FIRSTREGULARSESSION
HOUSEBILLNO.251
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVEBOSLEY.
0668H.01I DANARADEMANMILLER,ChiefClerk
ANACT
Torepealsections208.152and208.662,RSMo,andtoenactinlieuthereofthreenew
sectionsrelatingtohealthinsurancecoverageforchildbirtheducation.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Sections208.152and208.662,RSMo,arerepealedandthreenewsections
2enactedinlieuthereof,tobeknownassections208.152,208.662,and376.1213,toreadas
3follows:
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
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 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.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
40leaveofabsenceunlessitisspecificallyprovidedforinhisorherplanofcare.Asusedin
41thissubdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftime
42duringwhichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheor
43sheisvisitingafriendorrelative;
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;
HB251 2 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.
63SuchservicesshallbeprovidedinaccordancewiththeprovisionsofSection6403of[P.L.]
64Pub.L.101-239(42U.S.C.Sections1396aand1396d),asamended,andfederal
65regulationspromulgatedthereunder;
66 (11)Homehealthcareservices;
67 (12)Familyplanningasdefinedbyfederalrulesandregulations;provided,thatno
68fundsshallbeexpendedtoanyabortionfacility,asdefinedinsection188.015,ortoany
69affiliate,asdefinedinsection188.015,ofsuchabortionfacility;andfurtherprovided,
70however,thatsuchfamilyplanningservicesshallnotincludeabortionsoranyabortifacient
71drugordevicethatisusedforthepurposeofinducinganabortionunlesssuchabortionsare
72certifiedinwritingbyaphysiciantotheMOHealthNetagencythat,inthephysician's
73professionaljudgment,thelifeofthemotherwouldbeendangeredifthefetuswerecarriedto
74term;
75 (13)Inpatientpsychiatrichospitalservicesforindividualsunderagetwenty-oneas
76definedinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396d,etseq.);
77 (14)Outpatientsurgicalprocedures,includingpresurgicaldiagnosticservices
78performedinambulatorysurgicalfacilitieswhicharelicensedbythedepartmentofhealth
79andseniorservicesofthestateofMissouri;except,thatsuchoutpatientsurgicalservicesshall
80notincludepersonswhoareeligibleforcoverageunderPartBofTitleXVIII,PublicLaw89-
8197,1965amendmentstothefederalSocialSecurityAct,asamended,ifexclusionofsuch
82personsispermittedunderTitleXIX,PublicLaw89-97,1965amendmentstothefederal
83SocialSecurityAct,asamended;
84 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha
85person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea
86persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor
87residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal
88careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho
89isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin
HB251 3 90accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible
91toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire
92placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable
93forpersonalcareservicesshallnotexceedforanyoneparticipantonehundredpercentofthe
94averagestatewidechargeforcareandtreatmentinanintermediatecarefacilityfora
95comparableperiodoftime.Suchservices,whendeliveredinaresidentialcarefacilityor
96assistedlivingfacilitylicensedunderchapter198,shallbeauthorizedonatierlevelbasedon
97theservicestheresidentrequiresandthefrequencyoftheservices.Aresidentofsuchfacility
98whoqualifiesforassistanceundersection208.030shall,ataminimum,ifprescribedbya
99physician,qualifyforthetierlevelwiththefewestservices.Theratepaidtoprovidersfor
100eachtierofserviceshallbesetsubjecttoappropriations.Subjecttoappropriations,each
101residentofsuchfacilitywhoqualifiesforassistanceundersection208.030andmeetsthe
102levelofcarerequiredinthissectionshall,ataminimum,ifprescribedbyaphysician,be
103authorizeduptoonehourofpersonalcareservicesperday.Authorizedunitsofpersonalcare
104servicesshallnotbereducedortierlevelloweredunlessanorderapprovingsuchreductionor
105loweringisobtainedfromtheresident'spersonalphysician.Suchauthorizedunitsofpersonal
106careservicesortierlevelshallbetransferredwithsuchresidentifheorshetransfersto
107anothersuchfacility.Suchprovisionshallterminateuponreceiptofrelevantwaiversfrom
108thefederalDepartmentofHealthandHumanServices.IftheCentersforMedicareand
109MedicaidServicesdeterminesthatsuchprovisiondoesnotcomplywiththestateplan,this
110provisionshallbenullandvoid.TheMOHealthNetdivisionshallnotifytherevisorof
111statutesastowhethertherelevantwaiversareapprovedoradeterminationofnoncompliance
112ismade;
113 (16)Mentalhealthservices.Thestateplanforprovidingmedicalassistanceunder
114TitleXIXoftheSocialSecurityAct,42U.S.C.Section[301]1396etseq.,asamended,shall
115includethefollowingmentalhealthserviceswhensuchservicesareprovidedbycommunity
116mentalhealthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythe
117departmentofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrug
118abusefacilityorasachild-servingagencywithinthecomprehensivechildren'smentalhealth
119servicesystemestablishedinsection630.097.Thedepartmentofmentalhealthshall
120establishbyadministrativerulethedefinitionandcriteriafordesignationasacommunity
121mentalhealthfacilityandfordesignationasanalcoholanddrugabusefacility.Suchmental
122healthservicesshallinclude:
123 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
124rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
125settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
HB251 4 126established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
127apartofclientservicesmanagement;
128 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
129rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
130settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
131established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
132apartofclientservicesmanagement;
133 (c)Rehabilitativementalhealthandalcoholanddrugabuseservicesincludinghome
134andcommunity-basedpreventive,diagnostic,therapeutic,rehabilitative,andpalliative
135interventionsrenderedtoindividualsinanindividualorgroupsettingbyamentalhealth
136oralcoholanddrugabuseprofessionalinaccordancewithaplanoftreatmentappropriately
137established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
138apartofclientservicesmanagement.Asusedinthissection,mentalhealthprofessionaland
139alcoholanddrugabuseprofessionalshallbedefinedbythedepartmentofmentalhealth
140pursuanttodulypromulgatedrules.Withrespecttoservicesestablishedbythissubdivision,
