SB 1571

                                     SECOND REGULAR SESSION
               SENATE BILL NO. 1571
                                     103RD GENERAL ASSEMBLY
                                       INTRODUCED BY SENATOR LEWIS.
 6296S.01I  KRISTINA MARTIN, Secretary
                                                  AN ACT
 To repeal sections 208.152 and 376.1232, RSMo, and to enact in lieu thereof five new sections
          relating to insurance coverage of orthotic, prosthetic, and assistive devices.
 Be it enacted by the General Assembly of the State of Missouri, as follows:
1Section A.  Sections 208.152 and 376.1232, RSMo, are
2  repealed and five new sections enacted in lieu thereof, to be
3  known as sections 208.152, 208.830, 376.1232, 376.1233, and
4  376.1234, to read as follows:
1208.152.  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
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
 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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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 and -
43 operated institutions which are determined to conform to
44 standards equivalent to licensing requirements in Title XIX
45 of the federal Social Security Act (42 U.S.C. Section 1396,
46 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
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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 or her 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 or she 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
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
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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
109 inducing an abortion unless such abortions are certified in
110 writing by a physician to the MO HealthNet agency that, in
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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.
141 Benefits payable for personal care services shall not exceed
142 for any one participant one hundred percent of the average
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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
147 be 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;
173(16) Mental health services.    The state plan for
174 providing medical assistance under Title XIX of the Social
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175 Security Act, 42 U.S.C. Section 1396, et seq., as amended,
176 shall include the following mental health services when such
177 services are provided by community mental health facilities
178 operated by the department of mental health or designated by
179 the department of mental health as a community mental health
180 facility or as an alcohol and drug abuse facility or as a
181 child-serving agency within the comprehensive children's
182 mental health service system established in section
183 630.097. The department of mental health shall establish by
184 administrative rule the definition and criteria for
185 designation as a community mental health facility and for
186 designation as an alcohol and drug abuse facility.    Such
187 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;
204(c) Rehabilitative mental health and alcohol and drug
205 abuse services including home and community-based
206 preventive, diagnostic, therapeutic, rehabilitative, and
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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
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
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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:
246a. 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
252b. 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
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
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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);
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
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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;
330(26) Orthotic, prosthetic, and assistive devices,
331 supplies, and services in accordance with section 208.830;
332(27) The MO HealthNet division shall, by January 1,
333 2008, and annually thereafter, report the status of MO
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334 HealthNet provider reimbursement rates as compared to one
335 hundred percent of the Medicare reimbursement rates and
336 compared to the average dental reimbursement rates paid by
337 third-party payors licensed by the state.   The MO HealthNet
338 division shall, by July 1, 2008, provide to the general
339 assembly a four-year plan to achieve parity with Medicare
340 reimbursement rates and for third-party payor average dental
341 reimbursement rates.   Such plan shall be subject to
342 appropriation and the division shall include in its annual
343 budget request to the governor the necessary funding needed
344 to complete the four-year plan developed under this
345 subdivision.
3462. Additional benefit payments for medical assistance
347 shall be made on behalf of those eligible needy children,
348 pregnant women and blind persons with any payments to be
349 made on the basis of the reasonable cost of the care or
350 reasonable charge for the services as defined and determined
351 by the MO HealthNet division, unless otherwise hereinafter
352 provided, for the following:
353(1) Dental services;
354(2) Services of podiatrists as defined in section
355 330.010;
356(3) Optometric services as described in section
357 336.010;
358(4) Orthopedic devices [or other prosthetics,
359 including], eye glasses, and dentures[, and wheelchairs];
360(5) Hospice care.   As used in this subdivision, the
361 term "hospice care" means a coordinated program of active
362 professional medical attention within a home, outpatient and
363 inpatient care which treats the terminally ill patient and
364 family as a unit, employing a medically directed
365 interdisciplinary team.   The program provides relief of
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366 severe pain or other physical symptoms and supportive care
367 to meet the special needs arising out of physical,
368 psychological, spiritual, social, and economic stresses
369 which are experienced during the final stages of illness,
370 and during dying and bereavement and meets the Medicare
371 requirements for participation as a hospice as are provided
372 in 42 CFR Part 418.    The rate of reimbursement paid by the
373 MO HealthNet division to the hospice provider for room and
374 board furnished by a nursing home to an eligible hospice
375 patient shall not be less than ninety-five percent of the
376 rate of reimbursement which would have been paid for
377 facility services in that nursing home facility for that
378 patient, in accordance with subsection (c) of Section 6408
379 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);
380(6) Comprehensive day rehabilitation services
381 beginning early posttrauma as part of a coordinated system
382 of care for individuals with disabling impairments.
