| 16 | | - | Section A. Sections 191.648, 191.1145, 192.769, 208.152, 1 |
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| 17 | | - | 210.030, and 354.465, RSMo, are repealed and eight new sections 2 |
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| 18 | | - | enacted in lieu thereof, to be known as sections 191.648, 3 |
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| 19 | | - | 191.1145, 192.2521, 208.152, 210.030, 354.465, 376.1240, and 4 |
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| 20 | | - | 376.1850, to read as follows:5 |
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| 21 | | - | 191.648. 1. As used in this section, the following 1 |
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| 22 | | - | terms mean: 2 |
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| 23 | | - | (1) "Designated sexually transmitted infection", 3 |
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| 24 | | - | chlamydia, gonorrhea, trichomoniasis, or any other sexually 4 |
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| 25 | | - | transmitted infection designated as appropriate for 5 |
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| 26 | | - | expedited partner therapy by the department of health and 6 |
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| 27 | | - | senior services or for whi ch expedited partner therapy was 7 |
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| 28 | | - | recommended in the most recent Centers for Disease Control 8 |
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| 29 | | - | and Prevention guidelines for the prevention or treatment of 9 |
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| 30 | | - | sexually transmitted infections; 10 |
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| 31 | | - | (2) "Expedited partner therapy" [means], the practice 11 |
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| 32 | | - | of treating the sex partners of persons with [chlamydia or 12 |
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| 33 | | - | gonorrhea] designated sexually transmitted infections 13 SS#2 SB 79 2 |
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| 34 | | - | without an intervening medical evaluation or professional 14 |
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| 35 | | - | prevention counseling ; 15 |
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| 36 | | - | (3) "Health care professional", a member of any 16 |
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| 37 | | - | profession regulated by chapter 334 or 335 authorized to 17 |
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| 38 | | - | prescribe medications . 18 |
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| 39 | | - | 2. Any licensed physician or health care professional 19 |
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| 40 | | - | may, but shall not be required to, utilize expedited partner 20 |
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| 41 | | - | therapy for the management of the partners of persons with 21 |
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| 42 | | - | [chlamydia or gonorrhea ] designated sexually transmitted 22 |
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| 43 | | - | infections. Notwithstanding the requirements of 20 CSR 2150 - 23 |
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| 44 | | - | 5.020(5) or any other law to the contrary, a licensed 24 |
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| 45 | | - | physician or health care professional utilizing expedited 25 |
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| 46 | | - | partner therapy may pres cribe and dispense medications for 26 |
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| 47 | | - | the treatment of [chlamydia or gonorrhea ] a designated 27 |
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| 48 | | - | sexually transmitted infection for an individual who is the 28 |
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| 49 | | - | partner of a person with [chlamydia or gonorrhea ] a 29 |
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| 50 | | - | designated sexually transmitted infection and who does not 30 |
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| 51 | | - | have an established physician/patient relationship with such 31 |
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| 52 | | - | physician or an established health care professional/patient 32 |
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| 53 | | - | relationship with such health care professional . [Any 33 |
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| 54 | | - | antibiotic medications prescribed and dispensed for the 34 |
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| 55 | | - | treatment of chlamydia or gonorrhea under this section shall 35 |
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| 56 | | - | be in pill form.] 36 |
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| 57 | | - | 3. Any licensed physician or health care professional 37 |
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| 58 | | - | utilizing expedited partner therapy for the management of 38 |
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| 59 | | - | the partners with [chlamydia or gonorrhea ] designated 39 |
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| 60 | | - | sexually transmitted infections shall provide explanation 40 |
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| 61 | | - | and guidance to [a] each patient [diagnosed with chlamydia 41 |
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| 62 | | - | or gonorrhea] of the preventative measures that can be taken 42 |
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| 63 | | - | by the patient to stop the [spread] transmission of such 43 |
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| 64 | | - | [diagnosis] infection. 44 SS#2 SB 79 3 |
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| 65 | | - | 4. Any licensed physician or health care professional 45 |
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| 66 | | - | utilizing expedited partner therapy for the management of 46 |
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| 67 | | - | partners of persons with [chlamydia or gonorrhea ] designated 47 |
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| 68 | | - | sexually transmitted infections under this section shall 48 |
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| 69 | | - | have immunity from a ny civil liability that may otherwise 49 |
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| 70 | | - | result by reason of such actions, unless such physician or 50 |
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| 71 | | - | health care professional acts negligently, recklessly, in 51 |
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| 72 | | - | bad faith, or with malicious purpose. 52 |
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| 73 | | - | 5. The department of health and senior services and 53 |
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| 74 | | - | the division of professional registration within the 54 |
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| 75 | | - | department of commerce and insurance shall by rule develop 55 |
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| 76 | | - | guidelines for the implementation of subsection 2 of this 56 |
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| 77 | | - | section. Any rule or portion of a rule, as that term is 57 |
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| 78 | | - | defined in section 536.010 , that is created under the 58 |
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| 79 | | - | authority delegated in this section shall become effective 59 |
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| 80 | | - | only if it complies with and is subject to all of the 60 |
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| 81 | | - | provisions of chapter 536 and, if applicable, section 61 |
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| 82 | | - | 536.028. This section and chapter 536 are nonseverable a nd 62 |
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| 83 | | - | if any of the powers vested with the general assembly 63 |
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| 84 | | - | pursuant to chapter 536 to review, to delay the effective 64 |
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| 85 | | - | date, or to disapprove and annul a rule are subsequently 65 |
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| 86 | | - | held unconstitutional, then the grant of rulemaking 66 |
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| 87 | | - | authority and any rule prop osed or adopted after August 28, 67 |
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| 88 | | - | 2010, shall be invalid and void. 68 |
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| 89 | | - | 191.1145. 1. As used in sections 191.1145 and 1 |
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| 90 | | - | 191.1146, the following terms shall mean: 2 |
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| 91 | | - | (1) "Asynchronous store-and-forward transfer", the 3 |
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| 92 | | - | collection of a patie nt's relevant health information and 4 |
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| 93 | | - | the subsequent transmission of that information from an 5 |
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| 94 | | - | originating site to a health care provider at a distant site 6 |
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| 95 | | - | without the patient being present; 7 SS#2 SB 79 4 |
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| 96 | | - | (2) "Clinical staff", any health care provider 8 |
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| 97 | | - | licensed in this state; 9 |
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| 98 | | - | (3) "Distant site", a site at which a health care 10 |
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| 99 | | - | provider is located while providing health care services by 11 |
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| 100 | | - | means of telemedicine; 12 |
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| 101 | | - | (4) "Health care provider", as that term is defined in 13 |
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| 102 | | - | section 376.1350; 14 |
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| 103 | | - | (5) "Originating site", a site at which a patient is 15 |
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| 104 | | - | located at the time health care services are provided to him 16 |
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| 105 | | - | or her by means of telemedicine. For the purposes of 17 |
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| 106 | | - | asynchronous store-and-forward transfer, originating site 18 |
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| 107 | | - | shall also mean the location at which the health care 19 |
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| 108 | | - | provider transfers information to the distant site; 20 |
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| 109 | | - | (6) "Telehealth" or "telemedicine", the delivery of 21 |
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| 110 | | - | health care services by means of information and 22 |
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| 111 | | - | communication technologies , including audiovisual and audio - 23 |