141thedepartmentofsocialservices,MOHealthNetdivision,shallenterintoanagreementwith
142thedepartmentofmentalhealth.Matchingfundsforoutpatientmentalhealthservices,clinic
143mentalhealthservices,andrehabilitationservicesformentalhealthandalcoholanddrug
144abuseshallbecertifiedbythedepartmentofmentalhealthtotheMOHealthNetdivision.
145Theagreementshallestablishamechanismforthejointimplementationoftheprovisionsof
146thissubdivision.Inaddition,theagreementshallestablishamechanismbywhichratesfor
147servicesmaybejointlydeveloped;
148 (17)SuchadditionalservicesasdefinedbytheMOHealthNetdivisiontobe
149furnishedunderwaiversoffederalstatutoryrequirementsasprovidedforandauthorizedby
150thefederalSocialSecurityAct(42U.S.C.Section301,etseq.)subjecttoappropriationbythe
151generalassembly;
152 (18)Theservicesofanadvancedpracticeregisterednursewithacollaborative
153practiceagreementtotheextentthatsuchservicesareprovidedinaccordancewithchapters
154334and335,andregulationspromulgatedthereunder;
155 (19)Nursinghomecostsforparticipantsreceivingbenefitpaymentsunder
156subdivision(4)ofthissubsectiontoreserveabedfortheparticipantinthenursinghome
157duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich
158cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision:
159 (a)Theprovisionsofthissubdivisionshallapplyonlyif:
160 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO
161HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto
HB251 5 162thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis
163admittedtothehospital;and
164 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated
165stayofthreedaysorless;
166 (b)Thepaymenttobemadeunderthissubdivisionshallbeprovidedforamaximum
167ofthreedaysperhospitalstay;
168 (c)Foreachdaythatnursinghomecostsarepaidonbehalfofaparticipantunderthis
169subdivisionduringanyperiodofsixconsecutivemonthssuchparticipantshall,duringthe
170sameperiodofsixconsecutivemonths,beineligibleforpaymentofnursinghomecostsof
171twootherwiseavailabletemporaryleaveofabsencedaysprovidedundersubdivision(5)of
172thissubsection;and
173 (d)Theprovisionsofthissubdivisionshallnotapplyunlessthenursinghome
174receivesnoticefromtheparticipantortheparticipant'sresponsiblepartythattheparticipant
175intendstoreturntothenursinghomefollowingthehospitalstay.Ifthenursinghomereceives
176suchnotificationandallotherprovisionsofthissubsectionhavebeensatisfied,thenursing
177homeshallprovidenoticetotheparticipantortheparticipant'sresponsiblepartypriorto
178releaseofthereservedbed;
179 (20)Prescribedmedicallynecessarydurablemedicalequipment.Anelectronicweb-
180basedpriorauthorizationsystemusingbestmedicalevidenceandcareandtreatment
181guidelinesconsistentwithnationalstandardsshallbeusedtoverifymedicalneed;
182 (21)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
183coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
184inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
185medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
186physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
187psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
188stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
189participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
190paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
191nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
192rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
193facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
194(OmnibusBudgetReconciliationActof1989);
195 (22)Prescribedmedicallynecessarydentalservices.Suchservicesshallbesubjectto
196appropriations.Anelectronicweb-basedpriorauthorizationsystemusingbestmedical
197evidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshallbeusedto
198verifymedicalneed;
HB251 6 199 (23)Prescribedmedicallynecessaryoptometricservices.Suchservicesshallbe
200subjecttoappropriations.Anelectronicweb-basedpriorauthorizationsystemusingbest
201medicalevidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshall
202beusedtoverifymedicalneed;
203 (24)Bloodclottingproducts-relatedservices.Forpersonsdiagnosedwithableeding
204disorder,asdefinedinsection338.400,reliantonbloodclottingproducts,asdefinedin
205section338.400,suchservicesinclude:
206 (a)Homedeliveryofbloodclottingproductsandancillaryinfusionequipmentand
207supplies,includingtheemergencydeliveriesoftheproductwhenmedicallynecessary;
208 (b)Medicallynecessaryancillaryinfusionequipmentandsuppliesrequiredto
209administerthebloodclottingproducts;and
210 (c)Assessmentsconductedintheparticipant'shomebyapharmacist,nurse,orlocal
211homehealthcareagencytrainedinbleedingdisorderswhendeemednecessarybythe
212participant'streatingphysician;
213 (25)Childbirtheducationclassesforpregnantwomenandasupportperson;
214 (26)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter,
215reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred
216percentoftheMedicarereimbursementratesandcomparedtotheaveragedental
217reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet
218divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve
219paritywithMedicarereimbursementratesandforthird-partypayoraveragedental
220reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall
221includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete
222thefour-yearplandevelopedunderthissubdivision.
223 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof
224thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe
225madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas
226definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided,
227forthefollowing:
228 (1)Dentalservices;
229 (2)Servicesofpodiatristsasdefinedinsection330.010;
230 (3)Optometricservicesasdescribedinsection336.010;
231 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,hearing
232aids,andwheelchairs;
233 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
234coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
235inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
HB251 7 236medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
237physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
238psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
239stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
240participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
241paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
242nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
243rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
244facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
