barnes medcaid proposal

7/29/2019 Barnes Medcaid Proposal

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0714H.03Cb

ROUGH DRAFT NO. 2

HOUSE COMMITTEE SUBSTITUTE

FOR

HOUSE BILL NO. 700

AN ACT1

2

To repeal sections 208.146, 208.151, 208.631, 208.659,3

376.961, 376.962, 376.964, 376.966, 376.968, 376.970,4

and 376.973, RSMo, and to enact in lieu thereof twenty5

new sections relating to the show-me transformation6

act.7

8

9 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF MISSOURI,10

AS FOLLOWS:11

12

Section A. Sections 208.146, 208.151, 208.631, 208.659,13

376.961, 376.962, 376.964, 376.966, 376.968, 376.970, and14

376.973, RSMo, are repealed and twenty new sections enacted in15

lieu thereof, to be known as sections 208.151, 208.186, 208.631,16

208.659, 208.661, 208.662, 208.990, 208.995, 208.997, 208.998,17

208.999, 376.961, 376.962, 376.964, 376.966, 376.968, 376.970,18

376.973, 1 and 2, to read as follows:19

208.151. 1. Medical assistance on behalf of needy persons20

shall be known as "MO HealthNet". For the purpose of paying MO21

HealthNet benefits and to comply with Title XIX, Public Law22

89-97, 1965 amendments to the federal Social Security Act (4223

U.S.C. Section 301, et seq.) as amended, the following needy24

persons shall be eligible to receive MO HealthNet benefits to the25

extent and in the manner hereinafter provided:26

(1) All participants receiving state supplemental payments27

for the aged, blind and disabled;28

(2) All participants receiving aid to families with29


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dependent children benefits, including all persons under nineteen1

years of age who would be classified as dependent children except2

for the requirements of subdivision (1) of subsection 1 of3

section 208.040. Participants eligible under this subdivision4

who are participating in drug court, as defined in section5

478.001, shall have their eligibility automatically extended6

sixty days from the time their dependent child is removed from7

the custody of the participant, subject to approval of the8

Centers for Medicare and Medicaid Services;9

(3) All participants receiving blind pension benefits;10

(4) All persons who would be determined to be eligible for11

old age assistance benefits, permanent and total disability12

benefits, or aid to the blind benefits under the eligibility13

standards in effect December 31, 1973, or less restrictive14

standards as established by rule of the family support division,15

who are sixty-five years of age or over and are patients in state16

institutions for mental diseases or tuberculosis;17

(5) All persons under the age of twenty-one years who would18

be eligible for aid to families with dependent children except19

for the requirements of subdivision (2) of subsection 1 of20

section 208.040, and who are residing in an intermediate care21

facility, or receiving active treatment as inpatients in22

psychiatric facilities or programs, as defined in 42 U.S.C.23

1396d, as amended;24

(6) All persons under the age of twenty-one years who would25

be eligible for aid to families with dependent children benefits26

except for the requirement of deprivation of parental support as27

provided for in subdivision (2) of subsection 1 of section28


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208.040;1

(7) All persons eligible to receive nursing care benefits;2

(8) All participants receiving family foster home or3

nonprofit private child-care institution care, subsidized4

adoption benefits and parental school care wherein state funds5

are used as partial or full payment for such care;6

(9) All persons who were participants receiving old age7

assistance benefits, aid to the permanently and totally disabled,8

or aid to the blind benefits on December 31, 1973, and who9

continue to meet the eligibility requirements, except income, for10

these assistance categories, but who are no longer receiving such11

benefits because of the implementation of Title XVI of the12

federal Social Security Act, as amended;13

(10) Pregnant women who meet the requirements for aid to14

families with dependent children, except for the existence of a15

dependent child in the home;16

(11) Pregnant women who meet the requirements for aid to17

families with dependent children, except for the existence of a18

dependent child who is deprived of parental support as provided19

for in subdivision (2) of subsection 1 of section 208.040;20

(12) Pregnant women or infants under one year of age, or21

both, whose family income does not exceed an income eligibility22

standard equal to one hundred eighty-five percent of the federal23

poverty level as established and amended by the federal24

Department of Health and Human Services, or its successor agency;25

(13) Children who have attained one year of age but have26

not attained six years of age who are eligible for medical27

assistance under 6401 of P.L. 101-239 (Omnibus Budget28


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Reconciliation Act of 1989). The family support division shall1

