208.152. Medical services for which payment will be made--co-payments may be required--reimbursement for services.
Medical services for which payment will be made--co-payments may berequired--reimbursement for services.
208.152. 1. MO HealthNet payments shall be made on behalf of thoseeligible needy persons as defined in section 208.151 who are unable toprovide for it in whole or in part, with any payments to be made on thebasis of the reasonable cost of the care or reasonable charge for theservices as defined and determined by the MO HealthNet division, unlessotherwise hereinafter provided, for the following:
(1) Inpatient hospital services, except to persons in an institutionfor mental diseases who are under the age of sixty-five years and over theage of twenty-one years; provided that the MO HealthNet division shallprovide through rule and regulation an exception process for coverage ofinpatient costs in those cases requiring treatment beyond the seventy-fifthpercentile professional activities study (PAS) or the MO HealthNetchildren's diagnosis length-of-stay schedule; and provided further that theMO HealthNet division shall take into account through its payment systemfor hospital services the situation of hospitals which serve adisproportionate number of low-income patients;
(2) All outpatient hospital services, payments therefor to be inamounts which represent no more than eighty percent of the lesser ofreasonable costs or customary charges for such services, determined inaccordance with the principles set forth in Title XVIII A and B, Public Law89-97, 1965 amendments to the federal Social Security Act (42 U.S.C. 301,et seq.), but the MO HealthNet division may evaluate outpatient hospitalservices rendered under this section and deny payment for services whichare determined by the MO HealthNet division not to be medically necessary,in accordance with federal law and regulations;
(3) Laboratory and X-ray services;
(4) Nursing home services for participants, except to persons withmore than five hundred thousand dollars equity in their home or except forpersons in an institution for mental diseases who are under the age ofsixty-five years, when residing in a hospital licensed by the department ofhealth and senior services or a nursing home licensed by the department ofhealth and senior services or appropriate licensing authority of otherstates or government-owned and -operated institutions which are determinedto conform to standards equivalent to licensing requirements in Title XIXof the federal Social Security Act (42 U.S.C. 301, et seq.), as amended,for nursing facilities. The MO HealthNet division may recognize throughits payment methodology for nursing facilities those nursing facilitieswhich serve a high volume of MO HealthNet patients. The MO HealthNetdivision when determining the amount of the benefit payments to be made onbehalf of persons under the age of twenty-one in a nursing facility mayconsider nursing facilities furnishing care to persons under the age oftwenty-one as a classification separate from other nursing facilities;
(5) Nursing home costs for participants receiving benefit paymentsunder subdivision (4) of this subsection for those days, which shall notexceed twelve per any period of six consecutive months, during which theparticipant is on a temporary leave of absence from the hospital or nursinghome, provided that no such participant shall be allowed a temporary leaveof absence unless it is specifically provided for in his plan of care. Asused in this subdivision, the term "temporary leave of absence" shallinclude all periods of time during which a participant is away from thehospital or nursing home overnight because he is visiting a friend orrelative;
(6) Physicians' services, whether furnished in the office, home,hospital, nursing home, or elsewhere;
(7) Drugs and medicines when prescribed by a licensed physician,dentist, or podiatrist; except that no payment for drugs and medicinesprescribed on and after January 1, 2006, by a licensed physician, dentist,or podiatrist may be made on behalf of any person who qualifies forprescription drug coverage under the provisions of P.L. 108-173;
(8) Emergency ambulance services and, effective January 1, 1990,medically necessary transportation to scheduled, physician-prescribednonelective treatments;
(9) Early and periodic screening and diagnosis of individuals who areunder the age of twenty-one to ascertain their physical or mental defects,and health care, treatment, and other measures to correct or amelioratedefects and chronic conditions discovered thereby. Such services shall beprovided in accordance with the provisions of Section 6403 of P.L. 101-239and federal regulations promulgated thereunder;
(10) Home health care services;
(11) Family planning as defined by federal rules and regulations;provided, however, that such family planning services shall not includeabortions unless such abortions are certified in writing by a physician tothe MO HealthNet agency that, in his professional judgment, the life of themother would be endangered if the fetus were carried to term;
(12) Inpatient psychiatric hospital services for individuals underage twenty-one as defined in Title XIX of the federal Social Security Act(42 U.S.C. 1396d, et seq.);
