To repeal sections 190.010, 190.015, 190.043, 190.055, 190.060, 190.100, 190.105, 190.120, 190.160, 190.165, 190.171, 190.175, 190.180, 190.190, 190.241 and 190.245, RSMo 1994, and section 190.185, RSMo Supp. 1996, relating to emergency medical services, and to enact in lieu thereof thirty-seven new sections relating to the same subject, with penalty provisions.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF MISSOURI, AS FOLLOWS:

     Section A. Sections 190.010, 190.015, 190.043, 190.055, 190.060, 190.100, 190.105, 190.120, 190.160, 190.165, 190.171, 190.175, 190.180, 190.190, 190.241 and 190.245, RSMo 1994, and section 190.185, RSMo Supp. 1996, are repealed and thirty-seven new sections enacted in lieu thereof to be known as sections 190.001, 190.010, 190.015, 190.043, 190.055, 190.060, 190.100, 190.101, 190.102, 190.103, 190.104, 190.105, 190.106, 190.107, 190.108, 190.120, 190.126, 190.127, 190.128, 190.129, 190.131, 190.133, 190.134, 190.142, 190.160, 190.165, 190.171, 190.175, 190.180, 190.185, 190.190, 190.196, 190.200, 190.205, 190.241, 190.243 and 190.245, to read as follows:

     190.001. Sections 190.001 to 190.245 shall be known and may be cited as the "Comprehensive Emergency Medical Services Systems Act".

     190.010. 1. An ambulance district may be created, incorporated and managed as provided in sections 190.005 to 190.085 and may exercise the powers herein granted or necessarily implied. An ambulance district may include municipalities or territory not in municipalities or both or territory in one or more counties; except, that the provisions of sections 190.005 to 190.085 are not effective in counties having a population of more than four hundred thousand inhabitants at the time the ambulance district is formed. The territory contained within the corporate limits of an existing ambulance district shall not be incorporated in another ambulance district. Ambulance districts created and still operating before August 28, 1997, in counties of less than four hundred thousand population are authorized to continue operation subject to sections 190.005 to 190.085 if the population of the county within the ambulance district exceeds four hundred thousand after August 28, 1997.

     2. When an ambulance district is organized it shall be a body corporate and a political subdivision of the state and shall be known as "......... Ambulance District", and in that name may sue and be sued, levy and collect taxes within the limitations of sections 190.005 to 190.085 and the constitution and issue bonds as provided in sections 190.005 to 190.085.

     190.015. Whenever the creation of an ambulance district is desired, a number of voters residing in the proposed district equal to ten percent of the vote cast for governor in the proposed district in the next preceding gubernatorial election may file with the county clerk in which the territory or the greater part thereof is situated a petition requesting the creation thereof. In case the proposed district which shall be contiguous is situated in two or more counties, the petition shall be filed in the office of the county clerk of the county in which the greater part of the area is situated, and the commissioners of the county commission of the county shall set the petition for public hearing. The petition shall set forth:

     (1) A description of the territory to be embraced in the proposed district;

     (2) The names of the municipalities located within the area;

     (3) The name of the proposed district;

     (4) The population of the district which shall not be less than two thousand inhabitants;

     (5) The assessed valuation of the area, which shall not be less than [two] ten million [five hundred thousand] dollars; and

     (6) A request that the question be submitted to the voters residing within the limits of the proposed ambulance district whether they will establish an ambulance district [under] pursuant to the provisions of sections 190.005 to 190.085 to be known as ".......... Ambulance District" for the purpose of establishing and maintaining an ambulance service.

     190.043. Subject to the provisions of chapter 137, RSMo, in addition to the tax rate increase allowed pursuant to subdivision [(6)] (3) of subsection 5 of section 137.073, RSMo, if an ambulance district voluntarily decreases its tax rate duly authorized [under] pursuant to section 190.040 or 190.041 in any tax year, such ambulance district may in any subsequent tax year increase such tax rate, without voter approval, to the rate previously authorized [under] pursuant to section 190.040 or 190.041.

     190.055. 1. The board of directors of a district shall possess and exercise all of its legislative and executive powers. Within thirty days after the election of the initial directors, the board shall meet. The time and place of the first meeting of the board shall be designated by the county commission. At its first meeting and after each election of new board members the board shall elect a chairman from its members and select a secretary, treasurer and such officers or employees as it deems expedient or necessary for the accomplishment of its corporate objects. The secretary and treasurer need not be members of the board. At the meeting the board, by ordinance, shall define the first and subsequent fiscal years of the district, and shall adopt a corporate seal and bylaws, which shall determine the times for the annual election of officers and of other regular and special meetings of the board and shall contain the rules for the transaction of other business of the district and for amending the bylaws.

     2. Each director of any district shall devote such time to the duties of the office as the faithful discharge thereof may require, including educational programs provided by the state and may be reimbursed for [his] such director's actual expenditures in the performance of [his] such director's duties on behalf of the district.

     190.060. 1. An ambulance district shall have [and exercise] the following governmental powers, and all other powers incidental, necessary, convenient or desirable to carry out and effectuate the express powers:

     (1) To establish and maintain an ambulance service within its corporate limits, and to acquire for, develop, expand, extend and improve such service;

     (2) To acquire land in fee simple, rights in land and easements upon, over or across land and leasehold interests in land and tangible and intangible personal property used or useful for the location, establishment, maintenance, development, expansion, extension or improvement of an ambulance service. The acquisition may be by dedication, purchase, gift, agreement, lease, use or adverse possession;

     (3) To operate, maintain and manage the ambulance service, and to make and enter into contracts for the use, operation or management of and to provide rules and regulations for the operation, management or use of the ambulance service;

     (4) To fix, charge and collect reasonable fees and compensation for the use of the ambulance service according to the rules and regulations prescribed by the board from time to time;

     (5) To borrow money and to issue bonds, notes, certificates, or other evidences of indebtedness for the purpose of accomplishing any of its corporate purposes, subject to compliance with any condition or limitation set forth in sections 190.005 to 190.085 or otherwise provided by the Constitution of the State of Missouri;

     (6) To employ or enter into contracts for the employment of any person, firm, or corporation, and for professional services, necessary or desirable for the accomplishment of the objects of the district or the proper administration, management, protection or control of its property;