use an income eligibility standard equal to one hundred2

thirty-three percent of the federal poverty level established by3

the Department of Health and Human Services, or its successor4

agency;5

(14) Children who have attained six years of age but have6

not attained nineteen years of age. For children who have7

attained six years of age but have not attained nineteen years of8

age, the family support division shall use an income assessment9

methodology which provides for eligibility when family income is10

equal to or less than equal to one hundred percent of the federal11

poverty level established by the Department of Health and Human12

Services, or its successor agency. As necessary to provide MO13

HealthNet coverage under this subdivision, the department of14

social services may revise the state MO HealthNet plan to extend15

coverage under 42 U.S.C. 1396a (a)(10)(A)(i)(III) to children who16

have attained six years of age but have not attained nineteen17

years of age as permitted by paragraph (2) of subsection (n) of18

42 U.S.C. 1396d using a more liberal income assessment19

methodology as authorized by paragraph (2) of subsection (r) of20

42 U.S.C. 1396a;21

(15) The family support division shall not establish a22

resource eligibility standard in assessing eligibility for23

persons under subdivision (12), (13) or (14) of this subsection.24

The MO HealthNet division shall define the amount and scope of25

benefits which are available to individuals eligible under each26

of the subdivisions (12), (13), and (14) of this subsection, in27

accordance with the requirements of federal law and regulations28


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promulgated thereunder;1

(16) Notwithstanding any other provisions of law to the2

contrary, ambulatory prenatal care shall be made available to3

pregnant women during a period of presumptive eligibility4

pursuant to 42 U.S.C. Section 1396r-1, as amended;5

(17) A child born to a woman eligible for and receiving MO6

HealthNet benefits under this section on the date of the child's7

birth shall be deemed to have applied for MO HealthNet benefits8

and to have been found eligible for such assistance under such9

plan on the date of such birth and to remain eligible for such10

assistance for a period of time determined in accordance with11

applicable federal and state law and regulations so long as the12

child is a member of the woman's household and either the woman13

remains eligible for such assistance or for children born on or14

after January 1, 1991, the woman would remain eligible for such15

assistance if she were still pregnant. Upon notification of such16

child's birth, the family support division shall assign a MO17

HealthNet eligibility identification number to the child so that18

claims may be submitted and paid under such child's19

identification number;20

(18) Pregnant women and children eligible for MO HealthNet21

benefits pursuant to subdivision (12), (13) or (14) of this22

subsection shall not as a condition of eligibility for MO23

HealthNet benefits be required to apply for aid to families with24

dependent children. The family support division shall utilize an25

application for eligibility for such persons which eliminates26

information requirements other than those necessary to apply for27

MO HealthNet benefits. The division shall provide such28


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application forms to applicants whose preliminary income1

information indicates that they are ineligible for aid to2

families with dependent children. Applicants for MO HealthNet3

benefits under subdivision (12), (13) or (14) of this subsection4

shall be informed of the aid to families with dependent children5

program and that they are entitled to apply for such benefits.6

Any forms utilized by the family support division for assessing7

eligibility under this chapter shall be as simple as practicable;8

(19) Subject to appropriations necessary to recruit and9

train such staff, the family support division shall provide one10

or more full-time, permanent eligibility specialists to process11

applications for MO HealthNet benefits at the site of a health12

care provider, if the health care provider requests the placement13

of such eligibility specialists and reimburses the division for14

the expenses including but not limited to salaries, benefits,15

travel, training, telephone, supplies, and equipment of such16

eligibility specialists. The division may provide a health care17

provider with a part-time or temporary eligibility specialist at18

the site of a health care provider if the health care provider19

requests the placement of such an eligibility specialist and20

reimburses the division for the expenses, including but not21

limited to the salary, benefits, travel, training, telephone,22

supplies, and equipment, of such an eligibility specialist. The23

division may seek to employ such eligibility specialists who are24

otherwise qualified for such positions and who are current or25

former welfare participants. The division may consider training26

such current or former welfare participants as eligibility27

specialists for this program;28


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(20) Pregnant women who are eligible for, have applied for1

and have received MO HealthNet benefits under subdivision (2),2

(10), (11) or (12) of this subsection shall continue to be3

considered eligible for all pregnancy-related and postpartum MO4

HealthNet benefits provided under section 208.152 until the end5

of the sixty-day period beginning on the last day of their6

pregnancy;7

(21) Case management services for pregnant women and young8

children at risk shall be a covered service. To the greatest9

extent possible, and in compliance with federal law and10

regulations, the department of health and senior services shall11

provide case management services to pregnant women by contract or12

agreement with the department of social services through local13

health departments organized under the provisions of chapter 19214

or chapter 205 or a city health department operated under a city15

charter or a combined city-county health department or other16

department of health and senior services designees. To the17

greatest extent possible the department of social services and18

the department of health and senior services shall mutually19

coordinate all services for pregnant women and children with the20

crippled children's program, the prevention of intellectual21

disability and developmental disability program and the prenatal22

care program administered by the department of health and senior23

services. The department of social services shall by regulation24

establish the methodology for reimbursement for case management25

services provided by the department of health and senior26

services. For purposes of this section, the term "case27

management" shall mean those activities of local public health28


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personnel to identify prospective MO HealthNet-eligible high-risk1

mothers and enroll them in the state's MO HealthNet program,2

refer them to local physicians or local health departments who3

provide prenatal care under physician protocol and who4

participate in the MO HealthNet program for prenatal care and to5

ensure that said high-risk mothers receive support from all6

private and public programs for which they are eligible and shall7

not include involvement in any MO HealthNet prepaid, case-managed8

programs;9

(22) By January 1, 1988, the department of social services10

and the department of health and senior services shall study all11

significant aspects of presumptive eligibility for pregnant women12

and submit a joint report on the subject, including projected13

costs and the time needed for implementation, to the general14

assembly. The department of social services, at the direction of15

the general assembly, may implement presumptive eligibility by16

regulation promulgated pursuant to chapter 207;17

(23) All participants who would be eligible for aid to18

families with dependent children benefits except for the19

requirements of paragraph (d) of subdivision (1) of section20

208.150;21

(24) (a) All persons who would be determined to be22

eligible for old age assistance benefits under the eligibility23

standards in effect December 31, 1973, as authorized by 42 U.S.C.24

Section 1396a(f), or less restrictive methodologies as contained25

in the MO HealthNet state plan as of January 1, 2005; except26

that, on or after July 1, 2005, less restrictive income27

methodologies, as authorized in 42 U.S.C. Section 1396a(r)(2),28


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may be used to change the income limit if authorized by annual1

