COMMITTEE ON LEGISLATIVE RESEARCH
OVERSIGHT DIVISION
FISCAL NOTE
L.R. No.:0453S.10T Bill No.:Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SBs 45 &
90
Subject:Health Care; Medicaid/MO HealthNet; Public Assistance; Social Services,
Department of; Children and Minors; Children's Division; Health Care
Professionals; Medical Procedures and Personnel; Insurance - Health;
Emergencies; Hospitals; Holidays and Observances; Employees - Employers;
Disabilities; Pharmacy; Nurses; Physicians; Dentists; Drugs and Controlled
Substances; Public Assistance
Type:Original Date:June 21, 2023Bill Summary:This proposal modifies provisions relating to health care.
FISCAL SUMMARY
ESTIMATED NET EFFECT ON GENERAL REVENUE FUNDFUND
AFFECTED
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
General
Revenue
Could exceed
($127,786,899 to
$180,968,682)
Could exceed
($143,472,929 to
$215,971,027)
Could exceed
($144,100,058 to
$216,603,569)
Could exceed
($144,100,058 to
$216,603,569)
Total
Estimated Net
Effect on
General
Revenue
*/**/***/****
Could exceed
($127,786,899 to
$180,968,682)
Could exceed
($143,472,929 to
$215,971,027)
Could exceed
($144,100,058 to
$216,603,569)
Could exceed
($144,100,058 to
$216,603,569)
*Range based on waiver approvals for various programs.
**The medical residency grant program (§191.592) is subject to appropriation and the fiscal
impact reflects the cost to fund twenty (20) new residency slots each year. The actual number of
residency slots and the related fiscal impact could be materially different.
***The Health Professional Loan Incentive Fund is subject to appropriations (therefore reflected
as “$0 or”) 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 (§§191.430 - 191.831).
****Per subsection 208.146.9, the Ticket-to-Work Health Assurance Program expires August
28, 2025; therefore, Oversight is only showing two (2) months of impact in FY 2026 for that
section and no costs ongoing.
Numbers within parentheses: () indicate costs or losses. L.R. No. 0453S.10T
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ESTIMATED NET EFFECT ON OTHER STATE FUNDSFUND
AFFECTED
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Medical
Residency
Grant Program*$0 to Unknown$0 to Unknown$0 to Unknown$0 to Unknown
Health
Professional
Loan
Incentive**$0$0$0$0
Nurse Loan
Fund($66,000)($1,300,000)($66,000)($1,300,000)
Board of
Nursing Fund$56,120$1,211,515$57,465$1,211,515
Colleges &
Universities
$0 to
Unknown
$0 to
Unknown
$0 to
Unknown
$0 to
Unknown
Total
Estimated Net
Effect on
Other State
Funds
($9,880) to
Unknown
($88,485) to
Unknown
($8,535) to
Unknown
($88,485) to
Unknown
**General Revenue appropriations and program costs net to $0; Gifts, grants, bequests, etc.,
Unknown.
***Costs, losses and savings net to $0 (§§191.430 – 191.831).
ESTIMATED NET EFFECT ON FEDERAL FUNDSFUND
AFFECTED
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Federal*$0$0$0$0Total
Estimated Net
Effect on All
Federal Funds$0$0$0$0
*Income and costs are estimated at $23 million to $95 million annually and net to $0 based on
approved waivers. L.R. No. 0453S.10T
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ESTIMATED NET EFFECT ON FULL TIME EQUIVALENT (FTE)FUND
AFFECTED
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
General
Revenue34.5 to 35 34.5 to 3534.5 to 3534.5 to 35
Medical
Residency
Grant Program
(DHSS)Could exceed 1Could exceed 1Could exceed 1Could exceed 1
Federal Funds8 to 8.58 to 8.58 to 8.58 to 8.5Total
Estimated Net
Effect on FTE43.5 to 44.543.5 to 44.543.5 to 44.543.5 to 44.5
☒ 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 2026Fully
Implemented
(FY 2027)
Local Government$0$0$0$0 L.R. No. 0453S.10T
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FISCAL ANALYSIS
ASSUMPTION
§37.980 – Missouri as a Model Employer
Officials from the Office of Administration (OA) state this section of the proposal requires the
Office of Administration to submit a report to the general assembly describing the progress made
by the state with respect to the directives issued as part of the “Missouri as a Model Employer”
initiative described in executive order 19-16. Office of Administration, Division of Personnel
currently participates and offers support for Missouri as a Model Employer initiative. The survey
to collect data on the number of individuals with disabilities working for the state is anonymous.
In order to generate a report as outlined in this proposed bill it would take a minimum of an
additional 40 hours of staff member time to complete this work at the average rate of $30.40
along with the added cost to update MoCareers, the State's centralized application platform at
$50,000, with additional staff time of ten hours at the rate of $36.21 to implement the updates to
the application platform. The projected cost for this work is $51,578.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect to
cost estimated provided by OA to the General Revenue Fund.
Officials from the Department of Elementary and Secondary Education (DESE) state that, in
order to meet the reporting requirements and associated tasks outlined in this section, DESE
estimates the need for an additional FTE Human Resource Analyst.
Oversight does not have information to the contrary and therefore, Oversight will reflect the
estimates as provided by DESE.
Officials from the Missouri Department of Agriculture (MDA)
training and recruitment aspect of this bill, MDA would need 1 FTE (Human Resource
Specialist) to implement the provisions of §§37.980 and 209.700 combined.
Oversight does not have information to the contrary and therefore, Oversight will reflect the
estimates as provided by MDA.
Officials from the Department of Corrections (DOC) defer to (OA) for the potential fiscal
impact of this proposal.
Oversight notes DOC’s deferral to OA for a statement of fiscal impact; for fiscal note purposes,
Oversight assumes no fiscal impact for DOC. L.R. No. 0453S.10T
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§191.592 – Graduate medical education grant program
Officials from the Department of Health and Senior Services (DHSS) state §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. This calculation was made with the assumption that DHSS would fund twenty
residency slots each fiscal year beginning in FY 2024 through FY 2034; should additional slots
or appropriation be made available this amount would increase.
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. 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.
DHSS would be responsible for promulgating all rules and regulations relating to the program
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).
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.
This proposal provides that the DHSS may promulgate all necessary rules and regulations to
create and operate the Medical Residency Grant Program. This proposal does not contain
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. The provisions of this section 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 L.R. No. 0453S.10T
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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
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 L.R. No. 0453S.10T
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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.
§§191.430 - 191.831– Health professional loan repayment program
In response to similar legislation (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 L.R. No. 0453S.10T
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Other $2,256,790
Total $3,381,790
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.
Officials from the Department of Revenue (DOR) state 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 similar legislation (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. 0453S.10T
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In response to similar legislation from 2023 (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.
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.
§196.1050 – Proceeds of monetary settlements involving pharmacies
Officials from the Department of Public Safety (DPS), Missouri Highway Patrol (MHP)
defer to the Attorney General’s Office (AGO) and the Missouri Department of Transportation
(MODOT) for the potential fiscal impact of this section.
Oversight notes the AGO and MODOT each assume this section of the proposal will have no
fiscal impact on their respective organizations. Oversight does not have any information to the
contrary. Therefore, Oversight assumes the provisions of this section will have no fiscal impact.
208.035 - Transitional benefits program for TANF and SNAP recipients
Officials from the Department of Social Services (DSS), Family Support Division (FSD) state
the proposed legislation requires DSS to develop and implement a transitional benefits program
for Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance
Program (SNAP).
Currently, 7 CFR 273.26 and 7 CFR 273.27(a) provides states the option to provide transitional
SNAP benefits to households when they become ineligible for TANF and SNAP benefits
simultaneously due to excessive earned income. At this time, SNAP Transitional Benefit
Alternative (TBA) could be explored for up to five months at a level equal to the SNAP benefit
amount received at the time of their TANF grant termination with adjustment for the loss of the
TANF income. SNAP TBA would also require an amendment to the State Plan, which would
require at least 6 months for implementation.
However, the provisions of the proposed legislation create a transitional program for all SNAP
participants whose income exceeds the income maximum and requires DSS to apply for a
waiver. L.R. No. 0453S.10T
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The maximum gross income limit for SNAP eligibility is currently 130% of the Federal Poverty
Level (FPL). SNAP participants become ineligible when their total gross income exceeds the
130% FPL for their household size. SNAP participants whose monthly income has exceeded
130% FPL or $5,822, adjusted for inflation will continue receiving reduced benefits, as described
in the legislation until the income reaches or exceeds 200% FPL for their household size.
FSD determined that there would be approximately 8,104 SNAP households per year eligible for
transitional benefits. The FSD determined this in the following manner:
During SFY 22, there were 8,104 SNAP cases that closed due to income over 130% FPL and
below $5,822 per month and 200% FPL for their household size.
The provisions of this legislation require DSS to gradually step down the beneficiary’s monthly
benefit proportionate to the increase in the beneficiary’s income in the following manner:
than or equal to 150% FPL;
than or equal to 170% FPL;
than or equal to 190% FPL; and
than or equal to 200% FPL.
A household’s SNAP allotment amount is based on the income at eligibility determination. The
current language of this legislation could increase the allotment amount when a household moves
to transitional from regular SNAP eligibility. For the purpose of this fiscal note, FSD assumes
that 100% of the monthly benefit means 100% of the maximum benefit for a household, not
100% of the benefit households were receiving prior to moving to transitional benefits. To
determine the potential fiscal impact, FSD used the maximum monthly allotment amount of $740
for a household size of 3. It is unknown how much each household that reports increases in
income over 130% will be over the income maximum. Therefore, the fiscal impact is determined
based on a range of 20% to 100% of the $740 maximum allotment amount for a household of 3.
Twenty percent of the maximum allotment amount for households with income greater than
190% FPL but less than or equal to 200% FPL is $148 ($740*.20 = $148) and one hundred
percent of the maximum allotment amount for households with income less than or equal to
138% FPL is $740. Therefore, FSD determined the total transitional SNAP benefits per month
could range from $1,199,392 ($148* 8,104 = $1,199,392) to $5,996,960 ($740 * 8,104 =
$5,996,960). Annually, the total transitional SNAP benefits is estimated to be $14,392,704
($1,199,392 * 12 = $14,392,704) to $71,963,520 ($5,996,960 * 12 = $71,963,520). L.R. No. 0453S.10T
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Because the provisions of this legislation do not outline income reporting requirements, FSD
assumes individuals will be required to complete case reviews at regular intervals. FSD assumes
this would result in up to four notices per year per household. Sending out additional notices to
these households will result in additional mailing costs. The mailing cost at the bulk mailing rate
is $0.52 per notice.
FSD estimates the additional mailing costs will be up to $16,856 (8,104 * 4 * $0.52 =
$16,856.32, rounded down) per year.
Therefore, FSD estimates the potential fiscal impact for §208.035 for SNAP is $14,409,560
($14,392,704 + $16,856 = $14,409,560) to $71,980,376 ($71,963,520+ $16,856 = $71,980,376)
in SFY 24. This legislation does not outline any time restrictions to receive the transitional
benefits. Therefore, FSD assumes that the population could continue to grow each year. The
growth of the population is unknown. Therefore, the fiscal impact beginning in SFY 25 is
estimated to be $14,409,560 – unknown.
Temporary Assistance for Needy Families (TANF):
Currently, DSS administers a state funded transitional program for TANF cases closed for
excessive earned income. This program is named the Transitional Employment Benefit (TEB).
Participants can receive TEB for up to six months as long as they remain working during that
time. This is authorized under the approved TANF state plan by the Administration for Children
and Families (ACF). FSD assumes if the provisions of this legislation are enacted, the new
transitional program will replace the TEB program.
However, the provisions of the proposed legislation creates a transitional program for all TANF
participants whose income exceeds the income maximum and requires DSS to apply for a
waiver.
