Bill Text: MO HB1039 | 2013 | Regular Session | Introduced
Bill Title: Establishes the Show-me Transformation Act that changes the requirements for the MO HealthNet Program
Spectrum: Partisan Bill (Republican 2-0)
Status: (Introduced - Dead) 2013-05-17 - Referred: Government Oversight and Accountability(H) [HB1039 Detail]
Download: Missouri-2013-HB1039-Introduced.html
FIRST REGULAR SESSION
97TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES FRANKLIN (Sponsor), GUERNSEY, WOOD, LYNCH, MORRIS, NEELY, DAVIS, HICKS, FLANIGAN, MILLER, MUNTZEL, REMOLE, HAEFNER, ENTLICHER, MCGAUGH, CONWAY (104), LICHTENEGGER, DOHRMAN, PIKE, WALKER, LAIR, PHILLIPS AND SHULL (Co-sponsors).
2228L.02I D. ADAM CRUMBLISS, Chief Clerk
AN ACT
To repeal sections 208.146, 376.961, 376.962, 376.964, 376.966, 376.968, 376.970, and 376.973, RSMo, and to enact in lieu thereof eleven new sections relating to the Show-Me transformation act.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 208.146, 376.961, 376.962, 376.964, 376.966, 376.968, 376.970, and 376.973, RSMo, are repealed and eleven new sections enacted in lieu thereof, to be known as sections 208.998, 376.961, 376.962, 376.964, 376.966, 376.968, 376.970, 376.973, 1, 2, and 3, to read as follows:
208.998. 1. All individuals who receive MO HealthNet benefits shall receive covered services through health plans offered by managed care entities which are authorized by the department. Health plans authorized by the department:
(1) Shall resemble commercially available health plans while complying with federal Medicaid requirements;
(2) Shall promote, to the greatest extent possible, opportunity for children and their parents to be covered under the same plan;
(3) Shall offer at least one statewide plan and may offer plans regionally only if there is at least one statewide plan offered. The department shall ensure that all regions have adequate coverage through managed care contracts;
(4) Shall include cost-sharing for out-patient services as allowed by federal law;
(5) Shall provide incentives to health plans and providers to encourage cost-effective delivery of care;
(6) May provide multiple plan options and reward participants for choosing a low-cost plan; and
(7) May be offered by hospitals or health care systems. Such hospitals and health care systems shall be permitted to bid to provide health services as a health plan under the MO HealthNet program.
2. The department may designate that certain health care services be excluded from such health plans if it is determined cost effective by the department. The department shall establish uniform utilization review protocols to be used by all authorized health plans.
3. The department shall establish the following requirements for contracting with managed care plans:
(1) (a) For managed care plans utilizing capitation arrangements between the managed care plan and providers, the department shall establish the following requirements for contracting with managed care plans under this subdivision:
a. All capitation managed care plans shall be required to submit a blind bid on each of two levels of coverage with the department establishing the levels of coverage and the maximum capitation rate for each level. The department shall not disclose its maximum capitation rate during the initial bidding process. Each bidder shall include all actuarial and other relevant information utilized by the bidder in determining the bidder's capitation rate. The department may establish guidelines for the submission of such actuarial and other information;
b. The capitation managed care plan which submits the lowest bid below the maximum capitation rate established by the department shall be guaranteed participation;
c. Except as provided in item (ii) of subparagraph e. and subparagraph f. of this paragraph, all bids in excess of the maximum capitation rate established by the department shall not be considered;
d. If at least two submit bids which are equal to or less than the maximum capitation rate established by the department, the department shall contract with such plans as required under subparagraph a. of this paragraph and no further bidding shall be required;
e. If less than two, or three if the department elects to include an additional plan, capitation managed care plans submit bids equal to or less than the maximum capitation rate established by the department:
(i) The department shall guarantee participation to the plan or plans which submit bids equal to or less than the maximum capitation rate established by the department;
(ii) For any remaining plan or plans necessary to meet the required number of plans established under subparagraph b. of this paragraph, the department may select such plan or plans with the lowest bid within one hundred twenty-five percent of the maximum capitation rate established by the department or reopen the bidding in accordance with item (ii) of subparagraph f. of this paragraph;
f. If no capitation managed care plans submit a bid equal to or less than the maximum capitation rate established by the department:
(i) The department may select any such plan or plans with the lowest bids within one hundred twenty-five percent of the maximum capitation rate established by the department. If the required number of plans under subparagraph b. of this paragraph meet the requirements of this paragraph, the department may contract with such plans and no further bidding shall be required; or
(ii) The department may reevaluate and adjust its maximum capitation rate, discard all previous nonconforming bids, disclose to all bidders the adjusted maximum capitation rate established by the department, and open a second bidding process. All bids submitted with the adjusted capitation maximum established by the department shall be otherwise evaluated in accordance with this paragraph.
