Program" within the department of social services. The department shall have the same powers and authority to administer the program as are provided to the department in connection with the department's administration of the state's public assistance programs, including the children's health insurance program established in sections 208.631 to 208.657. The department shall coordinate the program with the existing children's health programs operated by the department and other state agencies.
208.1109. 1. To be eligible for the program, a person shall be a child:
(1) Who is a resident of the state of Missouri;
(2) Who is ineligible for other medical assistance under this chapter or benefits under the children's health insurance program under sections 208.631 to 208.657; and
(a) Who has been without health insurance coverage for a period set forth by the department in rules, but not less than six months during the first month of operation of the program, seven months during the second month of operation, eight months during the third month of operation, nine months during the fourth month of operation, ten months during the fifth month of operation, eleven months during the sixth month of operation, and twelve months thereafter;
(b) Whose parent has lost employment that made available affordable dependent health insurance coverage, until such time as affordable employer-sponsored dependent health insurance coverage is again available for the child as set forth by the department in rules;
(c) Who is a newborn whose responsible relative does not have available affordable private or employer-sponsored health insurance; or
(d) Who, within one year of applying for coverage under sections 208.1100 to 208.1139, lost medical benefits under this chapter or the children's health insurance program.
Any entity that provides health insurance coverage to Missouri residents shall provide health insurance data match to the department for the purpose of determining eligibility for the program under sections 208.1100 to 208.1139. The department, in collaboration with the department of insurance, financial institutions and professional registration, shall adopt rules governing the exchange of information under this section. Such rules shall be consistent with all laws relating to the confidentiality or privacy of personal information or medical records, including provisions under the federal Health Insurance Portability and Accountability Act (HIPAA).
2. The department shall monitor the availability and retention of employer-sponsored dependent health insurance coverage and shall modify the period described in subdivision (3) of subsection 1 of this section if necessary to promote retention of private or employer-sponsored health insurance and timely access to health care services, but at no time shall the period described in subdivision (3) of subsection 1 of this section be less than six months.
3. The department, in its discretion, may take into account the affordability of dependent health insurance when determining whether employer-sponsored dependent health insurance coverage is available upon reemployment of a child's parent as provided in subdivision (3) of subsection 1 of this section.
4. A child who is determined to be eligible for the program shall remain eligible for twelve months, provided that the child maintains his or her residence in this state, has not yet attained nineteen years of age, and is not excluded under subsection 5 of this section.
5. A child shall not be eligible for coverage under the program if:
(1) The premium required under section 208.1121 has not been timely paid. If the required premiums are not paid, the liability of the program shall be limited to benefits incurred under the program for the time period for which premiums have been paid. If the required monthly premium is not paid, the child is ineligible for reenrollment for a minimum period of three months. Reenrollment shall be completed before the next covered medical visit, and the first month's required premium shall be paid in advance of the next covered medical visit; or
(2) The child is an inmate in a public institution or mental health facility.
6. The department shall adopt eligibility rules, including but not limited to rules regarding annual renewals of eligiblity for the program, rules providing for reenrollment, grace periods, notice requirements, and hearing procedures under subdivision (1) of subsection 5 of this section, and rules regarding what constitutes availability and affordability of private or employer-sponsored health insurance, with consideration of such factors as the percentage of income needed to purchase children or family health insurance, the availability of employer subsidies, and other relevant factors.
7. 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 sections 208.1100 to 208.1139 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. Sections 208.1100 to 208.1139 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, 2008, shall be invalid and void.
208.1112. The department shall develop procedures to allow application agents to assist in enrolling children in the program or other children's health programs operated by the department. At the department's discretion, technical assistance payments may be made available for approved applications facilitated by an application agent.
208.1115. The department may provide grants to application agents and other community-based organizations to educate the public about the availability of the program. The department shall adopt rules regarding performance standards and outcomes measures expected of organizations that are awarded grants under this section, including penalties for nonperformance of contract standards.
208.1118. 1. The department shall purchase or provide health care benefits for eligible children that are identical to the benefits provided for children under the Missouri children's health insurance program established in sections 208.631 to 208.657, except for nonemergency transportation.
2. As an alternative to the benefits set forth in subsection 1 of this section and when cost-effective, the department may offer families subsidies toward the cost of privately sponsored health insurance, including employer-sponsored health insurance.
3. Notwithstanding the provisions of paragraph (a) of subdivision (3) of subsection 1 of section 208.1109, the department may consider offering, as an alternative to the benefits set forth in subsection 1 of this section:
(1) Partial coverage to children who are enrolled in a high-deductible private health insurance plan;
(2) A limited package of benefits to children in families who have private or employer-sponsored health insurance that does not cover certain benefits such as dental or vision benefits.
4. The content and availability of benefits described in subsections 2 and 3 of this section and the terms of eligibility for such benefits shall be at the department's discretion and the department's determination of efficacy and cost-effectiveness as a means of promoting retention of private or employer-sponsored health insurance.
