COMMITTEE ON LEGISLATIVE RESEARCH
OVERSIGHT DIVISION
FISCAL NOTE
L.R. No.:0779S.09T Bill No.:Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB 157 Subject:Health Care; Health Care Professionals; Medical Procedures and Personnel;
Pharmacy; Nurses; Physicians; Drugs and Controlled Substances; Vital Statistics;
Agriculture; Professional Registration and Licensing; Social Workers; Mental
Health; Animals; Veterinarians; Physical Therapists; Nursing Homes and Long-
Term Care Facilities
Type:Original Date:June 15, 2023Bill Summary:This proposal modifies provisions relating to professions requiring licensure.
FISCAL SUMMARY
ESTIMATED NET EFFECT ON GENERAL REVENUE FUNDFUND AFFECTEDFY 2024FY 2025FY 2026General Revenue
Fund*
(Could exceed
$1,173,622)
(Could exceed
$2,146,403)
(Could exceed
$3,151,138)
Total Estimated Net
Effect on General
Revenue
(Could exceed
$1,173,622)
(Could exceed
$2,146,403)
(Could exceed
$3,151,138)
*The Health Professional Loan Incentive Program (§191.430 – §191.450) is subject to
appropriation (therefore reflected as “$0 or (Unknown)”) by the General Assembly. Along with
the loss of revenue on forgiven loans, unknown costs for the program are assumed to exceed
$250,000 annually (if appropriated).
*The medical residency grant program is subject to appropriation (§191.592). The fiscal impact
reflects the cost to fund twenty (20) new residency slots each year. The CCS removed the count
(in prior versions it was 20) requirement from the bill; however, DHSS and Oversight have
continued to use this estimate for fiscal note purposes. The actual fiscal impact could be
materially different. This proposal has an emergency clause.
Numbers within parentheses: () indicate costs or losses. L.R. No. 0779S.09T
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ESTIMATED NET EFFECT ON OTHER STATE FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026
Board of Registration
for the Healing Arts
$0 or
(Could be less than
$257,062)
$0 or
(Could be less than
$194,785)
$0 or
(Could be less than
$263,668)
Social Workers Fund$0 or (Unknown)$0 or (Unknown)$0 or (Unknown)
Health Professional
Loan Incentive Fund*$0$0$0
Nurse Loan Fund($66,000)($1,300,000)($66,000)Board of Nursing
Fund $56,120$1,211,515$57,465
Colleges and
Universities
$0 to
Unknown
$0 to
Unknown
$0 to
Unknown
Committee of
Professional
Counselors Fund
(0672)
$0 or
($3,000 - $6,000)
$0 or
($3,000 - $6,000)
$0 or
($3,000 - $6,000)
Tattoo, Body Piercing
& Branding Fund
(0883) $11,500$12,500$500
Agriculture Protection
Fund** ($57,875)($57,875)$0University of MO**($200,000)($200,000)$0Medical Residency
Grant Program***$0 to Unknown$0 to Unknown$0 to UnknownTotal Estimated Net
Effect on Other State
Funds
(Less than
$256,255) to
(Could exceed
$519,317)
(Less than
$333,860) to
(Could exceed
$604,020)
Less than
$8,535 to
(Could exceed
$279,728)
*Income/appropriations and costs of loans distributed net to $0 L.R. No. 0779S.09T
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**Oversight notes the revenue and costs have been shifted from January 1, 2024 to January 1,
2025 per the proposal’s new effective date. The fiscal note for SB 26 (2021) reflected a net
positive fiscal impact to the Agriculture Protection Fund and the University of Missouri. With
the delayed implementation, Oversight will assume the state and the University will no longer
realize that net positive fiscal impact in FY 2024 and half of FY 2025, which is reflected as a
negative impact in FY’s 2024 & 2025 above.
****General Revenue appropriations and program costs net to $0; Gifts, grants, bequests, etc.,
Unknown.
ESTIMATED NET EFFECT ON FEDERAL FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Federal Funds*Total Estimated Net
Effect on All Federal
Funds $0$0$0
*Revenues and Expenses Net to Zero.
ESTIMATED NET EFFECT ON FULL TIME EQUIVALENT (FTE)FUND AFFECTEDFY 2024FY 2025FY 2026Board of Registration
for the Healing ArtsUp to 3 FTEUp to 3 FTEUp to 3 FTE
Agriculture Protection
Fund* <1 FTE>0 FTE0 FTE
Total Estimated Net
Effect on FTEUp to 2 FTEUp to 3 FTEUp to 3 FTE
* Oversight notes the FTE costs have been shifted from January 1, 2024 (FY 2024) to January 1,
2025 per the proposal’s new effective date (savings of 1 FTE in FY 2024).
☒ 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$0$0 L.R. No. 0779S.09T
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FISCAL ANALYSIS
ASSUMPTION
§§191.430 - 191.831 & 335.203 - 335.205 – Health professional loan repayment program
In response to a similar proposal from this year, (Perfected HB 542), officials from the
Department of Health and Senior Services (DHSS) stated the proposed legislation was written
in conjunction with a New Decision Item that would be necessary for successful implementation
of the legislative changes. This proposed legislation will require General Revenue (GR) to run
the Health Professional Loan Repayment Program, including funds for loan awards, based off
regular appropriation process.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect fiscal
impact as provided by DHSS.
DHSS stated in its FY2024 Budget Preview that it will transition fully to a loan repayment
program funding professionals and practitioners with educational debt for the purpose of paying
all or a portion of their existing educational loans.
The Primary Care Resource Initiative of Missouri (PRIMO) program addresses the needs of
areas with a shortage of health professionals by assisting in the development and expansion of
community-based health systems that provide medical, dental, and behavioral health services. In
addition, the PRIMO program provides forgivable student loans to health care professional
students who agree to work within shortage areas.
