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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. 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:
Section A. Sections 208.152 and 376.1232, RSMo, are 1
repealed and five new sections enacted in lieu thereof, to be 2
known as sections 208.152, 208.830, 376.1232, 376.1233, and 3
376.1234, to read as follows:4
208.152. 1. MO HealthNet payments shall be made on 1
behalf of those eligible needy persons as described in 2
section 208.151 who are unable to provide for it in whole or 3
in part, with any payments to be made on the basis of the 4
reasonable cost of the care or reasonable charge for the 5
services as defined and determined by the MO HealthNet 6
division, unless otherwise hereinafter provided, for the 7
following: 8
(1) Inpatient hospital services, except to persons in 9
an institution for mental diseases who are under the age of 10
sixty-five years and over the age of twenty-one years; 11
provided that the MO HealthNet division shall provide 12
through rule and regulation an exception process for 13
coverage of inpatient costs in those cases requiring 14
treatment beyond the seventy-fifth percentile professional 15
activities study (PAS) or the MO HealthNet children's 16
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diagnosis length-of-stay schedule; and provided further that 17
the MO HealthNet division shall take into account through 18
its payment system for hospital services the situation of 19
hospitals which serve a disproportionate number of low- 20
income patients; 21
(2) All outpatient hospital services, payments 22
therefor to be in amounts which represent no more than 23
eighty percent of the lesser of reasonable costs or 24
customary charges for such services, determined in 25
accordance with the principles set forth in Title XVIII A 26
and B, Public Law 89-97, 1965 amendments to the federal 27
Social Security Act (42 U.S.C. Section 301, et seq.), but 28
the MO HealthNet division may evaluate outpatient hospital 29
services rendered under this section and deny payment for 30
services which are determined by the MO HealthNet division 31
not to be medically necessary, in accordance with federal 32
law and regulations; 33
(3) Laboratory and X-ray services; 34
(4) Nursing home services for participants, except to 35
persons with more than five hundred thousand dollars equity 36
in their home or except for persons in an institution for 37
mental diseases who are under the age of sixty-five years, 38
when residing in a hospital licensed by the department of 39
health and senior services or a nursing home licensed by the 40
department of health and senior services or appropriate 41
licensing authority of other states or government-owned and - 42
operated institutions which are determined to conform to 43
standards equivalent to licensing requirements in Title XIX 44
of the federal Social Security Act (42 U.S.C. Section 1396, 45
et seq.), as amended, for nursing facilities. The MO 46
HealthNet division may recognize through its payment 47
methodology for nursing facilities those nursing facilities 48
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which serve a high volume of MO HealthNet patients. The MO 49
HealthNet division when determining the amount of the 50
benefit payments to be made on behalf of persons under the 51
age of twenty-one in a nursing facility may consider nursing 52
facilities furnishing care to persons under the age of 53
twenty-one as a classification separate from other nursing 54
facilities; 55
(5) Nursing home costs for participants receiving 56
benefit payments under subdivision (4) of this subsection 57
for those days, which shall not exceed twelve per any period 58
of six consecutive months, during which the participant is 59
on a temporary leave of absence from the hospital or nursing 60
home, provided that no such participant shall be allowed a 61
temporary leave of absence unless it is specifically 62
provided for in his or her plan of care. As used in this 63
subdivision, the term "temporary leave of absence" shall 64
include all periods of time during which a participant is 65
away from the hospital or nursing home overnight because he 66
or she is visiting a friend or relative; 67
(6) Physicians' services, whether furnished in the 68
office, home, hospital, nursing home, or elsewhere, 69
provided, that no funds shall be expended to any abortion 70
facility, as defined in section 188.015, or to any 71
affiliate, as defined in section 188.015, of such abortion 72
facility; 73
(7) Subject to appropriation, up to twenty visits per 74
year for services limited to examinations, diagnoses, 75
adjustments, and manipulations and treatments of 76
malpositioned articulations and structures of the body 77
provided by licensed chiropractic physicians practicing 78
within their scope of practice. Nothing in this subdivision 79
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shall be interpreted to otherwise expand MO HealthNet 80
services; 81
(8) Drugs and medicines when prescribed by a licensed 82
physician, dentist, podiatrist, or an advanced practice 83
registered nurse; except that no payment for drugs and 84
medicines prescribed on and after January 1, 2006, by a 85
licensed physician, dentist, podiatrist, or an advanced 86
practice registered nurse may be made on behalf of any 87
person who qualifies for prescription drug coverage under 88
the provisions of P.L. 108-173; 89
(9) Emergency ambulance services and, effective 90
January 1, 1990, medically necessary transportation to 91
scheduled, physician-prescribed nonelective treatments; 92
(10) Early and periodic screening and diagnosis of 93
individuals who are under the age of twenty-one to ascertain 94
their physical or mental defects, and health care, 95
treatment, and other measures to correct or ameliorate 96
defects and chronic conditions discovered thereby. Such 97
services shall be provided in accordance with the provisions 98
of Section 6403 of P.L. 101-239 and federal regulations 99
promulgated thereunder; 100
(11) Home health care services; 101
(12) Family planning as defined by federal rules and 102
regulations; provided, that no funds shall be expended to 103
any abortion facility, as defined in section 188.015, or to 104
any affiliate, as defined in section 188.015, of such 105
abortion facility; and further provided, however, that such 106
family planning services shall not include abortions or any 107
abortifacient drug or device that is used for the purpose of 108
inducing an abortion unless such abortions are certified in 109
writing by a physician to the MO HealthNet agency that, in 110
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the physician's professional judgment, the life of the 111
