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FIRST REGULAR SESSION
[TRULY AGREED TO AND FINALLY PASSED]
SENATE SUBSTITUTE NO. 2 FOR
SENATE BILL NO. 79
103RD GENERAL ASSEMBLY
2025
0769S.09T
AN ACT
To repeal sections 191.648, 191.1145, 192.769, 208.152, 210.030, and 354.465, RSMo, and to
enact in lieu thereof eight new sections relating to health care.
Be it enacted by the General Assembly of the State of Missouri, as follows:
1 Section A. Sections 191.648, 191.1145, 192.769, 208.152,
2 210.030, and 354.465, RSMo, are repealed and eight new sections
3 enacted in lieu thereof, to be known as sections 191.648,
4 191.1145, 192.2521, 208.152, 210.030, 354.465, 376.1240, and
5 376.1850, to read as follows:
1 191.648. 1. As used in this section, the following
2 terms mean:
3 (1) "Designated sexually transmitted infection",
4 chlamydia, gonorrhea, trichomoniasis, or any other sexually
5 transmitted infection designated as appropriate for
6 expedited partner therapy by the department of health and
7 senior services or for which expedited partner therapy was
8 recommended in the most recent Centers for Disease Control
9 and Prevention guidelines for the prevention or treatment of
10 sexually transmitted infections;
11 (2) "Expedited partner therapy" [means], the practice
12 of treating the sex partners of persons with [chlamydia or
13 gonorrhea] designated sexually transmitted infections
EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
and is intended to be omitted in the law.
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14 without an intervening medical evaluation or professional
15 prevention counseling;
16 (3) "Health care professional", a member of any
17 profession regulated by chapter 334 or 335 authorized to
18 prescribe medications.
19 2. Any licensed physician or health care professional
20 may, but shall not be required to, utilize expedited partner
21 therapy for the management of the partners of persons with
22 [chlamydia or gonorrhea] designated sexually transmitted
23 infections. Notwithstanding the requirements of 20 CSR 2150-
24 5.020(5) or any other law to the contrary, a licensed
25 physician or health care professional utilizing expedited
26 partner therapy may prescribe and dispense medications for
27 the treatment of [chlamydia or gonorrhea] a designated
28 sexually transmitted infection for an individual who is the
29 partner of a person with [chlamydia or gonorrhea] a
30 designated sexually transmitted infection and who does not
31 have an established physician/patient relationship with such
32 physician or an established health care professional/patient
33 relationship with such health care professional. [Any
34 antibiotic medications prescribed and dispensed for the
35 treatment of chlamydia or gonorrhea under this section shall
36 be in pill form.]
37 3. Any licensed physician or health care professional
38 utilizing expedited partner therapy for the management of
39 the partners with [chlamydia or gonorrhea] designated
40 sexually transmitted infections shall provide explanation
41 and guidance to [a] each patient [diagnosed with chlamydia
42 or gonorrhea] of the preventative measures that can be taken
43 by the patient to stop the [spread] transmission of such
44 [diagnosis] infection.
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45 4. Any licensed physician or health care professional
46 utilizing expedited partner therapy for the management of
47 partners of persons with [chlamydia or gonorrhea] designated
48 sexually transmitted infections under this section shall
49 have immunity from any civil liability that may otherwise
50 result by reason of such actions, unless such physician or
51 health care professional acts negligently, recklessly, in
52 bad faith, or with malicious purpose.
53 5. The department of health and senior services and
54 the division of professional registration within the
55 department of commerce and insurance shall by rule develop
56 guidelines for the implementation of subsection 2 of this
57 section. Any rule or portion of a rule, as that term is
58 defined in section 536.010, that is created under the
59 authority delegated in this section shall become effective
60 only if it complies with and is subject to all of the
61 provisions of chapter 536 and, if applicable, section
62 536.028. This section and chapter 536 are nonseverable and
63 if any of the powers vested with the general assembly
64 pursuant to chapter 536 to review, to delay the effective
65 date, or to disapprove and annul a rule are subsequently
66 held unconstitutional, then the grant of rulemaking
67 authority and any rule proposed or adopted after August 28,
68 2010, shall be invalid and void.
1 191.1145. 1. As used in sections 191.1145 and
2 191.1146, the following terms shall mean:
3 (1) "Asynchronous store-and-forward transfer", the
4 collection of a patient's relevant health information and
5 the subsequent transmission of that information from an
6 originating site to a health care provider at a distant site
7 without the patient being present;
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8 (2) "Clinical staff", any health care provider
9 licensed in this state;
10 (3) "Distant site", a site at which a health care
11 provider is located while providing health care services by
12 means of telemedicine;
13 (4) "Health care provider", as that term is defined in
14 section 376.1350;
15 (5) "Originating site", a site at which a patient is
16 located at the time health care services are provided to him
17 or her by means of telemedicine. For the purposes of
18 asynchronous store-and-forward transfer, originating site
19 shall also mean the location at which the health care
20 provider transfers information to the distant site;
21 (6) "Telehealth" or "telemedicine", the delivery of
22 health care services by means of information and
23 communication technologies, including audiovisual and audio-
24 only technologies, which facilitate the assessment,
25 diagnosis, consultation, treatment, education, care
26 management, and self-management of a patient's health care
27 while such patient is at the originating site and the health
28 care provider is at the distant site. Telehealth or
29 telemedicine shall also include the use of asynchronous
30 store-and-forward technology. Health care providers shall
31 not be limited in their choice of electronic platforms used
32 to deliver telehealth or telemedicine, provided that all
33 services delivered are in accordance with the Health
34 Insurance Portability and Accountability Act of 1996.
35 2. Any licensed health care provider shall be
36 authorized to provide telehealth services if such services
37 are within the scope of practice for which the health care
38 provider is licensed and are provided with the same standard
39 of care as services provided in person. This section shall
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40 not be construed to prohibit a health carrier, as defined in
41 section 376.1350, from reimbursing nonclinical staff for
42 services otherwise allowed by law.
