FIRSTREGULARSESSION
HOUSEBILLNO.842
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVEPETERS.
1868H.01I JOSEPHENGLER,ChiefClerk
ANACT
Torepealsection208.152,RSMo,andtoenactinlieuthereoftwonewsectionsrelatingto
paymentsforhomebloodpressuremonitoring.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Section208.152,RSMo,isrepealedandtwonewsectionsenactedinlieu
2thereof,tobeknownassections208.152and376.1960,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.Section301,
30etseq.),asamended,fornursingfacilities.TheMOHealthNetdivisionmayrecognize
31throughitspaymentmethodologyfornursingfacilitiesthosenursingfacilitieswhichservea
32highvolumeofMOHealthNetpatients.TheMOHealthNetdivisionwhendeterminingthe
33amountofthebenefitpaymentstobemadeonbehalfofpersonsundertheageoftwenty-one
34inanursingfacilitymayconsidernursingfacilitiesfurnishingcaretopersonsundertheageof
35twenty-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
HB842 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
HB842 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.Section301,asamended,shallincludethe
114followingmentalhealthserviceswhensuchservicesareprovidedbycommunitymental
115healthfacilitiesoperatedbythedepartmentofmentalhealthordesignatedbythedepartment
116ofmentalhealthasacommunitymentalhealthfacilityorasanalcoholanddrugabusefacility
117orasachild-servingagencywithinthecomprehensivechildren'smentalhealthservicesystem
118establishedinsection630.097.Thedepartmentofmentalhealthshallestablishby
119administrativerulethedefinitionandcriteriafordesignationasacommunitymentalhealth
120facilityandfordesignationasanalcoholanddrugabusefacility.Suchmentalhealthservices
121shallinclude:
122 (a)Outpatientmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
123rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
124settingbyamentalhealthprofessionalinaccordancewithaplanoftreatmentappropriately
125established,implemented,monitored,andrevisedundertheauspicesofatherapeuticteamas
126apartofclientservicesmanagement;
127 (b)Clinicmentalhealthservicesincludingpreventive,diagnostic,therapeutic,
128rehabilitative,andpalliativeinterventionsrenderedtoindividualsinanindividualorgroup
HB842 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;
HB842 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;
HB842 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)TheMOHealthNetdivisionshall,byJanuary1,2008,andannuallythereafter,
213reportthestatusofMOHealthNetproviderreimbursementratesascomparedtoonehundred
214percentoftheMedicarereimbursementratesandcomparedtotheaveragedental
215reimbursementratespaidbythird-partypayorslicensedbythestate.TheMOHealthNet
216divisionshall,byJuly1,2008,providetothegeneralassemblyafour-yearplantoachieve
217paritywithMedicarereimbursementratesandforthird-partypayoraveragedental
218reimbursementrates.Suchplanshallbesubjecttoappropriationandthedivisionshall
219includeinitsannualbudgetrequesttothegovernorthenecessaryfundingneededtocomplete
220thefour-yearplandevelopedunderthissubdivision.
