Creates provisions relating to insurance coverage of orthotic, prosthetic, and assistive devices

SECOND REGULAR SESSION
HOUSE COMMITTEE SUBSTITUTE FOR
HOUSE BILL NO. 2034
103RD GENERAL ASSEMBL Y
3872H.03C JOSEPH ENGLER, Chief Clerk
AN ACT
T o 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:
Section A. Sections 208.152 and 376.1232, RSMo, are repealed and five new sections
2 enacted in lieu thereof, to be known as sections 208.152, 208.830, 376.1232, 376.1233, and
3 376.1234, to read as follows:
208.152. 1. MO HealthNet payments shall be made on behalf of those eligible needy
2 persons as described in section 208.151 who are unable to provide for it in whole or in part,
3 with any payments to be made on the basis of the reasonable cost of the care or reasonable
4 char ge for the services as defined and determined by the MO HealthNet division, unless
5 otherwise hereinafter provided, for the following:
6 (1) Inpatient hospital services, except to persons in an institution for mental diseases
7 who are under the age of sixty-five years and over the age of twenty-one years; provided that
8 the MO HealthNet division shall provide through rule and regulation an exception process for
9 coverage of inpatient costs in those cases requiring treatment beyond the seventy-fifth
10 percentile professional activities study (P AS) or the MO HealthNet children's diagnosis
11 length-of-stay schedule; and provided further that the MO HealthNet division shall take into
12 account through its payment system for hospital services the situation of hospitals which
13 serve a disproportionate number of low-income patients;
14 (2) All outpatient hospital services, payments therefor to be in amounts which
15 represent no more than eighty percent of the lesser of reasonable costs or customary char ges
16 for such services, determined in accordance with the principles set forth in T itle XVIII A and
17 B, Public Law 89-97, 1965 amendments to the federal Social Security Act (42 U.S.C. Section
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
18 301, et seq.), but the MO HealthNet division may evaluate outpatient hospital services
19 rendered under this section and deny payment for services which are determined by the MO
20 HealthNet division not to be medically necessary , in accordance with federal law and
21 regulations;
22 (3) Laboratory and X-ray services;
23 (4) Nursing home services for participants, except to persons with more than five
24 hundred thousand dollars equity in their home or except for persons in an institution for
25 mental diseases who are under the age of sixty-five years, when residing in a hospital licensed
26 by the department of health and senior services or a nursing home licensed by the department
27 of health and senior services or appropriate licensing authority of other states or government-
28 owned and -operated institutions which are determined to conform to standards equivalent to
29 licensing requirements in T itle XIX of the federal Social Security Act (42 U.S.C. Section
30 1396, et seq.), as amended, for nursing facilities. The MO HealthNet division may recognize
31 through its payment methodology for nursing facilities those nursing facilities which serve a
32 high volume of MO HealthNet patients. The MO HealthNet division when determining the
33 amount of the benefit payments to be made on behalf of persons under the age of twenty-one
34 in a nursing facility may consider nursing facilities furnishing care to persons under the age of
35 twenty-one as a classification separate from other nursing facilities;
36 (5) Nursing home costs for participants receiving benefit payments under subdivision
37 (4) of this subsection for those days, which shall not exceed twelve per any period of six
38 consecutive months, during which the participant is on a temporary leave of absence from the
39 hospital or nursing home, provided that no such participant shall be allowed a temporary
40 leave of absence unless it is specifically provided for in his or her plan of care. As used in
41 this subdivision, the term "temporary leave of absence" shall include all periods of time
42 during which a participant is away from the hospital or nursing home overnight because he or
43 she is visiting a friend or relative;
44 (6) Physicians' services, whether furnished in the of fice, home, hospital, nursing
45 home, or elsewhere, provided, that no funds shall be expended to any abortion facility , as
46 defined in section 188.015, or to any af filiate, as defined in section 188.015, of such abortion
47 facility;
48 (7) Subject to appropriation, up to twenty visits per year for services limited to
49 examinations, diagnoses, adjustments, and manipulations and treatments of malpositioned
50 articulations and structures of the body provided by licensed chiropractic physicians
51 practicing within their scope of practice. Nothing in this subdivision shall be interpreted to
52 otherwise expand MO HealthNet services;
53 (8) Drugs and medicines when prescribed by a licensed physician, dentist, podiatrist,
54 or an advanced practice registered nurse; except that no payment for drugs and medicines
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55 prescribed on and after January 1, 2006, by a licensed physician, dentist, podiatrist, or an
56 advanced practice registered nurse may be made on behalf of any person who qualifies for
57 prescription drug coverage under the provisions of P .L. 108-173;
58 (9) Emer gency ambulance services and, ef fective January 1, 1990, medically
59 necessary transportation to scheduled, physician-prescribed nonelective treatments;
60 (10) Early and periodic screening and diagnosis of individuals who are under the age
61 of twenty-one to ascertain their physical or mental defects, and health care, treatment, and
62 other measures to correct or ameliorate defects and chronic conditions discovered thereby .