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| 112 | | - | only technologies, which facilitate the assessment, 24 |
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| 113 | | - | diagnosis, consultation, treatment, education, care 25 |
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| 114 | | - | management, and self -management of a patient's health care 26 |
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| 115 | | - | while such patient is at the originating site and the health 27 |
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| 116 | | - | care provider is at the distant site. Telehealth or 28 |
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| 117 | | - | telemedicine shall also include the use of asynchronous 29 |
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| 118 | | - | store-and-forward technology. Health care providers shall 30 |
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| 119 | | - | not be limited in their choice of electronic platforms used 31 |
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| 120 | | - | to deliver telehealth or telemedicine, provided that all 32 |
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| 121 | | - | services delivered are in accordance with the Health 33 |
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| 122 | | - | Insurance Portability and Accountability Act of 1996. 34 |
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| 123 | | - | 2. Any licensed health care provider shall be 35 |
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| 124 | | - | authorized to provide telehealth services if such services 36 |
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| 125 | | - | are within the scope of practice for which the he alth care 37 |
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| 126 | | - | provider is licensed and are provided with the same standard 38 |
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| 127 | | - | of care as services provided in person. This section shall 39 SS#2 SB 79 5 |
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| 128 | | - | not be construed to prohibit a health carrier, as defined in 40 |
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| 129 | | - | section 376.1350, from reimbursing nonclinical staff for 41 |
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| 130 | | - | services otherwise allowed by law. 42 |
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| 131 | | - | 3. In order to treat patients in this state through 43 |
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| 132 | | - | the use of telemedicine or telehealth, health care providers 44 |
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| 133 | | - | shall be fully licensed to practice in this state and shall 45 |
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| 134 | | - | be subject to regulation by their respect ive professional 46 |
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| 135 | | - | boards. 47 |
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| 136 | | - | 4. Nothing in subsection 3 of this section shall apply 48 |
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| 137 | | - | to: 49 |
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| 138 | | - | (1) Informal consultation performed by a health care 50 |
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| 139 | | - | provider licensed in another state, outside of the context 51 |
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| 140 | | - | of a contractual relationship, and on an irr egular or 52 |
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| 141 | | - | infrequent basis without the expectation or exchange of 53 |
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| 142 | | - | direct or indirect compensation; 54 |
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| 143 | | - | (2) Furnishing of health care services by a health 55 |
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| 144 | | - | care provider licensed and located in another state in case 56 |
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| 145 | | - | of an emergency or disaster; provide d that, no charge is 57 |
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| 146 | | - | made for the medical assistance; or 58 |
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| 147 | | - | (3) Episodic consultation by a health care provider 59 |
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| 148 | | - | licensed and located in another state who provides such 60 |
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| 149 | | - | consultation services on request to a physician in this 61 |
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| 150 | | - | state. 62 |
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| 151 | | - | 5. Nothing in this section shall be construed to alter 63 |
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| 152 | | - | the scope of practice of any health care provider or to 64 |
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| 153 | | - | authorize the delivery of health care services in a setting 65 |
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| 154 | | - | or in a manner not otherwise authorized by the laws of this 66 |
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| 155 | | - | state. 67 |
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| 156 | | - | 6. No originating site for services or activities 68 |
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| 157 | | - | provided under this section shall be required to maintain 69 |
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| 158 | | - | immediate availability of on -site clinical staff during the 70 |
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| 159 | | - | telehealth services, except as necessary to meet the 71 SS#2 SB 79 6 |
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| 160 | | - | standard of care for the treatment of the patient's medical 72 |
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| 161 | | - | condition if such condition is being treated by an eligible 73 |
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| 162 | | - | health care provider who is not at the originating site, has 74 |
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| 163 | | - | not previously seen the patient in person in a clinical 75 |
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| 164 | | - | setting, and is not providing coverage for a health care 76 |
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| 165 | | - | provider who has an established relationship with the 77 |
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| 166 | | - | patient. Health care providers shall not be limited in 78 |
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| 167 | | - | their choice of electronic platforms used to deliver 79 |
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| 168 | | - | telehealth or telemedicine. 80 |
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| 169 | | - | 7. Nothing in this section shall be construed to alter 81 |
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| 170 | | - | any collaborative practice requirement as provided in 82 |
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| 171 | | - | chapters 334 and 335. 83 |
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| 172 | | - | 192.2521. A specialty hospital is exempt from the 1 |
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| 173 | | - | provisions of sections 192.2520 and 197.135 if such hospital 2 |
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| 174 | | - | has a policy for transfer of a victim of a sexual assa ult to 3 |
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| 175 | | - | an appropriate hospital with an emergency department. As 4 |
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| 176 | | - | used in this section, "specialty hospital" means a hospital 5 |
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| 177 | | - | that has been designated by the department of health and 6 |
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| 178 | | - | senior services as something other than a general acute care 7 |
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| 179 | | - | hospital. 8 |
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| 180 | | - | 208.152. 1. MO HealthNet payments shall be made on 1 |
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| 181 | | - | behalf of those eligible needy persons as described in 2 |
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| 182 | | - | section 208.151 who are unable to provide for it in whole or 3 |
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| 183 | | - | in part, with any payments to be made on the basis of the 4 |
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| 184 | | - | reasonable cost of the care or reasonable charge for the 5 |
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| 185 | | - | services as defined and determined by the MO HealthNet 6 |
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| 186 | | - | division, unless otherwise hereinafter provided, for the 7 |
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| 187 | | - | following: 8 |
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| 188 | | - | (1) Inpatient hospital services, except to persons in 9 |
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| 189 | | - | an institution for mental diseases who are under the age of 10 |
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| 190 | | - | sixty-five years and over the age of twenty -one years; 11 |
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| 191 | | - | provided that the MO HealthNet division shall provide 12 SS#2 SB 79 7 |
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| 192 | | - | through rule and regulation an exception process for 13 |
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| 193 | | - | coverage of inpatient costs in those cases req uiring 14 |
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| 194 | | - | treatment beyond the seventy -fifth percentile professional 15 |
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| 195 | | - | activities study (PAS) or the MO HealthNet children's 16 |
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| 196 | | - | diagnosis length-of-stay schedule; and provided further that 17 |
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| 197 | | - | the MO HealthNet division shall take into account through 18 |
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| 198 | | - | its payment system for hospital services the situation of 19 |
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| 199 | | - | hospitals which serve a disproportionate number of low - 20 |
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| 200 | | - | income patients; 21 |
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| 201 | | - | (2) All outpatient hospital services, payments 22 |
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| 202 | | - | therefor to be in amounts which represent no more than 23 |
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| 203 | | - | eighty percent of the less er of reasonable costs or 24 |
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| 204 | | - | customary charges for such services, determined in 25 |
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| 205 | | - | accordance with the principles set forth in Title XVIII A 26 |
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| 206 | | - | and B, Public Law 89 -97, 1965 amendments to the federal 27 |
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| 207 | | - | Social Security Act (42 U.S.C. Section 301, et seq.), but 28 |
