1089S.04C
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SENATE COMMITTEE SUBSTITUTE
FOR
SENATE BILL NO. 317
AN ACT
To repeal sections 96.192, 96.196, 190.053, 190.098,
190.101, 190.109, 191.648, 191.1145, 192.769,
195.417, 196.990, 198.022, 206.110, 208.152, 210.030,
332.081, 335.081, 338.010, and 579.060, RSMo, and to
enact in lieu thereof twenty -three new sections
relating to health care, with penalty provisions.
Be it enacted by the General As sembly of the State of Missouri, as follows:
Section A. Sections 96.192, 96.196, 190.053, 190.098,
190.101, 190.109, 191.648, 191.1145, 192.769, 195.417, 196.990,
198.022, 206.110, 208.152, 210.030, 332.081, 335.081, 338.010,
and 579.060, RSMo, are repealed and twenty -three new sections
enacted in lieu thereof, to be known as sections 96.192, 96.196,
190.053, 190.076, 190.098, 190.101, 190.109, 190.112, 190.166,
191.648, 191.1145, 192.2521, 195.417, 196.990, 198.022,
206.110, 206.158, 208.152, 210.030, 332.081, 335.081, 338.010,
and 579.060, to read as follows:
96.192. 1. The board of trustees of any hospital
authorized under subsection 2 of this section, and
established and organized under the provisions of sections
96.150 to 96.229[,]:
(1) May invest up to [twenty-five] fifty percent of
the hospital's "available funds", defined in this section as
funds not required for immediate disbursement in obligations
or for the operation of the hospital [in any United States
investment grade fixed income funds or any diversified stock
funds, or both.], into:
(a) Any mutual funds that invest in stocks, bonds, or
real estate, or any combination thereof;
(b) Bonds that have:
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a. One of the five highest long -term ratings or the
highest short-term rating issued by a nati onally recognized
rating agency; and
b. A final maturity of ten years or less;
(c) Money market investments; or
(d) Any combination of investments described in
paragraphs (a) to (c) of this subdivision; and
(2) Shall invest the remaining percentage of any
available funds not invested as allowed under subdivision
(1) of this subsection into any investment in which the
state treasurer is allowed to invest.
2. The provisions of this section shall only apply if
the hospital:
(1) Receives less than [one] three percent of its
annual revenues from municipal, county, or state taxes; and
(2) Receives less than [one] three percent of its
annual revenue from appropriated funds from the municipality
in which such hospit al is located.
96.196. 1. A hospital organized under this chapter
may purchase, operate or lease, as lessor or lessee, related
facilities or engage in health care activities, except in
counties of the third or fourth classification (ot her than
the county in which the hospital is located) where there
already exists a hospital organized pursuant to this chapter
[and chapter 205 or 206 ]; provided, however, that this
exception shall not prohibit the continuation of existing
activities otherwise allowed by law.
2. If a hospital organized pursuant to this chapter
accepts appropriated funds from the city during the twelve
months immediately preceding the date that the hospital
purchases, operates or leases its first related facili ty
outside the city boundaries or engages in its first health
care activity outside the city boundaries, the governing
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body of the city shall approve the hospital's plan for such
purchase, operation or lease prior to implementation of the
plan.
190.053. 1. All members of the board of directors of
an ambulance district first elected on or after January 1,
2008, shall attend and complete an educational seminar or
conference or other suitable training on the role and duties
of a board member of an ambulance district. The training
required under this section shall be offered by a statewide
association organized for the benefit of ambulance districts
or be approved by the state advisory council on emergency
medical services. Such training shall include, at a minimum:
(1) Information relating to the roles and duties of an
ambulance district director;
(2) A review of all state statutes and regulations
relevant to ambulance districts;
(3) State ethics laws;
(4) State sunshine laws, chapter 610;
(5) Financial and fiduciary responsibility;
(6) State laws relating to the setting of tax rates;
and
(7) State laws relating to revenue limitations.
2. [If any ambulance district board me mber fails to
attend a training session within twelve months after taking
office, the board member shall not be compensated for
attendance at meetings thereafter until the board member has
completed such training session. If any ambulance district
board member fails to attend a training session within
twelve months of taking office regardless of whether the
board member received an attendance fee for a training
session, the board member shall be ineligible to run for
reelection for another term of office until the board member
satisfies the training requirement of this section; however,
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this requirement shall only apply to board members elected
after August 28, 2022 ] All members of the board of directors
of an ambulance district shall complete three hours of
continuing education for each term of office. The
continuing education shall be offered by a statewide
association organized for the benefit of ambulance districts
or be approved by the state advisory council on emergency
medical services.
3. Any ambulance district board member who fails to
complete the initial training and continuing education
requirements on or before the anniversary date of the
member's election or appointment as required under this
section shall immediatel y be disqualified from office. Upon
such disqualification, the member's position shall be deemed
vacant without further process or declaration. The vacancy
shall be filled in the manner provided for in section
190.052.
190.076. In addition to the annual audit required
under section 190.075, each ambulance district shall, at
least once every three years, arrange for a certified public
accountant or a firm of certified public accountants to
audit the records and accounts of the dist rict. The audit
shall be made freely available to the public on the
district's website or by other electronic means.
190.098. 1. As used in this section, the term
"community paramedic services" shall mean services provided
by any entity that employs licensed paramedics who are
certified by the department as community paramedics for
services that are:
(1) Provided in a nonemergent setting that is
independent of an emergency telephone service, 911 system,
or emergency summons;
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(2) Consistent with the training and education
requirements described in subdivision (2) of subsection 2 of
this section, the scope of skill and practice for community
paramedics, and the supervisory standard approved by the
entity's medical dir ector; and
(3) Reflected and documented in the entity's patient
care plans or protocols approved by the medical director in
accordance with the provisions of section 190.142.
2. In order for a person to be eligible for
certification by the d epartment as a community paramedic, an
individual shall:
(1) Be currently [certified] licensed as a paramedic;
(2) Successfully complete or have successfully
completed a community paramedic certification program from a
college, university, o r educational institution that has
been approved by the department or accredited by a national
accreditation organization approved by the department; and
(3) Complete an application form approved by the
department.
[2.] 3. A community paramedic shall practice in
accordance with protocols and supervisory standards
established by the medical director. A community paramedic
shall provide services of a health care plan if the plan has
been developed by the patient's physician or by an advanc ed
practice registered nurse through a collaborative practice
arrangement with a physician or a physician assistant
through a collaborative practice arrangement with a
physician and there is no duplication of services to the
patient from another provi der.
[3.] 4. (1) Any ambulance service shall enter into a
written contract to provide community paramedic services in
another ambulance service area, as that term is defined in
section 190.100. The contract that is agreed upon may be
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for an indefinite period of time, as long as it includes at
least a sixty-day cancellation notice by either ambulance
service.
(2) Any ambulance service that seeks to provide
community paramedic services outside of the ambulance
service's service area:
(a) Shall have a memorandum of understanding regarding
the provision of such services with the ambulance service in
that service area if that ambulance service is already
providing community paramedic services; or
(b) Shall not be required to h ave a memorandum of
understanding with the ambulance service in that service
area if that ambulance service is not already providing
community paramedic services, provided that the ambulance
service seeking to provide such services shall provide
notification to the other ambulance service of the community
paramedic services to be provided.
(3) Any emergency medical response agency that seeks
to provide community paramedic services within its
designated response service area may do so if the gr ound
ambulance service area within which the emergency medical
response agency operates does not already provide such
services. If the ground ambulance service does provide
community paramedic services, the ground ambulance service
may enter into a memorandum of understanding with the
emergency medical response agency in order to coordinate
programs and avoid service duplication. If the emergency
medical response agency provides community paramedic
services in the ground ambulance service's servi ce area
prior to the provision of such services by the ground
ambulance service, the emergency medical response agency and
the ground ambulance service shall enter into a memorandum
of understanding for the coordination of services.
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(4) Any community paramedic program shall notify the
appropriate local ambulance service when providing services
within the service area of an ambulance service.
(5) The department shall promulgate rules and
regulations for the purpose of identifying the commu nity
paramedic services entities that have met the standards
necessary to provide community paramedic services including,
but not limited to, physician medical oversight, training,
patient record retention, formal relationships with primary
care services as needed, and quality improvement policies.
Community paramedic services entities shall be certified by
the department. Any such certification shall allow the
entity to provide community paramedic services for a period
of five years.
[4.] 5. A community paramedic is subject to the
provisions of sections 190.001 to 190.245 and rules
promulgated under sections 190.001 to 190.245.
[5.] 6. No person shall hold himself or herself out as
a community paramedic or provide the services of a community
paramedic unless such person is certified by the department.
[6.] 7. The medical director shall approve the
implementation of the community paramedic program.
[7.] 8. Any rule or portion of a rule, as that term is
defined in section 536.010, that is created under the
authority delegated in this section shall become effective
only if it complies with and is subject to all of the
provisions of chapter 536 and, if applicable, section
536.028. This section and chapter 536 are nons everable and
if any of the powers vested with the general assembly
pursuant to chapter 536 to review, to delay the effective
date, or to disapprove and annul a rule are subsequently
held unconstitutional, then the grant of rulemaking
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authority and any rule proposed or adopted after August 28,
2013, shall be invalid and void.
190.101. 1. There is hereby established a "State
Advisory Council on Emergency Medical Services" which shall
consist of [sixteen] no more than twenty-three members[, one
of which shall be a resident of a city not within a
county]. The members of the council shall be appointed [by
the governor with the advice and consent of the senate ] in
accordance with subsection 2 of this section and shall serve
terms of four years. The [governor shall designate one of
the members as chairperson ] council members shall annually
select a chairperson, along with other officers as the
council deems necessary . The chairperson may appoint
subcommittees that include noncou ncil members.
2. Council members shall be appointed as follows:
(1) The director of the department of health and
senior services shall make appointments to the council from
the recommendations provided by the following:
(a) The statewide professional association
representing ambulance service managers;
(b) The statewide professional association
representing emergency medical technicians and paramedics;
(c) The statewide professional association
representing ambulance distr icts;
(d) The statewide professional association
representing fire chiefs;
(e) The statewide professional association
representing fire protection districts;
(f) The statewide professional association
representing firefighters;
(g) The statewide professional association
representing emergency nurses;
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(h) The statewide professional association
representing the air ambulance industry;
(i) The statewide professional association
representing emergency medicine physician s;
(j) The statewide association representing hospitals;
and
(k) The statewide association representing pediatric
emergency professionals;
(2) The director of health and senior services shall
appoint a member to the council with a back ground in mobile
integrated health care -community paramedicine (MIH -CP);
(3) Each regional EMS advisory committee shall appoint
one member; and
(4) The time-critical diagnosis advisory committee
established under section 190.257 shall appoin t one member.
3. The state EMS medical directors advisory committee
and the regional EMS advisory committees will be recognized
as subcommittees of the state advisory council on emergency
medical services.
[3.] 4. The council shall have geog raphical
representation and representation from appropriate areas of
expertise in emergency medical services including
volunteers, professional organizations involved in emergency
medical services, EMT's, paramedics, nurses, firefighters,
physicians, ambulance service administrators, hospital
administrators and other health care providers concerned
with emergency medical services. [The regional EMS advisory
committees shall serve as a resource for the identification
of potential members of the sta te advisory council on
emergency medical services.
4.] 5. The state EMS medical director, as described
under section 190.103, shall serve as an ex officio member
of the council.
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[5.] 6. The members of the council and subcommittees
shall serve without compensation except that members of the
council shall, subject to appropriations, be reimbursed for
reasonable travel expenses and meeting expenses related to
the functions of the council.
[6.] 7. The purpose of the council is to make
recommendations to the governor, the general assembly, and
the department on policies, plans, procedures and proposed
regulations on how to improve the statewide emergency
medical services system. The council shall advise the
governor, the general ass embly, and the department on all
aspects of the emergency medical services system.
