FIRST REGULAR SESSION
[TRULY AGREED TO AND FINALLY PASSED ]
SENATE SUBSTITUTE NO. 2 FOR
SENATE COMMITTEE SUBSTITUTE FOR
SENATE BILLS NOS. 49, 236 &
164
102ND GENERAL ASSEMBLY
2023
0202S.20T
AN ACT
To repeal sections 208.152, 217.230, and 221.120, RSMo, and to enact in lieu thereof four new
sections relating to gender transition procedures.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Sections 208.152, 217.230, and 221.120, RSMo, 1
are repealed and four new sections enacted in lieu thereof, to 2
be known as sections 191.1720, 208.152, 217.230, and 22 1.120, 3
to read as follows:4
191.1720. 1. This section shall be known and may be 1
cited as the "Missouri Save Adolescents from Experimentation 2
(SAFE) Act". 3
2. For purposes of this section, the following terms 4
mean: 5
(1) "Biological sex", the biological indication of 6
male or female in the context of reproductive potential or 7
capacity, such as sex chromosomes, naturally occurring sex 8
hormones, gonads, and nonambiguous internal and external 9
genitalia present at birth, without regard to a n 10
individual's psychological, chosen, or subjective experience 11
of gender; 12 SS#2 SCS SBs 49, 2
236 & 164
(2) "Cross-sex hormones", testosterone, estrogen, or 13
other androgens given to an individual in amounts that are 14
greater or more potent than would normally occur naturally 15
in a healthy individual of the same age and sex; 16
(3) "Gender", the psychological, behavioral, social, 17
and cultural aspects of being male or female; 18
(4) "Gender transition", the process in which an 19
individual transitions from identifying with and living as a 20
gender that corresponds to his or her biological sex to 21
identifying with and living as a gender different from his 22
or her biological sex, and may involve social, legal, or 23
physical changes; 24
(5) "Gender transition surgery", a surgi cal procedure 25
performed for the purpose of assisting an individual with a 26
gender transition, including, but not limited to: 27
(a) Surgical procedures that sterilize, including, but 28
not limited to, castration, vasectomy, hysterectomy, 29
oophorectomy, orchiectomy, or penectomy; 30
(b) Surgical procedures that artificially construct 31
tissue with the appearance of genitalia that differs from 32
the individual's biological sex, including, but not limited 33
to, metoidioplasty, phalloplasty, or vaginoplasty; or 34
(c) Augmentation mammoplasty or subcutaneous 35
mastectomy; 36
(6) "Health care provider", an individual who is 37
licensed, certified, or otherwise authorized by the laws of 38
this state to administer health care in the ordinary course 39
of the practice of his or her profession; 40
(7) "Puberty-blocking drugs", gonadotropin -releasing 41
hormone analogues or other synthetic drugs used to stop 42
luteinizing hormone secretion and follicle stimulating 43
hormone secretion, synthetic antiandrogen drugs to block the 44 SS#2 SCS SBs 49, 3
236 & 164
androgen receptor, or any other drug used to delay or 45
suppress pubertal development in children for the purpose of 46
assisting an individual with a gender transition. 47
3. A health care provider shall not knowingly perform 48
a gender transition surgery on any individual under eighteen 49
years of age. 50
4. (1) A health care provider shall not knowingly 51
prescribe or administer cross -sex hormones or puberty - 52
blocking drugs for the purpose of a gender transition for 53
any individual under eigh teen years of age. 54
(2) The provisions of this subsection shall not apply 55
to the prescription or administration of cross -sex hormones 56
or puberty-blocking drugs for any individual under eighteen 57
years of age who was prescribed or administered such 58
hormones or drugs prior to August 28, 2023, for the purpose 59
of assisting the individual with a gender transition. 60
(3) The provisions of this subsection shall expire on 61
August 28, 2027. 62
5. The performance of a gender transition surgery or 63
the prescription or administration of cross -sex hormones or 64
puberty-blocking drugs to an individual under eighteen years 65
of age in violation of this section shall be considered 66
unprofessional conduct and any health care provider doing so 67
shall have his or her license to practice revoked by the 68
appropriate licensing entity or disciplinary review board 69
with competent jurisdiction in this state. 70
6. (1) The prescription or administration of cross - 71
sex hormones or puberty -blocking drugs to an individua l 72
under eighteen years of age for the purpose of a gender 73
transition shall be considered grounds for a cause of action 74
against the health care provider. The provisions of chapter 75 SS#2 SCS SBs 49, 4
236 & 164
538 shall not apply to any action brought under this 76
subsection. 77
(2) An action brought pursuant to this subsection 78
shall be brought within fifteen years of the individual 79
injured attaining the age of twenty -one or of the date the 80
treatment of the injury at issue in the action by the 81
defendant has ceased, whichever i s later. 82
(3) An individual bringing an action under this 83
subsection shall be entitled to a rebuttable presumption 84
that the individual was harmed if the individual is 85
infertile following the prescription or administration of 86
cross-sex hormones or puberty-blocking drugs and that the 87
harm was a direct result of the hormones or drugs prescribed 88
