SECONDREGULARSESSION
HOUSEBILLNO.2634
102NDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVESMITH(163).
5500H.01I DANARADEMANMILLER,ChiefClerk
ANACT
Torepealsections188.220,208.152,208.153,208.164,and208.659,RSMo,andtoenactin
lieuthereofsixnewsectionsrelatingtohealthcare,withanemergencyclause.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Sections188.220,208.152,208.153,208.164,and208.659,RSMo,are
2repealedandsixnewsectionsenactedinlieuthereof,tobeknownassections188.207,
3188.220,208.152,208.153,208.164,and208.659,toreadasfollows:
188.207.Itshallbeunlawfulforanypublicfundstobeexpendedtoanyabortion
2facility,ortoanyaffiliateorassociateofsuchabortionfacility.
188.220.1.Anytaxpayerofthisstateoritspoliticalsubdivisionsshallhavestanding
2tobring[suitinacircuitcourtofpropervenue] acauseofactioninanycourtor
3administrativeagencyofcompetentjurisdictiontoenforcetheprovisionsofsections
4188.200to188.215.
5 2.Theattorneygeneralisauthorizedtobringacauseofactioninanycourtor
6administrativeagencyofcompetentjurisdictiontoenforcetheprovisionsofsections
7188.200to188.215.
8 3.Inanyactiontoenforcetheprovisionsofsections188.200to188.215bya
9taxpayerortheattorneygeneral,acourtofcompetentjurisdictionmayorderinjunctive
10orotherequitablerelief,recoveryofdamagesorotherlegalremedies,orboth,aswellas
11paymentofreasonableattorney'sfees,costs,andexpensesofthetaxpayerorthestate.
12Thereliefandremediessetforthshallnotbedeemedexclusiveandshallbeinaddition
13toanyotherrelieforremediespermittedbylaw.
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 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
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.Section301,
30etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmayrecognize
31throughitspaymentmethodologyfornursingfacilitiesthosenursingfacilitieswhichservea
32highvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhendeterminingthe
33amountofthebenefitpaymentstobemadeonbehalfofpersonsundertheageoftwenty-one
34inanursingfacilitymayconsidernursingfacilitiesfurnishingcaretopersonsundertheageof
35twenty-oneasaclassificationseparatefromothernursingfacilities;
36 (5)Nursinghomecostsforparticipantsreceivingbenefitpaymentsundersubdivision
37(4)ofthissubsectionforthosedays,whichshallnotexceedtwelveperanyperiodofsix
HB2634 2 38consecutivemonths,duringwhichtheparticipantisonatemporaryleaveofabsencefromthe
39hospitalornursinghome,providedthatnosuchparticipantshallbeallowedatemporary
40leaveofabsenceunlessitisspecificallyprovidedforinhisplanofcare.Asusedinthis
41subdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftimeduring
42whichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheisvisiting
43afriendorrelative;
44 (6)Physicians'services,whetherfurnishedintheoffice,home,hospital,nursing
45home,orelsewhere, provided,thatnofundsshallbeexpendedtoanyabortionfacility,as
46definedinsection188.015,ortoanyaffiliateorassociateofsuchabortionfacility;
47 (7)Subjecttoappropriation,uptotwentyvisitsperyearforserviceslimitedto
48examinations,diagnoses,adjustments,andmanipulationsandtreatmentsofmalpositioned
49articulationsandstructuresofthebodyprovidedbylicensedchiropracticphysicians
50practicingwithintheirscopeofpractice.Nothinginthissubdivisionshallbeinterpretedto
51otherwiseexpandMOHealthNetservices;
52 (8)Drugsandmedicineswhenprescribedbyalicensedphysician,dentist,podiatrist,
53oranadvancedpracticeregisterednurse;exceptthatnopaymentfordrugsandmedicines
54prescribedonandafterJanuary1,2006,byalicensedphysician,dentist,podiatrist,oran
55advancedpracticeregisterednursemaybemadeonbehalfofanypersonwhoqualifiesfor
56prescriptiondrugcoverageundertheprovisionsofP.L.108-173;
57 (9)Emergencyambulanceservicesand,effectiveJanuary1,1990,medically
58necessarytransportationtoscheduled,physician-prescribednonelectivetreatments;
59 (10)Earlyandperiodicscreeninganddiagnosisofindividualswhoareundertheage
60oftwenty-onetoascertaintheirphysicalormentaldefects,andhealthcare,treatment,and
61othermeasurestocorrectoramelioratedefectsandchronicconditionsdiscoveredthereby.
