| 12 | | - | SectionA.Sections188.015,188.220,208.152,208.153,208.164,and208.659, |
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| 13 | | - | 2RSMo,arerepealedandsevennewsectionsenactedinlieuthereof,tobeknownassections |
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| 14 | | - | 3188.015,188.207,188.220,208.152,208.153,208.164,and208.659,toreadasfollows: |
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| 15 | | - | 188.015.Asusedinthischapter,thefollowingtermsmean: |
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| 16 | | - | 2 (1)"Abortion": |
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| 17 | | - | 3 (a)Theactofusingorprescribinganyinstrument,device,medicine,drug,orany |
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| 18 | | - | 4othermeansorsubstancewiththeintenttodestroythelifeofanembryoorfetusinhisorher |
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| 19 | | - | 5mother'swomb;or |
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| 20 | | - | 6 (b)Theintentionalterminationofthepregnancyofamotherbyusingorprescribing |
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| 21 | | - | 7anyinstrument,device,medicine,drug,orothermeansorsubstancewithanintentionother |
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| 22 | | - | 8thantoincreasetheprobabilityofalivebirthortoremoveadeadunbornchild; |
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| 23 | | - | 9 (2)"Abortionfacility",aclinic,physician'soffice,oranyotherplaceorfacilityin |
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| 24 | | - | 10whichabortionsareperformedorinducedotherthanahospital; |
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| 25 | | - | 11 (3)"Affiliate",apersonwhoorentitythatentersinto,withanabortionfacility, |
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| 26 | | - | 12alegalrelationshipcreatedorgovernedbyatleastonewritteninstrument,includinga |
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| 27 | | - | 13certificateofformation,afranchiseagreement,standardsofaffiliation,bylaws,ora |
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| 28 | | - | 14license,thatdemonstrates: |
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| 29 | | - | EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis |
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| 30 | | - | intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 15 (a)Commonownership,management,orcontrolbetweenthepartiestothe |
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| 31 | | - | 16relationship; |
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| 32 | | - | 17 (b)Afranchisegrantedbythepersonorentitytotheaffiliate;or |
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| 33 | | - | 18 (c)Thegrantingorextensionofalicenseorotheragreementauthorizingthe |
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| 34 | | - | 19affiliatetousetheotherperson'sorentity'sbrandname,trademark,servicemark,or |
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| 35 | | - | 20otherregisteredidentificationmark; |
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| 36 | | - | 21 (4)"Conception",thefertilizationoftheovumofafemalebyaspermofamale; |
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| 37 | | - | 22 [(4)](5)"Department",thedepartmentofhealthandseniorservices; |
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| 38 | | - | 23 [(5)](6)"DownSyndrome",thesamemeaningasdefinedinsection191.923; |
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| 39 | | - | 24 [(6)](7)"Gestationalage",lengthofpregnancyasmeasuredfromthefirstdayofthe |
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| 40 | | - | 25woman'slastmenstrualperiod; |
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| 41 | | - | 26 [(7)](8)"Medicalemergency",aconditionwhich,basedonreasonablemedical |
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| 42 | | - | 27judgment,socomplicatesthemedicalconditionofapregnantwomanastonecessitatethe |
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| 43 | | - | 28immediateabortionofherpregnancytoavertthedeathofthepregnantwomanorforwhicha |
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| 44 | | - | 29delaywillcreateaseriousriskofsubstantialandirreversiblephysicalimpairmentofamajor |
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| 45 | | - | 30bodilyfunctionofthepregnantwoman; |
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| 46 | | - | 31 [(8)](9)"Physician",anypersonlicensedtopracticemedicineinthisstatebythe |
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| 47 | | - | 32stateboardofregistrationforthehealingarts; |
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| 48 | | - | 33 [(9)](10)"Reasonablemedicaljudgment",amedicaljudgmentthatwouldbemade |
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| 49 | | - | 34byareasonablyprudentphysician,knowledgeableaboutthecaseandthetreatment |
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| 50 | | - | 35possibilitieswithrespecttothemedicalconditionsinvolved; |
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| 51 | | - | 36 [(10)] (11)"Unbornchild",theoffspringofhumanbeingsfromthemomentof |
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| 52 | | - | 37conceptionuntilbirthandateverystageofitsbiologicaldevelopment,includingthehuman |
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| 53 | | - | 38conceptus,zygote,morula,blastocyst,embryo,andfetus; |
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| 54 | | - | 39 [(11)](12)"Viability"or"viable",thatstageoffetaldevelopmentwhenthelifeofthe |
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| 55 | | - | 40unbornchildmaybecontinuedindefinitelyoutsidethewombbynaturalorartificiallife- |
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| 56 | | - | 41supportivesystems; |
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| 57 | | - | 42 [(12)] (13)"Viablepregnancy"or"viableintrauterinepregnancy",inthefirst |
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| 58 | | - | 43trimesterofpregnancy,anintrauterinepregnancythatcanpotentiallyresultinaliveborn |
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| 59 | | - | 44baby. |
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| 60 | | - | 188.207.Itshallbeunlawfulforanypublicfundstobeexpendedtoanyabortion |
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| 61 | | - | 2facility,ortoanyaffiliateofsuchabortionfacility. |
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| 62 | | - | 188.220.1.Anytaxpayerofthisstateoritspoliticalsubdivisionsshallhavestanding |
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| 63 | | - | 2tobring[suitinacircuitcourtofpropervenue] acauseofactioninanycourtor |
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| 64 | | - | 3administrativeagencyofcompetentjurisdictiontoenforcetheprovisionsofsections |
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| 65 | | - | 4188.200to188.215. |
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| 66 | | - | SS#2HCSHB2634 2 5 2.Theattorneygeneralisauthorizedtobringacauseofactioninanycourtor |
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| 67 | | - | 6administrativeagencyofcompetentjurisdictiontoenforcetheprovisionsofsections |
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| 68 | | - | 7188.200to188.215. |
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| 69 | | - | 8 3.Inanyactiontoenforcetheprovisionsofsections188.200to188.215bya |
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| 70 | | - | 9taxpayerortheattorneygeneral,acourtofcompetentjurisdictionmayorderinjunctive |
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| 71 | | - | 10orotherequitablerelief,recoveryofdamagesorotherlegalremedies,orboth,aswellas |
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| 72 | | - | 11paymentofreasonableattorney'sfees,costs,andexpensesofthetaxpayerorthestate. |
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| 73 | | - | 12Thereliefandremediessetforthshallnotbedeemedexclusiveandshallbeinaddition |
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| 74 | | - | 13toanyotherrelieforremediespermittedbylaw. |
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| 75 | | - | 208.152.1.MOHealthNetpaymentsshallbemadeonbehalfofthoseeligibleneedy |
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| 76 | | - | 2personsasdescribedinsection208.151whoareunabletoprovideforitinwholeorinpart, |
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| 77 | | - | 3withanypaymentstobemadeonthebasisofthereasonablecostofthecareorreasonable |
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| 78 | | - | 4chargefortheservicesasdefinedanddeterminedbytheMOHealthNetdivision,unless |
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| 79 | | - | 5otherwisehereinafterprovided,forthefollowing: |
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| 80 | | - | 6 (1)Inpatienthospitalservices,excepttopersonsinaninstitutionformentaldiseases |
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| 81 | | - | 7whoareundertheageofsixty-fiveyearsandovertheageoftwenty-oneyears;providedthat |
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| 82 | | - | 8theMOHealthNetdivisionshallprovidethroughruleandregulationanexceptionprocessfor |
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| 83 | | - | 9coverageofinpatientcostsinthosecasesrequiringtreatmentbeyondtheseventy-fifth |
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| 84 | | - | 10percentileprofessionalactivitiesstudy(PAS)ortheMOHealthNetchildren'sdiagnosis |
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| 85 | | - | 11length-of-stayschedule;andprovidedfurtherthattheMOHealthNetdivisionshalltakeinto |
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| 86 | | - | 12accountthroughitspaymentsystemforhospitalservicesthesituationofhospitalswhich |
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| 87 | | - | 13serveadisproportionatenumberoflow-incomepatients; |
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| 88 | | - | 14 (2)Alloutpatienthospitalservices,paymentstherefortobeinamountswhich |
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| 89 | | - | 15representnomorethaneightypercentofthelesserofreasonablecostsorcustomarycharges |
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| 90 | | - | 16forsuchservices,determinedinaccordancewiththeprinciplessetforthinTitleXVIIIAand |
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| 91 | | - | 17B,PublicLaw89-97,1965amendmentstothefederalSocialSecurityAct(42U.S.C.Section |
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| 92 | | - | 18301,etseq.),buttheMOHealthNetdivisionmayevaluateoutpatienthospitalservices |
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| 93 | | - | 19renderedunderthissectionanddenypaymentforserviceswhicharedeterminedbytheMO |
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| 94 | | - | 20HealthNetdivisionnottobemedicallynecessary,inaccordancewithfederallawand |
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| 95 | | - | 21regulations; |
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| 96 | | - | 22 (3)LaboratoryandX-rayservices; |
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| 97 | | - | 23 (4)Nursinghomeservicesforparticipants,excepttopersonswithmorethanfive |
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| 98 | | - | 24hundredthousanddollarsequityintheirhomeorexceptforpersonsinaninstitutionfor |
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| 99 | | - | 25mentaldiseaseswhoareundertheageofsixty-fiveyears,whenresidinginahospitallicensed |
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| 100 | | - | 26bythedepartmentofhealthandseniorservicesoranursinghomelicensedbythedepartment |
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| 101 | | - | 27ofhealthandseniorservicesorappropriatelicensingauthorityofotherstatesorgovernment- |
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| 102 | | - | 28ownedand-operatedinstitutionswhicharedeterminedtoconformtostandardsequivalentto |
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| 103 | | - | SS#2HCSHB2634 3 29licensingrequirementsinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section301, |
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| 104 | | - | 30etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmayrecognize |
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| 105 | | - | 31throughitspaymentmethodologyfornursingfacilitiesthosenursingfacilitieswhichservea |
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| 106 | | - | 32highvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhendeterminingthe |
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| 107 | | - | 33amountofthebenefitpaymentstobemadeonbehalfofpersonsundertheageoftwenty-one |
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| 108 | | - | 34inanursingfacilitymayconsidernursingfacilitiesfurnishingcaretopersonsundertheageof |
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| 109 | | - | 35twenty-oneasaclassificationseparatefromothernursingfacilities; |
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| 110 | | - | 36 (5)Nursinghomecostsforparticipantsreceivingbenefitpaymentsundersubdivision |
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| 111 | | - | 37(4)ofthissubsectionforthosedays,whichshallnotexceedtwelveperanyperiodofsix |
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| 112 | | - | 38consecutivemonths,duringwhichtheparticipantisonatemporaryleaveofabsencefromthe |
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| 113 | | - | 39hospitalornursinghome,providedthatnosuchparticipantshallbeallowedatemporary |
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| 114 | | - | 40leaveofabsenceunlessitisspecificallyprovidedforinhisplanofcare.Asusedinthis |
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| 115 | | - | 41subdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftimeduring |
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| 116 | | - | 42whichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheisvisiting |
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| 117 | | - | 43afriendorrelative; |
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| 118 | | - | 44 (6)Physicians'services,whetherfurnishedintheoffice,home,hospital,nursing |
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| 119 | | - | 45home,orelsewhere, provided,thatnofundsshallbeexpendedtoanyabortionfacility,as |
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| 120 | | - | 46definedinsection188.015,ortoanyaffiliate,asdefinedinsection188.015,ofsuch |
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| 121 | | - | 47abortionfacility; |
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| 122 | | - | 48 (7)Subjecttoappropriation,uptotwentyvisitsperyearforserviceslimitedto |
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| 123 | | - | 49examinations,diagnoses,adjustments,andmanipulationsandtreatmentsofmalpositioned |
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| 124 | | - | 50articulationsandstructuresofthebodyprovidedbylicensedchiropracticphysicians |
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| 125 | | - | 51practicingwithintheirscopeofpractice.Nothinginthissubdivisionshallbeinterpretedto |
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| 126 | | - | 52otherwiseexpandMOHealthNetservices; |
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| 127 | | - | 53 (8)Drugsandmedicineswhenprescribedbyalicensedphysician,dentist,podiatrist, |
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| 128 | | - | 54oranadvancedpracticeregisterednurse;exceptthatnopaymentfordrugsandmedicines |
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| 129 | | - | 55prescribedonandafterJanuary1,2006,byalicensedphysician,dentist,podiatrist,oran |
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| 130 | | - | 56advancedpracticeregisterednursemaybemadeonbehalfofanypersonwhoqualifiesfor |
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| 131 | | - | 57prescriptiondrugcoverageundertheprovisionsofP.L.108-173; |
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| 132 | | - | 58 (9)Emergencyambulanceservicesand,effectiveJanuary1,1990,medically |
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| 133 | | - | 59necessarytransportationtoscheduled,physician-prescribednonelectivetreatments; |
