HB 3088

                                 SECOND REGULAR SESSION
                    HOUSE BILL NO. 3088
                           103RD GENERAL ASSEMBLY
                            INTRODUCED BY REPRESENTATIVE DIEHL.
 6664H.01I  JOSEPH ENGLER, Chief Clerk
                                            AN ACT
 To amend chapter 376, RSMo, by adding thereto one new section relating to conduct
      affecting 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 provision in a provider network contract that
3 restricts the ability of a general contracting entity to encourage an enrollee to obtain a
4 health care service from a competitor of the provider, including offering incentives to
5 encourage enrollees to use specific providers;
6(2) "Anti-tiering clause", a provision in a provider network contract that:
7(a) Restricts the ability of a general contracting entity to introduce or modify a
8 tiered network plan or assign providers into tiers; or
9(b) Requires a general contracting entity to place all members of a provider in
10 the same tier of a tiered network plan;
11(3) "Covered individual", an individual who is covered under a health benefit
12 plan;
13(4) "Enrollee", 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 provision in a provider network contract that restricts the
16 ability of a general contracting entity or provider to disclose:
 EXPLANATION — 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.
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17(a) Price or quality information, including the allowed amount, negotiated rates
18 or discounts, fees for services, or other claim-related financial obligations included in
19 the contract, to a governmental entity as authorized by law or its contractors or agents,
20 an enrollee, a treating provider of an enrollee, a plan sponsor, or potential eligible
21 enrollees and plan sponsors; or
22(b) Out-of-pocket costs to an enrollee;
23(7) "General contracting entity", a person who enters into a direct contract with
24 a provider for the delivery of health care services to covered individuals regardless of
25 whether the person, in the ordinary course of business, establishes a provider network
26 for access by another party. The term "general contracting entity" shall not include a
27 health care provider or facility unless the provider or facility is entering into the
28 contract in the provider'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-favored-nation clause", a provision in a provider network contract
34 that:
35(a) Prohibits or grants an option to prohibit:
36a. A provider from contracting with another general contracting entity to
37 provide health care services at a lower rate; or
38b. A general contracting entity from contracting with another provider to
39 provide health care services at a higher rate;
40(b) Requires or grants an option to require:
41a. A provider to accept a lower rate for health care services if the provider
42 agrees with another general contracting entity to accept a lower rate for the services; or
43b. A general contracting entity to pay a higher rate for health care services if the
44 entity agrees with another provider to pay a higher rate for the services;
45(c) Requires or grants an option to require termination or renegotiation of an
46 existing provider network contract if:
47a. A provider agrees with another general contracting entity to accept a lower
48 rate for providing health care services; or
49b. A general contracting entity agrees with a provider to pay a higher rate for
50 health care services; or
51(d) Requires:
52a. A provider to disclose the provider's contractual reimbursement rates with
53 other general contracting entities; or
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54b. A general contracting entity to disclose the general contracting entity's
55 contractual reimbursement rates with other providers;
56(11) "Provider", the same meaning given to the term in section 376.1350;
57(12) "Provider network contract", a contract between a general contracting
58 entity and a provider for the delivery of, and payment for, health care services to a
59 covered individual.
602. A provider shall not:
61(1) Offer to a general contracting entity a written provider network contract
62 that includes an anti-steering, anti-tiering, gag, or most-favored-nation clause;
63(2) Enter into a provider network contract that includes an anti-steering, anti-
64 tiering, gag, or most-favored-nation clause; or
65(3) Amend or renew an existing provider network contract previously entered
66 into with a general contracting entity so that the contract as amended or renewed adds
67 or retains an anti-steering, anti-tiering, gag, or most-favored-nation clause.
683. Any provision in a provider network contract that is an anti-steering, anti-
69 tiering, gag, or most-favored-nation clause is void and unenforceable. The remaining
70 provisions in the provider network contract shall remain in effect and are enforceable.
714. A health benefit plan issuer that encourages an enrollee to obtain a health care
72 service from a particular provider, including offering incentives to encourage enrollees
73 to use specific providers, or that introduces or modifies a tiered network plan or assigns
74 providers into tiers has a fiduciary duty to the enrollee or policyholder to engage in that
75 conduct only for the primary benefit of the enrollee or policyholder.
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