| 1 | 1 | | FIRSTREGULARSESSION |
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| 2 | 2 | | HOUSEBILLNO.469 |
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| 3 | 3 | | 103RDGENERALASSEMBLY |
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| 4 | 4 | | INTRODUCEDBYREPRESENTATIVEDOLL. |
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| 5 | 5 | | 1608H.01I DANARADEMANMILLER,ChiefClerk |
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| 6 | 6 | | ANACT |
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| 7 | 7 | | Torepealsection208.152,RSMo,andtoenactinlieuthereofonenewsectionrelatingtoMO |
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| 8 | 8 | | HealthNetcoverageofhearing-relateddevices. |
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| 9 | 9 | | BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows: |
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| 10 | 10 | | SectionA.Section208.152,RSMo,isrepealedandonenewsectionenactedinlieu |
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| 11 | 11 | | 2thereof,tobeknownassection208.152,toreadasfollows: |
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| 12 | 12 | | 208.152.1.MOHealthNetpaymentsshallbemadeonbehalfofthoseeligibleneedy |
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| 13 | 13 | | 2personsasdescribedinsection208.151whoareunabletoprovideforitinwholeorinpart, |
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| 14 | 14 | | 3withanypaymentstobemadeonthebasisofthereasonablecostofthecareorreasonable |
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| 15 | 15 | | 4chargefortheservicesasdefinedanddeterminedbytheMOHealthNetdivision,unless |
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| 16 | 16 | | 5otherwisehereinafterprovided,forthefollowing: |
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| 17 | 17 | | 6 (1)Inpatienthospitalservices,excepttopersonsinaninstitutionformentaldiseases |
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| 18 | 18 | | 7whoareundertheageofsixty-fiveyearsandovertheageoftwenty-oneyears;providedthat |
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| 19 | 19 | | 8theMOHealthNetdivisionshallprovidethroughruleandregulationanexceptionprocessfor |
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| 20 | 20 | | 9coverageofinpatientcostsinthosecasesrequiringtreatmentbeyondtheseventy-fifth |
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| 21 | 21 | | 10percentileprofessionalactivitiesstudy(PAS)ortheMOHealthNetchildren'sdiagnosis |
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| 22 | 22 | | 11length-of-stayschedule;andprovidedfurtherthattheMOHealthNetdivisionshalltakeinto |
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| 23 | 23 | | 12accountthroughitspaymentsystemforhospitalservicesthesituationofhospitalswhich |
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| 24 | 24 | | 13serveadisproportionatenumberoflow-incomepatients; |
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| 25 | 25 | | 14 (2)Alloutpatienthospitalservices,paymentstherefortobeinamountswhich |
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| 26 | 26 | | 15representnomorethaneightypercentofthelesserofreasonablecostsorcustomarycharges |
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| 27 | 27 | | 16forsuchservices,determinedinaccordancewiththeprinciplessetforthinTitleXVIIIAand |
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| 28 | 28 | | 17B,PublicLaw89-97,1965amendmentstothefederalSocialSecurityAct(42U.S.C.Section |
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| 29 | 29 | | EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis |
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| 30 | 30 | | intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 18301,etseq.),buttheMOHealthNetdivisionmayevaluateoutpatienthospitalservices |
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| 31 | 31 | | 19renderedunderthissectionanddenypaymentforserviceswhicharedeterminedbytheMO |
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| 32 | 32 | | 20HealthNetdivisionnottobemedicallynecessary,inaccordancewithfederallawand |
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| 33 | 33 | | 21regulations; |
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| 34 | 34 | | 22 (3)LaboratoryandX-rayservices; |
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| 35 | 35 | | 23 (4)Nursinghomeservicesforparticipants,excepttopersonswithmorethanfive |
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| 36 | 36 | | 24hundredthousanddollarsequityintheirhomeorexceptforpersonsinaninstitutionfor |
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| 37 | 37 | | 25mentaldiseaseswhoareundertheageofsixty-fiveyears,whenresidinginahospitallicensed |
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| 38 | 38 | | 26bythedepartmentofhealthandseniorservicesoranursinghomelicensedbythedepartment |
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| 39 | 39 | | 27ofhealthandseniorservicesorappropriatelicensingauthorityofotherstatesorgovernment- |
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| 40 | 40 | | 28ownedand-operatedinstitutionswhicharedeterminedtoconformtostandardsequivalentto |
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| 41 | 41 | | 29licensingrequirementsinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section |
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| 42 | 42 | | 30[301,] 1396etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmay |
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| 43 | 43 | | 31recognizethroughitspaymentmethodologyfornursingfacilitiesthosenursingfacilities |
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| 44 | 44 | | 32whichserveahighvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhen |
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| 45 | 45 | | 33determiningtheamountofthebenefitpaymentstobemadeonbehalfofpersonsunderthe |
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| 46 | 46 | | 34ageoftwenty-oneinanursingfacilitymayconsidernursingfacilitiesfurnishingcareto |