245(OmnibusBudgetReconciliationActof1989);
246 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa
247coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation
248servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated
249treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary
250assessmentdesignedtorestoreanindividualtoanoptimallevelofphysical,cognitive,and
251behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe
252definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility,
253benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis
254definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision
255shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof
256chapter536and,ifapplicable,section536.028.Thissectionandchapter536are
257nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter
258536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently
259heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor
260adoptedafterAugust28,2005,shallbeinvalidandvoid.
261 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet
262benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter
263July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall
264coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of
265subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner
266authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.)
267andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber
268accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the
269MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment
270pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods
271orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional
272paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein,
HB251 8 273ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade
274byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby
275thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy
276professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists.
277Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A
278providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired
279payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan
280individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder
281thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona
282historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor
283payment.Aprovider,representative,employee,independentcontractor,oragentofa
284pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection
285shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters
286forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan
287amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto
288denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices
289shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe
290acceptabilityofdenyingservicesastheresultofunpaidco-payments.
291 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom
292participantsinordertomaintainprogramintegrity.
293 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of
294subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare
295providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet
296benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral
297populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C.
298Section1396aandfederalregulationspromulgatedthereunder.
299 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded
300healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection
3016404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations
302promulgatedthereunder.
303 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification
304andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen
305whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe
306specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe
307departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe
308requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder.
HB251 9 309 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin
310accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42
311U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder.
312 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein
313ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation
314intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat
315wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42
316U.S.C.Section1396a(a)(13)(C).
317 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand
318assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders.
319 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata
320shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof
321determiningeligibilityunderthissection.
322 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor
323applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe
324interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO
325HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected
326MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof
327theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall
328entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis
329providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany
330paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent.
331EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail
332addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired
333underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor
334electronicmailtoeachprovider.
335 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's
336statutoryrequirementtopromulgaterulesunderchapter536.
337 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral,
338social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof
339physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand
340interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe
341CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch
342reimbursementshallincludepsychologists.
343 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition
344surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection
345191.1720,forthepurposeofagendertransition.
HB251 10 346 16.Thedepartmentofsocialservicesshallstudytheimpactthatthechildbirth
347educationclassesprovidedundersubdivision(25)ofsubsection1ofthissectionhaveon
348infantandmaternalmortalityamongpregnantwomenofcolor.Thedepartmentof
349socialservicesshallsubmitareporttothegeneralassemblywiththeresultsofthestudy
350beforeJanuary1,2028.
