FIRSTREGULARSESSION
HOUSEBILLNO.1589
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVEVEIT.
3181H.01I JOSEPHENGLER,ChiefClerk
ANACT
Torepealsections191.300and208.152,RSMo,andtoenactinlieuthereoffournewsections
relatingtomedicaltesting.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Sections191.300and208.152,RSMo,arerepealedandfournewsections
2enactedinlieuthereof,tobeknownassections191.300,191.312,208.152,and376.1270,to
3readasfollows:
191.300.Asusedinsections191.300to191.380,thefollowingtermsmean:
2 (1)"Committee",theMissourigeneticdiseaseadvisorycommittee;
3 (2)"Cysticfibrosis",aseriouslungproblemofchildren;aninheriteddisorderwhich
4produceschronicinvolvementoftherespiratoryanddigestivesystems;
5 (3)"Department",thedepartmentofhealthandseniorservices;
6 (4)"Director",thedirectorofthestatedepartmentofhealthandseniorservices;
7 (5)"Geneticcounseling",theprovisionandinterpretationofmedicalinformation
8basedonexpandingknowledgeofhumangenetics;
9 (6)"Geneticdisorders",abnormalitiesofstructure,function,orbodymetabolism
10whichmaybeinheritedormayresultfromdamagetothefetus;
11 (7)"Geneticscreening",thesearchthroughtestingforpersonswithgeneticdisorders;
12 (8)"Healthcareprofessional",aphysicianorotherhealthcarepractitionerlicensed,
13accredited,orcertifiedbythestateofMissouritoperformspecifiedhealthservices;
14 (9)"Healthcareservices",servicesforthediagnosis,treatment,cure,orreliefofa
15healthcondition,illness,injury,ordisease;
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 16 (10)"Hemophilia",ableedingtendencyresultingfromageneticallydetermined
17deficiencyfactorintheblood;
18 (11)"Outreachclinics",medicalclinicswhichprovidegeneticdiagnosisand
19counselingatsitesawayfromthetertiarygeneticcenters;
20 (12)"Pediatricrarediseases",anyrarediseaseswithonsetprimarilyin
21childhoodandtypicallygeneticinnaturethataffectfewerthantwohundredthousand
22individualsintheUnitedStates;
23 (13)"Program",thegeneticprogramauthorizedbytheprovisionsofsections191.300
24to191.331,191.340,and191.365to191.380;
25 [(13)] (14)"Sicklecellanemia",ablooddiseasecharacterizedbythepresenceof
26crescentshapedorsickleshapederythrocytesinperipheralblood,excessivehemolysis,and
27activehematopoiesis,resultingfromageneticdefect;
28 [(14)] (15)"Sicklecelltrait",thehealthystatewhereinonecarriesthegeneforsickle
29cellandcouldpossiblypassthatgenetohisoffspring;
30 [(15)] (16)"Tertiarygeneticcenters",permanentgeneticdivisionsthatprovide
31comprehensivediagnostictreatmentandcounselingservices.
191.312.1.Thedepartmentshallofferacommentperiodopentothepublic
2eachyearinwhichmembersofthepublic,suchaspatientadvocacyorganizations,
3researchinstitutions,healthcareproviders,andotherstakeholders,mayoffer
4commentsandinformationpertainingtobestpracticesingeneticallybasednewborn
5screeningforpediatricrarediseases.
6 2.Thedepartmentshallannuallyseekoutinformationandresearchupdates
7fromprenatalandearlychildhoodgeneticscreeningresearchorganizationsincluding,
8butnotlimitedto,SeqFirst,GUARDIANStudy,andEarlyCheck.
9 3.Thedepartmentshallprepareanannualreportforthegovernorandgeneral
10assemblynolaterthanDecemberthirty-firsteachyearsummarizingthedepartment's
11findingsunderthissectionandrecommendationsforanyupdatestonewbornscreening
12forpediatricrarediseases.
