Missouri Revised Statutes













Chapter 208

Old Age Assistance, Aid to Dependent Children and General Relief

←208.151

Section 208.152.1

208.153→

August 28, 2015

Medical services for which payment will be made--co-payments may be required--reimbursement for services--notification upon change in interpretation or application of reimbursement.

208.152. 1. MO HealthNet payments shall be made on behalf of those

eligible needy persons as defined in section 208.151 who are unable to

provide for it in whole or in part, with any payments to be made on the

basis of the reasonable cost of the care or reasonable charge for the

services as defined and determined by the MO HealthNet division, unless

otherwise hereinafter provided, for the following:



(1) Inpatient hospital services, except to persons in an institution

for mental diseases who are under the age of sixty-five years and over the

age of twenty-one years; provided that the MO HealthNet division shall

provide through rule and regulation an exception process for coverage of

inpatient costs in those cases requiring treatment beyond the seventy-fifth

percentile professional activities study (PAS) or the MO HealthNet

children's diagnosis length-of-stay schedule; and provided further that the

MO HealthNet division shall take into account through its payment system

for hospital services the situation of hospitals which serve a

disproportionate number of low-income patients;



(2) All outpatient hospital services, payments therefor to be in

amounts which represent no more than eighty percent of the lesser of

reasonable costs or customary charges for such services, determined in

accordance with the principles set forth in Title XVIII A and B, Public Law

89-97, 1965 amendments to the federal Social Security Act (42 U.S.C.

Section 301, et seq.), but the MO HealthNet division may evaluate

outpatient hospital services rendered under this section and deny payment

for services which are determined by the MO HealthNet division not to be

medically necessary, in accordance with federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for participants, except to persons with

more than five hundred thousand dollars equity in their home or except for

persons in an institution for mental diseases who are under the age of

sixty-five years, when residing in a hospital licensed by the department of

health and senior services or a nursing home licensed by the department of

health and senior services or appropriate licensing authority of other

states or government-owned and -operated institutions which are determined

to conform to standards equivalent to licensing requirements in Title XIX

of the federal Social Security Act (42 U.S.C. Section 301, et seq.), as

amended, for nursing facilities. The MO HealthNet division may recognize

through its payment methodology for nursing facilities those nursing

facilities which serve a high volume of MO HealthNet patients. The MO

HealthNet division when determining the amount of the benefit payments to

be made on behalf of persons under the age of twenty-one in a nursing

facility may consider nursing facilities furnishing care to persons under

the age of twenty-one as a classification separate from other nursing

facilities;



(5) Nursing home costs for participants receiving benefit payments

under subdivision (4) of this subsection for those days, which shall not

exceed twelve per any period of six consecutive months, during which the

participant is on a temporary leave of absence from the hospital or nursing

home, provided that no such participant shall be allowed a temporary leave

of absence unless it is specifically provided for in his plan of care. As

used in this subdivision, the term "temporary leave of absence" shall

include all periods of time during which a participant is away from the

hospital or nursing home overnight because he is visiting a friend or

relative;



(6) Physicians' services, whether furnished in the office, home,

hospital, nursing home, or elsewhere;



(7) Drugs and medicines when prescribed by a licensed physician,

dentist, podiatrist, or an advanced practice registered nurse; except that

no payment for drugs and medicines prescribed on and after January 1, 2006,

by a licensed physician, dentist, podiatrist, or an advanced practice

registered nurse may be made on behalf of any person who qualifies for

prescription drug coverage under the provisions of P.L. 108-173;



(8) Emergency ambulance services and, effective January 1, 1990,

medically necessary transportation to scheduled, physician-prescribed

nonelective treatments;



(9) Early and periodic screening and diagnosis of individuals who are

under the age of twenty-one to ascertain their physical or mental defects,

and health care, treatment, and other measures to correct or ameliorate

defects and chronic conditions discovered thereby. Such services shall be

provided in accordance with the provisions of Section 6403 of P.L. 101-239

and federal regulations promulgated thereunder;



(10) Home health care services;



(11) Family planning as defined by federal rules and regulations;

provided, however, that such family planning services shall not include

abortions unless such abortions are certified in writing by a physician to

the MO HealthNet agency that, in the physician's professional judgment, the

life of the mother would be endangered if the fetus were carried to term;



(12) Inpatient psychiatric hospital services for individuals under

age twenty-one as defined in Title XIX of the federal Social Security Act

(42 U.S.C. Section 1396d, et seq.);



(13) Outpatient surgical procedures, including presurgical diagnostic

services performed in ambulatory surgical facilities which are licensed by

the department of health and senior services of the state of Missouri;

except, that such outpatient surgical services shall not include persons

who are eligible for coverage under Part B of Title XVIII, Public Law

89-97, 1965 amendments to the federal Social Security Act, as amended, if

exclusion of such persons is permitted under Title XIX, Public Law 89-97,

1965 amendments to the federal Social Security Act, as amended;



(14) Personal care services which are medically oriented tasks having

to do with a person's physical requirements, as opposed to housekeeping

requirements, which enable a person to be treated by his or her physician

on an outpatient rather than on an inpatient or residential basis in a

hospital, intermediate care facility, or skilled nursing facility.

Personal care services shall be rendered by an individual not a member of

the participant's family who is qualified to provide such services where

the services are prescribed by a physician in accordance with a plan of

treatment and are supervised by a licensed nurse. Persons eligible to

receive personal care services shall be those persons who would otherwise

require placement in a hospital, intermediate care facility, or skilled

nursing facility. Benefits payable for personal care services shall not

exceed for any one participant one hundred percent of the average statewide

charge for care and treatment in an intermediate care facility for a

comparable period of time. Such services, when delivered in a residential

care facility or assisted living facility licensed under chapter 198 shall

be authorized on a tier level based on the services the resident requires

and the frequency of the services. A resident of such facility who

qualifies for assistance under section 208.030 shall, at a minimum, if

prescribed by a physician, qualify for the tier level with the fewest

services. The rate paid to providers for each tier of service shall be set

subject to appropriations. Subject to appropriations, each resident of

such facility who qualifies for assistance under section 208.030 and meets

the level of care required in this section shall, at a minimum, if

prescribed by a physician, be authorized up to one hour of personal care

services per day. Authorized units of personal care services shall not be

reduced or tier level lowered unless an order approving such reduction or

lowering is obtained from the resident's personal physician. Such

authorized units of personal care services or tier level shall be

transferred with such resident if he or she transfers to another such

facility. Such provision shall terminate upon receipt of relevant waivers

from the federal Department of Health and Human Services. If the Centers

for Medicare and Medicaid Services determines that such provision does not

comply with the state plan, this provision shall be null and void. The MO

HealthNet division shall notify the revisor of statutes as to whether the

relevant waivers are approved or a determination of noncompliance is made;



(15) Mental health services. The state plan for providing medical

assistance under Title XIX of the Social Security Act, 42 U.S.C. Section

301, as amended, shall include the following mental health services when

such services are provided by community mental health facilities operated

by the department of mental health or designated by the department of

mental health as a community mental health facility or as an alcohol and

drug abuse facility or as a child-serving agency within the comprehensive

children's mental health service system established in section 630.097.

The department of mental health shall establish by administrative rule the

definition and criteria for designation as a community mental health

facility and for designation as an alcohol and drug abuse facility. Such

mental health services shall include:



(a) Outpatient mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative interventions

rendered to individuals in an individual or group setting by a mental

health professional in accordance with a plan of treatment appropriately

established, implemented, monitored, and revised under the auspices of a

therapeutic team as a part of client services management;



(b) Clinic mental health services including preventive, diagnostic,

therapeutic, rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health

professional in accordance with a plan of treatment appropriately

established, implemented, monitored, and revised under the auspices of a

therapeutic team as a part of client services management;



(c) Rehabilitative mental health and alcohol and drug abuse services

including home and community-based preventive, diagnostic, therapeutic,

rehabilitative, and palliative interventions rendered to individuals in an

individual or group setting by a mental health or alcohol and drug abuse

professional in accordance with a plan of treatment appropriately

established, implemented, monitored, and revised under the auspices of a

therapeutic team as a part of client services management. As used in this

section, mental health professional and alcohol and drug abuse professional

shall be defined by the department of mental health pursuant to duly

promulgated rules. With respect to services established by this

subdivision, the department of social services, MO HealthNet division,

shall enter into an agreement with the department of mental health.

Matching funds for outpatient mental health services, clinic mental health

services, and rehabilitation services for mental health and alcohol and

drug abuse shall be certified by the department of mental health to the MO

HealthNet division. The agreement shall establish a mechanism for the

joint implementation of the provisions of this subdivision. In addition,

the agreement shall establish a mechanism by which rates for services may

be jointly developed;



(16) Such additional services as defined by the MO HealthNet division

to be furnished under waivers of federal statutory requirements as provided

for and authorized by the federal Social Security Act (42 U.S.C. Section

301, et seq.) subject to appropriation by the general assembly;



(17) The services of an advanced practice registered nurse with a

collaborative practice agreement to the extent that such services are

provided in accordance with chapters 334 and 335, and regulations

promulgated thereunder;



(18) Nursing home costs for participants receiving benefit payments

under subdivision (4) of this subsection to reserve a bed for the

participant in the nursing home during the time that the participant is

absent due to admission to a hospital for services which cannot be

performed on an outpatient basis, subject to the provisions of this

subdivision:



(a) The provisions of this subdivision shall apply only if:



a. The occupancy rate of the nursing home is at or above ninety-seven

percent of MO HealthNet certified licensed beds, according to the most

recent quarterly census provided to the department of health and senior

services which was taken prior to when the participant is admitted to the

hospital; and



b. The patient is admitted to a hospital for a medical condition with

an anticipated stay of three days or less;



(b) The payment to be made under this subdivision shall be provided

for a maximum of three days per hospital stay;



(c) For each day that nursing home costs are paid on behalf of a

participant under this subdivision during any period of six consecutive

months such participant shall, during the same period of six consecutive

months, be ineligible for payment of nursing home costs of two otherwise

available temporary leave of absence days provided under subdivision (5) of

this subsection; and



(d) The provisions of this subdivision shall not apply unless the

nursing home receives notice from the participant or the participant's

responsible party that the participant intends to return to the nursing

home following the hospital stay. If the nursing home receives such

notification and all other provisions of this subsection have been

satisfied, the nursing home shall provide notice to the participant or the

participant's responsible party prior to release of the reserved bed;



(19) Prescribed medically necessary durable medical equipment. An

electronic web-based prior authorization system using best medical evidence

and care and treatment guidelines consistent with national standards shall

be used to verify medical need;



(20) Hospice care. As used in this subdivision, the term "hospice

care" means a coordinated program of active professional medical attention

within a home, outpatient and inpatient care which treats the terminally

ill patient and family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe pain or

other physical symptoms and supportive care to meet the special needs

arising out of physical, psychological, spiritual, social, and economic

stresses which are experienced during the final stages of illness, and

during dying and bereavement and meets the Medicare requirements for

participation as a hospice as are provided in 42 CFR Part 418. The rate of

reimbursement paid by the MO HealthNet division to the hospice provider for

room and board furnished by a nursing home to an eligible hospice patient

shall not be less than ninety-five percent of the rate of reimbursement

which would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of Section

6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);



(21) Prescribed medically necessary dental services. Such services

shall be subject to appropriations. An electronic web-based prior

authorization system using best medical evidence and care and treatment

guidelines consistent with national standards shall be used to verify

medical need;



(22) Prescribed medically necessary optometric services. Such

services shall be subject to appropriations. An electronic web-based prior

authorization system using best medical evidence and care and treatment

guidelines consistent with national standards shall be used to verify

medical need;



(23) Blood clotting products-related services. For persons diagnosed

with a bleeding disorder, as defined in section 338.400, reliant on blood

clotting products, as defined in section 338.400, such services include:



(a) Home delivery of blood clotting products and ancillary infusion

equipment and supplies, including the emergency deliveries of the product

when medically necessary;



(b) Medically necessary ancillary infusion equipment and supplies

required to administer the blood clotting products; and



(c) Assessments conducted in the participant's home by a pharmacist,

nurse, or local home health care agency trained in bleeding disorders when

deemed necessary by the participant's treating physician;



(24) The MO HealthNet division shall, by January 1, 2008, and

annually thereafter, report the status of MO HealthNet provider

reimbursement rates as compared to one hundred percent of the Medicare

reimbursement rates and compared to the average dental reimbursement rates

paid by third-party payors licensed by the state. The MO HealthNet

division shall, by July 1, 2008, provide to the general assembly a

four-year plan to achieve parity with Medicare reimbursement rates and for

third-party payor average dental reimbursement rates. Such plan shall be

subject to appropriation and the division shall include in its annual

budget request to the governor the necessary funding needed to complete the

four-year plan developed under this subdivision.