208.1121. 1. Children enrolled in the program under subsection 1 of section 208.1118 are subject to the following cost-sharing requirements:
(1) The department shall, by rule, set forth requirements concerning copayments and coinsurance for health care services and monthly premiums. Such cost-sharing shall be on a sliding scale based on family income. The department may periodically modify such cost-sharing;
(2) Notwithstanding the provisions of subdivision (1) of this subsection, there shall be no copayment required for well-baby or well-child health care, including but not limited to age-appropriate immunizations as required under state or federal law.
2. Children enrolled in a privately sponsored health insurance plan under subsection 2 of section 208.1118 are subject to the cost-sharing provisions stated in the privately sponsored health insurance plan.
3. Notwithstanding any other provision of law, rates paid by the department shall not be used in any way to determine the usual and customary or reasonable charge, which is the charge for health care that is consistent with the average rate or charge for similar services furnished by similar providers in a certain geographic area.
208.1124. 1. The department shall conduct a study that includes but is not limited to the following:
(1) Establishing estimates, broken down by regions of the state, of the number of children with and without health insurance coverage, the number of children who are eligible for MO HealthNet or the children's health insurance program, and, of that number, the number who are enrolled in MO HealthNet or the children's health insurance program, and the number of children with access to dependent coverage through an employer, and, of that number, the number who are enrolled in dependent coverage through an employer;
(2) Surveying those families whose children have access to employer-sponsored dependent coverage but who decline such coverage as to the reasons for declining coverage;
(3) Ascertaining, for the population of children accessing employer-sponsored dependent coverage or who have access to such coverage, the comprehensiveness of dependent coverage available, the amount of cost-sharing currently paid by the employees, and the cost-sharing associated with such coverage;
(4) Measuring the health outcomes or other benefits for children utilizing the covering ALL KIDS health insurance program and analyzing the effects of utilization of health care services for children after enrollment in the program compared to the preceding period of uninsured status.
2. The studies described in subsection 1 of this section shall be conducted in a manner that compares a time period preceding or at the initiation of the program with a later period.
3. The department shall submit the preliminary results of the study to the governor and the general assembly no later than July 1, 2010, and shall submit the final results to the governor and general assembly no later than July 1, 2012.
208.1127. The department shall report to the general assembly no later than September first of each year beginning in 2009, all of the following information:
(1) The number of professionals serving in the primary care case management program, by licensed profession and by county, and, for counties with a population of one hundred thousand or more, by geographic zip code;
(2) The number of nonprimary care providers accepting referrals, by specialty designation, by licensed profession and by county, and, for counties with a population of one hundred thousand or more, by geographic zip code;
(3) The number of individuals enrolled in the covering ALL KIDS health insurance program by income or premium level and by county, and, for counties with a population of one hundred thousand or more, by geographic zip code.
208.1130. The department shall present details regarding implementation of the program to the appropriate committees of the general assembly, and such committees shall serve as the forum for health care providers, advocates, consumers, and other interested parties to advise the department with respect to the program. The department shall consult with stakeholders on the rules for health care professional participation in the program under sections 208.1133 and 208.1136.
208.1133. 1. The department shall ensure adequate access to specialty physician care for program participants by allowing referrals to be accomplished without undue delay.
2. The department shall allow a primary care provider to make appropriate referrals to specialist physicians or other health care providers for an enrollee who has a condition that requires care from a specialist physician or other health care provider. The department may specify the necessary criteria and conditions that shall be met in order for an enrollee to obtain a standing referral. A referral shall be effective for the period necessary to provide the referred services or one year, whichever is less. A primary care provider may renew and re-renew a referral.
3. The enrollee's primary care provider shall remain responsible for coordinating the care of an enrollee who has received a standing referral to a specialist physician or other health care provider. If a secondary referral is necessary, the specialist physician or other health care provider shall advise the primary care provider. The primary care provider or specialist physician shall be responsible for making the secondary referral. In addition, the department shall require the specialist physician or other health care provider to provide regular updates to the enrollee's primary care provider.
208.1136. 1. Any disease management program implemented by the department shall be or shall have been developed in consultation with physician organizations, such as state, national, and specialty medical societies, and any available standards or guidelines of such organizations. Such programs shall be based on evidence-based scientifically sound principles that are accepted by the medical community. An enrollee shall be excused from participation in a disease management program if the enrollee's physician licensed to practice medicine in all its branches, in his or her professional judgment, determines that participation is not beneficial to the enrollee.
2. Any performance measures, such as primary care provider monitoring, implemented by the department shall be or shall have been developed on consultation with physician organizations, such as state, national, and specialty medical societies, and any available standards and guidelines of such organizations. Such measures shall be based on evidence-based scientifically sound principles that are accepted by the medical community.
3. The department shall adopt variance procedures for the application of any disease management program or any performance measures to an individual enrollee.
208.1139. The department shall request any necessary state plan amendments or waivers of federal requirements in order to allow receipt of federal funds for implementing any or all of the provisions of the program. The failure of the responsible federal agency to approve a waiver or other state plan amendments shall not prevent the implementation of any provision of sections 208.1100 to 208.1139.