208.662.1.Thereisherebyestablishedwithinthedepartmentofsocialservicesthe
2"Show-MeHealthyBabiesProgram"asaseparatechildren'shealthinsuranceprogram
3(CHIP)foranylow-incomeunbornchild.Theprogramshallbeestablishedunderthe
4authorityofTitleXXIofthefederalSocialSecurityAct,theStateChildren'sHealth
5InsuranceProgram,asamended,and42CFR457.1.
6 2.Foranunbornchildtobeenrolledintheshow-mehealthybabiesprogram,hisor
7hermothershallnotbeeligibleforcoverageunderTitleXIXofthefederalSocialSecurity
8Act,theMedicaidprogram,asitisadministeredbythestate,andshallnothaveaccessto
9affordableemployer-subsidizedhealthcareinsuranceorotheraffordablehealthcarecoverage
10thatincludescoveragefortheunbornchild.Inaddition,theunbornchildshallbeinafamily
11withincomeeligibilityofnomorethanthreehundredpercentofthefederalpovertylevel,or
12theequivalentmodifiedadjustedgrossincome,unlesstheincomeeligibilityissetlowerby
13thegeneralassemblythroughappropriations.Incalculatingfamilysizeasitrelatestoincome
14eligibility,thefamilyshallinclude,inadditiontootherfamilymembers,theunbornchild,or
15inthecaseofamotherwithamultiplepregnancy,allunbornchildren.
16 3.Coverageforanunbornchildenrolledintheshow-mehealthybabiesprogram
17shallincludeallprenatalcareandpregnancy-relatedservicesthatbenefitthehealthofthe
18unbornchildandthatpromotehealthylabor,delivery,andbirth, includingchildbirth
19educationclasses. Coverageneednotincludeservicesthataresolelyforthebenefitofthe
20pregnantmother,thatareunrelatedtomaintainingorpromotingahealthypregnancy,andthat
21providenobenefittotheunbornchild.However,thedepartmentmayincludepregnancy-
22relatedassistanceasdefinedin42U.S.C.Section1397ll.
23 4.Thereshallbenowaitingperiodbeforeanunbornchildmaybeenrolledinthe
24show-mehealthybabiesprogram.Inaccordancewiththedefinitionofchildin42CFR
25457.10,coverageshallincludetheperiodfromconceptiontobirth.Thedepartmentshall
26developapresumptiveeligibilityprocedureforenrollinganunbornchild.Thereshallbe
27verificationofthepregnancy.
28 5.Coverageforthechildshallcontinueforuptooneyearafterbirth,unlessotherwise
29prohibitedbylaworunlessotherwiselimitedbythegeneralassemblythroughappropriations.
30 6.(1)Pregnancy-relatedandpostpartumcoverageforthemothershallbeginonthe
31daythepregnancyendsandextendthroughthelastdayofthemonththatincludesthesixtieth
32dayafterthepregnancyends,unlessotherwiseprohibitedbylaworunlessotherwiselimited
HB251 11 33bythegeneralassemblythroughappropriations.Thedepartmentmayincludepregnancy-
34relatedassistanceasdefinedin42U.S.C.Section1397ll.
35 (2)(a)Subjecttoapprovalofanynecessarystateplanamendmentsorwaivers,
36beginningonJuly6,2023,motherseligibletoreceivecoverageunderthissectionshall
37receivemedicalassistancebenefitsduringthepregnancyandduringthetwelve-monthperiod
38thatbeginsonthelastdayofthewoman'spregnancyandendsonthelastdayofthemonthin
39whichsuchtwelve-monthperiodends,consistentwiththeprovisionsof42U.S.C.Section
401397gg(e)(1)(J).Thedepartmentshallseekanynecessarystateplanamendmentsorwaivers
41toimplementtheprovisionsofthissubdivisionwhenthenumberofineligibleMOHealthNet
42participantsremovedfromtheprogramin2023pursuanttosection208.239exceedsthe
43projectednumberofbeneficiarieslikelytoenrollinbenefitsin2023underthissubdivision
44andsubdivision(28)ofsubsection1ofsection208.151,asdeterminedbythedepartment,by
45atleastonehundredindividuals.
46 (b)Theprovisionsofthissubdivisionshallremainineffectforanyperiodoftime
47duringwhichthefederalauthorityunder42U.S.C.Section1397gg(e)(1)(J),asamended,or
48anysuccessorstatutesorimplementingregulations,isineffect.
