FIRSTREGULARSESSION
[PERFECTED]
HOUSEBILLNO.618
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVESTINNETT.
0990H.01P JOSEPHENGLER,ChiefClerk
ANACT
Toamendchapter376,RSMo,byaddingtheretofivenewsectionsrelatingtoprior
authorizationofhealthcareservices.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Chapter376,RSMo,isamendedbyaddingtheretofivenewsections,tobe
2knownassections376.2100,376.2102,376.2104,376.2106,and376.2108,toreadas
3follows:
376.2100.1.Exceptasotherwiseprovidedinsubsection1ofsection376.2108,as
2usedinsections376.2100to376.2108,termsshallhavethesamemeaningsasare
3ascribedtothemundersection376.1350.
4 2.Asusedinsections376.2100to376.2108,thefollowingtermsmean:
5 (1)"Evaluationperiod",anyconsecutivetwelvemonths;
6 (2)"Value-basedcareagreement",acontractualagreementbetweenahealth
7careprovider,eitherdirectlyorindirectlythroughahealthcareprovidergroupor
8organization,andahealthcarrierthat:
9 (a)Incentivizesorrewardsprovidersbasedononeormoreofthefollowing:
10 a.Qualityofcare;
11 b.Safety;
12 c.Patientoutcomes;
13 d.Efficiency;
14 e.Costreduction;or
15 f.Otherfactors;and
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 16 (b)May,butisnotrequiredto,includesharedfinancialriskandrewardsbased
17onperformancemetrics.
376.2102.1.Exceptasotherwiseprovidedinthissection,beginningJanuary1,
22026,ahealthcarrierorutilizationreviewentityshallnotrequireahealthcareprovider
3toobtainpriorauthorizationforahealthcareserviceunlessthehealthcarrieror
4utilizationreviewentitymakesadeterminationthatinthemostrecentevaluationperiod
5thehealthcarrierorutilizationreviewentityhasapprovedorwouldhaveapprovedless
6thanninetypercentofthepriorauthorizationrequestssubmittedbythatproviderfor
7thathealthcareservice.
8 2.BeginningJanuary1,2026,ahealthcarrierorutilizationreviewentityshall
9notrequireahealthcareprovidertoobtainpriorauthorizationforanyhealthcare
10servicesunlessthehealthcarrierorutilizationreviewentitymakesadeterminationthat
11inthemostrecentevaluationperiodthehealthcarrierorutilizationreviewentityhas
12approvedorwouldhaveapprovedlessthanninetypercentofallpriorauthorization
13requestssubmittedbythatproviderforhealthcareservices.
14 3.(1)BeginningJanuary1,2026,ahealthcarrierorutilizationreviewentity
15mayelecttohaveahospital,asthattermisdefinedinsection197.020,determinewhich
16ofthefollowingconditionsthatsuchhospitalwillcomplywithtoobtainanexemption
17frompriorauthorizationrequirementsundersubsections1and2ofthissection:
18 (a)Thehospitalenteringinto,eitherdirectlyorindirectlythroughahealthcare
19providergroupororganizationavalue-basedcareagreementwiththehealthcarrier;
20 (b)Thehospital'sscoreofthreeorhigherontheCenterforMedicareand
21MedicaidServicesFive-StarQualityRatingSystem,42CFR§412.190,oritssuccessor
22ratingsystem;or
23 (c)Atleastninety-onepercentofthehospital'spriorauthorizationrequests
24submittedforpurposesofeligibilityforsubsections1or2ofthissectionwereapproved
25orwouldhavebeenapprovedbythehealthcarrierorutilizationreviewentity.
26 (2)CriticalaccesshospitalsandhospitalsthatdonotparticipateintheCenter
27forMedicareandMedicaidServicesFive-StarQualityRatingSystem,oritssuccessor
28ratingsystem,shallbeexemptfromtheprovisionsofthissubsection.
29 4.Theexemptionfrompriorauthorizationrequirementsdescribedin
30subsections1,2,and3ofthissectionshallnotinclude:
31 (1)Pharmacyservices,nottoexceedtheamountofonehundredthousand
32dollars;
33 (2)Imagingservices,nottoexceedtheamountofonehundredthousanddollars;
34 (3)Cosmeticproceduresthatarenotmedicallynecessary;or
35 (4)Investigativeorexperimentaltreatments.
HB618 2 36 5.Theamountofthelimitationsdescribedinsubdivisions(1)and(2)of
37subsection4ofthissectionshallbeincreasedeveryyear,roundedtothenearest
38thousanddollars,beginningJanuary1,2027,basedontheConsumerPriceIndexforAll
39UrbanConsumersfortheUnitedStates(CPI-U),oritssuccessorindex,assuchindexis
40definedandofficiallyreportedbytheUnitedStatesDepartmentofLabor,orits
41successoragency.
42 6.Inmakingadeterminationunderthissection,thehealthcarrierorutilization
43reviewentityshallnotcount:
44 (1)Anypriorauthorizationrequestsdeniedbyahealthcarrierorutilization
45reviewentityandbeingappealedbythehealthcareprovider;or
46 (2)Anyrequestmadebyahealthcareproviderforaservicethatisnotincluded
47inthehealthcarrier'sbenefitplan
48
49butshallcountasapprovedanypriorauthorizationrequestthatwasdeniedbyahealth
50carrierorutilizationreviewentitybutthatwassubsequentlyauthorized.
