HCS/SS/SB 401 - This act modifies various provisions relating to health insurance.HMOS AND DEDUCTIBLE PLANS - Under current law, health maintenance organizations (HMOs) are not allowed to charge deductibles for basic health care services. This act allows health maintenance organizations to charge deductibles and coinsurance for basic health care services. The act specifically provides that HMOs shall have the power to offer as an option one or more health benefit plans which contain deductibles, coinsurance, coinsurance differentials, or variable copayments. These types of health benefit plans must be combined with any health savings accounts as described under federal law. The total out-of-pocket expenses under the plan shall not exceed the annual contribution limits for health savings accounts and the health savings account must be sufficiently funded so that reimbursement for qualified medical expenses is made to a health care provider within 30 days of the submission of a claim (Sections 354.410, 354.415 and 354.430). These provisions are also contained in the truly agreed to version of SB 262 and in SB 403 (2013).
EXCLUSIVE IN-NETWORK PLANS - Under the terms of this act, HMOs and other health carriers may offer health benefit plans that are managed care plans that require all health care services to be delivered by participating providers in the HMO's or health carrier's network. The exclusive in-network plan shall not apply to emergency services and certain mental health benefit services. An exclusive in-network plan must be disclosed in the policy form (Sections 354.603, 376.426, and 376.777). Similar provisions can be found in the truly agreed to version of SB 262 and in SB 403 (2013).
INDIVIDUAL AND GROUP POLICY FORM APPROVAL PROCESS - This act modifies the process for approving group and individual health insurance policy forms. If a policy form is disapproved by the director, all specific reasons for nonconformance shall be stated in writing within 45 days from the date of filing. The failure of the director to take action approving or disapproving a submitted policy within 45 days (currently not to exceed 60 days) from the date of the filing, shall be deemed approval of the policy. If at any time after a policy form is approved or deemed approved, the director determines that any provision of the filing is contrary to state law, the director shall notify the health carrier of the specific provision that is contrary to state law and request that the health carrier file, within 30 days of the notification, an amendment form that modifies the provision to conform to state law. Upon approval of the amendment form by the director, the health carrier shall issue a copy of the amendment to each individual and entity to which the deemed filing was previously issued and shall attach a copy of the amendment to the deemed filing when it is subsequently issued. The amendment shall have the force and effect as if the amendment was in the original filing or policy. When a policy form is approved or deemed approved and subsequently amended at the request of the director, the health carrier issuing the policy form shall be considered to have committed a level one violation under the state insurance code (Sections 376.405 and 376.777). Similar provisions can be found in the truly agreed to version of SB 262 and in SB 403 (2013).
MISSOURI HEALTH INSURANCE POOL -TRANSITION TO FEDERAL HEALTH INSURANCE EXCHANGE - Under the terms of this act, the board of directors and employees of the Missouri Health Insurance Pool are authorized to provide assistance and resources to any department, agency, public official, employee or agent of the federal government for the purpose of transitioning pool enrollees to coverage outside of the pool on or before January 1, 2014. This authority does not authorize the pool to establish a state-based exchange (Section 376.961).
Under the act, the board must submit amendments to the pool's plan of operation as are necessary to ensure a reasonable transition period to allow for the termination of issuance of policies by the pool. The plan of operation amendments shall address the transition of pool enrollees to alternative health insurance coverage as it is available January 1, 2014. The plan of operation shall also address procedures for finalizing the financial matters of the pool, including assessments, claims expenses, and other matters (Section 376.962).
Under the terms of the act, the Missouri Health Insurance Pool shall not issue new health insurance policies on or after January 1, 2014 (Section 376.964). Coverage under the Missouri Health Insurance Pool shall expire on January 1, 2014 (Section 376.966).
Under the act, the board shall invite all insurers and third-party administrators to submit bids to serve as the administering insurer or third-party administrator for the pool. The board shall make its selection prior to January 1, 2014. Beginning January 1, 2014, the administering insurer or third-party administrator shall submit to the board and the director a detailed plan outlining the winding down of operations of the pool (Sections 376.968 and 376.970)
Assessments under the pool shall continue until all claims have been paid. Any assessments remaining shall be deposited in the state general revenue fund (Section 376.973).
