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Missouri House Bill HB1589

Missouri 2025 Regular Session

Missouri House Bill HB1589 Compare Versions

Only one version of the bill is available at this time.
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11 FIRSTREGULARSESSION
22 HOUSEBILLNO.1589
33 103RDGENERALASSEMBLY
44 INTRODUCEDBYREPRESENTATIVEVEIT.
55 3181H.01I JOSEPHENGLER,ChiefClerk
66 ANACT
77 Torepealsections191.300and208.152,RSMo,andtoenactinlieuthereoffournewsections
88 relatingtomedicaltesting.
99 BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
1010 SectionA.Sections191.300and208.152,RSMo,arerepealedandfournewsections
1111 2enactedinlieuthereof,tobeknownassections191.300,191.312,208.152,and376.1270,to
1212 3readasfollows:
1313 191.300.Asusedinsections191.300to191.380,thefollowingtermsmean:
1414 2 (1)"Committee",theMissourigeneticdiseaseadvisorycommittee;
1515 3 (2)"Cysticfibrosis",aseriouslungproblemofchildren;aninheriteddisorderwhich
1616 4produceschronicinvolvementoftherespiratoryanddigestivesystems;
1717 5 (3)"Department",thedepartmentofhealthandseniorservices;
1818 6 (4)"Director",thedirectorofthestatedepartmentofhealthandseniorservices;
1919 7 (5)"Geneticcounseling",theprovisionandinterpretationofmedicalinformation
2020 8basedonexpandingknowledgeofhumangenetics;
2121 9 (6)"Geneticdisorders",abnormalitiesofstructure,function,orbodymetabolism
2222 10whichmaybeinheritedormayresultfromdamagetothefetus;
2323 11 (7)"Geneticscreening",thesearchthroughtestingforpersonswithgeneticdisorders;
2424 12 (8)"Healthcareprofessional",aphysicianorotherhealthcarepractitionerlicensed,
2525 13accredited,orcertifiedbythestateofMissouritoperformspecifiedhealthservices;
2626 14 (9)"Healthcareservices",servicesforthediagnosis,treatment,cure,orreliefofa
2727 15healthcondition,illness,injury,ordisease;
2828 EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
2929 intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 16 (10)"Hemophilia",ableedingtendencyresultingfromageneticallydetermined
3030 17deficiencyfactorintheblood;
3131 18 (11)"Outreachclinics",medicalclinicswhichprovidegeneticdiagnosisand
3232 19counselingatsitesawayfromthetertiarygeneticcenters;
3333 20 (12)"Pediatricrarediseases",anyrarediseaseswithonsetprimarilyin
3434 21childhoodandtypicallygeneticinnaturethataffectfewerthantwohundredthousand
3535 22individualsintheUnitedStates;
3636 23 (13)"Program",thegeneticprogramauthorizedbytheprovisionsofsections191.300
3737 24to191.331,191.340,and191.365to191.380;
3838 25 [(13)] (14)"Sicklecellanemia",ablooddiseasecharacterizedbythepresenceof
3939 26crescentshapedorsickleshapederythrocytesinperipheralblood,excessivehemolysis,and
4040 27activehematopoiesis,resultingfromageneticdefect;
4141 28 [(14)] (15)"Sicklecelltrait",thehealthystatewhereinonecarriesthegeneforsickle
4242 29cellandcouldpossiblypassthatgenetohisoffspring;
4343 30 [(15)] (16)"Tertiarygeneticcenters",permanentgeneticdivisionsthatprovide
4444 31comprehensivediagnostictreatmentandcounselingservices.
4545 191.312.1.Thedepartmentshallofferacommentperiodopentothepublic
4646 2eachyearinwhichmembersofthepublic,suchaspatientadvocacyorganizations,
4747 3researchinstitutions,healthcareproviders,andotherstakeholders,mayoffer
4848 4commentsandinformationpertainingtobestpracticesingeneticallybasednewborn
4949 5screeningforpediatricrarediseases.
5050 6 2.Thedepartmentshallannuallyseekoutinformationandresearchupdates
5151 7fromprenatalandearlychildhoodgeneticscreeningresearchorganizationsincluding,
5252 8butnotlimitedto,SeqFirst,GUARDIANStudy,andEarlyCheck.