43 3. In order to treat patients in this state through
44 the use of telemedicine or telehealth, health care providers
45 shall be fully licensed to practice in this state and shall
46 be subject to regulation by their respective professional
47 boards.
48 4. Nothing in subsection 3 of this section shall apply
49 to:
50 (1) Informal consultation performed by a health care
51 provider licensed in another state, outside of the context
52 of a contractual relationship, and on an irregular or
53 infrequent basis without the expectation or exchange of
54 direct or indirect compensation;
55 (2) Furnishing of health care services by a health
56 care provider licensed and located in another state in case
57 of an emergency or disaster; provided that, no charge is
58 made for the medical assistance; or
59 (3) Episodic consultation by a health care provider
60 licensed and located in another state who provides such
61 consultation services on request to a physician in this
62 state.
63 5. Nothing in this section shall be construed to alter
64 the scope of practice of any health care provider or to
65 authorize the delivery of health care services in a setting
66 or in a manner not otherwise authorized by the laws of this
67 state.
68 6. No originating site for services or activities
69 provided under this section shall be required to maintain
70 immediate availability of on-site clinical staff during the
71 telehealth services, except as necessary to meet the
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72 standard of care for the treatment of the patient's medical
73 condition if such condition is being treated by an eligible
74 health care provider who is not at the originating site, has
75 not previously seen the patient in person in a clinical
76 setting, and is not providing coverage for a health care
77 provider who has an established relationship with the
78 patient. Health care providers shall not be limited in
79 their choice of electronic platforms used to deliver
80 telehealth or telemedicine.
81 7. Nothing in this section shall be construed to alter
82 any collaborative practice requirement as provided in
83 chapters 334 and 335.
1 192.2521. A specialty hospital is exempt from the
2 provisions of sections 192.2520 and 197.135 if such hospital
3 has a policy for transfer of a victim of a sexual assault to
4 an appropriate hospital with an emergency department. As
5 used in this section, "specialty hospital" means a hospital
6 that has been designated by the department of health and
7 senior services as something other than a general acute care
8 hospital.
1 208.152. 1. MO HealthNet payments shall be made on
2 behalf of those eligible needy persons as described in
3 section 208.151 who are unable to provide for it in whole or
4 in part, with any payments to be made on the basis of the
5 reasonable cost of the care or reasonable charge for the
6 services as defined and determined by the MO HealthNet
7 division, unless otherwise hereinafter provided, for the
8 following:
9 (1) Inpatient hospital services, except to persons in
10 an institution for mental diseases who are under the age of
11 sixty-five years and over the age of twenty-one years;
12 provided that the MO HealthNet division shall provide
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13 through rule and regulation an exception process for
14 coverage of inpatient costs in those cases requiring
15 treatment beyond the seventy-fifth percentile professional
16 activities study (PAS) or the MO HealthNet children's
17 diagnosis length-of-stay schedule; and provided further that
18 the MO HealthNet division shall take into account through
19 its payment system for hospital services the situation of
20 hospitals which serve a disproportionate number of low-
21 income patients;
22 (2) All outpatient hospital services, payments
23 therefor to be in amounts which represent no more than
24 eighty percent of the lesser of reasonable costs or
25 customary charges for such services, determined in
26 accordance with the principles set forth in Title XVIII A
27 and B, Public Law 89-97, 1965 amendments to the federal
28 Social Security Act (42 U.S.C. Section 301, et seq.), but
29 the MO HealthNet division may evaluate outpatient hospital
30 services rendered under this section and deny payment for
31 services which are determined by the MO HealthNet division
32 not to be medically necessary, in accordance with federal
33 law and regulations;
34 (3) Laboratory and X-ray services;
35 (4) Nursing home services for participants, except to
36 persons with more than five hundred thousand dollars equity
37 in their home or except for persons in an institution for
38 mental diseases who are under the age of sixty-five years,
39 when residing in a hospital licensed by the department of
40 health and senior services or a nursing home licensed by the
41 department of health and senior services or appropriate
42 licensing authority of other states or government-owned
43 and -operated institutions which are determined to conform to
44 standards equivalent to licensing requirements in Title XIX
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45 of the federal Social Security Act (42 U.S.C. Section [301]
46 1396, et seq.), as amended, for nursing facilities. The MO
47 HealthNet division may recognize through its payment
48 methodology for nursing facilities those nursing facilities
49 which serve a high volume of MO HealthNet patients. The MO
50 HealthNet division when determining the amount of the
51 benefit payments to be made on behalf of persons under the
52 age of twenty-one in a nursing facility may consider nursing
53 facilities furnishing care to persons under the age of
54 twenty-one as a classification separate from other nursing
55 facilities;
56 (5) Nursing home costs for participants receiving
57 benefit payments under subdivision (4) of this subsection
58 for those days, which shall not exceed twelve per any period
59 of six consecutive months, during which the participant is
60 on a temporary leave of absence from the hospital or nursing
61 home, provided that no such participant shall be allowed a
62 temporary leave of absence unless it is specifically
63 provided for in his plan of care. As used in this
64 subdivision, the term "temporary leave of absence" shall
65 include all periods of time during which a participant is
66 away from the hospital or nursing home overnight because he
67 is visiting a friend or relative;
68 (6) Physicians' services, whether furnished in the
69 office, home, hospital, nursing home, or elsewhere,
70 provided, that no funds shall be expended to any abortion
71 facility, as defined in section 188.015, or to any