appropriation;2

(b) All persons who would be determined to be eligible for3

aid to the blind benefits under the eligibility standards in4

effect December 31, 1973, as authorized by 42 U.S.C. Section5

1396a(f), or less restrictive methodologies as contained in the6

MO HealthNet state plan as of January 1, 2005, except that less7

restrictive income methodologies, as authorized in 42 U.S.C.8

Section 1396a(r)(2), shall be used to raise the income limit to9

one hundred percent of the federal poverty level;10

(c) All persons who would be determined to be eligible for11

permanent and total disability benefits under the eligibility12

standards in effect December 31, 1973, as authorized by 42 U.S.C.13

1396a(f); or less restrictive methodologies as contained in the14

MO HealthNet state plan as of January 1, 2005; except that, on or15

after July 1, 2005, less restrictive income methodologies, as16

authorized in 42 U.S.C. Section 1396a(r)(2), may be used to17

change the income limit if authorized by annual appropriations.18

Eligibility standards for permanent and total disability benefits19

shall not be limited by age;20

(25) Persons who have been diagnosed with breast or21

cervical cancer and who are eligible for coverage pursuant to 4222

U.S.C. 1396a (a)(10)(A)(ii)(XVIII). Such persons shall be23

eligible during a period of presumptive eligibility in accordance24

with 42 U.S.C. 1396r-1;25

(26) Persons who are [independent foster care adolescents,26

as defined in 42 U.S.C. Section 1396d, or who are within27

reasonable categories of such adolescents who are under28


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twenty-one years of age as specified by the state, are eligible1

for coverage under 42 U.S.C. Section 1396a (a)(10)(A)(ii)(XVII)2

without regard to income or assets] in foster care under the3

responsibility of the state of Missouri on the date such persons4

attain the age of eighteen years, without regard to income or5

assets, if such persons:6

(a) Are under twenty-six years of age;7

(b) Are not eligible for coverage under another mandatory8

coverage group; and9

(c) Were covered by Medicaid while they were in such foster10

care.11

2. Beginning July 1, 2014, eligibility for MO HealthNet12

benefits shall be affected as follows:13

(1) Persons eligible under subdivisions (3) and (25) of14

subsection 1 of this section shall no longer be eligible for MO15

HealthNet benefits as provided in this section;16

(2) Pregnant women who are eligible under subdivision (12)17

of subsection 1 of this section, with income between one hundred18

thirty-three and one hundred eighty-five percent of the federal19

poverty level who attempt to enroll in MO HealthNet during any20

open enrollment period for a health care exchange, whether21

federally facilitated, state-based, or operated on a partnership22

basis shall be directed to choose an exchange plan and shall be23

eligible for a premium subsidy equal to the amount of the24

percentage of income required for premium payments of the25

pregnant woman by federal rule;26

(3) Beginning October 1, 2019, infants under one year of27

age who are eligible under subdivision (12) of subsection 1 of28


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this section shall be limited to those infants whose family1

income does not exceed one hundred eighty-five percent of the2

federal poverty level as established and amended by the federal3

Department of Health and Human Services, or its successor agency;4

except that infants under one year of age of women who were5

covered under subdivision (2) of this subsection with income6

between one hundred thirty-three and one hundred eighty-five7

percent of the federal poverty level who have coverage through a8

plan in a health care exchange, whether federally facilitated,9

state-based, or operated on a partnership basis shall not be10

eligible if the infant is covered by the womans subsidized11

exchange plan;12

(4) The changes in eligibility under subdivisions (1) to13

(3) of this subsection shall not take place unless and until:14

(a) There are health insurance premium tax credits under15

Section 36B of the Internal Revenue Code of 1986, as amended,16

available to persons through the purchase of a health insurance17


state-based, or operated on a partnership basis;19

(b) Eligibility of persons set out in subsection 3 of20

section 208.995 has been approved by the federal Department of21

Health and Human Services and has been implemented by the22

department; and23

(c) The federal Department of Health and Human Services24

grants the required waivers and state plan amendments to25

implement this subsection;26

(5) Beginning October 1, 2019, sections 208.631 to 208.65827

shall no longer be in effect, except for unborn children who are28


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eligible for benefits under section 208.662 and for children1