(13) Outpatient surgical procedures, including presurgical diagnosticservices performed in ambulatory surgical facilities which are licensed bythe department of health and senior services of the state of Missouri;except, that such outpatient surgical services shall not include personswho are eligible for coverage under Part B of Title XVIII, Public Law89-97, 1965 amendments to the federal Social Security Act, as amended, ifexclusion of such persons is permitted under Title XIX, Public Law 89-97,1965 amendments to the federal Social Security Act, as amended;
(14) Personal care services which are medically oriented tasks havingto do with a person's physical requirements, as opposed to housekeepingrequirements, which enable a person to be treated by his physician on anoutpatient rather than on an inpatient or residential basis in a hospital,intermediate care facility, or skilled nursing facility. Personal careservices shall be rendered by an individual not a member of theparticipant's family who is qualified to provide such services where theservices are prescribed by a physician in accordance with a plan oftreatment and are supervised by a licensed nurse. Persons eligible toreceive personal care services shall be those persons who would otherwiserequire placement in a hospital, intermediate care facility, or skillednursing facility. Benefits payable for personal care services shall notexceed for any one participant one hundred percent of the average statewidecharge for care and treatment in an intermediate care facility for acomparable period of time. Such services, when delivered in a residentialcare facility or assisted living facility licensed under chapter 198, RSMo,shall be authorized on a tier level based on the services the residentrequires and the frequency of the services. A resident of such facilitywho qualifies for assistance under section 208.030 shall, at a minimum, ifprescribed by a physician, qualify for the tier level with the fewestservices. The rate paid to providers for each tier of service shall be setsubject to appropriations. Subject to appropriations, each resident ofsuch facility who qualifies for assistance under section 208.030 and meetsthe level of care required in this section shall, at a minimum, ifprescribed by a physician, be authorized up to one hour of personal careservices per day. Authorized units of personal care services shall not bereduced or tier level lowered unless an order approving such reduction orlowering is obtained from the resident's personal physician. Suchauthorized units of personal care services or tier level shall betransferred with such resident if her or she transfers to another suchfacility. Such provision shall terminate upon receipt of relevant waiversfrom the federal Department of Health and Human Services. If the Centersfor Medicare and Medicaid Services determines that such provision does notcomply with the state plan, this provision shall be null and void. The MOHealthNet division shall notify the revisor of statutes as to whether therelevant waivers are approved or a determination of noncompliance is made;
(15) Mental health services. The state plan for providing medicalassistance under Title XIX of the Social Security Act, 42 U.S.C. 301, asamended, shall include the following mental health services when suchservices are provided by community mental health facilities operated by thedepartment of mental health or designated by the department of mentalhealth as a community mental health facility or as an alcohol and drugabuse facility or as a child-serving agency within the comprehensivechildren's mental health service system established in section 630.097,RSMo. The department of mental health shall establish by administrativerule the definition and criteria for designation as a community mentalhealth facility and for designation as an alcohol and drug abuse facility.Such mental health services shall include:
(a) Outpatient mental health services including preventive,diagnostic, therapeutic, rehabilitative, and palliative interventionsrendered to individuals in an individual or group setting by a mentalhealth professional in accordance with a plan of treatment appropriatelyestablished, implemented, monitored, and revised under the auspices of atherapeutic team as a part of client services management;
(b) Clinic mental health services including preventive, diagnostic,therapeutic, rehabilitative, and palliative interventions rendered toindividuals in an individual or group setting by a mental healthprofessional in accordance with a plan of treatment appropriatelyestablished, implemented, monitored, and revised under the auspices of atherapeutic team as a part of client services management;
(c) Rehabilitative mental health and alcohol and drug abuse servicesincluding home and community-based preventive, diagnostic, therapeutic,rehabilitative, and palliative interventions rendered to individuals in anindividual or group setting by a mental health or alcohol and drug abuseprofessional in accordance with a plan of treatment appropriatelyestablished, implemented, monitored, and revised under the auspices of atherapeutic team as a part of client services management. As used in thissection, mental health professional and alcohol and drug abuse professionalshall be defined by the department of mental health pursuant to dulypromulgated rules.