TANF eligibility is not based on the FPL. TANF eligibility is determined by applying an income
test based on a Consolidated Standard Expense. The maximum gross income for TANF is 185%
of the Consolidated Standard Expense. TANF participants whose monthly income has exceeded
the maximum gross income for TANF or $5,822, adjusted for inflation, will continue receiving
reduced benefits, as described in the legislation until the income reaches or exceeds 200% FPL
for their household size.
The FSD determined that there would be approximately 2,018 TANF households per year
eligible for transitional benefits.
During SFY 22, there were 2,018 TANF cases that closed due to income over the Consolidated
Standard Expense and below $5,822 per month and 225% FPL for their household size. L.R. No. 0453S.10T
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The provisions of this legislation require DSS to gradually step down the beneficiary’s monthly
benefit proportionate to the increase in the beneficiary’s income in the following manner:
than or equal to 150% FPL;
than or equal to 170% FPL;
than or equal to 190% FPL; and
than or equal to 200% FPL.
A household’s TANF allotment amount is based on the income at eligibility determination. The
current language of this legislation could increase the allotment amount when a household moves
to transitional from regular TANF eligibility. For the purpose of this fiscal note, FSD assumes
that 100% of the monthly benefit means 100% of the maximum benefit for a household, not
100% of the benefit households were receiving prior to moving to transitional benefits. To
determine the potential fiscal impact, FSD used the maximum monthly allotment amount of $292
for a household size of 3.
It is unknown how much each household that reports increases in income over the Consolidated
Need Standard will be over the income maximum. Therefore, the fiscal impact is determined
based on a range of 20% to 100% of the $292 maximum allotment amount for a household of 3.
Twenty percent of the maximum allotment amount for households with income greater than
190% FPL but less than or equal to 200% FPL is $58 ($292*0.20 = $58.40, rounded down) and
one hundred percent of the maximum allotment amount for households with income less than or
equal to 138% FPL is $292. Therefore, FSD determined the total transitional TANF benefits per
month could range from $117,044 ($58*2,018 = $117,044) to $589,256 ($292*2,018 =
$589,256). Annually, the total transitional TANF benefits is estimated to be $1,404,528
($117,044*12 = $1,404,528) to $7,071,072 ($589,256*12 = $7,071,072).
Because the provisions of this legislation does not outline income reporting requirements, FSD
assumes individuals will be required to complete case reviews at regular intervals. FSD assumes
that this would result in up to four notices per year per household. Sending out additional notices
to these households will result in additional mailing costs. The mailing cost at the bulk mailing
rate is $0.52 per notice.
FSD estimates that the additional mailing costs will be up to $4,197 (2,018*4*$0.52 =
$4,197.44, rounded down) per year
Therefore, FSD estimates potential fiscal impact for section 208.035 for TANF is $1,408,705
($1,404,528 + $4,197 = $1,408,705) to $7,075,269 ($7,071,072+ $4,197 = $7,075,269) in SFY L.R. No. 0453S.10T
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24. This legislation does not outline any time restrictions to receive the transitional benefits.
Therefore, FSD assumes that the population could continue to grow each year. The growth of
the population is unknown. Therefore, the fiscal impact beginning in SFY 25 is estimated to
be $1,408,705 to unknown.
SNAP and TANF:
FSD will require additional FTE to process case reviews at regular intervals as a result of the
implementation of the transitional SNAP and TANF programs. FSD assumes regular intervals is
defined as two case reviews per year. For the purposes of this fiscal note, FSD makes the
assumption that those eligible for the SNAP transitional program that also had been receiving
TANF, would also be eligible for the TANF transitional program and the reviews would be
completed at the same time. FSD estimates it takes approximately 30 minutes to complete a case
review for a total of 1 hour per case per year. Therefore, FSD estimates it will take 8,104 hours
per year to complete case reviews of the transitional cases. Based on 2,080 working hours
annually, 4 Benefit Program Technicians (8,104/2,080 = 3.9, rounded up), 1 Benefit Program
Supervisor (4/10 = 0.4, rounded up), and 1 Program Coordinator (1/10 = 0.1, rounded up), for
a total of up to 6 FTE (4 + 1 + 1 = 6) are needed to implement the provisions of 208.035.
FSD currently utilizes a third party vendor to administer SNAP and TANF benefits. The current
EBT vendor estimates the necessary programming changes will cost approximately $8,000 per
year.
There are currently no state plan options for SNAP or TANF that would allow the state to
implement the provisions of this legislation. DSS would request waivers from the Food and
Nutrition Services (FNS) for SNAP and ACF for TANF. FSD assumes that if the waiver
requests are not approved by the federal partners, the provisions of this legislation will not be
implemented. If it is determined that the provisions of this legislation will be implemented
without waiver approval, an appropriation of General Revenue (GR) will be required to
fund the program.
FSD defers to OA- ITSD for system changes necessary to implement the provisions of this
section.
Officials from the Department of Social Services (DSS), Division of Legal Services (DLS)
state, because DLS conducts administrative hearings for the public assistance programs, the
creation of new transitional programs for temporary assistance for needy families (TANF) and
the supplemental nutrition assistance program (SNAP) will require additional resources for the
administrative hearings unit. Based on the enrollment for these transitional programs anticipated
by the Family Support Division, DLS will require one (1) additional FTE hearing officer to
implement this legislation.
Oversight does not have information to the contrary and therefore, Oversight will reflect the
estimates as provided by DSS, DLS. Oversight notes that in the previous version, DSS presented L.R. No. 0453S.10T
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the DLS FTE costs as 50% GR; 50% Federal. DSS now states this cost would be claimable for
reimbursement, but if the waivers needed are not approved, then the costs for implementing this
piece would be 100% GR. Therefore, Oversight will reflect this expenditure as follows:
FY24: $108,324 ($54,162 to $108,324 GR; $0 to $54,162 Federal)
FY25: $127,386 ($63,693 to $127,386 GR; $0 to $63,693 Federal)
FY26: $128,672 ($64,336 to $128,672 GR; $0 to $64,336 Federal)
Officials from the Office of Administration (OA), Information Technology Services Division
(ITSD)/DSS state updates to the Family Assistance Management Information Systems (FAMIS)
would be required for this section.
To include transitional benefits for the SNAP program would involve changes to the core
eligibility determination process and also involve changes to the payroll process. The system
needs to change the way case closings are handled today and this not only impacts the benefits
processing modules, but also the downstream functionalities like Forms & Notices processes
currently in place. Significant income eligibility determination changes are needed to implement
the requirement to "gradually step down the beneficiary's monthly benefit proportionate to the
increase in the beneficiary's income".
The same change above for the TANF program is simpler than that for SNAP and involves
changing the existing transitional benefits rules.
OA, ITSD/DSS assumes every new IT project/system will be bid out because all ITSD resources
are at full capacity. IT contract rates for FAMIS are estimated at $95/hour. It is assumed the
necessary modifications for SNAP and TANF will require 583.20 hours for a cost of $55,404
(583.20 * $95), split 50% GR; 50 % Federal.
Therefore, the total FAMIS upgrades will cost $55,404 ($27,702 GR; $27,702 Federal) in FY 24
and ongoing costs are estimated at $11,358 ($5,679 GR; $5,679 Federal) in FY 25; $11,642
($5,821 GR; $5,821 Federal) in FY 26 and $11,934 ($5,966 GR; $5,966 Federal) in FY 27.
Oversight does not have information to the contrary and therefore, Oversight will reflect the
estimates as provided by the OA, ITSD/DSS.
§208.053 - Changes to child care and transitional child care benefits
Officials from the Department of Elementary and Secondary Education (DESE) state the
Child Care and Development Fund (CCDF) requires that families meet the eligibility
requirements as stated in 45 CFR 98.21 in order to qualify to receive child care benefits.
Implementation of this bill would conflict with these regulations and would therefore require the
department to use other funds (e.g. general revenue) to pay for this child care subsidy benefit.
Based on the 2020 census: L.R. No. 0453S.10T
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children ages 3 to 4 years; and 690,022 children ages 5 to 13 years in Missouri;
need for care.
The base rate for child care in MO is:
DESE is unable to calculate a cost for Section (a) as eligibility less than 150% of the federal
poverty level is federally required to be covered under the traditional child care subsidy program.
The cost for (b), (c), and (d) is as follows: $123,341,920. This will need to be funded by
general revenue as entry into the Transitional level of benefit is not allowable use of federal child
care funds, and payment based on a percentage of the total daily rate is not in accordance with
federal guidelines.
(a) Eighty percent (80%) of the state base rate, the federal poverty level of one hundred fifty
percent (150%) is the Traditional subsidy level for full benefits that the state pays one hundred
percent (100%) per the federal subsidy program.
(b) For the sixty percent (60%) of the state base rate, the federal poverty level 151 to 170 percent
results as follows:
o
o
o
(c) For the new forty percent (40%) of the state base rate, the federal poverty level 171 to 190
percent results as follows:
o
o
o
(d) For the new twenty percent (20%) of the state base rate, the federal poverty level 191 to 220
percent results as follows: L.R. No. 0453S.10T
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o
o
o
Total cost for Transitional levels b, c, d = $123,341,920
This estimate does not include any estimates for children being served by subsidy currently. This
cost would be an additional cost to the current subsidy system.
Oversight notes, that after further review of the proposal, the Office of Childhood updated their
estimate of fiscal impact for (d) level benefits from the previous version.
DESE states that in 2022, DESE requested a waiver from ACF to be able to use CCDF dollars to
pay for tier of transitional benefits but was denied. Because the department would not be able to
use CCDF funding, the money for this level of transition would need to be funded through other
funds (e.g. general revenue).
Oversight does not have information to the contrary and therefore, Oversight will reflect the
estimates as provided by DESE for the child care transitional benefits program.
DESE states adding another level of transition could more than double the number of children
being served. In order to manage the increase in applications, payments and reporting for
services, the Office of Childhood would need a minimum of 21 additional staff:
• Twelve (12) additional Benefit Program Technicians.
• Two (2) Administrative Support Assistants.
• Four (4) Program Coordinators.
• Two (2) Program Managers.
• One (1) data collection staff person to manage the increase in applications, payments,
and reporting for services.
Oversight does not have information to the contrary. DESE submitted a range of FTE in their
fiscal impact:
• 10 - 12 additional Benefit Program Technicians.
• 1 - 2 Administrative Support Assistants.
• 3 - 4 Program Coordinators.
• 1 - 2 Program Managers.
• 1 data collection staff person to manage the increase in applications, payments, and
reporting for services. L.R. No. 0453S.10T
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Oversight notes, while this proposal expands access to the child care subsidy program, the lack
of workforce in the child care industry has short- and long-term implications on the ability for
the department to implement the increased access. Without adequate child care facility staff to
work in child care programs, there will likely be waiting lists for families to receive care.
Therefore, Oversight assumes there may be a shortfall of supply in relation to the demand of
child care services created by this proposal, thereby limiting the overall size of the program.
Therefore, Oversight will reflect the low end of the range for staffing estimates as provided by
DESE as: “Could exceed ($1,386,757)” in FY 2024; “Could exceed ($1,334,648)” in FY 2025;
“Could exceed ($1,346,920)” in FY 2026.
Officials from the Office of Administration (OA), Information Technology Services Division
(ITSD)/DESE state updates to the Child Care Data System (CCDS) would be required.
This bill proposal includes childcare subsidy and substantial changes to be known as "Low-Wage
Trap Elimination Act" and as "Hand-Up Program", and transitional childcare benefit calculations
and allowances, as well as the "state base rate". The Office of Childhood, which is part of DESE,
would be affected.
