Enacts provisions relating to insurance coverage of health care services

SECOND REGULAR SESSION
SENATE BILL NO. 846
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR BROWN (16).
4549S.02I KRISTINA MARTIN, Secretary
AN ACT
To amend chapter 376, RSMo, by adding thereto eight new sections relating to insurance coverage
of health care services, with penalty provisions.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto 1
eight new sections, to be known as sections 376.411, 376.415, 2
376.416, 376.2100, 376.2102, 376.2104, 376.2106, and 376.2108, 3
to read as follows:4
376.411. 1. For purposes of this section, the 1
following terms mean: 2
(1) "Clinician-administered drug", any legend drug, as 3
defined in section 338.330, that is administered by a health 4
care provider who is authorized to administer the drug; 5
(2) "Health carrier", the same meaning given to the 6
term in section 376.1350; 7
(3) "Participating provider", the same meaning given 8
to the term in section 376.1350; 9
(4) "Pharmacy benefits manager", the same meaning 10
given to the term in section 376.388. 11
2. A health carrier, a pharmacy benefits manager, or 12
an agent or affiliate of such health carrier or pharmacy 13
benefits manager shall not: 14
(1) Impose any penalty, impediment, differentiation, 15
or limitation on a participating provider for providing 16
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medically necessary clinician-administered drugs regardless 17
of whether the participating provider obtains such drugs 18
from a provider that is in the network including, but not 19
limited to, refusing to approve or pay or reimbursing less 20
than the contracted payment amount; 21
(2) Impose any penalty, impediment, differentiation, 22
or limitation on a covered person who is administered 23
medically necessary clinician-administered drugs regardless 24
of whether the participating provider obtains such drugs 25
from a provider that is in the network including, but not 26
limited to, limiting coverage or benefits; requiring an 27
additional fee, higher co-payment, or higher coinsurance 28
amount; or interfering with a patient's ability to obtain a 29
clinician-administered drug from the patient's provider or 30
pharmacy of choice by any means including, but not limited 31
to, inducing, steering, or offering financial or other 32
incentives; or 33
(3) Impose any penalty, impediment, differentiation, 34
or limitation on any pharmacy, including any class B 35
hospital pharmacy as defined in section 338.220, that is 36
dispensing medically necessary clinician-administered drugs 37
regardless of whether the participating provider obtains 38
such drugs from a provider that is in the network including, 39
but not limited to, requiring a pharmacy to dispense such 40
drugs to a patient with the intention that the patient will 41
transport the medication to a health care provider for 42
administration. 43
3. The provisions of this section shall not apply if 44
the clinician-administered drug is not otherwise covered by 45
the health carrier or pharmacy benefits manager. 46
376.415. 1. For purposes of this section, the 1
following terms mean: 2
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(1) "Biological product", the same meaning given to 3
the term in 42 U.S.C. Section 262(i); 4
(2) "Biosimilar", the same meaning given to the term 5
in 42 U.S.C. Section 262(i); 6
(3) "Health carrier", the same meaning given to the 7
term in section 376.1350; 8
(4) "Pharmacy benefits manager", the same meaning 9
given to the term in section 376.388; 10
(5) "Reference product", the same meaning given to the 11
term in 42 U.S.C. Section 262(i). 12
2. A health carrier, a pharmacy benefits manager, or 13
an agent or affiliate of such health carrier or pharmacy 14
benefits manager that provides coverage for a reference 15
product or a biological product that is biosimilar to the 16
reference product shall provide coverage for the reference 17
product and all biological products that have been deemed 18
biosimilar to the reference product. The scope, extent, and 19
amount of such required coverage shall be the same 20
including, but not limited to, any payment limitations or 21
cost-sharing obligations. 22
376.416. 1. For purposes of this section, the 1
following terms mean: 2
(1) "340B drug", the same meaning given to the term in 3
section 376.414; 4
(2) "Covered entity", the same meaning given to the 5
term in section 376.414; 6
(3) "Health carrier", the same meaning given to the 7
term in section 376.1350; 8
(4) "Pharmacy", an entity licensed under chapter 338; 9
(5) "Pharmacy benefits manager", the same meaning 10
given to the term in section 376.388; 11
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2. A health carrier, a pharmacy benefits manager, or 12
an agent or affiliate of such health carrier or pharmacy 13