383 Rehabilitation services must be based on an individualized,
384 goal-oriented, comprehensive and coordinated treatment plan
385 developed, implemented, and monitored through an
386 interdisciplinary assessment designed to restore an
387 individual to an optimal level of physical, cognitive, and
388 behavioral function.   The MO HealthNet division shall
389 establish by administrative rule the definition and criteria
390 for designation of a comprehensive day rehabilitation
391 service facility, benefit limitations and payment
392 mechanism. Any rule or portion of a rule, as that term is
393 defined in section 536.010, that is created under the
394 authority delegated in this subdivision shall become
395 effective only if it complies with and is subject to all of
396 the provisions of chapter 536 and, if applicable, section
397 536.028. This section and chapter 536 are nonseverable and
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398 if any of the powers vested with the general assembly
399 pursuant to chapter 536 to review, to delay the effective
400 date, or to disapprove and annul a rule are subsequently
401 held unconstitutional, then the grant of rulemaking
402 authority and any rule proposed or adopted after August 28,
403 2005, shall be invalid and void.
4043. The MO HealthNet division may require any
405 participant receiving MO HealthNet benefits to pay part of
406 the charge or cost until July 1, 2008, and an additional
407 payment after July 1, 2008, as defined by rule duly
408 promulgated by the MO HealthNet division, for all covered
409 services except for those services covered under
410 subdivisions (15) and (16) of subsection 1 of this section
411 and sections 208.631 to 208.657 to the extent and in the
412 manner authorized by Title XIX of the federal Social
413 Security Act (42 U.S.C. Section 1396, et seq.) and
414 regulations thereunder.   When substitution of a generic drug
415 is permitted by the prescriber according to section 338.056,
416 and a generic drug is substituted for a name-brand drug, the
417 MO HealthNet division may not lower or delete the
418 requirement to make a co-payment pursuant to regulations of
419 Title XIX of the federal Social Security Act.   A provider of
420 goods or services described under this section must collect
421 from all participants the additional payment that may be
422 required by the MO HealthNet division under authority
423 granted herein, if the division exercises that authority, to
424 remain eligible as a provider.   Any payments made by
425 participants under this section shall be in addition to and
426 not in lieu of payments made by the state for goods or
427 services described herein except the participant portion of
428 the pharmacy professional dispensing fee shall be in
429 addition to and not in lieu of payments to pharmacists.    A
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430 provider may collect the co-payment at the time a service is
431 provided or at a later date.       A provider shall not refuse to
432 provide a service if a participant is unable to pay a
433 required payment.    If it is the routine business practice of
434 a provider to terminate future services to an individual
435 with an unclaimed debt, the provider may include uncollected
436 co-payments under this practice.       Providers who elect not to
437 undertake the provision of services based on a history of
438 bad debt shall give participants advance notice and a
439 reasonable opportunity for payment.       A provider,
440 representative, employee, independent contractor, or agent
441 of a pharmaceutical manufacturer shall not make co-payment
442 for a participant.    This subsection shall not apply to other
443 qualified children, pregnant women, or blind persons.       If
444 the Centers for Medicare and Medicaid Services does not
445 approve the MO HealthNet state plan amendment submitted by
446 the department of social services that would allow a
447 provider to deny future services to an individual with
448 uncollected co-payments, the denial of services shall not be
449 allowed. The department of social services shall inform
450 providers regarding the acceptability of denying services as
451 the result of unpaid co-payments.