[7.] 8. (1) There is hereby established a standing
subcommittee of the council to monitor the implementation of
the recognition of the EMS personnel licensure inte rstate
compact under sections 190.900 to 190.939, the interstate
commission for EMS personnel practice, and the involvement
of the state of Missouri. The subcommittee shall meet at
least biannually and receive reports from the Missouri
delegate to the interstate commission for EMS personnel
practice. The subcommittee shall consist of at least seven
members appointed by the chair of the council, to include at
least two members as recommended by the Missouri state
council of firefighters and one me mber as recommended by the
Missouri Association of Fire Chiefs. The subcommittee may
submit reports and recommendations to the council, the
department of health and senior services, the general
assembly, and the governor regarding the participation of
Missouri with the recognition of the EMS personnel licensure
interstate compact.
(2) The subcommittee shall formally request a public
hearing for any rule proposed by the interstate commission
for EMS personnel practice in accordance with subsec tion 7
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of section 190.930. The hearing request shall include the
request that the hearing be presented live through the
internet. The Missouri delegate to the interstate
commission for EMS personnel practice shall be responsible
for ensuring that al l hearings, notices of, and related
rulemaking communications as required by the compact be
communicated to the council and emergency medical services
personnel under the provisions of subsections 4, 5, 6, and 8
of section 190.930.
(3) The department of health and senior services shall
not establish or increase fees for Missouri emergency
medical services personnel licensure in accordance with this
chapter for the purpose of creating the funds necessary for
payment of an annual assessment unde r subdivision (3) of
subsection 5 of section 190.924.
[8.] 9. The council shall consult with the time -
critical diagnosis advisory committee, as described under
section 190.257, regarding time -critical diagnosis.
190.109. 1. The department shall, within a reasonable
time after receipt of an application, cause such
investigation as the department deems necessary to be made
of the applicant for a ground ambulance license.
2. Any person that owned and operated a licensed
ambulance on December 31, 1997, shall receive an ambulance
service license from the department, unless suspended,
revoked or terminated, for that ambulance service area which
was, on December 31, 1997, described and filed with the
department as the primar y service area for its licensed
ambulances on August 28, 1998, provided that the person
makes application and adheres to the rules and regulations
promulgated by the department pursuant to sections 190.001
to 190.245.
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3. The department shall issu e a new ground ambulance
service license to an ambulance service that is not
currently licensed by the department, or is currently
licensed by the department and is seeking to expand its
ambulance service area, except as provided in subsection 4
of this section, to be valid for a period of five years,
unless suspended, revoked or terminated, when the director
finds that the applicant meets the requirements of ambulance
service licensure established pursuant to sections 190.100
to 190.245 and the ru les adopted by the department pursuant
to sections 190.001 to 190.245. In order to be considered
for a new ambulance service license, an ambulance service
shall submit to the department a letter of endorsement from
each ambulance district or fire prot ection district that is
authorized to provide ambulance service, or from each
municipality not within an ambulance district or fire
protection district that is authorized to provide ambulance
service, in which the ambulance service proposes to
operate. If an ambulance service proposes to operate in
unincorporated portions of a county not within an ambulance
district or fire protection district that is authorized to
provide ambulance service, in order to be considered for a
new ambulance service li cense, the ambulance service shall
submit to the department a letter of endorsement from the
county. Any letter of endorsement required pursuant to this
section shall verify that the political subdivision has
conducted a public hearing regarding the e ndorsement and
that the governing body of the political subdivision has
adopted a resolution approving the endorsement. The letter
of endorsement shall affirmatively state that the proposed
ambulance service:
(1) Will provide a benefit to public health that
outweighs the associated costs;
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(2) Will maintain or enhance the public's access to
ambulance services;
(3) Will maintain or improve the public health and
promote the continued development of the regional emergency
medical service system;
(4) Has demonstrated the appropriate expertise in the
operation of ambulance services; and
(5) Has demonstrated the financial resources necessary
for the operation of the proposed ambulance service.
4. A contract between a p olitical subdivision and a
licensed ambulance service for the provision of ambulance
services for that political subdivision shall expand,
without further action by the department, the ambulance
service area of the licensed ambulance service to include
the jurisdictional boundaries of the political subdivision.
The termination of the aforementioned contract shall result
in a reduction of the licensed ambulance service's ambulance
service area by removing the geographic area of the
political subdivision from its ambulance service area,
except that licensed ambulance service providers may provide
ambulance services as are needed at and around the state
fair grounds for protection of attendees at the state fair.
5. The department shall renew a ground ambulance
service license if the applicant meets the requirements
established pursuant to sections 190.001 to 190.245, and the
rules adopted by the department pursuant to sections 190.001
to 190.245.
6. The department shall promulgate ru les relating to
the requirements for a ground ambulance service license
including, but not limited to:
(1) Vehicle design, specification, operation and
maintenance standards;
(2) Equipment requirements;
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(3) Staffing requirements;
(4) Five-year license renewal;
(5) Records and forms;
(6) Medical control plans;
(7) Medical director qualifications;
(8) Standards for medical communications;
(9) Memorandums of understanding with emergency
medical response agencies that provide advanced life support;
(10) Quality improvement committees; [and]
(11) Response time, patient care and transportation
standards;
(12) Participation with regional EMS advisory
committees; and
(13) Ambulance service administrator qualifications .
7. Application for a ground ambulance service license
shall be made upon such forms as prescribed by the
department in rules adopted pursuant to sections 190.001 to
190.245. The application form shall contain such
information as the department deems necessary to make a
determination as to whether the ground ambulance service
meets all the requirements of sections 190.001 to 190.245
and rules promulgated pursuant to sections 190.001 to
190.245.
190.112. 1. Each ambulance service licensed under
this chapter shall identify to the department an individual
as the ambulance service administrator, who shall be
responsible for the operations and staffing of the ambulance
service.
2. Any individual identified as the ambulance service
administrator under subsection 1 of this section shall be
required to have achieved basic training of at least forty
hours regarding the operations of an ambulance service and
to complete two hours of annu al continuing education to
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maintain the individual's status as the ambulance service
administrator.
3. The training required under this section shall be
offered by a statewide association organized for the benefit
of ambulance districts or be app roved by the state advisory
council on emergency medical services. Such training shall
include information on:
(1) Basic principles of accounting and economics;
(2) State and federal laws applicable to ambulance
services;
(3) Regulatory requirements applicable to ambulance
services;
(4) Human resources management and laws;
(5) Grant writing, contracts, and fundraising;
(6) The state sunshine law requirements under chapter
610 and state ethics laws; and
(7) Volunteer and community involvement.
4. Any individual serving as an ambulance service
administrator as of August 28, 2025, shall have until
January 1, 2027, to demonstrate compliance with the
provisions of this section.
190.166. 1. In addition to the provisions of section
190.165, the department of health and senior services may
refuse to issue, deny renewal of, or suspend a license
required under section 190.109, or take other corrective
actions as described in this section, ba sed on the following
considerations:
(1) The license holder is determined to be financially
insolvent;
(2) The ambulance service has inadequate personnel to
operate the ambulance service to provide basic emergency
operations. The ambulance service shall not be deemed to
have such inadequate personnel as long as the ambulance
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service is staffed to meet the needs of its emergency call
volume. Each ambulance service shall have the ability to
staff a minimum of one ambulance unit twenty -four hours each
day, seven days each week, with at least two licensed
emergency medical technicians. Any ambulance service
operating only one ambulance unit shall have a reasonable
plan and schedule for the services of a second ambulance
unit;
(3) The ambulance service requires an inordinate
amount of mutual aid from neighboring services, such as more
than ten percent of the total runs in the service area in
any given month or more than would be considered prudent,
and thus cannot provide an a ppropriate level of emergency
response for the service area as would be considered prudent
by the typical ground ambulance services operator;
(4) The principal manager, board members, or other
executives are determined to be criminally liable for
actions related to the license or service provided;
(5) The license holder or principal manager, board
members, or other executives are determined by the Centers
for Medicare and Medicaid Services to be ineligible for
participation in Medicare;
(6) The license holder or principal manager, board
members, or other executives are determined by the MO
HealthNet division to be ineligible for participation in MO
HealthNet;
(7) The ambulance service administrator has failed to
meet the required qualifications or failed to complete the
training required under section 190.112; or
(8) If the ambulance service is an ambulance district,
three or more board members have failed to complete required
training under section 190.053.
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2. If the department makes a determination of
insolvency or insufficiency of operations of a license
holder under subsection 1 of this section, the department
may require the license holder to submit a corrective plan
within fifteen days and require imp lementation of the
corrective plan within thirty days.
3. The department shall be required to provide notice
of any determination by the department of insolvency or
insufficiency of operations of a license holder to other
license holders operatin g in the license holder's vicinity,
members of the general assembly who represent the license
holder's service area, the governing officials of any county
or municipal entity in the license holder's service area,
the appropriate regional emergency medi cal services advisory
committee, and the state advisory council on emergency
medical services.
4. The department shall immediately engage with other
license holders in the area to determine the extent to which
ground ambulance service may be prov ided to the affected
service area during the time in which the license holder is
unable to provide adequate services, including any long -term
service arrangements. The nature of the agreement between
the license holder and other license holders provid ing
services to the affected area may include an agreement to
provide services, a joint powers agreement, formal
consideration, or some payment for services rendered.
5. Any license holder who provides assistance in the
service area of another li cense holder whose license has
been suspended under this section shall have the right to
seek reasonable compensation from the license holder whose
license to operate has been suspended for all calls, stand -
by time, and responses to medical emergencies during such
time as the license remains suspended. The reasonable
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compensation shall not be limited to those expenses incurred
in actual responses but may also include reasonable expenses
to maintain ambulance service including, but not limited to,
the daily operation costs of maintaining the service,
personnel wages and benefits, equipment purchases and
maintenance, and other costs incurred in the operation of a
ground ambulance service. The license holder providing
assistance shall be entitled to an award of costs and
reasonable attorney's fees in any action to enforce the
provisions of this subsection.
191.648. 1. As used in this section, the following
terms mean:
(1) "Designated sexually transmitted infection",
chlamydia, gonorrhea, trichomoniasis, or any other sexually
transmitted infection designated as appropriate for
expedited partner therapy by the department of health and
senior services or for which expedited partner therapy was
recommended in the most re cent Centers for Disease Control
and Prevention guidelines for the prevention or treatment of
sexually transmitted infections;
(2) "Expedited partner therapy" [means], the practice
of treating the sex partners of persons with [chlamydia or
gonorrhea] designated sexually transmitted infections
without an intervening medical evaluation or professional
prevention counseling ;
(3) "Health care professional", a member of any
profession regulated by chapter 334 or 335 authorized to
prescribe medications.
2. Any licensed [physician] health care professional
may, but shall not be required to, utilize expedited partner
therapy for the management of the partners of persons with
[chlamydia or gonorrhea ] designated sexually transmitted
infections. Notwithstanding the requirements of 20 CSR
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2150- 5.020 (5) or any other law to the contrary, a licensed
[physician] health care professional utilizing expedited
partner therapy may prescribe and dispense medications for
the treatment of [chlamydia or gonorrhea] a designated
sexually transmitted infection for an individual who is the
partner of a person with [chlamydia or gonorrhea ] a
designated sexually transmitted infection and who does not
have an established [physician/patient] health care
professional/patient relationship with such [physician]
health care professional . [Any antibiotic medications
prescribed and dispensed for the treatment of chlamydia or
gonorrhea under this section shall be in pill form. ]
3. Any licensed [physician] health care professional
utilizing expedited partner therapy for the management of
the partners with [chlamydia or gonorrhea ] designated
sexually transmitted infections shall provide explanation
and guidance to [a] each patient [diagnosed with chlamydia
or gonorrhea] of the preventative measures that can be taken
by the patient to stop the [spread] transmission of such
[diagnosis] infection.
4. Any licensed [physician] health care professional
utilizing expedited partner therapy for the management of
partners of persons with [chlamydia or gonorrhea ] designated
sexually transmitted infections under this section shall
have immunity from any civil liability that may otherwise
result by reason of such actions, unless such [physician]
health care professional acts negligently, recklessly, in
bad faith, or with malicious purpose.