whose parents do not have access to affordable health insurance2

coverage for their children through their employment or through a3

health insurance plan in a health care exchange, whether4


basis. Such change in eligibility shall not take place unless6

and until, for a six-month period preceding the discontinuance of7

benefits under sections 208.631 to 208.658, there are health8

insurance premium tax credits available for children and family9

coverage under Section 36B of the Internal Revenue Code of 1986,10

as amended, available to persons through the purchase of a health11

insurance plan in a health care exchange, whether federally12

facilitated, state-based, or operated on a partnership basis13

which have been in place for a six-month period; and14

(6) The department shall inform participants six months15

prior to coverage being discontinued under paragraph (d) of this16

subdivision as to the possibility of insurance coverage through17

the purchase of a subsidized health insurance plan available18

through a health care exchange.19

3. Rules and regulations to implement this section shall be20

promulgated in accordance with section 431.064 and chapter 536.21

Any rule or portion of a rule, as that term is defined in section22

536.010, that is created under the authority delegated in this23

section shall become effective only if it complies with and is24

subject to all of the provisions of chapter 536 and, if25

applicable, section 536.028. This section and chapter 536 are26

nonseverable and if any of the powers vested with the general27

assembly pursuant to chapter 536 to review, to delay the28


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effective date or to disapprove and annul a rule are subsequently1

held unconstitutional, then the grant of rulemaking authority and2

any rule proposed or adopted after August 28, 2002, shall be3

invalid and void.4

[3.] 4. After December 31, 1973, and before April 1, 1990,5

any family eligible for assistance pursuant to 42 U.S.C. 601, et6

seq., as amended, in at least three of the last six months7

immediately preceding the month in which such family became8

ineligible for such assistance because of increased income from9

employment shall, while a member of such family is employed,10

remain eligible for MO HealthNet benefits for four calendar11

months following the month in which such family would otherwise12

be determined to be ineligible for such assistance because of13

income and resource limitation. After April 1, 1990, any family14

receiving aid pursuant to 42 U.S.C. 601, et seq., as amended, in15

at least three of the six months immediately preceding the month16

in which such family becomes ineligible for such aid, because of17

hours of employment or income from employment of the caretaker18

relative, shall remain eligible for MO HealthNet benefits for six19

calendar months following the month of such ineligibility as long20

as such family includes a child as provided in 42 U.S.C. 1396r-6.21

Each family which has received such medical assistance during the22

entire six-month period described in this section and which meets23

reporting requirements and income tests established by the24

division and continues to include a child as provided in 4225

U.S.C. 1396r-6 shall receive MO HealthNet benefits without fee26

for an additional six months. The MO HealthNet division may27

provide by rule and as authorized by annual appropriation the28


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scope of MO HealthNet coverage to be granted to such families.1

[4.] 5. When any individual has been determined to be2

eligible for MO HealthNet benefits, such medical assistance will3

be made available to him or her for care and services furnished4

in or after the third month before the month in which he made5

application for such assistance if such individual was, or upon6

application would have been, eligible for such assistance at the7

time such care and services were furnished; provided, further,8

that such medical expenses remain unpaid.9

[5.] 6. The department of social services may apply to the10

federal Department of Health and Human Services for a MO11

HealthNet waiver amendment to the Section 1115 demonstration12

waiver or for any additional MO HealthNet waivers necessary not13

to exceed one million dollars in additional costs to the state,14

unless subject to appropriation or directed by statute, but in no15

event shall such waiver applications or amendments seek to waive16

the services of a rural health clinic or a federally qualified17

health center as defined in 42 U.S.C. 1396d(l)(1) and (2) or the18

payment requirements for such clinics and centers as provided in19

42 U.S.C. 1396a(a)(15) and 1396a(bb) unless such waiver20

application is approved by the oversight committee created in21

section 208.955. A request for such a waiver so submitted shall22

only become effective by executive order not sooner than ninety23

days after the final adjournment of the session of the general24

assembly to which it is submitted, unless it is disapproved25

within sixty days of its submission to a regular session by a26

senate or house resolution adopted by a majority vote of the27

respective elected members thereof, unless the request for such a28


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waiver is made subject to appropriation or directed by statute.1

[6.] 7. Notwithstanding any other provision of law to the2

contrary, in any given fiscal year, any persons made eligible for3

MO HealthNet benefits under subdivisions (1) to (22) of4

subsection 1 of this section shall only be eligible if annual5

appropriations are made for such eligibility. This subsection6

shall not apply to classes of individuals listed in 42 U.S.C.7

Section 1396a(a)(10)(A)(i).8

8. The department shall notify any potential exchange-9

eligible participant who may be eligible for services due to10

spenddown of the participants potential ability to qualify for11

more cost-effective private insurance and premium tax credits12

under Section 36B of the Internal Revenue Code of 1986, as13

amended, available through the purchase of a health insurance14


state-based, or operated on a partnership basis and the benefits16

that would be potentially covered under such insurance.17

208.186. 1. Any person eligible for or participating in18

the MO HealthNet program who has been convicted of a crime19

involving alcohol or a controlled substance or any crime in which20

alcohol or substance abuse was, in the opinion of the court, a21

contributing factor to the persons commission of the offense22

shall, upon a finding by the court that the person is in need of23

alcohol or substance abuse treatment, be required to enroll and24

attend substance abuse treatment as a condition of sentencing.25

2. Any person eligible for or participating in the MO26

HealthNet program who is a parent of a child or children and27

party to proceedings in juvenile court as a result, in whole or28


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in part, of the persons use of controlled substances or alcohol1