benefits manager shall not discriminate against a covered 14
entity or a pharmacy including, but not limited to, by doing 15
any of the following: 16
(1) Reimbursing a covered entity or pharmacy for a 17
quantity of a 340B drug in an amount less than it would pay 18
to any other similarly situated pharmacy that is not a 19
covered entity or a pharmacy for such quantity of such drug 20
on the basis that the entity or pharmacy is a covered entity 21
or pharmacy or that the entity or pharmacy dispenses 340B 22
drugs; 23
(2) Imposing any terms or conditions on covered 24
entities or pharmacies that differ from such terms or 25
conditions applied to other similarly situated pharmacies or 26
entities that are not covered entities on the basis that the 27
entity or pharmacy is a covered entity or pharmacy or that 28
the entity or pharmacy dispenses 340B drugs including, but 29
not limited to, terms or conditions with respect to any of 30
the following: 31
(a) Fees, chargebacks, clawbacks, adjustments, or 32
other assessments; 33
(b) Professional dispensing fees; 34
(c) Restrictions or requirements regarding 35
participation in standard or preferred pharmacy networks; 36
(d) Requirements relating to the frequency or scope of 37
audits or to inventory management systems using generally 38
accepted accounting principles; and 39
(e) Any other restrictions, conditions, practices, or 40
policies that, as specified by the director of the 41
department of commerce and insurance, interfere with the 42
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ability of a covered entity to maximize the value of 43
discounts provided under 42 U.S.C. Section 256b; 44
(3) Interfering with an individual's choice to receive 45
a 340B drug from a covered entity or pharmacy, whether in 46
person or via direct delivery, mail, or other form of 47
shipment, by any means including, but not limited to, 48
modifying a patient's payment limitations or cost-sharing 49
obligations on the basis of participation, in whole or in 50
part, in the 340B drug pricing program; 51
(4) Discriminating in reimbursement to a covered 52
entity or pharmacy based on the determination or indication 53
a drug is a 340B drug; 54
(5) Requiring a covered entity or pharmacy to 55
identify, either directly or through a third party, a 340B 56
drug sooner than forty-five days after the point of sale of 57
the 340B drug; 58
(6) Refusing to contract with a covered entity or 59
pharmacy for reasons other than those that apply equally to 60
entities that are not covered entities or similarly situated 61
pharmacies, or on the basis that: 62
(a) The entity is a covered entity; or 63
(b) The entity or pharmacy is described in any of 64
subparagraphs (A) to (O) of 42 U.S.C. Section 235b(a)(4); 65
(7) Denying the covered entity the ability to purchase 66
drugs at 340B program pricing by substituting a rebate 67
discount; 68
(8) Refusing to cover drugs purchased under the 340B 69
drug pricing program; or 70
(9) Requiring a covered entity or pharmacy to reverse, 71
resubmit, or clarify a 340B drug pricing claim after the 72
initial adjudication unless these actions are in the normal 73
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course of pharmacy business and not related to 340B drug 74
pricing, except as required by federal law. 75
3. The director of the department of commerce and 76
insurance shall impose a civil penalty on any health 77
carrier, pharmacy benefits manager, or agent or affiliate of 78
such health carrier or pharmacy benefits manager that 79
violates the requirements of this section. Such penalty 80
shall not exceed five thousand dollars per violation per day. 81
4. The director of the department of commerce and 82
insurance shall promulgate rules to implement the provisions 83
of this section. Any rule or portion of a rule, as that 84
term is defined in section 536.010, that is created under 85
the authority delegated in this section shall become 86
effective only if it complies with and is subject to all of 87
the provisions of chapter 536 and, if applicable, section 88
536.028. This section and chapter 536 are nonseverable and 89
if any of the powers vested with the general assembly 90
pursuant to chapter 536 to review, to delay the effective 91
date, or to disapprove and annul a rule are subsequently 92
held unconstitutional, then the grant of rulemaking 93
authority and any rule proposed or adopted after August 28, 94
2026, shall be invalid and void. 95
376.2100. 1. Except as otherwise provided in 1
subsection 1 of section 376.2108, as used in sections 2
376.2100 to 376.2108, terms shall have the same meanings as 3
are ascribed to them under section 376.1350. 4
2. As used in sections 376.2100 to 376.2108, the 5
following terms mean: 6
(1) "Evaluation period", any consecutive twelve months; 7