72 affiliate, as defined in section 188.015, of such abortion
73 facility;
74 (7) Subject to appropriation, up to twenty visits per
75 year for services limited to examinations, diagnoses,
76 adjustments, and manipulations and treatments of
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77 malpositioned articulations and structures of the body
78 provided by licensed chiropractic physicians practicing
79 within their scope of practice. Nothing in this subdivision
80 shall be interpreted to otherwise expand MO HealthNet
81 services;
82 (8) Drugs and medicines when prescribed by a licensed
83 physician, dentist, podiatrist, or an advanced practice
84 registered nurse; except that no payment for drugs and
85 medicines prescribed on and after January 1, 2006, by a
86 licensed physician, dentist, podiatrist, or an advanced
87 practice registered nurse may be made on behalf of any
88 person who qualifies for prescription drug coverage under
89 the provisions of P.L. 108-173;
90 (9) Emergency ambulance services and, effective
91 January 1, 1990, medically necessary transportation to
92 scheduled, physician-prescribed nonelective treatments;
93 (10) Early and periodic screening and diagnosis of
94 individuals who are under the age of twenty-one to ascertain
95 their physical or mental defects, and health care,
96 treatment, and other measures to correct or ameliorate
97 defects and chronic conditions discovered thereby. Such
98 services shall be provided in accordance with the provisions
99 of Section 6403 of P.L. 101-239 and federal regulations
100 promulgated thereunder;
101 (11) Home health care services;
102 (12) Family planning as defined by federal rules and
103 regulations; provided, that no funds shall be expended to
104 any abortion facility, as defined in section 188.015, or to
105 any affiliate, as defined in section 188.015, of such
106 abortion facility; and further provided, however, that such
107 family planning services shall not include abortions or any
108 abortifacient drug or device that is used for the purpose of
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109 inducing an abortion unless such abortions are certified in
110 writing by a physician to the MO HealthNet agency that, in
111 the physician's professional judgment, the life of the
112 mother would be endangered if the fetus were carried to term;
113 (13) Inpatient psychiatric hospital services for
114 individuals under age twenty-one as defined in Title XIX of
115 the federal Social Security Act (42 U.S.C. Section 1396d, et
116 seq.);
117 (14) Outpatient surgical procedures, including
118 presurgical diagnostic services performed in ambulatory
119 surgical facilities which are licensed by the department of
120 health and senior services of the state of Missouri; except,
121 that such outpatient surgical services shall not include
122 persons who are eligible for coverage under Part B of Title
123 XVIII, Public Law 89-97, 1965 amendments to the federal
124 Social Security Act, as amended, if exclusion of such
125 persons is permitted under Title XIX, Public Law 89-97, 1965
126 amendments to the federal Social Security Act, as amended;
127 (15) Personal care services which are medically
128 oriented tasks having to do with a person's physical
129 requirements, as opposed to housekeeping requirements, which
130 enable a person to be treated by his or her physician on an
131 outpatient rather than on an inpatient or residential basis
132 in a hospital, intermediate care facility, or skilled
133 nursing facility. Personal care services shall be rendered
134 by an individual not a member of the participant's family
135 who is qualified to provide such services where the services
136 are prescribed by a physician in accordance with a plan of
137 treatment and are supervised by a licensed nurse. Persons
138 eligible to receive personal care services shall be those
139 persons who would otherwise require placement in a hospital,
140 intermediate care facility, or skilled nursing facility.
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141 Benefits payable for personal care services shall not exceed
142 for any one participant one hundred percent of the average
143 statewide charge for care and treatment in an intermediate
144 care facility for a comparable period of time. Such
145 services, when delivered in a residential care facility or
146 assisted living facility licensed under chapter 198 shall be
147 authorized on a tier level based on the services the
148 resident requires and the frequency of the services. A
149 resident of such facility who qualifies for assistance under
150 section 208.030 shall, at a minimum, if prescribed by a
151 physician, qualify for the tier level with the fewest
152 services. The rate paid to providers for each tier of
153 service shall be set subject to appropriations. Subject to
154 appropriations, each resident of such facility who qualifies
155 for assistance under section 208.030 and meets the level of
156 care required in this section shall, at a minimum, if
157 prescribed by a physician, be authorized up to one hour of
158 personal care services per day. Authorized units of
159 personal care services shall not be reduced or tier level
160 lowered unless an order approving such reduction or lowering
161 is obtained from the resident's personal physician. Such
162 authorized units of personal care services or tier level
163 shall be transferred with such resident if he or she
164 transfers to another such facility. Such provision shall
165 terminate upon receipt of relevant waivers from the federal
166 Department of Health and Human Services. If the Centers for
167 Medicare and Medicaid Services determines that such
168 provision does not comply with the state plan, this
169 provision shall be null and void. The MO HealthNet division
170 shall notify the revisor of statutes as to whether the
171 relevant waivers are approved or a determination of
172 noncompliance is made;
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173 (16) Mental health services. The state plan for
174 providing medical assistance under Title XIX of the Social
175 Security Act, 42 U.S.C. Section [301] 1396, et seq., as
176 amended, shall include the following mental health services
177 when such services are provided by community mental health
178 facilities operated by the department of mental health or
179 designated by the department of mental health as a community
180 mental health facility or as an alcohol and drug abuse
181 facility or as a child-serving agency within the
182 comprehensive children's mental health service system
183 established in section 630.097. The department of mental