g. In awarding contracts under this subdivision, the department shall consider the following factors:
(i) Cost to Missouri taxpayers;
(ii) The extent of the network of health care providers offering services within the bidder's plan;
(iii) Additional services offered to recipients under the bidder's plan;
(iv) The bidder's history of providing managed care plans for similar populations in Missouri or other states;
(v) Whether the bidder or an associated company offers an identical or substantially similar plan within a health care exchange in this state; whether federally facilitated, state-based, or operated on a partnership basis; and the bidder, if the bidder offers an identical or similar plan, or the bidder and the associated company, if the bidder has formed a partnership for purposes of its bid, has included in its bid a process by which MO HealthNet recipients who choose its plan will be automatically enrolled in the corresponding plan offered within the health care exchange if the recipient's income increases resulting in the recipient's ineligibility for MO HealthNet benefits; and
(vi) Any other criteria the department deems relevant to ensuring MO HealthNet benefits are provided to recipients in such manner as to save taxpayer money and improve health outcomes of recipients.
(b) If a recipient enrolls in a capitation managed care plan with a capitation rate which is less than the maximum capitation rate established by the department under the bidding process, the recipient shall be eligible to receive a portion of the difference between the plan's capitation rate and the maximum capitation rate established by the department.
(c) For purposes of paragraph (b) of this subdivision, the maximum capitation rate for all participating plans shall be the department's undisclosed maximum capitation rate if the bidding process is not reopened under subparagraph e. or f. of paragraph (a) of this subdivision. If the bidding process is reopened, the maximum capitation rate for all participating plans, including any plans which bid equal to or less than the undisclosed maximum capitation rate, shall be the disclosed adjusted maximum capitation rate;
(2) All managed care bidders shall submit a bid on the levels of coverage established in subsections 8 and 10 of this section;
(3) The department shall select a minimum of three plans from the conforming bids for statewide plans and for each region, if applicable;
(4) The department shall select all of the bidders' plans or none of the bidders' plans; and
(5) The lowest conforming bid for statewide plans and in each region, if applicable, shall be accepted by the department.
4. In awarding contracts under this section, the department shall consider the following factors:
(1) Cost to Missouri taxpayers;
(2) The extent of the network of health care providers offering services within the bidder's plan;
(3) Additional services offered to recipients under the bidder's plan;
(4) The managed care entity's history of outcomes and quality of the services offered in Missouri and other states;
(5) The bidder's history of providing managed care plans for similar populations in Missouri and other states;
(6) Wether the bidder or an associated company offers an identical or substantially similar plan within a health insurance marketplace in this state, whether it is federally facilitated, state-based, or operated on a partnership basis; and the bidder, if the bidder offers an identical or similar plan, or the bidder and the associated company, if the bidder has formed a partnership for purposes of its bid, has included in its bid a process by which MO HealthNet recipients who choose its plan will be automatically enrolled in the corresponding plan offered within the health insurance marketplace if the recipient's income increases or another circumstances arises resulting in the recipient's ineligibility for MO HealthNet benefits; and
(7) Any other criteria the department deems relevant to ensuring MO HealthNet benefits are provided to recipients in such manner as to save taxpayer money and improve health outcomes of recipients.
5. If a recipient enrolls in a managed care plan with a capitation rate which is less than the maximum capitation rate established by the department under the bidding process, the recipient shall be eligible to receive a portion of the difference between the plan's capitation rate and the maximum capitation rate established by the department. Any portion received by a participant shall be determined by the department and the department shall ensure a maximum return to taxpayers.
6. All MO HealthNet plans under this subdivision shall provide coverage for the following service unless they are specifically excluded under subsection 2 of this section:
(1) Ambulatory patient services;
(2) Emergency services;
(3) Hospitalization;
(4) Maternity and newborn care;
(5) Mental health and substance use disorders, including behavioral health treatment;
(6) Prescription drugs;
(7) Rehabilitative and habilitative services and devices;
(8) Laboratory services;
(9) Preventive and wellness and chronic disease management;
(10) Pediatric services, including oral and vision care;
(11) Health care counselor services, as described in subsection 10 of this section; and
(12) Any other service required by federal law.
