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EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
and is intended to be omitted in the law.
SECOND REGULAR SESSION
SENATE BILL NO. 1254
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR NICOLA.
5488S.02I KRISTINA MARTIN, Secretary
AN ACT
To repeal section 336.010, RSMo, and to enact in lieu thereof four new sections relating to licensed
medical professionals.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Section 336.010, RSMo, is repealed and four 1
new sections enacted in lieu thereof, to be known as sections 2
334.071, 336.010, 336.022, and 336.300, to read as follows:3
334.071. Only physicians licensed under this chapter 1
shall use the following medical titles or specialty 2
designations: 3
(1) "Physician", except individuals licensed under 4
chapter 331 may use the term "chiropractic physician"; 5
(2) "Doctor of medicine"; 6
(3) "Medical doctor"; 7
(4) "MD"; 8
(5) "Doctor of osteopathic medicine"; 9
(6) "Doctor of osteopathy"; 10
(7) "DO"; 11
(8) "Osteopath"; 12
(9) "Osteopathic physician"; 13
(10) "Osteopathic surgeon"; 14
(11) "Surgeon"; 15
(12) "Anesthesiologist"; 16
(13) "Cardiologist"; 17
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(14) "Dermatologist"; 18
(15) "Endocrinologist"; 19
(16) "Emergency physician"; 20
(17) "Family practice physician"; 21
(18) "Gastroenterologist"; 22
(19) "Gynecologist"; 23
(20) "Hematologist"; 24
(21) "Internist"; 25
(22) "Laryngologist"; 26
(23) "Nephrologist"; 27
(24) "Neurologist"; 28
(25) "Neurosurgeon"; 29
(26) "Obstetrician"; 30
(27) "Oncologist"; 31
(28) "Ophthalmologist"; 32
(29) "Orthopedic surgeon"; 33
(30) "Orthopedist"; 34
(31) "Otologist"; 35
(32) "Otolaryngologist"; 36
(33) "Otorhinolaryngologist"; 37
(34) "Pathologist"; 38
(35) "Pediatrician"; 39
(36) "Physiatrist"; 40
(37) "Primary care physician"; 41
(38) "Proctologist"; 42
(39) "Psychiatrist"; 43
(40) "Radiologist"; 44
(41) "Rheumatologist"; 45
(42) "Rhinologist"; and 46
(43) "Urologist". 47
336.010. 1. The "practice of optometry" is the 1
examination, diagnosis, treatment, and preventative care of 2
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the eye, adnexa, and vision. The practice includes, but is 3
not limited to: 4
(1) The examination of the eye, adnexa, and vision to 5
determine the accommodative and refractive states, visual 6
perception, conditions, and diseases; 7
(2) The diagnosis and treatment of conditions or 8
diseases of the eye, adnexa, and vision; 9
(3) The performance of diagnostic procedures and 10
ordering of laboratory and imaging tests for the diagnosis 11
of vision and conditions and diseases of the eye and adnexa; 12
(4) The prescription and administration of 13
pharmaceutical agents[, excluding injectable agents,] other 14
than vaccines for the purpose of examination, diagnosis, and 15
treatment of vision and conditions or diseases of the eye 16
and adnexa; 17
(5) The performance of the following procedures: 18
(a) The removal of superficial foreign bodies from the 19
eye or adnexa; 20
(b) The removal of embedded foreign bodies from the 21
eye or eyelid; 22
(c) The removal of corneal foreign bodies with or 23
without a slit lamp and that are equal to or less than one- 24
third depth off the visual axis; 25
(d) The removal of damaged or loose corneal epithelium 26
without the use of a blade; 27
(e) Epilation only by forceps; 28
(f) The expression of conjunctival follicles; 29
(g) The placement of punctal plugs; 30
(h) The placement of bandage contact lenses; 31
(i) The placement of self-retaining amniotic membranes; 32
(j) Procedures employing thermal pulsation and 33
noninvasive devices delivering intense pulsed light therapy 34
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or low-level light therapy that do not rely on laser 35
technology, limited to the treatment of conditions and 36
diseases of the adnexa; 37
(k) Use of an intranasal stimulator in conjunction 38
with treatment of dry eye syndrome; 39
(l) The therapeutic release of aqueous through a pre- 40
existing wound; and 41
(m) The application of ultraviolet light for 42
components of light adjustable lens; 43
(6) The employment of objective or subjective 44
mechanical means to determine the accommodative or 45
refractive states of the human eye; 46
(7) The prescription or adaptation of lenses, prisms, 47