184 health shall establish by administrative rule the definition
185 and criteria for designation as a community mental health
186 facility and for designation as an alcohol and drug abuse
187 facility. Such mental health services shall include:
188 (a) Outpatient mental health services including
189 preventive, diagnostic, therapeutic, rehabilitative, and
190 palliative interventions rendered to individuals in an
191 individual or group setting by a mental health professional
192 in accordance with a plan of treatment appropriately
193 established, implemented, monitored, and revised under the
194 auspices of a therapeutic team as a part of client services
195 management;
196 (b) Clinic mental health services including
197 preventive, diagnostic, therapeutic, rehabilitative, and
198 palliative interventions rendered to individuals in an
199 individual or group setting by a mental health professional
200 in accordance with a plan of treatment appropriately
201 established, implemented, monitored, and revised under the
202 auspices of a therapeutic team as a part of client services
203 management;
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204 (c) Rehabilitative mental health and alcohol and drug
205 abuse services including home and community-based
206 preventive, diagnostic, therapeutic, rehabilitative, and
207 palliative interventions rendered to individuals in an
208 individual or group setting by a mental health or alcohol
209 and drug abuse professional in accordance with a plan of
210 treatment appropriately established, implemented, monitored,
211 and revised under the auspices of a therapeutic team as a
212 part of client services management. As used in this
213 section, mental health professional and alcohol and drug
214 abuse professional shall be defined by the department of
215 mental health pursuant to duly promulgated rules. With
216 respect to services established by this subdivision, the
217 department of social services, MO HealthNet division, shall
218 enter into an agreement with the department of mental
219 health. Matching funds for outpatient mental health
220 services, clinic mental health services, and rehabilitation
221 services for mental health and alcohol and drug abuse shall
222 be certified by the department of mental health to the MO
223 HealthNet division. The agreement shall establish a
224 mechanism for the joint implementation of the provisions of
225 this subdivision. In addition, the agreement shall
226 establish a mechanism by which rates for services may be
227 jointly developed;
228 (17) Such additional services as defined by the MO
229 HealthNet division to be furnished under waivers of federal
230 statutory requirements as provided for and authorized by the
231 federal Social Security Act (42 U.S.C. Section 301, et seq.)
232 subject to appropriation by the general assembly;
233 (18) The services of an advanced practice registered
234 nurse with a collaborative practice agreement to the extent
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235 that such services are provided in accordance with chapters
236 334 and 335, and regulations promulgated thereunder;
237 (19) Nursing home costs for participants receiving
238 benefit payments under subdivision (4) of this subsection to
239 reserve a bed for the participant in the nursing home during
240 the time that the participant is absent due to admission to
241 a hospital for services which cannot be performed on an
242 outpatient basis, subject to the provisions of this
243 subdivision:
244 (a) The provisions of this subdivision shall apply
245 only if:
246 a. The occupancy rate of the nursing home is at or
247 above ninety-seven percent of MO HealthNet certified
248 licensed beds, according to the most recent quarterly census
249 provided to the department of health and senior services
250 which was taken prior to when the participant is admitted to
251 the hospital; and
252 b. The patient is admitted to a hospital for a medical
253 condition with an anticipated stay of three days or less;
254 (b) The payment to be made under this subdivision
255 shall be provided for a maximum of three days per hospital
256 stay;
257 (c) For each day that nursing home costs are paid on
258 behalf of a participant under this subdivision during any
259 period of six consecutive months such participant shall,
260 during the same period of six consecutive months, be
261 ineligible for payment of nursing home costs of two
262 otherwise available temporary leave of absence days provided
263 under subdivision (5) of this subsection; and
264 (d) The provisions of this subdivision shall not apply
265 unless the nursing home receives notice from the participant
266 or the participant's responsible party that the participant
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267 intends to return to the nursing home following the hospital
268 stay. If the nursing home receives such notification and
269 all other provisions of this subsection have been satisfied,
270 the nursing home shall provide notice to the participant or
271 the participant's responsible party prior to release of the
272 reserved bed;
273 (20) Prescribed medically necessary durable medical
274 equipment. An electronic web-based prior authorization
275 system using best medical evidence and care and treatment
276 guidelines consistent with national standards shall be used
277 to verify medical need;
278 (21) Hospice care. As used in this subdivision, the
279 term "hospice care" means a coordinated program of active
280 professional medical attention within a home, outpatient and
281 inpatient care which treats the terminally ill patient and
282 family as a unit, employing a medically directed
283 interdisciplinary team. The program provides relief of
284 severe pain or other physical symptoms and supportive care
285 to meet the special needs arising out of physical,
286 psychological, spiritual, social, and economic stresses
287 which are experienced during the final stages of illness,
288 and during dying and bereavement and meets the Medicare
289 requirements for participation as a hospice as are provided
290 in 42 CFR Part 418. The rate of reimbursement paid by the
291 MO HealthNet division to the hospice provider for room and
292 board furnished by a nursing home to an eligible hospice
293 patient shall not be less than ninety-five percent of the
294 rate of reimbursement which would have been paid for
295 facility services in that nursing home facility for that
296 patient, in accordance with subsection (c) of Section 6408
297 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
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298 (22) Prescribed medically necessary dental services.