208.152.1.MOHealthNetpaymentsshallbemadeonbehalfofthoseeligibleneedy
2personsasdescribedinsection208.151whoareunabletoprovideforitinwholeorinpart,
3withanypaymentstobemadeonthebasisofthereasonablecostofthecareorreasonable
4chargefortheservicesasdefinedanddeterminedbytheMOHealthNetdivision,unless
5otherwisehereinafterprovided,forthefollowing:
6 (1)Inpatienthospitalservices,excepttopersonsinaninstitutionformentaldiseases
7whoareundertheageofsixty-fiveyearsandovertheageoftwenty-oneyears;providedthat
8theMOHealthNetdivisionshallprovidethroughruleandregulationanexceptionprocessfor
9coverageofinpatientcostsinthosecasesrequiringtreatmentbeyondtheseventy-fifth
HB1589 2 10percentileprofessionalactivitiesstudy(PAS)ortheMOHealthNetchildren'sdiagnosis
11length-of-stayschedule;andprovidedfurtherthattheMOHealthNetdivisionshalltakeinto
12accountthroughitspaymentsystemforhospitalservicesthesituationofhospitalswhich
13serveadisproportionatenumberoflow-incomepatients;
14 (2)Alloutpatienthospitalservices,paymentstherefortobeinamountswhich
15representnomorethaneightypercentofthelesserofreasonablecostsorcustomarycharges
16forsuchservices,determinedinaccordancewiththeprinciplessetforthinTitleXVIIIAand
17B,PublicLaw89-97,1965amendmentstothefederalSocialSecurityAct(42U.S.C.Section
18301,etseq.),buttheMOHealthNetdivisionmayevaluateoutpatienthospitalservices
19renderedunderthissectionanddenypaymentforserviceswhicharedeterminedbytheMO
20HealthNetdivisionnottobemedicallynecessary,inaccordancewithfederallawand
21regulations;
22 (3)LaboratoryandX-rayservices;
23 (4)Nursinghomeservicesforparticipants,excepttopersonswithmorethanfive
24hundredthousanddollarsequityintheirhomeorexceptforpersonsinaninstitutionfor
25mentaldiseaseswhoareundertheageofsixty-fiveyears,whenresidinginahospitallicensed
26bythedepartmentofhealthandseniorservicesoranursinghomelicensedbythedepartment
27ofhealthandseniorservicesorappropriatelicensingauthorityofotherstatesorgovernment-
28ownedand-operatedinstitutionswhicharedeterminedtoconformtostandardsequivalentto
29licensingrequirementsinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section301,
30etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmayrecognize
31throughitspaymentmethodologyfornursingfacilitiesthosenursingfacilitieswhichservea
32highvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhendeterminingthe
33amountofthebenefitpaymentstobemadeonbehalfofpersonsundertheageoftwenty-one
34inanursingfacilitymayconsidernursingfacilitiesfurnishingcaretopersonsundertheageof
35twenty-oneasaclassificationseparatefromothernursingfacilities;
36 (5)Nursinghomecostsforparticipantsreceivingbenefitpaymentsundersubdivision
37(4)ofthissubsectionforthosedays,whichshallnotexceedtwelveperanyperiodofsix
38consecutivemonths,duringwhichtheparticipantisonatemporaryleaveofabsencefromthe
39hospitalornursinghome,providedthatnosuchparticipantshallbeallowedatemporary
40leaveofabsenceunlessitisspecificallyprovidedforinhisorherplanofcare.Asusedin
41thissubdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftime
42duringwhichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheor
43sheisvisitingafriendorrelative;
44 (6)Physicians'services,whetherfurnishedintheoffice,home,hospital,nursing
45home,orelsewhere,provided,thatnofundsshallbeexpendedtoanyabortionfacility,as
HB1589 3 46definedinsection188.015,ortoanyaffiliate,asdefinedinsection188.015,ofsuchabortion
47facility;
48 (7)Subjecttoappropriation,uptotwentyvisitsperyearforserviceslimitedto
49examinations,diagnoses,adjustments,andmanipulationsandtreatmentsofmalpositioned
50articulationsandstructuresofthebodyprovidedbylicensedchiropracticphysicians
51practicingwithintheirscopeofpractice.Nothinginthissubdivisionshallbeinterpretedto
52otherwiseexpandMOHealthNetservices;
53 (8)Drugsandmedicineswhenprescribedbyalicensedphysician,dentist,podiatrist,
54oranadvancedpracticeregisterednurse;exceptthatnopaymentfordrugsandmedicines
55prescribedonandafterJanuary1,2006,byalicensedphysician,dentist,podiatrist,oran
56advancedpracticeregisterednursemaybemadeonbehalfofanypersonwhoqualifiesfor
57prescriptiondrugcoverageundertheprovisionsofP.L.108-173;
58 (9)Emergencyambulanceservicesand,effectiveJanuary1,1990,medically
59necessarytransportationtoscheduled,physician-prescribednonelectivetreatments;
60 (10)Earlyandperiodicscreeninganddiagnosisofindividualswhoareundertheage
61oftwenty-onetoascertaintheirphysicalormentaldefects,andhealthcare,treatment,and
62othermeasurestocorrectoramelioratedefectsandchronicconditionsdiscoveredthereby.