2. Additional benefit payments for medical assistance shall be made

on behalf of those eligible needy children, pregnant women and blind

persons with any payments to be made on the basis of the reasonable cost of

the care or reasonable charge for the services as defined and determined by

the MO HealthNet division, unless otherwise hereinafter provided, for the

following:



(1) Dental services;



(2) Services of podiatrists as defined in section 330.010;



(3) Optometric services as defined in section 336.010;



(4) Orthopedic devices or other prosthetics, including eye glasses,

dentures, hearing aids, and wheelchairs;



(5) Hospice care. As used in this subdivision, the term "hospice

care" means a coordinated program of active professional medical attention

within a home, outpatient and inpatient care which treats the terminally

ill patient and family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe pain or

other physical symptoms and supportive care to meet the special needs

arising out of physical, psychological, spiritual, social, and economic

stresses which are experienced during the final stages of illness, and

during dying and bereavement and meets the Medicare requirements for

participation as a hospice as are provided in 42 CFR Part 418. The rate of

reimbursement paid by the MO HealthNet division to the hospice provider for

room and board furnished by a nursing home to an eligible hospice patient

shall not be less than ninety-five percent of the rate of reimbursement

which would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of Section

6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989);



(6) Comprehensive day rehabilitation services beginning early

posttrauma as part of a coordinated system of care for individuals with

disabling impairments. Rehabilitation services must be based on an

individualized, goal-oriented, comprehensive and coordinated treatment plan

developed, implemented, and monitored through an interdisciplinary

assessment designed to restore an individual to optimal level of physical,

cognitive, and behavioral function. The MO HealthNet division shall

establish by administrative rule the definition and criteria for

designation of a comprehensive day rehabilitation service facility, benefit

limitations and payment mechanism. Any rule or portion of a rule, as that

term is defined in section 536.010, that is created under the authority

delegated in this subdivision shall become effective only if it complies

with and is subject to all of the provisions of chapter 536 and, if

applicable, section 536.028. This section and chapter 536 are nonseverable

and if any of the powers vested with the general assembly pursuant to

chapter 536 to review, to delay the effective date, or to disapprove and

annul a rule are subsequently held unconstitutional, then the grant of

rulemaking authority and any rule proposed or adopted after August 28,

2005, shall be invalid and void.



3. The MO HealthNet division may require any participant receiving MO

HealthNet benefits to pay part of the charge or cost until July 1, 2008,

and an additional payment after July 1, 2008, as defined by rule duly

promulgated by the MO HealthNet division, for all covered services except

for those services covered under subdivisions (14) and (15) of subsection 1

of this section and sections 208.631 to 208.657 to the extent and in the

manner authorized by Title XIX of the federal Social Security Act (42

U.S.C. Section 1396, et seq.) and regulations thereunder. When

substitution of a generic drug is permitted by the prescriber according to

section 338.056, and a generic drug is substituted for a name-brand drug,

the MO HealthNet division may not lower or delete the requirement to make a

co-payment pursuant to regulations of Title XIX of the federal Social

Security Act. A provider of goods or services described under this section

must collect from all participants the additional payment that may be

required by the MO HealthNet division under authority granted herein, if

the division exercises that authority, to remain eligible as a provider.

Any payments made by participants under this section shall be in addition

to and not in lieu of payments made by the state for goods or services

described herein except the participant portion of the pharmacy

professional dispensing fee shall be in addition to and not in lieu of

payments to pharmacists. A provider may collect the co-payment at the time

a service is provided or at a later date. A provider shall not refuse to

provide a service if a participant is unable to pay a required payment. If

it is the routine business practice of a provider to terminate future

services to an individual with an unclaimed debt, the provider may include

uncollected co-payments under this practice. Providers who elect not to

undertake the provision of services based on a history of bad debt shall

give participants advance notice and a reasonable opportunity for payment.

A provider, representative, employee, independent contractor, or agent of a

pharmaceutical manufacturer shall not make co-payment for a participant.

This subsection shall not apply to other qualified children, pregnant

women, or blind persons. If the Centers for Medicare and Medicaid Services

does not approve the MO HealthNet state plan amendment submitted by the

department of social services that would allow a provider to deny future

services to an individual with uncollected co-payments, the denial of

services shall not be allowed. The department of social services shall

inform providers regarding the acceptability of denying services as the

result of unpaid co-payments.



4. The MO HealthNet division shall have the right to collect

medication samples from participants in order to maintain program

integrity.



5. Reimbursement for obstetrical and pediatric services under

subdivision (6) of subsection 1 of this section shall be timely and

sufficient to enlist enough health care providers so that care and services

are available under the state plan for MO HealthNet benefits at least to

the extent that such care and services are available to the general

population in the geographic area, as required under subparagraph

(a)(30)(A) of 42 U.S.C. Section 1396a and federal regulations promulgated

thereunder.



6. Beginning July 1, 1990, reimbursement for services rendered in

federally funded health centers shall be in accordance with the provisions

of subsection 6402(c) and Section 6404 of P.L. 101-239 (Omnibus Budget

Reconciliation Act of 1989) and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social services shall

provide notification and referral of children below age five, and pregnant,

breast-feeding, or postpartum women who are determined to be eligible for

MO HealthNet benefits under section 208.151 to the special supplemental

food programs for women, infants and children administered by the

department of health and senior services. Such notification and referral

shall conform to the requirements of Section 6406 of P.L. 101-239 and

regulations promulgated thereunder.



8. Providers of long-term care services shall be reimbursed for their

costs in accordance with the provisions of Section 1902 (a)(13)(A) of the

Social Security Act, 42 U.S.C. Section 1396a, as amended, and regulations

promulgated thereunder.



9. Reimbursement rates to long-term care providers with respect to a

total change in ownership, at arm's length, for any facility previously

licensed and certified for participation in the MO HealthNet program shall

not increase payments in excess of the increase that would result from the

application of Section 1902 (a)(13)(C) of the Social Security Act, 42

U.S.C. Section 1396a (a)(13)(C).



10. The MO HealthNet division, may enroll qualified residential care

facilities and assisted living facilities, as defined in chapter 198, as MO

HealthNet personal care providers.



11. Any income earned by individuals eligible for certified extended

employment at a sheltered workshop under chapter 178 shall not be

considered as income for purposes of determining eligibility under this

section.



12. If the Missouri Medicaid audit and compliance unit changes any

interpretation or application of the requirements for reimbursement for MO

HealthNet services from the interpretation or application that has been

applied previously by the state in any audit of a MO HealthNet provider,

the Missouri Medicaid audit and compliance unit shall notify all affected

MO HealthNet providers five business days before such change shall take

effect. Failure of the Missouri Medicaid audit and compliance unit to

notify a provider of such change shall entitle the provider to continue to

receive and retain reimbursement until such notification is provided and

shall waive any liability of such provider for recoupment or other loss of

any payments previously made prior to the five business days after such

notice has been sent. Each provider shall provide the Missouri Medicaid

audit and compliance unit a valid email address and shall agree to receive

communications electronically. The notification required under this

section shall be delivered in writing by the United States Postal Service

or electronic mail to each provider.



13. Nothing in this section shall be construed to abrogate or limit

the department's statutory requirement to promulgate rules under chapter

536.



(L. 1967 p. 325, A.L. 1969 p. 337, A.L. 1971 H.B. 17, A.L. 1972 H.B.

673, H.B. 1254, A.L. 1973 S.B. 302, A.L. 1975 H.B. 974, A.L. 1977

S.B. 334, A.L. 1978 S.B. 492, S.B. 671, A.L. 1978 S.B. 505 §§ 1,

2, 3, A.L. 1981 S.B. 63, H.B. 901, A.L. 1986 S.B. 463 & 629, A.L.

1988 H.B. 1139, A.L. 1990 S.B. 524 merged with S.B. 765, A.L.

1992 H.B. 899 merged with S.B. 573 & 634 merged with S.B. 721,

A.L. 1993 H.B. 564, A.L. 2004 S.B. 1003, A.L. 2005 S.B. 539, A.L.

2007 S.B. 577, A.L. 2011 H.B. 552, A.L. 2013 S.B. 127, A.L. 2014

H.B. 1299 Revision, A.L. 2015 S.B. 210)





2014

2013

2011

2007

2005

2004

1993



2014



208.152. 1. Benefit payments for medical assistance shall

be made on behalf of those eligible needy persons who are unable

to provide for it in whole or in part, with any payments to be

made on the basis of the reasonable cost of the care or

reasonable charge for the services as defined and determined by

the division of medical services, unless otherwise hereinafter

provided, for the following:



(1) Inpatient hospital services, except to persons in an

institution for mental diseases who are under the age of

sixty-five years and over the age of twenty-one years; provided

that the division of medical services shall provide through rule

and regulation an exception process for coverage of inpatient

costs in those cases requiring treatment beyond the 75th

percentile professional activities study (PAS) or the medicaid

children's diagnosis length of stay schedule; and provided

further that the division of medical services shall take into

account through its payment system for hospital services the

situation of hospitals which serve a disproportionate number of

low-income patients;



(2) All outpatient hospital services, payments therefor to

be in amounts which represent no more than eighty percent of the

lesser of reasonable costs or customary charges for such

services, determined in accordance with the principles set forth

in Title XVIII A and B, Public Law 89-97, 1965 amendments to the

federal Social Security Act (42 U.S.C. 301 et seq.), but the

division of medical services may evaluate outpatient hospital

services rendered under this section and deny payment for

services which are determined by the division of medical

services not to be medically necessary, in accordance with

federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for recipients, except to persons

in an institution for mental diseases who are under the age of

sixty-five years, when residing in a hospital licensed by the

department of health or nursing home licensed by the division of

aging or appropriate licensing authority of other states or

government-owned and -operated institutions which are determined

to conform to standards equivalent to licensing requirements in

Title XIX, of the federal Social Security Act (42 U.S.C. 301 et

seq.), as amended, for nursing facilities. The division of

medical services may recognize through its payment methodology

for nursing facilities those nursing facilities which serve a

high volume of medicaid patients. The division of medical

services when determining the amount of the benefit payments to

be made on behalf of persons under the age of twenty-one in a

nursing facility may consider nursing facilities furnishing care

to persons under the age of twenty-one as a classification

separate from other nursing facilities;



(5) Nursing home costs for recipients of benefit payments

under subdivision (4) of this section for those days, which

shall not exceed twelve per any period of six consecutive

months, during which the recipient is on a temporary leave of

absence from the hospital or nursing home, provided that no such

recipient shall be allowed a temporary leave of absence unless

it is specifically provided for in his plan of care. As used in

this subdivision, the term "temporary leave of absence" shall

include all periods of time during which a recipient is away

from the hospital or nursing home overnight because he is

visiting a friend or relative;



(6) Physicians' services, whether furnished in the office,

home, hospital, nursing home, or elsewhere;



(7) Dental services;



(8) Services of podiatrists as defined in section 330.010,

RSMo;



(9) Drugs and medicines when prescribed by a licensed

physician, dentist, or podiatrist;



(10) Emergency ambulance services and, effective January 1,

1990, medically necessary transportation to scheduled,

physician-prescribed nonelective treatments. The department of

social services may conduct demonstration projects related to

the provision of medically necessary transportation to

recipients of medical assistance under this chapter. Such

demonstration projects shall be funded only by appropriations

made for the purpose of such demonstration projects. If funds

are appropriated for such demonstration projects, the department

shall, not later than January 1, 1990, submit to the general

assembly a report on the significant aspects and results of such

demonstration projects;



(11) Early and periodic screening and diagnosis of

individuals who are under the age of twenty-one to ascertain

their physical or mental defects, and health care, treatment,

and other measures to correct or ameliorate defects and chronic

conditions discovered thereby. Such services shall be provided

in accordance with the provisions of section 6403 of P.L.

101-239 and federal regulations promulgated thereunder;



(12) Home health care services;



(13) Optometric services as defined in section 336.010,

RSMo;



(14) Family planning as defined by federal rules and

regulations; provided, however, that such family planning

services shall not include abortions unless such abortions are

certified in writing by a physician to the medicaid agency that,

in his professional judgment, the life of the mother would be

endangered if the fetus were carried to term;



(15) Orthopedic devices or other prosthetics, including eye

glasses, dentures, hearing aids, and wheelchairs;



(16) Inpatient psychiatric hospital services for

individuals under age twenty-one as defined in Title XIX of the

federal Social Security Act (42 U.S.C. 1396d et seq.);



(17) Outpatient surgical procedures, including presurgical

diagnostic services performed in ambulatory surgical facilities

which are licensed by the department of health of the state of

Missouri; except, that such outpatient surgical services shall

not include persons who are eligible for coverage under Part B

of Title XVIII, Public Law 89-97, 1965 amendments to the federal

Social Security Act, as amended, if exclusion of such persons is

permitted under Title XIX, Public Law 89-97, 1965 amendments to

the federal Social Security Act, as amended;



(18) Personal care services which are medically oriented

tasks having to do with a person's physical requirements, as

opposed to housekeeping requirements, which enable a person to

be treated by his physician on an outpatient, rather than on an

inpatient or residential basis in a hospital, intermediate care

facility, or skilled nursing facility. Personal care services

shall be rendered by an individual not a member of the

recipient's family who is qualified to provide such services

where the services are prescribed by a physician in accordance

with a plan of treatment and are supervised by a licensed nurse.