62SuchservicesshallbeprovidedinaccordancewiththeprovisionsofSection6403ofP.L.
63101-239andfederalregulationspromulgatedthereunder;
64 (11)Homehealthcareservices;
65 (12)Familyplanningasdefinedbyfederalrulesandregulations;provided,thatno
66fundsshallbeexpendedtoanyabortionfacility,asdefinedinsection188.015,ortoany
67affiliateorassociateofsuchabortionfacility;andfurtherprovided,however,thatsuch
68familyplanningservicesshallnotincludeabortionsoranyabortifacientdrugordevicethatis
69usedforthepurposeofinducinganabortionunlesssuchabortionsarecertifiedinwritingbya
70physiciantotheMOHealthNetagencythat,inthephysician'sprofessionaljudgment,thelife
71ofthemotherwouldbeendangeredifthefetuswerecarriedtoterm;
72 (13)Inpatientpsychiatrichospitalservicesforindividualsunderagetwenty-oneas
73definedinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396d,etseq.);
HB2634 3 74 (14)Outpatientsurgicalprocedures,includingpresurgicaldiagnosticservices
75performedinambulatorysurgicalfacilitieswhicharelicensedbythedepartmentofhealth
76andseniorservicesofthestateofMissouri;except,thatsuchoutpatientsurgicalservicesshall
77notincludepersonswhoareeligibleforcoverageunderPartBofTitleXVIII,PublicLaw89-
7897,1965amendmentstothefederalSocialSecurityAct,asamended,ifexclusionofsuch
79personsispermittedunderTitleXIX,PublicLaw89-97,1965amendmentstothefederal
80SocialSecurityAct,asamended;
81 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha
82person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea
83persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor
84residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal
85careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho
86isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin
87accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible
88toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire
89placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable
90forpersonalcareservicesshallnotexceedforanyoneparticipantonehundredpercentofthe
91averagestatewidechargeforcareandtreatmentinanintermediatecarefacilityfora
92comparableperiodoftime.Suchservices,whendeliveredinaresidentialcarefacilityor
93assistedlivingfacilitylicensedunderchapter198shallbeauthorizedonatierlevelbasedon
94theservicestheresidentrequiresandthefrequencyoftheservices.Aresidentofsuchfacility
95whoqualifiesforassistanceundersection208.030shall,ataminimum,ifprescribedbya
96physician,qualifyforthetierlevelwiththefewestservices.Theratepaidtoprovidersfor
97eachtierofserviceshallbesetsubjecttoappropriations.Subjecttoappropriations,each
98residentofsuchfacilitywhoqualifiesforassistanceundersection208.030andmeetsthe
99levelofcarerequiredinthissectionshall,ataminimum,ifprescribedbyaphysician,be
100authorizeduptoonehourofpersonalcareservicesperday.Authorizedunitsofpersonalcare
101servicesshallnotbereducedortierlevelloweredunlessanorderapprovingsuchreductionor
102loweringisobtainedfromtheresident'spersonalphysician.Suchauthorizedunitsofpersonal
103careservicesortierlevelshallbetransferredwithsuchresidentifheorshetransfersto
104anothersuchfacility.Suchprovisionshallterminateuponreceiptofrelevantwaiversfrom
105thefederalDepartmentofHealthandHumanServices.IftheCentersforMedicareand
106MedicaidServicesdeterminesthatsuchprovisiondoesnotcomplywiththestateplan,this
107provisionshallbenullandvoid.TheMOHealthNetdivisionshallnotifytherevisorof
108statutesastowhethertherelevantwaiversareapprovedoradeterminationofnoncompliance
109ismade;
HB2634 4 110 (16)Mentalhealthservices.Thestateplanforprovidingmedicalassistanceunder
111TitleXIXoftheSocialSecurityAct,42U.S.C.Section301,asamended,shallincludethe
112followingmentalhealthserviceswhensuchservicesareprovidedbycommunitymental
113healthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythedepartment
114ofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrugabusefacility
115orasachild-servingagencywithinthecomprehensivechildren'smentalhealthservicesystem
116establishedinsection630.097.Thedepartmentofmentalhealthshallestablishby
117administrativerulethedefinitionandcriteriafordesignationasacommunitymentalhealth
118facilityandfordesignationasanalcoholanddrugabusefacility.Suchmentalhealthservices
119shallinclude:
120 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
121rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
122settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
123established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
124apartofclientservicesmanagement;
125 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
126rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
127settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
128established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
129apartofclientservicesmanagement;
130 (c)Rehabilitativementalhealthandalcoholanddrugabuseservicesincludinghome
131andcommunity-basedpreventive,diagnostic,therapeutic,rehabilitative,andpalliative
132interventionsrenderedtoindividualsinanindividualorgroupsettingbyamentalhealth
133oralcoholanddrugabuseprofessionalinaccordancewithaplanoftreatmentappropriately
134established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
135apartofclientservicesmanagement.Asusedinthissection,mentalhealthprofessionaland
136alcoholanddrugabuseprofessionalshallbedefinedbythedepartmentofmentalhealth
137pursuanttodulypromulgatedrules.Withrespecttoservicesestablishedbythissubdivision,
138thedepartmentofsocialservices,MOHealthNetdivision,shallenterintoanagreementwith
139thedepartmentofmentalhealth.Matchingfundsforoutpatientmentalhealthservices,clinic
140mentalhealthservices,andrehabilitationservicesformentalhealthandalcoholanddrug
141abuseshallbecertifiedbythedepartmentofmentalhealthtotheMOHealthNetdivision.
142Theagreementshallestablishamechanismforthejointimplementationoftheprovisionsof
143thissubdivision.Inaddition,theagreementshallestablishamechanismbywhichratesfor
144servicesmaybejointlydeveloped;
145 (17)SuchadditionalservicesasdefinedbytheMOHealthNetdivisiontobe