4524. The MO HealthNet division shall have the right to
453 collect medication samples from participants in order to
454 maintain program integrity.
4555.   Reimbursement for obstetrical and pediatric
456 services under subdivision (6) of subsection 1 of this
457 section shall be timely and sufficient to enlist enough
458 health care providers so that care and services are
459 available under the state plan for MO HealthNet benefits at
460 least to the extent that such care and services are
461 available to the general population in the geographic area,
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462 as required under subparagraph (a)(30)(A) of 42 U.S.C.
463 Section 1396a and federal regulations promulgated thereunder.
4646. Beginning July 1, 1990, reimbursement for services
465 rendered in federally funded health centers shall be in
466 accordance with the provisions of subsection 6402(c) and
467 Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation
468 Act of 1989) and federal regulations promulgated thereunder.
4697. Beginning July 1, 1990, the department of social
470 services shall provide notification and referral of children
471 below age five, and pregnant, breast-feeding, or postpartum
472 women who are determined to be eligible for MO HealthNet
473 benefits under section 208.151 to the special supplemental
474 food programs for women, infants and children administered
475 by the department of health and senior services.    Such
476 notification and referral shall conform to the requirements
477 of Section 6406 of P.L. 101-239 and regulations promulgated
478 thereunder.
4798. Providers of long-term care services shall be
480 reimbursed for their costs in accordance with the provisions
481 of Section 1902 (a)(13)(A) of the Social Security Act, 42
482 U.S.C. Section 1396a, as amended, and regulations
483 promulgated thereunder.
4849. Reimbursement rates to long-term care providers
485 with respect to a total change in ownership, at arm's
486 length, for any facility previously licensed and certified
487 for participation in the MO HealthNet program shall not
488 increase payments in excess of the increase that would
489 result from the application of Section 1902 (a)(13)(C) of
490 the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C).
49110. The MO HealthNet division may enroll qualified
492 residential care facilities and assisted living facilities,
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493 as defined in chapter 198, as MO HealthNet personal care
494 providers.
49511. Any income earned by individuals eligible for
496 certified extended employment at a sheltered workshop under
497 chapter 178 shall not be considered as income for purposes
498 of determining eligibility under this section.
49912. If the Missouri Medicaid audit and compliance unit
500 changes any interpretation or application of the
501 requirements for reimbursement for MO HealthNet services
502 from the interpretation or application that has been applied
503 previously by the state in any audit of a MO HealthNet
504 provider, the Missouri Medicaid audit and compliance unit
505 shall notify all affected MO HealthNet providers five
506 business days before such change shall take effect.      Failure
507 of the Missouri Medicaid audit and compliance unit to notify
508 a provider of such change shall entitle the provider to
509 continue to receive and retain reimbursement until such
510 notification is provided and shall waive any liability of
511 such provider for recoupment or other loss of any payments
512 previously made prior to the five business days after such
513 notice has been sent.   Each provider shall provide the
514 Missouri Medicaid audit and compliance unit a valid email
515 address and shall agree to receive communications
516 electronically.   The notification required under this
517 section shall be delivered in writing by the United States
518 Postal Service or electronic mail to each provider.
51913. Nothing in this section shall be construed to
520 abrogate or limit the department's statutory requirement to
521 promulgate rules under chapter 536.
52214. Beginning July 1, 2016, and subject to
523 appropriations, providers of behavioral, social, and
524 psychophysiological services for the prevention, treatment,
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525 or management of physical health problems shall be
526 reimbursed utilizing the behavior assessment and
527 intervention reimbursement codes 96150 to 96154 or their
528 successor codes under the Current Procedural Terminology
529 (CPT) coding system.    Providers eligible for such
530 reimbursement shall include psychologists.