5353 9 3.Thedepartmentshallprepareanannualreportforthegovernorandgeneral
5454 10assemblynolaterthanDecemberthirty-firsteachyearsummarizingthedepartment's
5555 11findingsunderthissectionandrecommendationsforanyupdatestonewbornscreening
5656 12forpediatricrarediseases.
5757 208.152.1.MOHealthNetpaymentsshallbemadeonbehalfofthoseeligibleneedy
5858 2personsasdescribedinsection208.151whoareunabletoprovideforitinwholeorinpart,
5959 3withanypaymentstobemadeonthebasisofthereasonablecostofthecareorreasonable
6060 4chargefortheservicesasdefinedanddeterminedbytheMOHealthNetdivision,unless
6161 5otherwisehereinafterprovided,forthefollowing:
6262 6 (1)Inpatienthospitalservices,excepttopersonsinaninstitutionformentaldiseases
6363 7whoareundertheageofsixty-fiveyearsandovertheageoftwenty-oneyears;providedthat
6464 8theMOHealthNetdivisionshallprovidethroughruleandregulationanexceptionprocessfor
6565 9coverageofinpatientcostsinthosecasesrequiringtreatmentbeyondtheseventy-fifth
6666 HB1589 2 10percentileprofessionalactivitiesstudy(PAS)ortheMOHealthNetchildren'sdiagnosis
6767 11length-of-stayschedule;andprovidedfurtherthattheMOHealthNetdivisionshalltakeinto
6868 12accountthroughitspaymentsystemforhospitalservicesthesituationofhospitalswhich
6969 13serveadisproportionatenumberoflow-incomepatients;
7070 14 (2)Alloutpatienthospitalservices,paymentstherefortobeinamountswhich
7171 15representnomorethaneightypercentofthelesserofreasonablecostsorcustomarycharges
7272 16forsuchservices,determinedinaccordancewiththeprinciplessetforthinTitleXVIIIAand
7373 17B,PublicLaw89-97,1965amendmentstothefederalSocialSecurityAct(42U.S.C.Section
7474 18301,etseq.),buttheMOHealthNetdivisionmayevaluateoutpatienthospitalservices
7575 19renderedunderthissectionanddenypaymentforserviceswhicharedeterminedbytheMO
7676 20HealthNetdivisionnottobemedicallynecessary,inaccordancewithfederallawand
7777 21regulations;
7878 22 (3)LaboratoryandX-rayservices;
7979 23 (4)Nursinghomeservicesforparticipants,excepttopersonswithmorethanfive
8080 24hundredthousanddollarsequityintheirhomeorexceptforpersonsinaninstitutionfor
8181 25mentaldiseaseswhoareundertheageofsixty-fiveyears,whenresidinginahospitallicensed
8282 26bythedepartmentofhealthandseniorservicesoranursinghomelicensedbythedepartment
8383 27ofhealthandseniorservicesorappropriatelicensingauthorityofotherstatesorgovernment-
8484 28ownedand-operatedinstitutionswhicharedeterminedtoconformtostandardsequivalentto
8585 29licensingrequirementsinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section301,
8686 30etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmayrecognize
8787 31throughitspaymentmethodologyfornursingfacilitiesthosenursingfacilitieswhichservea
8888 32highvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhendeterminingthe
8989 33amountofthebenefitpaymentstobemadeonbehalfofpersonsundertheageoftwenty-one
9090 34inanursingfacilitymayconsidernursingfacilitiesfurnishingcaretopersonsundertheageof
9191 35twenty-oneasaclassificationseparatefromothernursingfacilities;
9292 36 (5)Nursinghomecostsforparticipantsreceivingbenefitpaymentsundersubdivision
9393 37(4)ofthissubsectionforthosedays,whichshallnotexceedtwelveperanyperiodofsix
9494 38consecutivemonths,duringwhichtheparticipantisonatemporaryleaveofabsencefromthe
9595 39hospitalornursinghome,providedthatnosuchparticipantshallbeallowedatemporary
9696 40leaveofabsenceunlessitisspecificallyprovidedforinhisorherplanofcare.Asusedin
9797 41thissubdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftime
9898 42duringwhichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheor
9999 43sheisvisitingafriendorrelative;
100100 44 (6)Physicians'services,whetherfurnishedintheoffice,home,hospital,nursing
101101 45home,orelsewhere,provided,thatnofundsshallbeexpendedtoanyabortionfacility,as