221 2.Additionalbenefitpaymentsformedicalassistanceshallbemadeonbehalfof
222thoseeligibleneedychildren,pregnantwomenandblindpersonswithanypaymentstobe
223madeonthebasisofthereasonablecostofthecareorreasonablechargefortheservicesas
224definedanddeterminedbytheMOHealthNetdivision,unlessotherwisehereinafterprovided,
225forthefollowing:
226 (1)Dentalservices;
227 (2)Servicesofpodiatristsasdefinedinsection330.010;
228 (3)Optometricservicesasdescribedinsection336.010;
229 (4)Orthopedicdevicesorotherprosthetics,includingeyeglasses,dentures,hearing
230aids,andwheelchairs;
231 (5)Forpregnantandpostpartumwomen,ahomebloodpressuremonitoring
232deviceandhomebloodpressuremonitoringdeviceservices.Asusedinthissubdivision,
233theterm"homebloodpressuremonitoringdevice"meansamobiledevicethatcanbe
234usedtomeasurebloodpressureandthatisvalidatedforclinicalaccuracyanddevice
235calibration.Asusedinthissubdivision,theterm"homebloodpressuremonitoring
236deviceservices"meanspatienteducationandtrainingservicesonthesetupanduseofa
237homebloodpressuremonitoringdevice,separateself-measurementbloodpressure
238readings,dailycollectionandtransmissionofdatareportsbythepatientorcaregiverto
HB842 7 239thehealthcareproviderinordertocommunicatebloodpressurereadings,reviewofthe
240reportsbythehealthcareprovider,andcreationormodificationoftreatmentplans
241basedonthereports;
242 (6)Hospicecare.Asusedinthissubdivision,theterm"hospicecare"meansa
243coordinatedprogramofactiveprofessionalmedicalattentionwithinahome,outpatientand
244inpatientcarewhichtreatstheterminallyillpatientandfamilyasaunit,employinga
245medicallydirectedinterdisciplinaryteam.Theprogramprovidesreliefofseverepainorother
246physicalsymptomsandsupportivecaretomeetthespecialneedsarisingoutofphysical,
247psychological,spiritual,social,andeconomicstresseswhichareexperiencedduringthefinal
248stagesofillness,andduringdyingandbereavementandmeetstheMedicarerequirementsfor
249participationasahospiceasareprovidedin42CFRPart418.Therateofreimbursement
250paidbytheMOHealthNetdivisiontothehospiceproviderforroomandboardfurnishedbya
251nursinghometoaneligiblehospicepatientshallnotbelessthanninety-fivepercentofthe
252rateofreimbursementwhichwouldhavebeenpaidforfacilityservicesinthatnursinghome
253facilityforthatpatient,inaccordancewithsubsection(c)ofSection6408ofP.L.101-239
254(OmnibusBudgetReconciliationActof1989);
255 [(6)](7)Comprehensivedayrehabilitationservicesbeginningearlyposttraumaas
256partofacoordinatedsystemofcareforindividualswithdisablingimpairments.
257Rehabilitationservicesmustbebasedonanindividualized,goal-oriented,comprehensive
258andcoordinatedtreatmentplandeveloped,implemented,andmonitoredthroughan
259interdisciplinaryassessmentdesignedtorestoreanindividualtoanoptimallevelof
260physical,cognitive,andbehavioralfunction.TheMOHealthNetdivisionshallestablishby
261administrativerulethedefinitionandcriteriafordesignationofacomprehensiveday
262rehabilitationservicefacility,benefitlimitationsandpaymentmechanism.Anyruleor
263portionofarule,asthattermisdefinedinsection536.010,thatiscreatedundertheauthority
264delegatedinthissubdivisionshallbecomeeffectiveonlyifitcomplieswithandissubjectto
265alloftheprovisionsofchapter536and,ifapplicable,section536.028.Thissectionand
266chapter536arenonseverableandifanyofthepowersvestedwiththegeneralassembly
267pursuanttochapter536toreview,todelaytheeffectivedate,ortodisapproveandannula
268rulearesubsequentlyheldunconstitutional,thenthegrantofrulemakingauthorityandany
269ruleproposedoradoptedafterAugust28,2005,shallbeinvalidandvoid.
270 3.TheMOHealthNetdivisionmayrequireanyparticipantreceivingMOHealthNet
271benefitstopaypartofthechargeorcostuntilJuly1,2008,andanadditionalpaymentafter
272July1,2008,asdefinedbyruledulypromulgatedbytheMOHealthNetdivision,forall
273coveredservicesexceptforthoseservicescoveredundersubdivisions(15)and(16)of
274subsection1ofthissectionandsections208.631to208.657totheextentandinthemanner
275authorizedbyTitleXIXofthefederalSocialSecurityAct(42U.S.C.Section1396,etseq.)
