SB 577 Enacts the "Missouri Health Improvement Act of 2007"
Sponsor: Shields Co-Sponsor(s)
LR Number: 2227L.16T Fiscal Note: 2227-07
Committee: Health and Mental Health
Last Action: 7/2/2007 - Signed by Governor Journal Page:
Title: CCS HCS SS SCS SB 577 Calendar Position:
Effective Date: EC on certain sections
House Handler: Schaaf

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Current Bill Summary


CCS/HCS/SS/SCS/SB 577 - This act establishes the Missouri Continuing Health Improvement Act of 2007, modifying various provisions relating to the state medical assistance program and changing the name of the program to MO HealthNet.

STATE LEGAL EXPENSE FUND - This act adds coverage for liability under the state legal expense fund to podiatrists, chiropractors, optometrists, pharmacists, certain mental health professionals, certain other health care providers who provide health care services at certain health departments or health centers, any social welfare board, the officers and members of such a board, and certain health care providers who are referred to provide specialty care without compensation for such a board.

The moneys in the fund shall also be available to pay claims or judgments against certain physicians and dentists providing specialty care without compensation to an individual referred to him or her by certain health departments or health centers. The payment for claims arising under this specific provision shall not exceed one million dollars in the aggregate for all claims arising out of the same act or acts alleged in a single cause, and shall not exceed one million dollars for any one claimant, and insurance policies purchased for such persons with moneys appropriated to the legal expense fund shall not exceed one million dollars. Additionally, liability or malpractice insurance for any physician or dentist shall not be considered available to pay any portion of a judgment or claim for which the legal expense fund is liable under this provision. (SECTION 105.711)

These provisions are substantially similar to SB 273 (2007).

INCOME TAX DEDUCTION FOR LONG-TERM CARE INSURANCE PREMIUMS - Beginning January 1, 2007, this bill authorizes 100% of the amount paid for nonreimbursed qualified long-term care insurance premiums to be deducted from a taxpayer's Missouri taxable income to the extent the amount is not already included in the taxpayer's itemized deductions. (SECTION 135.096)

This provision is in SCS/SB 15 and in HB 40 (2007).

MISSOURI HEALTHCARE ACCESS FUND - This act creates the Missouri Healthcare Access Fund to be used to expand healthcare services in state and federally designated areas with healthcare shortages and is subject to appropriations. In addition, the state shall provide matching moneys from the general revenue fund equaling one-half of the amount deposited into the fund. The total annual amount available to the fund from state sources under such a match program shall be five hundred thousand dollars for fiscal year 2008, one million five hundred thousand dollars for fiscal year 2009, and one million dollars annually thereafter.

The Department of Health and Senior Services has the authority to designate eligible facilities in an area of defined need and is required to re-evaluate eligible facilities every six years. Beginning January 1, 2007, individuals making a donation in excess of $100 to the fund will be eligible for a tax credit that is subject to the approval of the House and Senate Budget Committees. The provisions of these sections will expire six years from the effective date. (SECTIONS 135.575, 191.1050, 191.1053, 191.1056)

These provisions are substantially similar to HB 878 (2007).

PRIMO PROGRAM - This act adds psychiatrists and psychologists and other mental health providers, such as psychologists, professional counselors, and social workers, licensed under chapter 337, to the list of providers eligible for assistance through the Primary Care Resource Initiative for Missouri (PRIMO) program. This act also requires the Department of Health and Senior Services to submit an annual report to the Mo HealthNet Oversight Committee established under this act regarding the implementation of the program. (SECTION 191.411)

MO HEALTHNET (MEDICAID) FRAUD - A person commits a "knowing" violation of sections prohibiting Medicaid fraud if he or she has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information, but provides that the use of the terms "knowing" or "knowingly" shall be construed to include the term "intentionally." This act also expands the definition of "health care provider" to include any employee, representative, or subcontractor of the state.

Current law provides that any person committing such a violation shall be guilty of a Class D felony upon a first conviction, and shall be guilty of a Class C felony upon subsequent convictions; this act provides that such person shall be guilty of a Class C felony upon a first conviction, and shall be guilty of a Class B felony upon subsequent convictions. Also, any person who has been convicted of such violations shall be referred to the federal Office of Inspector General.

Any person who is the original source of the information used by the attorney general to bring a Medicaid fraud action shall receive 10 percent of any recovery by the Attorney General unless he or she participated in the fraud or abuse.