63SuchservicesshallbeprovidedinaccordancewiththeprovisionsofSection6403ofP.L.
64101-239andfederalregulationspromulgatedthereunder;
65 (11)Homehealthcareservices;
66 (12)Familyplanningasdefinedbyfederalrulesandregulations;provided,thatno
67fundsshallbeexpendedtoanyabortionfacility,asdefinedinsection188.015,ortoany
68affiliate,asdefinedinsection188.015,ofsuchabortionfacility;andfurtherprovided,
69however,thatsuchfamilyplanningservicesshallnotincludeabortionsoranyabortifacient
70drugordevicethatisusedforthepurposeofinducinganabortionunlesssuchabortionsare
71certifiedinwritingbyaphysiciantotheMOHealthNetagencythat,inthephysician's
72professionaljudgment,thelifeofthemotherwouldbeendangeredifthefetuswerecarriedto
73term;
74 (13)Inpatientpsychiatrichospitalservicesforindividualsunderagetwenty-oneas
75definedinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396d,etseq.);
76 (14)Outpatientsurgicalprocedures,includingpresurgicaldiagnosticservices
77performedinambulatorysurgicalfacilitieswhicharelicensedbythedepartmentofhealth
78andseniorservicesofthestateofMissouri;except,thatsuchoutpatientsurgicalservicesshall
79notincludepersonswhoareeligibleforcoverageunderPartBofTitleXVIII,PublicLaw89-
8097,1965amendmentstothefederalSocialSecurityAct,asamended,ifexclusionofsuch
81personsispermittedunderTitleXIX,PublicLaw89-97,1965amendmentstothefederal
82SocialSecurityAct,asamended;
HB1589 4 83 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha
84person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea
85persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor
86residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal
87careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho
88isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin
89accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible
90toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire
91placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable
92forpersonalcareservicesshallnotexceedforanyoneparticipantonehundredpercentofthe
93averagestatewidechargeforcareandtreatmentinanintermediatecarefacilityfora
94comparableperiodoftime.Suchservices,whendeliveredinaresidentialcarefacilityor
95assistedlivingfacilitylicensedunderchapter198,shallbeauthorizedonatierlevelbasedon
96theservicestheresidentrequiresandthefrequencyoftheservices.Aresidentofsuchfacility
97whoqualifiesforassistanceundersection208.030shall,ataminimum,ifprescribedbya
98physician,qualifyforthetierlevelwiththefewestservices.Theratepaidtoprovidersfor
99eachtierofserviceshallbesetsubjecttoappropriations.Subjecttoappropriations,each
100residentofsuchfacilitywhoqualifiesforassistanceundersection208.030andmeetsthe
101levelofcarerequiredinthissectionshall,ataminimum,ifprescribedbyaphysician,be
102authorizeduptoonehourofpersonalcareservicesperday.Authorizedunitsofpersonalcare
103servicesshallnotbereducedortierlevelloweredunlessanorderapprovingsuchreductionor
104loweringisobtainedfromtheresident'spersonalphysician.Suchauthorizedunitsofpersonal
105careservicesortierlevelshallbetransferredwithsuchresidentifheorshetransfersto
106anothersuchfacility.Suchprovisionshallterminateuponreceiptofrelevantwaiversfrom
107thefederalDepartmentofHealthandHumanServices.IftheCentersforMedicareand
108MedicaidServicesdeterminesthatsuchprovisiondoesnotcomplywiththestateplan,this
109provisionshallbenullandvoid.TheMOHealthNetdivisionshallnotifytherevisorof
110statutesastowhethertherelevantwaiversareapprovedoradeterminationofnoncompliance
111ismade;
112 (16)Mentalhealthservices.Thestateplanforprovidingmedicalassistanceunder
113TitleXIXoftheSocialSecurityAct,42U.S.C.Section301,asamended,shallincludethe
114followingmentalhealthserviceswhensuchservicesareprovidedbycommunitymental
115healthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythedepartment
116ofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrugabusefacility
117orasachild-servingagencywithinthecomprehensivechildren'smentalhealthservicesystem
118establishedinsection630.097.Thedepartmentofmentalhealthshallestablishby
119administrativerulethedefinitionandcriteriafordesignationasacommunitymentalhealth
HB1589 5 120facilityandfordesignationasanalcoholanddrugabusefacility.Suchmentalhealthservices
121shallinclude:
122 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
123rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
124settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
125established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
126apartofclientservicesmanagement;
127 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
128rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
129settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
