COMMITTEE ON LEGISLATIVE RESEARCH
OVERSIGHT DIVISION
FISCAL NOTE
L.R. No.:0453S.02C Bill No.:SCS for SB Nos. 45 & 90 Subject:Health Care; Medicaid/MO HealthNet; Public Assistance; Department of Social
Services
Type:Original Date:February 3, 2023Bill Summary:This proposal modifies provisions relating to MO HealthNet services for
pregnant and postpartum women.
FISCAL SUMMARY
ESTIMATED NET EFFECT ON GENERAL REVENUE FUNDFUND AFFECTEDFY 2024FY 2025FY 2026General Revenue($4,542,330)($10,590,121)($11,156,896)Total Estimated Net
Effect on General
Revenue($4,542,330)($10,590,121)($11,156,896)
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. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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ESTIMATED NET EFFECT ON FEDERAL FUNDSFUND AFFECTEDFY 2024FY 2025FY 2026Federal* $0$0$0Total Estimated Net
Effect on All Federal
Funds $0$0$0
*Income and expenses are estimated at $20 million annually beginning in FY 2025 and net to $0.
ESTIMATED NET EFFECT ON FULL TIME EQUIVALENT (FTE)FUND AFFECTEDFY 2024FY 2025FY 2026General Revenue1 FTE1 FTE1 FTETotal Estimated Net
Effect on FTE1 FTE1 FTE1 FTE
☒ 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. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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FISCAL ANALYSIS
ASSUMPTION
§208.151 and §208.662 - 12 month post-partum coverage for MPW and SMHB participants
Officials from the Department of Social Services (DSS), Family Support Division (FSD) state
this proposal amends §208.151 to extend pregnancy-related and postpartum coverage from the
last day of the month that includes the sixtieth day to one year after the pregnancy ends for
individuals receiving MO HealthNet for Pregnancy (MPW) effective upon passage and approval.
DSS shall submit a state plan amendment (SPA) to the Centers for Medicare and Medicaid
Services (CMS) within sixty days of the effective date of this act and the provisions of this
legislation shall remain in effect for any period of time during which there is federal authority
under 42 U.S.C. Section 1396a(e)(16) or any successor statutes or regulations, is in effect.
Subsection 208.662.6 is amended to extend pregnancy-related and postpartum coverage from the
last day of the month that includes the sixtieth day to one year after the pregnancy ends for
individuals receiving Show Me Healthy Babies (SMHB). DSS shall submit a SPA to CMS
within sixty days of the effective date of this act and the provisions of this legislation shall
remain in effect for any period of time during which there is federal authority under 42 U.S.C.
Section 1397gg(e)(1)(J) or any successor statutes or regulations, is in effect.
Beginning April 1, 2022, sections 9812 and 9822 of The American Rescue Plan Act of 2021
(ARPA) give states the option to extend Medicaid coverage for pregnant women beyond the
required 60-day postpartum period through the end of the month in which a 12-month
postpartum period ends. The option provides for continuous eligibility. States electing this option
must provide full state plan benefits during the pregnancy and postpartum period; they may not
limit coverage to pregnancy-related services. If adopted for Medicaid, the extended postpartum
coverage election applies automatically to the Children’s Health Insurance Program (CHIP) in
the state. This option is time-limited to a 5-year period beginning on the effective date of the
provision, April 1, 2022. On December 29, 2022, the Consolidated Appropriations Act, 2023
(CAA, 2023) was enacted, making the option for states to provide 12-months of continuous post-
partum coverage a permanent state plan option, overriding the previous authorization for a 5-year
limit in ARPA.
Due to the Families First Coronavirus Response Act (HR 6201, Section 6008), MO HealthNet
coverage was maintained at the same benefit level for all cases as of March 18, 2020, and
coverage was only closed for voluntary requests, deceased participants, participants moving out
of the state, or aging out of CHIP under Title XXI. Due to this requirement, FSD has used data
from FY 2020.
