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Senate Passes HMO Regulation

By: ELISA CROUCH
State Capital Bureau

April 03, 1995

JEFFERSON CITY _ HMO members would have stronger assurances they could keep their family doctors under a measure given first-round approval by the Missouri Senate Monday (April 3).

The bill would require HMO plans to allow all medical providers (doctors, hospitals, etc.) in their geographic area to apply, if the HMO usually contracts with that type of provider.

Plans also would have to tell applicants why they are rejected.

In addition, the bill would require that HMOs explain benefits packages to perspective patients in easily understood terms.

HMOs, or health maintenance organizations, are a growing method of providing health care coverage as alternative to traditional insurance.

Generally, an HMO will restrict coverage to only those medical providers admitted into the HMO who agree to charge at rates set by the HMO.

Segments of the medical community have complained that some HMOs arbitrarily refuse to accept medical providers, even if the providers agree to the HMO rates.

Under the Senate-approved bill, managed health care plans would have to be certified and undergo periodic reviews by the state. The Insurance Department director would set certification conditions for managed care plans.

"The objective is to try to restore some balance in the market of health care delivery," said the bill's co-sponsor, Sen. Franc Flotron, R-St. Louis County. "As the market has changed, you have these oligopolies that are huge players of health care."

"I'm concerned," said Sen. John Russell, R-Lebanon, "that we're trying to reduce health costs, yet we're trying to constrain those who are trying to reduce them by making it more difficult."

Once certified, the managed care plans would undergo periodic review and recertification. If the director determines that the plan no longer meets the applicable requirements for certification, then the certification would be terminated.

In earlier debate, the Senate rejected a proposal that would have prohibited HMOs from dropping physicians without cause.

The bill faces one more Senate vote before going to the House.