130established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
131apartofclientservicesmanagement;
132 (c)Rehabilitativementalhealthandalcoholanddrugabuseservicesincludinghome
133andcommunity-basedpreventive,diagnostic,therapeutic,rehabilitative,andpalliative
134interventionsrenderedtoindividualsinanindividualorgroupsettingbyamentalhealth
135oralcoholanddrugabuseprofessionalinaccordancewithaplanoftreatmentappropriately
136established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
137apartofclientservicesmanagement.Asusedinthissection,mentalhealthprofessionaland
138alcoholanddrugabuseprofessionalshallbedefinedbythedepartmentofmentalhealth
139pursuanttodulypromulgatedrules.Withrespecttoservicesestablishedbythissubdivision,
140thedepartmentofsocialservices,MOHealthNetdivision,shallenterintoanagreementwith
141thedepartmentofmentalhealth.Matchingfundsforoutpatientmentalhealthservices,clinic
142mentalhealthservices,andrehabilitationservicesformentalhealthandalcoholanddrug
143abuseshallbecertifiedbythedepartmentofmentalhealthtotheMOHealthNetdivision.
144Theagreementshallestablishamechanismforthejointimplementationoftheprovisionsof
145thissubdivision.Inaddition,theagreementshallestablishamechanismbywhichratesfor
146servicesmaybejointlydeveloped;
147 (17)SuchadditionalservicesasdefinedbytheMOHealthNetdivisiontobe
148furnishedunderwaiversoffederalstatutoryrequirementsasprovidedforandauthorizedby
149thefederalSocialSecurityAct(42U.S.C.Section301,etseq.)subjecttoappropriationbythe
150generalassembly;
151 (18)Theservicesofanadvancedpracticeregisterednursewithacollaborative
152practiceagreementtotheextentthatsuchservicesareprovidedinaccordancewithchapters
153334and335,andregulationspromulgatedthereunder;
154 (19)Nursinghomecostsforparticipantsreceivingbenefitpaymentsunder
155subdivision(4)ofthissubsectiontoreserveabedfortheparticipantinthenursinghome
HB1589 6 156duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich
157cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision:
158 (a)Theprovisionsofthissubdivisionshallapplyonlyif:
159 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO
160HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto
161thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis
162admittedtothehospital;and
163 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated
164stayofthreedaysorless;
165 (b)Thepaymenttobemadeunderthissubdivisionshallbeprovidedforamaximum
166ofthreedaysperhospitalstay;
167 (c)Foreachdaythatnursinghomecostsarepaidonbehalfofaparticipantunderthis
168subdivisionduringanyperiodofsixconsecutivemonthssuchparticipantshall,duringthe
169sameperiodofsixconsecutivemonths,beineligibleforpaymentofnursinghomecostsof
170twootherwiseavailabletemporaryleaveofabsencedaysprovidedundersubdivision(5)of
171thissubsection;and
172 (d)Theprovisionsofthissubdivisionshallnotapplyunlessthenursinghome
173receivesnoticefromtheparticipantortheparticipant'sresponsiblepartythattheparticipant
174intendstoreturntothenursinghomefollowingthehospitalstay.Ifthenursinghomereceives
175suchnotificationandallotherprovisionsofthissubsectionhavebeensatisfied,thenursing
176homeshallprovidenoticetotheparticipantortheparticipant'sresponsiblepartypriorto
177releaseofthereservedbed;
178 (20)Prescribedmedicallynecessarydurablemedicalequipment.Anelectronicweb-
179basedpriorauthorizationsystemusingbestmedicalevidenceandcareandtreatment
180guidelinesconsistentwithnationalstandardsshallbeusedtoverifymedicalneed;
181 (21)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
182coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
183inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
184medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
185physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
186psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
187stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
188participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
189paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
190nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
191rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
HB1589 7 192facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
193(OmnibusBudgetReconciliationActof1989);
194 (22)Prescribedmedicallynecessarydentalservices.Suchservicesshallbesubjectto
195appropriations.Anelectronicweb-basedpriorauthorizationsystemusingbestmedical
196evidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshallbeusedto
197verifymedicalneed;
198 (23)Prescribedmedicallynecessaryoptometricservices.Suchservicesshallbe
199subjecttoappropriations.Anelectronicweb-basedpriorauthorizationsystemusingbest
200medicalevidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshall
201beusedtoverifymedicalneed;