or administered by the health care provider. Such 89
presumption may be rebutted only by clear and convincing 90
evidence. 91
(4) In any action brought pursu ant to this subsection, 92
a plaintiff may recover economic and noneconomic damages and 93
punitive damages, without limitation to the amount and no 94
less than five hundred thousand dollars in the aggregate. 95
The judgment against a defendant in an action brou ght 96
pursuant to this subsection shall be in an amount of three 97
times the amount of any economic and noneconomic damages or 98
punitive damages assessed. Any award of damages in an 99
action brought pursuant to this subsection to a prevailing 100
plaintiff shall include attorney's fees and court costs. 101
(5) An action brought pursuant to this subsection may 102
be brought in any circuit court of this state. 103
(6) No health care provider shall require a waiver of 104
the right to bring an action pursuant to thi s subsection as 105
a condition of services. The right to bring an action by or 106 SS#2 SCS SBs 49, 5
236 & 164
through an individual under the age of eighteen shall not be 107
waived by a parent or legal guardian. 108
(7) A plaintiff to an action brought under this 109
subsection may enter i nto a voluntary agreement of 110
settlement or compromise of the action, but no agreement 111
shall be valid until approved by the court. No agreement 112
allowed by the court shall include a provision regarding the 113
nondisclosure or confidentiality of the terms o f such 114
agreement unless such provision was specifically requested 115
and agreed to by the plaintiff. 116
(8) If requested by the plaintiff, any pleadings, 117
attachments, or exhibits filed with the court in any action 118
brought pursuant to this subsection, a s well as any 119
judgments issued by the court in such actions, shall not 120
include the personal identifying information of the 121
plaintiff. Such information shall be provided in a 122
confidential information filing sheet contemporaneously 123
filed with the court or entered by the court, which shall 124
not be subject to public inspection or availability. 125
7. The provisions of this section shall not apply to 126
any speech protected by the First Amendment of the United 127
States Constitution. 128
8. The provisions of this section shall not apply to 129
the following: 130
(1) Services to individuals born with a medically - 131
verifiable disorder of sex development, including, but not 132
limited to, an individual with external biological sex 133
characteristics that are irresol vably ambiguous, such as 134
those born with 46,XX chromosomes with virilization, 46,XY 135
chromosomes with undervirilization, or having both ovarian 136
and testicular tissue; 137 SS#2 SCS SBs 49, 6
236 & 164
(2) Services provided when a physician has otherwise 138
diagnosed an individual wit h a disorder of sex development 139
and determined through genetic or biochemical testing that 140
the individual does not have normal sex chromosome 141
structure, sex steroid hormone production, or sex steroid 142
hormone action; 143
(3) The treatment of any infec tion, injury, disease, 144
or disorder that has been caused by or exacerbated by the 145
performance of gender transition surgery or the prescription 146
or administration of cross -sex hormones or puberty -blocking 147
drugs regardless of whether the surgery was perfor med or the 148
hormones or drugs were prescribed or administered in 149
accordance with state and federal law; or 150
(4) Any procedure undertaken because the individual 151
suffers from a physical disorder, physical injury, or 152
physical illness that would, as ce rtified by a physician, 153
place the individual in imminent danger of death or 154
impairment of a major bodily function unless surgery is 155
performed. 156
208.152. 1. MO HealthNet payments shall be made on 1
behalf of those eligible needy person s as described in 2
section 208.151 who are unable to provide for it in whole or 3
in part, with any payments to be made on the basis of the 4
reasonable cost of the care or reasonable charge for the 5
services as defined and determined by the MO HealthNet 6
division, unless otherwise hereinafter provided, for the 7
following: 8
(1) Inpatient hospital services, except to persons in 9
an institution for mental diseases who are under the age of 10
sixty-five years and over the age of twenty -one years; 11
provided that the MO HealthNet division shall provide 12
through rule and regulation an exception process for 13 SS#2 SCS SBs 49, 7
236 & 164
coverage of inpatient costs in those cases requiring 14
treatment beyond the seventy -fifth percentile professional 15
activities study (PAS) or the MO HealthNet c hildren's 16
diagnosis length-of-stay schedule; and provided further that 17
the MO HealthNet division shall take into account through 18
its payment system for hospital services the situation of 19
hospitals which serve a disproportionate number of low - 20
income patients; 21
(2) All outpatient hospital services, payments 22
therefor to be in amounts which represent no more than 23
eighty percent of the lesser of reasonable costs or 24
customary charges for such services, determined in 25
accordance with the principles se t forth in Title XVIII A 26
and B, Public Law 89 -97, 1965 amendments to the federal 27
Social Security Act (42 U.S.C. Section 301, et seq.), but 28