     (7) To maintain the ambulance service for the benefit of the inhabitants of the area comprising the district regardless of race, creed or color, and to adopt such reasonable rules and regulations as may be necessary to render the highest quality of emergency medical care; to exclude from the use of the ambulance service all persons who willfully disregard any of the rules and regulations so established; to extend the privileges and use of the ambulance service to persons residing outside the area of the district upon such terms and conditions as the board of directors prescribes by its rules and regulations; [and]

     (8) To provide for health, accident, disability and pension benefits for the salaried members of its organized ambulance district and such other benefits for the members' spouses and minor children, through either, or both, a contributory or noncontributory plan. The type and amount of such benefits shall be determined by the board of directors of the ambulance district within the level of available revenue of the pension program and other available revenue of the district. If an employee contributory plan is adopted, then at least one voting member of the board of trustees shall be a member of the ambulance district elected by the contributing members. The board of trustees shall not be the same as the board of directors[.]; and

     (9) To purchase insurance indemnifying the district and its employees, officers, volunteers and directors against liability in rendering services incidental to the furnishing of ambulance services. Purchase of insurance pursuant to this section shall not waive sovereign or official immunity.

     2. The use of any ambulance service of a district shall be subject to the reasonable regulation and control of the district and upon such reasonable terms and conditions as shall be established by its board of directors.

     3. A regulatory ordinance of a district adopted [under] pursuant to any provision of this section may provide for a suspension or revocation of any rights or privileges within the control of the district for a violation of any regulatory ordinance.

     4. [To purchase insurance indemnifying against liability of the district and the driver and attendants of the ambulance or other equipment or supplies or in rendering services incidental to the furnishing of the ambulance service.

     5.] Nothing in this section or in other provisions of sections [190.005] 190.001 to 190.085 shall be construed to authorize the district or board to establish or enforce any regulation or rule in respect to the operation or maintenance of the ambulance service within its jurisdiction which is in conflict with any federal or state law or regulation applicable to the same subject matter.

     190.100. As used in sections [190.100 to 190.190] 190.001 to 190.245, the following words and terms mean:

     (1) "Advanced life support (ALS)", an advanced level of care provided to an adult or pediatric patient as defined by national curricula, and any modifications to that curricula specified in rules adopted by the department pursuant to sections 190.001 to 190.245;

     [(1)] (2) "Ambulance", any privately or publicly owned [motor vehicle or, on or after January 1, 1988, any aircraft, if such motor vehicle or aircraft] vehicle or craft that is specially designed [or constructed and equipped and is intended to be used for and is maintained or operated for the transportation of patients, including dual-purpose police patrol cars and funeral coaches or hearses which otherwise comply with the provisions of sections 190.100 to 190.190], constructed or modified, staffed or equipped for, and is intended or used, maintained or operated for the transportation of persons who are sick, injured, wounded or otherwise incapacitated or helpless, or who require the presence of medical equipment being used on such individuals, but the term does not include any motor vehicle specially designed, constructed or converted for the regular transportation of persons [permanently disabled and] who are disabled, handicapped, normally using a wheelchair, or [handicapped persons] otherwise not acutely ill, or emergency vehicles [at] used within airports;

     [(2) "Apprentice", any individual who is not a licensed attendant or attendant-driver, but who holds a certificate of apprenticeship issued by the license officer;

     (3) "Attendant", a trained and qualified individual responsible for the operation of an ambulance and the care of the patients transported thereby whether or not the attendant also serves as driver;

     (4) "Attendant-driver", a person who is qualified as an attendant and a driver;

     (5) "Board", the state board of health of Missouri;

     (6) "Dual-purpose police patrol car", a vehicle, operated by a police department, which is equipped as an ambulance, even though it is also used for patrol or other police purposes;

     (7) "Emergency medical technician", any person who has successfully completed a course of training approved by the health officer and is certified by the health officer in preliminary emergency medical care;

     (8) "Health officer", the director of the department of health of the state of Missouri or his duly authorized representative;

     (9) "License officer", the director of the department of health of the state of Missouri or his duly authorized representative;

     (10) "Local physician medical advisor" or "local physician medical advisory committee", a physician or group of physicians licensed pursuant to chapter 334, RSMo, appointed by the ambulance service and who meet criteria established by the department of health. The local physician medical advisor or local physician medical advisory committee shall have the responsibility to monitor prehospital medical care and ensure that prehospital standards of care and protocols are met;]

     (3) "Ambulance service", a person that provides emergency or nonemergency medical transportation and services, or both, in compliance with sections 190.001 to 190.245, and the rules promulgated by the department pursuant to sections 190.001 to 190.245;

     (4) "Ambulance service area", a specific geographic area in which an ambulance service has been authorized to operate by the department, or as modified by the director or by a political subdivision pursuant to sections 190.001 to 190.245;

     (5) "Basic life support (BLS)", a basic level of care, provided to an adult or pediatric patient as supported by national curricula, and any modifications to that curricula specified in rules adopted by the department pursuant to sections 190.001 to 190.245;

     (6) "Council", the state advisory council on emergency medical service;

     (7) "Department", the Missouri department of health;

     (8) "Director", the director of the department of health, or the director's duly authorized representative;

     (9) "Dispatch agency", any person or organization that receives requests for emergency medical services from the public, by telephone or other means, and is responsible for dispatching emergency medical services;

     (10) "Emergency", a medical condition, the onset of which is sudden, or a medical condition involving the exacerbation of a chronic condition, that manifests itself by symptoms of sufficient severity, which may include severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

     (a) Placing the person's health in significant jeopardy;

     (b) Serious impairment of bodily functions;

     (c) Serious dysfunction of any bodily organ or part; and

     (d) Inadequately controlled pain;

     (11) "Emergency medical dispatcher", a person who has successfully completed an emergency medical dispatcher course, meeting or exceeding the national curriculum of the United States Department of Transportation and any modifications to such curriculum specified by the department through rules adopted pursuant to sections 190.001 to 190.245;

     (12) "Emergency medical response agency", any person that uses public highways or streets to regularly provide a level of care that includes first response, basic life support or advanced life support, exclusive of patient transportation;