299 Such services shall be subject to appropriations. An
300 electronic web-based prior authorization system using best
301 medical evidence and care and treatment guidelines
302 consistent with national standards shall be used to verify
303 medical need;
304 (23) Prescribed medically necessary optometric
305 services. Such services shall be subject to
306 appropriations. An electronic web-based prior authorization
307 system using best medical evidence and care and treatment
308 guidelines consistent with national standards shall be used
309 to verify medical need;
310 (24) Blood clotting products-related services. For
311 persons diagnosed with a bleeding disorder, as defined in
312 section 338.400, reliant on blood clotting products, as
313 defined in section 338.400, such services include:
314 (a) Home delivery of blood clotting products and
315 ancillary infusion equipment and supplies, including the
316 emergency deliveries of the product when medically necessary;
317 (b) Medically necessary ancillary infusion equipment
318 and supplies required to administer the blood clotting
319 products; and
320 (c) Assessments conducted in the participant's home by
321 a pharmacist, nurse, or local home health care agency
322 trained in bleeding disorders when deemed necessary by the
323 participant's treating physician;
324 (25) Medically necessary cochlear implants and hearing
325 instruments, as defined in section 345.015, that are:
326 (a) Prescribed by an audiologist, as defined in
327 section 345.015; or
328 (b) Dispensed by a hearing instrument specialist, as
329 defined in section 346.010;
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330 (26) The MO HealthNet division shall, by January 1,
331 2008, and annually thereafter, report the status of MO
332 HealthNet provider reimbursement rates as compared to one
333 hundred percent of the Medicare reimbursement rates and
334 compared to the average dental reimbursement rates paid by
335 third-party payors licensed by the state. The MO HealthNet
336 division shall, by July 1, 2008, provide to the general
337 assembly a four-year plan to achieve parity with Medicare
338 reimbursement rates and for third-party payor average dental
339 reimbursement rates. Such plan shall be subject to
340 appropriation and the division shall include in its annual
341 budget request to the governor the necessary funding needed
342 to complete the four-year plan developed under this
343 subdivision.
344 2. Additional benefit payments for medical assistance
345 shall be made on behalf of those eligible needy children,
346 pregnant women and blind persons with any payments to be
347 made on the basis of the reasonable cost of the care or
348 reasonable charge for the services as defined and determined
349 by the MO HealthNet division, unless otherwise hereinafter
350 provided, for the following:
351 (1) Dental services;
352 (2) Services of podiatrists as defined in section
353 330.010;
354 (3) Optometric services as described in section
355 336.010;
356 (4) Orthopedic devices or other prosthetics, including
357 eye glasses, dentures, [hearing aids,] and wheelchairs;
358 (5) Hospice care. As used in this subdivision, the
359 term "hospice care" means a coordinated program of active
360 professional medical attention within a home, outpatient and
361 inpatient care which treats the terminally ill patient and
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362 family as a unit, employing a medically directed
363 interdisciplinary team. The program provides relief of
364 severe pain or other physical symptoms and supportive care
365 to meet the special needs arising out of physical,
366 psychological, spiritual, social, and economic stresses
367 which are experienced during the final stages of illness,
368 and during dying and bereavement and meets the Medicare
369 requirements for participation as a hospice as are provided
370 in 42 CFR Part 418. The rate of reimbursement paid by the
371 MO HealthNet division to the hospice provider for room and
372 board furnished by a nursing home to an eligible hospice
373 patient shall not be less than ninety-five percent of the
374 rate of reimbursement which would have been paid for
375 facility services in that nursing home facility for that
376 patient, in accordance with subsection (c) of Section 6408
377 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
378 (6) Comprehensive day rehabilitation services
379 beginning early posttrauma as part of a coordinated system
380 of care for individuals with disabling impairments.
381 Rehabilitation services must be based on an individualized,
382 goal-oriented, comprehensive and coordinated treatment plan
383 developed, implemented, and monitored through an
384 interdisciplinary assessment designed to restore an
385 individual to optimal level of physical, cognitive, and
386 behavioral function. The MO HealthNet division shall
387 establish by administrative rule the definition and criteria
388 for designation of a comprehensive day rehabilitation
389 service facility, benefit limitations and payment
390 mechanism. Any rule or portion of a rule, as that term is
391 defined in section 536.010, that is created under the
392 authority delegated in this subdivision shall become
393 effective only if it complies with and is subject to all of
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394 the provisions of chapter 536 and, if applicable, section
395 536.028. This section and chapter 536 are nonseverable and
396 if any of the powers vested with the general assembly
397 pursuant to chapter 536 to review, to delay the effective
398 date, or to disapprove and annul a rule are subsequently
399 held unconstitutional, then the grant of rulemaking
400 authority and any rule proposed or adopted after August 28,
401 2005, shall be invalid and void.
