5500S.04F
1
SENATE SUBSTITUTE
FOR
HOUSE COMMITTEE SUBSTITUTE
FOR
HOUSE BILL NO. 2634
AN ACT
To repeal sections 188.015, 188.220, 208.152,
208.153, 208.164, and 208.659, RSMo, and to enact in
lieu thereof seven new sections relating to health
care, with an emergency clause.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Sections 188.015, 188.220, 208.152, 208.153, 1
208.164, and 208.659, RSMo, are repealed and seven new sections 2
enacted in lieu thereof, to be known as sections 188.015, 3
188.207, 188.220, 208.152, 208.153, 208.164, and 208.659, to 4
read as follows:5
188.015. As used in this chapter, the following terms 1
mean: 2
(1) "Abortion": 3
(a) The act of using or prescribing any instrument, 4
device, medicine, drug, or any other means or substance with 5
the intent to destroy the life of an em bryo or fetus in his 6
or her mother's womb; or 7
(b) The intentional termination of the pregnancy of a 8
mother by using or prescribing any instrument, device, 9
medicine, drug, or other means or substance with an 10
intention other than to increase the pr obability of a live 11
birth or to remove a dead unborn child; 12
(2) "Abortion facility", a clinic, physician's office, 13
or any other place or facility in which abortions are 14
performed or induced other than a hospital; 15
2
(3) "Affiliate", a person wh o or entity that enters 16
into, with an abortion facility, a legal relationship 17
created or governed by at least one written instrument, 18
including a certificate of formation, a franchise agreement, 19
standards of affiliation, bylaws, or a license, that 20
demonstrates: 21
(a) Common ownership, management, or control between 22
the parties to the relationship; 23
(b) A franchise granted by the person or entity to the 24
affiliate; or 25
(c) The granting or extension of a license or other 26
agreement authorizing the affiliate to use the other 27
person's or entity's brand name, trademark, service mark, or 28
other registered identification mark; 29
(4) "Conception", the fertilization of the ovum of a 30
female by a sperm of a male; 31
[(4)] (5) "Department", the department of health and 32
senior services; 33
[(5)] (6) "Down Syndrome", the same meaning as defined 34
in section 191.923; 35
[(6)] (7) "Gestational age", length of pregnancy as 36
measured from the first day of the woman's last menstrual 37
period; 38
[(7)] (8) "Medical emergency", a condition which, 39
based on reasonable medical judgment, so complicates the 40
medical condition of a pregnant woman as to necessitate the 41
immediate abortion of her pregnancy to avert the death of 42
the pregnant woman or for which a delay will create a 43
serious risk of substantial and irreversible physical 44
impairment of a major bodily function of the pregnant woman; 45
[(8)] (9) "Physician", any person licensed to practice 46
medicine in this state by the state board of registration 47
for the healing arts; 48
3
[(9)] (10) "Reasonable medical judgment", a medical 49
judgment that would be made by a reasonably prudent 50
physician, knowledgeable about the case and the treatment 51
possibilities with respect to the medical conditi ons 52
involved; 53
[(10)] (11) "Unborn child", the offspring of human 54
beings from the moment of conception until birth and at 55
every stage of its biological development, including the 56
human conceptus, zygote, morula, blastocyst, embryo, and 57
fetus; 58
[(11)] (12) "Viability" or "viable", that stage of 59
fetal development when the life of the unborn child may be 60
continued indefinitely outside the womb by natural or 61
artificial life-supportive systems; 62
[(12)] (13) "Viable pregnancy" or "viable in trauterine 63
pregnancy", in the first trimester of pregnancy, an 64
intrauterine pregnancy that can potentially result in a 65
liveborn baby. 66
188.207. It shall be unlawful for any public funds to 1
be expended to any abortion facility, or t o any affiliate of 2
such abortion facility. 3
188.220. 1. Any taxpayer of this state or its 1
political subdivisions shall have standing to bring [suit in 2
a circuit court of proper venue ] a cause of action in any 3
court or administrati ve agency of competent jurisdiction to 4
enforce the provisions of sections 188.200 to 188.215. 5
2. The attorney general is authorized to bring a cause 6
of action in any court or administrative agency of competent 7
jurisdiction to enforce the provision s of sections 188.200 8
to 188.215. 9
3. In any action to enforce the provisions of sections 10
188.200 to 188.215 by a taxpayer or the attorney general, a 11
court of competent jurisdiction may order injunctive or 12
4
other equitable relief, recovery of damag es or other legal 13
remedies, or both, as well as payment of reasonable 14
attorney's fees, costs, and expenses of the taxpayer or the 15
state. The relief and remedies set forth shall not be 16
deemed exclusive and shall be in addition to any other 17
relief or remedies permitted by law. 18
208.152. 1. MO HealthNet payments shall be made on 1
behalf of those eligible needy persons 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 pe rsons 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
coverage of inpatien t costs in those cases requiring 14
treatment beyond the seventy -fifth percentile professional 15
activities study (PAS) or the MO HealthNet children's 16
diagnosis length-of-stay schedule; and provided further that 17
the MO HealthNet division shall take into acc ount 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 set forth in Title XVIII A 26
and B, Public Law 89 -97, 1965 amendments to the federal 27
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Social Security Act (42 U.S.C. Sect ion 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 fed eral 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 ot her states or government -owned and - 42
operated institutions which are determined to conform to 43
standards equivalent to licensing requirements in Title XIX 44
of the federal Social Security Act (42 U.S.C. Section 301, 45
et seq.), as amended, for nursing facili ties. 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 fr om the hospital or nursing 60