     (13) "Emergency medical services for children (EMS-C) system", the arrangement of personnel, facilities and equipment for effective and coordinated delivery of pediatric emergency medical services required in prevention and management of incidents which occur as a result of a medical emergency or of an injury event, natural disaster or similar situation;

     (14) "Emergency medical services (EMS) system", the arrangement of personnel, facilities and equipment for the effective and coordinated delivery of emergency medical services required in management of incidents occurring as a result of an illness, injury, natural disaster or similar situation;

     (15) "Emergency medical technician", a person trained in emergency medical care in accordance with sections 190.001 to 190.245, or by rules and regulations pursuant to sections 190.001 to 190.245;

     (16) "Emergency medical technician-basic" or "EMT-B", a person who has successfully completed a course of instruction in basic life support as prescribed by the department, is licensed by the department in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245;

     (17) "Emergency medical technician-paramedic" or "EMT-P", a person who has successfully completed a course of instruction in advanced life support care as prescribed by the department, is licensed by the department in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245;

     (18) "Emergency services", any health care services provided to evaluate and treat a medical condition, the onset of which is sudden, or which involves the exacerbation of a chronic condition, that manifests itself by symptoms of sufficient severity, which may include severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

     (a) Placing the person's health in significant jeopardy;

     (b) Serious impairment of bodily functions;

     (c) Serious dysfunction of any bodily organ or part; or

     (d) Inadequately controlled pain;

     (19) "First responder", a person who has successfully completed an emergency first response course meeting or exceeding the national curriculum of the United States Department of Transportation and any modifications to such curriculum specified by the department through rules adopted pursuant to sections 190.001 to 190.245 and who provides emergency medical care through employment by or in association with an emergency medical response agency;

     (20) "Health care facility", a hospital, nursing home, physician's office or other fixed location at which medical and health care services are performed;

     (21) "Hospital", a medical facility which is subject to provisions of section 197.020, RSMo, or a hospital operated by the state;

     (22) "Medical director", a physician licensed pursuant to chapter 334, RSMo, designated by the ambulance service or emergency medical response agency and who meets criteria established by the department by rule and regulation pursuant to sections 190.001 to 190.245;

     (23) "Medical control", supervision provided by or under the direction of physicians to emergency medical services providers by written or verbal communications;

     (24) "Medical direction", medical guidance and supervision provided by a physician to an emergency services provider or emergency medical services system;

     (25) "Memorandum of understanding", an agreement between an emergency medical response agency or dispatch agency and an ambulance service or services within whose territory the agency operates, in order to coordinate emergency medical services;

     [(11)] (26) "Patient", an individual who is sick, injured, wounded, diseased, or otherwise incapacitated or helpless, or dead, excluding deceased individuals being transported from or between private or public institutions, homes or cemeteries, and individuals declared dead prior to the time an ambulance is called for assistance;

     [(12)] (27) "Person", any individual, firm, partnership, copartnership, joint venture, association, cooperative organization, corporation, [company, group of individuals acting together for a common purpose or organization of any kind, including any governmental agency other than the United States or the state of Missouri;

     (13) "Mobile emergency medical technician", a licensed attendant who has been specially trained in emergency cardiac and noncardiac care, and who has successfully completed an emergency service training program certified by the health officer as meeting the requirements of sections 190.100 to 190.190.] municipal or private, and whether organized for profit or not, state, county, political subdivision, state department, commission, board, bureau or any fraternal organization, estate, public trust, business or common law trust, receiver, assignee for the benefit of creditors, trustee or trustee in bankruptcy, or any other service user or provider;

     (28) "Physician", a person licensed pursuant to chapter 334, RSMo;

     (29) "Political subdivision", any municipality, city, county, ambulance district or fire protection district located in whole or in part within this state which provides or has authority to provide ambulance service;

     (30) "Protocol", a predetermined, written medical care guideline, which may include standing orders;

     (31) "Regional emergency medical services advisory committee", a committee formed within any emergency medical services (EMS) region to advise ambulance services, the state advisory council on emergency medical services and the department;

     (32) "Regional emergency medical services system", an organization of hospitals, ambulance services and personnel approved by the department in a specific geographic area of sufficient size, population, and economic diversity, which coordinates emergency care and nonemergency medical transports pursuant to the emergency medical services region plan adopted for the emergency medical services region in which the system is located;

     (33) "State advisory council on emergency medical services", a committee formed to advise the department on policy affecting emergency medical services throughout the state;

     (34) "State emergency medical services medical directors advisory committee", a subcommittee of the state advisory council on emergency medical services formed to advise the department and the state advisory council on emergency medical services on medical issues;

     (35) "Trauma", an injury to human tissues and organs resulting from the transfer of energy from the environment;

     (36) "Trauma care", includes injury prevention, triage, acute care, and rehabilitative services for major single system or multisystem injuries that potentially require immediate medical or surgical intervention or treatment;

     (37) "Trauma center", a hospital that is currently designated as such by the department.

     190.101. 1. There is hereby established within the department of health a "State Advisory Council on Emergency Medical Services" which shall consist of fifteen members. The members of the council shall be appointed by the governor with the advice and consent of the senate and shall serve terms of four years. The governor shall designate one of the members as chairperson. The chairperson may appoint subcommittees that include noncouncil members.

     2. The state emergency medical services medical directors advisory committee and the regional emergency medical services advisory committees will be recognized as subcommittees of the state advisory council on emergency medical services.

     3. The council shall have geographical representation and representation from appropriate areas of expertise in emergency medical services including volunteers, professional organizations involved in emergency medical services, emergency medical technicians, paramedics, nurses, firefighters, physicians, ambulance service administrators, hospital administrators and other health care providers concerned with emergency medical services. The regional emergency medical services advisory committees shall serve as a resource for the identification of potential members of the state advisory council on emergency medical services.

     4. The members of the council and subcommittees shall serve without compensation but shall be reimbursed for reasonable travel expenses and meeting expenses related to the functions of the council.

     5. The council shall make recommendations to the governor, the general assembly, and the department on policies, plans, procedures, and proposed regulations to improve the statewide emergency medical services system. The council shall advise the governor, the general assembly, and the department on all aspects of the emergency medical services system.