63 Such services shall be provided in accordance with the provisions of Section 6403 of P .L.
64 101-239 and federal regulations promulgated thereunder;
65 (1 1) Home health care services;
66 (12) Family planning as defined by federal rules and regulations; provided, that no
67 funds shall be expended to any abortion facility , as defined in section 188.015, or to any
68 af filiate, as defined in section 188.015, of such abortion facility; and further provided,
69 however , that such family planning services shall not include abortions or any abortifacient
70 drug or device that is used for the purpose of inducing an abortion unless such abortions are
71 certified in writing by a physician to the MO HealthNet agency that, in the physician's
72 professional judgment, the life of the mother would be endangered if the fetus were carried to
73 term;
74 (13) Inpatient psychiatric hospital services for individuals under age twenty-one as
75 defined in T itle XIX of the federal Social Security Act (42 U.S.C. Section 1396d, et seq.);
76 (14) Outpatient sur gical procedures, including presurg ical diagnostic services
77 performed in ambulatory surg ical facilities which are licensed by the department of health
78 and senior services of the state of Missouri; except, that such outpatient surgical services shall
79 not include persons who are eligible for coverage under Part B of T itle XVIII, Public Law 89-
80 97, 1965 amendments to the federal Social Security Act, as amended, if exclusion of such
81 persons is permitted under T itle XIX, Public Law 89-97, 1965 amendments to the federal
82 Social Security Act, as amended;
83 (15) Personal care services which are medically oriented tasks having to do with a
84 person's physical requirements, as opposed to housekeeping requirements, which enable a
85 person to be treated by his or her physician on an outpatient rather than on an inpatient or
86 residential basis in a hospital, intermediate care facility , or skilled nursing facility . Personal
87 care services shall be rendered by an individual not a member of the participant's family who
88 is qualified to provide such services where the services are prescribed by a physician in
89 accordance with a plan of treatment and are supervised by a licensed nurse. Persons eligible
90 to receive personal care services shall be those persons who would otherwise require
91 placement in a hospital, intermediate care facility , or skilled nursing facility . Benefits payable
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92 for personal care services shall not exceed for any one participant one hundred percent of the
93 average statewide char ge for care and treatment in an intermediate care facility for a
94 comparable period of time. Such services, when delivered in a residential care facility or
95 assisted living facility licensed under chapter 198 , shall be authorized on a tier level based on
96 the services the resident requires and the frequency of the services. A resident of such facility
97 who qualifies for assistance under section 208.030 shall, at a minimum, if prescribed by a
98 physician, qualify for the tier level with the fewest services. The rate paid to providers for
99 each tier of service shall be set subject to appropriations. Subject to appropriations, each
100 resident of such facility who qualifies for assistance under section 208.030 and meets the
101 level of care required in this section shall, at a minimum, if prescribed by a physician, be
102 authorized up to one hour of personal care services per day . Authorized units of personal care
103 services shall not be reduced or tier level lowered unless an order approving such reduction or
104 lowering is obtained from the resident's personal physician. Such authorized units of personal
105 care services or tier level shall be transferred with such resident if he or she transfers to
106 another such facility . Such provision shall terminate upon receipt of relevant waivers from
107 the federal Department of Health and Human Services. If the Centers for Medicare and
108 Medicaid Services determines that such provision does not comply with the state plan, this
109 provision shall be null and void. The MO HealthNet division shall notify the revisor of
110 statutes as to whether the relevant waivers are approved or a determination of noncompliance
111 is made;
112 (16) Mental health services. The state plan for providing medical assistance under
113 T itle XIX of the Social Security Act, 42 U.S.C. Section 1396, et seq., as amended, shall
114 include the following mental health services when such services are provided by community
115 mental health facilities operated by the department of mental health or designated by the
116 department of mental health as a community mental health facility or as an alcohol and drug
117 abuse facility or as a child-serving agency within the comprehensive children's mental health
118 service system established in section 630.097. The department of mental health shall
119 establish by administrative rule the definition and criteria for designation as a community
120 mental health facility and for designation as an alcohol and drug abuse facility . Such mental
121 health services shall include:
122 (a) Outpatient mental health services including preventive, diagnostic, therapeutic,
123 rehabilitative, and palliative interventions rendered to individuals in an individual or group
124 setting by a mental health professional in accordance with a plan of treatment appropriately
125 established, implemented, monitored, and revised under the auspices of a therapeutic team as
126 a part of client services management;
127 (b) Clinic mental health services including preventive, diagnostic, therapeutic,
128 rehabilitative, and palliative interventions rendered to individuals in an individual or group
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129 setting by a mental health professional in accordance with a plan of treatment appropriately
130 established, implemented, monitored, and revised under the auspices of a therapeutic team as
131 a part of client services management;
132 (c) Rehabilitative mental health and alcohol and drug abuse services including home
133 and community-based preventive, diagnostic, therapeutic, rehabilitative, and palliative
134 interventions rendered to individuals in an individual or group setting by a mental health
135 or alcohol and drug abuse professional in accordance with a plan of treatment appropriately
136 established, implemented, monitored, and revised under the auspices of a therapeutic team as
137 a part of client services management. As used in this section, mental health professional and
138 alcohol and drug abuse professional shall be defined by the department of mental health
139 pursuant to duly promulgated rules. W ith respect to services established by this subdivision,
140 the department of social services, MO HealthNet division, shall enter into an agreement with
141 the department of mental health. Matching funds for outpatient mental health services, clinic
142 mental health services, and rehabilitation services for mental health and alcohol and drug
143 abuse shall be certified by the department of mental health to the MO HealthNet division.