Persons eligible to receive personal care services shall be

those persons who would otherwise require placement in a

hospital, intermediate care facility, or skilled nursing

facility. Benefits payable for personal care services shall not

exceed for any one recipient one hundred percent of the average

statewide charge for care and treatment in an intermediate care

facility for a comparable period of time;



(19) Mental health services. The state plan for providing

medical assistance under Title XIX of the Social Security Act,

42 U.S.C. 301, as amended, shall include the following mental

health services when such services are provided by community

mental health facilities operated by the department of mental

health or designated by the department of mental health as a

community mental health facility or as an alcohol and drug abuse

facility. The department of mental health shall establish by

administrative rule the definition and criteria for designation

as a community mental health facility and for designation as an

alcohol and drug abuse facility. Such mental health services

shall include:



(a) Outpatient mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(b) Clinic mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(c) Rehabilitative mental health and alcohol and drug abuse

services including preventive, diagnostic, therapeutic,

rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health

or alcohol and drug abuse professional in accordance with a plan

of treatment appropriately established, implemented, monitored,

and revised under the auspices of a therapeutic team as a part

of client services management.





As used in this section, "mental health professional" and

"alcohol and drug abuse professional" shall be defined by the

department of mental health pursuant to duly promulgated rules.

With respect to services established by this subdivision, the

department of social services, division of medical services,

shall enter into an agreement with the department of mental

health. Matching funds for outpatient mental health services,

clinic mental health services, and rehabilitation services for

mental health and alcohol and drug abuse shall be certified by

the department of mental health to the division of medical

services. The agreement shall establish a mechanism for the

joint implementation of the provisions of this subdivision. In

addition, the agreement shall establish a mechanism by which

rates for services may be jointly developed;



(20) Comprehensive day rehabilitation services beginning

early post-trauma as part of a coordinated system of care for

individuals with disabling impairments. Rehabilitation services

must be based on an individualized, goal-oriented, comprehensive

and coordinated treatment plan developed, implemented, and

monitored through an interdisciplinary assessment designed to

restore an individual to optimal level of physical, cognitive

and behavioral function. The division of medical services shall

establish by administrative rule the definition and criteria for

designation of a comprehensive day rehabilitation service

facility, benefit limitations and payment mechanism;



(21) Hospice care. As used in this subsection, the term

"hospice care" means a coordinated program of active

professional medical attention within home, outpatient and

inpatient care which treats the terminally ill patient and

family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe

pain or other physical symptoms and supportive care to meet the

special needs arising out of physical, psychological, spiritual,

social and economic stresses which are experienced during the

final stages of illness, and during dying and bereavement and

meets the medicare requirements for participation as a hospice

as are provided in 42 CFR Part 418. Beginning July 1, 1990, the

rate of reimbursement paid by the division of medical services

to the hospice provider for room and board furnished by a

nursing home to an eligible hospice patient shall not be less

than ninety-five percent of the rate of reimbursement which

would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of

section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act

of 1989);



(22) Such additional services as defined by the division of

medical services to be furnished under waivers of federal

statutory requirements as provided for and authorized by the

federal Social Security Act (42 U.S.C. 301 et seq.) subject to

appropriation by the general assembly;



(23) Beginning July 1, 1990, the services of a certified

pediatric or family nursing practitioner to the extent that such

services are provided in accordance with chapter 335, RSMo, and

regulations promulgated thereunder, regardless of whether the

nurse practitioner is supervised by or in association with a

physician or other health care provider;



(24) Subject to appropriations, the department of social

services shall conduct demonstration projects for nonemergency,

physician-prescribed transportation for pregnant women who are

recipients of medical assistance under this chapter in counties

selected by the director of the division of medical services.

The funds appropriated pursuant to this subdivision shall be

used for the purposes of this subdivision and for no other

purpose. The department shall not fund such demonstration

projects with revenues received for any other purpose. This

subdivision shall not authorize transportation of a pregnant

woman in active labor. The division of medical services shall

notify recipients of nonemergency transportation services under

this subdivision of such other transportation services which may

be appropriate during active labor or other medical emergency.



2. Benefit payments for medical assistance for surgery as

defined by rule duly promulgated by the division of medical

services, and any costs related directly thereto, shall be made

only when a second medical opinion by a licensed physician as to

the need for the surgery is obtained prior to the surgery being

performed.



3. The division of medical services may require any

recipient of medical assistance to pay part of the charge or

cost, as defined by rule duly promulgated by the division of

medical services, for dental services, drugs and medicines,

optometric services, eye glasses, dentures, hearing aids, and

other services, to the extent and in the manner authorized by

Title XIX of the federal Social Security Act (42 U.S.C. 1396, et

seq.) and regulations thereunder. When substitution of a

generic drug is permitted by the prescriber according to section

338.056, RSMo, and a generic drug is substituted for a name

brand drug, the division of medical services may not lower or

delete the requirement to make a copayment pursuant to regulation

established by the division of medical services and regulations

of Title XIX of the federal Social Security Act. A provider of

goods or services described under this section must collect from

all recipients the partial payment that may be required by the

division of medical services under authority granted herein, if

the division exercises that authority, to remain eligible as a

provider. Any payments made by recipients under this section

shall be in addition to, and not in lieu of, any payments made

by the state for goods or services described herein.



4. The division of medical services shall have the right to

collect medication samples from recipients in order to maintain

program integrity.



5. Reimbursement for obstetrical and pediatric services

under subdivision (6) of subsection 1 of this section shall be

timely and sufficient to enlist enough health care providers so

that care and services are available under the state plan for

medical assistance plan at least to the extent that such care

and services are available to the general population in the

geographic area, as required under subparagraph (a)(30)(A) of 42

U.S.C. 1396a and federal regulations promulgated thereunder.



6. Beginning July 1, 1990, reimbursement for services

rendered in federally funded health centers shall be in

accordance with the provisions of subsection 6402(c) and section

6404 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989)

and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social

services shall provide notification and referral of children

below age five, and pregnant, breast-feeding, or postpartum women

who are determined to be eligible for medical assistance under

section 208.151 to the special supplemental food programs for

women, infants and children administered by the department of

health. Such notification and referral shall conform to the

requirements of section 6406 of P.L. 101-239 and regulations

promulgated thereunder.



8. Providers of long-term care services shall be reimbursed

for their costs in accordance with the provisions of section

1902 (a)(13)(A) of the Social Security Act, 42 U.S.C. 1396a, as

amended, and regulations promulgated thereunder.



9. Reimbursement rates to long-term care providers with

respect to a total change in ownership, at arm's length, for any

facility previously licensed and certified for participation in

the medicaid program shall not increase payments in excess of

the increase that would result from the application of section

1902 (a)(13)(C) of the Social Security Act, 42 U.S.C. 1396a

(a)(13)(C).



2013



208.152. 1. Benefit payments for medical assistance shall

be made on behalf of those eligible needy persons who are unable

to provide for it in whole or in part, with any payments to be

made on the basis of the reasonable cost of the care or

reasonable charge for the services as defined and determined by

the division of medical services, unless otherwise hereinafter

provided, for the following:



(1) Inpatient hospital services, except to persons in an

institution for mental diseases who are under the age of

sixty-five years and over the age of twenty-one years; provided

that the division of medical services shall provide through rule

and regulation an exception process for coverage of inpatient

costs in those cases requiring treatment beyond the 75th

percentile professional activities study (PAS) or the medicaid

children's diagnosis length of stay schedule; and provided

further that the division of medical services shall take into

account through its payment system for hospital services the

situation of hospitals which serve a disproportionate number of

low-income patients;



(2) All outpatient hospital services, payments therefor to

be in amounts which represent no more than eighty percent of the

lesser of reasonable costs or customary charges for such

services, determined in accordance with the principles set forth

in Title XVIII A and B, Public Law 89-97, 1965 amendments to the

federal Social Security Act (42 U.S.C. 301 et seq.), but the

division of medical services may evaluate outpatient hospital

services rendered under this section and deny payment for

services which are determined by the division of medical

services not to be medically necessary, in accordance with

federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for recipients, except to persons

in an institution for mental diseases who are under the age of

sixty-five years, when residing in a hospital licensed by the

department of health or nursing home licensed by the division of

aging or appropriate licensing authority of other states or

government-owned and -operated institutions which are determined

to conform to standards equivalent to licensing requirements in

Title XIX, of the federal Social Security Act (42 U.S.C. 301 et

seq.), as amended, for nursing facilities. The division of

medical services may recognize through its payment methodology

for nursing facilities those nursing facilities which serve a

high volume of medicaid patients. The division of medical

services when determining the amount of the benefit payments to

be made on behalf of persons under the age of twenty-one in a

nursing facility may consider nursing facilities furnishing care

to persons under the age of twenty-one as a classification

separate from other nursing facilities;



(5) Nursing home costs for recipients of benefit payments

under subdivision (4) of this section for those days, which

shall not exceed twelve per any period of six consecutive

months, during which the recipient is on a temporary leave of

absence from the hospital or nursing home, provided that no such

recipient shall be allowed a temporary leave of absence unless

it is specifically provided for in his plan of care. As used in

this subdivision, the term "temporary leave of absence" shall

include all periods of time during which a recipient is away

from the hospital or nursing home overnight because he is

visiting a friend or relative;



(6) Physicians' services, whether furnished in the office,

home, hospital, nursing home, or elsewhere;



(7) Dental services;



(8) Services of podiatrists as defined in section 330.010,

RSMo;



(9) Drugs and medicines when prescribed by a licensed

physician, dentist, or podiatrist;



(10) Emergency ambulance services and, effective January 1,

1990, medically necessary transportation to scheduled,

physician-prescribed nonelective treatments. The department of

social services may conduct demonstration projects related to

the provision of medically necessary transportation to

recipients of medical assistance under this chapter. Such

demonstration projects shall be funded only by appropriations

made for the purpose of such demonstration projects. If funds

are appropriated for such demonstration projects, the department

shall, not later than January 1, 1990, submit to the general

assembly a report on the significant aspects and results of such

demonstration projects;



(11) Early and periodic screening and diagnosis of

individuals who are under the age of twenty-one to ascertain

their physical or mental defects, and health care, treatment,

and other measures to correct or ameliorate defects and chronic

conditions discovered thereby. Such services shall be provided

in accordance with the provisions of section 6403 of P.L.

101-239 and federal regulations promulgated thereunder;



(12) Home health care services;



(13) Optometric services as defined in section 336.010,

RSMo;



(14) Family planning as defined by federal rules and

regulations; provided, however, that such family planning

services shall not include abortions unless such abortions are

certified in writing by a physician to the medicaid agency that,

in his professional judgment, the life of the mother would be

endangered if the fetus were carried to term;



(15) Orthopedic devices or other prosthetics, including eye

glasses, dentures, hearing aids, and wheelchairs;



(16) Inpatient psychiatric hospital services for

individuals under age twenty-one as defined in Title XIX of the

federal Social Security Act (42 U.S.C. 1396d et seq.);



(17) Outpatient surgical procedures, including presurgical

diagnostic services performed in ambulatory surgical facilities

which are licensed by the department of health of the state of

Missouri; except, that such outpatient surgical services shall

not include persons who are eligible for coverage under Part B

of Title XVIII, Public Law 89-97, 1965 amendments to the federal

Social Security Act, as amended, if exclusion of such persons is

permitted under Title XIX, Public Law 89-97, 1965 amendments to

the federal Social Security Act, as amended;



(18) Personal care services which are medically oriented

tasks having to do with a person's physical requirements, as

opposed to housekeeping requirements, which enable a person to

be treated by his physician on an outpatient, rather than on an

inpatient or residential basis in a hospital, intermediate care

facility, or skilled nursing facility. Personal care services

shall be rendered by an individual not a member of the

recipient's family who is qualified to provide such services

where the services are prescribed by a physician in accordance

with a plan of treatment and are supervised by a licensed nurse.

Persons eligible to receive personal care services shall be

those persons who would otherwise require placement in a

hospital, intermediate care facility, or skilled nursing

facility. Benefits payable for personal care services shall not

exceed for any one recipient one hundred percent of the average

statewide charge for care and treatment in an intermediate care

facility for a comparable period of time;



(19) Mental health services. The state plan for providing

medical assistance under Title XIX of the Social Security Act,

42 U.S.C. 301, as amended, shall include the following mental

health services when such services are provided by community

mental health facilities operated by the department of mental

health or designated by the department of mental health as a

community mental health facility or as an alcohol and drug abuse

facility. The department of mental health shall establish by

administrative rule the definition and criteria for designation

as a community mental health facility and for designation as an

alcohol and drug abuse facility. Such mental health services

shall include:



(a) Outpatient mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(b) Clinic mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(c) Rehabilitative mental health and alcohol and drug abuse

services including preventive, diagnostic, therapeutic,

rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health

or alcohol and drug abuse professional in accordance with a plan

of treatment appropriately established, implemented, monitored,

and revised under the auspices of a therapeutic team as a part

of client services management.





As used in this section, "mental health professional" and

"alcohol and drug abuse professional" shall be defined by the

department of mental health pursuant to duly promulgated rules.