The Missouri Professional and Practical Nursing Student Loan (NSL) and Loan Repayment
Program (LRP) provides forgivable student loans to nursing students in exchange for service in
designated underserved communities and/or facilities that are experiencing nursing shortages
upon completion of training. The program also provides loan repayment to practicing nurses in
exchange for service in communities and/or facilities that are experiencing nursing shortages.
The Health Professional Loan and Health Professional Student Loan Repayment Program
provides educational loan repayment to practicing primary care medical and dental health
professionals in exchange for service in areas with a shortage of primary care medical and dental
professionals.
FY 2024 Governor’s Recommended Program funding for PRIMO, NSL and Loan Repayment
Programs:
GR $700,000
Fed $425,000
Other $2,256,790
Total $3,381,790 L.R. No. 0779S.09T
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FY 2020 Actual appropriations $3,131,542
FY 2021 Actual appropriation $3,310,292
FY 2022 Actual appropriations $3,060,540
FY 2023 Actual appropriations $3,181,790
Oversight notes that forgiveness of student loans includes the forgiveness of any accrued
interest associated with those loans while the health professional meets the service obligations
determined by DHSS.
Oversight assumes appropriations to the Health Professional Loan Repayment Program and
loans/expenses incurred by the program will net to $0.
In response to a similar proposal from this year, (Perfected HB 542), officials from the
Department of Revenue (DOR) stated this proposal will create a Health Professional Loan
Repayment Program that would provide certain taxpayers a loan. The loans are to be used to pay
off a qualified taxpayer’s student loan debt. The loans offered under this program are eligible for
forgiveness if certain criteria are met.
The Department of Health and Senior Services is the administrator of this program and has the
authority to set criteria for receipt of the loans.
It should be noted that under current federal law IRC Section 108(f)(1)-(2), income from the
discharge/forgiveness of a student loan from December 31, 2020 to January 1, 2026 is not
taxable. However, after January 1, 2026, such income may potentially be taxable. At this time,
DOR cannot determine how many students may receive these loans, how much of these loans
will be distributed, or if any of the loans received will be discharged/forgiven or when and,
therefore, the DOR is unable to determine an impact from this portion of the proposal. Any loss
would be unknown and would be considered foregone revenue.
This does not have an administrative impact on DOR.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect no
fiscal impact for this agency for these sections.
In response to a similar proposal from this year, (Perfected HB 542), officials from the
University of Central Missouri (UCM) stated this proposal would have an indeterminate fiscal
impact on UCM.
Oversight notes, in response to the previous version of this proposal, UCM indicated the
proposal could potentially increase revenue if it leads to increased enrollment. Therefore,
Oversight will reflect a $0 to Unknown increase in revenues for Colleges and Universities for
fiscal note purposes. L.R. No. 0779S.09T
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In response to a similar proposal from this year, (Perfected HB 542), officials from the
University of Missouri Health Care System stated they had reviewed the proposed legislation
and has determined that as written it should not create expenses in excess of $100,000.
Oversight does not have any information to the contrary. Oversight assumes less than $100,000
in expenses to the University of Missouri Health Care is an amount that can be absorbed within
current funding levels and is not significant. Therefore, Oversight will reflect no fiscal impact for
the University of Missouri Health Care System.
In response to a similar proposal from this year, (Perfected HB 542), officials from the Office of
Administration and the St. Charles Community College each assumed the proposal would
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
agencies for these sections.
Oversight notes a standard monthly payment (at current rates) for $100,000 in student loans
would be approximately $1,150, or $13,800 annually. To reach the $250,000 annual threshold,
the program would only have to include 19 participants (19 x $13,800 = $262,200). Oversight
assumes the $250,000 threshold, subject to appropriation, could be met in any given year.
§191.592 – Graduate medical education grant program
In response to a similar proposal from this year (Perfected HCS for HB 1162), officials from the
Department of Health and Senior Services (DHSS) stated §191.592 of the proposed
legislation adds the requirement that the DHSS establish a graduate medical education grant
program to award grants to entities operating graduate medical education programs in Missouri.
The amount awarded will need to be sufficient to fund twenty (20) residency slots each fiscal
year beginning in FY 2024 through FY 2034. The individuals who have their residency funded,
even partially, will be required to work in Missouri for three years after completing residency
and if the individuals fail to do so, will be required to pay back the funds they received to the
entity operating the graduate medical education program who shall return the funds for deposit
into the Graduate Medical Education Grant Program fund.
Section 191.592 proposes the establishment of the “Graduate Medical Education Program Fund”;
however, no specific revenue is cited and the amount required to fund the minimum of twenty
residency slots is unknown. The average cost per student for the University of Missouri system is
$50,000 per year, however, the university system has three campuses and each have differing
costs and those costs are not for medical residents. The fiscal impact analysis includes a
minimum of $1,000,000 to $5,000,000 ($250,000 per student is the cost calculated from another
private program) per resident to cover the residency slots and the applicable expenses associated
with the graduate medical education entity operating the graduate medical program. Actual cost
will be dependent upon the number of residencies funded and the costs of the residency at the
specific institution.
DHSS would be responsible for promulgating all rules and regulations relating to the program L.R. No. 0779S.09T
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and administering the program, which would require creating and reviewing applications,
contracts, residency and employment verification forms, making awardee selections, monitoring
of entities awarded and monitoring those who receive funding for their residency to ensure all
requirements are being met.
To implement this program, the Office of Rural Health and Primary Care would need a minimum
of two (2) additional FTE: one (1) Senior Public Health Program Specialist and one (1) Public
Health Program Specialist with an average salary within the Division of Community and Public
Health (DCPH) of $63,999 and $52,016 (respectively) as of March 2023.
It is assumed that the Division of Administration can absorb the costs of this bill with current
resources. However, if the workload significantly increased or other legislation was enacted,
additional resources would be requested through the appropriation process.