mother would be endangered if the fetus were carried to term; 112
(13) Inpatient psychiatric hospital services for 113
individuals under age twenty-one as defined in Title XIX of 114
the federal Social Security Act (42 U.S.C. Section 1396d, et 115
seq.); 116
(14) Outpatient surgical procedures, including 117
presurgical diagnostic services performed in ambulatory 118
surgical facilities which are licensed by the department of 119
health and senior services of the state of Missouri; except, 120
that such outpatient surgical services shall not include 121
persons who are eligible for coverage under Part B of Title 122
XVIII, Public Law 89-97, 1965 amendments to the federal 123
Social Security Act, as amended, if exclusion of such 124
persons is permitted under Title XIX, Public Law 89-97, 1965 125
amendments to the federal Social Security Act, as amended; 126
(15) Personal care services which are medically 127
oriented tasks having to do with a person's physical 128
requirements, as opposed to housekeeping requirements, which 129
enable a person to be treated by his or her physician on an 130
outpatient rather than on an inpatient or residential basis 131
in a hospital, intermediate care facility, or skilled 132
nursing facility. Personal care services shall be rendered 133
by an individual not a member of the participant's family 134
who is qualified to provide such services where the services 135
are prescribed by a physician in accordance with a plan of 136
treatment and are supervised by a licensed nurse. Persons 137
eligible to receive personal care services shall be those 138
persons who would otherwise require placement in a hospital, 139
intermediate care facility, or skilled nursing facility. 140
Benefits payable for personal care services shall not exceed 141
for any one participant one hundred percent of the average 142
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statewide charge for care and treatment in an intermediate 143
care facility for a comparable period of time. Such 144
services, when delivered in a residential care facility or 145
assisted living facility licensed under chapter 198, shall 146
be authorized on a tier level based on the services the 147
resident requires and the frequency of the services. A 148
resident of such facility who qualifies for assistance under 149
section 208.030 shall, at a minimum, if prescribed by a 150
physician, qualify for the tier level with the fewest 151
services. The rate paid to providers for each tier of 152
service shall be set subject to appropriations. Subject to 153
appropriations, each resident of such facility who qualifies 154
for assistance under section 208.030 and meets the level of 155
care required in this section shall, at a minimum, if 156
prescribed by a physician, be authorized up to one hour of 157
personal care services per day. Authorized units of 158
personal care services shall not be reduced or tier level 159
lowered unless an order approving such reduction or lowering 160
is obtained from the resident's personal physician. Such 161
authorized units of personal care services or tier level 162
shall be transferred with such resident if he or she 163
transfers to another such facility. Such provision shall 164
terminate upon receipt of relevant waivers from the federal 165
Department of Health and Human Services. If the Centers for 166
Medicare and Medicaid Services determines that such 167
provision does not comply with the state plan, this 168
provision shall be null and void. The MO HealthNet division 169
shall notify the revisor of statutes as to whether the 170
relevant waivers are approved or a determination of 171
noncompliance is made; 172
(16) Mental health services. The state plan for 173
providing medical assistance under Title XIX of the Social 174
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Security Act, 42 U.S.C. Section 1396, et seq., as amended, 175
shall include the following mental health services when such 176
services are provided by community mental health facilities 177
operated by the department of mental health or designated by 178
the department of mental health as a community mental health 179
facility or as an alcohol and drug abuse facility or as a 180
child-serving agency within the comprehensive children's 181
mental health service system established in section 182
630.097. The department of mental health shall establish by 183
administrative rule the definition and criteria for 184
designation as a community mental health facility and for 185
designation as an alcohol and drug abuse facility. Such 186
mental health services shall include: 187
(a) Outpatient mental health services including 188
preventive, diagnostic, therapeutic, rehabilitative, and 189
palliative interventions rendered to individuals in an 190
individual or group setting by a mental health professional 191
in accordance with a plan of treatment appropriately 192
established, implemented, monitored, and revised under the 193
auspices of a therapeutic team as a part of client services 194
management; 195
(b) Clinic mental health services including 196
preventive, diagnostic, therapeutic, rehabilitative, and 197
palliative interventions rendered to individuals in an 198
individual or group setting by a mental health professional 199
in accordance with a plan of treatment appropriately 200
established, implemented, monitored, and revised under the 201
auspices of a therapeutic team as a part of client services 202
management; 203
(c) Rehabilitative mental health and alcohol and drug 204
abuse services including home and community-based 205
preventive, diagnostic, therapeutic, rehabilitative, and 206
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palliative interventions rendered to individuals in an 207
individual or group setting by a mental health or alcohol 208
and drug abuse professional in accordance with a plan of 209
treatment appropriately established, implemented, monitored, 210
and revised under the auspices of a therapeutic team as a 211
part of client services management. As used in this 212
section, mental health professional and alcohol and drug 213
abuse professional shall be defined by the department of 214
mental health pursuant to duly promulgated rules. With 215
respect to services established by this subdivision, the 216
department of social services, MO HealthNet division, shall 217
enter into an agreement with the department of mental 218
health. Matching funds for outpatient mental health 219
services, clinic mental health services, and rehabilitation 220
services for mental health and alcohol and drug abuse shall 221
be certified by the department of mental health to the MO 222
HealthNet division. The agreement shall establish a 223
mechanism for the joint implementation of the provisions of 224