CMS issued guidance for extending postpartum coverage in State Health Official Letter 21-007
on December 7, 2021. The guidance directs states opting to accept this coverage to provide L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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twelve months of continuous coverage at the level of care the participant received when the
pregnancy ended.
The Family Support Division (FSD) determined that approximately 4,565 individuals who
received MPW postpartum benefits beginning on the last day of their pregnancy would have
coverage extended to twelve months.
FSD arrived at the number in the following manner:
In FY 2020, 46,455 MPW participants lost postpartum coverage after 60 days. Of these:
14,513 MPW moved to other assistance assuming a full benefit package
12,449 MPW moved to Extended Women's Health Services (EWHS) with limited
benefits
19,493 MPW received no other assistance
Total: 46,455 MPW participants lost postpartum coverage after 60 days
Under Amendment 2, Missouri Constitution Article IV, Section 36(c), effective July 1, 2021, the
DSS extended MO HealthNet coverage to persons age 19 to 64 with income under 138% of the
federal poverty level (FPL), known as the Adult Expansion Group (AEG). The extension of this
MO HealthNet coverage results in MPW participants that would have previously moved to
Extended Women’s Health Services (EWHS) or received no other assistance to potentially be
eligible for AEG. To estimate the number of MPW participants that could now move directly
from MPW to AEG, DSS analyzed MPW participants receiving in February 2020 with income
under 138% FPL that do not receive Medicare and determined 87% of the MPW population will
now be eligible for AEG and receive a full benefit package. DSS then used the 87% to estimate
27,790 ((12,449 + 19,493 = 31,942) and (31,942 * 0.87 = 27,789.54, rounded up)) could move to
AEG after the 12 months of postpartum coverage expires.
Therefore, the total MPW participants estimated to receive extended postpartum for twelve
months is 4,152 (46,455 – 14,513 – 27,790 = 4,152).
46,455 MPW participants lost postpartum coverage after 60 days
(14,513) MPW moved to other assistance assuming a full benefit package
(27,790)MPW moved to AEG
Total: 4,152 estimated to receive extended postpartum for twelve months
In FY 2020, 553 SMHB participants lost postpartum coverage after 60 days. Of these:
140 moved to other assistance assuming a full benefit package
68 moved to Women’s Health Services (WHS) with limited benefits
345 received no other assistance
Total: 553 SMHB participants lost postpartum coverage after 60 days L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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FSD assumes SMHB participants who moved to EWHS will not be eligible for AEG as their
income at the SMHB determination exceeds eligibility guidelines for AEG. The total SMHB
participants estimated to receive extended postpartum for twelve months is 413 (553 total – 140
moved to other assistance = 413).
In SFY 2020, 1,846 participants were eligible for and received other MO HealthNet benefits that
were not pregnancy related, but received pregnancy related services. These individuals would
also be eligible to have their MO HealthNet benefits continuously extended for twelve months
from the date the pregnancy ended.
Amending these sections would extend coverage for 48,854 (46,455 + 553 + 1,846 = 48,854)
total individuals after the pregnancy ended. DSS assumes that eligibility for the extended
coverage would also include any postpartum participant currently within the initial 60-days of
coverage as of the effective date.
Therefore, FSD determined that approximately 4,565 (4,152 + 413 = 4,565) individuals would be
newly eligible for coverage extended to twelve months.
In discussions with DSS, Oversight learned the 1,846 MO HealthNet participants who were not
covered by MPW or SMHB, but did receive pregnancy related services, are not counted in the
newly eligible extended post-partum coverage participant numbers because they are assumed to
remain eligible for that MO HealthNet coverage for the entire 12 months. This results in those
beneficiaries being included in the population that already has MO HealthNet costs. DSS
assumes, for example, a participant with MO HealthNet for Families coverage will remain
eligible for that coverage for the extended post-partum period. When Oversight asked DSS
about any potential additional costs for continuing coverage on participants (excluding MPW and
SMHB) for which they are not otherwise eligible and would be removed if they had not received
pregnancy related services, officials from DSS stated there could potentially be some participants
that would not be eligible for the entire 12 months, but DSS is not currently able to estimate how
many there might be at this time because they have not removed any Adult Expansion Group
(AEG) participants since implementation of that program due to the Public Health Emergency.