102102 HB1589 3 46definedinsection188.015,ortoanyaffiliate,asdefinedinsection188.015,ofsuchabortion
103103 47facility;
104104 48 (7)Subjecttoappropriation,uptotwentyvisitsperyearforserviceslimitedto
105105 49examinations,diagnoses,adjustments,andmanipulationsandtreatmentsofmalpositioned
106106 50articulationsandstructuresofthebodyprovidedbylicensedchiropracticphysicians
107107 51practicingwithintheirscopeofpractice.Nothinginthissubdivisionshallbeinterpretedto
108108 52otherwiseexpandMOHealthNetservices;
109109 53 (8)Drugsandmedicineswhenprescribedbyalicensedphysician,dentist,podiatrist,
110110 54oranadvancedpracticeregisterednurse;exceptthatnopaymentfordrugsandmedicines
111111 55prescribedonandafterJanuary1,2006,byalicensedphysician,dentist,podiatrist,oran
112112 56advancedpracticeregisterednursemaybemadeonbehalfofanypersonwhoqualifiesfor
113113 57prescriptiondrugcoverageundertheprovisionsofP.L.108-173;
114114 58 (9)Emergencyambulanceservicesand,effectiveJanuary1,1990,medically
115115 59necessarytransportationtoscheduled,physician-prescribednonelectivetreatments;
116116 60 (10)Earlyandperiodicscreeninganddiagnosisofindividualswhoareundertheage
117117 61oftwenty-onetoascertaintheirphysicalormentaldefects,andhealthcare,treatment,and
118118 62othermeasurestocorrectoramelioratedefectsandchronicconditionsdiscoveredthereby.
119119 63SuchservicesshallbeprovidedinaccordancewiththeprovisionsofSection6403ofP.L.
120120 64101-239andfederalregulationspromulgatedthereunder;
121121 65 (11)Homehealthcareservices;
122122 66 (12)Familyplanningasdefinedbyfederalrulesandregulations;provided,thatno
123123 67fundsshallbeexpendedtoanyabortionfacility,asdefinedinsection188.015,ortoany
124124 68affiliate,asdefinedinsection188.015,ofsuchabortionfacility;andfurtherprovided,
125125 69however,thatsuchfamilyplanningservicesshallnotincludeabortionsoranyabortifacient
126126 70drugordevicethatisusedforthepurposeofinducinganabortionunlesssuchabortionsare
127127 71certifiedinwritingbyaphysiciantotheMOHealthNetagencythat,inthephysician's
128128 72professionaljudgment,thelifeofthemotherwouldbeendangeredifthefetuswerecarriedto
129129 73term;
130130 74 (13)Inpatientpsychiatrichospitalservicesforindividualsunderagetwenty-oneas
131131 75definedinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396d,etseq.);
132132 76 (14)Outpatientsurgicalprocedures,includingpresurgicaldiagnosticservices
133133 77performedinambulatorysurgicalfacilitieswhicharelicensedbythedepartmentofhealth
134134 78andseniorservicesofthestateofMissouri;except,thatsuchoutpatientsurgicalservicesshall
135135 79notincludepersonswhoareeligibleforcoverageunderPartBofTitleXVIII,PublicLaw89-
136136 8097,1965amendmentstothefederalSocialSecurityAct,asamended,ifexclusionofsuch
137137 81personsispermittedunderTitleXIX,PublicLaw89-97,1965amendmentstothefederal
138138 82SocialSecurityAct,asamended;
139139 HB1589 4 83 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha
140140 84person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea
141141 85persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor
142142 86residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal
143143 87careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho
144144 88isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin
145145 89accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible
146146 90toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire
147147 91placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable
148148 92forpersonalcareservicesshallnotexceedforanyoneparticipantonehundredpercentofthe
149149 93averagestatewidechargeforcareandtreatmentinanintermediatecarefacilityfora
150150 94comparableperiodoftime.Suchservices,whendeliveredinaresidentialcarefacilityor
151151 95assistedlivingfacilitylicensedunderchapter198,shallbeauthorizedonatierlevelbasedon