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| 47 | 47 | | 35personsundertheageoftwenty-oneasaclassificationseparatefromothernursingfacilities; |
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| 48 | 48 | | 36 (5)Nursinghomecostsforparticipantsreceivingbenefitpaymentsundersubdivision |
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| 49 | 49 | | 37(4)ofthissubsectionforthosedays,whichshallnotexceedtwelveperanyperiodofsix |
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| 50 | 50 | | 38consecutivemonths,duringwhichtheparticipantisonatemporaryleaveofabsencefromthe |
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| 51 | 51 | | 39hospitalornursinghome,providedthatnosuchparticipantshallbeallowedatemporary |
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| 52 | 52 | | 40leaveofabsenceunlessitisspecificallyprovidedforinhisplanofcare.Asusedinthis |
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| 53 | 53 | | 41subdivision,theterm"temporaryleaveofabsence"shallincludeallperiodsoftimeduring |
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| 54 | 54 | | 42whichaparticipantisawayfromthehospitalornursinghomeovernightbecauseheisvisiting |
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| 55 | 55 | | 43afriendorrelative; |
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| 56 | 56 | | 44 (6)Physicians'services,whetherfurnishedintheoffice,home,hospital,nursing |
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| 57 | 57 | | 45home,orelsewhere,provided,thatnofundsshallbeexpendedtoanyabortionfacility,as |
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| 58 | 58 | | 46definedinsection188.015,ortoanyaffiliate,asdefinedinsection188.015,ofsuchabortion |
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| 59 | 59 | | 47facility; |
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| 60 | 60 | | 48 (7)Subjecttoappropriation,uptotwentyvisitsperyearforserviceslimitedto |
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| 61 | 61 | | 49examinations,diagnoses,adjustments,andmanipulationsandtreatmentsofmalpositioned |
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| 62 | 62 | | 50articulationsandstructuresofthebodyprovidedbylicensedchiropracticphysicians |
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| 63 | 63 | | 51practicingwithintheirscopeofpractice.Nothinginthissubdivisionshallbeinterpretedto |
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| 64 | 64 | | 52otherwiseexpandMOHealthNetservices; |
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| 65 | 65 | | 53 (8)Drugsandmedicineswhenprescribedbyalicensedphysician,dentist,podiatrist, |
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| 66 | 66 | | 54oranadvancedpracticeregisterednurse;exceptthatnopaymentfordrugsandmedicines |
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| 67 | 67 | | HB469 2 55prescribedonandafterJanuary1,2006,byalicensedphysician,dentist,podiatrist,oran |
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| 68 | 68 | | 56advancedpracticeregisterednursemaybemadeonbehalfofanypersonwhoqualifiesfor |
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| 69 | 69 | | 57prescriptiondrugcoverageundertheprovisionsofP.L.108-173; |
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| 70 | 70 | | 58 (9)Emergencyambulanceservicesand,effectiveJanuary1,1990,medically |
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| 71 | 71 | | 59necessarytransportationtoscheduled,physician-prescribednonelectivetreatments; |
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| 72 | 72 | | 60 (10)Earlyandperiodicscreeninganddiagnosisofindividualswhoareundertheage |
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| 73 | 73 | | 61oftwenty-onetoascertaintheirphysicalormentaldefects,andhealthcare,treatment,and |
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| 74 | 74 | | 62othermeasurestocorrectoramelioratedefectsandchronicconditionsdiscoveredthereby. |
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| 75 | 75 | | 63SuchservicesshallbeprovidedinaccordancewiththeprovisionsofSection6403ofP.L. |
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| 76 | 76 | | 64101-239andfederalregulationspromulgatedthereunder; |
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| 77 | 77 | | 65 (11)Homehealthcareservices; |
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| 78 | 78 | | 66 (12)Familyplanningasdefinedbyfederalrulesandregulations;provided,thatno |
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| 79 | 79 | | 67fundsshallbeexpendedtoanyabortionfacility,asdefinedinsection188.015,ortoany |
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| 80 | 80 | | 68affiliate,asdefinedinsection188.015,ofsuchabortionfacility;andfurtherprovided, |
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| 81 | 81 | | 69however,thatsuchfamilyplanningservicesshallnotincludeabortionsoranyabortifacient |
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| 82 | 82 | | 70drugordevicethatisusedforthepurposeofinducinganabortionunlesssuchabortionsare |
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| 83 | 83 | | 71certifiedinwritingbyaphysiciantotheMOHealthNetagencythat,inthephysician's |
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| 84 | 84 | | 72professionaljudgment,thelifeofthemotherwouldbeendangeredifthefetuswerecarriedto |
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| 85 | 85 | | 73term; |
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| 86 | 86 | | 74 (13)Inpatientpsychiatrichospitalservicesforindividualsunderagetwenty-oneas |
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| 87 | 87 | | 75definedinTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396d,etseq.); |
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| 88 | 88 | | 76 (14)Outpatientsurgicalprocedures,includingpresurgicaldiagnosticservices |
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| 89 | 89 | | 77performedinambulatorysurgicalfacilitieswhicharelicensedbythedepartmentofhealth |
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| 90 | 90 | | 78andseniorservicesofthestateofMissouri;except,thatsuchoutpatientsurgicalservicesshall |