146furnishedunderwaiversoffederalstatutoryrequirementsasprovidedforandauthorizedby
HB2634 5 147thefederalSocialSecurityAct(42U.S.C.Section301,etseq.)subjecttoappropriationbythe
148generalassembly;
149 (18)Theservicesofanadvancedpracticeregisterednursewithacollaborative
150practiceagreementtotheextentthatsuchservicesareprovidedinaccordancewithchapters
151334and335,andregulationspromulgatedthereunder;
152 (19)Nursinghomecostsforparticipantsreceivingbenefitpaymentsunder
153subdivision(4)ofthissubsectiontoreserveabedfortheparticipantinthenursinghome
154duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich
155cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision:
156 (a)Theprovisionsofthissubdivisionshallapplyonlyif:
157 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO
158HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto
159thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis
160admittedtothehospital;and
161 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated
162stayofthreedaysorless;
163 (b)Thepaymenttobemadeunderthissubdivisionshallbeprovidedforamaximum
164ofthreedaysperhospitalstay;
165 (c)Foreachdaythatnursinghomecostsarepaidonbehalfofaparticipantunderthis
166subdivisionduringanyperiodofsixconsecutivemonthssuchparticipantshall,duringthe
167sameperiodofsixconsecutivemonths,beineligibleforpaymentofnursinghomecostsof
168twootherwiseavailabletemporaryleaveofabsencedaysprovidedundersubdivision(5)of
169thissubsection;and
170 (d)Theprovisionsofthissubdivisionshallnotapplyunlessthenursinghome
171receivesnoticefromtheparticipantortheparticipant'sresponsiblepartythattheparticipant
172intendstoreturntothenursinghomefollowingthehospitalstay.Ifthenursinghomereceives
173suchnotificationandallotherprovisionsofthissubsectionhavebeensatisfied,thenursing
174homeshallprovidenoticetotheparticipantortheparticipant'sresponsiblepartypriorto
175releaseofthereservedbed;
176 (20)Prescribedmedicallynecessarydurablemedicalequipment.Anelectronicweb-
177basedpriorauthorizationsystemusingbestmedicalevidenceandcareandtreatment
178guidelinesconsistentwithnationalstandardsshallbeusedtoverifymedicalneed;
179 (21)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
180coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
181inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
182medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
183physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
HB2634 6 184psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
185stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
186participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
187paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
188nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
189rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
190facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
191(OmnibusBudgetReconciliationActof1989);
192 (22)Prescribedmedicallynecessarydentalservices.Suchservicesshallbesubjectto
193appropriations.Anelectronicweb-basedpriorauthorizationsystemusingbestmedical
194evidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshallbeusedto
195verifymedicalneed;
196 (23)Prescribedmedicallynecessaryoptometricservices.Suchservicesshallbe
197subjecttoappropriations.Anelectronicweb-basedpriorauthorizationsystemusingbest
198medicalevidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshall
199beusedtoverifymedicalneed;
200 (24)Bloodclottingproducts-relatedservices.Forpersonsdiagnosedwithableeding
201disorder,asdefinedinsection338.400,reliantonbloodclottingproducts,asdefinedin
202section338.400,suchservicesinclude:
203 (a)Homedeliveryofbloodclottingproductsandancillaryinfusionequipmentand
204supplies,includingtheemergencydeliveriesoftheproductwhenmedicallynecessary;
205 (b)Medicallynecessaryancillaryinfusionequipmentandsuppliesrequiredto
206administerthebloodclottingproducts;and
207 (c)Assessmentsconductedintheparticipant'shomebyapharmacist,nurse,orlocal
208homehealthcareagencytrainedinbleedingdisorderswhendeemednecessarybythe
209participant'streatingphysician;
210 (25)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter,
211reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred
212percentoftheMedicarereimbursementratesandcomparedtotheaveragedental
213reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet
214divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve
215paritywithMedicarereimbursementratesandforthird-partypayoraveragedental
216reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall
217includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete
218thefour-yearplandevelopedunderthissubdivision.
219 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof
220thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe
HB2634 7 221madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas
222definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided,
223forthefollowing:
224 (1)Dentalservices;
225 (2)Servicesofpodiatristsasdefinedinsection330.010;
226 (3)Optometricservicesasdescribedinsection336.010;
227 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,hearing
228aids,andwheelchairs;
229 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
230coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
231inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
232medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
233physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
234psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
235stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
236participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
237paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
238nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
239rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
240facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
241(OmnibusBudgetReconciliationActof1989);
242 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa
243coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation
244servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated
245treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary
246assessmentdesignedtorestoreanindividualtooptimallevelofphysical,cognitive,and
247behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe
248definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility,
249benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis
250definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision
251shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof
252chapter536and,ifapplicable,section536.028.Thissectionandchapter536are
253nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter
254536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently
255heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor
256adoptedafterAugust28,2005,shallbeinvalidandvoid.
HB2634 8 257 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet
258benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter
259July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall
260coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of
261subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner
262authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.)
263andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber
264accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the
265MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment
266pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods
267orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional
268paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein,
269ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade
270byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby
271thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy
272professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists.
273Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A
274providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired
275payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan
276individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder
277thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona
278historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor
279payment.Aprovider,representative,employee,independentcontractor,oragentofa
280pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection
281shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters
282forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan
283amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto
284denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices
285shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe
286acceptabilityofdenyingservicesastheresultofunpaidco-payments.
287 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom
288participantsinordertomaintainprogramintegrity.
289 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of
290subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare
291providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet
292benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral
HB2634 9 293populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C.
294Section1396aandfederalregulationspromulgatedthereunder.
295 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded
296healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection
2976404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations
298promulgatedthereunder.
299 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification
300andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen
301whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe
302specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe
303departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe
304requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder.
305 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin
306accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42
307U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder.
308 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein
309ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation
310intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat
311wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42
312U.S.C.Section1396a(a)(13)(C).
313 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand
314assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders.
315 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata
316shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof
317determiningeligibilityunderthissection.
318 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor
319applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe
320interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO
321HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected
322MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof
323theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall
324entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis
325providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany
326paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent.
327EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail
328addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired
HB2634 10 329underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor
330electronicmailtoeachprovider.
331 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's
332statutoryrequirementtopromulgaterulesunderchapter536.
333 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral,
334social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof
335physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand
336interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe
337CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch
338reimbursementshallincludepsychologists.
339 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition
340surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection
341191.1720,forthepurposeofagendertransition.