202 (24)Bloodclottingproducts-relatedservices.Forpersonsdiagnosedwithableeding
203disorder,asdefinedinsection338.400,reliantonbloodclottingproducts,asdefinedin
204section338.400,suchservicesinclude:
205 (a)Homedeliveryofbloodclottingproductsandancillaryinfusionequipmentand
206supplies,includingtheemergencydeliveriesoftheproductwhenmedicallynecessary;
207 (b)Medicallynecessaryancillaryinfusionequipmentandsuppliesrequiredto
208administerthebloodclottingproducts;and
209 (c)Assessmentsconductedintheparticipant'shomebyapharmacist,nurse,orlocal
210homehealthcareagencytrainedinbleedingdisorderswhendeemednecessarybythe
211participant'streatingphysician;
212 (25)Subjecttoappropriationsandnecessaryfederalapproval,geneticscreening
213forpediatricrarediseases.Suchscreeningshallinclude:
214 (a)Rapidwholegenomesequencingininpatientsettingsforpatientswhoare
215undertwenty-twoyearsofage;whohaveacomplexoracuteillnessofunknownorigin
216notattributedtoenvironmentalfactors,toxicingestion,infectionwithanormal
217response,ortrauma;andforwhomthetreatinghealthcareproviderdeterminesthatan
218immediatemoleculardiagnosisisnecessarytoprovideclinicaldecision-making;and
219 (b)Biomarkertestinginoutpatientcaresettingsforthepurposesofdiagnosis,
220treatment,appropriatemanagement,orongoingmonitoringofaparticipant'sdiseaseor
221conditiontoguidetreatmentdecisionsifdeemedmedicallynecessary.Testingmaybe
222medicallynecessaryifthetestingisclinicallyappropriateasdeemedbythetreating
223healthcareprovidertoguidetreatment,thefindingsofthetestmaydirectlyimpactthe
224participant'streatmentplan,andthepatientpresentscomplexorunexplained
225symptomsconsistentwithapotentialgeneticetiology.Thereshallbenoage
226restrictiononbiomarkertestinginoutpatientsettings.
227
HB1589 8 228Thedepartmentofsocialservicesshallseekanynecessarywaiversorstateplan
229amendmentsfromtheCentersforMedicareandMedicaidServicestoimplementthe
230provisionsofthissubdivision;
231 (26)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter,
232reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred
233percentoftheMedicarereimbursementratesandcomparedtotheaveragedental
234reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet
235divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve
236paritywithMedicarereimbursementratesandforthird-partypayoraveragedental
237reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall
238includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete
239thefour-yearplandevelopedunderthissubdivision.
240 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof
241thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe
242madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas
243definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided,
244forthefollowing:
245 (1)Dentalservices;
246 (2)Servicesofpodiatristsasdefinedinsection330.010;
247 (3)Optometricservicesasdescribedinsection336.010;
248 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,hearing
249aids,andwheelchairs;
250 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
251coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
252inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
253medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
254physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
255psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
256stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
257participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
258paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
259nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
260rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
261facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
262(OmnibusBudgetReconciliationActof1989);
263 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa
264coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation
HB1589 9 265servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated
266treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary
267assessmentdesignedtorestoreanindividualtoanoptimallevelofphysical,cognitive,and
268behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe
269definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility,
270benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis
271definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision
272shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof
273chapter536and,ifapplicable,section536.028.Thissectionandchapter536are
274nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter
275536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently
276heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor
277adoptedafterAugust28,2005,shallbeinvalidandvoid.