The high risk pool provisions can also be found in the truly agreed to version of SB 262 (2013).
UTILIZATION REVIEW PROCEDURE - This act updates Missouri's current utilization review procedure so that health carriers may notify health care providers of certain insurance determinations in an electronic manner. Current law only allows health carriers to notify providers by telephone (Section 376.1363). This portion of the act may also be found in the truly agreed to version of SB 262 and in SB 403 (2013).
LICENSURE OF NAVIGATORS - This act provides that no individual or entity shall perform, offer to perform, or advertise any service as a navigator in Missouri or receive navigator funding from Missouri or a health insurance exchange unless licensed as a navigator by the Department of Insurance, Financial Institutions and Professional Registration.
Under the act, navigators may provide fair and impartial information and services in connection with eligibility, enrollment, and program specifications of any health benefit exchange operating in this state, including information about the costs of coverage, advance payments of premium tax credits, and cost sharing reductions. In addition, navigators may facilitate the selection of a qualified health plan and initiate the enrollment process. Navigators may provide referrals to any applicable office of health insurance consumer assistance, ombudsman, or other agency for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or determination under the plan.
Unless properly licensed as a health insurance producer in this state, a navigator shall not:
(1) Sell, solicit, or negotiate health insurance;
(2) Engage in any activity that would require an insurance producer license;
(3) Provide advice concerning the benefits, terms, and features of a particular health plan or offer advice about which exchange health plan is better or worse for a particular individual or employer;
(4) Recommend or endorse a particular health plan or advise consumers about which health plan to choose; or
(5) Provide any information or services related to health benefit plans or other products not offered in the exchange.
The act specifically exempts certain entities from being the licensure requirements. Specifically, health insurance producers, law firms, licensed attorneys, and certain health care providers are exempt from licensure.
The act delineates the process for obtaining a navigator license, including the qualifications for obtaining such a license, the payment of licensing fees, the posting of surety bonds, and other ancillary matters.
A navigation license is valid for 2 years. The act sets forth the process for renewing a navigator license. In order to renew a license, an individual licensee must comply with any training and continuing education requirements established by the director. Failure to satisfy training and continuing education requirements shall result in the expiration of the license.
Under the act, any navigator who has contact with a person who acknowledges having existing health insurance coverage obtained through an insurance producer must advise the person to consult with a licensed insurance producer regarding coverage in the private market.
The act establishes a procedure for suspending, revoking, or refusing to issue or renew a navigator license. The grounds for suspension or revocation are similar to the grounds for suspending an insurance producer license. A navigator license may also be suspended or revoked for engaging in unfair trade practices.
The act allows the director to issue administrative orders and maintain civil actions against persons who are violating the navigator licensure provisions. Under the act, a violation of the navigator licensure provisions is a level 2 violation under the state insurance code.
Under the terms of the act, each licensed navigator shall report to the director within 30 calendar days of the final disposition of the matter of any administrative action taken against him or her in another jurisdiction or by another governmental agency in this state. The act further requires, within 30 days of the initial pretrial hearing date, a navigator to report any criminal prosecution of the navigator in any jurisdiction.
The provisions pertaining to navigator licensing are severable.
The act authorizes the director to promulgate rules and regulations to implement the licensing provisions.
The navigator provisions are subject to an emergency clause. This portion of the act is similar to the provisions contained in the truly agreed to version of SB 262 (2013). The provisions may also be found in SB 403 (2013)(Sections 376.2000 to 376.2014).
REGULATORY AUTHORITY OVER HEALTH INSURANCE PRODUCTS - This act provides that the Department of Insurance shall exercise its authority and responsibility over health insurance product form filings, consumer complaints, and investigations into compliance with state law, regardless as to how a health insurance product may be sold or marketed in this state or to residents of this state (Section 1). This provision may also be found in the truly agreed to version of SB 262 (2013).
STEPHEN WITTE