(2) "Value-based care agreement", a contractual 8
agreement between a health care provider, either directly or 9
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indirectly through a health care provider group or 10
organization, and a health carrier that: 11
(a) Incentivizes or rewards providers based on one or 12
more of the following: 13
a. Quality of care; 14
b. Safety; 15
c. Patient outcomes; 16
d. Efficiency; 17
e. Cost reduction; or 18
f. Other factors; and 19
(b) May, but is not required to, include shared 20
financial risk and rewards based on performance metrics. 21
376.2102. 1. Except as otherwise provided in this 1
section, beginning January 1, 2027, a health carrier or 2
utilization review entity shall not require a health care 3
provider to obtain prior authorization for a health care 4
service unless the health carrier or utilization review 5
entity makes a determination that in the most recent 6
evaluation period the health carrier or utilization review 7
entity has approved or would have approved less than ninety 8
percent of the prior authorization requests submitted by 9
that provider for that health care service. 10
2. Beginning January 1, 2027, a health carrier or 11
utilization review entity shall not require a health care 12
provider to obtain prior authorization for any health care 13
services unless the health carrier or utilization review 14
entity makes a determination that in the most recent 15
evaluation period the health carrier or utilization review 16
entity has approved or would have approved less than ninety 17
percent of all prior authorization requests submitted by 18
that provider for health care services. 19
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3. (1) Beginning January 1, 2027, a health carrier or 20
utilization review entity may elect to have a hospital, as 21
that term is defined in section 197.020, determine which of 22
the following conditions that such hospital will comply with 23
to obtain an exemption from prior authorization requirements 24
under subsections 1 and 2 of this section: 25
(a) The hospital entering into, either directly or 26
indirectly through a health care provider group or 27
organization, a value-based care agreement with the health 28
carrier; 29
(b) The hospital's score of three or higher on the 30
Center for Medicare and Medicaid Services Five-Star Quality 31
Rating System, 42 CFR Section 412.190, or its successor 32
rating system; or 33
(c) At least ninety-one percent of the hospital's 34
prior authorization requests submitted for purposes of 35
eligibility for subsections 1 or 2 of this section were 36
approved or would have been approved by the health carrier 37
or utilization review entity. 38
(2) Critical access hospitals and hospitals that do 39
not participate in the Center for Medicare and Medicaid 40
Services Five-Star Quality Rating System, or its successor 41
rating system, shall be exempt from the provisions of this 42
subsection. 43
4. The exemption from prior authorization requirements 44
described in subsections 1, 2, and 3 of this section shall 45
not include: 46
(1) Pharmacy services, not to exceed the amount of one 47
hundred thousand dollars; 48
(2) Imaging services, not to exceed the amount of one 49
hundred thousand dollars; 50
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(3) Cosmetic procedures that are not medically 51
necessary; or 52
(4) Investigative or experimental treatments. 53
5. The amount of the limitations described in 54
subdivisions (1) and (2) of subsection 4 of this section 55
shall be increased every year, rounded to the nearest 56
thousand dollars, beginning January 1, 2028, based on the 57
Consumer Price Index for All Urban Consumers for the United 58
States (CPI-U), or its successor index, as such index is 59
defined and officially reported by the United States 60
Department of Labor, or its successor agency. 61
6. In making a determination under this section, the 62
health carrier or utilization review entity shall not count: 63
(1) Any prior authorization requests denied by a 64
health carrier or utilization review entity and being 65
appealed by the health care provider; or 66
(2) Any request made by a health care provider for a 67
service that is not included in the health carrier's benefit 68
plan but shall count as approved any prior authorization 69
request that was denied by a health carrier or utilization 70
review entity but that was subsequently authorized. 71
7. In making a determination under this section, the 72
health carrier or utilization review entity shall use either 73
the provider's national provider identifier or a taxpayer 74
identification number. Such designation shall remain unless 75
requested to be changed by the provider. 76
8. The exemption from prior authorization requirements 77