208.153.1.Pursuanttoandnotinconsistentwiththeprovisionsofsections208.151
2and208.152,theMOHealthNetdivisionshallbyruleandregulationdefinethereasonable
3costs,manner,extent,quantity,quality,chargesandfeesofMOHealthNetbenefitsherein
4provided.Thebenefitsavailableunderthesesectionsshallnotreplacethoseprovidedunder
5otherfederalorstatelaworunderothercontractualorlegalentitlementsofthepersons
6receivingthem,andallpersonsshallberequiredtoapplyforandutilizeallbenefitsavailable
7tothemandtopursueallcausesofactiontowhichtheyareentitled.Anypersonentitledto
8MOHealthNetbenefitsmayobtainitfromanyproviderofservicesthatisnotexcludedor
9disqualifiedasaproviderunderanyprovisionoflawincluding,butnotlimitedto,
10section208.164,withwhichanagreementisineffectunderthissectionandwhich
11undertakestoprovidetheservices,asauthorizedbytheMOHealthNetdivision.Atthe
12discretionofthedirectoroftheMOHealthNetdivisionandwiththeapprovalofthegovernor,
13theMOHealthNetdivisionisauthorizedtoprovidemedicalbenefitsforparticipants
14receivingpublicassistancebyexpendingfundsforthepaymentoffederalmedicalinsurance
15premiums,coinsuranceanddeductiblespursuanttotheprovisionsofTitleXVIIIBandXIX,
16PublicLaw89-97,1965amendmentstothefederalSocialSecurityAct(42U.S.C.301,et
17seq.),asamended.
18 2.MOHealthNetshallincludebenefitpaymentsonbehalfofqualifiedMedicare
19beneficiariesasdefinedin42U.S.C.Section1396d(p).Thefamilysupportdivisionshallby
20ruleandregulationestablishwhichqualifiedMedicarebeneficiariesareeligible.TheMO
21HealthNetdivisionshalldefinethepremiums,deductibleandcoinsuranceprovidedforin42
22U.S.C.Section1396d(p)tobeprovidedonbehalfofthequalifiedMedicarebeneficiaries.
23 3.MOHealthNetshallincludebenefitpaymentsforMedicarePartAcostsharingas
24definedinclause(p)(3)(A)(i)of42U.S.C.1396donbehalfofqualifieddisabledandworking
HB2634 11 25individualsasdefinedinsubsection(s)ofSection42U.S.C.1396dasrequiredbysubsection
26(d)ofSection6408ofP.L.101-239(OmnibusBudgetReconciliationActof1989).TheMO
27HealthNetdivisionmayimposeapremiumforsuchbenefitpaymentsasauthorizedby
28paragraph(d)(3)ofSection6408ofP.L.101-239.
29 4.MOHealthNetshallincludebenefitpaymentsforMedicarePartBcostsharing
30describedin42U.S.C.Section1396(d)(p)(3)(A)(ii)forindividualsdescribedinsubsection2
31ofthissection,butforthefactthattheirincomeexceedstheincomelevelestablishedbythe
32stateunder42U.S.C.Section1396(d)(p)(2)butislessthanonehundredandtenpercent
33beginningJanuary1,1993,andlessthanonehundredandtwentypercentbeginningJanuary
341,1995,oftheofficialpovertylineforafamilyofthesizeinvolved.
35 5.ForanindividualeligibleforMOHealthNetunderTitleXIXoftheSocialSecurity
36Act,MOHealthNetshallincludepaymentofenrolleepremiumsinagrouphealthplanandall
37deductibles,coinsuranceandothercost-sharingforitemsandservicesotherwisecovered
38underthestateTitleXIXplanunderSection1906ofthefederalSocialSecurityActand
39regulationsestablishedundertheauthorityofSection1906,asmaybeamended.Enrollment
40inagrouphealthplanmustbecosteffective,asestablishedbytheSecretaryofHealthand
41HumanServices,beforeenrollmentinthegrouphealthplanisrequired.Ifallmembersofa
42familyarenoteligibleforMOHealthNetandenrollmentoftheTitleXIXeligiblemembersin
43agrouphealthplanisnotpossibleunlessallfamilymembersareenrolled,allpremiumsfor
44noneligiblemembersshallbetreatedaspaymentforMOHealthNetofeligiblefamily
45members.Paymentfornoneligiblefamilymembersmustbecosteffective,takinginto
46accountpaymentofallsuchpremiums.Non-TitleXIXeligiblefamilymembersshallpayall
47deductible,coinsuranceandothercost-sharingobligations.Eachindividualasaconditionof
48eligibilityforMOHealthNetbenefitsshallapplyforenrollmentinthegrouphealthplan.