7. No MO HealthNet plan shall provide coverage for abortion unless such abortions are certified in writing by a physician to the MO HealthNet agency that, in the physician's professional judgment, the life of the mother would be endangered if the fetus were carried to term.
8. The MO HEalthNet program shall provide a high deductible health plan option for uninsured adults between the ages of nineteen and sixty-four with incomes of less than one hundred percent of the federal poverty level. The high deductible plan shall include:
(1) High deductible coverage. After meeting a one thousand dollar deductible, individuals shall be covered for benefits as specified by regulation of the department;
(2) An account of at least one thousand dollars per adult to pay medical costs for the initial deductible funded by the department. The department shall fund such account;
(3) Preventive care, as defined by the department by rule, that is not subject to the deductible and does not require a payment of moneys from the account described in subdivision (2) of this subsection;
(4) A basic benefits package once annual medical costs exceed one thousand dollars;
(5) A minimum deductible of one thousand dollars;
(6) As soon as practicable, the health plan shall establish and maintain a record keeping system for each health care visit or service received by recipients under this subsection. The plan shall require that the recipient's prepaid card number card number be entered or electronic strip be swiped by the health care provider for purposes of maintaining a record of every health care visit or service received by the recipient by such provider, regardless of any balance on the recipient's card. Such information shall include only the date, provider name, and general description of the visit or service provided. The plan shall maintain a complete history of all health care visits and services for which the recipient's prepaid card is entered or swiped in accordance with this subdivision. If required under the federal Health Insurance Portability and Accountability Act (HIPAA) or other relevant state or federal law or regulation, a recipient shall, as a condition of participation in the prepaid card incentive, be required to provide a written waiver for disclosure of any information required under this subdivision; and
(7) The department shall by rule determine the amount credited to a co-payment prepaid card for a recipient and the percentage of any remaining moneys which may be received by a recipient under subdivision (2) of this subsection; except that, the minimum amounted credited to a co-payment prepaid card shall not be less than forty percent of the minimum deductible required for the high deductible plans under this subsection. No recipient shall be eligible unless such recipient receives a yearly checkup with such recipient's primary care physician.
9. The department shall establish and implement a co-payment cost-sharing program for MO HealthNet recipients not otherwise participating in an option under subsection 8 of this section. Participants shall receive a prepaid card which shall be used to cover the costs of co-payments required under the MO HealthNet program. The department shall require recipients to fund the prepaid card with the maximum cost-share allowed by federal law with the remainder to be funded by the MO HealthNet program. Under this program:
(1) No co-payments shall be imposed for primary care services as defined by the department by rule; and
(2) Recipients shall be eligible to receive a portion of the remaining balance on the card at the end of the coverage year in an amount to be determined by the department by rule. Any such amounts shall be electronically transferred to the recipient's electronic benefit transfer (EBT) card and all such amounts transferred shall be subject to the use requirements and restrictions of EBT cards.
10. (1) The division shall establish a preventative care incentive program for all MO HealthNet recipients identified by the division as having a chronic condition. The preventative care incentive program shall encourage recipients to follow a medically indicated regimen for treatment and control of such recipients' chronic conditions through utilization of outreach health care navigators to provide assistance and guidance for such recipients. The criteria for the program shall include:
(a) Each recipient receives integrated person-centered care and services designed to provide choice, independence, and dignity;
(b) Each recipient has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery;
(c) The supportive and therapeutic needs of each recipient are addressed in a holistic fashion, using patient-centered primary care and individualized care plans to the extent feasible;
(d) Recipients receive appropriate follow-up care when entering and leaving an acute care facility or long-term care setting;
(e) Recipients receive assistance in navigating the health care delivery system and accessing support services and statewide resources; and
(f) Services and supports are geographically located throughout the state to adequately provide such services and supports.
(2) The division shall employ and have available outreach health care navigators throughout the state in sufficient locations and numbers to ensure access to all recipients with chronic conditions as identified by the division.
(3) Every hospital that is a provider under the MO HealthNet program shall, as a condition of the hospital's provider contract, agree to allow outreach health care navigators assigned by the division to work at such hospital and provide a workplace for such navigators within the hospital.
(4) Primary care providers under the MO HealthNet program shall be team leaders in collaborative arrangements with outreach health care navigators for the design of treatment plans to improve health care outcomes for MO HealthNet recipients with chronic conditions as identified by the division. In the collaborative arrangement, the outreach health care navigator shall be responsible for providing such recipient with assistance, guidance, and monitoring regarding implementation and ongoing compliance with the treatment plan developed for the recipient.