5. The department of health and senior services and
the division of professional registration within the
department of commerce and insurance shall by ru le develop
guidelines for the implementation of subsection 2 of this
section. Any rule or portion of a rule, as that term is
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defined in section 536.010, that is created under the
authority delegated in this section shall become effective
only if it complies with and is subject to all of the
provisions of chapter 536 and, if applicable, section
536.028. This section and chapter 536 are nonseverable and
if any of the powers vested with the general assembly
pursuant to chapter 536 to review, to dela y the effective
date, or to disapprove and annul a rule are subsequently
held unconstitutional, then the grant of rulemaking
authority and any rule proposed or adopted after August 28,
2010, shall be invalid and void.
191.1145. 1. As used in sections 191.1145 and
191.1146, the following terms shall mean:
(1) "Asynchronous store-and-forward transfer", the
collection of a patient's relevant health information and
the subsequent transmission of that information from an
originating site to a health care provider at a distant site
without the patient being present;
(2) "Clinical staff", any health care provider
licensed in this state;
(3) "Distant site", a site at which a health care
provider is located while providi ng health care services by
means of telemedicine;
(4) "Health care provider", as that term is defined in
section 376.1350;
(5) "Originating site", a site at which a patient is
located at the time health care services are provided to him
or her by means of telemedicine. For the purposes of
asynchronous store-and-forward transfer, originating site
shall also mean the location at which the health care
provider transfers information to the distant site;
(6) "Telehealth" or "telemedicin e", the delivery of
health care services by means of information and
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communication technologies , including audiovisual and audio -
only technologies, which facilitate the assessment,
diagnosis, consultation, treatment, education, care
management, and self-management of a patient's health care
while such patient is at the originating site and the health
care provider is at the distant site. Telehealth or
telemedicine shall also include the use of asynchronous
store-and-forward technology. Health care providers shall
not be limited in their choice of electronic platforms used
to deliver telehealth or telemedicine, provided that all
services delivered are in accordance with the Health
Insurance Portability and Accountability Act of 1996.
2. Any licensed health care provider shall be
authorized to provide telehealth services if such services
are within the scope of practice for which the health care
provider is licensed and are provided with the same standard
of care as services provided in person. This section shall
not be construed to prohibit a health carrier, as defined in
section 376.1350, from reimbursing nonclinical staff for
services otherwise allowed by law.
3. In order to treat patients in this state through
the use of telemedicine or telehealth, health care providers
shall be fully licensed to practice in this state and shall
be subject to regulation by their respective professional
boards.
4. Nothing in subsection 3 of this section shall apply
to:
(1) Informal consultation performed by a health care
provider licensed in another state, outside of the context
of a contractual relationship, and on an irregular or
infrequent basis without the expectation or exchange of
direct or indirect compensation;
22
(2) Furnishing of health care services by a health
care provider licensed and located in another state in case
of an emergency or disaster; provided that, no charge is
made for the medical assistance; or
(3) Episodic consultation by a health ca re provider
licensed and located in another state who provides such
consultation services on request to a physician in this
state.
5. Nothing in this section shall be construed to alter
the scope of practice of any health care provider or to
authorize the delivery of health care services in a setting
or in a manner not otherwise authorized by the laws of this
state.
6. No originating site for services or activities
provided under this section shall be required to maintain
immediate availability of on-site clinical staff during the
telehealth services, except as necessary to meet the
standard of care for the treatment of the patient's medical
condition if such condition is being treated by an eligible
health care provider who is not a t the originating site, has
not previously seen the patient in person in a clinical
setting, and is not providing coverage for a health care
provider who has an established relationship with the
patient. Health care providers shall not be limited in
their choice of electronic platforms used to deliver
telehealth or telemedicine.
7. Nothing in this section shall be construed to alter
any collaborative practice requirement as provided in
chapters 334 and 335.
192.2521. A specialty hospital is exempt from the
provisions of sections 192.2520 and 197.135 if such hospital
has a policy for the transfer of a victim of a sexual
assault to an appropriate hospital with an emergency
23
department. As used in this section, "specialty hos pital"
means a hospital that has been designated by the department
of health and senior services as something other than a
general acute care hospital.
195.417. 1. The limits specified in this section
shall not apply to any quantity o f such product, mixture, or
preparation which must be dispensed, sold, or distributed in
a pharmacy pursuant to a valid prescription.
2. Within any thirty-day period, no person shall sell,
dispense, or otherwise provide to the same individual, and
no person shall purchase, receive, or otherwise acquire more
than the following amount: any number of packages of any
drug product containing any detectable amount of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts or optical isomers, or salts of optical isomers,
either as:
(1) The sole active ingredient; or
(2) One of the active ingredients of a combination
drug; or
(3) A combination of any of the products specified in
subdivisions (1) and (2) of this s ubsection;
in any total amount greater than seven and two -tenths
grams, without regard to the number of transactions.
3. Within any twenty-four-hour period, no pharmacist,
intern pharmacist, or registered pharmacy technician shall
sell, dispense, or otherwise provide to the same individual,
and no person shall purchase, receive, or otherwise acquire
more than the following amount: any number of packages of
any drug product containing any detectable amount of
ephedrine, phenylpropanolamine , or pseudoephedrine, or any
of their salts or optical isomers, or salts of optical
isomers, either as:
(1) The sole active ingredient; or
24
(2) One of the active ingredients of a combination
drug; or
(3) A combination of any of the prod ucts specified in
subdivisions (1) and (2) of this subsection;
in any total amount greater than three and six -tenths
grams without regard to the number of transactions.
4. Within any twelve-month period, no person shall
sell, dispense, or oth erwise provide to the same individual,
and no person shall purchase, receive, or otherwise acquire
more than the following amount: any number of packages of
any drug product containing any detectable amount of
ephedrine, phenylpropanolamine, or pseudo ephedrine, or any
of their salts or optical isomers, or salts of optical
isomers, either as:
(1) The sole active ingredient; or
(2) One of the active ingredients of a combination
drug; or
(3) A combination of any of the products specif ied in
subdivisions (1) and (2) of this subsection;
in any total amount greater than [forty-three] sixty-
one and two-tenths grams, without regard to the number of
transactions.
5. All packages of any compound, mixture, or
preparation containing any detectable quantity of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts or optical isomers, or salts of optical isomers,
except those that are excluded from Schedule V in subsection
17 or 18 of section 195.017, shall be offered for sale only
from behind a pharmacy counter where the public is not
permitted, and only by a registered pharmacist or registered
pharmacy technician under section 195.017.
6. Each pharmacy shall submit information regarding
sales of any compound, mixture, or preparation as specified
25
in this section in accordance with transmission methods and
frequency established by the department by regulation.
7. No prescription shall be required for the
dispensation, sale, or distribution of any drug product
containing any detectable amount of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts or optical isomers, or salts of optical isomers, in an
amount within the limits described in subsections 2, 3, and
4 of this section. The superintendent of the Missouri state
highway patrol shall report to the revisor of statutes and
the general assembly by February first when the statewide
number of methamphetamine laboratory seizure incidents
exceeds three hundred incide nts in the previous calendar
year. The provisions of this subsection shall expire on
April first of the calendar year in which the revisor of
statutes receives such notification.
8. This section shall supersede and preempt any local
ordinances or regulations, including any ordinances or
regulations enacted by any political subdivision of the
state. This section shall not apply to the sale of any
animal feed products containing ephedrine or any naturally
occurring or herbal ephedra or extract of ephedra.
9. Any local ordinances or regulations enacted by any
political subdivision of the state prior to August 28, 2020,
requiring a prescription for the dispensation, sale, or
distribution of any drug product containing any detectable
amount of ephedrine, phenylpropanolamine, or
pseudoephedrine, or any of their salts or optical isomers,
or salts of optical isomers, in an amount within the limits
described in subsections 2, 3, and 4 of this section shall
be void and of no effect and no such political subdivision
shall maintain or enforce such ordinance or regulation.
26
10. All logs, records, documents, and electronic
information maintained for the dispensing of these products
shall be open for inspection and copying by municipal,
county, and state or federal law enforcement officers whose
duty it is to enforce the controlled substances laws of this
state or the United States.
11. All persons who dispense or offer for sale
pseudoephedrine and ephedrine products, except tho se that
are excluded from Schedule V in subsection 17 or 18 of
section 195.017, shall ensure that all such products are
located only behind a pharmacy counter where the public is
not permitted.
12. The penalty for a knowing or reckless violation of
this section is found in section 579.060.
196.990. 1. As used in this section, the following
terms shall mean:
(1) "Administer", the direct application of an
epinephrine auto-injector to the body of an individual;
(2) "Authorized entity", any entity or organization at
or in connection with which allergens capable of causing
anaphylaxis may be present including, but not limited to,
qualified first responders, as such term is defined in
section 321.621, facilities licensed under chapter 198,
restaurants, recreation camps, youth sports leagues,
amusement parks, and sports arenas. "Authorized entity"
shall not include any public school or public charter school;
(3) "Epinephrine auto-injector", a single-use device
used for the automatic injection of a premeasured dose of
epinephrine into the human body;
(4) "Physician", a physician licensed in this state
under chapter 334;
(5) "Provide", the supply of one or more epinephrine
auto-injectors to an individual;
27
(6) "Self-administration", a person's discretionary
use of an epinephrine auto -injector.
2. A physician may prescribe epinephrine auto -
injectors in the name of an authorized entity for use in
accordance with this section, and pharma cists, physicians,
and other persons authorized to dispense prescription
medications may dispense epinephrine auto -injectors under a
prescription issued in the name of an authorized entity.
3. An authorized entity may acquire and stock a supply
of epinephrine auto-injectors under a prescription issued in
accordance with this section. Such epinephrine auto -
injectors shall be stored in a location readily accessible
in an emergency and in accordance with the epinephrine auto -
injector's instructi ons for use and any additional
requirements established by the department of health and
senior services by rule. An authorized entity shall
designate employees or agents who have completed the
training required under this section to be responsible for
the storage, maintenance, and general oversight of
epinephrine auto-injectors acquired by the authorized entity.
4. An authorized entity that acquires a supply of
epinephrine auto-injectors under a prescription issued in
accordance with this sec tion shall ensure that:
(1) Expected epinephrine auto -injector users receive
training in recognizing symptoms of severe allergic
reactions including anaphylaxis and the use of epinephrine
auto-injectors from a nationally recognized organization
experienced in training laypersons in emergency health
treatment or another entity or person approved by the
department of health and senior services;
(2) All epinephrine auto -injectors are maintained and
stored according to the epinephrine auto -injector's
instructions for use;
28
(3) Any person who provides or administers an
epinephrine auto-injector to an individual who the person
believes in good faith is experiencing anaphylaxis activates
the emergency medical services system as soon as p ossible;
and
(4) A proper review of all situations in which an
epinephrine auto-injector is used to render emergency care
is conducted.
5. Any authorized entity that acquires a supply of
epinephrine auto-injectors under a prescription issue d in
accordance with this section shall notify the emergency
communications district or the ambulance dispatch center of
the primary provider of emergency medical services where the
epinephrine auto-injectors are to be located within the
entity's facility.
6. No person shall provide or administer an
epinephrine auto-injector to any individual who is under
eighteen years of age without the verbal consent of a parent
or guardian who is present at the time when provision or
administration of the epinephrine auto-injector is needed.
Provided, however, that a person may provide or administer
an epinephrine auto-injector to such an individual without
the consent of a parent or guardian if the parent or
guardian is not physically present and the person reasonably
believes the individual shall be in imminent danger without
the provision or administration of the epinephrine auto -
injector.
7. The following persons and entities shall not be
liable for any injuries or related damages that re sult from
the administration or self -administration of an epinephrine
auto-injector in accordance with this section that may
constitute ordinary negligence:
29
(1) An authorized entity that possesses and makes
available epinephrine auto -injectors and its employees,
agents, and other trained persons;
(2) Any person who uses an epinephrine auto -injector
made available under this section;
(3) A physician that prescribes epinephrine auto -
injectors to an authorized entity; or
(4) Any person or entity that conducts the training
described in this section.