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| 134 | | - | 60 (10)Earlyandperiodicscreeninganddiagnosisofindividualswhoareundertheage |
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| 135 | | - | 61oftwenty-onetoascertaintheirphysicalormentaldefects,andhealthcare,treatment,and |
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| 136 | | - | 62othermeasurestocorrectoramelioratedefectsandchronicconditionsdiscoveredthereby. |
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| 137 | | - | 63SuchservicesshallbeprovidedinaccordancewiththeprovisionsofSection6403ofP.L. |
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| 138 | | - | 64101-239andfederalregulationspromulgatedthereunder; |
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| 139 | | - | 65 (11)Homehealthcareservices; |
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| 140 | | - | SS#2HCSHB2634 4 66 (12)Familyplanningasdefinedbyfederalrulesandregulations;provided,thatno |
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| 141 | | - | 67fundsshallbeexpendedtoanyabortionfacility,asdefinedinsection188.015,ortoany |
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| 142 | | - | 68affiliate,asdefinedinsection188.015,ofsuchabortionfacility;andfurtherprovided, |
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| 143 | | - | 69however,thatsuchfamilyplanningservicesshallnotincludeabortionsoranyabortifacient |
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| 144 | | - | 70drugordevicethatisusedforthepurposeofinducinganabortionunlesssuchabortionsare |
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| 145 | | - | 71certifiedinwritingbyaphysiciantotheMOHealthNetagencythat,inthephysician's |
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| 146 | | - | 72professionaljudgment,thelifeofthemotherwouldbeendangeredifthefetuswerecarriedto |
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| 147 | | - | 73term; |
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| 148 | | - | 74 (13)Inpatientpsychiatrichospitalservicesforindividualsunderagetwenty-oneas |
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| 149 | | - | 75definedinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396d,etseq.); |
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| 150 | | - | 76 (14)Outpatientsurgicalprocedures,includingpresurgicaldiagnosticservices |
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| 151 | | - | 77performedinambulatorysurgicalfacilitieswhicharelicensedbythedepartmentofhealth |
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| 152 | | - | 78andseniorservicesofthestateofMissouri;except,thatsuchoutpatientsurgicalservicesshall |
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| 153 | | - | 79notincludepersonswhoareeligibleforcoverageunderPartBofTitleXVIII,PublicLaw89- |
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| 154 | | - | 8097,1965amendmentstothefederalSocialSecurityAct,asamended,ifexclusionofsuch |
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| 155 | | - | 81personsispermittedunderTitleXIX,PublicLaw89-97,1965amendmentstothefederal |
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| 156 | | - | 82SocialSecurityAct,asamended; |
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| 157 | | - | 83 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha |
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| 158 | | - | 84person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea |
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| 159 | | - | 85persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor |
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| 160 | | - | 86residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal |
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| 161 | | - | 87careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho |
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| 162 | | - | 88isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin |
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| 163 | | - | 89accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible |
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| 164 | | - | 90toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire |
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| 165 | | - | 91placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable |
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| 166 | | - | 92forpersonalcareservicesshallnotexceedforanyoneparticipantonehundredpercentofthe |
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| 167 | | - | 93averagestatewidechargeforcareandtreatmentinanintermediatecarefacilityfora |
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| 168 | | - | 94comparableperiodoftime.Suchservices,whendeliveredinaresidentialcarefacilityor |
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| 169 | | - | 95assistedlivingfacilitylicensedunderchapter198shallbeauthorizedonatierlevelbasedon |
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| 170 | | - | 96theservicestheresidentrequiresandthefrequencyoftheservices.Aresidentofsuchfacility |
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| 171 | | - | 97whoqualifiesforassistanceundersection208.030shall,ataminimum,ifprescribedbya |
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| 172 | | - | 98physician,qualifyforthetierlevelwiththefewestservices.Theratepaidtoprovidersfor |
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| 173 | | - | 99eachtierofserviceshallbesetsubjecttoappropriations.Subjecttoappropriations,each |
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| 174 | | - | 100residentofsuchfacilitywhoqualifiesforassistanceundersection208.030andmeetsthe |
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| 175 | | - | 101levelofcarerequiredinthissectionshall,ataminimum,ifprescribedbyaphysician,be |
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| 176 | | - | 102authorizeduptoonehourofpersonalcareservicesperday.Authorizedunitsofpersonalcare |
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| 177 | | - | SS#2HCSHB2634 5 103servicesshallnotbereducedortierlevelloweredunlessanorderapprovingsuchreductionor |
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| 178 | | - | 104loweringisobtainedfromtheresident'spersonalphysician.Suchauthorizedunitsofpersonal |
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| 179 | | - | 105careservicesortierlevelshallbetransferredwithsuchresidentifheorshetransfersto |
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| 180 | | - | 106anothersuchfacility.Suchprovisionshallterminateuponreceiptofrelevantwaiversfrom |
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| 181 | | - | 107thefederalDepartmentofHealthandHumanServices.IftheCentersforMedicareand |
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| 182 | | - | 108MedicaidServicesdeterminesthatsuchprovisiondoesnotcomplywiththestateplan,this |
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| 183 | | - | 109provisionshallbenullandvoid.TheMOHealthNetdivisionshallnotifytherevisorof |
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| 184 | | - | 110statutesastowhethertherelevantwaiversareapprovedoradeterminationofnoncompliance |
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| 185 | | - | 111ismade; |
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| 186 | | - | 112 (16)Mentalhealthservices.Thestateplanforprovidingmedicalassistanceunder |
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| 187 | | - | 113TitleXIXoftheSocialSecurityAct,42U.S.C.Section301,asamended,shallincludethe |
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| 188 | | - | 114followingmentalhealthserviceswhensuchservicesareprovidedbycommunitymental |
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| 189 | | - | 115healthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythedepartment |
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| 190 | | - | 116ofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrugabusefacility |
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| 191 | | - | 117orasachild-servingagencywithinthecomprehensivechildren'smentalhealthservicesystem |
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| 192 | | - | 118establishedinsection630.097.Thedepartmentofmentalhealthshallestablishby |
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| 193 | | - | 119administrativerulethedefinitionandcriteriafordesignationasacommunitymentalhealth |
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| 194 | | - | 120facilityandfordesignationasanalcoholanddrugabusefacility.Suchmentalhealthservices |
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| 195 | | - | 121shallinclude: |
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| 196 | | - | 122 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic, |
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| 197 | | - | 123rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup |
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| 198 | | - | 124settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately |
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| 199 | | - | 125established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas |
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| 200 | | - | 126apartofclientservicesmanagement; |
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| 201 | | - | 127 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic, |
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| 202 | | - | 128rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup |
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| 203 | | - | 129settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately |
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| 204 | | - | 130established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas |
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| 205 | | - | 131apartofclientservicesmanagement; |
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| 206 | | - | 132 (c)Rehabilitativementalhealthandalcoholanddrugabuseservicesincludinghome |
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| 207 | | - | 133andcommunity-basedpreventive,diagnostic,therapeutic,rehabilitative,andpalliative |
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| 208 | | - | 134interventionsrenderedtoindividualsinanindividualorgroupsettingbyamentalhealth |
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| 209 | | - | 135oralcoholanddrugabuseprofessionalinaccordancewithaplanoftreatmentappropriately |
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| 210 | | - | 136established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas |
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| 211 | | - | 137apartofclientservicesmanagement.Asusedinthissection,mentalhealthprofessionaland |
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| 212 | | - | 138alcoholanddrugabuseprofessionalshallbedefinedbythedepartmentofmentalhealth |
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| 213 | | - | 139pursuanttodulypromulgatedrules.Withrespecttoservicesestablishedbythissubdivision, |
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| 214 | | - | SS#2HCSHB2634 6 140thedepartmentofsocialservices,MOHealthNetdivision,shallenterintoanagreementwith |
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| 215 | | - | 141thedepartmentofmentalhealth.Matchingfundsforoutpatientmentalhealthservices,clinic |
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| 216 | | - | 142mentalhealthservices,andrehabilitationservicesformentalhealthandalcoholanddrug |
|---|
| 217 | | - | 143abuseshallbecertifiedbythedepartmentofmentalhealthtotheMOHealthNetdivision. |
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| 218 | | - | 144Theagreementshallestablishamechanismforthejointimplementationoftheprovisionsof |
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| 219 | | - | 145thissubdivision.Inaddition,theagreementshallestablishamechanismbywhichratesfor |
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| 220 | | - | 146servicesmaybejointlydeveloped; |
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| 221 | | - | 147 (17)SuchadditionalservicesasdefinedbytheMOHealthNetdivisiontobe |
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| 222 | | - | 148furnishedunderwaiversoffederalstatutoryrequirementsasprovidedforandauthorizedby |
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| 223 | | - | 149thefederalSocialSecurityAct(42U.S.C.Section301,etseq.)subjecttoappropriationbythe |
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| 224 | | - | 150generalassembly; |
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| 225 | | - | 151 (18)Theservicesofanadvancedpracticeregisterednursewithacollaborative |
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| 226 | | - | 152practiceagreementtotheextentthatsuchservicesareprovidedinaccordancewithchapters |
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| 227 | | - | 153334and335,andregulationspromulgatedthereunder; |
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| 228 | | - | 154 (19)Nursinghomecostsforparticipantsreceivingbenefitpaymentsunder |
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| 229 | | - | 155subdivision(4)ofthissubsectiontoreserveabedfortheparticipantinthenursinghome |
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| 230 | | - | 156duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich |
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| 231 | | - | 157cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision: |
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| 232 | | - | 158 (a)Theprovisionsofthissubdivisionshallapplyonlyif: |
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| 233 | | - | 159 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO |
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| 234 | | - | 160HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto |
|---|
| 235 | | - | 161thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis |
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| 236 | | - | 162admittedtothehospital;and |
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| 237 | | - | 163 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated |
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| 238 | | - | 164stayofthreedaysorless; |
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| 239 | | - | 165 (b)Thepaymenttobemadeunderthissubdivisionshallbeprovidedforamaximum |
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| 240 | | - | 166ofthreedaysperhospitalstay; |
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| 241 | | - | 167 (c)Foreachdaythatnursinghomecostsarepaidonbehalfofaparticipantunderthis |
|---|
| 242 | | - | 168subdivisionduringanyperiodofsixconsecutivemonthssuchparticipantshall,duringthe |
|---|
| 243 | | - | 169sameperiodofsixconsecutivemonths,beineligibleforpaymentofnursinghomecostsof |
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| 244 | | - | 170twootherwiseavailabletemporaryleaveofabsencedaysprovidedundersubdivision(5)of |
|---|
| 245 | | - | 171thissubsection;and |
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| 246 | | - | 172 (d)Theprovisionsofthissubdivisionshallnotapplyunlessthenursinghome |
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| 247 | | - | 173receivesnoticefromtheparticipantortheparticipant'sresponsiblepartythattheparticipant |
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| 248 | | - | 174intendstoreturntothenursinghomefollowingthehospitalstay.Ifthenursinghomereceives |
|---|
| 249 | | - | 175suchnotificationandallotherprovisionsofthissubsectionhavebeensatisfied,thenursing |
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| 250 | | - | SS#2HCSHB2634 7 176homeshallprovidenoticetotheparticipantortheparticipant'sresponsiblepartypriorto |
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| 251 | | - | 177releaseofthereservedbed; |
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| 252 | | - | 178 (20)Prescribedmedicallynecessarydurablemedicalequipment.Anelectronicweb- |
|---|
| 253 | | - | 179basedpriorauthorizationsystemusingbestmedicalevidenceandcareandtreatment |
|---|
| 254 | | - | 180guidelinesconsistentwithnationalstandardsshallbeusedtoverifymedicalneed; |
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| 255 | | - | 181 (21)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa |
|---|
| 256 | | - | 182coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand |
|---|
| 257 | | - | 183inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga |
|---|
| 258 | | - | 184medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother |
|---|
| 259 | | - | 185physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical, |
|---|
| 260 | | - | 186psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal |
|---|
| 261 | | - | 187stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor |
|---|
| 262 | | - | 188participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement |
|---|
| 263 | | - | 189paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya |
|---|
| 264 | | - | 190nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe |
|---|
| 265 | | - | 191rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome |
|---|
| 266 | | - | 192facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239 |
|---|
| 267 | | - | 193(OmnibusBudgetReconciliationActof1989); |
|---|
| 268 | | - | 194 (22)Prescribedmedicallynecessarydentalservices.Suchservicesshallbesubjectto |
|---|
| 269 | | - | 195appropriations.Anelectronicweb-basedpriorauthorizationsystemusingbestmedical |
|---|
| 270 | | - | 196evidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshallbeusedto |
|---|
| 271 | | - | 197verifymedicalneed; |
|---|
| 272 | | - | 198 (23)Prescribedmedicallynecessaryoptometricservices.Suchservicesshallbe |
|---|
| 273 | | - | 199subjecttoappropriations.Anelectronicweb-basedpriorauthorizationsystemusingbest |
|---|
| 274 | | - | 200medicalevidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshall |
|---|
| 275 | | - | 201beusedtoverifymedicalneed; |
|---|
| 276 | | - | 202 (24)Bloodclottingproducts-relatedservices.Forpersonsdiagnosedwithableeding |
|---|
| 277 | | - | 203disorder,asdefinedinsection338.400,reliantonbloodclottingproducts,asdefinedin |
|---|
| 278 | | - | 204section338.400,suchservicesinclude: |
|---|
| 279 | | - | 205 (a)Homedeliveryofbloodclottingproductsandancillaryinfusionequipmentand |
|---|
| 280 | | - | 206supplies,includingtheemergencydeliveriesoftheproductwhenmedicallynecessary; |
|---|
| 281 | | - | 207 (b)Medicallynecessaryancillaryinfusionequipmentandsuppliesrequiredto |
|---|
| 282 | | - | 208administerthebloodclottingproducts;and |
|---|
| 283 | | - | 209 (c)Assessmentsconductedintheparticipant'shomebyapharmacist,nurse,orlocal |
|---|
| 284 | | - | 210homehealthcareagencytrainedinbleedingdisorderswhendeemednecessarybythe |
|---|
| 285 | | - | 211participant'streatingphysician; |
|---|
| 286 | | - | SS#2HCSHB2634 8 212 (25)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter, |
|---|
| 287 | | - | 213reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred |
|---|
| 288 | | - | 214percentoftheMedicarereimbursementratesandcomparedtotheaveragedental |
|---|
| 289 | | - | 215reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet |
|---|
| 290 | | - | 216divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve |
|---|
| 291 | | - | 217paritywithMedicarereimbursementratesandforthird-partypayoraveragedental |
|---|
| 292 | | - | 218reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall |
|---|
| 293 | | - | 219includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete |
|---|
| 294 | | - | 220thefour-yearplandevelopedunderthissubdivision. |
|---|
| 295 | | - | 221 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof |
|---|
| 296 | | - | 222thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe |
|---|
| 297 | | - | 223madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas |
|---|
| 298 | | - | 224definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided, |
|---|
| 299 | | - | 225forthefollowing: |
|---|
| 300 | | - | 226 (1)Dentalservices; |
|---|
| 301 | | - | 227 (2)Servicesofpodiatristsasdefinedinsection330.010; |
|---|
| 302 | | - | 228 (3)Optometricservicesasdescribedinsection336.010; |
|---|
| 303 | | - | 229 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,hearing |
|---|
| 304 | | - | 230aids,andwheelchairs; |
|---|
| 305 | | - | 231 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa |
|---|
| 306 | | - | 232coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand |
|---|
| 307 | | - | 233inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga |
|---|
| 308 | | - | 234medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother |
|---|
| 309 | | - | 235physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical, |
|---|
| 310 | | - | 236psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal |
|---|
| 311 | | - | 237stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor |
|---|
| 312 | | - | 238participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement |
|---|
| 313 | | - | 239paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya |
|---|
| 314 | | - | 240nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe |
|---|
| 315 | | - | 241rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome |
|---|
| 316 | | - | 242facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239 |
|---|
| 317 | | - | 243(OmnibusBudgetReconciliationActof1989); |
|---|
| 318 | | - | 244 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa |
|---|
| 319 | | - | 245coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation |
|---|
| 320 | | - | 246servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated |
|---|
| 321 | | - | 247treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary |
|---|
| 322 | | - | 248assessmentdesignedtorestoreanindividualtooptimallevelofphysical,cognitive,and |
|---|
| 323 | | - | SS#2HCSHB2634 9 249behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe |
|---|
| 324 | | - | 250definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility, |
|---|
| 325 | | - | 251benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis |
|---|
| 326 | | - | 252definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision |
|---|
| 327 | | - | 253shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof |
|---|
| 328 | | - | 254chapter536and,ifapplicable,section536.028.Thissectionandchapter536are |
|---|
| 329 | | - | 255nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter |
|---|
| 330 | | - | 256536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently |
|---|
| 331 | | - | 257heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor |
|---|
| 332 | | - | 258adoptedafterAugust28,2005,shallbeinvalidandvoid. |
|---|
| 333 | | - | 259 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet |
|---|
| 334 | | - | 260benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter |
|---|
| 335 | | - | 261July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall |
|---|
| 336 | | - | 262coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of |
|---|
| 337 | | - | 263subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner |
|---|
| 338 | | - | 264authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.) |
|---|
| 339 | | - | 265andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber |
|---|
| 340 | | - | 266accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the |
|---|
| 341 | | - | 267MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment |
|---|
| 342 | | - | 268pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods |
|---|
| 343 | | - | 269orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional |
|---|
| 344 | | - | 270paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein, |
|---|
| 345 | | - | 271ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade |
|---|
| 346 | | - | 272byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby |
|---|
| 347 | | - | 273thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy |
|---|
| 348 | | - | 274professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists. |
|---|
| 349 | | - | 275Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A |
|---|
| 350 | | - | 276providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired |
|---|
| 351 | | - | 277payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan |
|---|
| 352 | | - | 278individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder |
|---|
| 353 | | - | 279thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona |
|---|
| 354 | | - | 280historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor |
|---|
| 355 | | - | 281payment.Aprovider,representative,employee,independentcontractor,oragentofa |
|---|
| 356 | | - | 282pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection |
|---|
| 357 | | - | 283shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters |
|---|
| 358 | | - | 284forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan |
|---|
| 359 | | - | 285amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto |
|---|
| 360 | | - | SS#2HCSHB2634 10 286denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices |
|---|
| 361 | | - | 287shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe |
|---|
| 362 | | - | 288acceptabilityofdenyingservicesastheresultofunpaidco-payments. |
|---|
| 363 | | - | 289 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom |
|---|
| 364 | | - | 290participantsinordertomaintainprogramintegrity. |
|---|
| 365 | | - | 291 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of |
|---|
| 366 | | - | 292subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare |
|---|
| 367 | | - | 293providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet |
|---|
| 368 | | - | 294benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral |
|---|
| 369 | | - | 295populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C. |
|---|
| 370 | | - | 296Section1396aandfederalregulationspromulgatedthereunder. |
|---|
| 371 | | - | 297 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded |
|---|
| 372 | | - | 298healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection |
|---|
| 373 | | - | 2996404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations |
|---|
| 374 | | - | 300promulgatedthereunder. |
|---|
| 375 | | - | 301 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification |
|---|
| 376 | | - | 302andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen |
|---|
| 377 | | - | 303whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe |
|---|
| 378 | | - | 304specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe |
|---|
| 379 | | - | 305departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe |
|---|
| 380 | | - | 306requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder. |
|---|
| 381 | | - | 307 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin |
|---|
| 382 | | - | 308accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42 |
|---|
| 383 | | - | 309U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder. |
|---|
| 384 | | - | 310 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein |
|---|
| 385 | | - | 311ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation |
|---|
| 386 | | - | 312intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat |
|---|
| 387 | | - | 313wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42 |
|---|
| 388 | | - | 314U.S.C.Section1396a(a)(13)(C). |
|---|
| 389 | | - | 315 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand |
|---|
| 390 | | - | 316assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders. |
|---|
| 391 | | - | 317 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata |
|---|
| 392 | | - | 318shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof |
|---|
| 393 | | - | 319determiningeligibilityunderthissection. |
|---|
| 394 | | - | 320 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor |
|---|
| 395 | | - | 321applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe |
|---|
| 396 | | - | 322interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO |
|---|
| 397 | | - | SS#2HCSHB2634 11 323HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected |
|---|
| 398 | | - | 324MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof |
|---|
| 399 | | - | 325theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall |
|---|
| 400 | | - | 326entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis |
|---|
| 401 | | - | 327providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany |
|---|
| 402 | | - | 328paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent. |
|---|
| 403 | | - | 329EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail |
|---|
| 404 | | - | 330addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired |
|---|
| 405 | | - | 331underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor |
|---|
| 406 | | - | 332electronicmailtoeachprovider. |
|---|
| 407 | | - | 333 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's |
|---|
| 408 | | - | 334statutoryrequirementtopromulgaterulesunderchapter536. |
|---|
| 409 | | - | 335 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral, |
|---|
| 410 | | - | 336social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof |
|---|
| 411 | | - | 337physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand |
|---|
| 412 | | - | 338interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe |
|---|
| 413 | | - | 339CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch |
|---|
| 414 | | - | 340reimbursementshallincludepsychologists. |
|---|
| 415 | | - | 341 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition |
|---|
| 416 | | - | 342surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection |
|---|
| 417 | | - | 343191.1720,forthepurposeofagendertransition. |
|---|
| 418 | | - | 208.153.1.Pursuanttoandnotinconsistentwiththeprovisionsofsections208.151 |
|---|
| 419 | | - | 2and208.152,theMOHealthNetdivisionshallbyruleandregulationdefinethereasonable |
|---|
| 420 | | - | 3costs,manner,extent,quantity,quality,chargesandfeesofMOHealthNetbenefitsherein |
|---|
| 421 | | - | 4provided.Thebenefitsavailableunderthesesectionsshallnotreplacethoseprovidedunder |
|---|
| 422 | | - | 5otherfederalorstatelaworunderothercontractualorlegalentitlementsofthepersons |
|---|
| 423 | | - | 6receivingthem,andallpersonsshallberequiredtoapplyforandutilizeallbenefitsavailable |
|---|
| 424 | | - | 7tothemandtopursueallcausesofactiontowhichtheyareentitled.Anypersonentitledto |
|---|
| 425 | | - | 8MOHealthNetbenefitsmayobtainitfromanyproviderofservicesthatisnotexcludedor |
|---|
| 426 | | - | 9disqualifiedasaproviderunderanyprovisionoflawincluding,butnotlimitedto, |
|---|
| 427 | | - | 10section208.164,withwhichanagreementisineffectunderthissectionandwhich |
|---|
| 428 | | - | 11undertakestoprovidetheservices,asauthorizedbytheMOHealthNetdivision.Atthe |
|---|
| 429 | | - | 12discretionofthedirectoroftheMOHealthNetdivisionandwiththeapprovalofthegovernor, |
|---|
| 430 | | - | 13theMOHealthNetdivisionisauthorizedtoprovidemedicalbenefitsforparticipants |
|---|
| 431 | | - | 14receivingpublicassistancebyexpendingfundsforthepaymentoffederalmedicalinsurance |
|---|
| 432 | | - | 15premiums,coinsuranceanddeductiblespursuanttotheprovisionsofTitleXVIIIBandXIX, |
|---|
| 433 | | - | SS#2HCSHB2634 12 16PublicLaw89-97,1965amendmentstothefederalSocialSecurityAct(42U.S.C.301,et |
|---|
| 434 | | - | 17seq.),asamended. |
|---|
| 435 | | - | 18 2.MOHealthNetshallincludebenefitpaymentsonbehalfofqualifiedMedicare |
|---|
| 436 | | - | 19beneficiariesasdefinedin42U.S.C.Section1396d(p).Thefamilysupportdivisionshallby |
|---|
| 437 | | - | 20ruleandregulationestablishwhichqualifiedMedicarebeneficiariesareeligible.TheMO |
|---|
| 438 | | - | 21HealthNetdivisionshalldefinethepremiums,deductibleandcoinsuranceprovidedforin42 |
|---|
| 439 | | - | 22U.S.C.Section1396d(p)tobeprovidedonbehalfofthequalifiedMedicarebeneficiaries. |
|---|
| 440 | | - | 23 3.MOHealthNetshallincludebenefitpaymentsforMedicarePartAcostsharingas |
|---|
| 441 | | - | 24definedinclause(p)(3)(A)(i)of42U.S.C.1396donbehalfofqualifieddisabledandworking |
|---|
| 442 | | - | 25individualsasdefinedinsubsection(s)ofSection42U.S.C.1396dasrequiredbysubsection |
|---|
| 443 | | - | 26(d)ofSection6408ofP.L.101-239(OmnibusBudgetReconciliationActof1989).TheMO |
|---|
| 444 | | - | 27HealthNetdivisionmayimposeapremiumforsuchbenefitpaymentsasauthorizedby |
|---|
| 445 | | - | 28paragraph(d)(3)ofSection6408ofP.L.101-239. |
|---|
| 446 | | - | 29 4.MOHealthNetshallincludebenefitpaymentsforMedicarePartBcostsharing |
|---|
| 447 | | - | 30describedin42U.S.C.Section1396(d)(p)(3)(A)(ii)forindividualsdescribedinsubsection2 |
|---|
| 448 | | - | 31ofthissection,butforthefactthattheirincomeexceedstheincomelevelestablishedbythe |
|---|
| 449 | | - | 32stateunder42U.S.C.Section1396(d)(p)(2)butislessthanonehundredandtenpercent |