144 The agreement shall establish a mechanism for the joint implementation of the provisions of
145 this subdivision. In addition, the agreement shall establish a mechanism by which rates for
146 services may be jointly developed;
147 (17) Such additional services as defined by the MO HealthNet division to be
148 furnished under waivers of federal statutory requirements as provided for and authorized by
149 the federal Social Security Act (42 U.S.C. Section 301, et seq.) subject to appropriation by the
150 general assembly;
151 (18) The services of an advanced practice registered nurse with a collaborative
152 practice agreement to the extent that such services are provided in accordance with chapters
153 334 and 335, and regulations promulgated thereunder;
154 (19) Nursing home costs for participants receiving benefit payments under
155 subdivision (4) of this subsection to reserve a bed for the participant in the nursing home
156 during the time that the participant is absent due to admission to a hospital for services which
157 cannot be performed on an outpatient basis, subject to the provisions of this subdivision:
158 (a) The provisions of this subdivision shall apply only if:
159 a. The occupancy rate of the nursing home is at or above ninety-seven percent of MO
160 HealthNet certified licensed beds, according to the most recent quarterly census provided to
161 the department of health and senior services which was taken prior to when the participant is
162 admitted to the hospital; and
163 b. The patient is admitted to a hospital for a medical condition with an anticipated
164 stay of three days or less;
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165 (b) The payment to be made under this subdivision shall be provided for a maximum
166 of three days per hospital stay;
167 (c) For each day that nursing home costs are paid on behalf of a participant under this
168 subdivision during any period of six consecutive months such participant shall, during the
169 same period of six consecutive months, be ineligible for payment of nursing home costs of
170 two otherwise available temporary leave of absence days provided under subdivision (5) of
171 this subsection; and
172 (d) The provisions of this subdivision shall not apply unless the nursing home
173 receives notice from the participant or the participant's responsible party that the participant
174 intends to return to the nursing home following the hospital stay . If the nursing home receives
175 such notification and all other provisions of this subsection have been satisfied, the nursing
176 home shall provide notice to the participant or the participant's responsible party prior to
177 release of the reserved bed;
178 (20) Prescribed medically necessary durable medical equipment. An electronic web-
179 based prior authorization system using best medical evidence and care and treatment
180 guidelines consistent with national standards shall be used to verify medical need;
181 (21) Hospice care. As used in this subdivision, the term "hospice care" means a
182 coordinated program of active professional medical attention within a home, outpatient and
183 inpatient care which treats the terminally ill patient and family as a unit, employing a
184 medically directed interdisciplinary team. The program provides relief of severe pain or other
185 physical symptoms and supportive care to meet the special needs arising out of physical,
186 psychological, spiritual, social, and economic stresses which are experienced during the final
187 stages of illness, and during dying and bereavement and meets the Medicare requirements for
188 participation as a hospice as are provided in 42 CFR Part 418. The rate of reimbursement
189 paid by the MO HealthNet division to the hospice provider for room and board furnished by a
190 nursing home to an eligible hospice patient shall not be less than ninety-five percent of the
191 rate of reimbursement which would have been paid for facility services in that nursing home
192 facility for that patient, in accordance with subsection (c) of Section 6408 of P .L. 101-239
193 (Omnibus Budget Reconciliation Act of 1989);
194 (22) Prescribed medically necessary dental services. Such services shall be subject to
195 appropriations. An electronic web-based prior authorization system using best medical
196 evidence and care and treatment guidelines consistent with national standards shall be used to
197 verify medical need;
198 (23) Prescribed medically necessary optometric services. Such services shall be
199 subject to appropriations. An electronic web-based prior authorization system using best
200 medical evidence and care and treatment guidelines consistent with national standards shall
201 be used to verify medical need;
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202 (24) Blood clotting products-related services. For persons diagnosed with a bleeding
203 disorder , as defined in section 338.400, reliant on blood clotting products, as defined in
204 section 338.400, such services include:
205 (a) Home delivery of blood clotting products and ancillary infusion equipment and
206 supplies, including the emer gency deliveries of the product when medically necessary;
207 (b) Medically necessary ancillary infusion equipment and supplies required to
208 administer the blood clotting products; and
209 (c) Assessments conducted in the participant's home by a pharmacist, nurse, or local
210 home health care agency trained in bleeding disorders when deemed necessary by the
211 participant's treating physician;
212 (25) Medically necessary cochlear implants and hearing instruments, as defined in
213 section 345.015, that are:
214 (a) Prescribed by an audiologist, as defined in section 345.015; or
215 (b) Dispensed by a hearing instrument specialist, as defined in section 346.010;
216 (26) Orthotic, pr osthetic, and complex r ehabilitation technology devices,
217 supplies, and services in accordance with section 208.830;
218 (27) The MO HealthNet division shall, by January 1, 2008, and annually thereafter ,
219 report the status of MO HealthNet provider reimbursement rates as compared to one hundred
220 percent of the Medicare reimbursement rates and compared to the average dental
22 1 reimbursement rates paid by third-party payors licensed by the state. The MO HealthNet
222 division shall, by July 1, 2008, provide to the general assembly a four -year plan to achieve
223 parity with Medicare reimbursement rates and for third-party payor average dental
224 reimbursement rates. Such plan shall be subject to appropriation and the division shall
225 include in its annual budget request to the governor the necessary funding needed to complete
226 the four -year plan developed under this subdivision.
227 2. Additional benefit payments for medical assistance shall be made on behalf of
228 those eligible needy children, pregnant women and blind persons with any payments to be
229 made on the basis of the reasonable cost of the care or reasonable char ge for the services as
230 defined and determined by the MO HealthNet division, unless otherwise hereinafter provided,
231 for the following:
232 (1) Dental services;
233 (2) Services of podiatrists as defined in section 330.010;
234 (3) Optometric services as described in section 336.010;
235 (4) Orthopedic devices [ or other prosthetics, including ] , eye glasses, and dentures[ ,
236 and wheelchairs ];
237 (5) Hospice care. As used in this subdivision, the term "hospice care" means a
238 coordinated program of active professional medical attention within a home, outpatient and
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239 inpatient care which treats the terminally ill patient and family as a unit, employing a
240 medically directed interdisciplinary team. The program provides relief of severe pain or other
241 physical symptoms and supportive care to meet the special needs arising out of physical,
242 psychological, spiritual, social, and economic stresses which are experienced during the final
243 stages of illness, and during dying and bereavement and meets the Medicare requirements for
244 participation as a hospice as are provided in 42 CFR Part 418. The rate of reimbursement
245 paid by the MO HealthNet division to the hospice provider for room and board furnished by a
246 nursing home to an eligible hospice patient shall not be less than ninety-five percent of the
247 rate of reimbursement which would have been paid for facility services in that nursing home
248 facility for that patient, in accordance with subsection (c) of Section 6408 of P .L. 101-239
249 (Omnibus Budget Reconciliation Act of 1989);
250 (6) Comprehensive day rehabilitation services beginning early posttrauma as part of a
251 coordinated system of care for individuals with disabling impairments. Rehabilitation
252 services must be based on an individualized, goal-oriented, comprehensive and coordinated
253 treatment plan developed, implemented, and monitored through an interdisciplinary
25 4 assessment designed to restore an individual to an optimal level of physical, cognitive, and
255 behavioral function. The MO HealthNet division shall establish by administrative rule the
256 definition and criteria for designation of a comprehensive day rehabilitation service facility ,
257 benefit limitations and payment mechanism. Any rule or portion of a rule, as that term is
258 defined in section 536.010, that is created under the authority delegated in this subdivision
259 shall become ef fective only if it complies with and is subject to all of the provisions of
260 chapter 536 and, if applicable, section 536.028. This section and chapter 536 are
261 nonseverable and if any of the powers vested with the general assembly pursuant to chapter
262 536 to review , to delay the effecti ve date, or to disapprove and annul a rule are subsequently
263 held unconstitutional, then the grant of rulemaking authority and any rule proposed or
264 adopted after August 28, 2005, shall be invalid and void.
