Summary of the Perfected Version of the Bill
HCS#2 HB 609 -- SHOW-ME HEALTH INSURANCE EXCHANGE ACT (Molendorp)
COMMITTEE OF ORIGIN: Committee on Health Insurance
This substitute establishes the Show-Me Health Insurance Exchange
Act to comply with the requirements of the federal Patient
Protection and Affordable Care Act (PPACA) of 2010 to facilitate
the purchase and sale of qualified health plans and qualified
dental plans in the individual market and to provide for the
establishment of a small business health option program (SHOP
exchange) to assist qualified small employers enrolling their
employees in qualified health plans and dental plans offered in
the small group market. The intent of the exchange is to reduce
the number of uninsured; provide a transparent marketplace;
increase competition in the health insurance market; increase
portability of health insurance coverage; reduce health care
costs; provide consumer education; and assist individuals with
access to programs, tax credits, and cost-sharing reductions.
The exchange must conduct extensive consumer outreach to increase
the awareness and effectiveness of the exchange.
SHOW-ME HEALTH INSURANCE EXCHANGE
The exchange is established as a quasi-public governmental agency
under the direction of the 17-member Show-Me Health Insurance
Exchange Board of Trustees including two members of the House of
Representatives, one from the majority party and one from the
minority party, appointed by the Speaker; two members of the
Senate, one from the majority party and one from the minority
party, appointed by the President Pro Tem; the directors of the
departments of Mental Health, Health and Senior Services, Social
Services, and Insurance, Financial Institutions and Professional
Registration; and nine members to be appointed by the Governor
with the advice and consent of the Senate to include a licensed
health insurance producer, a large market-share licensed health
insurer, a small market-share licensed health insurer, a public
health consumer advocate for individuals who purchase coverage
through the exchange, a small employer representative, a large
employer representative, an individual with expertise in
administering and negotiating health plan contracts on behalf of
employees, and two at-large members. The duties and powers of
the board are specified including the hiring of an executive
director and preparing annual audits and reports of the financial
condition of the exchange. The provisions regarding the Health
Insurance Advisory Committee are repealed and its duties assigned
to the board.
DUTIES OF THE EXCHANGE
The exchange must:
(1) Facilitate the purchase and sale of qualified health plans
and qualified dental plans;
(2) Provide for the establishment of a unified exchange to
assist both individuals who purchase coverage in the individual
market and qualified small employers in this state in
facilitating the enrollment of their employees in qualified
health plans and dental plans in the SHOP exchange;
(3) Implement procedures to certify, re-certify, or de-certify a
health plan as a qualified health plan or dental plan consistent
with the PPACA guidelines;
(4) Operate a toll-free hotline;
(5) Provide for an initial enrollment period, annual open
enrollment periods, and special enrollment periods in accordance
with the PPACA, as well as on a quarterly basis;
(6) Maintain a web site that provides comparative data on
qualified health plans and dental plans available through the
exchange;
(7) Assign a rating, in accordance with PPACA guidelines
regarding quality and price, for each qualified health plan and
dental plan offered through the exchange and determine the level
of coverage provided by each qualified health plan and dental
plan in accordance with federal regulations regarding actuarial
guidelines for standard populations;
(8) Use a standardized format for presenting health options in
the exchange, including the use of the PPACA outline of coverage;
(9) Inform individuals of eligibility requirements for the
federal Medicaid Program, the Children's Health Insurance
Program, or any other state public program; screen applications
to determine eligibility for programs; and enroll any individual
who is eligible;
(10) Establish and make available by electronic means a
calculator to determine the actual cost of coverage, any
cost-sharing reduction, and a consumer tool to calculate
out-of-pocket costs of coverage;
(11) Develop a standardized application for a qualified
individual or small employer to use to apply for health benefits
through the exchange. Each health insurer or health plan that
offers a qualified health plan through the exchange must use this
application;
(12) Grant, subject to PPACA exemption criteria, an individual a
certification attesting that the individual is exempt from the
PPACA individual responsibility requirement or from the penalty
to obtain health care coverage if affordable coverage cannot be
obtained through the exchange or the individual meets additional
exemption requirements;
(l3) Transfer specified information to the United States
Secretary of the Treasury regarding the individuals exempted from
obtaining health care coverage; employed individuals eligible for
the federal premium tax credit because the employer didn't
provide minimum essential coverage, affordable coverage, or the
required minimum actuarial value; and individuals with changes to
their employer-sponsored coverage;
(14) Notify an employer when an employee becomes eligible for
the federal premium tax credit;
(15) Perform the required duties of the PPACA related to
determining eligibility for premium tax credits, reduced
cost-sharing, or individual responsibility requirement
exemptions;
(16) Establish a navigator program to award grants to selected
entities to carry out the functions of a navigator. Grants must
be made from the exchange's operational funds, and federal funds
received by the state to establish the exchange cannot be used
for grants;
(17) Establish a fair and impartial health insurance producer
referral network to assist with enrollment. The producers in the
network must be compensated in an appropriate manner to the
health insurance producer industry;
(18) Apply any qualified employee free-choice voucher to the
monthly premium collected from the offering employer;
(19) Consult with health insurance industry stakeholders
regarding the activities of the exchange;
(20) Conduct appropriate accounting activities and submit an
annual report of the activities to the United States Secretary of
the Treasury, Governor, and General Assembly and fully cooperate
with federal investigations;
(21) Develop guidelines for qualified health plans and dental
plans to mitigate the occurrence of adverse selection within the
exchange; and
(22) Review the rate of premium growth within and outside of the
exchange and consider the information in developing
recommendations on whether to continue limiting qualified
employer status to small employers.