With respect to services established by this subdivision, the

department of social services, division of medical services,

shall enter into an agreement with the department of mental

health. Matching funds for outpatient mental health services,

clinic mental health services, and rehabilitation services for

mental health and alcohol and drug abuse shall be certified by

the department of mental health to the division of medical

services. The agreement shall establish a mechanism for the

joint implementation of the provisions of this subdivision. In

addition, the agreement shall establish a mechanism by which

rates for services may be jointly developed;



(20) Comprehensive day rehabilitation services beginning

early post-trauma as part of a coordinated system of care for

individuals with disabling impairments. Rehabilitation services

must be based on an individualized, goal-oriented, comprehensive

and coordinated treatment plan developed, implemented, and

monitored through an interdisciplinary assessment designed to

restore an individual to optimal level of physical, cognitive

and behavioral function. The division of medical services shall

establish by administrative rule the definition and criteria for

designation of a comprehensive day rehabilitation service

facility, benefit limitations and payment mechanism;



(21) Hospice care. As used in this subsection, the term

"hospice care" means a coordinated program of active

professional medical attention within home, outpatient and

inpatient care which treats the terminally ill patient and

family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe

pain or other physical symptoms and supportive care to meet the

special needs arising out of physical, psychological, spiritual,

social and economic stresses which are experienced during the

final stages of illness, and during dying and bereavement and

meets the medicare requirements for participation as a hospice

as are provided in 42 CFR Part 418. Beginning July 1, 1990, the

rate of reimbursement paid by the division of medical services

to the hospice provider for room and board furnished by a

nursing home to an eligible hospice patient shall not be less

than ninety-five percent of the rate of reimbursement which

would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of

section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act

of 1989);



(22) Such additional services as defined by the division of

medical services to be furnished under waivers of federal

statutory requirements as provided for and authorized by the

federal Social Security Act (42 U.S.C. 301 et seq.) subject to

appropriation by the general assembly;



(23) Beginning July 1, 1990, the services of a certified

pediatric or family nursing practitioner to the extent that such

services are provided in accordance with chapter 335, RSMo, and

regulations promulgated thereunder, regardless of whether the

nurse practitioner is supervised by or in association with a

physician or other health care provider;



(24) Subject to appropriations, the department of social

services shall conduct demonstration projects for nonemergency,

physician-prescribed transportation for pregnant women who are

recipients of medical assistance under this chapter in counties

selected by the director of the division of medical services.

The funds appropriated pursuant to this subdivision shall be

used for the purposes of this subdivision and for no other

purpose. The department shall not fund such demonstration

projects with revenues received for any other purpose. This

subdivision shall not authorize transportation of a pregnant

woman in active labor. The division of medical services shall

notify recipients of nonemergency transportation services under

this subdivision of such other transportation services which may

be appropriate during active labor or other medical emergency.



2. Benefit payments for medical assistance for surgery as

defined by rule duly promulgated by the division of medical

services, and any costs related directly thereto, shall be made

only when a second medical opinion by a licensed physician as to

the need for the surgery is obtained prior to the surgery being

performed.



3. The division of medical services may require any

recipient of medical assistance to pay part of the charge or

cost, as defined by rule duly promulgated by the division of

medical services, for dental services, drugs and medicines,

optometric services, eye glasses, dentures, hearing aids, and

other services, to the extent and in the manner authorized by

Title XIX of the federal Social Security Act (42 U.S.C. 1396, et

seq.) and regulations thereunder. When substitution of a

generic drug is permitted by the prescriber according to section

338.056, RSMo, and a generic drug is substituted for a name

brand drug, the division of medical services may not lower or

delete the requirement to make a copayment pursuant to regulation

established by the division of medical services and regulations

of Title XIX of the federal Social Security Act. A provider of

goods or services described under this section must collect from

all recipients the partial payment that may be required by the

division of medical services under authority granted herein, if

the division exercises that authority, to remain eligible as a

provider. Any payments made by recipients under this section

shall be in addition to, and not in lieu of, any payments made

by the state for goods or services described herein.



4. The division of medical services shall have the right to

collect medication samples from recipients in order to maintain

program integrity.



5. Reimbursement for obstetrical and pediatric services

under subdivision (6) of subsection 1 of this section shall be

timely and sufficient to enlist enough health care providers so

that care and services are available under the state plan for

medical assistance plan at least to the extent that such care

and services are available to the general population in the

geographic area, as required under subparagraph (a)(30)(A) of 42

U.S.C. 1396a and federal regulations promulgated thereunder.



6. Beginning July 1, 1990, reimbursement for services

rendered in federally funded health centers shall be in

accordance with the provisions of subsection 6402(c) and section

6404 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989)

and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social

services shall provide notification and referral of children

below age five, and pregnant, breast-feeding, or postpartum women

who are determined to be eligible for medical assistance under

section 208.151 to the special supplemental food programs for

women, infants and children administered by the department of

health. Such notification and referral shall conform to the

requirements of section 6406 of P.L. 101-239 and regulations

promulgated thereunder.



8. Providers of long-term care services shall be reimbursed

for their costs in accordance with the provisions of section

1902 (a)(13)(A) of the Social Security Act, 42 U.S.C. 1396a, as

amended, and regulations promulgated thereunder.



9. Reimbursement rates to long-term care providers with

respect to a total change in ownership, at arm's length, for any

facility previously licensed and certified for participation in

the medicaid program shall not increase payments in excess of

the increase that would result from the application of section

1902 (a)(13)(C) of the Social Security Act, 42 U.S.C. 1396a

(a)(13)(C).



2011



208.152. 1. Benefit payments for medical assistance shall

be made on behalf of those eligible needy persons who are unable

to provide for it in whole or in part, with any payments to be

made on the basis of the reasonable cost of the care or

reasonable charge for the services as defined and determined by

the division of medical services, unless otherwise hereinafter

provided, for the following:



(1) Inpatient hospital services, except to persons in an

institution for mental diseases who are under the age of

sixty-five years and over the age of twenty-one years; provided

that the division of medical services shall provide through rule

and regulation an exception process for coverage of inpatient

costs in those cases requiring treatment beyond the 75th

percentile professional activities study (PAS) or the medicaid

children's diagnosis length of stay schedule; and provided

further that the division of medical services shall take into

account through its payment system for hospital services the

situation of hospitals which serve a disproportionate number of

low-income patients;



(2) All outpatient hospital services, payments therefor to

be in amounts which represent no more than eighty percent of the

lesser of reasonable costs or customary charges for such

services, determined in accordance with the principles set forth

in Title XVIII A and B, Public Law 89-97, 1965 amendments to the

federal Social Security Act (42 U.S.C. 301 et seq.), but the

division of medical services may evaluate outpatient hospital

services rendered under this section and deny payment for

services which are determined by the division of medical

services not to be medically necessary, in accordance with

federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for recipients, except to persons

in an institution for mental diseases who are under the age of

sixty-five years, when residing in a hospital licensed by the

department of health or nursing home licensed by the division of

aging or appropriate licensing authority of other states or

government-owned and -operated institutions which are determined

to conform to standards equivalent to licensing requirements in

Title XIX, of the federal Social Security Act (42 U.S.C. 301 et

seq.), as amended, for nursing facilities. The division of

medical services may recognize through its payment methodology

for nursing facilities those nursing facilities which serve a

high volume of medicaid patients. The division of medical

services when determining the amount of the benefit payments to

be made on behalf of persons under the age of twenty-one in a

nursing facility may consider nursing facilities furnishing care

to persons under the age of twenty-one as a classification

separate from other nursing facilities;



(5) Nursing home costs for recipients of benefit payments

under subdivision (4) of this section for those days, which

shall not exceed twelve per any period of six consecutive

months, during which the recipient is on a temporary leave of

absence from the hospital or nursing home, provided that no such

recipient shall be allowed a temporary leave of absence unless

it is specifically provided for in his plan of care. As used in

this subdivision, the term "temporary leave of absence" shall

include all periods of time during which a recipient is away

from the hospital or nursing home overnight because he is

visiting a friend or relative;



(6) Physicians' services, whether furnished in the office,

home, hospital, nursing home, or elsewhere;



(7) Dental services;



(8) Services of podiatrists as defined in section 330.010,

RSMo;



(9) Drugs and medicines when prescribed by a licensed

physician, dentist, or podiatrist;



(10) Emergency ambulance services and, effective January 1,

1990, medically necessary transportation to scheduled,

physician-prescribed nonelective treatments. The department of

social services may conduct demonstration projects related to

the provision of medically necessary transportation to

recipients of medical assistance under this chapter. Such

demonstration projects shall be funded only by appropriations

made for the purpose of such demonstration projects. If funds

are appropriated for such demonstration projects, the department

shall, not later than January 1, 1990, submit to the general

assembly a report on the significant aspects and results of such

demonstration projects;



(11) Early and periodic screening and diagnosis of

individuals who are under the age of twenty-one to ascertain

their physical or mental defects, and health care, treatment,

and other measures to correct or ameliorate defects and chronic

conditions discovered thereby. Such services shall be provided

in accordance with the provisions of section 6403 of P.L.

101-239 and federal regulations promulgated thereunder;



(12) Home health care services;



(13) Optometric services as defined in section 336.010,

RSMo;



(14) Family planning as defined by federal rules and

regulations; provided, however, that such family planning

services shall not include abortions unless such abortions are

certified in writing by a physician to the medicaid agency that,

in his professional judgment, the life of the mother would be

endangered if the fetus were carried to term;



(15) Orthopedic devices or other prosthetics, including eye

glasses, dentures, hearing aids, and wheelchairs;



(16) Inpatient psychiatric hospital services for

individuals under age twenty-one as defined in Title XIX of the

federal Social Security Act (42 U.S.C. 1396d et seq.);



(17) Outpatient surgical procedures, including presurgical

diagnostic services performed in ambulatory surgical facilities

which are licensed by the department of health of the state of

Missouri; except, that such outpatient surgical services shall

not include persons who are eligible for coverage under Part B

of Title XVIII, Public Law 89-97, 1965 amendments to the federal

Social Security Act, as amended, if exclusion of such persons is

permitted under Title XIX, Public Law 89-97, 1965 amendments to

the federal Social Security Act, as amended;



(18) Personal care services which are medically oriented

tasks having to do with a person's physical requirements, as

opposed to housekeeping requirements, which enable a person to

be treated by his physician on an outpatient, rather than on an

inpatient or residential basis in a hospital, intermediate care

facility, or skilled nursing facility. Personal care services

shall be rendered by an individual not a member of the

recipient's family who is qualified to provide such services

where the services are prescribed by a physician in accordance

with a plan of treatment and are supervised by a licensed nurse.

Persons eligible to receive personal care services shall be

those persons who would otherwise require placement in a

hospital, intermediate care facility, or skilled nursing

facility. Benefits payable for personal care services shall not

exceed for any one recipient one hundred percent of the average

statewide charge for care and treatment in an intermediate care

facility for a comparable period of time;



(19) Mental health services. The state plan for providing

medical assistance under Title XIX of the Social Security Act,

42 U.S.C. 301, as amended, shall include the following mental

health services when such services are provided by community

mental health facilities operated by the department of mental

health or designated by the department of mental health as a

community mental health facility or as an alcohol and drug abuse

facility. The department of mental health shall establish by

administrative rule the definition and criteria for designation

as a community mental health facility and for designation as an

alcohol and drug abuse facility. Such mental health services

shall include:



(a) Outpatient mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(b) Clinic mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(c) Rehabilitative mental health and alcohol and drug abuse

services including preventive, diagnostic, therapeutic,

rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health

or alcohol and drug abuse professional in accordance with a plan

of treatment appropriately established, implemented, monitored,

and revised under the auspices of a therapeutic team as a part

of client services management.





As used in this section, "mental health professional" and

"alcohol and drug abuse professional" shall be defined by the

department of mental health pursuant to duly promulgated rules.

With respect to services established by this subdivision, the

department of social services, division of medical services,

shall enter into an agreement with the department of mental

health. Matching funds for outpatient mental health services,

clinic mental health services, and rehabilitation services for

mental health and alcohol and drug abuse shall be certified by

the department of mental health to the division of medical

services. The agreement shall establish a mechanism for the

joint implementation of the provisions of this subdivision. In

addition, the agreement shall establish a mechanism by which

rates for services may be jointly developed;



(20) Comprehensive day rehabilitation services beginning

early post-trauma as part of a coordinated system of care for

individuals with disabling impairments. Rehabilitation services

must be based on an individualized, goal-oriented, comprehensive

and coordinated treatment plan developed, implemented, and

monitored through an interdisciplinary assessment designed to

restore an individual to optimal level of physical, cognitive

and behavioral function. The division of medical services shall

establish by administrative rule the definition and criteria for

designation of a comprehensive day rehabilitation service

facility, benefit limitations and payment mechanism;



(21) Hospice care. As used in this subsection, the term

"hospice care" means a coordinated program of active

professional medical attention within home, outpatient and

inpatient care which treats the terminally ill patient and

family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe

pain or other physical symptoms and supportive care to meet the

special needs arising out of physical, psychological, spiritual,

social and economic stresses which are experienced during the

final stages of illness, and during dying and bereavement and

meets the medicare requirements for participation as a hospice

as are provided in 42 CFR Part 418. Beginning July 1, 1990, the

rate of reimbursement paid by the division of medical services

to the hospice provider for room and board furnished by a

nursing home to an eligible hospice patient shall not be less

than ninety-five percent of the rate of reimbursement which

would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of

section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act

of 1989);



(22) Such additional services as defined by the division of

medical services to be furnished under waivers of federal

statutory requirements as provided for and authorized by the

federal Social Security Act (42 U.S.C. 301 et seq.) subject to

appropriation by the general assembly;



(23) Beginning July 1, 1990, the services of a certified

pediatric or family nursing practitioner to the extent that such

services are provided in accordance with chapter 335, RSMo, and

regulations promulgated thereunder, regardless of whether the

nurse practitioner is supervised by or in association with a

physician or other health care provider;



(24) Subject to appropriations, the department of social

services shall conduct demonstration projects for nonemergency,

physician-prescribed transportation for pregnant women who are

recipients of medical assistance under this chapter in counties

selected by the director of the division of medical services.