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home, provided that no such participant shall be allowed a 61
temporary leave of absence unless it is specifically 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 or relative; 67
(6) Physicians' services, whether furnished in the 68
office, home, hospital, nursing home, or elsewhe re, 69
provided, that no funds shall be expended to any abortion 70
facility, as defined in section 188.015, or to any 71
affiliate, as defined in section 188.015, of such abortion 72
facility; 73
(7) Subject to appropriation, up to twenty visits per 74
year for services limited to examinations, diagnoses, 75
adjustments, and manipulations and treatments of 76
malpositioned articulations and structures of the body 77
provided by licensed chiropractic physicians practicing 78
within their scope of practice. Nothing in this subdivision 79
shall be interpreted to otherwise expand MO HealthNet 80
services; 81
(8) Drugs and medicines when prescribed by a licensed 82
physician, dentist, podiatrist, or an advanced practice 83
registered nurse; except that no payment for drugs and 84
medicines prescribed on and after January 1, 2006, by a 85
licensed physician, dentist, podiatrist, or an advanced 86
practice registered nurse may be made on behalf of any 87
person who qualifies for prescription drug coverage under 88
the provisions of P.L. 108 -173; 89
(9) Emergency ambulance services and, effective 90
January 1, 1990, medically necessary transportation to 91
scheduled, physician -prescribed nonelective treatments; 92
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(10) Early and periodic screening and diagnosis of 93
individuals who are under th e age of twenty-one to ascertain 94
their physical or mental defects, and health care, 95
treatment, and other measures to correct or ameliorate 96
defects and chronic conditions discovered thereby. Such 97
services shall be provided in accordance with the provis ions 98
of Section 6403 of P.L. 101 -239 and federal regulations 99
promulgated thereunder; 100
(11) Home health care services; 101
(12) Family planning as defined by federal rules and 102
regulations; provided, that no funds shall be expended to 103
any abortion facility, as defined in section 188.015, or to 104
any affiliate, as defined in section 188.015, of such 105
abortion facility; and further provided, however, that such 106
family planning services shall not include abortions or any 107
abortifacient drug or device t hat is used for the purpose of 108
inducing an abortion unless such abortions are certified in 109
writing by a physician to the MO HealthNet agency that, in 110
the physician's professional judgment, the life of the 111
mother would be endangered if the fetus were ca rried to term; 112
(13) Inpatient psychiatric hospital services for 113
individuals under age twenty -one as defined in Title XIX of 114
the federal Social Security Act (42 U.S.C. Section 1396d, et 115
seq.); 116
(14) Outpatient surgical procedures, including 117
presurgical diagnostic services performed in ambulatory 118
surgical facilities which are licensed by the department of 119
health and senior services of the state of Missouri; except, 120
that such outpatient surgical services shall not include 121
persons who are eligible for coverage under Part B of Title 122
XVIII, Public Law 89 -97, 1965 amendments to the federal 123
Social Security Act, as amended, if exclusion of such 124
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persons is permitted under Title XIX, Public Law 89 -97, 1965 125
amendments to the federal Social Securit y Act, as amended; 126
(15) Personal care services which are medically 127
oriented tasks having to do with a person's physical 128
requirements, as opposed to housekeeping requirements, which 129
enable a person to be treated by his or her physician on an 130
outpatient rather than on an inpatient or residential basis 131
in a hospital, intermediate care facility, or skilled 132
nursing facility. Personal care services shall be rendered 133
by an individual not a member of the participant's family 134
who is qualified to provi de such services where the services 135
are prescribed by a physician in accordance with a plan of 136
treatment and are supervised by a licensed nurse. Persons 137
eligible to receive personal care services shall be those 138
persons who would otherwise require plac ement in a hospital, 139
intermediate care facility, or skilled nursing facility. 140
Benefits payable for personal care services shall not exceed 141
for any one participant one hundred percent of the average 142
statewide charge for care and treatment in an interme diate 143
care facility for a comparable period of time. Such 144
services, when delivered in a residential care facility or 145
assisted living facility licensed under chapter 198 shall be 146
authorized on a tier level based on the services the 147
resident requires and the frequency of the services. A 148
resident of such facility who qualifies for assistance under 149
section 208.030 shall, at a minimum, if prescribed by a 150
physician, qualify for the tier level with the fewest 151
services. The rate paid to providers for ea ch tier of 152
service shall be set subject to appropriations. Subject to 153
appropriations, each resident of such facility who qualifies 154
for assistance under section 208.030 and meets the level of 155
care required in this section shall, at a minimum, if 156
prescribed by a physician, be authorized up to one hour of 157
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personal care services per day. Authorized units of 158
personal care services shall not be reduced or tier level 159
lowered unless an order approving such reduction or lowering 160
is obtained from the resid ent's personal physician. Such 161
authorized units of personal care services or tier level 162
shall be transferred with such resident if he or she 163
transfers to another such facility. Such provision shall 164
terminate upon receipt of relevant waivers from the federal 165