With respect to services established by this subdivision, the department ofsocial services, MO HealthNet division, shall enter into an agreement withthe department of mental health. Matching funds for outpatient mentalhealth services, clinic mental health services, and rehabilitation servicesfor mental health and alcohol and drug abuse shall be certified by thedepartment of mental health to the MO HealthNet division. The agreementshall establish a mechanism for the joint implementation of the provisionsof this subdivision. In addition, the agreement shall establish amechanism by which rates for services may be jointly developed;
(16) Such additional services as defined by the MO HealthNet divisionto be furnished under waivers of federal statutory requirements as providedfor and authorized by the federal Social Security Act (42 U.S.C. 301, etseq.) subject to appropriation by the general assembly;
(17) Beginning July 1, 1990, the services of a certified pediatric orfamily nursing practitioner with a collaborative practice agreement to theextent that such services are provided in accordance with chapters 334 and335, RSMo, and regulations promulgated thereunder;
(18) Nursing home costs for participants receiving benefit paymentsunder subdivision (4) of this subsection to reserve a bed for theparticipant in the nursing home during the time that the participant isabsent due to admission to a hospital for services which cannot beperformed on an outpatient basis, subject to the provisions of thissubdivision:
(a) The provisions of this subdivision shall apply only if:
a. The occupancy rate of the nursing home is at or above ninety-sevenpercent of MO HealthNet certified licensed beds, according to the mostrecent quarterly census provided to the department of health and seniorservices which was taken prior to when the participant is admitted to thehospital; and
b. The patient is admitted to a hospital for a medical condition withan anticipated stay of three days or less;
(b) The payment to be made under this subdivision shall be providedfor a maximum of three days per hospital stay;
(c) For each day that nursing home costs are paid on behalf of aparticipant under this subdivision during any period of six consecutivemonths such participant shall, during the same period of six consecutivemonths, be ineligible for payment of nursing home costs of two otherwiseavailable temporary leave of absence days provided under subdivision (5) ofthis subsection; and
(d) The provisions of this subdivision shall not apply unless thenursing home receives notice from the participant or the participant'sresponsible party that the participant intends to return to the nursinghome following the hospital stay. If the nursing home receives suchnotification and all other provisions of this subsection have beensatisfied, the nursing home shall provide notice to the participant or theparticipant's responsible party prior to release of the reserved bed;
(19) Prescribed medically necessary durable medical equipment. Anelectronic web-based prior authorization system using best medical evidenceand care and treatment guidelines consistent with national standards shallbe used to verify medical need;
(20) Hospice care. As used in this subsection, the term "hospicecare" means a coordinated program of active professional medical attentionwithin a home, outpatient and inpatient care which treats the terminallyill patient and family as a unit, employing a medically directedinterdisciplinary team. The program provides relief of severe pain orother physical symptoms and supportive care to meet the special needsarising out of physical, psychological, spiritual, social, and economicstresses which are experienced during the final stages of illness, andduring dying and bereavement and meets the Medicare requirements forparticipation as a hospice as are provided in 42 CFR Part 418. The rate ofreimbursement paid by the MO HealthNet division to the hospice provider forroom and board furnished by a nursing home to an eligible hospice patientshall not be less than ninety-five percent of the rate of reimbursementwhich would have been paid for facility services in that nursing homefacility for that patient, in accordance with subsection (c) of Section6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
(21) Prescribed medically necessary dental services. Such servicesshall be subject to appropriations. An electronic web-based priorauthorization system using best medical evidence and care and treatmentguidelines consistent with national standards shall be used to verifymedical need;
(22) Prescribed medically necessary optometric services. Suchservices shall be subject to appropriations. An electronic web-based priorauthorization system using best medical evidence and care and treatmentguidelines consistent with national standards shall be used to verifymedical need;
(23) The MO HealthNet division shall, by January 1, 2008, andannually thereafter, report the status of MO HealthNet providerreimbursement rates as compared to one hundred percent of the Medicarereimbursement rates and compared to the average dental reimbursement ratespaid by third-party payors licensed by the state. The MO HealthNetdivision shall, by July 1, 2008, provide to the general assembly afour-year plan to achieve parity with Medicare reimbursement rates and forthird-party payor average dental reimbursement rates. Such plan shall besubject to appropriation and the division shall include in its annualbudget request to the governor the necessary funding needed to complete thefour-year plan developed under this subdivision.