The funds appropriated pursuant to this subdivision shall be

used for the purposes of this subdivision and for no other

purpose. The department shall not fund such demonstration

projects with revenues received for any other purpose. This

subdivision shall not authorize transportation of a pregnant

woman in active labor. The division of medical services shall

notify recipients of nonemergency transportation services under

this subdivision of such other transportation services which may

be appropriate during active labor or other medical emergency.



2. Benefit payments for medical assistance for surgery as

defined by rule duly promulgated by the division of medical

services, and any costs related directly thereto, shall be made

only when a second medical opinion by a licensed physician as to

the need for the surgery is obtained prior to the surgery being

performed.



3. The division of medical services may require any

recipient of medical assistance to pay part of the charge or

cost, as defined by rule duly promulgated by the division of

medical services, for dental services, drugs and medicines,

optometric services, eye glasses, dentures, hearing aids, and

other services, to the extent and in the manner authorized by

Title XIX of the federal Social Security Act (42 U.S.C. 1396, et

seq.) and regulations thereunder. When substitution of a

generic drug is permitted by the prescriber according to section

338.056, RSMo, and a generic drug is substituted for a name

brand drug, the division of medical services may not lower or

delete the requirement to make a copayment pursuant to regulation

established by the division of medical services and regulations

of Title XIX of the federal Social Security Act. A provider of

goods or services described under this section must collect from

all recipients the partial payment that may be required by the

division of medical services under authority granted herein, if

the division exercises that authority, to remain eligible as a

provider. Any payments made by recipients under this section

shall be in addition to, and not in lieu of, any payments made

by the state for goods or services described herein.



4. The division of medical services shall have the right to

collect medication samples from recipients in order to maintain

program integrity.



5. Reimbursement for obstetrical and pediatric services

under subdivision (6) of subsection 1 of this section shall be

timely and sufficient to enlist enough health care providers so

that care and services are available under the state plan for

medical assistance plan at least to the extent that such care

and services are available to the general population in the

geographic area, as required under subparagraph (a)(30)(A) of 42

U.S.C. 1396a and federal regulations promulgated thereunder.



6. Beginning July 1, 1990, reimbursement for services

rendered in federally funded health centers shall be in

accordance with the provisions of subsection 6402(c) and section

6404 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989)

and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social

services shall provide notification and referral of children

below age five, and pregnant, breast-feeding, or postpartum women

who are determined to be eligible for medical assistance under

section 208.151 to the special supplemental food programs for

women, infants and children administered by the department of

health. Such notification and referral shall conform to the

requirements of section 6406 of P.L. 101-239 and regulations

promulgated thereunder.



8. Providers of long-term care services shall be reimbursed

for their costs in accordance with the provisions of section

1902 (a)(13)(A) of the Social Security Act, 42 U.S.C. 1396a, as

amended, and regulations promulgated thereunder.



9. Reimbursement rates to long-term care providers with

respect to a total change in ownership, at arm's length, for any

facility previously licensed and certified for participation in

the medicaid program shall not increase payments in excess of

the increase that would result from the application of section

1902 (a)(13)(C) of the Social Security Act, 42 U.S.C. 1396a

(a)(13)(C).



2007



208.152. 1. Benefit payments for medical assistance shall

be made on behalf of those eligible needy persons who are unable

to provide for it in whole or in part, with any payments to be

made on the basis of the reasonable cost of the care or

reasonable charge for the services as defined and determined by

the division of medical services, unless otherwise hereinafter

provided, for the following:



(1) Inpatient hospital services, except to persons in an

institution for mental diseases who are under the age of

sixty-five years and over the age of twenty-one years; provided

that the division of medical services shall provide through rule

and regulation an exception process for coverage of inpatient

costs in those cases requiring treatment beyond the 75th

percentile professional activities study (PAS) or the medicaid

children's diagnosis length of stay schedule; and provided

further that the division of medical services shall take into

account through its payment system for hospital services the

situation of hospitals which serve a disproportionate number of

low-income patients;



(2) All outpatient hospital services, payments therefor to

be in amounts which represent no more than eighty percent of the

lesser of reasonable costs or customary charges for such

services, determined in accordance with the principles set forth

in Title XVIII A and B, Public Law 89-97, 1965 amendments to the

federal Social Security Act (42 U.S.C. 301 et seq.), but the

division of medical services may evaluate outpatient hospital

services rendered under this section and deny payment for

services which are determined by the division of medical

services not to be medically necessary, in accordance with

federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for recipients, except to persons

in an institution for mental diseases who are under the age of

sixty-five years, when residing in a hospital licensed by the

department of health or nursing home licensed by the division of

aging or appropriate licensing authority of other states or

government-owned and -operated institutions which are determined

to conform to standards equivalent to licensing requirements in

Title XIX, of the federal Social Security Act (42 U.S.C. 301 et

seq.), as amended, for nursing facilities. The division of

medical services may recognize through its payment methodology

for nursing facilities those nursing facilities which serve a

high volume of medicaid patients. The division of medical

services when determining the amount of the benefit payments to

be made on behalf of persons under the age of twenty-one in a

nursing facility may consider nursing facilities furnishing care

to persons under the age of twenty-one as a classification

separate from other nursing facilities;



(5) Nursing home costs for recipients of benefit payments

under subdivision (4) of this section for those days, which

shall not exceed twelve per any period of six consecutive

months, during which the recipient is on a temporary leave of

absence from the hospital or nursing home, provided that no such

recipient shall be allowed a temporary leave of absence unless

it is specifically provided for in his plan of care. As used in

this subdivision, the term "temporary leave of absence" shall

include all periods of time during which a recipient is away

from the hospital or nursing home overnight because he is

visiting a friend or relative;



(6) Physicians' services, whether furnished in the office,

home, hospital, nursing home, or elsewhere;



(7) Dental services;



(8) Services of podiatrists as defined in section 330.010,

RSMo;



(9) Drugs and medicines when prescribed by a licensed

physician, dentist, or podiatrist;



(10) Emergency ambulance services and, effective January 1,

1990, medically necessary transportation to scheduled,

physician-prescribed nonelective treatments. The department of

social services may conduct demonstration projects related to

the provision of medically necessary transportation to

recipients of medical assistance under this chapter. Such

demonstration projects shall be funded only by appropriations

made for the purpose of such demonstration projects. If funds

are appropriated for such demonstration projects, the department

shall, not later than January 1, 1990, submit to the general

assembly a report on the significant aspects and results of such

demonstration projects;



(11) Early and periodic screening and diagnosis of

individuals who are under the age of twenty-one to ascertain

their physical or mental defects, and health care, treatment,

and other measures to correct or ameliorate defects and chronic

conditions discovered thereby. Such services shall be provided

in accordance with the provisions of section 6403 of P.L.

101-239 and federal regulations promulgated thereunder;



(12) Home health care services;



(13) Optometric services as defined in section 336.010,

RSMo;



(14) Family planning as defined by federal rules and

regulations; provided, however, that such family planning

services shall not include abortions unless such abortions are

certified in writing by a physician to the medicaid agency that,

in his professional judgment, the life of the mother would be

endangered if the fetus were carried to term;



(15) Orthopedic devices or other prosthetics, including eye

glasses, dentures, hearing aids, and wheelchairs;



(16) Inpatient psychiatric hospital services for

individuals under age twenty-one as defined in Title XIX of the

federal Social Security Act (42 U.S.C. 1396d et seq.);



(17) Outpatient surgical procedures, including presurgical

diagnostic services performed in ambulatory surgical facilities

which are licensed by the department of health of the state of

Missouri; except, that such outpatient surgical services shall

not include persons who are eligible for coverage under Part B

of Title XVIII, Public Law 89-97, 1965 amendments to the federal

Social Security Act, as amended, if exclusion of such persons is

permitted under Title XIX, Public Law 89-97, 1965 amendments to

the federal Social Security Act, as amended;



(18) Personal care services which are medically oriented

tasks having to do with a person's physical requirements, as

opposed to housekeeping requirements, which enable a person to

be treated by his physician on an outpatient, rather than on an

inpatient or residential basis in a hospital, intermediate care

facility, or skilled nursing facility. Personal care services

shall be rendered by an individual not a member of the

recipient's family who is qualified to provide such services

where the services are prescribed by a physician in accordance

with a plan of treatment and are supervised by a licensed nurse.

Persons eligible to receive personal care services shall be

those persons who would otherwise require placement in a

hospital, intermediate care facility, or skilled nursing

facility. Benefits payable for personal care services shall not

exceed for any one recipient one hundred percent of the average

statewide charge for care and treatment in an intermediate care

facility for a comparable period of time;



(19) Mental health services. The state plan for providing

medical assistance under Title XIX of the Social Security Act,

42 U.S.C. 301, as amended, shall include the following mental

health services when such services are provided by community

mental health facilities operated by the department of mental

health or designated by the department of mental health as a

community mental health facility or as an alcohol and drug abuse

facility. The department of mental health shall establish by

administrative rule the definition and criteria for designation

as a community mental health facility and for designation as an

alcohol and drug abuse facility. Such mental health services

shall include:



(a) Outpatient mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(b) Clinic mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(c) Rehabilitative mental health and alcohol and drug abuse

services including preventive, diagnostic, therapeutic,

rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health

or alcohol and drug abuse professional in accordance with a plan

of treatment appropriately established, implemented, monitored,

and revised under the auspices of a therapeutic team as a part

of client services management.





As used in this section, "mental health professional" and

"alcohol and drug abuse professional" shall be defined by the

department of mental health pursuant to duly promulgated rules.

With respect to services established by this subdivision, the

department of social services, division of medical services,

shall enter into an agreement with the department of mental

health. Matching funds for outpatient mental health services,

clinic mental health services, and rehabilitation services for

mental health and alcohol and drug abuse shall be certified by

the department of mental health to the division of medical

services. The agreement shall establish a mechanism for the

joint implementation of the provisions of this subdivision. In

addition, the agreement shall establish a mechanism by which

rates for services may be jointly developed;



(20) Comprehensive day rehabilitation services beginning

early post-trauma as part of a coordinated system of care for

individuals with disabling impairments. Rehabilitation services

must be based on an individualized, goal-oriented, comprehensive

and coordinated treatment plan developed, implemented, and

monitored through an interdisciplinary assessment designed to

restore an individual to optimal level of physical, cognitive

and behavioral function. The division of medical services shall

establish by administrative rule the definition and criteria for

designation of a comprehensive day rehabilitation service

facility, benefit limitations and payment mechanism;



(21) Hospice care. As used in this subsection, the term

"hospice care" means a coordinated program of active

professional medical attention within home, outpatient and

inpatient care which treats the terminally ill patient and

family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe

pain or other physical symptoms and supportive care to meet the

special needs arising out of physical, psychological, spiritual,

social and economic stresses which are experienced during the

final stages of illness, and during dying and bereavement and

meets the medicare requirements for participation as a hospice

as are provided in 42 CFR Part 418. Beginning July 1, 1990, the

rate of reimbursement paid by the division of medical services

to the hospice provider for room and board furnished by a

nursing home to an eligible hospice patient shall not be less

than ninety-five percent of the rate of reimbursement which

would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of

section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act

of 1989);



(22) Such additional services as defined by the division of

medical services to be furnished under waivers of federal

statutory requirements as provided for and authorized by the

federal Social Security Act (42 U.S.C. 301 et seq.) subject to

appropriation by the general assembly;



(23) Beginning July 1, 1990, the services of a certified

pediatric or family nursing practitioner to the extent that such

services are provided in accordance with chapter 335, RSMo, and

regulations promulgated thereunder, regardless of whether the

nurse practitioner is supervised by or in association with a

physician or other health care provider;



(24) Subject to appropriations, the department of social

services shall conduct demonstration projects for nonemergency,

physician-prescribed transportation for pregnant women who are

recipients of medical assistance under this chapter in counties

selected by the director of the division of medical services.

The funds appropriated pursuant to this subdivision shall be

used for the purposes of this subdivision and for no other

purpose. The department shall not fund such demonstration

projects with revenues received for any other purpose. This

subdivision shall not authorize transportation of a pregnant

woman in active labor. The division of medical services shall

notify recipients of nonemergency transportation services under

this subdivision of such other transportation services which may

be appropriate during active labor or other medical emergency.



2. Benefit payments for medical assistance for surgery as

defined by rule duly promulgated by the division of medical

services, and any costs related directly thereto, shall be made

only when a second medical opinion by a licensed physician as to

the need for the surgery is obtained prior to the surgery being

performed.



3. The division of medical services may require any

recipient of medical assistance to pay part of the charge or

cost, as defined by rule duly promulgated by the division of

medical services, for dental services, drugs and medicines,

optometric services, eye glasses, dentures, hearing aids, and

other services, to the extent and in the manner authorized by

Title XIX of the federal Social Security Act (42 U.S.C. 1396, et

seq.) and regulations thereunder. When substitution of a

generic drug is permitted by the prescriber according to section

338.056, RSMo, and a generic drug is substituted for a name

brand drug, the division of medical services may not lower or

delete the requirement to make a copayment pursuant to regulation

established by the division of medical services and regulations

of Title XIX of the federal Social Security Act. A provider of

goods or services described under this section must collect from

all recipients the partial payment that may be required by the

division of medical services under authority granted herein, if

the division exercises that authority, to remain eligible as a

provider. Any payments made by recipients under this section

shall be in addition to, and not in lieu of, any payments made

by the state for goods or services described herein.