Such immunity does not apply to acts or omissions
constituting a reckless disregard for the safety of others
or willful or wanton conduct. The administration of an
epinephrine auto-injector in accordance with this section
shall not be considered the practice of medicine. The
immunity from liability provided under this subsection is in
addition to and not in lieu of that provided under section
537.037. An authorized entity loca ted in this state shall
not be liable for any injuries or related damages that
result from the provision or administration of an
epinephrine auto-injector by its employees or agents outside
of this state if the entity or its employee or agent is not
liable for such injuries or related damages under the laws
of the state in which such provision or administration
occurred. No trained person who is in compliance with this
section and who in good faith and exercising reasonable care
fails to administer an epinephrine auto -injector shall be
liable for such failure.
8. All basic life support ambulances and stretcher
vans operated in the state shall be equipped with
epinephrine auto-injectors and be staffed by at least one
individual trained in the use of epinephrine auto -injectors.
9. The provisions of this section shall apply in all
counties within the state and any city not within a county.
30
10. Nothing in this section shall be construed as
superseding the provisions of section 16 7.630.
198.022. 1. Upon receipt of an application for a
license to operate a facility, the department shall review
the application, investigate the applicant and the
statements sworn to in the application for license and
conduct any necessary inspections. A license shall be
issued if the following requirements are met:
(1) The statements in the application are true and
correct;
(2) The facility and the operator are in substantial
compliance with the provisions of sectio ns 198.003 to
198.096 and the standards established thereunder;
(3) The applicant has the financial capacity to
operate the facility;
(4) The administrator of an assisted living facility,
a skilled nursing facility, or an intermediate care f acility
is currently licensed under the provisions of chapter 344;
(5) Neither the operator nor any principals in the
operation of the facility have ever been convicted of a
felony offense concerning the operation of a long -term
health care facility or other health care facility or ever
knowingly acted or knowingly failed to perform any duty
which materially and adversely affected the health, safety,
welfare or property of a resident, while acting in a
management capacity. The operator of the facility or any
principal in the operation of the facility shall not be
under exclusion from participation in the Title XVIII
(Medicare) or Title XIX (Medicaid) program of any state or
territory;
(6) Neither the operator nor any principals invol ved
in the operation of the facility have ever been convicted of
a felony in any state or federal court arising out of
31
conduct involving either management of a long -term care
facility or the provision or receipt of health care;
(7) All fees due to the state have been paid.
2. Upon denial of any application for a license, the
department shall so notify the applicant in writing, setting
forth therein the reasons and grounds for denial.
3. The department may inspect any facility and any
records and may make copies of records, at the facility, at
the department's own expense, required to be maintained by
sections 198.003 to 198.096 or by the rules and regulations
promulgated thereunder at any time if a license has been
issued to or an application for a license has been filed by
the operator of such facility. Copies of any records
requested by the department shall be prepared by the staff
of such facility within two business days or as determined
by the department. The department shall not remove or
disassemble any medical record during any inspection of the
facility, but may observe the photocopying or may make its
own copies if the facility does not have the technology to
make the copies. In accordance with the provisions o f
section 198.525, the department shall make at least one
inspection per year, which shall be unannounced to the
operator. The department may make such other inspections,
announced or unannounced, as it deems necessary to carry out
the provisions of sections 198.003 to 198.136.
4. Whenever the department has reasonable grounds to
believe that a facility required to be licensed under
sections 198.003 to 198.096 is operating without a license,
and the department is not permitted access to inspe ct the
facility, or when a licensed operator refuses to permit
access to the department to inspect the facility, the
department shall apply to the circuit court of the county in
which the premises is located for an order authorizing entry
32
for such inspection, and the court shall issue the order if
it finds reasonable grounds for inspection or if it finds
that a licensed operator has refused to permit the
department access to inspect the facility.
5. Whenever the department is inspecting a faci lity in
response to an application from an operator located outside
of Missouri not previously licensed by the department, the
department may request from the applicant the past five
years compliance history of all facilities owned by the
applicant located outside of this state.
6. If a licensee of a residential care facility or
assisted living facility is accredited by a recognized
accrediting entity, then the licensee may submit to the
department documentation of the licensee's current
accreditation status. If a licensee submits to the
department documentation from a recognized accrediting
entity that the licensee is in good standing, then the
department shall not conduct an annual onsite inspection of
the licensee. Nothing in this subsection shall preclude the
department from conducting inspections for violations of
standards or requirements contained within this chapter or
any other applicable law or regulation. As used in this
subsection, the term "recognized accrediting entity" shall
mean the Joint Commission or another nationally -recognized
accrediting entity approved by the department that has
specific residential care facility or assisted living
facility program standards equivalent to the standards
established by the de partment under this chapter.
206.110. 1. A hospital district, both within and
outside such district, except in counties of the third or
fourth classification (other than within the district
boundaries) where there already exists a hosp ital organized
pursuant to [chapters 96, 205 or] this chapter; provided,
33
however, that this exception shall not prohibit the
continuation or expansion of existing activities otherwise
allowed by law, shall have and exercise the following
governmental powers, and all other powers incidental,
necessary, convenient or desirable to carry out and
effectuate the express powers:
(1) To establish and maintain a hospital or hospitals
and hospital facilities, and to construct, acquire, develop,
expand, extend and improve any such hospital or hospital
facility including medical office buildings to provide
offices for rental to physicians and dentists on the
district hospital's medical or dental staff, and the
providing of sites therefor, including of fstreet parking
space for motor vehicles;
(2) To acquire land in fee simple, rights in land and
easements upon, over or across land and leasehold interest
in land and tangible and intangible personal property used
or useful for the location, esta blishment, maintenance,
development, expansion, extension or improvement of any
hospital or hospital facility. The acquisition may be by
dedication, purchase, gift, agreement, lease, use or adverse
possession or by condemnation;
(3) To operate, maintain and manage a hospital and
hospital facilities, and to make and enter into contracts,
for the use, operation or management of a hospital or
hospital facilities; to engage in health care activities;
and to make and enter into leases of equipment and real
property, a hospital or hospital facilities, as lessor or
lessee, regardless of the duration of such lease; and to
provide rules and regulations for the operation, management
or use of a hospital or hospital facilities. Any agreement
entered into pursuant to this subsection pertaining to the
lease of the hospital shall have a definite termination date
34
as negotiated by the parties, but this shall not preclude
the trustees from entering into a renewal of the agreement
with the same or othe r parties pertaining to the same or
other subjects upon such terms and conditions as the parties
may agree;
(4) To fix, charge and collect reasonable fees and
compensation for the use or occupancy of the hospital or any
part thereof, or any hospi tal facility, and for nursing
care, medicine, attendance, or other services furnished by
the hospital or hospital facilities, according to the rules
and regulations prescribed by the board from time to time;
(5) To borrow money and to issue bonds, notes,
certificates, or other evidences of indebtedness for the
purpose of accomplishing any of its corporate purposes,
subject to compliance with any condition or limitation set
forth in this chapter or otherwise provided by the
Constitution of the state of Missouri;
(6) To employ or enter into contracts for the
employment of any person, firm, or corporation, and for
professional services, necessary or desirable for the
accomplishment of the corporate objects of the district or
the proper administration, management, protection or control
of its property;
(7) To maintain the hospital for the benefit of the
inhabitants of the area comprising the district who are
sick, injured, or maimed regardless of race, creed or color,
and to adopt such reasonable rules and regulations as may be
necessary to render the use of the hospital of the greatest
benefit to the greatest number; to exclude from the use of
the hospital all persons who willfully disregard any of the
rules and regulations s o established; to extend the
privileges and use of the hospital to persons residing
outside the area of the district upon such terms and
35
conditions as the board of directors prescribes by its rules
and regulations;
(8) To police its property and to exercise police
powers in respect thereto or in respect to the enforcement
of any rule or regulation provided by the ordinances of the
district and to employ and commission police officers and
other qualified persons to enforce the same;
(9) To lease to or allow for any institution of higher
education to use or occupy the hospital, any real estate or
facility owned or leased by the district or any part thereof
for the purpose of health care -related and general education
or training.
2. The use of any hospital or hospital facility of a
district shall be subject to the reasonable regulation and
control of the district and upon such reasonable terms and
conditions as shall be established by its board of directors.
3. A regulatory ordinance of a district adopted under
any provision of this section may provide for a suspension
or revocation of any rights or privileges within the control
of the district for a violation of any such regulatory
ordinance.
4. Nothing in this section or in other provisions of
this chapter shall be construed to authorize the district or
board to establish or enforce any regulation or rule in
respect to hospitalization or the operation or maintenance
of such hospital or any hospital facilities within its
jurisdiction which is in conflict with any federal or state
law or regulation applicable to the same subject matter.
206.158. 1. The board of directors of any hospital
district authorized under subsection 2 of this section, and
established and organized under the provisions of this
chapter:
36
(1) May invest up to fifty percent of its "available
funds", defined in this section as funds not required for
immediate disbursement in obligations or for the operation
of the hospital district, into:
(a) Any mutual funds that invest in stocks, bonds, or
real estate, or any combination thereof;
(b) Bonds that have:
a. One of the five highest long -term ratings or the
highest short-term rating issued by a natio nally recognized
rating agency; and
b. A final maturity of ten years or less;
(c) Money market investments; or
(d) Any combination of investments described in
paragraphs (a) to (c) of this subdivision; and
(2) Shall invest the rem aining percentage of any
available funds not invested as allowed under subdivision
(1) of this subsection into any investment in which the
state treasurer is allowed to invest.
2. The provisions of this section shall apply only if
the hospital district receives less than three percent of
its annual revenues from hospital district or state taxes.
