SB 230 - This act provides that a health carrier or utilization review entity shall not require health care providers to obtain prior authorization for health care services, except under certain circumstances. Prior authorization shall not be required unless the health carrier or utilization review entity makes a determination that less than 90% of prior authorization requests submitted by that health care provider in the previous evaluation period, as defined in the act, were or would have been approved. The act establishes separate 90% thresholds for requiring prior authorization for individual health care services or requiring prior authorization for any health care service.
The act specifies requirements for notifying the provider of determinations under the act, requires health carriers and utilization review entities to establish an appeals process for determinations under the act, and requires carriers and utilization review entities to maintain an online portal giving providers access to certain information.
Lastly, no health carrier or utilization review entity shall deny or reduce payments to a health care provider who had a prior authorization, unless the provider made a knowing and material misrepresentation with the intent to deceive the carrier or utilization review entity, or unless the health care service was not substantially performed.
This act shall not apply to Medicaid, except with regard to a Medicaid managed care organization as defined by law. The act also does not apply to providers who have not participated in a health benefit plan offered by the carrier for at least one full evaluation period. This act shall not be construed to authorize providers to provide services outside the scope of their licenses, nor to require health carriers or utilization review entities to pay for care provided outside the scope of a provider's license.
This act is identical to HB 1976 (2024), and similar to SB 983 (2024) and SB 576 (2023), and to HB 1045 (2023).
ERIC VANDER WEERD
Statutes affected: Introduced (0591S.01):
376.2100,
376.2102,
376.2104,
376.2106,
376.2108
Senate Committee Minutes: SENATE COMMITTEE MINUTES Bill No.: SB 230
Sponsor: Brown (26)
Hearing Date: 2/18/2025
COMMITTEE: Insurance and Banking
CHAIRMAN: Crawford
DATE REFERRED: 2/3/2025 DATE HEARING REQUESTED: 2/4/2025
STAFF:
Barbara Mustoe
Scott Svagera
Eric Vander Weerd
WITNESSES GIVING INFORMATION:
WITNESSES FOR:
Andrew Wheeler - Missouri Hospital Association
Dr. Michael Rothermich - Hermann Area District Hospital
David Barbe, M.D. - Missouri State Medical Association
Deepa Mokshagundam, M.D. - Missouri Chapter of the American Academy of Pediatrics
Jacob Scott - Missouri State Medical Association/Missouri Association of Osteopathic Physicians and Surgeons
Rachel Bauer - Missouri Gastroenterology Society/Missouri State Orthopaedic Association
Shanon Hawk - Missouri Society of Eye Physicians & Surgeons
Kathi Harness - St. Luke's Health System
Cara Hoover - SSM Health
David Winton - BJC Healthcare/Cox Health/Rankin Jordan Pediatric Bridge Hospital/Reach Foundation/ National Assn.
of Social Workers/Missouri Assn of Rural Health Clinics.
Garrett Webb - Missouri Psychological Association
Sarah Schlemeier - Quest Diagnostics/American College of Ob/Gyn/ Jeff City Medical Group/Signature Medical
Group/Missouri Ambulatory Surgery Center Assn.
Will Marrs - Mercy Health Systems
Alex Tuttle - Hannibal Regional Hospital/University Health Kansas City, Missouri/Golden Valley Memorial Hospital
Olivia Wilson - University of Missouri Health Care
Henrio Thelemaque - Missouri Pharmacy Association
Brian Bernskoetter - Missouri Academy of Family Physicians
Arnie C. AC Dienoff
Meagan Howerton - Mosaic Life Care/Missouri Ambulance Association
WITNESSES AGAINST:
Hampton Williams - Missouri Insurance Coalition
David Willis - Missouri Health Plan Association
Shannon Cooper - America's Health Insurance Plans/Blue Cross Blue Shield of Kansas City