4. The division of medical services shall have the right to

collect medication samples from recipients in order to maintain

program integrity.



5. Reimbursement for obstetrical and pediatric services

under subdivision (6) of subsection 1 of this section shall be

timely and sufficient to enlist enough health care providers so

that care and services are available under the state plan for

medical assistance plan at least to the extent that such care

and services are available to the general population in the

geographic area, as required under subparagraph (a)(30)(A) of 42

U.S.C. 1396a and federal regulations promulgated thereunder.



6. Beginning July 1, 1990, reimbursement for services

rendered in federally funded health centers shall be in

accordance with the provisions of subsection 6402(c) and section

6404 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989)

and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social

services shall provide notification and referral of children

below age five, and pregnant, breast-feeding, or postpartum women

who are determined to be eligible for medical assistance under

section 208.151 to the special supplemental food programs for

women, infants and children administered by the department of

health. Such notification and referral shall conform to the

requirements of section 6406 of P.L. 101-239 and regulations

promulgated thereunder.



8. Providers of long-term care services shall be reimbursed

for their costs in accordance with the provisions of section

1902 (a)(13)(A) of the Social Security Act, 42 U.S.C. 1396a, as

amended, and regulations promulgated thereunder.



9. Reimbursement rates to long-term care providers with

respect to a total change in ownership, at arm's length, for any

facility previously licensed and certified for participation in

the medicaid program shall not increase payments in excess of

the increase that would result from the application of section

1902 (a)(13)(C) of the Social Security Act, 42 U.S.C. 1396a

(a)(13)(C).



2005



208.152. 1. Benefit payments for medical assistance shall

be made on behalf of those eligible needy persons who are unable

to provide for it in whole or in part, with any payments to be

made on the basis of the reasonable cost of the care or

reasonable charge for the services as defined and determined by

the division of medical services, unless otherwise hereinafter

provided, for the following:



(1) Inpatient hospital services, except to persons in an

institution for mental diseases who are under the age of

sixty-five years and over the age of twenty-one years; provided

that the division of medical services shall provide through rule

and regulation an exception process for coverage of inpatient

costs in those cases requiring treatment beyond the 75th

percentile professional activities study (PAS) or the medicaid

children's diagnosis length of stay schedule; and provided

further that the division of medical services shall take into

account through its payment system for hospital services the

situation of hospitals which serve a disproportionate number of

low-income patients;



(2) All outpatient hospital services, payments therefor to

be in amounts which represent no more than eighty percent of the

lesser of reasonable costs or customary charges for such

services, determined in accordance with the principles set forth

in Title XVIII A and B, Public Law 89-97, 1965 amendments to the

federal Social Security Act (42 U.S.C. 301 et seq.), but the

division of medical services may evaluate outpatient hospital

services rendered under this section and deny payment for

services which are determined by the division of medical

services not to be medically necessary, in accordance with

federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for recipients, except to persons

in an institution for mental diseases who are under the age of

sixty-five years, when residing in a hospital licensed by the

department of health or nursing home licensed by the division of

aging or appropriate licensing authority of other states or

government-owned and -operated institutions which are determined

to conform to standards equivalent to licensing requirements in

Title XIX, of the federal Social Security Act (42 U.S.C. 301 et

seq.), as amended, for nursing facilities. The division of

medical services may recognize through its payment methodology

for nursing facilities those nursing facilities which serve a

high volume of medicaid patients. The division of medical

services when determining the amount of the benefit payments to

be made on behalf of persons under the age of twenty-one in a

nursing facility may consider nursing facilities furnishing care

to persons under the age of twenty-one as a classification

separate from other nursing facilities;



(5) Nursing home costs for recipients of benefit payments

under subdivision (4) of this section for those days, which

shall not exceed twelve per any period of six consecutive

months, during which the recipient is on a temporary leave of

absence from the hospital or nursing home, provided that no such

recipient shall be allowed a temporary leave of absence unless

it is specifically provided for in his plan of care. As used in

this subdivision, the term "temporary leave of absence" shall

include all periods of time during which a recipient is away

from the hospital or nursing home overnight because he is

visiting a friend or relative;



(6) Physicians' services, whether furnished in the office,

home, hospital, nursing home, or elsewhere;



(7) Dental services;



(8) Services of podiatrists as defined in section 330.010,

RSMo;



(9) Drugs and medicines when prescribed by a licensed

physician, dentist, or podiatrist;



(10) Emergency ambulance services and, effective January 1,

1990, medically necessary transportation to scheduled,

physician-prescribed nonelective treatments. The department of

social services may conduct demonstration projects related to

the provision of medically necessary transportation to

recipients of medical assistance under this chapter. Such

demonstration projects shall be funded only by appropriations

made for the purpose of such demonstration projects. If funds

are appropriated for such demonstration projects, the department

shall, not later than January 1, 1990, submit to the general

assembly a report on the significant aspects and results of such

demonstration projects;



(11) Early and periodic screening and diagnosis of

individuals who are under the age of twenty-one to ascertain

their physical or mental defects, and health care, treatment,

and other measures to correct or ameliorate defects and chronic

conditions discovered thereby. Such services shall be provided

in accordance with the provisions of section 6403 of P.L.

101-239 and federal regulations promulgated thereunder;



(12) Home health care services;



(13) Optometric services as defined in section 336.010,

RSMo;



(14) Family planning as defined by federal rules and

regulations; provided, however, that such family planning

services shall not include abortions unless such abortions are

certified in writing by a physician to the medicaid agency that,

in his professional judgment, the life of the mother would be

endangered if the fetus were carried to term;



(15) Orthopedic devices or other prosthetics, including eye

glasses, dentures, hearing aids, and wheelchairs;



(16) Inpatient psychiatric hospital services for

individuals under age twenty-one as defined in Title XIX of the

federal Social Security Act (42 U.S.C. 1396d et seq.);



(17) Outpatient surgical procedures, including presurgical

diagnostic services performed in ambulatory surgical facilities

which are licensed by the department of health of the state of

Missouri; except, that such outpatient surgical services shall

not include persons who are eligible for coverage under Part B

of Title XVIII, Public Law 89-97, 1965 amendments to the federal

Social Security Act, as amended, if exclusion of such persons is

permitted under Title XIX, Public Law 89-97, 1965 amendments to

the federal Social Security Act, as amended;



(18) Personal care services which are medically oriented

tasks having to do with a person's physical requirements, as

opposed to housekeeping requirements, which enable a person to

be treated by his physician on an outpatient, rather than on an

inpatient or residential basis in a hospital, intermediate care

facility, or skilled nursing facility. Personal care services

shall be rendered by an individual not a member of the

recipient's family who is qualified to provide such services

where the services are prescribed by a physician in accordance

with a plan of treatment and are supervised by a licensed nurse.

Persons eligible to receive personal care services shall be

those persons who would otherwise require placement in a

hospital, intermediate care facility, or skilled nursing

facility. Benefits payable for personal care services shall not

exceed for any one recipient one hundred percent of the average

statewide charge for care and treatment in an intermediate care

facility for a comparable period of time;



(19) Mental health services. The state plan for providing

medical assistance under Title XIX of the Social Security Act,

42 U.S.C. 301, as amended, shall include the following mental

health services when such services are provided by community

mental health facilities operated by the department of mental

health or designated by the department of mental health as a

community mental health facility or as an alcohol and drug abuse

facility. The department of mental health shall establish by

administrative rule the definition and criteria for designation

as a community mental health facility and for designation as an

alcohol and drug abuse facility. Such mental health services

shall include:



(a) Outpatient mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(b) Clinic mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(c) Rehabilitative mental health and alcohol and drug abuse

services including preventive, diagnostic, therapeutic,

rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health

or alcohol and drug abuse professional in accordance with a plan

of treatment appropriately established, implemented, monitored,

and revised under the auspices of a therapeutic team as a part

of client services management.





As used in this section, "mental health professional" and

"alcohol and drug abuse professional" shall be defined by the

department of mental health pursuant to duly promulgated rules.

With respect to services established by this subdivision, the

department of social services, division of medical services,

shall enter into an agreement with the department of mental

health. Matching funds for outpatient mental health services,

clinic mental health services, and rehabilitation services for

mental health and alcohol and drug abuse shall be certified by

the department of mental health to the division of medical

services. The agreement shall establish a mechanism for the

joint implementation of the provisions of this subdivision. In

addition, the agreement shall establish a mechanism by which

rates for services may be jointly developed;



(20) Comprehensive day rehabilitation services beginning

early post-trauma as part of a coordinated system of care for

individuals with disabling impairments. Rehabilitation services

must be based on an individualized, goal-oriented, comprehensive

and coordinated treatment plan developed, implemented, and

monitored through an interdisciplinary assessment designed to

restore an individual to optimal level of physical, cognitive

and behavioral function. The division of medical services shall

establish by administrative rule the definition and criteria for

designation of a comprehensive day rehabilitation service

facility, benefit limitations and payment mechanism;



(21) Hospice care. As used in this subsection, the term

"hospice care" means a coordinated program of active

professional medical attention within home, outpatient and

inpatient care which treats the terminally ill patient and

family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe

pain or other physical symptoms and supportive care to meet the

special needs arising out of physical, psychological, spiritual,

social and economic stresses which are experienced during the

final stages of illness, and during dying and bereavement and

meets the medicare requirements for participation as a hospice

as are provided in 42 CFR Part 418. Beginning July 1, 1990, the

rate of reimbursement paid by the division of medical services

to the hospice provider for room and board furnished by a

nursing home to an eligible hospice patient shall not be less

than ninety-five percent of the rate of reimbursement which

would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of

section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act

of 1989);



(22) Such additional services as defined by the division of

medical services to be furnished under waivers of federal

statutory requirements as provided for and authorized by the

federal Social Security Act (42 U.S.C. 301 et seq.) subject to

appropriation by the general assembly;



(23) Beginning July 1, 1990, the services of a certified

pediatric or family nursing practitioner to the extent that such

services are provided in accordance with chapter 335, RSMo, and

regulations promulgated thereunder, regardless of whether the

nurse practitioner is supervised by or in association with a

physician or other health care provider;



(24) Subject to appropriations, the department of social

services shall conduct demonstration projects for nonemergency,

physician-prescribed transportation for pregnant women who are

recipients of medical assistance under this chapter in counties

selected by the director of the division of medical services.

The funds appropriated pursuant to this subdivision shall be

used for the purposes of this subdivision and for no other

purpose. The department shall not fund such demonstration

projects with revenues received for any other purpose. This

subdivision shall not authorize transportation of a pregnant

woman in active labor. The division of medical services shall

notify recipients of nonemergency transportation services under

this subdivision of such other transportation services which may

be appropriate during active labor or other medical emergency.



2. Benefit payments for medical assistance for surgery as

defined by rule duly promulgated by the division of medical

services, and any costs related directly thereto, shall be made

only when a second medical opinion by a licensed physician as to

the need for the surgery is obtained prior to the surgery being

performed.



3. The division of medical services may require any

recipient of medical assistance to pay part of the charge or

cost, as defined by rule duly promulgated by the division of

medical services, for dental services, drugs and medicines,

optometric services, eye glasses, dentures, hearing aids, and

other services, to the extent and in the manner authorized by

Title XIX of the federal Social Security Act (42 U.S.C. 1396, et

seq.) and regulations thereunder. When substitution of a

generic drug is permitted by the prescriber according to section

338.056, RSMo, and a generic drug is substituted for a name

brand drug, the division of medical services may not lower or

delete the requirement to make a copayment pursuant to regulation

established by the division of medical services and regulations

of Title XIX of the federal Social Security Act. A provider of

goods or services described under this section must collect from

all recipients the partial payment that may be required by the

division of medical services under authority granted herein, if

the division exercises that authority, to remain eligible as a

provider. Any payments made by recipients under this section

shall be in addition to, and not in lieu of, any payments made

by the state for goods or services described herein.



4. The division of medical services shall have the right to

collect medication samples from recipients in order to maintain

program integrity.



5. Reimbursement for obstetrical and pediatric services

under subdivision (6) of subsection 1 of this section shall be

timely and sufficient to enlist enough health care providers so

that care and services are available under the state plan for

medical assistance plan at least to the extent that such care

and services are available to the general population in the

geographic area, as required under subparagraph (a)(30)(A) of 42

U.S.C. 1396a and federal regulations promulgated thereunder.



6. Beginning July 1, 1990, reimbursement for services

rendered in federally funded health centers shall be in

accordance with the provisions of subsection 6402(c) and section

6404 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989)

and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social

services shall provide notification and referral of children

below age five, and pregnant, breast-feeding, or postpartum women

who are determined to be eligible for medical assistance under

section 208.151 to the special supplemental food programs for

women, infants and children administered by the department of

health. Such notification and referral shall conform to the

requirements of section 6406 of P.L. 101-239 and regulations

promulgated thereunder.



8. Providers of long-term care services shall be reimbursed

for their costs in accordance with the provisions of section

1902 (a)(13)(A) of the Social Security Act, 42 U.S.C. 1396a, as

amended, and regulations promulgated thereunder.