this subdivision. In addition, the agreement shall 225
establish a mechanism by which rates for services may be 226
jointly developed; 227
(17) Such additional services as defined by the MO 228
HealthNet division to be furnished under waivers of federal 229
statutory requirements as provided for and authorized by the 230
federal Social Security Act (42 U.S.C. Section 301, et seq.) 231
subject to appropriation by the general assembly; 232
(18) The services of an advanced practice registered 233
nurse with a collaborative practice agreement to the extent 234
that such services are provided in accordance with chapters 235
334 and 335, and regulations promulgated thereunder; 236
(19) Nursing home costs for participants receiving 237
benefit payments under subdivision (4) of this subsection to 238
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reserve a bed for the participant in the nursing home during 239
the time that the participant is absent due to admission to 240
a hospital for services which cannot be performed on an 241
outpatient basis, subject to the provisions of this 242
subdivision: 243
(a) The provisions of this subdivision shall apply 244
only if: 245
a. The occupancy rate of the nursing home is at or 246
above ninety-seven percent of MO HealthNet certified 247
licensed beds, according to the most recent quarterly census 248
provided to the department of health and senior services 249
which was taken prior to when the participant is admitted to 250
the hospital; and 251
b. The patient is admitted to a hospital for a medical 252
condition with an anticipated stay of three days or less; 253
(b) The payment to be made under this subdivision 254
shall be provided for a maximum of three days per hospital 255
stay; 256
(c) For each day that nursing home costs are paid on 257
behalf of a participant under this subdivision during any 258
period of six consecutive months such participant shall, 259
during the same period of six consecutive months, be 260
ineligible for payment of nursing home costs of two 261
otherwise available temporary leave of absence days provided 262
under subdivision (5) of this subsection; and 263
(d) The provisions of this subdivision shall not apply 264
unless the nursing home receives notice from the participant 265
or the participant's responsible party that the participant 266
intends to return to the nursing home following the hospital 267
stay. If the nursing home receives such notification and 268
all other provisions of this subsection have been satisfied, 269
the nursing home shall provide notice to the participant or 270
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the participant's responsible party prior to release of the 271
reserved bed; 272
(20) Prescribed medically necessary durable medical 273
equipment. An electronic web-based prior authorization 274
system using best medical evidence and care and treatment 275
guidelines consistent with national standards shall be used 276
to verify medical need; 277
(21) Hospice care. As used in this subdivision, the 278
term "hospice care" means a coordinated program of active 279
professional medical attention within a home, outpatient and 280
inpatient care which treats the terminally ill patient and 281
family as a unit, employing a medically directed 282
interdisciplinary team. The program provides relief of 283
severe pain or other physical symptoms and supportive care 284
to meet the special needs arising out of physical, 285
psychological, spiritual, social, and economic stresses 286
which are experienced during the final stages of illness, 287
and during dying and bereavement and meets the Medicare 288
requirements for participation as a hospice as are provided 289
in 42 CFR Part 418. The rate of reimbursement paid by the 290
MO HealthNet division to the hospice provider for room and 291
board furnished by a nursing home to an eligible hospice 292
patient shall not be less than ninety-five percent of the 293
rate of reimbursement which would have been paid for 294
facility services in that nursing home facility for that 295
patient, in accordance with subsection (c) of Section 6408 296
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 297
(22) Prescribed medically necessary dental services. 298
Such services shall be subject to appropriations. An 299
electronic web-based prior authorization system using best 300
medical evidence and care and treatment guidelines 301
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consistent with national standards shall be used to verify 302
medical need; 303
(23) Prescribed medically necessary optometric 304
services. Such services shall be subject to 305
appropriations. An electronic web-based prior authorization 306
system using best medical evidence and care and treatment 307
guidelines consistent with national standards shall be used 308
to verify medical need; 309
(24) Blood clotting products-related services. For 310
persons diagnosed with a bleeding disorder, as defined in 311
section 338.400, reliant on blood clotting products, as 312
defined in section 338.400, such services include: 313
(a) Home delivery of blood clotting products and 314
ancillary infusion equipment and supplies, including the 315
emergency deliveries of the product when medically necessary; 316
(b) Medically necessary ancillary infusion equipment 317
and supplies required to administer the blood clotting 318
products; and 319
(c) Assessments conducted in the participant's home by 320
a pharmacist, nurse, or local home health care agency 321
trained in bleeding disorders when deemed necessary by the 322
participant's treating physician; 323
(25) Medically necessary cochlear implants and hearing 324
instruments, as defined in section 345.015, that are: 325
(a) Prescribed by an audiologist, as defined in 326
section 345.015; or 327
(b) Dispensed by a hearing instrument specialist, as 328
defined in section 346.010; 329
(26) Orthotic, prosthetic, and assistive devices, 330
supplies, and services in accordance with section 208.830; 331
(27) The MO HealthNet division shall, by January 1, 332
2008, and annually thereafter, report the status of MO 333
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HealthNet provider reimbursement rates as compared to one 334
hundred percent of the Medicare reimbursement rates and 335
compared to the average dental reimbursement rates paid by 336
third-party payors licensed by the state. The MO HealthNet 337
division shall, by July 1, 2008, provide to the general 338
assembly a four-year plan to achieve parity with Medicare 339
reimbursement rates and for third-party payor average dental 340
reimbursement rates. Such plan shall be subject to 341
appropriation and the division shall include in its annual 342