402 3. The MO HealthNet division may require any
403 participant receiving MO HealthNet benefits to pay part of
404 the charge or cost until July 1, 2008, and an additional
405 payment after July 1, 2008, as defined by rule duly
406 promulgated by the MO HealthNet division, for all covered
407 services except for those services covered under
408 subdivisions (15) and (16) of subsection 1 of this section
409 and sections 208.631 to 208.657 to the extent and in the
410 manner authorized by Title XIX of the federal Social
411 Security Act (42 U.S.C. Section 1396, et seq.) and
412 regulations thereunder. When substitution of a generic drug
413 is permitted by the prescriber according to section 338.056,
414 and a generic drug is substituted for a name-brand drug, the
415 MO HealthNet division may not lower or delete the
416 requirement to make a co-payment pursuant to regulations of
417 Title XIX of the federal Social Security Act. A provider of
418 goods or services described under this section must collect
419 from all participants the additional payment that may be
420 required by the MO HealthNet division under authority
421 granted herein, if the division exercises that authority, to
422 remain eligible as a provider. Any payments made by
423 participants under this section shall be in addition to and
424 not in lieu of payments made by the state for goods or
425 services described herein except the participant portion of
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426 the pharmacy professional dispensing fee shall be in
427 addition to and not in lieu of payments to pharmacists. A
428 provider may collect the co-payment at the time a service is
429 provided or at a later date. A provider shall not refuse to
430 provide a service if a participant is unable to pay a
431 required payment. If it is the routine business practice of
432 a provider to terminate future services to an individual
433 with an unclaimed debt, the provider may include uncollected
434 co-payments under this practice. Providers who elect not to
435 undertake the provision of services based on a history of
436 bad debt shall give participants advance notice and a
437 reasonable opportunity for payment. A provider,
438 representative, employee, independent contractor, or agent
439 of a pharmaceutical manufacturer shall not make co-payment
440 for a participant. This subsection shall not apply to other
441 qualified children, pregnant women, or blind persons. If
442 the Centers for Medicare and Medicaid Services does not
443 approve the MO HealthNet state plan amendment submitted by
444 the department of social services that would allow a
445 provider to deny future services to an individual with
446 uncollected co-payments, the denial of services shall not be
447 allowed. The department of social services shall inform
448 providers regarding the acceptability of denying services as
449 the result of unpaid co-payments.
450 4. The MO HealthNet division shall have the right to
451 collect medication samples from participants in order to
452 maintain program integrity.
453 5. Reimbursement for obstetrical and pediatric
454 services under subdivision (6) of subsection 1 of this
455 section shall be timely and sufficient to enlist enough
456 health care providers so that care and services are
457 available under the state plan for MO HealthNet benefits at
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458 least to the extent that such care and services are
459 available to the general population in the geographic area,
460 as required under subparagraph (a)(30)(A) of 42 U.S.C.
461 Section 1396a and federal regulations promulgated thereunder.
462 6. Beginning July 1, 1990, reimbursement for services
463 rendered in federally funded health centers shall be in
464 accordance with the provisions of subsection 6402(c) and
465 Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation
466 Act of 1989) and federal regulations promulgated thereunder.
467 7. Beginning July 1, 1990, the department of social
468 services shall provide notification and referral of children
469 below age five, and pregnant, breast-feeding, or postpartum
470 women who are determined to be eligible for MO HealthNet
471 benefits under section 208.151 to the special supplemental
472 food programs for women, infants and children administered
473 by the department of health and senior services. Such
474 notification and referral shall conform to the requirements
475 of Section 6406 of P.L. 101-239 and regulations promulgated
476 thereunder.
477 8. Providers of long-term care services shall be
478 reimbursed for their costs in accordance with the provisions
479 of Section 1902 (a)(13)(A) of the Social Security Act, 42
480 U.S.C. Section 1396a, as amended, and regulations
481 promulgated thereunder.
482 9. Reimbursement rates to long-term care providers
483 with respect to a total change in ownership, at arm's
484 length, for any facility previously licensed and certified
485 for participation in the MO HealthNet program shall not
486 increase payments in excess of the increase that would
487 result from the application of Section 1902 (a)(13)(C) of
488 the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C).
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489 10. The MO HealthNet division may enroll qualified
490 residential care facilities and assisted living facilities,
491 as defined in chapter 198, as MO HealthNet personal care
492 providers.
493 11. Any income earned by individuals eligible for
494 certified extended employment at a sheltered workshop under
495 chapter 178 shall not be considered as income for purposes
496 of determining eligibility under this section.
497 12. If the Missouri Medicaid audit and compliance unit
498 changes any interpretation or application of the
499 requirements for reimbursement for MO HealthNet services
500 from the interpretation or application that has been applied
501 previously by the state in any audit of a MO HealthNet
502 provider, the Missouri Medicaid audit and compliance unit
503 shall notify all affected MO HealthNet providers five
504 business days before such change shall take effect. Failure
505 of the Missouri Medicaid audit and compliance unit to notify
506 a provider of such change shall entitle the provider to
507 continue to receive and retain reimbursement until such
508 notification is provided and shall waive any liability of
509 such provider for recoupment or other loss of any payments
510 previously made prior to the five business days after such
511 notice has been sent. Each provider shall provide the
512 Missouri Medicaid audit and compliance unit a valid email
513 address and shall agree to receive communications
514 electronically. The notification required under this
515 section shall be delivered in writing by the United States
516 Postal Service or electronic mail to each provider.
517 13. Nothing in this section shall be construed to
518 abrogate or limit the department's statutory requirement to
519 promulgate rules under chapter 536.
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520 14. Beginning July 1, 2016, and subject to
521 appropriations, providers of behavioral, social, and
522 psychophysiological services for the prevention, treatment,
523 or management of physical health problems shall be
524 reimbursed utilizing the behavior assessment and
525 intervention reimbursement codes 96150 to 96154 or their
526 successor codes under the Current Procedural Terminology
527 (CPT) coding system. Providers eligible for such
528 reimbursement shall include psychologists.
529 15. There shall be no payments made under this section
530 for gender transition surgeries, cross-sex hormones, or
531 puberty-blocking drugs, as such terms are defined in section
532 191.1720, for the purpose of a gender transition.