shall, upon a finding by the court that the person is in need of2

substance abuse treatment, be required to enroll and attend3

substance abuse treatment as part of the persons reunification4

plan with their child or children.5

208.631. 1. Notwithstanding any other provision of law to6

the contrary, the MO HealthNet division shall establish a program7

to pay for health care for uninsured children. Coverage pursuant8

to sections 208.631 to 208.659 is subject to appropriation. The9

provisions of sections 208.631 to 208.569, health care for10

uninsured children, shall be void and of no effect if there are11

no funds of the United States appropriated by Congress to be12

provided to the state on the basis of a state plan approved by13

the federal government under the federal Social Security Act. If14

funds are appropriated by the United States Congress, the15

department of social services is authorized to manage the state16

children's health insurance program (SCHIP) allotment in order to17

ensure that the state receives maximum federal financial18

participation. Children in households with incomes up to one19

hundred fifty percent of the federal poverty level may meet all20

Title XIX program guidelines as required by the Centers for21

Medicare and Medicaid Services. Children in households with22

incomes of one hundred fifty percent to three hundred percent of23

the federal poverty level shall continue to be eligible as they24

were and receive services as they did on June 30, 2007, unless25

changed by the Missouri general assembly.26

2. For the purposes of sections 208.631 to 208.659,27

"children" are persons up to nineteen years of age. "Uninsured28


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children" are persons up to nineteen years of age who are1

emancipated and do not have access to affordable2

employer-subsidized health care insurance or other health care3

coverage or persons whose parent or guardian have not had access4

to affordable employer-subsidized health care insurance or other5

health care coverage for their children for six months prior to6

application, are residents of the state of Missouri, and have7

parents or guardians who meet the requirements in section8

208.636. A child who is eligible for MO HealthNet benefits as9

authorized in section 208.151 is not uninsured for the purposes10

of sections 208.631 to 208.659.11

3. Beginning October 1, 2019, sections 208.631 to 208.65812

shall no longer be in effect for children, except for unborn13

children who are eligible for benefits under section 208.662 and14

those children whose parents do not have access to affordable15

health insurance coverage for their children through their16

employment or through a health insurance plan in a health care17

exchange, whether federally facilitated, state-based, or operated18

on a partnership basis. Such change in eligibility shall not19

take place unless and until, for a six-month period preceding the20

discontinuance of benefits under sections 208.631 to 208.658,21

there are health insurance premium tax credits available for22

children and family coverage under Section 36B of the Internal23

Revenue Code of 1986, as amended, available to persons through24

the purchase of a health insurance plan in a health care25

exchange, whether federally facilitated, state-based, or operated26

on a partnership basis which have been in place for a six-month27

period.28


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4. The department shall inform participants six months1

prior to coverage being discontinued under subsection 3 of this2

section as to the possibility of insurance coverage through the3

purchase of a subsidized health insurance plan available through4

a health care exchange.5

208.659. 1. The MO HealthNet division shall revise the6

eligibility requirements for the uninsured women's health7

program, as established in 13 CSR Section 70-4.090, to include8

women who are at least eighteen years of age and with a net9

family income of at or below one hundred eighty-five percent of10

the federal poverty level. In order to be eligible for such11

program, the applicant shall not have assets in excess of two12

hundred and fifty thousand dollars, nor shall the applicant have13

access to employer-sponsored health insurance. Such change in14

eligibility requirements shall not result in any change in15

services provided under the program.16

2. Beginning July 1, 2014, the provisions of this section17

shall no longer be in effect. Such change in eligibility shall18

not take place unless and until:19

(1) For a six-month period preceding the discontinuance of20

benefits under sections 208.631 to 208.658 there are health21

insurance premium tax credits available for children and family22

coverage under Section 36B of the Internal Revenue Code of 1986,23

as amended, available to persons through the purchase of a health24

insurance plan in a health care exchange, whether federally25

facilitated, state-based, or operated on a partnership basis26

which have been in place for a six-month period; and27

(2) Eligibility of persons set out in subsection 3 of28


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department.3

3. The department shall inform participants six months4

prior to coverage being discontinued under subsection 2 of this5

section as to the possibility of insurance coverage through the6

purchase of a subsidized health insurance plan available through7

a health care exchange.8

208.661. To the extent allowed by federal law, the9

department shall develop incentive programs to encourage the10

construction and operation of school-based health care clinics in11

public elementary and secondary education schools with fifty12

percent or more students who are eligible for free or reduced13

price lunch, subject to appropriations.14

208.662. 1. There is hereby established within the15

department of social services the Show-Me Healthy Babies16

Program as a separate childrens health insurance program (CHIP)17

for low-income, unborn children whose parents do not have access18

to affordable health insurance coverage for their unborn child19

through their employment or through a health insurance plan in a20

health care exchange, whether federally facilitated, state-based,21

or operated on a partnership basis. The program shall be22

established under the authority of Title XXI of the federal23

Social Security Act, the State Childrens Health Insurance24

Program, as amended, and 42 CFR 457.10.25

2. In order for the unborn child to be enrolled in the26

show-me healthy babies program, the mother of an unborn child27

shall not be eligible for coverage under Title XIX of the federal28


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Social Security Act, the Medicaid program, as it is administered1