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| 208 | | - | the MO HealthNet division may evaluate outpatient hospital 29 |
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| 209 | | - | services rendered under this section and deny payment for 30 |
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| 210 | | - | services which are determined by the MO HealthNet division 31 |
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| 211 | | - | not to be medically necessary, in accordance with federal 32 |
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| 212 | | - | law and regulations; 33 |
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| 213 | | - | (3) Laboratory and X-ray services; 34 |
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| 214 | | - | (4) Nursing home services for participants, except to 35 |
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| 215 | | - | persons with more than five hundred thousand dollars equity 36 |
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| 216 | | - | in their home or except for persons in an institution for 37 |
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| 217 | | - | mental diseases who are under the age of sixty-five years, 38 |
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| 218 | | - | when residing in a hospital licensed by the department of 39 |
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| 219 | | - | health and senior services or a nursing home licensed by the 40 |
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| 220 | | - | department of health and senior services or appropriate 41 |
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| 221 | | - | licensing authority of other states or government -owned and - 42 |
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| 222 | | - | operated institutions which are determined to conform to 43 |
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| 223 | | - | standards equivalent to licensing requirements in Title XIX 44 SS#2 SB 79 8 |
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| 224 | | - | of the federal Social Security Act (42 U.S.C. Section [301] 45 |
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| 225 | | - | 1396, et seq.), as amended, for nursing facilities. The MO 46 |
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| 226 | | - | HealthNet division may recognize through its payment 47 |
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| 227 | | - | methodology for nursing facilities those nursing facilities 48 |
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| 228 | | - | which serve a high volume of MO HealthNet patients. The MO 49 |
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| 229 | | - | HealthNet division when determining the amount of the 50 |
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| 230 | | - | benefit payments to be made o n behalf of persons under the 51 |
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| 231 | | - | age of twenty-one in a nursing facility may consider nursing 52 |
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| 232 | | - | facilities furnishing care to persons under the age of 53 |
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| 233 | | - | twenty-one as a classification separate from other nursing 54 |
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| 234 | | - | facilities; 55 |
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| 235 | | - | (5) Nursing home costs for pa rticipants receiving 56 |
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| 236 | | - | benefit payments under subdivision (4) of this subsection 57 |
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| 237 | | - | for those days, which shall not exceed twelve per any period 58 |
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| 238 | | - | of six consecutive months, during which the participant is 59 |
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| 239 | | - | on a temporary leave of absence from the hospital or nursing 60 |
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| 240 | | - | home, provided that no such participant shall be allowed a 61 |
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| 241 | | - | temporary leave of absence unless it is specifically 62 |
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| 242 | | - | provided for in his plan of care. As used in this 63 |
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| 243 | | - | subdivision, the term "temporary leave of absence" shall 64 |
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| 244 | | - | include all periods of time during which a participant is 65 |
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| 245 | | - | away from the hospital or nursing home overnight because he 66 |
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| 246 | | - | is visiting a friend or relative; 67 |
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| 247 | | - | (6) Physicians' services, whether furnished in the 68 |
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| 248 | | - | office, home, hospital, nursing home, or elsewhere, 69 |
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| 249 | | - | provided, that no funds shall be expended to any abortion 70 |
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| 250 | | - | facility, as defined in section 188.015, or to any 71 |
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| 251 | | - | affiliate, as defined in section 188.015, of such abortion 72 |
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| 252 | | - | facility; 73 |
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| 253 | | - | (7) Subject to appropriation, up to twenty visits per 74 |
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| 254 | | - | year for services limited to examinations, diagnoses, 75 |
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| 255 | | - | adjustments, and manipulations and treatments of 76 SS#2 SB 79 9 |
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| 256 | | - | malpositioned articulations and structures of the body 77 |
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| 257 | | - | provided by licensed chiropractic physicians practicing 78 |
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| 258 | | - | within their scope of practice. Nothing in this subdivision 79 |
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| 259 | | - | shall be interpreted to otherwise expand MO HealthNet 80 |
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| 260 | | - | services; 81 |
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| 261 | | - | (8) Drugs and medicines when prescribed by a licensed 82 |
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| 262 | | - | physician, dentist, podiatrist, or an advanced practice 83 |
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| 263 | | - | registered nurse; except that no payment for drugs and 84 |
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| 264 | | - | medicines prescribed on and after January 1, 2006, by a 85 |
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| 265 | | - | licensed physician, dentist, podiatrist, or an advanced 86 |
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| 266 | | - | practice registered nurse may be made on behalf of any 87 |
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| 267 | | - | person who qualifies for prescription drug coverage under 88 |
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| 268 | | - | the provisions of P.L. 108 -173; 89 |
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| 269 | | - | (9) Emergency ambulance services and, effective 90 |
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| 270 | | - | January 1, 1990, medically necessary transportation to 91 |
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| 271 | | - | scheduled, physician -prescribed nonelective treatments; 92 |
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| 272 | | - | (10) Early and periodic screening and diagnosis of 93 |
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| 273 | | - | individuals who are under the age of twenty -one to ascertain 94 |
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| 274 | | - | their physical or mental defects, and health care, 95 |
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| 275 | | - | treatment, and other measures to correct or ameliorate 96 |
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| 276 | | - | defects and chronic conditions discovered thereby. Such 97 |
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| 277 | | - | services shall be provided in accordance with the provisions 98 |
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| 278 | | - | of Section 6403 of P.L. 101-239 and federal regulations 99 |
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| 279 | | - | promulgated thereunder; 100 |
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| 280 | | - | (11) Home health care services; 101 |
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| 281 | | - | (12) Family planning as defined by federal rules and 102 |
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| 282 | | - | regulations; provided, that no funds shall be expended to 103 |
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| 283 | | - | any abortion facility, as defin ed in section 188.015, or to 104 |
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| 284 | | - | any affiliate, as defined in section 188.015, of such 105 |
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| 285 | | - | abortion facility; and further provided, however, that such 106 |
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| 286 | | - | family planning services shall not include abortions or any 107 |
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| 287 | | - | abortifacient drug or device that is used for the purpose of 108 SS#2 SB 79 10 |
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| 288 | | - | inducing an abortion unless such abortions are certified in 109 |
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| 289 | | - | writing by a physician to the MO HealthNet agency that, in 110 |
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| 290 | | - | the physician's professional judgment, the life of the 111 |
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| 291 | | - | mother would be endangered if the fetus were carried to term; 112 |
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| 292 | | - | (13) Inpatient psychiatric hospital services for 113 |
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| 293 | | - | individuals under age twenty -one as defined in Title XIX of 114 |
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| 294 | | - | the federal Social Security Act (42 U.S.C. Section 1396d, et 115 |
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| 295 | | - | seq.); 116 |
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| 296 | | - | (14) Outpatient surgical procedures, including 117 |
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| 297 | | - | presurgical diagnost ic services performed in ambulatory 118 |
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| 298 | | - | surgical facilities which are licensed by the department of 119 |
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| 299 | | - | health and senior services of the state of Missouri; except, 120 |
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| 300 | | - | that such outpatient surgical services shall not include 121 |
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| 301 | | - | persons who are eligible for coverage under Part B of Title 122 |