|---|
| 450 | | - | 33beginningJanuary1,1993,andlessthanonehundredandtwentypercentbeginningJanuary |
|---|
| 451 | | - | 341,1995,oftheofficialpovertylineforafamilyofthesizeinvolved. |
|---|
| 452 | | - | 35 5.ForanindividualeligibleforMOHealthNetunderTitleXIXoftheSocialSecurity |
|---|
| 453 | | - | 36Act,MOHealthNetshallincludepaymentofenrolleepremiumsinagrouphealthplanandall |
|---|
| 454 | | - | 37deductibles,coinsuranceandothercost-sharingforitemsandservicesotherwisecovered |
|---|
| 455 | | - | 38underthestateTitleXIXplanunderSection1906ofthefederalSocialSecurityActand |
|---|
| 456 | | - | 39regulationsestablishedundertheauthorityofSection1906,asmaybeamended.Enrollment |
|---|
| 457 | | - | 40inagrouphealthplanmustbecosteffective,asestablishedbytheSecretaryofHealthand |
|---|
| 458 | | - | 41HumanServices,beforeenrollmentinthegrouphealthplanisrequired.Ifallmembersofa |
|---|
| 459 | | - | 42familyarenoteligibleforMOHealthNetandenrollmentoftheTitleXIXeligiblemembersin |
|---|
| 460 | | - | 43agrouphealthplanisnotpossibleunlessallfamilymembersareenrolled,allpremiumsfor |
|---|
| 461 | | - | 44noneligiblemembersshallbetreatedaspaymentforMOHealthNetofeligiblefamily |
|---|
| 462 | | - | 45members.Paymentfornoneligiblefamilymembersmustbecosteffective,takinginto |
|---|
| 463 | | - | 46accountpaymentofallsuchpremiums.Non-TitleXIXeligiblefamilymembersshallpayall |
|---|
| 464 | | - | 47deductible,coinsuranceandothercost-sharingobligations.Eachindividualasaconditionof |
|---|
| 465 | | - | 48eligibilityforMOHealthNetbenefitsshallapplyforenrollmentinthegrouphealthplan. |
|---|
| 466 | | - | 49 6.AnySocialSecuritycost-of-livingincreaseatthebeginningofanyyearshallbe |
|---|
| 467 | | - | 50disregardeduntilthefederalpovertylevelforsuchyearisimplemented. |
|---|
| 468 | | - | 51 7.IfaMOHealthNetparticipanthaspaidtherequestedspenddownincashforany |
|---|
| 469 | | - | 52monthandsubsequentlypaysanout-of-pocketvalidmedicalexpenseforsuchmonth,such |
|---|
| 470 | | - | SS#2HCSHB2634 13 53expenseshallbeallowedasadeductiontofuturerequiredspenddownforuptothreemonths |
|---|
| 471 | | - | 54fromthedateofsuchexpense. |
|---|
| 472 | | - | 208.164.1.Asusedinthissection,unlessthecontextclearlyrequiresotherwise,the |
|---|
| 473 | | - | 2followingtermsmean: |
|---|
| 474 | | - | 3 (1)"Abuse",adocumentedpatternofinducing,furnishing,orotherwisecausinga |
|---|
| 475 | | - | 4recipienttoreceiveservicesormerchandisenototherwiserequiredorrequestedbythe |
|---|
| 476 | | - | 5recipient,attendingphysicianorappropriateutilizationreviewteam;adocumentedpatternof |
|---|
| 477 | | - | 6performingandbillingtests,examinations,patientvisits,surgeries,drugsormerchandisethat |
|---|
| 478 | | - | 7exceedlimitsorfrequenciesdeterminedbythedepartmentforlikepractitionersforwhich |
|---|
| 479 | | - | 8thereisnodemonstrableneed,orforwhichtheproviderhascreatedtheneedthrough |
|---|
| 480 | | - | 9ineffectiveservicesormerchandisepreviouslyrendered.Thedecisiontoimposeanyofthe |
|---|
| 481 | | - | 10sanctionsauthorizedinthissectionshallbemadebythedirectorofthedepartment,following |
|---|
| 482 | | - | 11adeterminationofdemonstrableneedoracceptedmedicalpracticemadeinconsultationwith |
|---|
| 483 | | - | 12medicalorotherhealthcareprofessionals,orqualifiedpeerreviewteams; |
|---|
| 484 | | - | 13 (2)"Department",thedepartmentofsocialservices; |
|---|
| 485 | | - | 14 (3)"Excessiveuse",theact,byapersoneligibleforservicesunderacontractor |
|---|
| 486 | | - | 15provideragreementbetweenthedepartmentofsocialservicesoritsdivisionsandaprovider, |
|---|
| 487 | | - | 16ofseekingand/orobtainingmedicalassistancebenefitsfromanumberoflikeprovidersand |
|---|
| 488 | | - | 17inquantitieswhichexceedthelevelsthatareconsideredmedicallynecessarybycurrent |
|---|
| 489 | | - | 18medicalpracticesandstandardsfortheeligibleperson'sneeds; |
|---|
| 490 | | - | 19 (4)"Fraud",aknownfalserepresentation,includingtheconcealmentofamaterial |
|---|
| 491 | | - | 20factthattheproviderkneworshouldhaveknownthroughtheusualconductofhisprofession |
|---|
| 492 | | - | 21oroccupation,uponwhichtheproviderclaimsreimbursementunderthetermsandconditions |
|---|
| 493 | | - | 22ofacontractorprovideragreementandthepoliciespertainingtosuchcontractorprovider |
|---|
| 494 | | - | 23agreementofthedepartmentoritsdivisionsincarryingouttheprovidingofservices,or |
|---|
| 495 | | - | 24underanyapprovedstateplanauthorizedbythefederalSocialSecurityAct; |
|---|
| 496 | | - | 25 (5)"Healthplan",agroupofservicesprovidedtorecipientsofmedicalassistance |
|---|
| 497 | | - | 26benefitsbyprovidersunderacontractwiththedepartment; |
|---|
| 498 | | - | 27 (6)"Medicalassistancebenefits",thosebenefitsauthorizedtobeprovidedbysections |
|---|
| 499 | | - | 28208.152and208.162; |
|---|
| 500 | | - | 29 (7)"Priorauthorization",approvaltoaprovidertoperformaserviceorservicesfor |
|---|
| 501 | | - | 30aneligiblepersonrequiredbythedepartmentoritsdivisionsinadvanceoftheactualservice |
|---|
| 502 | | - | 31beingprovidedorapprovedforarecipienttoreceiveaserviceorservicesfromaprovider, |
|---|
| 503 | | - | 32requiredbythedepartmentoritsdesignateddivisioninadvanceoftheactualserviceor |
|---|
| 504 | | - | 33servicesbeingreceived; |
|---|
| 505 | | - | 34 (8)"Provider",anyperson,partnership,corporation,not-for-profitcorporation, |
|---|
| 506 | | - | 35professionalcorporation,orotherbusinessentitythatentersintoacontractorprovider |
|---|
| 507 | | - | SS#2HCSHB2634 14 36agreementwiththedepartmentoritsdivisionsforthepurposeofprovidingservicesto |
|---|
| 508 | | - | 37eligiblepersons,andobtainingfromthedepartmentoritsdivisionsreimbursementtherefor; |
|---|
| 509 | | - | 38 (9)"Recipient",apersonwhoiseligibletoreceivemedicalassistancebenefits |
|---|
| 510 | | - | 39allocatedthroughthedepartment; |
|---|
| 511 | | - | 40 (10)"Service",thespecificfunction,act,successiveacts,benefits,continuing |
|---|
| 512 | | - | 41benefits,requestedbyaneligiblepersonorprovidedbytheproviderundercontractwiththe |
|---|
| 513 | | - | 42departmentoritsdivisions. |
|---|
| 514 | | - | 43 2.Thedepartmentoritsdivisionsshallhavetheauthoritytosuspend,revoke,or |
|---|
| 515 | | - | 44cancelanycontractorprovideragreementorrefusetoenterintoanewcontractorprovider |
|---|
| 516 | | - | 45agreementwithanyproviderwhereitisdeterminedtheproviderhascommittedorallowedits |
|---|
| 517 | | - | 46agents,servants,oremployeestocommitactsdefinedasabuseorfraudinthissection. |
|---|
| 518 | | - | 47 3.Thedepartmentoritsdivisionsshallhavetheauthoritytoimposeprior |
|---|
| 519 | | - | 48authorizationasdefinedinthissection: |
|---|
| 520 | | - | 49 (1)Whenithasreasonablecausetobelieveaproviderorrecipienthasknowingly |
|---|
| 521 | | - | 50followedacourseofconductwhichisdefinedasabuseorfraudorexcessiveusebythis |
|---|
| 522 | | - | 51section;or |
|---|
| 523 | | - | 52 (2)Whenitdeterminesbyrulethatpriorauthorizationisreasonableforaspecified |
|---|
| 524 | | - | 53serviceorprocedure. |
|---|
| 525 | | - | 54 4.Ifaproviderorrecipientreportstothedepartmentoritsdivisionsthenameor |
|---|
| 526 | | - | 55namesofprovidersorrecipientswho,basedupontheirpersonalknowledgehasreasonable |
|---|
| 527 | | - | 56causetobelieveanactoractsarebeingcommittedwhicharedefinedasabuse,fraudor |
|---|
| 528 | | - | 57excessiveusebythissection,suchreportshallbeconfidentialandthereporter'snameshall |
|---|
| 529 | | - | 58notbedivulgedtoanyonebythedepartmentoranyofitsdivisions,exceptatajudicial |
|---|
| 530 | | - | 59proceedinguponaproperprotectiveorderbeingenteredbythecourt. |
|---|
| 531 | | - | 60 5.Paymentsforservicesunderanycontractorprovideragreementbetweenthe |
|---|
| 532 | | - | 61departmentoritsdivisionsandaprovidermaybewithheldbythedepartmentoritsdivisions |
|---|
| 533 | | - | 62fromtheproviderforactsoromissionsdefinedasabuseorfraudbythissection,untilsuch |
|---|
| 534 | | - | 63timeasanagreementbetweenthepartiesisreachedorthedisputeisadjudicatedunderthe |
|---|
| 535 | | - | 64lawsofthisstate. |
|---|
| 536 | | - | 65 6.Thedepartmentoritsdesignateddivisionshallhavetheauthoritytoreviewall |
|---|
| 537 | | - | 66casesandclaimrecordsforanyrecipientofpublicassistancebenefitsandtodeterminefrom |
|---|
| 538 | | - | 67theserecordsiftherecipienthas,asdefinedinthissection,committedexcessiveuseofsuch |
|---|
| 539 | | - | 68servicesbyseekingorobtainingservicesfromanumberoflikeprovidersofservicesandin |
|---|
| 540 | | - | 69quantitieswhichexceedthelevelsconsiderednecessarybycurrentmedicalorhealthcare |
|---|
| 541 | | - | 70professionalpracticestandardsandpoliciesoftheprogram. |
|---|
| 542 | | - | 71 7.Thedepartmentoritsdesignateddivisionshallhavetheauthoritywithrespectto |
|---|
| 543 | | - | 72recipientsofmedicalassistancebenefitswhohavecommittedexcessiveusetolimitorrestrict |
|---|
| 544 | | - | SS#2HCSHB2634 15 73theuseoftherecipient'sMedicaididentificationcardtodesignatedprovidersandfor |
|---|
| 545 | | - | 74designatedservices;theactualmethodbywhichsuchrestrictionsareimposedshallbeatthe |
|---|
| 546 | | - | 75discretionofthedepartmentofsocialservicesoritsdesignateddivision. |
|---|
| 547 | | - | 76 8.Thedepartmentoritsdesignateddivisionshallhavetheauthoritywithrespectto |
|---|
| 548 | | - | 77anyrecipientofmedicalassistancebenefitswhoseusehasbeenrestrictedundersubsection7 |
|---|
| 549 | | - | 78ofthissectionandwhoobtainsorseekstoobtainmedicalassistancebenefitsfromaprovider |
|---|
| 550 | | - | 79otherthanoneoftheprovidersfordesignatedservicestoterminatemedicalassistance |
|---|
| 551 | | - | 80benefitsasdefinedbythischapter,whereallowedbytheprovisionsofthefederalSocial |
|---|
| 552 | | - | 81SecurityAct. |
|---|
| 553 | | - | 82 9.Thedepartmentoritsdesignateddivisionshallhavetheauthoritywithrespectto |
|---|
| 554 | | - | 83anyproviderwhoknowinglyallowsarecipienttoviolatesubsection7ofthissectionorwho |
|---|
| 555 | | - | 84failstoreportaknownviolationofsubsection7ofthissectiontothedepartmentofsocial |
|---|
| 556 | | - | 85servicesoritsdesignateddivisiontoterminateorotherwisesanctionsuchprovider'sstatusas |
|---|
| 557 | | - | 86aparticipantinthemedicalassistanceprogram.Anypersonmakingsuchareportshallnotbe |
|---|
| 558 | | - | 87civillyliablewhenthereportismadeingoodfaith. |
|---|
| 559 | | - | 88 10.Inordertocomplywiththeprovisionsof42U.S.C.Section1320a-7(a) |
|---|
| 560 | | - | 89relatingtomandatoryexclusionofcertainindividualsandentitiesfromparticipationin |
|---|
| 561 | | - | 90anyfederalhealthcareprogram,andinfurtheranceofthestate'sauthorityunder |
|---|
| 562 | | - | 91federallaw,asimplementedby42CFR1002.3(b),toexcludeanindividualorentity |
|---|
| 563 | | - | 92fromMOHealthNetforanyreasonorperiodauthorizedbystatelaw,thedepartmentor |
|---|
| 564 | | - | 93itsdivisionsshallsuspend,revoke,orcancelanycontractorprovideragreementor |
|---|
| 565 | | - | 94refusetoenterintoanewcontractorprovideragreementwithanyproviderwhereitis |
|---|
| 566 | | - | 95determinedthatsuchproviderisnotqualifiedtoperformtheserviceorservices |
|---|
| 567 | | - | 96required,asdescribedin42U.S.C.Section1396a(a)(23),becausesuchprovider,orsuch |
|---|
| 568 | | - | 97provider'sagent,servant,oremployeeactingundersuchprovider'sauthority: |
|---|
| 569 | | - | 98 (1)Hasaconvictionrelatedtothedeliveryofanyitemorserviceunder |
|---|
| 570 | | - | 99Medicareorunderanystatehealthcareprogram,asdescribedin42U.S.C.Section |
|---|
| 571 | | - | 1001320a-7(a)(1); |
|---|
| 572 | | - | 101 (2)Hasaconvictionrelatedtotheneglectorabuseofapatientinconnection |
|---|
| 573 | | - | 102withthedeliveryofanyhealthcareitemorservice,asdescribedin42U.S.C.Section |
|---|
| 574 | | - | 1031320a-7(a)(2); |
|---|
| 575 | | - | 104 (3)Hasafelonyconvictionrelatedtohealthcarefraud,theft,embezzlement, |
|---|
| 576 | | - | 105breachoffiduciaryresponsibility,orotherfinancialmisconduct,asdescribedin42 |
|---|
| 577 | | - | 106U.S.C.Section1320a-7(a)(3); |
|---|
| 578 | | - | 107 (4)Hasafelonyconvictionrelatedtotheunlawfulmanufacture,distribution, |
|---|
| 579 | | - | 108prescription,ordispensationofacontrolledsubstance,asdescribedin42U.S.C.Section |
|---|
| 580 | | - | 1091320a-7(a)(4); |
|---|
| 581 | | - | SS#2HCSHB2634 16 110 (5)Hasbeenfoundguiltyof,orcivillyliablefor,apatternofintentional |
|---|
| 582 | | - | 111discriminationinthedeliveryornondeliveryofanyhealthcareitemorservicebasedon |
|---|
| 583 | | - | 112therace,color,ornationaloriginofrecipients,asdescribedin42U.S.C.Section2000d; |
|---|
| 584 | | - | 113or |
|---|
| 585 | | - | 114 (6)Isanabortionfacility,asdefinedinsection188.015,oranaffiliate,asdefined |
|---|
| 586 | | - | 115insection188.015,ofsuchabortionfacility. |
|---|
| 587 | | - | 208.659.TheMOHealthNetdivisionshallrevisetheeligibilityrequirementsforthe |
|---|
| 588 | | - | 2uninsuredwomen'shealthprogram,asestablishedin13CSRSection70-4.090,toinclude |
|---|
| 589 | | - | 3womenwhoareatleasteighteenyearsofageandwithanetfamilyincomeofatorbelowone |
|---|
| 590 | | - | 4hundredeighty-fivepercentofthefederalpovertylevel.Inordertobeeligibleforsuch |
|---|
| 591 | | - | 5program,theapplicantshallnothaveassetsinexcessoftwohundredandfiftythousand |
|---|
| 592 | | - | 6dollars,norshalltheapplicanthaveaccesstoemployer-sponsoredhealthinsurance.Such |
|---|
| 593 | | - | 7changeineligibilityrequirementsshallnotresultinanychangeinservicesprovidedunderthe |
|---|
| 594 | | - | 8program.Nofundsshallbeexpendedtoanyabortionfacility,asdefinedinsection |
|---|
| 595 | | - | 9188.015,ortoanyaffiliate,asdefinedinsection188.015,ofsuchabortionfacility. |
|---|
| 596 | | - | âś” |
|---|
| 597 | | - | SS#2HCSHB2634 17 |
|---|
| 15 | + | Section A. Sections 188.015, 188.220, 208.152, 208.153, 1 |
|---|
| 16 | + | 208.164, and 208.659, RSMo, are repealed and seven new sections 2 |
|---|
| 17 | + | enacted in lieu thereof, to be known as sections 188.015, 3 |
|---|
| 18 | + | 188.207, 188.220, 208.152, 208.153, 208.164, and 208.659, to 4 |
|---|
| 19 | + | read as follows:5 |
|---|
| 20 | + | 188.015. As used in this chapter, the following terms 1 |
|---|
| 21 | + | mean: 2 |
|---|
| 22 | + | (1) "Abortion": 3 |
|---|
| 23 | + | (a) The act of using or prescribing any instrument, 4 |
|---|
| 24 | + | device, medicine, drug, or any other means or substance with 5 |
|---|
| 25 | + | the intent to destroy the life of an em bryo or fetus in his 6 |
|---|
| 26 | + | or her mother's womb; or 7 |
|---|
| 27 | + | (b) The intentional termination of the pregnancy of a 8 |
|---|
| 28 | + | mother by using or prescribing any instrument, device, 9 |
|---|
| 29 | + | medicine, drug, or other means or substance with an 10 |
|---|
| 30 | + | intention other than to increase the pr obability of a live 11 |
|---|
| 31 | + | birth or to remove a dead unborn child; 12 |
|---|
| 32 | + | (2) "Abortion facility", a clinic, physician's office, 13 |
|---|
| 33 | + | or any other place or facility in which abortions are 14 |
|---|
| 34 | + | performed or induced other than a hospital; 15 |
|---|
| 35 | + | 2 |
|---|
| 36 | + | (3) "Affiliate", a person wh o or entity that enters 16 |
|---|
| 37 | + | into, with an abortion facility, a legal relationship 17 |
|---|
| 38 | + | created or governed by at least one written instrument, 18 |
|---|
| 39 | + | including a certificate of formation, a franchise agreement, 19 |
|---|
| 40 | + | standards of affiliation, bylaws, or a license, that 20 |
|---|
| 41 | + | demonstrates: 21 |
|---|
| 42 | + | (a) Common ownership, management, or control between 22 |
|---|
| 43 | + | the parties to the relationship; 23 |
|---|
| 44 | + | (b) A franchise granted by the person or entity to the 24 |
|---|
| 45 | + | affiliate; or 25 |
|---|
| 46 | + | (c) The granting or extension of a license or other 26 |
|---|
| 47 | + | agreement authorizing the affiliate to use the other 27 |
|---|
| 48 | + | person's or entity's brand name, trademark, service mark, or 28 |
|---|
| 49 | + | other registered identification mark; 29 |
|---|
| 50 | + | (4) "Conception", the fertilization of the ovum of a 30 |
|---|
| 51 | + | female by a sperm of a male; 31 |
|---|
| 52 | + | [(4)] (5) "Department", the department of health and 32 |
|---|
| 53 | + | senior services; 33 |
|---|
| 54 | + | [(5)] (6) "Down Syndrome", the same meaning as defined 34 |
|---|
| 55 | + | in section 191.923; 35 |
|---|
| 56 | + | [(6)] (7) "Gestational age", length of pregnancy as 36 |
|---|
| 57 | + | measured from the first day of the woman's last menstrual 37 |
|---|
| 58 | + | period; 38 |
|---|
| 59 | + | [(7)] (8) "Medical emergency", a condition which, 39 |
|---|
| 60 | + | based on reasonable medical judgment, so complicates the 40 |