OA, ITSD/DESE makes the following assumptions:
benefits and rates.
benefits possible, are in place and in working order according to laws and governance.
able to meet their requirements in the proposal, not limited to the sharing of necessary
data, securely and timely. As many of the Office of Childhood systems and applications
are in the process of being stood-up, it is unknown where this functionality and/or
changes fit best.
basis of the childcare subsidy program including qualifications, award, and
redeterminations. These programs would be new to that application/system, currently in
the vendor procurement process - Child Care Data System (CCDS).
OA, ITSD/DESE assumes every new IT project/system will be bid out because all ITSD
resources are at full capacity. IT contract rates for CCDS are estimated at $95/hour. It is assumed
the necessary modifications will require 1,188 hours for a cost of $112,860 (1,188 * $95) in FY
2024. Ongoing support is estimated at $23,136 in FY 2025; $23,714 in FY 2026 and $24,915 in
FY 2028. L.R. No. 0453S.10T
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Oversight does not have any information to the contrary. Therefore, Oversight will reflect the
costs provided by ITSD/DESE for fiscal note purposes.
§208.066 – Combination of application for SNAP, TANF, Child Care and MO HealthNet
Officials from the DSS, Family Support Division (FSD) state §208.066 adds a requirement that
DSS limit any application for the Supplemental Nutrition Assistance Program (SNAP), the
Temporary Assistance for Needy Families program (TANF), the child care assistance program,
or MO HealthNet to a one-page form that is easily accessible on the DSS website. In addition,
DSS is required to cooperate with the Department of Revenue (DOR) to allow any renewal for
SNAP, TANF, child care assistance, or MO HealthNet to be attached to the Missouri state tax
form.
FSD administers eligibility for SNAP, TANF, Child Care Subsidy, and MO HealthNet programs.
Department of Elementary and Secondary Education (DESE) administers the development of
applications for the Child Care Subsidy program. FSD develops applications for the remaining
programs.
FSD could create a one-page applications for the SNAP and TANF programs. These forms
would functionally preserve an application filing date only, as a one-page form would not
capture all of the information federally required to determine eligibility for these programs. FSD
would need to follow up with each applicant to obtain the required information to determine
eligibility, which could require additional staffing. If FSD is unable to get in contact with the
applicant to obtain the necessary information to process the application within the established
processing deadline of 30 days, the application will be denied and the individual would have to
reapply for benefits.
The federal Medicaid program has developed a single streamlined application that states are
required to utilize or, subject to federal approval per 42 CFR 435.907, states may develop an
alternative application that require CMS approval. The current applications for MO HealthNet
programs are CMS approved alternative applications that exceed one page in length. Based on
the approval process for the current applications, FSD assumes CMS would not provide approval
for a one-page application for MO HealthNet programs.
DSS has consulted with a contractor to implement a combined simplified application process in
Missouri for the programs identified in this legislation. This application is subject to approval
and has not been approved by federal partners at this time. Upon implementation, this application
will be available on the DSS website and if the provisions of this legislation are enacted, DSS
will make this available for posting on the DOR website.
Currently, DSS is in the process of implementing SNAP into the Missouri Eligibility
Determination and Enrollment System (MEDES) and upon implementation, there will be a joint
SNAP and MO HealthNet streamlined application available on the citizen portal. L.R. No. 0453S.10T
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FSD will continue to make SNAP, TANF, Child Care Subsidy, and MO HealthNet applications
available on the DSS website, as required in this legislation.
42 CFR 435.916 requires that FSD must send a pre-populated review form to all MAGI based
MO HealthNet households that contains all eligibility information regarding the recipients that is
known to FSD. Therefore, based on federal guidelines, MAGI based MO HealthNet review
forms could not be made available on either DSS or DOR websites as required in this legislation
due to the confidential information included in each pre-populated form. In addition, 42 CFR
435.916 requires that FSD must make a redetermination of eligibility without requiring
information from the individual if able to do so based on available information to the agency.
Before sending the pre-populated review forms to MO HealthNet participants, FSD accesses
electronic data sources to attempt to complete the annual review from available information. If
FSD is able to make a redetermination of eligibility based on available information, the
eligibility determination is completed without requiring information from the participant and the
pre-populated form is not sent out to participants. However, DSS could make a fillable MAGI
review form available on the DSS and DOR websites for participants.
The Child Care Subsidy program does not allow for a periodic review of eligibility to be
completed to continue eligibility. Participants must complete a new application at the end of the
certification period.
SNAP periodic eligibility reviews are completed through a mid-certification review in the middle
of the certification period. Mid-certification reviews are completed at 6 months for non-elderly
and disabled households with a 12 month certification period and at 12 months for elderly and
disabled households with a 24 month certification period.
TANF periodic eligibility review forms are completed once every 12 months, based on the most
recent approval date.
DSS will coordinate with DOR to allow any renewal for SNAP, TANF and MO HealthNet to be
attached to the Missouri state tax form. Based on discussions with DOR, FSD assumes that this
legislation would apply only to mail in tax forms. FSD renewal forms will continue to be
available on the DSS website for individuals to print and submit in paper form to the DOR. FSD
will coordinate with DOR to receive any renewal forms that are submitted with the Missouri tax
form.
Although much of the same information is collected for each program, periodic reviews for each
program are based on the most recent approval date for the individual program type and are not
always due at the same time. This legislation allows individuals to submit a renewal form if it is
due at the same time as their state tax return. However, any individual could submit a renewal
form through the process established in this legislation. Therefore, FSD may receive an
additional influx of renewal forms when the periodic eligibility review form is not due. Any
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of the data for any programs the individual participates in. For the periodic review forms that are
due when submitted with the state tax form, DSS assumes the processing time allotted to DSS
employees will lessen due to the time it will take for DOR to receive the forms, identify them,
and forward them to DSS. FSD will need additional FTE to process additional review forms
received with less time to complete the eligibility determination.
It is unknown how many SNAP, TANF, and MO HealthNet participants may submit the periodic
eligibility review form with their Missouri state tax form. According to DOR, for the tax filing
year 2021, 13% of Missouri tax filers submitted their returns via mail. For the purposes of this
fiscal note, FSD applied this percentage to the total current Missouri SNAP, TANF, and
Medicaid caseload as of October 2022 of 856,744 cases and estimated approximately 111,377
(856,744 * 0.13 = 111,376.72, rounded up) of the Missouri public assistance cases file tax
returns by mail. FSD calculated the monthly average of 9,281 (111,377/12 = 9,281.4166,
rounded down). FSD assumes individuals will submit these forms from January through April
15
th
of each year. Therefore, it is estimated that 0 to 32,484 (9,281 * 3.5 = 32,483.5, rounded up)
may submit their periodic eligibility review form with their taxes.
For the up to 32,484 cases identified, FSD estimates it will take an average of 30 minutes per
case, for a total of 16,242 hours (30 minutes * 32,484 cases = 974,520 minutes/60 minutes =
16,242 hours). Based on 2,080 working hours annually, 8 Benefit Program Technicians
(16,242/2,080 = 7.8, rounded up), 1 Benefit Program Supervisor (8/10 = 0.08, rounded up),
and 1 Program Coordinatorup to 10 FTE (8 + 1 + 1
=10) needed to implement the provisions of this legislation.
FSD assumes a one-time mailing cost will be incurred for a notice of changes to SNAP, TANF,
and MO HealthNet programs as outlined in this response. The mailing costs for a one-time
notice for each case at the bulk mailing rate of $0.52 would be $445,507 (856,744 * $0.52 =
$445,506.88, rounded up).
FSD estimates the fiscal impact will be the one-time mailing costs of $445,507 in SFY 2024
and up to 10 FTE if the provisions of this legislation are enacted.
Oversight does not have information to the contrary. Oversight notes FSD must also meet the
federal regulations regarding timeliness of application and renewal processing under 7 CFR
273.2(g) for normal SNAP application/renewal processing; 7 CFR 273.2(i) for expedited SNAP
application processing; and 45 CFR 201.10(a)(3) for TANF application/renewal processing.
Therefore, Oversight will reflect the estimates as provided by DSS/FSD. Given the potential
increased submission of applications and renewals over a brief time and the federal rules
regarding timely processing, Oversight will reflect the FTE estimates and one-time mailing costs
as provided by DSS/FSD.
Officials from OA, ITSD/DSS state updates to the FAMIS application would be required for this
section. L.R. No. 0453S.10T
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There is no change in FAMIS for the one page initial application on the DSS website. However,
there is no interface in place currently to allow a review form to be submitted with a tax return.
FAMIS might have to factor in time for system changes to build a data exchange functionality
with the Department of Revenue (or) this must be linked with the above one page initial
application.
OA, ITSD/DSS assumes every new IT project/system will be bid out because all ITSD resources
are at full capacity. IT contract rates for FAMIS are estimated at $95/hour. It is assumed the
necessary modifications for this section will require 436.32 hours for a cost of $41,450 (436.32 *
$95), split 50% GR; 50 % Federal.
Therefore, the FAMIS upgrades for this section will cost $41,450 ($20,725 GR; $20,725
Federal) in FY 24 and ongoing costs are estimated at $8,496 ($4,248 GR; $4,248) in FY 25;
$8,710 ($4,355 GR; $4,355 Federal) in FY 26 and $9,150 ($4,575 GR; $4,575 Federal) in FY 28.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect the
costs provided by ITSD/DSS for fiscal note purposes.
Officials from the Department of Revenue (DOR) state this proposal requires the Department
of Social Services (DSS) to make the initial application that clients complete to receive benefits
under the SNAP, TANF, child care assistance or medical assistance or health insurance programs
a one-page application form. This provision will not fiscally impact the Department of Revenue
(DOR) and they deferred to DSS to determine if this one page form is possible.
This proposal in Section 208.066.2 requires DSS to also make the periodic eligibility review
forms for those same programs a one page form. Additionally, these one page periodic eligibility
review forms are to be put on DOR’s website. Adding these forms to their website will not have
a fiscal impact. DOR defers to DSS to determine if this one page form is possible.
This proposal also allows the DSS clients receiving benefits under the previously listed programs
to mail their periodic eligibility review forms as an attachment to their Missouri state tax form.
In discussions with DSS, DOR was made aware that the periodic eligibility review forms are
currently multiple pages each and that several attachments are required to be provided to DSS by
the clients. Much of the information on the forms is required by the federal government. DOR
notes that even if DSS makes these a one page review form, the attachments may still be required
to be submitted. For purposes of the fiscal note, DOR assumes 3 pages for each form received (1
application page + 2 supporting document pages).
These forms are due annually when a client needs to renew their benefits as well as throughout
the year if the clients have had a change in their circumstances. Per information on the DSS
website, the SNAP renewal must be done 6 months after initial applications and annually
thereafter, generating additional potential forms. L.R. No. 0453S.10T
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DSS informed DOR they have approximately 856,744 unique cases that receive benefits from
DSS. Many of those cases have participants that receive benefits from more than one DSS
program (such as SNAP and MO HealthNet). Therefore DOR has the potential of receiving more
than the 856,744 forms annually. DOR estimates that up to 5,140,464 pages of forms could
potentially be sent to DOR. (856,744 clients * 3 supporting documents per renewal * 2 programs
per client)
This proposal says DSS clients can attach their review form(s) to their Missouri state individual
income tax return. This proposal now requires that the DSS participants will only be allowed to
submit their review forms with their individual income tax return. Should they be allowed to
attach to any of their other forms this will result in additional costs not identified in this fiscal
note.
This proposal implies that DOR would receive these review statements on behalf of clients and
then give them to DSS. However, due to the rules established by the IRS regarding taxpayer
private information and due to the confidentiality laws under §32.057, any documents received
with a tax return are considered confidential and DOR is prohibited from sharing. It is unclear
how DOR could provide these review documents to DSS or what DOR is to do with them.
Regardless of the confidentiality question, DOR will provide the fiscal impact of processing and
providing these forms to DSS, for determining the fiscal impact only.