49 7.Thedepartmentshallprovidecoverageforanunbornchildenrolledintheshow-
50mehealthybabiesprograminthesamemannerinwhichthedepartmentprovidescoverage
51forthechildren'shealthinsuranceprogram(CHIP)inthecountyoftheprimaryresidenceof
52themother.
53 8.Thedepartmentshallprovideinformationabouttheshow-mehealthybabies
54programtomaternityhomesasdefinedinsection135.600,pregnancyresourcecentersas
55definedinsection135.630,andothersimilaragenciesandprogramsinthestatethatassist
56unbornchildrenandtheirmothers.Thedepartmentshallconsiderallowingsuchagenciesand
57programstoassistintheenrollmentofunbornchildrenintheprogram,andinmaking
58determinationsaboutpresumptiveeligibilityandverificationofthepregnancy.
59 9.WithinsixtydaysafterAugust28,2014,thedepartmentshallsubmitastateplan
60amendmentorseekanynecessarywaiversfromthefederalDepartmentofHealthandHuman
61Servicesrequestingapprovalfortheshow-mehealthybabiesprogram.
62 10.Atleastannually,thedepartmentshallprepareandsubmitareporttothe
63governor,thespeakerofthehouseofrepresentatives,andthepresidentprotemporeofthe
64senateanalyzingandprojectingthecostsavingsandbenefits,ifany,tothestate,counties,
65localcommunities,schooldistricts,lawenforcementagencies,correctionalcenters,health
66careproviders,employers,otherpublicandprivateentities,andpersonsbyenrollingunborn
67childrenintheshow-mehealthybabiesprogram.Theanalysisandprojectionofcostsavings
68andbenefits,ifany,mayincludebutneednotbelimitedto:
HB251 12 69 (1)Thehigherfederalmatchingrateforhavinganunbornchildenrolledintheshow-
70mehealthybabiesprogramversusthelowerfederalmatchingrateforapregnantwoman
71beingenrolledinMOHealthNetorotherfederalprograms;
72 (2)Theefficacyinprovidingservicestounbornchildrenthroughmanagedcare
73organizations,grouporindividualhealthinsuranceprovidersorpremiumassistance,or
74throughothernontraditionalarrangementsofprovidinghealthcare;
75 (3)Thechangeintheproportionofunbornchildrenwhoreceivecareinthefirst
76trimesterofpregnancyduetoalackofwaitingperiods,byallowingpresumptiveeligibility,
77orbyremovalofotherbarriers,andanyresultingorprojecteddecreaseinhealthproblems
78andotherproblemsforunbornchildrenandwomenthroughoutpregnancy;atlabor,delivery,
79andbirth;andduringinfancyandchildhood;
80 (4)Thechangeinhealthybehaviorsbypregnantwomen,suchasthecessationofthe
81useoftobacco,alcohol,illicitdrugs,orotherharmfulpractices,andanyresultingorprojected
82short-termandlong-termdecreaseinbirthdefects;poormotorskills;vision,speech,and
83hearingproblems;breathingandrespiratoryproblems;feedinganddigestiveproblems;and
84otherphysical,mental,educational,andbehavioralproblems;and
85 (5)Thechangeininfantandmaternalmortality,pretermbirthsandlowbirthweight
86babiesandanyresultingorprojecteddecreaseinshort-termandlong-termmedicalandother
87interventions.
88 11.Theshow-mehealthybabiesprogramshallnotbedeemedanentitlement
89program,butinsteadshallbesubjecttoafederalallotmentorotherfederalappropriationsand
90matchingstateappropriations.
91 12.Nothinginthissectionshallbeconstruedasobligatingthestatetocontinuethe
92show-mehealthybabiesprogramiftheallotmentorpaymentsfromthefederalgovernment
93endorarenotsufficientfortheprogramtooperate,orifthegeneralassemblydoesnot
94appropriatefundsfortheprogram.
95 13.NothinginthissectionshallbeconstruedasexpandingMOHealthNetor
96fulfillingamandateimposedbythefederalgovernmentonthestate.
376.1213.Eachentityofferingindividualandgrouphealthinsurancepolicies
2providingcoverageonanexpense-incurredbasis,individualandgroupserviceor
3indemnitytypecontractsissuedbyanonprofitcorporation,individualandgroup
4servicecontractsissuedbyahealthmaintenanceorganization,allself-insuredgroup
5arrangementstotheextentnotpreemptedbyfederallaw,andallmanagedhealthcare
6deliveryentitiesofanytypeordescription,thataredelivered,issuedfordelivery,
HB251 13 7continued,orrenewedinthisstateonorafterJanuary1,2026,andprovidingfor
8maternitybenefits,shallprovidecoverageforchildbirtheducationclasses.
âś”
HB251 14