budget request to the governor the necessary funding needed 343
to complete the four-year plan developed under this 344
subdivision. 345
2. Additional benefit payments for medical assistance 346
shall be made on behalf of those eligible needy children, 347
pregnant women and blind persons with any payments to be 348
made on the basis of the reasonable cost of the care or 349
reasonable charge for the services as defined and determined 350
by the MO HealthNet division, unless otherwise hereinafter 351
provided, for the following: 352
(1) Dental services; 353
(2) Services of podiatrists as defined in section 354
330.010; 355
(3) Optometric services as described in section 356
336.010; 357
(4) Orthopedic devices [or other prosthetics, 358
including], eye glasses, and dentures[, and wheelchairs]; 359
(5) Hospice care. As used in this subdivision, the 360
term "hospice care" means a coordinated program of active 361
professional medical attention within a home, outpatient and 362
inpatient care which treats the terminally ill patient and 363
family as a unit, employing a medically directed 364
interdisciplinary team. The program provides relief of 365
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severe pain or other physical symptoms and supportive care 366
to meet the special needs arising out of physical, 367
psychological, spiritual, social, and economic stresses 368
which are experienced during the final stages of illness, 369
and during dying and bereavement and meets the Medicare 370
requirements for participation as a hospice as are provided 371
in 42 CFR Part 418. The rate of reimbursement paid by the 372
MO HealthNet division to the hospice provider for room and 373
board furnished by a nursing home to an eligible hospice 374
patient shall not be less than ninety-five percent of the 375
rate of reimbursement which would have been paid for 376
facility services in that nursing home facility for that 377
patient, in accordance with subsection (c) of Section 6408 378
of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 379
(6) Comprehensive day rehabilitation services 380
beginning early posttrauma as part of a coordinated system 381
of care for individuals with disabling impairments. 382
Rehabilitation services must be based on an individualized, 383
goal-oriented, comprehensive and coordinated treatment plan 384
developed, implemented, and monitored through an 385
interdisciplinary assessment designed to restore an 386
individual to an optimal level of physical, cognitive, and 387
behavioral function. The MO HealthNet division shall 388
establish by administrative rule the definition and criteria 389
for designation of a comprehensive day rehabilitation 390
service facility, benefit limitations and payment 391
mechanism. Any rule or portion of a rule, as that term is 392
defined in section 536.010, that is created under the 393
authority delegated in this subdivision shall become 394
effective only if it complies with and is subject to all of 395
the provisions of chapter 536 and, if applicable, section 396
536.028. This section and chapter 536 are nonseverable and 397
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if any of the powers vested with the general assembly 398
pursuant to chapter 536 to review, to delay the effective 399
date, or to disapprove and annul a rule are subsequently 400
held unconstitutional, then the grant of rulemaking 401
authority and any rule proposed or adopted after August 28, 402
2005, shall be invalid and void. 403
3. The MO HealthNet division may require any 404
participant receiving MO HealthNet benefits to pay part of 405
the charge or cost until July 1, 2008, and an additional 406
payment after July 1, 2008, as defined by rule duly 407
promulgated by the MO HealthNet division, for all covered 408
services except for those services covered under 409
subdivisions (15) and (16) of subsection 1 of this section 410
and sections 208.631 to 208.657 to the extent and in the 411
manner authorized by Title XIX of the federal Social 412
Security Act (42 U.S.C. Section 1396, et seq.) and 413
regulations thereunder. When substitution of a generic drug 414
is permitted by the prescriber according to section 338.056, 415
and a generic drug is substituted for a name-brand drug, the 416
MO HealthNet division may not lower or delete the 417
requirement to make a co-payment pursuant to regulations of 418
Title XIX of the federal Social Security Act. A provider of 419
goods or services described under this section must collect 420
from all participants the additional payment that may be 421
required by the MO HealthNet division under authority 422
granted herein, if the division exercises that authority, to 423
remain eligible as a provider. Any payments made by 424
participants under this section shall be in addition to and 425
not in lieu of payments made by the state for goods or 426
services described herein except the participant portion of 427
the pharmacy professional dispensing fee shall be in 428
addition to and not in lieu of payments to pharmacists. A 429
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provider may collect the co-payment at the time a service is 430
provided or at a later date. A provider shall not refuse to 431
provide a service if a participant is unable to pay a 432
required payment. If it is the routine business practice of 433
a provider to terminate future services to an individual 434
with an unclaimed debt, the provider may include uncollected 435
co-payments under this practice. Providers who elect not to 436
undertake the provision of services based on a history of 437
bad debt shall give participants advance notice and a 438
reasonable opportunity for payment. A provider, 439
representative, employee, independent contractor, or agent 440
of a pharmaceutical manufacturer shall not make co-payment 441
for a participant. This subsection shall not apply to other 442
qualified children, pregnant women, or blind persons. If 443
the Centers for Medicare and Medicaid Services does not 444
approve the MO HealthNet state plan amendment submitted by 445
the department of social services that would allow a 446
provider to deny future services to an individual with 447
uncollected co-payments, the denial of services shall not be 448
allowed. The department of social services shall inform 449
providers regarding the acceptability of denying services as 450
the result of unpaid co-payments. 451
4. The MO HealthNet division shall have the right to 452
collect medication samples from participants in order to 453
maintain program integrity. 454
5. Reimbursement for obstetrical and pediatric 455
services under subdivision (6) of subsection 1 of this 456
section shall be timely and sufficient to enlist enough 457