152152 96theservicestheresidentrequiresandthefrequencyoftheservices.Aresidentofsuchfacility
153153 97whoqualifiesforassistanceundersection208.030shall,ataminimum,ifprescribedbya
154154 98physician,qualifyforthetierlevelwiththefewestservices.Theratepaidtoprovidersfor
155155 99eachtierofserviceshallbesetsubjecttoappropriations.Subjecttoappropriations,each
156156 100residentofsuchfacilitywhoqualifiesforassistanceundersection208.030andmeetsthe
157157 101levelofcarerequiredinthissectionshall,ataminimum,ifprescribedbyaphysician,be
158158 102authorizeduptoonehourofpersonalcareservicesperday.Authorizedunitsofpersonalcare
159159 103servicesshallnotbereducedortierlevelloweredunlessanorderapprovingsuchreductionor
160160 104loweringisobtainedfromtheresident'spersonalphysician.Suchauthorizedunitsofpersonal
161161 105careservicesortierlevelshallbetransferredwithsuchresidentifheorshetransfersto
162162 106anothersuchfacility.Suchprovisionshallterminateuponreceiptofrelevantwaiversfrom
163163 107thefederalDepartmentofHealthandHumanServices.IftheCentersforMedicareand
164164 108MedicaidServicesdeterminesthatsuchprovisiondoesnotcomplywiththestateplan,this
165165 109provisionshallbenullandvoid.TheMOHealthNetdivisionshallnotifytherevisorof
166166 110statutesastowhethertherelevantwaiversareapprovedoradeterminationofnoncompliance
167167 111ismade;
168168 112 (16)Mentalhealthservices.Thestateplanforprovidingmedicalassistanceunder
169169 113TitleXIXoftheSocialSecurityAct,42U.S.C.Section301,asamended,shallincludethe
170170 114followingmentalhealthserviceswhensuchservicesareprovidedbycommunitymental
171171 115healthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythedepartment
172172 116ofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrugabusefacility
173173 117orasachild-servingagencywithinthecomprehensivechildren'smentalhealthservicesystem
174174 118establishedinsection630.097.Thedepartmentofmentalhealthshallestablishby
175175 119administrativerulethedefinitionandcriteriafordesignationasacommunitymentalhealth
176176 HB1589 5 120facilityandfordesignationasanalcoholanddrugabusefacility.Suchmentalhealthservices
177177 121shallinclude:
178178 122 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
179179 123rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
180180 124settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
181181 125established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
182182 126apartofclientservicesmanagement;
183183 127 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
184184 128rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
185185 129settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
186186 130established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
187187 131apartofclientservicesmanagement;
188188 132 (c)Rehabilitativementalhealthandalcoholanddrugabuseservicesincludinghome
189189 133andcommunity-basedpreventive,diagnostic,therapeutic,rehabilitative,andpalliative
190190 134interventionsrenderedtoindividualsinanindividualorgroupsettingbyamentalhealth
191191 135oralcoholanddrugabuseprofessionalinaccordancewithaplanoftreatmentappropriately
192192 136established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
193193 137apartofclientservicesmanagement.Asusedinthissection,mentalhealthprofessionaland
194194 138alcoholanddrugabuseprofessionalshallbedefinedbythedepartmentofmentalhealth
195195 139pursuanttodulypromulgatedrules.Withrespecttoservicesestablishedbythissubdivision,
196196 140thedepartmentofsocialservices,MOHealthNetdivision,shallenterintoanagreementwith
197197 141thedepartmentofmentalhealth.Matchingfundsforoutpatientmentalhealthservices,clinic
198198 142mentalhealthservices,andrehabilitationservicesformentalhealthandalcoholanddrug
199199 143abuseshallbecertifiedbythedepartmentofmentalhealthtotheMOHealthNetdivision.
