Missouri 2025 Regular Session

Missouri Senate Bill SB539 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2	EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
3	3	and is intended to be omitted in the law.
4	4	FIRST REGULAR SESSION
5	5	SENATE BILL NO. 539
6	6	103RD GENERAL ASSEMBLY
7	7	INTRODUCED BY SENATOR NURRENBERN.
8	8	1839S.01I KRISTINA MARTIN, Secretary
9	9	AN ACT
10	10	To repeal section 208.152, RSMo, and to enact in lieu thereof two new sections relating to
11	11	payments for home blood pressure monitoring.
12	12
13	13	Be it enacted by the General Assembly of the State of Missouri, as follows:
14	14	Section A. Section 208.152, RSMo, is repealed and two new 1
15	15	sections enacted in lieu thereof, to be known as sections 2
16	16	208.152 and 376.1960, to read as follows:3
17	17	208.152. 1. MO HealthNet payments shall be made on 1
18	18	behalf of those eligible needy persons as described in 2
19	19	section 208.151 who are unable to provide for it in whole or 3
20	20	in part, with any payments to be made on the basis of the 4
21	21	reasonable cost of the care or reasonable charge for the 5
22	22	services as defined and determined by the MO HealthNet 6
23	23	division, unless otherwise hereinafter provided, for the 7
24	24	following: 8
25	25	(1) Inpatient hospital services, except to persons in 9
26	26	an institution for mental diseases who are under the age of 10
27	27	sixty-five years and over the age of twenty -one years; 11
28	28	provided that the MO HealthNet division shall provide 12
29	29	through rule and regulation an exception process for 13
30	30	coverage of inpatient costs in those cases requir ing 14
31	31	treatment beyond the seventy -fifth percentile professional 15
32	32	activities study (PAS) or the MO HealthNet children's 16
33	33	diagnosis length-of-stay schedule; and provided further that 17
34	34	the MO HealthNet division shall take into account through 18 SB 539 2
35	35	its payment system for hospital services the situation of 19
36	36	hospitals which serve a disproportionate number of low - 20
37	37	income patients; 21
38	38	(2) All outpatient hospital services, payments 22
39	39	therefor to be in amounts which represent no more than 23
40	40	eighty percent of the lesser of reasonable costs or 24
41	41	customary charges for such services, determined in 25
42	42	accordance with the principles set forth in Title XVIII A 26
43	43	and B, Public Law 89 -97, 1965 amendments to the federal 27
44	44	Social Security Act (42 U.S.C. Section 301, et seq.), but 28
45	45	the MO HealthNet division may evaluate outpatient hospital 29
46	46	services rendered under this section and deny payment for 30
47	47	services which are determined by the MO HealthNet division 31
48	48	not to be medically necessary, in accordance with federal 32
49	49	law and regulations; 33
50	50	(3) Laboratory and X-ray services; 34
51	51	(4) Nursing home services for participants, except to 35
52	52	persons with more than five hundred thousand dollars equity 36
53	53	in their home or except for persons in an institution for 37
54	54	mental diseases who are under the ag e of sixty-five years, 38
55	55	when residing in a hospital licensed by the department of 39
56	56	health and senior services or a nursing home licensed by the 40
57	57	department of health and senior services or appropriate 41
58	58	licensing authority of other states or government -owned and - 42
59	59	operated institutions which are determined to conform to 43
60	60	standards equivalent to licensing requirements in Title XIX 44
61	61	of the federal Social Security Act (42 U.S.C. Section 301, 45
62	62	et seq.), as amended, for nursing facilities. The MO 46
63	63	HealthNet division may recognize through its payment 47
64	64	methodology for nursing facilities those nursing facilities 48
65	65	which serve a high volume of MO HealthNet patients. The MO 49
66	66	HealthNet division when determining the amount of the 50 SB 539 3
67	67	benefit payments to be made on behalf o f persons under the 51
68	68	age of twenty-one in a nursing facility may consider nursing 52
69	69	facilities furnishing care to persons under the age of 53
70	70	twenty-one as a classification separate from other nursing 54
71	71	facilities; 55
72	72	(5) Nursing home costs for participants receiving 56
73	73	benefit payments under subdivision (4) of this subsection 57
74	74	for those days, which shall not exceed twelve per any period 58
75	75	of six consecutive months, during which the participant is 59
76	76	on a temporary leave of absence from the hospital or nursing 60
77	77	home, provided that no such participant shall be allowed a 61
78	78	temporary leave of absence unless it is specifically 62