DSS, FSD
CMS for approval. DSS estimates that it will take approximately 90 days for the SPA to be
approved. Therefore, DSS estimates that implementation of the provisions of this legislation
cannot occur until July 1, 2023.
The extension of coverage would have no fiscal impact to FSD.
FSD defers to the MO HealthNet Division (MHD) for costs to the program. L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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FSD assumes the Office of Administration (OA), Information Technology Services Division
(ITSD)/DSS will include the MEDES programming costs for the system changes needed to
implement provisions of this bill in their response.
Oversight notes FSD’s deferral to MHD and OA, ITSD/DSS for a statement of fiscal impact; for
fiscal note purposes, Oversight assumes no fiscal impact for FSD.
Officials from the DSS, MHD state, currently, MHD covers pregnancy-related and postpartum
mothers for up to 60 days after the pregnancy ends. This legislation would extend coverage to
twelve months after the pregnancy ends. A waiver, SPA amendment, and Managed Care
Organization (MCO) Contract Amendment would be needed for this legislation. Therefore, the
MHD may not start seeing additional costs until the approval of the spa amendment and MCO
Contract Amendment.
FSD determined a grand total of 4,565 (413 SMHB plus 4,152 MPW) participants would qualify
for coverage under this legislation. MHD assumes new Medical Eligibility (ME) code(s) would
need to be created for this population, with a total cost of $323,550, split 25% GR ($80,886);
75% Federal. MHD also found an average monthly per member per month (PMPM) rate of
$533.57 for this population. This rate includes carved-out services, which mainly includes DMH
services as well as Pharmacy related services.
The MHD assumes that system work will be needed for this added population. The MHD would
assume that only new eligible mothers would qualify for extended coverage when this legislation
takes effect, so the population was ramped up in FY24. The SMHB costs for extended coverage
are below:
FY24 Total: $12,269,115 (GR: $4,141,782; Federal: $8,127,333)
FY25 Total: $30,807,329 (GR: $10,472,952; Federal: $20,334,377)
FY26 Total: $32,470,924 (GR: $11,038,490; Federal: $21,432,434)
Oversight does not have information to the contrary and therefore, Oversight will reflect the
estimates as provided by MHD.
The DSS, Division of Legal Services (DLS) estimates it will require one (1) additional FTE
Hearing Officer to implement this legislation. This need stems from a likely increase in
administrative appeals associated with the bill's new requirements. The Family Support Division
estimates that 4,565 new participants would qualify for services under this legislation. MO
HealthNet Division estimates that 5% of those new participants would need an administrative
hearing for some reason during the year. DLS's hearings unit will need to adjudicate an
additional 229 administrative hearings. Given the hearings officer's normal caseload of 696
hearings, one (1) additional hearing officer will be needed to absorb this increase in hearings
[((4,565 * 0.05) / (696)) = 0.33 = 1 new FTE hearings officer]. L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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Oversight does not have any information to the contrary. Therefore, Oversight will reflect the
costs provided by DLS for fiscal note purposes.
Officials from OA, ITSD/DSS state the Missouri Eligibility Determination and Enrollment
System (MEDES) currently provides eligibility determinations and case management functions
for family MO HealthNet programs, including the MO HealthNet for Pregnant Women (MPW)
and Show-me Healthy Babies (SMHB) programs, and the Children’s Health Insurance Program
(CHIP) administered by the DSS Family Support Division using the Modified Adjusted Gross
Income (MAGI) criteria established under the Patient Protection and Affordable Care Act of
2010 (ACA). IBM Curam is a commercial off-the-shelf (COTS) software package that provides
the core eligibility determination and case management functionality for MEDES. The proposed
change to Sections 208.151 and 208.662 will require significant modifications to MEDES.