Department of Health and Human Services. If the Centers for 166
Medicare and Medicaid Services determines that such 167
provision does not comply with the state plan, this 168
provision shall be null and void. The MO HealthNet division 169
shall notify the revisor of statutes as to whether the 170
relevant waivers are approved or a determination of 171
noncompliance is made; 172
(16) Mental health services. The state plan for 173
providing medical assistance under Title XIX of the Social 174
Security Act, 42 U.S.C. S ection 301, as amended, shall 175
include the following mental health services when such 176
services are provided by community mental health facilities 177
operated by the department of mental health or designated by 178
the department of mental health as a community mental health 179
facility or as an alcohol and drug abuse facility or as a 180
child-serving agency within the comprehensive children's 181
mental health service system established in section 182
630.097. The department of mental health shall establish by 183
administrative rule the definition and criteria for 184
designation as a community mental health facility and for 185
designation as an alcohol and drug abuse facility. Such 186
mental health services shall include: 187
(a) Outpatient mental health services including 188
preventive, diagnostic, therapeutic, rehabilitative, and 189
palliative interventions rendered to individuals in an 190
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individual or group setting by a mental health professional 191
in accordance with a plan of treatment appropriately 192
established, implemented, mo nitored, and revised under the 193
auspices of a therapeutic team as a part of client services 194
management; 195
(b) Clinic mental health services including 196
preventive, diagnostic, therapeutic, rehabilitative, and 197
palliative interventions rendered to indiv iduals in an 198
individual or group setting by a mental health professional 199
in accordance with a plan of treatment appropriately 200
established, implemented, monitored, and revised under the 201
auspices of a therapeutic team as a part of client services 202
management; 203
(c) Rehabilitative mental health and alcohol and drug 204
abuse services including home and community -based 205
preventive, diagnostic, therapeutic, rehabilitative, and 206
palliative interventions rendered to individuals in an 207
individual or group sett ing by a mental health or alcohol 208
and drug abuse professional in accordance with a plan of 209
treatment appropriately established, implemented, monitored, 210
and revised under the auspices of a therapeutic team as a 211
part of client services management. As used in this 212
section, mental health professional and alcohol and drug 213
abuse professional shall be defined by the department of 214
mental health pursuant to duly promulgated rules. With 215
respect to services established by this subdivision, the 216
department of social services, MO HealthNet division, shall 217
enter into an agreement with the department of mental 218
health. Matching funds for outpatient mental health 219
services, clinic mental health services, and rehabilitation 220
services for mental health and alcohol and drug abuse shall 221
be certified by the department of mental health to the MO 222
HealthNet division. The agreement shall establish a 223
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mechanism for the joint implementation of the provisions of 224
this subdivision. In addition, the agreement shall 225
establish a mechanism by which rates for services may be 226
jointly developed; 227
(17) Such additional services as defined by the MO 228
HealthNet division to be furnished under waivers of federal 229
statutory requirements as provided for and authorized by the 230
federal Social Security Act (42 U.S.C. Section 301, et seq.) 231
subject to appropriation by the general assembly; 232
(18) The services of an advanced practice registered 233
nurse with a collaborative practice agreement to the extent 234
that such services are prov ided in accordance with chapters 235
334 and 335, and regulations promulgated thereunder; 236
(19) Nursing home costs for participants receiving 237
benefit payments under subdivision (4) of this subsection to 238
reserve a bed for the participant in the nursing home during 239
the time that the participant is absent due to admission to 240
a hospital for services which cannot be performed on an 241
outpatient basis, subject to the provisions of this 242
subdivision: 243
(a) The provisions of this subdivision shall apply 244
only if: 245
a. The occupancy rate of the nursing home is at or 246
above ninety-seven percent of MO HealthNet certified 247
licensed beds, according to the most recent quarterly census 248
provided to the department of health and senior services 249
which was taken prior to when the participant is admitted to 250
the hospital; and 251
b. The patient is admitted to a hospital for a medical 252
condition with an anticipated stay of three days or less; 253
(b) The payment to be made under this subdivision 254
shall be provided for a maximum of three days per hospital 255
stay; 256
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(c) For each day that nursing home costs are paid on 257
behalf of a participant under this subdivision during any 258
period of six consecutive months such participant shall, 259
during the same period of si x consecutive months, be 260
ineligible for payment of nursing home costs of two 261
otherwise available temporary leave of absence days provided 262
under subdivision (5) of this subsection; and 263
(d) The provisions of this subdivision shall not apply 264
unless the nursing home receives notice from the participant 265
or the participant's responsible party that the participant 266
intends to return to the nursing home following the hospital 267
stay. If the nursing home receives such notification and 268
all other provisions of this subsection have been satisfied, 269
the nursing home shall provide notice to the participant or 270