79	79	provided for in his plan of care. As used in this 63
80	80	subdivision, the term "temporary leave of absence" shall 64
81	81	include all periods of time durin g which a participant is 65
82	82	away from the hospital or nursing home overnight because he 66
83	83	is visiting a friend or relative; 67
84	84	(6) Physicians' services, whether furnished in the 68
85	85	office, home, hospital, nursing home, or elsewhere, 69
86	86	provided, that no funds shall be expended to any abortion 70
87	87	facility, as defined in section 188.015, or to any 71
88	88	affiliate, as defined in section 188.015, of such abortion 72
89	89	facility; 73
90	90	(7) Subject to appropriation, up to twenty visits per 74
91	91	year for services limited to examinati ons, diagnoses, 75
92	92	adjustments, and manipulations and treatments of 76
93	93	malpositioned articulations and structures of the body 77
94	94	provided by licensed chiropractic physicians practicing 78
95	95	within their scope of practice. Nothing in this subdivision 79
96	96	shall be interpreted to otherwise expand MO HealthNet 80
97	97	services; 81 SB 539 4
98	98	(8) Drugs and medicines when prescribed by a licensed 82
99	99	physician, dentist, podiatrist, or an advanced practice 83
100	100	registered nurse; except that no payment for drugs and 84
101	101	medicines prescribed on and aft er January 1, 2006, by a 85
102	102	licensed physician, dentist, podiatrist, or an advanced 86
103	103	practice registered nurse may be made on behalf of any 87
104	104	person who qualifies for prescription drug coverage under 88
105	105	the provisions of P.L. 108 -173; 89
106	106	(9) Emergency ambulance services and, effective 90
107	107	January 1, 1990, medically necessary transportation to 91
108	108	scheduled, physician -prescribed nonelective treatments; 92
109	109	(10) Early and periodic screening and diagnosis of 93
110	110	individuals who are under the age of twenty -one to ascertain 94
111	111	their physical or mental defects, and health care, 95
112	112	treatment, and other measures to correct or ameliorate 96
113	113	defects and chronic conditions discovered thereby. Such 97
114	114	services shall be provided in accordance with the provisions 98
115	115	of Section 6403 of P.L. 101-239 and federal regulations 99
116	116	promulgated thereunder; 100
117	117	(11) Home health care services; 101
118	118	(12) Family planning as defined by federal rules and 102
119	119	regulations; provided, that no funds shall be expended to 103
120	120	any abortion facility, as defined in sect ion 188.015, or to 104
121	121	any affiliate, as defined in section 188.015, of such 105
122	122	abortion facility; and further provided, however, that such 106
123	123	family planning services shall not include abortions or any 107
124	124	abortifacient drug or device that is used for the purpose o f 108
125	125	inducing an abortion unless such abortions are certified in 109
126	126	writing by a physician to the MO HealthNet agency that, in 110
127	127	the physician's professional judgment, the life of the 111
128	128	mother would be endangered if the fetus were carried to term; 112 SB 539 5
129	129	(13) Inpatient psychiatric hospital services for 113
130	130	individuals under age twenty -one as defined in Title XIX of 114
131	131	the federal Social Security Act (42 U.S.C. Section 1396d, et 115
132	132	seq.); 116
133	133	(14) Outpatient surgical procedures, including 117
134	134	presurgical diagnostic service s performed in ambulatory 118
135	135	surgical facilities which are licensed by the department of 119
136	136	health and senior services of the state of Missouri; except, 120
137	137	that such outpatient surgical services shall not include 121
138	138	persons who are eligible for coverage under Part B of Title 122
139	139	XVIII, Public Law 89 -97, 1965 amendments to the federal 123
140	140	Social Security Act, as amended, if exclusion of such 124
141	141	persons is permitted under Title XIX, Public Law 89 -97, 1965 125
142	142	amendments to the federal Social Security Act, as amended; 126
143	143	(15) Personal care services which are medically 127
144	144	oriented tasks having to do with a person's physical 128
145	145	requirements, as opposed to housekeeping requirements, which 129
146	146	enable a person to be treated by his or her physician on an 130
147	147	outpatient rather than on an inpat ient or residential basis 131
148	148	in a hospital, intermediate care facility, or skilled 132
149	149	nursing facility. Personal care services shall be rendered 133
150	150	by an individual not a member of the participant's family 134
151	151	who is qualified to provide such services where the se rvices 135