208.152. 1. MO HealthNet payments shall be made on
behalf of those eligible needy persons as described in
section 208.151 who are una ble to provide for it in whole or
in part, with any payments to be made on the basis of the
reasonable cost of the care or reasonable charge for the
services as defined and determined by the MO HealthNet
division, unless otherwise hereinafter provided, for the
following:
(1) Inpatient hospital services, except to persons in
an institution for mental diseases who are under the age of
sixty-five years and over the age of twenty -one years;
provided that the MO HealthNet division shall provide
37
through rule and regulation an exception process for
coverage of inpatient costs in those cases requiring
treatment beyond the seventy -fifth percentile professional
activities study (PAS) or the MO HealthNet children's
diagnosis length-of-stay schedule; and provided further that
the MO HealthNet division shall take into account through
its payment system for hospital services the situation of
hospitals which serve a disproportionate number of low -
income patients;
(2) All outpatient hospital serv ices, payments
therefor to be in amounts which represent no more than
eighty percent of the lesser of reasonable costs or
customary charges for such services, determined in
accordance with the principles set forth in Title XVIII A
and B, Public Law 89 -97, 1965 amendments to the federal
Social Security Act (42 U.S.C. Section 301, et seq.), but
the MO HealthNet division may evaluate outpatient hospital
services rendered under this section and deny payment for
services which are determined by the MO H ealthNet division
not to be medically necessary, in accordance with federal
law and regulations;
(3) Laboratory and X-ray services;
(4) Nursing home services for participants, except to
persons with more than five hundred thousand dollars eq uity
in their home or except for persons in an institution for
mental diseases who are under the age of sixty -five years,
when residing in a hospital licensed by the department of
health and senior services or a nursing home licensed by the
department of health and senior services or appropriate
licensing authority of other states or government -owned and -
operated institutions which are determined to conform to
standards equivalent to licensing requirements in Title XIX
of the federal Social Securi ty Act (42 U.S.C. Section [301,]
38
1396 et seq.), as amended, for nursing facilities. The MO
HealthNet division may recognize through its payment
methodology for nursing facilities those nursing facilities
which serve a high volume of MO HealthNet patie nts. The MO
HealthNet division when determining the amount of the
benefit payments to be made on behalf of persons under the
age of twenty-one in a nursing facility may consider nursing
facilities furnishing care to persons under the age of
twenty-one as a classification separate from other nursing
facilities;
(5) Nursing home costs for participants receiving
benefit payments under subdivision (4) of this subsection
for those days, which shall not exceed twelve per any period
of six consecutive months, during which the participant is
on a temporary leave of absence from the hospital or nursing
home, provided that no such participant shall be allowed a
temporary leave of absence unless it is specifically
provided for in his plan of care. As used in this
subdivision, the term "temporary leave of absence" shall
include all periods of time during which a participant is
away from the hospital or nursing home overnight because he
is visiting a friend or relative;
(6) Physicians' services, whether furnished in the
office, home, hospital, nursing home, or elsewhere,
provided, that no funds shall be expended to any abortion
facility, as defined in section 188.015, or to any
affiliate, as defined in section 188.015, of such abortion
facility;
(7) Subject to appropriation, up to twenty visits per
year for services limited to examinations, diagnoses,
adjustments, and manipulations and treatments of
malpositioned articulations and structures of the body
provided by licensed chir opractic physicians practicing
39
within their scope of practice. Nothing in this subdivision
shall be interpreted to otherwise expand MO HealthNet
services;
(8) Drugs and medicines when prescribed by a licensed
physician, dentist, podiatrist, or a n advanced practice
registered nurse; except that no payment for drugs and
medicines prescribed on and after January 1, 2006, by a
licensed physician, dentist, podiatrist, or an advanced
practice registered nurse may be made on behalf of any
person who qualifies for prescription drug coverage under
the provisions of P.L. 108 -173;
(9) Emergency ambulance services and, effective
January 1, 1990, medically necessary transportation to
scheduled, physician -prescribed nonelective treatments;
(10) Early and periodic screening and diagnosis of
individuals who are under the age of twenty -one to ascertain
their physical or mental defects, and health care,
treatment, and other measures to correct or ameliorate
defects and chronic conditions disc overed thereby. Such
services shall be provided in accordance with the provisions
of Section 6403 of P.L. 101 -239 and federal regulations
promulgated thereunder;
(11) Home health care services;
(12) Family planning as defined by federal rul es and
regulations; provided, that no funds shall be expended to
any abortion facility, as defined in section 188.015, or to
any affiliate, as defined in section 188.015, of such
abortion facility; and further provided, however, that such
family planning services shall not include abortions or any
abortifacient drug or device that is used for the purpose of
inducing an abortion unless such abortions are certified in
writing by a physician to the MO HealthNet agency that, in
40
the physician's professi onal judgment, the life of the
mother would be endangered if the fetus were carried to term;
(13) Inpatient psychiatric hospital services for
individuals under age twenty -one as defined in Title XIX of
the federal Social Security Act (42 U.S.C. Se ction 1396d, et
seq.);
(14) Outpatient surgical procedures, including
presurgical diagnostic services performed in ambulatory
surgical facilities which are licensed by the department of
health and senior services of the state of Missouri; except,
that such outpatient surgical services shall not include
persons who are eligible for coverage under Part B of Title
XVIII, Public Law 89 -97, 1965 amendments to the federal
Social Security Act, as amended, if exclusion of such
persons is permitted un der Title XIX, Public Law 89 -97, 1965
amendments to the federal Social Security Act, as amended;
(15) Personal care services which are medically
oriented tasks having to do with a person's physical
requirements, as opposed to housekeeping requirem ents, which
enable a person to be treated by his or her physician on an
outpatient rather than on an inpatient or residential basis
in a hospital, intermediate care facility, or skilled
nursing facility. Personal care services shall be rendered
by an individual not a member of the participant's family
who is qualified to provide such services where the services
are prescribed by a physician in accordance with a plan of
treatment and are supervised by a licensed nurse. Persons
eligible to receive personal care services shall be those
persons who would otherwise require placement in a hospital,
intermediate care facility, or skilled nursing facility.
Benefits payable for personal care services shall not exceed
for any one participant one hundre d percent of the average
statewide charge for care and treatment in an intermediate
41
care facility for a comparable period of time. Such
services, when delivered in a residential care facility or
assisted living facility licensed under chapter 198 , shall
be authorized on a tier level based on the services the
resident requires and the frequency of the services. A
resident of such facility who qualifies for assistance under
section 208.030 shall, at a minimum, if prescribed by a
physician, qualify for the tier level with the fewest
services. The rate paid to providers for each tier of
service shall be set subject to appropriations. Subject to
appropriations, each resident of such facility who qualifies
for assistance under section 208.030 and meets the level of
care required in this section shall, at a minimum, if
prescribed by a physician, be authorized up to one hour of
personal care services per day. Authorized units of
personal care services shall not be reduced or tier level
lowered unless an order approving such reduction or lowering
is obtained from the resident's personal physician. Such
authorized units of personal care services or tier level
shall be transferred with such resident if he or she
transfers to another such facil ity. Such provision shall
terminate upon receipt of relevant waivers from the federal
Department of Health and Human Services. If the Centers for
Medicare and Medicaid Services determines that such
provision does not comply with the state plan, this
provision shall be null and void. The MO HealthNet division
shall notify the revisor of statutes as to whether the
relevant waivers are approved or a determination of
noncompliance is made;
(16) Mental health services. The state plan for
providing medical assistance under Title XIX of the Social
Security Act, 42 U.S.C. Section [301] 1396 et seq., as
amended, shall include the following mental health services
42
when such services are provided by community mental health
facilities operated by t he department of mental health or
designated by the department of mental health as a community
mental health facility or as an alcohol and drug abuse
facility or as a child -serving agency within the
comprehensive children's mental health service system
established in section 630.097. The department of mental
health shall establish by administrative rule the definition
and criteria for designation as a community mental health
facility and for designation as an alcohol and drug abuse
facility. Such mental health services shall include:
(a) Outpatient mental health services including
preventive, diagnostic, therapeutic, rehabilitative, and
palliative interventions rendered to individuals in an
individual or group setting by a mental health p rofessional
in accordance with a plan of treatment appropriately
established, implemented, monitored, and revised under the
auspices of a therapeutic team as a part of client services
management;
(b) Clinic mental health services including
preventive, diagnostic, therapeutic, rehabilitative, and
palliative interventions rendered to individuals in an
individual or group setting by a mental health professional
in accordance with a plan of treatment appropriately
established, implemented, monito red, and revised under the
auspices of a therapeutic team as a part of client services
management;
(c) Rehabilitative mental health and alcohol and drug
abuse services including home and community -based
preventive, diagnostic, therapeutic, rehabi litative, and
palliative interventions rendered to individuals in an
individual or group setting by a mental health or alcohol
and drug abuse professional in accordance with a plan of
43
treatment appropriately established, implemented, monitored,
and revised under the auspices of a therapeutic team as a
part of client services management. As used in this
section, mental health professional and alcohol and drug
abuse professional shall be defined by the department of
mental health pursuant to duly pr omulgated rules. With
respect to services established by this subdivision, the
department of social services, MO HealthNet division, shall
enter into an agreement with the department of mental
health. Matching funds for outpatient mental health
services, clinic mental health services, and rehabilitation
services for mental health and alcohol and drug abuse shall
be certified by the department of mental health to the MO
HealthNet division. The agreement shall establish a
mechanism for the joint i mplementation of the provisions of
this subdivision. In addition, the agreement shall
establish a mechanism by which rates for services may be
jointly developed;
(17) Such additional services as defined by the MO
HealthNet division to be furnish ed under waivers of federal
statutory requirements as provided for and authorized by the
federal Social Security Act (42 U.S.C. Section 301, et seq.)
subject to appropriation by the general assembly;
(18) The services of an advanced practice regis tered
nurse with a collaborative practice agreement to the extent
that such services are provided in accordance with chapters
334 and 335, and regulations promulgated thereunder;
(19) Nursing home costs for participants receiving
benefit payments under subdivision (4) of this subsection to
reserve a bed for the participant in the nursing home during
the time that the participant is absent due to admission to
a hospital for services which cannot be performed on an
44
outpatient basis, subject to t he provisions of this
subdivision:
(a) The provisions of this subdivision shall apply
only if:
a. The occupancy rate of the nursing home is at or
above ninety-seven percent of MO HealthNet certified
licensed beds, according to the most rece nt quarterly census
provided to the department of health and senior services
which was taken prior to when the participant is admitted to
the hospital; and
b. The patient is admitted to a hospital for a medical
condition with an anticipated stay of three days or less;
(b) The payment to be made under this subdivision
shall be provided for a maximum of three days per hospital
stay;
(c) For each day that nursing home costs are paid on
behalf of a participant under this subdivision dur ing any
period of six consecutive months such participant shall,
during the same period of six consecutive months, be
ineligible for payment of nursing home costs of two
otherwise available temporary leave of absence days provided
under subdivision (5 ) of this subsection; and
(d) The provisions of this subdivision shall not apply
unless the nursing home receives notice from the participant
or the participant's responsible party that the participant
intends to return to the nursing home followi ng the hospital
stay. If the nursing home receives such notification and
all other provisions of this subsection have been satisfied,
the nursing home shall provide notice to the participant or
the participant's responsible party prior to release of t he
reserved bed;
(20) Prescribed medically necessary durable medical
equipment. An electronic web-based prior authorization
45
system using best medical evidence and care and treatment
guidelines consistent with national standards shall be used
to verify medical need;
(21) Hospice care. As used in this subdivision, the
term "hospice care" means a coordinated program of active
professional medical attention within a home, outpatient and
inpatient care which treats the terminally ill patien t and
family as a unit, employing a medically directed
interdisciplinary team. The program provides relief of
severe pain or other physical symptoms and supportive care
to meet the special needs arising out of physical,
psychological, spiritual, soci al, and economic stresses
which are experienced during the final stages of illness,
and during dying and bereavement and meets the Medicare
requirements for participation as a hospice as are provided
in 42 CFR Part 418. The rate of reimbursement paid by the
MO HealthNet division to the hospice provider for room and
board furnished by a nursing home to an eligible hospice
patient shall not be less than ninety -five percent of the
rate of reimbursement which would have been paid for
facility services in that nursing home facility for that
patient, in accordance with subsection (c) of Section 6408
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
(22) Prescribed medically necessary dental services.
Such services shall be subject to appropriations. An
electronic web-based prior authorization system using best
medical evidence and care and treatment guidelines
consistent with national standards shall be used to verify
medical need;
(23) Prescribed medically necessary optome tric
services. Such services shall be subject to
appropriations. An electronic web-based prior authorization
system using best medical evidence and care and treatment
46
guidelines consistent with national standards shall be used
to verify medical need ;
(24) Blood clotting products -related services. For
persons diagnosed with a bleeding disorder, as defined in
section 338.400, reliant on blood clotting products, as
defined in section 338.400, such services include:
(a) Home delivery of blood clotting products and
ancillary infusion equipment and supplies, including the
emergency deliveries of the product when medically necessary;
(b) Medically necessary ancillary infusion equipment
and supplies required to administer the blood cl otting
products; and
(c) Assessments conducted in the participant's home by
a pharmacist, nurse, or local home health care agency
trained in bleeding disorders when deemed necessary by the
participant's treating physician;
(25) Medically necessary cochlear implants and hearing
instruments, as defined in section 345.015, that are:
(a) Prescribed by an audiologist, as defined in
section 345.015; or
(b) Dispensed by a hearing instrument specialist, as
defined in section 346.010;
(26) The MO HealthNet division shall, by January 1,
2008, and annually thereafter, report the status of MO
HealthNet provider reimbursement rates as compared to one
hundred percent of the Medicare reimbursement rates and
compared to the average d ental reimbursement rates paid by
third-party payors licensed by the state. The MO HealthNet
division shall, by July 1, 2008, provide to the general
assembly a four-year plan to achieve parity with Medicare
reimbursement rates and for third -party payor average dental
reimbursement rates. Such plan shall be subject to
appropriation and the division shall include in its annual
47
budget request to the governor the necessary funding needed
to complete the four -year plan developed under this
subdivision.
