SECONDREGULARSESSION
[PERFECTED]
HOUSECOMMITTEESUBSTITUTEFOR
HOUSEBILLNOS.2626&1918
102NDGENERALASSEMBLY
5464H.02P DANARADEMANMILLER,ChiefClerk
ANACT
Torepealsection208.152,RSMo,andtoenactinlieuthereofonenewsectionrelatingtoMO
HealthNetcoverageofhearing-relateddevices.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Section208.152,RSMo,isrepealedandonenewsectionenactedinlieu
2thereof,tobeknownassection208.152,toreadasfollows:
208.152.1.MOHealthNetpaymentsshallbemadeonbehalfofthoseeligibleneedy
2personsasdescribedinsection208.151whoareunabletoprovideforitinwholeorinpart,
3withanypaymentstobemadeonthebasisofthereasonablecostofthecareorreasonable
4chargefortheservicesasdefinedanddeterminedbytheMOHealthNetdivision,unless
5otherwisehereinafterprovided,forthefollowing:
6 (1)Inpatienthospitalservices,excepttopersonsinaninstitutionformentaldiseases
7whoareundertheageofsixty-fiveyearsandovertheageoftwenty-oneyears;providedthat
8theMOHealthNetdivisionshallprovidethroughruleandregulationanexceptionprocessfor
9coverageofinpatientcostsinthosecasesrequiringtreatmentbeyondtheseventy-fifth
10percentileprofessionalactivitiesstudy(PAS)ortheMOHealthNetchildren'sdiagnosis
11length-of-stayschedule;andprovidedfurtherthattheMOHealthNetdivisionshalltakeinto
12accountthroughitspaymentsystemforhospitalservicesthesituationofhospitalswhich
13serveadisproportionatenumberoflow-incomepatients;
14 (2)Alloutpatienthospitalservices,paymentstherefortobeinamountswhich
15representnomorethaneightypercentofthelesserofreasonablecostsorcustomarycharges
16forsuchservices,determinedinaccordancewiththeprinciplessetforthinTitleXVIIIAand
17B,PublicLaw89-97,1965amendmentstothefederalSocialSecurityAct(42U.S.C.Section
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 18301,etseq.),buttheMOHealthNetdivisionmayevaluateoutpatienthospitalservices
19renderedunderthissectionanddenypaymentforserviceswhicharedeterminedbytheMO
20HealthNetdivisionnottobemedicallynecessary,inaccordancewithfederallawand
21regulations;
22 (3)LaboratoryandX-rayservices;
23 (4)Nursinghomeservicesforparticipants,excepttopersonswithmorethanfive
24hundredthousanddollarsequityintheirhomeorexceptforpersonsinaninstitutionfor
25mentaldiseaseswhoareundertheageofsixty-fiveyears,whenresidinginahospitallicensed
26bythedepartmentofhealthandseniorservicesoranursinghomelicensedbythedepartment
27ofhealthandseniorservicesorappropriatelicensingauthorityofotherstatesorgovernment-
28ownedand-operatedinstitutionswhicharedeterminedtoconformtostandardsequivalentto
29licensingrequirementsinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section
30[301,] 1396etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmay
31recognizethroughitspaymentmethodologyfornursingfacilitiesthosenursingfacilities
32whichserveahighvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhen
33determiningtheamountofthebenefitpaymentstobemadeonbehalfofpersonsunderthe
34ageoftwenty-oneinanursingfacilitymayconsidernursingfacilitiesfurnishingcareto
35personsundertheageoftwenty-oneasaclassificationseparatefromothernursingfacilities;
36 (5)Nursinghomecostsforparticipantsreceivingbenefitpaymentsundersubdivision
37(4)ofthissubsectionforthosedays,whichshallnotexceedtwelveperanyperiodofsix
38consecutivemonths,duringwhichtheparticipantisonatemporaryleaveofabsencefromthe
39hospitalornursinghome,providedthatnosuchparticipantshallbeallowedatemporary
40leaveofabsenceunlessitisspecificallyprovidedforinhisplanofcare.Asusedinthis
41subdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftimeduring
42whichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheisvisiting
43afriendorrelative;
44 (6)Physicians'services,whetherfurnishedintheoffice,home,hospital,nursing
45home,orelsewhere;
46 (7)Subjecttoappropriation,uptotwentyvisitsperyearforserviceslimitedto
47examinations,diagnoses,adjustments,andmanipulationsandtreatmentsofmalpositioned
48articulationsandstructuresofthebodyprovidedbylicensedchiropracticphysicians
49practicingwithintheirscopeofpractice.Nothinginthissubdivisionshallbeinterpretedto
50otherwiseexpandMOHealthNetservices;
51 (8)Drugsandmedicineswhenprescribedbyalicensedphysician,dentist,podiatrist,
52oranadvancedpracticeregisterednurse;exceptthatnopaymentfordrugsandmedicines
53prescribedonandafterJanuary1,2006,byalicensedphysician,dentist,podiatrist,oran
HCSHBs2626&1918 2 54advancedpracticeregisterednursemaybemadeonbehalfofanypersonwhoqualifiesfor
55prescriptiondrugcoverageundertheprovisionsofP.L.108-173;
56 (9)Emergencyambulanceservicesand,effectiveJanuary1,1990,medically
57necessarytransportationtoscheduled,physician-prescribednonelectivetreatments;
58 (10)Earlyandperiodicscreeninganddiagnosisofindividualswhoareundertheage
59oftwenty-onetoascertaintheirphysicalormentaldefects,andhealthcare,treatment,and
60othermeasurestocorrectoramelioratedefectsandchronicconditionsdiscoveredthereby.