by the state, and shall not have access to affordable employer-2

subsidized health care insurance or other affordable health care3

coverage that includes coverage for the unborn child including4

any health insurance plan in a health care exchange, whether5


basis.7

3. Coverage for an unborn child enrolled in the show-me8

healthy babies program shall include all prenatal care and9

pregnancy-related services that benefit the health of the unborn10

child and that promote healthy labor, delivery, and birth.11

Coverage shall not include services that are solely for the12

benefit of the pregnant mother, that are unrelated to maintaining13

or promoting a healthy pregnancy, and that provide no benefit to14

the unborn child.15

4. There shall be no waiting period before an unborn child16

may be enrolled in the show-me healthy babies program. In17

accordance with the definition of child in 42 CFR 457.10,18

coverage shall include the period from conception to birth. The19

department shall develop a presumptive eligibility procedure for20

enrolling an unborn child.21

5. Coverage for the child shall continue for up to one year22

after birth, unless otherwise prohibited by law or unless23

otherwise limited by the general assembly through appropriations.24

6. Pregnancy-related and postpartum coverage for the mother25

shall begin on the day the pregnancy ends through the last day of26

the month that includes the sixtieth day after the pregnancy27

ends, unless otherwise prohibited by law or unless otherwise28


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limited by the general assembly through appropriations. Coverage1

for the mother shall be limited to pregnancy-related and2

postpartum care.3

7. Nothing in this section shall be construed to prohibit4

an unborn child from being enrolled in the show-me healthy babies5

program at the same time his or her mother is enrolled in MO6

HealthNet, the children's health insurance program (CHIP),7

Medicare, or other health care program. The department shall8

ensure that there is no duplication of payments for services for9

an unborn child enrolled in the show-me healthy babies program10

that are payable under a governmental or nongovernmental health11

care program for services to an eligible pregnant woman.12

8. The department may provide coverage for an unborn child13

enrolled in the show-me healthy babies program through:14

(1) Direct coverage whereby the state pays health care15

providers directly or by contracting with a managed care16

organization or with a group or individual health insurance17

provider;18

(2) A premium assistance program whereby the state assists19

in payment of the premiums, co-payments, coinsurance, or20

deductibles for a person who is eligible for health coverage21

through an employer, former employer, labor union, credit union,22

church, spouse, other organizations, other individuals, or23

through an individual health insurance policy that includes24

coverage for the unborn child, when such person needs assistance25

in paying such premiums, co-payments, coinsurance or deductibles;26

(3) A combination of direct coverage, such as when the27

unborn child is first enrolled, and premium assistance, such as28


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after the child is born; or1

(4) Any other similar arrangement whereby there:2

(a) Are lower program costs without sacrificing health care3

coverage for the unborn child or the child up to one year after4

birth;5

(b) Are greater covered services for the unborn child or6

the child up to one year after birth;7

(c) Is also coverage for siblings or other family members;8

or9

(d) Will be an ability for the child to transition more10

easily to nongovernment or less government-subsidized group or11

individual health insurance coverage after the child is no longer12

enrolled in the show-me healthy babies program.13

9. The department shall provide information about the show-14

me healthy babies program to maternity homes as defined in15

section 135.600, pregnancy resource centers as defined in section16

135.630, and other similar agencies and programs in the state17

that assist unborn children and their mothers. The department18

shall consider allowing such agencies and programs to assist in19

the enrollment of unborn children in the program and in making20

determinations about presumptive eligibility.21

10. Within sixty days after the effective date of this22

section, the department shall submit a state plan amendment to23

the federal Department of Health and Human Services requesting24

approval for the show-me healthy babies program.25

11. At least annually, the department shall prepare and26

submit a report to the governor, the speaker of the house of27

representatives, and the president pro tem of the senate28


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analyzing the cost savings and benefits, if any, to the state,1

counties, local communities, school districts, law enforcement2

agencies, health care providers, employers, other public and3

private entities, and persons by enrolling unborn children in the4

show-me healthy babies program. The analysis of cost savings and5

benefits, if any, shall include but not be limited to:6

(1) The higher federal matching rate for having an unborn7

child enrolled in the show-me healthy babies program versus the8

lower federal matching rate for a pregnant woman being enrolled9

in MO HealthNet or other federal programs;10

(2) The efficacy in providing services through managed care11

organizations, group or individual health insurance providers or12

premium assistance, or through other nontraditional arrangements13

of providing health care;14

(3) The increase in the proportion of unborn children who15

receive care in the first trimester of pregnancy due to a lack of16

waiting periods, presumptive eligibility, or removal of other17

barriers, and the attendant decrease in health problems and other18

problems for unborn children and women throughout pregnancy, at19

labor, delivery, and birth, and during infancy and childhood;20

(4) The increase in abstinence by pregnant women from21

alcohol, binge drinking, tobacco use, illicit drug use, or other22

harmful behaviors, and the attendant short-term and long-term23

decrease in birth defects, poor motor skills, vision, speech and24

hearing problems, breathing and respiratory problems, feeding and25

digestive problems, and other physical, mental, educational, and26

behavioral problems; and27

(5) The decrease in preterm births and low birth weight28


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babies and the attendant decrease in short-term and long-term1