265 3. The MO HealthNet division may require any participant receiving MO HealthNet
266 benefits to pay part of the charg e or cost until July 1, 2008, and an additional payment after
267 July 1, 2008, as defined by rule duly promulgated by the MO HealthNet division, for all
268 covered services except for those services covered under subdivisions (15) and (16) of
269 subsection 1 of this section and sections 208.631 to 208.657 to the extent and in the manner
270 authorized by T itle XIX of the federal Social Security Act (42 U.S.C. Section 1396, et seq.)
271 and regulations thereunder . When substitution of a generic drug is permitted by the prescriber
272 according to section 338.056, and a generic drug is substituted for a name-brand drug, the
273 MO HealthNet division may not lower or delete the requirement to make a co-payment
274 pursuant to regulations of T itle XIX of the federal Social Security Act. A provider of goods
275 or services described under this section must collect from all participants the additional
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276 payment that may be required by the MO HealthNet division under authority granted herein,
277 if the division exercises that authority , to remain eligible as a provider . Any payments made
278 by participants under this section shall be in addition to and not in lieu of payments made by
279 the state for goods or services described herein except the participant portion of the pharmacy
280 professional dispensing fee shall be in addition to and not in lieu of payments to pharmacists.
281 A provider may collect the co-payment at the time a service is provided or at a later date. A
282 provider shall not refuse to provide a service if a participant is unable to pay a required
283 payment. If it is the routine business practice of a provider to terminate future services to an
284 individual with an unclaimed debt, the provider may include uncollected co-payments under
285 this practice. Providers who elect not to undertake the provision of services based on a
286 history of bad debt shall give participants advance notice and a reasonable opportunity for
287 payment. A provider , representative, employee, independent contractor , or agent of a
288 pharmaceutical manufacturer shall not make co-payment for a participant. This subsection
289 shall not apply to other qualified children, pregnant women, or blind persons. If the Centers
290 for Medicare and Medicaid Services does not approve the MO HealthNet state plan
291 amendment submitted by the department of social services that would allow a provider to
292 deny future services to an individual with uncollected co-payments, the denial of services
293 shall not be allowed. The department of social services shall inform providers regarding the
294 acceptability of denying services as the result of unpaid co-payments.
295 4. The MO HealthNet division shall have the right to collect medication samples from
296 participants in order to maintain program integrity .
297 5. Reimbursement for obstetrical and pediatric services under subdivision (6) of
298 subsection 1 of this section shall be timely and suff icient to enlist enough health care
299 providers so that care and services are available under the state plan for MO HealthNet
300 benefits at least to the extent that such care and services are available to the general
301 population in the geographic area, as required under subparagraph (a)(30)(A) of 42 U.S.C.
302 Section 1396a and federal regulations promulgated thereunder .
303 6. Beginning July 1, 1990, reimbursement for services rendered in federally funded
304 health centers shall be in accordance with the provisions of subsection 6402(c) and Section
305 6404 of P .L. 101-239 (Omnibus Budget Reconciliation Act of 1989) and federal regulations
306 promulgated thereunder .
307 7. Beginning July 1, 1990, the department of social services shall provide notification
308 and referral of children below age five, and pregnant, breast-feeding, or postpartum women
309 who are determined to be eligible for MO HealthNet benefits under section 208.151 to the
310 special supplemental food programs for women, infants and children administered by the
311 department of health and senior services. Such notification and referral shall conform to the
312 requirements of Section 6406 of P .L. 101-239 and regulations promulgated thereunder .
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313 8. Providers of long-term care services shall be reimbursed for their costs in
314 accordance with the provisions of Section 1902 (a)(13)(A) of the Social Security Act, 42
315 U.S.C. Section 1396a, as amended, and regulations promulgated thereunder .
316 9. Reimbursement rates to long-term care providers with respect to a total change in
317 ownership, at arm's length, for any facility previously licensed and certified for participation
318 in the MO HealthNet program shall not increase payments in excess of the increase that
319 would result from the application of Section 1902 (a)(13)(C) of the Social Security Act, 42
320 U.S.C. Section 1396a (a)(13)(C).
321 10. The MO HealthNet division may enroll qualified residential care facilities and
322 assisted living facilities, as defined in chapter 198, as MO HealthNet personal care providers.
323 1 1. Any income earned by individuals eligible for certified extended employment at a
324 sheltered workshop under chapter 178 shall not be considered as income for purposes of
325 determining eligibility under this section.
326 12. If the Missouri Medicaid audit and compliance unit changes any interpretation or
327 application of the requirements for reimbursement for MO HealthNet services from the
328 interpretation or application that has been applied previously by the state in any audit of a MO
329 HealthNet provider , the Missouri Medicaid audit and compliance unit shall notify all af fected
330 MO HealthNet providers five business days before such change shall take ef fect. Failure of
331 the Missouri Medicaid audit and compliance unit to notify a provider of such change shall
332 entitle the provider to continue to receive and retain reimbursement until such notification is
333 provided and shall waive any liability of such provider for recoupment or other loss of any
334 payments previously made prior to the five business days after such notice has been sent.