2. Additional benefit payments for medical assistance shall be madeon behalf of those eligible needy children, pregnant women and blindpersons with any payments to be made on the basis of the reasonable cost ofthe care or reasonable charge for the services as defined and determined bythe division of medical services, unless otherwise hereinafter provided,for the following:
(1) Dental services;
(2) Services of podiatrists as defined in section 330.010, RSMo;
(3) Optometric services as defined in section 336.010, RSMo;
(4) Orthopedic devices or other prosthetics, including eye glasses,dentures, hearing aids, and wheelchairs;
(5) Hospice care. As used in this subsection, the term "hospicecare" means a coordinated program of active professional medical attentionwithin a home, outpatient and inpatient care which treats the terminallyill patient and family as a unit, employing a medically directedinterdisciplinary team. The program provides relief of severe pain orother physical symptoms and supportive care to meet the special needsarising out of physical, psychological, spiritual, social, and economicstresses which are experienced during the final stages of illness, andduring dying and bereavement and meets the Medicare requirements forparticipation as a hospice as are provided in 42 CFR Part 418. The rate ofreimbursement paid by the MO HealthNet division to the hospice provider forroom and board furnished by a nursing home to an eligible hospice patientshall not be less than ninety-five percent of the rate of reimbursementwhich would have been paid for facility services in that nursing homefacility for that patient, in accordance with subsection (c) of Section6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
(6) Comprehensive day rehabilitation services beginning earlyposttrauma as part of a coordinated system of care for individuals withdisabling impairments. Rehabilitation services must be based on anindividualized, goal-oriented, comprehensive and coordinated treatment plandeveloped, implemented, and monitored through an interdisciplinaryassessment designed to restore an individual to optimal level of physical,cognitive, and behavioral function. The MO HealthNet division shallestablish by administrative rule the definition and criteria fordesignation of a comprehensive day rehabilitation service facility, benefitlimitations and payment mechanism. Any rule or portion of a rule, as thatterm is defined in section 536.010, RSMo, that is created under theauthority delegated in this subdivision shall become effective only if itcomplies with and is subject to all of the provisions of chapter 536, RSMo,and, if applicable, section 536.028, RSMo. This section and chapter 536,RSMo, are nonseverable and if any of the powers vested with the generalassembly pursuant to chapter 536, RSMo, to review, to delay the effectivedate, or to disapprove and annul a rule are subsequently heldunconstitutional, then the grant of rulemaking authority and any ruleproposed or adopted after August 28, 2005, shall be invalid and void.