DOR receives over 3.2 million individual income tax returns annually. DOR notes that
approximately 90% of those individual income tax returns are received electronically or on a
scannable paper return. The Department assumes it would need to convert the DSS forms to an
electronic format so DOR can continue to receive documents electronically. This is estimated to
cost $10,000 per form type
Additionally, DOR will need to notify electronic filing vendors of the need to upgrade their
systems to allow for the DSS forms and attachments to be submitted. Plus DOR will need to
upgrade the computer system and scanners to read these new forms. DOR’s costs are estimated
at $100,000 for all the upgrades.
If a customer were to attach the DSS document to an electronically filed tax return, DOR would
be required to locate and print the documents out of their electronic filing system. The search
would need to be done manually by a DOR employee who would have to review each page of
the return in the system, looking for the DSS attachments. Then DOR would need to manually
print off the DSS documents to be transferred to DSS. For customers who file their tax return on
paper, DOR anticipates that processing staff will pull these documents out as they open and sort
the mail. This will require an increase in DOR’s average temporary staffing needs as the mail
opening process will be slowed down to look through each document to discover the DSS forms
and separate them for transfer to DSS. L.R. No. 0453S.10T
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During the busy tax filing season of February to May, DOR estimates needing 96 additional
temporary staff ($12,750) to locate and print these documents. This would increase DOR’s
annual salary costs for temps by $1,224,000 annually. DOR currently has 2 shifts of temporary
staff and assume may potentially be able to run a third shift which would allow DOR to need
equipment for 24 which includes tables ($250), chairs ($719) and computers ($1,531).
DOR notes that annually they bring on a large group of temporary staff to help process the 3.2
million returns received from January 1st to April 15th. DOR is currently budgeted for 65
daytime and 50 night time temporary staff (115) but only have 74 positions filled this year. Like
most state agencies, DOR has trouble filling not only their full-time employee positions but their
temporary staff positions. If DOR is unable to fill their current positions this will strain their
already burdened staff.
DOR notes that should taxpayers stop electronically filing their tax return and send them by
paper in order to file their DSS forms, it would transfer the temporary staff to handle the load.
DOR will need another 5 Associate Customer Service Representatives ($31,200) to supervise
and assist the temporary employees and to handle the volume of returns once the temporary
employees leave. Due to the staffing shortages throughout the DOR, they believe they can move
equipment around and provide for these staff members.
Additionally, DOR will need printers, paper and ink to print the documents for DSS. DOR
contracts out for printers and ink. DOR is in the process of renegotiating current contracts. DOR
estimates the need for several more printers to handle this proposal. Additionally, DOR will need
the paper to print all these documents. DOR purchases them at $41 per case based on the price of
a truckload. They buy paper 840 cases at a time. Therefore this will have an estimated impact of
$34,440 (840 cases * $41 per case).
DOR notes that while this proposal appears to help the clients of DSS to save postage with
mailing all their state owed documents to one place, it has the potential to do more harm to the
state and clients. Allowing these forms to go to DOR before DSS, will not only increase DOR’s
processing times for individual income tax returns, but it will slow down their issuing of refunds.
Sending the documents to DOR first, may potentially result in the forms not being received by
DSS prior to the recipient’s benefits expiring, which would negatively impact the clients.
Additionally, when the processing of the returns is slowed down, the refunds are slowed down
and the potential for increased interest payments is greater. All taxpayers could be negatively
impacted by delayed refund payments.
This proposal has the potential to increase confusion as to where a DSS client’s forms are.
Clients may call DOR’s call center looking for their forms, when they have been transferred to
DSS. This could impact DOR’s ability to help taxpayers, if this generates additional calls and
wait times. Additionally, should DOR be required to mail copies of the periodic review forms to
taxpayers who request them from their call center staff, then they will have mailing costs. Those
costs are unknown at this time. L.R. No. 0453S.10T
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Based on current hiring trends DOR anticipates difficulties in hiring the number of temporary
staff needed to perform these functions. If the staffing cannot be hired, then all return processing
will slow down, which will delay refund processing and increase the interest payments made.
Oversight does not have information to the contrary. Oversight assumes delayed refund
processing could result in a minimum of $100,000 in interest payments. Therefore, Oversight
will reflect the estimates as provided by the DOR with an additional “Unknown to could exceed
$100,000” annually in expenditures for this section of the proposal.
§208.146 – Changes to the Ticket to Work Health Assurance program
Officials from the Department of Social Services (DSS), Family Support Division (FSD) state
this proposal changes the income disregards and countable assets of the current Ticket to Work
Health Assurance program. The act removed the current gross and net income maximums and
changes the total income test after deductions to 250% of the federal poverty level (FPL). The
first $50,000 per year of the earned income of the disabled worker's spouse would be included in
the deduction to income prior to the 250% FPL test in addition to these current deductions; a
twenty dollar standard deduction, health insurance premiums, a seventy-five dollar a month
standard deduction for optical and dental insurance when the premiums are less than seventy-five
dollars, all supplemental security income and first fifty dollars of social security disability
income, and a standard impairment-related employment deduction of one-half of the disabled
worker's earned income. The act also excludes all retirement accounts in consideration of assets
and keeps the current asset limit of $5,301.85 for an individual and $10,603.70 for a couple.
Resources exempted from inclusion in the asset limit are: medical savings accounts valued less
than $5,000 per year; independent living account annual deposits and earnings under $5,000 per
year; and retirement accounts.
FSD determined there would be 13,628 individuals eligible for this program already receiving
some type of MO HealthNet benefits. FSD determined these individuals by identifying the
current population who meet the new eligibility parameters described in the proposal. This
population includes the 2,144 current Ticket to Work Health Assurance program eligibles,
10,966 individuals receiving other MO HealthNet benefits and 507 receiving Qualified Medicaid
Beneficiary/ Specified Low-Income Medicare Beneficiary (QMB/SLMB) only. Because these
QMB/SLMB only cases do not currently receive full MO HealthNet benefits, any new cases
resulting from that population are included in the calculation of new eligibles.
FSD determined there will be 523 new MO HealthNet cases eligible for the MO HealthNet
TWHA program if the income and countable asset eligibility are changed as proposed.
FSD arrived at 523 new cases in this manner:
The data collected to determine the number of individuals assumed to be eligible include all
individuals age 16 to 64, employed with taxes withheld from their income, and income after
deductions under 250% of Federal Poverty Level (FPL). The income was determined by L.R. No. 0453S.10T
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deducting the first $50,000 of the disabled worker’s spouse’s income, all SSI payments and all of
any other individual’s income in the household. FSD was not able to also include the other
applicable deductions in the calculation due to system limitations.
In FY 2022, FSD closed or rejected (due to excess resources over $5,301.85 for an individual
and $10,603.70 for a couple, including retirement funds as countable assets) 101 MO HealthNet
for Aged, Blind and Disabled (MHABD) applications of employed individuals, age 16 to 64,
claiming a disability. Of those, 16 individuals had income after deductions (using the parameters
explained above) of less than 250% FPL. Fifteen (15) of these individuals would be eligible for
the TWHA program at a non-premium level while one (1) would be eligible at a premium level.
Total New Cases from MHABD Rejections:
15 (non-premium)
1 (premium)
16 Subtotal
FSD would also see an increase in eligibles from the QMB/SLMB population due to the change
in countable assets. In FY 2022, there was an average of 2,315 QMB persons. Of these, 178
individuals would be eligible for the TWHA program. 169 of these individuals would be eligible
at a non-premium level, while 9 would be eligible at a premium level.
Total New Cases from QMB:
169 (non-premium)
9 (premium)
178 Total
In FY 2022, there was an average of 5,408 SLMB persons who would meet the current resource
limits if the changes in countable assets are implemented. Of these, 329 would be eligible for the
TWHA program. 193 of these individuals would be eligible at a non-premium level, while 136
would be eligible at a premium level.
Total New Cases from SLMB:
193 (non-premium)
136 (premium)
329 Total
Total New Cases from QMB and SLMB:
178 (QMB)
329 (SLMB)
507 New Cases Total
FSD anticipates a potential increase in applications as a result of the change in types of countable
resources and changes in income calculations. These applications would come from a previously L.R. No. 0453S.10T
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unknown population who currently choose not to apply due to the current countable resource
inclusions and/or income guidelines.
FSD previously reported the number of Missouri individuals age 19 to 64, who are uninsured/not
on MHN, who claim a health problem limiting work, who are employed, have income between
101% - 200% FPL, but are not married. According to the most recent U.S. Census Bureau data,
there are zero individuals in this population.
Total New MO HealthNet Cases:
16 (MHABD rejections/closures)
178 (QMB)
329 (SLMB)
523 New Cases Total
Under Amendment 2, Missouri Constitution Article IV, Section 36(c), effective July 1, 2021,
DSS extended MO HealthNet coverage to persons age 19-64 with income under 138% of the
federal poverty level, known as the Adult Expansion Group (AEG). FSD assumes all new
individuals eligible for this program are ineligible for AEG due to receipt of Medicare, SSI, or
income greater than 138% of the federal poverty level as the deductions for the Ticket to Work
Health Assurance Program outlined in the provisions of this legislation are not allowable in AEG
eligibility guidelines.
FSD assumes existing staff will be able to complete necessary additional work as a result of this
proposal.
FSD assumes the Office of Administration (OA), Information Technology Services Division
(ITSD)/DSS will include the Family Assistance Management Information System (FAMIS)
programming costs for the system changes as well as the system-generated notice needed to
implement provisions of this bill in their response.
Therefore, there is no fiscal impact to the Family Support Division if the provisions in §208.146
are enacted.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect a zero
impact in the fiscal note for FSD for this section.
Officials from the DSS, MO HealthNet Division (MHD) state FSD provided MHD with data on
eligibles who would qualify for the TWHA program provisions under this bill. Out of these
eligibles, there are two groups: Those who currently receive MO HealthNet benefits under a
different eligibility category; and those who are not currently receiving MO HealthNet benefits
and would be new eligibles.
There are 13,617 eligibles who meet eligibility requirements to receive MO HealthNet benefits
that also meet the new eligibility parameters described above. Out of the 13,617 eligibles, 2,144 L.R. No. 0453S.10T
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are currently in the TWHA program. That leaves 11,473 (13,617 – 2,144) eligibles who could
switch to this new program. Out of the 11,473 eligibles, there are 9,579 that would not switch
(i.e. no regular source of earned income, already receive full medical coverage, etc.). In addition,
there are 178 individuals that currently receive full MO HealthNet benefits as dual eligibles
(QMB only) that would not switch. That leaves 1,716 (11,473 – 9,579 – 178) eligibles that could
switch.
Out of the 1,716 eligibles, 498 qualify under the "non-premium" will likely enroll in the
modified Workers with Disabilities program because they do not currently meet spenddown; 330
non-premium will be added because they are only receiving limited medical benefits under
Medicare now (SLMB and (Qualifying Individuals (QI) only); and 891 (356 non-premium and
535 premium) who currently meet spenddown. MHD assumes all individuals who currently meet
spenddown that qualify for the non-premium program (0-100%) would switch over to avoid
paying spenddown. MHD further assumes those that currently meet spenddown and qualify for
the premium program would likely switch because paying the annual premium (4% to 6% of
income) would be more affordable than meeting spenddown. However, the 891 individuals who
meet spenddown receive full Medicaid coverage now. Therefore, the only costs MHD
includes in this estimate for this group are their spenddown amounts as MO HealthNet
would now cover the costs of these services in lieu of the individual.
FSD also identified 723 (488 non-premium and 235 premium) newly eligible individuals that are
not receiving MO HealthNet benefits. Of those 723 individuals, 529 have already been identified
as SLMB and QI individuals and 178 are QMB individuals that currently receive full MO
HealthNet benefits as dual eligibles that would not switch, which leaves 16 individuals that are
not receiving MO HealthNet benefits. Due to this legislation, there are also 827 (437 non-
premium and 390 premium) participants that will switch because they do not meet the
spenddown now, or will add the TWHA program because they are getting limited Medicare now.