335 Each provider shall provide the Missouri Medicaid audit and compliance unit a valid email
336 address and shall agree to receive communications electronically . The notification required
337 under this section shall be delivered in writing by the United States Postal Service or
338 electronic mail to each provider .
339 13. Nothing in this section shall be construed to abrogate or limit the department's
340 statutory requirement to promulgate rules under chapter 536.
341 14. Beginning July 1, 2016, and subject to appropriations, providers of behavioral,
342 social, and psychophysiological services for the prevention, treatment, or management of
343 physical health problems shall be reimbursed utilizing the behavior assessment and
344 intervention reimbursement codes 96150 to 96154 or their successor codes under the
345 Current Procedural T erminology (CPT) coding system. Providers eligible for such
346 reimbursement shall include psychologists.
347 15. There shall be no payments made under this section for gender transition
348 sur geries, cross-sex hormones, or puberty-blocking drugs, as such terms are defined in section
349 191.1720, for the purpose of a gender transition.
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208.830. 1. As used in this section, terms shall have the same meanings given to
2 them in section 376.1232.
3 2. The MO HealthNet prog ram shall cover orthotic, pr osthetic, and complex
4 r ehabilitation technology devices, supplies, and services furnished under an order by a
5 pr escribing physician or licensed health car e prescriber who has authority in this state
6 to prescribe orthotic, pr osthetic, and complex r ehabilitation technology devices. The
7 coverage shall be at least equal to the coverage pro vided under federal law for health
8 insurance for the aged and disabled under 42 U.S.C. Sections 1395k, 1395l, and 1395m,
9 but only to the extent consistent with this section.
10 3. Coverage for orthotic, pro sthetic, and complex r ehabilitation technology
11 devices, supplies, accessories, and services under this section includes those devices or
12 device systems, supplies, accessories, and services that ar e customized to the enr ollee's
13 needs for purposes of participating in normal life activities in any setting wher e these
14 activities take place. This re quir ement applies to the type of device as follows:
15 (1) For orthotic and pr osthetic devices, this subsection requ ires coverage of
16 devices intended for primary or daily use; and
17 (2) For complex rehab ilitation technology devices, this subsection req uires
18 coverage of:
19 (a) One wheelchair for daily use that meets the enro llee's needs for mobility and
20 positioning; and
21 (b) One wheelchair for backup use.
22 4. The MO HealthNet prog ram shall cover orthotic, pr osthetic, and complex
23 r ehabilitation technology devices determined by the enr ollee's pr ovider to be the most
24 appr opriate model that meets the medical, physical, functional, and envir onmental
25 needs of the enr ollee for purposes of participating in normal life activities in any setting
26 wher e these activities take place; performing physical activities, as applicable, including
27 but not limited to running, biking, and swimming; and maximizing the enrol lee's whole-
28 body health and function, including coverage of a high-performance wheelchair to
29 achieve the enr ollee's health goals.
30 5. The MO HealthNet prog ram shall cover orthotic, pr osthetic, and complex
31 r ehabilitation technology devices for showering or bathing.
32 6. Any pro vision of a complex re habilitation technology device shall not be
33 cover ed by the MO HealthNet pr ogram for an enr ollee under this section unless:
34 (1) The complex r ehabilitation technology device is furnished by an accr edited
35 complex rehab ilitation technology device pr ovider that employs at least one assistive
36 technology profes sional who is certified and in good standing, without exception, by the
37 Rehabilitation Engineering and Assistive T echnology Society of North America
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38 (RESNA); who specializes in seating, positioning, and mobility; and who r egularly
39 r eceives a Form W -2 fr om the provi der; and
40 (2) The enro llee receive s an in-person assessment pro vided by the assistive
41 technology pr ofessional employed by the accr edited complex reh abilitation technology
42 device prov ider as described in subdivision (1) of this subsection.
43 7. The coverage set forth in this section includes the r epair and repl acement of
44 those orthotic, pr osthetic, and complex r ehabilitation technology devices, supplies, and
45 services described in this section.
46 8. Coverage of an orthotic, pr osthetic, or complex rehab ilitation technology
47 benefit shall not be denied for an individual with a disability or complex medical
48 condition, including but not limited to limb loss or absence, that would otherwise be
49 cover ed for a nondisabled person seeking medical or surgical intervention to re store or
50 maintain the ability to perform the same activities.
51 9. If coverage for pr osthetic, custom orthotic, or complex rehab ilitation
52 technology devices is pr ovided, payment shall be made for the replac ement of a
53 pr osthetic, custom orthotic, or complex reh abilitation technology device or for the
54 r eplacement of any part of such devices, without regard to continuous use or useful
55 lifetime res trictions, if an ordering health care pro vider determines that the pr ovision of
56 a rep lacement device, or a repl acement part of a device, is necessary because:
57 (1) Of a change in the physiological condition of the enrol lee;
58 (2) Of an irr eparable change in the condition of the device or in a part of the
59 device; or
60 (3) The condition of the device, or the part of the device, r equir es r epairs, and
61 the cost of such repai rs would be mor e than sixty per cent of the cost of a r eplacement
62 device or of the part being rep laced.
63 10. An entity shall not r eceive reim bursement fro m the MO HealthNet pr ogram
64 for orthotic, pr osthetic, or complex r ehabilitation technology devices unless the entity is
65 accr edited.
66 1 1. Prior authorization may be req uired for orthotic, pr osthetic, and complex
67 r ehabilitation technology devices, supplies, and services.
68 12. Utilization review determinations shall be render ed in a nondiscriminatory
69 manner and shall not deny coverage for habilitative or reh abilitative benefits, including
70 pr osthetics, orthotics, or complex reh abilitation technology services, solely on the basis
71 of an enroll ee's actual or perceiv ed disability .
72 13. Evidence of coverage and any benefit denial letters shall include language
73 describing an enrol lee's rights under subsection 12 of this section. Any denial of
74 coverage shall be issued in writing with an explanation that contains clear reas oning and
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75 a description of how and why the re quest or claim does not meet medical necessity
76 standards.