Oversight notes provisions of this proposal (§191.592.2) provide that DHSS shall establish a
medical residency grant program to award grants to eligible entities for the purpose of
establishing and funding new general primary care and psychiatry medical residency positions
and continuing the funding of the new positions for the duration of the funded residency.
Perfected HCS for HB 1162 (with House Amendment #1) provides that the DHSS may
promulgate all necessary rules and regulations to create and operate the Medical Residency
Grant Program. The perfected version of this proposal no longer contains specific provisions
relating to grant recipients who fail to work in Missouri a required period of time after they
complete their residency or whether the entity operating the grant program is required to pay
back the funds relating to those individuals. However, the current provisions do provide that if a
grant-funded position is not filled, the Medical Residency Grant Program Fund is to receive
reimbursements from awarded eligible entities who were not able to fill the residency position(s).
Oversight assumes a $0 to unknown amount of funds may be returned to the Medical Residency
Grant Program Fund beginning in FY2025 for unfilled grant-funded positions. It is assumed the
amounts returned would be less than $250,000 annually (5 unfilled positions based on DHSS
assumptions of a cost of approximately $50,000 per position per year).
This program is subject to appropriations plus reimbursements from awarded eligible entities
who were not able to fill the residency positions and any gifts, contributions, grants or bequests
received. Funding for grant-funded residency positions is to be available for three years (3) for
residency positions in family medicine, general internal medicine and general pediatrics and for
four (4) years for residency positions in general obstetrics and gynecology, internal medicine-
pediatrics and general psychiatry is to be available.
This proposal does not contain provisions indicating the number of grant-funded residency
positions the DHSS shall award or the amount of those grants. However, DHSS shall expend
moneys in the fund (Medical Residency Grant Program Fund) to pay for necessary costs to
implement the provisions of the proposal and then to fund grant positions in the following order:
1) for residency positions of individuals in their fourth (4
th
) year of residency, 2) for residency L.R. No. 0779S.09T
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positions for individuals in their third (3
rd
) year of their residency, 3) for residency positions for
individuals in their second (2
nd
) year of residency and then 4) for residency positions for
individuals in their first (1
st
) year of residency. Finally, DHSS shall expend funds to establish
new grant-funded residency positions at awarded eligible institutions. Therefore, Oversight
assumes the DHSS continues to plan to fund 20 grant-funded residency positions as provided for
in their response.
Oversight notes the provisions of this proposal provide that no new grant-funded residency
positions are to be established after the tenth (10
th
) fiscal year in which the grants are awarded.
Any residency position funded before the 10
th
fiscal year will continue to be funded until
completion of the resident’s medical residency. The provisions of this proposal expire on January
1, 2038.
For fiscal note purposes, Oversight assumes a residency program is 3 years and that costs for
each new cohort of grants could exceed $1,000,000 annually ($50,000 estimate provided by
DHSS * 20 residencies = $1,000,000 annually). Therefore, grants for FY 2024 could exceed
$1,000,000; grants for FY2025 could exceed $2,000,000 (20 grants for 2
nd
year of FY2024
awards + 20 grants for FY2025 new awards) and so on. Oversight assumes FY2027 is the first
year the grant-funded program is fully implemented as some residency positions will be for four
(4) years.
Since entities (colleges and universities) operating graduate medical education programs and
receiving the medical residency grants are responsible for paying back grants for unfilled
residency positions, Oversight will present $0 to Unknown income transferred from colleges and
universities to the Medical Residency Grant Program Fund beginning in FY2025.
Oversight also assumes the DHSS would not need 2 FTE in the first year or two of the program,
but as the program continues could require additional FTE as the number of grant recipients
increases. Therefore, for fiscal note purposes, Oversight assumes FTE and related costs could
exceed the amounts provided by DHSS for the one (1) FTE Senior Public Health Program
Specialist. Oversight, however, assumes DHSS would not need additional rental space for 1 new
FTE for this single proposal. Oversight notes, depending on the number of proposals passed
during the legislative session that, cumulatively, DHSS may need additional rental space or
capital improvements as determined by the Office of Administration, Facilities Management,
Design and Construction.
In response to the previous version of this proposal, officials from the University of Missouri
System (University) stated the proposed legislation could have a positive impact for the
University of Missouri. The impact amount cannot be determined.
In response to a similar proposal from this year (Perfected HCS for HB 1162) from the
University of Central Missouri (UCM) assumed 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 UCM. L.R. No. 0779S.09T
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In response to a similar proposal from this year (Perfected HCS for HB 1162), officials from
Missouri State University and Missouri Western State University assumed the proposal
would have no fiscal impact on their respective organizations.
Oversight does not have any information to the contrary. However, Oversight will reflect an
unknown positive fiscal impact for colleges and universities as this proposal may encourage
students to enroll in graduate medical education programs.
This part of the proposal has an emergency clause.
§281.102 – Pesticide Certification and Training Extension
In response to a similar proposal from this year (HB 1022), officials from the Missouri
Department of Agriculture (MDA) assumed there could be increased costs since the original
program was enacted in SB 26 (2021) due to economic conditions; however, MDA assumes the
same fiscal impact from SB 26 (2021).
In response to a similar proposal from 2023 (HB 1022), officials from the University of
Missouri (UM) assumed this legislation will have a fiscal impact on the University of Missouri
System in an amount exceeding $100,000 in lost revenue due to delayed implementation of
statute permitting the University to charge a fee for the Private Pesticide Applicator Training.
This training is required to purchase restricted use pesticides and approximately 3,600 licenses
expire each year. Fee revenue is needed to sustain a high-quality training program at scale.