152	152	are prescribed by a physician in accordance with a plan of 136
153	153	treatment and are supervised by a licensed nurse. Persons 137
154	154	eligible to receive personal care services shall be those 138
155	155	persons who would otherwise require placement in a hospital, 139
156	156	intermediate care facility, or skilled nursing facility. 140
157	157	Benefits payable for personal care services shall not exceed 141
158	158	for any one participant one hundred percent of the average 142
159	159	statewide charge for care and treatment in an intermediate 143
160	160	care facility for a co mparable period of time. Such 144 SB 539 6
161	161	services, when delivered in a residential care facility or 145
162	162	assisted living facility licensed under chapter 198 shall be 146
163	163	authorized on a tier level based on the services the 147
164	164	resident requires and the frequency of the servi ces. A 148
165	165	resident of such facility who qualifies for assistance under 149
166	166	section 208.030 shall, at a minimum, if prescribed by a 150
167	167	physician, qualify for the tier level with the fewest 151
168	168	services. The rate paid to providers for each tier of 152
169	169	service shall be set subject to appropriations. Subject to 153
170	170	appropriations, each resident of such facility who qualifies 154
171	171	for assistance under section 208.030 and meets the level of 155
172	172	care required in this section shall, at a minimum, if 156
173	173	prescribed by a physician, be auth orized up to one hour of 157
174	174	personal care services per day. Authorized units of 158
175	175	personal care services shall not be reduced or tier level 159
176	176	lowered unless an order approving such reduction or lowering 160
177	177	is obtained from the resident's personal physician. Such 161
178	178	authorized units of personal care services or tier level 162
179	179	shall be transferred with such resident if he or she 163
180	180	transfers to another such facility. Such provision shall 164
181	181	terminate upon receipt of relevant waivers from the federal 165
182	182	Department of Health and Human Services. If the Centers for 166
183	183	Medicare and Medicaid Services determines that such 167
184	184	provision does not comply with the state plan, this 168
185	185	provision shall be null and void. The MO HealthNet division 169
186	186	shall notify the revisor of statutes as to whe ther the 170
187	187	relevant waivers are approved or a determination of 171
188	188	noncompliance is made; 172
189	189	(16) Mental health services. The state plan for 173
190	190	providing medical assistance under Title XIX of the Social 174
191	191	Security Act, 42 U.S.C. Section 301, as amended, shall 175
192	192	include the following mental health services when such 176 SB 539 7
193	193	services are provided by community mental health facilities 177
194	194	operated by the department of mental health or designated by 178
195	195	the department of mental health as a community mental health 179
196	196	facility or as an alcohol and drug abuse facility or as a 180
197	197	child-serving agency within the comprehensive children's 181
198	198	mental health service system established in section 182
199	199	630.097. The department of mental health shall establish by 183
200	200	administrative rule the definition an d criteria for 184
201	201	designation as a community mental health facility and for 185
202	202	designation as an alcohol and drug abuse facility. Such 186
203	203	mental health services shall include: 187
204	204	(a) Outpatient mental health services including 188
205	205	preventive, diagnostic, therap eutic, rehabilitative, and 189
206	206	palliative interventions rendered to individuals in an 190
207	207	individual or group setting by a mental health professional 191
208	208	in accordance with a plan of treatment appropriately 192
209	209	established, implemented, monitored, and revised under th e 193
210	210	auspices of a therapeutic team as a part of client services 194
211	211	management; 195
212	212	(b) Clinic mental health services including 196
213	213	preventive, diagnostic, therapeutic, rehabilitative, and 197
214	214	palliative interventions rendered to individuals in an 198
215	215	individual or group setting by a mental health professional 199
216	216	in accordance with a plan of treatment appropriately 200
217	217	established, implemented, monitored, and revised under the 201
218	218	auspices of a therapeutic team as a part of client services 202
219	219	management; 203
220	220	(c) Rehabilitative mental health and alcohol and drug 204
221	221	abuse services including home and community -based 205
222	222	preventive, diagnostic, therapeutic, rehabilitative, and 206