|---|
| 61 | + | medical condition of a pregnant woman as to necessitate the 41 |
|---|
| 62 | + | immediate abortion of her pregnancy to avert the death of 42 |
|---|
| 63 | + | the pregnant woman or for which a delay will create a 43 |
|---|
| 64 | + | serious risk of substantial and irreversible physical 44 |
|---|
| 65 | + | impairment of a major bodily function of the pregnant woman; 45 |
|---|
| 66 | + | [(8)] (9) "Physician", any person licensed to practice 46 |
|---|
| 67 | + | medicine in this state by the state board of registration 47 |
|---|
| 68 | + | for the healing arts; 48 |
|---|
| 69 | + | 3 |
|---|
| 70 | + | [(9)] (10) "Reasonable medical judgment", a medical 49 |
|---|
| 71 | + | judgment that would be made by a reasonably prudent 50 |
|---|
| 72 | + | physician, knowledgeable about the case and the treatment 51 |
|---|
| 73 | + | possibilities with respect to the medical conditi ons 52 |
|---|
| 74 | + | involved; 53 |
|---|
| 75 | + | [(10)] (11) "Unborn child", the offspring of human 54 |
|---|
| 76 | + | beings from the moment of conception until birth and at 55 |
|---|
| 77 | + | every stage of its biological development, including the 56 |
|---|
| 78 | + | human conceptus, zygote, morula, blastocyst, embryo, and 57 |
|---|
| 79 | + | fetus; 58 |
|---|
| 80 | + | [(11)] (12) "Viability" or "viable", that stage of 59 |
|---|
| 81 | + | fetal development when the life of the unborn child may be 60 |
|---|
| 82 | + | continued indefinitely outside the womb by natural or 61 |
|---|
| 83 | + | artificial life-supportive systems; 62 |
|---|
| 84 | + | [(12)] (13) "Viable pregnancy" or "viable in trauterine 63 |
|---|
| 85 | + | pregnancy", in the first trimester of pregnancy, an 64 |
|---|
| 86 | + | intrauterine pregnancy that can potentially result in a 65 |
|---|
| 87 | + | liveborn baby. 66 |
|---|
| 88 | + | 188.207. It shall be unlawful for any public funds to 1 |
|---|
| 89 | + | be expended to any abortion facility, or t o any affiliate of 2 |
|---|
| 90 | + | such abortion facility. 3 |
|---|
| 91 | + | 188.220. 1. Any taxpayer of this state or its 1 |
|---|
| 92 | + | political subdivisions shall have standing to bring [suit in 2 |
|---|
| 93 | + | a circuit court of proper venue ] a cause of action in any 3 |
|---|
| 94 | + | court or administrati ve agency of competent jurisdiction to 4 |
|---|
| 95 | + | enforce the provisions of sections 188.200 to 188.215. 5 |
|---|
| 96 | + | 2. The attorney general is authorized to bring a cause 6 |
|---|
| 97 | + | of action in any court or administrative agency of competent 7 |
|---|
| 98 | + | jurisdiction to enforce the provision s of sections 188.200 8 |
|---|
| 99 | + | to 188.215. 9 |
|---|
| 100 | + | 3. In any action to enforce the provisions of sections 10 |
|---|
| 101 | + | 188.200 to 188.215 by a taxpayer or the attorney general, a 11 |
|---|
| 102 | + | court of competent jurisdiction may order injunctive or 12 |
|---|
| 103 | + | 4 |
|---|
| 104 | + | other equitable relief, recovery of damag es or other legal 13 |
|---|
| 105 | + | remedies, or both, as well as payment of reasonable 14 |
|---|
| 106 | + | attorney's fees, costs, and expenses of the taxpayer or the 15 |
|---|
| 107 | + | state. The relief and remedies set forth shall not be 16 |
|---|
| 108 | + | deemed exclusive and shall be in addition to any other 17 |
|---|
| 109 | + | relief or remedies permitted by law. 18 |
|---|
| 110 | + | 208.152. 1. MO HealthNet payments shall be made on 1 |
|---|
| 111 | + | behalf of those eligible needy persons as described in 2 |
|---|
| 112 | + | section 208.151 who are unable to provide for it in whole or 3 |
|---|
| 113 | + | in part, with any payments to be made on the basis of the 4 |
|---|
| 114 | + | reasonable cost of the care or reasonable charge for the 5 |
|---|
| 115 | + | services as defined and determined by the MO HealthNet 6 |
|---|
| 116 | + | division, unless otherwise hereinafter provided, for the 7 |
|---|
| 117 | + | following: 8 |
|---|
| 118 | + | (1) Inpatient hospital services, except to pe rsons in 9 |
|---|
| 119 | + | an institution for mental diseases who are under the age of 10 |
|---|
| 120 | + | sixty-five years and over the age of twenty -one years; 11 |
|---|
| 121 | + | provided that the MO HealthNet division shall provide 12 |
|---|
| 122 | + | through rule and regulation an exception process for 13 |
|---|
| 123 | + | coverage of inpatien t costs in those cases requiring 14 |
|---|
| 124 | + | treatment beyond the seventy -fifth percentile professional 15 |
|---|
| 125 | + | activities study (PAS) or the MO HealthNet children's 16 |
|---|
| 126 | + | diagnosis length-of-stay schedule; and provided further that 17 |
|---|
| 127 | + | the MO HealthNet division shall take into acc ount through 18 |
|---|
| 128 | + | its payment system for hospital services the situation of 19 |
|---|
| 129 | + | hospitals which serve a disproportionate number of low - 20 |
|---|
| 130 | + | income patients; 21 |
|---|
| 131 | + | (2) All outpatient hospital services, payments 22 |
|---|
| 132 | + | therefor to be in amounts which represent no more than 23 |
|---|
| 133 | + | eighty percent of the lesser of reasonable costs or 24 |
|---|
| 134 | + | customary charges for such services, determined in 25 |
|---|
| 135 | + | accordance with the principles set forth in Title XVIII A 26 |
|---|
| 136 | + | and B, Public Law 89 -97, 1965 amendments to the federal 27 |
|---|
| 137 | + | 5 |
|---|
| 138 | + | Social Security Act (42 U.S.C. Sect ion 301, et seq.), but 28 |
|---|
| 139 | + | the MO HealthNet division may evaluate outpatient hospital 29 |
|---|
| 140 | + | services rendered under this section and deny payment for 30 |
|---|
| 141 | + | services which are determined by the MO HealthNet division 31 |
|---|
| 142 | + | not to be medically necessary, in accordance with fed eral 32 |
|---|
| 143 | + | law and regulations; 33 |
|---|
| 144 | + | (3) Laboratory and X-ray services; 34 |
|---|
| 145 | + | (4) Nursing home services for participants, except to 35 |
|---|
| 146 | + | persons with more than five hundred thousand dollars equity 36 |
|---|
| 147 | + | in their home or except for persons in an institution for 37 |
|---|
| 148 | + | mental diseases who are under the age of sixty -five years, 38 |
|---|
| 149 | + | when residing in a hospital licensed by the department of 39 |
|---|
| 150 | + | health and senior services or a nursing home licensed by the 40 |
|---|
| 151 | + | department of health and senior services or appropriate 41 |
|---|
| 152 | + | licensing authority of ot her states or government -owned and - 42 |
|---|
| 153 | + | operated institutions which are determined to conform to 43 |
|---|
| 154 | + | standards equivalent to licensing requirements in Title XIX 44 |
|---|
| 155 | + | of the federal Social Security Act (42 U.S.C. Section 301, 45 |
|---|
| 156 | + | et seq.), as amended, for nursing facili ties. The MO 46 |
|---|
| 157 | + | HealthNet division may recognize through its payment 47 |
|---|
| 158 | + | methodology for nursing facilities those nursing facilities 48 |
|---|
| 159 | + | which serve a high volume of MO HealthNet patients. The MO 49 |
|---|
| 160 | + | HealthNet division when determining the amount of the 50 |
|---|
| 161 | + | benefit payments to be made on behalf of persons under the 51 |
|---|
| 162 | + | age of twenty-one in a nursing facility may consider nursing 52 |
|---|
| 163 | + | facilities furnishing care to persons under the age of 53 |
|---|
| 164 | + | twenty-one as a classification separate from other nursing 54 |
|---|
| 165 | + | facilities; 55 |
|---|
| 166 | + | (5) Nursing home costs for participants receiving 56 |
|---|
| 167 | + | benefit payments under subdivision (4) of this subsection 57 |
|---|
| 168 | + | for those days, which shall not exceed twelve per any period 58 |
|---|
| 169 | + | of six consecutive months, during which the participant is 59 |
|---|
| 170 | + | on a temporary leave of absence fr om the hospital or nursing 60 |
|---|
| 171 | + | 6 |
|---|
| 172 | + | home, provided that no such participant shall be allowed a 61 |
|---|
| 173 | + | temporary leave of absence unless it is specifically 62 |
|---|
| 174 | + | provided for in his plan of care. As used in this 63 |
|---|
| 175 | + | subdivision, the term "temporary leave of absence" shall 64 |
|---|
| 176 | + | include all periods of time during which a participant is 65 |
|---|
| 177 | + | away from the hospital or nursing home overnight because he 66 |
|---|
| 178 | + | is visiting a friend or relative; 67 |
|---|
| 179 | + | (6) Physicians' services, whether furnished in the 68 |
|---|
| 180 | + | office, home, hospital, nursing home, or elsewhe re, 69 |
|---|
| 181 | + | provided, that no funds shall be expended to any abortion 70 |
|---|
| 182 | + | facility, as defined in section 188.015, or to any 71 |
|---|
| 183 | + | affiliate, as defined in section 188.015, of such abortion 72 |
|---|
| 184 | + | facility; 73 |
|---|
| 185 | + | (7) Subject to appropriation, up to twenty visits per 74 |
|---|
| 186 | + | year for services limited to examinations, diagnoses, 75 |
|---|
| 187 | + | adjustments, and manipulations and treatments of 76 |
|---|
| 188 | + | malpositioned articulations and structures of the body 77 |
|---|
| 189 | + | provided by licensed chiropractic physicians practicing 78 |
|---|
| 190 | + | within their scope of practice. Nothing in this subdivision 79 |
|---|
| 191 | + | shall be interpreted to otherwise expand MO HealthNet 80 |
|---|
| 192 | + | services; 81 |
|---|
| 193 | + | (8) Drugs and medicines when prescribed by a licensed 82 |
|---|
| 194 | + | physician, dentist, podiatrist, or an advanced practice 83 |
|---|
| 195 | + | registered nurse; except that no payment for drugs and 84 |
|---|
| 196 | + | medicines prescribed on and after January 1, 2006, by a 85 |
|---|
| 197 | + | licensed physician, dentist, podiatrist, or an advanced 86 |
|---|
| 198 | + | practice registered nurse may be made on behalf of any 87 |
|---|
| 199 | + | person who qualifies for prescription drug coverage under 88 |
|---|
| 200 | + | the provisions of P.L. 108 -173; 89 |
|---|
| 201 | + | (9) Emergency ambulance services and, effective 90 |
|---|
| 202 | + | January 1, 1990, medically necessary transportation to 91 |
|---|
| 203 | + | scheduled, physician -prescribed nonelective treatments; 92 |
|---|
| 204 | + | 7 |
|---|
| 205 | + | (10) Early and periodic screening and diagnosis of 93 |
|---|
| 206 | + | individuals who are under th e age of twenty-one to ascertain 94 |
|---|
| 207 | + | their physical or mental defects, and health care, 95 |
|---|
| 208 | + | treatment, and other measures to correct or ameliorate 96 |
|---|
| 209 | + | defects and chronic conditions discovered thereby. Such 97 |
|---|
| 210 | + | services shall be provided in accordance with the provis ions 98 |
|---|
| 211 | + | of Section 6403 of P.L. 101 -239 and federal regulations 99 |
|---|
| 212 | + | promulgated thereunder; 100 |
|---|
| 213 | + | (11) Home health care services; 101 |
|---|
| 214 | + | (12) Family planning as defined by federal rules and 102 |
|---|
| 215 | + | regulations; provided, that no funds shall be expended to 103 |
|---|
| 216 | + | any abortion facility, as defined in section 188.015, or to 104 |
|---|
| 217 | + | any affiliate, as defined in section 188.015, of such 105 |
|---|
| 218 | + | abortion facility; and further provided, however, that such 106 |
|---|
| 219 | + | family planning services shall not include abortions or any 107 |
|---|
| 220 | + | abortifacient drug or device t hat is used for the purpose of 108 |
|---|
| 221 | + | inducing an abortion unless such abortions are certified in 109 |
|---|
| 222 | + | writing by a physician to the MO HealthNet agency that, in 110 |
|---|
| 223 | + | the physician's professional judgment, the life of the 111 |
|---|
| 224 | + | mother would be endangered if the fetus were ca rried to term; 112 |
|---|
| 225 | + | (13) Inpatient psychiatric hospital services for 113 |
|---|
| 226 | + | individuals under age twenty -one as defined in Title XIX of 114 |
|---|
| 227 | + | the federal Social Security Act (42 U.S.C. Section 1396d, et 115 |
|---|
| 228 | + | seq.); 116 |
|---|
| 229 | + | (14) Outpatient surgical procedures, including 117 |
|---|
| 230 | + | presurgical diagnostic services performed in ambulatory 118 |
|---|
| 231 | + | surgical facilities which are licensed by the department of 119 |
|---|
| 232 | + | health and senior services of the state of Missouri; except, 120 |
|---|
| 233 | + | that such outpatient surgical services shall not include 121 |
|---|
| 234 | + | persons who are eligible for coverage under Part B of Title 122 |
|---|
| 235 | + | XVIII, Public Law 89 -97, 1965 amendments to the federal 123 |
|---|
| 236 | + | Social Security Act, as amended, if exclusion of such 124 |
|---|
| 237 | + | 8 |
|---|
| 238 | + | persons is permitted under Title XIX, Public Law 89 -97, 1965 125 |
|---|
| 239 | + | amendments to the federal Social Securit y Act, as amended; 126 |
|---|
| 240 | + | (15) Personal care services which are medically 127 |
|---|
| 241 | + | oriented tasks having to do with a person's physical 128 |
|---|
| 242 | + | requirements, as opposed to housekeeping requirements, which 129 |
|---|
| 243 | + | enable a person to be treated by his or her physician on an 130 |
|---|
| 244 | + | outpatient rather than on an inpatient or residential basis 131 |
|---|
| 245 | + | in a hospital, intermediate care facility, or skilled 132 |
|---|
| 246 | + | nursing facility. Personal care services shall be rendered 133 |
|---|
| 247 | + | by an individual not a member of the participant's family 134 |
|---|
| 248 | + | who is qualified to provi de such services where the services 135 |
|---|
| 249 | + | are prescribed by a physician in accordance with a plan of 136 |
|---|
| 250 | + | treatment and are supervised by a licensed nurse. Persons 137 |
|---|
| 251 | + | eligible to receive personal care services shall be those 138 |
|---|
| 252 | + | persons who would otherwise require plac ement in a hospital, 139 |
|---|
| 253 | + | intermediate care facility, or skilled nursing facility. 140 |
|---|
| 254 | + | Benefits payable for personal care services shall not exceed 141 |
|---|
| 255 | + | for any one participant one hundred percent of the average 142 |
|---|
| 256 | + | statewide charge for care and treatment in an interme diate 143 |
|---|
| 257 | + | care facility for a comparable period of time. Such 144 |
|---|
| 258 | + | services, when delivered in a residential care facility or 145 |
|---|
| 259 | + | assisted living facility licensed under chapter 198 shall be 146 |
|---|
| 260 | + | authorized on a tier level based on the services the 147 |
|---|
| 261 | + | resident requires and the frequency of the services. A 148 |
|---|
| 262 | + | resident of such facility who qualifies for assistance under 149 |
|---|
| 263 | + | section 208.030 shall, at a minimum, if prescribed by a 150 |
|---|
| 264 | + | physician, qualify for the tier level with the fewest 151 |
|---|
| 265 | + | services. The rate paid to providers for ea ch tier of 152 |
|---|
| 266 | + | service shall be set subject to appropriations. Subject to 153 |
|---|
| 267 | + | appropriations, each resident of such facility who qualifies 154 |
|---|
| 268 | + | for assistance under section 208.030 and meets the level of 155 |
|---|
| 269 | + | care required in this section shall, at a minimum, if 156 |
|---|
| 270 | + | prescribed by a physician, be authorized up to one hour of 157 |
|---|
| 271 | + | 9 |
|---|
| 272 | + | personal care services per day. Authorized units of 158 |
|---|
| 273 | + | personal care services shall not be reduced or tier level 159 |
|---|
| 274 | + | lowered unless an order approving such reduction or lowering 160 |
|---|
| 275 | + | is obtained from the resid ent's personal physician. Such 161 |
|---|
| 276 | + | authorized units of personal care services or tier level 162 |
|---|
| 277 | + | shall be transferred with such resident if he or she 163 |
|---|
| 278 | + | transfers to another such facility. Such provision shall 164 |
|---|
| 279 | + | terminate upon receipt of relevant waivers from the federal 165 |
|---|
| 280 | + | Department of Health and Human Services. If the Centers for 166 |
|---|
| 281 | + | Medicare and Medicaid Services determines that such 167 |
|---|
| 282 | + | provision does not comply with the state plan, this 168 |
|---|
