Senate Amendment

SS/SCS/HCS/HB 1682 - This act modifies several provisions relating to health care, including: (1) health awareness month designations; (2) automated external defibrillators; (3) physician assistants; (4) outside the hospital do-not-resuscitate orders; (5) vapor products in public schools; (6) medical marijuana telehealth; (7) the Office of State Ombudsman for Long-Term Care Facility Residents; (8) the administration of controlled substances; (9) prescriptions for pseudoephedrine and related drugs; (10) medical marijuana edibles; (11) medical marijuana background checks; (12) epinephrine auto-injectors; (13) state-settled opioid causes of action; (14) dissolution of a hospital district; (15) personal care assistance services; (16) remote dispensing site pharmacies; (17) charitable pharmacies; (18) reimbursement of health care claims; (19) pharmacy benefits managers; (20) life care contracts; (21) health care practitioner credentialing; and (22) and the confidentiality of certain health records.

HEALTH AWARENESS MONTH DESIGNATIONS (Section 9.152, 9.166, and 9.182)

This act designates the month of May as "Mental Health Awareness Month". The month of July shall be known as "Minority Mental Health Awareness Month". Finally, the month of September shall be designated as "Deaf Awareness Month".

These provisions are identical to provisions in HB 1383 (2020).

AUTOMATED EXTERNAL DEFIBRILLATORS (Sections 190.092 and 190.1005)

This act modifies provisions of the "Public Access to Automated External Defibrillator Act". Under current law, persons or entities that have acquired an automated external defibrillator are required to ensure that: (1) expected users receive training from the American Red Cross, American Heart Association, or other equivalent training course; (2) the defibrillator is maintained and tested according to the manufacturer's operational guidelines; (3) the user activates the emergency medical services system as soon as possible; and (4) a person or entity placing a defibrillator outside of a health care facility has a physician review and approve the protocol and training.

This act repeals these provisions and requires a person or entity who acquires an automated external defibrillator to do the following: (1) comply with all regulations governing placement of the defibrillator; (2) ensure that the defibrillator is maintained and tested to the manufacturer's guidelines; (3) ensure that testing of the defibrillator occurs at least every 2 years and after each use; and (4) ensure that an inspection of all defibrillators on the premises is made every 90 days.

Currently, a person who gratuitously and in good faith renders emergency care through the use or provision of an automated external defibrillator shall not be held liable for any civil damages, unless he or she acted in a willful and wanton or reckless manner. This act extends this immunity to criminal penalties. Additionally, a person who or entity that provides training, owns the defibrillator, or is responsible for the site where the defibrillator is located shall likewise not be held liable. This act repeals such immunity for the person or entity that provided the clinical protocol for the sites or programs and for the licensed physician who reviews and approved the clinical protocol.

Finally, this act requires any training or course in cardiopulmonary resuscitation to include instruction in the proper use of an automated external defibrillator.

These provisions are identical to SCS/SB 692 (2020) and similar to HCS/HB 1460 (2020), SB 423 (2019), and provisions in HCS/SS/SB 145 (2019), HCS/SB 333 (2019), HCS/SCS/SB 363 (2019), SS#3/SCS/HB 113 (2019), and HB 1038 (2019).

PHYSICIAN ASSISTANTS (Sections 190.094, 190.105, 190.143, and 190.196)

Under this act, physician assistants may serve as staff on an ambulance. When attending a patient on an ambulance, the physician assistant shall be exempt from any mileage limitations in any collaborative practice arrangement prescribed under law.

These provisions are identical to the perfected SB 866 (2020).


Under this act, emergency medical services personnel shall comply with an outside the hospital do-not-resuscitate order from another state, the District of Columbia, or a U.S. territory if such order is on a standardized form, signed by the patient or the patient's representative and a licensed physician, and such form has been previously reviewed and approved by the Department of Health and Senior Services. Emergency medical services personnel shall not comply with the order if the patient or the patient's representative expresses to such personnel the desire to be resuscitated. Physicians, emergency medical service personnel, and health care facilities shall not be subject to civil, criminal, or administrative liability for complying with an outside the hospital do-not-resuscitate order from another state, the District of Columbia, or a U.S. territory.