described in subsections 1, 2, and 3 of this section may be 78
subject to internal auditing of the most recent consecutive 79
six months, up to a maximum of two times per year, by the 80
health carrier or utilization review entity and may be 81
rescinded if: 82
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(1) Such carrier or utilization review entity 83
determines that the carrier or utilization review entity 84
would have approved less than ninety percent of prior 85
authorization requests for a health care service that the 86
provider was exempt from the prior authorization requirement 87
under subsection 1 of this section; 88
(2) Such carrier or utilization review entity 89
determines that the carrier or utilization review entity 90
would have approved less than ninety percent of all prior 91
authorization requests if the provider was exempt from the 92
prior authorization requirement under subsection 2 of this 93
section; or 94
(3) There has been an increase in the provision of 95
exempt procedures by a health care provider of more than 96
fifty percent or more than twenty procedures, whichever 97
amount is greater. 98
9. The exemption described in subsections 1, 2, and 3 99
of this section shall be null and void upon a determination 100
that the health care provider has been found by a court of 101
law to have civilly or criminally engaged in any fraud or 102
abuse after the exemption is granted by a health carrier or 103
utilization review entity. 104
10. A health carrier or utilization review entity may 105
require health care providers in the health carrier's or 106
utilization review entity's network to use an online portal 107
to submit requests for prior authorization. 108
11. No adverse determination shall be finalized under 109
subsections 1, 2, 3, or 8 unless reviewed by a clinical peer. 110
12. Any patient who has received prior authorization 111
for the coverage of a ninety-day supply of medication whose 112
health coverage plan changes following such authorization 113
shall be permitted a ninety-day grace period from the date 114
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of such change in order to determine whether such patient's 115
new plan covers the previously authorized medication or 116
whether prior authorization is required. 117
376.2104. 1. The health carrier or utilization review 1
entity shall notify the health care provider no later than 2
twenty-five days after any determination made under section 3
376.2102. The notification shall include the statistics, 4
data, and any supporting documentation for making the 5
determination for the relevant evaluation period. 6
2. The health carrier or utilization review entity 7
shall establish a process for health care providers to 8
appeal any determinations made under section 376.2102. 9
3. The health carrier or utilization review entity 10
shall maintain an online portal to allow health care 11
providers to access all prior authorization decisions, 12
including determinations made under section 376.2102. For 13
health care providers subject to prior authorizations, the 14
portal shall include the status of each prior authorization 15
request, all notifications to the health care provider, the 16
dates the health care provider received such notifications, 17
and any other information relevant to the determination. 18
376.2106. No health carrier or utilization review 1
entity shall deny or reduce payment to a health care 2
provider for a health care service for which the provider 3
has a prior authorization unless the provider: 4
(1) Knowingly and materially misrepresented the health 5
care service in a request for payment submitted to the 6
health carrier or utilization review entity with the 7
specific intent to deceive and obtain an unlawful payment 8
from the carrier or entity; or 9
(2) Failed to substantially perform the health care 10
service. 11
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376.2108. 1. The provisions of sections 376.2100 to 1
376.2108 shall not apply to MO HealthNet, except that a 2
Medicaid managed care organization as defined in section 3
208.431 shall be considered a health carrier for purposes of 4
sections 376.2100 to 376.2108. 5
2. The provisions of sections 376.2100 to 376.2108 6
shall not apply to health care providers who have not 7
participated in a health benefit plan offered by the health 8
carrier for at least one full evaluation period. 9
3. Nothing in sections 376.2100 to 376.2108 shall be 10
construed to: 11
(1) Authorize a health care provider to provide a 12
health care service outside the scope of his or her 13
applicable license; or 14
(2) Require a health carrier or utilization review 15
entity to pay for a health care service described in 16
subdivision (1) of this subsection. 17
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