2. Additional benefit payments for medical assistance
shall be made on behalf of those eligible needy children,
pregnant women and blind persons with any payments to be
made on the basis of the reasonable cost of the care or
reasonable charge for the services as defined and determined
by the MO HealthNet division, unless otherwise hereinafter
provided, for the following:
(1) Dental services;
(2) Services of podiatrists as defined in section
330.010;
(3) Optometric services a s described in section
336.010;
(4) Orthopedic devices or other prosthetics, including
eye glasses, dentures, [hearing aids,] and wheelchairs;
(5) Hospice care. As used in this subdivision, the
term "hospice care" means a coordinated progra m of active
professional medical attention within a home, outpatient and
inpatient care which treats the terminally ill patient and
family as a unit, employing a medically directed
interdisciplinary team. The program provides relief of
severe pain or other physical symptoms and supportive care
to meet the special needs arising out of physical,
psychological, spiritual, social, and economic stresses
which are experienced during the final stages of illness,
and during dying and bereavement and meets the Medicare
requirements for participation as a hospice as are provided
in 42 CFR Part 418. The rate of reimbursement paid by the
MO HealthNet division to the hospice provider for room and
board furnished by a nursing home to an eligible hospice
patient shall not be less than ninety -five percent of the
48
rate of reimbursement which would have been paid for
facility services in that nursing home facility for that
patient, in accordance with subsection (c) of Section 6408
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
(6) Comprehensive day rehabilitation services
beginning early posttrauma as part of a coordinated system
of care for individuals with disabling impairments.
Rehabilitation services must be based on an individuali zed,
goal-oriented, comprehensive and coordinated treatment plan
developed, implemented, and monitored through an
interdisciplinary assessment designed to restore an
individual to an optimal level of physical, cognitive, and
behavioral function. The MO HealthNet division shall
establish by administrative rule the definition and criteria
for designation of a comprehensive day rehabilitation
service facility, benefit limitations and payment
mechanism. Any rule or portion of a rule, as that term is
defined in section 536.010, that is created under the
authority delegated in this subdivision shall become
effective only if it complies with and is subject to all of
the provisions of chapter 536 and, if applicable, section
536.028. This section and chapter 536 are nonseverable and
if any of the powers vested with the general assembly
pursuant to chapter 536 to review, to delay the effective
date, or to disapprove and annul a rule are subsequently
held unconstitutional, then the grant of rulemaki ng
authority and any rule proposed or adopted after August 28,
2005, shall be invalid and void.
3. The MO HealthNet division may require any
participant receiving MO HealthNet benefits to pay part of
the charge or cost until July 1, 2008, and an additional
payment after July 1, 2008, as defined by rule duly
promulgated by the MO HealthNet division, for all covered
49
services except for those services covered under
subdivisions (15) and (16) of subsection 1 of this section
and sections 208.631 t o 208.657 to the extent and in the
manner authorized by Title XIX of the federal Social
Security Act (42 U.S.C. Section 1396, et seq.) and
regulations thereunder. When substitution of a generic drug
is permitted by the prescriber according to section 338.056,
and a generic drug is substituted for a name -brand drug, the
MO HealthNet division may not lower or delete the
requirement to make a co -payment pursuant to regulations of
Title XIX of the federal Social Security Act. A provider of
goods or services described under this section must collect
from all participants the additional payment that may be
required by the MO HealthNet division under authority
granted herein, if the division exercises that authority, to
remain eligible as a provider. Any payments made by
participants under this section shall be in addition to and
not in lieu of payments made by the state for goods or
services described herein except the participant portion of
the pharmacy professional dispensing fee shall be in
addition to and not in lieu of payments to pharmacists. A
provider may collect the co -payment at the time a service is
provided or at a later date. A provider shall not refuse to
provide a service if a participant is unable to pay a
required payment. If it is the routine business practice of
a provider to terminate future services to an individual
with an unclaimed debt, the provider may include uncollected
co-payments under this practice. Providers who elect not to
undertake the provision of se rvices based on a history of
bad debt shall give participants advance notice and a
reasonable opportunity for payment. A provider,
representative, employee, independent contractor, or agent
of a pharmaceutical manufacturer shall not make co -payment
50
for a participant. This subsection shall not apply to other
qualified children, pregnant women, or blind persons. If
the Centers for Medicare and Medicaid Services does not
approve the MO HealthNet state plan amendment submitted by
the department of social services that would allow a
provider to deny future services to an individual with
uncollected co-payments, the denial of services shall not be
allowed. The department of social services shall inform
providers regarding the acceptability of deny ing services as
the result of unpaid co -payments.
4. The MO HealthNet division shall have the right to
collect medication samples from participants in order to
maintain program integrity.
5. Reimbursement for obstetrical and pediatric
services under subdivision (6) of subsection 1 of this
section shall be timely and sufficient to enlist enough
health care providers so that care and services are
available under the state plan for MO HealthNet benefits at
least to the extent that such care and services are
available to the general population in the geographic area,
as required under subparagraph (a)(30)(A) of 42 U.S.C.
Section 1396a and federal regulations promulgated thereunder.
6. Beginning July 1, 1990, reimbursement for service s
rendered in federally funded health centers shall be in
accordance with the provisions of subsection 6402(c) and
Section 6404 of P.L. 101 -239 (Omnibus Budget Reconciliation
Act of 1989) and federal regulations promulgated thereunder.
7. Beginning July 1, 1990, the department of social
services shall provide notification and referral of children
below age five, and pregnant, breast -feeding, or postpartum
women who are determined to be eligible for MO HealthNet
benefits under section 208.151 t o the special supplemental
food programs for women, infants and children administered
51
by the department of health and senior services. Such
notification and referral shall conform to the requirements
of Section 6406 of P.L. 101 -239 and regulations pro mulgated
thereunder.
8. Providers of long-term care services shall be
reimbursed for their costs in accordance with the provisions
of Section 1902 (a)(13)(A) of the Social Security Act, 42
U.S.C. Section 1396a, as amended, and regulations
promulgated thereunder.
9. Reimbursement rates to long -term care providers
with respect to a total change in ownership, at arm's
length, for any facility previously licensed and certified
for participation in the MO HealthNet program shall not
increase payments in excess of the increase that would
result from the application of Section 1902 (a)(13)(C) of
the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C).
10. The MO HealthNet division may enroll qualified
residential care facilities an d assisted living facilities,
as defined in chapter 198, as MO HealthNet personal care
providers.
11. Any income earned by individuals eligible for
certified extended employment at a sheltered workshop under
chapter 178 shall not be considered as income for purposes
of determining eligibility under this section.
12. If the Missouri Medicaid audit and compliance unit
changes any interpretation or application of the
requirements for reimbursement for MO HealthNet services
from the interpretation or application that has been applied
previously by the state in any audit of a MO HealthNet
provider, the Missouri Medicaid audit and compliance unit
shall notify all affected MO HealthNet providers five
business days before such change shall ta ke effect. Failure
of the Missouri Medicaid audit and compliance unit to notify
52
a provider of such change shall entitle the provider to
continue to receive and retain reimbursement until such
notification is provided and shall waive any liability of
such provider for recoupment or other loss of any payments
previously made prior to the five business days after such
notice has been sent. Each provider shall provide the
Missouri Medicaid audit and compliance unit a valid email
address and shall agr ee to receive communications
electronically. The notification required under this
section shall be delivered in writing by the United States
Postal Service or electronic mail to each provider.
13. Nothing in this section shall be construed to
abrogate or limit the department's statutory requirement to
promulgate rules under chapter 536.
14. Beginning July 1, 2016, and subject to
appropriations, providers of behavioral, social, and
psychophysiological services for the prevention, treatmen t,
or management of physical health problems shall be
reimbursed utilizing the behavior assessment and
intervention reimbursement codes 96150 to 96154 or their
successor codes under the Current Procedural Terminology
(CPT) coding system. Providers eligible for such
reimbursement shall include psychologists.
15. There shall be no payments made under this section
for gender transition surgeries, cross -sex hormones, or
puberty-blocking drugs, as such terms are defined in section
191.1720, for the purpose of a gender transition.
210.030. 1. Every licensed physician, midwife,
registered nurse and all persons who may undertake, in a
professional way, the obstetrical and gynecological care of
a pregnant woman in the state of Mis souri shall, if the
woman consents, take or cause to be taken a sample of venous
blood of such woman at the time of the first prenatal
53
examination, or not later than twenty days after the first
prenatal examination, another sample at twenty -eight weeks
of pregnancy, and another sample immediately after birth and
subject such [sample] samples to an approved and standard
serological test for syphilis [, an] and approved serological
[test] tests for hepatitis B, hepatitis C, human
immunodeficiency viru s (HIV), and such other treatable
diseases and metabolic disorders as are prescribed by the
department of health and senior services. [In any area of
the state designated as a syphilis outbreak area by the
department of health and senior services, if the mother
consents, a sample of her venous blood shall be taken later
in the course of pregnancy and at delivery for additional
testing for syphilis as may be prescribed by the department ]
If a mother tests positive for syphilis, hepatitis B,
hepatitis C, or HIV, or any combination of such diseases,
the physician or person providing care shall administer
treatment in accordance with the most recent accepted
medical practice. If a mother tests positive for hepatitis
B, the physician or person who professionally undertakes the
pediatric care of a newborn shall also administer the
appropriate doses of hepatitis B vaccine and hepatitis B
immune globulin (HBIG) in accordance with the current
recommendations of the Advisory Committee on Immunization
Practices (ACIP). If the mother's hepatitis B status is
unknown, the appropriate dose of hepatitis B vaccine shall
be administered to the newborn in accordance with the
current ACIP recommendations. If the mother consents, a
sample of her venous bl ood shall be taken. If she tests
positive for hepatitis B, hepatitis B immune globulin (HBIG)
shall be administered to the newborn in accordance with the
current ACIP recommendations.
54
2. The department of health and senior services
shall[, in consultation with the Missouri genetic disease
advisory committee,] make such rules pertaining to such
tests as shall be dictated by accepted medical practice, and
tests shall be of the types approved or accepted by the
[department of health and senior s ervices] United States
Food and Drug Administration . [An approved and standard
test for syphilis, hepatitis B, and other treatable diseases
and metabolic disorders shall mean a test made in a
laboratory approved by the department of health and senior
services.] No individual shall be denied testing by the
department of health and senior services because of
inability to pay.
332.081. 1. Notwithstanding any other provision of
law to the contrary, hospitals licensed under chapter 19 7
shall be authorized to employ any or all of the following
oral health providers:
(1) A dentist licensed under this chapter for the
purpose of treating on hospital premises those patients who
present with a dental condition and such treatment is
necessary to ameliorate the condition for which they
presented such as severe pain or tooth abscesses;
(2) An oral and maxillofacial surgeon licensed under
this chapter for the purpose of treating oral conditions
that need to be ameliorated as p art of treating the
underlying cause of the patient's medical needs including,
but not limited to, head and neck cancer, HIV or AIDS,
severe trauma resulting in admission to the hospital, organ
transplant, diabetes, or seizure disorders. It shall be a
condition of treatment that such patients are admitted to
the hospital on either an in - or out-patient basis; and
(3) A maxillofacial prosthodontist licensed under this
chapter for the purpose of treating and supporting patients
55
of a head and neck cancer team or other complex care or
surgical team for the fabrication of appliances following
ablative surgery, surgery to correct birth anomalies,
extensive radiation treatment of the head or neck, or trauma -
related surgery.
