HCS/SCS/SB 524 - This act modifies provisions relating to health and welfare. BENEFITS FOR ELECTED OFFICIALS (Section 67.150) Currently, a political subdivision may elect to contribute to a health insurance plan or similar benefit for its elected officials and employees as part of their compensation. When a county elects to furnish all or part of medical expenses then it must provide the benefit to all elected officials. This act modifies that language to provide that if a county elects to furnish all or part of the medical expenses, then it must do so only for those elected officials who are compensated by the county. The county may furnish medical expenses to other elected officials not compensated by the county. This act modifies provisions relating to public assistance. HEALTH CARE COST TRANSPARENCY (Section 191.870) Upon request from a patient, potential patient, or the person's parent or guardian, a health care provider shall provide an estimated cost, if known, for a health care service based on the patient or potential patient's health benefit plan coverage, Medicaid coverage, Medicare coverage, or uninsured status. If covered by a health benefit plan, Medicaid, or Medicare, the health care provider shall provide the contractual reimbursement rate for the service, if known, and, if applicable, the amount the patient or potential patient would pay as a result of a deductible, coinsurance, or co-payment. If a patient or potential patient is uninsured, the health care provider shall provide the estimated out-of-pocket cost and information regarding any payment plan or other financial assistance that may be available. The health care provider's response need not be in writing unless so requested by those authorized to receive such response. Health care providers providing estimated costs under these provisions shall include with any price quote a specified statement. No provision in a contract entered into, amended, or renewed on or after August 28, 2014, between a health carrier and a health care provider shall be enforceable if the contractual provision prohibits, conditions, or in any way restricts any party to the contract from disclosing to an enrollee, patient, potential patient, or the person’s parent or legal guardian the contractual reimbursement rate for a health care service if the payment amount is less than the health care provider’s usual charge for the health care service and if the contractual provision prevents the determination of the potential out-of-pocket cost for the health care service by the enrollee, patient, potential patient, parent, or legal guardian. Any violation of these provisions shall result in a fine not to exceed $1,000 for each instance of violation. This provision is substantially similar to a provision in HB 1901 (2014). PRICE TRANSPARENCY (Section 191.875) By January 1, 2015,this act requires all health care providers and insurers to provide cost estimates prior to the provision of such services, if feasible, but in no event later than 3 business days after such request. These provisions shall not apply to emergency health care services. Health care providers and health carriers shall include with any estimate a specified disclaimer stating that the estimated cost is an estimate and shall also make available the percentage or amount of any discounts for cash payment of any charges incurred by a posting on the provider's website or in person. Nothing in these provisions shall be construed as violating any provider contract provision with a health carrier that prohibits disclosure of the provider's fee schedule with a health carrier to third parties. This provision is identical to a provision in HCS/HB 1793 (2014) and substantially similar to a provision in SB 847 (2014). REPORTING OF PRICES FOR MOST COMMON PROCEDURES (Sections 197.170 & 197.173) This act requires hospitals and ambulatory surgical centers to submit to the Department of Health and Senior Services prices for 140 of the most common procedures, including 100 of the most common procedures in hospital inpatient settings as well as 20 of the most common surgery and 20 of the most common imaging procedures conducted in both outpatient hospital and ambulatory surgical settings. The Department shall provide such information on its internet website in a manner that is easily understood by the public. Information for each hospital shall be listed separately and hospitals shall be listed in groups by category as determined by the Department through the promulgation of rules. Information for each hospital outpatient Department and each ambulatory surgical center shall also be listed separately. The information regarding hospital inpatient procedures shall be submitted beginning with the quarter ending June 30, 2015, and quarterly thereafter. The information regarding outpatient surgical and imaging procedures shall be submitted beginning with the quarter ending September 30, 2015, and quarterly thereafter. These provisions are identical to SB 684 (2014) and to provisions contained in SB 847 (2014) and HCS/HB 1793 (2014). CERTIFICATE OF NEED (Sections 197.300 TO 197.330) This act amends the certificate of need (CON) law as follows: (1) Limits the radius area for "affected persons" to a 5 mile radius of proposed new