Missouri

SUMMARY

Missouri has already introduced four bills in the 2018 legislative session aimed at lowering healthcare costs by reducing prescription prices and improving their state insurance exchange.  

In the 2017 legislative session, Missouri introduced, but did not pass legislation that requires greater price transparency. In addition, Missouri has collected inpatient and outpatient charge and utilization data since 1993, although there is no consumer website available to facilitate comparisons between providers and facilities. 

 

LEGISLATION/REGULATION

Legislative Calendar

Missouri’s current regular legislative session runs from 1/3/2018 – 5/30/2018.

 

Recent Legislative Developments

Healthcare Transparency

2018 SB 860 MODIFIES PROVISIONS RELATING TO SHORT-TERM MAJOR MEDICAL INSURANCE: specifies that all short-term major medical policies delivered or issued for delivery in the state shall include on applications and fact pages a conspicuous and clearly labeled paragraph stating that the policy may not cover preexisting conditions or essential health benefits, and a recommendation to discuss the policy with the individual’s insurance broker. No short-term major medical policy shall be delivered or issued for delivery in this state until the prospective insured has confirmed receipt of a benefit summary statement, as defined in the act. Active – Bill placed on Informal Calendar on 2/28/18.
SB 744  MISSOURI RIGHT TO SHOP ACT: Health carriers are required to develop and implement a program that provides financial incentives to enrollees in a health plan who choose to receive comparable health care services from providers that charge less than the average amount paid by that carrier to in-network providers for that service.  This incentive program must be a component of all health plans offered by the carrier in this state, and carriers shall annually provide a description of the program and notice to enrollees about its availability. Incentive payments made by a health carrier shall not be considered an administrative expense for purposes of rate development or rate filing.  Active -Referred to Seniors, Families, and Children Committee on 1/16/18. 
HB 2125 RIGHT TO SHOP ACT: Requires a health care provider to disclose within two business day the allowed amount or the amount that will be charged for a nonemergency admission, procedure, or service if requested by a patient or prospective patient. Additionally, the health care provider must disclose enough information regarding the proposed nonemergency admission, procedure, or service so that the patient can receive a cost estimate from his or her insurance carrier. Active – Referred to Rules Committee on 3/1/18.
2017 SB 193 This act requires any health insurer engaged in the act of contracting with providers for the delivery of dental services, or in the act of selling or assigning dental network plans, to update their electronic and paper provider materials made available to plan members or other potential plan members upon being notified of changes by participating providers. Inactive – Died.
2016 HB1579 HEALTH INFORMATION ORGANIZATIONS – The bill requires all approved health information organizations to exchange standards-based clinical summaries for patients and all clinical and claims data from any agency within the state with all other approved health information organizations within the state. Establishes the Missouri Health Information Exchange Commission Inactive – Died.
HB2269 HEALTH CARE TRANSPARENCY: This bill establishes the Health Care Cost Reduction and Transparency Act that requires each health care provider licensed in Missouri to make available to the public and on its Internet website the most current price information required under these provisions in a manner that is easily understood by the public. Inactive – Died.
2015 HB617 HEALTH CARE COST REDUCTION AND TRANSPARENCY ACT: would require health care providers licensed in Missouri to make public on their websites, the following information about the 25 most frequently reported health care services or procedures: (i) the amount that will be charged to a patient for each of the services as if all charges are paid in full without a public or third-party paying for any portion of the charges; (ii) the average negotiated settlement of the amount that will be charged to a patient; and (iii) the amount of Medicaid and Medicare reimbursements for health service. If a patient requests the cost of a particular service, procedure, imaging procedure, or surgery procedure, the health care provider would need to provide it within three business days.

HB617 would require hospitals and ambulatory surgical centers to make publicly available the total costs for the 25 most common surgical procedures and the 20 most common imaging procedures, by volume, performed in he hospital or outpatient settings or ambulatory surgical centers—along with CPT and HCPCS codes. If a patient requests the cost of a particular service, procedure, imaging procedure, or surgery procedure, the health care entity would need to provide it within three business days.