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| 91 | 91 | | 79notincludepersonswhoareeligibleforcoverageunderPartBofTitleXVIII,PublicLaw89- |
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| 92 | 92 | | 8097,1965amendmentstothefederalSocialSecurityAct,asamended,ifexclusionofsuch |
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| 93 | 93 | | 81personsispermittedunderTitleXIX,PublicLaw89-97,1965amendmentstothefederal |
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| 94 | 94 | | 82SocialSecurityAct,asamended; |
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| 95 | 95 | | 83 (15)Personalcareserviceswhicharemedicallyorientedtaskshavingtodowitha |
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| 96 | 96 | | 84person'sphysicalrequirements,asopposedtohousekeepingrequirements,whichenablea |
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| 97 | 97 | | 85persontobetreatedbyhisorherphysicianonanoutpatientratherthanonaninpatientor |
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| 98 | 98 | | 86residentialbasisinahospital,intermediatecarefacility,orskillednursingfacility.Personal |
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| 99 | 99 | | 87careservicesshallberenderedbyanindividualnotamemberoftheparticipant'sfamilywho |
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| 100 | 100 | | 88isqualifiedtoprovidesuchserviceswheretheservicesareprescribedbyaphysicianin |
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| 101 | 101 | | 89accordancewithaplanoftreatmentandaresupervisedbyalicensednurse.Personseligible |
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| 102 | 102 | | 90toreceivepersonalcareservicesshallbethosepersonswhowouldotherwiserequire |
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| 103 | 103 | | 91placementinahospital,intermediatecarefacility,orskillednursingfacility.Benefitspayable |
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| 104 | 104 | | HB469 3 92forpersonalcareservicesshallnotexceedforanyoneparticipantonehundredpercentofthe |
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| 105 | 105 | | 93averagestatewidechargeforcareandtreatmentinanintermediatecarefacilityfora |
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| 106 | 106 | | 94comparableperiodoftime.Suchservices,whendeliveredinaresidentialcarefacilityor |
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| 107 | 107 | | 95assistedlivingfacilitylicensedunderchapter198,shallbeauthorizedonatierlevelbasedon |
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| 108 | 108 | | 96theservicestheresidentrequiresandthefrequencyoftheservices.Aresidentofsuchfacility |
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| 109 | 109 | | 97whoqualifiesforassistanceundersection208.030shall,ataminimum,ifprescribedbya |
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| 110 | 110 | | 98physician,qualifyforthetierlevelwiththefewestservices.Theratepaidtoprovidersfor |
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| 111 | 111 | | 99eachtierofserviceshallbesetsubjecttoappropriations.Subjecttoappropriations,each |
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| 112 | 112 | | 100residentofsuchfacilitywhoqualifiesforassistanceundersection208.030andmeetsthe |
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| 113 | 113 | | 101levelofcarerequiredinthissectionshall,ataminimum,ifprescribedbyaphysician,be |
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| 114 | 114 | | 102authorizeduptoonehourofpersonalcareservicesperday.Authorizedunitsofpersonalcare |
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| 115 | 115 | | 103servicesshallnotbereducedortierlevelloweredunlessanorderapprovingsuchreductionor |
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| 116 | 116 | | 104loweringisobtainedfromtheresident'spersonalphysician.Suchauthorizedunitsofpersonal |
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| 117 | 117 | | 105careservicesortierlevelshallbetransferredwithsuchresidentifheorshetransfersto |
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| 118 | 118 | | 106anothersuchfacility.Suchprovisionshallterminateuponreceiptofrelevantwaiversfrom |
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| 119 | 119 | | 107thefederalDepartmentofHealthandHumanServices.IftheCentersforMedicareand |
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| 120 | 120 | | 108MedicaidServicesdeterminesthatsuchprovisiondoesnotcomplywiththestateplan,this |
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| 121 | 121 | | 109provisionshallbenullandvoid.TheMOHealthNetdivisionshallnotifytherevisorof |
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| 122 | 122 | | 110statutesastowhethertherelevantwaiversareapprovedoradeterminationofnoncompliance |
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| 123 | 123 | | 111ismade; |
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| 124 | 124 | | 112 (16)Mentalhealthservices.Thestateplanforprovidingmedicalassistanceunder |
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| 125 | 125 | | 113TitleXIXoftheSocialSecurityAct,42U.S.C.Section[301]1396etseq.,asamended,shall |
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| 126 | 126 | | 114includethefollowingmentalhealthserviceswhensuchservicesareprovidedbycommunity |
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| 127 | 127 | | 115mentalhealthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythe |
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| 128 | 128 | | 116departmentofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrug |
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| 129 | 129 | | 117abusefacilityorasachild-servingagencywithinthecomprehensivechildren'smentalhealth |
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| 130 | 130 | | 118servicesystemestablishedinsection630.097.Thedepartmentofmentalhealthshall |
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| 131 | 131 | | 119establishbyadministrativerulethedefinitionandcriteriafordesignationasacommunity |
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| 132 | 132 | | 120mentalhealthfacilityandfordesignationasanalcoholanddrugabusefacility.Suchmental |