medical and other interventions.2

12. The show-me healthy babies program shall not be deemed3

an entitlement program, but instead shall be subject to a federal4

allotment or other federal appropriations and matching state5

appropriations.6

13. Nothing in this section shall be construed as7

obligating the state to continue the show-me healthy babies8

program if the allotment or payments from the federal government9

end or are not sufficient for the program to operate, or if the10

general assembly does not appropriate funds for the program.11

14. Nothing in this section shall be construed as expanding12

MO HealthNet or fulfilling a mandate imposed by the federal13

government on the state.14

208.990. 1. The provisions of sections 208.151, 208.186,15

208.631, 208.659, 208.661, 208.662, 208.990, 208.995, 208.997,16

208.998, 208.999, 376.961, 376.962, 376.964, 376.966, 376.968,17

376.970, 376.973, 1 and 2 shall be known and may be cited as the18

"Show-Me Transformation Act".19

2. Notwithstanding any other provisions of law to the20

contrary, in order to be eligible for MO HealthNet coverage21

individuals shall meet the eligibility criteria set forth in 4222

CFR 435, including, but not limited to the requirements that:23

(1) The individual is a resident of the state of Missouri;24

(2) The individual has a valid Social Security number;25

(3) The individual is a citizen of the United States or a26

qualified alien as described in Section 431 of the Personal27

Responsibility and Work Opportunity Reconciliation Act of 1996, 828


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U.S.C. Section 1641, who has provided satisfactory documentary1

evidence of qualified alien status which has been verified with2

the Department of Homeland Security under a declaration required3

by Section 1137(d) of the Personal Responsibility and Work4

Opportunity Reconciliation Act of 1996 that the applicant or5

beneficiary is an alien in a satisfactory immigration status; and6

(4) An individual claiming eligibility as a pregnant woman7

shall verify pregnancy.8


contrary, effective January 1, 2014, the family support division10

shall conduct annual electronic searches to redetermine all MO11

HealthNet participants' eligibility as provided in 42 CFR12

435.916. The department may allow an administrative service13

organization to conduct the annual electronic searches if it is14

cost-effective.15

4. The department, or family support division, shall16

conduct electronic searches to redetermine eligibility on the17

basis of income, residency, citizenship, identity and other18

criteria as described in 42 CFR 435.916 upon availability of19

federal, state, and commercially available electronic data20

sources. The department, or family support division, may enter21

into a contract with a vendor to perform the electronic search of22

eligibility information not disclosed during the application23

process and obtain an applicable case management system. The24

department shall retain final authority over eligibility25

determinations made during the redetermination process.26


contrary, applications for MO HealthNet benefits shall be28


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submitted in accordance with the requirements of 42 CFR 435.9071

and other applicable federal law. The individual shall provide2

all required information and documentation necessary to make an3

eligibility determination, resolve discrepancies found during the4

redetermination process, or for a purpose directly connected to5

the administration of the medical assistance program.6


contrary, in order to be eligible for MO HealthNet coverage under8

section 208.995, individuals shall meet the eligibility9

requirements set forth in subsection 2 of this section and all10

other eligibility criteria set forth in 42 CFR 435 and 457,11

including, but not limited to the requirements that:12

(1) The department of social services shall determine the13

individual's financial eligibility based on projected annual14

household income and family size for the remainder of the current15

calendar year;16

(2) The department of social services shall determine17

household income for purposes of determining the modified18

adjusted gross income by including all available cash support19

provided by the person claiming such individual as a tax20

dependent;21

(3) The department of social services shall determine a22

pregnant woman's household size by counting the pregnant woman23

plus the number of children she is expected to deliver;24

(4) CHIP-eligible children shall be uninsured, shall not25

have access to affordable insurance, and shall pay the required26

premium;27

(5) An individual claiming eligibility as an uninsured28


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woman shall be uninsured.1

7. The MO HealthNet program shall not provide MO HealthNet2

coverage under subsection 3 of section 208.995 to a parent or3

other caretaker relative living with a dependent child unless the4

child is receiving benefits under the MO HealthNet program, the5

Children's Health Insurance Program (CHIP) under 42 CFR Chapter6

IV, Subchapter D, or otherwise is enrolled in minimum essential7

coverage as defined in 42 CFR Section 435.4.8

8. (1) The provisions of the show-me transformation act9

shall be null and void unless and until:10

(a) There are health insurance premium tax credits under11

Section 36B of the Internal Revenue Code of 1986, as amended,12

available to persons through the purchase of a health insurance13

plan in a heath care exchange, whether federally facilitated,14

state-based, or operated on a partnership basis;15

(b) Eligibility of persons set out in subsection 3 of16



department;19

(c) The federal Department of Health and Human Services20

grants the required waivers, state plan amendments, and enhanced21

federal funding rate;22

(2) If the federal funds at the disposal of the state23

shall at any time become less than ninety percent of the funds24

necessary or are not appropriated to pay the percentages25

specified in Section 2001 of Public Law 111-148, as that section26

existed on March 28, 2010, the provisions of this act shall be27

null and void. If the director is notified that federal funding28


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will fall below ninety percent of the funds necessary,1

