COMMITTEE ON LEGISLATIVE RESEARCH
OVERSIGHT DIVISION
FISCAL NOTE
L.R. No.:1332H.05P Bill No.:Perfected HCS for HB Nos. 700 & 445 Subject:Health Care; Employees - Employers; Political Subdivisions; Health, Public Type:Original Date:March 21, 2023Bill Summary:This proposal creates provisions relating to refusal of medical procedures or
treatment.
FISCAL SUMMARY
ESTIMATED NET EFFECT ON GENERAL REVENUE FUNDFUND AFFECTEDFY 2024FY 2025FY 2026Total Estimated Net
Effect on General
Revenue $0$0$0
ESTIMATED NET EFFECT ON OTHER STATE FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Total Estimated Net
Effect on Other State
Funds $0$0$0
Numbers within parentheses: () indicate costs or losses. L.R. No. 1332H.05P
Bill No. Perfected HCS for HB Nos. 700 & 445
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ESTIMATED NET EFFECT ON FEDERAL FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Total Estimated Net
Effect on All Federal
Funds $0$0$0
ESTIMATED NET EFFECT ON FULL TIME EQUIVALENT (FTE)FUND AFFECTEDFY 2024FY 2025FY 2026Total Estimated Net
Effect on FTE 000
☐ Estimated Net Effect (expenditures or reduced revenues) expected to exceed $250,000 in any
of the three fiscal years after implementation of the act or at full implementation of the act.
☐ Estimated Net Effect (savings or increased revenues) expected to exceed $250,000 in any of
the three fiscal years after implementation of the act or at full implementation of the act.
ESTIMATED NET EFFECT ON LOCAL FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Local Government$0 or (Unknown)$0 or (Unknown)$0 or (Unknown) L.R. No. 1332H.05P
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FISCAL ANALYSIS
ASSUMPTION
Officials from the Department of Mental Health (DMH) assume this proposal adds
Sections 191.230 and 292.648 prohibiting a public body and employers in the state from
requiring individuals to receive a COVID-19 vaccination. It also prohibits medical treatment
as a condition of employment if the individual has religious or medical reason for exemption.
CMS expects all facilities’ staff to have received vaccination unless exempted as required by
law. Facility staff vaccination rates under 100% constitute non-compliance (CMS guidance
QSO-23-02-ALL). CMS rule currently allows for exemption in certain circumstances.
However, in the event that CMS removes exemption option for vaccination, this requirement
may put some DMH facilities and agencies at odds with federal requirements for licensure
and/or CMS funding. This proposal will have an unknown impact on DMH.
Oversight notes the DMH assumes the proposal could affect their funding because the
facility staff vaccination rates under 100% constitute non-compliance (CMS guidance QSO-
23-02-ALL).
Oversight received additional information from the DMH, via e-mail, and confirmed that
officials from the DMH believe this bill, considering the allowable exclusions, could still
have a potential impact on the funding reaching beyond $250,000, due to the loss of CMS
funding.
Oversight notes the proposal, specifically Section 191.230.4 (1) thru (6), allows for
exclusions of certain organizations certified by the Centers for Medicare and Medicaid
Services, and employees of state department and agency who are part of an onsite survey
team performing federal oversight of certified providers and suppliers for the Centers for
Medicare and Medicaid Services.
Oversight assumes both Sections, 191.230 and 292.648, provide for exceptions which are
applicable for facilities defined in Section 199.170. The exceptions would effectively include the
Department of Mental Health facilities. Therefore, Oversight will reflect a zero impact in the
fiscal note for DMH.
Oversight notes the officials from the Department of Social Services (DSS) assume the
proposal, specifically Section(s) 191.230 and 292.648, will have no fiscal impact on their
organization. Oversight does not have any information to the contrary. Therefore, Oversight will
reflect a zero impact in the fiscal note for DSS.
Officials from the Department of Corrections (DOC) assume that section 292.648.1(2) is
referring to any drug in the treatment of COVID 19, which would be no impact. If this is truly
defined as “any drug”, then the DOC could see a significant fiscal impact. L.R. No. 1332H.05P
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Officials from the DOC assume the proposal will have no fiscal impact on their organization.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect a zero
impact in the fiscal note for DOC for this provision.
Officials from the Missouri Department of Transportation (MoDOT) assume the proposal
will have no fiscal impact on their organization. Oversight does not have any information to the
contrary. Therefore, Oversight will reflect a zero impact in the fiscal note for MoDOT.
Officials from the Department of Public Safety – Highway Patrol (DPS-MSHP) defer to the
MoDOT for the potential fiscal impact of this proposal.
