SB 406 – Prohibits health carriers from requiring prior authorization for serious and urgent conditions and requires certain health benefit determinations to be made within 4 hours rather than 2 working days

• Sponsor: Wallingford
• LR Number: 1864S.01I
• Committee: Small Business, Insurance and Industry
• Last Action: 4/16/2013 - SCS Voted Do Pass S Small Business, Insurance and Industry Committee - (1864S.02C)
• Effective Date: August 28, 2013

Current Bill Summary

SCS/SB 406 - This act changes Missouri's law regarding health insurance benefit determinations. Under current Missouri law, a health carrier is required to make an initial determination within two working days of obtaining all necessary information regarding a proposed admission, procedure, or service requiring a review determination. This act modifies this provision of law by changing the time period from two working days to within 24 hours of obtaining the necessary information regarding a proposed admission, procedure, or service.

Under the terms of the act, when conducting utilization review or making a benefit determination for emergency services or health care services involving serious and urgent conditions, the health carrier must cover emergency services necessary to screen and stabilize the enrollee and cannot require prior authorization for the services and must cover services for a serious and urgent condition and shall not require prior authorization of the services.

The act defines the term "serious and urgent condition" as a patient's condition or diagnostic information which would lead a reasonably prudent licensed health care professional to determine that:

(1) The patient has inadequately controlled undiagnosed pain;

(2) A delay in diagnosis may cause disease progression, impairment to a bodily function, or serious dysfunction of any body organ or part; or

(3) A delay in providing diagnostic testing will result in serious risk or jeopardy of harm to the patient's health.

Coverage of serious and urgent conditions is subject to applicable co-payments, coinsurance, and deductibles.

When an enrollee receives services for a serious and urgent condition requiring immediate post evaluation or stabilization services, the health carrier must provide an authorization decision within 60 minutes of receipt of the request. If the health carrier fails to provide an authorization determination within 30 minutes, the services must be deemed approved.

The provisions of this act are identical to House Bill 499 (2013).

STEPHEN WITTE