200200 144Theagreementshallestablishamechanismforthejointimplementationoftheprovisionsof
201201 145thissubdivision.Inaddition,theagreementshallestablishamechanismbywhichratesfor
202202 146servicesmaybejointlydeveloped;
203203 147 (17)SuchadditionalservicesasdefinedbytheMOHealthNetdivisiontobe
204204 148furnishedunderwaiversoffederalstatutoryrequirementsasprovidedforandauthorizedby
205205 149thefederalSocialSecurityAct(42U.S.C.Section301,etseq.)subjecttoappropriationbythe
206206 150generalassembly;
207207 151 (18)Theservicesofanadvancedpracticeregisterednursewithacollaborative
208208 152practiceagreementtotheextentthatsuchservicesareprovidedinaccordancewithchapters
209209 153334and335,andregulationspromulgatedthereunder;
210210 154 (19)Nursinghomecostsforparticipantsreceivingbenefitpaymentsunder
211211 155subdivision(4)ofthissubsectiontoreserveabedfortheparticipantinthenursinghome
212212 HB1589 6 156duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich
213213 157cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision:
214214 158 (a)Theprovisionsofthissubdivisionshallapplyonlyif:
215215 159 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO
216216 160HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto
217217 161thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis
218218 162admittedtothehospital;and
219219 163 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated
220220 164stayofthreedaysorless;
221221 165 (b)Thepaymenttobemadeunderthissubdivisionshallbeprovidedforamaximum
222222 166ofthreedaysperhospitalstay;
223223 167 (c)Foreachdaythatnursinghomecostsarepaidonbehalfofaparticipantunderthis
224224 168subdivisionduringanyperiodofsixconsecutivemonthssuchparticipantshall,duringthe
225225 169sameperiodofsixconsecutivemonths,beineligibleforpaymentofnursinghomecostsof
226226 170twootherwiseavailabletemporaryleaveofabsencedaysprovidedundersubdivision(5)of
227227 171thissubsection;and
228228 172 (d)Theprovisionsofthissubdivisionshallnotapplyunlessthenursinghome
229229 173receivesnoticefromtheparticipantortheparticipant'sresponsiblepartythattheparticipant
230230 174intendstoreturntothenursinghomefollowingthehospitalstay.Ifthenursinghomereceives
231231 175suchnotificationandallotherprovisionsofthissubsectionhavebeensatisfied,thenursing
232232 176homeshallprovidenoticetotheparticipantortheparticipant'sresponsiblepartypriorto
233233 177releaseofthereservedbed;
234234 178 (20)Prescribedmedicallynecessarydurablemedicalequipment.Anelectronicweb-
235235 179basedpriorauthorizationsystemusingbestmedicalevidenceandcareandtreatment
236236 180guidelinesconsistentwithnationalstandardsshallbeusedtoverifymedicalneed;
237237 181 (21)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
238238 182coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
239239 183inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
240240 184medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
241241 185physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
242242 186psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
243243 187stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
244244 188participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
245245 189paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
246246 190nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
247247 191rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
248248 HB1589 7 192facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
249249 193(OmnibusBudgetReconciliationActof1989);
250250 194 (22)Prescribedmedicallynecessarydentalservices.Suchservicesshallbesubjectto
251251 195appropriations.Anelectronicweb-basedpriorauthorizationsystemusingbestmedical
252252 196evidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshallbeusedto
253253 197verifymedicalneed;
254254 198 (23)Prescribedmedicallynecessaryoptometricservices.Suchservicesshallbe
255255 199subjecttoappropriations.Anelectronicweb-basedpriorauthorizationsystemusingbest
256256 200medicalevidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshall
257257 201beusedtoverifymedicalneed;
258258 202 (24)Bloodclottingproducts-relatedservices.Forpersonsdiagnosedwithableeding
259259 203disorder,asdefinedinsection338.400,reliantonbloodclottingproducts,asdefinedin
260260 204section338.400,suchservicesinclude:
261261 205 (a)Homedeliveryofbloodclottingproductsandancillaryinfusionequipmentand
262262 206supplies,includingtheemergencydeliveriesoftheproductwhenmedicallynecessary;
263263 207 (b)Medicallynecessaryancillaryinfusionequipmentandsuppliesrequiredto
264264 208administerthebloodclottingproducts;and
265265 209 (c)Assessmentsconductedintheparticipant'shomebyapharmacist,nurse,orlocal
266266 210homehealthcareagencytrainedinbleedingdisorderswhendeemednecessarybythe
267267 211participant'streatingphysician;
268268 212 (25)Subjecttoappropriationsandnecessaryfederalapproval,geneticscreening
269269 213forpediatricrarediseases.Suchscreeningshallinclude:
270270 214 (a)Rapidwholegenomesequencingininpatientsettingsforpatientswhoare
271271 215undertwenty-twoyearsofage;whohaveacomplexoracuteillnessofunknownorigin
272272 216notattributedtoenvironmentalfactors,toxicingestion,infectionwithanormal
273273 217response,ortrauma;andforwhomthetreatinghealthcareproviderdeterminesthatan
274274 218immediatemoleculardiagnosisisnecessarytoprovideclinicaldecision-making;and
275275 219 (b)Biomarkertestinginoutpatientcaresettingsforthepurposesofdiagnosis,
276276 220treatment,appropriatemanagement,orongoingmonitoringofaparticipant'sdiseaseor
277277 221conditiontoguidetreatmentdecisionsifdeemedmedicallynecessary.Testingmaybe
278278 222medicallynecessaryifthetestingisclinicallyappropriateasdeemedbythetreating
279279 223healthcareprovidertoguidetreatment,thefindingsofthetestmaydirectlyimpactthe
280280 224participant'streatmentplan,andthepatientpresentscomplexorunexplained
281281 225symptomsconsistentwithapotentialgeneticetiology.Thereshallbenoage
