5374S.02C
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SENATE COMMITTEE SUBSTITUTE
FOR
SENATE BILL NO. 1382
AN ACT
To repeal sections 190.053, 190.098, 190.101, and
190.109, RSMo, and to enact in lieu thereof seven new
sections relating to emergency medical services.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Sections 190.053, 190.098, 190.101, and
190.109, RSMo, are repealed and seven new sections enacted in
lieu thereof, to be known as sections 190.053, 190.076, 190.098,
190.101, 190.109, 190.112, and 190.166, to read as follows:
190.053. 1. All members of the board of directors of
an ambulance district first elected on or after January 1,
2008, shall attend and complete an educational seminar or
conference or other suitable training on the role and duties
of a board member of an a mbulance district. The training
required under this section shall be offered by a statewide
association organized for the benefit of ambulance districts
or be approved by the state advisory council on emergency
medical services. Such training shall i nclude, at a minimum:
(1) Information relating to the roles and duties of an
ambulance district director;
(2) A review of all state statutes and regulations
relevant to ambulance districts;
(3) State ethics laws;
(4) State sunshine laws, chapter 610;
(5) Financial and fiduciary responsibility;
(6) State laws relating to the setting of tax rates;
and
(7) State laws relating to revenue limitations.
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2. [If any ambulance district board member fails to
attend a training session within twelve months after taking
office, the board member shall not be compensated for
attendance at meetings thereafter until the board member has
completed such training session. If any ambulance district
board member fails to att end a training session within
twelve months of taking office regardless of whether the
board member received an attendance fee for a training
session, the board member shall be ineligible to run for
reelection for another term of office until the board member
satisfies the training requirement of this section; however,
this requirement shall only apply to board members elected
after August 28, 2022 ] All members of the board of directors
of an ambulance district shall complete three hours of
continuing education for each term of office. The
continuing education shall be offered by a statewide
association organized for the benefit of ambulance districts
or be approved by the state advisory council on emergency
medical services.
3. Any ambulance district board member who fails to
complete the initial training and continuing education
requirements on or before the anniversary date of his or her
election or appointment shall immediately be disqualified
from office and his or her position sh all be vacant without
further process or declaration. The vacancy shall be filled
in the manner provided for pursuant to section 190.052 .
190.076. Each ambulance district shall arrange for an
audit of the records and accounts of the di strict at least
every three years by a certified public accountant or firm
of certified public accountants. The audit shall be made
available to the public on the district's website or
otherwise freely available by other electronic means.
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190.098. 1. In order for a person to be eligible for
certification by the department as a community paramedic, an
individual shall:
(1) Be currently [certified] licensed as a paramedic;
(2) Successfully complete or have successfully
completed a community paramedic certification program from a
college, university, or educational institution that has
been approved by the department or accredited by a national
accreditation organization approved by the department; and
(3) Complete an application form approved by the
department.
2. [A community paramedic shall practice in accordance
with protocols and supervisory standards established by the
medical director. A community paramedic shall provide
services of a health care p lan if the plan has been
developed by the patient's physician or by an advanced
practice registered nurse through a collaborative practice
arrangement with a physician or a physician assistant
through a collaborative practice arrangement with a
physician and there is no duplication of services to the
patient from another provider.
3. Any ambulance service shall enter into a written
contract to provide community paramedic services in another
ambulance service area, as that term is defined in se ction
190.100. The contract that is agreed upon may be for an
indefinite period of time, as long as it includes at least a
sixty-day cancellation notice by either ambulance service. ]
As used in this section, the term "community paramedic
services" shall mean services provided by any entity that
employs licensed paramedics who are certified by the
department as community paramedics for services that are:
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(1) Provided in a nonemergent setting that is
independent of an emergency telephone servic e, 911 system,
or emergency summons;
(2) Consistent with the training and education
requirements described in subdivision (2) of subsection 1 of
this section, the scope of skill and practice for community
paramedics, and the supervisory standard approved by the
entity's medical director; and
(3) Reflected and documented in the entity's medical
director-approved patient care plans or protocols in
accordance with the provisions of section 190.142.
3. (1) Any ambulance service that se eks to provide
community paramedic services outside of the ambulance
service's service area:
(a) Shall have a memorandum of understanding (MOU)
regarding the provision of such services with the ambulance
service in that service area if that ambul ance service is
already providing community paramedic services; or
(b) Shall not be required to have an MOU with the
ambulance service in that service area if that ambulance
service is not already providing community paramedic
services, provided that the ambulance service seeking to
provide such services shall provide notification to the
other ambulance service of the community paramedic services
to be provided.