Officials from the Department of Commerce and Insurance, the Department of Economic
Development, the Department of Elementary and Secondary Education, the Department of
Higher Education and Workforce Development, the Department of Health and Senior
Services Department of Mental Health, the Department of Natural Resources, the
Department of Labor and Industrial Relations, the Department of Revenue the
Department of Public Safety (Office of the Director Capitol Police, Alcohol & Tobacco
Control, Fire Safety, Gaming Commission, Missouri National Guard, State Emergency
Management Agency and Veterans Commission), the Department of Social Services, the
Office of the Governor, the Joint Committee on Administrative Rules, the Joint Committee
on Public Employee Retirement, the Missouri Lottery Commission the Missouri
Consolidated Health Care Plan, the Department of Agriculture, the Missouri Department
of Conservation, the Missouri Ethics Commission, the Missouri House of Representatives,
the Department of Transportation, the Office of Prosecution Services, the Office of
Administration (Administrative Hearing Commission and Budget and Planning), the Office
of the State Courts Administrator the Office of the State Auditor the Missouri Senate, the
Office of the Secretary of State, the Office of the State Public Defender, the Office of the
State Treasurer and the State Tax Commission each assume the proposal will have no fiscal
impact on their respective organizations.
Officials from the University of Central Missouri
impact on their organization. Oversight does not have any information to the contrary.
Therefore, Oversight will reflect a zero impact in the fiscal note for UCM.
In response to the similar proposal, HB 1686 – 2022, officials from the Northwest Missouri
State University note the University was unable to determine fiscal impact at this time;
however, it would be contingent upon Federal mandates affecting grants and government grant
fund recipients.
Oversight notes the proposal, specifically 191.230 3 (1) and (2), allows for exclusions of certain
school organizations and states the proposal shall not apply to public colleges and universities
where a COVID-19 vaccination is required for employees or select student participants in order L.R. No. 1332H.05P
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for the colleges or universities to receive federal funds. Therefore, Oversight will reflect zero for
all college and university organizations in the fiscal note.
Officials from the City of Kansas City, and the City of Springfieldassume the proposal
will have no fiscal impact on their respective organizations. Oversight does not have any
information to the contrary. Therefore, Oversight will reflect a zero impact in the fiscal note for
these cities.
FISCAL IMPACT – State GovernmentFY 2024
(10 Mo.)
FY 2025FY 2026$0$0$0FISCAL IMPACT – Local GovernmentFY 2024
(10 Mo.)
FY 2025FY 2026$0$0$0
FISCAL IMPACT – Small Business
A fiscal impact to small businesses would be potentially expected as a result of this proposal.
FISCAL DESCRIPTION
No public body, political subdivision, public school district, state department or agency, public
official, peace officer, or person appointed by the Governor acting in an official capacity shall:
(1) Require any person to receive a COVID-19 vaccination;
(2) Condition any personal right or public service on a COVID-19 vaccination; or
(3) Impose any fine, tax, or criminal or civil penalty on a COVID19 vaccination.
The proposal contains exclusions for specified schools, health care facilities, and individuals
from the provisions regarding COVID-19 vaccinations.
Additionally, an employee shall be exempt from an employer's requirement to receive medical
treatment as a condition of employment and shall not be subject to adverse employment action
for declining to receive the treatment if: L.R. No. 1332H.05P
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(1) The employee holds a sincerely held religious belief that forbids the employee from receiving
the treatment and the reasonable accommodation of such belief would not pose an undue
hardship on the employer;
(2) The employee has received a written recommendation, based upon the employee’s unique
and individual situation, that a treatment is likely to be harmful to the employee or is not in the
best interest of the employee or is harmful for the employee according to a licensed physician
based on the employee's medical situation; and
(3) The employee submits a written request for the exemption to the employer.
Additionally, an student shall be exempt from a public college or university’s requirement to
receive medical treatment as a condition of participation in any project or activity sponsored by
the college or university and shall not be subject to adverse action by the college or university for
declining to receive the treatment if:
(1) The student holds a sincerely held religious belief that forbids the student from receiving the
treatment and the reasonable accommodation of such belief would not pose an undue hardship on
the college or university;
(2) The student has received a written recommendation, based upon the student’s unique and
individual situation, that a treatment is likely to be harmful to the student or is not in the best
interest of the student or is harmful for the student according to a licensed physician based on the
student’s medical situation; and
(3) The student submits a written request for the exemption to the college or university.
This legislation is not federally mandated, would not duplicate any other program and would not
require additional capital improvements or rental space.
SOURCES OF INFORMATION
Department of Commerce and Insurance
Department of Economic Development
Department of Elementary and Secondary Education
Department of Higher Education and Workforce Development
Department of Health and Senior Services
Department of Mental Health
Department of Natural Resources
Department of Corrections
Department of Labor and Industrial Relations
Department of Revenue
Department of Public Safety
Department of Social Services
Office of the Governor L.R. No. 1332H.05P
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Joint Committee on Public Employee Retirement
Joint Committee on Administrative Rules
Missouri Lottery Commission
Legislative Research
Oversight Division
Missouri Consolidated Health Care Plan
Missouri Department of Agriculture
Missouri Department of Conservation
Missouri Ethics Commission
Missouri House of Representatives
Office of the Lieutenant Governor
Missouri Department of Transportation
Missouri State Employee's Retirement System
MoDOT & Patrol Employees’ Retirement System
Missouri Office of Prosecution Services
Office of Administration
Office of the State Courts Administrator
Office of the State Auditor
Missouri Senate
Office of the Secretary of State
Office of the State Public Defender
Office of the State Treasurer
City of O’Fallon
City of Springfield
University of Central Missouri
Julie MorffRoss StropeDirectorAssistant DirectorMarch 21, 2023March 21, 2023