     190.102. 1. The department shall designate by rule emergency medical services regions. The purpose of the regional emergency medical services advisory committees is to better coordinate the emergency resources in the region, to improve public and professional education, to foster cooperation in research, and advise on the development of standards, protocols and policies.

     2. The members of the committees shall serve without compensation but shall be reimbursed for reasonable travel expenses and meeting expenses related to the functions of the committees.

     3. The director will appoint personnel to no less than six regional emergency medical services committees from recommendations provided by recognized professional organizations. Appointments will be for four-year terms with individuals serving until reappointed or replaced.

     190.103. 1. Expertise in emergency medical services from each of the emergency medical services regions shall select a physician to serve as a regional emergency medical services medical director. The regional emergency medical services medical directors shall constitute the state emergency medical services medical director's advisory committee and shall advise the department and their region's ambulance services on matters relating to medical control and medical direction in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245.

     2. Each ambulance service, as well as each emergency medical response agency that provides advanced life support services, shall have a medical director. The medical director will provide medical direction to the ambulance service or emergency medical response agency that provides advanced life support services.

     3. The medical director in cooperation with the service or agency administrator shall ensure that the personnel working under their supervision are able to provide care meeting established standards of care with consideration for state and national standards as well as local area needs and resources. The medical director in cooperation with the service or agency administrator shall establish and develop triage, treatment and transport protocols, which may include authorization for standing orders.

     4. All ambulance services and emergency medical response agencies that are required to have a medical director shall establish an agreement between the agency and their medical director. The agreement will include the roles, responsibilities and authority of the medical director beyond what is granted in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245. The agreement shall also include grievance resolution procedures between the emergency medical response agencies or ambulance service and the medical director.

     190.104. 1. The department is authorized to establish a program to improve the quality of emergency care for pediatric patients throughout the state and to implement a comprehensive pediatric emergency medical services system in accordance with standards prescribed by sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245.

     2. The department is authorized to receive contributions, grants, donations or funds from any private entity. Any moneys received pursuant to sections 190.001 to 190.245 shall be transferred to the director of revenue to the credit of general revenue to be expended, upon appropriation, for the program authorized pursuant to this section.

     190.105. 1. No person, either as owner, agent or otherwise, shall furnish, operate, conduct, maintain, advertise, or otherwise be engaged in or profess to be engaged in the business or service of the transportation of patients by ambulance in the air, upon the streets, alleys, or any public way or place of the state of Missouri unless [he] such person holds a currently valid license for an ambulance service issued pursuant to the provisions of sections [190.100 to 190.195] 190.001 to 190.245.

     2. No ambulance shall be operated for ambulance purposes, and no individual shall drive, attend or permit it to be operated for such purposes on the streets, alleys, or any public way or place of the state of Missouri unless [it] the ground ambulance is under the immediate supervision and direction of a person who is holding a currently valid [license as an attendant-driver or attendant; except that, nothing in this section shall be construed to mean that a duly licensed registered nurse or a duly licensed physician be required to hold an attendant-driver or attendant] emergency medical technician license. Each ambulance service is responsible for assuring that any person driving its ambulance is competent in emergency vehicle operations.

     3. No person, as either owner, agent or otherwise, who holds a currently valid license for an ambulance service, shall, incident to [his] such person's business or service of transporting patients, transport, carry or convey patients in any vehicle other than an ambulance, but no such licenses shall be required for an ambulance service, or for the attendant[, attendant-driver, or certificated apprentice] of an ambulance, which:

     (1) Is rendering assistance to [licensed ambulances in the case of a major catastrophe or emergency with which the licensed ambulances of that locality are insufficient or unable to cope] a licensed ambulance service at the request of the local ambulance service in the case of an emergency or major catastrophe; or

     (2) Is operated from a location or headquarters outside of Missouri in order to transport patients who are picked up beyond the limits of Missouri to locations within or outside of Missouri, but no such outside ambulance service shall be used to pick up patients within Missouri for transportation to locations within Missouri, [except in emergency, unless the driver, attendant and attendant-driver and the person subject to the provisions of sections 190.100 to 190.195 in respect of such ambulance hold currently valid licenses issued pursuant to sections 190.100 to 190.195] except as provided in subdivision (1) of this subsection.

     4. [The issuance of a license under the provisions of sections 190.100 to 190.195 shall not be construed so as to authorize any person, firm, corporation, or association to provide ambulance services or to operate any ambulances without a franchise in any county, municipality or political subdivision which has enacted an ordinance making it unlawful to do so.] Any political subdivision authorized to provide ambulance service may adopt relevant ordinances, orders, or regulations which establish standards that exceed state standards.

     5. The provisions of section 67.300, RSMo to the contrary notwithstanding, a municipality or county which is located within an ambulance district shall not adopt ordinances, orders or regulations related to the provision of ambulance services. This provision shall not apply to any municipality or county which operates an ambulance service established prior to August 28, 1997.

     6. A municipality or county which is located within an ambulance district shall not operate an ambulance service within such district if the ambulance district has enacted an ordinance making it unlawful to do so. This provision shall not apply to any municipality or county which operates an ambulance service established prior to August 28, 1997.

     7. A person acting as owner, agent or otherwise, who holds a valid license for an ambulance service, shall not, incident to such person's business or service of transporting patients, violate any applicable law, ordinance, order or regulation of any political subdivision by providing ambulance services or operating any ambulances without a franchise, contract or mutual aid agreement in such political subdivision, or by violating any ordinances or orders of a political subdivision making it unlawful to provide such services. Any person violating, or failing to comply with, any such law, ordinance, order, regulation, franchise, contract or mutual aid agreement is guilty of a class B misdemeanor and, upon conviction thereof, shall be fined or imprisoned or both in accordance with section 190.180.

     8. Any ambulance service which provides unauthorized ambulance services or otherwise violated the terms and conditions set forth in any law, ordinance, order, regulation, franchise, contract or mutual aid agreement is subject to suspension or revocation of its license by the department, upon proper notification and hearing as set forth in regulation promulgated by the department. No provision of this section is intended to limit or supersede a political subdivision's right to enforce any law, ordinance, order, regulation, franchise, contract or mutual aid agreement.

     9. All ambulance services in existence before August 28, 1997, shall maintain their ambulance service areas unless they are modified by the director to assure ambulance service coverage throughout the state or unless they are modified by law, ordinance, order or regulation adopted by a political subdivision.