(2) Any emergency medical response agency (EMRA) that
seeks to provide commu nity paramedic services within its
designated response service area may do so if the ground
ambulance service area within which the EMRA operates does
not already provide such services. If the ground ambulance
service does provide community paramedic services, then the
ground ambulance service may enter into an MOU with the EMRA
in order to coordinate programs and avoid service
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duplication. If the EMRA provides community paramedic
services in the ground ambulance service's service area
prior to the provision of such services by the ground
ambulance service, then the EMRA and the ground ambulance
service shall enter into an MOU for the coordination of
services.
(3) Any community paramedic program shall notify the
appropriate local ambulan ce service when providing services
within the service area of an ambulance service.
(4) The department shall promulgate rules and
regulations for the purpose of recognizing which community
paramedic services entities have met the standards necessa ry
to provide community paramedic services, including, but not
limited to, physician medical oversight, training, patient
record retention, formal relationships with primary care
services as needed, and quality improvement policies.
Community paramedic services entities shall be certified by
the department, allowing such entities to provide community
paramedic services for a period of five years.
4. A community paramedic is subject to the provisions
of sections 190.001 to 190.245 and rules pr omulgated under
sections 190.001 to 190.245.
5. No person shall hold himself or herself out as a
community paramedic or provide the services of a community
paramedic unless such person is certified by the department.
6. The medical director shall approve the
implementation of the community paramedic program.
7. Any rule or portion of a rule, as that term is
defined in section 536.010, that is created under the
authority delegated in this section shall become effective
only if it complies with and is subject to all of the
provisions of chapter 536 and, if applicable, section
536.028. This section and chapter 536 are nonseverable and
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if any of the powers vested with the general assembly
pursuant to chapter 536 to review, to delay the effective
date, or to disapprove and annul a rule are subsequently
held unconstitutional, then the grant of rulemaking
authority and any rule proposed or adopted after August 28,
2013, shall be invalid and void.
190.101. 1. There is hereby established a "State
Advisory Council on Emergency Medical Services" which shall
consist of [sixteen] no more than twenty-three members[, one
of which shall be a resident of a city not within a
county]. The members of the council shall be ap pointed [by
the governor with the advice and consent of the senate ]
pursuant to subsection 2 of this subsection and shall serve
terms of four years. The [governor shall designate one of
the members as chairperson ] council members shall annually
select a chairperson, along with other officers as the
council deems necessary . The chairperson may appoint
subcommittees that include noncouncil members.
2. Council members shall be appointed as follows:
(1) The director of the department of hea lth and
senior services shall make appointments to the council from
the recommendations provided by the following:
(a) The statewide professional association
representing ambulance service managers;
(b) The statewide professional association
representing EMT's and paramedics;
(c) The statewide professional association
representing ambulance districts;
(d) The statewide professional association
representing fire chiefs;
(e) The statewide professional association
representing fire protection districts;
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(f) The statewide professional association
representing firefighters;
(g) The statewide professional association
representing emergency nurses;
(h) The statewide professional association
representing the air ambulance industry;
(i) The statewide professional association
representing emergency medicine physicians;
(j) The statewide association representing hospitals;
and
(k) The statewide association representing pediatric
emergency professionals;
(2) The director of health and senior services shall
appoint a member to the council with a background in mobile
integrated healthcare -community paramedicine (MIH -CP);
(3) Each regional EMS advisory committee shall appoint
one member; and
(4) The time-critical diagnosis advisory committee
established under section 190.257 shall appoint one member.
3. The state EMS medical directors advisory committee
and the regional EMS advisory committees will be recognized
as subcommittees of the state advisory council on emergency
medical services.
[3.] 4. The council shall have geographical
representation and representation from appropriate areas of
expertise in emergency medical services including
volunteers, professi onal organizations involved in emergency
medical services, EMT's, paramedics, nurses, firefighters,
physicians, ambulance service administrators, hospital
administrators and other health care providers concerned
with emergency medical services. [The regional EMS advisory
committees shall serve as a resource for the identification
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of potential members of the state advisory council on
emergency medical services.
4.] 5. The state EMS medical director, as described
under section 190.103, shall se rve as an ex officio member
of the council.
[5.] 6. The members of the council and subcommittees
shall serve without compensation except that members of the
council shall, subject to appropriations, be reimbursed for
reasonable travel expenses an d meeting expenses related to
the functions of the council.
[6.] 7. The purpose of the council is to make
recommendations to the governor, the general assembly, and
the department on policies, plans, procedures and proposed
regulations on how to improve the statewide emergency
medical services system. The council shall advise the
governor, the general assembly, and the department on all
aspects of the emergency medical services system.