282282 226restrictiononbiomarkertestinginoutpatientsettings.
283283 227
284284 HB1589 8 228Thedepartmentofsocialservicesshallseekanynecessarywaiversorstateplan
285285 229amendmentsfromtheCentersforMedicareandMedicaidServicestoimplementthe
286286 230provisionsofthissubdivision;
287287 231 (26)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter,
288288 232reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred
289289 233percentoftheMedicarereimbursementratesandcomparedtotheaveragedental
290290 234reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet
291291 235divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve
292292 236paritywithMedicarereimbursementratesandforthird-partypayoraveragedental
293293 237reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall
294294 238includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete
295295 239thefour-yearplandevelopedunderthissubdivision.
296296 240 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof
297297 241thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe
298298 242madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas
299299 243definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided,
300300 244forthefollowing:
301301 245 (1)Dentalservices;
302302 246 (2)Servicesofpodiatristsasdefinedinsection330.010;
303303 247 (3)Optometricservicesasdescribedinsection336.010;
304304 248 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,hearing
305305 249aids,andwheelchairs;
306306 250 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
307307 251coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
308308 252inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
309309 253medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
310310 254physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
311311 255psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
312312 256stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
313313 257participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
314314 258paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
315315 259nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
316316 260rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
317317 261facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
318318 262(OmnibusBudgetReconciliationActof1989);
319319 263 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa
320320 264coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation
321321 HB1589 9 265servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated
322322 266treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary
323323 267assessmentdesignedtorestoreanindividualtoanoptimallevelofphysical,cognitive,and
324324 268behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe
325325 269definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility,
326326 270benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis
327327 271definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision
328328 272shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof
329329 273chapter536and,ifapplicable,section536.028.Thissectionandchapter536are
330330 274nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter
331331 275536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently
332332 276heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor
333333 277adoptedafterAugust28,2005,shallbeinvalidandvoid.
334334 278 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet
335335 279benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter
336336 280July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall
337337 281coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of
338338 282subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner
339339 283authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.)
340340 284andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber
341341 285accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the
342342 286MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment
343343 287pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods
344344 288orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional
345345 289paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein,
346346 290ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade
347347 291byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby
348348 292thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy
349349 293professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists.
350350 294Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A
351351 295providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired
352352 296payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan
353353 297individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder
354354 298thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona
355355 299historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor
356356 300payment.Aprovider,representative,employee,independentcontractor,oragentofa
357357 301pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection
358358 HB1589 10 302shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters
359359 303forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan
360360 304amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto
361361 305denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices
362362 306shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe
363363 307acceptabilityofdenyingservicesastheresultofunpaidco-payments.
364364 308 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom
365365 309participantsinordertomaintainprogramintegrity.
366366 310 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of
367367 311subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare
368368 312providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet
369369 313benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral
370370 314populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C.