49 6.AnySocialSecuritycost-of-livingincreaseatthebeginningofanyyearshallbe
50disregardeduntilthefederalpovertylevelforsuchyearisimplemented.
51 7.IfaMOHealthNetparticipanthaspaidtherequestedspenddownincashforany
52monthandsubsequentlypaysanout-of-pocketvalidmedicalexpenseforsuchmonth,such
53expenseshallbeallowedasadeductiontofuturerequiredspenddownforuptothreemonths
54fromthedateofsuchexpense.
208.164.1.Asusedinthissection,unlessthecontextclearlyrequiresotherwise,the
2followingtermsmean:
3 (1)"Abuse",adocumentedpatternofinducing,furnishing,orotherwisecausinga
4recipienttoreceiveservicesormerchandisenototherwiserequiredorrequestedbythe
5recipient,attendingphysicianorappropriateutilizationreviewteam;adocumentedpatternof
6performingandbillingtests,examinations,patientvisits,surgeries,drugsormerchandisethat
7exceedlimitsorfrequenciesdeterminedbythedepartmentforlikepractitionersforwhich
HB2634 12 8thereisnodemonstrableneed,orforwhichtheproviderhascreatedtheneedthrough
9ineffectiveservicesormerchandisepreviouslyrendered.Thedecisiontoimposeanyofthe
10sanctionsauthorizedinthissectionshallbemadebythedirectorofthedepartment,following
11adeterminationofdemonstrableneedoracceptedmedicalpracticemadeinconsultationwith
12medicalorotherhealthcareprofessionals,orqualifiedpeerreviewteams;
13 (2)"Department",thedepartmentofsocialservices;
14 (3)"Excessiveuse",theact,byapersoneligibleforservicesunderacontractor
15provideragreementbetweenthedepartmentofsocialservicesoritsdivisionsandaprovider,
16ofseekingand/orobtainingmedicalassistancebenefitsfromanumberoflikeprovidersand
17inquantitieswhichexceedthelevelsthatareconsideredmedicallynecessarybycurrent
18medicalpracticesandstandardsfortheeligibleperson'sneeds;
19 (4)"Fraud",aknownfalserepresentation,includingtheconcealmentofamaterial
20factthattheproviderkneworshouldhaveknownthroughtheusualconductofhisprofession
21oroccupation,uponwhichtheproviderclaimsreimbursementunderthetermsandconditions
22ofacontractorprovideragreementandthepoliciespertainingtosuchcontractorprovider
23agreementofthedepartmentoritsdivisionsincarryingouttheprovidingofservices,or
24underanyapprovedstateplanauthorizedbythefederalSocialSecurityAct;
25 (5)"Healthplan",agroupofservicesprovidedtorecipientsofmedicalassistance
26benefitsbyprovidersunderacontractwiththedepartment;
27 (6)"Medicalassistancebenefits",thosebenefitsauthorizedtobeprovidedbysections
28208.152and208.162;
29 (7)"Priorauthorization",approvaltoaprovidertoperformaserviceorservicesfor
30aneligiblepersonrequiredbythedepartmentoritsdivisionsinadvanceoftheactualservice
31beingprovidedorapprovedforarecipienttoreceiveaserviceorservicesfromaprovider,
32requiredbythedepartmentoritsdesignateddivisioninadvanceoftheactualserviceor
33servicesbeingreceived;
34 (8)"Provider",anyperson,partnership,corporation,not-for-profitcorporation,
35professionalcorporation,orotherbusinessentitythatentersintoacontractorprovider
36agreementwiththedepartmentoritsdivisionsforthepurposeofprovidingservicesto
37eligiblepersons,andobtainingfromthedepartmentoritsdivisionsreimbursementtherefor;
38 (9)"Recipient",apersonwhoiseligibletoreceivemedicalassistancebenefits
39allocatedthroughthedepartment;
40 (10)"Service",thespecificfunction,act,successiveacts,benefits,continuing
41benefits,requestedbyaneligiblepersonorprovidedbytheproviderundercontractwiththe
42departmentoritsdivisions.