[7.] 8. (1) There is hereby established a standing
subcommittee of the council to monitor the implementation of
the recognition of the EMS personnel licensure interstate
compact under sections 190.900 to 190.939, the interstate
commission for EMS personnel practice, and the involvement
of the state of Missouri. The subcommittee shall meet at
least biannually and receive reports from the Missouri
delegate to the interstate commission for EMS personnel
practice. The subcommittee shall consist of at least seven
members appointed by the chair of the council, to include at
least two members as recommended by the Missouri state
council of firefighters and one member as recommended by the
Missouri Association of Fire Chiefs. The subcommittee may
submit reports and recommendations to the council, the
department of health and senior services, the general
assembly, and the governor regarding the participation of
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Missouri with the recognition of the EMS personnel licensure
interstate compact.
(2) The subcommittee shall formally request a public
hearing for any rule proposed by the interstate commission
for EMS personnel practice in accordance with subsection 7
of section 190.930. The hearing request shall include the
request that the hearing be presented live through the
internet. The Missouri delegate to the interstate
commission for EMS personnel practice shall be responsible
for ensuring that all hearings, notices of, and related
rulemaking communications as required by the compact be
communicated to the council and emergency medica l services
personnel under the provisions of subsections 4, 5, 6, and 8
of section 190.930.
(3) The department of health and senior services shall
not establish or increase fees for Missouri emergency
medical services personnel licensure in accor dance with this
chapter for the purpose of creating the funds necessary for
payment of an annual assessment under subdivision (3) of
subsection 5 of section 190.924.
[8.] 9. The council shall consult with the time -
critical diagnosis advisory comm ittee, as described under
section 190.257, regarding time -critical diagnosis.
190.109. 1. The department shall, within a reasonable
time after receipt of an application, cause such
investigation as the department deems necessary to be made
of the applicant for a ground ambulance license.
2. Any person that owned and operated a licensed
ambulance on December 31, 1997, shall receive an ambulance
service license from the department, unless suspended,
revoked or terminated, for th at ambulance service area which
was, on December 31, 1997, described and filed with the
department as the primary service area for its licensed
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ambulances on August 28, 1998, provided that the person
makes application and adheres to the rules and regul ations
promulgated by the department pursuant to sections 190.001
to 190.245.
3. The department shall issue a new ground ambulance
service license to an ambulance service that is not
currently licensed by the department, or is currently
licensed by the department and is seeking to expand its
ambulance service area, except as provided in subsection 4
of this section, to be valid for a period of five years,
unless suspended, revoked or terminated, when the director
finds that the applicant meet s the requirements of ambulance
service licensure established pursuant to sections 190.100
to 190.245 and the rules adopted by the department pursuant
to sections 190.001 to 190.245. In order to be considered
for a new ambulance service license, an am bulance service
shall submit to the department a letter of endorsement from
each ambulance district or fire protection district that is
authorized to provide ambulance service, or from each
municipality not within an ambulance district or fire
protection district that is authorized to provide ambulance
service, in which the ambulance service proposes to
operate. If an ambulance service proposes to operate in
unincorporated portions of a county not within an ambulance
district or fire protection di strict that is authorized to
provide ambulance service, in order to be considered for a
new ambulance service license, the ambulance service shall
submit to the department a letter of endorsement from the
county. Any letter of endorsement required pur suant to this
section shall verify that the political subdivision has
conducted a public hearing regarding the endorsement and
that the governing body of the political subdivision has
adopted a resolution approving the endorsement. The letter
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of endorsement shall affirmatively state that the proposed
ambulance service:
(1) Will provide a benefit to public health that
outweighs the associated costs;
(2) Will maintain or enhance the public's access to
ambulance services;
(3) Will maintain or improve the public health and
promote the continued development of the regional emergency
medical service system;
(4) Has demonstrated the appropriate expertise in the
operation of ambulance services; and
(5) Has demonstrated the f inancial resources necessary
for the operation of the proposed ambulance service.
4. A contract between a political subdivision and a
licensed ambulance service for the provision of ambulance
services for that political subdivision shall expand,
without further action by the department, the ambulance
service area of the licensed ambulance service to include
the jurisdictional boundaries of the political subdivision.
The termination of the aforementioned contract shall result
in a reduction of the licensed ambulance service's ambulance
service area by removing the geographic area of the
political subdivision from its ambulance service area,
except that licensed ambulance service providers may provide
ambulance services as are needed at and around the state
fair grounds for protection of attendees at the state fair.
5. The department shall renew a ground ambulance
service license if the applicant meets the requirements
established pursuant to sections 190.001 to 190.245, and the
rules adopted by the department pursuant to sections 190.001
to 190.245.
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6. The department shall promulgate rules relating to
the requirements for a ground ambulance service license
including, but not limited to:
(1) Vehicle design, specificati on, operation and
maintenance standards;
(2) Equipment requirements;
(3) Staffing requirements;
(4) Five-year license renewal;
(5) Records and forms;
(6) Medical control plans;
(7) Medical director qualifications;
(8) Standards for medical communications;
(9) Memorandums of understanding with emergency
medical response agencies that provide advanced life support;
(10) Quality improvement committees; [and]
(11) Response time, patient care and tran sportation
standards;
(12) Participation with regional emergency medical
services advisory committees; and
(13) Ambulance service administrator qualifications .