Oversight notes this proposal changes the effective date of the pesticide certification program
from January 1, 2024 to January 1, 2025; therefore, Oversight will shift the costs and revenue
reflected on the fiscal note for SB 26 (2021) from FY 2024 (six months) to FY 2025. Oversight
notes the fiscal impact after January 1, 2025 will assumed to be the same as was reflected on the
fiscal note for SB 26.
§324.520 – Definition of Tattoo
Officials from the Department of Commerce and Insurance (DCI) estimate the following:
Initial Licensure
$8,500 85 Practitioners with a licensure fee of $100 (85 x $100) in FY 24
$3,000 15 Establishments with a licensure fee of $200 (15 x $200) in FY 24
$ 300 3 Practitioners with a licensure fee of $100 in FY 25 based upon a 3% growth rate
$ 200 1 Establishment with a licensure fee of $200 in FY25
$ 300 3 Practitioners with a licensure fee of $100 in FY 26 based upon a 3% growth rate
$ 200 1 Establishment with a licensure fee of $200 in FY26
Renewal
$8,800 88 Practitioners with a renewal fee of $100 (88 x $100) in FY 25
$3,200 16 Establishments with a renewal fee of $200 (16 x $200) in FY 25 L.R. No. 0779S.09T
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The biennial renewal years for Tattoo licenses are FY 23 and FY 25. Licenses issued in FY 24
will renew in FY25.
FY 2024
85 Practitioners at $100 fee = $8,500
15 Establishments at $200 fee = $3,000
Total - $11,500
FY 2025
88 Practitioners Renewal at $100 fee = $8,800
16 Establishments Renewal at $200 fee = $3,200
3 (3% growth rate) Practitioners at $100 fee =$300
1 (3% growth rate) Establishment at $200 fee = $200
Total - $12,500
FY 2026
3 (3% growth rate) Practitioners at $100 fee =$300
1 (3% growth rate) Establishment at $200 fee = $200
Total - $500
In summary, DCI assumes a Revenue of $11,500 in FY 2024, $12,500 in FY 2025 and $500 in
FY 2026 as a result of this proposal.
Oversight has no information to the contrary, therefore, Oversight will reflect the estimated
revenue provided by the DCI to the Tattoo, Body Piercing & Branding Fund (0883).
§§331.020-331.060 & 340.200-340.222 – Animal Chiropractic
In response to a similar proposal from this year (SCS for SB 471), officials from the Missouri
Department of Agriculture (MDA) assumed 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 this agency.
Oversight notes that the MDA has stated the proposal would not have a direct fiscal impact on
their organization. Oversight does not have any information to the contrary. Therefore,
Oversight will reflect a zero impact on the fiscal note for these sections.
§§334.043 & 334.1600-334.1720 – Interstate Medical Licensure Compact
Officials from the Department of Commerce and Insurance (DCI) state that this legislative
language establishes Missouri as a member of the Interstate Medical Licensure Compact.
DCI assumes the following:
Licensee/Revenue L.R. No. 0779S.09T
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225 State of principal licensure applications (Board Estimate)
$75 License Fee
$100 Renewal Fee
175 Applications for letters of qualification (Board Estimate)
$300 ($300 of the $700 fee paid to the Compact for letters of qualification)
225 State of principal licensure applicants and 175 applications for letter of qualification.
under the PT Compact the licensee pays $25 for a license. The board receives $19 and the
Compact retains $6. At this time, DCI does not know what percentage, if any, the
Medical Compact will keep.
In summary, DCI assumes a revenue of $69,375 (225 applicants x $75 fee + 175 applicants for
letters of qualification x $300 onetime fee) in FY 2025 and $2,025 in FY 2026 to the Board of
Registration for the Healing Arts Fund (0634) as a result of the changes in this proposal.
The following board-specific expenses are being calculated to determine the additional
appropriation needed by the division to support the board and to assist in calculating the
anticipated license and renewal fees.
Staffing
1 Legal Counsel ($70,000/annually) needed to assist with implementation of the program
by assisting with any rules that are deemed necessary, responding to legal questions
pertaining to the qualifications for licensure, compact and investigations. Prepare
documents for disqualified applicants who appeal the Board’s decision and serve as legal
advisors to the Board and its staff.
1 Customer Service Representative ($35,000/annually) needed to provide technical support,
process applications for licensure, and respond to inquiries related to the licensure law
and/or rules and regulations.
1 Non Commissioned Investigator ($38,000/annually) needed to conduct investigations and
inspections, serve notices, and gather information required by the board.
Complaints and Investigations
It is estimated the board will receive approximately 7 complaints. The division does not
anticipate receiving any complaints until FY 2025. It is estimated 30% of the complaints filed
will require field investigations with 50% requiring overnight travel. One car is needed to L.R. No. 0779S.09T
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conduct investigations and will need to be eventually replaced based upon usage. Therefore, the
vehicle cost is considered an ongoing expense and appropriation need.
Interstate Commission Annual Fee
The commission may charge participating boards an assessment if the projected revenue shortfall
is greater than 50% of the reserve fund at the time the budget is adopted. This amount is
unknown.
In summary, DCI assumes a cost of $257,062 in FY 2024, $194,785 in FY 2025 and $263,668 in
FY 2026 to provide for the implementation of the changes in this proposal.
Oversight assumes DCI is provided with core funding to handle a certain amount of activity
each year. Oversight assumes DCI could absorb some of the FTE costs related to this proposal.
Therefore, Oversight will reflect the cost and the FTE as “up to” the estimate provided by DCI to
the Board of Registration for the Healing Arts Fund (0634).
Oversight will also reflect a possibility that not enough other states will join the Compact,
therefore, Oversight will reflect a $0 impact to Missouri until that threshold is reached.
Oversight notes that the balance in the Board of Registration for the Healing Arts Fund (0634)
was $8,663,267 as of December 2022.
Oversight notes the fiscal impact of this legislation differs from years past due to updated
estimates. The Board of Healing Arts does not currently have a $300 licensing fee, so it was
updated to a $75.00 License Fee and $100.00 Renewal fee.