the MO HealthNet division may evaluate outpatient hospital 29
services rendered under this section and deny payment for 30
services which are determined by the MO HealthNet division 31
not to be medically necessary, in accordance with federal 32
law and regulations; 33
(3) Laboratory and X-ray services; 34
(4) Nursing home services for participants, except to 35
persons with more than five hundred thousand dollars equity 36
in their home or except for persons in an institution for 37
mental diseases who are under the age of sixty -five years, 38
when residing in a hospital licensed by the department of 39
health and senior services or a nursing home licensed by the 40
department of health and senior services or appropriate 41
licensing authority of other states or government -owned and - 42
operated institutions which are determined to conform to 43
standards equivalent to licensing requireme nts in Title XIX 44
of the federal Social Security Act (42 U.S.C. Section 301, 45 SS#2 SCS SBs 49, 8
236 & 164
et seq.), as amended, for nursing facilities. The MO 46
HealthNet division may recognize through its payment 47
methodology for nursing facilities those nursing facilities 48
which serve a high volume of MO HealthNet patients. The MO 49
HealthNet division when determining the amount of the 50
benefit payments to be made on behalf of persons under the 51
age of twenty-one in a nursing facility may consider nursing 52
facilities furnishing care to persons under the age of 53
twenty-one as a classification separate from other nursing 54
facilities; 55
(5) Nursing home costs for participants receiving 56
benefit payments under subdivision (4) of this subsection 57
for those days, which shall not exceed twelve per any period 58
of six consecutive months, during which the participant is 59
on a temporary leave of absence from the hospital or nursing 60
home, provided that no such participant shall be allowed a 61
temporary leave of absence unless it is specifical ly 62
provided for in his plan of care. As used in this 63
subdivision, the term "temporary leave of absence" shall 64
include all periods of time during which a participant is 65
away from the hospital or nursing home overnight because he 66
is visiting a friend o r relative; 67
(6) Physicians' services, whether furnished in the 68
office, home, hospital, nursing home, or elsewhere; 69
(7) Subject to appropriation, up to twenty visits per 70
year for services limited to examinations, diagnoses, 71
adjustments, and manipulations and treatments of 72
malpositioned articulations and structures of the body 73
provided by licensed chiropractic physicians practicing 74
within their scope of practice. Nothing in this subdivision 75
shall be interpreted to otherwise expand MO Healt hNet 76
services; 77 SS#2 SCS SBs 49, 9
236 & 164
(8) Drugs and medicines when prescribed by a licensed 78
physician, dentist, podiatrist, or an advanced practice 79
registered nurse; except that no payment for drugs and 80
medicines prescribed on and after January 1, 2006, by a 81
licensed physician, dentist, podiatrist, or an advanced 82
practice registered nurse may be made on behalf of any 83
person who qualifies for prescription drug coverage under 84
the provisions of P.L. 108 -173; 85
(9) Emergency ambulance services and, effective 86
January 1, 1990, medically necessary transportation to 87
scheduled, physician -prescribed nonelective treatments; 88
(10) Early and periodic screening and diagnosis of 89
individuals who are under the age of twenty -one to ascertain 90
their physical or mental defec ts, and health care, 91
treatment, and other measures to correct or ameliorate 92
defects and chronic conditions discovered thereby. Such 93
services shall be provided in accordance with the provisions 94
of Section 6403 of P.L. 101 -239 and federal regulations 95
promulgated thereunder; 96
(11) Home health care services; 97
(12) Family planning as defined by federal rules and 98
regulations; provided, however, that such family planning 99
services shall not include abortions or any abortifacient 100
drug or device that is used for the purpose of inducing an 101
abortion unless such abortions are certified in writing by a 102
physician to the MO HealthNet agency that, in the 103
physician's professional judgment, the life of the mother 104
would be endangered if the fetus were car ried to term; 105
(13) Inpatient psychiatric hospital services for 106
individuals under age twenty -one as defined in Title XIX of 107
the federal Social Security Act (42 U.S.C. Section 1396d, et 108
seq.); 109 SS#2 SCS SBs 49, 10
236 & 164
(14) Outpatient surgical procedures, including 110
presurgical diagnostic services performed in ambulatory 111
surgical facilities which are licensed by the department of 112
health and senior services of the state of Missouri; except, 113
that such outpatient surgical services shall not include 114
persons who are elig ible for coverage under Part B of Title 115
XVIII, Public Law 89 -97, 1965 amendments to the federal 116
Social Security Act, as amended, if exclusion of such 117
persons is permitted under Title XIX, Public Law 89 -97, 1965 118
amendments to the federal Social Security Act, as amended; 119
(15) Personal care services which are medically 120
oriented tasks having to do with a person's physical 121
requirements, as opposed to housekeeping requirements, which 122