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| 133 | 133 | | 121healthservicesshallinclude: |
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| 134 | 134 | | 122 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic, |
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| 135 | 135 | | 123rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup |
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| 136 | 136 | | 124settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately |
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| 137 | 137 | | 125established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas |
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| 138 | 138 | | 126apartofclientservicesmanagement; |
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| 139 | 139 | | 127 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic, |
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| 140 | 140 | | 128rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup |
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| 141 | 141 | | HB469 4 129settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately |
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| 142 | 142 | | 130established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas |
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| 143 | 143 | | 131apartofclientservicesmanagement; |
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| 144 | 144 | | 132 (c)Rehabilitativementalhealthandalcoholanddrugabuseservicesincludinghome |
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| 145 | 145 | | 133andcommunity-basedpreventive,diagnostic,therapeutic,rehabilitative,andpalliative |
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| 146 | 146 | | 134interventionsrenderedtoindividualsinanindividualorgroupsettingbyamentalhealth |
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| 147 | 147 | | 135oralcoholanddrugabuseprofessionalinaccordancewithaplanoftreatmentappropriately |
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| 148 | 148 | | 136established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas |
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| 149 | 149 | | 137apartofclientservicesmanagement.Asusedinthissection,mentalhealthprofessionaland |
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| 150 | 150 | | 138alcoholanddrugabuseprofessionalshallbedefinedbythedepartmentofmentalhealth |
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| 151 | 151 | | 139pursuanttodulypromulgatedrules.Withrespecttoservicesestablishedbythissubdivision, |
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| 152 | 152 | | 140thedepartmentofsocialservices,MOHealthNetdivision,shallenterintoanagreementwith |
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| 153 | 153 | | 141thedepartmentofmentalhealth.Matchingfundsforoutpatientmentalhealthservices,clinic |
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| 154 | 154 | | 142mentalhealthservices,andrehabilitationservicesformentalhealthandalcoholanddrug |
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| 155 | 155 | | 143abuseshallbecertifiedbythedepartmentofmentalhealthtotheMOHealthNetdivision. |
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| 156 | 156 | | 144Theagreementshallestablishamechanismforthejointimplementationoftheprovisionsof |
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| 157 | 157 | | 145thissubdivision.Inaddition,theagreementshallestablishamechanismbywhichratesfor |
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| 158 | 158 | | 146servicesmaybejointlydeveloped; |
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| 159 | 159 | | 147 (17)SuchadditionalservicesasdefinedbytheMOHealthNetdivisiontobe |
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| 160 | 160 | | 148furnishedunderwaiversoffederalstatutoryrequirementsasprovidedforandauthorizedby |
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| 161 | 161 | | 149thefederalSocialSecurityAct(42U.S.C.Section301,etseq.)subjecttoappropriationbythe |
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| 162 | 162 | | 150generalassembly; |
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| 163 | 163 | | 151 (18)Theservicesofanadvancedpracticeregisterednursewithacollaborative |
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| 164 | 164 | | 152practiceagreementtotheextentthatsuchservicesareprovidedinaccordancewithchapters |
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| 165 | 165 | | 153334and335,andregulationspromulgatedthereunder; |
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| 166 | 166 | | 154 (19)Nursinghomecostsforparticipantsreceivingbenefitpaymentsunder |
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| 167 | 167 | | 155subdivision(4)ofthissubsectiontoreserveabedfortheparticipantinthenursinghome |
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| 168 | 168 | | 156duringthetimethattheparticipantisabsentduetoadmissiontoahospitalforserviceswhich |
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| 169 | 169 | | 157cannotbeperformedonanoutpatientbasis,subjecttotheprovisionsofthissubdivision: |
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| 170 | 170 | | 158 (a)Theprovisionsofthissubdivisionshallapplyonlyif: |
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| 171 | 171 | | 159 a.Theoccupancyrateofthenursinghomeisatoraboveninety-sevenpercentofMO |
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| 172 | 172 | | 160HealthNetcertifiedlicensedbeds,accordingtothemostrecentquarterlycensusprovidedto |
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| 173 | 173 | | 161thedepartmentofhealthandseniorserviceswhichwastakenpriortowhentheparticipantis |
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| 174 | 174 | | 162admittedtothehospital;and |
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| 175 | 175 | | 163 b.Thepatientisadmittedtoahospitalforamedicalconditionwithananticipated |
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| 176 | 176 | | 164stayofthreedaysorless; |
