Senate Substitute

HEALTH IMPROVEMENT PLANS

This act provides that beginning no later than July 1, 2008, the Mo HealthNet Division, within the Department of Social Services, shall function as a third party administrator, providing by July 1, 2013, all participants of MO HealthNet a choice of three health improvement plans. The three choices for a health improvement plan include the following:

- a risk-bearing care coordination plan, which consists of coordinated care with a guaranteed savings level that is actuarially sound.

- an administrative services organizations plan, which consists of a system of health care delivery providing care management and health plan administration services on a non-capitated basis where the financial terms shall require that the vendor fees are reduced if savings and quality targets specified by the department are not met.

- a state care management point of service plan, which consists of a system of health care delivery administered by the Department of Social Services.

The department shall implement a risk-bearing care coordination plan, an administrative services organization plan, and a state care management point of service plan. The Office of Administration shall commission and independent evaluation and comparison on the basis of quality, cost, health improvement, health outcomes, social and behavioral outcomes, health status, customer satisfaction, use of evidenced-based medicine, and use of best practices. The annual evaluation by the department shall be submitted to the "Oversight Committee on Health Improvement Plans", which is established in this act. The Oversight Committee shall review participant and provider satisfaction reports and other specified data to analyze and determine the health or other outcomes and financial impact from the programs. The committee shall also perform other tasks as necessary to ensure quality of care, availability, participant satisfaction and status information on the programs. By July 1, 2013, the oversight committee shall issue findings to the General Assembly on the success and failures of the health improvement plans and recommend whether to discontinue any of the programs. The oversight committee shall also create a subcommittee to develop a Comprehensive System Point of Entry for long-term care.

The department shall have rules outlining an exemption process for participants whose current treating physicians are not participating in either a risk-bearing care coordination or ASO network in order to prevent interruption in the continuity of medical care. However, the department shall formulate a plan so that by July 1, 2013, all participants are enrolled in one of the health improvement programs.

By July 1, 2008, the department shall begin enrollment of parents and children not already enrolled in Missouri Medicaid managed care in a health improvement plan, with complete enrollment by July 1, 2009. By July 1, 2009, the department shall begin enrollment in a health improvement plan one-half of the aged, blind and disabled participants, on an opt-out basis, with complete enrollment by July 1, 2013.

This act specifies the elements required of all health improvement plans, including offering a health care advocate for the participant of a health improvement plan to provide comprehensive coordinated physical and behavioral health in partnership with the patient, their family, and their caregivers to assure optimal consideration of medical, behavioral or psychosocial needs. The services of the health care advocate shall provide a health care home for the participant, where the primary goal is to assist patients and their support system with accessing more choices in obtaining primary care, coordinating referrals, and obtaining specialty care. The health care advocate shall be a licensed health care professional trained and certified by the department of social services to provide the services outlined in the act.

For all health improvement plans, the vendor shall issue electronic access cards to participants. Such cards may be used to satisfy cost-sharing at the hospital, physician's office, pharmacy, or any other health care professional and also allow participants to earn enhanced health improvement points by signing a health improvement participant agreement, participating in healthy practices, and making responsible lifestyle choices consistent with the participant's plan of care and unique health care needs and goals. These points will provide participants the ability to use the card to pay for approved health care expenditures. The health care advocate shall advise the participant regarding the appropriate health care expenditures for each participant consistent with the participant's plan of care. Participants engaging in a discussion with their health care advocate on the plan of care may access, under certain circumstances, physical therapy, speech therapy, occupational therapy or comprehensive day services. The MO HealthNet Division shall promulgate a list of expenditures, including but not limited to: Medicaid eligible services, co-pays, spenddown, over-the-counter drugs, and vitamins.

All plans shall also establish a twenty-four, confidential, toll-free nurse health line to be staffed by licensed registered nurses. Participants shall be encouraged to call when symptomatic, before making appointments or visiting an urgent care room. The nurse shall assess symptoms and provide care recommendation to seek services at the appropriate time and level of intervention. The nurses shall not diagnose nor provide treatment.

All plans shall partner with FQHCs, Rural Health Clinics, Community Mental Health Centers, local public health agencies, or a program designated by the department of mental health within a 60 mile radius to ensure availability of care, as well as with telehealth providers. SECTIONS 208.950 and 208.955

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.

The department shall promulgate rules setting forth the procedures and methods for implementing the provisions the section and establish criteria for the disbursement of funds to include preference for not-for-profit health care entities where the majority of the patients and clients served are either MO HealthNet participants or are from the medically underserved population. SECTION 208.975

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

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).