The act also contains "whistle-blower" protections, providing that a person who is discharged, demoted, suspended, threatened, harassed, or in any way discriminated against in terms of employment due to a lawful act taken by the person in furtherance of an action for Medicaid fraud shall be entitled to reinstatement with the same seniority status, not less than two times the amount of back pay, interest on the back pay. However, such protections shall not apply if the court finds that the employee brought a frivolous or clearly vexatious claim, planned, initiated, or participated in the conduct upon which the action is brought, or is convicted of criminal conduct arising from Medicaid fraud violations.

The Attorney General's office and the Department of Social Services shall make a detailed report to the General Assembly and the Governor regarding implementation and administration of the provisions of this act, as provided therein. Additionally, a financial audit of the medicaid fraud unit within the Attorney General's office and of the program integrity unit of the Department of Social Services shall be annually conducted by the State Auditor, to quantitatively determine the amount of money invested in such units and the amount of money actually recovered by them.

All Medicaid health care providers shall maintain adequate records regarding services provided, claims submitted, and payments requested, and shall maintain such records for at least five years after the date payment was received or for at least five years after the date on which the claim was submitted, if payment was not received. No person shall conceal or destroy such records before five years time, or he or she shall be guilty of a Class A misdemeanor.

Any person who intentionally files a false report or claim alleging a Medicaid fraud violation is guilty of a Class A misdemeanor and guilty of a Class D felony for any subsequent violations. In addition, it shall be a class D felony for any person to receive any compensation in exchange for knowingly failing to report any Medicaid fraud violations.

An advisory working group is created to study and determine whether an Office of Inspector General shall be established. Such office would be responsible for oversight, auditing, investigation, and performance review to provide increased accountability, integrity, and oversight of state medical assistance programs. The commission will consist of ten members, five from the House and five from the Senate. Additionally, the directors of the Departments of Social Services, Health and Senior Services, and Mental Health shall serve as ex-officio members of the advisory working group.

This act also allows for the deposit of moneys recovered in a Medicaid fraud action to be used to increase Medicaid provider reimbursement until amount equals the average Medicare provider reimbursement for comparable services. Such funds shall be deposited for this purpose so long as there are any funds remaining after the appropriation of funds to the Attorney General for cost of investigation and prosecution and which have been appropriated to the Department of Social Services for administering the state medical assistance program. (SECTIONS 191.900 TO 191.914)

These provisions are substantially similar to HB 353 (2007).

CHRONIC KIDNEY DISEASE TASK FORCE - This act creates the "Chronic Kidney Disease Task Force." The list of 17 members are specified in the act. The duties of the task force include developing a plan to educate the public and health care professionals about the advantages and methods of early screening, diagnosis, and treatment of chronic kidney disease. Also, the task force shall submit a report of its findings and recommendations to the General Assembly by August 30, 2008, at which time the task force shall expire. (SECTION 192.632)

This act is substantially similar to SB 677 and HB 1084 (2007).

ASSISTED LIVING FACILITIES - This act requires assisted living facilities to immediately implement and review, within 24 hours, any physician order and update a resident's care plan when the resident returns from a hospital or skilled nursing facility. The Department of Health and Senior Services shall adjust personal care units authorized upon effective date of the physicians orders to reflect the services required by such orders. (SECTION 198.069)

MISAPPROPRIATION OF FUNDS OF ELDERLY OR DISABLED FACILITY CARE RESIDENT - This act also modifies the offense of misappropriation of funds of elderly or disabled facility care resident. This act provides that evidence of misappropriating funds and failing to pay for the facility care of an elderly or disabled person may include, but shall not be limited to proof that the facility has sent, by certified mail with confirmation receipt requested, notification of failure to pay nursing home expenses incurred by a resident to the person who has assumed responsibility of managing the financial affairs of the resident.

These provisions shall not be construed to limit the investigations or prosecutions of this crime or the crime of financial exploitation of an elderly or disabled person. (SECTION 198.097)

These provisions are substantially similar to SB 675 (2007).

TICKET TO WORK PROGRAM - This act establishes the Ticket to Work Health Assurance Program, which is authorized by the federal Ticket to Work and Work Incentives Improvement Act.

This act allows MO HealthNet eligibility for an employed person who meets the definition of disabled, satisfies asset limits, and who has an annual gross income of 300 percent or less of the federal poverty level.

The asset limit for the new program is the same as that for the Medical Assistance – Permanently and Totally Disabled (MA-PTD) program, currently $999.99 for a single person and $2,000 for a couple with the standard exemptions. The available asset limit does not include medical savings accounts or independent living accounts. The individual must have a gross income of 300 percent or less of the federal poverty level. Individuals with gross income in excess of one hundred percent of the federal poverty level shall pay a specified monthly premium for participation. For income to qualify as earned income for the purposes of this program, the individual must demonstrate that Social Security and Medicare taxes are paid on the earnings.