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| 177 | 177 | | HB469 5 165 (b)Thepaymenttobemadeunderthissubdivisionshallbeprovidedforamaximum |
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| 178 | 178 | | 166ofthreedaysperhospitalstay; |
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| 179 | 179 | | 167 (c)Foreachdaythatnursinghomecostsarepaidonbehalfofaparticipantunderthis |
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| 180 | 180 | | 168subdivisionduringanyperiodofsixconsecutivemonthssuchparticipantshall,duringthe |
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| 181 | 181 | | 169sameperiodofsixconsecutivemonths,beineligibleforpaymentofnursinghomecostsof |
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| 182 | 182 | | 170twootherwiseavailabletemporaryleaveofabsencedaysprovidedundersubdivision(5)of |
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| 183 | 183 | | 171thissubsection;and |
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| 184 | 184 | | 172 (d)Theprovisionsofthissubdivisionshallnotapplyunlessthenursinghome |
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| 185 | 185 | | 173receivesnoticefromtheparticipantortheparticipant'sresponsiblepartythattheparticipant |
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| 186 | 186 | | 174intendstoreturntothenursinghomefollowingthehospitalstay.Ifthenursinghomereceives |
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| 187 | 187 | | 175suchnotificationandallotherprovisionsofthissubsectionhavebeensatisfied,thenursing |
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| 188 | 188 | | 176homeshallprovidenoticetotheparticipantortheparticipant'sresponsiblepartypriorto |
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| 189 | 189 | | 177releaseofthereservedbed; |
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| 190 | 190 | | 178 (20)Prescribedmedicallynecessarydurablemedicalequipment.Anelectronicweb- |
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| 191 | 191 | | 179basedpriorauthorizationsystemusingbestmedicalevidenceandcareandtreatment |
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| 192 | 192 | | 180guidelinesconsistentwithnationalstandardsshallbeusedtoverifymedicalneed; |
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| 193 | 193 | | 181 (21)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa |
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| 194 | 194 | | 182coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand |
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| 195 | 195 | | 183inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga |
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| 196 | 196 | | 184medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother |
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| 197 | 197 | | 185physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical, |
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| 198 | 198 | | 186psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal |
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| 199 | 199 | | 187stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor |
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| 200 | 200 | | 188participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement |
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| 201 | 201 | | 189paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya |
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| 202 | 202 | | 190nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe |
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| 203 | 203 | | 191rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome |
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| 204 | 204 | | 192facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239 |
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| 205 | 205 | | 193(OmnibusBudgetReconciliationActof1989); |
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| 206 | 206 | | 194 (22)Prescribedmedicallynecessarydentalservices.Suchservicesshallbesubjectto |
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| 207 | 207 | | 195appropriations.Anelectronicweb-basedpriorauthorizationsystemusingbestmedical |
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| 208 | 208 | | 196evidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshallbeusedto |
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| 209 | 209 | | 197verifymedicalneed; |
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| 210 | 210 | | 198 (23)Prescribedmedicallynecessaryoptometricservices.Suchservicesshallbe |
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| 211 | 211 | | 199subjecttoappropriations.Anelectronicweb-basedpriorauthorizationsystemusingbest |
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| 212 | 212 | | 200medicalevidenceandcareandtreatmentguidelinesconsistentwithnationalstandardsshall |
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| 213 | 213 | | 201beusedtoverifymedicalneed; |
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| 214 | 214 | | HB469 6 202 (24)Bloodclottingproducts-relatedservices.Forpersonsdiagnosedwithableeding |
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| 215 | 215 | | 203disorder,asdefinedinsection338.400,reliantonbloodclottingproducts,asdefinedin |
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| 216 | 216 | | 204section338.400,suchservicesinclude: |
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| 217 | 217 | | 205 (a)Homedeliveryofbloodclottingproductsandancillaryinfusionequipmentand |
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| 218 | 218 | | 206supplies,includingtheemergencydeliveriesoftheproductwhenmedicallynecessary; |
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| 219 | 219 | | 207 (b)Medicallynecessaryancillaryinfusionequipmentandsuppliesrequiredto |
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| 220 | 220 | | 208administerthebloodclottingproducts;and |
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| 221 | 221 | | 209 (c)Assessmentsconductedintheparticipant'shomebyapharmacist,nurse,orlocal |