This provision is identical to SB 1010 (2020).


Under this act, no person shall use vapor products in any indoor area of a public elementary or secondary school building or on school buses. School boards may set policy on permissible uses of vapor products in any other nonclassroom or nonstudent occupant facility or outdoor school grounds.

This provision is substantially similar to a provision in SCS/SB 829 (2020).


Under this act, a physician using telehealth to provide a certification for a patient's qualifying medical condition for medical marijuana shall comply with current statutes regarding patient interviews and examinations.

This provision is identical to a provision in SCS/HB 1383 (2020).


This act authorizes the Office of State Ombudsman for Long-Term Care Facility Residents to receive, respond to, and resolve complaints made by or on behalf of residents of Missouri veterans' homes relating to the action, inaction, or decisions of providers or agencies affecting resident health, safety, welfare, or rights. The State Ombudsman or representatives of the Office, in addition to all current authority granted by state statute, shall have the authority to enter any veterans' home and have access to residents in a reasonable time and manner and have access to resident records with the permission of the resident or the resident's guardian. Additionally, the Office shall analyze and monitor the development and implementation of federal, state, and local law and regulations regarding Missouri veterans' homes.

This provision is identical to the perfected SB 846 (2020) and a provision in the perfected SS/SCS/SB 718 (2020).


Under current law, a health care practitioner shall not accept any portion of a controlled substance unused by a patient if the practitioner did not originally dispense the drug, unless as part of an authorized drug disposal program. This act permits a non-dispensing practitioner to accept the unused controlled substance when the controlled substance is prescribed to the patient and delivered to the practitioner to administer to the patient. Practitioners shall maintain records and secure the medication.

This provision is identical to the perfected SB 928 (2020).


This act prohibits the requirement of a prescription for the dispensation, sale, or distribution of any drug containing any detectable amount of ephedrine, phenylpropanolamine, or psuedoephedrine, or any of their salts or optical isomers, or salts of optical isomers, in an amount within the limits set forth in law. This provision shall expire when state's methamphetamine laboratory seizure incidents, as reported by the Missouri State Highway Patrol, exceed 300 incidents in a year.

All current local ordinances and regulations regarding prescriptions for the dispensation, sale, or distribution of any drug containing any detectable amount of ephedrine, phenylpropanolamine, or psuedoephedrine, or any of their salts or optical isomers, or salts of optical isomers, in an amount within the limits set forth in law that are in effect prior to August 28, 2020, shall be void and of no effect on August 28, 2020.

This act also changes the amounts that can be sold, dispensed, or otherwise provided to a person in a 30-day period without a prescription from a maximum of 9 grams to a maximum of 7.2 grams and adds an annual limit of 43.2 grams.

These provisions are identical to provisions in SS/SCS/HCS#2/HB 1896, as amended, and similar to provisions in the perfected SS/SCS/SB 523 (2020) and SB 706 (2020).


This act prohibits the sale of edible marijuana-infused products, packaging, or logos in the shape of a human, animal, or fruit, but geometric shapes shall be permitted. Each package, or packages within a package, containing ten or more milligrams of tetrahydrocannabinols (THC) shall be stamped with a universal symbol and the amount of THC, as described in the act.

Any medical marijuana licensed or certified entity regulated by the Department of Health and Senior Services found to have violated this provision shall be subject to sanctions, including an administrative penalty. The Department shall promulgate rules regarding prohibiting edible marijuana-infused products designed to appeal to persons under 18 years of age, as well as developing a process by which a licensed or certified entity may seek approval of a product design, package, or label prior to manufacture or sale to determine compliance with these provisions.

This provision is identical to provisions in SS/SCS/HCS#2/HB 1896, as amended, and similar to a provision in SCS/SB 764 (2020), the perfected SCS/SB 6 (2019), and SB 335 (2019).


The Department shall require all officers, managers, contractors, employees, and other support staff of licensed or certified medical marijuana facilities, and all owners of such facilities who will have access to the facilities or the facilities' supply of medical marijuana, to submit fingerprints to the Highway Patrol for a state and federal criminal background check. The Highway Patrol shall notify the Department of any criminal history record information or lack thereof discovered on the individual. All such records shall be accessible and available to the Department.