the participant's responsible party prior to release of the 271
reserved bed; 272
(20) Prescribed medically necessary durable medical 273
equipment. An electronic web-based prior authorization 274
system using best medical evidence and care and treatment 275
guidelines consistent with national standards shall be used 276
to verify medical need; 277
(21) Hospice care. As used in this subdivision, the 278
term "hospice care" means a coordinated program of active 279
professional medical attention within a home, outpatient and 280
inpatient care which treats the terminally ill patient and 281
family as a unit, employing a medically directed 282
interdisciplinary team. The program provides relief of 283
severe pain or other physical symptoms and supportive care 284
to meet the special needs arising out of physical, 285
psychological, spiritual, social, and economic stresses 286
which are experienced during the final stages of illness, 287
and during dying and bereavement and meets the Medicare 288
requirements for participation as a hospice as are provided 289
13
in 42 CFR Part 418. The rate of reimbursement paid by the 290
MO HealthNet division to the hospice provider for room and 291
board furnished by a nursin g home to an eligible hospice 292
patient shall not be less than ninety -five percent of the 293
rate of reimbursement which would have been paid for 294
facility services in that nursing home facility for that 295
patient, in accordance with subsection (c) of Section 6408 296
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 297
(22) Prescribed medically necessary dental services. 298
Such services shall be subject to appropriations. An 299
electronic web-based prior authorization system using best 300
medical evidence and care and treatment guidelines 301
consistent with national standards shall be used to verify 302
medical need; 303
(23) Prescribed medically necessary optometric 304
services. Such services shall be subject to 305
appropriations. An electronic web-based prior authorization 306
system using best medical evidence and care and treatment 307
guidelines consistent with national standards shall be used 308
to verify medical need; 309
(24) Blood clotting products -related services. For 310
persons diagnosed with a bleeding disorder, as defined in 311
section 338.400, reliant on blood clotting products, as 312
defined in section 338.400, such services include: 313
(a) Home delivery of blood clotting products and 314
ancillary infusion equipment and supplies, including the 315
emergency deliveries of the product when medically necessary; 316
(b) Medically necessary ancillary infusion equipment 317
and supplies required to administer the blood clotting 318
products; and 319
(c) Assessments conducted in the participant's home by 320
a pharmacist, nurse, or local home health care agency 321
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trained in bleeding disorders when deemed necessary by the 322
participant's treating physician; 323
(25) The MO HealthNet division shall, by January 1, 324
2008, and annually thereafter, report the status of MO 325
HealthNet provider reimbursement rates as compared to one 326
hundred percent of the Medicare reimbursement rates and 327
compared to the average dental reimbursement rates paid by 328
third-party payors licensed by the state. The MO HealthNet 329
division shall, by Jul y 1, 2008, provide to the general 330
assembly a four-year plan to achieve parity with Medicare 331
reimbursement rates and for third -party payor average dental 332
reimbursement rates. Such plan shall be subject to 333
appropriation and the division shall include in its annual 334
budget request to the governor the necessary funding needed 335
to complete the four -year plan developed under this 336
subdivision. 337
2. Additional benefit payments for medical assistance 338
shall be made on behalf of those eligible needy childre n, 339
pregnant women and blind persons with any payments to be 340
made on the basis of the reasonable cost of the care or 341
reasonable charge for the services as defined and determined 342
by the MO HealthNet division, unless otherwise hereinafter 343
provided, for the following: 344
(1) Dental services; 345
(2) Services of podiatrists as defined in section 346
330.010; 347
(3) Optometric services as described in section 348
336.010; 349
(4) Orthopedic devices or other prosthetics, including 350
eye glasses, dentures, hearing aids, and wheelchairs; 351
(5) Hospice care. As used in this subdivision, the 352
term "hospice care" means a coordinated program of active 353
professional medical attention within a home, outpatient and 354
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inpatient care which treats the terminally il l patient and 355
family as a unit, employing a medically directed 356
interdisciplinary team. The program provides relief of 357
severe pain or other physical symptoms and supportive care 358
to meet the special needs arising out of physical, 359
psychological, spiritu al, social, and economic stresses 360
which are experienced during the final stages of illness, 361
and during dying and bereavement and meets the Medicare 362
requirements for participation as a hospice as are provided 363
in 42 CFR Part 418. The rate of reimburseme nt paid by the 364
MO HealthNet division to the hospice provider for room and 365
board furnished by a nursing home to an eligible hospice 366
patient shall not be less than ninety -five percent of the 367
rate of reimbursement which would have been paid for 368
facility services in that nursing home facility for that 369
patient, in accordance with subsection (c) of Section 6408 370
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 371
(6) Comprehensive day rehabilitation services 372
beginning early posttrauma as par t of a coordinated system 373
of care for individuals with disabling impairments. 374
Rehabilitation services must be based on an individualized, 375
goal-oriented, comprehensive and coordinated treatment plan 376
developed, implemented, and monitored through an 377
interdisciplinary assessment designed to restore an 378