Subsection 208.151.1 currently retains eligibility for pregnancy-related and postpartum coverage
through the last day of the month in which the 60th day after the pregnancy ends occurs. The
added changes indicate that pregnant women shall be eligible for medical assistance during the
pregnancy and during the 12-month period that begins on the last day of the woman’s pregnancy
and ends on the last day of the month in which the 12-month period ends. Due to the level of
coverage under the existing postpartum subprograms, it is assumed the same MPW Post-partum
Medicaid Eligibility (ME) codes will be used for the entire extended 12 month period.
Subsection 208.662.6(2) states mothers eligible under the SMHB program shall receive medical
assistance benefits during the pregnancy and through the last day of the month 12 months after
the pregnancy ends. Due to the level of coverage under the existing postpartum subprograms, it
is assumed the same SMHB Post-partum Medicaid Eligibility code will be used for the entire
extended 12 month period. Individuals on SMHB that are not citizens are assumed to not be
eligible for the extended coverage.
The following modifications would be required for this group:
currently do not have postpartum coverage (i.e. programs other than MPW and SMHB).
postpartum 60 day extensions will be updated for the 12 month extension.
program under the new ME code(s).
from the MMIS to MEDES. The evidence will be stored in MEDES to be accessed/
checked prior to performing a closing action.
will be necessary for eligibility specialists to enter the pregnancy termination date so the
system can calculate the end date for the 12 months of extended coverage. L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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about the 12 months of extended coverage and advise of importance of reporting
pregnancy so the additional benefit will be considered when a closing action is being
processed.
Systems modifications will be executed via a Project Assessment Quotation (PAQ) under the
existing Redmane contract for MEDES Maintenance and Operations as an enhancement. Hourly
IT costs under this contract vary by position title and work type. It is estimated to take 4,712.48
hours for a total cost of $801,314 in FY 2024 exclusively (25% GR; 75% Federal). Ongoing
maintenance will be covered under the existing Redmane maintenance and operations contract.
Therefore, the total MEDES upgrades will be split $200,329 GR; $600,984 Federal in FY 2024
exclusively.
Oversight does not have any information to the contrary. Oversight notes the increased OA,
ITSD/DSS costs from similar legislation (HB 2604) from the previous session. In discussions
with DSS officials, Oversight learned the added costs come from the changes that must be made
to several MO HealthNet programs, rather than alterations to only MPW and SMHB. Therefore,
Oversight will reflect the costs provided by ITSD/DSS for fiscal note purposes.
Officials from the Department of Mental Health (DMH) defer to DSS for the anticipated fiscal
impact to the Comprehensive Psychiatric Rehab (CPR), Comprehensive Substance Treatment
and Rehabilitation (CSTAR), Certified Community Behavioral Health Clinics (CCBHO) and
Developmental Disabilities (DD) waiver services.
Oversight notes DMH’s deferral to DSS for a statement of fiscal impact; for fiscal note
purposes, Oversight assumes no fiscal impact for DMH.
Officials from the Office of Administration (OA) - Budget and Planning (B&P) defer to DSS
for the potential fiscal impact of this proposal.
Oversight notes OA, B&P’s deferral to DSS for a statement of fiscal impact; for fiscal note
purposes, Oversight assumes no fiscal impact for OA, B&P.
Officials from the Department of Health and Senior Services and the Newton County Health
Department each assume 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.
In response to similar legislation (HB 254), officials from the St. Louis County Health
Department 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.
L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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Oversight only reflects the responses received from state agencies and political subdivisions;
however, other County and City Health Departments and hospitals were requested to respond to
this proposed legislation but did not. A listing of political subdivisions included in the Missouri
Legislative Information System (MOLIS) database is available upon request.
Rule Promulgation
In response to a previous version, officials from the Joint Committee on Administrative Rules
assumed this proposal is not anticipated to cause a fiscal impact beyond its current appropriation.
In response to a previous version, officials from the Office of the Secretary of State noted many
bills considered by the General Assembly include provisions allowing or requiring agencies to
submit rules and regulations to implement the act. The Secretary of State's office 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 Secretary of State's office for
Administrative Rules is less than $5,000. The Secretary of State's office recognizes that this is a
small amount and does not expect that additional funding would be required to meet these costs.
