208.166. Department to facilitate cost-effective purchase of comprehensive health care, definitions--authority of department, conditions--recipient's freedom of selection of plans and sponsors not
Department to facilitate cost-effective purchase of comprehensivehealth care, definitions--authority of department,conditions--recipient's freedom of selection of plans andsponsors not limited.
208.166. 1. As used in this section, the following terms mean:
(1) "Department", the Missouri department of social services;
(2) "Prepaid capitated", a mode of payment by which the departmentperiodically reimburse a contracted health provider plan or primary carephysician sponsor for delivering health care services for the duration of acontract to a maximum specified number of members based on a fixed rate permember, notwithstanding:
(a) The actual number of members who receive care from the provider; or
(b) The amount of health care services provided to any members;
(3) "Primary care case-management", a mode of payment by which thedepartment reimburses a contracted primary care physician sponsor on afee-for-service schedule plus a monthly fee to manage each recipient's case;
(4) "Primary care physician sponsor", a physician licensed pursuant tochapter 334, RSMo, who is a family practitioner, general practitioner,pediatrician, general internist or an obstetrician or gynecologist;
(5) "Specialty physician services arrangement", an arrangement where thedepartment may restrict recipients of specialty services to designatedproviders of such services, even in the absence of a primary carecase-management system.
2. The department or its designated division shall maximize the use ofprepaid health plans, where appropriate, and other alternative servicedelivery and reimbursement methodologies, including, but not limited to,individual primary care physician sponsors or specialty physician servicesarrangements, designed to facilitate the cost-effective purchase ofcomprehensive health care.
3. In order to provide comprehensive health care, the department or itsdesignated division shall have authority to:
(1) Purchase medical services for recipients of public assistance fromprepaid health plans, health maintenance organizations, health insuringorganizations, preferred provider organizations, individual practiceassociations, local health units, community health centers, or primary carephysician sponsors;
(2) Reimburse those health care plans or primary care physicians'sponsors who enter into direct contract with the department on a prepaidcapitated or primary care case-management basis on the following conditions:
(a) That the department or its designated division shall ensure,whenever possible and consistent with quality of care and cost factors, thatpublicly supported neighborhood and community-supported health clinics shallbe utilized as providers;
(b) That the department or its designated division shall ensurereasonable access to medical services in geographic areas where managed orcoordinated care programs are initiated; and
(c) That the department shall ensure full freedom of choice forprescription drugs at any Medicaid participating pharmacy;
(3) Limit providers of medical assistance benefits to those whodemonstrate efficient and economic service delivery for the level of servicethey deliver, and provided that such limitation shall not limit recipientsfrom reasonable access to such levels of service;
(4) Provide recipients of public assistance with alternative services asprovided for in state law, subject to appropriation by the general assembly;
(5) Designate providers of medical assistance benefits to assurespecifically defined medical assistance benefits at a reduced cost to thestate, to assure reasonable access to all levels of health services and toassure maximization of federal financial participation in the delivery ofhealth related services to Missouri citizens; provided, all qualifiedproviders that deliver such specifically defined services shall be afforded anopportunity to compete to meet reasonable state criteria and to be sodesignated;
(6) Upon mutual agreement with any entity of local government, to electto use local government funds as the matching share for Title XIX payments, asallowed by federal law or regulation;
(7) To elect not to offset local government contributions from theallowable costs under the Title XIX program, unless prohibited by federal lawand regulation.
4. Nothing in this section shall be construed to authorize thedepartment or its designated division to limit the recipient's freedom ofselection among health care plans or primary care physician sponsors, asauthorized in this section, who have entered into contract with the departmentor its designated division to provide a comprehensive range of health careservices on a prepaid capitated or primary care case-management basis, exceptin those instances of overutilization of Medicaid services by the recipient.
(L. 1982 H.B. 1086 § 3, A.L. 1990 S.B. 765, A.L. 1992 H.B. 899)