223	223	palliative interventions rendered to individuals in an 207
224	224	individual or group setting by a mental health or alc ohol 208 SB 539 8
225	225	and drug abuse professional in accordance with a plan of 209
226	226	treatment appropriately established, implemented, monitored, 210
227	227	and revised under the auspices of a therapeutic team as a 211
228	228	part of client services management. As used in this 212
229	229	section, mental health professional and alcohol and drug 213
230	230	abuse professional shall be defined by the department of 214
231	231	mental health pursuant to duly promulgated rules. With 215
232	232	respect to services established by this subdivision, the 216
233	233	department of social services, MO HealthNe t division, shall 217
234	234	enter into an agreement with the department of mental 218
235	235	health. Matching funds for outpatient mental health 219
236	236	services, clinic mental health services, and rehabilitation 220
237	237	services for mental health and alcohol and drug abuse shall 221
238	238	be certified by the department of mental health to the MO 222
239	239	HealthNet division. The agreement shall establish a 223
240	240	mechanism for the joint implementation of the provisions of 224
241	241	this subdivision. In addition, the agreement shall 225
242	242	establish a mechanism by which rate s for services may be 226
243	243	jointly developed; 227
244	244	(17) Such additional services as defined by the MO 228
245	245	HealthNet division to be furnished under waivers of federal 229
246	246	statutory requirements as provided for and authorized by the 230
247	247	federal Social Security Act (42 U .S.C. Section 301, et seq.) 231
248	248	subject to appropriation by the general assembly; 232
249	249	(18) The services of an advanced practice registered 233
250	250	nurse with a collaborative practice agreement to the extent 234
251	251	that such services are provided in accordance with chapt ers 235
252	252	334 and 335, and regulations promulgated thereunder; 236
253	253	(19) Nursing home costs for participants receiving 237
254	254	benefit payments under subdivision (4) of this subsection to 238
255	255	reserve a bed for the participant in the nursing home during 239
256	256	the time that the participant is absent due to admission to 240 SB 539 9
257	257	a hospital for services which cannot be performed on an 241
258	258	outpatient basis, subject to the provisions of this 242
259	259	subdivision: 243
260	260	(a) The provisions of this subdivision shall apply 244
261	261	only if: 245
262	262	a. The occupancy rate of the nursing home is at or 246
263	263	above ninety-seven percent of MO HealthNet certified 247
264	264	licensed beds, according to the most recent quarterly census 248
265	265	provided to the department of health and senior services 249
266	266	which was taken prior to when the participant is admitted to 250
267	267	the hospital; and 251
268	268	b. The patient is admitted to a hospital for a medical 252
269	269	condition with an anticipated stay of three days or less; 253
270	270	(b) The payment to be made under this subdivision 254
271	271	shall be provided for a maximum of three day s per hospital 255
272	272	stay; 256
273	273	(c) For each day that nursing home costs are paid on 257
274	274	behalf of a participant under this subdivision during any 258
275	275	period of six consecutive months such participant shall, 259
276	276	during the same period of six consecutive months, be 260
277	277	ineligible for payment of nursing home costs of two 261
278	278	otherwise available temporary leave of absence days provided 262
279	279	under subdivision (5) of this subsection; and 263
280	280	(d) The provisions of this subdivision shall not apply 264
281	281	unless the nursing home receives not ice from the participant 265
282	282	or the participant's responsible party that the participant 266
283	283	intends to return to the nursing home following the hospital 267
284	284	stay. If the nursing home receives such notification and 268
285	285	all other provisions of this subsection have bee n satisfied, 269
286	286	the nursing home shall provide notice to the participant or 270
287	287	the participant's responsible party prior to release of the 271
288	288	reserved bed; 272 SB 539 10
289	289	(20) Prescribed medically necessary durable medical 273
290	290	equipment. An electronic web-based prior authorization 274
291	291	system using best medical evidence and care and treatment 275
292	292	guidelines consistent with national standards shall be used 276
293	293	to verify medical need; 277
294	294	(21) Hospice care. As used in this subdivision, the 278
295	295	term "hospice care" means a coordinated pr ogram of active 279