77 14. Confirmation fr om a pr escribing health car e provi der may be req uired if the
78 pr osthetic, custom orthotic, or complex rehab ilitation technology device or part being
79 r eplaced is less than thr ee years old.
80 15. (1) Managed car e plans subject to this section shall ensure access to
81 medically necessary clinical car e and to pro sthetic, custom orthotic, and complex
82 r ehabilitation technology devices fr om at least thr ee accr edited pr osthetic, custom
83 orthotic, and complex reh abilitation technology device facilities or pr oviders in the
84 plan's pr ovider network located in this state, including at least one small business, if any
85 is located in this state.
86 (2) If medically necessary covere d orthotic, pr osthetic, and complex
8 7 r ehabilitation technology devices are not available fr om an in-network pr ovider , the
88 plan shall pr ovide process es to r efer an enr ollee to an out-of-network pro vider and shall
89 fully r eimburse the out-of-network prov ider at a mutually agr eed-upon rate less
90 enr ollee cost sharing determined on an in-network basis.
376.1232. 1. As used in sections 376.1232 to 376.1234, the following terms mean:
2 (1) "Accr edited", accred itation of an entity to pro vide compre hensive orthotic,
3 pr osthetic, or complex reh abilitation technology devices or services by a Centers for
4 Medicar e and Medicaid Services-appr oved accr editing agency;
5 (2) "Complex rehab ilitation technology device", any individually configur ed
6 medical device, including but not limited to mobility assistive equipment, that:
7 (a) Allows an individual with a mobility limitation to move in indoor and
8 outdoor spaces including, but not limited to, a manual wheelchair , a power wheelchair , a
9 high-performance wheelchair , or a shower or commode chair;
10 (b) Is recomme nded by a health care profession al licensed in this state and
11 operating within his or her scope of practice; and
12 (c) Is deemed medically necessary by a prescribi ng physician or licensed health
13 car e provi der who has authority in this state to pr escribe complex rehab ilitation
14 technology devices;
15 (3) "Complex re habilitation technology services":
16 (a) The science and practice of evaluating, fitting, adjusting, or servicing, as well
17 as pro viding the initial training necessary to accomplish the fitting of, a complex
18 r ehabilitation technology device for mobility;
19 (b) Evaluation, tr eatment, and consultation relat ed to a complex rehab ilitation
20 technology device;
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21 (c) Assessment of complex reha bilitation technology devices to maximize
22 function and pr ovide support and alignment necessary to improve the safety and
23 efficiency of mobility and locomotion;
24 (d) Continuation of patient care to assess the effect of the complex rehab ilitation
25 technology device on the enr ollee's mobility; and
26 (e) Assurance of pr oper fit and function of the complex reha bilitation technology
27 device by periodic evaluation;
28 (4) "Enro llee", the same meaning given to the term in section 376.1350;
29 (5) "Health benefit plan", the same meaning given to the term in section
30 376.1350. The term "health benefit plan" shall also include the Missouri consolidated
31 health car e plan established under chapter 103 and any other state-sponsor ed health
32 insurance pro gram;
33 (6) "Health carrier", the same meaning given to the term in section 376.1350;
34 (7) "High-performance wheelchair", a manual or power wheelchair that is
35 designed specifically to enable individuals with mobility limitations to participate in
36 physical activities that support their health goals;
37 (8) "Orthosis" or "orthotic device", an external medical device that is:
38 (a) Custom-fabricated or custom-fitted to a specific patient based on the
39 patient's unique physical condition;
40 (b) Applied to a part of the body to corr ect a deformity , pr ovide support and
41 pr otection, res trict motion, impr ove function, or rel ieve symptoms of a disease,
42 syndr ome, injury , or postoperative condition; and
43 (c) Deemed medically necessary by a pre scribing physician or licensed health
44 car e provi der who has authority in this state to pr escribe orthotic devices, supplies, and
45 services;
46 (9) "Orthotics":
47 (a) The science and practice of evaluating, measuring, designing, fabricating,
48 assembling, fitting, adjusting, or servicing, as well as pr oviding the initial training
49 necessary to accomplish the fitting of, an orthosis for the support, corr ection, or
50 alleviation of a neur omuscular or musculoskeletal dysfunction, disease, injury , or
51 deformity;
52 (b) Evaluation, tr eatment, and consultation rela ted to an orthotic device;
53 (c) Basic observation of gait and postural analysis;
54 (d) Assessment and design of orthoses to maximize function and pr ovide support
55 and alignment necessary to pr event or corr ect a deformity or to impr ove the safety and
56 efficiency of mobility and locomotion;
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57 (e) Continuation of patient car e to assess the effect of an orthotic device on the
58 patient's tissues;
59 (f) Assurance of pr oper fit and function of the orthotic device by periodic
60 evaluation; and
61 (g) Any prov ision, repair , or r eplacement of an orthotic device that is furnished
62 or performed by:
63 a. An accredi ted facility in compr ehensive orthotic services; or
64 b. A health care provi der licensed in this state and operating within the
65 pr ovider's scope of practice that allows the pro vider to pr ovide orthotic devices,
66 supplies, or services;
67 (10) "Prost hesis" or "pr osthetic device", an external medical device that is:
68 (a) Used to repl ace or re store a missing limb, appendage, or other external
69 human body part; and
70 (b) Deemed medically necessary by a pr escribing physician or licensed health
71 car e prov ider who has authority in this state to prescrib e pr osthetic devices, supplies,
72 and services;
73 (1 1) "Prost hetics":
74 (a) The science and practice of evaluating, measuring, designing, fabricating,
75 assembling, fitting, aligning, adjusting, or servicing, as well as provi ding the initial
76 training necessary to accomplish the fitting of, a pr osthesis thr ough the replac ement of
77 external parts of a human body lost due to amputation or congenital deformities or
78 absences;
79 (b) The generation of an image, form, or mold that repli cates the patient's body
80 segment and that req uire s rect ification of dimensions, contours, and volumes for use in
81 the design and fabrication of a socket to accept a res idual anatomic limb to, in turn,
82 cr eate an artificial appendage that is designed either to support body weight or to
83 impr ove or r estore function or anatomical appearance, or both;
84 (c) Observational gait analysis and clinical assessment of the r equir ements
85 necessary to ref ine and mechanically fix the r elative position of various parts of the
86 pr osthesis to maximize function, stability , and safety of the patient;
87 (d) The pr ovision and continuation of patient car e in order to assess the
88 pr osthetic device's effect on the patient's tissues;
89 (e) Assurance of pr oper fit and function of the pr osthetic device by periodic
90 evaluation; and
91 (f) Any provi sion, rep air , or rep lacement of a pr osthetic device that is furnished
92 or performed by:
93 a. An accredi ted facility in compr ehensive pro sthetic services; or
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94 b. A health care provi der licensed in this state and operating within the
95 pr ovider's scope of practice that allows the pr ovider to pr ovide prosth etic devices,
96 supplies, or services;
97 (12) "Utilization revie w", the same meaning given to the term in section
98 376.1350.