§§334.100 - 334.613 – Physical Therapist Scope of Practice
In response to a previous version, officials from the Department of Social Services (DSS)
assumed this legislation revises Chapter 334, RSMo, by adding three sections that would allow
physical therapists to treat patients without a prescription or referral from an approved health
care provider. Since this legislation revises Chapter 334, RSMo, and since there is no specific
exemption for physical therapists that contract with the Health Maintenance Organizations
(HMOs) that contact with the state to provide health benefits to MO HealthNet managed Care
members, it is assumed this will apply to them.
The HMOs that contract with the state have current policies and procedures that outline
treatment guidelines for members for physical therapy services. This legislation revises current
language to remove the requirement for a prescription or referral from an approved healthcare
provider provided the physical therapist has a doctorate of physical therapy degree or has five
years of clinical practice as a physical therapist. In addition, this legislation revises language that
states consultation with an approved health care provider is not required if the course of physical
therapy services or treatment is completed within ten visits or twenty-one business days. L.R. No. 0779S.09T
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Providers enrolled with MO HealthNet must be licensed by the state in which they practice. In
order to receive reimbursement for services provided to a MO HealthNet participant, providers
must be enrolled with the state as a MO HealthNet provider. Physical therapy services must be
prescribed by a primary care provider and is only a covered benefit for children. Additionally,
any service included in the Individualized Education Program (IEP) developed through the
public school is covered through Fee-For-Service.
Medicaid’s requirement for medical necessity of physical therapy services would be impacted if
the need for prescription and referral by a primary care provider (or specialist) were removed. By
removing this connection to the primary care/specialist provider, utilization for these services
will inevitably increase over time due to provider induced demand, potential for over treatment
(due to lack of utilization controls), and difficulty in enforcement. In addition, utilization
increases may be expected based on the use of in-office ancillary. Without the need for a script
or other utilization control, utilization increases may be anticipated as clinicians have the ability
to bill up to ten visits before they must seek further consult, and without an enforcement process,
it is assumed this type of behavior will increase.
It is assumed that the Managed Care capitation rates would increase at least $100,000 based on
this legislation. For FY25 and FY26, a 5.4% medical inflation rate was used. They estimate the
actuarial cost to evaluate this program change to the Managed Care capitation rates to be no
more than $50,000.
FY24: Total - $150,000 (GR - $58,995; Federal - $91,005)
FY25: Total - $105,400 (GR - $35,831; Federal - $69,569)
FY26: Total - $111,092 (GR - $37,766; Federal - $73,326)
Oversight will reflect the cost as estimated by DSS.
§§335.036 and 335.056 – Advanced Practice Registered Nurse (APRN)
Officials from the Department of Commerce and Insurance (DCI) state it is estimated that to
fully investigate and prosecute complaints, the board may need additional resources. An
unknown cost of up to $100,000 from the Board of Nursing Fund may be necessary, depending
on the number of cases and legal expenses that occur.
Oversight assumes because the potential for litigation is speculative that the Department of
Commerce and Insurance will not incur significant cost related to this proposal. If a fiscal impact
were to result, the DCI may request additional funding through the appropriation process.
Oversight contacted DCI officials and learned there are currently 14,673 registered APRNs in
Missouri. APRNs are required to pay a one-time fee of $150 for recognition of their APRN
status. DCI officials state this proposal does not change the fee structure or requirements related L.R. No. 0779S.09T
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to APRNs. The proposal instead changes the current APRN recognition model to a licensure
model.
§§335.203 - 335.257 – Nursing Education
§335.203.2
In response to a previous version, officials from the Department of Health and Senior Services
(DHSS) assumed §335.203.2, of the proposed legislation, proposes the removal of the $150,000
grant limit for those awarded under the Nursing Education Incentive Program.
Oversight assumes removal of the $150,000 grant limit for those awarded the Nursing Education
Incentive Program in this subsection will have no fiscal impact on state or local government.
Oversight notes the Department of Commerce and Insurance (DCI) budget request included the
following information: The Nursing Education Incentive Program (NEIP) was established in
2011 through legislative action and appropriation of State Board of Nursing (Board) funds to
increase the number of nursing graduates by expanding the physical and educational capacity of
professional nursing programs in Missouri. This grant program is supported by nurse licensure
fees and represents continued action by the Board to support nursing education. The board
currently has the authority to award up to $2,000,000 each fiscal year for the NEIP Program.
This new decision item would allow the Board to award up to $3,000,000 each fiscal year in
NEIP funding. Oversight notes the DCI asked for a $1,000,000 new decision item from the State
Board of Nursing Fund (0635).
§335.205
DHSS also noted §335.205, of proposed legislation, proposes the collection of a nursing
education incentive program surcharge in addition to the nurse licensure fees for any initial nurse
license and license renewal application to be deposited into the state board of nursing fund.
Officials from the Department of Commerce and Insurance (DCI) state that the board projects
a 2% increase in licensees each year.
DCI assumes the surcharge only applies to applicants for a license by endorsement. (Those
numbers could decrease as more states join the nursing compact. Nurses will not need a Missouri
license because they are able to practice in Missouri on the license from the other state.)
DCI assumes the following:
FY 2024
LPN – Renewal Surcharge - $45,668
LPN – Initial License Surcharge $252
RN – Renewal Surcharge - $0
RN – Initial Licensure Surcharge - $10,200
Total - $56,120 L.R. No. 0779S.09T
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FY 2025
LPN – Renewal Surcharge - $0
LPN – Initial License Surcharge $260
RN – Renewal Surcharge - $1,200,850
RN – Initial Licensure Surcharge - $10,405
Total - $1,211,515
FY 2026
LPN – Renewal Surcharge - $46,582
LPN – Initial License Surcharge $268
RN – Renewal Surcharge - $0
RN – Initial Licensure Surcharge - $10,615
Total - $57,465
DCI Notes:
RNs are currently in renewal so the 120,085 number could decrease for multiple reasons:
- Licensees that retire and do not renew their license.