53115. There shall be no payments made under this section
532 for gender transition surgeries, cross-sex hormones, or
533 puberty-blocking drugs, as such terms are defined in section
534 191.1720, for the purpose of a gender transition.
1208.830.    1. As used in this section, terms shall have
2  the same meanings given to them in section 376.1232.
32.    The MO HealthNet program shall cover orthotic,
4  prosthetic, and assistive devices, supplies, and services
5  furnished under an order by a prescribing physician or
6  licensed health care provider who has authority in this
7  state to prescribe orthotic, prosthetic, and assistive
8  devices.     The coverage shall be at least equal to the
9  coverage provided under federal law for health insurance for
10  the aged and disabled under 42 U.S.C. Sections 1395k, 1395l,
11  and 1395m, but only to the extent consistent with this
12  section.
133.    Coverage for orthotic, prosthetic, and assistive
14  devices, supplies, accessories, and services under this
15  section includes those devices or device systems, supplies,
16  accessories, and services that are customized to the
17  participant's needs for purposes of activities of daily
18  living and essential job-related activities.     This
19  requirement applies to the type of device as follows:
20(1)    For orthotic and prosthetic devices, this
21  subsection requires coverage of devices intended for primary
22  or daily use; and
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23(2)    For assistive devices, this subsection requires
24 coverage of:
25(a)    One wheelchair for daily use; and
26(b)    One manual wheelchair for backup use.
274.    The MO HealthNet program shall cover orthotic,
28 prosthetic, and assistive devices determined by the
29 participant's provider to be the most appropriate model that
30 meets the medical needs of the participant for purposes of
31 performing physical activities, as applicable, including,
32 but not limited to, running, biking, and swimming, and
33 maximizing the participant's whole-body health and function,
34 including coverage of an activity wheelchair if medically
35 necessary.
365.    The MO HealthNet program shall cover orthotic,
37 prosthetic, and assistive devices for showering or bathing.
386.    The coverage set forth in this section includes the
39 repair and replacement of those orthotic, prosthetic, and
40 assistive devices, supplies, and services described in this
41 section.
427.    Coverage of an orthotic, prosthetic, or assistive
43 benefit shall not be denied for an individual with limb loss
44 or absence that would otherwise be covered for a nondisabled
45 person seeking medical or surgical intervention to restore
46 or maintain the ability to perform the same physical
47 activity.
488.    If coverage for prosthetic, custom orthotic, or
49 assistive devices is provided, payment shall be made for the
50 replacement of a prosthetic, custom orthotic, or assistive
51 device or for the replacement of any part of such devices,
52 without regard to continuous use or useful lifetime
53 restrictions, if an ordering health care provider determines
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54 that the provision of a replacement device, or a replacement
55 part of a device, is necessary because:
56(1)    Of a change in the physiological condition of the
57 patient;
58(2)    Of an irreparable change in the condition of the
59 device or in a part of the device; or
60(3)    The condition of the device, or the part of the
61 device, requires repairs and the cost of such repairs would
62 be more than sixty percent of the cost of a replacement
63 device or of the part being replaced.
649.    Prior authorization may be required for orthotic,
65 prosthetic, and assistive devices, supplies, and services.
6610.    Utilization review determinations shall be
67 rendered in a nondiscriminatory manner and shall not deny
68 coverage for habilitative or rehabilitative benefits,
69 including prosthetics, orthotics, or assistive services,
70 solely on the basis of a participant's actual or perceived
71 disability.
7211.    Evidence of coverage and any benefit denial
73 letters shall include language describing a participant's
74 rights under subsection 10 of this section.      Any denial of
75 coverage shall be issued in writing with an explanation that
76 contains clear reasoning and a description of how and why
77 the request or claim does not meet medical necessity
78 standards.