This brings a grand total of 843 [452 = (15 + 437) non-premium, and 391 = (1 + 390) premium]
participants that could be added.
An annual cost per person was calculated for the premium for personal care services ($959) and
nonemergency medical transportation (NEMT) ($296) using FY 22 TWHA expenditures. Also,
an annual cost per person was calculated for the non-premium for personal care services ($995)
eligibles using FY 22 TWHA expenditures.
The cost for new premium eligibles is $603,831 [(personal care plus NEMT average cost) * 481
possible premium participants added].
There are 438 additional eligibles who would switch for a total cost of $1,921,639. The 97
premium eligibles would have to pay a premium. MHD calculated a total savings of $1,233,280
from premium payments and QI/SLMB savings. The total cost for the premium group would be
$2,490,618 (Cost for new premium eligibles + Spenddown eligibles – Premium collections –
SLMB and QI savings). L.R. No. 0453S.10T
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$603,831 Cost for new premium eligibles
+ $3,120,067 Spend Down eligibles from TWHA population
- $788,050 Premium collections
- $445,230 QI/SLMB savings
$2,490,618 Total cost for premium group
The costs for new non-premium eligibles is $560,128 (average cost * 563 possible non-premium
participants added). There are 356 spenddown eligibles who would switch for a total cost of
$619,437. The total cost for non-premium eligibles is $578,009 (Cost for new eligibles +
Spenddown eligibles – SLMB and QI savings).
$560,128 Cost for new non-premium eligibles
+ $619,436 Spend Down eligibles
- $381,908 SLMB
- $219,647 QI savings
$578,009 Total cost for non-premium group
The total cost for the premium and non-premium groups is $3,068,628 ($2,490,619 + $578,009).
This estimate includes costs for services provided by DHSS. MHD assumed a portion of these
costs would be funded through other funding sources. To calculate the FY 24 cost, it is assumed
there would only be 10 months of expenditures.
The proposed legislation is only including services for Personal Care and NEMT. If the proposed
legislation passes, a waiver would need to be required to only have these services be covered.
Also, an update to the MMIS system would be needed due to limiting these individuals to only
include Personal Care and NEMT services. An estimated cost for this update would be
$126,000.
For FY 24, MHD further assumed new eligibles would phase in, with 1/10 of the annual total
adding to the program monthly. Beginning in FY 25, all eligibles are fully phased in.
For new non premium members, the annual total number of participants is estimated to be
phased in at the end of ten months is 925. With phase in at 1/10 of this total per month (925 *
1/10 = 92.5 individuals), MHD expects a cumulative effect of all new non premium participants
phased in (92.5 in month 1; 185 in month 2; etc.) by the close of FY 24 for a cost of $421,796.
Total cost for the non-premium group in FY 24 is estimated to be $762,951:
$516,197 = ($619,437/12) * 10 (Spend Down eligibles from TWHA)
+ $421,797 (New non premium eligibles)
- $175,041 (Cumulative Medicare premium payments for new non premium eligibles)
$762,951 Total costs for non-premium eligibles in FY 24 L.R. No. 0453S.10T
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For new premium members, the annual total number of participants is estimated to be phased in
at the end of ten month is 625. With phase in at 1/10 of this total per month (625 * 1/10 = 62.5
individuals), MHD expects a cumulative effect of all premium participants phased in (62.5 in
month 1; 125 in month 2; etc.) by the close of FY 24 for a cost of $274,800.
$1,601,366 = ($1,921,639/12) * 10 (Spend Down eligibles from TWHA population)
+ $988,394 = ($1,186,073/12) * 10 (Other Spend Down eligibles)
- $252,434 = ($302,921/12) * 10 (Loss in premium collections from current eligibles)
+ $274,800 (Cumulative cost for new premium eligibles)
- $122,439 (Cumulative Medicare premium payments for new premium eligibles)
- $222,373 (Total estimated premium collections)
$2,267,314 Total costs for premium eligibles in FY 24
The total cost of the new program eligibles in FY 24 is estimated at $2,109,667 ($1,983,667 cost
for new eligibles and $126,000 for MMIS updates).
A 5.47% inflation factor was used to calculate the total cost for FY 25 and beyond. Until the FY
24 budget is finalized, specific funding sources cannot be identified.
The total costs including MMIS changes for this legislation are:
FY 24 (10 months): Total: $3,156,266 ($1,194,267 GR; $1,961,999 Federal)
FY 25: Total: $3,234,334 ($1,234,050 GR; $2,000,283 Federal)
FY 26: Total: $3,408,988 ($1,293,424 GR; $2,115,564 Federal)
Oversight does not have information to the contrary. However, Oversight notes the program
expires on August 28, 2025. Therefore, Oversight will reflect the estimates as provided by MHD
with only 2 months of program costs for FY 2026 and no program costs ongoing.
DSS officials provided the response from the Office of Administration (OA), Information
Technology Services Division (ITSD)/DSS. Officials from OA, ITSD/DSS state the bill will
require changes to eligibility determinations, table values and reporting requirements, impacting
the Family Assistance Management Information System (FAMIS) application.
OA, ITSD/DSS assumes every new IT project/system will be bid out because all ITSD resources
are at full capacity. IT contract rates for FAMIS are estimated at $95/hour. It is assumed FAMIS
modifications will require 267.84 hours for a cost of $25,444 (267.84 * $95), split 50% GR; 50%
Federal in FY 24 exclusively.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect the
costs provided by ITSD/DSS for fiscal note purposes.
Officials from the Department of Corrections (DOC) defer to (OA) for the potential fiscal
impact of this proposal. L.R. No. 0453S.10T
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Oversight notes DOC’s deferral to OA for a statement of fiscal impact; for fiscal note purposes,
Oversight assumes no fiscal impact for DOC.
§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 1396 a(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.10T
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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.10T
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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.10T
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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 for these sections.
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.10T
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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.10T
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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.
§208.186 - Prohibits Medicaid payments for non-Missouri residents
Officials from DSS, FSD state §208.186 prohibits the state from utilizing general revenue funds
to provide payments, add-ons, or reimbursements to health care providers through Medicaid for
medical services provided to persons who do not reside in this state, as determined under 42 CFR
435.403, or any amendments or successor regulations thereto.
Officials from FSD
Gross Income (MAGI) and MO HealthNet for Aged, Blind and Disabled (MHABD)
programs. 42 CFR 435.403 requires states to provide Medicaid to eligible residents of the
state. Individuals who are not a resident of Missouri are not currently eligible for any MO
HealthNet programs. The provisions of this bill do not alter any eligibility criteria for any MO
HealthNet programs FSD administers.
Therefore, there is no fiscal impact to FSD.
In response to a similar proposal from the current session (SB 282), officials from MHD stated,
effective July 1, 2022, MHD rebased the inpatient per diem and changed the add-on payments
paid to hospitals. The add-on payments no longer include reimbursement for non-Missouri
residents, therefore, there would be no impact to MHD.
Oversight does not have any information to the contrary. In discussions with DSS officials,
Oversight learned that effective July 1, 2022, the Missouri Code of State Regulations (CSR)
regarding payments to Missouri hospitals was updated to eliminate payments, add-ons, and L.R. No. 0453S.10T
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reimbursements to health care providers through MO HealthNet for medical assistance services
provided to non-Missouri Medicaid patients.
Prior to the CSR changes, the Direct Medicaid payment, which included the reimbursement for
non-Missouri residents, was included 13 CSR 70-15.015. When MHD rebased and updated the
methodology, this payment was repurposed into the payments now outlined in 13 CSR 70-
15.010 and 13 CSR 70-15.230. Prior regulation language which included non-Missouri residents,
was removed. Because the new payment calculations in the updated CSRs do not impact the
amount of funds collected, only how the funds are disbursed, the recalculations have a budget
neutral result. The provisions of this proposal will not change MHD’s current reimbursement
calculation or methodology. Therefore, Oversight will reflect a zero impact in the fiscal note for
DSS, MHD for these provisions.
§208.239 – DSS to resume eligibility redeterminations/timeframes
Officials from DSS state §208.239 requires DSS to resume annual MO HealthNet
redeterminations, renewals, and post enrollment verifications within 30 days of the effective
date.
FSD resumed annual renewals for the Modified Adjusted Gross Income (MAGI) and MO
HealthNet for Aged, Blind and Disabled (MHABD) programs effective April 1, 2023 as part of
the unwinding process approved by the Centers for Medicare & Medicaid Services (CMS).
Therefore, there is no fiscal impact to FSD.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect a zero
impact in the fiscal note for this section.
Oversight notes the Centers for Medicare and Medicaid Services (CMS) released a state health
official letter (SHO# 23-002) on January 27, 2023 which states the following:
On December 29, 2022, the Consolidated Appropriations Act, 2023 (P.L. 117-328) (CAA, 2023)
was enacted…section 5131 of subtitle D of title V of division FF of the CAA, 2023… makes
significant changes to the continuous enrollment condition and availability of the temporary
increase in the Federal Medical Assistance Percentage (FMAP) under section 6008 of the
Families First Coronavirus Response Act (FFCRA) (hereinafter referred to as “temporary
FMAP increase”) and establishes new state reporting requirements and enforcement authorities
for the Centers for Medicare & Medicaid Services (CMS).
Section 5131(a)(2)(C) separates the end of the continuous enrollment condition from the end of
the COVID-19 PHE by amending section 6008(b)(3) of the FFCRA to end continuous Medicaid
enrollment as a condition for claiming the temporary FMAP increase on March 31, 2023. This
means that, on or after April 1, 2023, states claiming the temporary FMAP increase will no
longer be required to maintain the enrollment of a Medicaid beneficiary for whom the state L.R. No. 0453S.10T
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completes a renewal and who no longer meets Medicaid eligibility requirements. With the
changes made in section 5131, states must end the enrollment of ineligible beneficiaries on or
after April 1, 2023, after a full renewal is conducted during the state’s unwinding period, no
matter when the COVID-19 PHE ends.
§209.700 – Missouri Employment First Act
Officials from the Office of Administration (OA) state this section of the proposal indicates that
all state agencies that provide employment-related services or that provide services or support to
persons with disabilities shall implement an employment first policy by considering competitive
integrated employment as the first and preferred outcome when planning or providing services or
supports to persons with disabilities, offer information on competitive integrated employment,
ensure that persons with disabilities receive the opportunity to understand and explore education
and training as pathways to employment, promote the availability and accessibility of
individualized training, promote partnerships with private agencies that offer support, ensure
staff members of public schools, vocational service programs, and community providers have
support, guidance, and training to contribute to the attainment of the goal of competitive
integrated employment for all persons with disabilities, ensure that competitive integrated
employment and discuss basic information about competitive integrated employment with
parents and guardians of youth with a disability.
Office of Administration, Division of Personnel assumes that to comply with the requirements
listed within the Missouri Employment First Act that additional training, new recruitment efforts,
and educational information would need to be developed to ensure that the integrated
employment was implemented and successful.
Office of Administration, Division of Personnel would require four (4) new FTE to comply with
the Missouri Employment First Act including one Senior Staff Development Training Specialist,
two Human Resources Consultants, and one Administrative Professional Assistant. Currently,
the average salary of a team member in the Office of Administration, Division of Personnel is
$95,924.55 yearly including fringe benefits multiplied by four with a total of $383,698.20. Each
additional FTE would require new equipment and working space with a cost of $6,620
multiplied by 4 with a total of $26,479. Additional funding of zero to unknown would be needed
for travel reimbursement costs associated with statewide travel for training purposes including
mileage reimbursement (approximately $0.55 per mile), meal per diem reimbursement (current
rate is approximately $38 a day,) and lodging reimbursement (current rate is approximately $98 a
day).