43 2.Thedepartmentoritsdivisionsshallhavetheauthoritytosuspend,revoke,or
44cancelanycontractorprovideragreementorrefusetoenterintoanewcontractorprovider
HB2634 13 45agreementwithanyproviderwhereitisdeterminedtheproviderhascommittedorallowedits
46agents,servants,oremployeestocommitactsdefinedasabuseorfraudinthissection.
47 3.Thedepartmentoritsdivisionsshallhavetheauthoritytoimposeprior
48authorizationasdefinedinthissection:
49 (1)Whenithasreasonablecausetobelieveaproviderorrecipienthasknowingly
50followedacourseofconductwhichisdefinedasabuseorfraudorexcessiveusebythis
51section;or
52 (2)Whenitdeterminesbyrulethatpriorauthorizationisreasonableforaspecified
53serviceorprocedure.
54 4.Ifaproviderorrecipientreportstothedepartmentoritsdivisionsthenameor
55namesofprovidersorrecipientswho,basedupontheirpersonalknowledgehasreasonable
56causetobelieveanactoractsarebeingcommittedwhicharedefinedasabuse,fraudor
57excessiveusebythissection,suchreportshallbeconfidentialandthereporter'snameshall
58notbedivulgedtoanyonebythedepartmentoranyofitsdivisions,exceptatajudicial
59proceedinguponaproperprotectiveorderbeingenteredbythecourt.
60 5.Paymentsforservicesunderanycontractorprovideragreementbetweenthe
61departmentoritsdivisionsandaprovidermaybewithheldbythedepartmentoritsdivisions
62fromtheproviderforactsoromissionsdefinedasabuseorfraudbythissection,untilsuch
63timeasanagreementbetweenthepartiesisreachedorthedisputeisadjudicatedunderthe
64lawsofthisstate.
65 6.Thedepartmentoritsdesignateddivisionshallhavetheauthoritytoreviewall
66casesandclaimrecordsforanyrecipientofpublicassistancebenefitsandtodeterminefrom
67theserecordsiftherecipienthas,asdefinedinthissection,committedexcessiveuseofsuch
68servicesbyseekingorobtainingservicesfromanumberoflikeprovidersofservicesandin
69quantitieswhichexceedthelevelsconsiderednecessarybycurrentmedicalorhealthcare
70professionalpracticestandardsandpoliciesoftheprogram.
71 7.Thedepartmentoritsdesignateddivisionshallhavetheauthoritywithrespectto
72recipientsofmedicalassistancebenefitswhohavecommittedexcessiveusetolimitorrestrict
73theuseoftherecipient'sMedicaididentificationcardtodesignatedprovidersandfor
74designatedservices;theactualmethodbywhichsuchrestrictionsareimposedshallbeatthe
75discretionofthedepartmentofsocialservicesoritsdesignateddivision.
76 8.Thedepartmentoritsdesignateddivisionshallhavetheauthoritywithrespectto
77anyrecipientofmedicalassistancebenefitswhoseusehasbeenrestrictedundersubsection7
78ofthissectionandwhoobtainsorseekstoobtainmedicalassistancebenefitsfromaprovider
79otherthanoneoftheprovidersfordesignatedservicestoterminatemedicalassistance
80benefitsasdefinedbythischapter,whereallowedbytheprovisionsofthefederalSocial
81SecurityAct.
HB2634 14 82 9.Thedepartmentoritsdesignateddivisionshallhavetheauthoritywithrespectto
83anyproviderwhoknowinglyallowsarecipienttoviolatesubsection7ofthissectionorwho
84failstoreportaknownviolationofsubsection7ofthissectiontothedepartmentofsocial
85servicesoritsdesignateddivisiontoterminateorotherwisesanctionsuchprovider'sstatusas
86aparticipantinthemedicalassistanceprogram.Anypersonmakingsuchareportshallnotbe
87civillyliablewhenthereportismadeingoodfaith.