enable a person to be treated by his or her physician on an 123
outpatient rather than on an inpatient or residential basis 124
in a hospital, intermediate care facility, or skilled 125
nursing facility. Personal care services shall be rendered 126
by an individual not a member of the participant's family 127
who is qualified to provid e such services where the services 128
are prescribed by a physician in accordance with a plan of 129
treatment and are supervised by a licensed nurse. Persons 130
eligible to receive personal care services shall be those 131
persons who would otherwise require place ment in a hospital, 132
intermediate care facility, or skilled nursing facility. 133
Benefits payable for personal care services shall not exceed 134
for any one participant one hundred percent of the average 135
statewide charge for care and treatment in an intermed iate 136
care facility for a comparable period of time. Such 137
services, when delivered in a residential care facility or 138
assisted living facility licensed under chapter 198 shall be 139
authorized on a tier level based on the services the 140
resident requires an d the frequency of the services. A 141 SS#2 SCS SBs 49, 11
236 & 164
resident of such facility who qualifies for assistance under 142
section 208.030 shall, at a minimum, if prescribed by a 143
physician, qualify for the tier level with the fewest 144
services. The rate paid to providers for eac h tier of 145
service shall be set subject to appropriations. Subject to 146
appropriations, each resident of such facility who qualifies 147
for assistance under section 208.030 and meets the level of 148
care required in this section shall, at a minimum, if 149
prescribed by a physician, be authorized up to one hour of 150
personal care services per day. Authorized units of 151
personal care services shall not be reduced or tier level 152
lowered unless an order approving such reduction or lowering 153
is obtained from the reside nt's personal physician. Such 154
authorized units of personal care services or tier level 155
shall be transferred with such resident if he or she 156
transfers to another such facility. Such provision shall 157
terminate upon receipt of relevant waivers from the f ederal 158
Department of Health and Human Services. If the Centers for 159
Medicare and Medicaid Services determines that such 160
provision does not comply with the state plan, this 161
provision shall be null and void. The MO HealthNet division 162
shall notify the revisor of statutes as to whether the 163
relevant waivers are approved or a determination of 164
noncompliance is made; 165
(16) Mental health services. The state plan for 166
providing medical assistance under Title XIX of the Social 167
Security Act, 42 U.S.C. Se ction 301, as amended, shall 168
include the following mental health services when such 169
services are provided by community mental health facilities 170
operated by the department of mental health or designated by 171
the department of mental health as a community mental health 172
facility or as an alcohol and drug abuse facility or as a 173 SS#2 SCS SBs 49, 12
236 & 164
child-serving agency within the comprehensive children's 174
mental health service system established in section 175
630.097. The department of mental health shall establish by 176
administrative rule the definition and criteria for 177
designation as a community mental health facility and for 178
designation as an alcohol and drug abuse facility. Such 179
mental health services shall include: 180
(a) Outpatient mental health services including 181
preventive, diagnostic, therapeutic, rehabilitative, and 182
palliative interventions rendered to individuals in an 183
individual or group setting by a mental health professional 184
in accordance with a plan of treatment appropriately 185
established, implemented, mon itored, and revised under the 186
auspices of a therapeutic team as a part of client services 187
management; 188
(b) Clinic mental health services including 189
preventive, diagnostic, therapeutic, rehabilitative, and 190
palliative interventions rendered to indivi duals in an 191
individual or group setting by a mental health professional 192
in accordance with a plan of treatment appropriately 193
established, implemented, monitored, and revised under the 194
auspices of a therapeutic team as a part of client services 195
management; 196
(c) Rehabilitative mental health and alcohol and drug 197
abuse services including home and community -based 198
preventive, diagnostic, therapeutic, rehabilitative, and 199
palliative interventions rendered to individuals in an 200
individual or group setti ng by a mental health or alcohol 201
and drug abuse professional in accordance with a plan of 202
treatment appropriately established, implemented, monitored, 203
and revised under the auspices of a therapeutic team as a 204
part of client services management. As used in this 205 SS#2 SCS SBs 49, 13
236 & 164
section, mental health professional and alcohol and drug 206
abuse professional shall be defined by the department of 207
mental health pursuant to duly promulgated rules. With 208
respect to services established by this subdivision, the 209
department of social services, MO HealthNet division, shall 210
enter into an agreement with the department of mental 211
health. Matching funds for outpatient mental health 212