If an individual's employer offers health insurance that is more cost effective, the individual shall participate in the employer-sponsored insurance. The Department of Social Services, however, will be responsible for costs associated with the employer insurance. (SECTION 208.146)

These provisions are similar to SCS/HCS/HB 39 (2007).

MO HEALTHNET ELIGIBILITY AND SERVICES

DRUG COURT - Under this act, individuals who receive medical assistance due to the receipt of aid to families with dependent children, shall continue to be eligible for such assistance for sixty days despite having a child or children removed from their custody, if such person is a participant in a drug court program and upon federal approval by the Centers for Medicare and Medicaid Services. (SECTION 208.151.1(2))

EXTENSION OF SERVICES FOR FORMER FOSTER CARE CHILDREN - This act extends MO HealthNet coverage for foster care children from the age of 18 to 21 without regard to income or assets. (SECTION 208.151.1 (26))

LONG-TERM CARE SERVICES - This act also provides that individuals with more than $500,000 in home equity will no longer qualify for long-term care services under MO HealthNet. (SECTION 208.152.1(4))

Benefits for personal care services, when delivered in a residential care facility or assisted living facility shall be authorized on a four tier level based on the services the resident requires and frequency of services. The rate paid to providers for each tier of service shall be subject to appropriations. Services provided by in-home providers to participants who are qualified for the aged and disabled waiver and/or personal care, shall be authorized on a tier-level basis on the services required, frequency of delivery, and time needed to perform tasks. The rate paid for services shall be set subject to appropriations. (SECTION 208.152.1(14))

PEDIATRIC OR FAMILY NURSING PRACTITIONER - Under current law the services of certified pediatric or family nursing practitioners are covered under Medicaid, regardless of whether the nurse practitioner is supervised by or in association with a physician or other health care provider. This act provides that such services may only be covered if such pediatric or family nursing practitioners have a collaborative practice agreement. (SECTION 208.152.(17))

OPTIONAL SERVICES - This act also allows for durable medical equipment, if medically necessary. An electronic web-based prior authorization system shall use best medical evidence and care and treatment. Hospice services are also reinstated as covered services (SECTION 208.152.(19), (20), and (26))

This act also reinstates dental and optometry services. Such services shall be subject to appropriations and shall be medically necessary (SECTION 208.152.(21) and (22) )

REIMBURSEMENT RATES FOR MO HEALTHNET PROVIDERS - By January 1, 2008, the MO HealthNet Division shall report the status of MO HealthNet provider reimbursement rates as compared to one hundred percent of the Medicare reimbursement rate and compared to the average dental reimbursement rates paid by 3rd party payors in the state. The division shall also by that date provide to the General Assembly a four-year plan to achieve parity with Medicare reimbursement rates. By July 1, 2008, the division shall provide to the General Assembly a 4-year plan to achieve parity with Medicare rates and for third party payer 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 4-year plan developed under this subdivision. (SECTION 208.152.(23))

CO-PAYS - Beginning July 1, 2008, the division may require any participant receiving services to pay an additional payment for all covered services except for personal care services, mental health services, and CHIP services. (SECTION 208.152.4)

SECOND MEDICAL OPINION FOR SURGERY-REPEALED - Under current law, benefit payments for medical assistance for surgery shall be made only when a second medical opinion by a licensed physician as to the need for the surgery is obtained. This act repeals such provision. (SECTION 208.152.3)

ASSISTED LIVING FACILITIES AS MO HEALTHNET PROVIDERS - This act adds assisted living facilities as well as residential care facilities to the list of qualified MO HealthNet personal care providers. (SECTION 208.152.10)

SHELTERED WORKSHOP INCOME - This act also provides that as to the permanent and totally disabled population, any income derived through certified extended employment at a sheltered workshop shall not be considered as income for determining Medicaid eligibility. (SECTION 208.152.10)

SOCIAL SECURITY COST OF LIVING INCREASE - Any social security cost-of-living increase at the beginning of any year shall be disregarded until the federal poverty level for such year is implemented. (SECTION 208.153.7)

PAY-FOR-PERFORMANCE - Subject to appropriations, this act requires pay for performance to be developed by the Pay for Performance Committee. (SECTION 208.153.2)

The committee shall be composed of 18 members, geographically balanced, including 9 physicians, one consumer advocate, and one patient advocate. The other members shall be persons actively engaged in hospital administration and nursing home administration. The MO HealthNet Division shall maintain the program to ensure quality, foster relationships between the patient and the provider, uses clinically relevant and evidence-based measures which are statistically valid. (SECTION 208.197)