Office of Administration, Division of Personnel would also assume that Legal would have
additional staff time invested in the review of newly developed policies and training.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect to
cost estimated provided by OA to the General Revenue Fund. L.R. No. 0453S.10T
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Officials from the Department of Social Services – Family Services Division (FSD) state that
currently, FSD provides vocational rehabilitation through Rehabilitative Services for the Blind
(RSB). The RSB already provides information on competitive integrated employment to blind
Missourians who request services and offer in-depth benefits counseling when requested to their
Vocational Rehabilitation (VR) clients. In addition, FSD has entered into a combined state plan
under the Workforce Innovation and Opportunity Act (WIOA), further aligning services to serve
the most vulnerable populations first. FSD currently follows state and federal regulations that
already follow the provisions outlined in this bill.
FSD assumes that the requirements of the proposed legislation could be met by developing a
brochure that provides general information on competitive integrated employment, resources to
obtain and secure assistive technologies to help an individual go to work (which would include
Rehabilitation Technology devices and services under the VR program), information on how
earned income might affect their public benefits, and information about Achieving a Better Life
Experience (ABLE) accounts.
Since FSD would not know which households include an individual with a disability, to ensure
the brochure reached all potential disabled persons, FSD would complete a mass mailing of the
brochure to all participants active in FSD programs. In addition, a brochure will be provided by
RSB to clients’ age 16 and higher upon application for services. For Youth with Disabilities,
RSB will attend annual Individual Education Program (IEP) meetings when requested and it is
assumed the brochure could be provided at the annual IEP meetings.
Due to the Families First Coronavirus Response Act (HR 6201, Section 6008), MO HealthNet
(MHN) 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 Children’s Health Insurance Program (CHIP) under Title XXI. The
annual review process required in 42 CFR 435.916 and RSMo 208.147 is temporarily waived
while operating under the provisions of HR 6201, Section 6008. The number of MHN cases
included in the total number of FSD IM cases may be higher as this resulted in limited closings
after March 18, 2020. As of October 31, 2022 there were a combined total of 857,194 active
FSD Income Maintenance (IM) cases that would receive the informational brochure
annually. FSD calculated the cost to produce the brochure based on production costs of similar
brochures produced by the division at $0.10 per brochure, and mailing costs at the bulk-mailing
rate of $0.52 per item. It is estimated that the cost to produce and mail the informational
brochure to IM households would total $531,460 [(857,194*$0.10) + (857,194*$0.52) =
$531,460.28, rounded down)].
As of January 6, 2023, there are a total of 1,735 active RSB participants in all programs age 16
or higher. Of those, it is estimated that the majority prefers printed communication to be in large
print, with a minority requesting regular print or braille. Assuming 85% large print, 10% regular
print, and 5% braille, the RSB calculated the following amounts of the informational brochure
will be needed for the initial mailing: L.R. No. 0453S.10T
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FSD calculated the cost to produce the brochure based on production costs of similar brochures
produced by the division at $0.45 per brochure in regular print, $3.50 per brochure in large print,
and $5.00 per brochure in braille. The mailing costs are calculated at the bulk mailing rate of
$0.52 per item. It is estimated that the cost to produce and mail the informational brochure in the
following formats to RSB participants the first year would total $6,578 ($5,930+$168+$480).
$5,929.50, rounded up]
rounded up]
down]
As RSB receives approximately 1,800 new referrals a year, it is assumed that the following
amounts of informational brochures would be needed ongoing to provide to RSB clients during
the application process and at annual IEP meetings:
The RSB estimates the ongoing annual fiscal impact of $6,823 ($6,151+$175+$497) as follows:
up]
The total fiscal impact to the FSD as a result of the provisions of this legislation is a one-time
cost of $6,578 and an ongoing cost of $538,283 annually (split between GR & Fed.).
In summary, FSD assumes a cost of $538,038 in FY 2024 and a cost of $538,283 in FY 2025 and
FY 2026 to provide for the implementation of the changes in this section of the proposal.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect cost
estimate as provided by FSD. L.R. No. 0453S.10T
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Officials from the Department of Corrections (DOC) defer to (OA) for the potential fiscal
impact of this proposal.
Oversight notes DOC’s deferral to OA for a statement of fiscal impact; for fiscal note purposes,
Oversight assumes no fiscal impact for DOC.
§210.1360 - Disclosures of identifiable information regarding certain children
Officials from DSS state §210.1360 prohibits disclosure of personally identifiable information
(PII) regarding any child under eighteen years of age who applies for or receives any services
through a state program. The section does not prohibit a state agency from disclosing PII to
governmental entities or its agents, vendors, and contractors in connection to matters relating to
its official duties. Parents or legal guardians are not prevented from accessing the parent’s or
legal guardian’s child’s records.
Officials from the DSS, FSD
the program. Therefore, there is no fiscal impact to FSD.
Oversight does not have any information to the contrary. Therefore, Oversight will reflect a zero
impact in the fiscal note for DSS, FSD for this section.
§335.203.2 – Nursing education
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 – Nursing education
DHSS notes §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 L.R. No. 0453S.10T
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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
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)
Officials assume this legislation proposes the removal 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 L.R. No. 0453S.10T
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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
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.
§376.1060 - The delivery of health care services by dentists
None of the agencies responding to similar legislation (HCS for HB 100) indicated any direct
fiscal impact. (The Missouri Department of Conservation, the Missouri Department of
Transportation, the City of Kansas City, and the City of O’Fallon responded..)
Officials from the Department of Public Safety - Missouri Highway Patrol defer to the
Missouri Department of Transportation for the potential fiscal impact of this section of the
proposal.
Responses regarding the proposed legislation as a whole
Officials from the Department of Mental Health (DMH) state the anticipated fiscal impact to
DMH for Comprehensive Psychiatric Rehab (CPR), Comprehensive Substance Treatment and
Rehabilitation (CSTAR), Certified Community Behavioral Health Clinics (CCBHO) and
Developmental Disabilities (DD) waiver services are included in the DSS estimates.
Officials from the Office of Administration - Budget and Planning defer to the Department of
Social Services for the potential fiscal impact of this proposal.
Oversight notes DMH’s and OA, B&P’s deferral to DSS for a statement of fiscal impact; for
fiscal note purposes, Oversight assumes no fiscal impact for DMH or OA, B&P to the sections in
the underlying bill.
Officials from the Office of Attorney General (AGO)
arising from this proposal can be absorbed with existing personnel and resources. However, the
AGO may seek additional appropriations if there is a significant increase in litigation. L.R. No. 0453S.10T
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Oversight does not have any information to the contrary. Therefore, Oversight assumes the
AGO will be able to perform any additional duties required by this proposal with current staff
and resources and will reflect no fiscal impact to the AGO for fiscal note purposes.
Officials from the Department of Economic DevelopmentDepartment of Higher
Education and Workforce Development, the Department of Labor and Industrial
Relations, the Department of Natural Resources, the Department of Public Safety (Office of
the Director, Capitol Police, Division of Alcohol and Tobacco Control, Fire Safety, Gaming
Commission, State Emergency Management Agency and the Veterans Commission), the
Joint Committee On Education, the Joint Committee on Public Employee Retirement, the
Missouri Department of Conservation, the Missouri Ethics Commission, the Missouri
Department of Transportation, the MoDOT & Patrol Employees’ Retirement System, the
Missouri Consolidated Health Care Plan, the Missouri Higher Education Loan Authority,
the Missouri House of Representatives, the Missouri Lottery Commission, the Missouri
National Guard, the Missouri Office of Prosecution Services the Missouri Senate
Missouri State Employee's Retirement System, the Office of Administration
(Administrative Hearing Commission), the Office of the Governor, the Office of the State
Courts AdministratorOffice of the State Public Defender, the Oversight Division, the
State Tax Commission, the City of Kansas City, the City of Springfield, the Kansas City
Health Department, , the Newton County Health Department, the
Phelps County Sheriff’s Department, the St. Louis County Police 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.
Oversight only reflects the responses received from state agencies and political subdivisions;
however, other County and City Health Departments nursing homes, county prosecutors, cities,
counties, county clerks, sheriffs, police departments, fire protection districts, EMS services,
schools and colleges 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.
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 L.R. No. 0453S.10T
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office can sustain with the 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 Government
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
GENERAL
REVENUE FUND
Cost – OA (§37.980)
General Assembly
Report and update to
MoCareers p. 4($51,578)$0$0$0
Cost – DESE (§37.980)
Implementation of
Missouri as a Model
Employer program
changes p. 4
Could
exceed…
Personal service ($44,980)($55,056)($56,157)($56,157) Fringe benefits($29,815)($36,182)($36,594)($36,594) Equipment and
expense($9,642)($6,180)($6,304)($6,304)
Total Costs – DESE
($84,437)($97,418)($99,055)
Could exceed
($99,055)
FTE Changes1 FTE1 FTE1 FTE1 FTECost – MDA (§§37.980
& 209.700)
Implementation of
certain targeted work
programs p. 4
Could
exceed…
Personal service ($60,000)($61,200)($62,424)($62,424) Fringe benefits($38,032)($38,481)($38,939)($38,939) Equipment and
expense($15,896)($5,082)($5,184)($5,184)
Total Costs – DESE
($113,928)($104,763)($106,547)
Could exceed
($106,547)
FTE Changes1 FTE1 FTE1 FTE1 FTE L.R. No. 0453S.10T
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Transfer to – Health
Professional Loan
Incentive Fund –
appropriations
(§191.430) p. 7-8
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
Transfer-out – to
Medical Residency
Grant Program Fund
(§191.592) p. 5
(Could exceed
$1,114,627)
(Could exceed
$2,110,572)
(Could exceed
$3,113,372)
(Could exceed
$3,113,372)
Costs – DSS, FSD
(§208.035) Transitional
Benefits
Could
exceed…
Personal service p. 13($110,123)($133,469)($134,804)($134,804) Fringe benefits($79,138)($95,448)($95,935)($95,935) Equipment and
expense($48,186)($33,585)($34,425)($34,425)
SNAP additional
annual mailings p. 11($7,023)($8,428)($8,428)($8,428)
TANF additional
mailings p. 12($3,498)($4,197)($4,197)($4,197)
SNAP transitional
benefits p. 10-11
$0 or Up to
($11,993,920
to
$59,969,600)
$0 or Up to
($14,392,704
to
$71,963,520)
$0 or Up to
($14,392,704
to
$71,963,520)
$0 or Up to
($14,392,704
to
$71,963,520)
TANF transitional
benefits p. 11-12
Up to
($1,170,440 to
$5,892,560)
($1,408,705 to
Unknown)
($1,408,705 to
Unknown)
($1,408,705 to
Unknown)
EBT vendor costs p.
13 ($4,000)($4,000)($4,000)($4,000)
Total Costs – DSS, FSDCould exceed
($13,416,328
to
$66,114,128)
Could exceed
($1,687,832 to
$73,651,352)
Could exceed
($1,690,494 to
$73,654,014)
Could exceed
($1,690,494 to
$73,654,014)
FTE Changes3 FTE3 FTE3 FTE3 FTE L.R. No. 0453S.10T
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Costs – DSS, DLS
(§208.035) p. 13-14
Could
exceed…
Personal service($30,410 to
$60,820)
($36,857 to
$73,714)
($37,226to
$74,451)
($37,226to
$74,451)
Fringe benefits($17,588 to
$35,175)
($21,239 to
$42,477)
($21,373 to
$42,746)
($21,373 to
$42,746)
Equipment and
expense
($6,165 to
$12,329)
($5,598 to
$11,195)
($5,738to
$11,475)
($5,738to
$11,475)
Total Costs – DSS, DLS
($54,162 to
$108,324)
($63,693 to
$127,386)
($64,336 to
$128,672)
Could exceed
($64,336 to
$128,672)
FTE Changes0.5 to 1 FTE0.5 to 1 FTE0.5 to 1 FTE0.5 to 1 FTECosts – OA, ITSD/DSS
(§208.035) FAMIS
updates for SNAP and
TANF p. 14($27,702)($5,679)($5,821)
Could exceed
($5,821)
Costs – DESE, Office of
Childhood (§208.053) p.