development as well as when consideration shall be given to the facilities located within the 5 mile radius when determining if a CON shall be issued; (2) Provides that a certificate of need shall not be required for a proposed project which creates ten or more new full-time jobs; (3) Raises the expenditure minimum for falling under CON review for capital expenditures to one million dollars and for major medical equipment to 2 million dollars; (4) Requires all testimony and other evidence taken during the hearings to be under oath and subject to penalty of perjury; (5) Changes the procedures and evidentiary standard at the certificate of need hearing; (6) Prohibits all ex parte communications between members of the committee and any interested party or witness regarding the subject matter of the hearing at any time prior to, during, or after the hearing and (7) Modifies the membership and requirements for Missouri Health Facilities Review Committee for the Certificate of Need Program. These provisions are identical to provisions contained in SB 847 (2014); HCS/HB 1793 (2014); SB 10 (2011 Special); SB 640 (2012) and substantially similar to HB 2355 (2008). ASSET LIMITS INCREASE FOR MEDICAID (Section 208.010) This act modifies the amount of cash, securities or other total non-exempt assets an aged or disabled participant is allowed to retain in order to qualify for MO HealthNet benefits from less than $1,000 to $2,000 for a single person and from $2,000 to $4,000 for a married couple. This provision is identical to provisions contained in SCS/SB 582 (2014) and SS/SCS/SB 739 (2014). SNAP FARMERS' MARKETS PILOT PROJECT (Section 208.018) Subject to appropriations, this act requires the Department of Social Services to establish a pilot program for the purpose of providing Supplemental Nutrition Assistance Program (SNAP) participants with access and the ability to afford fresh food when purchasing fresh food at farmers' markets. There shall be pilot programs in at least one rural and one urban area. Under the pilot program, such participants shall be able to purchase fresh fruit, vegetables, meat, fish, poultry, eggs, and honey with SNAP benefits with an electronic benefit transfer (EBT) card and receive a dollar-for-dollar match for every SNAP dollar spent at a participating farmer's market or vending agricultural zone in an amount up to ten dollars per week whenever the participant purchases fresh food with an EBT card. In addition, purchases of approved fresh food by SNAP participants under this act shall automatically trigger matching funds reimbursement into the vendor accounts by the Department. The Department shall be required to promulgate rules setting forth the procedures and methods of implementing this act. This program shall sunset on August 28, 2020. This provision is substantially similar to SCS/SB 850 (2014). SNAP REQUIREMENTS (Section 208.023) This act requires the Department of Social Services to imprint a photograph of a recipient on all EBT cards distributed for Supplemental Nutrition Assistance Program (SNAP) benefits. The card shall expire and be subject to renewal every three years. (Section 208.203(1)) Under this act, certain SNAP applicants are required to sign an affidavit stating that such individuals will follow certain requirements such as registering to work, providing sufficient information of job status and availability, accepting suitable jobs if offered, continuing employment if hired, and to not voluntarily reduce employment hours and failure to comply with requirements may result in loss of SNAP benefits (Section 208.023(2)) SNAP recipients are required to participate in any one or a combination of certain activities such as a condition of eligibility, secondary education, job search and readiness, community service, job training or employment. (Section 208.023(3)). SNAP recipients shall report any time their monthly gross income is over the maximum allowed for household size and shall also complete recertification once every 12 months. (Section 208.023(4) and (5)). This provision is substantially similar to HB 1213(2014). EBT USE BY TANF RECIPIENTS IN CERTAIN ESTABLISHMENTS (Section 208.024.1 AND 2) This act changes the prohibition on the use of EBT cards in specified establishments to the prohibition on the purchase of alcoholic beverage, lottery tickets, or tobacco products in those establishments and repeals the prohibition on using the EBT card in places and for items that are primarily marketed for use or by adults. This act prohibits the owner or proprietor of a specified business from adopting any policy that encourages, permits, or acquiesces in its employees knowingly accepting EBT cards for prohibited purchases. OUT-OF-STATE USE OF EBT CARDS (Section 208.024.3 and 4) This act also requires recipients of benefits who do not make at least one transaction in the state during a 90 day period to have his or her benefit payments to the EBT account temporarily suspended, pending an investigation by the Department of Social Services to determine if he or she no longer is a Missouri resident. If the department finds that the recipient is no longer a Missouri resident, it shall close the recipient's benefits. To ensure that benefits are not erroneously closed, a recipient shall notify the