     10. The director shall establish by a rule a process to resolve issues regarding ground ambulance service area boundaries. This authority does not allow the director to modify the jurisdictional boundaries of any existing ambulance district or fire protection district which operates an ambulance service established prior to August 28, 1997.

     11. No provider of ambulance service within the state of Missouri which is licensed by the department to provide such service shall discriminate regarding treatment or transportation of emergency patients on the basis of race, sex, age, color, religion, sexual preference, national origin, ancestry, handicap, medical condition or ability to pay.

     [5.] 12. Sections [190.100 to 190.195] 190.001 to 190.245 shall not preclude the adoption of any law, ordinance, order or regulation [not in conflict with] stricter than [this statute] sections 190.001 to 190.245 by any county, municipality or political subdivision.

     [6.] 13. An ambulance service when operated for the purpose of transporting persons who are sick, injured, or otherwise incapacitated shall not be treated as a common or contract carrier under the jurisdiction of the Missouri public service commission.

     [7.] 14. Sections [190.100 to 190.195] 190.001 to 190.245 shall not apply to, nor be construed to include, any motor vehicle used by an employer for the transportation of [his] such employer's employees whose illness or injury occurs on private property, and not on a public highway, nor to any person operating such a motor vehicle.

     15. No provision of this section, other than subsections 5 and 6, is intended to limit or supersede the powers of ambulance districts pursuant to this chapter or to fire protection districts pursuant to chapter 321, RSMo, or to counties, cities, towns and villages.

     190.106. 1. Any ambulance service may enter into contracts providing for mutual aid regarding emergency services provided by such ambulance service. The contracts that are agreed upon may provide for compensation from the parties and other terms that are agreeable to the parties and may be for an indefinite period as long as they include a minimum of a sixty-day cancellation notice by either party.

     2. Any ambulance service may provide assistance to any other ambulance service in the state that requests it, at the time of an emergency such as a fire, earthquake, flood, tornado, major catastrophe or any other unforeseen event or series of events which jeopardize the ability of the local ambulance service to promptly respond to emergencies.

     3. When responding on mutual aid or emergency aid requests, the ambulance service shall be subject to all provisions of law as if it were providing service within its own jurisdiction.

     4. Mutual aid contracts may be agreed to between ambulance services in the states neighboring Missouri and ambulance services in the state of Missouri in the exact same manner as contracts between ambulance services within the state of Missouri.

     190.107. The department shall license an air ambulance service in accordance with sections 190.001 to 190.245, and in accordance with rules adopted by the department pursuant to sections 190.001 to 190.245, including but not limited to:

     (1) Medical control plans;

     (2) Medical director qualification;

     (3) Air medical staff qualifications;

     (4) Response and operations standards to assure that the health and safety needs of the public are met;

     (5) Standards for air medical communications;

     (6) Licensure fees;

     (7) Criteria for compliance with licensure requirements;

     (8) Convenience and necessity hearings;

     (9) Records and forms;

     (10) Equipment requirements; and

     (11) Three-year license renewal.

     190.108. The department shall license a ground ambulance service in accordance with sections 190.001 to 190.245, and rules adopted by the department pursuant to sections 190.001 to 190.245, including, but not limited to:

     (1) Vehicle design, specification, operation and maintenance standards;

     (2) Equipment requirements;

     (3) Staffing requirements;

     (4) Three-year license renewal;

     (5) Licensure fees;

     (6) Ambulance service areas;

     (7) Records and forms;

     (8) Medical control plans;

     (9) Medical director qualifications; and

     (10) Standards for medical communications.

     190.120. 1. No ambulance service license shall be issued [under] pursuant to sections [190.100 to 190.195] 190.001 to 190.245, nor shall such license be valid after issuance, nor shall any ambulance be operated in Missouri unless there is at all times in force and effect insurance coverage issued by an insurance company for each and every ambulance owned or operated by or for the applicant or licensee, or unless any city not within a county which owns or operates the license has at all times sufficient self-insurance coverage to provide for the payment of damages in an amount as prescribed by [the board] rule:

     (1) For injury to or death of individuals in accidents resulting from any cause for which the owner of said vehicle would be liable on account of liability imposed on him by law, regardless of whether the ambulance was being driven by the owner or his agent; and

     (2) For the loss of or damage to the property of another, including personal property, under like circumstances.

     2. The insurance policy, or in the case of a self-insured city which is a city not within a county, proof of self-insurance, shall be submitted by all licensees required to provide such insurance under sections [190.100 to 190.195] 190.001 to 190.245. The insurance policy, or proof of the existence of self-insurance of a city which is a city not within a county, shall be submitted to the [license officer] director, in such form as [he] the director may specify, for [his] the director's approval prior to the issuance of each ambulance service license.

     3. Every insurance policy required by the provisions of this section shall contain or in the case of a self-insured city which is a city not within a county shall have proof of a provision for a continuing liability thereunder to the full amount thereof, notwithstanding any recovery thereon; that the liability of the insurer shall not be affected by the insolvency or the bankruptcy of the assured; and that until the policy is revoked the insurance company or self-insured city not within a county will not be relieved from liability on account of nonpayment of premium, failure to renew license at the end of the year, or any act or omission of the named assured. Such policy of insurance or self-insurance shall be further conditioned for the payment of any judgments up to the limits of said policy, recovered against any person other than the owner, [his] the owner's agent or employee, who may operate the same with the consent of the owner.

     4. Every insurance policy or self-insured city which is a city not within a county as required by the provisions of this section shall extend for the period to be covered by the license applied for and the insurer shall be obligated to give not less than thirty days' written notice to the [license officer] director and to the insured before any cancellation or termination thereof earlier than its expiration date, and the cancellation or other termination of any such policy shall automatically revoke and terminate the licenses issued for the [ambulances] ambulance service covered by such policy unless covered by another insurance policy in compliance with sections [190.100 to 190.195] 190.001 to 190.245.

     190.126. Every ambulance service which is located within the state of Missouri shall have a lien upon any and all claims, counterclaims, demands suits or rights of action of any person treated or transported by the ambulance service for any cause including any personal injury sustained by such person as the result of the negligence or wrongful act of another, which such injured person may have, assert or maintain against the person or persons causing such injury for damages on account of such injury, for the cost of such services, computed at reasonable rates, as such ambulance service shall render such injured person on account of his conditions, provided further, that the lien herein set forth shall not be applied or considered valid against anyone coming under the provisions of chapter 287, RSMo.

