MISSOURI

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The Missouri SBL became effective January 1, 2022. Missouri Revised Statutes, Section 376.690. The relevant provisions of the Missouri law:

• The carrier is required to pay “reasonable” reimbursement within 45 days.
• If the medical provider objects, they have 60 days to negotiate.
• There is an arbitration process, which must be initiated within 120 days of the end of the negotiation period.
• The process applies to emergency treatment and does not include inadvertent OON treatment.
• Claims can be consolidated.
• It is not baseball-style arbitration. The arbitrator can choose an amount between 120% of Medicare and the 70th percentile of an objective value for UCR.
• Several factors can be considered, including standard measures of UCR.

According to CMS,

Missouri does not have an applicable All-Payer Model Agreement that would determine the [OON] rate. Based on the survey response and CMS communications with Missouri Department of Insurance staff, CMS understands that Section 376.690, Missouri Revised Statute (RSMo), is a specified state law that will apply for purposes of determining the [OON] rate with respect to unanticipated out-of-network care furnished to individuals with coverage from health carriers in Missouri by [OON] health care professionals at an [INN] facility.4 The [Federal IDR] process under section 2799A-1(c) of the PHS Act and 45 CFR 149.510 will apply for purposes of determining the [OON] rate with respect to any items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Missouri by nonparticipating providers and nonparticipating emergency facilities to which Section 376.690 RSMo does not apply. The [Federal IDR] process under section 2799A-2(b) of the PHS Act and 45 CFR 149.520 will apply for purposes of determining the [OON] rate with respect to services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Missouri by nonparticipating providers of air ambulance services. CMS will enforce the outcome of the [Federal IDR] process for cases in Missouri.

Letter from CMS to Governor of Missouri, dated December 23, 2021.