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| 302 | | - | XVIII, Public Law 89 -97, 1965 amendments to the federal 123 |
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| 303 | | - | Social Security Act, as amended, if exclusion of such 124 |
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| 304 | | - | persons is permitted under Title XIX, Public Law 89 -97, 1965 125 |
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| 305 | | - | amendments to the federal Social Security Act, as amended; 126 |
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| 306 | | - | (15) Personal care services which are medically 127 |
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| 307 | | - | oriented tasks having to do with a person's physical 128 |
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| 308 | | - | requirements, as opposed to housekeeping requirements, which 129 |
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| 309 | | - | enable a person to be treated by his or her physician on an 130 |
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| 310 | | - | outpatient rather than o n an inpatient or residential basis 131 |
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| 311 | | - | in a hospital, intermediate care facility, or skilled 132 |
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| 312 | | - | nursing facility. Personal care services shall be rendered 133 |
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| 313 | | - | by an individual not a member of the participant's family 134 |
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| 314 | | - | who is qualified to provide such services wh ere the services 135 |
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| 315 | | - | are prescribed by a physician in accordance with a plan of 136 |
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| 316 | | - | treatment and are supervised by a licensed nurse. Persons 137 |
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| 317 | | - | eligible to receive personal care services shall be those 138 |
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| 318 | | - | persons who would otherwise require placement in a hospital , 139 |
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| 319 | | - | intermediate care facility, or skilled nursing facility. 140 SS#2 SB 79 11 |
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| 320 | | - | Benefits payable for personal care services shall not exceed 141 |
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| 321 | | - | for any one participant one hundred percent of the average 142 |
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| 322 | | - | statewide charge for care and treatment in an intermediate 143 |
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| 323 | | - | care facility for a comparable period of time. Such 144 |
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| 324 | | - | services, when delivered in a residential care facility or 145 |
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| 325 | | - | assisted living facility licensed under chapter 198 shall be 146 |
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| 326 | | - | authorized on a tier level based on the services the 147 |
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| 327 | | - | resident requires and the frequency of the services. A 148 |
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| 328 | | - | resident of such facility who qualifies for assistance under 149 |
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| 329 | | - | section 208.030 shall, at a minimum, if prescribed by a 150 |
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| 330 | | - | physician, qualify for the tier level with the fewest 151 |
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| 331 | | - | services. The rate paid to providers for each tier of 152 |
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| 332 | | - | service shall be set subject to appropriations. Subject to 153 |
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| 333 | | - | appropriations, each resident of such facility who qualifies 154 |
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| 334 | | - | for assistance under section 208.030 and meets the level of 155 |
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| 335 | | - | care required in this section shall, at a minimum, if 156 |
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| 336 | | - | prescribed by a physicia n, be authorized up to one hour of 157 |
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| 337 | | - | personal care services per day. Authorized units of 158 |
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| 338 | | - | personal care services shall not be reduced or tier level 159 |
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| 339 | | - | lowered unless an order approving such reduction or lowering 160 |
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| 340 | | - | is obtained from the resident's personal phys ician. Such 161 |
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| 341 | | - | authorized units of personal care services or tier level 162 |
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| 342 | | - | shall be transferred with such resident if he or she 163 |
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| 343 | | - | transfers to another such facility. Such provision shall 164 |
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| 344 | | - | terminate upon receipt of relevant waivers from the federal 165 |
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| 345 | | - | Department of Health and Human Services. If the Centers for 166 |
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| 346 | | - | Medicare and Medicaid Services determines that such 167 |
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| 347 | | - | provision does not comply with the state plan, this 168 |
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| 348 | | - | provision shall be null and void. The MO HealthNet division 169 |
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| 349 | | - | shall notify the revisor of statutes as to whether the 170 |
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| 350 | | - | relevant waivers are approved or a determination of 171 |
|---|
| 351 | | - | noncompliance is made; 172 SS#2 SB 79 12 |
|---|
| 352 | | - | (16) Mental health services. The state plan for 173 |
|---|
| 353 | | - | providing medical assistance under Title XIX of the Social 174 |
|---|
| 354 | | - | Security Act, 42 U.S.C. Section [301] 1396, et seq., as 175 |
|---|
| 355 | | - | amended, shall include the following mental health services 176 |
|---|
| 356 | | - | when such services are provided by community mental health 177 |
|---|
| 357 | | - | facilities operated by the department of mental health or 178 |
|---|
| 358 | | - | designated by the department of mental health as a community 179 |
|---|
| 359 | | - | mental health facility or as an alcohol and drug abuse 180 |
|---|
| 360 | | - | facility or as a child -serving agency within the 181 |
|---|
| 361 | | - | comprehensive children's mental health service system 182 |
|---|
| 362 | | - | established in section 630.097. The department of mental 183 |
|---|
| 363 | | - | health shall establish by administrat ive rule the definition 184 |
|---|
| 364 | | - | and criteria for designation as a community mental health 185 |
|---|
| 365 | | - | facility and for designation as an alcohol and drug abuse 186 |
|---|
| 366 | | - | facility. Such mental health services shall include: 187 |
|---|
| 367 | | - | (a) Outpatient mental health services including 188 |
|---|
| 368 | | - | preventive, diagnostic, therapeutic, rehabilitative, and 189 |
|---|
| 369 | | - | palliative interventions rendered to individuals in an 190 |
|---|
| 370 | | - | individual or group setting by a mental health professional 191 |
|---|
| 371 | | - | in accordance with a plan of treatment appropriately 192 |
|---|
| 372 | | - | established, implemented, monit ored, and revised under the 193 |
|---|
| 373 | | - | auspices of a therapeutic team as a part of client services 194 |
|---|
| 374 | | - | management; 195 |
|---|
| 375 | | - | (b) Clinic mental health services including 196 |
|---|
| 376 | | - | preventive, diagnostic, therapeutic, rehabilitative, and 197 |
|---|
| 377 | | - | palliative interventions rendered to individu als in an 198 |
|---|
| 378 | | - | individual or group setting by a mental health professional 199 |
|---|
| 379 | | - | in accordance with a plan of treatment appropriately 200 |
|---|
| 380 | | - | established, implemented, monitored, and revised under the 201 |
|---|
| 381 | | - | auspices of a therapeutic team as a part of client services 202 |
|---|
| 382 | | - | management; 203 SS#2 SB 79 13 |
|---|
| 383 | | - | (c) Rehabilitative mental health and alcohol and drug 204 |
|---|
| 384 | | - | abuse services including home and community -based 205 |
|---|
| 385 | | - | preventive, diagnostic, therapeutic, rehabilitative, and 206 |
|---|
| 386 | | - | palliative interventions rendered to individuals in an 207 |
|---|
| 387 | | - | individual or group setting by a mental health or alcohol 208 |
|---|
| 388 | | - | and drug abuse professional in accordance with a plan of 209 |
|---|
| 389 | | - | treatment appropriately established, implemented, monitored, 210 |
|---|
| 390 | | - | and revised under the auspices of a therapeutic team as a 211 |
|---|
| 391 | | - | part of client services management. As used in this 212 |
|---|
| 392 | | - | section, mental health professional and alcohol and drug 213 |
|---|
| 393 | | - | abuse professional shall be defined by the department of 214 |
|---|
| 394 | | - | mental health pursuant to duly promulgated rules. With 215 |
|---|
| 395 | | - | respect to services established by this subdivision, the 216 |
|---|
| 396 | | - | department of social services, MO HealthNet division, shall 217 |
|---|
| 397 | | - | enter into an agreement with the department of mental 218 |
|---|
| 398 | | - | health. Matching funds for outpatient mental health 219 |
|---|
| 399 | | - | services, clinic mental health services, and rehabilitation 220 |
|---|
| 400 | | - | services for mental health and alcohol an d drug abuse shall 221 |
|---|
| 401 | | - | be certified by the department of mental health to the MO 222 |
|---|
| 402 | | - | HealthNet division. The agreement shall establish a 223 |
|---|
| 403 | | - | mechanism for the joint implementation of the provisions of 224 |
|---|
| 404 | | - | this subdivision. In addition, the agreement shall 225 |
|---|
| 405 | | - | establish a mechanism by which rates for services may be 226 |
|---|
| 406 | | - | jointly developed; 227 |
|---|
| 407 | | - | (17) Such additional services as defined by the MO 228 |
|---|
| 408 | | - | HealthNet division to be furnished under waivers of federal 229 |
|---|
| 409 | | - | statutory requirements as provided for and authorized by the 230 |
|---|
| 410 | | - | federal Social Security Act (42 U.S.C. Section 301, et seq.) 231 |
|---|
| 411 | | - | subject to appropriation by the general assembly; 232 |
|---|
| 412 | | - | (18) The services of an advanced practice registered 233 |
|---|
| 413 | | - | nurse with a collaborative practice agreement to the extent 234 SS#2 SB 79 14 |
|---|
| 414 | | - | that such services are provide d in accordance with chapters 235 |
|---|
| 415 | | - | 334 and 335, and regulations promulgated thereunder; 236 |
|---|
| 416 | | - | (19) Nursing home costs for participants receiving 237 |
|---|
| 417 | | - | benefit payments under subdivision (4) of this subsection to 238 |
|---|
