Effective 28 Aug 2016

376.465. Missouri health insurance rate transparency act — definitions — rate filing requirements, procedure — rulemaking authority. — 1. This section shall be known and may be cited as the "Missouri Health Insurance Rate Transparency Act".

2. It is the intent of the Missouri general assembly that the review of health insurance rates as specified in this section is consistent with the general powers of the department as outlined under section 374.010.

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

(1) "Director", the director of the department of commerce and insurance, or his or her designee;

(2) "Excepted health benefit plan", a health benefit plan providing the following coverage or any combination thereof:

(a) Coverage only for accident insurance, including accidental death and dismemberment insurance;

(b) Coverage only for disability income insurance;

(c) Credit-only insurance;

(d) Short-term medical insurance of less than twelve months( duration; or

(e) If provided under a separate policy, certificate, or contract of insurance, any of the following:

a. Dental or vision benefits;

b. Coverage only for a specified disease or illness; or

c. Hospital indemnity or other fixed indemnity insurance;

(3) "Grandfathered health benefit plan", a health benefit plan in the small group market that was issued, or a health benefit plan in the individual market that was purchased, on or before March 23, 2010;

(4) "Health benefit plan", the same meaning given to such term under section 376.1350; however, for purposes of this section, the term shall exclude plans sold in the large group market, as that term is defined under section 376.450, and shall exclude long-term care and Medicare supplement plans;

(5) "Health carrier", the same meaning given to such term under section 376.1350;

(6) "Individual market", the market for health insurance coverage offered directly to individuals and their dependents and not in connection with a group health benefit plan;

(7) "Small group market", the health insurance market under which individuals obtain health insurance coverage, directly or through an arrangement on behalf of themselves and their dependents, through a group health plan maintained by a small employer, as defined under section 379.930.

4. No health carrier shall deliver, issue for delivery, continue, or renew any health benefit plan until rates have been filed with the director.

5. For excepted health benefit plans, such rates shall be filed, thirty days prior to use, for informational purposes only. Rates shall not be excessive, inadequate, or unfairly discriminatory.

6. For grandfathered health benefit plans, such rates shall be filed, thirty days prior to use, for informational purposes only.

7. (1) For health benefit plans that are not grandfathered health benefit plans or excepted health benefit plans, a health carrier may use rates on the earliest of:

(a) The date the director determines the rates are reasonable;

(b) The date the health carrier notifies the director of its intent to use rates that the director has deemed unreasonable; or

(c) Sixty days after the date of filing rates with the director.

(2) The director may notify the health carrier within sixty days of the date of filing rates with the director that the health carrier has failed to provide sufficient rate filing documentation to review the proposed rates. The health carrier may, as described in this section, provide additional information to support the rate filing.

8. For health benefit plans described under subsection 7 of this section, all proposed rates and rate filing documentation shall be submitted in the form and content prescribed by rule, which is consistent with the requirements of 45 CFR 154, and shall include review standards and criteria consistent with 45 CFR 154.

9. The director shall determine by rule when rates filed under this section shall be made publicly available. Rate filing documentation and other supporting information that is a trade secret or of a proprietary nature, and has been designated as such by the health carrier, shall not be considered a public record.

10. For rates filed for health benefit plans described under subsection 7 of this section, the director shall:

(1) Provide a means by which the public can submit written comments concerning proposed rate increases;

(2) Review proposed rates and rate filing documentation;

(3) Determine that a proposed rate is an unreasonable rate if the increase is an excessive rate, an inadequate rate, an unfairly discriminatory rate, or an unjustified rate, consistent with 45 CFR 154; and

(4) Within sixty days after submission, provide a written notice to the health carrier detailing whether the proposed rates are reasonable or unreasonable. For proposed rates deemed unreasonable, the written notice shall specify deficiencies and provide detailed reasons for the director's decision that the proposed rate is excessive, inadequate, unjustified, or unfairly discriminatory.

11. Within thirty days after receiving written notice of the director's determination that the proposed rates are unreasonable, as described under subsection 10 of this section, a health carrier may amend its rates, request reconsideration based upon additional information, or implement the proposed rates. The health carrier shall notify the director of its intention no later than thirty days after its receipt of the written notice of the determination of unreasonable rates.

12. If a health carrier implements a rate that the director has determined is unreasonable under subsection 10 of this section, the department shall make such determination public, in a form and manner determined by rule.

13. For health benefit plans described under subsection 7 of this section, the director shall publish final rates on the department's website no earlier than thirty days prior to the first day of the annual open enrollment period in the individual market for the applicable calendar year. The final rate is the rate that will be implemented by the health carrier on a specified date.

14. Time frames described under this section may be extended upon mutual agreement between the director and the health carrier.

15. The director may promulgate rules to promote health insurance rate transparency including, but not limited to, prescribing the form and content of the information required to be submitted and of the standards of review that are consistent with 45 CFR 154. Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly under chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2016, shall be invalid and void.

16. This section shall apply to health benefit plans that are delivered, issued for delivery, continued, or renewed on or after January 1, 2018. In order to ensure that health benefit plans comply with the provisions of this section, the director shall promulgate rules regarding the initial implementation of the provisions of this section. Such rules shall be effective no later than March 1, 2017, and, for health benefit plans described under subsection 7 of this section, shall include, but not be limited to, the form and content of the information required to be submitted and of the standards of review, consistent with 45 CFR 154.

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(L. 2016 S.B. 865 & 866)