health care providers so that care and services are 458
available under the state plan for MO HealthNet benefits at 459
least to the extent that such care and services are 460
available to the general population in the geographic area, 461
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as required under subparagraph (a)(30)(A) of 42 U.S.C. 462
Section 1396a and federal regulations promulgated thereunder. 463
6. Beginning July 1, 1990, reimbursement for services 464
rendered in federally funded health centers shall be in 465
accordance with the provisions of subsection 6402(c) and 466
Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation 467
Act of 1989) and federal regulations promulgated thereunder. 468
7. Beginning July 1, 1990, the department of social 469
services shall provide notification and referral of children 470
below age five, and pregnant, breast-feeding, or postpartum 471
women who are determined to be eligible for MO HealthNet 472
benefits under section 208.151 to the special supplemental 473
food programs for women, infants and children administered 474
by the department of health and senior services. Such 475
notification and referral shall conform to the requirements 476
of Section 6406 of P.L. 101-239 and regulations promulgated 477
thereunder. 478
8. Providers of long-term care services shall be 479
reimbursed for their costs in accordance with the provisions 480
of Section 1902 (a)(13)(A) of the Social Security Act, 42 481
U.S.C. Section 1396a, as amended, and regulations 482
promulgated thereunder. 483
9. Reimbursement rates to long-term care providers 484
with respect to a total change in ownership, at arm's 485
length, for any facility previously licensed and certified 486
for participation in the MO HealthNet program shall not 487
increase payments in excess of the increase that would 488
result from the application of Section 1902 (a)(13)(C) of 489
the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C). 490
10. The MO HealthNet division may enroll qualified 491
residential care facilities and assisted living facilities, 492
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as defined in chapter 198, as MO HealthNet personal care 493
providers. 494
11. Any income earned by individuals eligible for 495
certified extended employment at a sheltered workshop under 496
chapter 178 shall not be considered as income for purposes 497
of determining eligibility under this section. 498
12. If the Missouri Medicaid audit and compliance unit 499
changes any interpretation or application of the 500
requirements for reimbursement for MO HealthNet services 501
from the interpretation or application that has been applied 502
previously by the state in any audit of a MO HealthNet 503
provider, the Missouri Medicaid audit and compliance unit 504
shall notify all affected MO HealthNet providers five 505
business days before such change shall take effect. Failure 506
of the Missouri Medicaid audit and compliance unit to notify 507
a provider of such change shall entitle the provider to 508
continue to receive and retain reimbursement until such 509
notification is provided and shall waive any liability of 510
such provider for recoupment or other loss of any payments 511
previously made prior to the five business days after such 512
notice has been sent. Each provider shall provide the 513
Missouri Medicaid audit and compliance unit a valid email 514
address and shall agree to receive communications 515
electronically. The notification required under this 516
section shall be delivered in writing by the United States 517
Postal Service or electronic mail to each provider. 518
13. Nothing in this section shall be construed to 519
abrogate or limit the department's statutory requirement to 520
promulgate rules under chapter 536. 521
14. Beginning July 1, 2016, and subject to 522
appropriations, providers of behavioral, social, and 523
psychophysiological services for the prevention, treatment, 524
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or management of physical health problems shall be 525
reimbursed utilizing the behavior assessment and 526
intervention reimbursement codes 96150 to 96154 or their 527
successor codes under the Current Procedural Terminology 528
(CPT) coding system. Providers eligible for such 529
reimbursement shall include psychologists. 530
15. There shall be no payments made under this section 531
for gender transition surgeries, cross-sex hormones, or 532
puberty-blocking drugs, as such terms are defined in section 533
191.1720, for the purpose of a gender transition. 534
208.830. 1. As used in this section, terms shall have 1
the same meanings given to them in section 376.1232. 2
2. The MO HealthNet program shall cover orthotic, 3
prosthetic, and assistive devices, supplies, and services 4
furnished under an order by a prescribing physician or 5
licensed health care provider who has authority in this 6
state to prescribe orthotic, prosthetic, and assistive 7
devices. The coverage shall be at least equal to the 8
coverage provided under federal law for health insurance for 9
the aged and disabled under 42 U.S.C. Sections 1395k, 1395l, 10
and 1395m, but only to the extent consistent with this 11
section. 12
3. Coverage for orthotic, prosthetic, and assistive 13
devices, supplies, accessories, and services under this 14
section includes those devices or device systems, supplies, 15
accessories, and services that are customized to the 16
participant's needs for purposes of activities of daily 17
living and essential job-related activities. This 18
requirement applies to the type of device as follows: 19
(1) For orthotic and prosthetic devices, this 20
subsection requires coverage of devices intended for primary 21
or daily use; and 22
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(2) For assistive devices, this subsection requires 23
coverage of: 24
(a) One wheelchair for daily use; and 25
(b) One manual wheelchair for backup use. 26
4. The MO HealthNet program shall cover orthotic, 27
prosthetic, and assistive devices determined by the 28
participant's provider to be the most appropriate model that 29
meets the medical needs of the participant for purposes of 30
performing physical activities, as applicable, including, 31
but not limited to, running, biking, and swimming, and 32
maximizing the participant's whole-body health and function, 33
including coverage of an activity wheelchair if medically 34
necessary. 35
5. The MO HealthNet program shall cover orthotic, 36
prosthetic, and assistive devices for showering or bathing. 37
6. The coverage set forth in this section includes the 38
repair and replacement of those orthotic, prosthetic, and 39
assistive devices, supplies, and services described in this 40
section. 41