services, clinic mental health services, and rehabilitation 213
services for mental health and alcohol and drug abuse shall 214
be certified by the department of mental health to the MO 215
HealthNet division. The agreement shall establish a 216
mechanism for the joint implementation of the provisions of 217
this subdivision. In addition, the agreement shall 218
establish a mechanism by which rates for services may be 219
jointly developed; 220
(17) Such additional services as defined by the MO 221
HealthNet division to be furnished under waivers of federal 222
statutory requirements as provided for and authorized by the 223
federal Social Security Act (42 U.S.C. Section 301, et seq.) 224
subject to appropriation by the general assembly; 225
(18) The services of an advanced practice registered 226
nurse with a collaborative practice agreement to the extent 227
that such services are provi ded in accordance with chapters 228
334 and 335, and regulations promulgated thereunder; 229
(19) Nursing home costs for participants receiving 230
benefit payments under subdivision (4) of this subsection to 231
reserve a bed for the participant in the nursing h ome during 232
the time that the participant is absent due to admission to 233
a hospital for services which cannot be performed on an 234
outpatient basis, subject to the provisions of this 235
subdivision: 236 SS#2 SCS SBs 49, 14
236 & 164
(a) The provisions of this subdivision shall apply 237
only if: 238
a. The occupancy rate of the nursing home is at or 239
above ninety-seven percent of MO HealthNet certified 240
licensed beds, according to the most recent quarterly census 241
provided to the department of health and senior services 242
which was taken prior to when the participant is admitted to 243
the hospital; and 244
b. The patient is admitted to a hospital for a medical 245
condition with an anticipated stay of three days or less; 246
(b) The payment to be made under this subdivision 247
shall be provided for a maximum of three days per hospital 248
stay; 249
(c) For each day that nursing home costs are paid on 250
behalf of a participant under this subdivision during any 251
period of six consecutive months such participant shall, 252
during the same period of six consecutive months, be 253
ineligible for payment of nursing home costs of two 254
otherwise available temporary leave of absence days provided 255
under subdivision (5) of this subsection; and 256
(d) The provisions of this subdivision shall not apply 257
unless the nursing home receives notice from the participant 258
or the participant's responsible party that the participant 259
intends to return to the nursing home following the hospital 260
stay. If the nursing home receives such notification and 261
all other provisions of this subsection have been satisfied, 262
the nursing home shall provide notice to the participant or 263
the participant's responsible party prior to release of the 264
reserved bed; 265
(20) Prescribed medically necessary durable medical 266
equipment. An electronic web-based prior authorization 267
system using best medical evidence and care and treatment 268 SS#2 SCS SBs 49, 15
236 & 164
guidelines consistent with national standards shall be used 269
to verify medical need; 270
(21) Hospice care. As used in this subdivision, the 271
term "hospice care" means a coordinated program of active 272
professional medical attention within a home, outpatient and 273
inpatient care which treats the terminally ill patient and 274
family as a unit, employing a medically directed 275
interdisciplinary team. The program provides relief of 276
severe pain or other physical symptoms and supportive care 277
to meet the special needs arising out of physical, 278
psychological, spiritual, social, and economic stresses 279
which are experienced during the final stages of illness, 280
and during dying and bereavement and meets the Medicare 281
requirements for participation as a hospice as are provided 282
in 42 CFR Part 418. The rate of reimbursement paid by the 283
MO HealthNet division to the hospice provider for room and 284
board furnished by a nursing home to an eligible hospice 285
patient shall not be less than ninety -five percent of the 286
rate of reimbursement which would have been paid for 287
facility services in that nursing home facility for that 288
patient, in accordance with subsection (c) of Section 6 408 289
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 290
(22) Prescribed medically necessary dental services. 291
Such services shall be subject to appropriations. An 292
electronic web-based prior authorization system using best 293
medical evidence and care and treatment guidelines 294
consistent with national standards shall be used to verify 295
medical need; 296
(23) Prescribed medically necessary optometric 297
services. Such services shall be subject to 298
appropriations. An electronic web-based prior authorization 299
system using best medical evidence and care and treatment 300 SS#2 SCS SBs 49, 16
236 & 164
guidelines consistent with national standards shall be used 301
to verify medical need; 302
(24) Blood clotting products -related services. For 303
persons diagnosed with a bleeding d isorder, as defined in 304
section 338.400, reliant on blood clotting products, as 305
defined in section 338.400, such services include: 306