88 10.Inordertocomplywiththeprovisionsof42U.S.C.Section1320a-7(a)
89relatingtomandatoryexclusionofcertainindividualsandentitiesfromparticipationin
90anyfederalhealthcareprogram,andinfurtheranceofthestate'sauthorityunder
91federallaw,asimplementedby42CFR1002.3(b),toexcludeanindividualorentity
92fromMOHealthNetforanyreasonorperiodauthorizedbystatelaw,thedepartmentor
93itsdivisionsshallsuspend,revoke,orcancelanycontractorprovideragreementor
94refusetoenterintoanewcontractorprovideragreementwithanyproviderwhereitis
95determinedthatsuchproviderisnotqualifiedtoperformtheserviceorservices
96required,asdescribedin42U.S.C.Section1396a(a)(23),becausesuchprovider,orsuch
97provider'sagent,servant,oremployeeactingundersuchprovider'sauthority:
98 (1)Hasaconvictionrelatedtothedeliveryofanyitemorserviceunder
99Medicareorunderanystatehealthcareprogram,asdescribedin42U.S.C.Section
1001320a-7(a)(1);
101 (2)Hasaconvictionrelatedtotheneglectorabuseofapatientinconnection
102withthedeliveryofanyhealthcareitemorservice,asdescribedin42U.S.C.Section
1031320a-7(a)(2);
104 (3)Hasafelonyconvictionrelatedtohealthcarefraud,theft,embezzlement,
105breachoffiduciaryresponsibility,orotherfinancialmisconduct,asdescribedin42
106U.S.C.Section1320a-7(a)(3);
107 (4)Hasafelonyconvictionrelatedtotheunlawfulmanufacture,distribution,
108prescription,ordispensationofacontrolledsubstance,asdescribedin42U.S.C.Section
1091320a-7(a)(4);
110 (5)Hasbeenfoundguiltyof,orcivillyliablefor,apatternofintentional
111discriminationinthedeliveryornondeliveryofanyhealthcareitemorservicebasedon
112therace,color,ornationaloriginofrecipients,asdescribedin42U.S.C.Section2000d;
113 (6)Hasdiscriminatedorhadhistoricallydiscriminatedagainstpersonsof
114certainraces,colors,ornationaloriginbypromotingeugenicsasameansoflimitingthe
115procreationofsuchpersonsofsuchraces,colors,ornationalorigin,including,butnot
116limitedto,sterilizationortheuseoftargetedabortions;
117 (7)Hasbeenfoundcivillyliablefor,orhaspaidanyfee,fine,penalty,or
118settlementofgreaterthanonemilliondollars,inconnectionwith,anyactivityrelatedto
HB2634 15 119healthcarefraud,theft,embezzlement,breachoffiduciaryresponsibility,falseclaim,or
120otherfinancialmisconduct,under42U.S.C.Section1320a-7(a),thefederalFalseClaims
121Act,31U.S.C.Section3729etseq.,otherfederallaw,orthelawsofthisoranyother
122state,orhasotherwiseviolatedanysuchlaw;or
123 (8)Isanabortionfacility,asdefinedinsection188.015,oranaffiliateor
124associateofsuchabortionfacility.
208.659.TheMOHealthNetdivisionshallrevisetheeligibilityrequirementsforthe
2uninsuredwomen'shealthprogram,asestablishedin13CSRSection70-4.090,toinclude
3womenwhoareatleasteighteenyearsofageandwithanetfamilyincomeofatorbelowone
4hundredeighty-fivepercentofthefederalpovertylevel.Inordertobeeligibleforsuch
5program,theapplicantshallnothaveassetsinexcessoftwohundredandfiftythousand
6dollars,norshalltheapplicanthaveaccesstoemployer-sponsoredhealthinsurance.Such
7changeineligibilityrequirementsshallnotresultinanychangeinservicesprovidedunderthe
8program.Nofundsshallbeexpendedtoanyabortionfacility,asdefinedinsection
9188.015,ortoanyaffiliateorassociateofsuchabortionfacility.
SectionB.BecauseoftheneedtoprotectalllifeinMissouri,bornandunborn,
2sectionAofthisactisdeemednecessaryfortheimmediatepreservationofthepublichealth,
3welfare,peace,andsafety,andisherebydeclaredtobeanemergencyactwithinthemeaning
4oftheconstitution,andsectionAofthisactshallbeinfullforceandeffectuponitspassage
5andapproval.
âś”
HB2634 16