- Not having to renew due to the added nurse licensure compact states.
-This is the first renewal period since Kansas joined the nursing compact. The board does not
know how many RNs that are Kansas residents that will not renew their Missouri license because
they do not have to.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect the
revenues as estimated by the DCI to the Board of Nursing Fund (0635).
§335.212 - 335.242 (Removal)
DHSS also assumed this proposal, removes of §§335.212 through 335.242 which would
eliminate the Nursing Student Loan Program and §§335.245 through 335.257, which would
eliminate the Nursing Student Loan Repayment Program.
Additionally, eliminating §§335.212 through 335.257 would eliminate the established
Professional and Practical Nursing Student Loan and Nurse Loan Repayment Fund which is also
used to collect repayment and fees on any defaulted contracts. This section also gives the
authority to the DHSS to institute any action to recover any amount due. Therefore, the
Department may lose the authority to collect on bad debt from nurses who defaulted on their
loans.
Currently, the educational surcharge collected on nurse licensure and licensure renewal
applications is expended on administering the Nurse Student Loan (NSL) program and Nurse
Loan Repayment Program (NLRP). This fee is based on either the Registered Nurse (RN) or
Licensed Practical Nurse (LPN) and the year; the program receives $5 for each RN license
during odd numbered years and then $1 from each LPN license during even numbered years. The
removal of these sections results in a loss of revenue that is utilized for the NSL program and L.R. No. 0779S.09T
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NLRP. If these funds are not received by DHSS, this would result in a loss of approximately
$1,300,000 on odd numbered years and $66,000 on even numbered years.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect the
estimated loss provided by DHSS to the Nurse Loan Fund.
§§337.510 - 337.550 - Counseling Interstate Compact
Oversight assumes this legislation enacts the Counseling Interstate Compact.
Officials from the Department of Commerce and Insurance (DCI) state it is uncertain if the
compact would be enacted in FY24, FY25 or FY26. Once the compact is enacted the Division
would have the following fiscal impact: $3,000 to $6,000 estimated annual fees to participate in
the compact.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect the
estimated fiscal impact as a range of $0 (the compact is not enacted) to $3,000 - $6,000 (the
compact is enacted) to the Committee of Professional Counselors Fund (0672).
§§337.615 - 337.1075 - Social Work Licensure Compact
Officials from the Department of Commerce and Insurance state it is uncertain if the compact
would be enacted in FY2024, FY2025 or FY2026. Once the compact is enacted, the Committee
for Social Workers would be required to pay fees charged to member states including an annual
assessment to cover costs of operations and activities of the compact commission. Costs are
unknown at this time.
Since the compact will only be effective once seven states have enacted legislation to join the
compact, Oversight will reflect a $0 (the compact is not enacted) to an unknown cost less than
$250,000 to the Social Worker Fund (0574).
§§338.010 - 338.012 – Administration of Medication
In response to a similar proposal from this year (SB 41), officials from Department of Health
and Senior Services assumed 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 on the fiscal note for these sections.
§§344.045-344.102 – Nursing Home Administrator Provisions
In response to a similar proposal from this year (HCS for HB 773), officials from the
Department of Health and Senior Services (DHSS) assumed the proposed legislation requires
the Board of Nursing Home Administrators to receive and investigate complaints concerning its
licensees’ professional practices. The legislation also creates provisions related to record
disclosure, as well as restrictions related to an administrator operating on an expired license.
The provisions of the proposed legislation would be part of the normal ebb and flow of the Board
of Nursing Home Administrators. L.R. No. 0779S.09T
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DHSS anticipates being able to absorb the costs of this bill with current resources. However, if
the workload significantly increased or other legislation was enacted, additional resources would
be requested through the appropriation process.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect a zero
impact in the fiscal note for these sections as DHSS anticipates being able to absorb the cost of
the proposal.
Section 1 and deletes §192.530 – Non-opioid directive
Oversight notes that in response to HB 1286, officials from the Department of Health and
Senior Services (DHSS) stated the proposed legislation would require the DHSS to develop a
voluntary non-opioid direct form for patients who want to deny or refuse the administration or
prescription of a controlled substance containing opioids by a health care provider. This language
is similar to the provisions of Section 1 of HA 4.
DHSS assumed they could absorb the costs associated with HB 1286 with current resources, but
if the workload significantly increased or other legislation was enacted, additional resources
would be requested through the appropriation process.
Oversight does not have any information to the contrary and, therefore, assumes the DHSS has
sufficient staff and resources available to absorb the minimal additional duties required by this
this section and will reflect no fiscal impact for this agency.
As the provisions of this amendment do not provide for the DHSS to promulgate rules and
regulations, Oversight assumes no fiscal impact to the Joint Committee on Administrative
Rules or the Office of the Secretary of State.
Bill as a whole:
Officials from the Attorney General’s Office, the Department of Mental Health, the
Department of Revenue, the Department of Public Safety - Missouri Highway Patrol the
Missouri Department of Conservation, the Missouri Department of Transportation
Missouri Consolidated Health Care Plan, the Missouri Office of Prosecution Services and
the Office of the State Courts Administrator each assume the proposal will have no fiscal
impact on their respective organizations.
In response to a previous version, officials from the Department of Public Safety - Missouri
Gaming Commission and the Department of Higher Education and Workforce
Development each assumed 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 agencies. L.R. No. 0779S.09T
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Officials from the Office of Administration - Budget and Planning defer to the Department of
Commerce and Insurance for the potential fiscal impact of this proposal.
Rule Promulgation
Officials from the Joint Committee on Administrative Rules assume this proposal is not
anticipated to cause a fiscal impact beyond its current appropriation.