CONTRACTING AUTHORITY
The exchange is allowed to enter into a contract or a memorandum
of understanding with an eligible entity or the Missouri
Consolidated Health Care Plan (MCHCP) for any or all of its
administrative functions. If the exchange contracts with MO
HealthNet, MO HealthNet beneficiaries may select any plan offered
by a health insurer contracted with MO HealthNet. MO HealthNet
beneficiary plans must be maintained in a separate and distinct
risk pool within the exchange from all other qualified health
plans and qualified dental plans. An insurer participating in
the exchange cannot be required to offer a health plan to MO
HealthNet beneficiaries. A state employee may select a qualified
health plan or dental plan through the exchange. The exchange
may contract with the Department of Insurance, Financial
Institutions and Professional Registration for the certification,
re-certification, and de-certification of health plans and dental
plans as qualified health plans and dental plans. An eligible
entity that contracts with the exchange cannot offer a qualified
health or dental plan through the exchange. The exchange may
enter into information-sharing agreements, subject to state and
federal confidentiality laws, with state and federal agencies and
other state exchanges to carry out its responsibilities.
HEALTH AND DENTAL PLAN CERTIFICATION
The exchange must certify a health plan as a qualified health
plan or qualified dental plan if that plan has met federal
requirements. The exchange cannot exclude a health plan because
it is a fee-for-service plan; through the imposition of premium
price controls by the exchange; on the basis that the health plan
provides death-preventing treatments that are inappropriate or
too costly; or on the basis that the health plan is offered by a
health issuer that is not contracted with MO HealthNet. In order
to have a health or dental plan certified by the exchange, a
health insurer must provide premium increase justification;
disclose the health plan specifics in plain language; provide
consumer education; provide notification of health plan changes;
and provide timely updates on cost, changes, and provider network
changes to consumers.
The exchange cannot exempt a health insurer seeking certification
of a qualified health or dental plan from state licensure or
solvency requirements. An insurer must be licensed to offer
dental coverage but does not need to be licensed to offer other
health benefits. The exchange cannot make available a health or
dental plan that is not a qualified health plan or dental plan.
A dental plan must offer at a minimum the PPACA-required
essential pediatric dental benefits as well as any benefits as
the exchange or the United States Secretary of the Treasury may
specify by regulation. An insurer can jointly offer a
comprehensive plan through the exchange that includes health and
dental plans.
In order for a plan to be certified, the Director of the
Department of Insurance, Financial Institutions and Professional
Registration must determine if it meets all licensure and
solvency requirements; and the exchange must determine if it
meets all other PPACA and exchange requirements. The exchange
must establish a health insurance issuer appeals process for a
health issuer to appeal a decertification decision or the denial
of certification as a qualified health plan or dental plan.
IMPLEMENTATION OF HEALTH AND DENTAL PLANS
Beginning January 1, 2014, the exchange must be operational to
make qualified health and qualified dental plans available to
qualified individuals and employers but may disclose price and
coverage information prior to that date. An individual cannot be
charged a fee or penalty for terminating coverage and enrolling
in another health plan if he or she has become newly eligible for
the coverage or because it has become more affordable under
federal standards. A qualified employer in the small market
group may make its employees eligible for one or more qualified
health plans at a specified level of coverage so that any of its
employees may enroll in a qualified health plan or dental plan
offered through the SHOP exchange at the specified coverage
level. The exchange can encourage health insurers participating
in the exchange to include a personal health record component in
the qualified health plan benefits.
EXCHANGE FUNDING
Federal funds must be provided under federal law for the direct
costs related to the development and operation of the exchange
through 2014. By January 1, 2015, the exchange must be
financially self-sustained through health insurer fees and
assessments. The board must submit an annual budget to the
Speaker of the House of Representatives and the President Pro Tem
of the Senate until 2015. The exchange must charge assessments
or user fees to health insurers, regardless of exchange
participation, for each policyholder of an individual health
insurance policy issued in this state and for each employee
covered under a small group policy issued in the state to fund
the operations of the exchange. The assessments or fees must be
limited to the minimum amount necessary to pay for the
administration and capital costs and expenses that have been
approved in the annual budget process, considering other
available funding sources. Any unexpended exchange funds must be
used to further exchange operations or be returned to health
insurers and health plans as a credit for future imposed
assessments or fees. Any unexpended funds at the end of the
biennium cannot revert to the credit of the General Revenue Fund.
The exchange must publish specified information regarding its
fees and costs on a web site. Taxes, fees, or assessments used
to finance the exchange must be considered a state tax and,
therefore, be excluded from being considered an administrative
cost for a health plan for the purpose of calculating medical
loss ratios or rebates as allowed by federal regulation.
GENERAL PROVISIONS
The provisions of the substitute cannot prohibit a qualified
individual or employer from purchasing any health or dental plan
outside the exchange. Certain supplemental insurance policies
are exempt from the provisions of the substitute.
The provisions of the act cannot be construed to preempt or
supersede the authority of the Director of the Department of
Insurance, Financial Institutions and Professional Registration
to regulate insurance businesses within this state.
The provisions of the substitute will become null and void and be
unenforceable in this state as of the date the PPACA in its
entirety or Section 1311 of the act is declared unconstitutional
or otherwise invalid by the United States Supreme Court or is
repealed by the United States Congress.
FISCAL NOTE: No impact on state funds in FY 2012, FY 2013, and
FY 2014.
Copyright (c) Missouri House of Representatives
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Missouri House of Representatives
96th General Assembly, 1st Regular Session
Last Updated August 9, 2011 at 1:23 pm