7. Coverage of an orthotic, prosthetic, or assistive 42
benefit shall not be denied for an individual with limb loss 43
or absence that would otherwise be covered for a nondisabled 44
person seeking medical or surgical intervention to restore 45
or maintain the ability to perform the same physical 46
activity. 47
8. If coverage for prosthetic, custom orthotic, or 48
assistive devices is provided, payment shall be made for the 49
replacement of a prosthetic, custom orthotic, or assistive 50
device or for the replacement of any part of such devices, 51
without regard to continuous use or useful lifetime 52
restrictions, if an ordering health care provider determines 53
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that the provision of a replacement device, or a replacement 54
part of a device, is necessary because: 55
(1) Of a change in the physiological condition of the 56
patient; 57
(2) Of an irreparable change in the condition of the 58
device or in a part of the device; or 59
(3) The condition of the device, or the part of the 60
device, requires repairs and the cost of such repairs would 61
be more than sixty percent of the cost of a replacement 62
device or of the part being replaced. 63
9. Prior authorization may be required for orthotic, 64
prosthetic, and assistive devices, supplies, and services. 65
10. Utilization review determinations shall be 66
rendered in a nondiscriminatory manner and shall not deny 67
coverage for habilitative or rehabilitative benefits, 68
including prosthetics, orthotics, or assistive services, 69
solely on the basis of a participant's actual or perceived 70
disability. 71
11. Evidence of coverage and any benefit denial 72
letters shall include language describing a participant's 73
rights under subsection 10 of this section. Any denial of 74
coverage shall be issued in writing with an explanation that 75
contains clear reasoning and a description of how and why 76
the request or claim does not meet medical necessity 77
standards. 78
12. Confirmation from a prescribing health care 79
provider may be required if the prosthetic, custom orthotic, 80
or assistive device or part being replaced is less than 81
three years old. 82
13. (1) Managed care plans subject to this section 83
shall ensure access to medically necessary clinical care and 84
to prosthetic, custom orthotic, and assistive devices and 85
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technology from at least two distinct prosthetic, custom 86
orthotic, and assistive device providers in the plan's 87
provider network located in this state. 88
(2) If medically necessary covered orthotic, 89
prosthetic, and assistive devices are not available from an 90
in-network provider, the plan shall provide processes to 91
refer a participant to an out-of-network provider and shall 92
fully reimburse the out-of-network provider at a mutually 93
agreed upon rate less participant cost sharing determined on 94
an in-network basis. 95
376.1232. 1. As used in sections 376.1232 to 1
376.1234, the following terms mean: 2
(1) "Accredited facility", any entity that is 3
accredited to provide comprehensive orthotic, prosthetic, or 4
assistive devices or services by a Centers for Medicare and 5
Medicaid Services-approved accrediting agency; 6
(2) "Activity wheelchair", a wheelchair that is 7
designed specifically to enable individuals with mobility 8
issues to participate in sports or fitness activities by 9
providing better speed, maneuverability, and balance than a 10
standard wheelchair used for activities of daily living; 11
(3) "Assistive device": 12
(a) Any external medical device that: 13
a. Allows an individual with a mobility impairment to 14
move in indoor and outdoor spaces including, but not limited 15
to, a manual wheelchair, a motorized wheelchair, or an 16
activity wheelchair; and 17
b. Is deemed medically necessary by a prescribing 18
physician or licensed health care provider who has authority 19
in this state to prescribe assistive devices; and 20
(b) Any provision, repair, or replacement of the 21
device that is furnished or performed by: 22
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a. An accredited facility in comprehensive assistive 23
services; or 24
b. A health care provider licensed in this state and 25
operating within the provider's scope of practice that 26
allows the provider to provide assistive devices, supplies, 27
or services; 28
(4) "Assistive services": 29
(a) The science and practice of evaluating, fitting, 30
adjusting, or servicing, as well as providing the initial 31
training necessary to accomplish the fitting of, an 32
assistive device for mobility; 33
(b) Evaluation, treatment, and consultation related to 34
an assistive device; 35
(c) Assessment of assistive devices to maximize 36
function and provide support and alignment necessary to 37
improve the safety and efficiency of mobility and locomotion; 38
(d) Continuation of patient care to assess the effect 39
of an assistive device on the patient's mobility; and 40
(e) Assurance of proper fit and function of the 41
assistive device by periodic evaluation; 42
(5) "Enrollee", the same meaning given to the term in 43
section 376.1350; 44
(6) "Health benefit plan", the same meaning given to 45
the term in section 376.1350. The term "health benefit 46
plan" shall also include the Missouri consolidated health 47
care plan established under chapter 103 and any other state- 48
sponsored health insurance program; 49
(7) "Health carrier", the same meaning given to the 50
term in section 376.1350; 51
(8) "Orthosis" or "orthotic device": 52
(a) An external medical device that is: 53
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a. Custom-fabricated or custom-fitted to a specific 54
patient based on the patient's unique physical condition; 55
b. Applied to a part of the body to correct a 56
deformity, provide support and protection, restrict motion, 57
improve function, or relieve symptoms of a disease, 58
syndrome, injury, or postoperative condition; and 59
c. Deemed medically necessary by a prescribing 60
physician or licensed health care provider who has authority 61
in this state to prescribe orthotic devices, supplies, and 62
services; and 63
(b) Any provision, repair, or replacement of the 64
device that is furnished or performed by: 65
a. An accredited facility in comprehensive orthotic 66
services; or 67
b. A health care provider licensed in this state and 68
operating within the provider's scope of practice that 69
allows the provider to provide orthotic devices, supplies, 70
or services; 71
(9) "Orthotics": 72
(a) The science and practice of evaluating, measuring, 73
designing, fabricating, assembling, fitting, adjusting, or 74
servicing, as well as providing the initial training 75