| 418 | | - | reserve a bed for the participant in the nursing hom e during 239 |
|---|
| 419 | | - | the time that the participant is absent due to admission to 240 |
|---|
| 420 | | - | a hospital for services which cannot be performed on an 241 |
|---|
| 421 | | - | outpatient basis, subject to the provisions of this 242 |
|---|
| 422 | | - | subdivision: 243 |
|---|
| 423 | | - | (a) The provisions of this subdivision shall apply 244 |
|---|
| 424 | | - | only if: 245 |
|---|
| 425 | | - | a. The occupancy rate of the nursing home is at or 246 |
|---|
| 426 | | - | above ninety-seven percent of MO HealthNet certified 247 |
|---|
| 427 | | - | licensed beds, according to the most recent quarterly census 248 |
|---|
| 428 | | - | provided to the department of health and senior services 249 |
|---|
| 429 | | - | which was taken prior to when the participant is admitted to 250 |
|---|
| 430 | | - | the hospital; and 251 |
|---|
| 431 | | - | b. The patient is admitted to a hospital for a medical 252 |
|---|
| 432 | | - | condition with an anticipated stay of three days or less; 253 |
|---|
| 433 | | - | (b) The payment to be made under this subdivision 254 |
|---|
| 434 | | - | shall be provided for a maximum of three days per hospital 255 |
|---|
| 435 | | - | stay; 256 |
|---|
| 436 | | - | (c) For each day that nursing home costs are paid on 257 |
|---|
| 437 | | - | behalf of a participant under this subdivision during any 258 |
|---|
| 438 | | - | period of six consecutive months such participant shall, 259 |
|---|
| 439 | | - | during the same period of six c onsecutive months, be 260 |
|---|
| 440 | | - | ineligible for payment of nursing home costs of two 261 |
|---|
| 441 | | - | otherwise available temporary leave of absence days provided 262 |
|---|
| 442 | | - | under subdivision (5) of this subsection; and 263 |
|---|
| 443 | | - | (d) The provisions of this subdivision shall not apply 264 |
|---|
| 444 | | - | unless the nursing home receives notice from the participant 265 |
|---|
| 445 | | - | or the participant's responsible party that the participant 266 SS#2 SB 79 15 |
|---|
| 446 | | - | intends to return to the nursing home following the hospital 267 |
|---|
| 447 | | - | stay. If the nursing home receives such notification and 268 |
|---|
| 448 | | - | all other provisions o f this subsection have been satisfied, 269 |
|---|
| 449 | | - | the nursing home shall provide notice to the participant or 270 |
|---|
| 450 | | - | the participant's responsible party prior to release of the 271 |
|---|
| 451 | | - | reserved bed; 272 |
|---|
| 452 | | - | (20) Prescribed medically necessary durable medical 273 |
|---|
| 453 | | - | equipment. An electronic web-based prior authorization 274 |
|---|
| 454 | | - | system using best medical evidence and care and treatment 275 |
|---|
| 455 | | - | guidelines consistent with national standards shall be used 276 |
|---|
| 456 | | - | to verify medical need; 277 |
|---|
| 457 | | - | (21) Hospice care. As used in this subdivision, the 278 |
|---|
| 458 | | - | term "hospice care" means a coordinated program of active 279 |
|---|
| 459 | | - | professional medical attention within a home, outpatient and 280 |
|---|
| 460 | | - | inpatient care which treats the terminally ill patient and 281 |
|---|
| 461 | | - | family as a unit, employing a medically directed 282 |
|---|
| 462 | | - | interdisciplinary team. The program provides relief of 283 |
|---|
| 463 | | - | severe pain or other physical symptoms and supportive care 284 |
|---|
| 464 | | - | to meet the special needs arising out of physical, 285 |
|---|
| 465 | | - | psychological, spiritual, social, and economic stresses 286 |
|---|
| 466 | | - | which are experienced during the final stages of illness, 287 |
|---|
| 467 | | - | and during dying and bereavement and meets the Medicare 288 |
|---|
| 468 | | - | requirements for participation as a hospice as are provided 289 |
|---|
| 469 | | - | in 42 CFR Part 418. The rate of reimbursement paid by the 290 |
|---|
| 470 | | - | MO HealthNet division to the hospice provider for room and 291 |
|---|
| 471 | | - | board furnished by a nursing h ome to an eligible hospice 292 |
|---|
| 472 | | - | patient shall not be less than ninety -five percent of the 293 |
|---|
| 473 | | - | rate of reimbursement which would have been paid for 294 |
|---|
| 474 | | - | facility services in that nursing home facility for that 295 |
|---|
| 475 | | - | patient, in accordance with subsection (c) of Section 640 8 296 |
|---|
| 476 | | - | of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 297 SS#2 SB 79 16 |
|---|
| 477 | | - | (22) Prescribed medically necessary dental services. 298 |
|---|
| 478 | | - | Such services shall be subject to appropriations. An 299 |
|---|
| 479 | | - | electronic web-based prior authorization system using best 300 |
|---|
| 480 | | - | medical evidence and care and treatment guidelines 301 |
|---|
| 481 | | - | consistent with national standards shall be used to verify 302 |
|---|
| 482 | | - | medical need; 303 |
|---|
| 483 | | - | (23) Prescribed medically necessary optometric 304 |
|---|
| 484 | | - | services. Such services shall be subject to 305 |
|---|
| 485 | | - | appropriations. An electronic web-based prior authorization 306 |
|---|
| 486 | | - | system using best medical evidence and care and treatment 307 |
|---|
| 487 | | - | guidelines consistent with national standards shall be used 308 |
|---|
| 488 | | - | to verify medical need; 309 |
|---|
| 489 | | - | (24) Blood clotting products -related services. For 310 |
|---|
| 490 | | - | persons diagnosed with a bleeding dis order, as defined in 311 |
|---|
| 491 | | - | section 338.400, reliant on blood clotting products, as 312 |
|---|
| 492 | | - | defined in section 338.400, such services include: 313 |
|---|
| 493 | | - | (a) Home delivery of blood clotting products and 314 |
|---|
| 494 | | - | ancillary infusion equipment and supplies, including the 315 |
|---|
| 495 | | - | emergency deliveries of the product when medically necessary; 316 |
|---|
| 496 | | - | (b) Medically necessary ancillary infusion equipment 317 |
|---|
| 497 | | - | and supplies required to administer the blood clotting 318 |
|---|
| 498 | | - | products; and 319 |
|---|
| 499 | | - | (c) Assessments conducted in the participant's home by 320 |
|---|
| 500 | | - | a pharmacist, nurse, or local home health care agency 321 |
|---|
| 501 | | - | trained in bleeding disorders when deemed necessary by the 322 |
|---|
| 502 | | - | participant's treating physician; 323 |
|---|
| 503 | | - | (25) Medically necessary cochlear implants and hearing 324 |
|---|
| 504 | | - | instruments, as defined in section 345.015, that are: 325 |
|---|
| 505 | | - | (a) Prescribed by an audiologist, as defined in 326 |
|---|
| 506 | | - | section 345.015; or 327 |
|---|
| 507 | | - | (b) Dispensed by a hearing instrument specialist, as 328 |
|---|
| 508 | | - | defined in section 346.010; 329 SS#2 SB 79 17 |
|---|
| 509 | | - | (26) The MO HealthNet division shall, by January 1, 330 |
|---|
| 510 | | - | 2008, and annually thereafter, report t he status of MO 331 |
|---|
| 511 | | - | HealthNet provider reimbursement rates as compared to one 332 |
|---|
| 512 | | - | hundred percent of the Medicare reimbursement rates and 333 |
|---|
| 513 | | - | compared to the average dental reimbursement rates paid by 334 |
|---|
| 514 | | - | third-party payors licensed by the state. The MO HealthNet 335 |
|---|
| 515 | | - | division shall, by July 1, 2008, provide to the general 336 |
|---|
| 516 | | - | assembly a four-year plan to achieve parity with Medicare 337 |
|---|
| 517 | | - | reimbursement rates and for third -party payor average dental 338 |
|---|
| 518 | | - | reimbursement rates. Such plan shall be subject to 339 |
|---|
| 519 | | - | appropriation and the divis ion shall include in its annual 340 |
|---|
| 520 | | - | budget request to the governor the necessary funding needed 341 |
|---|
| 521 | | - | to complete the four -year plan developed under this 342 |
|---|
| 522 | | - | subdivision. 343 |
|---|
| 523 | | - | 2. Additional benefit payments for medical assistance 344 |
|---|
| 524 | | - | shall be made on behalf of those el igible needy children, 345 |
|---|
| 525 | | - | pregnant women and blind persons with any payments to be 346 |
|---|
| 526 | | - | made on the basis of the reasonable cost of the care or 347 |
|---|
| 527 | | - | reasonable charge for the services as defined and determined 348 |
|---|
| 528 | | - | by the MO HealthNet division, unless otherwise hereinaf ter 349 |
|---|
| 529 | | - | provided, for the following: 350 |
|---|
| 530 | | - | (1) Dental services; 351 |
|---|
| 531 | | - | (2) Services of podiatrists as defined in section 352 |
|---|
| 532 | | - | 330.010; 353 |
|---|
| 533 | | - | (3) Optometric services as described in section 354 |
|---|
| 534 | | - | 336.010; 355 |
|---|
| 535 | | - | (4) Orthopedic devices or other prosthetics, including 356 |
|---|
| 536 | | - | eye glasses, dentures, [hearing aids,] and wheelchairs; 357 |
|---|
| 537 | | - | (5) Hospice care. As used in this subdivision, the 358 |
|---|
| 538 | | - | term "hospice care" means a coordinated program of active 359 |
|---|
| 539 | | - | professional medical attention within a home, outpatient and 360 |
|---|
| 540 | | - | inpatient care which tr eats the terminally ill patient and 361 SS#2 SB 79 18 |
|---|
| 541 | | - | family as a unit, employing a medically directed 362 |
|---|
| 542 | | - | interdisciplinary team. The program provides relief of 363 |
|---|
| 543 | | - | severe pain or other physical symptoms and supportive care 364 |
|---|
| 544 | | - | to meet the special needs arising out of physical, 365 |
|---|
| 545 | | - | psychological, spiritual, social, and economic stresses 366 |
|---|
| 546 | | - | which are experienced during the final stages of illness, 367 |
|---|
| 547 | | - | and during dying and bereavement and meets the Medicare 368 |
|---|
| 548 | | - | requirements for participation as a hospice as are provided 369 |
|---|
| 549 | | - | in 42 CFR Part 418. The rate of reimbursement paid by the 370 |
|---|
| 550 | | - | MO HealthNet division to the hospice provider for room and 371 |
|---|
| 551 | | - | board furnished by a nursing home to an eligible hospice 372 |
|---|
| 552 | | - | patient shall not be less than ninety -five percent of the 373 |
|---|
| 553 | | - | rate of reimbursement which would have be en paid for 374 |
|---|
| 554 | | - | facility services in that nursing home facility for that 375 |
|---|
| 555 | | - | patient, in accordance with subsection (c) of Section 6408 376 |
|---|
| 556 | | - | of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 377 |
|---|
| 557 | | - | (6) Comprehensive day rehabilitation services 378 |
|---|
| 558 | | - | beginning early posttrauma as part of a coordinated system 379 |
|---|
| 559 | | - | of care for individuals with disabling impairments. 380 |
|---|
| 560 | | - | Rehabilitation services must be based on an individualized, 381 |
|---|
| 561 | | - | goal-oriented, comprehensive and coordinated treatment plan 382 |
|---|
| 562 | | - | developed, implemented, and mon itored through an 383 |
|---|
| 563 | | - | interdisciplinary assessment designed to restore an 384 |
|---|
| 564 | | - | individual to optimal level of physical, cognitive, and 385 |
|---|
| 565 | | - | behavioral function. The MO HealthNet division shall 386 |
|---|
| 566 | | - | establish by administrative rule the definition and criteria 387 |
|---|
| 567 | | - | for designation of a comprehensive day rehabilitation 388 |
|---|
| 568 | | - | service facility, benefit limitations and payment 389 |
|---|
| 569 | | - | mechanism. Any rule or portion of a rule, as that term is 390 |