(5) For purposes of this section, the following terms shall mean:
(a) "Chronic condition", diabetes, hypertension, high cholesterol, heart disease, and other chronic conditions identified by the Centers for Medicare and Medicaid Services (CMS) or the MO HealthNet division;
(b) "Outreach health care navigator", an individual who provides information, assistance, tools, and support to enable a recipient to make the best health care decisions in the recipient's particular circumstances and in light of the recipient's needs, lifestyle, combination of conditions and desired outcomes. The MO HealthNet division shall by rule establish competency and quality measures for outreach health care navigators.
(5) The division shall seek all necessary federal waivers to implement the provisions of this subsection.
11. A MO HealthNet recipient shall be eligible for participation in only one of either the high deductible plan under subsection 8 of this section, the co-payment cost-sharing program under subsection 9 of this section, or the incentive program under subsection 10 of this section. No MO HealthNet recipient shall be eligible to combine or otherwise participate in more than one option under subsections 8 to 10 of this section.
12. All incentives or credits paid to or on behalf of a MO HealthNet participant under a program established by the department under this section shall not be deemed to be income to the participant in any means tested benefit program unless otherwise specifically required by law or rule of the department.
13. Managed care entities shall give participants who choose the high deductible plan under subsection 8 of this section or the co-payment cost-sharing program under subsection 9 of this section information notifying the participant that the participant may lose his or her payment if the participant utilizes visits to the emergency department for nonemergency purposes. Such information shall be included on every electronic and paper correspondence between the managed care plan and the participant.
14. The department shall seek all waivers and state plan amendments from the United States Department of Health and Human Services necessary to implement the provisions of this section. The provisions of this section shall not be implemented unless such waivers are granted. If this section is approved in part by the federal government, the department is authorized to proceed on those sections which approval has been granted; except that, any increase in eligibility shall be contingent upon the receipt of all necessary waivers and state plan amendments.
15. The department may promulgate rules to implement this section. Any rule or portion of a rule, as the term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2013, shall be invalid and void.
376.961. 1. There is hereby created a nonprofit entity to be known as the "Missouri Health Insurance Pool". All insurers issuing health insurance in this state and insurance arrangements providing health plan benefits in this state shall be members of the pool.
2. Beginning January 1, 2007, the board of directors shall consist of the director of the department of insurance, financial institutions and professional registration or the director's designee, and eight members appointed by the director. Of the initial eight members appointed, three shall serve a three-year term, three shall serve a two-year term, and two shall serve a one-year term. All subsequent appointments to the board shall be for three-year terms. Members of the board shall have a background and experience in health insurance plans or health maintenance organization plans, in health care finance, or as a health care provider or a member of the general public; except that, the director shall not be required to appoint members from each of the categories listed. The director may reappoint members of the board. The director shall fill vacancies on the board in the same manner as appointments are made at the expiration of a member's term and may remove any member of the board for neglect of duty, misfeasance, malfeasance, or nonfeasance in office.
3. Beginning August 28, 2007, the board of directors shall consist of fourteen members. The board shall consist of the director and the eight members described in subsection 2 of this section and shall consist of the following additional five members:
(1) One member from a hospital located in Missouri, appointed by the governor, with the advice and consent of the senate;
(2) Two members of the senate, with one member from the majority party appointed by the president pro tem of the senate and one member of the minority party appointed by the president pro tem of the senate with the concurrence of the minority floor leader of the senate; and
(3) Two members of the house of representatives, with one member from the majority party appointed by the speaker of the house of representatives and one member of the minority party appointed by the speaker of the house of representatives with the concurrence of the minority floor leader of the house of representatives.
4. The members appointed under subsection 3 of this section shall serve in an ex officio capacity. The terms of the members of the board of directors appointed under subsection 3 of this section shall expire on December 31, 2009. On such date, the membership of the board shall revert back to nine members as provided for in subsection 2 of this section.
5. Beginning on August 28, 2013, the board of directors on behalf of the pool, the executive director, and any other employees of the pool shall have the authority to provide assistance or resources to any department, agency, public official, employee, or agent of the federal government for the specific purpose of transitioning individuals enrolled in the pool to coverage outside of the pool beginning on or before January 1, 2014. Such authority does not extend to authorizing the pool to implement, establish, create, administer, or otherwise operate a state-based exchange.