necessary to accomplish the fitting of, an orthosis for the 76
support, correction, or alleviation of a neuromuscular or 77
musculoskeletal dysfunction, disease, injury, or deformity; 78
(b) Evaluation, treatment, and consultation related to 79
an orthotic device; 80
(c) Basic observation of gait and postural analysis; 81
(d) Assessment and design of orthoses to maximize 82
function and provide support and alignment necessary to 83
prevent or correct a deformity or to improve the safety and 84
efficiency of mobility and locomotion; 85
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(e) Continuation of patient care to assess the effect 86
of an orthotic device on the patient's tissues; and 87
(f) Assurance of proper fit and function of the 88
orthotic device by periodic evaluation; 89
(10) "Prosthesis" or "prosthetic device": 90
(a) An external medical device that is: 91
a. Used to replace or restore a missing limb, 92
appendage, or other external human body part; and 93
b. Deemed medically necessary by a prescribing 94
physician or licensed health care provider who has authority 95
in this state to prescribe prosthetic devices, supplies, and 96
services; and 97
(b) Any provision, repair, or replacement of the 98
device that is furnished or performed by: 99
a. An accredited facility in comprehensive prosthetic 100
services; or 101
b. A health care provider licensed in this state and 102
operating within the provider's scope of practice that 103
allows the provider to provide prosthetic devices, supplies, 104
or services; 105
(11) "Prosthetics": 106
(a) The science and practice of evaluating, measuring, 107
designing, fabricating, assembling, fitting, aligning, 108
adjusting, or servicing, as well as providing the initial 109
training necessary to accomplish the fitting of, a 110
prosthesis through the replacement of external parts of a 111
human body lost due to amputation or congenital deformities 112
or absences; 113
(b) The generation of an image, form, or mold that 114
replicates the patient's body segment and that requires 115
rectification of dimensions, contours, and volumes for use 116
in the design and fabrication of a socket to accept a 117
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residual anatomic limb to, in turn, create an artificial 118
appendage that is designed either to support body weight or 119
to improve or restore function or anatomical appearance, or 120
both; 121
(c) Observational gait analysis and clinical 122
assessment of the requirements necessary to refine and 123
mechanically fix the relative position of various parts of 124
the prosthesis to maximize function, stability, and safety 125
of the patient; 126
(d) The provision and continuation of patient care in 127
order to assess the prosthetic device's effect on the 128
patient's tissues; and 129
(e) Assurance of proper fit and function of the 130
prosthetic device by periodic evaluation; 131
(12) "Utilization review", the same meaning given to 132
the term in section 376.1350. 133
2. Each health carrier or health benefit plan that 134
offers or issues health benefit plans which are delivered, 135
issued for delivery, continued, or renewed in this state on 136
or after January 1, 2010, shall [offer] provide coverage for 137
orthotic, prosthetic, and assistive devices, supplies, and 138
services, including [original] repair and replacement 139
[devices, as prescribed by a physician acting within the 140
scope of his or her practice]. The coverage shall be at 141
least equal to the coverage provided under federal law for 142
health insurance for the aged and disabled under 42 U.S.C. 143
Sections 1395k, 1395l, and 1395m, but only to the extent 144
consistent with this section. 145
[2. For the purposes of this section, "health carrier" 146
and "health benefit plan" shall have the same meaning as 147
defined in section 376.1350.] 148
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3. The amount of the benefit for orthotic, prosthetic, 149
and assistive devices and services under this section shall 150
be no less than the annual and lifetime benefit maximums 151
applicable to the basic health care services required to be 152
provided under the health benefit plan. If the health 153
benefit plan does not include any annual or lifetime 154
maximums applicable to basic health care services, the 155
amount of the benefit for orthotic, prosthetic, and 156
assistive devices and services shall not be subject to an 157
annual or lifetime maximum benefit level. Any co-payment, 158
coinsurance, deductible, and maximum out-of-pocket amount 159
applied to the benefit for orthotic, prosthetic, and 160
assistive devices and services shall be no more than the 161
most common amounts applied to the basic health care 162
services required to be provided under the health benefit 163
plan. 164
4. A health carrier or health benefit plan may limit 165
the benefits for, or alter the financial requirements for, 166
out-of-network coverage of orthotic, prosthetic, and 167
assistive devices, except that the restrictions and 168
requirements that apply to those benefits shall not be more 169
restrictive than the financial requirements that apply to 170
the out-of-network coverage for the basic health care 171
services to be provided under the health benefit plan. 172
5. A health carrier or health benefit plan shall not 173
subject coverage for orthotic, prosthetic, and assistive 174
devices, supplies, and services to any limitations for 175
preexisting conditions. 176
6. A health carrier or health benefit plan shall cover 177
orthotic, prosthetic, and assistive devices when furnished 178
under an order by a prescribing physician or licensed health 179
care prescriber who has authority in this state to prescribe 180
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orthotic, prosthetic, and assistive devices. The coverage 181
for orthotic, prosthetic, and assistive devices, supplies, 182
accessories, and services shall include those devices or 183
device systems, supplies, accessories, and services that are 184
customized to the covered individual's needs for purposes of 185
activities of daily living and essential job-related 186
activities. 187
7. A health carrier or health benefit plan shall cover 188
orthotic, prosthetic, and assistive devices determined by 189
the enrollee's provider to be the most appropriate model 190
that meets the medical needs of the enrollee for purposes of 191
performing physical activities, as applicable, including, 192
but not limited to, running, biking, and swimming, and 193
maximizing the enrollee's whole-body health and function. 194
8. A health carrier or health benefit plan shall cover 195
orthotic, prosthetic, and assistive devices for showering or 196
bathing. 197
9. A health carrier or health benefit plan shall cover 198