department of the reasons why he or she cannot be within the state for more than 90 days. A recipient who does not make an EBT transaction within the state for 60 days shall be given notice of the possibility of suspension of funds. DRUG TESTING OF TANF RECIPIENTS (Section 208.027) This act repeals the provision requiring an automatic administrative hearing after an applicant or recipient of temporary assistance for needy families benefits tests positive for a controlled substance or refused to submit to a test. The applicant may request a administrative hearing. This act adds "other information" in addition to information from the screening to the provision regarding requiring an applicant or recipient to test for drug use. CASH WITHDRAWALS AT GAMING ESTABLISHMENTS (Section 208.031) This act requires any TANF recipient who is found to have made a cash withdrawal at any casino, gambling casino, or gaming establishment after an administrative hearing to be declared ineligible for TANF benefits for a period of 3 years from the date of the hearing decision. Other members of the household who remain eligible for TANF shall continue to receive benefits as protective or vendor payments to a third-party payee. This provision is substantially similar to HB 1213(2014). AUTOMATIC ELIGIBILITY VERIFICATION PROCESS FOR BENEFIT PROGRAMS (Section 208.238) Under this act, the Department of Social Services is required to implement an automated process to ensure an applicant is eligible to apply for a benefit program. The automated process shall be designed to periodically review any current beneficiary to ensure he or she is still eligible for any benefit he or she is receiving. The system shall check applicant and recipient information against multiple sources of information through an automated process. PUBLIC ASSISTANCE FRAUD (Section 208.249) This act specifies that any person who knowingly commits fraud in obtaining or attempting to obtain public assistance benefits shall permanently lose eligibility for the benefits. CHILDREN'S HEALTH INSURANCE PROGRAM and UNINSURED WOMEN'S HEALTH PROGRAM (Sections 208.631 to 659) This act reduces the waiting period that children must be uninsured before enrolling in the Children's Health Insurance Program (CHIP) from six months to 90 days. This act also eliminates the asset limit for CHIP. The Uninsured Women's health program is repealed beginning July 1, 2015, with such change not going into effect unless and until federal health insurance premium tax credits are available for children and family coverage to purchase a health insurance plan from a health care exchange and the credits are available. SHOW-ME HEALTHY BABIES PROGRAM (Section 208.662) This act establishes the Show-Me Healthy Babies Program within the Department of Social Services as a separate children's health insurance program for any low-income unborn child. For an unborn child to be eligible for enrollment in the program, the mother of the child shall not be eligible for coverage under the Medicaid Program as administered by the state and shall not have access to affordable employer-subsidized health care insurance or other affordable health care coverage that includes coverage for the unborn child. The unborn child shall be in a family with income eligibility of no more than 300% of the federal poverty level or the equivalent modified adjusted gross income unless the income eligibility is set lower by the General Assembly through appropriations. The act delineates all of the parameters of the program. The department shall provide coverage for an unborn child under this program in the same manner in which the department provides CHIP coverage in the county of the primary residence of the mother. This provision is substantially similar to a provision in HB 1969 (2014). REVISED JOINT COMMITTEE ON MO HEALTHNET AND REPEAL OF MO HEALTHNET OVERSIGHT COMMITTEE (Sections 208.950; 208.952; 208.955; 208.975; 208.985) This act amends the Joint Committee on MO HealthNet to have as its purpose of study the efficacy of the program as well as the resources needed to continue and improve the MO HealthNet program over time. The committee shall meet at least twice a year. The committee may also hire or contract for an executive director to conduct investigations to fulfill the duties of the committee. This act also repeals the MO HealthNet Oversight Committee and references made to it. This provision is contained in SS/SCS/SB 739 (2014) and SCS/SB 518 (2014). MO HEALTHNET ELIGIBILITY (Section 208.991) Effective January 1, 2015, and subject to federal approval, individuals aged 19 to 64 with incomes up to 133% of the federal poverty level (FPL), and who are not pregnant, not entitled to Medicare, and not otherwise eligible for mandatory MO HealthNet coverage shall be eligible for the alternative package of MO HealthNet benefits. If the waivers and enhanced federal funding rate for newly eligible participants is not granted, these provisions shall be null and void. The provisions of this change in eligibility shall sunset on January 1, 2020, unless reauthorized by an act of the General Assembly. The Department of Social Services shall seek a federal waiver to promote healthy behaviors and personal responsibility through copayments to discourage