HB617 would require the five largest health carrier providing payment to the health care provider on behalf of insureds and state employees, to post on their websites the range of the average of the amount of payment made for each health care service or procedure. If a patient requests the cost of a particular service, procedure, imaging procedure, or surgery procedure, the health care provider would need to provide it within three business days.

Inactive – Died.
SB8 PROHIBITION ON NON-DISCLOSURE CONTRACT PROVISIONS: would prohibit the enforceability of all contract provisions entered into, amended, or renewed, between health care carriers and providers, that restrict either party from disclosing to an enrollee, patient, potential patient, or such party’s parent or legal guardian, the contractual payment amount for a health care service if the payment amount is less than the health care provider’s usual charge for the service and if such provision prevents the determination of the potential out-of-pocket cost for the service. Inactive – Died.
SB46 HEALTH CARE COST AND REDUCTION TRANSPARENCY ACT: would require the Department of Health and Senior Services to make available on its website the most current price information it receives from hospitals and ambulatory surgical centers. Current price information would be listed for the 100 most frequently reported admissions, by DRG, for inpatients in each department and, for each: (i) the amount a patient will be charged if paid in full without public or private third parties paying any portion; (ii) the average negotiated settlement of the amount that will be charged to a patient; and (iii) the amount of Medicaid and Medicare reimbursements for each DRG. If a patient requests the cost of a particular service, procedure, imaging procedure, or surgery procedure, the health care provider would need to provide it within three business days.

SB46 would require hospitals and ambulatory surgical centers to make publicly available the total costs for the 20 most common surgical procedures and the 20 most common imaging procedures, by volume, performed in he hospital or outpatient settings or ambulatory surgical centers—along with CPT and HCPCS codes. If a patient requests the cost of a particular service, procedure, imaging procedure, or surgery procedure, the health care provider would need to provide it within three business days.

SB46 would require the five largest health carrier providing payment to the health care provider on behalf of insureds and state employees, to post on their websites the range of the average of the amount of payment made for each DRG. If a patient requests the cost of a particular service, procedure, imaging procedure, or surgery procedure, the carrier would need to provide it within three business days.

Inactive – Died.
SB298 HEALTH OBSERVATION STATUS CONSUMER NOTIFICATION ACT: would require hospitals to provide patients with oral and written notice about the patient’s outpatient status, the billing implications of the outpatient status on her insurance coverage for hospital services. Inactive – Died.

 