7912.    Confirmation from a prescribing health care
80 provider may be required if the prosthetic, custom orthotic,
81 or assistive device or part being replaced is less than
82 three years old.
8313.    (1)   Managed care plans subject to this section
84 shall ensure access to medically necessary clinical care and
85 to prosthetic, custom orthotic, and assistive devices and
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86 technology from at least two distinct prosthetic, custom
87 orthotic, and assistive device providers in the plan's
88 provider network located in this state.
89(2)    If medically necessary covered orthotic,
90 prosthetic, and assistive devices are not available from an
91 in-network provider, the plan shall provide processes to
92 refer a participant to an out-of-network provider and shall
93 fully reimburse the out-of-network provider at a mutually
94 agreed upon rate less participant cost sharing determined on
95 an in-network basis.
1376.1232.   1. As used in sections 376.1232 to
2 376.1234, the following terms mean:
3(1)    "Accredited facility", any entity that is
4 accredited to provide comprehensive orthotic, prosthetic, or
5 assistive devices or services by a Centers for Medicare and
6 Medicaid Services-approved accrediting agency;
7(2)    "Activity wheelchair", a wheelchair that is
8 designed specifically to enable individuals with mobility
9 issues to participate in sports or fitness activities by
10 providing better speed, maneuverability, and balance than a
11 standard wheelchair used for activities of daily living;
12(3)    "Assistive device":
13(a)    Any external medical device that:
14a.    Allows an individual with a mobility impairment to
15 move in indoor and outdoor spaces including, but not limited
16 to, a manual wheelchair, a motorized wheelchair, or an
17 activity wheelchair; and
18b.    Is deemed medically necessary by a prescribing
19 physician or licensed health care provider who has authority
20 in this state to prescribe assistive devices; and
21(b)    Any provision, repair, or replacement of the
22 device that is furnished or performed by:
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23a.    An accredited facility in comprehensive assistive
24 services; or
25b.    A health care provider licensed in this state and
26 operating within the provider's scope of practice that
27 allows the provider to provide assistive devices, supplies,
28 or services;
29(4)    "Assistive services":
30(a)    The science and practice of evaluating, fitting,
31 adjusting, or servicing, as well as providing the initial
32 training necessary to accomplish the fitting of, an
33 assistive device for mobility;
34(b)    Evaluation, treatment, and consultation related to
35 an assistive device;
36(c)    Assessment of assistive devices to maximize
37 function and provide support and alignment necessary to
38 improve the safety and efficiency of mobility and locomotion;
39(d)    Continuation of patient care to assess the effect
40 of an assistive device on the patient's mobility; and
41(e)    Assurance of proper fit and function of the
42 assistive device by periodic evaluation;
43(5)    "Enrollee", the same meaning given to the term in
44 section 376.1350;
45(6)    "Health benefit plan", the same meaning given to
46 the term in section 376.1350.        The term "health benefit
47 plan" shall also include the Missouri consolidated health
48 care plan established under chapter 103 and any other state-
49 sponsored health insurance program;
50(7)    "Health carrier", the same meaning given to the
51 term in section 376.1350;
52(8)    "Orthosis" or "orthotic device":
53(a)    An external medical device that is:
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54a.    Custom-fabricated or custom-fitted to a specific
55 patient based on the patient's unique physical condition;
56b.    Applied to a part of the body to correct a
57 deformity, provide support and protection, restrict motion,
58 improve function, or relieve symptoms of a disease,
59 syndrome, injury, or postoperative condition; and
60c.    Deemed medically necessary by a prescribing
61 physician or licensed health care provider who has authority
62 in this state to prescribe orthotic devices, supplies, and
63 services; and
64(b)    Any provision, repair, or replacement of the
65 device that is furnished or performed by:
66a.    An accredited facility in comprehensive orthotic
67 services; or
68b.    A health care provider licensed in this state and
69 operating within the provider's scope of practice that
70 allows the provider to provide orthotic devices, supplies,
71 or services;
72(9)    "Orthotics":
73(a)    The science and practice of evaluating, measuring,
74 designing, fabricating, assembling, fitting, adjusting, or
75 servicing, as well as providing the initial training
76 necessary to accomplish the fitting of, an orthosis for the
77 support, correction, or alleviation of a neuromuscular or
78 musculoskeletal dysfunction, disease, injury, or deformity;
79(b)    Evaluation, treatment, and consultation related to
80 an orthotic device;
81(c)    Basic observation of gait and postural analysis;
82(d)    Assessment and design of orthoses to maximize
83 function and provide support and alignment necessary to
84 prevent or correct a deformity or to improve the safety and
85 efficiency of mobility and locomotion;
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86(e)    Continuation of patient care to assess the effect
87  of an orthotic device on the patient's tissues; and
88(f)    Assurance of proper fit and function of the
89  orthotic device by periodic evaluation;
90(10)    "Prosthesis" or "prosthetic device":
91(a)    An external medical device that is:
92a.    Used to replace or restore a missing limb,
93  appendage, or other external human body part; and
94b.    Deemed medically necessary by a prescribing
95  physician or licensed health care provider who has authority
96  in this state to prescribe prosthetic devices, supplies, and
97  services; and
98(b)    Any provision, repair, or replacement of the
99  device that is furnished or performed by:
100a.    An accredited facility in comprehensive prosthetic
101 services; or
102b.    A health care provider licensed in this state and
103 operating within the provider's scope of practice that
104 allows the provider to provide prosthetic devices, supplies,
105 or services;
106(11)    "Prosthetics":
107(a)    The science and practice of evaluating, measuring,
108 designing, fabricating, assembling, fitting, aligning,
109 adjusting, or servicing, as well as providing the initial
110 training necessary to accomplish the fitting of, a
111 prosthesis through the replacement of external parts of a
112 human body lost due to amputation or congenital deformities
113 or absences;
114(b)    The generation of an image, form, or mold that
115 replicates the patient's body segment and that requires
116 rectification of dimensions, contours, and volumes for use
117 in the design and fabrication of a socket to accept a
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118 residual anatomic limb to, in turn, create an artificial
119 appendage that is designed either to support body weight or
120 to improve or restore function or anatomical appearance, or
121 both;
122(c)    Observational gait analysis and clinical
123 assessment of the requirements necessary to refine and
124 mechanically fix the relative position of various parts of
125 the prosthesis to maximize function, stability, and safety
126 of the patient;
127(d)    The provision and continuation of patient care in
128 order to assess the prosthetic device's effect on the
129 patient's tissues; and
130(e)    Assurance of proper fit and function of the
131 prosthetic device by periodic evaluation;
132(12)    "Utilization review", the same meaning given to
133 the term in section 376.1350.
1342. Each health carrier or health benefit plan that
135 offers or issues health benefit plans which are delivered,
136 issued for delivery, continued, or renewed in this state on
137 or after January 1, 2010, shall [offer] provide coverage for
138 orthotic, prosthetic, and assistive devices, supplies, and
139 services, including [original] repair and replacement
140 [devices, as prescribed by a physician acting within the
141 scope of his or her practice].     The coverage shall be at
142 least equal to the coverage provided under federal law for
143 health insurance for the aged and disabled under 42 U.S.C.
144 Sections 1395k, 1395l, and 1395m, but only to the extent
145 consistent with this section.
146[2. For the purposes of this section, "health carrier"
147 and "health benefit plan" shall have the same meaning as
148 defined in section 376.1350.]