PREMIUM OFFSET PROGRAM - This act allows for the development of a premium offset pilot project to make standardized health insurance coverage available to qualified individuals. Subject to approval by the oversight committee, the MO HealthNet Division shall implement the program in two regions in the state, one in an urban area and one in a rural area. No employer shall participate in the pilot project for more than 5 years. The provisions of this pilot shall expire on June 30, 2011. (SECTION 208.202)

THIRD PARTY LIABILITY AND ESTATE RECOVERY - This act modifies provisions relating to the MO HealthNet Division's authority to collect from third party payers. This act provides that in order for annuities not to be counted as income for purposes of MO Healthnet eligibility in a long-term care facility, the annuities must be in the name of spouse residing in long-term care facility. This act also provides for the ability of the MO HealthNet Division to obtain eligibility data from third party insurance carriers, health plans, pharmacy benefits managers, and third party administrators at least twice a year in a usable format. Also, this act provides for the recovery of medical assistance program payments made on behalf of the decedent from a decedent's estate. (SECTIONS 208.212 TO 208.217 AND 473.398)

PERSONAL CARE SERVICES CONTRACTS - Under this act, if a personal care contract is received as fair and valuable consideration in exchange for personal property, real property, cash or securities, such exchange shall not render an institutionalized individual ineligible for Medicaid based on an improper transfer of assets. A personal care contract is fair and valuable consideration when:

- There is a written agreement between the individual providing services and the individual receiving care which specifies the type, frequency, and duration of the services to be provided that was signed and dated on or before the date the services began;

- The services do not duplicate those which another party is being paid to provide;

- The individual receiving the services has a documented need for the personal care services provided;

- The services are essential to avoid institutionalization of the individual receiving benefit of the services;

- Compensation for the services must be made at the time services are performed or within two months of the provision of the services; and

- The fair market value of the services provided prior to the month of institutionalization is equal to the fair market value of the assets exchanged for the services. (SECTION 208.213)

MO HEALTHNET BENEFICIARY EMPLOYER REPORTS - Requires the Department of Social Services to submit a Mo HealthNet beneficiary quarterly report to the governor and requires applicants for Mo HealthNet benefits to disclose their employer. (SECTION 208.230)

HEALTH INSURANCE FOR UNINSURED CHILDREN PROGRAM - Changes the eligibility requirement for the State Children's Health Insurance Program and specifies that the program will remain in effect only if the federal government appropriates funds. (SECTION 208.631)

Under current law, children who qualify for the health insurance for uninsured children program (MC+ for Kids) must lack access to affordable employer-sponsored health insurance. This act modifies the definition of "affordable employer-sponsored health insurance" as follows:

- for families with gross income above 150 percent to 185 percent of the federal poverty level, the health insurance should require a monthly premium of 3 percent of 150 percent of the federal poverty level for a family of three;

- for families with gross income above 185 percent to 225 percent of the federal poverty level, the health insurance should require a monthly premium of 4 percent of 185 percent of the federal poverty level for a family of three;

- for families with gross income above 225 percent and below 300 percent of the federal poverty level, the health insurance should require a monthly premium of 5 percent of 225 percent of the federal poverty level for a family of three.

In addition, health insurance plans that do not cover an eligible child's pre-existing condition shall not be considered "affordable employer-sponsored health care insurance." Also, if the child has exceed the annual coverage limits for all health care services, the child is not considered insured and does not have access to affordable health insurance. (SECTION 208.640)

UNINSURED WOMEN'S HEALTH PROGRAM - This act requires revision of eligibility requirements for the uninsured women's health program to include women who are at least 18 years old and with a net family income of at or below 185 percent of the federal poverty level. Such women shall not have assets in excess of 250,000 dollars, nor shall they have access to employer-sponsored health insurance. There is an emergency clause for the provisions relating to foster care eligibility. (SECTION 208.659)

This provision is substantially similar to SB 653 (2007).

TELEHEALTH - This act provides that the Department of Social Services shall promulgate rules governing the practice of telehealth in the MO HealthNet program. Telehealth providers shall be required to obtain patient consent before telehealth services are initiated and to ensure confidentiality of medical information. (SECTION 208.670)

LONG-TERM CARE PARTNERSHIP PROGRAM - This act establishes the Missouri Long-Term Care Partnership Program and provides that the Department of Social Services shall, in conjunction with the Department of Insurance, Financial Institutions and Professional Registration, coordinate the program so that private insurance and MO Health Net funds shall be used to finance long-term care.