371371 315Section1396aandfederalregulationspromulgatedthereunder.
372372 316 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded
373373 317healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection
374374 3186404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations
375375 319promulgatedthereunder.
376376 320 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification
377377 321andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen
378378 322whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe
379379 323specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe
380380 324departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe
381381 325requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder.
382382 326 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin
383383 327accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42
384384 328U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder.
385385 329 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein
386386 330ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation
387387 331intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat
388388 332wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42
389389 333U.S.C.Section1396a(a)(13)(C).
390390 334 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand
391391 335assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders.
392392 336 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata
393393 337shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof
394394 338determiningeligibilityunderthissection.
395395 HB1589 11 339 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor
396396 340applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe
397397 341interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO
398398 342HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected
399399 343MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof
400400 344theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall
401401 345entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis
402402 346providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany
403403 347paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent.
404404 348EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail
405405 349addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired
406406 350underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor
407407 351electronicmailtoeachprovider.
408408 352 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's
409409 353statutoryrequirementtopromulgaterulesunderchapter536.
410410 354 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral,
411411 355social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof
412412 356physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand
413413 357interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe
414414 358CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch
415415 359reimbursementshallincludepsychologists.
416416 360 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition
417417 361surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection
418418 362191.1720,forthepurposeofagendertransition.
419419 376.1270.1.Asusedinthissection,termsshallhavethemeaningsascribedto
420420 2theminsection376.1350,andthefollowingtermsmean:
421421 3 (1)"Biomarker",ameasurablemolecularcharacteristicthatmaybeevidenceof
422422 4raregeneticdisordersorabnormalbiologicalprocesses;
423423 5 (2)"Biomarkertesting",testingspecificallydesignedtodetectgeneticmarkers
424424 6forrarediseasesincluding,butnotlimitedto,exomesequencingandgenome
425425 7sequencing;
426426 8 (3)"Geneticcounseling",theprovisionandinterpretationofmedical
427427 9informationbasedonexpandingknowledgeofhumangenetics;
428428 10 (4)"Pediatricraredisease",ararediseasewithonsetprimarilyinchildhoodand
429429 11typicallygeneticinnature,affectingfewerthantwohundredthousandindividualsinthe
430430 12UnitedStates;
431431 HB1589 12 13 (5)"Rapidwholegenomesequencing"or"rWGS",ananalysisofaperson's
432432 14entirehumangenome,includingcodingandnoncodingregionsandmitochondrialDNA,
433433 15todetectdisease-causinggeneticchanges,providingpreliminarytestresultswithin
434434 16sevendaysofreceivingasampleandfinalresultswithinfifteendaysofreceivinga
435435 17sample.
436436 18 2.Forenrolleesreceivinghigh-acuityinpatientcare,including,butnotlimited
437437 19to,intensivecareorcareinneonatalunits,whomeetcriteriaforapediatricraredisease
438438 20suspectedtobegeneticinnature:
439439 21 (1)HealthbenefitplansshallcoverrWGSifcoverageforbiomarkertesting
440440 22wouldotherwiseberequiredundersubsection3ofthissectionand:
441441 23 (a)Theenrolleeisundertwenty-twoyearsofage;
442442 24 (b)Theenrolleehasacomplexoracuteillnessofunknownoriginnotattributed
443443 25toenvironmentalfactors,toxicingestion,infectionwithanormalresponse,ortrauma;
444444 26and
445445 27 (c)Thetreatingproviderdeterminesanimmediatemoleculardiagnosisis
446446 28necessarytoguideclinicaldecision-making;
447447 29 (2)ReimbursementforrWGSunderthissubsectionshallbemadeseparately
448448 30fromtheinpatientstay,allowingtheperforminglaboratorytobillseparatelyasifthe
449449 31testwereprovidedinanoutpatientsetting;and
450450 32 (3)Healthbenefitplansshallnotrequirepriorauthorizationforcoverage
451451 33requiredunderthissubsectionbutmayperformretrospectivereview.