296	296	professional medical attention within a home, outpatient and 280
297	297	inpatient care which treats the terminally ill patient and 281
298	298	family as a unit, employing a medically directed 282
299	299	interdisciplinary team. The program provides relief of 283
300	300	severe pain or other physical symptoms and supportive care 284
301	301	to meet the special needs arising out of physical, 285
302	302	psychological, spiritual, social, and economic stresses 286
303	303	which are experienced during the final stages of illness, 287
304	304	and during dying and bereavement and m eets the Medicare 288
305	305	requirements for participation as a hospice as are provided 289
306	306	in 42 CFR Part 418. The rate of reimbursement paid by the 290
307	307	MO HealthNet division to the hospice provider for room and 291
308	308	board furnished by a nursing home to an eligible hospice 292
309	309	patient shall not be less than ninety -five percent of the 293
310	310	rate of reimbursement which would have been paid for 294
311	311	facility services in that nursing home facility for that 295
312	312	patient, in accordance with subsection (c) of Section 6408 296
313	313	of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 297
314	314	(22) Prescribed medically necessary dental services. 298
315	315	Such services shall be subject to appropriations. An 299
316	316	electronic web-based prior authorization system using best 300
317	317	medical evidence and care and treatment gu idelines 301
318	318	consistent with national standards shall be used to verify 302
319	319	medical need; 303 SB 539 11
320	320	(23) Prescribed medically necessary optometric 304
321	321	services. Such services shall be subject to 305
322	322	appropriations. An electronic web-based prior authorization 306
323	323	system using best medical evidence and care and treatment 307
324	324	guidelines consistent with national standards shall be used 308
325	325	to verify medical need; 309
326	326	(24) Blood clotting products -related services. For 310
327	327	persons diagnosed with a bleeding disorder, as defined in 311
328	328	section 338.400, reliant on blood clotting products, as 312
329	329	defined in section 338.400, such services include: 313
330	330	(a) Home delivery of blood clotting products and 314
331	331	ancillary infusion equipment and supplies, including the 315
332	332	emergency deliveries of the product wh en medically necessary; 316
333	333	(b) Medically necessary ancillary infusion equipment 317
334	334	and supplies required to administer the blood clotting 318
335	335	products; and 319
336	336	(c) Assessments conducted in the participant's home by 320
337	337	a pharmacist, nurse, or local home healt h care agency 321
338	338	trained in bleeding disorders when deemed necessary by the 322
339	339	participant's treating physician; 323
340	340	(25) The MO HealthNet division shall, by January 1, 324
341	341	2008, and annually thereafter, report the status of MO 325
342	342	HealthNet provider reimbursement rates as compared to one 326
343	343	hundred percent of the Medicare reimbursement rates and 327
344	344	compared to the average dental reimbursement rates paid by 328
345	345	third-party payors licensed by the state. The MO HealthNet 329
346	346	division shall, by July 1, 2008, provide to the gen eral 330
347	347	assembly a four-year plan to achieve parity with Medicare 331
348	348	reimbursement rates and for third -party payor average dental 332
349	349	reimbursement rates. Such plan shall be subject to 333
350	350	appropriation and the division shall include in its annual 334
351	351	budget request to the governor the necessary funding needed 335 SB 539 12
352	352	to complete the four -year plan developed under this 336
353	353	subdivision. 337
354	354	2. Additional benefit payments for medical assistance 338
355	355	shall be made on behalf of those eligible needy children, 339
356	356	pregnant women and blind persons with any payments to be 340
357	357	made on the basis of the reasonable cost of the care or 341
358	358	reasonable charge for the services as defined and determined 342
359	359	by the MO HealthNet division, unless otherwise hereinafter 343
360	360	provided, for the following: 344
361	361	(1) Dental services; 345
362	362	(2) Services of podiatrists as defined in section 346
363	363	330.010; 347
364	364	(3) Optometric services as described in section 348
365	365	336.010; 349
366	366	(4) Orthopedic devices or other prosthetics, including 350
367	367	eye glasses, dentures, hearing aids, and wheelchairs ; 351
368	368	(5) For pregnant and postpartum women, a home blood 352
369	369	pressure monitoring device and home blood pressure 353