51 7.Inmakingadeterminationunderthissection,thehealthcarrierorutilization
52reviewentityshalluseeithertheprovider'snationalprovideridentifierorataxpayer
53identificationnumber.Suchdesignationshallremainunlessrequestedtobechangedby
54theprovider.
55 8.Theexemptionfrompriorauthorizationrequirementsdescribedin
56subsections1,2,and3ofthissectionmaybesubjecttointernalauditingofthemost
57recentconsecutivesixmonths,uptoamaximumoftwotimesperyear,bythehealth
58carrierorutilizationreviewentityandmayberescindedif:
59 (1)Suchcarrierorutilizationreviewentitydeterminesthatthecarrieror
60utilizationreviewentitywouldhaveapprovedlessthanninetypercentofprior
61authorizationrequestsforahealthcareservicethattheproviderwasexemptfromthe
62priorauthorizationrequirementundersubsection1ofthissection;
63 (2)Suchcarrierorutilizationreviewentitydeterminesthatthecarrieror
64utilizationreviewentitywouldhaveapprovedlessthanninetypercentofallprior
65authorizationrequestsiftheproviderwasexemptfromthepriorauthorization
66requirementundersubsection2ofthissection;or
67 (3)Therehasbeenanincreaseintheprovisionofexemptproceduresbyahealth
68careproviderofmorethanfiftypercentormorethantwentyprocedures,whichever
69amountisgreater.
70 9.Theexemptiondescribedinsubsections1,2,and3ofthissectionshallbenull
71andvoiduponadeterminationthatthehealthcareproviderhasbeenfoundbyacourt
HB618 3 72oflawtohavecivillyorcriminallyengagedinanyfraudorabuseaftertheexemptionis
73grantedbyahealthcarrierorutilizationreviewentity.
74 10.Ahealthcarrierorutilizationreviewentitymayrequirehealthcare
75providersinthehealthcarrier'sorutilizationreviewentity'snetworktouseanonline
76portaltosubmitrequestsforpriorauthorization.
77 11.Noadversedeterminationshallbefinalizedundersubsections1,2,3,or8
78unlessreviewedbyaclinicalpeer.
79 12.Anypatientwhohasreceivedpriorauthorizationforthecoverageofa
80ninety-daysupplyofmedicationwhosehealthcoverageplanchangesfollowingsuch
81authorizationshallbepermittedaninety-daygraceperiodfromthedateofsuchchange
82inordertodeterminewhethersuchpatient'snewplancoversthepreviouslyauthorized
83medicationorwhetherpriorauthorizationisrequired.
376.2104.1.Thehealthcarrierorutilizationreviewentityshallnotifythehealth
2careprovidernolaterthantwenty-fivedaysafteranydeterminationmadeunder
3section376.2102.Thenotificationshallincludethestatistics,data,andanysupporting
4documentationformakingthedeterminationfortherelevantevaluationperiod.
5 2.Thehealthcarrierorutilizationreviewentityshallestablishaprocessfor
6healthcareproviderstoappealanydeterminationsmadeundersection376.2102.
7 3.Thehealthcarrierorutilizationreviewentityshallmaintainanonlineportal
8toallowhealthcareproviderstoaccessallpriorauthorizationdecisions,including
9determinationsmadeundersection376.2102.Forhealthcareproviderssubjecttoprior
10authorizations,theportalshallincludethestatusofeachpriorauthorizationrequest,all
11notificationstothehealthcareprovider,thedatesthehealthcareproviderreceivedsuch
12notifications,andanyotherinformationrelevanttothedetermination.
376.2106.Nohealthcarrierorutilizationreviewentityshalldenyorreduce
2paymenttoahealthcareproviderforahealthcareserviceforwhichtheproviderhasa
3priorauthorizationunlesstheprovider:
4 (1)Knowinglyandmateriallymisrepresentedthehealthcareserviceinarequest
5forpaymentsubmittedtothehealthcarrierorutilizationreviewentitywiththespecific
6intenttodeceiveandobtainanunlawfulpaymentfromthecarrierorentity;or
7 (2)Failedtosubstantiallyperformthehealthcareservice.
376.2108.1.Theprovisionsofsections376.2100to376.2108shallnotapplyto
2MOHealthNet,exceptthataMedicaidmanagedcareorganizationasdefinedinsection
3208.431shallbeconsideredahealthcarrierforpurposesofsections376.2100to
4376.2108.
HB618 4 5 2.Theprovisionsofsections376.2100to376.2108shallnotapplytohealthcare
6providerswhohavenotparticipatedinahealthbenefitplanofferedbythehealth
7carrierforatleastonefullevaluationperiod.
8 3.Nothinginsections376.2100to376.2108shallbeconstruedto:
9 (1)Authorizeahealthcareprovidertoprovideahealthcareserviceoutsidethe
10scopeofhisorherapplicablelicense;or
11 (2)Requireahealthcarrierorutilizationreviewentitytopayforahealthcare
12servicedescribedinsubdivision(1)ofthissubsection.
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HB618 5