(a) Home delivery of blood clotting products and 307
ancillary infusion equipment and supplies, including the 308
emergency deliveries of the product when medically necessary; 309
(b) Medically necessary ancillary infusion equipment 310
and supplies required to administer the blood clotting 311
products; and 312
(c) Assessments conducted in the participant's home by 313
a pharmacist, nurse, or local home health care agency 314
trained in bleeding disorders when deemed necessary by the 315
participant's treating physician; 316
(25) The MO HealthNet division shall, by January 1, 317
2008, and annually thereafter, report the status of MO 318
HealthNet provider reimbursement rates as compared to one 319
hundred percent of the Medicare reimbursement rates and 320
compared to the average dental reimbursement rates paid by 321
third-party payors licensed by the state. The MO HealthNet 322
division shall, by July 1, 2008, provide to the general 323
assembly a four-year plan to achieve parity with Medicare 324
reimbursement rates and for third -party payor average dental 325
reimbursement rates. Such plan shall be subject to 326
appropriation and the division shall include in its annual 327
budget request to the governor the necessary funding needed 328
to complete the four -year plan developed under this 329
subdivision. 330
2. Additional benefit payments for medical assistance 331
shall be made on behalf of those eligible needy children , 332 SS#2 SCS SBs 49, 17
236 & 164
pregnant women and blind persons with any payments to be 333
made on the basis of the reasonable cost of the care or 334
reasonable charge for the services as defined and determined 335
by the MO HealthNet division, unless otherwise hereinafter 336
provided, for the following: 337
(1) Dental services; 338
(2) Services of podiatrists as defined in section 339
330.010; 340
(3) Optometric services as described in section 341
336.010; 342
(4) Orthopedic devices or other prosthetics, including 343
eye glasses, dentures, h earing aids, and wheelchairs; 344
(5) Hospice care. As used in this subdivision, the 345
term "hospice care" means a coordinated program of active 346
professional medical attention within a home, outpatient and 347
inpatient care which treats the terminally ill patient and 348
family as a unit, employing a medically directed 349
interdisciplinary team. The program provides relief of 350
severe pain or other physical symptoms and supportive care 351
to meet the special needs arising out of physical, 352
psychological, spiritua l, social, and economic stresses 353
which are experienced during the final stages of illness, 354
and during dying and bereavement and meets the Medicare 355
requirements for participation as a hospice as are provided 356
in 42 CFR Part 418. The rate of reimbursemen t paid by the 357
MO HealthNet division to the hospice provider for room and 358
board furnished by a nursing home to an eligible hospice 359
patient shall not be less than ninety -five percent of the 360
rate of reimbursement which would have been paid for 361
facility services in that nursing home facility for that 362
patient, in accordance with subsection (c) of Section 6408 363
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 364 SS#2 SCS SBs 49, 18
236 & 164
(6) Comprehensive day rehabilitation services 365
beginning early posttrauma as part of a coordinated system 366
of care for individuals with disabling impairments. 367
Rehabilitation services must be based on an individualized, 368
goal-oriented, comprehensive and coordinated treatment plan 369
developed, implemented, and monitored through an 370
interdisciplinary assessment designed to restore an 371
individual to optimal level of physical, cognitive, and 372
behavioral function. The MO HealthNet division shall 373
establish by administrative rule the definition and criteria 374
for designation of a comprehensiv e day rehabilitation 375
service facility, benefit limitations and payment 376
mechanism. Any rule or portion of a rule, as that term is 377
defined in section 536.010, that is created under the 378
authority delegated in this subdivision shall become 379
effective only if it complies with and is subject to all of 380
the provisions of chapter 536 and, if applicable, section 381
536.028. This section and chapter 536 are nonseverable and 382
if any of the powers vested with the general assembly 383
pursuant to chapter 536 to review, to delay the effective 384
date, or to disapprove and annul a rule are subsequently 385
held unconstitutional, then the grant of rulemaking 386
authority and any rule proposed or adopted after August 28, 387
2005, shall be invalid and void. 388
3. The MO HealthNet division may require any 389
participant receiving MO HealthNet benefits to pay part of 390
the charge or cost until July 1, 2008, and an additional 391
payment after July 1, 2008, as defined by rule duly 392
promulgated by the MO HealthNet division, for all covered 393
services except for those services covered under 394
subdivisions (15) and (16) of subsection 1 of this section 395
and sections 208.631 to 208.657 to the extent and in the 396 SS#2 SCS SBs 49, 19
236 & 164
manner authorized by Title XIX of the federal Social 397
Security Act (42 U.S.C. Section 13 96, et seq.) and 398
regulations thereunder. When substitution of a generic drug 399
is permitted by the prescriber according to section 338.056, 400