non-emergent use of emergency services. The act specifies such incentive programs for healthy behavior including the use of health savings accounts and garnishment of an individual's state income tax returns to collect copayments. The department shall include in the federal waiver a requirement that MO HealthNet participants in the newly eligible category provide proof of workforce participation. Such requirement shall not apply to participants who are elderly, disabled, or medically frail. The department shall also provide premium subsidy and other cost supports for individuals eligible for MO HealthNet benefits to enroll in employer-sponsored health plans or other private health plans based on cost-effective principles determined by the department. Beginning January 1, 2015, the department shall obtain health care coverage for persons with incomes between 100% and 133% FPL who meet all other requirements for the alternative package, and have not been determined to be medically frail by the department, through a health care exchange in this state or through an employer. All individuals who meet the definition of medically frail shall receive all benefits that they are entitled to under Sections 208.152, 208.900, 208.903, 208.909, and 208.930. The department in conjunction with the Departments of Mental and Health and Senior Services, shall establish a screening process for determining whether an individual is medically frail and shall enroll all such individuals deemed so in the health care home program or other care coordination program. Such individuals may opt out of a health home program. HEALTH CARE HOMES PROGRAM (Section 208.997) The MO HealthNet Division shall implement the Health Care Homes Program as a provider-directed care coordination program for MO HealthNet participants who are not enrolled in a prepaid MO HealthNet benefits option and who are receiving services on a fee-for-service basis. The program shall provide payment to primary care clinics, community mental health centers, and other appropriate providers for care coordination for individuals deemed medically frail. Clinics shall meet certain specified criteria, including the capacity to develop care plans; a dedicated care coordinator; an adequate number of clients, evaluation mechanisms, and quality improvement processes to qualify for reimbursement; and the capability to maintain and use a disease registry. The act specifies the other parameters of the program. MO HEALTHNET MANAGED CARE (Sections 208.998) Except for those individuals deemed medically frail, recipients of the alternative package of MO HealthNet benefits shall receive covered services through health plans offered by managed care entities authorized by the department. The health plans shall resemble commercially available health plans while complying with federal Medicaid Program requirements as authorized by federal law or through a federal waiver and may include accountable care organizations, administrative service organizations, and managed care organizations paid on a capitated basis; shall promote, to the greatest extent possible, the opportunity for children and their parents to be covered under the same plan; shall offer plans statewide; shall include cost sharing for out patient services to the maximum extent allowed by federal law. The plans must include cost sharing for out-patient services to the maximum extent allowed by federal law and may include other co-payments and provide incentives that encourage and reward the prudent use of the health benefit provided. In addition, the plans must encourage access to care through provider rates that include pay-for-performance and are comparable to commercial rates. The managed care health plans shall also require all MO HealthNet managed care plans to provide coverage for ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse treatment, including behavioral health treatment; prescription drugs; habilitative services and devices; laboratory services; preventive and wellness care, and chronic disease management; pediatric services, including oral and vision care; case management; and preventive services and any other services required by federal law. The health plans shall also provide a high-deductible health plan option. Such high deductible health plan must include coverage for benefits as specified by Department rule after meeting a $1,000 deductible; an account, funded by the Department, of at least $1,000 per adult to pay the medical costs for the initial deductible; preventive care, as defined by Department rule, that is not subject to the deductible and does not require a payment of money from the account. The managed care health plans shall also offer all participants with chronic conditions, as specified by the Department, an option to be included in an incentive program for MO HealthNet participants who obtain specified primary care and preventive services and who participate or refrain from specified activities to improve the participant's overall health. A MO HealthNet participant is eligible to participate in only one of either the high deductible health plan or the incentive program for chronic conditions. The department may accept regional proposals as an additional option for beneficiaries. The proposals