FIRSTREGULARSESSION
[PERFECTED]
HOUSECOMMITTEESUBSTITUTEFOR
HOUSEBILLNOS.177&469
103RDGENERALASSEMBLY
0167H.02P JOSEPHENGLER,ChiefClerk
ANACT
Torepealsection208.152,RSMo,andtoenactinlieuthereofonenewsectionrelatingtoMO
HealthNetcoverageofhearing-relateddevices.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Section208.152,RSMo,isrepealedandonenewsectionenactedinlieu
2thereof,tobeknownassection208.152,toreadasfollows:
208.152.1.MOHealthNetpaymentsshallbemadeonbehalfofthoseeligibleneedy
2personsasdescribedinsection208.151whoareunabletoprovideforitinwholeorinpart,
3withanypaymentstobemadeonthebasisofthereasonablecostofthecareorreasonable
4chargefortheservicesasdefinedanddeterminedbytheMOHealthNetdivision,unless
5otherwisehereinafterprovided,forthefollowing:
6 (1)Inpatienthospitalservices,excepttopersonsinaninstitutionformentaldiseases
7whoareundertheageofsixty-fiveyearsandovertheageoftwenty-oneyears;providedthat
8theMOHealthNetdivisionshallprovidethroughruleandregulationanexceptionprocessfor
9coverageofinpatientcostsinthosecasesrequiringtreatmentbeyondtheseventy-fifth
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
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 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.Section
30[301,] 1396etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmay
31recognizethroughitspaymentmethodologyfornursingfacilitiesthosenursingfacilities
32whichserveahighvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhen
33determiningtheamountofthebenefitpaymentstobemadeonbehalfofpersonsunderthe
34ageoftwenty-oneinanursingfacilitymayconsidernursingfacilitiesfurnishingcareto
35personsundertheageoftwenty-oneasaclassificationseparatefromothernursingfacilities;
36 (5)Nursinghomecostsforparticipantsreceivingbenefitpaymentsundersubdivision
37(4)ofthissubsectionforthosedays,whichshallnotexceedtwelveperanyperiodofsix
38consecutivemonths,duringwhichtheparticipantisonatemporaryleaveofabsencefromthe
39hospitalornursinghome,providedthatnosuchparticipantshallbeallowedatemporary
40leaveofabsenceunlessitisspecificallyprovidedforinhisplanofcare.Asusedinthis
41subdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftimeduring
42whichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheisvisiting
43afriendorrelative;
44 (6)Physicians'services,whetherfurnishedintheoffice,home,hospital,nursing
45home,orelsewhere,provided,thatnofundsshallbeexpendedtoanyabortionfacility,as
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
HCSHBs177&469 2 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;
83 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha
84person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea
85persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor
86residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal
87careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho
88isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin
89accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible
90toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire
91placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable
HCSHBs177&469 3 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.Section[301]1396etseq.,asamended,shall
114includethefollowingmentalhealthserviceswhensuchservicesareprovidedbycommunity
115mentalhealthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythe
116departmentofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrug
117abusefacilityorasachild-servingagencywithinthecomprehensivechildren'smentalhealth
118servicesystemestablishedinsection630.097.Thedepartmentofmentalhealthshall
119establishbyadministrativerulethedefinitionandcriteriafordesignationasacommunity
120mentalhealthfacilityandfordesignationasanalcoholanddrugabusefacility.Suchmental
121healthservicesshallinclude:
122 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
123rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
124settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
125established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
126apartofclientservicesmanagement;
127 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
128rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
HCSHBs177&469 4 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
156duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich
157cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision:
158 (a)Theprovisionsofthissubdivisionshallapplyonlyif:
159 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO
160HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto
161thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis
162admittedtothehospital;and
163 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated
164stayofthreedaysorless;
HCSHBs177&469 5 165 (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
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;
HCSHBs177&469 6 202 (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)Medicallynecessarycochlearimplantsandhearinginstruments,asdefined
213insection345.015,thatare:
214 (a)Prescribedbyanaudiologist,asdefinedinsection345.015;or
215 (b)Dispensedbyahearinginstrumentspecialist,asdefinedinsection346.010;
216 (26)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter,
217reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred
218percentoftheMedicarereimbursementratesandcomparedtotheaveragedental
219reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet
220divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve
221paritywithMedicarereimbursementratesandforthird-partypayoraveragedental
222reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall
223includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete
224thefour-yearplandevelopedunderthissubdivision.
225 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof
226thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe
227madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas
228definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided,
229forthefollowing:
230 (1)Dentalservices;
231 (2)Servicesofpodiatristsasdefinedinsection330.010;
232 (3)Optometricservicesasdescribedinsection336.010;
233 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,[hearing
234aids,] andwheelchairs;
235 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
236coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
237inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
238medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
HCSHBs177&469 7 239physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
240psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
241stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
242participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
243paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
244nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
245rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
246facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
247(OmnibusBudgetReconciliationActof1989);
248 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa
249coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation
250servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated
251treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary
252assessmentdesignedtorestoreanindividualtoanoptimallevelofphysical,cognitive,and
253behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe
254definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility,
255benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis
256definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision
257shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof
258chapter536and,ifapplicable,section536.028.Thissectionandchapter536are
259nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter
260536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently
261heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor
262adoptedafterAugust28,2005,shallbeinvalidandvoid.
263 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet
264benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter
265July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall
266coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of
267subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner
268authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.)
269andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber
270accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the
271MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment
272pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods
273orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional
274paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein,
275ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade
HCSHBs177&469 8 276byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby
277thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy
278professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists.
279Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A
280providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired
281payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan
282individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder
283thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona
284historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor
285payment.Aprovider,representative,employee,independentcontractor,oragentofa
286pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection
287shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters
288forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan
289amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto
290denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices
291shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe
292acceptabilityofdenyingservicesastheresultofunpaidco-payments.
293 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom
294participantsinordertomaintainprogramintegrity.
295 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of
296subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare
297providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet
298benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral
299populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C.
300Section1396aandfederalregulationspromulgatedthereunder.
301 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded
302healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection
3036404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations
304promulgatedthereunder.
305 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification
306andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen
307whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe
308specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe
309departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe
310requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder.
HCSHBs177&469 9 311 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin
312accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42
313U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder.
314 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein
315ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation
316intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat
317wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42
318U.S.C.Section1396a(a)(13)(C).
319 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand
320assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders.
321 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata
322shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof
323determiningeligibilityunderthissection.
324 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor
325applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe
326interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO
327HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected
328MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof
329theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall
330entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis
331providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany
332paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent.
333EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail
334addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired
335underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor
336electronicmailtoeachprovider.
337 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's
338statutoryrequirementtopromulgaterulesunderchapter536.
339 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral,
340social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof
341physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand
342interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe
343CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch
344reimbursementshallincludepsychologists.
HCSHBs177&469 10 345 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition
346surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection
347191.1720,forthepurposeofagendertransition.
âś”
HCSHBs177&469 11