Under such a program, an individual may purchase a qualified long-term care partnership approved policy in accordance with the requirements of the Federal Deficit Reduction Act of 2005 to provide a mechanism for individuals to qualify for coverage of the cost of the individual's long-term care needs under Mo HealthNet without first being required to substantially exhaust his or her resources. Individuals seeking to qualify for MO HealthNet are permitted to retain assets equal to the dollar amount of qualified long-term care partnership insurance benefits received beyond the level of assets otherwise permitted to be retained under Mo HealthNet.

The Department of Insurance, Financial Institutions and Professional Registration may certify qualified state long-term care insurance partnership policies that meet the applicable provisions of the National Association of Insurance Commissioners (NAIC) Long-Term Care Insurance Model Act and Regulation as specified in the Federal Deficit Reduction Act of 2005. In addition, the department shall develop requirements regarding training for those who sell qualified long-term care partnership policies.

The issuers of qualified long-term care partnership policies in this state shall provide regular reports to both the Secretary of the federal Department of Health and Human Services and to the Departments of Social Services and Insurance, Financial and Professional Regulation.

The Departments of Social Services and Insurance, Financial and Professional Regulation shall promulgate rules to implement the provisions of this act.

This act repeals Sections 660.546 to 660.557, RSMo, relating to a similar long-term care partnership program but that was never approved by federal law. (SECTIONS 208.690 TO 208.698)

The provisions of these sections are substantially similar to SCS/SB 15 (2007).

COMMUNITY-BASED ORGANIZATIONS IN THE FAMILY DEVELOPMENT ACCOUNT PROGRAM - The act revises the definition of "community-based organizations" to include any nonprofit corporations formed under Chapter 355 for which the department can approve to implement the Family Development Account Program. (SECTION 208.750)

HEALTH IMPROVEMENT PLANS - The Department of Social Services shall, with the advice and approval of the MO HealthNet Oversight Committee, create health improvement plans for all participants in MO HealthNet. Such health improvement plans shall include but not be limited to, risk-bearing coordinated care plans, administrative services organizations, and coordinated fee-for-service plans. The development of the plans and enrollment into such plans shall begin July 2008 and be completed by July 2011. The contracts for such plans shall require that the contracted per diem rate be reduced or other financial penalty occur if the quality targets are not met by the department. Every participant shall be enrolled in a health improvement plan and have a health care home.

The department is also required to use a public process for the design, development, and implementation of health improvement plans. The department shall establish a sliding scale schedule of co-payments for hospital emergency room visits.

All health improvement plans are required to help participants remain in the least restrictive level of care possible, use domestic call centers and nursing help lines, report participant and provider satisfaction information annually. Additionally, for purposes of a request for proposal for the health improvement plans, there shall be such requests in at least six regions in the state, however, in no case shall there be a single state-wide contract.

This act establishes the MO HealthNet Oversight Committee which will advise the department and study various aspects of the program including, but not limited to, satisfaction reports, pilot project results, and health risk assessment results. This committee shall also develop recommendations relating to the expenditure of funds appropriated to the healthcare technology fund. A subcommittee is established within the oversight committee to advise the department on the development of a comprehensive entry-point system for long-term care. The Joint Committee on MO HealthNet is also established to study the resources needed to continue improvements to the program. (SECTIONS 208.950, 208.952, 208.955, Section 3)

HEALTH CARE TECHNOLOGY FUND - This act establishes the Healthcare Technology Fund, which shall be administered by the Department of Social Services.

Upon appropriation, moneys in the fund shall be used to promote technological advances to improve patient care, decrease administrative burdens, and increase patient and health care provider satisfaction. Any programs or improvements on technology shall include encouragement and implementation of technologies intended to improve the safety, quality and costs of health care services in the state. (SECTION 208.975)

The provisions of this section are similar to SB 274 (2007)

COMMITTEES AND STUDIES - Under this act, the Legislative Budget Office shall conduct an annual five-year rolling MO HealthNet budget forecast. (SECTION 1)

PRESCRIPTION DRUGS - This act specifies that the fee for service policies that prescribe psychotropic medications will not include any new limits to the initial access requirements. (SECTION 2)

SUNSET PROVISION - This act repeals the provision establishing the Medicaid Reform Commission and the June 30, 2008, expiration date for the current Medicaid system. This act also repeals the expiration date for the Health Care for Uninsured Children program and provides that the program shall be void and of no affect if there are no funds appropriated by Congress to be provided to Missouri. This act also extends the sunset date for the consumer-directed personal care assistance services program for non-Medicaid eligible clients from June 30,2008 to June 30, 2019. SECTIONS 208.014, 208.631, AND 208.930.

ADRIANE CROUSE