To repeal section 376.995, RSMo 1994, and section 167.181, RSMo Supp. 1995, and to enact in lieu thereof four new sections for the purpose of improving access to immunizations for children.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF MISSOURI, AS FOLLOWS:

Section A. Section 376.995, RSMo 1994, and section 167.181, RSMo Supp. 1995, are repealed and four new sections enacted in lieu thereof, to be known as sections 167.181, 376.995, 1 and 2, to read as follows:

167.181. 1. The department of health, after consultation with the department of elementary and secondary education, shall promulgate rules and regulations governing the immunization against poliomyelitis, rubella, rubeola, mumps, tetanus, pertussis [and], diphtheria, and hepatitis B, to be required of children attending public, private, parochial or parish schools. Such rules and regulations may modify the immunizations that are required of children in this subsection. The immunizations required and the manner and frequency of their administration shall conform to recognized standards of medical practice. The department of health shall supervise and secure the enforcement of the required immunization program.

2. It is unlawful for any student to attend school unless he has been immunized as required under the rules and regulations of the department of health, and can provide satisfactory evidence of such immunization; except that if he produces satisfactory evidence of having begun the process of immunization, he may continue to attend school as long as the immunization process is being accomplished in the prescribed manner. It is unlawful for any parent or guardian to refuse or neglect to have his child immunized as required by this section, unless the child is properly exempted.

3. This section shall not apply to any child if one parent or guardian objects in writing to his school administrator against the immunization of the child, because of religious beliefs or medical contraindications. In cases where any such objection is for reasons of medical contraindications, a statement from a duly licensed physician must also be provided to the school administrator.

4. Each school superintendent, whether of a public, private, parochial or parish school, shall cause to be prepared a record showing the immunization status of every child enrolled in or attending a school under his jurisdiction. The name of any parent or guardian who neglects or refuses to permit a nonexempted child to be immunized against diseases as required by the rules and regulations promulgated [hereunder] pursuant to the provisions of this section shall be reported by the school superintendent to the department of health.

5. The immunization required may be done by any duly licensed physician or by someone under his direction. If the parent or guardian is unable to pay, the child shall be immunized at public expense by a physician or nurse at or from the county, district, city public health center or a school nurse or by a nurse or physician in the private office or clinic of the child's personal physician with the costs of immunization paid through the state medicaid program, private insurance or in a manner to be determined by the department of health subject to state and federal appropriations, and after consultation with the school superintendent and the advisory committee established in section 192.630, RSMo.

6. Funds for the administration of this section and for the purchase of vaccines for children of families unable to afford them shall be appropriated to the department of health from general revenue or from federal funds if available.

7. No rule or portion of a rule promulgated under the authority of this section shall become effective unless it has been promulgated pursuant to the provisions of section 536.024, RSMo.

376.995. 1. This section shall be known as the "Limited Mandate Health Insurance Act".

2. Limited mandate health insurance policies and contracts shall mean those policies and contracts of health insurance as defined in section 376.960 and which cover individuals and their families (but not including any medicare supplement policy or contract) and groups sponsored by an employer who employs fifty or fewer persons.

3. No law requiring the coverage of a particular health care service or benefit, or requiring the reimbursement, utilization or inclusion of a specific category of licensed health care practitioner, shall apply to limited mandate health insurance policies and contracts, except the following provisions:

(1) Subsection 1 of section 354.095, RSMo, to the extent that it regulates maternity benefits;

(2) Section 375.995, RSMo;

(3) Section 376.406;

(4) Section 376.428;

(5) [Section 376.816; and

(6)] Section 376.782[.];

(6) Section 376.816; and

(7) Section 1 of this act.

4. In order for an insurer as defined in section 376.960 to be eligible to market, sell or issue limited mandate health insurance, the insurer shall:

(1) Restrict its marketing and sales efforts to only those persons or groups as defined in subsection 2 of this section which currently do not have health insurance coverage or to those persons or employers which certify in writing to the insurer that they will terminate the coverage they currently have at the time they would otherwise renew coverage because of cost;

(2) Fully and clearly disclose to the person or group to whom the limited mandate health insurance policy or contract is to be issued that the reason coverage for this product is less expensive than other coverage is because the policy or contract does not contain coverages or health professional payment mechanisms that are required by subsection 3 of this section;

(3) Clearly disclose in all sales, promotional and advertising material related thereto that the product is a limited mandate health insurance policy or contract.

5. The provisions of section 376.441 shall not apply to any group which replaces its current coverage with a limited mandate health insurance policy or contract if the benefit to be extended is one for services which are not covered by the replacing policy or contract.

