HOUSE BILL NO. 1275 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE THOMAS.
2642H.01I JOSEPH ENGLER, Chief Clerk
AN ACT To repeal sections 191.1720, 208.152, 217.230, and 221.120, RSMo, and to enact in lieu thereof three new sections relating to gender transition procedures.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 191.1720, 208.152, 217.230, and 221.120, RSMo, are repealed 2 and three new sections enacted in lieu thereof, to be known as sections 208.152, 217.230, and 3 221.120, to read as follows: 208.152. 1. MO HealthNet payments shall be made on behalf of those eligible needy 2 persons as described in section 208.151 who are unable to provide for it in whole or in part, 3 with any payments to be made on the basis of the reasonable cost of the care or reasonable 4 charge for the services as defined and determined by the MO HealthNet division, unless 5 otherwise hereinafter provided, for the following: 6 (1) Inpatient hospital services, except to persons in an institution for mental diseases 7 who are under the age of sixty-five years and over the age of twenty-one years; provided that 8 the MO HealthNet division shall provide through rule and regulation an exception process for 9 coverage of inpatient costs in those cases requiring treatment beyond the seventy-fifth 10 percentile professional activities study (PAS) or the MO HealthNet children's diagnosis 11 length-of-stay schedule; and provided further that the MO HealthNet division shall take into 12 account through its payment system for hospital services the situation of hospitals which 13 serve a disproportionate number of low-income patients; 14 (2) All outpatient hospital services, payments therefor to be in amounts which 15 represent no more than eighty percent of the lesser of reasonable costs or customary charges 16 for such services, determined in accordance with the principles set forth in Title XVIII A and
EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language. HB 1275 2
17 B, Public Law 89-97, 1965 amendments to the federal Social Security Act (42 U.S.C. Section 18 301, et seq.), but the MO HealthNet division may evaluate outpatient hospital services 19 rendered under this section and deny payment for services which are determined by the MO 20 HealthNet division not to be medically necessary, in accordance with federal law and 21 regulations; 22 (3) Laboratory and X-ray services; 23 (4) Nursing home services for participants, except to persons with more than five 24 hundred thousand dollars equity in their home or except for persons in an institution for 25 mental diseases who are under the age of sixty-five years, when residing in a hospital licensed 26 by the department of health and senior services or a nursing home licensed by the department 27 of health and senior services or appropriate licensing authority of other states or government- 28 owned and -operated institutions which are determined to conform to standards equivalent to 29 licensing requirements in Title XIX of the federal Social Security Act (42 U.S.C. Section 301, 30 et seq.), as amended, for nursing facilities. The MO HealthNet division may recognize 31 through its payment methodology for nursing facilities those nursing facilities which serve a 32 high volume of MO HealthNet patients. The MO HealthNet division when determining the 33 amount of the benefit payments to be made on behalf of persons under the age of twenty-one 34 in a nursing facility may consider nursing facilities furnishing care to persons under the age of 35 twenty-one as a classification separate from other nursing facilities; 36 (5) Nursing home costs for participants receiving benefit payments under subdivision 37 (4) of this subsection for those days, which shall not exceed twelve per any period of six 38 consecutive months, during which the participant is on a temporary leave of absence from the 39 hospital or nursing home, provided that no such participant shall be allowed a temporary 40 leave of absence unless it is specifically provided for in his or her plan of care. As used in 41 this subdivision, the term "temporary leave of absence" shall include all periods of time 42 during which a participant is away from the hospital or nursing home overnight because he or 43 she is visiting a friend or relative; 44 (6) Physicians' services, whether furnished in the office, home, hospital, nursing 45 home, or elsewhere, provided, that no funds shall be expended to any abortion facility, as 46 defined in section 188.015, or to any affiliate, as defined in section 188.015, of such abortion 47 facility; 48 (7) Subject to appropriation, up to twenty visits per year for services limited to 49 examinations, diagnoses, adjustments, and manipulations and treatments of malpositioned 50 articulations and structures of the body provided by licensed chiropractic physicians 51 practicing within their scope of practice. Nothing in this subdivision shall be interpreted to 52 otherwise expand MO HealthNet services; HB 1275 3
53 (8) Drugs and medicines when prescribed by a licensed physician, dentist, podiatrist, 54 or an advanced practice registered nurse; except that no payment for drugs and medicines 55 prescribed on and after January 1, 2006, by a licensed physician, dentist, podiatrist, or an 56 advanced practice registered nurse may be made on behalf of any person who qualifies for 57 prescription drug coverage under the provisions of P.L. 108-173; 58 (9) Emergency ambulance services and, effective January 1, 1990, medically 59 necessary transportation to scheduled, physician-prescribed nonelective treatments; 60 (10) Early and periodic screening and diagnosis of individuals who are under the age 61 of twenty-one to ascertain their physical or mental defects, and health care, treatment, and 62 other measures to correct or ameliorate defects and chronic conditions discovered thereby. 