|---|
| 570 | | - | defined in section 536.010, that is created under the 391 |
|---|
| 571 | | - | authority delegated in this subdivision shall become 392 |
|---|
| 572 | | - | effective only if it complies with and is subject to all of 393 SS#2 SB 79 19 |
|---|
| 573 | | - | the provisions of chapter 536 and, if applicable, section 394 |
|---|
| 574 | | - | 536.028. This section and chapter 536 are nonseverable and 395 |
|---|
| 575 | | - | if any of the powers vested with the general assembly 396 |
|---|
| 576 | | - | pursuant to chapter 536 to review, to delay the effective 397 |
|---|
| 577 | | - | date, or to disapprove and annul a rule are subsequently 398 |
|---|
| 578 | | - | held unconstitutional, then the grant of rulemaking 399 |
|---|
| 579 | | - | authority and any rule proposed or adopted after August 28, 400 |
|---|
| 580 | | - | 2005, shall be invalid and void. 401 |
|---|
| 581 | | - | 3. The MO HealthNet division may require any 402 |
|---|
| 582 | | - | participant receiving MO HealthNet benefits to pay part of 403 |
|---|
| 583 | | - | the charge or cost until July 1, 2008, and an additional 404 |
|---|
| 584 | | - | payment after July 1, 2008, as defined by rule duly 405 |
|---|
| 585 | | - | promulgated by the MO HealthNet divi sion, for all covered 406 |
|---|
| 586 | | - | services except for those services covered under 407 |
|---|
| 587 | | - | subdivisions (15) and (16) of subsection 1 of this section 408 |
|---|
| 588 | | - | and sections 208.631 to 208.657 to the extent and in the 409 |
|---|
| 589 | | - | manner authorized by Title XIX of the federal Social 410 |
|---|
| 590 | | - | Security Act (42 U.S.C. Section 1396, et seq.) and 411 |
|---|
| 591 | | - | regulations thereunder. When substitution of a generic drug 412 |
|---|
| 592 | | - | is permitted by the prescriber according to section 338.056, 413 |
|---|
| 593 | | - | and a generic drug is substituted for a name -brand drug, the 414 |
|---|
| 594 | | - | MO HealthNet division may not lower or delete the 415 |
|---|
| 595 | | - | requirement to make a co -payment pursuant to regulations of 416 |
|---|
| 596 | | - | Title XIX of the federal Social Security Act. A provider of 417 |
|---|
| 597 | | - | goods or services described under this section must collect 418 |
|---|
| 598 | | - | from all participants the additional payment that may be 419 |
|---|
| 599 | | - | required by the MO HealthNet division under authority 420 |
|---|
| 600 | | - | granted herein, if the division exercises that authority, to 421 |
|---|
| 601 | | - | remain eligible as a provider. Any payments made by 422 |
|---|
| 602 | | - | participants under this section shall be in addition to and 423 |
|---|
| 603 | | - | not in lieu of payments made by the state for goods or 424 |
|---|
| 604 | | - | services described herein except the participant portion of 425 SS#2 SB 79 20 |
|---|
| 605 | | - | the pharmacy professional dispensing fee shall be in 426 |
|---|
| 606 | | - | addition to and not in lieu of payments to pharmacists. A 427 |
|---|
| 607 | | - | provider may collect the co -payment at the time a service is 428 |
|---|
| 608 | | - | provided or at a later date. A provider shall not refuse to 429 |
|---|
| 609 | | - | provide a service if a participant is unable to pay a 430 |
|---|
| 610 | | - | required payment. If it is the routine business practice of 431 |
|---|
| 611 | | - | a provider to terminate future services to an individual 432 |
|---|
| 612 | | - | with an unclaimed debt, the provider may include uncollected 433 |
|---|
| 613 | | - | co-payments under this practice. Providers who elect not to 434 |
|---|
| 614 | | - | undertake the provision of services based on a history of 435 |
|---|
| 615 | | - | bad debt shall give participants advance notice and a 436 |
|---|
| 616 | | - | reasonable opportunity for payment. A provider, 437 |
|---|
| 617 | | - | representative, employee, independent contractor, or agent 438 |
|---|
| 618 | | - | of a pharmaceutical manufacturer shall not make co -payment 439 |
|---|
| 619 | | - | for a participant. This subsection shall not apply to other 440 |
|---|
| 620 | | - | qualified children, pregnant women, or b lind persons. If 441 |
|---|
| 621 | | - | the Centers for Medicare and Medicaid Services does not 442 |
|---|
| 622 | | - | approve the MO HealthNet state plan amendment submitted by 443 |
|---|
| 623 | | - | the department of social services that would allow a 444 |
|---|
| 624 | | - | provider to deny future services to an individual with 445 |
|---|
| 625 | | - | uncollected co-payments, the denial of services shall not be 446 |
|---|
| 626 | | - | allowed. The department of social services shall inform 447 |
|---|
| 627 | | - | providers regarding the acceptability of denying services as 448 |
|---|
| 628 | | - | the result of unpaid co -payments. 449 |
|---|
| 629 | | - | 4. The MO HealthNet division shall have the right to 450 |
|---|
| 630 | | - | collect medication samples from participants in order to 451 |
|---|
| 631 | | - | maintain program integrity. 452 |
|---|
| 632 | | - | 5. Reimbursement for obstetrical and pediatric 453 |
|---|
| 633 | | - | services under subdivision (6) of subsection 1 of this 454 |
|---|
| 634 | | - | section shall be timely and sufficient to enlist e nough 455 |
|---|
| 635 | | - | health care providers so that care and services are 456 |
|---|
| 636 | | - | available under the state plan for MO HealthNet benefits at 457 SS#2 SB 79 21 |
|---|
| 637 | | - | least to the extent that such care and services are 458 |
|---|
| 638 | | - | available to the general population in the geographic area, 459 |
|---|
| 639 | | - | as required under sub paragraph (a)(30)(A) of 42 U.S.C. 460 |
|---|
| 640 | | - | Section 1396a and federal regulations promulgated thereunder. 461 |
|---|
| 641 | | - | 6. Beginning July 1, 1990, reimbursement for services 462 |
|---|
| 642 | | - | rendered in federally funded health centers shall be in 463 |
|---|
| 643 | | - | accordance with the provisions of subsect ion 6402(c) and 464 |
|---|
| 644 | | - | Section 6404 of P.L. 101 -239 (Omnibus Budget Reconciliation 465 |
|---|
| 645 | | - | Act of 1989) and federal regulations promulgated thereunder. 466 |
|---|
| 646 | | - | 7. Beginning July 1, 1990, the department of social 467 |
|---|
| 647 | | - | services shall provide notification and referral of childr en 468 |
|---|
| 648 | | - | below age five, and pregnant, breast -feeding, or postpartum 469 |
|---|
| 649 | | - | women who are determined to be eligible for MO HealthNet 470 |
|---|
| 650 | | - | benefits under section 208.151 to the special supplemental 471 |
|---|
| 651 | | - | food programs for women, infants and children administered 472 |
|---|
| 652 | | - | by the department of health and senior services. Such 473 |
|---|
| 653 | | - | notification and referral shall conform to the requirements 474 |
|---|
| 654 | | - | of Section 6406 of P.L. 101 -239 and regulations promulgated 475 |
|---|
| 655 | | - | thereunder. 476 |
|---|
| 656 | | - | 8. Providers of long-term care services shall be 477 |
|---|
| 657 | | - | reimbursed for their co sts in accordance with the provisions 478 |
|---|
| 658 | | - | of Section 1902 (a)(13)(A) of the Social Security Act, 42 479 |
|---|
| 659 | | - | U.S.C. Section 1396a, as amended, and regulations 480 |
|---|
| 660 | | - | promulgated thereunder. 481 |
|---|
| 661 | | - | 9. Reimbursement rates to long -term care providers 482 |
|---|
| 662 | | - | with respect to a total c hange in ownership, at arm's 483 |
|---|
| 663 | | - | length, for any facility previously licensed and certified 484 |
|---|
| 664 | | - | for participation in the MO HealthNet program shall not 485 |
|---|
| 665 | | - | increase payments in excess of the increase that would 486 |
|---|
| 666 | | - | result from the application of Section 1902 (a)(13)(C ) of 487 |
|---|
| 667 | | - | the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C). 488 SS#2 SB 79 22 |
|---|
| 668 | | - | 10. The MO HealthNet division may enroll qualified 489 |
|---|
| 669 | | - | residential care facilities and assisted living facilities, 490 |
|---|
| 670 | | - | as defined in chapter 198, as MO HealthNet personal care 491 |
|---|
| 671 | | - | providers. 492 |
|---|
| 672 | | - | 11. Any income earned by individuals eligible for 493 |
|---|
| 673 | | - | certified extended employment at a sheltered workshop under 494 |
|---|
| 674 | | - | chapter 178 shall not be considered as income for purposes 495 |
|---|
| 675 | | - | of determining eligibility under this section. 496 |
|---|
| 676 | | - | 12. If the Missouri Medica id audit and compliance unit 497 |
|---|
| 677 | | - | changes any interpretation or application of the 498 |
|---|
| 678 | | - | requirements for reimbursement for MO HealthNet services 499 |
|---|
| 679 | | - | from the interpretation or application that has been applied 500 |
|---|
| 680 | | - | previously by the state in any audit of a MO HealthNet 501 |
|---|
| 681 | | - | provider, the Missouri Medicaid audit and compliance unit 502 |
|---|
| 682 | | - | shall notify all affected MO HealthNet providers five 503 |
|---|
| 683 | | - | business days before such change shall take effect. Failure 504 |
|---|
| 684 | | - | of the Missouri Medicaid audit and compliance unit to notify 505 |
|---|
| 685 | | - | a provider of such change shall entitle the provider to 506 |
|---|
| 686 | | - | continue to receive and retain reimbursement until such 507 |
|---|
| 687 | | - | notification is provided and shall waive any liability of 508 |
|---|
| 688 | | - | such provider for recoupment or other loss of any payments 509 |
|---|
| 689 | | - | previously made prior to the five busines s days after such 510 |
|---|
| 690 | | - | notice has been sent. Each provider shall provide the 511 |
|---|
| 691 | | - | Missouri Medicaid audit and compliance unit a valid email 512 |
|---|
| 692 | | - | address and shall agree to receive communications 513 |
|---|
| 693 | | - | electronically. The notification required under this 514 |
|---|
| 694 | | - | section shall be delivered in writing by the United States 515 |
|---|
| 695 | | - | Postal Service or electronic mail to each provider. 516 |
|---|
| 696 | | - | 13. Nothing in this section shall be construed to 517 |
|---|
| 697 | | - | abrogate or limit the department's statutory requirement to 518 |
|---|
| 698 | | - | promulgate rules under chapter 536. 519 SS#2 SB 79 23 |
|---|
| 699 | | - | 14. Beginning July 1, 2016, and subject to 520 |
|---|
| 700 | | - | appropriations, providers of behavioral, social, and 521 |
|---|
| 701 | | - | psychophysiological services for the prevention, treatment, 522 |
|---|
| 702 | | - | or management of physical health problems shall be 523 |
|---|
| 703 | | - | reimbursed utilizing the behavior assessment and 524 |
|---|
| 704 | | - | intervention reimbursement codes 96150 to 96154 or their 525 |
|---|
| 705 | | - | successor codes under the Current Procedural Terminology 526 |
|---|
| 706 | | - | (CPT) coding system. Providers eligible for such 527 |
|---|
| 707 | | - | reimbursement shall include psychologists. 528 |
|---|
| 708 | | - | 15. There shall be no payments made under this section 529 |
|---|
| 709 | | - | for gender transition surgeries, cross -sex hormones, or 530 |
|---|
| 710 | | - | puberty-blocking drugs, as such terms are defined in section 531 |
|---|
| 711 | | - | 191.1720, for the purpose of a gender transition. 532 |
|---|
| 712 | | - | 210.030. 1. Every licensed physician, midwife , 1 |
|---|
| 713 | | - | registered nurse and all persons who may undertake, in a 2 |
|---|
| 714 | | - | professional way, the obstetrical and gynecological care of 3 |
|---|
| 715 | | - | a pregnant woman in the state of Missouri shall, if the 4 |