9. Reimbursement rates to long-term care providers with

respect to a total change in ownership, at arm's length, for any

facility previously licensed and certified for participation in

the medicaid program shall not increase payments in excess of

the increase that would result from the application of section

1902 (a)(13)(C) of the Social Security Act, 42 U.S.C. 1396a

(a)(13)(C).



2004



208.152. 1. Benefit payments for medical assistance shall

be made on behalf of those eligible needy persons who are unable

to provide for it in whole or in part, with any payments to be

made on the basis of the reasonable cost of the care or

reasonable charge for the services as defined and determined by

the division of medical services, unless otherwise hereinafter

provided, for the following:



(1) Inpatient hospital services, except to persons in an

institution for mental diseases who are under the age of

sixty-five years and over the age of twenty-one years; provided

that the division of medical services shall provide through rule

and regulation an exception process for coverage of inpatient

costs in those cases requiring treatment beyond the 75th

percentile professional activities study (PAS) or the medicaid

children's diagnosis length of stay schedule; and provided

further that the division of medical services shall take into

account through its payment system for hospital services the

situation of hospitals which serve a disproportionate number of

low-income patients;



(2) All outpatient hospital services, payments therefor to

be in amounts which represent no more than eighty percent of the

lesser of reasonable costs or customary charges for such

services, determined in accordance with the principles set forth

in Title XVIII A and B, Public Law 89-97, 1965 amendments to the

federal Social Security Act (42 U.S.C. 301 et seq.), but the

division of medical services may evaluate outpatient hospital

services rendered under this section and deny payment for

services which are determined by the division of medical

services not to be medically necessary, in accordance with

federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for recipients, except to persons

in an institution for mental diseases who are under the age of

sixty-five years, when residing in a hospital licensed by the

department of health or nursing home licensed by the division of

aging or appropriate licensing authority of other states or

government-owned and -operated institutions which are determined

to conform to standards equivalent to licensing requirements in

Title XIX, of the federal Social Security Act (42 U.S.C. 301 et

seq.), as amended, for nursing facilities. The division of

medical services may recognize through its payment methodology

for nursing facilities those nursing facilities which serve a

high volume of medicaid patients. The division of medical

services when determining the amount of the benefit payments to

be made on behalf of persons under the age of twenty-one in a

nursing facility may consider nursing facilities furnishing care

to persons under the age of twenty-one as a classification

separate from other nursing facilities;



(5) Nursing home costs for recipients of benefit payments

under subdivision (4) of this section for those days, which

shall not exceed twelve per any period of six consecutive

months, during which the recipient is on a temporary leave of

absence from the hospital or nursing home, provided that no such

recipient shall be allowed a temporary leave of absence unless

it is specifically provided for in his plan of care. As used in

this subdivision, the term "temporary leave of absence" shall

include all periods of time during which a recipient is away

from the hospital or nursing home overnight because he is

visiting a friend or relative;



(6) Physicians' services, whether furnished in the office,

home, hospital, nursing home, or elsewhere;



(7) Dental services;



(8) Services of podiatrists as defined in section 330.010,

RSMo;



(9) Drugs and medicines when prescribed by a licensed

physician, dentist, or podiatrist;



(10) Emergency ambulance services and, effective January 1,

1990, medically necessary transportation to scheduled,

physician-prescribed nonelective treatments. The department of

social services may conduct demonstration projects related to

the provision of medically necessary transportation to

recipients of medical assistance under this chapter. Such

demonstration projects shall be funded only by appropriations

made for the purpose of such demonstration projects. If funds

are appropriated for such demonstration projects, the department

shall, not later than January 1, 1990, submit to the general

assembly a report on the significant aspects and results of such

demonstration projects;



(11) Early and periodic screening and diagnosis of

individuals who are under the age of twenty-one to ascertain

their physical or mental defects, and health care, treatment,

and other measures to correct or ameliorate defects and chronic

conditions discovered thereby. Such services shall be provided

in accordance with the provisions of section 6403 of P.L.

101-239 and federal regulations promulgated thereunder;



(12) Home health care services;



(13) Optometric services as defined in section 336.010,

RSMo;



(14) Family planning as defined by federal rules and

regulations; provided, however, that such family planning

services shall not include abortions unless such abortions are

certified in writing by a physician to the medicaid agency that,

in his professional judgment, the life of the mother would be

endangered if the fetus were carried to term;



(15) Orthopedic devices or other prosthetics, including eye

glasses, dentures, hearing aids, and wheelchairs;



(16) Inpatient psychiatric hospital services for

individuals under age twenty-one as defined in Title XIX of the

federal Social Security Act (42 U.S.C. 1396d et seq.);



(17) Outpatient surgical procedures, including presurgical

diagnostic services performed in ambulatory surgical facilities

which are licensed by the department of health of the state of

Missouri; except, that such outpatient surgical services shall

not include persons who are eligible for coverage under Part B

of Title XVIII, Public Law 89-97, 1965 amendments to the federal

Social Security Act, as amended, if exclusion of such persons is

permitted under Title XIX, Public Law 89-97, 1965 amendments to

the federal Social Security Act, as amended;



(18) Personal care services which are medically oriented

tasks having to do with a person's physical requirements, as

opposed to housekeeping requirements, which enable a person to

be treated by his physician on an outpatient, rather than on an

inpatient or residential basis in a hospital, intermediate care

facility, or skilled nursing facility. Personal care services

shall be rendered by an individual not a member of the

recipient's family who is qualified to provide such services

where the services are prescribed by a physician in accordance

with a plan of treatment and are supervised by a licensed nurse.

Persons eligible to receive personal care services shall be

those persons who would otherwise require placement in a

hospital, intermediate care facility, or skilled nursing

facility. Benefits payable for personal care services shall not

exceed for any one recipient one hundred percent of the average

statewide charge for care and treatment in an intermediate care

facility for a comparable period of time;



(19) Mental health services. The state plan for providing

medical assistance under Title XIX of the Social Security Act,

42 U.S.C. 301, as amended, shall include the following mental

health services when such services are provided by community

mental health facilities operated by the department of mental

health or designated by the department of mental health as a

community mental health facility or as an alcohol and drug abuse

facility. The department of mental health shall establish by

administrative rule the definition and criteria for designation

as a community mental health facility and for designation as an

alcohol and drug abuse facility. Such mental health services

shall include:



(a) Outpatient mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(b) Clinic mental health services including preventive,

diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group

setting by a mental health professional in accordance with a

plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team

as a part of client services management;



(c) Rehabilitative mental health and alcohol and drug abuse

services including preventive, diagnostic, therapeutic,

rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health

or alcohol and drug abuse professional in accordance with a plan

of treatment appropriately established, implemented, monitored,

and revised under the auspices of a therapeutic team as a part

of client services management.





As used in this section, "mental health professional" and

"alcohol and drug abuse professional" shall be defined by the

department of mental health pursuant to duly promulgated rules.

With respect to services established by this subdivision, the

department of social services, division of medical services,

shall enter into an agreement with the department of mental

health. Matching funds for outpatient mental health services,

clinic mental health services, and rehabilitation services for

mental health and alcohol and drug abuse shall be certified by

the department of mental health to the division of medical

services. The agreement shall establish a mechanism for the

joint implementation of the provisions of this subdivision. In

addition, the agreement shall establish a mechanism by which

rates for services may be jointly developed;



(20) Comprehensive day rehabilitation services beginning

early post-trauma as part of a coordinated system of care for

individuals with disabling impairments. Rehabilitation services

must be based on an individualized, goal-oriented, comprehensive

and coordinated treatment plan developed, implemented, and

monitored through an interdisciplinary assessment designed to

restore an individual to optimal level of physical, cognitive

and behavioral function. The division of medical services shall

establish by administrative rule the definition and criteria for

designation of a comprehensive day rehabilitation service

facility, benefit limitations and payment mechanism;



(21) Hospice care. As used in this subsection, the term

"hospice care" means a coordinated program of active

professional medical attention within home, outpatient and

inpatient care which treats the terminally ill patient and

family as a unit, employing a medically directed

interdisciplinary team. The program provides relief of severe

pain or other physical symptoms and supportive care to meet the

special needs arising out of physical, psychological, spiritual,

social and economic stresses which are experienced during the

final stages of illness, and during dying and bereavement and

meets the medicare requirements for participation as a hospice

as are provided in 42 CFR Part 418. Beginning July 1, 1990, the

rate of reimbursement paid by the division of medical services

to the hospice provider for room and board furnished by a

nursing home to an eligible hospice patient shall not be less

than ninety-five percent of the rate of reimbursement which

would have been paid for facility services in that nursing home

facility for that patient, in accordance with subsection (c) of

section 6408 of P.L. 101-239 (Omnibus Budget Reconciliation Act

of 1989);



(22) Such additional services as defined by the division of

medical services to be furnished under waivers of federal

statutory requirements as provided for and authorized by the

federal Social Security Act (42 U.S.C. 301 et seq.) subject to

appropriation by the general assembly;



(23) Beginning July 1, 1990, the services of a certified

pediatric or family nursing practitioner to the extent that such

services are provided in accordance with chapter 335, RSMo, and

regulations promulgated thereunder, regardless of whether the

nurse practitioner is supervised by or in association with a

physician or other health care provider;



(24) Subject to appropriations, the department of social

services shall conduct demonstration projects for nonemergency,

physician-prescribed transportation for pregnant women who are

recipients of medical assistance under this chapter in counties

selected by the director of the division of medical services.

The funds appropriated pursuant to this subdivision shall be

used for the purposes of this subdivision and for no other

purpose. The department shall not fund such demonstration

projects with revenues received for any other purpose. This

subdivision shall not authorize transportation of a pregnant

woman in active labor. The division of medical services shall

notify recipients of nonemergency transportation services under

this subdivision of such other transportation services which may

be appropriate during active labor or other medical emergency.



2. Benefit payments for medical assistance for surgery as

defined by rule duly promulgated by the division of medical

services, and any costs related directly thereto, shall be made

only when a second medical opinion by a licensed physician as to

the need for the surgery is obtained prior to the surgery being

performed.



3. The division of medical services may require any

recipient of medical assistance to pay part of the charge or

cost, as defined by rule duly promulgated by the division of

medical services, for dental services, drugs and medicines,

optometric services, eye glasses, dentures, hearing aids, and

other services, to the extent and in the manner authorized by

Title XIX of the federal Social Security Act (42 U.S.C. 1396, et

seq.) and regulations thereunder. When substitution of a

generic drug is permitted by the prescriber according to section

338.056, RSMo, and a generic drug is substituted for a name

brand drug, the division of medical services may not lower or

delete the requirement to make a copayment pursuant to regulation

established by the division of medical services and regulations

of Title XIX of the federal Social Security Act. A provider of

goods or services described under this section must collect from

all recipients the partial payment that may be required by the

division of medical services under authority granted herein, if

the division exercises that authority, to remain eligible as a

provider. Any payments made by recipients under this section

shall be in addition to, and not in lieu of, any payments made

by the state for goods or services described herein.



4. The division of medical services shall have the right to

collect medication samples from recipients in order to maintain

program integrity.



5. Reimbursement for obstetrical and pediatric services

under subdivision (6) of subsection 1 of this section shall be

timely and sufficient to enlist enough health care providers so

that care and services are available under the state plan for

medical assistance plan at least to the extent that such care

and services are available to the general population in the

geographic area, as required under subparagraph (a)(30)(A) of 42

U.S.C. 1396a and federal regulations promulgated thereunder.



6. Beginning July 1, 1990, reimbursement for services

rendered in federally funded health centers shall be in

accordance with the provisions of subsection 6402(c) and section

6404 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989)

and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social

services shall provide notification and referral of children

below age five, and pregnant, breast-feeding, or postpartum women

who are determined to be eligible for medical assistance under

section 208.151 to the special supplemental food programs for

women, infants and children administered by the department of

health. Such notification and referral shall conform to the

requirements of section 6406 of P.L. 101-239 and regulations

promulgated thereunder.



8. Providers of long-term care services shall be reimbursed

for their costs in accordance with the provisions of section

1902 (a)(13)(A) of the Social Security Act, 42 U.S.C. 1396a, as

amended, and regulations promulgated thereunder.



9. Reimbursement rates to long-term care providers with

respect to a total change in ownership, at arm's length, for any

facility previously licensed and certified for participation in

the medicaid program shall not increase payments in excess of

the increase that would result from the application of section

1902 (a)(13)(C) of the Social Security Act, 42 U.S.C. 1396a

(a)(13)(C).