may be submitted by accountable care organizations or other organizations and entities. The department shall advance the development of systems of care for medically complex children who are MO HealthNet benefit recipients by accepting cost-effective regional proposals from and contracting with appropriate pediatric care networks, pediatric centers for excellence, and medical homes for children to provide MO HealthNet benefits when the department determines it is cost effective to do so. The entities shall be treated as accountable care organizations. The department shall seek all necessary waivers and state plan amendments from the federal Department of Health and Human Services that are necessary to implement the provisions of the act. No provisions of the act may be implemented unless the waivers and state plan amendments are approved. MANAGED CARE DATA AND NETWORK ADEQUACY REQUIREMENTS (208.999) This act requires managed care organizations to provide to the Department of Social Services, and the department to publicly report, certain information regarding medical loss ratios, total payments to the managed care organization in any form, provider compensation rates, service utilization information, data regarding complaints, grievances and appeals, quality measurements and consumer satisfaction. This act specifies all of the data and reporting requirements for the managed care organizations. HEALTH INSURANCE COVERAGE (376.998) This act exempts health benefit plans categorized as "excepted benefit plans" from requirements of any health insurance mandate, but requires that such excepted benefit plans shall provide a disclaimer conspicuously indicating that the plan is not minimum essential coverage on policies, certificates, application and enrollment forms, advertising materials, and plan identification cards. MEDICAID SAVINGS BUDGET AND TAXPAYER PROTECTION FUND (660.013) This act creates the "Medicaid Savings Budget and Taxpayer Protection Fund". The Office of Administration (OA) in conjunction with the Departments of Social Services and Mental Health shall track the general revenue savings achieved due to the reduction in the number of participants determined eligible under other MO HealthNet categories such as CHIP and Ticket to Work or state programs paid for with state-only funds as a result of expansion of Medicaid eligibility to 133% of the federal poverty level and as a result of federal subsidies available under the federal health care exchange, whether federally facilitated, state based, or operated on a partnership basis. The Department of Social Services (DSS) shall determine the additional pharmacy provider assessment revenue generated as a result of expansion of Medicaid eligibility to 133% of the federal poverty level. The department shall determine the amount of that additional pharmacy provider assessment that is needed to make payments to pharmacies for services. Any amount generated that is not needed for such payments shall be reported as excess and may be transferred to the Medicaid Savings State Budget and Taxpayer Protection Fund ("The fund"). The department shall also determine the additional hospital provider assessment revenue generated as a result of expansion of Medicaid eligibility to 133% of the federal poverty level. The department shall determine the amount of that additional hospital provider assessment that is needed to make payments to hospitals for services to newly eligible participants. Any amount generated that is not needed for such payment shall be reported as excess and may be transferred to the fund. By October first of each year, OA shall report the amounts pursuant in this fund in the prior fiscal year to the Governor and the appropriate committees in the General Assembly. OA shall, subject to appropriation, transfer the amounts reported to the fund. The transfers shall be made in three installments of relatively equal size no later than November, February, and May of each fiscal year. Subject to appropriation, moneys in the fund shall be used solely to pay the general revenue share of costs for individuals eligible for Medicaid services as a result of expansion of eligibility to 133% of the federal poverty level under this act. If revenue in the fund is not sufficient to cover the general revenue share of the costs outlined in this act, rates paid to providers for those services shall be reduced accordingly. Provider rates that shall be subject to reduction under this act shall include rates paid to hospitals, federally qualified health centers, rural health clinics, community mental health centers, pharmacies, physicians, chiropractors, and Medicaid managed care plans. Also, if, due to federal requirements, rates to one or more of the provider types listed in this act cannot be reduced sufficiently to cover the costs outlined in this act, rates to the remaining providers listed in this act shall be reduced by no more than an additional 5 percent. This act also provides that if the United States Congress passes legislation to convert the Medicaid program into a block grant program, the department shall seek the necessary approval to operate Missouri's Medicaid program under a block grant program within six months of federal implementation of such program. MEGHAN LUECKE