| 283 | + | provision shall be null and void. The MO HealthNet division 169 |
|---|
| 284 | + | shall notify the revisor of statutes as to whether the 170 |
|---|
| 285 | + | relevant waivers are approved or a determination of 171 |
|---|
| 286 | + | noncompliance is made; 172 |
|---|
| 287 | + | (16) Mental health services. The state plan for 173 |
|---|
| 288 | + | providing medical assistance under Title XIX of the Social 174 |
|---|
| 289 | + | Security Act, 42 U.S.C. S ection 301, as amended, shall 175 |
|---|
| 290 | + | include the following mental health services when such 176 |
|---|
| 291 | + | services are provided by community mental health facilities 177 |
|---|
| 292 | + | operated by the department of mental health or designated by 178 |
|---|
| 293 | + | the department of mental health as a community mental health 179 |
|---|
| 294 | + | facility or as an alcohol and drug abuse facility or as a 180 |
|---|
| 295 | + | child-serving agency within the comprehensive children's 181 |
|---|
| 296 | + | mental health service system established in section 182 |
|---|
| 297 | + | 630.097. The department of mental health shall establish by 183 |
|---|
| 298 | + | administrative rule the definition and criteria for 184 |
|---|
| 299 | + | designation as a community mental health facility and for 185 |
|---|
| 300 | + | designation as an alcohol and drug abuse facility. Such 186 |
|---|
| 301 | + | mental health services shall include: 187 |
|---|
| 302 | + | (a) Outpatient mental health services including 188 |
|---|
| 303 | + | preventive, diagnostic, therapeutic, rehabilitative, and 189 |
|---|
| 304 | + | palliative interventions rendered to individuals in an 190 |
|---|
| 305 | + | 10 |
|---|
| 306 | + | individual or group setting by a mental health professional 191 |
|---|
| 307 | + | in accordance with a plan of treatment appropriately 192 |
|---|
| 308 | + | established, implemented, mo nitored, and revised under the 193 |
|---|
| 309 | + | auspices of a therapeutic team as a part of client services 194 |
|---|
| 310 | + | management; 195 |
|---|
| 311 | + | (b) Clinic mental health services including 196 |
|---|
| 312 | + | preventive, diagnostic, therapeutic, rehabilitative, and 197 |
|---|
| 313 | + | palliative interventions rendered to indiv iduals in an 198 |
|---|
| 314 | + | individual or group setting by a mental health professional 199 |
|---|
| 315 | + | in accordance with a plan of treatment appropriately 200 |
|---|
| 316 | + | established, implemented, monitored, and revised under the 201 |
|---|
| 317 | + | auspices of a therapeutic team as a part of client services 202 |
|---|
| 318 | + | management; 203 |
|---|
| 319 | + | (c) Rehabilitative mental health and alcohol and drug 204 |
|---|
| 320 | + | abuse services including home and community -based 205 |
|---|
| 321 | + | preventive, diagnostic, therapeutic, rehabilitative, and 206 |
|---|
| 322 | + | palliative interventions rendered to individuals in an 207 |
|---|
| 323 | + | individual or group sett ing by a mental health or alcohol 208 |
|---|
| 324 | + | and drug abuse professional in accordance with a plan of 209 |
|---|
| 325 | + | treatment appropriately established, implemented, monitored, 210 |
|---|
| 326 | + | and revised under the auspices of a therapeutic team as a 211 |
|---|
| 327 | + | part of client services management. As used in this 212 |
|---|
| 328 | + | section, mental health professional and alcohol and drug 213 |
|---|
| 329 | + | abuse professional shall be defined by the department of 214 |
|---|
| 330 | + | mental health pursuant to duly promulgated rules. With 215 |
|---|
| 331 | + | respect to services established by this subdivision, the 216 |
|---|
| 332 | + | department of social services, MO HealthNet division, shall 217 |
|---|
| 333 | + | enter into an agreement with the department of mental 218 |
|---|
| 334 | + | health. Matching funds for outpatient mental health 219 |
|---|
| 335 | + | services, clinic mental health services, and rehabilitation 220 |
|---|
| 336 | + | services for mental health and alcohol and drug abuse shall 221 |
|---|
| 337 | + | be certified by the department of mental health to the MO 222 |
|---|
| 338 | + | HealthNet division. The agreement shall establish a 223 |
|---|
| 339 | + | 11 |
|---|
| 340 | + | mechanism for the joint implementation of the provisions of 224 |
|---|
| 341 | + | this subdivision. In addition, the agreement shall 225 |
|---|
| 342 | + | establish a mechanism by which rates for services may be 226 |
|---|
| 343 | + | jointly developed; 227 |
|---|
| 344 | + | (17) Such additional services as defined by the MO 228 |
|---|
| 345 | + | HealthNet division to be furnished under waivers of federal 229 |
|---|
| 346 | + | statutory requirements as provided for and authorized by the 230 |
|---|
| 347 | + | federal Social Security Act (42 U.S.C. Section 301, et seq.) 231 |
|---|
| 348 | + | subject to appropriation by the general assembly; 232 |
|---|
| 349 | + | (18) The services of an advanced practice registered 233 |
|---|
| 350 | + | nurse with a collaborative practice agreement to the extent 234 |
|---|
| 351 | + | that such services are prov ided in accordance with chapters 235 |
|---|
| 352 | + | 334 and 335, and regulations promulgated thereunder; 236 |
|---|
| 353 | + | (19) Nursing home costs for participants receiving 237 |
|---|
| 354 | + | benefit payments under subdivision (4) of this subsection to 238 |
|---|
| 355 | + | reserve a bed for the participant in the nursing home during 239 |
|---|
| 356 | + | the time that the participant is absent due to admission to 240 |
|---|
| 357 | + | a hospital for services which cannot be performed on an 241 |
|---|
| 358 | + | outpatient basis, subject to the provisions of this 242 |
|---|
| 359 | + | subdivision: 243 |
|---|
| 360 | + | (a) The provisions of this subdivision shall apply 244 |
|---|
| 361 | + | only if: 245 |
|---|
| 362 | + | a. The occupancy rate of the nursing home is at or 246 |
|---|
| 363 | + | above ninety-seven percent of MO HealthNet certified 247 |
|---|
| 364 | + | licensed beds, according to the most recent quarterly census 248 |
|---|
| 365 | + | provided to the department of health and senior services 249 |
|---|
| 366 | + | which was taken prior to when the participant is admitted to 250 |
|---|
| 367 | + | the hospital; and 251 |
|---|
| 368 | + | b. The patient is admitted to a hospital for a medical 252 |
|---|
| 369 | + | condition with an anticipated stay of three days or less; 253 |
|---|
| 370 | + | (b) The payment to be made under this subdivision 254 |
|---|
| 371 | + | shall be provided for a maximum of three days per hospital 255 |
|---|
| 372 | + | stay; 256 |
|---|
| 373 | + | 12 |
|---|
| 374 | + | (c) For each day that nursing home costs are paid on 257 |
|---|
| 375 | + | behalf of a participant under this subdivision during any 258 |
|---|
| 376 | + | period of six consecutive months such participant shall, 259 |
|---|
| 377 | + | during the same period of si x consecutive months, be 260 |
|---|
| 378 | + | ineligible for payment of nursing home costs of two 261 |
|---|
| 379 | + | otherwise available temporary leave of absence days provided 262 |
|---|
| 380 | + | under subdivision (5) of this subsection; and 263 |
|---|
| 381 | + | (d) The provisions of this subdivision shall not apply 264 |
|---|
| 382 | + | unless the nursing home receives notice from the participant 265 |
|---|
| 383 | + | or the participant's responsible party that the participant 266 |
|---|
| 384 | + | intends to return to the nursing home following the hospital 267 |
|---|
| 385 | + | stay. If the nursing home receives such notification and 268 |
|---|
| 386 | + | all other provisions of this subsection have been satisfied, 269 |
|---|
| 387 | + | the nursing home shall provide notice to the participant or 270 |
|---|
| 388 | + | the participant's responsible party prior to release of the 271 |
|---|
| 389 | + | reserved bed; 272 |
|---|
| 390 | + | (20) Prescribed medically necessary durable medical 273 |
|---|
| 391 | + | equipment. An electronic web-based prior authorization 274 |
|---|
| 392 | + | system using best medical evidence and care and treatment 275 |
|---|
| 393 | + | guidelines consistent with national standards shall be used 276 |
|---|
| 394 | + | to verify medical need; 277 |
|---|
| 395 | + | (21) Hospice care. As used in this subdivision, the 278 |
|---|
| 396 | + | term "hospice care" means a coordinated program of active 279 |
|---|
| 397 | + | professional medical attention within a home, outpatient and 280 |
|---|
| 398 | + | inpatient care which treats the terminally ill patient and 281 |
|---|
| 399 | + | family as a unit, employing a medically directed 282 |
|---|
| 400 | + | interdisciplinary team. The program provides relief of 283 |
|---|
| 401 | + | severe pain or other physical symptoms and supportive care 284 |
|---|
| 402 | + | to meet the special needs arising out of physical, 285 |
|---|
| 403 | + | psychological, spiritual, social, and economic stresses 286 |
|---|
| 404 | + | which are experienced during the final stages of illness, 287 |
|---|
| 405 | + | and during dying and bereavement and meets the Medicare 288 |
|---|
| 406 | + | requirements for participation as a hospice as are provided 289 |
|---|
| 407 | + | 13 |
|---|
| 408 | + | in 42 CFR Part 418. The rate of reimbursement paid by the 290 |
|---|
| 409 | + | MO HealthNet division to the hospice provider for room and 291 |
|---|
| 410 | + | board furnished by a nursin g home to an eligible hospice 292 |
|---|
| 411 | + | patient shall not be less than ninety -five percent of the 293 |
|---|
| 412 | + | rate of reimbursement which would have been paid for 294 |
|---|
| 413 | + | facility services in that nursing home facility for that 295 |
|---|
| 414 | + | patient, in accordance with subsection (c) of Section 6408 296 |
|---|
| 415 | + | of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 297 |
|---|
| 416 | + | (22) Prescribed medically necessary dental services. 298 |
|---|
| 417 | + | Such services shall be subject to appropriations. An 299 |
|---|
| 418 | + | electronic web-based prior authorization system using best 300 |
|---|
| 419 | + | medical evidence and care and treatment guidelines 301 |
|---|
| 420 | + | consistent with national standards shall be used to verify 302 |
|---|
| 421 | + | medical need; 303 |
|---|
| 422 | + | (23) Prescribed medically necessary optometric 304 |
|---|
| 423 | + | services. Such services shall be subject to 305 |
|---|
| 424 | + | appropriations. An electronic web-based prior authorization 306 |
|---|
| 425 | + | system using best medical evidence and care and treatment 307 |
|---|
| 426 | + | guidelines consistent with national standards shall be used 308 |
|---|
| 427 | + | to verify medical need; 309 |
|---|
| 428 | + | (24) Blood clotting products -related services. For 310 |
|---|
| 429 | + | persons diagnosed with a bleeding disorder, as defined in 311 |
|---|
| 430 | + | section 338.400, reliant on blood clotting products, as 312 |
|---|
| 431 | + | defined in section 338.400, such services include: 313 |
|---|
| 432 | + | (a) Home delivery of blood clotting products and 314 |
|---|
| 433 | + | ancillary infusion equipment and supplies, including the 315 |
|---|
| 434 | + | emergency deliveries of the product when medically necessary; 316 |
|---|
| 435 | + | (b) Medically necessary ancillary infusion equipment 317 |
|---|
| 436 | + | and supplies required to administer the blood clotting 318 |
|---|
| 437 | + | products; and 319 |
|---|
| 438 | + | (c) Assessments conducted in the participant's home by 320 |
|---|
| 439 | + | a pharmacist, nurse, or local home health care agency 321 |
|---|
| 440 | + | 14 |
|---|
| 441 | + | trained in bleeding disorders when deemed necessary by the 322 |
|---|
| 442 | + | participant's treating physician; 323 |
|---|
| 443 | + | (25) The MO HealthNet division shall, by January 1, 324 |
|---|
| 444 | + | 2008, and annually thereafter, report the status of MO 325 |
|---|
| 445 | + | HealthNet provider reimbursement rates as compared to one 326 |
|---|
| 446 | + | hundred percent of the Medicare reimbursement rates and 327 |
|---|
| 447 | + | compared to the average dental reimbursement rates paid by 328 |
|---|
| 448 | + | third-party payors licensed by the state. The MO HealthNet 329 |
|---|
| 449 | + | division shall, by Jul y 1, 2008, provide to the general 330 |
|---|
| 450 | + | assembly a four-year plan to achieve parity with Medicare 331 |
|---|
| 451 | + | reimbursement rates and for third -party payor average dental 332 |
|---|
| 452 | + | reimbursement rates. Such plan shall be subject to 333 |
|---|
| 453 | + | appropriation and the division shall include in its annual 334 |
|---|
| 454 | + | budget request to the governor the necessary funding needed 335 |
|---|
| 455 | + | to complete the four -year plan developed under this 336 |
|---|
| 456 | + | subdivision. 337 |
|---|
| 457 | + | 2. Additional benefit payments for medical assistance 338 |
|---|
| 458 | + | shall be made on behalf of those eligible needy childre n, 339 |
|---|
| 459 | + | pregnant women and blind persons with any payments to be 340 |
|---|
| 460 | + | made on the basis of the reasonable cost of the care or 341 |
|---|
| 461 | + | reasonable charge for the services as defined and determined 342 |
|---|
| 462 | + | by the MO HealthNet division, unless otherwise hereinafter 343 |
|---|
| 463 | + | provided, for the following: 344 |
|---|
| 464 | + | (1) Dental services; 345 |
|---|
| 465 | + | (2) Services of podiatrists as defined in section 346 |
|---|
| 466 | + | 330.010; 347 |
|---|
| 467 | + | (3) Optometric services as described in section 348 |
|---|
| 468 | + | 336.010; 349 |
|---|
| 469 | + | (4) Orthopedic devices or other prosthetics, including 350 |
|---|
| 470 | + | eye glasses, dentures, hearing aids, and wheelchairs; 351 |
|---|
| 471 | + | (5) Hospice care. As used in this subdivision, the 352 |
|---|
| 472 | + | term "hospice care" means a coordinated program of active 353 |
|---|
| 473 | + | professional medical attention within a home, outpatient and 354 |
|---|
| 474 | + | 15 |
|---|
| 475 | + | inpatient care which treats the terminally il l patient and 355 |
|---|
| 476 | + | family as a unit, employing a medically directed 356 |
|---|
| 477 | + | interdisciplinary team. The program provides relief of 357 |
|---|
| 478 | + | severe pain or other physical symptoms and supportive care 358 |
|---|
| 479 | + | to meet the special needs arising out of physical, 359 |
|---|
| 480 | + | psychological, spiritu al, social, and economic stresses 360 |
|---|
| 481 | + | which are experienced during the final stages of illness, 361 |
|---|
| 482 | + | and during dying and bereavement and meets the Medicare 362 |
|---|
| 483 | + | requirements for participation as a hospice as are provided 363 |
|---|
| 484 | + | in 42 CFR Part 418. The rate of reimburseme nt paid by the 364 |
|---|
| 485 | + | MO HealthNet division to the hospice provider for room and 365 |
|---|
| 486 | + | board furnished by a nursing home to an eligible hospice 366 |
|---|
| 487 | + | patient shall not be less than ninety -five percent of the 367 |
|---|
| 488 | + | rate of reimbursement which would have been paid for 368 |
|---|
| 489 | + | facility services in that nursing home facility for that 369 |
|---|
| 490 | + | patient, in accordance with subsection (c) of Section 6408 370 |
|---|
| 491 | + | of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 371 |
|---|
| 492 | + | (6) Comprehensive day rehabilitation services 372 |
|---|
| 493 | + | beginning early posttrauma as par t of a coordinated system 373 |
|---|
| 494 | + | of care for individuals with disabling impairments. 374 |
|---|
| 495 | + | Rehabilitation services must be based on an individualized, 375 |
|---|
| 496 | + | goal-oriented, comprehensive and coordinated treatment plan 376 |
|---|
| 497 | + | developed, implemented, and monitored through an 377 |
|---|
| 498 | + | interdisciplinary assessment designed to restore an 378 |
|---|
| 499 | + | individual to optimal level of physical, cognitive, and 379 |
|---|
| 500 | + | behavioral function. The MO HealthNet division shall 380 |
|---|
| 501 | + | establish by administrative rule the definition and criteria 381 |
|---|
| 502 | + | for designation of a comprehensi ve day rehabilitation 382 |
|---|
| 503 | + | service facility, benefit limitations and payment 383 |
|---|