99 2. Each health carrier or health benefit plan that of fers or issues health benefit plans
100 which are delivered, issued for delivery , continued, or renewed in this state on or after
101 January 1, 2010, shall [ of fer ] pr ovide coverage for orthotic, prosthetic , and complex
102 r ehabilitation technology devices , supplies, and services, including [ original ] re pair and
103 replacement [ devices, as prescribed by a physician acting within the scope of his or her
104 practice ]. The coverage shall be at least equal to the coverage provi ded under federal
105 law for health insurance for the aged and disabled under 42 U.S.C. Sections 1395k,
106 1395l, and 1395m, but only to the extent consistent with this section.
107 [ 2. For the purposes of this section, "health carrier" and "health benefit plan" shall
108 have the same meaning as defined in section 376.1350.]
109 3. The amount of the benefit for orthotic, prosthetic , and complex rehab ilitation
110 technology devices and services under this section shall be no less than the annual and
111 lifetime benefit maximums applicable to the basic health care services required to be provided
112 under the health benefit plan. If the health benefit plan does not include any annual or
113 lifetime maximums applicable to basic health care services, the amount of the benefit for
114 orthotic, prosthetic , and complex reh abilitation technology devices and services shall not
115 be subject to an annual or lifetime maximum benefit level. Any co-payment, coinsurance,
116 deductible, and maximum out-of-pocket amount applied to the benefit for orthotic,
117 prosthetic , and complex r ehabilitation technology devices and services shall be no more
118 than the most common amounts applied to the basic health care services required to be
119 provided under the health benefit plan.
120 4. A health carrier or health benefit plan may limit the benefits for , or alter the
121 financial r equir ements for , out-of-network coverage of orthotic, pr osthetic, and complex
122 r ehabilitation technology devices, except that the res trictions and req uire ments that
123 apply to those benefits shall not be mor e re strictive than the financial req uirements that
124 apply to the out-of-network coverage for the basic health car e services to be pr ovided
125 under the health benefit plan.
126 5. A health carrier or health benefit plan shall not subject coverage for orthotic,
127 pr osthetic, and complex re habilitation technology devices, supplies, and services to any
128 limitations for pree xisting conditions.
129 6. A health carrier or health benefit plan shall cover orthotic, pr osthetic, and
130 complex r ehabilitation technology devices when furnished under an order by a
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131 pr escribing physician or licensed health car e prescriber who has authority in this state
132 to prescribe orthotic, pr osthetic, and complex r ehabilitation technology devices. The
133 coverage for orthotic, pr osthetic, and complex r ehabilitation technology devices,
134 supplies, accessories, and services shall include those devices or device systems,
135 supplies, accessories, and services that are customized to the cover ed individual's needs
136 for purposes of participating in normal life activities in any setting where these activities
137 take place.
138 7. A health carrier or health benefit plan shall cover orthotic, pr osthetic, and
139 complex reh abilitation technology devices determined by the enrol lee's provi der to be
140 the most appr opriate model that meets the medical, physical, functional, and
14 1 envir onmental needs of the enr ollee for purposes of participating in normal life
142 activities in any setting where these activities take place; performing physical activities,
143 as applicable, including but not limited to running, biking, and swimming; and
144 maximizing the enr ollee's whole-body health and function, including coverage of a high-
145 performance wheelchair to achieve the enr ollee's health goals.
146 8. A health carrier or health benefit plan shall cover orthotic, pr osthetic, and
147 complex rehab ilitation technology devices for showering or bathing.
148 9. A health carrier or health benefit plan shall cover at least the following for an
149 enr ollee entitled to coverage of pr ostheses or orthoses:
150 (1) One prost hesis or orthosis for daily use;
151 (2) One prost hesis or orthosis designed for physical activity; and
152 (3) One prost hesis or orthosis for showering or bathing.
153 10. A health carrier or health benefit plan shall cover at least the following for
154 an enr ollee entitled to coverage of complex r ehabilitation technology devices:
155 (1) One wheelchair for daily use that meets the enro llee's needs for mobility and
156 positioning;
157 (2) One wheelchair for backup use; and
158 (3) One high-performance wheelchair if medically necessary to enable the
159 enr ollee to engage in physical activities, as applicable, including but not limited to
160 running, biking, swimming, and str ength training, and to maximize the enr ollee's whole-
161 body health and lower or upper limb function.
162 1 1. Any prov ision of a complex rehab ilitation technology device shall not be
163 cover ed by a health carrier or health benefit plan for an enroll ee under this section
164 unless:
165 (1) The complex r ehabilitation technology device is furnished by an accr edited
166 complex rehab ilitation technology device pr ovider that employs at least one assistive
167 technology profes sional who is certified and in good standing, without exception, by the
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168 Rehabilitation Engineering and Assistive T echnology Society of North America
16 9 (RESNA); who specializes in seating, positioning, and mobility; and who r egularly
170 r eceives a Form W -2 fr om the provi der; and
171 (2) The enro llee receive s an in-person assessment pro vided by the assistive
172 technology pr ofessional employed by the accr edited complex reh abilitation technology
173 device prov ider as described in subdivision (1) of this subsection.