370	370	monitoring device services. As used in this subdivision, 354
371	371	the term "home blood pressure monitoring device" means a 355
372	372	mobile device that can be used to measure blood pressure, 356
373	373	and that is validated for clinical accuracy and device 357
374	374	calibration. As used in this subdivision, the term "home 358
375	375	blood pressure monitoring device services" means patient 359
376	376	education and training services on the setup and u se of a 360
377	377	home blood pressure monitoring device, separate self - 361
378	378	measurement blood pressure readings, daily collection and 362
379	379	transmission of data reports by the patient or caregiver to 363
380	380	the health care provider in order to communicate blood 364
381	381	pressure readings, review of the reports by the health care 365
382	382	provider, and creation or modification of treatment plans 366
383	383	based on the reports; 367 SB 539 13
384	384	(6) Hospice care. As used in this subdivision, the 368
385	385	term "hospice care" means a coordinated program of active 369
386	386	professional medical attention within a home, outpatient and 370
387	387	inpatient care which treats the terminally ill patient and 371
388	388	family as a unit, employing a medically directed 372
389	389	interdisciplinary team. The program provides relief of 373
390	390	severe pain or other physical symptoms a nd supportive care 374
391	391	to meet the special needs arising out of physical, 375
392	392	psychological, spiritual, social, and economic stresses 376
393	393	which are experienced during the final stages of illness, 377
394	394	and during dying and bereavement and meets the Medicare 378
395	395	requirements for participation as a hospice as are provided 379
396	396	in 42 CFR Part 418. The rate of reimbursement paid by the 380
397	397	MO HealthNet division to the hospice provider for room and 381
398	398	board furnished by a nursing home to an eligible hospice 382
399	399	patient shall not be less th an ninety-five percent of the 383
400	400	rate of reimbursement which would have been paid for 384
401	401	facility services in that nursing home facility for that 385
402	402	patient, in accordance with subsection (c) of Section 6408 386
403	403	of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 387
404	404	[(6)] (7) Comprehensive day rehabilitation services 388
405	405	beginning early posttrauma as part of a coordinated system 389
406	406	of care for individuals with disabling impairments. 390
407	407	Rehabilitation services must be based on an individualized, 391
408	408	goal-oriented, comprehensive and coordinated treatment plan 392
409	409	developed, implemented, and monitored through an 393
410	410	interdisciplinary assessment designed to restore an 394
411	411	individual to optimal level of physical, cognitive, and 395
412	412	behavioral function. The MO HealthNet division s hall 396
413	413	establish by administrative rule the definition and criteria 397
414	414	for designation of a comprehensive day rehabilitation 398
415	415	service facility, benefit limitations and payment 399 SB 539 14
416	416	mechanism. Any rule or portion of a rule, as that term is 400
417	417	defined in section 536 .010, that is created under the 401
418	418	authority delegated in this subdivision shall become 402
419	419	effective only if it complies with and is subject to all of 403
420	420	the provisions of chapter 536 and, if applicable, section 404
421	421	536.028. This section and chapter 536 are nonsev erable and 405
422	422	if any of the powers vested with the general assembly 406
423	423	pursuant to chapter 536 to review, to delay the effective 407
424	424	date, or to disapprove and annul a rule are subsequently 408
425	425	held unconstitutional, then the grant of rulemaking 409
426	426	authority and any rule proposed or adopted after August 28, 410
427	427	2005, shall be invalid and void. 411
428	428	3. The MO HealthNet division may require any 412
429	429	participant receiving MO HealthNet benefits to pay part of 413
430	430	the charge or cost until July 1, 2008, and an additional 414
431	431	payment after July 1, 2008, as defined by rule duly 415
432	432	promulgated by the MO HealthNet division, for all covered 416
433	433	services except for those services covered under 417
434	434	subdivisions (15) and (16) of subsection 1 of this section 418
435	435	and sections 208.631 to 208.657 to the extent and in the 419
436	436	manner authorized by Title XIX of the federal Social 420
437	437	Security Act (42 U.S.C. Section 1396, et seq.) and 421
438	438	regulations thereunder. When substitution of a generic drug 422