376.962. 1. The board of directors on behalf of the pool shall submit to the director a plan of operation for the pool and any amendments thereto necessary or suitable to assure the fair, reasonable and equitable administration of the pool. After notice and hearing, the director shall approve the plan of operation, provided it is determined to be suitable to assure the fair, reasonable and equitable administration of the pool, and it provides for the sharing of pool gains or losses on an equitable proportionate basis. The plan of operation shall become effective upon approval in writing by the director consistent with the date on which the coverage under sections 376.960 to 376.989 becomes available. If the pool fails to submit a suitable plan of operation within one hundred eighty days after the appointment of the board of directors, or at any time thereafter fails to submit suitable amendments to the plan, the director shall, after notice and hearing, adopt and promulgate such reasonable rules as are necessary or advisable to effectuate the provisions of this section. Such rules shall continue in force until modified by the director or superseded by a plan submitted by the pool and approved by the director.
2. In its plan, the board of directors of the pool shall:
(1) Establish procedures for the handling and accounting of assets and moneys of the pool;
(2) Select an administering insurer or third-party administrator in accordance with section 376.968;
(3) Establish procedures for filling vacancies on the board of directors; and
(4) Establish procedures for the collection of assessments from all members to provide for claims paid under the plan and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board pursuant to the provisions of section 376.973. Assessment shall occur at the end of each calendar year and shall be due and payable within thirty days of receipt of the assessment notice[;
(5) Develop and implement a program to publicize the existence of the plan, the eligibility requirements, and procedures for enrollment, and to maintain public awareness of the plan].
3. On or before September 1, 2013, the board shall submit the amendments to the plan of operation as are necessary or suitable to ensure a reasonable transition period to allow for the termination of issuance of policies by the pool.
4. The amendments to the plan of operation submitted by the board shall include all of the requirements outlined in subsection 2 of this section and shall address the transition of individuals covered under the pool to alternative health insurance coverage as it is available after 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 identified in subsection 2 of this section.
5. The director shall review the plan of operation submitted under subsection 3 of this section and shall promulgate rules to effectuate the transitional plan of operation. Such rule shall be effective no later than October 1, 2013. Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2013, shall be invalid and void.
376.964. The board of directors and administering insurers of the pool shall have the general powers and authority granted under the laws of this state to insurance companies licensed to transact health insurance as defined in section 376.960, and, in addition thereto, the specific authority to:
(1) Enter into contracts as are necessary or proper to carry out the provisions and purposes of sections 376.960 to 376.989, including the authority, with the approval of the director, to enter into contracts with similar pools of other states for the joint performance of common administrative functions, or with persons or other organizations for the performance of administrative functions;
(2) Sue or be sued, including taking any legal actions necessary or proper for recovery of any assessments for, on behalf of, or against pool members;
(3) Take such legal actions as necessary to avoid the payment of improper claims against the pool or the coverage provided by or through the pool;
(4) Establish appropriate rates, rate schedules, rate adjustments, expense allowances, agents' referral fees, claim reserve formulas and any other actuarial function appropriate to the operation of the pool. Rates shall not be unreasonable in relation to the coverage provided, the risk experience and expenses of providing the coverage. Rates and rate schedules may be adjusted for appropriate risk factors such as age and area variation in claim costs and shall take into consideration appropriate risk factors in accordance with established actuarial and underwriting practices;
(5) Assess members of the pool in accordance with the provisions of this section, and to make advance interim assessments as may be reasonable and necessary for the organizational and interim operating expenses. Any such interim assessments are to be credited as offsets against any regular assessments due following the close of the fiscal year;
(6) Prior to January 1, 2014, issue policies of insurance in accordance with the requirements of sections 376.960 to 376.989. In no event shall new policies of insurance be issued on or after January 1, 2014;
(7) Appoint, from among members, appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the pool, policy or other contract design, and any other function within the authority of the pool;
(8) Establish rules, conditions and procedures for reinsuring risks of pool members desiring to issue pool plan coverages in their own name. Such reinsurance facility shall not subject the pool to any of the capital or surplus requirements, if any, otherwise applicable to reinsurers;
(9) Negotiate rates of reimbursement with health care providers on behalf of the association and its members;
(10) Administer separate accounts to separate federally defined eligible individuals and trade act eligible individuals who qualify for plan coverage from the other eligible individuals entitled to pool coverage and apportion the costs of administration among such separate accounts.