individual to optimal level of physical, cognitive, and 379
behavioral function. The MO HealthNet division shall 380
establish by administrative rule the definition and criteria 381
for designation of a comprehensi ve day rehabilitation 382
service facility, benefit limitations and payment 383
mechanism. Any rule or portion of a rule, as that term is 384
defined in section 536.010, that is created under the 385
authority delegated in this subdivision shall become 386
effective only if it complies with and is subject to all of 387
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the provisions of chapter 536 and, if applicable, section 388
536.028. This section and chapter 536 are nonseverable and 389
if any of the powers vested with the general assembly 390
pursuant to chapter 536 to review , to delay the effective 391
date, or to disapprove and annul a rule are subsequently 392
held unconstitutional, then the grant of rulemaking 393
authority and any rule proposed or adopted after August 28, 394
2005, shall be invalid and void. 395
3. The MO HealthNet division may require any 396
participant receiving MO HealthNet benefits to pay part of 397
the charge or cost until July 1, 2008, and an additional 398
payment after July 1, 2008, as defined by rule duly 399
promulgated by the MO HealthNet division, for all covered 400
services except for those services covered under 401
subdivisions (15) and (16) of subsection 1 of this section 402
and sections 208.631 to 208.657 to the extent and in the 403
manner authorized by Title XIX of the federal Social 404
Security Act (42 U.S.C. Section 1 396, et seq.) and 405
regulations thereunder. When substitution of a generic drug 406
is permitted by the prescriber according to section 338.056, 407
and a generic drug is substituted for a name -brand drug, the 408
MO HealthNet division may not lower or delete the 409
requirement to make a co -payment pursuant to regulations of 410
Title XIX of the federal Social Security Act. A provider of 411
goods or services described under this section must collect 412
from all participants the additional payment that may be 413
required by the MO HealthNet division under authority 414
granted herein, if the division exercises that authority, to 415
remain eligible as a provider. Any payments made by 416
participants under this section shall be in addition to and 417
not in lieu of payments made by the st ate for goods or 418
services described herein except the participant portion of 419
the pharmacy professional dispensing fee shall be in 420
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addition to and not in lieu of payments to pharmacists. A 421
provider may collect the co -payment at the time a service is 422
provided or at a later date. A provider shall not refuse to 423
provide a service if a participant is unable to pay a 424
required payment. If it is the routine business practice of 425
a provider to terminate future services to an individual 426
with an unclaimed de bt, the provider may include uncollected 427
co-payments under this practice. Providers who elect not to 428
undertake the provision of services based on a history of 429
bad debt shall give participants advance notice and a 430
reasonable opportunity for payment. A provider, 431
representative, employee, independent contractor, or agent 432
of a pharmaceutical manufacturer shall not make co -payment 433
for a participant. This subsection shall not apply to other 434
qualified children, pregnant women, or blind persons. If 435
the Centers for Medicare and Medicaid Services does not 436
approve the MO HealthNet state plan amendment submitted by 437
the department of social services that would allow a 438
provider to deny future services to an individual with 439
uncollected co-payments, the denial of services shall not be 440
allowed. The department of social services shall inform 441
providers regarding the acceptability of denying services as 442
the result of unpaid co -payments. 443
4. The MO HealthNet division shall have the right to 444
collect medication samples from participants in order to 445
maintain program integrity. 446
5. Reimbursement for obstetrical and pediatric 447
services under subdivision (6) of subsection 1 of this 448
section shall be timely and sufficient to enlist enough 449
health care providers so that care and services are 450
available under the state plan for MO HealthNet benefits at 451
least to the extent that such care and services are 452
available to the general population in the geographic area, 453
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as required under subparagraph (a)(30)(A) o f 42 U.S.C. 454
Section 1396a and federal regulations promulgated thereunder. 455
6. Beginning July 1, 1990, reimbursement for services 456
rendered in federally funded health centers shall be in 457
accordance with the provisions of subsection 6402(c) and 458
Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation 459
Act of 1989) and federal regulations promulgated thereunder. 460
7. Beginning July 1, 1990, the department of social 461
services shall provide notification and referral of children 462
below age five, and pregnant, breast-feeding, or postpartum 463
women who are determined to be eligible for MO HealthNet 464
benefits under section 208.151 to the special supplemental 465
food programs for women, infants and children administered 466
by the department of health and sen ior services. Such 467
notification and referral shall conform to the requirements 468
of Section 6406 of P.L. 101 -239 and regulations promulgated 469
thereunder. 470
8. Providers of long-term care services shall be 471
reimbursed for their costs in accordance with the provisions 472
of Section 1902 (a)(13)(A) of the Social Security Act, 42 473
U.S.C. Section 1396a, as amended, and regulations 474
promulgated thereunder. 475
9. Reimbursement rates to long -term care providers 476
with respect to a total change in ownership, at arm's 477
length, for any facility previously licensed and certified 478
for participation in the MO HealthNet program shall not 479