HB842 8 276andregulationsthereunder.Whensubstitutionofagenericdrugispermittedbytheprescriber
277accordingtosection338.056,andagenericdrugissubstitutedforaname-branddrug,the
278MOHealthNetdivisionmaynotlowerordeletetherequirementtomakeaco-payment
279pursuanttoregulationsofTitleXIXofthefederalSocialSecurityAct.Aproviderofgoods
280orservicesdescribedunderthissectionmustcollectfromallparticipantstheadditional
281paymentthatmayberequiredbytheMOHealthNetdivisionunderauthoritygrantedherein,
282ifthedivisionexercisesthatauthority,toremaineligibleasaprovider.Anypaymentsmade
283byparticipantsunderthissectionshallbeinadditiontoandnotinlieuofpaymentsmadeby
284thestateforgoodsorservicesdescribedhereinexcepttheparticipantportionofthepharmacy
285professionaldispensingfeeshallbeinadditiontoandnotinlieuofpaymentstopharmacists.
286Aprovidermaycollecttheco-paymentatthetimeaserviceisprovidedoratalaterdate.A
287providershallnotrefusetoprovideaserviceifaparticipantisunabletopayarequired
288payment.Ifitistheroutinebusinesspracticeofaprovidertoterminatefutureservicestoan
289individualwithanunclaimeddebt,theprovidermayincludeuncollectedco-paymentsunder
290thispractice.Providerswhoelectnottoundertaketheprovisionofservicesbasedona
291historyofbaddebtshallgiveparticipantsadvancenoticeandareasonableopportunityfor
292payment.Aprovider,representative,employee,independentcontractor,oragentofa
293pharmaceuticalmanufacturershallnotmakeco-paymentforaparticipant.Thissubsection
294shallnotapplytootherqualifiedchildren,pregnantwomen,orblindpersons.IftheCenters
295forMedicareandMedicaidServicesdoesnotapprovetheMOHealthNetstateplan
296amendmentsubmittedbythedepartmentofsocialservicesthatwouldallowaproviderto
297denyfutureservicestoanindividualwithuncollectedco-payments,thedenialofservices
298shallnotbeallowed.Thedepartmentofsocialservicesshallinformprovidersregardingthe
299acceptabilityofdenyingservicesastheresultofunpaidco-payments.
300 4.TheMOHealthNetdivisionshallhavetherighttocollectmedicationsamplesfrom
301participantsinordertomaintainprogramintegrity.
302 5.Reimbursementforobstetricalandpediatricservicesundersubdivision(6)of
303subsection1ofthissectionshallbetimelyandsufficienttoenlistenoughhealthcare
304providerssothatcareandservicesareavailableunderthestateplanforMOHealthNet
305benefitsatleasttotheextentthatsuchcareandservicesareavailabletothegeneral
306populationinthegeographicarea,asrequiredundersubparagraph(a)(30)(A)of42U.S.C.
307Section1396aandfederalregulationspromulgatedthereunder.
308 6.BeginningJuly1,1990,reimbursementforservicesrenderedinfederallyfunded
309healthcentersshallbeinaccordancewiththeprovisionsofsubsection6402(c)andSection
3106404ofP.L.101-239(OmnibusBudgetReconciliationActof1989)andfederalregulations
311promulgatedthereunder.
HB842 9 312 7.BeginningJuly1,1990,thedepartmentofsocialservicesshallprovidenotification
313andreferralofchildrenbelowagefive,andpregnant,breast-feeding,orpostpartumwomen
314whoaredeterminedtobeeligibleforMOHealthNetbenefitsundersection208.151tothe
315specialsupplementalfoodprogramsforwomen,infantsandchildrenadministeredbythe
316departmentofhealthandseniorservices.Suchnotificationandreferralshallconformtothe
317requirementsofSection6406ofP.L.101-239andregulationspromulgatedthereunder.
318 8.Providersoflong-termcareservicesshallbereimbursedfortheircostsin
319accordancewiththeprovisionsofSection1902(a)(13)(A)oftheSocialSecurityAct,42
320U.S.C.Section1396a,asamended,andregulationspromulgatedthereunder.