278 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet
279benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter
280July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall
281coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of
282subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner
283authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.)
284andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber
285accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the
286MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment
287pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods
288orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional
289paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein,
290ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade
291byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby
292thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy
293professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists.
294Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A
295providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired
296payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan
297individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder
298thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona
299historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor
300payment.Aprovider,representative,employee,independentcontractor,oragentofa
301pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection
HB1589 10 302shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters
303forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan
304amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto
305denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices
306shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe
307acceptabilityofdenyingservicesastheresultofunpaidco-payments.
308 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom
309participantsinordertomaintainprogramintegrity.
310 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of
311subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare
312providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet
313benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral
314populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C.
315Section1396aandfederalregulationspromulgatedthereunder.
316 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded
317healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection
3186404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations
319promulgatedthereunder.
320 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification
321andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen
322whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe
323specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe
324departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe
325requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder.
326 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin
327accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42
328U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder.
329 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein
330ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation
331intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat
332wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42
333U.S.C.Section1396a(a)(13)(C).
334 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand
335assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders.
336 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata
337shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof
338determiningeligibilityunderthissection.
HB1589 11 339 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor
340applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe
341interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO
342HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected
343MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof
344theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall
345entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis
346providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany
347paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent.
348EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail
349addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired
350underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor
351electronicmailtoeachprovider.
352 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's
353statutoryrequirementtopromulgaterulesunderchapter536.
354 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral,
355social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof
356physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand
357interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe
358CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch
359reimbursementshallincludepsychologists.
360 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition
361surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection
362191.1720,forthepurposeofagendertransition.
376.1270.1.Asusedinthissection,termsshallhavethemeaningsascribedto
2theminsection376.1350,andthefollowingtermsmean:
3 (1)"Biomarker",ameasurablemolecularcharacteristicthatmaybeevidenceof
4raregeneticdisordersorabnormalbiologicalprocesses;
5 (2)"Biomarkertesting",testingspecificallydesignedtodetectgeneticmarkers
6forrarediseasesincluding,butnotlimitedto,exomesequencingandgenome
7sequencing;
8 (3)"Geneticcounseling",theprovisionandinterpretationofmedical
9informationbasedonexpandingknowledgeofhumangenetics;
10 (4)"Pediatricraredisease",ararediseasewithonsetprimarilyinchildhoodand
11typicallygeneticinnature,affectingfewerthantwohundredthousandindividualsinthe
12UnitedStates;
HB1589 12 13 (5)"Rapidwholegenomesequencing"or"rWGS",ananalysisofaperson's
14entirehumangenome,includingcodingandnoncodingregionsandmitochondrialDNA,
15todetectdisease-causinggeneticchanges,providingpreliminarytestresultswithin
16sevendaysofreceivingasampleandfinalresultswithinfifteendaysofreceivinga
17sample.
18 2.Forenrolleesreceivinghigh-acuityinpatientcare,including,butnotlimited
19to,intensivecareorcareinneonatalunits,whomeetcriteriaforapediatricraredisease
20suspectedtobegeneticinnature:
21 (1)HealthbenefitplansshallcoverrWGSifcoverageforbiomarkertesting
22wouldotherwiseberequiredundersubsection3ofthissectionand:
23 (a)Theenrolleeisundertwenty-twoyearsofage;
24 (b)Theenrolleehasacomplexoracuteillnessofunknownoriginnotattributed
25toenvironmentalfactors,toxicingestion,infectionwithanormalresponse,ortrauma;
26and
27 (c)Thetreatingproviderdeterminesanimmediatemoleculardiagnosisis
28necessarytoguideclinicaldecision-making;
29 (2)ReimbursementforrWGSunderthissubsectionshallbemadeseparately
30fromtheinpatientstay,allowingtheperforminglaboratorytobillseparatelyasifthe
31testwereprovidedinanoutpatientsetting;and
32 (3)Healthbenefitplansshallnotrequirepriorauthorizationforcoverage
33requiredunderthissubsectionbutmayperformretrospectivereview.
