§ 376.1060 — Health care services — definitions — limitations on third-party access, requirements — inapplicability, when.

Missouri § 376.1060

• Jurisdiction: Missouri
• Title XXIV: BUSINESS AND FINANCIAL INSTITUTIONS
• Ch. 376: Life, Health and Accident Insurance

Text

1.  As used in this section, the following terms shall mean:

(1) "Contracting entity" , any person or entity, including a health carrier, that is engaged in the act of contracting with providers for the delivery of health care services;

(2) "Health care service" , the same meaning given to the term in section 376.1350 ;

(3) "Health carrier" , the same meaning given to the term in section 376.1350 .  The term "health carrier" shall also include any entity described in subdivision (4) of section 354.700 ;

(4) "Participating provider" , a provider who, under a contract with a contracting entity, has agreed to provide health care services with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the contracting entity;

(5) "Provider" , any person licensed under section 332.071 ;

(6) "Provider network contract" , a contract between a contracting entity and a provider that specifies the rights and responsibilities of the contracting entity and provides for the delivery and payment of health care services;

(7) "Third party" , a person or entity that enters into a contract with a contracting entity or with another third party to gain access to the health care services or contractual discounts of a provider network contract.  "Third party" does not include an employer or other group for whom the health carrier or contracting entity provides administrative services.

2.  A contracting entity shall only grant a third party access to a participating provider's health care services or contractual discounts provided in accordance with a contract between a participating provider and a contracting entity and only if:

(1)  The contract specifically states that the contracting entity may enter into an agreement with a third party allowing the third party to obtain the contracting entity's rights and responsibilities as if the third party were the contracting entity, and the contract allows the provider to choose not to participate in third-party access at the time the contract is entered into or renewed or when there are material modifications to the contract.  The third-party access provision of any provider network contract shall also specifically state that the contract grants third-party access to the provider's health care services and that the provider has the right to choose not to participate in third-party access to the contract or to enter into a contract directly with the third party.  A provider's decision not to participate in third-party access shall not permit the contracting entity to cancel or otherwise end a contractual relationship with the provider.  When initially contracting with a provider, a contracting entity shall accept a qualified provider even if the provider chooses not to participate in the third-party access provision;

(2)  The third party accessing the contract agrees to comply with all of the contract's terms;

(3)  The contracting entity identifies, in writing or electronic form to the provider, all third parties in existence as of the date the contract is entered into or renewed;

(4)  The contracting entity identifies all third parties in existence in a list on its internet website that is updated at least once every ninety days;

(5)  The contracting entity notifies providers that a new third party is accessing a provider network contract at least thirty days in advance of the relationship taking effect;

(6)  The contracting entity notifies the third party of the termination of a provider network contract no later than thirty days from the termination date with the contracting entity;

(7)  A third party's right to a provider's discounted rate ceases as of the termination date of the provider network contract;

(8)  The provider is not already a participating provider of the third party; and

(9)  The contracting entity makes available a copy of the provider network contract relied on in the adjudication of a claim to a participating provider within thirty days of a request from the provider.

3.  No provider shall be bound by or required to perform health care services under a provider network contract that has been granted to a third party in violation of the provisions of this section.

4.  A contracting entity that sells, assigns, or otherwise grants a third party access to a participating provider's health care services shall maintain an internet website or a toll-free telephone number through which the participating provider may obtain information which identifies the third party to be used to reimburse the participating provider for the covered health care services.

5.  A contracting entity that sells, assigns, or otherwise grants a third party access to a participating provider's health care services shall ensure that an explanation of benefits or remittance advice furnished to the participating provider that delivers health care services for the third party identifies the contractual source of any applicable discount.

6.  (1)  The provisions of this section shall not apply if access to a provider network contract is granted to any entity operating in accordance with the same brand licensee program as the contracting entity or to any entity that is an affiliate of the contracting entity.  A list of the contracting entity's affiliates shall be made available to a provider on the contracting entity's website.

(2)  The provisions of this section shall not apply to a provider network contract for health care services provided to beneficiaries of any state-sponsored health insurance programs including, but not limited to, MO HealthNet and the state children's health insurance program authorized in sections 208.631 to 208.658 .

Legislative History

(L. 2014 S.B. 884, A.L. 2023 S.B. 45 & 90)