|---|
| 716 | | - | woman consents, take or cause to be taken a sample of venous 5 |
|---|
| 717 | | - | blood of such woman at the time of the first prenatal 6 |
|---|
| 718 | | - | examination, or not later than twenty days after the first 7 |
|---|
| 719 | | - | prenatal examination, another sample at twenty -eight weeks 8 |
|---|
| 720 | | - | of pregnancy, and another sample immediately after birth and 9 |
|---|
| 721 | | - | subject such [sample] samples to an approved and standard 10 |
|---|
| 722 | | - | serological test for syphilis [, an] and approved serological 11 |
|---|
| 723 | | - | [test] tests for hepatitis B, hepatitis C, human 12 |
|---|
| 724 | | - | immunodeficiency virus (HIV), and such other treatable 13 |
|---|
| 725 | | - | diseases and metabolic disorders as are prescribed by the 14 |
|---|
| 726 | | - | department of health and senior services. [In any area of 15 |
|---|
| 727 | | - | the state designated as a syphilis outbreak area by the 16 |
|---|
| 728 | | - | department of health and senior services, if the mother 17 |
|---|
| 729 | | - | consents, a sample of her venous blood shall be taken later 18 |
|---|
| 730 | | - | in the course of pregnanc y and at delivery for additional 19 SS#2 SB 79 24 |
|---|
| 731 | | - | testing for syphilis as may be prescribed by the department ] 20 |
|---|
| 732 | | - | If a mother tests positive for syphilis, hepatitis B, 21 |
|---|
| 733 | | - | hepatitis C, or HIV, or any combination of such diseases, 22 |
|---|
| 734 | | - | the physician or person providing care shall a dminister 23 |
|---|
| 735 | | - | treatment in accordance with the most recent accepted 24 |
|---|
| 736 | | - | medical practice. If a mother tests positive for hepatitis 25 |
|---|
| 737 | | - | B, the physician or person who professionally undertakes the 26 |
|---|
| 738 | | - | pediatric care of a newborn shall also administer the 27 |
|---|
| 739 | | - | appropriate doses of hepatitis B vaccine and hepatitis B 28 |
|---|
| 740 | | - | immune globulin (HBIG) in accordance with the current 29 |
|---|
| 741 | | - | recommendations of the Advisory Committee on Immunization 30 |
|---|
| 742 | | - | Practices (ACIP). If the mother's hepatitis B status is 31 |
|---|
| 743 | | - | unknown, the appropriate dose of hepat itis B vaccine shall 32 |
|---|
| 744 | | - | be administered to the newborn in accordance with the 33 |
|---|
| 745 | | - | current ACIP recommendations. If the mother consents, a 34 |
|---|
| 746 | | - | sample of her venous blood shall be taken. If she tests 35 |
|---|
| 747 | | - | positive for hepatitis B, hepatitis B immune globulin (HBIG) 36 |
|---|
| 748 | | - | shall be administered to the newborn in accordance with the 37 |
|---|
| 749 | | - | current ACIP recommendations. 38 |
|---|
| 750 | | - | 2. The department of health and senior services 39 |
|---|
| 751 | | - | shall[, in consultation with the Missouri genetic disease 40 |
|---|
| 752 | | - | advisory committee,] make such rules pertaining to s uch 41 |
|---|
| 753 | | - | tests as shall be dictated by accepted medical practice, and 42 |
|---|
| 754 | | - | tests shall be of the types approved or accepted by the 43 |
|---|
| 755 | | - | [department of health and senior services. An approved and 44 |
|---|
| 756 | | - | standard test for syphilis, hepatitis B, and other treatable 45 |
|---|
| 757 | | - | diseases and metabolic disorders shall mean a test made in a 46 |
|---|
| 758 | | - | laboratory approved by the department of health and senior 47 |
|---|
| 759 | | - | services] United States Food and Drug Administration . No 48 |
|---|
| 760 | | - | individual shall be denied testing by the department of 49 |
|---|
| 761 | | - | health and senior services because of inability to pay. 50 SS#2 SB 79 25 |
|---|
| 762 | | - | 3. All persons providing care under this section shall 51 |
|---|
| 763 | | - | do so pursuant to the provisions of section 431.061. 52 |
|---|
| 764 | | - | 354.465. 1. The director, or any duly appointed 1 |
|---|
| 765 | | - | representative, may make an examination of the affairs of 2 |
|---|
| 766 | | - | any health maintenance organization as often as he deems it 3 |
|---|
| 767 | | - | necessary for the protection of the interests of the people 4 |
|---|
| 768 | | - | of this state[, but not less frequently than once every five 5 |
|---|
| 769 | | - | years]. 6 |
|---|
| 770 | | - | 2. All costs incurred by the state as a r esult of 7 |
|---|
| 771 | | - | making examinations under this section shall be paid by the 8 |
|---|
| 772 | | - | organization being examined and remitted as provided in 9 |
|---|
| 773 | | - | section 374.160. 10 |
|---|
| 774 | | - | 376.1240. 1. For purposes of this section, terms 1 |
|---|
| 775 | | - | shall have the same meanings as ascribed to them in section 2 |
|---|
| 776 | | - | 376.1350, and the term "self -administered hormonal 3 |
|---|
| 777 | | - | contraceptive" shall mean a drug that is composed of one or 4 |
|---|
| 778 | | - | more hormones and that is approved by the Food and Drug 5 |
|---|
| 779 | | - | Administration to prevent pregnancy, excluding emergency 6 |
|---|
| 780 | | - | contraception. Nothing in this section shall be construed 7 |
|---|
| 781 | | - | to apply to medications approved by the Food and Drug 8 |
|---|
| 782 | | - | Administration to terminate an existing pregnancy. 9 |
|---|
| 783 | | - | 2. Any health benefit plan delivered, issued for 10 |
|---|
| 784 | | - | delivery, continued, or renewed in this s tate on or after 11 |
|---|
| 785 | | - | January 1, 2026, that provides coverage for self - 12 |
|---|
| 786 | | - | administered hormonal contraceptives shall provide coverage 13 |
|---|
| 787 | | - | to reimburse a health care provider or dispensing entity for 14 |
|---|
| 788 | | - | the dispensing of a supply of self -administered hormonal 15 |
|---|
| 789 | | - | contraceptives intended to last up to ninety days, or 16 |
|---|
| 790 | | - | intended to last up to one hundred eighty days for generic 17 |
|---|
| 791 | | - | self-administered hormonal contraceptives. 18 |
|---|
| 792 | | - | 3. The coverage required under this section shall not 19 |
|---|
| 793 | | - | be subject to any greater deductible or co -payment than 20 SS#2 SB 79 26 |
|---|
| 794 | | - | other similar health care services provided by the health 21 |
|---|
| 795 | | - | benefit plan. 22 |
|---|
| 12 | + | Section A. Chapter 376, RSMo, i s amended by adding thereto 1 |
|---|
| 13 | + | one new section, to be known as section 376.1850, to read as 2 |
|---|
| 14 | + | follows:3 |
|---|
| 798 | | - | (1) "Contract for health care benefits", a self -funded 3 |
|---|
| 799 | | - | contractual arrangemen t made in accordance with this section 4 |
|---|
| 800 | | - | between a qualified membership organization and its members 5 |
|---|
| 801 | | - | to provide, deliver, arrange for, pay for, or reimburse any 6 |
|---|
| 802 | | - | of the costs of health care services; 7 |
|---|
| 803 | | - | (2) "Farm bureau", a nonprofit agricultural member ship 8 |
|---|
| 804 | | - | organization first incorporated in this state at least one 9 |
|---|
| 805 | | - | hundred years ago, or an affiliate designated by the 10 |
|---|
| 806 | | - | nonprofit agricultural membership organization; 11 |
|---|
| 807 | | - | (3) "Health care service", the same meaning as is 12 |
|---|
| 808 | | - | ascribed to such term in sectio n 376.1350; 13 |
|---|
| 809 | | - | (4) "Member of a qualified membership organization", a 14 |
|---|
| 810 | | - | natural person who pays periodic dues or fees, other than 15 |
|---|
| 811 | | - | payments for a contract for health care benefits, for 16 |
|---|
| 812 | | - | membership in a qualified membership organization, and the 17 |
|---|
| 813 | | - | natural person's spouse or dependent children under the age 18 |
|---|
| 814 | | - | of twenty-six; 19 |
|---|
| 815 | | - | (5) "Qualified membership organization", a farm 20 |
|---|
| 816 | | - | bureau, or an entity with at least one hundred thousand dues 21 |
|---|
| 817 | | - | paying members, that is governed by a council of its 22 |
|---|
| 818 | | - | members, that has at least five hundred million dollars in 23 |
|---|
| 819 | | - | assets, and that exists to serve its members beyond solely 24 |
|---|
| 820 | | - | offering health coverage. 25 |
|---|
| 821 | | - | 2. The provisions of this chapter relating to health 26 |
|---|
| 822 | | - | insurance, health maintenance organizations, health benefit 27 |
|---|
| 823 | | - | plans, group health services, and health carriers shall not 28 |
|---|
| 824 | | - | apply to contracts for health care benefits provided by a 29 |
|---|
| 825 | | - | qualified membership organization. A qualified membership 30 SS#2 SB 79 27 |
|---|
| 826 | | - | organization providing contracts for health care benefits 31 |
|---|
| 827 | | - | shall not be considered to be engaging in the business of 32 |
|---|
| 828 | | - | insurance for purposes of any provision of chapters 361 to 33 |
|---|
| 829 | | - | 385. 34 |
|---|
| 830 | | - | 3. It is unlawful to provide a contract for health 35 |
|---|
| 831 | | - | care benefits under this section unless the qualified 36 |
|---|
| 832 | | - | membership organization providing the cont ract is registered 37 |
|---|
| 833 | | - | with the department of commerce and insurance as provided in 38 |
|---|
| 834 | | - | this subsection. To register as a qualified membership 39 |
|---|
| 835 | | - | organization, an applicant shall file information with the 40 |
|---|
| 836 | | - | director demonstrating it meets the requirements of this 41 |
|---|
| 837 | | - | section and pay an application fee of two hundred and fifty 42 |
|---|
| 838 | | - | dollars. A registration is valid for five years and may be 43 |
|---|
| 839 | | - | renewed for additional five year terms if the qualified 44 |
|---|
| 840 | | - | membership organization continues to meet the requirements 45 |
|---|
| 841 | | - | of this section and pays a renewal fee of two hundred and 46 |
|---|
| 842 | | - | fifty dollars. All amounts collected as registration or 47 |
|---|
| 843 | | - | renewal fees shall be deposited into the insurance dedicated 48 |
|---|
| 844 | | - | fund established under section 374.150. 49 |
|---|
| 845 | | - | 4. Contracts for health care benefits provided under 50 |
|---|
| 846 | | - | this section shall be offered only to members of a qualified 51 |
|---|
| 847 | | - | membership organization who have been members of the 52 |
|---|
| 848 | | - | organization for at least thirty days; and shall be sold, 53 |
|---|
| 849 | | - | solicited, or negotiated only by insurance producers 54 |
|---|
| 850 | | - | licensed under chapt er 375 to produce accident and health or 55 |
|---|
| 851 | | - | sickness coverage. 56 |
|---|
| 852 | | - | 5. Notwithstanding any provision of law to the 57 |
|---|
| 853 | | - | contrary, a qualified membership organization providing a 58 |
|---|
| 854 | | - | contract for health care benefits under this section shall 59 |
|---|
| 855 | | - | use the services of an administrator permitted to provide 60 |
|---|
| 856 | | - | services in accordance with sections 376.1075 to 376.1095, 61 |
|---|
| 857 | | - | and shall agree in the contract with such administrator to 62 SS#2 SB 79 28 |
|---|
| 858 | | - | utilize processes for benefit determinations and claims 63 |
|---|
| 859 | | - | payment procedures in accordance with the requirements 64 |
|---|
| 860 | | - | applicable to health carriers and health benefit plans under 65 |
|---|
| 861 | | - | sections 376.383, 376.690, and 376.1367. A contract for 66 |
|---|
| 862 | | - | health care benefits provided under this section shall not 67 |
|---|
| 863 | | - | be subject to the laws of this state relating to insurance 68 |