321 9.Reimbursementratestolong-termcareproviderswithrespecttoatotalchangein
322ownership,atarm'slength,foranyfacilitypreviouslylicensedandcertifiedforparticipation
323intheMOHealthNetprogramshallnotincreasepaymentsinexcessoftheincreasethat
324wouldresultfromtheapplicationofSection1902(a)(13)(C)oftheSocialSecurityAct,42
325U.S.C.Section1396a(a)(13)(C).
326 10.TheMOHealthNetdivisionmayenrollqualifiedresidentialcarefacilitiesand
327assistedlivingfacilities,asdefinedinchapter198,asMOHealthNetpersonalcareproviders.
328 11.Anyincomeearnedbyindividualseligibleforcertifiedextendedemploymentata
329shelteredworkshopunderchapter178shallnotbeconsideredasincomeforpurposesof
330determiningeligibilityunderthissection.
331 12.IftheMissouriMedicaidauditandcomplianceunitchangesanyinterpretationor
332applicationoftherequirementsforreimbursementforMOHealthNetservicesfromthe
333interpretationorapplicationthathasbeenappliedpreviouslybythestateinanyauditofaMO
334HealthNetprovider,theMissouriMedicaidauditandcomplianceunitshallnotifyallaffected
335MOHealthNetprovidersfivebusinessdaysbeforesuchchangeshalltakeeffect.Failureof
336theMissouriMedicaidauditandcomplianceunittonotifyaproviderofsuchchangeshall
337entitletheprovidertocontinuetoreceiveandretainreimbursementuntilsuchnotificationis
338providedandshallwaiveanyliabilityofsuchproviderforrecoupmentorotherlossofany
339paymentspreviouslymadepriortothefivebusinessdaysaftersuchnoticehasbeensent.
340EachprovidershallprovidetheMissouriMedicaidauditandcomplianceunitavalidemail
341addressandshallagreetoreceivecommunicationselectronically.Thenotificationrequired
342underthissectionshallbedeliveredinwritingbytheUnitedStatesPostalServiceor
343electronicmailtoeachprovider.
344 13.Nothinginthissectionshallbeconstruedtoabrogateorlimitthedepartment's
345statutoryrequirementtopromulgaterulesunderchapter536.
346 14.BeginningJuly1,2016,andsubjecttoappropriations,providersofbehavioral,
347social,andpsychophysiologicalservicesfortheprevention,treatment,ormanagementof
348physicalhealthproblemsshallbereimbursedutilizingthebehaviorassessmentand
HB842 10 349interventionreimbursementcodes96150to96154ortheirsuccessorcodesundertheCurrent
350ProceduralTerminology(CPT)codingsystem.Providerseligibleforsuchreimbursement
351shallincludepsychologists.
352 15.Thereshallbenopaymentsmadeunderthissectionforgendertransition
353surgeries,cross-sexhormones,orpuberty-blockingdrugs,assuchtermsaredefinedinsection
354191.1720,forthepurposeofagendertransition.
376.1960.1.Asusedinthissection,thefollowingtermsmean:
2 (1)"Healthbenefitplan",thesamemeaninggiventotheterminsection
3376.1350;
4 (2)"Homebloodpressuremonitoringdevice",amobiledevicethatcanbeused
5tomeasurebloodpressureandthatisvalidatedforclinicalaccuracyanddevice
6calibration;
7 (3)"Homebloodpressuremonitoringdeviceservices",patienteducationand
8trainingservicesonthesetupanduseofahomebloodpressuremonitoringdevice,
9separateself-measurementbloodpressurereadings,dailycollectionandtransmissionof
10datareportsbythepatientorcaregivertothehealthcareproviderinorderto
11communicatebloodpressurereadings,reviewofthereportsbythehealthcareprovider,
12andcreationormodificationoftreatmentplansbasedonthereports.
13 2.Healthbenefitplansthataredelivered,issuedfordelivery,continued,or
14renewedinthisstateonorafterJanuary1,2026,andthatprovideformaternity
15benefitsshallprovidecoverageforahomebloodpressuremonitoringdeviceandhome
16bloodpressuremonitoringdeviceservicesforpregnantandpostpartumwomen.
✔
HB842 11