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| 222 | 222 | | 210homehealthcareagencytrainedinbleedingdisorderswhendeemednecessarybythe |
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| 223 | 223 | | 211participant'streatingphysician; |
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| 224 | 224 | | 212 (25)Medicallynecessarycochlearimplantsandhearinginstruments,asdefined |
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| 225 | 225 | | 213insection345.015,thatare: |
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| 226 | 226 | | 214 (a)Prescribedbyanaudiologist,asdefinedinsection345.015;or |
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| 227 | 227 | | 215 (b)Dispensedbyahearinginstrumentspecialist,asdefinedinsection346.010; |
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| 228 | 228 | | 216 (26)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter, |
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| 229 | 229 | | 217reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred |
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| 230 | 230 | | 218percentoftheMedicarereimbursementratesandcomparedtotheaveragedental |
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| 231 | 231 | | 219reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet |
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| 232 | 232 | | 220divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve |
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| 233 | 233 | | 221paritywithMedicarereimbursementratesandforthird-partypayoraveragedental |
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| 234 | 234 | | 222reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall |
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| 235 | 235 | | 223includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete |
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| 236 | 236 | | 224thefour-yearplandevelopedunderthissubdivision. |
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| 237 | 237 | | 225 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof |
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| 238 | 238 | | 226thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe |
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| 239 | 239 | | 227madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas |
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| 240 | 240 | | 228definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided, |
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| 241 | 241 | | 229forthefollowing: |
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| 242 | 242 | | 230 (1)Dentalservices; |
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| 243 | 243 | | 231 (2)Servicesofpodiatristsasdefinedinsection330.010; |
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| 244 | 244 | | 232 (3)Optometricservicesasdescribedinsection336.010; |
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| 245 | 245 | | 233 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,[hearing |
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| 246 | 246 | | 234aids,] andwheelchairs; |
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| 247 | 247 | | 235 (5)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa |
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| 248 | 248 | | 236coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand |
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| 249 | 249 | | 237inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga |
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| 250 | 250 | | 238medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother |
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| 251 | 251 | | HB469 7 239physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical, |
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| 252 | 252 | | 240psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal |
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| 253 | 253 | | 241stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor |
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| 254 | 254 | | 242participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement |
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| 255 | 255 | | 243paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya |
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| 256 | 256 | | 244nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe |
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| 257 | 257 | | 245rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome |
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| 258 | 258 | | 246facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239 |
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| 259 | 259 | | 247(OmnibusBudgetReconciliationActof1989); |
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| 260 | 260 | | 248 (6)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaaspartofa |
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| 261 | 261 | | 249coordinatedsystemofcareforindividualswithdisablingimpairments.Rehabilitation |
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| 262 | 262 | | 250servicesmustbebasedonanindividualized,goal-oriented,comprehensiveandcoordinated |
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| 263 | 263 | | 251treatmentplandeveloped,implemented,andmonitoredthroughaninterdisciplinary |
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| 264 | 264 | | 252assessmentdesignedtorestoreanindividualtoanoptimallevelofphysical,cognitive,and |
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| 265 | 265 | | 253behavioralfunction.TheMOHealthNetdivisionshallestablishbyadministrativerulethe |
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| 266 | 266 | | 254definitionandcriteriafordesignationofacomprehensivedayrehabilitationservicefacility, |
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| 267 | 267 | | 255benefitlimitationsandpaymentmechanism.Anyruleorportionofarule,asthattermis |
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| 268 | 268 | | 256definedinsection536.010,thatiscreatedundertheauthoritydelegatedinthissubdivision |