devices, or ocular exercises to correct defects or abnormal 48
conditions of the human eye or vision or to adjust the human 49
eye to special conditions; 50
(8) The prescription and fitting of ophthalmic or 51
contact lenses and devices; 52
(9) The prescription and administration of vision 53
therapy; and 54
(10) The prescription and administration of low vision 55
care. 56
2. An optometrist may not perform surgery, including 57
the use of lasers for treatment of any disease or condition 58
or for the correction of refractive error. 59
3. As used in this chapter, except as the context may 60
otherwise require, the following terms mean: 61
(1) "Eye", the human eye; 62
(2) "Adnexa", all structures adjacent to the eye and 63
the conjunctiva, lids, lashes, and lacrimal system; 64
(3) "Board", the Missouri state board of optometry; 65
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(4) "Diagnostic pharmaceutical agents", topically 66
applied pharmaceuticals used for the purpose of conducting 67
an examination of the eye, adnexa, and vision; 68
(5) "Low vision care", the examination, treatment, and 69
management of patients with visual impairments not treatable 70
by conventional eyewear or contact lenses and may include a 71
vision rehabilitation program to enhance remaining vision 72
skills; 73
(6) "Pharmaceutical agents", any diagnostic and 74
therapeutic drug or combination of drugs that assist the 75
diagnosis, prevention, treatment, or mitigation of abnormal 76
conditions or symptoms of the human eye, adnexa, and vision; 77
(7) "Therapeutic pharmaceutical agents", those 78
pharmaceuticals[, excluding injectable agents,] other than 79
vaccines used for the treatment of conditions or diseases of 80
the eye, adnexa, and vision; 81
(8) "Vision therapy", a treatment regiment to improve 82
a patient's diagnosed visual dysfunctions, prevent the 83
development of visual problems, or enhance visual 84
performance to meet the defined needs of the patient. 85
336.022. 1. Notwithstanding any other provision of 1
the law to the contrary, an optometrist shall be required to 2
disclose, either verbally or by written communication, to 3
every patient of the optometrist that: 4
(1) The optometrist is not a physician licensed by 5
chapter 334; 6
(2) The patient has the option to seek care from a 7
physician for treatments; and 8
(3) The patient has waived a referral to a physician. 9
2. An optometrist shall be required to obtain from a 10
patient informed written consent prior to the treatment of 11
such patient. The optometrist shall retain records of the 12
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written consent for no less than seven years from the date 13
the written consent was made by the patient. The records of 14
written consent of patients of an optometrist shall be made 15
available upon request for review by the board and the state 16
board of registration for the healing arts. Failure to 17
obtain informed written consent of the patient prior to 18
treatment may result in disciplinary action, including the 19
revocation or suspension of a license by the board under 20
section 336. 21
336.300. 1. As used in this section, the following 1
terms mean: 2
(1) "Ancillary personnel", a person who is not an eye 3
care provider; 4
(2) "Comanagement safe harbor", protection from 5
disciplinary proceedings against an eye care provider with 6
respect to surgical comanagement of an eye surgery patient 7
when the eye care provider adheres to the requirements of 8
this section; 9
(3) "Eye care provider", an ophthalmologist or 10
optometrist; 11
(4) "Eye surgery patient", a patient who has an eye 12
surgery performed by a licensed physician or surgeon; 13
(5) "Ophthalmologist", a physician licensed under 14
chapter 334 who specializes in care of the eye and who has 15
completed a residency in ophthalmology accredited by the 16
Accreditation Council for Graduate Medical Education; 17
(6) "Optometrist", an optometrist licensed to practice 18
under this chapter; 19
(7) "Surgical comanagement", the collaboration and 20
sharing of responsibilities among eye care providers with 21
respect to the preoperative or postoperative care of an eye 22
surgery patient. The term "surgical comanagement" shall not 23
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include delegating tasks relating to the care of an eye 24