6. Notwithstanding any other provision of this section to the contrary, the provisions of paragraph (b) of subdivision (11) of section 375.936, RSMo, shall apply to limited mandate health insurance policies with respect to physician services covered under such policies, which can be provided by persons licensed pursuant to section 332.181, RSMo.

Section 1. 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 health services corporation, individual and group service contracts issued by a health maintenance organization and all self- insured group arrangements to the extent not preempted by federal law and all managed health care delivery entities of any type or description shall provide coverage for immunizations of a child from birth to five years of age as provided by department of health regulations.

2. Such coverage shall not be subject to any deductible or copayment limits.

3. The contract issued by a health maintenance organization may provide that the benefits required pursuant to this section shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization, except that the health maintenance organization shall, as a condition of participation, comply with the immunization requirements of state or federally funded health programs.

4. This section shall not apply to supplemental insurance policies, including life care contracts, accident-only policies, specified disease policies, hospital policies providing a fixed daily benefit only, medicare supplement policies, long- term care policies, and other supplemental policies as determined by the department of insurance.

5. The department of health shall promulgate rules and regulations to determine which immunizations shall be covered by policies, plans or contracts described in this section. No rule or portion of a rule promulgated under the authority of this section shall become effective unless it has been promulgated pursuant to the provisions of section 536.024, RSMo.

Section 2. 1. As used in this section, the following terms mean:

(1) "Child", a child less than eighteen years of age;

(2) "Health care provider", a person licensed to practice medicine and surgery by the state board of registration for the healing arts, a person who holds a temporary permit to practice medicine and surgery issued by the state board of registration for the healing arts, a person engaged in a postgraduate training program in medicine and surgery approved by the state board of registration for the healing arts, a medical care facility licensed by the department of health, a health maintenance organization issued a certificate of authority by the director of insurance, a licensed professional nurse, a licensed practical nurse and a registered physician's assistant. The term "health care provider" shall also include the following entities: a professional corporation organized pursuant to the professional corporation law of Missouri by persons who are health care providers, a Missouri limited liability company organized for the purpose of rendering professional services by its members who are health care providers, a partnership of persons who are health care providers or a Missouri not for profit corporation organized for the purpose of rendering professional services by persons who are health care providers;

(3) "Parent":

(a) A child's parent by birth or adoption;

(b) A child's legal guardian; or

(c) Any person who under court order is authorized to give consent for a child.

2. A parent may delegate in writing the parent's authority to consent to the immunization of a child to another adult.

3. Subject to the provisions of subsections 3 to 6 of this section, any adult may consent to the immunization of a child if a parent is not reasonably available and the authority to consent is not denied under subsection 4 of this section.

4. A person may not consent to the immunization of a child under subsection 3 of this section if:

(1) The person has actual knowledge that the parent has expressly refused to give consent to the immunization; or

(2) The parent has told the person that the person may not consent to the immunization of the child or, in the case of a written authorization, has withdrawn the authorization in writing.

5. For purposes of this section, a parent is not reasonably available if:

(1) The location of the parent or legal guardian is unknown and could not be ascertained, despite diligent searching; or

(2) The parent or legal guardian has been contacted and requested to consent to the immunization and has failed to act, within fifteen days, on such request.

6. A person authorized to consent to the immunization of a child under the provisions of subsections 3 to 6 of this section shall confirm in writing that the parent is not reasonably available, and the written confirmation shall be included in the child's medical record.

7. A grandparent, brother or sister, aunt or uncle or stepparent of a child who is the primary caregiver of a child and who may consent to the immunization of the child pursuant to the provisions of subsection 2 of this section may delegate in writing the authority to consent to immunization of the child to another adult.

8. A health care provider may rely on a document from another state, territory or country that contains substantially the same information as is required in any immunization consent rules and regulations of the department of health if the document is presented for consent by a person as authorized pursuant to the provisions of this section.

9. A person who consents to immunization of a child under this section shall provide the health care provider with sufficient and accurate health information about the child for whom the consent is given and, if necessary, sufficient and accurate health information about the child's family to enable the person providing the consent and the health care provider to determine adequately the risks and benefits inherent in the proposed immunization and determine whether the immunization is advisable.

10. The responsibility of a health care provider to provide information to a person consenting to the immunization of a child as provided by this section is the same as the health care provider's responsibility to a parent.

11. Except for acts of willful misconduct or gross negligence, a person who consents to the immunization of a child as provided by this section shall not be liable for damages arising from any such immunization administered by a person authorized by law to administer immunizations in this state.