|---|
| 864 | | - | or insurance companies except as specified in this section. 69 |
|---|
| 865 | | - | 6. The risk under contracts provided in accordance 70 |
|---|
| 866 | | - | with this section may be reinsured in accordance with 71 |
|---|
| 867 | | - | section 375.246. 72 |
|---|
| 868 | | - | 7. (1) Contracts for health care benefits under this 73 |
|---|
| 869 | | - | section shall include the following written disclaimer on 74 |
|---|
| 870 | | - | the front of the contract and all related applications and 75 |
|---|
| 871 | | - | renewal forms in a bold font no smaller than sixteen point: 76 |
|---|
| 872 | | - | "NOTICE 77 |
|---|
| 873 | | - | This contract is not health insurance and is not 78 |
|---|
| 874 | | - | subject to federal or stat e laws relating to 79 |
|---|
| 875 | | - | health insurance. This contract offers fewer 80 |
|---|
| 876 | | - | benefits than an ACA -compliant health plan and 81 |
|---|
| 877 | | - | may exclude coverage for preexisting 82 |
|---|
| 878 | | - | conditions. You may qualify for income -based 83 |
|---|
| 879 | | - | subsidies through the ACA Health Insurance 84 |
|---|
| 880 | | - | Marketplace. This contract is not covered by 85 |
|---|
| 881 | | - | the Missouri Insurance Guaranty Association. 86 |
|---|
| 882 | | - | You may be financially responsible for costs of 87 |
|---|
| 883 | | - | medical treatment that may not be covered under 88 |
|---|
| 884 | | - | this contract.". 89 |
|---|
| 885 | | - | (2) The written disclaimers required by subdivision 90 |
|---|
| 886 | | - | (1) of this subsection on applications and renewal forms 91 |
|---|
| 887 | | - | shall be signed by the member entering into or renewing the 92 |
|---|
| 888 | | - | contract, specifically acknowledging that the coverage is 93 SS#2 SB 79 29 |
|---|
| 889 | | - | not considered insurance and is not subject to regulation by 94 |
|---|
| 890 | | - | the department of commerce and insurance. 95 |
|---|
| 891 | | - | (3) The qualified membership organization providing 96 |
|---|
| 892 | | - | the contract shall retain a copy of written acknowledgements 97 |
|---|
| 893 | | - | required under subdivision (2) of this subsection for the 98 |
|---|
| 894 | | - | duration for which claims may be submitted under t he 99 |
|---|
| 895 | | - | contract, and shall provide a copy of the acknowledgement to 100 |
|---|
| 896 | | - | the member upon the member's request. 101 |
|---|
| 897 | | - | 8. Contracts provided under this section shall not be 102 |
|---|
| 898 | | - | subject to individual post -claim medical underwriting while 103 |
|---|
| 899 | | - | coverage remains in effect, an d no member covered under a 104 |
|---|
| 900 | | - | contract provided under this section shall be subject to 105 |
|---|
| 901 | | - | cancellation, nonrenewal, modification, or increase in 106 |
|---|
| 902 | | - | premium for reason of a medical event. 107 |
|---|
| 903 | | - | 9. Notwithstanding subsection 2 of this section, the 108 |
|---|
| 904 | | - | department of commerce and insurance shall receive and 109 |
|---|
| 905 | | - | review complaints and inquiries from members of a qualified 110 |
|---|
| 906 | | - | membership organization, pursuant to section 374.085, 111 |
|---|
| 907 | | - | subject to section 374.071. 112 |
|---|
| 908 | | - | 10. By March thirty-first of each year, each qualified 113 |
|---|
| 909 | | - | membership organization providing a contract for health care 114 |
|---|
| 910 | | - | benefits under this section, or its administrator, shall pay 115 |
|---|
| 911 | | - | to the director a fee equal to one percent of the Missouri 116 |
|---|
| 912 | | - | claims paid under this section during the immediately 117 |
|---|
| 913 | | - | preceding year. Funds collected by the director shall be 118 |
|---|
| 914 | | - | deposited in the insurance dedicated fund established under 119 |
|---|
| 915 | | - | section 374.150. 120 |
|---|
| 916 | | - | 11. No qualified membership organization, or other 121 |
|---|
| 917 | | - | entity on behalf of a qualified membership organization, 122 |
|---|
| 918 | | - | shall refer to a contract fo r health care benefits under 123 |
|---|
| 919 | | - | this section as insurance or health insurance in any 124 |
|---|
| 920 | | - | marketing, advertising, or other communication with the 125 SS#2 SB 79 30 |
|---|
| 921 | | - | public or members of the qualified membership organization. 126 |
|---|
| 922 | | - | Violation of this subsection shall be an unlawful pra ctice 127 |
|---|
| 923 | | - | under section 407.020. 128 |
|---|
| 924 | | - | 12. Contracts for health care benefits provided under 129 |
|---|
| 925 | | - | this section: 130 |
|---|
| 926 | | - | (1) Shall include coverage for: 131 |
|---|
| 927 | | - | (a) Ambulatory patient services; 132 |
|---|
| 928 | | - | (b) Hospitalization; 133 |
|---|
| 929 | | - | (c) Emergency services, as defined in sec tion 134 |
|---|
| 930 | | - | 376.1350; and 135 |
|---|
| 931 | | - | (d) Laboratory services; and 136 |
|---|
| 932 | | - | (2) Shall not be subject to an annual limit of less 137 |
|---|
| 933 | | - | than two million dollars per year. 138 |
|---|
| 934 | | - | [192.769. 1. On completion of a 1 |
|---|
| 935 | | - | mammogram, a mammography facility certified by 2 |
|---|
| 936 | | - | the United States Food and Drug Administration 3 |
|---|
| 937 | | - | (FDA) or by a certification agency approved by 4 |
|---|
| 938 | | - | the FDA shall provide to the patient the 5 |
|---|
| 939 | | - | following notice: 6 |
|---|
| 940 | | - | "If your mammogram demonstrates 7 |
|---|
| 941 | | - | that you have dense breast 8 |
|---|
| 942 | | - | tissue, which could hide 9 |
|---|
| 943 | | - | abnormalities, and you have other 10 |
|---|
| 944 | | - | risk factors for breast cancer 11 |
|---|
| 945 | | - | that have been identified, you 12 |
|---|
| 946 | | - | might benefit from supplemental 13 |
|---|
| 947 | | - | screening tests that may be 14 |
|---|
| 948 | | - | suggested by your ordering 15 |
|---|
| 949 | | - | physician. Dense breast tissue, 16 |
|---|
| 950 | | - | in and of itself, is a relatively 17 |
|---|
| 951 | | - | common condition. Therefore, 18 |
|---|
| 952 | | - | this information is not provided 19 |
|---|
| 953 | | - | to cause undue concern, but 20 |
|---|
| 954 | | - | rather to raise your awareness 21 |
|---|
| 955 | | - | and to promote discussion with 22 |
|---|
| 956 | | - | your physician regarding the 23 |
|---|
| 957 | | - | presence of other risk factors, 24 |
|---|
| 958 | | - | in addition to dense breast 25 |
|---|
| 959 | | - | tissue. A report of your 26 SS#2 SB 79 31 |
|---|
| 960 | | - | mammography results will be sent 27 |
|---|
| 961 | | - | to you and your physician. You 28 |
|---|
| 962 | | - | should contact your physician if 29 |
|---|
| 963 | | - | you have any questions or 30 |
|---|
| 964 | | - | concerns regarding this report.". 31 |
|---|
| 965 | | - | 2. Nothing in this section shall be 32 |
|---|
| 966 | | - | construed to create a duty of care beyond the 33 |
|---|
| 967 | | - | duty to provide notice as set forth in this 34 |
|---|
| 968 | | - | section. 35 |
|---|
| 969 | | - | 3. The information required by this 36 |
|---|
| 970 | | - | section or evidence that a person violated this 37 |
|---|
| 971 | | - | section is not admissible in a civil, judicial, 38 |
|---|
| 972 | | - | or administrative proceeding. 39 |
|---|
| 973 | | - | 4. A mammography facilit y is not required 40 |
|---|
| 974 | | - | to comply with the requirements of this section 41 |
|---|
| 975 | | - | until January 1, 2015. ] 42 |
|---|
| 17 | + | (1) "Contract for health care benefits", any contract, 3 |
|---|
| 18 | + | certificate, or agreeme nt entered into, offered or issued to 4 |
|---|
| 19 | + | provide, deliver, arrange for, pay for, or reimburse any of 5 |
|---|
| 20 | + | the costs of health care services; 6 |
|---|
| 21 | + | (2) "Farm bureau", a nonprofit agricultural membership 7 |
|---|
| 22 | + | organization first incorporated in this state at least one 8 |
|---|
| 23 | + | hundred years ago, or an affiliate designated by the 9 |
|---|
| 24 | + | nonprofit agricultural membership organization; 10 |
|---|
| 25 | + | (3) "Health care service", the same meaning as is 11 |
|---|
| 26 | + | ascribed to such term in section 376.1350; 12 |
|---|
| 27 | + | (4) "Member of a qualified membership organizat ion", a 13 |
|---|
| 28 | + | natural person who pays periodic dues or fees, other than 14 |
|---|
| 29 | + | payments for a contract for health care benefits, for 15 |
|---|
| 30 | + | membership in a qualified membership organization, and the 16 |
|---|
| 31 | + | natural person's spouse or dependent children under the age 17 |
|---|
| 32 | + | of twenty-six; 18 SB 79 2 |
|---|
| 33 | + | (5) "Qualified membership organization", a farm 19 |
|---|
| 34 | + | bureau, or an entity with at least one hundred thousand dues 20 |
|---|
| 35 | + | paying members, that is governed by a council of its 21 |
|---|
| 36 | + | members, that has at least five hundred million dollars in 22 |
|---|
| 37 | + | assets, and that exist s to serve its members beyond solely 23 |
|---|
| 38 | + | offering health coverage. 24 |
|---|
| 39 | + | 2. Contracts for health care benefits provided by a 25 |
|---|
| 40 | + | qualified membership organization to a natural person in 26 |
|---|
| 41 | + | accordance with this section shall not be considered 27 |
|---|
| 42 | + | insurance under the l aws of this state. Contracts for 28 |
|---|
| 43 | + | health care benefits provided in accordance with this 29 |
|---|
| 44 | + | section shall be offered only to members of a qualified 30 |
|---|
| 45 | + | membership organization. 31 |
|---|
| 46 | + | 3. Notwithstanding any provision of law to the 32 |
|---|
| 47 | + | contrary, a qualified membersh ip organization providing a 33 |
|---|
| 48 | + | contract for health care benefits under this section shall 34 |
|---|
| 49 | + | use the services of an entity permitted to provide 35 |
|---|
| 50 | + | administration services in accordance with sections 376.1075 36 |
|---|
| 51 | + | to 376.1095, and shall agree in the contract with suc h 37 |
|---|
| 52 | + | entity to processes for benefit determinations and claims 38 |
|---|
| 53 | + | payment procedures comparable to those required by law for 39 |
|---|
| 54 | + | health carriers and health benefit plans, including, but not 40 |
|---|
| 55 | + | limited to, those required under sections 376.383, 376.690, 41 |
|---|
| 56 | + | and 376.1367. 42 |
|---|
| 57 | + | 4. The risk under contracts provided in accordance 43 |
|---|
| 58 | + | with this section may be reinsured in accordance with 44 |
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| 59 | + | section 375.246. 45 |
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| 60 | + | 5. Contracts for health care benefits under this 46 |
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| 61 | + | section shall include the following written disclaimer on 47 |
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| 62 | + | the contract and on all related applications and renewal 48 |
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| 63 | + | forms: 49 |
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| 64 | + | "NOTICE 50 SB 79 3 |
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| 65 | + | This contract is not health insurance and is not 51 |
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| 66 | + | subject to laws and regulations relating to 52 |
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| 67 | + | insurance. This contract is not covered by the 53 |
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| 68 | + | Missouri Insurance Guaranty Association.". 54 |
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