     190.127. Notwithstanding the provisions of section 190.126, every ambulance service which is located within the state of Missouri shall have a lien upon any and all claims, counterclaims, demands, suits or rights of action of any person treated or transported by the ambulance service for any cause including any personal injury sustained by such person as the result of the negligence or wrongful act of another, which such injured person may have, assert or maintain against the person or persons causing such injury for damages on account of such injury, for the cost of such services, computed at reasonable rates not to exceed the customary charges for the services, as such ambulance service shall render such injured person on account of his conditions. The lien set forth in this section shall not be applied or considered valid against anyone coming under the provisions of chapter 287, RSMo. The lien set forth in this section shall be considered valid and may be applied against medical benefits paid anyone under provisions of chapter 208, RSMo, whether such benefits are paid from state or federal funds or a combination thereof.

     190.128. No such lien shall be effective, however, unless a written notice containing the name and address of the injured person, the date of the accident, the name and location of the ambulance service and the name of the person or persons, firm or firms, corporation or corporations alleged to be liable to the injured party for the injuries received, shall be sent by registered mail with return receipt requested to the person or persons, firm or firms, corporation or corporations, if known alleged to be liable to the injured party, if known, for the injuries sustained prior to the payment of any moneys to such injured person, his attorneys or legal representative, as compensation for such injuries. Such ambulance service shall send by registered mail with return receipt requested a copy of such notice to any insurance carrier, if known, which has insured such person, firm or corporation against such liability.

     190.129. Any person or persons, firm or firms, corporation or corporations, including an insurance carrier, making any payment to such patient or to his attorneys or heirs or legal representatives as compensation for the injury sustained, after the receipt of such notice in accordance with the requirements of section 190.128, without paying to such ambulance service the amount of its lien or so much thereof as can be satisfied out of ten percent of the moneys due to such patient under any final judgment or compromise or settlement agreement after paying the amount of attorneys' liens, federal and Missouri workers' compensation liens, and any prior liens, shall have a period of one year, after such settlement is made known to the ambulance service, from the date of payment to such patient or his heirs, attorneys or legal representatives, as aforesaid, be and remain liable to such ambulance service for the amount which such ambulance service was entitled to receive as aforesaid, and any such association, corporation or other institution maintaining such ambulance service may, within such period, enforce its lien by a suit at law against such person or persons, firm or firms, corporation or corporations making any such payments.

     190.131. 1. The department shall certify training entities for first responders, emergency medical dispatchers, emergency medical technicians-basic and emergency medical technicians-paramedic in accordance with sections 190.001 to 190.245, and rules adopted by the department pursuant to sections 190.001 to 190.245, and to fix reasonable application, accreditation and certification fees as are necessary to accomplish this purpose.

     2. Such rules promulgated by the department shall set forth the minimum requirements for entrance criteria, training program curricula, instructors, facilities, equipment, medical oversight, recordkeeping, and reporting.

     3. Application for training entity accreditation or certification shall be made upon such forms as prescribed by the department in rules adopted pursuant to sections 190.001 to 190.245. The application form shall contain such information as the department deems reasonably necessary to make a determination as to whether the training entity meets all requirements of section 190.001 to 190.245 and rules promulgated pursuant to sections 190.001 to 190.245.

     4. Upon receipt of such application for training entity accreditation or certification, the department shall determine whether the training entity, its instructors, facilities, equipment, curricula and medical oversight meet the requirements of sections 190.001 to 190.245 and rules promulgated pursuant to sections 190.001 to 190.245.

     5. Upon finding these requirements satisfied, the department shall issue a training entity accreditation or certification valid for a period of three years unless earlier suspended or revoked.

     6. Subsequent to the issuance of a training entity accreditation or certification, the department shall conduct a periodic review of the training entity to assure continued compliance with the requirements of sections 190.001 to 190.245 and all rules promulgated pursuant to sections 190.001 to 190.245.

     7. No person or entity shall hold itself out or provide training required by section 190.131 without accreditation or certification by the department.

     190.133. Any emergency medical response agency which provides advanced life support shall be licensed by the department in accordance with sections 190.001 to 190.245, and rules adopted by the department pursuant to sections 190.001 to 190.245, including but not limited to:

     (1) A licensure period of three years;

     (2) License fees;

     (3) Medical direction;

     (4) Records and forms; and

     (5) Memoranda of understanding with local ambulance services.

     190.134. A dispatch agency is required to have a memorandum of understanding with all ambulance services that it dispatches. If a dispatch agency provides pre-arrival medical instructions, it is required to have a medical director.

     190.142. 1. The department shall license, and to relicense for a period of not to exceed three years, all levels of emergency medical technicians in accordance with sections 190.001 to 190.245 and rules adopted pursuant to sections 190.001 to 190.245. Such rules shall include but are not limited to:

     (1) Education and training requirements based on respective national curricula of the United States Department of Transportation and any modification to such curricula specified by the department through rules adopted pursuant to sections 190.001 to 190.245;

     (2) Initial licensure testing requirements; and

     (3) Continuing education and relicensure requirements.

     2. Emergency medical technicians shall receive medical direction or be authorized to operate under protocols while performing advanced life support services.

     190.160. The renewal of any license shall require conformance with all the requirements of sections [190.100 to 190.195 as upon original licensing] 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245.

     190.165. 1. The [license officer] director may deny a license or license renewal application, or suspend or revoke a license issued under the provisions of sections [190.100 to 190.195] 190.001 to 190.245 for failure of a licensee to comply with the provisions of sections [190.100 to 190.195] 190.001 to 190.245, or of regulations promulgated hereunder, or of any other applicable laws [or] , orders ordinances or regulations, or [he] the department may place the licensee on probation for any of the same reasons.

