To repeal sections 354.400 and 354.535, RSMo 1994, relating to health maintenance organizations, and to enact in lieu thereof two new sections relating to the same subject.

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

Section A. Sections 354.400 and 354.535, RSMo 1994, are repealed and two new sections enacted in lieu thereof, to be known as sections 354.400 and 354.535, to read as follows:

354.400. As used in sections 354.400 to 354.550, the following terms [shall] mean:

(1) "Basic health care services", health care services which an enrolled population might reasonably require in order to be maintained in good health, including, as a minimum, emergency care, inpatient hospital and physician care, and outpatient medical services;

(2) "Director", the director of the department of insurance;

(3) "Emergency services", those health care services provided in a licensed hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that urgent or unscheduled medical care is required;

(4) "Enrollee", an individual who has been enrolled in a health maintenance organization;

[(4)] (5) "Evidence of coverage", any certificate, agreement, or contract issued to an enrollee setting out the coverage to which [he] the enrollee is entitled;

[(5)] (6) "Health care services", any services included in the furnishing to any individual of medical or dental care or hospitalization, or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability;

[(6)] (7) "Health maintenance organization", any person which undertakes to provide or arrange for basic and supplemental health care services to enrollees on a prepaid basis, or which meets the requirements of section 1301 of the United States Public Health Service Act;

[(7)] (8) "Health maintenance organization plan", any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services and at least part of such arrangement consists of providing and assuring the availability of basic health care services to enrollees, as distinguished from mere indemnification against the cost of such services, on a prepaid basis through insurance or otherwise, and as distinguished from the mere provision of service benefits under health service corporation programs;

[(8)] (9) "Individual practice association", a partnership, corporation, association, or other legal entity which delivers or arranges for the delivery of health care services and which has entered into a services arrangement with persons who are licensed to practice medicine, osteopathy, dentistry, chiropractic, pharmacy, podiatry, optometry, or any other health profession and a majority of whom are licensed to practice medicine or osteopathy. Such an arrangement shall provide:

(a) That such persons shall provide their professional services in accordance with a compensation arrangement established by the entity; and

(b) To the extent feasible for the sharing by such persons of medical and other records, equipment, and professional, technical, and administrative staff;

[(9)] (10) "Medical group/staff model", a partnership, association, or other group:

(a) Which is composed of health professionals licensed to practice medicine or osteopathy and of such other licensed health professionals (including dentists, chiropractors, pharmacists, optometrists, and podiatrists) as are necessary for the provisions of health services for which the group is responsible;

(b) A majority of the members of which are licensed to practice medicine or osteopathy; and

(c) The members of which (i) as their principal professional activity over fifty percent individually and as a group responsibility engaged in the coordinated practice of their profession for a health maintenance organization; (ii) pool their income from practice as members of the group and distribute it among themselves according to a prearranged salary or drawing account or other plan, or are salaried employees of the health maintenance organization; (iii) share medical and other records and substantial portions of major equipment and of professional, technical, and administrative staff; (iv) establish an arrangement whereby an enrollee's enrollment status is not known to the member of the group who provides health services to the enrollee;

[(10)] (11) "Person", any partnership, association, or corporation;

[(11)] (12) "Provider", any physician, hospital, or other person which is licensed or otherwise authorized in this state to furnish health care services;

[(12)] (13) "Uncovered expenditures", the costs of health care services that are covered by a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or organization other than the health maintenance organization, or those costs which a provider has not agreed to forgive enrollees if the provider is not paid by the health maintenance organization.

354.535. [In the event that] 1. If a pharmacy, operated by or contracted with by a health maintenance organization, is closed or is unable to provide health care services to an enrollee in an emergency, a pharmacist may take an assignment of such enrollee's right to reimbursement, if the policy or contract provides for such reimbursement, for those goods or services provided to a [member] enrollee of a health maintenance organization. No health maintenance organization shall refuse to pay the pharmacists any payment due the enrollee under the terms of the policy or contract.

2. Health maintenance organization plan shall include twenty-four hours access to emergency services. A plan may not require prior authorization for emergency services, which include a medical screening exam and stabilizing treatment as defined in Section 1867 of the Social Security Act.

3. A health maintenance organization plan may require prior authorization for medically necessary services arising from such screening exam. A health maintenance organization plan or its contracting medical providers shall provide twenty-four hour access for enrollees and providers to request timely authorization for medically necessary care. Prior authorization shall be deemed to be approved unless the request for authorization is denied within thirty minutes. The access line shall be staffed twenty-four hours a day. The personnel staffing the line shall have access to a physician whenever necessary to make a determination regarding preauthorization.

4. A health maintenance organization plan shall reimburse providers for emergency services, federally mandated screening examinations as required by Section 1867 of the Social Security Act, and care of its enrollees, until such care results in the stabilization of the enrollee and the health maintenance organization plan assumes care of the enrollee, whether or not such providers have a contractual relationship with the health maintenance organization plan.

5. If the health maintenance organization staff person licensed by the state of Missouri to make determinations and give authorization for treatment and the attending physician disagree concerning the proper treatment for an enrollee who, following emergency services, is unstable as defined by section 1867 of the Social Security Act, the health maintenance organization shall take all legal and financial responsibility if the health maintenance organization acts against the recommendations of the attending physician.

6. If a primary care physician or health maintenance organization has authorized the evaluation or treatment of an enrollee, the health maintenance organization may not retrospectively deny the authorization for such evaluation and treatment.