surgery patient to ancillary personnel working under the 25
direct supervision of an eye care provider. 26
2. Surgical comanagement is permitted when the 27
following are met: 28
(1) The eye surgery patient has indicated a preference 29
to have preoperative or postoperative care furnished by an 30
eye care provider other than the operating physician or 31
surgeon; or 32
(2) The distance from the eye surgery patient's home 33
to the operating physician or surgeon's office would result 34
in an unreasonable hardship for the eye surgery patient; or 35
(3) Extenuating circumstances exist which prevent the 36
eye surgery patient from visiting the physician or surgeon's 37
office for routine preoperative or postoperative care and 38
such care can be provided by another qualified eye care 39
provider; or 40
(4) The physician or surgeon chosen by the eye surgery 41
patient is not available to perform the operation and 42
associated care within a reasonable proximity to the eye 43
surgery patient's home; or 44
(5) The operating physician or surgeon will not be 45
available to provide postoperative care after the surgery, 46
provided that the absence of the operating physician or 47
surgeon does not fall within rules pertaining to patient 48
abandonment or improper itinerant surgery; and 49
(6) The eye surgery patient chooses to have 50
preoperative or postoperative care furnished by an eye care 51
provider other than the operating physician or surgeon after 52
being fully informed about the proposed comanagement 53
arrangement as described in subsection 5 of this section. 54
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3. None of the comanaging eye care providers shall 55
receive a percentage of the global surgical fee that exceeds 56
the relative value of services provided to an eye surgery 57
patient which are reasonable and necessary for such eye 58
surgery patient's care. 59
4. Each comanaging eye care provider shall be licensed 60
or certified and qualified for the services the eye care 61
provider provides to an eye surgery patient. If surgical 62
intervention is required during the postoperative period for 63
medically necessary reasons, an eye surgery patient shall be 64
referred back to the original operating physician or surgeon 65
or to another physician or surgeon with comparable skills. 66
5. An eye surgery patient or legal guardian of an eye 67
surgery patient shall be fully informed in writing about the 68
surgical comanagement arrangement and shall sign and be 69
offered to receive a statement acknowledging that the 70
details of the surgical comanagement arrangement have been 71
fully explained to the eye surgery patient, including all of 72
the following: 73
(1) The licensure and qualifications of the comanaging 74
eye care providers who will be managing the eye surgery 75
patient's care preoperatively, during the operation, and 76
postoperatively; 77
(2) The financial arrangement between the comanaging 78
eye care providers, including the division of the global 79
surgical fee among the eye care providers participating in 80
the surgical comanagement arrangement; 81
(3) The eye surgery patient's right to receive care 82
from any of the comanaging eye care providers that they are 83
licensed and qualified to provide; and 84
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(4) The eye surgery patient's right to accept or 85
decline to participate in the surgical comanagement 86
arrangement. 87
The comanagement informed consent shall be documented in the 88
eye surgery patient's medical records maintained by each of 89
the comanaging eye care providers, including the eye surgery 90
patient's acknowledgment of and agreement to the surgical 91
comanagement arrangement. 92
6. The comanaging eye care providers shall establish 93
protocols governing the manner in which care will be offered 94
and provided to an eye surgery patient, including but not 95
limited to: 96
(1) The nature of routine care expected; 97
(2) Who will deliver each aspect of care; 98
(3) How complications will be handled; 99
(4) The parameters which will determine when an eye 100
surgery patient is fully healed and may be released from 101
further care, and how the release will be accomplished; and 102
(5) The manner in which communication between the eye 103
care providers will occur. 104
7. Comanaging eye care providers shall communicate 105