     2. [The initial or other ambulance, equipment and premises inspection reports of the health officer provided for by the provisions of sections 190.100 to 190.195 shall be prima facie evidence of compliance or noncompliance with, or violation of, the provisions, standards and requirements provided herein, and of the regulations promulgated hereunder, for the licensing of ambulances.] Grounds for taking disciplinary action against a licensee may include but are not limited to:

     (1) Incompetency;

     (2) Gross negligence or repeated negligence;

     (3) Falsifying any application or record required pursuant to sections 190.001 to 190.245; or

     (4) Conviction of a crime, pursuant to rules adopted by the department.

     3. Upon suspension, revocation or termination of an ambulance service license hereunder, no person shall be permitted to operate the ambulance service. Upon suspension, revocation or termination of an [attendant's or attendant-driver's] EMT-B or EMT-P license, the [attendant or attendant-driver] EMT-B or EMT-P shall cease to [drive or attend an ambulance, and no person shall employ or permit such individual to drive or attend an ambulance] function as an EMT-B or EMT-P.

     4. Any license suspended, revoked or terminated under any provision of sections [190.100 to 190.195] 190.001 to 190.245 will be returned to the [license officer] department within ten days of such suspension, revocation or termination. Parties aggrieved by the decision rendered by the department may appeal to the administrative hearing commission.

     190.171. [Any person aggrieved by an official action of the department of health affecting the licensed status of a person under the provisions of sections 190.100 to 190.195, including the refusal to grant, the grant, the revocation, the suspension, or the failure to renew a license, may seek a determination thereon by the administrative hearing commission pursuant to the provisions of section 621.045, RSMo, and it shall not be a condition to such determination that the person aggrieved seek a reconsideration, a rehearing, or exhaust any other procedure within the department of health or the department of social services.] Any action taken by the department as authorized in this chapter may be appealed within thirty days by filing an appeal with the administrative hearing commission. Provisions of chapter 536, RSMo, and section 621.045, RSMo, shall apply.

          [190.175. 1. Each licensee of an ambulance shall maintain accurate records, which contain the following information concerning the transportation of each patient within the state of Missouri, from one place herein to another place within or beyond its limits:

          (1) Each ambulance licensee will maintain a daily log to contain such data as the license officer may prescribe on each and every ambulance run which he or a duly authorized agent accepts;

          (2) The entries will be consecutive, with no blank spaces or blank paper. Records will be retained by the ambulance licensee for five years, readily available for inspection by the license officer, notwithstanding transfer, sale or discontinuance of the ambulance services or business;

          (3) Trip tickets for each ambulance run on which are entered pertinent remarks by the ambulance attendant, or attendant-driver, signed instructions of the physician requesting special service, official receipt for patient at destination, and such other items as the license officer may prescribe.

          2. Such records shall be available for inspection by the health officer at any reasonable time during business hours.]

     190.175. 1. The department shall develop and administer a uniform data collection system on all ambulance runs and injured patients, as defined by the department for the purpose of injury etiology, patient care outcome, peer review, injury prevention and research purposes. The department may require health care providers to provide additional data for regional medical peer review for regional quality improvement activities. The department shall not require disclosure by hospitals of data elements pursuant to this section unless those data elements are required by a federal agency or were submitted to the department as of January 1, 1997, pursuant to:

     (1) Departmental regulation of trauma centers; or

     (2) The Missouri head and spinal cord injury registry established by sections 192.735 to 192.745, RSMo; or

     (3) Abstracts of inpatient hospital data.

     2. Nothing in sections 190.001 to 190.245 shall be construed as protecting from disclosure or discovery, in any civil action, information and documents otherwise discoverable from any person or entity providing information pursuant to the provisions of such sections, except for information, data or documents generated by quality improvement or quality assurance activities performed by or on behalf of the medical director as required by section 190.103, which shall be considered "peer review activity" protected from discovery or disclosure by section 537.035, RSMo, and information generated for the sole purpose of complying with a request made by the department pursuant to sections 190.001 to 190.245 which also shall be protected from disclosure to the public.

     190.180. 1. Any person violating, or failing to comply with, the provisions of sections [190.100 to 190.195] 190.001 to 190.245 is guilty of a class B misdemeanor and, upon conviction thereof, shall be [fined an amount not exceeding one thousand dollars or imprisonment for a period not exceeding thirty days, or by both such fine and imprisonment,] sentenced to pay a fine in accordance with chapter 560, RSMo, or to imprisonment in accordance with chapter 558, RSMo, or by both such fine and imprisonment for each offense.

     2. Each day that any violation of, or failure to comply with, sections [190.100 to 190.195] 190.001 to 190.245 is committed or permitted to continue shall constitute a separate and distinct offense and shall be punishable as such hereunder; but the court may, in appropriate cases, stay the cumulation of penalties.

     3. The attorney general of Missouri shall have concurrent jurisdiction with any and all prosecuting attorneys to prosecute persons in violation of sections [190.100 to 190.195] 190.001 to 190.245, and the attorney general or prosecuting attorney may institute injunctive proceedings against any person operating an ambulance service in violation of sections [190.100 to 190.195] 190.001 to 190.245.

     4. The prosecuting attorney for the county in which the violation of an ambulance district's ordinance or regulation occurs shall prosecute such violations in the circuit court of that county. The legal officer or attorney for the ambulance district may be appointed by the prosecuting attorney as special assistant prosecuting attorney for the prosecution of any such violation.

     190.185. The [state board of health of Missouri] department shall adopt, amend, promulgate, and enforce such rules, regulations and standards with respect to [all ambulances, ambulance service, attendant mobile emergency medical technicians, attendant-drivers and certificated apprentices to be licensed under the provisions of sections 190.093 to 190.249, and all emergency medical technicians to be certified under the provisions of sections 190.093 to 190.249,] the provisions of this chapter as may be designed to further the accomplishment of the purpose of this law in promoting [safe and adequate ambulance] state of the art emergency medical services in the interest of public health, safety and welfare. When promulgating such rules and regulations, the department shall consider the recommendations of the state advisory council on emergency medical services. No rule or portion of a rule promulgated [under] pursuant to the authority of sections [190.093 to 190.249] 190.001 to 190.245 shall become effective unless it has been promulgated pursuant to the provisions of section 536.024, RSMo.

          [190.190. Any ambulance, attendant or attendant-driver which is engaged in the business or service of the transportation of patients at the time of the promulgation of any applicable rule or regulation or minimum standard under this law shall be given a reasonable time under the particular circumstances, not to exceed six months from the date of such promulgation, within which to comply with such rules and regulations and minimum standards.]