376.966. 1. No employee shall involuntarily lose his or her group coverage by decision of his or her employer on the grounds that such employee may subsequently enroll in the pool. The department shall have authority to promulgate rules and regulations to enforce this subsection.
2. Prior to January 1, 2014, the following individual persons shall be eligible for coverage under the pool if they are and continue to be residents of this state:
(1) An individual person who provides evidence of the following:
(a) A notice of rejection or refusal to issue substantially similar health insurance for health reasons by at least two insurers; or
(b) A refusal by an insurer to issue health insurance except at a rate exceeding the plan rate for substantially similar health insurance;
(2) A federally defined eligible individual who has not experienced a significant break in coverage;
(3) A trade act eligible individual;
(4) Each resident dependent of a person who is eligible for plan coverage;
(5) Any person, regardless of age, that can be claimed as a dependent of a trade act eligible individual on such trade act eligible individual's tax filing;
(6) Any person whose health insurance coverage is involuntarily terminated for any reason other than nonpayment of premium or fraud, and who is not otherwise ineligible under subdivision (4) of subsection 3 of this section. If application for pool coverage is made not later than sixty-three days after the involuntary termination, the effective date of the coverage shall be the date of termination of the previous coverage;
(7) Any person whose premiums for health insurance coverage have increased above the rate established by the board under paragraph (a) of subdivision (1) of subsection 3 of this section;
(8) Any person currently insured who would have qualified as a federally defined eligible individual or a trade act eligible individual between the effective date of the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 and the effective date of this act.
3. The following individual persons shall not be eligible for coverage under the pool:
(1) Persons who have, on the date of issue of coverage by the pool, or obtain coverage under health insurance or an insurance arrangement substantially similar to or more comprehensive than a plan policy, or would be eligible to have coverage if the person elected to obtain it, except that:
(a) This exclusion shall not apply to a person who has such coverage but whose premiums have increased to one hundred fifty percent to two hundred percent of rates established by the board as applicable for individual standard risks;
(b) A person may maintain other coverage for the period of time the person is satisfying any preexisting condition waiting period under a pool policy; and
(c) A person may maintain plan coverage for the period of time the person is satisfying a preexisting condition waiting period under another health insurance policy intended to replace the pool policy;
(2) Any person who is at the time of pool application receiving health care benefits under section 208.151;
(3) Any person having terminated coverage in the pool unless twelve months have elapsed since such termination, unless such person is a federally defined eligible individual;
(4) Any person on whose behalf the pool has paid out one million dollars in benefits;
(5) Inmates or residents of public institutions, unless such person is a federally defined eligible individual, and persons eligible for public programs;
(6) Any person whose medical condition which precludes other insurance coverage is directly due to alcohol or drug abuse or self-inflicted injury, unless such person is a federally defined eligible individual or a trade act eligible individual;
(7) Any person who is eligible for Medicare coverage.
4. Any person who ceases to meet the eligibility requirements of this section may be terminated at the end of such person's policy period.
5. If an insurer issues one or more of the following or takes any other action based wholly or partially on medical underwriting considerations which is likely to render any person eligible for pool coverage, the insurer shall notify all persons affected of the existence of the pool, as well as the eligibility requirements and methods of applying for pool coverage:
(1) A notice of rejection or cancellation of coverage;
(2) A notice of reduction or limitation of coverage, including restrictive riders, if the effect of the reduction or limitation is to substantially reduce coverage compared to the coverage available to a person considered a standard risk for the type of coverage provided by the plan.
6. Coverage under the pool shall expire on January 1, 2014.
376.968. The board shall select an insurer [or] , insurers, or third-party administrators through a competitive bidding process to administer the pool. The board shall evaluate bids submitted based on criteria established by the board which shall include:
(1) The insurer's proven ability to handle individual accident and health insurance;
(2) The efficiency of the insurer's claim-paying procedures;
(3) An estimate of total charges for administering the plan;
(4) The insurer's ability to administer the pool in a cost-efficient manner.
376.970. 1. The administering insurer shall serve for a period of three years subject to removal for cause. At least one year prior to the expiration of each three-year period of service by an administering insurer, the board shall invite all insurers, including the current administering insurer, to submit bids to serve as the administering insurer for the succeeding three-year period. Selection of the administering insurer for the succeeding period shall be made at least six months prior to the end of the current three-year period.