439	439	is permitted by the prescriber according to section 338.056, 423
440	440	and a generic drug is substituted for a name -brand drug, the 424
441	441	MO HealthNet division may not lower or delete the 425
442	442	requirement to make a co -payment pursuant to regulations of 426
443	443	Title XIX of the federal Social Security Act. A provider of 427
444	444	goods or services described under this section must collect 428
445	445	from all participants the additional payment that may be 429
446	446	required by the MO HealthNet division under authority 430
447	447	granted herein, if the division exercises that authority, to 431 SB 539 15
448	448	remain eligible as a provider. Any payments made by 432
449	449	participants under this section shall be in addition to and 433
450	450	not in lieu of payments made by the state for goods or 434
451	451	services described herein except the participant portion of 435
452	452	the pharmacy professional dispensing fee shall be in 436
453	453	addition to and not in lieu of payments to pharmacists. A 437
454	454	provider may collect the co -payment at the time a service is 438
455	455	provided or at a later date. A provider shall not refuse to 439
456	456	provide a service if a participant is unable to pay a 440
457	457	required payment. If it is the routine business practice of 441
458	458	a provider to terminate future services to an individual 442
459	459	with an unclaimed debt, the provider may include uncollected 443
460	460	co-payments under this practice. Providers who elect not to 444
461	461	undertake the provision of services based on a histo ry of 445
462	462	bad debt shall give participants advance notice and a 446
463	463	reasonable opportunity for payment. A provider, 447
464	464	representative, employee, independent contractor, or agent 448
465	465	of a pharmaceutical manufacturer shall not make co -payment 449
466	466	for a participant. This subsection shall not apply to other 450
467	467	qualified children, pregnant women, or blind persons. If 451
468	468	the Centers for Medicare and Medicaid Services does not 452
469	469	approve the MO HealthNet state plan amendment submitted by 453
470	470	the department of social services that wou ld allow a 454
471	471	provider to deny future services to an individual with 455
472	472	uncollected co-payments, the denial of services shall not be 456
473	473	allowed. The department of social services shall inform 457
474	474	providers regarding the acceptability of denying services as 458
475	475	the result of unpaid co-payments. 459
476	476	4. The MO HealthNet division shall have the right to 460
477	477	collect medication samples from participants in order to 461
478	478	maintain program integrity. 462 SB 539 16
479	479	5. Reimbursement for obstetrical and pediatric 463
480	480	services under subdivision ( 6) of subsection 1 of this 464
481	481	section shall be timely and sufficient to enlist enough 465
482	482	health care providers so that care and services are 466
483	483	available under the state plan for MO HealthNet benefits at 467
484	484	least to the extent that such care and services are 468
485	485	available to the general population in the geographic area, 469
486	486	as required under subparagraph (a)(30)(A) of 42 U.S.C. 470
487	487	Section 1396a and federal regulations promulgated thereunder. 471
488	488	6. Beginning July 1, 1990, reimbursement for services 472
489	489	rendered in federall y funded health centers shall be in 473
490	490	accordance with the provisions of subsection 6402(c) and 474
491	491	Section 6404 of P.L. 101 -239 (Omnibus Budget Reconciliation 475
492	492	Act of 1989) and federal regulations promulgated thereunder. 476
493	493	7. Beginning July 1, 1990, the de partment of social 477
494	494	services shall provide notification and referral of children 478
495	495	below age five, and pregnant, breast -feeding, or postpartum 479
496	496	women who are determined to be eligible for MO HealthNet 480
497	497	benefits under section 208.151 to the special supplemen tal 481
498	498	food programs for women, infants and children administered 482
499	499	by the department of health and senior services. Such 483
500	500	notification and referral shall conform to the requirements 484
501	501	of Section 6406 of P.L. 101 -239 and regulations promulgated 485
502	502	thereunder. 486
503	503	8. Providers of long-term care services shall be 487
504	504	reimbursed for their costs in accordance with the provisions 488
505	505	of Section 1902 (a)(13)(A) of the Social Security Act, 42 489
506	506	U.S.C. Section 1396a, as amended, and regulations 490
507	507	promulgated thereunder. 491
508	508	9. Reimbursement rates to long -term care providers 492