452452 34 3.Forenrolleesmeetingcriteriaforapediatricrarediseasesuspectedtobe
453453 35geneticinnature:
454454 36 (1)Healthbenefitplansshallprovidecoverageforbiomarkertestingforthe
455455 37purposesofdiagnosis,treatment,management,orongoingmonitoringofanenrollee's
456456 38diseaseorconditioninordertoguidetreatmentdecisionsifmedicalandscientific
457457 39evidenceindicatesthebiomarkertestingmayprovideclinicalutilitytotheenrollee.
458458 40Suchmedicalandscientificevidenceincludes,butisnotlimitedto:
459459 41 (a)AlabeledindicationforatestapprovedorclearedbytheUnitedStatesFood
460460 42andDrugAdministration;
461461 43 (b)AnindicatedtestforadrugapprovedbytheUnitedStatesFoodandDrug
462462 44Administration;
463463 45 (c)AnationalcoveragedeterminationmadebytheCentersforMedicareand
464464 46MedicaidServicesoralocalcoveragedeterminationmadebytheMedicare
465465 47administrativecontractor;or
466466 48 (d)Anationallyrecognizedclinicalpracticeguideline;
467467 HB1589 13 49 (2)Nohealthbenefitplanshallimposeanagerestrictiononcoverageunderthis
468468 50subsection;
469469 51 (3)Coverageunderthissectionmaybedeemedmedicallynecessaryifanyofthe
470470 52followingcircumstances,butnotlimitedthereto,apply:
471471 53 (a)Thetestisindicatedforararediseasediagnosisbasedonclinicalguidelines
472472 54orthetestisrecommendedasmedicallynecessarybythetreatingprovidertoguide
473473 55treatmentormanagementdecisions;
474474 56 (b)Thetestmayuncoveractionablefindingsthatwilldirectlyimpactthe
475475 57patient'streatmentplanorhelpclarifyabroaddifferentialdiagnosisthatwouldrequire
476476 58multipletestsifbiomarkertestingwereunavailable;or
477477 59 (c)Thepatientpresentscomplexorunexplainedsymptomsthatareconsistent
478478 60withapotentialgeneticetiologyincluding,butnotlimitedto:
479479 61 a.Unexplainedcongenitalabnormalitiesormulti-systemorganinvolvement;
480480 62 b.Abnormallaboratoryfindingsorchemistryprofilesconsistentwithagenetic
481481 63ormetabolicdisorder;
482482 64 c.Refractoryortreatment-resistantsymptomssuchasseizures,muscle
483483 65weakness,severeendocrinedisturbances,globaldevelopmentaldelay,orfailureto
484484 66thrive;
485485 67 d.Documentedfamilialhistoryofageneticallysuspectedconditionorrare
486486 68disease;or
487487 69 e.Adiagnosisofautism,cancer,orAlzheimer'sdiseaseorarelateddementia;
488488 70and
489489 71 (4)Coverageunderthissubsectionshallnotrequirepriorauthorizationifthe
490490 72testisorderedbyaclinicalspecialistwitharelevantspecialty.Noutilizationreview
491491 73entityshallrevoke,limit,condition,orotherwiserestrictapriorauthorizationfor
492492 74coverageunderthissubsection,providedthepatientisanenrolleeofthehealthbenefit
493493 75plan.
494494 76 4.Coverageunderthissectionshallnotbedeniedonthebasisofthetestbeing
495495 77experimentalorinvestigationalifthetestmeetsestablishedclinicalguidelinesoris
496496 78recommendedbyarecognizedmedicalsociety.
497497 79 5.Coverageunderthissectionshallincludegeneticcounseling,includingboth
498498 80pretestandposttestgeneticcounseling.
499499 81 6.Healthcarriersshallmaintain,accessibleontheirpublicwebsites,up-to-date
500500 82policiesoncoveredgenomicandbiomarkertests,includingthecriteriaformedical
501501 83necessity.
502502 HB1589 14 84 7.Testingcoveredunderthissectionshallbeperformedbyalaboratorycertified
503503 85bytheCentersforMedicareandMedicaidServicesasmeetingthestandardsofthe
504504 86ClinicalLaboratoryImprovementAmendmentsof1988(CLIA).
505505 87 8.Thissectionshallapplytohealthbenefitplansdelivered,issuedfordelivery,
506506 88continued,orrenewedonorafterJanuary1,2026.
507507 âś”
508508 HB1589 15