Missouri

SUMMARY

In the most recent 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 1/6/2017 – 5/13/2017. Missouri called a special session on 6/8/2017.

 

Recent Legislative Developments

Healthcare Transparency

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

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

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 proposal, 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