509	509	with respect to a total change in ownership, at arm's 493
510	510	length, for any facility previously licensed and certified 494 SB 539 17
511	511	for participation in the MO HealthNet program shall not 495
512	512	increase payments in excess of the increase that would 496
513	513	result from the application of Section 1902 (a)(13)(C) of 497
514	514	the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C). 498
515	515	10. The MO HealthNet division may enroll qualified 499
516	516	residential care facilities and assisted living facil ities, 500
517	517	as defined in chapter 198, as MO HealthNet personal care 501
518	518	providers. 502
519	519	11. Any income earned by individuals eligible for 503
520	520	certified extended employment at a sheltered workshop under 504
521	521	chapter 178 shall not be considered as income for purposes 505
522	522	of determining eligibility under this section. 506
523	523	12. If the Missouri Medicaid audit and compliance unit 507
524	524	changes any interpretation or application of the 508
525	525	requirements for reimbursement for MO HealthNet services 509
526	526	from the interpretation or application t hat has been applied 510
527	527	previously by the state in any audit of a MO HealthNet 511
528	528	provider, the Missouri Medicaid audit and compliance unit 512
529	529	shall notify all affected MO HealthNet providers five 513
530	530	business days before such change shall take effect. Failure 514
531	531	of the Missouri Medicaid audit and compliance unit to notify 515
532	532	a provider of such change shall entitle the provider to 516
533	533	continue to receive and retain reimbursement until such 517
534	534	notification is provided and shall waive any liability of 518
535	535	such provider for recou pment or other loss of any payments 519
536	536	previously made prior to the five business days after such 520
537	537	notice has been sent. Each provider shall provide the 521
538	538	Missouri Medicaid audit and compliance unit a valid email 522
539	539	address and shall agree to receive communica tions 523
540	540	electronically. The notification required under this 524
541	541	section shall be delivered in writing by the United States 525
542	542	Postal Service or electronic mail to each provider. 526 SB 539 18
543	543	13. Nothing in this section shall be construed to 527
544	544	abrogate or limit the dep artment's statutory requirement to 528
545	545	promulgate rules under chapter 536. 529
546	546	14. Beginning July 1, 2016, and subject to 530
547	547	appropriations, providers of behavioral, social, and 531
548	548	psychophysiological services for the prevention, treatment, 532
549	549	or management of physical health problems shall be 533
550	550	reimbursed utilizing the behavior assessment and 534
551	551	intervention reimbursement codes 96150 to 96154 or their 535
552	552	successor codes under the Current Procedural Terminology 536
553	553	(CPT) coding system. Providers eligible for such 537
554	554	reimbursement shall include psychologists. 538
555	555	15. There shall be no payments made under this section 539
556	556	for gender transition surgeries, cross -sex hormones, or 540
557	557	puberty-blocking drugs, as such terms are defined in section 541
558	558	191.1720, for the purpose of a gender transition. 542
559	559	376.1960. 1. As used in this section, the following 1
560	560	terms mean: 2
561	561	(1) "Health benefit plan", the same meaning given to 3
562	562	the term in section 376.1350; 4
563	563	(2) "Home blood pressure monitoring device", a mobile 5
564	564	device that can be used to measure blood pressure, and that 6
565	565	is validated for clinical accuracy and device calibration; 7
566	566	(3) "Home blood pressure monitoring device services", 8
567	567	patient education and training services on the setup and use 9
568	568	of a home blood pres sure monitoring device, separate self - 10
569	569	measurement blood pressure readings, daily collection and 11
570	570	transmission of data reports by the patient or caregiver to 12
571	571	the health care provider in order to communicate blood 13
572	572	pressure readings, review of the reports by the health care 14
573	573	provider, and creation or modification of treatment plans 15
574	574	based on the reports. 16 SB 539 19
575	575	2. Health benefit plans delivered, issued for 17
576	576	delivery, continued or renewed in this state on or after 18
577	577	January 1, 2026, and providing for maternity benefits, shall 19
578	578	provide coverage for a home blood pressure monitoring device 20
579	579	and home blood pressure monitoring device services for 21
580	580	pregnant and postpartum women. 22
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