16-17
Could
exceed…
Could
exceed…
Could
exceed…
Could
exceed…
Personal service($677,664)($691,217)($705,042)($705,042) Fringe benefits($502,890)($507,960)($513,132)($513,132) Equipment and
expense($206,203)($144,768)($146,746)($146,746)
Total Costs - DESE,
Office of Childhood
Could exceed
($1,386,757)
Could exceed
($1,343,945)
Could exceed
($1,364,920)
Could exceed
($1,364,920)
FTE Changes16 FTE16 FTE16 FTE16 FTECosts – DESE, Office of
Childhood (§208.053)
Child Care Subsidy
Distributions p. 15-16
($102,784,933)($123,341,920)($123,341,920)($123,341,920)
Cost – OA, ITSD/DESE
p. (§208.053) Changes
to CCDS p. 17
($112,860 to
Unknown)
($23,136 to
Unknown)
($23,714 to
Unknown)
($23,714 to
Unknown) L.R. No. 0453S.10T
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Costs – DSS/FSD
(§208.066) p. 20
Up to…Up to…Up to…
Up to and
could
exceed…
Personal service($203,720)($246,909)($249,378)($249,378) Fringe benefits($139,259)($168,002)($168,903)($168,903) Equipment and
expense($86,843)($55,975)($57,375)($57,375)
One-time mailing
costs p. 20($222,754)$0$0$0
Total Costs - DSS/FSD
($222,754 to
$652,576)
Up to
($470,886)
Up to
($475,656)
Up to and
could exceed
($475,656)
FTE Change -
DSS/FSD5 FTE5 FTE5 FTE5 FTE
Costs – OA, ITSD/DSS
(§208.066) FAMIS
interface updates p. 21 ($20,725)($4,248)($4,355)
Could exceed
($4,355)
Costs – DOR
(§208.066) p. 21
Could
exceed…
Personal service
(FTE)($130,000)($159,120)($162,302)($162,302)
Fringe benefits (FTE)($112,366)($135,977)($137,138)($137,138)Recurring expense
(FTE)($2,329)($2,851)(2,908)(2,908)
Personal service
(Temps)($1,020,000)($1,248,480)($1,273,450)($1,273,450)
Social Security and
Medicare benefits
(Temps)($372,096)($455,445)($464,554)($464,554)
Equipment and
expense (Temps)($108,447)($59,299)($60,485)($60,485)
Forms and system
updates p. 22($160,000)$0$0$0
Paper p. 23($28,700)($35,129)($35,831)($35,831) Printers p. 23(Unknown)$0$0$0 L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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June 21, 2023
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Costs – DOR
(§208.066) continued p.
21-24
Could
exceed…
Postage/ mailing p. 23 (Unknown)(Unknown)(Unknown)(Unknown) Interest p. 24(Unknown to
could exceed
$100,000)
(Unknown to
could exceed
$100,000)
(Unknown to
could exceed
$100,000)
(Unknown to
could exceed
$100,000)
Total Costs – DOR(Unknown to
could exceed
$2,033,938)
(Unknown to
could exceed
$2,196,301)
(Unknown to
could exceed
$2,236,668)
(Unknown to
could exceed
$2,236,668)
FTE Change – DOR5 FTE5 FTE5 FTE5 FTECosts - DSS (§208.146)
Increase in state share of
Ticket to Work Health
Assurance Program
costs p. 28-29($1,131,267)($1,234,050)($215,571)$0
Costs - DSS/MHD
(§208.146) MMIS
system updates p. 28($63,000)$0$0$0
Costs - OA, ITSD/DSS
(§208.146) FAMIS
system updates p. 29($12,722)$0$0$0
Costs – DSS/MHD
(§§208.151 and
208.662) new ME codes
for Post-partum
Extension p. 33($80,886)$0$0$0
Costs - DSS/MHD
(§§208.151 and
208.662) Program
distributions for Post-
partum Extension p. 33($4,141,782)($10,472,952)($11,038,490)
Could exceed
($11,038,490) L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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June 21, 2023
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Costs – DSS/DLS
(§§208.151 and
208.662) p. 33
Could
exceed…
Personal service($72,984)($73,714)($74,451)($74,451) Fringe benefits($42,211)($42,477)($42,746)($42,746) Equipment and
expense($17,929)($11,195)($11,475)($11,475)
Total Costs - DSS/DLS
($133,124)($127,386)($128,672)
Could exceed
($128,672)
FTE Changes1 FTE1 FTE1 FTE1 FTECosts – OA,ITSD/DSS
(§§208.151 and
208.662) MEDES
system changes for
Post-partum Extension
p. 34-35($200,329) $0$0$0
Cost – OA (§209.700)
p. 37
Could
exceed…
Personal service($210,752)($257,960)($263,119)($263,119) Fringe Benefits($130,796)($158,847)($160,777)($160,777) Equipment($15,395)$0$0$0Total Cost – OA
($356,943)($416,807)($423,896)
Could exceed
($423,896)
FTE Change – OA4 FTE4 FTE4 FTE4 FTECost – DSS - (§209.700)
Brochure development
and mailing p. 38-39 ($242,117)($242,227)($242,227) ($242,227)
ESTIMATED NET
EFFECT ON THE
GENERAL
REVENUE FUND
Could exceed
($127,786,899
to
$180,968,682)
Could exceed
($143,472,929
to
$215,971,027)
Could exceed
($144,100,058
to
$216,603,569)
Could exceed
($144,100,058
to
$216,603,569) L.R. No. 0453S.10T
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Estimated Net FTE
Change on the General
Revenue Fund34.5 to 35 34.5 to 3534.5 to 3534.5 to 35
FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
HEALTH
PROFESSIONAL
LOAN INCENTIVE
FUND
Transfer in – from
General Revenue –
appropriations
(§191.450) p. 7-8$0 to Unknown$0 to Unknown$0 to Unknown$0 to Unknown
Income – DHSS
(§§191.430 – 191.831) -
Loan repayments/
penalties for breach of
contract p. 7-8$0 to Unknown$0 to Unknown$0 to Unknown$0 to Unknown
Costs – DHSS – Loans
to health professionals
(§§191.430 - 191.831)
p. 7-8
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATED NET
EFFECT ON THE
HEALTH
PROFESSIONAL
LOAN INCENTIVE
FUND* $0$0$0$0
*Income/appropriations and costs of loans distributed net to $0. L.R. No. 0453S.10T
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
MEDICAL
RESIDENCY GRANT
PROGRAM FUND
Transfer-in – from
General Revenue
(§191.592) p. 5
Could exceed
$1,114,627
Could exceed
$2,110,572
Could exceed
$3,113,372
Could exceed
$4,115,326
Income – gifts,
contributions, grants or
bequests p. 5
$0 or
Unknown
$0 or
Unknown
$0 or
Unknown
$0 or
Unknown
Transfer-in – from
Colleges and
Universities – grant
repayments p. 5$0$0 to Unknown$0 to Unknown$0 to Unknown
Costs – DHSS
(§191.592) p. 5Could exceed...Could exceed...Could exceed...Could exceed...
Personal service($63,999)($64,639)($66,585) ($67,916) Fringe benefits($39,529)($39,769)($40,497)($40,995) Equipment and
expense($11,099)($6,164)($6,290)($6,415)
Medical education
grants($1,000,000)($2,000,000)($3,000,000)($4,000,000)
Total Costs - DHSS($1,114,627)($2,110,572)($3,113,372)($4,115,326) FTE Change – DHSSCould exceed 1
FTE
Could 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
$0 to
Unknown L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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Estimated Net FTE
Change on the Medical
Residency Grant
Program Fund
Could exceed 1
FTE
Could exceed 1
FTE
Could exceed 1
FTE
Could exceed 1
FTE
FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
NURSE LOAN FUNDLoss – DHSS
(§§<335.212 -
335.242>) Loss of
educational surcharge
collection p. 41-42($66,000)($1,300,000)($66,000)($1,300,000)
ESIMATED NET
EFFECT ON THE
NURSE LOAN FUND($66,000)($1,300,000)($66,000)($1,300,000)
BOARD OF
NURSING FUND
(0635)
Could
exceed…
Revenue – DCI
(§335.205) - Nursing
Education Incentive
Program Surcharge p.
40-41$56,120$1,211,515$57,465$1,211,515
ESTIMATED NET
EFFECT TO THE
BOARD OF
NURSING FUND$56,120$1,211,515$57,465 $1,211,515 L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
COLLEGES AND
UNIVERSITIES
Income – Colleges and
Universities (§191.592)
increase in tuition and
fees p. 5-6$0 to Unknown$0 to Unknown$0 to Unknown$0 to Unknown
Income – Colleges &
Universities (§§191.430
- 191.831) increase in
tuition and fees p. 8-9$0 to Unknown$0 to Unknown$0 to Unknown$0 to Unknown
Transfer-out – to
Medical Residency
Grant Program Fund
from Colleges and
Universities (§191.592)
grant repayments p. 5-6$0
$0 to
(Unknown)
$0 to
(Unknown)
$0 to
(Unknown)
ESTIMATE NET
EFFECT ON
COLLEGES AND
UNIVERSITIES
$0 to
Unknown
$0 to
Unknown
$0 to
Unknown
$0 to
Unknown
FEDERAL FUNDSIncome – DSS, FSD
(§208.035) Transitional
benefits program
reimbursements p. 10-
13
(Could
significantly
exceed
$12,242,390 to
$60,218,070)
(Could
significantly
exceed
$274,930 to
$72,238,450)
(Could
significantly
exceed
$277,592 to
$72,241,112)
(Could
significantly
exceed
$277,592 to
$72,241,112)
Income – DSS, DLS
(§208.035) Transitional $0 to $54,162$0 to $63,693$0 to $64,336
Could exceed
$0 to $64,336 L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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June 21, 2023
KP:LR:OD
benefits program
reimbursements p. 13-
14
FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Income – OA,
ITSD/DSS (§208.035)
Reimbursement FAMIS
updates for SNAP and
TANF p. 14$27,702 $5,679 $5,821
Could exceed
$5,821
Income – DSS, FSD
(§208.066) Program
reimbursements p. 20
$222,754 to
$652,576
Up to
$470,886
Up to
$475,656
Up to and
could exceed
$475,656
Income – OA,
ITSD/DSS (§208.066)
Reimbursement for
FAMIS interface
updates p. 21$20,725$4,248$4,355
Could exceed
$4,355
Income - DSS
(§208.146) Increase in
program
reimbursements p. 28-
29$1,898,999$2,000,283$352,594$0
Income - DSS/MHD
(§208.146) MMIS
system update
reimbursements p. 28$63,000$0$0$0
Income - OA,
ITSD/DSS (§208.146)
FAMIS system update
reimbursements p. 29$12,722$0$0$0
Income - DSS/MHD
(§§208.151 and
208.662) $8,127,333$20,334,377$21,432,434
Could exceed
$21,432,434 L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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Reimbursement for
Post-partum Extension
p. 33
FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Income – DSS/MHD
(§§208.151 and
208.662)
Reimbursement for new
ME codes for Post-
partum Extension p. 33$242,663$0$0$0
Income –
OA,ITSD/DSS
(§§208.151 and
208.662)
Reimbursement for
MEDES system changes
for Post-partum
Extension p. 34-35$600,984$0$0$0
Income – DSS -
(§209.700) Brochure
development and
mailing p. 38-39$297,434$296,056$296,056$296,056
Costs – DSS, FSD
(§208.035) Transitional
Benefits
Could
exceed…
Personal service p. ($110,123)($133,469)($134,804)($134,804) Fringe benefits($79,138)($95,448)($95,935)($95,935) Equipment and
expense($48,186)($33,585)($34,425)($34,425)
SNAP additional
annual mailings p. ($7,023)($8,428)($8,428)($8,428)
SNAP transitional
benefits p.