and a generic drug is substituted for a name -brand drug, the 401
MO HealthNet division may not lower or delete the 402
requirement to make a co -payment pursuant to regulations of 403
Title XIX of the federal Social Security Act. A provider of 404
goods or services described under this section must collect 405
from all participants the additional payment that may be 406
required by the MO HealthNet division under authority 407
granted herein, if the division exercises that authority, to 408
remain eligible as a provider. Any payments made by 409
participants under this section shall be in addition to and 410
not in lieu of payments made by the sta te for goods or 411
services described herein except the participant portion of 412
the pharmacy professional dispensing fee shall be in 413
addition to and not in lieu of payments to pharmacists. A 414
provider may collect the co -payment at the time a service is 415
provided or at a later date. A provider shall not refuse to 416
provide a service if a participant is unable to pay a 417
required payment. If it is the routine business practice of 418
a provider to terminate future services to an individual 419
with an unclaimed deb t, the provider may include uncollected 420
co-payments under this practice. Providers who elect not to 421
undertake the provision of services based on a history of 422
bad debt shall give participants advance notice and a 423
reasonable opportunity for payment. A provider, 424
representative, employee, independent contractor, or agent 425
of a pharmaceutical manufacturer shall not make co -payment 426
for a participant. This subsection shall not apply to other 427
qualified children, pregnant women, or blind persons. If 428 SS#2 SCS SBs 49, 20
236 & 164
the Centers for Medicare and Medicaid Services does not 429
approve the MO HealthNet state plan amendment submitted by 430
the department of social services that would allow a 431
provider to deny future services to an individual with 432
uncollected co-payments, the denial of services shall not be 433
allowed. The department of social services shall inform 434
providers regarding the acceptability of denying services as 435
the result of unpaid co -payments. 436
4. The MO HealthNet division shall have the right to 437
collect medication samples from participants in order to 438
maintain program integrity. 439
5. Reimbursement for obstetrical and pediatric 440
services under subdivision (6) of subsection 1 of this 441
section shall be timely and sufficient to enlist enough 442
health care providers so that care and services are 443
available under the state plan for MO HealthNet benefits at 444
least to the extent that such care and services are 445
available to the general population in the geographic area, 446
as required under subparagraph (a)(30)(A) of 42 U.S.C. 447
Section 1396a and federal regulations promulgated thereunder. 448
6. Beginning July 1, 1990, reimbursement for services 449
rendered in federally funded health centers shall be in 450
accordance with the provisions of subsection 6402(c) and 451
Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation 452
Act of 1989) and federal regulations promulgated thereunder. 453
7. Beginning July 1, 1990, the department of social 454
services shall provide notification and referral of children 455
below age five, and pregnant, breast-feeding, or postpartum 456
women who are determined to be eligible for MO HealthNet 457
benefits under section 208.151 to the special supplemental 458
food programs for women, infants and children administered 459
by the department of health and seni or services. Such 460 SS#2 SCS SBs 49, 21
236 & 164
notification and referral shall conform to the requirements 461
of Section 6406 of P.L. 101 -239 and regulations promulgated 462
thereunder. 463
8. Providers of long-term care services shall be 464
reimbursed for their costs in accordance with the provisions 465
of Section 1902 (a)(13)(A) of the Social Security Act, 42 466
U.S.C. Section 1396a, as amended, and regulations 467
promulgated thereunder. 468
9. Reimbursement rates to long -term care providers 469
with respect to a total change in ownership, at arm's 470
length, for any facility previously licensed and certified 471
for participation in the MO HealthNet program shall not 472
increase payments in excess of the increase that would 473
result from the application of Section 1902 (a)(13)(C) of 474
the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C). 475
10. The MO HealthNet division may enroll qualified 476
residential care facilities and assisted living facilities, 477
as defined in chapter 198, as MO HealthNet personal care 478
providers. 479
11. Any income earned by individuals eligible for 480
certified extended employment at a sheltered workshop under 481
chapter 178 shall not be considered as income for purposes 482
of determining eligibility under this section. 483
12. If the Missouri Medicaid audit and compliance unit 484
changes any interpretation or application of the 485
requirements for reimbursement for MO HealthNet services 486
from the interpretation or application that has been applied 487
previously by the state in any audit of a MO HealthNet 488
provider, the Missouri Medicaid audit and compliance unit 489
shall notify all affected MO HealthNet providers five 490
business days before such change shall take effect. Failure 491