However, they also recognize 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 their office can sustain with
their core budget. Therefore, they reserve 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. L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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FISCAL IMPACT – State GovernmentFY 2024FY 2025FY 2026GENERAL REVENUE FUNDCosts – DSS/MHD (§§208.151 and
208.662) new ME codes for Post-partum
Extension p. 6($80,886)$0$0
Costs - DSS/MHD (§§208.151 and
208.662) Program distributions for Post-
partum Extension p. 6($4,141,782)($10,472,952)($11,038,490)
Costs – DSS/DLS (§§208.151 and
208.662) p. 6
Personal service($72,984)($73,714)($74,451) Fringe benefits($28,420)($32,260)($32,480) Equipment and expense($17,929)($11,195)($11,475)Total Costs - DSS/DLS($119,333)($117,169)($118,406) FTE Changes1 FTE1 FTE1 FTECosts – OA,ITSD/DSS (§§208.151 and
208.662) MEDES system changes for
Post-partum Extension pp. 6-7($200,329) $0$0
ESTIMATED NET EFFECT ON THE
GENERAL REVENUE FUND($4,542,330)($10,590,121)($11,156,896)
Estimated Net FTE Change on the
General Revenue Fund1 FTE1 FTE1 FTE L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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FISCAL IMPACT – State Government –
(continued)
FY 2024FY 2025FY 2026FEDERAL FUNDSIncome - DSS/MHD (§§208.151 and
208.662) Reimbursement for Post-partum
Extension p. 5$8,127,333$20,334,377$21,432,434
Income – DSS/MHD (§§208.151 and
208.662) Reimbursement for new ME
codes for Post-partum Extension p. 5$242,663$0$0
Income – OA,ITSD/DSS (§§208.151 and
208.662) Reimbursement for MEDES
system changes for Post-partum Extension
p. 6-7$600,984$0$0
Costs - DSS/MHD (§§208.151 and
208.662) Program distributions for Post-
partum Extension p. 5($8,127,333)($20,334,377)($21,432,434)
Costs – DSS/MHD (§§208.151 and
208.662) New ME codes for Post-partum
Extension p. 5($242,663)$0$0
Costs – OA,ITSD/DSS (§§208.151 and
208.662) MEDES system changes for
Post-partum Extension p. 6-7($600,984)$0$0
ESTIMATED NET EFFECT ON
FEDERAL FUNDS$0$0$0
FISCAL IMPACT – Local GovernmentFY 2024FY 2025FY 2026$0$0$0
FISCAL IMPACT – Small Business
No direct fiscal impact to small businesses would be expected as a result of this proposal. L.R. No. 0453S.02C
Bill No. SCS for SB Nos. 45 & 90
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FISCAL DESCRIPTION
Currently, low-income pregnant and postpartum women receiving benefits through MO
HealthNet for Pregnant Women or Show-Me Healthy Babies are eligible for pregnancy-related
coverage throughout the pregnancy and for 60 days following the end of the pregnancy. Under
this act, MO HealthNet coverage for these low-income women will include full Medicaid
benefits for the duration of the pregnancy and for one year following the end of the pregnancy.
This coverage shall begin on the effective date of the act and shall continue during any period of
time the federal authorization for such coverage is in effect. Currently, the federal American
Rescue Plan of 2021 has authorized 5 years of this coverage (§208.151 and §208.662).
This proposal contains an emergency clause.
This legislation is not federally mandated, would not duplicate any other program and would not
require additional capital improvements, but would require rental space.
SOURCES OF INFORMATION
Department of Health and Senior Services
Department of Mental Health
Department of Social Services
Joint Committee on Administrative Rules
Office of Administration - Budget and Planning
Office of the Secretary of State
Newton County Health Department
St. Louis County Health Department
Julie MorffRoss StropeDirectorAssistant DirectorFebruary 3, 2023February 3, 2023