     190.190. 1. All ground ambulance vehicles and air ambulance aircraft that have or are qualified to have a valid license issued by the department on the effective date of this act will have their ambulance vehicle or aircraft license expiration date extended until August 28, 1998.

     2. All air ambulance services and ground ambulance services shall have until one year after the effective date of this act to comply with rules developed pursuant to sections 190.001 to 190.245. The department may adjust the initial period of licensure, from one year to three years, of any air ambulance service or ground ambulance service licensed pursuant to sections 190.001 to 190.245, to equalize the number of licenses that may be renewed during each year of any three-year licensure period.

     3. License fees shall be pro rata for any air or ground ambulance service license issued by the department with an adjusted license period.

     190.196. l. No employer shall knowingly employ or permit any employee to perform any services for which a license, certificate or other authorization is required by sections 190.001 to 190.245, or by rules adopted pursuant to sections 190.001 to 190.245, unless and until the persons employed possesses all licenses, certificates or authorizations that are so required.

     2. Any person or entity that employs or supervises a person's activities as a first responder or emergency medical dispatcher shall cooperate with the department's efforts to monitor and enforce compliance by those individuals with the requirements of sections 190.001 to 190.245.

     190.200. The department of health in cooperation with local and regional emergency medical services systems and agencies, may provide public and professional information and education programs related to emergency medical services systems including trauma systems and emergency medical care and treatment. The department of health may also provide public information and education programs for informing residents of and visitors to the state of the availability and proper use of emergency medical services, of the value and nature of programs to involve citizens in the administering of prehospital emergency care, including cardiopulmonary-resuscitation, and of the availability of training programs in emergency care for members of the general public.

     190.205. 1. Insurance carriers and managed care plans shall pay benefits directly to ambulance services or emergency medical response agencies.

     2. Insurance carriers and managed care plans shall not prohibit or discourage the use of an emergency telephone service system when emergency services are needed as defined in section 190.100 and shall not require preauthorization for a plan enrollee's use of emergency services as defined in section 190.100. If review of the plan enrollee's use of emergency services reveals a violation of the definition of emergency as defined in section 190.100, payment of benefits may be denied. No retrospective denial shall occur for services delivered as a result of receiving authorization to provide evaluation and treatment from an insurance carrier or managed care plan's representative or the patient's primary care physician. Insurance carriers and managed care plans shall pay for services provided to fulfill the obligations of Section 1867 of the Social Security Act, otherwise known as the Patient Transfer Act.

     3. If a request for emergency services is made to an ambulance service which is not the emergency telephone service provider or the recognized emergency provider in areas not covered by emergency telephone ambulance services, then the provider or the recognized emergency provider shall be notified immediately by the ambulance service receiving the request. Agencies will consider a joint response in order to ensure a rapid response, appropriate level of care and transport to an appropriate receiving hospital.

     190.241. 1. The department shall designate a hospital as [a] an adult, pediatric or adult/pediatric trauma center when a hospital, upon proper application submitted by the hospital and site review, has been found by the department to meet the applicable level of trauma center criteria for designation in accordance with rules adopted by the department.

     2. The department of health shall, not less than once every [five] three years, conduct an on-site review of every trauma center through appropriate department personnel or a qualified contractor. No person shall be a qualified contractor for purposes of this subsection who has a substantial conflict of interest in the operation of any trauma center [already existing in this state] under review. The department may deny, place on probation, suspend or revoke a trauma center designation in any case in which it has reasonable cause to believe that there has been a substantial failure to comply with the provisions of [sections 190.235 to 190.249] this chapter or any rules or regulations promulgated [under the provisions of sections 190.235 to 190.249] pursuant to this chapter. If the department of health has reasonable cause to believe that a hospital is not in compliance with such provisions or regulations, it may conduct additional announced or unannounced site reviews of the hospital to verify compliance. If a trauma center fails two consecutive on-site reviews because of substantial noncompliance with standards prescribed by sections 190.001 to 190.245 or rules adopted by the department pursuant to sections 190.001 to 190.245, its trauma center designation shall be revoked.

     3. The department of health may establish appropriate fees to offset [some of] the costs of [reverification of trauma centers if the department has reasonable cause to believe that such verification is necessary] trauma center reviews.

     4. No hospital shall hold itself out to the public as an adult, pediatric or adult/pediatric trauma center unless it is designated as such by the department of health.

     5. Any person aggrieved by an action of the department of health affecting the trauma center designation [under the provisions of sections 190.235 to 190.249] pursuant to this chapter, including the revocation, the suspension, or the granting of, refusal to grant, or failure to renew a designation, may seek a determination thereon by the administrative hearing commission pursuant to the provisions of [section 621.045] chapter 536, RSMo. It shall not be a condition to such determination that the person aggrieved seek a reconsideration, a rehearing, or exhaust any other procedure within the department.

     190.243. 1. Severely injured patients shall be transported to a trauma center. When initial transport from the scene of injury to a trauma center would be prolonged, a severely injured patient may be transported to the nearest appropriate facility for stabilization prior to transport to a trauma center.

     2. Transport of the severely injured patient shall be governed by principles of timely and medically appropriate care and consideration of reimbursement mechanisms shall not supersede those principles.

     3. Patients who are not severely injured shall be transported to and cared for at the hospital of their choice so long as such ambulance service is not in violation of local protocols.

     190.245. The department shall require hospitals, as defined by chapter 197, RSMo, designated as trauma centers to provide for a peer review system, approved by the department, for trauma cases pursuant to the provisions of section 537.035, RSMo. For purposes of sections [190.235 to 190.249] 190.241 to 190.245, the department of health shall have the same powers and authority of a health care licensing board pursuant to subsection 6 of section 537.035, RSMo. Failure of a hospital to provide all medical records necessary for the department to implement provisions of sections [190.235 to 190.249] 190.241 to 190.245 shall result in the revocation of the hospital's designation as a trauma center. Any medical records obtained by the department or peer review committees shall be used only for purposes of implementing the provisions of sections [190.235 to 190.249] 190.241 to 190.245 and the names of hospitals, physicians and patients shall not be released by the department or members of review committees.