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| 269 | 269 | | 257shallbecomeeffectiveonlyifitcomplieswithandissubjecttoalloftheprovisionsof |
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| 270 | 270 | | 258chapter536and,ifapplicable,section536.028.Thissectionandchapter536are |
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| 271 | 271 | | 259nonseverableandifanyofthepowersvestedwiththegeneralassemblypursuanttochapter |
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| 272 | 272 | | 260536toreview,todelaytheeffectivedate,ortodisapproveandannularulearesubsequently |
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| 273 | 273 | | 261heldunconstitutional,thenthegrantofrulemakingauthorityandanyruleproposedor |
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| 274 | 274 | | 262adoptedafterAugust28,2005,shallbeinvalidandvoid. |
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| 275 | 275 | | 263 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet |
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| 276 | 276 | | 264benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter |
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| 277 | 277 | | 265July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall |
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| 278 | 278 | | 266coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of |
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| 279 | 279 | | 267subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner |
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| 280 | 280 | | 268authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.) |
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| 281 | 281 | | 269andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber |
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| 282 | 282 | | 270accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the |
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| 283 | 283 | | 271MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment |
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| 284 | 284 | | 272pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods |
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| 285 | 285 | | 273orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional |
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| 286 | 286 | | 274paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein, |
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| 287 | 287 | | 275ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade |
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| 288 | 288 | | HB469 8 276byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby |
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| 289 | 289 | | 277thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy |
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| 290 | 290 | | 278professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists. |
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| 291 | 291 | | 279Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A |
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| 292 | 292 | | 280providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired |
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| 293 | 293 | | 281payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan |
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| 294 | 294 | | 282individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder |
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| 295 | 295 | | 283thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona |
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| 296 | 296 | | 284historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor |
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| 297 | 297 | | 285payment.Aprovider,representative,employee,independentcontractor,oragentofa |
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| 298 | 298 | | 286pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection |
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| 299 | 299 | | 287shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters |
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| 300 | 300 | | 288forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan |
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| 301 | 301 | | 289amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto |
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| 302 | 302 | | 290denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices |
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| 303 | 303 | | 291shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe |
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| 304 | 304 | | 292acceptabilityofdenyingservicesastheresultofunpaidco-payments. |
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| 305 | 305 | | 293 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom |
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| 306 | 306 | | 294participantsinordertomaintainprogramintegrity. |
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| 307 | 307 | | 295 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of |
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| 308 | 308 | | 296subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare |
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| 309 | 309 | | 297providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet |
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| 310 | 310 | | 298benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral |
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| 311 | 311 | | 299populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C. |
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| 312 | 312 | | 300Section1396aandfederalregulationspromulgatedthereunder. |
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| 313 | 313 | | 301 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded |
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| 314 | 314 | | 302healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection |
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| 315 | 315 | | 3036404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations |
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| 316 | 316 | | 304promulgatedthereunder. |
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| 317 | 317 | | 305 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification |
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| 318 | 318 | | 306andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen |
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| 319 | 319 | | 307whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe |
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| 320 | 320 | | 308specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe |
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| 321 | 321 | | 309departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe |
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| 322 | 322 | | 310requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder. |
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| 323 | 323 | | HB469 9 311 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin |
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| 324 | 324 | | 312accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42 |
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| 325 | 325 | | 313U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder. |
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| 326 | 326 | | 314 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein |
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| 327 | 327 | | 315ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation |
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| 328 | 328 | | 316intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat |
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| 329 | 329 | | 317wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42 |
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| 330 | 330 | | 318U.S.C.Section1396a(a)(13)(C). |
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| 331 | 331 | | 319 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand |
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| 332 | 332 | | 320assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders. |
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| 333 | 333 | | 321 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata |
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| 334 | 334 | | 322shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof |
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| 335 | 335 | | 323determiningeligibilityunderthissection. |
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| 336 | 336 | | 324 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor |
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| 337 | 337 | | 325applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe |
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| 338 | 338 | | 326interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO |
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| 339 | 339 | | 327HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected |
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| 340 | 340 | | 328MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof |
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| 341 | 341 | | 329theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall |
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| 342 | 342 | | 330entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis |
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| 343 | 343 | | 331providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany |
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| 344 | 344 | | 332paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent. |
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| 345 | 345 | | 333EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail |
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| 346 | 346 | | 334addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired |
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| 347 | 347 | | 335underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor |
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| 348 | 348 | | 336electronicmailtoeachprovider. |
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| 349 | 349 | | 337 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's |
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| 350 | 350 | | 338statutoryrequirementtopromulgaterulesunderchapter536. |
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| 351 | 351 | | 339 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral, |
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| 352 | 352 | | 340social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof |
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| 353 | 353 | | 341physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand |
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| 354 | 354 | | 342interventionreimbursementcodes96150to96154ortheirsuccessorcodesunderthe |
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| 355 | 355 | | 343CurrentProceduralTerminology(CPT)codingsystem.Providerseligibleforsuch |
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| 356 | 356 | | 344reimbursementshallincludepsychologists. |
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| 357 | 357 | | HB469 10 345 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition |
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| 358 | 358 | | 346surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection |
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| 359 | 359 | | 347191.1720,forthepurposeofagendertransition. |
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| 360 | 360 | | âś” |
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| 361 | 361 | | HB469 11 |
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