2. No person or other entity shall practice dentistry
in Missouri or provide dental services as [defined]
described in section 332.071 unless and until the board has
issued to the person a certificate certifying that the
person has been duly registered as a dentist in Missouri or
the board has issued such certificate to an entity that has
been duly registered to provide dental services by licensed
dentists and dental hygienists and unless and until the
board has issued to the person a license, to be renewed each
period, as provided in this chapter, to practice dentistry
or as a dental hygienist, or has issued to the person or
entity a permit, to be renewed each period, to provide
dental services in Missouri. Nothing in this chapter shall
be so construed as to make it unlawful for:
(1) A legally qualified physician or surgeon, who does
not practice dentistry as a specialty, from extracting teeth;
(2) A dentist licensed in a state other than Missouri
from making a clinical demonstration before a mee ting of
dentists in Missouri;
(3) Dental students in any accredited dental school to
practice dentistry under the personal direction of
instructors;
(4) Dental hygiene students in any accredited dental
hygiene school to practice dental hygi ene under the personal
direction of instructors;
(5) A duly registered and licensed dental hygienist in
Missouri to practice dental hygiene as defined in section
332.091;
56
(6) A dental assistant, certified dental assistant, or
expanded functions dental assistant to be delegated duties
as defined in section 332.093;
(7) A duly registered dentist or dental hygienist to
teach in an accredited dental or dental hygiene school;
(8) A person who has been granted a dental faculty
permit under section 332.183 to practice dentistry in the
scope of his or her employment at an accredited dental
school, college, or program in Missouri;
(9) A duly qualified anesthesiologist or nurse
anesthetist to administer an anesthetic in connecti on with
dental services or dental surgery;
(10) A person to practice dentistry in or for:
(a) The United States Armed Forces;
(b) The United States Public Health Service;
(c) Migrant, community, or health care for the
homeless health centers provided in Section 330 of the
Public Health Service Act (42 U.S.C. Section 254b);
(d) Federally qualified health centers as defined in
Section 1905(l) (42 U.S.C. Section 1396d(l)) of the Social
Security Act;
(e) Governmental entities, including county health
departments; or
(f) The United States Veterans Bureau; or
(11) A dentist licensed in a state other than Missouri
to evaluate a patient or render an oral, written, or
otherwise documented dental opinion when pro viding testimony
or records for the purpose of a civil or criminal action
before any judicial or administrative proceeding of this
state or other forum in this state.
3. No corporation shall practice dentistry as defined
in section 332.071 unless that corporation is organized
under the provisions of chapter 355 or 356 provided that a
57
corporation organized under the provisions of chapter 355
and qualifying as an organization under 26 U.S.C. Section
501(c)(3) may only employ dentists and dental hygienists
licensed in this state to render dental services to Medicaid
recipients, low-income individuals who have available income
below two hundred percent of the federal poverty level, and
all participants in the SCHIP program, unless such
limitation is contrary to or inconsistent with federal or
state law or regulation. This subsection shall not apply to:
(1) A hospital licensed under chapter 197 that
provides care and treatment only to children under the age
of eighteen at which a perso n regulated under this chapter
provides dental care within the scope of his or her license
or registration;
(2) A federally qualified health center as defined in
Section 1905(l) of the Social Security Act (42 U.S.C.
Section 1396d(l)), or a migran t, community, or health care
for the homeless health center provided for in Section 330
of the Public Health Services Act (42 U.S.C. Section 254b)
at which a person regulated under this chapter provides
dental care within the scope of his or her licens e or
registration;
(3) A city or county health department organized under
chapter 192 or chapter 205 at which a person regulated under
this chapter provides dental care within the scope of his or
her license or registration;
(4) A social welfare board organized under section
205.770, a city health department operating under a city
charter, or a city-county health department at which a
person regulated under this chapter provides dental care
within the scope of his or her license or regis tration;
(5) Any entity that has received a permit from the
dental board and does not receive compensation from the
58
patient or from any third party on the patient's behalf at
which a person regulated under this chapter provides dental
care within the scope of his or her license or registration;
or
(6) Any hospital nonprofit corporation exempt from
taxation under Section 501(c)(3) of the Internal Revenue
Code, as amended, that engages in its operations and
provides dental services at faci lities owned by a city,
county, or other political subdivision of the state , or any
entity contracted with the state to provide care in a
correctional center, as such term is defined in section
217.010, at which a person regulated under this chapter
provides dental care within the scope of his or her license
or registration.
If any of the entities exempted from the requirements of
this subsection are unable to provide services to a patient
due to the lack of a qualified provider and a referral to
another entity is made, the exemption shall extend to the
person or entity that subsequently provides services to the
patient.
4. No unincorporated organization shall practice
dentistry as defined in section 332.071 unless such
organization is exempt from federal taxation under Section
501(c)(3) of the Internal Revenue Code of 1986, as amended,
and provides dental treatment without compensation from the
patient or any third party on their behalf as a part of a
broader program of social services including food
distribution. Nothing in this chapter shall prohibit
organizations under this subsection from employing any
person regulated by this chapter.
5. A dentist shall not enter into a contract that
allows a person who is not a dentist to influence or
59
interfere with the exercise of the dentist's independent
professional judgment.
6. A not-for-profit corporation organized under the
provisions of chapter 355 and qualifying as an organization
under 26 U.S.C. Section 501(c)(3), an unincorporated
organization operating pursuant to subsection 4 of this
section, or any other person should not direct or interfere
or attempt to direct or interfere with a licensed dentist's
professional judgment and competent practice of dentistry.
Nothing in this subsection shall be so construed as to make
it unlawful for not-for-profit organizations to enforce
employment contracts, corporate policy and procedure
manuals, or quality improvement or assurance requirements.
7. All entities defined in subsection 3 of this
section and those exempted under subsection 4 of this
section shall apply for a permit to employ dentists and
dental hygienists licensed in this state to render dental
services, and the entity shall apply for the permit in
writing on forms provided by the Missouri dental board. The
board shall not charge a fee of any kind for the issuance or
renewal of such permit. The provisions of this subsection
shall not apply to a federally qualified health center as
defined in Section 1905(l) of the Social Security Act (42
U.S.C. Section 1396d(l)).
8. Any entity that obtains a permit to render dental
services in this state is subject to discipline pursuant to
section 332.321. If the board concludes that the person or
entity has committed an act or is engaging in a course of
conduct that would be grounds for disciplinary action, the
board may file a complaint before the administrative hearing
commission. The board may refuse to issue or renew the
permit of any entity for one or any combination of causes
stated in subsection 2 of section 332.321. The board shall
60
notify the applicant in writing of the reasons for the
refusal and shall advise the applicant of his or her right
to file a complaint with the administra tive hearing
commission as provided by chapter 621.
9. A federally qualified health center as defined in
Section 1905(l) of the Social Security Act (42 U.S.C.
Section 1396d(l)) shall register with the board. The
information provided to the board as part of the
registration shall include the name of the health center,
the nonprofit status of the health center, sites where
dental services will be provided, and the names of all
persons employed by, or contracting with, the health center
who are required to hold a license pursuant to this
chapter. The registration shall be renewed every twenty -
four months. The board shall not charge a fee of any kind
for the issuance or renewal of the registration. The
registration of the health center sha ll not be subject to
discipline pursuant to section 332.321. Nothing in this
subsection shall prohibit disciplinary action against a
licensee of this chapter who is employed by, or contracts
with, such health center for the actions of the licensee in
connection with such employment or contract.
10. The board may promulgate rules and regulations to
ensure not-for-profit corporations are rendering care to the
patient populations as set forth herein, including
requirements for covered not -for-profit corporations to
report patient census data to the board. The provisions of
this subsection shall not apply to a federally qualified
health center as defined in Section 1905(l) of the Social
Security Act (42 U.S.C. Section 1396d(l)).
11. All not-for-profit corporations organized or
operated pursuant to the provisions of chapter 355 and
qualifying as an organization under 26 U.S.C. Section
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501(c)(3), or the requirements relating to migrant,
community, or health care for the homeless health centers
provided in Section 330 of the Public Health Service Act (42
U.S.C. Section 254b) and federally qualified health centers
as defined in Section 1905(l) (42 U.S.C. Section 1396d(l))
of the Social Security Act, that employ persons who practice
dentistry or dental hygiene in this state shall do so in
accordance with the relevant laws of this state except to
the extent that such laws are contrary to, or inconsistent
with, federal statute or regulation.
335.081. So long as the person involved does not
represent or hold himself or herself out as a nurse licensed
to practice in this state, no provision of sections 335.011
to 335.096 shall be construed as prohibiting:
(1) The practice of any profession for which a license
is required and issued pursuant to the laws of this state by
a person duly licensed to practice that profession;
(2) The services rendered by technicians, nurses'
aides or their equivalent trained and employed in public or
private hospitals and lic ensed long-term care facilities
except the services rendered in licensed long -term care
facilities shall be limited to administering medication,
excluding injectable medications other than:
(a) Insulin;
(b) Subcutaneous injectable medicatio ns to treat
diabetes as ordered by an individual legally authorized to
prescribe such medications; and
(c) Epinephrine auto-injectors ordered for stock
supply in accordance with section 196.990 or prescribed for
a resident's individual use by an individual legally
authorized to prescribe such epinephrine auto -injectors.
Expected epinephrine auto -injector users shall receive
training set forth in section 196.990. As used in this
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paragraph, the term "epinephrine auto -injector" means a
single-use device used for the automatic injection of a
premeasured dose of epinephrine into the human body or
another epinephrine delivery system approved by the United
States Food and Drug Administration for public use;
(3) The providing of nursing car e by friends or
members of the family of the person receiving such care;
(4) The incidental care of the sick, aged, or infirm
by domestic servants or persons primarily employed as
housekeepers;
(5) The furnishing of nursing assistance in the case
of an emergency situation;
(6) The practice of nursing under proper supervision:
(a) As a part of the course of study by students
enrolled in approved schools of professional nursing or in
schools of practical nursing;
(b) By graduates of accredited nursing programs
pending the results of the first licensing examination or
ninety days after graduation, whichever first occurs;
(c) A graduate nurse who is prevented from attending
the first licensing examination following gr aduation by
reason of active duty in the military may practice as a
graduate nurse pending the results of the first licensing
examination scheduled by the board following the release of
such graduate nurse from active military duty or pending the
results of the first licensing examination taken by the
graduate nurse while involved in active military service
whichever comes first;
(7) The practice of nursing in this state by any
legally qualified nurse duly licensed to practice in another
state whose engagement requires such nurse to accompany and
care for a patient temporarily residing in this state for a
period not to exceed six months;
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(8) The practice of any legally qualified nurse who is
employed by the government of the United St ates or any
bureau, division or agency thereof, while in the discharge
of his or her official duties or to the practice of any
legally qualified nurse serving in the Armed Forces of the
United States while stationed within this state;
(9) Nonmedical nursing care of the sick with or
without compensation when done in connection with the
practice of the religious tenets of any church by adherents
thereof, as long as they do not engage in the practice of
nursing as defined in sections 335.011 to 3 35.096;
(10) The practice of any legally qualified and
licensed nurse of another state, territory, or foreign
country whose responsibilities include transporting patients
into, out of, or through this state while actively engaged
in patient transport that does not exceed forty -eight hours
in this state.
338.010. 1. The "practice of pharmacy" includes:
(1) The interpretation, implementation, and evaluation
of medical prescription orders, including any legend drugs
under 21 U.S.C. Section 353, and the receipt, transmission,
or handling of such orders or facilitating the dispensing of
such orders;
(2) The designing, initiating, implementing, and
monitoring of a medication therapeutic plan in accordance
with the provisions of this section;
(3) The compounding, dispensing, labeling, and
administration of drugs and devices pursuant to medical
prescription orders;
(4) The ordering and administration of vaccines
approved or authorized by the U.S. Food and Drug
Administration, excluding vaccines for cholera, monkeypox,
Japanese encephalitis, typhoid, rabies, yellow fever, tick -
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borne encephalitis, anthrax, tuberculosis, dengue, Hib,
polio, rotavirus, smallpox, chikungunya, and any vaccine
approved after January 1, [2023] 2025, to persons at least
seven years of age or the age recommended by the Centers for
Disease Control and Prevention, whichever is older, pursuant
to joint promulgation of rules established by the board of
pharmacy and the state boar d of registration for the healing
arts unless rules are established under a state of emergency
as described in section 44.100;
(5) The participation in drug selection according to
state law and participation in drug utilization reviews;
(6) The proper and safe storage of drugs and devices
and the maintenance of proper records thereof;
(7) Consultation with patients and other health care
practitioners, and veterinarians and their clients about
legend drugs, about the safe and effectiv e use of drugs and
devices;
(8) The prescribing and dispensing of any nicotine
replacement therapy product under section 338.665;
(9) The dispensing of HIV postexposure prophylaxis
pursuant to section 338.730; and
(10) The offering or performing of those acts,
services, operations, or transactions necessary in the
conduct, operation, management and control of a pharmacy.
