SECOND REGULAR SESSION
95TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE DIEHL.
4998L.01I D. ADAM CRUMBLISS, Chief Clerk
AN ACT
To amend chapter 376, RSMo, by adding thereto one new section relating to health insurance networks.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be known as section 376.1373, to read as follows:
376.1373. 1. As used in this section, the following terms shall mean:
(1) "Affiliate", any person or entity that has ownership or control of a contracting entity, is owned or controlled by a contracting entity, or is under common ownership or control with a contracting entity;
(2) "Contracting entity", any person that has a primary business purpose of contracting with participating providers for the delivery of health care services;
(3) "Electronic claims transport", to accept and digitize claims or to accept claims already digitized, to place such claims into a format that complies with the electronic transaction standards issued by the United States Department of Health and Human Services under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. Section 1320d, et seq., as amended, as those electronic standards are applicable to the parties and as those electronic standards are updated from time to time, and to electronically transmit such claims to the appropriate contracting entity, payer, or third-party administrator;
(4) "Health care contract", a contract entered into, materially amended, or renewed between a contracting entity and a participating provider for the delivery of health care services to enrollees;
(5) "Participating provider", a provider that has a health care contract with a contracting entity and is entitled to reimbursement for health care services rendered to an enrollee under a health care contract;
(6) "Payer", any person that assumes the financial risk for the payment of claims under a health care contract or the reimbursement for health care services provided to enrollees by participating providers under a health care contract.
2. No contracting entity shall sell, rent, or give a third party the contracting entity's rights to a participating provider's services under the contracting entity's health care contract with the participating provider unless one of the following applies:
(1) The third party accessing the participating provider's services under the health care contract is an employer or other entity providing coverage for health care services to its employees or members, and such employer or entity has a contract with the contracting entity or its affiliate for the administration or processing of claims for payment for services provided under a health care contract with the participating provider;
(2) The third party accessing the participating provider's services under the health care contract either is an affiliate or subsidiary of the contracting entity or is providing administrative services to or receiving administrative services from the contracting entity or an affiliate or subsidiary of the contracting entity;
(3) The health care contract specifically provides that it applies to network rental arrangements and states that one purpose of the contract is selling, renting, or giving the contracting entity's rights to the services of the participating provider, including other preferred provider organizations, and the third party accessing the participating provider's services is any one of the following:
(a) A payer or third-party administrator or other entity responsible for administering claims on behalf of the payer;
(b) A preferred provider organization or preferred provider network that receives access to the participating provider's services under an arrangement with the preferred provider organization or preferred provider network in a contract with the participating provider that is in compliance with this subdivision and is required to comply with all of the terms, conditions, and affirmative obligations to which the originally contracted primary participating provider network is bound under its contract with the participating provider, including but not limited to obligations concerning patient steerage and the timeliness and manner of reimbursement;
(c) An entity that is engaged in the business of providing electronic claims transport between the contracting entity and the payer or third-party administrator and complies with all of the applicable terms, conditions, and affirmative obligations of the contracting entity's contract with the participating provider, including but not limited to obligations concerning patient steerage and the timeliness and manner of reimbursement.
3. The contracting entity that sells, rents, or gives the contracting entity's rights to the participating provider's services under the contracting entity's health care contract with the participating provider as provided in subsection 2 of this section shall do both of the following:
(1) Maintain a webpage that contains a listing of third parties described in subdivisions (2) and (3) of subsection 2 of this section with whom a contracting entity contracts for the purpose of selling, renting, or giving the contracting entity's rights to the services of participating providers that is updated at least every six months and is accessible to all participating providers, or maintains a toll-free telephone number accessible to all participating providers by means of which participating providers may access the same listing of third parties; and
(2) Require that the third party accessing the participating provider's services through the participating provider's health care contract is obligated to comply with all of the applicable terms and conditions of the contract, including but not limited to the products for which the participating provider has agreed to provide services; except that, a payer receiving administrative services from the contracting entity or its affiliate shall be solely responsible for payment to the participating provider.
4. Except as provided in subsection 2 of this section, no entity shall sell, rent, or give a contracting entity's rights to the participating provider's services under a health care contract.
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