2. The administering insurer shall:
(1) Perform all eligibility and administrative claim-payment functions relating to the pool;
(2) Establish a premium billing procedure for collection of premium from insured persons. Billings shall be made on a period basis as determined by the board;
(3) Perform all necessary functions to assure timely payment of benefits to covered persons under the pool including:
(a) Making available information relating to the proper manner of submitting a claim for benefits to the pool and distributing forms upon which submission shall be made;
(b) Evaluating the eligibility of each claim for payment by the pool;
(4) Submit regular reports to the board regarding the operation of the pool. The frequency, content and form of the report shall be determined by the board;
(5) Following the close of each calendar year, determine net written and earned premiums, the expense of administration, and the paid and incurred losses for the year and report this information to the board and the department on a form prescribed by the director;
(6) Be paid as provided in the plan of operation for its expenses incurred in the performance of its services.
3. On or before September 1, 2013, the board shall invite all insurers and third-party administrators, including the current administering insurer, to submit bids to serve as the administering insurer or third-party administrator for the pool. Selection of the administering insurer or third-party administrator shall be made prior to January 1, 2014.
4. Beginning January 1, 2014, the administering insurer or third-party administrator shall:
(1) Submit to the board and director a detailed plan outlining the winding down of operations of the pool. The plan shall be submitted no later than January 31, 2014, and shall be updated quarterly thereafter;
(2) Perform all administrative claim-payment functions relating to the pool;
(3) Perform all necessary functions to assure timely payment of benefits to covered persons under the pool including:
(a) Making available information relating to the proper manner of submitting a claim for benefits to the pool and distributing forms upon which submission shall be made;
(b) Evaluating the eligibility of each claim for payment by the pool;
(4) Submit regular reports to the board regarding the operation of the pool. The frequency, content and form of the report shall be determined by the board;
(5) Following the close of each calendar year, determine the expense of administration, and the paid and incurred losses for the year, and report such information to the board and department on a form prescribed by the director;
(6) Be paid as provided in the plan of operation for its expenses incurred in the performance of its services.
376.973. 1. Following the close of each fiscal year, the pool administrator shall determine the net premiums (premiums less administrative expense allowances), the pool expenses of administration and the incurred losses for the year, taking into account investment income and other appropriate gains and losses. Health insurance premiums and benefits paid by an insurance arrangement that are less than an amount determined by the board to justify the cost of collection shall not be considered for purposes of determining assessments. The total cost of pool operation shall be the amount by which all program expenses, including pool expenses of administration, incurred losses for the year, and other appropriate losses exceeds all program revenues, including net premiums, investment income, and other appropriate gains.
2. Each insurer's assessment shall be determined by multiplying the total cost of pool operation by a fraction, the numerator of which equals that insurer's premium and subscriber contract charges for health insurance written in the state during the preceding calendar year and the denominator of which equals the total of all premiums, subscriber contract charges written in the state and one hundred ten percent of all claims paid by insurance arrangements in the state during the preceding calendar year; provided, however, that the assessment for each health maintenance organization shall be determined through the application of an equitable formula based upon the value of services provided in the preceding calendar year.
3. Each insurance arrangement's assessment shall be determined by multiplying the total cost of pool operation calculated under subsection 1 of this section by a fraction, the numerator of which equals one hundred ten percent of the benefits paid by that insurance arrangement on behalf of insureds in this state during the preceding calendar year and the denominator of which equals the total of all premiums, subscriber contract charges and one hundred ten percent of all benefits paid by insurance arrangements made on behalf of insureds in this state during the preceding calendar year. Insurance arrangements shall report to the board claims payments made in this state on an annual basis on a form prescribed by the director.
4. If assessments exceed actual losses and administrative expenses of the pool, the excess shall be held at interest and used by the board to offset future losses or to reduce pool premiums. As used in this subsection, "future losses" include reserves for incurred but not paid claims.
5. Assessments shall continue until such a time as the executive director of the pool provides notice to the board and director that all claims have been paid.
6. Any assessment funds remaining at the time the executive director provides notice that all claims have been paid shall be deposited in the state general revenue fund.
Section 1. 1. Notwithstanding any other provision of law, beginning July 1, 2014, any MO HealthNet recipient who elects to receive medical coverage through a private health insurance plan instead of through the MO HealthNet program shall be eligible for a private insurance premium subsidy to assist the recipient in paying the costs of such private insurance. The subsidy shall be provided on a sliding scale based on income, with a graduated reduction in subsidy over a period of time not to exceed two years.
2. The department may promulgate rules to implement the provisions of this section. Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2013, shall be invalid and void.