1 210.030. 1. Every licensed physician, midwife,
2 registered nurse and all persons who may undertake, in a
3 professional way, the obstetrical and gynecological care of
4 a pregnant woman in the state of Missouri shall, if the
5 woman consents, take or cause to be taken a sample of venous
6 blood of such woman at the time of the first prenatal
7 examination, or not later than twenty days after the first
8 prenatal examination, another sample at twenty-eight weeks
9 of pregnancy, and another sample immediately after birth and
10 subject such [sample] samples to an approved and standard
11 serological test for syphilis[, an] and approved serological
12 [test] tests for hepatitis B, hepatitis C, human
13 immunodeficiency virus (HIV), and such other treatable
14 diseases and metabolic disorders as are prescribed by the
15 department of health and senior services. [In any area of
16 the state designated as a syphilis outbreak area by the
17 department of health and senior services, if the mother
18 consents, a sample of her venous blood shall be taken later
19 in the course of pregnancy and at delivery for additional
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20 testing for syphilis as may be prescribed by the department]
21 If a mother tests positive for syphilis, hepatitis B,
22 hepatitis C, or HIV, or any combination of such diseases,
23 the physician or person providing care shall administer
24 treatment in accordance with the most recent accepted
25 medical practice. If a mother tests positive for hepatitis
26 B, the physician or person who professionally undertakes the
27 pediatric care of a newborn shall also administer the
28 appropriate doses of hepatitis B vaccine and hepatitis B
29 immune globulin (HBIG) in accordance with the current
30 recommendations of the Advisory Committee on Immunization
31 Practices (ACIP). If the mother's hepatitis B status is
32 unknown, the appropriate dose of hepatitis B vaccine shall
33 be administered to the newborn in accordance with the
34 current ACIP recommendations. If the mother consents, a
35 sample of her venous blood shall be taken. If she tests
36 positive for hepatitis B, hepatitis B immune globulin (HBIG)
37 shall be administered to the newborn in accordance with the
38 current ACIP recommendations.
39 2. The department of health and senior services
40 shall[, in consultation with the Missouri genetic disease
41 advisory committee,] make such rules pertaining to such
42 tests as shall be dictated by accepted medical practice, and
43 tests shall be of the types approved or accepted by the
44 [department of health and senior services. An approved and
45 standard test for syphilis, hepatitis B, and other treatable
46 diseases and metabolic disorders shall mean a test made in a
47 laboratory approved by the department of health and senior
48 services] United States Food and Drug Administration. No
49 individual shall be denied testing by the department of
50 health and senior services because of inability to pay.
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51 3. All persons providing care under this section shall
52 do so pursuant to the provisions of section 431.061.
1 354.465. 1. The director, or any duly appointed
2 representative, may make an examination of the affairs of
3 any health maintenance organization as often as he deems it
4 necessary for the protection of the interests of the people
5 of this state[, but not less frequently than once every five
6 years].
7 2. All costs incurred by the state as a result of
8 making examinations under this section shall be paid by the
9 organization being examined and remitted as provided in
10 section 374.160.
1 376.1240. 1. For purposes of this section, terms
2 shall have the same meanings as ascribed to them in section
3 376.1350, and the term "self-administered hormonal
4 contraceptive" shall mean a drug that is composed of one or
5 more hormones and that is approved by the Food and Drug
6 Administration to prevent pregnancy, excluding emergency
7 contraception. Nothing in this section shall be construed
8 to apply to medications approved by the Food and Drug
9 Administration to terminate an existing pregnancy.
10 2. Any health benefit plan delivered, issued for
11 delivery, continued, or renewed in this state on or after
12 January 1, 2026, that provides coverage for self-
13 administered hormonal contraceptives shall provide coverage
14 to reimburse a health care provider or dispensing entity for
15 the dispensing of a supply of self-administered hormonal
16 contraceptives intended to last up to ninety days, or
17 intended to last up to one hundred eighty days for generic
18 self-administered hormonal contraceptives.
19 3. The coverage required under this section shall not
20 be subject to any greater deductible or co-payment than
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21 other similar health care services provided by the health
22 benefit plan.
1 376.1850. 1. As used in this section, the following
2 terms mean:
3 (1) "Contract for health care benefits", a self-funded
4 contractual arrangement made in accordance with this section
5 between a qualified membership organization and its members
6 to provide, deliver, arrange for, pay for, or reimburse any
7 of the costs of health care services;
8 (2) "Farm bureau", a nonprofit agricultural membership
9 organization first incorporated in this state at least one
10 hundred years ago, or an affiliate designated by the
11 nonprofit agricultural membership organization;
12 (3) "Health care service", the same meaning as is
13 ascribed to such term in section 376.1350;
14 (4) "Member of a qualified membership organization", a
15 natural person who pays periodic dues or fees, other than
16 payments for a contract for health care benefits, for
17 membership in a qualified membership organization, and the
18 natural person's spouse or dependent children under the age
19 of twenty-six;
20 (5) "Qualified membership organization", a farm
21 bureau, or an entity with at least one hundred thousand dues-
22 paying members, that is governed by a council of its
23 members, that has at least five hundred million dollars in
24 assets, and that exists to serve its members beyond solely
25 offering health coverage.
26 2. The provisions of this chapter relating to health
27 insurance, health maintenance organizations, health benefit
28 plans, group health services, and health carriers shall not
29 apply to contracts for health care benefits provided by a
30 qualified membership organization. A qualified membership
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31 organization providing contracts for health care benefits
32 shall not be considered to be engaging in the business of
33 insurance for purposes of any provision of chapters 361 to
34 385.