Healthcare Costs

2018 SB 722  PRESCRIPTION DRUG IMPORTATION STUDY: Would require the Department of Health and Senior Services to study the importation of certain prescription drugs from other countries for Missouri consumers. The act details the goals of the study, including how the state may be certified to operate a prescription drug importation program, what drugs may be imported, the cost savings associated with importation, how imported drugs may be distributed and to whom, and consultation with experts. The Department would report the study’s findings and recommendations to the General Assembly by December 31, 2019.  Active -Introduced on 1/3/18.  
HB 2337 MODIFIES FEE REQUIREMENTS FOR INSURANCE COMPANIES: modifies the fee requirements for every individual or entity making a filing with the Department of Insurance, Financial Institutions and Professional Registration. These fees will be deposited into the State Treasury to the credit of the insurance dedicated fund. Insurance receives no General Revenue and is funded by these fees. Active – Perfected on 3/28/18 and sent to floor vote.
HB 1542 PROHIBIT CERTAIN ACTIONS BY PHARMACY BENEFIT MANAGERS: prohibits a pharmacy benefits manager from charging a copayment for a prescription or pharmacy service that exceeds the amount retained by the pharmacy from all payment sources for filling that prescription or providing that service. Active – Passed Committee on 3/28/18.
SB 1057 MODIFIES PROVISIONS RELATING TO UNANTICIPATED OUT-OF-NETWORK HEALTH CARE SERVICES: This act specifies that health care professionals shall send any bill for charges incurred for unanticipated out-of-network care to the patient’s health carrier, and the carrier shall pay the professional directly. The act specifies how the payments are to be calculated, including with regard to cost-sharing requirements such as copayments, coinsurance, deductibles, and out-of-pocket maximums. Active – Second Read in Insurance and Banking Committee on 3/8/18.
SB 928 MODIFIES PROVISIONS RELATING TO HEALTH INSURER REIMBURSEMENT PRACTICES: Prohibits carriers from reducing payments for evaluation and management services that are otherwise eligible for reimbursement when reported by the same provider on the same day as a procedure. Active – Bill placed on Informal Calendar on 3/26/18.
HB 1542  PHARMACY BENEFIT MANAGERS: Would prohibit pharmacy benefit managers from charging or collecting a copayment that is greater than the amount paid to pharmacist or pharmacy. Would require informing a covered person of the difference between their insurance copayment and amount if insurance is not used. Would limit ability of pharmacy benefit manager to interfere or restrict communication with persons on copayment amount in comparison to not using insurance. Would prohibit PBM interference with alternative drug discussions. Would prohibit pharmacy or pharmacist being charged a fee related to a claim.  Active – Referred to Insurance Committee on 2/15/18.   
2017 HB 125 Establishes the “Right to Shop Act” to allow state employees to obtain cost estimates for health care services. Inactive –Died.
SB 155 This act requires an enrollee in an HMO or health insurance plan to pay only the usual and customary retail price of a prescription drug if the co-payment applied by an HMO or health insurer exceeds the usual and customary retail price, and provides that there shall be no further charge to the enrollee or plan sponsor for such prescription. Inactive – Died.
2016 HB 1537 Establishes the Missouri Universal Health Assurance Program to provide a publicly financed, statewide insurance program for all residents of the state. Inactive – Died.
HB 2045 PRESCRIPTION DRUG COVERAGE – The bill requires health carriers or managed care plans offering health benefit plans with prescription drug coverage to offer medication synchronization services that aligns prescription refill dates. Charging more than the normal co-payment is prohibited for quantities less than prescribed. Inactive – Died.

 

Healthcare Markets

2018 HB 1884  MISSOURI HEALTHNET SERVICES: Beginning January 1, 2019, this bill extends benefits under the MO HealthNet program to individuals age 19 or older, but younger than 65, who are not otherwise eligible for MO HealthNet services, who qualify for MO HealthNet services under the provisions of the Affordable Care Act (ACA) of 2010, and who have income at or below 133% of the federal poverty level plus 5% of the applicable family size. This bill also provides that the reimbursement rate to MO HealthNet providers for MO HealthNet services provided to individuals qualifying under the provisions of the bill must be comparable to commercial reimbursement payment levels with trend adjustment for comparable services.   Active – Introduced on 1/4/18.  
HB 1690 MODIFIES PROVISION OF THE MISSOURI LIFE AND HEALTH INSURANCE GUARANTEE ACT: updates the laws regarding the Missouri Life and Health Insurance Guaranty Association Act to mirror the National Association of Insurance Commissioners model act which was approved by the commission in 2017. The association provides protection to insureds and claimants against the impairment or insolvency of a life or health insurance company and provides continuation of coverage for policyholders. Active – Passed House Floor vote on 2/13/18 and sent to Senate.
HB 1617 MODIFIES PROVISIONS RELATING TO TELEHEALTH: specifies that the Department of Social Services shall reimburse providers for services provided through telehealth if the providers can ensure that services are rendered meeting the standard of care that would be expected if the services were rendered in person. This bill clarifies that current statute authorizing a health care provider to provide telehealth services shall not be construed to prohibit a health carrier from reimbursing non-clinical staff for services otherwise allowed by law. Active – Passed House on 2/1/18 and sent to Senate.
HB 1833 MISSOURI UNIVERSAL HEALTH ASSURANCE PROGRAM: Establishes a publicly financed, statewide program to provide comprehensive necessary health, mental health, and dental care services and preventive screenings for Missouri residents. The bill also creates the Missouri Health Care Trust Fund to be used to finance the program, including federal funds received as a result of any waiver of requirements granted by the federal government. Active – Referred to Insurance Committee on 1/4/18.
2017 HB 124 Establishes the “Patients First Medicaid Reform Act.” Inactive – Died in Committee.
SB 203 This act changes the Ticket to Work Health Assurance Program to the “MO HealthNet Buy-in for Workers with Disabilities Program”. MO HealthNet Buy-In differs from the Ticket to Work Health Assurance Program in the following ways: (1) removes asset limits from qualification calculations; (2) modifies the income calculation from a net/gross calculation to a broader definition that would consider income for those disabled persons with incomes up to 300% of the federal poverty level, while retaining the requirement that persons with incomes over 100% of the federal poverty level pay a premium; (3) all earned income of a spouse shall be disregarded from income calculations; (4) if the Department elects to pay the person’s costs of employer-sponsored health insurance, MO HealthNet assistance shall be provided as a secondary or supplemental policy. Inactive – Died.