Officials from the Office of the Secretary of State (SOS) note many bills considered by the
General Assembly include provisions allowing or requiring agencies to submit rules and
regulations to implement the act. The SOS is provided with core funding to handle a certain
amount of normal activity resulting from each year's legislative session. The fiscal impact for
this fiscal note to the SOS for Administrative Rules is less than $5,000. The SOS recognizes that
this is a small amount and does not expect that additional funding would be required to meet
these costs. However, the SOS also recognizes that many such bills may be passed by the
General Assembly in a given year and that collectively the costs may be in excess of what the
office can sustain with its core budget. Therefore, the SOS reserves the right to request funding
for the cost of supporting administrative rules requirements should the need arise based on a
review of the finally approved bills signed by the governor.
FISCAL IMPACT – State GovernmentFY 2024
(10 Mo.)
FY 2025FY 2026GENERAL REVENUETransfer to – Health Professional Loan
Incentive Fund – appropriations
(§191.430) p.4-6
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
Transfer-out – to Medical Residency
Grant Program Fund (§191.592) p. 6-9
(Could exceed
$1,114,627)
(Could exceed
$2,110,572)
(Could exceed
$3,113,372)
Cost – DSS
(§§334.100 - 334.613) p.12-13
Increase in Managed Care Capitation
Rates physical therapists (state portion)($33,995)($35,831)($37,766)
Actuarial Study (state portion)($25,000)$0$0ESTIMATED NET EFFECT TO
THE GENERAL REVENUE FUND
(Could exceed
$1,173,622)
(Could exceed
$2,146,403)
(Could exceed
$3,151,138) L.R. No. 0779S.09T
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FISCAL IMPACT – State Government
(continued)
FY 2024
(10 Mo.)
FY 2025FY 2026MEDICAL RESIDENCY GRANT
PROGRAM FUND
Transfer-in – from General Revenue
(§191.592) p. 6-9
Could exceed
$1,114,627
Could exceed
$2,110,572
Could exceed
$3,113,372
Income – gifts, contributions, grants or
bequests. (§191.592) p. 6-9
$0 or
Unknown
$0 or
Unknown
$0 or
Unknown
Transfer-in – from Colleges and
Universities – grant repayments
(§191.592) p. 6-9
$0$0 to Unknown$0 to UnknownCosts – DHSS (§191.592) p. 6-9Could exceed...Could exceed...Could exceed... Personal service (1 FTE)($63,999)($64,639)($66,585) Fringe benefits($39,529)($39,769)($40,497) Equipment and expense($11,099)($6,164)($6,290) Medical education grants($1,000,000)($2,000,000)($3,000,000)Total Costs – DHSS($1,114,627)($2,110,572)($3,113,372) FTE Change – DHSSCould exceed 1
FTE
Could exceed 1
FTE
Could exceed 1
FTE
ESTIMATED NET EFFECT ON
THE MEDICAL RESIDENCY
GRANT PROGRAM FUND$0 to
Unknown
$0 to
Unknown
$0 to
Unknown
Estimated Net FTE Change on the
Medical Residency Grant Program
Fund
Could exceed 1
FTE
Could exceed 1
FTE
Could exceed 1
FTE L.R. No. 0779S.09T
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FISCAL IMPACT – State Government
(continued)
FY 2024
(10 Mo.)
FY 2025FY 2026FEDERAL FUNDSRevenue - DSS
(§§334.100 - 334.613) p.12-13
Increase in Managed Care Capitation
Rates$66,005$69,569$73,326
Actuarial Study$25,000$0$0Cost - DSS (§§334.100-334.613)
p.12-13
Increase in Managed Care Capitation
Rates (federal portion)($66,005)($69,569)($73,326)
Actuarial Study (federal portion)($25,000)$0$0ESTIMATED NET EFFECT TO
FEDERAL FUNDS$0$0$0
BOARD OF REGISTRATION FOR
THE HEALING ARTS FUND (0634)
Revenue – DCI
§§334.1600 - 334.1720 p.10-12
interstate medical licensure compact$0$0 or $69,375$0 or $2,025
Cost – DCI –
§§334.1600 - 334.1720 p.10-12$0 or ….$0 or….$0 or….. Personal Service
(Up to
$119,167)
(Up to
$145,860)
(Up to
$148,777) Fringe Benefits(Up to $83,545)
(Up to
$101,324)
(Up to
$102,416)
Equipment and Expense(Up to $42,500)$0$0 Other Fund Cost(Up to $11,850)(Up to $16,976)(Up to $14,500)
Total Cost – DCI
Up to
($257,062)
(Up to
$264,160)
(Up to
$265,693)
FTE Change – DCIUp to 3 FTEUp to 3 FTEUp to 3 FTE L.R. No. 0779S.09T
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FISCAL IMPACT – State Government
(continued)
FY 2024
(10 Mo.)
FY 2025FY 2026
ESTIMATED NET EFFECT ON
BOARD OF REGISTRATION FOR
THE HEALING ARTS FUND (0634)
$0 or (Could
be less than
$257,062)
$0 or
(Could be less
than $194,785)
$0 or
(Could be less
than $263,668)
Estimated Net FTE Change to the
Board of Registration for the Healing
Arts Fund (0634)Up to 3 FTEUp to 3 FTEUp to 3 FTE
SOCIAL WORKER FUND (0574)Cost – DCI
(§§337.615 - 337.1075) p.16
Compact Cost
$0 or
(Unknown)
$0 or
(Unknown)
$0 or
(Unknown)
ESTIMATED NET EFFECT TO
THE SOCIAL WORKER FUND
(0574)
$0 or
(Unknown)
$0 or
(Unknown)
$0 or
(Unknown)
HEALTH PROFESSIONAL LOAN
INCENTIVE FUND
Transfer in – from General Revenue –
appropriations (§191.430) p.4-6$0 to Unknown$0 to Unknown$0 to Unknown
Income – DHSS (§§191.430 – 191.831)
– Loan repayments/penalties for breach
of contract p.4-6$0 to Unknown$0 to Unknown$0 to Unknown
Costs – DHSS – Loans to health
professionals (§§191.430 - 191.831) p.4-
6
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATED NET EFFECT ON
THE HEALTH PROFESSIONAL
LOAN INCENTIVE FUND*$0$0$0
*Income/appropriations and costs of loans distributed net to $0 L.R. No. 0779S.09T
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FISCAL IMPACT – State Government
(continued)
FY 2024
(10 Mo.)