35 3. It is unlawful to provide a contract for health
36 care benefits under this section unless the qualified
37 membership organization providing the contract is registered
38 with the department of commerce and insurance as provided in
39 this subsection. To register as a qualified membership
40 organization, an applicant shall file information with the
41 director demonstrating it meets the requirements of this
42 section and pay an application fee of two hundred and fifty
43 dollars. A registration is valid for five years and may be
44 renewed for additional five year terms if the qualified
45 membership organization continues to meet the requirements
46 of this section and pays a renewal fee of two hundred and
47 fifty dollars. All amounts collected as registration or
48 renewal fees shall be deposited into the insurance dedicated
49 fund established under section 374.150.
50 4. Contracts for health care benefits provided under
51 this section shall be offered only to members of a qualified
52 membership organization who have been members of the
53 organization for at least thirty days; and shall be sold,
54 solicited, or negotiated only by insurance producers
55 licensed under chapter 375 to produce accident and health or
56 sickness coverage.
57 5. Notwithstanding any provision of law to the
58 contrary, a qualified membership organization providing a
59 contract for health care benefits under this section shall
60 use the services of an administrator permitted to provide
61 services in accordance with sections 376.1075 to 376.1095,
62 and shall agree in the contract with such administrator to
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63 utilize processes for benefit determinations and claims
64 payment procedures in accordance with the requirements
65 applicable to health carriers and health benefit plans under
66 sections 376.383, 376.690, and 376.1367. A contract for
67 health care benefits provided under this section shall not
68 be subject to the laws of this state relating to insurance
69 or insurance companies except as specified in this section.
70 6. The risk under contracts provided in accordance
71 with this section may be reinsured in accordance with
72 section 375.246.
73 7. (1) Contracts for health care benefits under this
74 section shall include the following written disclaimer on
75 the front of the contract and all related applications and
76 renewal forms in a bold font no smaller than sixteen point:
77 "NOTICE
78 This contract is not health insurance and is not
79 subject to federal or state laws relating to
80 health insurance. This contract offers fewer
81 benefits than an ACA-compliant health plan and
82 may exclude coverage for preexisting
83 conditions. You may qualify for income-based
84 subsidies through the ACA Health Insurance
85 Marketplace. This contract is not covered by
86 the Missouri Insurance Guaranty Association.
87 You may be financially responsible for costs of
88 medical treatment that may not be covered under
89 this contract.".
90 (2) The written disclaimers required by subdivision
91 (1) of this subsection on applications and renewal forms
92 shall be signed by the member entering into or renewing the
93 contract, specifically acknowledging that the coverage is
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94 not considered insurance and is not subject to regulation by
95 the department of commerce and insurance.
96 (3) The qualified membership organization providing
97 the contract shall retain a copy of written acknowledgements
98 required under subdivision (2) of this subsection for the
99 duration for which claims may be submitted under the
100 contract, and shall provide a copy of the acknowledgement to
101 the member upon the member's request.
102 8. Contracts provided under this section shall not be
103 subject to individual post-claim medical underwriting while
104 coverage remains in effect, and no member covered under a
105 contract provided under this section shall be subject to
106 cancellation, nonrenewal, modification, or increase in
107 premium for reason of a medical event.
108 9. Notwithstanding subsection 2 of this section, the
109 department of commerce and insurance shall receive and
110 review complaints and inquiries from members of a qualified
111 membership organization, pursuant to section 374.085,
112 subject to section 374.071.
113 10. By March thirty-first of each year, each qualified
114 membership organization providing a contract for health care
115 benefits under this section, or its administrator, shall pay
116 to the director a fee equal to one percent of the Missouri
117 claims paid under this section during the immediately
118 preceding year. Funds collected by the director shall be
119 deposited in the insurance dedicated fund established under
120 section 374.150.
121 11. No qualified membership organization, or other
122 entity on behalf of a qualified membership organization,
123 shall refer to a contract for health care benefits under
124 this section as insurance or health insurance in any
125 marketing, advertising, or other communication with the
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126 public or members of the qualified membership organization.
127 Violation of this subsection shall be an unlawful practice
128 under section 407.020.
129 12. Contracts for health care benefits provided under
130 this section:
131 (1) Shall include coverage for:
132 (a) Ambulatory patient services;
133 (b) Hospitalization;
134 (c) Emergency services, as defined in section
135 376.1350; and
136 (d) Laboratory services; and
137 (2) Shall not be subject to an annual limit of less
138 than two million dollars per year.
1 [192.769. 1. On completion of a
2 mammogram, a mammography facility certified by
3 the United States Food and Drug Administration
4 (FDA) or by a certification agency approved by
5 the FDA shall provide to the patient the
6 following notice:
7 "If your mammogram demonstrates
8 that you have dense breast
9 tissue, which could hide
10 abnormalities, and you have other
11 risk factors for breast cancer
12 that have been identified, you
13 might benefit from supplemental
14 screening tests that may be
15 suggested by your ordering
16 physician. Dense breast tissue,
17 in and of itself, is a relatively
18 common condition. Therefore,
19 this information is not provided
20 to cause undue concern, but
21 rather to raise your awareness
22 and to promote discussion with
23 your physician regarding the
24 presence of other risk factors,
25 in addition to dense breast
26 tissue. A report of your
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27 mammography results will be sent
28 to you and your physician. You
29 should contact your physician if
30 you have any questions or
31 concerns regarding this report.".
32 2. Nothing in this section shall be
33 construed to create a duty of care beyond the
34 duty to provide notice as set forth in this
35 section.
36 3. The information required by this
37 section or evidence that a person violated this
38 section is not admissible in a civil, judicial,
39 or administrative proceeding.
40 4. A mammography facility is not required
41 to comply with the requirements of this section
42 until January 1, 2015.]
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