of the Missouri Medicaid audit and compliance unit to notify 492 SS#2 SCS SBs 49, 22
236 & 164
a provider of such change shall entitle t he provider to 493
continue to receive and retain reimbursement until such 494
notification is provided and shall waive any liability of 495
such provider for recoupment or other loss of any payments 496
previously made prior to the five business days after such 497
notice has been sent. Each provider shall provide the 498
Missouri Medicaid audit and compliance unit a valid email 499
address and shall agree to receive communications 500
electronically. The notification required under this 501
section shall be delivered in writing b y the United States 502
Postal Service or electronic mail to each provider. 503
13. Nothing in this section shall be construed to 504
abrogate or limit the department's statutory requirement to 505
promulgate rules under chapter 536. 506
14. Beginning July 1, 2016, and subject to 507
appropriations, providers of behavioral, social, and 508
psychophysiological services for the prevention, treatment, 509
or management of physical health problems shall be 510
reimbursed utilizing the behavior assessment and 511
intervention reimbursement codes 96150 to 96154 or their 512
successor codes under the Current Procedural Terminology 513
(CPT) coding system. Providers eligible for such 514
reimbursement shall include psychologists. 515
15. There shall be no payments made under this section 516
for gender transition surgeries, cross -sex hormones, or 517
puberty-blocking drugs, as such terms are defined in section 518
191.1720, for the purpose of a gender transition. 519
217.230. The director shall arrange for necessary 1
health care services for offenders confined in correctional 2
centers, which shall not include any gender transition 3
surgery, as defined in section 191.1720 . 4 SS#2 SCS SBs 49, 23
236 & 164
221.120. 1. If any prisoner confined in the county 1
jail is sick and in the judgment of the jai ler, requires the 2
attention of a physician, dental care, or medicine, the 3
jailer shall procure the necessary medicine, dental care or 4
medical attention necessary or proper to maintain the health 5
of the prisoner; provided, that this shall not include an y 6
gender transition surgery, as defined in section 191.1720 . 7
The costs of such medicine, dental care, or medical 8
attention shall be paid by the prisoner through any health 9
insurance policy as defined in subsection 3 of this section, 10
from which the prisoner is eligible to receive benefits. If 11
the prisoner is not eligible for such health insurance 12
benefits then the prisoner shall be liable for the payment 13
of such medical attention, dental care, or medicine, and the 14
assets of such prisoner may be su bject to levy and execution 15
under court order to satisfy such expenses in accordance 16
with the provisions of section 221.070, and any other 17
applicable law. The county commission of the county may at 18
times authorize payment of certain medical costs that the 19
county commission determines to be necessary and 20
reasonable. As used in this section, the term "medical 21
costs" includes the actual costs of medicine, dental care or 22
other medical attention and necessary costs associated with 23
such medical care su ch as transportation, guards and 24
inpatient care. 25
2. The county commission may, in their discretion, 26
employ a physician by the year, to attend such prisoners, 27
and make such reasonable charge for his service and 28
medicine, when required, to be taxed and collected as 29
provided by law. 30
3. As used in this section, the following terms mean: 31 SS#2 SCS SBs 49, 24
236 & 164
(1) "Assets", property, tangible or intangible, real 32
or personal, belonging to or due a prisoner or a former 33
prisoner, including income or payments to s uch prisoner from 34
Social Security, workers' compensation, veterans' 35
compensation, pension benefits, previously earned salary or 36
wages, bonuses, annuities, retirement benefits, compensation 37
paid to the prisoner per work or services performed while a 38
prisoner or from any other source whatsoever, including any 39
of the following: 40
(a) Money or other tangible assets received by the 41
prisoner as a result of a settlement of a claim against the 42
state, any agency thereof, or any claim against an employee 43
or independent contractor arising from and in the scope of 44
the employee's or contractor's official duties on behalf of 45
the state or any agency thereof; 46
(b) A money judgment received by the prisoner from the 47
state as a result of a civil action in which the state, an 48
agency thereof or any state employee or independent 49
contractor where such judgment arose from a claim arising 50
from the conduct of official duties on behalf of the state 51
by the employee or subcontractor or for any agency of the 52
state; 53
(c) A current stream of income from any source 54
whatsoever, including a salary, wages, disability benefits, 55
retirement benefits, pension benefits, insurance or annuity 56
benefits, or similar payments; and 57
(2) "Health insurance policy", any g roup insurance 58
policy providing coverage on an expense -incurred basis, any 59
group service or indemnity contract issued by a not -for- 60
profit health services corporation or any self -insured group 61
health benefit plan of any type or description. 62