increase payments in excess of the increase that would 480
result from the application of Section 1902 (a)(13)(C) of 481
the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C). 482
10. The MO HealthNet division may enroll qualified 483
residential care facilities and assisted living facilities, 484
as defined in chapter 198, as MO HealthNet personal care 485
providers. 486
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11. Any income earned by individuals eligible for 487
certified extended employment at a sheltered workshop under 488
chapter 178 shall not be considered as income for purposes 489
of determining eligibility under this section. 490
12. If the Missouri Medicaid audit and complianc e unit 491
changes any interpretation or application of the 492
requirements for reimbursement for MO HealthNet services 493
from the interpretation or application that has been applied 494
previously by the state in any audit of a MO HealthNet 495
provider, the Missouri Medicaid audit and compliance unit 496
shall notify all affected MO HealthNet providers five 497
business days before such change shall take effect. Failure 498
of the Missouri Medicaid audit and compliance unit to notify 499
a provider of such change shall entitle the provider to 500
continue to receive and retain reimbursement until such 501
notification is provided and shall waive any liability of 502
such provider for recoupment or other loss of any payments 503
previously made prior to the five business days after such 504
notice has been sent. Each provider shall provide the 505
Missouri Medicaid audit and compliance unit a valid email 506
address and shall agree to receive communications 507
electronically. The notification required under this 508
section shall be delivered in writing by the United States 509
Postal Service or electronic mail to each provider. 510
13. Nothing in this section shall be construed to 511
abrogate or limit the department's statutory requirement to 512
promulgate rules under chapter 536. 513
14. Beginning July 1, 2016, and subject to 514
appropriations, providers of behavioral, social, and 515
psychophysiological services for the prevention, treatment, 516
or management of physical health problems shall be 517
reimbursed utilizing the behavior assessment and 518
intervention reimbursement codes 96150 to 96154 or their 519
20
successor codes under the Current Procedural Terminology 520
(CPT) coding system. Providers eligible for such 521
reimbursement shall include psychologists. 522
15. There shall be no payments made under this section 523
for gender transition surgeries, cross -sex hormones, or 524
puberty-blocking drugs, as such terms are defined in section 525
191.1720, for the purpose of a gender transition. 526
208.153. 1. Pursuant to and not inconsistent with the 1
provisions of sections 208.151 and 208.152, the MO HealthNet 2
division shall by rule and regulation define the reasonable 3
costs, manner, extent, quantity, quality, charges and fees 4
of MO HealthNet benefits herein provided. The benefits 5
available under these sect ions shall not replace those 6
provided under other federal or state law or under other 7
contractual or legal entitlements of the persons receiving 8
them, and all persons shall be required to apply for and 9
utilize all benefits available to them and to purs ue all 10
causes of action to which they are entitled. Any person 11
entitled to MO HealthNet benefits may obtain it from any 12
provider of services that is not excluded or disqualified as 13
a provider under any provision of law including, but not 14
limited to, section 208.164, with which an agreement is in 15
effect under this section and which undertakes to provide 16
the services, as authorized by the MO HealthNet division. 17
At the discretion of the director of the MO HealthNet 18
division and with the approval of the governor, the MO 19
HealthNet division is authorized to provide medical benefits 20
for participants receiving public assistance by expending 21
funds for the payment of federal medical insurance premiums, 22
coinsurance and deductibles pursuant to the provisi ons of 23
Title XVIII B and XIX, Public Law 89 -97, 1965 amendments to 24
the federal Social Security Act (42 U.S.C. 301, et seq.), as 25
amended. 26
21
2. MO HealthNet shall include benefit payments on 27
behalf of qualified Medicare beneficiaries as defined in 42 28
U.S.C. Section 1396d(p). The family support division shall 29
by rule and regulation establish which qualified Medicare 30
beneficiaries are eligible. The MO HealthNet division shall 31
define the premiums, deductible and coinsurance provided for 32
in 42 U.S.C. Section 1396d(p) to be provided on behalf of 33
the qualified Medicare beneficiaries. 34
3. MO HealthNet shall include benefit payments for 35
Medicare Part A cost sharing as defined in clause 36
(p)(3)(A)(i) of 42 U.S.C. 1396d on behalf of qualified 37
disabled and working individuals as defined in subsection 38
(s) of Section 42 U.S.C. 1396d as required by subsection (d) 39
of Section 6408 of P.L. 101 -239 (Omnibus Budget 40
Reconciliation Act of 1989). The MO HealthNet division may 41
impose a premium for such ben efit payments as authorized by 42
paragraph (d)(3) of Section 6408 of P.L. 101 -239. 43
4. MO HealthNet shall include benefit payments for 44
Medicare Part B cost sharing described in 42 U.S.C. Section 45
1396(d)(p)(3)(A)(ii) for individuals described in subse ction 46
2 of this section, but for the fact that their income 47
exceeds the income level established by the state under 42 48
U.S.C. Section 1396(d)(p)(2) but is less than one hundred 49
and ten percent beginning January 1, 1993, and less than one 50
hundred and twenty percent beginning January 1, 1995, of the 51
official poverty line for a family of the size involved. 52
5. For an individual eligible for MO HealthNet under 53
Title XIX of the Social Security Act, MO HealthNet shall 54
include payment of enrollee prem iums in a group health plan 55
and all deductibles, coinsurance and other cost -sharing for 56
items and services otherwise covered under the state Title 57