7. Application for a ground ambulance service license
shall be made upon su ch forms as prescribed by the
department in rules adopted pursuant to sections 190.001 to
190.245. The application form shall contain such
information as the department deems necessary to make a
determination as to whether the ground ambulance service
meets all the requirements of sections 190.001 to 190.245
and rules promulgated pursuant to sections 190.001 to
190.245.
190.112. 1. Each ambulance service licensed under
this chapter shall identify to the department the individual
serving as the ambulance service administrator who is
responsible for the operations and staffing of the ambulance
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service. The ambulance service administrator shall be
required to have achieved basic training of at least forty
hours regarding the ope rations of an ambulance service and
two hours of annual continuing education. The training
required under this section shall be offered by a statewide
association organized for the benefit of ambulance districts
or be approved by the state advisory co uncil on emergency
medical services and shall include the following:
(1) Basic principles of accounting and economics;
(2) State and federal laws applicable to ambulance
services;
(3) Regulatory requirements applicable to ambulance
services;
(4) Human resources management and laws;
(5) Grant writing, contracts, and fundraising;
(6) State sunshine laws in chapter 610, as well as
applicable ethics requirements; and
(7) Volunteer and community involvement.
2. Ambulance service administrators serving in this
capacity as of August 28, 2024, shall have until January 1,
2026, to demonstrate compliance with the provisions of this
section.
190.166. 1. In addition to the provisions of section
190.165, the department of health and senior services may
refuse to issue, deny renewal of, or suspend a license
required pursuant to section 190.109, or take other
corrective actions as described in this section, based on
the following considerations:
(1) The license holder is determined to be financially
insolvent;
(2) The ambulance service has inadequate personnel to
operate the ambulance service to provide for basic emergency
operations, determined by the ability to staff a minimum of
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one ambulance unit twenty -four hours per day, seven days per
week, with at least two licensed emergency medical
technicians and a reasonable plan and schedule for the
services of a second ambulance;
(3) The ambulance service requires an inordinate
amount of mutual aid from neighboring services, such as more
than ten percent of the total runs in the service area in
any given month, or than would be considered prudent and
thus cannot provide an appropriate level of emergency
response for the ser vice area as would be considered prudent
by the typical ground ambulance services operator;
(4) The principal manager, board members, or other
executives are determined to be criminally liable for
actions related to the license or service provided ;
(5) The license holder or principal manager, board
members, or other executives are determined by the Centers
for Medicare and Medicaid Services to be ineligible for
participation in Medicare;
(6) The license holder or principal manager, b oard
members, or other executives are determined by the MO
HealthNet division to be ineligible for participation in MO
HealthNet;
(7) The ambulance service administrator has failed to
meet the required qualifications or failed to complete the
training required pursuant to section 190.112; and
(8) Three or more board members have failed to
complete required training pursuant to section 190.053 if
the ambulance service is an ambulance district.
2. If the department makes a determinati on of
insolvency or insufficiency of operations of a license
holder under subsection 1 of this section, then the
department may require the license holder to submit a
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corrective plan within fifteen days and require
implementation of the corrective pla n within thirty days.
3. The department shall be required to provide notice
of any determination by the department of insolvency or
insufficiency of operations of a license holder to other
license holders operating in the license holder's vicinity ,
members of the general assembly who represent the license
holder's service area, the governing officials of any county
or municipal entity in the license holder's service area,
the appropriate regional emergency medical services advisory
committee, and the state advisory council on emergency
medical services.
4. The department shall immediately engage with other
license holders in the area to determine the extent to which
ground ambulance service may be provided to the affected
service area during the time in which the license holder is
unable to provide adequate services, including any long -term
service arrangements. The nature of the agreement between
the license holder and other license holders providing
services to the affected area may include an agreement to
provide services, a joint powers agreement, formal
consideration, or some payment for services rendered.
5. Any license holder who provides assistance in the
service area of another license holder whose license has
been suspended under this section shall have the right to
seek reasonable compensation from the license holder whose
license to operate has been suspended for all calls, stand -
by time, and responses to medical emergencies during such
time as the license remains suspended. The reasonable
compensation shall not be limited to those expenses incurred
in actual responses, but may also include reasonable
expenses to maintain ambulance service, including, but not
limited to, the daily operation costs of mai ntaining the
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service, personnel wages and benefits, equipment purchases
and maintenance, and other costs incurred in the operation
of a ground ambulance service. The license holder providing
assistance shall be entitled to an award of costs and
reasonable attorney fees in any action to enforce the
provisions of this subsection.