at least the following for an enrollee entitled to coverage 199
of prostheses or orthoses: 200
(1) One prosthesis or orthosis for daily use; 201
(2) One prosthesis or orthosis designed for physical 202
activity; and 203
(3) One prosthesis or orthosis for showering or 204
bathing. 205
10. A health carrier or health benefit plan shall 206
cover at least the following for an enrollee entitled to 207
coverage of assistive devices: 208
(1) One wheelchair for daily use; 209
(2) One manual wheelchair for backup use; and 210
(3) One activity wheelchair if medically necessary to 211
enable the enrollee to engage in physical activities, as 212
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applicable, including, but not limited to, running, biking, 213
swimming, and strength training, and to maximize the 214
enrollee's whole-body health and lower or upper limb 215
function. 216
11. A health carrier or health benefit plan may 217
require prior authorization for orthotic, prosthetic, and 218
assistive devices, supplies, and services in the same manner 219
and to the same extent as prior authorization is required 220
for any other covered benefit. 221
12. Except as provided in subsection 13 of this 222
section, the provisions of this section shall not apply to a 223
supplemental insurance policy, including a life care 224
contract, accident-only policy, specified disease policy, 225
hospital policy providing a fixed daily benefit only, 226
[Medicare supplement policy,] long-term care policy, short- 227
term major medical policies of six months or less duration, 228
or any other supplemental policy as determined by the 229
director of the department of commerce and insurance. 230
13. Notwithstanding section 376.998 or any other 231
provision of law to the contrary, the provisions of this 232
section shall apply to a Medicare supplement policy. 233
376.1233. 1. A health carrier or health benefit plan 1
shall render utilization review determinations in a 2
nondiscriminatory manner and shall not deny coverage for 3
habilitative or rehabilitative benefits, including 4
prosthetics, orthotics, or assistive services, solely on the 5
basis of an enrollee's actual or perceived disability. 6
2. A health carrier or health benefit plan shall not 7
deny a prosthetic, orthotic, or assistive benefit for an 8
individual with limb loss or absence that would otherwise be 9
covered for a nondisabled person seeking medical or surgical 10
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intervention to restore or maintain the ability to perform 11
the same physical activity. 12
3. A health benefit plan offered, issued, or renewed 13
in this state that offers coverage for prosthetics, custom 14
orthotic devices, and assistive devices shall include 15
language describing an enrollee's rights under subsections 1 16
and 2 of this section in its evidence of coverage and any 17
benefit denial letters. Any denial of coverage shall be 18
issued in writing with an explanation that contains clear 19
reasoning and a description of how and why the request or 20
claim does not meet medical necessity standards. 21
4. A health carrier or health benefit plan that 22
provides coverage for prosthetic, orthotic, or assistive 23
services shall ensure access to medically necessary clinical 24
care and to prosthetic, custom orthotic, and assistive 25
devices and technology from not less than two distinct 26
prosthetic, custom orthotic, and assistive device providers 27
in the plan's provider network located in this state. If 28
medically necessary covered orthotics, prosthetics, and 29
assistive services are not available from an in-network 30
provider, the health carrier or health benefit plan shall 31
provide processes to refer a member to an out-of-network 32
provider and shall fully reimburse the out-of-network 33
provider at a mutually agreed upon rate less member cost 34
sharing determined on an in-network basis. 35
5. If coverage for prosthetic, custom orthotic, or 36
assistive devices is provided, payment shall be made for the 37
replacement of a prosthetic, custom orthotic, or assistive 38
device or for the replacement of any part of such devices, 39
without regard to continuous use or useful lifetime 40
restrictions, if an ordering health care provider determines 41
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that the provision of a replacement device, or a replacement 42
part of a device, is necessary because: 43
(1) Of a change in the physiological condition of the 44
patient; 45
(2) Of an irreparable change in the condition of the 46
device or in a part of the device; or 47
(3) The condition of the device, or the part of the 48
device, requires repairs and the cost of such repairs would 49
be more than sixty percent of the cost of a replacement 50
device or of the part being replaced. 51
6. Confirmation from a prescribing health care 52
provider may be required if the prosthetic, custom orthotic, 53
or assistive device or part being replaced is less than 54
three years old. 55
376.1234. 1. Before October 1, 2027, each health 1
carrier that issues a health benefit plan providing coverage 2
of orthotic, prosthetic, and assistive devices, supplies, 3
and services as required under sections 376.1232 to 376.1234 4
shall report to the director of the department of commerce 5
and insurance on its experience with the requirements of 6
sections 376.1232 to 376.1234 for the first year following 7
August 28, 2026. The report shall be in a form prescribed 8
by the director and shall include the number of claims and 9
the total amount of claims paid in this state for the 10
services required by sections 376.1232 to 376.1234. The 11
director shall aggregate this data in a report and submit 12
the report to the house and senate standing committees 13
having jurisdiction over health insurance matters before 14
December 1, 2027. 15
2. The director may promulgate any necessary rules and 16
regulations to implement sections 376.1232 to 376.1234. Any 17
rule or portion of a rule, as that term is defined in 18
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section 536.010, that is created under the authority 19
delegated in this section shall become effective only if it 20
complies with and is subject to all of the provisions of 21
chapter 536 and, if applicable, section 536.028. This 22
section and chapter 536 are nonseverable and if any of the 23
powers vested with the general assembly pursuant to chapter 24
536 to review, to delay the effective date, or to disapprove 25
and annul a rule are subsequently held unconstitutional, 26
then the grant of rulemaking authority and any rule proposed 27
or adopted after August 28, 2026, shall be invalid and void. 28
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