1993



208.152. 1. Benefit payments for medical assistance shall be made on

behalf of those eligible needy persons who are unable to provide for it in

whole or in part, with any payments to be made on the basis of the reasonable

cost of the care or reasonable charge for the services as defined and

determined by the division of medical services, unless otherwise hereinafter

provided, for the following:



(1) Inpatient hospital services, except to persons in an institution for

mental diseases who are under the age of sixty-five years and over the age of

twenty-one years; provided that the division of medical services shall provide

through rule and regulation an exception process for coverage of inpatient

costs in those cases requiring treatment beyond the seventy-fifth percentile

professional activities study (PAS) or the Medicaid children's diagnosis

length-of-stay schedule; and provided further that the division of medical

services shall take into account through its payment system for hospital

services the situation of hospitals which serve a disproportionate number of

low-income patients;



(2) All outpatient hospital services, payments therefor to be in amounts

which represent no more than eighty percent of the lesser of reasonable costs

or customary charges for such services, determined in accordance with the

principles set forth in Title XVIII A and B, Public Law 89-97, 1965 amendments

to the federal Social Security Act (42 U.S.C. 301, et seq.), but the division

of medical services may evaluate outpatient hospital services rendered under

this section and deny payment for services which are determined by the

division of medical services not to be medically necessary, in accordance with

federal law and regulations;



(3) Laboratory and X-ray services;



(4) Nursing home services for recipients, except to persons in an

institution for mental diseases who are under the age of sixty-five years,

when residing in a hospital licensed by the department of health and senior

services or a nursing home licensed by the division of aging or appropriate

licensing authority of other states or government-owned and -operated

institutions which are determined to conform to standards equivalent to

licensing requirements in Title XIX, of the federal Social Security Act (42

U.S.C. 301, et seq.), as amended, for nursing facilities. The division of

medical services may recognize through its payment methodology for nursing

facilities those nursing facilities which serve a high volume of Medicaid

patients. The division of medical services when determining the amount of the

benefit payments to be made on behalf of persons under the age of twenty-one

in a nursing facility may consider nursing facilities furnishing care to

persons under the age of twenty-one as a classification separate from other

nursing facilities;



(5) Nursing home costs for recipients of benefit payments under

subdivision (4) of this section for those days, which shall not exceed twelve

per any period of six consecutive months, during which the recipient is on a

temporary leave of absence from the hospital or nursing home, provided that no

such recipient shall be allowed a temporary leave of absence unless it is

specifically provided for in his plan of care. As used in this subdivision,

the term "temporary leave of absence" shall include all periods of time during

which a recipient is away from the hospital or nursing home overnight because

he is visiting a friend or relative;



(6) Physicians' services, whether furnished in the office, home,

hospital, nursing home, or elsewhere;



(7) Dental services;



(8) Services of podiatrists as defined in section 330.010, RSMo;



(9) Drugs and medicines when prescribed by a licensed physician,

dentist, or podiatrist;



(10) Emergency ambulance services and, effective January 1, 1990,

medically necessary transportation to scheduled, physician-prescribed

nonelective treatments. The department of social services may conduct

demonstration projects related to the provision of medically necessary

transportation to recipients of medical assistance under this chapter. Such

demonstration projects shall be funded only by appropriations made for the

purpose of such demonstration projects. If funds are appropriated for such

demonstration projects, the department shall submit to the general assembly a

report on the significant aspects and results of such demonstration projects;



(11) Early and periodic screening and diagnosis of individuals who are

under the age of twenty-one to ascertain their physical or mental defects, and

health care, treatment, and other measures to correct or ameliorate defects

and chronic conditions discovered thereby. Such services shall be provided in

accordance with the provisions of section 6403 of P.L.53 101-239 and federal

regulations promulgated thereunder;



(12) Home health care services;



(13) Optometric services as defined in section 336.010, RSMo;



(14) Family planning as defined by federal rules and regulations;

provided, however, that such family planning services shall not include

abortions unless such abortions are certified in writing by a physician to the

Medicaid agency that, in his professional judgment, the life of the mother

would be endangered if the fetus were carried to term;



(15) Orthopedic devices or other prosthetics, including eye glasses,

dentures, hearing aids, and wheelchairs;



(16) Inpatient psychiatric hospital services for individuals under age

twenty-one as defined in Title XIX of the federal Social Security Act (42

U.S.C. 1396d, et seq.);



(17) Outpatient surgical procedures, including presurgical diagnostic

services performed in ambulatory surgical facilities which are licensed by the

department of health and senior services of the state of Missouri; except,

that such outpatient surgical services shall not include persons who are

eligible for coverage under Part B of Title XVIII, Public Law 89-97, 1965

amendments to the federal Social Security Act, as amended, if exclusion of

such persons is permitted under Title XIX, Public Law 89-97, 1965 amendments

to the federal Social Security Act, as amended;



(18) Personal care services which are medically oriented tasks having to

do with a person's physical requirements, as opposed to housekeeping

requirements, which enable a person to be treated by his physician on an

outpatient, rather than on an inpatient or residential basis in a hospital,

intermediate care facility, or skilled nursing facility. Personal care

services shall be rendered by an individual not a member of the recipient's

family who is qualified to provide such services where the services are

prescribed by a physician in accordance with a plan of treatment and are

supervised by a licensed nurse. Persons eligible to receive personal care

services shall be those persons who would otherwise require placement in a

hospital, intermediate care facility, or skilled nursing facility. Benefits

payable for personal care services shall not exceed for any one recipient one

hundred percent of the average statewide charge for care and treatment in an

intermediate care facility for a comparable period of time;



(19) Mental health services. The state plan for providing medical

assistance under Title XIX of the Social Security Act, 42 U.S.C. 301, as

amended, shall include the following mental health services when such services

are provided by community mental health facilities operated by the department

of mental health or designated by the department of mental health as a

community mental health facility or as an alcohol and drug abuse facility.

The department of mental health shall establish by administrative rule the

definition and criteria for designation as a community mental health facility

and for designation as an alcohol and drug abuse facility. Such mental health

services shall include:



(a) Outpatient mental health services including preventive, diagnostic,

therapeutic, rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health professional

in accordance with a plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team as a part of

client services management;



(b) Clinic mental health services including preventive, diagnostic,

therapeutic, rehabilitative, and palliative interventions rendered to

individuals in an individual or group setting by a mental health professional

in accordance with a plan of treatment appropriately established, implemented,

monitored, and revised under the auspices of a therapeutic team as a part of

client services management;



(c) Rehabilitative mental health and alcohol and drug abuse services

including preventive, diagnostic, therapeutic, rehabilitative, and palliative

interventions rendered to individuals in an individual or group setting by a

mental health or alcohol and drug abuse professional in accordance with a plan

of treatment appropriately established, implemented, monitored, and revised

under the auspices of a therapeutic team as a part of client services

management. As used in this section, "mental health professional" and

"alcohol and drug abuse professional" shall be defined by the department of

mental health pursuant to duly promulgated rules. With respect to services

established by this subdivision, the department of social services, division

of medical services, shall enter into an agreement with the department of

mental health. Matching funds for outpatient mental health services, clinic

mental health services, and rehabilitation services for mental health and

alcohol and drug abuse shall be certified by the department of mental health

to the division of medical services. The agreement shall establish a

mechanism for the joint implementation of the provisions of this subdivision.

In addition, the agreement shall establish a mechanism by which rates for

services may be jointly developed;



(20) Comprehensive day rehabilitation services beginning early

posttrauma as part of a coordinated system of care for individuals with

disabling impairments. Rehabilitation services must be based on an

individualized, goal-oriented, comprehensive and coordinated treatment plan

developed, implemented, and monitored through an interdisciplinary assessment

designed to restore an individual to optimal level of physical, cognitive and

behavioral function. The division of medical services shall establish by

administrative rule the definition and criteria for designation of a

comprehensive day rehabilitation service facility, benefit limitations and

payment mechanism;



(21) Hospice care. As used in this subsection, the term "hospice care"

means a coordinated program of active professional medical attention within a

home, outpatient and inpatient care which treats the terminally ill patient

and family as a unit, employing a medically directed interdisciplinary team.

The program provides relief of severe pain or other physical symptoms and

supportive care to meet the special needs arising out of physical,

psychological, spiritual, social and economic stresses which are experienced

during the final stages of illness, and during dying and bereavement and meets

the Medicare requirements for participation as a hospice as are provided in 42

CFR Part 418. Beginning July 1, 1990, the rate of reimbursement paid by the

division of medical services to the hospice provider for room and board

furnished by a nursing home to an eligible hospice patient shall not be less

than ninety-five percent of the rate of reimbursement which would have been

paid for facility services in that nursing home facility for that patient, in

accordance with subsection (c) of section 6408 of P.L. 101-239 (Omnibus Budget

Reconciliation Act of 1989);



(22) Such additional services as defined by the division of medical

services to be furnished under waivers of federal statutory requirements as

provided for and authorized by the federal Social Security Act (42 U.S.C. 301,

et seq.) subject to appropriation by the general assembly;



(23) Beginning July 1, 1990, the services of a certified pediatric or

family nursing practitioner to the extent that such services are provided in

accordance with chapter 335, RSMo, and regulations promulgated thereunder,

regardless of whether the nurse practitioner is supervised by or in

association with a physician or other health care provider;



(24) Subject to appropriations, the department of social services shall

conduct demonstration projects for nonemergency, physician-prescribed

transportation for pregnant women who are recipients of medical assistance

under this chapter in counties selected by the director of the division of

medical services. The funds appropriated pursuant to this subdivision shall

be used for the purposes of this subdivision and for no other purpose. The

department shall not fund such demonstration projects with revenues received

for any other purpose. This subdivision shall not authorize transportation of

a pregnant woman in active labor. The division of medical services shall

notify recipients of nonemergency transportation services under this

subdivision of such other transportation services which may be appropriate

during active labor or other medical emergency;



(25) Nursing home costs for recipients of benefit payments under

subdivision (4) of this subsection to reserve a bed for the recipient in the

nursing home during the time that the recipient is absent due to admission to

a hospital for services which cannot be performed on an outpatient basis,

subject to the provisions of this subdivision:



(a) The provisions of this subdivision shall apply only if:



a. The occupancy rate of the nursing home is at or above ninety-seven

percent of Medicaid certified licensed beds, according to the most recent

quarterly census provided to the division of aging which was taken prior to

when the recipient is admitted to the hospital; and



b. The patient is admitted to a hospital for a medical condition with an

anticipated stay of three days or less;



(b) The payment to be made under this subdivision shall be provided for

a maximum of three days per hospital stay;



(c) For each day that nursing home costs are paid on behalf of a

recipient pursuant to this subdivision during any period of six consecutive

months such recipient shall, during the same period of six consecutive months,

be ineligible for payment of nursing home costs of two otherwise available

temporary leave of absence days provided under subdivision (5) of this

subsection; and



(d) The provisions of this subdivision shall not apply unless the

nursing home receives notice from the recipient or the recipient's responsible

party that the recipient intends to return to the nursing home following the

hospital stay. If the nursing home receives such notification and all other

provisions of this subsection have been satisfied, the nursing home shall

provide notice to the recipient or the recipient's responsible party prior to

release of the reserved bed.



2. Benefit payments for medical assistance for surgery as defined by

rule duly promulgated by the division of medical services, and any costs

related directly thereto, shall be made only when a second medical opinion by

a licensed physician as to the need for the surgery is obtained prior to the

surgery being performed.



3. The division of medical services may require any recipient of medical

assistance to pay part of the charge or cost, as defined by rule duly

promulgated by the division of medical services, for dental services, drugs

and medicines, optometric services, eye glasses, dentures, hearing aids, and

other services, to the extent and in the manner authorized by Title XIX of the

federal Social Security Act (42 U.S.C. 1396, et seq.) and regulations

thereunder. When substitution of a generic drug is permitted by the

prescriber according to section 338.056, RSMo, and a generic drug is

substituted for a name brand drug, the division of medical services may not

lower or delete the requirement to make a co-payment pursuant to regulations

of Title XIX of the federal Social Security Act. A provider of goods or

services described under this section must collect from all recipients the

partial payment that may be required by the division of medical services under

authority granted herein, if the division exercises that authority, to remain

eligible as a provider. Any payments made by recipients under this section

shall be in addition to, and not in lieu of, any payments made by the state

for goods or services described herein.



4. The division of medical services shall have the right to collect

medication samples from recipients in order to maintain program integrity.



5. Reimbursement for obstetrical and pediatric services under

subdivision (6) of subsection 1 of this section shall be timely and sufficient

to enlist enough health care providers so that care and services are available

under the state plan for medical assistance at least to the extent that such

care and services are available to the general population in the geographic

area, as required under subparagraph (a)(30)(A) of 42 U.S.C. 1396a and federal

regulations promulgated thereunder.



6. Beginning July 1, 1990, reimbursement for services rendered in

federally funded health centers shall be in accordance with the provisions of

subsection 6402(c) and section 6404 of P.L. 101-239 (Omnibus Budget

Reconciliation Act of 1989) and federal regulations promulgated thereunder.



7. Beginning July 1, 1990, the department of social services shall

provide notification and referral of children below age five, and pregnant,

breast-feeding, or postpartum women who are determined to be eligible for

medical assistance under section 208.151 to the special supplemental food

programs for women, infants and children administered by the department of

health and senior services. Such notification and referral shall conform to

the requirements of section 6406 of P.L. 101-239 and regulations promulgated

thereunder.



8. Providers of long-term care services shall be reimbursed for their

costs in accordance with the provisions of section 1902 (a)(13)(A) of the

Social Security Act, 42 U.S.C. 1396a, as amended, and regulations promulgated

thereunder.



9. Reimbursement rates to long-term care providers with respect to a

total change in ownership, at arm's length, for any facility previously

licensed and certified for participation in the Medicaid program shall not

increase payments in excess of the increase that would result from the

application of section 1902 (a)(13)(C) of the Social Security Act, 42 U.S.C.

1396a (a)(13)(C).



10. The department of social services, division of medical services, may

enroll qualified residential care facilities, as defined in chapter 198, RSMo,

as Medicaid personal care providers.



Top



Missouri General Assembly



Copyright © Missouri Legislature, all rights reserved.