3. The MO HealthNet division may require any participant receiving MOHealthNet benefits to pay part of the charge or cost until July 1, 2008,and an additional payment after July 1, 2008, as defined by rule dulypromulgated by the MO HealthNet division, for all covered services exceptfor those services covered under subdivisions (14) and (15) of subsection 1of this section and sections 208.631 to 208.657 to the extent and in themanner authorized by Title XIX of the federal Social Security Act (42U.S.C. 1396, et seq.) and regulations thereunder. When substitution of ageneric drug is permitted by the prescriber according to section 338.056,RSMo, and a generic drug is substituted for a name-brand drug, the MOHealthNet division may not lower or delete the requirement to make aco-payment pursuant to regulations of Title XIX of the federal SocialSecurity Act. A provider of goods or services described under this sectionmust collect from all participants the additional payment that may berequired by the MO HealthNet division under authority granted herein, ifthe division exercises that authority, to remain eligible as a provider.Any payments made by participants under this section shall be in additionto and not in lieu of payments made by the state for goods or servicesdescribed herein except the participant portion of the pharmacyprofessional dispensing fee shall be in addition to and not in lieu ofpayments to pharmacists. A provider may collect the co-payment at the timea service is provided or at a later date. A provider shall not refuse toprovide a service if a participant is unable to pay a required payment. Ifit is the routine business practice of a provider to terminate futureservices to an individual with an unclaimed debt, the provider may includeuncollected co-payments under this practice. Providers who elect not toundertake the provision of services based on a history of bad debt shallgive participants advance notice and a reasonable opportunity for payment.A provider, representative, employee, independent contractor, or agent of apharmaceutical manufacturer shall not make co-payment for a participant.This subsection shall not apply to other qualified children, pregnantwomen, or blind persons. If the Centers for Medicare and Medicaid Servicesdoes not approve the Missouri MO HealthNet state plan amendment submittedby the department of social services that would allow a provider to denyfuture services to an individual with uncollected co-payments, the denialof services shall not be allowed. The department of social services shallinform providers regarding the acceptability of denying services as theresult of unpaid co-payments.
4. The MO HealthNet division shall have the right to collectmedication samples from participants in order to maintain programintegrity.
5. Reimbursement for obstetrical and pediatric services undersubdivision (6) of subsection 1 of this section shall be timely andsufficient to enlist enough health care providers so that care and servicesare available under the state plan for MO HealthNet benefits at least tothe extent that such care and services are available to the generalpopulation in the geographic area, as required under subparagraph(a)(30)(A) of 42 U.S.C. 1396a and federal regulations promulgatedthereunder.
6. Beginning July 1, 1990, reimbursement for services rendered infederally funded health centers shall be in accordance with the provisionsof subsection 6402(c) and Section 6404 of P.L. 101-239 (Omnibus BudgetReconciliation Act of 1989) and federal regulations promulgated thereunder.
7. Beginning July 1, 1990, the department of social services shallprovide notification and referral of children below age five, and pregnant,breast-feeding, or postpartum women who are determined to be eligible forMO HealthNet benefits under section 208.151 to the special supplementalfood programs for women, infants and children administered by thedepartment of health and senior services. Such notification and referralshall conform to the requirements of Section 6406 of P.L. 101-239 andregulations promulgated thereunder.
8. Providers of long-term care services shall be reimbursed for theircosts in accordance with the provisions of Section 1902 (a)(13)(A) of theSocial Security Act, 42 U.S.C. 1396a, as amended, and regulationspromulgated thereunder.
9. Reimbursement rates to long-term care providers with respect to atotal change in ownership, at arm's length, for any facility previouslylicensed and certified for participation in the MO HealthNet program shallnot increase payments in excess of the increase that would result from theapplication of Section 1902 (a)(13)(C) of the Social Security Act, 42U.S.C. 1396a (a)(13)(C).
10. The MO HealthNet division, may enroll qualified residential carefacilities and assisted living facilities, as defined in chapter 198, RSMo,as MO HealthNet personal care providers.
11. Any income earned by individuals eligible for certified extendedemployment at a sheltered workshop under chapter 178, RSMo, shall not beconsidered as income for purposes of determining eligibility under thissection.
(L. 1967 p. 325, A.L. 1969 p. 337, A.L. 1971 H.B. 17, A.L. 1972 H.B. 673, H.B. 1254, A.L. 1973 S.B. 302, A.L. 1975 H.B. 974, A.L. 1977 S.B. 334, A.L. 1978 S.B. 492, S.B. 671, A.L. 1978 S.B. 505 §§ 1, 2, 3, A.L. 1981 S.B. 63, H.B. 901, A.L. 1986 S.B. 463 & 629, A.L. 1988 H.B. 1139, A.L. 1990 S.B. 524 merged with S.B. 765, A.L. 1992 H.B. 899 merged with S.B. 573 & 634 merged with S.B. 721, A.L. 1993 H.B. 564, A.L. 2004 S.B. 1003, A.L. 2005 S.B. 539, A.L. 2007 S.B. 577)