Perfected

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 an 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. No provision in the act shall be construed to require the aged, blind, or disabled population to enroll in a risk-bearing care coordination plan unless there is no other plan available in the area.

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. A participant shall not be denied currently eligible services if such participant fails or is unable to follow their health improvement participation agreement. 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

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 191.907

These provisions are identical to HB 353 (2007).

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 as well as hospice care.

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. SECTIONS 208.151 AND 208.152

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).

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.

PUBLIC ASSISTANCE BENEFICIARY EMPLOYER ACT

An applicant for benefits under the state Medicaid system, or any person requesting uncompensated care in a hospital, shall identify his or her employer. The department of social services shall to submit to the General Assembly an annual report, starting in calendar year 2008, identifying all such identified employers who employ 25 or more public assistance program beneficiaries. There shall also be public access to the report through the department's Internet website. SECTION 208.230

These provisions are identical to SB 179 (2007).

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