This provision is identical to a provision in SS/SCS/HCS#2/HB 1896, as amended, and similar to a provision in SCS/SB 764 (2020).

This provision has an emergency clause.

EPINEPHRINE AUTO-INJECTOR DEVICES (Sections 196.990 and 321.621)

This act adds "qualified first responders" to the definition of "authorized entities" authorized to dispense prescription epinephrine auto-injectors (epi-pens).

Additionally, current law requires certain emergency health care entities and other organizations to maintain epi-pens according to the rules and regulations of the Department of Health and Senior Services. Under this act, the Director of the Department of Health and Senior Services, if a licensed physician, or a licensed physician operating on behalf of the Director, may issue a statewide standing order for epi-pens for adult patients to fire protection districts in nonmetropolitan areas of Missouri. Possession and use of epi-pens under this act is limited to only such qualified first responders who have completed a training course and maintain the epi-pens pursuant to Department rules. Additionally, every use of an epi-pen shall be reported to a emergency health care provider.

Under this act, the use of an epi-pen is considered first aid or emergency treatment for purposes of liability under the law and shall not constitute the unlawful practice of medicine.

This act establishes the "Epinephrine Auto-injector Devices for Fire Personnel Fund". The Fund shall be used solely by the Department for the purpose of providing epi-pens to qualified first responder agencies pursuant to this act.

These provisions are identical to provisions in SCS/HB 1383 (2020) and substantially similar to the perfected SCS/SB 617 (2020).


Under this act, the proceeds of any monetary settlement or portion of a global settlement between the Attorney General and any drug manufacturers, distributors, or combination thereof to resolve an opioid-related cause of action in a state or federal court shall only be utilized to pay for opioid addiction treatment and prevention services and health care and law enforcement costs related to opioid addiction treatment and prevention. Under no circumstances shall such moneys be utilized to fund other services, programs, or expenses not reasonably related to opioid addiction treatment and prevention.

This act creates the "Opioid Addiction Treatment and Recovery Fund", which shall consist of the settlement funds, as well as any other appropriations, gifts, grants, donations, or bequests. The Department of Mental Health, the Department of Health and Senior Services, the Department of Social Services, and the Department of Public Safety shall administer the fund and the moneys shall only be used as specified in the act.

These provisions are identical to the perfected SCS/SB 609 (2020).


This act provides that, upon the dissolution of a county hospital district in Ripley County levying a sales tax for the purpose of funding the district, the sales tax shall be automatically repealed and twenty-five percent of the funds remaining in the special trust fund shall be distributed to the county public health center and seventy-five percent shall be distributed to a federally qualified health center located in the county.

This provision is identical to SCS/SB 616 (2020) and HB 2376 (2020).

PERSONAL CARE ASSISTANCE SERVICES (Sections 208.909, 208.918, 208.924, and 208.935)

Under current law, vendors of consumer-directed services shall monitor the performance of personal care assistance service plans. This act requires the consumer to permit the vendor to comply with its quality assurance and supervision process, including annual face-to-face home visits and monthly case management activities. During the home visits, the vendor shall document if the attendant providing services as set forth in the plan of care and report to the Department if the attendant is not providing services, which may result in a suspension of services to the consumer.

This act repeals language permitting the Department of Health and Senior Services to establish certain pilot projects for telephone tracking systems.

This act also requires vendors to notify consumers during orientation that falsification of personal care attendant time sheets shall be considered and reported to the Department as fraud.

Under this act, a vendor shall submit an annual financial statement audit or annual financial statement review performed by a certified public accountant to the Department upon request. Beginning July 1, 2022, the Department shall require the vendor to maintain a business location in compliance with any and all city, county, state, and federal requirements. Additionally, this act requires the Department to create a consumer-directed services division provider certification manager course. No state or federal funds shall be authorized or expended for personal care assistance services if a direct employee of the vendor is conducting the home visit and is also the personal care attendant, unless such person provides services solely on a temporary basis on no more than three days in a thirty-day period.

