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SECOND REGULAR SESSION
HOUSE BILL NO. 3088
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE DIEHL.
6664H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o amend chapter 376, RSMo, by adding thereto one new section relating to conduct
af fecting health care provider 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
2 known as section 376.1068, to read as follows:
376.1068. 1. As used in this section, the following terms mean:
2 (1) "Anti-steering clause", a prov ision in a prov ider network contract that
3 r estricts the ability of a general contracting entity to encourage an enrol lee to obtain a
4 health care service fro m a competitor of the pr ovider , including offering incentives to
5 encourage enr ollees to use specific provi ders;
6 (2) "Anti-tiering clause", a prov ision in a pr ovider network contract that:
7 (a) Restricts the ability of a general contracting entity to intr oduce or modify a
8 tier ed network plan or assign pro viders into tiers; or
9 (b) Requires a general contracting entity to place all members of a pr ovider in
10 the same tier of a tier ed network plan;
11 (3) "Covered individual", an individual who is covered under a health benefit
12 plan;
13 (4) "Enro llee", the same meaning given to the term in section 376.1350;
14 (5) "Facility", the same meaning given to the term in section 376.1350;
15 (6) "Gag clause", a pro vision in a pr ovider network contract that res tricts the
16 ability of a general contracting entity or provi der to disclose:
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
17 (a) Price or quality information, including the allowed amount, negotiated rates
18 or discounts, fees for services, or other claim-r elated financial obligations included in
19 the contract, to a governmental entity as authorized by law or its contractors or agents,
20 an enr ollee, a tre ating pr ovider of an enr ollee, a plan sponsor , or potential eligible
21 enr ollees and plan sponsors; or
22 (b) Out-of-pocket costs to an enro llee;
23 (7) "General contracting entity", a person who enters into a dir ect contract with
24 a pr ovider for the delivery of health care services to cover ed individuals rega rdless of
25 whether the person, in the ordinary course of business, establishes a pro vider network
26 for access by another party . The term "general contracting entity" shall not include a
27 health car e pr ovider or facility unless the pr ovider or facility is entering into the
28 contract in the pr ovider's or facility's role as a health benefit plan;
29 (8) "Health benefit plan", the same meaning given to the term in section
30 376.1350;
31 (9) "Health care service", the same meaning given to the term in section
32 376.1350;
33 (10) "Most-favor ed-nation clause", a prov ision in a pr ovider network contract
34 that:
35 (a) Pr ohibits or grants an option to pr ohibit:
36 a. A pr ovider fro m contracting with another general contracting entity to
37 pr ovide health car e services at a lower rate; or
38 b. A general contracting entity fro m contracting with another pro vider to
39 pr ovide health car e services at a higher rate;
40 (b) Requires or grants an option to req uire:
41 a. A pro vider to accept a lower rate for health car e services if the provi der
42 agr ees with another general contracting entity to accept a lower rate for the services; or
43 b. A general contracting entity to pay a higher rate for health care services if the
44 entity agrees with another pr ovider to pay a higher rate for the services;
45 (c) Requires or grants an option to requ ire termination or reneg otiation of an
46 existing pr ovider network contract if:
47 a. A prov ider agree s with another general contracting entity to accept a lower
48 rate for pro viding health car e services; or
49 b. A general contracting entity agre es with a pro vider to pay a higher rate for
50 health car e services; or
51 (d) Requires :
52 a. A pr ovider to disclose the provi der's contractual reim bursement rates with
53 other general contracting entities; or
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54 b. A general contracting entity to disclose the general contracting entity's
55 contractual r eimbursement rates with other pro viders;
56 (1 1) "Prov ider", the same meaning given to the term in section 376.1350;
57 (12) "Provi der network contract", a contract between a general contracting
58 entity and a pr ovider for the delivery of, and payment for , health care services to a
59 cover ed individual.
60 2. A pr ovider shall not:
61 (1) Offer to a general contracting entity a written provi der network contract
62 that includes an anti-steering, anti-tiering, gag, or most-favor ed-nation clause;
63 (2) Enter into a pr ovider network contract that includes an anti-steering, anti-
64 tiering, gag, or most-favor ed-nation clause; or
65 (3) Amend or renew an existing pr ovider network contract prev iously enter ed
66 into with a general contracting entity so that the contract as amended or rene wed adds
67 or ret ains an anti-steering, anti-tiering, gag, or most-favor ed-nation clause.
68 3. Any provi sion in a pro vider network contract that is an anti-steering, anti-
69 tiering, gag, or most-favor ed-nation clause is void and unenfor ceable. The rem aining
70 pr ovisions in the pr ovider network contract shall rem ain in effect and are enforceab le.
71 4. A health benefit plan issuer that encourages an enro llee to obtain a health car e
72 service fr om a particular prov ider , including offering incentives to encourage enr ollees
73 to use specific provi ders, or that introdu ces or modifies a tier ed network plan or assigns
74 pr oviders into tiers has a fiduciary duty to the enr ollee or policyholder to engage in that
75 conduct only for the primary benefit of the enr ollee or policyholder .
✔
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