63 Such services shall be provided in accordance with the provisions of Section 6403 of P.L. 64 101-239 and federal regulations promulgated thereunder; 65 (11) Home health care services; 66 (12) Family planning as defined by federal rules and regulations; provided, that no 67 funds shall be expended to any abortion facility, as defined in section 188.015, or to any 68 affiliate, as defined in section 188.015, of such abortion facility; and further provided, 69 however, that such family planning services shall not include abortions or any abortifacient 70 drug or device that is used for the purpose of inducing an abortion unless such abortions are 71 certified in writing by a physician to the MO HealthNet agency that, in the physician's 72 professional judgment, the life of the mother would be endangered if the fetus were carried to 73 term; 74 (13) Inpatient psychiatric hospital services for individuals under age twenty-one as 75 defined in Title XIX of the federal Social Security Act (42 U.S.C. Section 1396d, et seq.); 76 (14) Outpatient surgical procedures, including presurgical diagnostic services 77 performed in ambulatory surgical facilities which are licensed by the department of health 78 and senior services of the state of Missouri; except, that such outpatient surgical services shall 79 not include persons who are eligible for coverage under Part B of Title XVIII, Public Law 89- 80 97, 1965 amendments to the federal Social Security Act, as amended, if exclusion of such 81 persons is permitted under Title XIX, Public Law 89-97, 1965 amendments to the federal 82 Social Security Act, as amended; 83 (15) Personal care services which are medically oriented tasks having to do with a 84 person's physical requirements, as opposed to housekeeping requirements, which enable a 85 person to be treated by his or her physician on an outpatient rather than on an inpatient or 86 residential basis in a hospital, intermediate care facility, or skilled nursing facility. Personal 87 care services shall be rendered by an individual not a member of the participant's family who 88 is qualified to provide such services where the services are prescribed by a physician in 89 accordance with a plan of treatment and are supervised by a licensed nurse. Persons eligible HB 1275 4
90 to receive personal care services shall be those persons who would otherwise require 91 placement in a hospital, intermediate care facility, or skilled nursing facility. Benefits payable 92 for personal care services shall not exceed for any one participant one hundred percent of the 93 average statewide charge for care and treatment in an intermediate care facility for a 94 comparable period of time. Such services, when delivered in a residential care facility or 95 assisted living facility licensed under chapter 198, shall be authorized on a tier level based on 96 the services the resident requires and the frequency of the services. A resident of such facility 97 who qualifies for assistance under section 208.030 shall, at a minimum, if prescribed by a 98 physician, qualify for the tier level with the fewest services. The rate paid to providers for 99 each tier of service shall be set subject to appropriations. Subject to appropriations, each 100 resident of such facility who qualifies for assistance under section 208.030 and meets the 101 level of care required in this section shall, at a minimum, if prescribed by a physician, be 102 authorized up to one hour of personal care services per day. Authorized units of personal care 103 services shall not be reduced or tier level lowered unless an order approving such reduction or 104 lowering is obtained from the resident's personal physician. Such authorized units of personal 105 care services or tier level shall be transferred with such resident if he or she transfers to 106 another such facility. Such provision shall terminate upon receipt of relevant waivers from 107 the federal Department of Health and Human Services. If the Centers for Medicare and 108 Medicaid Services determines that such provision does not comply with the state plan, this 109 provision shall be null and void. The MO HealthNet division shall notify the revisor of 110 statutes as to whether the relevant waivers are approved or a determination of noncompliance 111 is made; 112 (16) Mental health services. The state plan for providing medical assistance under 113 Title XIX of the Social Security Act, 42 U.S.C. Section 301, as amended, shall include the 114 following mental health services when such services are provided by community mental 115 health facilities operated by the department of mental health or designated by the department 116 of mental health as a community mental health facility or as an alcohol and drug abuse facility 117 or as a child-serving agency within the comprehensive children's mental health service system 118 established in section 630.097. The department of mental health shall establish by 119 administrative rule the definition and criteria for designation as a community mental health 120 facility and for designation as an alcohol and drug abuse facility. Such mental health services 121 shall include: 122 (a) Outpatient mental health services including preventive, diagnostic, therapeutic, 123 rehabilitative, and palliative interventions rendered to individuals in an individual or group 124 setting by a mental health professional in accordance with a plan of treatment appropriately 125 established, implemented, monitored, and revised under the auspices of a therapeutic team as 126 a part of client services management; HB 1275 5