| 504 | + | mechanism. Any rule or portion of a rule, as that term is 384 |
|---|
| 505 | + | defined in section 536.010, that is created under the 385 |
|---|
| 506 | + | authority delegated in this subdivision shall become 386 |
|---|
| 507 | + | effective only if it complies with and is subject to all of 387 |
|---|
| 508 | + | 16 |
|---|
| 509 | + | the provisions of chapter 536 and, if applicable, section 388 |
|---|
| 510 | + | 536.028. This section and chapter 536 are nonseverable and 389 |
|---|
| 511 | + | if any of the powers vested with the general assembly 390 |
|---|
| 512 | + | pursuant to chapter 536 to review , to delay the effective 391 |
|---|
| 513 | + | date, or to disapprove and annul a rule are subsequently 392 |
|---|
| 514 | + | held unconstitutional, then the grant of rulemaking 393 |
|---|
| 515 | + | authority and any rule proposed or adopted after August 28, 394 |
|---|
| 516 | + | 2005, shall be invalid and void. 395 |
|---|
| 517 | + | 3. The MO HealthNet division may require any 396 |
|---|
| 518 | + | participant receiving MO HealthNet benefits to pay part of 397 |
|---|
| 519 | + | the charge or cost until July 1, 2008, and an additional 398 |
|---|
| 520 | + | payment after July 1, 2008, as defined by rule duly 399 |
|---|
| 521 | + | promulgated by the MO HealthNet division, for all covered 400 |
|---|
| 522 | + | services except for those services covered under 401 |
|---|
| 523 | + | subdivisions (15) and (16) of subsection 1 of this section 402 |
|---|
| 524 | + | and sections 208.631 to 208.657 to the extent and in the 403 |
|---|
| 525 | + | manner authorized by Title XIX of the federal Social 404 |
|---|
| 526 | + | Security Act (42 U.S.C. Section 1 396, et seq.) and 405 |
|---|
| 527 | + | regulations thereunder. When substitution of a generic drug 406 |
|---|
| 528 | + | is permitted by the prescriber according to section 338.056, 407 |
|---|
| 529 | + | and a generic drug is substituted for a name -brand drug, the 408 |
|---|
| 530 | + | MO HealthNet division may not lower or delete the 409 |
|---|
| 531 | + | requirement to make a co -payment pursuant to regulations of 410 |
|---|
| 532 | + | Title XIX of the federal Social Security Act. A provider of 411 |
|---|
| 533 | + | goods or services described under this section must collect 412 |
|---|
| 534 | + | from all participants the additional payment that may be 413 |
|---|
| 535 | + | required by the MO HealthNet division under authority 414 |
|---|
| 536 | + | granted herein, if the division exercises that authority, to 415 |
|---|
| 537 | + | remain eligible as a provider. Any payments made by 416 |
|---|
| 538 | + | participants under this section shall be in addition to and 417 |
|---|
| 539 | + | not in lieu of payments made by the st ate for goods or 418 |
|---|
| 540 | + | services described herein except the participant portion of 419 |
|---|
| 541 | + | the pharmacy professional dispensing fee shall be in 420 |
|---|
| 542 | + | 17 |
|---|
| 543 | + | addition to and not in lieu of payments to pharmacists. A 421 |
|---|
| 544 | + | provider may collect the co -payment at the time a service is 422 |
|---|
| 545 | + | provided or at a later date. A provider shall not refuse to 423 |
|---|
| 546 | + | provide a service if a participant is unable to pay a 424 |
|---|
| 547 | + | required payment. If it is the routine business practice of 425 |
|---|
| 548 | + | a provider to terminate future services to an individual 426 |
|---|
| 549 | + | with an unclaimed de bt, the provider may include uncollected 427 |
|---|
| 550 | + | co-payments under this practice. Providers who elect not to 428 |
|---|
| 551 | + | undertake the provision of services based on a history of 429 |
|---|
| 552 | + | bad debt shall give participants advance notice and a 430 |
|---|
| 553 | + | reasonable opportunity for payment. A provider, 431 |
|---|
| 554 | + | representative, employee, independent contractor, or agent 432 |
|---|
| 555 | + | of a pharmaceutical manufacturer shall not make co -payment 433 |
|---|
| 556 | + | for a participant. This subsection shall not apply to other 434 |
|---|
| 557 | + | qualified children, pregnant women, or blind persons. If 435 |
|---|
| 558 | + | the Centers for Medicare and Medicaid Services does not 436 |
|---|
| 559 | + | approve the MO HealthNet state plan amendment submitted by 437 |
|---|
| 560 | + | the department of social services that would allow a 438 |
|---|
| 561 | + | provider to deny future services to an individual with 439 |
|---|
| 562 | + | uncollected co-payments, the denial of services shall not be 440 |
|---|
| 563 | + | allowed. The department of social services shall inform 441 |
|---|
| 564 | + | providers regarding the acceptability of denying services as 442 |
|---|
| 565 | + | the result of unpaid co -payments. 443 |
|---|
| 566 | + | 4. The MO HealthNet division shall have the right to 444 |
|---|
| 567 | + | collect medication samples from participants in order to 445 |
|---|
| 568 | + | maintain program integrity. 446 |
|---|
| 569 | + | 5. Reimbursement for obstetrical and pediatric 447 |
|---|
| 570 | + | services under subdivision (6) of subsection 1 of this 448 |
|---|
| 571 | + | section shall be timely and sufficient to enlist enough 449 |
|---|
| 572 | + | health care providers so that care and services are 450 |
|---|
| 573 | + | available under the state plan for MO HealthNet benefits at 451 |
|---|
| 574 | + | least to the extent that such care and services are 452 |
|---|
| 575 | + | available to the general population in the geographic area, 453 |
|---|
| 576 | + | 18 |
|---|
| 577 | + | as required under subparagraph (a)(30)(A) o f 42 U.S.C. 454 |
|---|
| 578 | + | Section 1396a and federal regulations promulgated thereunder. 455 |
|---|
| 579 | + | 6. Beginning July 1, 1990, reimbursement for services 456 |
|---|
| 580 | + | rendered in federally funded health centers shall be in 457 |
|---|
| 581 | + | accordance with the provisions of subsection 6402(c) and 458 |
|---|
| 582 | + | Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation 459 |
|---|
| 583 | + | Act of 1989) and federal regulations promulgated thereunder. 460 |
|---|
| 584 | + | 7. Beginning July 1, 1990, the department of social 461 |
|---|
| 585 | + | services shall provide notification and referral of children 462 |
|---|
| 586 | + | below age five, and pregnant, breast-feeding, or postpartum 463 |
|---|
| 587 | + | women who are determined to be eligible for MO HealthNet 464 |
|---|
| 588 | + | benefits under section 208.151 to the special supplemental 465 |
|---|
| 589 | + | food programs for women, infants and children administered 466 |
|---|
| 590 | + | by the department of health and sen ior services. Such 467 |
|---|
| 591 | + | notification and referral shall conform to the requirements 468 |
|---|
| 592 | + | of Section 6406 of P.L. 101 -239 and regulations promulgated 469 |
|---|
| 593 | + | thereunder. 470 |
|---|
| 594 | + | 8. Providers of long-term care services shall be 471 |
|---|
| 595 | + | reimbursed for their costs in accordance with the provisions 472 |
|---|
| 596 | + | of Section 1902 (a)(13)(A) of the Social Security Act, 42 473 |
|---|
| 597 | + | U.S.C. Section 1396a, as amended, and regulations 474 |
|---|
| 598 | + | promulgated thereunder. 475 |
|---|
| 599 | + | 9. Reimbursement rates to long -term care providers 476 |
|---|
| 600 | + | with respect to a total change in ownership, at arm's 477 |
|---|
| 601 | + | length, for any facility previously licensed and certified 478 |
|---|
| 602 | + | for participation in the MO HealthNet program shall not 479 |
|---|
| 603 | + | increase payments in excess of the increase that would 480 |
|---|
| 604 | + | result from the application of Section 1902 (a)(13)(C) of 481 |
|---|
| 605 | + | the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C). 482 |
|---|
| 606 | + | 10. The MO HealthNet division may enroll qualified 483 |
|---|
| 607 | + | residential care facilities and assisted living facilities, 484 |
|---|
| 608 | + | as defined in chapter 198, as MO HealthNet personal care 485 |
|---|
| 609 | + | providers. 486 |
|---|
| 610 | + | 19 |
|---|
| 611 | + | 11. Any income earned by individuals eligible for 487 |
|---|
| 612 | + | certified extended employment at a sheltered workshop under 488 |
|---|
| 613 | + | chapter 178 shall not be considered as income for purposes 489 |
|---|
| 614 | + | of determining eligibility under this section. 490 |
|---|
| 615 | + | 12. If the Missouri Medicaid audit and complianc e unit 491 |
|---|
| 616 | + | changes any interpretation or application of the 492 |
|---|
| 617 | + | requirements for reimbursement for MO HealthNet services 493 |
|---|
| 618 | + | from the interpretation or application that has been applied 494 |
|---|
| 619 | + | previously by the state in any audit of a MO HealthNet 495 |
|---|
| 620 | + | provider, the Missouri Medicaid audit and compliance unit 496 |
|---|
| 621 | + | shall notify all affected MO HealthNet providers five 497 |
|---|
| 622 | + | business days before such change shall take effect. Failure 498 |
|---|
| 623 | + | of the Missouri Medicaid audit and compliance unit to notify 499 |
|---|
| 624 | + | a provider of such change shall entitle the provider to 500 |
|---|
| 625 | + | continue to receive and retain reimbursement until such 501 |
|---|
| 626 | + | notification is provided and shall waive any liability of 502 |
|---|
| 627 | + | such provider for recoupment or other loss of any payments 503 |
|---|
| 628 | + | previously made prior to the five business days after such 504 |
|---|
| 629 | + | notice has been sent. Each provider shall provide the 505 |
|---|
| 630 | + | Missouri Medicaid audit and compliance unit a valid email 506 |
|---|
| 631 | + | address and shall agree to receive communications 507 |
|---|
| 632 | + | electronically. The notification required under this 508 |
|---|
| 633 | + | section shall be delivered in writing by the United States 509 |
|---|
| 634 | + | Postal Service or electronic mail to each provider. 510 |
|---|
| 635 | + | 13. Nothing in this section shall be construed to 511 |
|---|
| 636 | + | abrogate or limit the department's statutory requirement to 512 |
|---|
| 637 | + | promulgate rules under chapter 536. 513 |
|---|
| 638 | + | 14. Beginning July 1, 2016, and subject to 514 |
|---|
| 639 | + | appropriations, providers of behavioral, social, and 515 |
|---|
| 640 | + | psychophysiological services for the prevention, treatment, 516 |
|---|
| 641 | + | or management of physical health problems shall be 517 |
|---|
| 642 | + | reimbursed utilizing the behavior assessment and 518 |
|---|
| 643 | + | intervention reimbursement codes 96150 to 96154 or their 519 |
|---|
| 644 | + | 20 |
|---|
| 645 | + | successor codes under the Current Procedural Terminology 520 |
|---|
| 646 | + | (CPT) coding system. Providers eligible for such 521 |
|---|
| 647 | + | reimbursement shall include psychologists. 522 |
|---|
| 648 | + | 15. There shall be no payments made under this section 523 |
|---|
| 649 | + | for gender transition surgeries, cross -sex hormones, or 524 |
|---|
| 650 | + | puberty-blocking drugs, as such terms are defined in section 525 |
|---|
| 651 | + | 191.1720, for the purpose of a gender transition. 526 |
|---|
| 652 | + | 208.153. 1. Pursuant to and not inconsistent with the 1 |
|---|
| 653 | + | provisions of sections 208.151 and 208.152, the MO HealthNet 2 |
|---|
| 654 | + | division shall by rule and regulation define the reasonable 3 |
|---|
| 655 | + | costs, manner, extent, quantity, quality, charges and fees 4 |
|---|
| 656 | + | of MO HealthNet benefits herein provided. The benefits 5 |
|---|
| 657 | + | available under these sect ions shall not replace those 6 |
|---|
| 658 | + | provided under other federal or state law or under other 7 |
|---|
| 659 | + | contractual or legal entitlements of the persons receiving 8 |
|---|
| 660 | + | them, and all persons shall be required to apply for and 9 |
|---|
| 661 | + | utilize all benefits available to them and to purs ue all 10 |
|---|
| 662 | + | causes of action to which they are entitled. Any person 11 |
|---|
| 663 | + | entitled to MO HealthNet benefits may obtain it from any 12 |
|---|
| 664 | + | provider of services that is not excluded or disqualified as 13 |
|---|
| 665 | + | a provider under any provision of law including, but not 14 |
|---|
| 666 | + | limited to, section 208.164, with which an agreement is in 15 |
|---|
| 667 | + | effect under this section and which undertakes to provide 16 |
|---|
| 668 | + | the services, as authorized by the MO HealthNet division. 17 |
|---|
| 669 | + | At the discretion of the director of the MO HealthNet 18 |
|---|
| 670 | + | division and with the approval of the governor, the MO 19 |
|---|
| 671 | + | HealthNet division is authorized to provide medical benefits 20 |
|---|
| 672 | + | for participants receiving public assistance by expending 21 |
|---|
| 673 | + | funds for the payment of federal medical insurance premiums, 22 |
|---|
| 674 | + | coinsurance and deductibles pursuant to the provisi ons of 23 |
|---|
| 675 | + | Title XVIII B and XIX, Public Law 89 -97, 1965 amendments to 24 |
|---|
| 676 | + | the federal Social Security Act (42 U.S.C. 301, et seq.), as 25 |
|---|
| 677 | + | amended. 26 |
|---|
| 678 | + | 21 |
|---|
| 679 | + | 2. MO HealthNet shall include benefit payments on 27 |
|---|
| 680 | + | behalf of qualified Medicare beneficiaries as defined in 42 28 |
|---|
| 681 | + | U.S.C. Section 1396d(p). The family support division shall 29 |
|---|
| 682 | + | by rule and regulation establish which qualified Medicare 30 |
|---|
| 683 | + | beneficiaries are eligible. The MO HealthNet division shall 31 |
|---|
| 684 | + | define the premiums, deductible and coinsurance provided for 32 |
|---|
| 685 | + | in 42 U.S.C. Section 1396d(p) to be provided on behalf of 33 |
|---|
| 686 | + | the qualified Medicare beneficiaries. 34 |
|---|
| 687 | + | 3. MO HealthNet shall include benefit payments for 35 |
|---|
| 688 | + | Medicare Part A cost sharing as defined in clause 36 |
|---|
| 689 | + | (p)(3)(A)(i) of 42 U.S.C. 1396d on behalf of qualified 37 |
|---|
| 690 | + | disabled and working individuals as defined in subsection 38 |
|---|
| 691 | + | (s) of Section 42 U.S.C. 1396d as required by subsection (d) 39 |
|---|
| 692 | + | of Section 6408 of P.L. 101 -239 (Omnibus Budget 40 |
|---|
| 693 | + | Reconciliation Act of 1989). The MO HealthNet division may 41 |
|---|
| 694 | + | impose a premium for such ben efit payments as authorized by 42 |
|---|
| 695 | + | paragraph (d)(3) of Section 6408 of P.L. 101 -239. 43 |
|---|
| 696 | + | 4. MO HealthNet shall include benefit payments for 44 |
|---|
| 697 | + | Medicare Part B cost sharing described in 42 U.S.C. Section 45 |
|---|
| 698 | + | 1396(d)(p)(3)(A)(ii) for individuals described in subse ction 46 |
|---|
| 699 | + | 2 of this section, but for the fact that their income 47 |
|---|
| 700 | + | exceeds the income level established by the state under 42 48 |
|---|
| 701 | + | U.S.C. Section 1396(d)(p)(2) but is less than one hundred 49 |
|---|
| 702 | + | and ten percent beginning January 1, 1993, and less than one 50 |
|---|
| 703 | + | hundred and twenty percent beginning January 1, 1995, of the 51 |
|---|
| 704 | + | official poverty line for a family of the size involved. 52 |
|---|
| 705 | + | 5. For an individual eligible for MO HealthNet under 53 |
|---|
| 706 | + | Title XIX of the Social Security Act, MO HealthNet shall 54 |
|---|
| 707 | + | include payment of enrollee prem iums in a group health plan 55 |
|---|
| 708 | + | and all deductibles, coinsurance and other cost -sharing for 56 |
|---|
| 709 | + | items and services otherwise covered under the state Title 57 |
|---|
| 710 | + | XIX plan under Section 1906 of the federal Social Security 58 |
|---|
| 711 | + | Act and regulations established under the auth ority of 59 |
|---|
| 712 | + | 22 |
|---|
| 713 | + | Section 1906, as may be amended. Enrollment in a group 60 |
|---|
| 714 | + | health plan must be cost effective, as established by the 61 |
|---|
| 715 | + | Secretary of Health and Human Services, before enrollment in 62 |
|---|
| 716 | + | the group health plan is required. If all members of a 63 |
|---|
| 717 | + | family are not eligible for MO HealthNet and enrollment of 64 |
|---|
| 718 | + | the Title XIX eligible members in a group health plan is not 65 |
|---|