regularly and in a timely manner consistent with the 106
comanagement surgical protocol procedures established in 107
subsection 6 of this section regarding an eye surgery 108
patient's care and progress during the postoperative period 109
or until the eye surgery patient is released from further 110
care. 111
8. (1) Any person who engages in the following acts 112
shall not receive the protection of the comanagement safe 113
harbor: 114
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(a) Entering into a surgical comanagement arrangement 115
for the purpose of splitting a fee without providing a 116
commensurate medically necessary service to an eye surgery 117
patient; 118
(b) Demanding to manage the postoperative care in 119
return for making a surgical referral; 120
(c) Threatening to withhold referrals to a surgeon who 121
does not agree to comanage an eye surgery patient; 122
(d) Offering to comanage a patient in return for 123
receiving a surgical referral; 124
(e) Intentionally referring an eye surgery patient for 125
surgery in a manner that has no other legitimate purpose 126
than to justify a surgical comanagement arrangement; 127
(f) Initiating a surgical comanagement arrangement 128
when an eye surgery patient otherwise would have been 129
released from further care following surgery; 130
(g) Failing to fully inform an eye surgery patient 131
about the surgical comanagement arrangement; 132
(h) Misleading an eye surgery patient as to the 133
appropriateness of surgical comanagement for their 134
particular circumstances or leading the eye surgery patient 135
to believe that the eye surgery patient does not have the 136
right to receive postoperative care from the operating 137
surgeon or other comanaging eye care providers; 138
(i) Any other act that is not in the best interest of 139
the eye surgery patient as determined by the eye care 140
provider's respective licensing board. 141
(2) Nothing in this subsection shall be construed to 142
infringe upon an eye care provider's prerogative to 143
recommend a physician or surgeon or refer an eye surgery 144
patient to a physician or surgeon based on that eye care 145
provider's opinion or assessment of the physician or 146
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surgeon's ability or fitness to provide appropriate surgical 147
care to the eye surgery patient. 148
9. The state board of registration for the healing 149
arts shall be responsible for enforcement of the provisions 150
of this section for ophthalmologist and other physicians or 151
surgeons licensed pursuant to chapter 334. 152
10. The board shall be responsible for enforcement of 153
the provisions of this section for optometrists. 154
11. The state board of registration for the healing 155
arts may promulgate rules to implement the provisions of 156
this section as it affects licensees pursuant to chapter 157
334. The board may promulgate rules to implement the 158
provisions of this section as it affects licensees pursuant 159
to this chapter. To the extent possible and appropriate, 160
the board of registration for the healing arts and the board 161
shall coordinate the content of any rules they may adopt. 162
Any rule or portion of a rule, as that term is defined in 163
section 536.010, that is created under the authority 164
delegated in this section shall become effective only if it 165
complies with and is subject to all of the provisions of 166
chapter 536 and, if applicable, section 536.028. This 167
section and chapter 536 are nonseverable and if any of the 168
powers vested with the general assembly pursuant to chapter 169
536 to review, to delay the effective date, or to disapprove 170
and annul a rule are subsequently held unconstitutional, 171
then the grant of rulemaking authority and any rule proposed 172
or adopted after August 28, 2026, shall be invalid and void. 173
12. Nothing in this section shall be construed to 174
infringe upon the right of any eye care provider to decide 175
whether or not to participate in comanagement arrangements 176
either as a matter of policy or in a particular instance. 177
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13. Nothing in this section shall be construed to 178
limit civil liability of a physician or an optometrist with 179
respect to any aspect of patient care. 180
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