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1493. The amount of the benefit for orthotic, prosthetic,
150 and assistive devices and services under this section shall
151 be no less than the annual and lifetime benefit maximums
152 applicable to the basic health care services required to be
153 provided under the health benefit plan.    If the health
154 benefit plan does not include any annual or lifetime
155 maximums applicable to basic health care services, the
156 amount of the benefit for orthotic, prosthetic, and
157 assistive devices and services shall not be subject to an
158 annual or lifetime maximum benefit level.    Any co-payment,
159 coinsurance, deductible, and maximum out-of-pocket amount
160 applied to the benefit for orthotic, prosthetic, and
161 assistive devices and services shall be no more than the
162 most common amounts applied to the basic health care
163 services required to be provided under the health benefit
164 plan.
1654. A health carrier or health benefit plan may limit
166 the benefits for, or alter the financial requirements for,
167 out-of-network coverage of orthotic, prosthetic, and
168 assistive devices, except that the restrictions and
169 requirements that apply to those benefits shall not be more
170 restrictive than the financial requirements that apply to
171 the out-of-network coverage for the basic health care
172 services to be provided under the health benefit plan.
1735.   A health carrier or health benefit plan shall not
174 subject coverage for orthotic, prosthetic, and assistive
175 devices, supplies, and services to any limitations for
176 preexisting conditions.
1776.   A health carrier or health benefit plan shall cover
178 orthotic, prosthetic, and assistive devices when furnished
179 under an order by a prescribing physician or licensed health
180 care prescriber who has authority in this state to prescribe
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181 orthotic, prosthetic, and assistive devices.     The coverage
182 for orthotic, prosthetic, and assistive devices, supplies,
183 accessories, and services shall include those devices or
184 device systems, supplies, accessories, and services that are
185 customized to the covered individual's needs for purposes of
186 activities of daily living and essential job-related
187 activities.
1887.    A health carrier or health benefit plan shall cover
189 orthotic, prosthetic, and assistive devices determined by
190 the enrollee's provider to be the most appropriate model
191 that meets the medical needs of the enrollee for purposes of
192 performing physical activities, as applicable, including,
193 but not limited to, running, biking, and swimming, and
194 maximizing the enrollee's whole-body health and function.
1958.    A health carrier or health benefit plan shall cover
196 orthotic, prosthetic, and assistive devices for showering or
197 bathing.
1989.    A health carrier or health benefit plan shall cover
199 at least the following for an enrollee entitled to coverage
200 of prostheses or orthoses:
201(1)    One prosthesis or orthosis for daily use;
202(2)    One prosthesis or orthosis designed for physical
203 activity; and
204(3)    One prosthesis or orthosis for showering or
205 bathing.
20610.    A health carrier or health benefit plan shall
207 cover at least the following for an enrollee entitled to
208 coverage of assistive devices:
209(1)    One wheelchair for daily use;
210(2)    One manual wheelchair for backup use; and
211(3)    One activity wheelchair if medically necessary to
212 enable the enrollee to engage in physical activities, as
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213 applicable, including, but not limited to, running, biking,
214 swimming, and strength training, and to maximize the
215 enrollee's whole-body health and lower or upper limb
216 function.
21711.    A health carrier or health benefit plan may
218 require prior authorization for orthotic, prosthetic, and
219 assistive devices, supplies, and services in the same manner
220 and to the same extent as prior authorization is required
221 for any other covered benefit.
22212.    Except as provided in subsection 13 of this
223 section, the provisions of this section shall not apply to a
224 supplemental insurance policy, including a life care
225 contract, accident-only policy, specified disease policy,
226 hospital policy providing a fixed daily benefit only,
227 [Medicare supplement policy,] long-term care policy, short-
228 term major medical policies of six months or less duration,
229 or any other supplemental policy as determined by the
230 director of the department of commerce and insurance.
23113.    Notwithstanding section 376.998 or any other
232 provision of law to the contrary, the provisions of this
233 section shall apply to a Medicare supplement policy.
1376.1233.    1.   A health carrier or health benefit plan
2  shall render utilization review determinations in a
3  nondiscriminatory manner and shall not deny coverage for
4  habilitative or rehabilitative benefits, including
5  prosthetics, orthotics, or assistive services, solely on the
6  basis of an enrollee's actual or perceived disability.