2. No person shall engage in the practice of pharmacy
unless he or she is licensed under the provisions of t his
chapter.
3. This chapter shall not be construed to prohibit the
use of auxiliary personnel under the direct supervision of a
pharmacist from assisting the pharmacist in any of his or
her duties. This assistance in no way is intended to
relieve the pharmacist from his or her responsibilities for
compliance with this chapter and he or she will be
65
responsible for the actions of the auxiliary personnel
acting in his or her assistance.
4. This chapter shall not be construed to prohibit o r
interfere with any legally registered practitioner of
medicine, dentistry, or podiatry, or veterinary medicine
only for use in animals, or the practice of optometry in
accordance with and as provided in sections 195.070 and
336.220 in the compoundin g, administering, prescribing, or
dispensing of his or her own prescriptions.
5. A pharmacist with a certificate of medication
therapeutic plan authority may provide medication therapy
services pursuant to a written protocol from a physician
licensed under chapter 334 to patients who have established
a physician-patient relationship, as described in
subdivision (1) of subsection 1 of section 191.1146, with
the protocol physician. The written protocol authorized by
this section shall come only from the physician and shall
not come from a nurse engaged in a collaborative practice
arrangement under section 334.104, or from a physician
assistant engaged in a collaborative practice arrangement
under section 334.735.
6. Nothing in this section shall be construed as to
prevent any person, firm or corporation from owning a
pharmacy regulated by sections 338.210 to 338.315, provided
that a licensed pharmacist is in charge of such pharmacy.
7. Nothing in this section shall be construed to apply
to or interfere with the sale of nonprescription drugs and
the ordinary household remedies and such drugs or medicines
as are normally sold by those engaged in the sale of general
merchandise.
8. No health carrier as defined in chapter 376 shall
require any physician with which they contract to enter into
66
a written protocol with a pharmacist for medication
therapeutic services.
9. This section shall not be construed to allow a
pharmacist to diagnose or independently prescribe
pharmaceuticals.
10. The state board of registration for the healing
arts, under section 334.125, and the state board of
pharmacy, under section 338.140, shall jointly promulgate
rules regulating the use of protocols for medication therapy
services. Such rules shall require protocols to include
provisions allowing for timely communication between the
pharmacist and the protocol physician or similar body
authorized by this section, and any other patient protection
provisions deemed appropriate by both boards. In order to
take effect, such rules shall be approved by a majority vote
of a quorum of each board. Neither board shall separately
promulgate rules regulating the use of protocols for
medication therapy services. Any rule or portion of a rule,
as that term is defined in section 536.010, that is created
under the authority delegated in this section shall become
effective only if it complies with and is subject to all of
the provisions of chapter 536 and, if applicable, section
536.028. This section and chapter 536 are nonseverable and
if any of the powers vested with the general assembly
pursuant to chapter 536 to review, to delay the effective
date, or to disapprove and annul a rule are subsequently
held unconstitutional, th en the grant of rulemaking
authority and any rule proposed or adopted after August 28,
2007, shall be invalid and void.
11. The state board of pharmacy may grant a
certificate of medication therapeutic plan authority to a
licensed pharmacist who submits proof of successful
completion of a board -approved course of academic clinical
67
study beyond a bachelor of science in pharmacy, including
but not limited to clinical assessment skills, from a
nationally accredited college or university, or a
certification of equivalence issued by a nationally
recognized professional organization and approved by the
board of pharmacy.
12. Any pharmacist who has received a certificate of
medication therapeutic plan authority may engage in the
designing, initiating, implementing, and monitoring of a
medication therapeutic plan as defined by a written protocol
from a physician that may be specific to each patient for
care by a pharmacist.
13. Nothing in this section shall be construed to
allow a pharmacist to make a therapeutic substitution of a
pharmaceutical prescribed by a physician unless authorized
by the written protocol or the physician's prescription
order.
14. "Veterinarian", "doctor of veterinary medicine",
"practitioner of vete rinary medicine", "DVM", "VMD", "BVSe",
"BVMS", "BSe (Vet Science)", "VMB", "MRCVS", or an
equivalent title means a person who has received a doctor's
degree in veterinary medicine from an accredited school of
veterinary medicine or holds an Educationa l Commission for
Foreign Veterinary Graduates (EDFVG) certificate issued by
the American Veterinary Medical Association (AVMA).
15. In addition to other requirements established by
the joint promulgation of rules by the board of pharmacy and
the state board of registration for the healing arts:
(1) A pharmacist shall administer vaccines by protocol
in accordance with treatment guidelines established by the
Centers for Disease Control and Prevention (CDC);
(2) A pharmacist who is admi nistering a vaccine shall
request a patient to remain in the pharmacy a safe amount of
68
time after administering the vaccine to observe any adverse
reactions. Such pharmacist shall have adopted emergency
treatment protocols.
16. In addition to other requirements by the board, a
pharmacist shall receive additional training as required by
the board and evidenced by receiving a certificate from the
board upon completion, and shall display the certification
in his or her pharmacy where vaccines ar e delivered.
17. A pharmacist shall inform the patient that the
administration of a vaccine will be entered into the
ShowMeVax system, as administered by the department of
health and senior services. The patient shall attest to the
inclusion of such information in the system by signing a
form provided by the pharmacist. If the patient indicates
that he or she does not want such information entered into
the ShowMeVax system, the pharmacist shall provide a written
report within fourteen days o f administration of a vaccine
to the patient's health care provider, if provided by the
patient, containing:
(1) The identity of the patient;
(2) The identity of the vaccine or vaccines
administered;
(3) The route of administration;
(4) The anatomic site of the administration;
(5) The dose administered; and
(6) The date of administration.
18. A pharmacist licensed under this chapter may order
and administer vaccines approved or authorized by the U.S.
Food and Drug Administration to address a public health
need, as lawfully authorized by the state or federal
government, or a department or agency thereof, during a
state or federally declared public health emergency.
69
579.060. 1. A person commits the offense of unlawful
sale, distribution, or purchase of over -the-counter
methamphetamine precursor drugs if he or she knowingly:
(1) Sells, distributes, dispenses, or otherwise
provides any number of packages of any drug product
containing detectable amounts of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts, optical isomers, or salts of optical isomers, in a
total amount greater than seven and two -tenths grams to the
same individual within a thirty -day period, unless the
amount is dispensed, sold, or distributed pursuant to a
valid prescription; or
(2) Purchases, receives, or otherwise acquires within
a thirty-day period any number of packages of any drug
product containing any detectable amount of ephe drine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts or optical isomers, or salts of optical isomers in a
total amount greater than seven and two -tenths grams,
without regard to the number of transactions, unless the
amount is purchased, received, or acquired pursuant to a
valid prescription; or
(3) Purchases, receives, or otherwise acquires within
a twenty-four-hour period any number of packages of any drug
product containing any detectable amount of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts or optical isomers, or salts of optical isomers in a
total amount greater than three and six -tenths grams,
without regard to the number of transactions, unless the
amount is purchased, received, or acqu ired pursuant to a
valid prescription; or
(4) Sells, distributes, dispenses, or otherwise
provides any number of packages of any drug product
containing detectable amounts of ephedrine,
70
phenylpropanolamine, or pseudoephedrine, or any of their
salts, optical isomers, or salts of optical isomers, in a
total amount greater than [forty-three] sixty-one and two-
tenths grams to the same individual within a twelve -month
period, unless the amount is dispensed, sold, or distributed
pursuant to a valid prescription; or
(5) Purchases, receives, or otherwise acquires within
a twelve-month period any number of packages of any drug
product containing any detectable amount of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts or optical isomers, or salts of optical isomers in a
total amount greater than [forty-three] sixty-one and two-
tenths grams, without regard to the number of transactions,
unless the amount is purchased, received, or acquired
pursuant to a valid prescr iption; or
(6) Dispenses or offers drug products that are not
excluded from Schedule V in subsection 17 or 18 of section
195.017 and that contain detectable amounts of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts, optical isomers, or salts of optical isomers, without
ensuring that such products are located behind a pharmacy
counter where the public is not permitted and that such
products are dispensed by a registered pharmacist or
pharmacy technician under subsecti on 11 of section 195.017;
or
(7) Holds a retail sales license issued under chapter
144 and knowingly sells or dispenses packages that do not
conform to the packaging requirements of section 195.418.
2. A pharmacist, intern pharmacist, or reg istered
pharmacy technician commits the offense of unlawful sale,
distribution, or purchase of over -the-counter
methamphetamine precursor drugs if he or she knowingly:
71
(1) Sells, distributes, dispenses, or otherwise
provides any number of package s of any drug product
containing detectable amounts of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts or optical isomers, or salts of optical isomers, in a
total amount greater than three and six -tenth grams to the
same individual within a twenty -four hour period, unless the
amount is dispensed, sold, or distributed pursuant to a
valid prescription; or
(2) Fails to submit information under subsection 13 of
section 195.017 and subsection 6 of section 195.417 about
the sales of any compound, mixture, or preparation of
products containing detectable amounts of ephedrine,
phenylpropanolamine, or pseudoephedrine, or any of their
salts, optical isomers, or salts of optical isomers, in
accordance with transmission metho ds and frequency
established by the department of health and senior services;
or
(3) Fails to implement and maintain an electronic log,
as required by subsection 12 of section 195.017, of each
transaction involving any detectable quantity of
pseudoephedrine, its salts, isomers, or salts of optical
isomers or ephedrine, its salts, optical isomers, or salts
of optical isomers; or
(4) Sells, distributes, dispenses or otherwise
provides to an individual under eighteen years of age
without a valid prescription any number of packages of any
drug product containing any detectable quantity of
pseudoephedrine, its salts, isomers, or salts of optical
isomers, or ephedrine, its salts or optical isomers, or
salts of optical isomers.
3. Any person who violates the packaging requirements
of section 195.418 and is considered the general owner or
72
operator of the outlet where ephedrine, pseudoephedrine, or
phenylpropanolamine products are available for sale shall
not be penalized if he or sh e documents that an employee
training program was in place to provide the employee who
made the unlawful retail sale with information on the state
and federal regulations regarding ephedrine,
pseudoephedrine, or phenylpropanolamine.
4. The offense of unlawful sale, distribution, or
purchase of over-the-counter methamphetamine precursor drugs
is a class A misdemeanor.
[192.769. 1. On completion of a
mammogram, a mammography facility certified by
the United States Food and Drug Administration
(FDA) or by a certification agency approved by
the FDA shall provide to the patient the
following notice:
"If your mammogram demonstrates that you
have dense breast tissue, which could hide
abnormalities, and you have other risk f actors
for breast cancer that have been identified, you
might benefit from supplemental screening tests
that may be suggested by your ordering
physician. Dense breast tissue, in and of
itself, is a relatively common condition.
Therefore, this infor mation is not provided to
cause undue concern, but rather to raise your
awareness and to promote discussion with your
physician regarding the presence of other risk
factors, in addition to dense breast tissue. A
report of your mammography results wil l be sent
to you and your physician. You should contact
your physician if you have any questions or
concerns regarding this report.".
2. Nothing in this section shall be
construed to create a duty of care beyond the
duty to provide notice as se t forth in this
section.
3. The information required by this
section or evidence that a person violated this
section is not admissible in a civil, judicial,
or administrative proceeding.
73
4. A mammography facility is not required
to comply with the requirements of this section
until January 1, 2015. ]