 

Key Statutes

We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.

 

Transparency in Healthcare

  • Rev. Stat. § 192.667 requires that all healthcare providers provide charge data, patient abstract data and financial data as required by the Department of Health and Senior Services at least annually. Information obtained under this section shall not be public information; however, reports and studies prepared by the department based upon such information is public information and may identify individual providers. The Department is directed to “undertake a reasonable number of studies and public information, including at least an annual consumer guide” based upon the information obtained pursuant to this section. Data and reports collected under the Patient Abstract System are available here.

 

  • Rev. Stat. § 192.068 requires that an health maintenance organization provide data regarding quality of care, access to care, member satisfaction and member health status to the Director of the Department of Health and Senior Services. The Department has discretion to perform studies and publish the information collected pursuant to this section, including the making of a consumer guide. Reports through 2010 are available here.

 

Healthcare Markets

  • Rev. Stat. § 197.300 to 197.366 prohibits health care providers from acquiring, replacing, or adding to their facilities and equipment, except in specified circumstances, without the prior approval of the Missouri Health Facilities Need Committee through the state’s Certificate of Need process. A Certificate of Need regime aims to reduce healthcare overheard by reducing unnecessary or duplicative services, but can be anticompetitive by increasing regulatory barriers for new entrants.

 

Network Adequacy

  • Rev. Stat. § 354.603 requires that a health carrier maintain a network “that is sufficient in number and types of providers to assure that all services to enrollees shall be accessible without unreasonable delay.” Sufficiency for the purposes of network adequacy shall be determined “by reference to any reasonable criteria, including but not limited to provider-enrollee ratios by specialty, primary care provider-enrollee ratios, geographic accessibility, reasonable distance accessibility criteria for pharmacy and other services, waiting times for appointments with participating providers, hours of operation, and the volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care.”

 

FY 2018 BUDGET

Missouri’s fiscal year begins on July 1 and ends on June 30 in the following year. The Missouri legislature passed its FY 2018 Budget during the regular legislative session and is currently waiting to be signed by the Governor. To view Missouri’s FY 2018 Budget, click here.

 

LITIGATION/ENFORCEMENT

  • Precision Rx Compounding, LLC et al v Express Scripts Holding Company et al: In January 2016, several independent compounding pharmacies sued pharmacy benefit manager Express Scripts in January, accusing it and CVS Health Corp., OptumRx Inc. and Prime Therapeutics LLC of cutting the compounding pharmacies from the market in violation of federal and state antitrust laws. The suit was brought in federal court in Missouri, and is in discovery as of December 2016.

 

  • Consumers Council of Missouri v. Department of Health and Human Services: In August 2015, the U.S. District Court for the Eastern District of Missouri Oct. 1, 2014, the Consumer Council of Missouri filed a federal complaint against the HHS’s Centers for Medicare and Medicaid Services alleging that federal law (principally, the Freedom of Information Act) requires that the agency make rate information public so consumers have the chance to challenge the costs they pay for health insurance. In response to the complaint, in March 2015 HHS fully responded to Plaintiff’s FOIA request. The district court found that because HHS released the information to the Consumers Council, the case was rendered moot.

 

KEY RESOURCES

Missouri General Assembly

Missouri Attorney General

Missouri Department of Insurance