XIX plan under Section 1906 of the federal Social Security 58
Act and regulations established under the auth ority of 59
22
Section 1906, as may be amended. Enrollment in a group 60
health plan must be cost effective, as established by the 61
Secretary of Health and Human Services, before enrollment in 62
the group health plan is required. If all members of a 63
family are not eligible for MO HealthNet and enrollment of 64
the Title XIX eligible members in a group health plan is not 65
possible unless all family members are enrolled, all 66
premiums for noneligible members shall be treated as payment 67
for MO HealthNet of eligible family members. Payment for 68
noneligible family members must be cost effective, taking 69
into account payment of all such premiums. Non-Title XIX 70
eligible family members shall pay all deductible, 71
coinsurance and other cost -sharing obligations. Each 72
individual as a condition of eligibility for MO HealthNet 73
benefits shall apply for enrollment in the group health plan. 74
6. Any Social Security cost -of-living increase at the 75
beginning of any year shall be disregarded until the federal 76
poverty level for such year is implemented. 77
7. If a MO HealthNet participant has paid the 78
requested spenddown in cash for any month and subsequently 79
pays an out-of-pocket valid medical expense for such month, 80
such expense shall be allowed as a deduction to futu re 81
required spenddown for up to three months from the date of 82
such expense. 83
208.164. 1. As used in this section, unless the 1
context clearly requires otherwise, the following terms mean: 2
(1) "Abuse", a documented pattern of i nducing, 3
furnishing, or otherwise causing a recipient to receive 4
services or merchandise not otherwise required or requested 5
by the recipient, attending physician or appropriate 6
utilization review team; a documented pattern of performing 7
and billing tests, examinations, patient visits, surgeries, 8
drugs or merchandise that exceed limits or frequencies 9
23
determined by the department for like practitioners for 10
which there is no demonstrable need, or for which the 11
provider has created the need through in effective services 12
or merchandise previously rendered. The decision to impose 13
any of the sanctions authorized in this section shall be 14
made by the director of the department, following a 15
determination of demonstrable need or accepted medical 16
practice made in consultation with medical or other health 17
care professionals, or qualified peer review teams; 18
(2) "Department", the department of social services; 19
(3) "Excessive use", the act, by a person eligible for 20
services under a contract or pr ovider agreement between the 21
department of social services or its divisions and a 22
provider, of seeking and/or obtaining medical assistance 23
benefits from a number of like providers and in quantities 24
which exceed the levels that are considered medically 25
necessary by current medical practices and standards for the 26
eligible person's needs; 27
(4) "Fraud", a known false representation, including 28
the concealment of a material fact that the provider knew or 29
should have known through the usual conduct of his 30
profession or occupation, upon which the provider claims 31
reimbursement under the terms and conditions of a contract 32
or provider agreement and the policies pertaining to such 33
contract or provider agreement of the department or its 34
divisions in carrying out the providing of services, or 35
under any approved state plan authorized by the federal 36
Social Security Act; 37
(5) "Health plan", a group of services provided to 38
recipients of medical assistance benefits by providers under 39
a contract with the department; 40
(6) "Medical assistance benefits", those benefits 41
authorized to be provided by sections 208.152 and 208.162; 42
24
(7) "Prior authorization", approval to a provider to 43
perform a service or services for an eligible person 44
required by the department or its divisions in advance of 45
the actual service being provided or approved for a 46
recipient to receive a service or services from a provider, 47
required by the department or its designated division in 48
advance of the actual service or ser vices being received; 49
(8) "Provider", any person, partnership, corporation, 50
not-for-profit corporation, professional corporation, or 51
other business entity that enters into a contract or 52
provider agreement with the department or its divisions for 53
the purpose of providing services to eligible persons, and 54
obtaining from the department or its divisions reimbursement 55
therefor; 56
(9) "Recipient", a person who is eligible to receive 57
medical assistance benefits allocated through the department; 58
(10) "Service", the specific function, act, successive 59
acts, benefits, continuing benefits, requested by an 60
eligible person or provided by the provider under contract 61
with the department or its divisions. 62
2. The department or its divisions sha ll have the 63
authority to suspend, revoke, or cancel any contract or 64
provider agreement or refuse to enter into a new contract or 65
provider agreement with any provider where it is determined 66
the provider has committed or allowed its agents, servants, 67
or employees to commit acts defined as abuse or fraud in 68
this section. 69
3. The department or its divisions shall have the 70
authority to impose prior authorization as defined in this 71
section: 72
(1) When it has reasonable cause to believe a provider 73
or recipient has knowingly followed a course of conduct 74
25
which is defined as abuse or fraud or excessive use by this 75
section; or 76
(2) When it determines by rule that prior 77
authorization is reasonable for a specified service or 78
procedure. 79
4. If a provider or recipient reports to the 80
department or its divisions the name or names of providers 81
or recipients who, based upon their personal knowledge has 82
reasonable cause to believe an act or acts are being 83
committed which are defined as abuse, fraud or excessive use 84