FY 2025FY 2026NURSE LOAN FUNDLoss – DHSS (§335.212 - 335.242)
Loss of educational surcharge
collection p.15-16($66,000)($1,300,000)($66,000)
ESIMATED NET EFFECT ON THE
NURSE LOAN FUND($66,000)($1,300,000)($66,000)
BOARD OF NURSING FUND (0635)Revenue – DCI (§335.205)
Nursing Education Incentive Program
Surcharge p.14-15$56,120$1,211,515$57,465
ESTIMATED NET EFFECT TO
THE BOARD OF NURSING FUND$56,120$1,211,515$57,465
COLLEGES AND UNIVERSITIESIncome – Colleges & Universities –
increase in tuition and fees (§§191.430 -
191.831) p.4-6
$0 to
Unknown
$0 to
Unknown
$0 to
Unknown
Income – Colleges and Universities –
increase in tuition and fees (§191.592) p.
6-9
$0 to Unknown$0 to Unknown$0 to Unknown
Transfer-out – to Medical Residency
Grant Program Fund from Colleges and
Universities – grant repayments
(§191.592) p. 6-9$0
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATED NET EFFECT ON
COLLEGES AND UNIVERSITIES
$0 to Unknown$0 to Unknown$0 to Unknown L.R. No. 0779S.09T
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FISCAL IMPACT – State
Government (continued)
FY 2024
(10 Mo.)
FY 2025FY 2026COMMITTEE OF
PROFESSIONAL COUNSELORS
FUND (0672)
Cost – DCI §§337.510 - 337.550
(p.16)
Counseling Interstate Compact fees
$0 or ($3,000-
$6,000)
$0 or ($3,000-
$6,000)
$0 or ($3,000-
$6,000)
ESTIMATED NET EFFECT TO
THE COMMITTEE OF
PROFESSIONAL COUNSELORS
FUND (0672)
$0 or ($3,000-
$6,000)
$0 or ($3,000-
$6,000)
$0 or ($3,000-
$6,000)
TATTOO, BODY PIERCING &
BRANDING FUND (0883)
Revenue - DCI - definition change to
include more practitioners and
establishments §324.520 p. 9-10$11,500$12,500$500
ESTIMATED NET EFFECT TO
THE TATTOO, BODY PIERCING
& BRANDING FUND$11,500$12,500$500
AGRICULTURE PROTECTION FUND
(0970)
Loss of Revenue –(delayed 1 year) MDA –
increase in number of commercial NRUP
license fees ⸹281.035($91,630)($91,630)$0
Loss of Revenue – (delayed 1 year) MDA –
increase in number of non-
commercial NRUP license fees §281.102
(⸹281.037) p.9-10
($16,083)($16,083)$0 L.R. No. 0779S.09T
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FISCAL IMPACT – State Government
(continued)
FY 2024
(10 Mo.)
FY 2025FY 2026Savings of Costs (delayed 1 year) – MDA
§281.102 (§§281.035 and 281.037) p.9-10
Personal Services$16,016$16,016$0Fringe Benefits$11,079$11,079$0Computer network$20,000$20,000$0Equipment and expense$2,743$2,743$0Total costs – MDA$49,838$49,838$0FTE Change – MDA0 FTE0 FTE0 FTEESTIMATED NET EFFECT ON THE
AGRICULTURE PROTECTION FUND
($57,875)($57,875)$0
Estimated Net FTE Change to the Agriculture
Protection Fund<1 FTE>0 FTE0 FTE
UNIVERSITY OF MISSOURILoss of Revenue – UM – (delayed 1 year)
revenue from fees for pesticide training
§281.102 (§281.040) p.9-10($200,000)($200,000)$0
ESTIMATED NET EFFECT ON THE
UNIVERSITY OF MISSOURI($200,000)($200,000)$0
FISCAL IMPACT – Local GovernmentFY 2024
(10 Mo.)
FY 2025FY 2026$0$0$0
FISCAL IMPACT – Small Business
Licensed Professional Counselors, health care providers and businesses who employ with
physicians with an expedited license could have a direct fiscal impact as a result of this proposal.
Licensed cosmetologist and/or a licensed cosmetology establishment could be impacted by this
proposal. Any small business that now falls into the new definition of tattoo will be fiscally
impacted by the proposed legislation. L.R. No. 0779S.09T
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Small pesticide applicator businesses could be impacted as a result of this proposal.
FISCAL DESCRIPTION
This proposal modifies provisions relating to professions requiring licensure.
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
Attorney General’s Office
Department of Commerce and Insurance
Department of Health and Senior Services
Department of Mental Health
Department of Public Safety - Missouri Highway Patrol
Department of Social Services
Missouri Department of Transportation
Office of Administration - Budget and Planning
Department of Revenue
Missouri Department of Conservation
Office of Administration
Office of the Secretary of State
Joint Committee on Administrative Rules
Missouri Consolidated Health Care Plan
Missouri Office of Prosecution Services
St. Charles Committee College
University of Central Missouri
University of Missouri Health Care System
Julie MorffRoss StropeDirectorAssistant DirectorJune 15, 2023June 15, 2023