Section 2. Under the MO HealthNet program, primary care providers shall be the team leaders in any collaborative practice arrangements entered into between providers under the program.
Section 3. All electronic cards used by recipients under the MO HealthNet program shall contain a photograph of the recipient on the front of the electronic card.
[208.146. 1. The program established under this section shall be known as the "Ticket to Work Health Assurance Program". Subject to appropriations and in accordance with the federal Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA), Public Law 106-170, the medical assistance provided for in section 208.151 may be paid for a person who is employed and who:
(1) Except for earnings, meets the definition of disabled under the Supplemental Security Income Program or meets the definition of an employed individual with a medically improved disability under TWWIIA;
(2) Has earned income, as defined in subsection 2 of this section;
(3) Meets the asset limits in subsection 3 of this section;
(4) Has net income, as defined in subsection 3 of this section, that does not exceed the limit for permanent and totally disabled individuals to receive nonspenddown MO HealthNet under subdivision (24) of subsection 1 of section 208.151; and
(5) Has a gross income of two hundred fifty percent or less of the federal poverty level, excluding any earned income of the worker with a disability between two hundred fifty and three hundred percent of the federal poverty level. For purposes of this subdivision, "gross income" includes all income of the person and the person's spouse that would be considered in determining MO HealthNet eligibility for permanent and totally disabled individuals under subdivision (24) of subsection 1 of section 208.151. Individuals with gross incomes in excess of one hundred percent of the federal poverty level shall pay a premium for participation in accordance with subsection 4 of this section.
2. For income to be considered earned income for purposes of this section, the department of social services shall document that Medicare and Social Security taxes are withheld from such income. Self-employed persons shall provide proof of payment of Medicare and Social Security taxes for income to be considered earned.
3. (1) For purposes of determining eligibility under this section, the available asset limit and the definition of available assets shall be the same as those used to determine MO HealthNet eligibility for permanent and totally disabled individuals under subdivision (24) of subsection 1 of section 208.151 except for:
(a) Medical savings accounts limited to deposits of earned income and earnings on such income while a participant in the program created under this section with a value not to exceed five thousand dollars per year; and
(b) Independent living accounts limited to deposits of earned income and earnings on such income while a participant in the program created under this section with a value not to exceed five thousand dollars per year. For purposes of this section, an "independent living account" means an account established and maintained to provide savings for transportation, housing, home modification, and personal care services and assistive devices associated with such person's disability.
(2) To determine net income, the following shall be disregarded:
(a) All earned income of the disabled worker;
(b) The first sixty-five dollars and one-half of the remaining earned income of a nondisabled spouse's earned income;
(c) A twenty dollar standard deduction;
(d) Health insurance premiums;
(e) A seventy-five dollar a month standard deduction for the disabled worker's dental and optical insurance when the total dental and optical insurance premiums are less than seventy-five dollars;
(f) All Supplemental Security Income payments, and the first fifty dollars of SSDI payments;
(g) A standard deduction for impairment-related employment expenses equal to one-half of the disabled worker's earned income.
4. Any person whose gross income exceeds one hundred percent of the federal poverty level shall pay a premium for participation in the medical assistance provided in this section. Such premium shall be:
(1) For a person whose gross income is more than one hundred percent but less than one hundred fifty percent of the federal poverty level, four percent of income at one hundred percent of the federal poverty level;
(2) For a person whose gross income equals or exceeds one hundred fifty percent but is less than two hundred percent of the federal poverty level, four percent of income at one hundred fifty percent of the federal poverty level;
(3) For a person whose gross income equals or exceeds two hundred percent but less than two hundred fifty percent of the federal poverty level, five percent of income at two hundred percent of the federal poverty level;
(4) For a person whose gross income equals or exceeds two hundred fifty percent up to and including three hundred percent of the federal poverty level, six percent of income at two hundred fifty percent of the federal poverty level.
5. Recipients of services through this program shall report any change in income or household size within ten days of the occurrence of such change. An increase in premiums resulting from a reported change in income or household size shall be effective with the next premium invoice that is mailed to a person after due process requirements have been met. A decrease in premiums shall be effective the first day of the month immediately following the month in which the change is reported.
6. If an eligible person's employer offers employer-sponsored health insurance and the department of social services determines that it is more cost effective, such person shall participate in the employer-sponsored insurance. The department shall pay such person's portion of the premiums, co-payments, and any other costs associated with participation in the employer-sponsored health insurance.
7. The provisions of this section shall expire six years after August 28, 2007.]
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