PREMIUM OFFSET PROGRAM

The Department of Social Services is authorized to implement a premium offset program for making standardized private health insurance coverage available to qualified individuals. The department shall seek to obtain federal financial participation in the program. The premium offset from the MO HealthNet division shall only be due if the employer and employee, or both, pay their share of the required premium. The qualified uninsured individual shall not be entitled to Mo HealthNet wraparound services. SECTION 208.202

ELIGIBILITY AND SERVICES

This act extends MO HealthNet coverage for foster care children from the age of 18 to 21 without regard to income or assets. 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. This act also allows for durable medical equipment if medically necessary. SECTIONS 208.151 AND 208.152

There is an emergency clause for the provisions relating to foster care eligibility.

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. 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, 2009. SECTIONS 208.014, 208.631, AND 208.930

MO HEALTHNET DIVISION

This act modifies provisions relating to the MO HealthNet Division's authority to collect from third party payers. The provisions relating to annuities and estate recovery. SECTIONS 208.212 TO 208.217 AND 473.398.

PRIMO PROGRAM

Adds psychiatrists and psychologists to the list of providers eligible for assistance through the Primary Care Resource Initiative for Missouri (PRIMO) program. SECTION 191.411

ADRIANE CROUSE

SA 1- PROVIDES THAT THE DEPARTMENTS SHALL GOVERN RATHER THAN PERMIT THE PRACTICE OF TELEHEALTH IN THE MO HEALTHNET PROGRAM RATHER THAN IN THE "STATE OF MISSOURI."

SA 1 TO SSA 1 FOR SA 2- MODIFIES THE MAKE-UP OF THE PROFESSIONAL SERVICES PAYMENT COMMITTEE FROM 15 MEMBERS TO 18 MEMBERS, GEOGRAPHICALLY BALANCED. THE MEMBERS SHALL ALSO INCLUDE THE ATTORNEY GENERAL AND TWO PATIENT ADVOCATES.

SA 3- INCLUDES OTHER MENTAL HEALTH PROVIDERS LICENSED UNDER CHAPTER 337, RSMO, IN THE PRIMO PROGRAM.

SA 4- ADDS LANGUAGE SPECIFYING THAT THE DEPARTMENT OF SOCIAL SERVICES SHALL PROVIDE PAYMENT TO THE RECORDER OF DEEDS THE FEES SET FOR SIMILAR FILINGS IN CONNECTION WITH THE FILING OF A LIEN AND ANY OTHER NECESSARY DOCUMENTS

SA 5- PROVIDES THAT THE OVERSIGHT COMMITTEE ON HEALTH IMPROVEMENT PLANS SHALL HAVE 14 MEMBERS INSTEAD OF 13, TO INCLUDE THE ATTORNEY GENERAL.

SA 6- PROVIDES THAT THE DEPARTMENT OF SOCIAL SERVICES SHALL ENGAGE IN A PUBLIC PROCESS FOR THE DESIGN, DEVELOPMENT, AND IMPLEMENTATION OF THE HEALTH IMPROVEMENT PLANS, HEALTH ADVOCATES, AND HEALTH IMPROVEMENT POINTS AND OTHER PROVISIONS OF MO HEALTHNET AND INCLUDE CONSUMERS, HEALTH ADVOCATES, DISABILITY ADVOCATES, AND OTHER KEY STAKEHOLDER PARTIES.

SA 7- SPECIFIES THAT PARTICIPANTS OF MO HEALTHNET SHALL HAVE A CHOICE OF WHICH HEALTH IMPROVEMENT PLAN TO ENROLL IN. THE STATE IS TO PROVIDE INFORMATION ON ALL THREE PLANS AND THE PARTICIPANT SHALL CHOOSE BETWEEN AVAILABLE VENDORS IN THE PLANS. NO PROVISION SHALL BE CONSTRUED TO REQUIRE THE ABD POPULATION TO ENROLL IN A RISK-BEARING CARE COORDINATION PLAN UNLESS THERE IS NO OTHER PLAN AVAILABLE IN THE AREA.

SSA 1 for SA 8- SPECIFIES THAT NOTHING IN THE ACT SHALL BE CONSTRUED TO DENY A CURRENTLY ELIGIBLE SERVICE IF SUCH PARTICIPANT FAILS OR IS UNABLE TO FOLLOW THEIR HEALTH IMPROVEMENT PARTICIPATION AGREEMENT.

SA 11- ENACTS PROVISIONS OF THE PUBLIC ASSISTANCE BENEFICIARY EMPLOYER DISCLOSURE ACT.

SSA 1 FOR SA 12, AS AMENDED- ADDS MEMBERS TO THE SUBCOMMITTEE ON THE CENTRAL ENTRY POINT SYSTEM.

SA 13- AMENDS PROVISIONS REGARDING THIRD PARTY PAYERS AND MO HEALTHNET SUBROGATION CLAIMS.

SA 15- ADDS PROVISIONS REGARDING THE REQUEST FOR PROPOSAL PROCESS FOR HEALTH IMPROVEMENT PLANS.