61SuchservicesshallbeprovidedinaccordancewiththeprovisionsofSection6403ofP.L.
62101-239andfederalregulationspromulgatedthereunder;
63 (11)Homehealthcareservices;
64 (12)Familyplanningasdefinedbyfederalrulesandregulations;provided,however,
65thatsuchfamilyplanningservicesshallnotincludeabortionsoranyabortifacientdrugor
66devicethatisusedforthepurposeofinducinganabortionunlesssuchabortionsarecertified
67inwritingbyaphysiciantotheMOHealthNetagencythat,inthephysician'sprofessional
68judgment,thelifeofthemotherwouldbeendangeredifthefetuswerecarriedtoterm;
69 (13)Inpatientpsychiatrichospitalservicesforindividualsunderagetwenty-oneas
70definedinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396d,etseq.);
71 (14)Outpatientsurgicalprocedures,includingpresurgicaldiagnosticservices
72performedinambulatorysurgicalfacilitieswhicharelicensedbythedepartmentofhealth
73andseniorservicesofthestateofMissouri;except,thatsuchoutpatientsurgicalservicesshall
74notincludepersonswhoareeligibleforcoverageunderPartBofTitleXVIII,PublicLaw89-
7597,1965amendmentstothefederalSocialSecurityAct,asamended,ifexclusionofsuch
76personsispermittedunderTitleXIX,PublicLaw89-97,1965amendmentstothefederal
77SocialSecurityAct,asamended;
78 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha
79person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea
80persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor
81residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal
82careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho
83isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin
84accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible
85toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire
86placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable
87forpersonalcareservicesshallnotexceedforanyoneparticipantonehundredpercentofthe
88averagestatewidechargeforcareandtreatmentinanintermediatecarefacilityfora
89comparableperiodoftime.Suchservices,whendeliveredinaresidentialcarefacilityor
90assistedlivingfacilitylicensedunderchapter198shallbeauthorizedonatierlevelbasedon
HCSHBs2626&1918 3 91theservicestheresidentrequiresandthefrequencyoftheservices.Aresidentofsuchfacility
92whoqualifiesforassistanceundersection208.030shall,ataminimum,ifprescribedbya
93physician,qualifyforthetierlevelwiththefewestservices.Theratepaidtoprovidersfor
94eachtierofserviceshallbesetsubjecttoappropriations.Subjecttoappropriations,each
95residentofsuchfacilitywhoqualifiesforassistanceundersection208.030andmeetsthe
96levelofcarerequiredinthissectionshall,ataminimum,ifprescribedbyaphysician,be
97authorizeduptoonehourofpersonalcareservicesperday.Authorizedunitsofpersonalcare
98servicesshallnotbereducedortierlevelloweredunlessanorderapprovingsuchreductionor
99loweringisobtainedfromtheresident'spersonalphysician.Suchauthorizedunitsofpersonal
100careservicesortierlevelshallbetransferredwithsuchresidentifheorshetransfersto
101anothersuchfacility.Suchprovisionshallterminateuponreceiptofrelevantwaiversfrom
102thefederalDepartmentofHealthandHumanServices.IftheCentersforMedicareand
103MedicaidServicesdeterminesthatsuchprovisiondoesnotcomplywiththestateplan,this
104provisionshallbenullandvoid.TheMOHealthNetdivisionshallnotifytherevisorof
105statutesastowhethertherelevantwaiversareapprovedoradeterminationofnoncompliance
106ismade;
107 (16)Mentalhealthservices.Thestateplanforprovidingmedicalassistanceunder
108TitleXIXoftheSocialSecurityAct,42U.S.C.Section[301]1396etseq.,asamended,shall
109includethefollowingmentalhealthserviceswhensuchservicesareprovidedbycommunity
110mentalhealthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythe
111departmentofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrug
112abusefacilityorasachild-servingagencywithinthecomprehensivechildren'smentalhealth
113servicesystemestablishedinsection630.097.Thedepartmentofmentalhealthshall
114establishbyadministrativerulethedefinitionandcriteriafordesignationasacommunity
115mentalhealthfacilityandfordesignationasanalcoholanddrugabusefacility.Suchmental
116healthservicesshallinclude:
117 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
118rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
119settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
120established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
121apartofclientservicesmanagement;
122 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
123rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
124settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
125established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
126apartofclientservicesmanagement;
HCSHBs2626&1918 4 127 (c)Rehabilitativementalhealthandalcoholanddrugabuseservicesincludinghome
128andcommunity-basedpreventive,diagnostic,therapeutic,rehabilitative,andpalliative
129interventionsrenderedtoindividualsinanindividualorgroupsettingbyamentalhealth
130oralcoholanddrugabuseprofessionalinaccordancewithaplanoftreatmentappropriately
131established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
132apartofclientservicesmanagement.Asusedinthissection,mentalhealthprofessionaland
133alcoholanddrugabuseprofessionalshallbedefinedbythedepartmentofmentalhealth
134pursuanttodulypromulgatedrules.Withrespecttoservicesestablishedbythissubdivision,
135thedepartmentofsocialservices,MOHealthNetdivision,shallenterintoanagreementwith
136thedepartmentofmentalhealth.Matchingfundsforoutpatientmentalhealthservices,clinic
137mentalhealthservices,andrehabilitationservicesformentalhealthandalcoholanddrug
138abuseshallbecertifiedbythedepartmentofmentalhealthtotheMOHealthNetdivision.
139Theagreementshallestablishamechanismforthejointimplementationoftheprovisionsof
140thissubdivision.Inaddition,theagreementshallestablishamechanismbywhichratesfor
141servicesmaybejointlydeveloped;
142 (17)SuchadditionalservicesasdefinedbytheMOHealthNetdivisiontobe
143furnishedunderwaiversoffederalstatutoryrequirementsasprovidedforandauthorizedby
144thefederalSocialSecurityAct(42U.S.C.Section301,etseq.)subjecttoappropriationbythe
145generalassembly;