| 719 | + | possible unless all family members are enrolled, all 66 |
|---|
| 720 | + | premiums for noneligible members shall be treated as payment 67 |
|---|
| 721 | + | for MO HealthNet of eligible family members. Payment for 68 |
|---|
| 722 | + | noneligible family members must be cost effective, taking 69 |
|---|
| 723 | + | into account payment of all such premiums. Non-Title XIX 70 |
|---|
| 724 | + | eligible family members shall pay all deductible, 71 |
|---|
| 725 | + | coinsurance and other cost -sharing obligations. Each 72 |
|---|
| 726 | + | individual as a condition of eligibility for MO HealthNet 73 |
|---|
| 727 | + | benefits shall apply for enrollment in the group health plan. 74 |
|---|
| 728 | + | 6. Any Social Security cost -of-living increase at the 75 |
|---|
| 729 | + | beginning of any year shall be disregarded until the federal 76 |
|---|
| 730 | + | poverty level for such year is implemented. 77 |
|---|
| 731 | + | 7. If a MO HealthNet participant has paid the 78 |
|---|
| 732 | + | requested spenddown in cash for any month and subsequently 79 |
|---|
| 733 | + | pays an out-of-pocket valid medical expense for such month, 80 |
|---|
| 734 | + | such expense shall be allowed as a deduction to futu re 81 |
|---|
| 735 | + | required spenddown for up to three months from the date of 82 |
|---|
| 736 | + | such expense. 83 |
|---|
| 737 | + | 208.164. 1. As used in this section, unless the 1 |
|---|
| 738 | + | context clearly requires otherwise, the following terms mean: 2 |
|---|
| 739 | + | (1) "Abuse", a documented pattern of i nducing, 3 |
|---|
| 740 | + | furnishing, or otherwise causing a recipient to receive 4 |
|---|
| 741 | + | services or merchandise not otherwise required or requested 5 |
|---|
| 742 | + | by the recipient, attending physician or appropriate 6 |
|---|
| 743 | + | utilization review team; a documented pattern of performing 7 |
|---|
| 744 | + | and billing tests, examinations, patient visits, surgeries, 8 |
|---|
| 745 | + | drugs or merchandise that exceed limits or frequencies 9 |
|---|
| 746 | + | 23 |
|---|
| 747 | + | determined by the department for like practitioners for 10 |
|---|
| 748 | + | which there is no demonstrable need, or for which the 11 |
|---|
| 749 | + | provider has created the need through in effective services 12 |
|---|
| 750 | + | or merchandise previously rendered. The decision to impose 13 |
|---|
| 751 | + | any of the sanctions authorized in this section shall be 14 |
|---|
| 752 | + | made by the director of the department, following a 15 |
|---|
| 753 | + | determination of demonstrable need or accepted medical 16 |
|---|
| 754 | + | practice made in consultation with medical or other health 17 |
|---|
| 755 | + | care professionals, or qualified peer review teams; 18 |
|---|
| 756 | + | (2) "Department", the department of social services; 19 |
|---|
| 757 | + | (3) "Excessive use", the act, by a person eligible for 20 |
|---|
| 758 | + | services under a contract or pr ovider agreement between the 21 |
|---|
| 759 | + | department of social services or its divisions and a 22 |
|---|
| 760 | + | provider, of seeking and/or obtaining medical assistance 23 |
|---|
| 761 | + | benefits from a number of like providers and in quantities 24 |
|---|
| 762 | + | which exceed the levels that are considered medically 25 |
|---|
| 763 | + | necessary by current medical practices and standards for the 26 |
|---|
| 764 | + | eligible person's needs; 27 |
|---|
| 765 | + | (4) "Fraud", a known false representation, including 28 |
|---|
| 766 | + | the concealment of a material fact that the provider knew or 29 |
|---|
| 767 | + | should have known through the usual conduct of his 30 |
|---|
| 768 | + | profession or occupation, upon which the provider claims 31 |
|---|
| 769 | + | reimbursement under the terms and conditions of a contract 32 |
|---|
| 770 | + | or provider agreement and the policies pertaining to such 33 |
|---|
| 771 | + | contract or provider agreement of the department or its 34 |
|---|
| 772 | + | divisions in carrying out the providing of services, or 35 |
|---|
| 773 | + | under any approved state plan authorized by the federal 36 |
|---|
| 774 | + | Social Security Act; 37 |
|---|
| 775 | + | (5) "Health plan", a group of services provided to 38 |
|---|
| 776 | + | recipients of medical assistance benefits by providers under 39 |
|---|
| 777 | + | a contract with the department; 40 |
|---|
| 778 | + | (6) "Medical assistance benefits", those benefits 41 |
|---|
| 779 | + | authorized to be provided by sections 208.152 and 208.162; 42 |
|---|
| 780 | + | 24 |
|---|
| 781 | + | (7) "Prior authorization", approval to a provider to 43 |
|---|
| 782 | + | perform a service or services for an eligible person 44 |
|---|
| 783 | + | required by the department or its divisions in advance of 45 |
|---|
| 784 | + | the actual service being provided or approved for a 46 |
|---|
| 785 | + | recipient to receive a service or services from a provider, 47 |
|---|
| 786 | + | required by the department or its designated division in 48 |
|---|
| 787 | + | advance of the actual service or ser vices being received; 49 |
|---|
| 788 | + | (8) "Provider", any person, partnership, corporation, 50 |
|---|
| 789 | + | not-for-profit corporation, professional corporation, or 51 |
|---|
| 790 | + | other business entity that enters into a contract or 52 |
|---|
| 791 | + | provider agreement with the department or its divisions for 53 |
|---|
| 792 | + | the purpose of providing services to eligible persons, and 54 |
|---|
| 793 | + | obtaining from the department or its divisions reimbursement 55 |
|---|
| 794 | + | therefor; 56 |
|---|
| 795 | + | (9) "Recipient", a person who is eligible to receive 57 |
|---|
| 796 | + | medical assistance benefits allocated through the department; 58 |
|---|
| 797 | + | (10) "Service", the specific function, act, successive 59 |
|---|
| 798 | + | acts, benefits, continuing benefits, requested by an 60 |
|---|
| 799 | + | eligible person or provided by the provider under contract 61 |
|---|
| 800 | + | with the department or its divisions. 62 |
|---|
| 801 | + | 2. The department or its divisions sha ll have the 63 |
|---|
| 802 | + | authority to suspend, revoke, or cancel any contract or 64 |
|---|
| 803 | + | provider agreement or refuse to enter into a new contract or 65 |
|---|
| 804 | + | provider agreement with any provider where it is determined 66 |
|---|
| 805 | + | the provider has committed or allowed its agents, servants, 67 |
|---|
| 806 | + | or employees to commit acts defined as abuse or fraud in 68 |
|---|
| 807 | + | this section. 69 |
|---|
| 808 | + | 3. The department or its divisions shall have the 70 |
|---|
| 809 | + | authority to impose prior authorization as defined in this 71 |
|---|
| 810 | + | section: 72 |
|---|
| 811 | + | (1) When it has reasonable cause to believe a provider 73 |
|---|
| 812 | + | or recipient has knowingly followed a course of conduct 74 |
|---|
| 813 | + | 25 |
|---|
| 814 | + | which is defined as abuse or fraud or excessive use by this 75 |
|---|
| 815 | + | section; or 76 |
|---|
| 816 | + | (2) When it determines by rule that prior 77 |
|---|
| 817 | + | authorization is reasonable for a specified service or 78 |
|---|
| 818 | + | procedure. 79 |
|---|
| 819 | + | 4. If a provider or recipient reports to the 80 |
|---|
| 820 | + | department or its divisions the name or names of providers 81 |
|---|
| 821 | + | or recipients who, based upon their personal knowledge has 82 |
|---|
| 822 | + | reasonable cause to believe an act or acts are being 83 |
|---|
| 823 | + | committed which are defined as abuse, fraud or excessive use 84 |
|---|
| 824 | + | by this section, such report shall be confidential and the 85 |
|---|
| 825 | + | reporter's name shall not be divulged to anyone by the 86 |
|---|
| 826 | + | department or any of its divisions, except at a judicial 87 |
|---|
| 827 | + | proceeding upon a proper protective order being entered by 88 |
|---|
| 828 | + | the court. 89 |
|---|
| 829 | + | 5. Payments for services under any contract or 90 |
|---|
| 830 | + | provider agreement between the department or its divisions 91 |
|---|
| 831 | + | and a provider may be withheld by the department or its 92 |
|---|
| 832 | + | divisions from the provider for acts or omissions defined as 93 |
|---|
| 833 | + | abuse or fraud by this section, until such time as an 94 |
|---|
| 834 | + | agreement between the parties is reached or the dispute is 95 |
|---|
| 835 | + | adjudicated under the laws of this state. 96 |
|---|
| 836 | + | 6. The department or its designated division shall 97 |
|---|
| 837 | + | have the authority to review all cases and claim re cords for 98 |
|---|
| 838 | + | any recipient of public assistance benefits and to determine 99 |
|---|
| 839 | + | from these records if the recipient has, as defined in this 100 |
|---|
| 840 | + | section, committed excessive use of such services by seeking 101 |
|---|
| 841 | + | or obtaining services from a number of like providers of 102 |
|---|
| 842 | + | services and in quantities which exceed the levels 103 |
|---|
| 843 | + | considered necessary by current medical or health care 104 |
|---|
| 844 | + | professional practice standards and policies of the program. 105 |
|---|
| 845 | + | 7. The department or its designated division shall 106 |
|---|
| 846 | + | have the authority with respect to recipients of medical 107 |
|---|
| 847 | + | 26 |
|---|
| 848 | + | assistance benefits who have committed excessive use to 108 |
|---|
| 849 | + | limit or restrict the use of the recipient's Medicaid 109 |
|---|
| 850 | + | identification card to designated providers and for 110 |
|---|
| 851 | + | designated services; the actual method by which such 111 |
|---|
| 852 | + | restrictions are imposed shall be at the discretion of the 112 |
|---|
| 853 | + | department of social services or its designated division. 113 |
|---|
| 854 | + | 8. The department or its designated division shall 114 |
|---|
| 855 | + | have the authority with respect to any recipient of medical 115 |
|---|
| 856 | + | assistance benefits whose use has been restricted under 116 |
|---|
| 857 | + | subsection 7 of this section and who obtains or seeks to 117 |
|---|
| 858 | + | obtain medical assistance benefits from a provider other 118 |
|---|
| 859 | + | than one of the providers for designated services to 119 |
|---|
| 860 | + | terminate medical assistance benefits as defined by this 120 |
|---|
| 861 | + | chapter, where allowed by the provisions of the federal 121 |
|---|
| 862 | + | Social Security Act. 122 |
|---|
| 863 | + | 9. The department or its designated division shall 123 |
|---|
| 864 | + | have the authority with respect to any provider who 124 |
|---|
| 865 | + | knowingly allows a recipient to violate subsection 7 of this 125 |
|---|
| 866 | + | section or who fails to report a known violation of 126 |
|---|
| 867 | + | subsection 7 of this section to the department of social 127 |
|---|
| 868 | + | services or its designated division to terminate or 128 |
|---|
| 869 | + | otherwise sanction such provider's status as a participant 129 |
|---|
| 870 | + | in the medical assistance program. Any person making such a 130 |
|---|
| 871 | + | report shall not be civilly liable when the report is made 131 |
|---|
| 872 | + | in good faith. 132 |
|---|
| 873 | + | 10. In order to comply with the provisions of 42 133 |
|---|
| 874 | + | U.S.C. Section 1320a -7(a) relating to mandatory exclusion of 134 |
|---|
| 875 | + | certain individuals and entities from participation in any 135 |
|---|
| 876 | + | federal health care program, and in furtherance of the 136 |
|---|
| 877 | + | state's authority under federal law, as implemented by 42 137 |
|---|
| 878 | + | CFR 1002.3(b), to exclude an individual or entity from MO 138 |
|---|
| 879 | + | HealthNet for any reason or period authorized by state law, 139 |
|---|
| 880 | + | the department or its divisions shall suspend, revoke, or 140 |
|---|
| 881 | + | 27 |
|---|
| 882 | + | cancel any contract or provider agreement or refuse to enter 141 |
|---|
| 883 | + | into a new contract or provider agreement with any provider 142 |
|---|
| 884 | + | where it is determined that such provider is not qualified 143 |
|---|
| 885 | + | to perform the service or services required, as described in 144 |
|---|
| 886 | + | 42 U.S.C. Section 1396a(a)(23), because such provider, or 145 |
|---|
| 887 | + | such provider's agent, servant, or employee acting under 146 |
|---|
| 888 | + | such provider's authority: 147 |
|---|
| 889 | + | (1) Has a conviction related to the delivery of any 148 |
|---|
| 890 | + | item or service under Medicare or under any state health 149 |
|---|
| 891 | + | care program, as described in 42 U.S.C. Section 1320a - 150 |
|---|
| 892 | + | 7(a)(1); 151 |
|---|
| 893 | + | (2) Has a conviction related to the neglect or abuse 152 |
|---|
| 894 | + | of a patient in connection with the delivery of any health 153 |
|---|
| 895 | + | care item or service, as described in 42 U.S.C. Section 154 |
|---|
| 896 | + | 1320a-7(a)(2); 155 |
|---|
| 897 | + | (3) Has a felony conviction related to health care 156 |
|---|
| 898 | + | fraud, theft, embezzlement, breach of fiduciary 157 |
|---|
| 899 | + | responsibility, or other financial misconduct, as described 158 |
|---|
| 900 | + | in 42 U.S.C. Section 1320a -7(a)(3); 159 |
|---|
| 901 | + | (4) Has a felony conviction related to the unlawful 160 |
|---|
| 902 | + | manufacture, distribution, prescription, or dispensation of 161 |
|---|
| 903 | + | a controlled substance, as described in 42 U.S.C. Section 162 |
|---|
| 904 | + | 1320a-7(a)(4); 163 |
|---|
| 905 | + | (5) Has been found guilty of, or civilly liable for, a 164 |
|---|
| 906 | + | pattern of intentional discrimination in the delivery or 165 |
|---|
| 907 | + | nondelivery of any health care item or service based on the 166 |
|---|
| 908 | + | race, color, or national origin of recipients, as described 167 |
|---|
| 909 | + | in 42 U.S.C. Section 2000d; or 168 |
|---|
| 910 | + | (6) Is an abortion facility, as defin ed in section 169 |
|---|
| 911 | + | 188.015, or an affiliate, as defined in section 188.015, of 170 |
|---|
| 912 | + | such abortion facility. 171 |
|---|
| 913 | + | 208.659. The MO HealthNet division shall revise the 1 |
|---|
| 914 | + | eligibility requirements for the uninsured women's health 2 |
|---|
| 915 | + | 28 |
|---|
| 916 | + | program, as establishe d in 13 CSR Section 70 - 4.090, to 3 |
|---|
| 917 | + | include women who are at least eighteen years of age and 4 |
|---|
| 918 | + | with a net family income of at or below one hundred eighty - 5 |
|---|
| 919 | + | five percent of the federal poverty level. In order to be 6 |
|---|
| 920 | + | eligible for such program, the applicant sh all not have 7 |
|---|
| 921 | + | assets in excess of two hundred and fifty thousand dollars, 8 |
|---|
| 922 | + | nor shall the applicant have access to employer -sponsored 9 |
|---|
| 923 | + | health insurance. Such change in eligibility requirements 10 |
|---|
| 924 | + | shall not result in any change in services provided under 11 |
|---|
| 925 | + | the program. No funds shall be expended to any abortion 12 |
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| 926 | + | facility, as defined in section 188.015, or to any 13 |
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| 927 | + | affiliate, as defined in section 188.015, of such abortion 14 |
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| 928 | + | facility. 15 |
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| 929 | + | Section B. Because of the need to protect all life in 1 |
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| 930 | + | Missouri, born and unborn, section A of this act is deemed 2 |
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| 931 | + | necessary for the immediate preservation of the public 3 |
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| 932 | + | health, welfare, peace, and safety, and is hereby declared 4 |
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| 933 | + | to be an emergency act within the meaning of the 5 |
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| 934 | + | constitution, and section A of t his act shall be in full 6 |
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| 935 | + | force and effect upon its passage and approval. 7 |
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