127 (b) Clinic mental health services including preventive, diagnostic, therapeutic, 128 rehabilitative, and palliative interventions rendered to individuals in an individual or group 129 setting by a mental health professional in accordance with a plan of treatment appropriately 130 established, implemented, monitored, and revised under the auspices of a therapeutic team as 131 a part of client services management; 132 (c) Rehabilitative mental health and alcohol and drug abuse services including home 133 and community-based preventive, diagnostic, therapeutic, rehabilitative, and palliative 134 interventions rendered to individuals in an individual or group setting by a mental health 135 or alcohol and drug abuse professional in accordance with a plan of treatment appropriately 136 established, implemented, monitored, and revised under the auspices of a therapeutic team as 137 a part of client services management. As used in this section, mental health professional and 138 alcohol and drug abuse professional shall be defined by the department of mental health 139 pursuant to duly promulgated rules. With respect to services established by this subdivision, 140 the department of social services, MO HealthNet division, shall enter into an agreement with 141 the department of mental health. Matching funds for outpatient mental health services, clinic 142 mental health services, and rehabilitation services for mental health and alcohol and drug 143 abuse shall be certified by the department of mental health to the MO HealthNet division. 144 The agreement shall establish a mechanism for the joint implementation of the provisions of 145 this subdivision. In addition, the agreement shall establish a mechanism by which rates for 146 services may be jointly developed; 147 (17) Such additional services as defined by the MO HealthNet division to be 148 furnished under waivers of federal statutory requirements as provided for and authorized by 149 the federal Social Security Act (42 U.S.C. Section 301, et seq.) subject to appropriation by the 150 general assembly; 151 (18) The services of an advanced practice registered nurse with a collaborative 152 practice agreement to the extent that such services are provided in accordance with chapters 153 334 and 335, and regulations promulgated thereunder; 154 (19) Nursing home costs for participants receiving benefit payments under 155 subdivision (4) of this subsection to reserve a bed for the participant in the nursing home 156 during the time that the participant is absent due to admission to a hospital for services which 157 cannot be performed on an outpatient basis, subject to the provisions of this subdivision: 158 (a) The provisions of this subdivision shall apply only if: 159 a. The occupancy rate of the nursing home is at or above ninety-seven percent of MO 160 HealthNet certified licensed beds, according to the most recent quarterly census provided to 161 the department of health and senior services which was taken prior to when the participant is 162 admitted to the hospital; and HB 1275 6
163 b. The patient is admitted to a hospital for a medical condition with an anticipated 164 stay of three days or less; 165 (b) The payment to be made under this subdivision shall be provided for a maximum 166 of three days per hospital stay; 167 (c) For each day that nursing home costs are paid on behalf of a participant under this 168 subdivision during any period of six consecutive months such participant shall, during the 169 same period of six consecutive months, be ineligible for payment of nursing home costs of 170 two otherwise available temporary leave of absence days provided under subdivision (5) of 171 this subsection; and 172 (d) The provisions of this subdivision shall not apply unless the nursing home 173 receives notice from the participant or the participant's responsible party that the participant 174 intends to return to the nursing home following the hospital stay. If the nursing home receives 175 such notification and all other provisions of this subsection have been satisfied, the nursing 176 home shall provide notice to the participant or the participant's responsible party prior to 177 release of the reserved bed; 178 (20) Prescribed medically necessary durable medical equipment. An electronic web- 179 based prior authorization system using best medical evidence and care and treatment 180 guidelines consistent with national standards shall be used to verify medical need; 181 (21) Hospice care. As used in this subdivision, the term "hospice care" means a 182 coordinated program of active professional medical attention within a home, outpatient and 183 inpatient care which treats the terminally ill patient and family as a unit, employing a 184 medically directed interdisciplinary team. The program provides relief of severe pain or other 185 physical symptoms and supportive care to meet the special needs arising out of physical, 186 psychological, spiritual, social, and economic stresses which are experienced during the final 187 stages of illness, and during dying and bereavement and meets the Medicare requirements for 188 participation as a hospice as are provided in 42 CFR Part 418. The rate of reimbursement 189 paid by the MO HealthNet division to the hospice provider for room and board furnished by a 190 nursing home to an eligible hospice patient shall not be less than ninety-five percent of the 191 rate of reimbursement which would have been paid for facility services in that nursing home 192 facility for that patient, in accordance with subsection (c) of Section 6408 of P.L. 101-239 193 (Omnibus Budget Reconciliation Act of 1989); 194 (22) Prescribed medically necessary dental services. Such services shall be subject to 195 appropriations. An electronic web-based prior authorization system using best medical 196 evidence and care and treatment guidelines consistent with national standards shall be used to 197 verify medical need; 198 (23) Prescribed medically necessary optometric services. Such services shall be 199 subject to appropriations. An electronic web-based prior authorization system using best HB 1275 7
200 medical evidence and care and treatment guidelines consistent with national standards shall 201 be used to verify medical need; 202 (24) Blood clotting products-related services. For persons diagnosed with a bleeding 203 disorder, as defined in section 338.400, reliant on blood clotting products, as defined in 204 section 338.400, such services include: 205 (a) Home delivery of blood clotting products and ancillary infusion equipment and 206 supplies, including the emergency deliveries of the product when medically necessary; 207 (b) Medically necessary ancillary infusion equipment and supplies required to 208 administer the blood clotting products; and 209 (c) Assessments conducted in the par