208.930. Consumer-directed personal care assistance services, reimbursement for through eligible vendors--eligibility requirements--documentation--service plan required--premiums, amount--annual reeva
Consumer-directed personal care assistance services, reimbursement forthrough eligible vendors--eligibilityrequirements--documentation--service plan required--premiums,amount--annual reevaluation--denial of benefits,procedure--expiration date.
208.930. 1. As used in this section, the term "department" shallmean the department of health and senior services.
2. Subject to appropriations, the department may provide financialassistance for consumer-directed personal care assistance services througheligible vendors, as provided in sections 208.900 through 208.927, to eachperson who was participating as a non-MO HealthNet eligible client pursuantto sections 178.661 through 178.673*, RSMo, on June 30, 2005, and who:
(1) Makes application to the department;
(2) Demonstrates financial need and eligibility under subsection 3 ofthis section;
(3) Meets all the criteria set forth in sections 208.900 through208.927, except for subdivision (5) of subsection 1 of section 208.903;
(4) Has been found by the department of social services not to beeligible to participate under guidelines established by the MO HealthNetplan; and
(5) Does not have access to affordable employer-sponsored health careinsurance or other affordable health care coverage for personal careassistance services as defined in section 208.900. For purposes of thissection, "access to affordable employer-sponsored health care insurance orother affordable health care coverage" refers to health insurance requiringa monthly premium less than or equal to one hundred thirty-three percent ofthe monthly average premium required in the state's current Missouriconsolidated health care plan.
Payments made by the department under the provisions of this section shallbe made only after all other available sources of payment have beenexhausted.
3. (1) In order to be eligible for financial assistance forconsumer-directed personal care assistance services under this section, aperson shall demonstrate financial need, which shall be based on theadjusted gross income and the assets of the person seeking financialassistance and such person's spouse.
(2) In order to demonstrate financial need, a person seekingfinancial assistance under this section and such person's spouse must havean adjusted gross income, less disability-related medical expenses, asapproved by the department, that is equal to or less than three hundredpercent of the federal poverty level. The adjusted gross income shall bebased on the most recent income tax return.
(3) No person seeking financial assistance for personal care servicesunder this section and such person's spouse shall have assets in excess oftwo hundred fifty thousand dollars.
4. The department shall require applicants and the applicant'sspouse, and consumers and the consumer's spouse, to provide documentationfor income, assets, and disability-related medical expenses for the purposeof determining financial need and eligibility for the program. In additionto the most recent income tax return, such documentation may include, butshall not be limited to:
(1) Current wage stubs for the applicant or consumer and theapplicant's or consumer's spouse;
(2) A current W-2 form for the applicant or consumer and theapplicant's or consumer's spouse;
(3) Statements from the applicant's or consumer's and the applicant'sor consumer's spouse's employers;
(4) Wage matches with the division of employment security;
(5) Bank statements; and
(6) Evidence of disability-related medical expenses and proof ofpayment.
5. A personal care assistance services plan shall be developed by thedepartment pursuant to section 208.906 for each person who is determined tobe eligible and in financial need under the provisions of this section.The plan developed by the department shall include the maximum amount offinancial assistance allowed by the department, subject to appropriation,for such services.
6. Each consumer who participates in the program is responsible for amonthly premium equal to the average premium required for the Missouriconsolidated health care plan; provided that the total premium described inthis section shall not exceed five percent of the consumer's and theconsumer's spouse's adjusted gross income for the year involved.
7. (1) Nonpayment of the premium required in subsection 6 shallresult in the denial or termination of assistance, unless the persondemonstrates good cause for such nonpayment.
(2) No person denied services for nonpayment of a premium shallreceive services unless such person shows good cause for nonpayment andmakes payments for past-due premiums as well as current premiums.
(3) Any person who is denied services for nonpayment of a premium andwho does not make any payments for past-due premiums for sixty consecutivedays shall have their enrollment in the program terminated.
(4) No person whose enrollment in the program is terminated fornonpayment of a premium when such nonpayment exceeds sixty consecutive daysshall be reenrolled unless such person pays any past-due premiums as wellas current premiums prior to being reenrolled. Nonpayment shall includepayment with a returned, refused, or dishonored instrument.
8. (1) Consumers determined eligible for personal care assistanceservices under the provisions of this section shall be reevaluated annuallyto verify their continued eligibility and financial need. The amount offinancial assistance for consumer-directed personal care assistanceservices received by the consumer shall be adjusted or eliminated based onthe outcome of the reevaluation. Any adjustments made shall be recorded inthe consumer's personal care assistance services plan.
(2) In performing the annual reevaluation of financial need, thedepartment shall annually send a reverification eligibility form letter tothe consumer requiring the consumer to respond within ten days of receivingthe letter and to provide income and disability-related medical expenseverification documentation. If the department does not receive theconsumer's response and documentation within the ten-day period, thedepartment shall send a letter notifying the consumer that he or she hasten days to file an appeal or the case will be closed.
(3) The department shall require the consumer and the consumer'sspouse to provide documentation for income and disability-related medicalexpense verification for purposes of the eligibility review. Suchdocumentation may include but shall not be limited to the documentationlisted in subsection 4 of this section.
9. (1) Applicants for personal care assistance services andconsumers receiving such services pursuant to this section are entitled toa hearing with the department of social services if eligibility forpersonal care assistance services is denied, if the type or amount ofservices is set at a level less than the consumer believes is necessary, ifdisputes arise after preparation of the personal care assistance planconcerning the provision of such services, or if services are discontinuedas provided in section 208.924. Services provided under the provisions ofthis section shall continue during the appeal process.
(2) A request for such hearing shall be made to the department ofsocial services in writing in the form prescribed by the department ofsocial services within ninety days after the mailing or delivery of thewritten decision of the department of health and senior services. Theprocedures for such requests and for the hearings shall be as set forth insection 208.080.
10. Unless otherwise provided in this section, all other provisionsof sections 208.900 through 208.927 shall apply to individuals who areeligible for financial assistance for personal care assistance servicesunder this section.
11. The department may promulgate rules and regulations, includingemergency rules, to implement the provisions of this section. Any rule orportion of a rule, as that term is defined in section 536.010, RSMo, thatis created under the authority delegated in this section shall becomeeffective only if it complies with and is subject to all of the provisionsof chapter 536, RSMo, and, if applicable, section 536.028, RSMo. Anyprovisions of the existing rules regarding the personal care assistanceprogram promulgated by the department of elementary and secondary educationin title 5, code of state regulations, division 90, chapter 7, which areinconsistent with the provisions of this section are void and of no forceand effect.
12. The provisions of this section shall expire on June 30, 2019.
(L. 2005 S.B. 74 & 49 § 1, A.L. 2006 S.B. 1084, A.L. 2007 S.B. 577)Expires 6-30-19
*Sections 178.661 to 178.673 were repealed by S.B. 539, 2005.