$0 or Up to
($11,993,920
to
$59,969,600)
$0 or Up to
($14,392,704
to
$71,963,520)
$0 or Up to
($14,392,704
to
$71,963,520)
$0 or Up to
($14,392,704
to
$71,963,520)
EBT vendor costs p. ($4,000)($4,000)($4,000)($4,000) L.R. No. 0453S.10T
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June 21, 2023
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Costs – DSS, FSD
(§208.035) continued p.
10-13
Could
exceed…
Total Costs – DSS, FSD (Could
significantly
exceed
$12,242,390 to
$60,218,070)
(Could
significantly
exceed
$274,930 to
$72,238,450)
(Could
significantly
exceed
$277,592 to
$72,241,112)
(Could
significantly
exceed
$277,592 to
$72,241,112)
FTE Changes3 FTE3 FTE3 FTE3 FTECosts – DSS, DLS
(§208.035) p. 13-14
Could
exceed…
Personal service($0 to $30,410)($0 to $36,857)($0 to $37,226)($0 to $37,226) Fringe benefits($0 to $35,175)($0 to $21,239)($0 to $21,373)($0 to $21,373) Equipment and
expense($0 to $6,165)($0 to $5,598)($0 to $5,738)($0 to $5,738)
Total Costs – DSS, DLS
($0 to $54,162)($0 to $63,693)($0 to $64,336)
Could exceed
($0 to $64,336)
FTE Changes0 to 0.5 FTE0 to 0.5 FTE0 to 0.5 FTE0 to 0.5 FTECosts – OA, ITSD/DSS
(§208.035) FAMIS
updates for SNAP and
TANF p. 14($27,702)($5,679)($5,821)
Could exceed
($5,821)
Costs – DSS/FSD
(§208.066) p. 20
Up to…Up to…Up to…
Up to and
could
exceed…
Personal service($203,720)($246,909)($249,378)($249,378) Fringe benefits($139,259)($168,002)($168,903)($168,903) Equipment and
expense($86,843)($55,975)($57,375)($57,375) L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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June 21, 2023
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FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Costs – DSS, FSD
(§208.066) continued p.
Could
exceed…
Costs – DSS, FSD
(§208.066) One-time
mailing costs p. 20($222,754)$0$0$0
Total Costs - DSS/FSD
($222,754 to
$652,576)
Up to
($470,886)
Up to
($475,656)
Up to and
could exceed
($475,656)
FTE Change -
DSS/FSD5 FTE5 FTE5 FTE5 FTE
Costs – OA, ITSD/DSS
(§208.066) FAMIS
interface updates p. 21($20,725)($4,248)($4,355)
Could exceed
($4,355)
Costs - DSS (§208.146)
Increase in program
expenditures p. 28-29($1,898,999)($2,000,283)($352,594)$0
Costs - DSS/MHD
(§208.146) MMIS
system update
expenditures p. 28($63,000)$0$0$0
Costs - OA, ITSD/DSS
(§208.146) FAMIS
system update
expenditures p. 29 ($12,722)$0$0$0
Costs - DSS/MHD
(§§208.151 and
208.662) Program
distributions for Post-
partum Extension p. 33($8,127,333)($20,334,377)($21,432,434)
Could exceed
($21,432,434) L.R. No. 0453S.10T
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Page 58 of 63
June 21, 2023
KP:LR:OD
Costs – DSS/MHD
(§§208.151 and 208.662)
New ME codes for Post-
partum Extension p. 33($242,663)$0$0$0
FISCAL IMPACT –
State Government -
continued
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
Costs – OA,ITSD/DSS
(§§208.151 and
208.662) MEDES
system changes for
Post-partum Extension
p. 34-35($600,984)$0$0$0
Cost – DSS - (§209.700)
Brochure development
and mailing p. 38-39 ($297,434)($296,056)($296,056)($296,056)
ESTIMATED NET
EFFECT ON
FEDERAL FUNDS$0$0$0$0
Estimated Net FTE
Change on Federal
Funds8 to 8.58 to 8.58 to 8.58 to 8.5
FISCAL IMPACT –
Local Government
FY 2024FY 2025FY 2026Fully
Implemented
(FY 2027)
$0$0$0$0
FISCAL IMPACT – Small Business
This proposal could directly impact small business health care providers. (§§191.430 – 191.831)
FISCAL DESCRIPTION
This bill requires the Office of Administration to submit a report to the General Assembly by
December 31st of each year beginning in 2023. The report's content is specified in the bill and L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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June 21, 2023
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relates to the "Missouri as a Model Employer" initiative under executive order 19-16 (§37.980).
This bill establishes the Health Professional Loan Repayment Program within the Department of
Health and Senior Services, offering forgivable loans to pay off existing student loans and other
education expenses for health care, mental health, and public health professionals.
The Department of Health and Senior Services is the chief administrative agency and is
responsible for oversight and rulemaking of the program, the Director shall be in charge of
determining who will receive forgivable health professional loans, and the professionals or
disciplines that receive funding in any given year are contingent on consultation with the
Department of Mental Health and the Department of Higher Education and Workforce
Development.
The Department will enter into a written contract with each qualifying individual for a forgivable
loan, the provisions of which are specified in the bill. The contract shall include an agreement
that the individual serve for a period equal to at least two years in an area of defined need, in
order for the loan to be forgiven. The Department of Health and Senior Services will designate
counties, communities, or sections of areas in the state as "areas of defined need" for health care,
mental health, or public health services.
All health professional loans shall be made from funds appropriated to the health professional
loan incentive fund by the General Assembly, which also includes funds from an individual
and/or funds generated by loan repayments. Further stipulations of the fund may be found in the
bill.
This bill repeals an existing loan program for students enrolled in certain health care degree
programs (§§191.430 – 191.831).
This bill establishes, subject to appropriations, a transitional benefits program for Temporary
Assistance for Needy Families (TANF) and the Supplemental Nutrition Assistance Program
(SNAP). The transitional benefits are designed to assist any recipient, whose monthly income
has exceeded the maximum allowable income for program eligibility, to continue receiving
reduced benefits, as specified in the bill. Any recipient of transitional benefits must comply with
all requirements for each program that the recipient is eligible for, including work requirements.
Transitional benefits received under these provisions shall not be included in the lifetime limit
for TANF benefits (§208.035).
This bill modifies provisions relating to transitional child care benefits by expanding the Hand-
Up pilot program statewide for any individual whose income exceeds the maximum allowable
amount for the full child care subsidy benefit. Transitional child care benefits are reduced
benefits determined on a sliding scale as the recipient's income increases, with the recipient
paying the remainder of the fee to the child care provider (§208.053). L.R. No. 0453S.10T
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June 21, 2023
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The bill requires the Department of Social Services (DSS) to limit any initial application for
SNAP, TANF, child care assistance, or any medical assistance or health insurance program to a
concise, non-duplicative, and easily accessible form on the DSS website. Program participants
who are required to complete a periodic eligibility review form may submit the form as an
attachment to their Missouri state individual income tax return if the form is due at the same time
as the tax return. The eligibility forms must be available and easily accessible on the Department
of Revenue's website (§208.066).
The Ticket to Work Health Assurance Program provides medical assistance through MO
HealthNet for employed disabled persons who meet certain qualifications, including asset limits
and earned, net, and gross income calculations. This bill modifies the Program as follows:
(1) Excludes retirement accounts from asset limit calculations;
(2) Modifies the income calculation from a net/gross calculation to a broader definition that
would consider income for those disabled persons with incomes up to 250% FPL, with earned
income of the disabled worker from 250% to 300% FPL disregarded, and retaining the
requirement that persons with incomes over 100% FPL pay a premium;
(3) Removes all earned income of the disabled worker from the list of disregards in income
determinations;
(4) Adds to the list of disregards the first $50,000 of earned income of a spouse;
(5) If the Department elects to pay the person's costs of employer-sponsored health insurance,
MO HealthNet assistance shall be provided as a secondary or supplemental policy for only
personal care assistance services and non-emergency medical transportation; and
(6) The Department shall provide an annual report to the General
Assembly concerning the number of participants and outreach and education efforts (§208.146).
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. A
woman shall be enrolled in benefits under this program when her child is enrolled in MO
HealthNet or the Children's Health Insurance Program (CHIP) or when a physician or the
managed care plan notifies the MO HealthNet program of the pregnancy ending involuntarily or
necessarily to save the life of the mother. No woman who knowingly receives services that are in
violation of state law shall be eligible for benefits under this program. The Department shall
submit any necessary state plan amendments or waivers, as described in the act (§208.151 and
§208.662).
The bill also establishes the "Missouri Employment First Act". The Act specifies that all state
agencies that provide employment-related services or services or support to persons with
disabilities are required to coordinate with other agencies, promote competitive integrated
employment, and implement an employment-first policy when providing services to persons with
disabilities of working age. In addition, state agencies will offer specified information to all L.R. No. 0453S.10T
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Page 61 of 63
June 21, 2023
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working-age persons with disabilities and to the parents or guardians of youth with a disability,
as explained in the bill (§209.700).
The "Nursing Education Incentive Program" within the State Board of Nursing is a program that
awards grants to eligible institutions of higher education based on criteria jointly determined by
the Board and the Department of Higher Education and Workforce Development. There is
currently a cap on the grants of $150,000. This bill removes that cap.
This bill also creates a new nursing education incentive program surcharge for initial license
applications and renewal applications for nurses. Practical nurses will pay a $1 fee per year and
registered professional nurses will pay $5 per year. The fee will be deposited in the State Board
of Nursing Fund. This bill also repeals both the Nursing Student Loan Program and the Nursing
Student Loan Repayment Program. (§§335.203 and 335.205)
This proposal contains an emergency clause for sections 208.151, 208.662, 208.186, 208.239 and
191.592.
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
Attorney General’s Office
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
Office of the Director
Division of Alcohol and Tobacco Control
Capitol Police
Fire Safety
Missouri Gaming Commission
Missouri Highway Patrol
Missouri National Guard
State Emergency Management Agency
Missouri Veterans Commission
Department of Social Services L.R. No. 0453S.10T
Bill No. Truly Agreed To and Finally Passed CCS for HCS for SS for SCS for SB Nos. 45 & 90
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Joint Committee on Administrative Rules
Joint Committee on Education
Joint Committee on Public Employee Retirement
Missouri Lottery Commission
Oversight Division
Missouri Consolidated Health Care Plan
Missouri Department of Agriculture
Missouri Department of Conservation
Missouri Ethics Commission
Missouri Higher Education Loan Authority
Missouri House of Representatives
Missouri Department of Transportation
Missouri State Employee's Retirement System
MoDOT & Patrol Employees’ Retirement System
Missouri Office of Prosecution Services
Office of Administration
Administrative Hearing Commission
Division of Personnel
Office of the Governor
Office of the State Courts Administrator
Missouri Senate
Office of the Secretary of State
Office of the State Public Defender
State Tax Commission
City of Kansas City
City of Springfield
Kansas City Health Department
Missouri State University L.R. No. 0453S.10T
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June 21, 2023
KP:LR:OD
Newton County Health Department
Phelps County Sheriff’s Department
St. Louis County Police Department
University of Central Missouri
University of Missouri Health Care System
Julie MorffRoss StropeDirectorAssistant DirectorJune 21, 2023June 21, 2023