Currently, a consumer's services may be discontinued if the consumer has falsified records. This act adds language to include providing false information of his or her condition, functional capacity, or level of care needs.

This act requires the consumer, the personal care attendant, and the vendor to report to the Department if the consumer's health or his or her ability to self-direct care has significantly changed.

Finally, the Department shall, subject to appropriations, develop an interactive assessment tool for utilization by the Division of Senior and Disability Services when implementing the assessment and authorization process for home and community-based services authorized by the Division.

This act is identical to SCS/SB 595 (2020) and similar to provisions in the truly agreed to and finally passed CCS/SS/SCS/HCS/HB 399 (2019), the perfected SS/SCS/SBs 70 & 128 (2019), SB 441 (2019), HCS/HB 1885 (2018) and HB 2500 (2018), provisions in HB 377 (2019), SCS/HCS/HB 466 (2019), SB 969 (2018), and provisions of SB 526 (2017).

REMOTE DISPENSING SITE PHARMACIES (Sections 338.035, 338.210, 338.215, 338.220, and 338.260)

Current law permits a licensed intern pharmacist to practice pharmacy under the direct supervision of a pharmacist licensed by the Board of Pharmacy. Under this act, an intern pharmacist working at a remote dispensing site pharmacy may be remotely supervised by a pharmacist working at a supervising pharmacy.

Under this act, "remote dispensing site pharmacy" shall mean any location in Missouri where the practice of pharmacy occurs, that is licensed as a pharmacy to dispense prescription drugs, and is staffed by one or more qualified pharmacy technicians or intern pharmacists who are supervised by a pharmacist at a supervising pharmacy through a continuous, real-time audio and video link.

A supervising pharmacy that operates a remote dispensing site pharmacy, and the remote dispensing site pharmacy, shall be licensed as a pharmacy by the Board of Pharmacy as described in the act. The remote dispensing site pharmacy shall be under the supervision and control of a supervising pharmacist employed by the supervising pharmacy. Such pharmacist shall not be required to be immediately physically present to supervise any activities at the remote dispensing site pharmacy, but shall make monthly visits to the remote dispensing site pharmacy to ensure compliance with this act. A pharmacist shall not be designated or act as the supervising pharmacist for more than two remote dispensing site pharmacies at one time.

A pharmacist at the supervising pharmacy shall verify each prescription before such prescription leaves the remote dispensing site pharmacy. Verification of prescriptions shall occur as set forth in the act.

Unless a pharmacist is onsite at the remote dispensing site pharmacy, counseling shall be done by a supervising pharmacist via a HIPAA-compliant continuous real-time video and audio link prior to any drug or medical device being dispensed. Such system shall retain the initials or unique identifier of the pharmacist performing the consultation. The pharmacist shall have access to all relevant patient information maintained by the remote dispensing site pharmacy.

A remote dispensing site pharmacy shall be located at least 10 miles from an existing retail pharmacy unless such pharmacy is part of a community mental health center, federally qualified health center, hospital, rural health clinic, or outpatient clinical setting, or if the applicant with the proposed remote dispensing site pharmacy demonstrates that the pharmacy will promote public health. A remote dispensing site pharmacy shall be staffed by a pharmacist for at least 8 hours per month who shall have certain responsibilities set forth in the act.

If the average number of prescriptions dispensed per day by the remote dispensing site pharmacy exceeds 150, over a 90-day period, such remote pharmacy shall apply to the Board for licensure as a Class A, B, or C pharmacy within 10 days.

Unless otherwise approved by the Board, the supervising pharmacy shall be located in Missouri and within 50 miles of a remote dispensing site pharmacy to ensure sufficient support and to ensure that necessary personnel or supplies may be delivered within a reasonable period of time.

This act adds "remote dispensing site pharmacy" as a Class R pharmacy.

These provisions are similar to provisions in HB 2422 (2020) and SB 976 (2020).


Current law sets forth classes of pharmacy permits or licenses. This act adds "charitable pharmacy" as a Class Q pharmacy.

This provision is identical to SB 1088 (2020).