174 12. A health carrier or health benefit plan may req uire prior authorization for
175 orthotic, prost hetic, and complex reha bilitation technology devices, supplies, and
176 services in the same manner and to the same extent as prior authorization is r equir ed
177 for any other cover ed benefit.
178 13. An entity shall not receive re imbursement fr om a state-sponsored health
179 insurance pr ogram for orthotic, pr osthetic, or complex reh abilitation technology devices
180 unless the entity is accred ited.
181 14. Except as pro vided in subsection 15 of this section, the provisions of this
182 section shall not apply to a supplemental insurance policy , including a life care contract,
183 accident-only policy , specified disease policy , hospital policy providing a fixed daily benefit
184 only , [ Medicare supplement policy , ] long-term care policy , short-term major medical policies
185 of six months or less duration, or any other supplemental policy as determined by the director
186 of the department of commerce and insurance.
187 15. Notwithstanding section 376.998 or any other pr ovision of law to the
188 contrary , the pro visions of this section shall apply to a Medicare supplement policy .
376.1233. 1. A health carrier or health benefit plan shall r ender utilization
2 r eview determinations in a nondiscriminatory manner and shall not deny coverage for
3 habilitative or rehab ilitative benefits, including pr osthetics, orthotics, or complex
4 r ehabilitation technology devices and services, solely on the basis of an enr ollee's actual
5 or per ceived disability .
6 2. A health carrier or health benefit plan shall not deny a pr osthetic, orthotic, or
7 complex reh abilitation technology benefit for an individual with a disability or complex
8 medical condition, including but not limited to limb loss or absence, that would
9 otherwise be covered for a nondisabled person seeking medical or surgical intervention
10 to res tor e or maintain the ability to perform the same activities.
11 3. A health benefit plan offer ed, issued, or renew ed in this state that offers
12 coverage for pro sthetics, custom orthotic devices, and complex reh abilitation technology
13 devices shall include language describing an enrol lee's rights under subsections 1 and 2
14 of this section in its evidence of coverage and any benefit denial letters. Any denial of
15 coverage shall be issued in writing with an explanation that contains clear reas oning and
HCS HB 2034 18
16 a description of how and why the re quest or claim does not meet medical necessity
17 standards.
18 4. A health carrier or health benefit plan that pro vides coverage for pro sthetic,
19 orthotic, or complex r ehabilitation technology services shall ensur e access to medically
20 necessary clinical car e and to pr osthetic, custom orthotic, and complex rehab ilitation
21 technology devices fro m not less than thr ee accr edited pr osthetic, custom orthotic, and
22 complex r ehabilitation technology device facilities or pr oviders in the plan's provi der
23 network located in this state, including at least one small business, if any is located in
24 this state. If medically necessary covere d orthotics, pr osthetics, and complex
25 r ehabilitation technology services are not available fr om an in-network prov ider , the
26 health carrier or health benefit plan shall pr ovide process es to ref er a member to an out-
27 of-network provi der and shall fully re imburse the out-of-network pro vider at a
28 mutually agr eed-upon rate less member cost sharing determined on an in-network
29 basis.
30 5. If coverage for pr osthetic, custom orthotic, or complex rehab ilitation
31 technology devices is pr ovided, payment shall be made for the replac ement of a
32 pr osthetic, custom orthotic, or complex reh abilitation technology device or for the
33 r eplacement of any part of such devices, without regard to continuous use or useful
34 lifetime res trictions, if an ordering health care pro vider determines that the pr ovision of
35 a rep lacement device, or a repl acement part of a device, is necessary because:
36 (1) Of a change in the physiological condition of the patient;
37 (2) Of an irr eparable change in the condition of the device or in a part of the
38 device; or
39 (3) The condition of the device, or the part of the device, r equir es r epairs, and
40 the cost of such repai rs would be mor e than sixty per cent of the cost of a r eplacement
41 device or of the part being rep laced.
42 6. Confirmation fr om a prescribi ng health care pr ovider may be r equir ed if the
43 pr osthetic, custom orthotic, or complex rehab ilitation technology device or part being
44 r eplaced is less than thr ee years old.
376.1234. 1. Befor e October 1, 2027, each health carrier that issues a health
2 benefit plan provi ding coverage of orthotic, prost hetic, and complex rehab ilitation
3 technology devices, supplies, and services as req uired under sections 376.1232 to
4 376.1234 shall rep ort to the director of the department of commer ce and insurance on
5 its experience with the req uire ments of sections 376.1232 to 376.1234 for the first year
6 following the effective date of this section. The report shall be in a form pr escribed by
7 the dir ector and shall include the number of claims and the total amount of claims paid
8 in this state for the services r equir ed by sections 376.1232 to 376.1234. The dir ector
HCS HB 2034 19
9 shall aggr egate this data in a rep ort and submit the r eport to the house and senate
10 standing committees having jurisdiction over health insurance matters befor e December
11 1, 2027.
12 2. The dir ector may pr omulgate any necessary rules and reg ulations to
13 implement sections 376.1232 to 376.1234. Any rule or portion of a rule, as that term is
14 defined in section 536.010, that is cr eated under the authority delegated in this section
15 shall become effective only if it complies with and is subject to all of the provi sions of
16 chapter 536 and, if applicable, section 536.028. This section and chapter 536 are
17 nonseverable and if any of the powers vested with the general assembly pursuant to
18 chapter 536 to review , to delay the effective date, or to disappr ove and annul a rule ar e
19 subsequently held unconstitutional, then the grant of rulemaking authority and any rule
20 pr oposed or adopted after August 28, 2026, shall be invalid and void.
✔
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