146 (18)Theservicesofanadvancedpracticeregisterednursewithacollaborative
147practiceagreementtotheextentthatsuchservicesareprovidedinaccordancewithchapters
148334and335,andregulationspromulgatedthereunder;
149 (19)Nursinghomecostsforparticipantsreceivingbenefitpaymentsunder
150subdivision(4)ofthissubsectiontoreserveabedfortheparticipantinthenursinghome
151duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich
152cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision:
153 (a)Theprovisionsofthissubdivisionshallapplyonlyif:
154 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO
155HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto
156thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis
157admittedtothehospital;and
158 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated
159stayofthreedaysorless;
160 (b)Thepaymenttobemadeunderthissubdivisionshallbeprovidedforamaximum
161ofthreedaysperhospitalstay;
162 (c)Foreachdaythatnursinghomecostsarepaidonbehalfofaparticipantunderthis
163subdivisionduringanyperiodofsixconsecutivemonthssuchparticipantshall,duringthe
HCSHBs2626&1918 5 164sameperiodofsixconsecutivemonths,beineligibleforpaymentofnursinghomecostsof
165twootherwiseavailabletemporaryleaveofabsencedaysprovidedundersubdivision(5)of
166thissubsection;and
167 (d)Theprovisionsofthissubdivisionshallnotapplyunlessthenursinghome
168receivesnoticefromtheparticipantortheparticipant'sresponsiblepartythattheparticipant
169intendstoreturntothenursinghomefollowingthehospitalstay.Ifthenursinghomereceives
170suchnotificationandallotherprovisionsofthissubsectionhavebeensatisfied,thenursing
171homeshallprovidenoticetotheparticipantortheparticipant'sresponsiblepartypriorto
172releaseofthereservedbed;
173 (20)Prescribedmedicallynecessarydurablemedicalequipment.Anelectronicweb-
174basedpriorauthorizationsystemusingbestmedicalevidenceandcareandtreatment
175guidelinesconsistentwithnationalstandardsshallbeusedtoverifymedicalneed;
176 (21)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
177coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
178inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
179medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
180physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
181psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
182stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
183participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
184paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
185nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
186rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
187facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
188(OmnibusBudgetReconciliationActof1989);
189 (22)Prescribedmedicallynecessarydentalservices.Suchservicesshallbesubjectto
190appropriations.Anelectronicweb-basedpriorauthorizationsystemusingbestmedical
191evidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshallbeusedto
192verifymedicalneed;
193 (23)Prescribedmedicallynecessaryoptometricservices.Suchservicesshallbe
194subjecttoappropriations.Anelectronicweb-basedpriorauthorizationsystemusingbest
195medicalevidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshall
196beusedtoverifymedicalneed;
197 (24)Bloodclottingproducts-relatedservices.Forpersonsdiagnosedwithableeding
198disorder,asdefinedinsection338.400,reliantonbloodclottingproducts,asdefinedin
199section338.400,suchservicesinclude:
HCSHBs2626&1918 6 200 (a)Homedeliveryofbloodclottingproductsandancillaryinfusionequipmentand
201supplies,includingtheemergencydeliveriesoftheproductwhenmedicallynecessary;
202 (b)Medicallynecessaryancillaryinfusionequipmentandsuppliesrequiredto
203administerthebloodclottingproducts;and
204 (c)Assessmentsconductedintheparticipant'shomebyapharmacist,nurse,orlocal
205homehealthcareagencytrainedinbleedingdisorderswhendeemednecessarybythe
206participant'streatingphysician;
207 (25)Medicallynecessarycochlearimplantsandhearinginstruments,asdefined
208insection345.015,thatare:
209 (a)Prescribedbyanaudiologist,asdefinedinsection345.015;or
210 (b)Dispensedbyahearinginstrumentspecialist,asdefinedinsection346.010;
211 (26)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter,
212reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred
213percentoftheMedicarereimbursementratesandcomparedtotheaveragedental
214reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet
215divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve
216paritywithMedicarereimbursementratesandforthird-partypayoraveragedental
217reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall
218includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete
219thefour-yearplandevelopedunderthissubdivision.
220 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof
221thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe
222madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas
223definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided,
224forthefollowing:
225 (1)Dentalservices;
226 (2)Servicesofpodiatristsasdefinedinsection330.010;
227 (3)Optometricservicesasdescribedinsection336.010;
228 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,[hearing
229aids,] andwheelchairs;
230 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
231coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
232inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
233medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
234physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
235psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
236stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
HCSHBs2626&1918 7 237participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
238paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
239nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
240rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
241facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
242(OmnibusBudgetReconciliationActof1989);
243 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa
244coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation
245servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated
246treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary
247assessmentdesignedtorestoreanindividualtooptimallevelofphysical,cognitive,and
248behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe
249definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility,
250benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis
251definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision
252shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof
253chapter536and,ifapplicable,section536.028.Thissectionandchapter536are
254nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter
255536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently
256heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor
257adoptedafterAugust28,2005,shallbeinvalidandvoid.
258 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet
259benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter
260July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall
261coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of
262subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner
263authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.)
264andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber
265accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the
266MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment
267pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods
268orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional
269paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein,
270ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade
271byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby
272thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy
273professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists.
HCSHBs2626&1918 8 274Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A
275providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired
276payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan
277individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder
278thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona
279historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor
280payment.Aprovider,representative,employee,independentcontractor,oragentofa
281pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection
282shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters
283forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan
284amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto
285denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices
286shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe
287acceptabilityofdenyingservicesastheresultofunpaidco-payments.
288 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom
289participantsinordertomaintainprogramintegrity.
290 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of
291subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare
292providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet
293benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral
294populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C.
295Section1396aandfederalregulationspromulgatedthereunder.
296 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded
297healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection
2986404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations
299promulgatedthereunder.
300 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification
301andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen
302whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe
303specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe
304departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe
305requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder.
306 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin
307accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42
308U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder.
309 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein
310ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation
HCSHBs2626&1918 9 311intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat
312wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42
313U.S.C.Section1396a(a)(13)(C).
314 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand
315assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders.
316 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata
317shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof
318determiningeligibilityunderthissection.
319 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor
320applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe
321interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO
322HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected
323MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof
324theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall
325entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis
326providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany
327paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent.
328EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail
329addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired
330underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor
331electronicmailtoeachprovider.
332 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's
333statutoryrequirementtopromulgaterulesunderchapter536.
334 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral,
335social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof
336physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand
337interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe
338CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch
339reimbursementshallincludepsychologists.
340 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition
341surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection
342191.1720,forthepurposeofagendertransition.
✔
HCSHBs2626&1918 10