34 3.Forenrolleesmeetingcriteriaforapediatricrarediseasesuspectedtobe
35geneticinnature:
36 (1)Healthbenefitplansshallprovidecoverageforbiomarkertestingforthe
37purposesofdiagnosis,treatment,management,orongoingmonitoringofanenrollee's
38diseaseorconditioninordertoguidetreatmentdecisionsifmedicalandscientific
39evidenceindicatesthebiomarkertestingmayprovideclinicalutilitytotheenrollee.
40Suchmedicalandscientificevidenceincludes,butisnotlimitedto:
41 (a)AlabeledindicationforatestapprovedorclearedbytheUnitedStatesFood
42andDrugAdministration;
43 (b)AnindicatedtestforadrugapprovedbytheUnitedStatesFoodandDrug
44Administration;
45 (c)AnationalcoveragedeterminationmadebytheCentersforMedicareand
46MedicaidServicesoralocalcoveragedeterminationmadebytheMedicare
47administrativecontractor;or
48 (d)Anationallyrecognizedclinicalpracticeguideline;
HB1589 13 49 (2)Nohealthbenefitplanshallimposeanagerestrictiononcoverageunderthis
50subsection;
51 (3)Coverageunderthissectionmaybedeemedmedicallynecessaryifanyofthe
52followingcircumstances,butnotlimitedthereto,apply:
53 (a)Thetestisindicatedforararediseasediagnosisbasedonclinicalguidelines
54orthetestisrecommendedasmedicallynecessarybythetreatingprovidertoguide
55treatmentormanagementdecisions;
56 (b)Thetestmayuncoveractionablefindingsthatwilldirectlyimpactthe
57patient'streatmentplanorhelpclarifyabroaddifferentialdiagnosisthatwouldrequire
58multipletestsifbiomarkertestingwereunavailable;or
59 (c)Thepatientpresentscomplexorunexplainedsymptomsthatareconsistent
60withapotentialgeneticetiologyincluding,butnotlimitedto:
61 a.Unexplainedcongenitalabnormalitiesormulti-systemorganinvolvement;
62 b.Abnormallaboratoryfindingsorchemistryprofilesconsistentwithagenetic
63ormetabolicdisorder;
64 c.Refractoryortreatment-resistantsymptomssuchasseizures,muscle
65weakness,severeendocrinedisturbances,globaldevelopmentaldelay,orfailureto
66thrive;
67 d.Documentedfamilialhistoryofageneticallysuspectedconditionorrare
68disease;or
69 e.Adiagnosisofautism,cancer,orAlzheimer'sdiseaseorarelateddementia;
70and
71 (4)Coverageunderthissubsectionshallnotrequirepriorauthorizationifthe
72testisorderedbyaclinicalspecialistwitharelevantspecialty.Noutilizationreview
73entityshallrevoke,limit,condition,orotherwiserestrictapriorauthorizationfor
74coverageunderthissubsection,providedthepatientisanenrolleeofthehealthbenefit
75plan.
76 4.Coverageunderthissectionshallnotbedeniedonthebasisofthetestbeing
77experimentalorinvestigationalifthetestmeetsestablishedclinicalguidelinesoris
78recommendedbyarecognizedmedicalsociety.
79 5.Coverageunderthissectionshallincludegeneticcounseling,includingboth
80pretestandposttestgeneticcounseling.
81 6.Healthcarriersshallmaintain,accessibleontheirpublicwebsites,up-to-date
82policiesoncoveredgenomicandbiomarkertests,includingthecriteriaformedical
83necessity.
HB1589 14 84 7.Testingcoveredunderthissectionshallbeperformedbyalaboratorycertified
85bytheCentersforMedicareandMedicaidServicesasmeetingthestandardsofthe
86ClinicalLaboratoryImprovementAmendmentsof1988(CLIA).
87 8.Thissectionshallapplytohealthbenefitplansdelivered,issuedfordelivery,
88continued,orrenewedonorafterJanuary1,2026.
âś”
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