by this section, such report shall be confidential and the 85
reporter's name shall not be divulged to anyone by the 86
department or any of its divisions, except at a judicial 87
proceeding upon a proper protective order being entered by 88
the court. 89
5. Payments for services under any contract or 90
provider agreement between the department or its divisions 91
and a provider may be withheld by the department or its 92
divisions from the provider for acts or omissions defined as 93
abuse or fraud by this section, until such time as an 94
agreement between the parties is reached or the dispute is 95
adjudicated under the laws of this state. 96
6. The department or its designated division shall 97
have the authority to review all cases and claim re cords for 98
any recipient of public assistance benefits and to determine 99
from these records if the recipient has, as defined in this 100
section, committed excessive use of such services by seeking 101
or obtaining services from a number of like providers of 102
services and in quantities which exceed the levels 103
considered necessary by current medical or health care 104
professional practice standards and policies of the program. 105
7. The department or its designated division shall 106
have the authority with respect to recipients of medical 107
26
assistance benefits who have committed excessive use to 108
limit or restrict the use of the recipient's Medicaid 109
identification card to designated providers and for 110
designated services; the actual method by which such 111
restrictions are imposed shall be at the discretion of the 112
department of social services or its designated division. 113
8. The department or its designated division shall 114
have the authority with respect to any recipient of medical 115
assistance benefits whose use has been restricted under 116
subsection 7 of this section and who obtains or seeks to 117
obtain medical assistance benefits from a provider other 118
than one of the providers for designated services to 119
terminate medical assistance benefits as defined by this 120
chapter, where allowed by the provisions of the federal 121
Social Security Act. 122
9. The department or its designated division shall 123
have the authority with respect to any provider who 124
knowingly allows a recipient to violate subsection 7 of this 125
section or who fails to report a known violation of 126
subsection 7 of this section to the department of social 127
services or its designated division to terminate or 128
otherwise sanction such provider's status as a participant 129
in the medical assistance program. Any person making such a 130
report shall not be civilly liable when the report is made 131
in good faith. 132
10. In order to comply with the provisions of 42 133
U.S.C. Section 1320a -7(a) relating to mandatory exclusion of 134
certain individuals and entities from participation in any 135
federal health care program, and in furtherance of the 136
state's authority under federal law, as implemented by 42 137
CFR 1002.3(b), to exclude an individual or entity from MO 138
HealthNet for any reason or period authorized by state law, 139
the department or its divisions shall suspend, revoke, or 140
27
cancel any contract or provider agreement or refuse to enter 141
into a new contract or provider agreement with any provider 142
where it is determined that such provider is not qualified 143
to perform the service or services required, as described in 144
42 U.S.C. Section 1396a(a)(23), because such provider, or 145
such provider's agent, servant, or employee acting under 146
such provider's authority: 147
(1) Has a conviction related to the delivery of any 148
item or service under Medicare or under any state health 149
care program, as described in 42 U.S.C. Section 1320a - 150
7(a)(1); 151
(2) Has a conviction related to the neglect or abuse 152
of a patient in connection with the delivery of any health 153
care item or service, as described in 42 U.S.C. Section 154
1320a-7(a)(2); 155
(3) Has a felony conviction related to health care 156
fraud, theft, embezzlement, breach of fiduciary 157
responsibility, or other financial misconduct, as described 158
in 42 U.S.C. Section 1320a -7(a)(3); 159
(4) Has a felony conviction related to the unlawful 160
manufacture, distribution, prescription, or dispensation of 161
a controlled substance, as described in 42 U.S.C. Section 162
1320a-7(a)(4); 163
(5) Has been found guilty of, or civilly liable for, a 164
pattern of intentional discrimination in the delivery or 165
nondelivery of any health care item or service based on the 166
race, color, or national origin of recipients, as described 167
in 42 U.S.C. Section 2000d; or 168
(6) Is an abortion facility, as defin ed in section 169
188.015, or an affiliate, as defined in section 188.015, of 170
such abortion facility. 171
208.659. The MO HealthNet division shall revise the 1
eligibility requirements for the uninsured women's health 2
28
program, as establishe d in 13 CSR Section 70 - 4.090, to 3
include women who are at least eighteen years of age and 4
with a net family income of at or below one hundred eighty - 5
five percent of the federal poverty level. In order to be 6
eligible for such program, the applicant sh all not have 7
assets in excess of two hundred and fifty thousand dollars, 8
nor shall the applicant have access to employer -sponsored 9
health insurance. Such change in eligibility requirements 10
shall not result in any change in services provided under 11
the program. No funds shall be expended to any abortion 12
facility, as defined in section 188.015, or to any 13
affiliate, as defined in section 188.015, of such abortion 14
facility. 15
Section B. Because of the need to protect all life in 1
Missouri, born and unborn, section A of this act is deemed 2
necessary for the immediate preservation of the public 3
health, welfare, peace, and safety, and is hereby declared 4
to be an emergency act within the meaning of the 5
constitution, and section A of t his act shall be in full 6
force and effect upon its passage and approval. 7