72.    A health carrier or health benefit plan shall not
8  deny a prosthetic, orthotic, or assistive benefit for an
9  individual with limb loss or absence that would otherwise be
10  covered for a nondisabled person seeking medical or surgical
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11 intervention to restore or maintain the ability to perform
12 the same physical activity.
133.   A health benefit plan offered, issued, or renewed
14 in this state that offers coverage for prosthetics, custom
15 orthotic devices, and assistive devices shall include
16 language describing an enrollee's rights under subsections 1
17 and 2 of this section in its evidence of coverage and any
18 benefit denial letters.    Any denial of coverage shall be
19 issued in writing with an explanation that contains clear
20 reasoning and a description of how and why the request or
21 claim does not meet medical necessity standards.
224.   A health carrier or health benefit plan that
23 provides coverage for prosthetic, orthotic, or assistive
24 services shall ensure access to medically necessary clinical
25 care and to prosthetic, custom orthotic, and assistive
26 devices and technology from not less than two distinct
27 prosthetic, custom orthotic, and assistive device providers
28 in the plan's provider network located in this state.     If
29 medically necessary covered orthotics, prosthetics, and
30 assistive services are not available from an in-network
31 provider, the health carrier or health benefit plan shall
32 provide processes to refer a member to an out-of-network
33 provider and shall fully reimburse the out-of-network
34 provider at a mutually agreed upon rate less member cost
35 sharing determined on an in-network basis.
365.   If coverage for prosthetic, custom orthotic, or
37 assistive devices is provided, payment shall be made for the
38 replacement of a prosthetic, custom orthotic, or assistive
39 device or for the replacement of any part of such devices,
40 without regard to continuous use or useful lifetime
41 restrictions, if an ordering health care provider determines
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42 that the provision of a replacement device, or a replacement
43 part of a device, is necessary because:
44(1)    Of a change in the physiological condition of the
45 patient;
46(2)    Of an irreparable change in the condition of the
47 device or in a part of the device; or
48(3)    The condition of the device, or the part of the
49 device, requires repairs and the cost of such repairs would
50 be more than sixty percent of the cost of a replacement
51 device or of the part being replaced.
526.    Confirmation from a prescribing health care
53 provider may be required if the prosthetic, custom orthotic,
54 or assistive device or part being replaced is less than
55 three years old.
1376.1234.    1.    Before October 1, 2027, each health
2 carrier that issues a health benefit plan providing coverage
3 of orthotic, prosthetic, and assistive devices, supplies,
4 and services as required under sections 376.1232 to 376.1234
5 shall report to the director of the department of commerce
6 and insurance on its experience with the requirements of
7 sections 376.1232 to 376.1234 for the first year following
8 August 28, 2026.        The report shall be in a form prescribed
9 by the director and shall include the number of claims and
10 the total amount of claims paid in this state for the
11 services required by sections 376.1232 to 376.1234.        The
12 director shall aggregate this data in a report and submit
13 the report to the house and senate standing committees
14 having jurisdiction over health insurance matters before
15 December 1, 2027.
162.    The director may promulgate any necessary rules and
17 regulations to implement sections 376.1232 to 376.1234.  Any
18 rule or portion of a rule, as that term is defined in
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19 section 536.010, that is created under the authority
20 delegated in this section shall become effective only if it
21 complies with and is subject to all of the provisions of
22 chapter 536 and, if applicable, section 536.028.   This
23 section and chapter 536 are nonseverable and if any of the
24 powers vested with the general assembly pursuant to chapter
25 536 to review, to delay the effective date, or to disapprove
26 and annul a rule are subsequently held unconstitutional,
27 then the grant of rulemaking authority and any rule proposed
28 or adopted after August 28, 2026, shall be invalid and void.
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