Currently, a health carrier that has not paid a claimant on or before the 45th processing day from the date of receipt of the claim shall pay the claimant interest and a penalty based on the unpaid balance of the claim as of the 45th processing day. On claims exceeding $35,000 on the unpaid balance of the claim, the health carrier under this act shall pay the claimant 1% interest per month and a penalty in an amount equal to 1% of the claim per day for a maximum of 100 days and thereafter shall pay the claimant 2% interest per month.

Currently, any claim or portion of a claim that has been properly denied before the 45th processing day shall not be subject to interest or penalties. Under this act, denied claims before the 45th processing day shall begin to accrue interest and penalties during the claimant's appeal with the health carrier until such claim is paid, if the claim is approved. If the appeal does not result in an approved claim and a petition is filed with a court of competent jurisdiction to recover payment of the claim, interest and penalties shall continue to accrue for no more than 100 days from the day the first appeal was filed with the health carrier and continue to accrue until ten days after the court finds that the claim shall be paid to the claimant.

PHARMACY BENEFITS MANAGERS (Sections 376.387 and 376.393)

Under this act, pharmacy benefits managers (PBM) shall notify health carriers in writing of any conflict of interest, including, but not limited to, common ownership or any other relationship between the PBM and any other health carrier with which the PBM contracts.

Additionally, this act specifies that no entity subject to the jurisdiction of Missouri shall act as a PBM without a license issued by the Department of Commerce and Insurance. The Department may cause a complaint to be filed with the Administrative Hearing Commission against the holder of a PBM license for the reasons specified in the act. Proceedings shall be conducted before the Administrative Hearing Commission as provided by law. The Department may take action against a PBM's license, as specified in the act, upon a finding that a rule has been violated.

These provisions are substantially similar to provisions in SB 971 (2020).

LIFE CARE CONTRACTS (Section 376.945)

This act specifies that the "entire amount" of entrance fee funds held in reserve for a life care contract shall be earned by "and available for release to" the care provider as provided by law, provided that the reserve and interest thereon shall not exceed "one hundred percent", rather than "one and one-half times the percentage", of the annual long-term debt principal and interest payments of the provider applicable only to living units occupied under life care contracts. The requirement to hold reserve funds may be met in whole or in part by other reserve funds held for the purpose of meeting loan obligations, provided that the total amount equals or exceeds the amount otherwise required.

This provision is identical to SCS/SB 804 (2020) and similar to HB 2205 (2020).


This act provides that if a health carrier receives a credentialing application, the carrier shall have ten days from sending notice of the application's receipt to request additional information from the practitioner. The application shall be deemed complete upon receipt of the additional information. Within two working days of receipt of the additional information, the carrier shall send notice to the practitioner that the practitioner has submitted a completed application. If the carrier does not request additional information, the application shall be deemed completed as of the date the notice of receipt was sent by the carrier to the practitioner.

The act specifies that the carrier's credentialing decision and notification to the practitioner of such decision shall be made within 60 days of receipt of the "completed credentialing application", rather than 60 "business" days of receiving the practitioner's "credentialing information".

If a practitioner's application is approved, the carrier shall provide payments for covered health services performed by the practitioner during the credentialing period if the services were on behalf of an entity that had a contract with the carrier during the credentialing period. The contract entity shall submit to the carrier all claims for services provided by the practitioner during the credentialing period within six months after the carrier has approved the practitioner's credentialing application. Claims submitted for reimbursement under this provision shall be sent to the carrier by the provider in a single request or as few requests as practical.

A health carrier shall not require a practitioner to be credentialed to receive payments for covered health services if the practitioner is providing coverage for an absent credentialed practitioner during a temporary period not exceed 60 days. Any practitioner authorized to receive payments for covered services under this provision shall provide notice to the carrier as described in the act. A carrier may deny payments if the practitioner providing services in lieu of the credentialed provider meets one of the conditions described in the act.

All claims eligible for payment under these provisions shall be subject to the prompt payment statute.

These provisions are similar to SB 938 (2020).


Under this act, any reports or records in the possession of the Department of Health and Senior Services' Missouri State Public Health Laboratory, which were the result of testing performed at the request of any municipal, county, state, or federal law enforcement agency, shall be considered closed records until such investigation becomes inactive.

This provision is identical to SB 918 (2020).















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