participants will be notified as soon as practicable that the2

benefits they receive will terminate on such date that federal3

funding falls below ninety percent.4

208.995. 1. For purposes of sections 208.990 to 208.9985

the following terms mean:6

(1) "Caretaker relative", a relative of a dependent child7

by blood, adoption, or marriage with whom the child is living,8

who assumes primary responsibility for the child's care, which9

may, but is not required to, be indicated by claiming the child10

as a tax dependent for federal income tax purposes, and who is11

one of the following:12

(a) The child's father, mother, grandfather, grandmother,13

brother, sister, stepfather, stepmother, stepbrother, stepsister,14

uncle, aunt, first cousin, nephew, or niece; or15

(b) The spouse of such parent or relative, even after the16

marriage is terminated by death or divorce;17

(2) "Child" or "children", a person or persons who are18

under nineteen years of age;19

(3) "CHIP-eligible children", children who are eligible for20

Missouri's children's health insurance program as provided in21

sections 208.631 to 208.658, including paying the premiums22

required under sections 208.631 to 208.658;23

(4) "Department", the Missouri department of social24

services, or a division or unit within the department as25

designated by the department's director;26

(5) "MAGI", the individual's modified adjusted gross income27

as defined in Section 36B(d)(2) of the Internal Revenue Code of28


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1986, as amended, and:1

(a) Any foreign earned income or housing costs;2

(b) Tax exempt interest received or accrued by the3

individual; and4

(c) Tax exempt Social Security income;5

(6) "MAGI equivalent net income standard", an income6

eligibility threshold based on modified adjusted gross income7

that is not less than the income eligibility levels that were in8

effect prior to the enactment of Public Law 111-148 and Public9

Law 111-152;10

(7) "Medically frail", individuals with:11

(a) Serious emotional disturbances;12

(b) Disabling mental disorders;13

(c) Substance use disorders who are at high risk for14

significant medical and social costs;15

(d) Serious and complex medical conditions;16

(e) Physical or mental disabilities that significantly17

impair their ability to perform one or more activities of daily18

living; or19

(f) Recipients adjudicated to have a level of care of20

twenty-one points or greater as determined by the level of care21

screening process under 42 CFR 483.100 to 483.138, or deemed22

eligible for skilled nursing facility placement, but who are not23

currently residing in a nursing facility.24

2. (1) Effective January 1, 2014, notwithstanding any25

other provision of law to the contrary, the following individuals26

shall be eligible for MO HealthNet coverage as provided in this27

section:28


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(a) Individuals covered by MO HealthNet for families as1

provided in section 208.145;2

(b) Individuals covered by transitional MO HealthNet as3

provided in 42 U.S.C. Section 1396r-6;4

(c) Individuals covered by extended MO HealthNet for5

families on child support closings as provided in 42 U.S.C.6

Section 1396r-6;7

(d) Pregnant women as provided in subdivisions (10), (11),8

and (12) of subsection 1 of section 208.151;9

(e) Children under one year of age as provided in10

subdivision (12) of subsection 1 of section 208.151;11

(f) Children under six years of age as provided in12


(g) Children under nineteen years of age as provided in14


(h) CHIP-eligible children; and16

(i) Uninsured women as provided in section 208.659.17

(2) Effective January 1, 2014, the department shall18

determine eligibility for individuals eligible for MO HealthNet19

under subdivision (1) of this subsection based on the following20

income eligibility standards, unless and until they are changed21

under subsection 2 of section 208.151:22

(a) For individuals listed in paragraphs (a), (b) and (c)23

of subdivision (1) of this subsection, the department shall apply24

the July 16, 1996, Aid to Families with Dependent Children (AFDC)25

income standard as converted to the MAGI equivalent net income26

standard;27

(b) For individuals listed in paragraph (f) of subdivision28


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(1) of this subsection, the department shall apply one hundred1

thirty-three percent of the federal poverty level converted to2

the MAGI equivalent net income standard;3

(c) For individuals listed in paragraph (h) of subdivision4

(1) of this subsection, the department shall convert the income5

eligibility standard set forth in section 208.633 to the MAGI6

equivalent net income standard;7

(d) For individuals listed in paragraphs (d), (e) and (i)8

of subdivision (1) of this subsection, the department shall apply9

one hundred eighty-five percent of the federal poverty level10

converted to the MAGI equivalent net income standard;11

(e) For individuals listed in paragraph (g) of subdivision12

1 of this subsection, the department shall apply one hundred13

percent of the federal poverty level converted to the MAGI14

equivalent net income standard.15

(3) Individuals eligible for MO HealthNet under subdivision16

(1) of this subsection shall receive all applicable benefits17

under section 208.152.18

3. (1) Effective January 1, 2014, and subject to the19

receipt of appropriate waivers and approval of state plan20

amendments, individuals who meet the following qualifications21

shall be eligible for the alternative package of MO HealthNet22

benefits as set forth in subsection 5 of this section, subject to23

the other requirements of this section:24

(a) Are nineteen years of age or older and under sixty-five25

years of age;26

(b) Are not pregnant;27

(c) Are not entitled to or enrolled for Medicare benefits28


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under Part A or B of Title XVIII of the Social Security Act;1

(d) Are not otherwise eligible for and enrolled in2

mandatory coverage under Missouri's MO HealthNet program in3

accordance with 42 CFR 435, Subpart B; and4

(e) Have household income that is at or below one hundred5

percent of the federal poverty level for the applicable family6

size for the applicable year under the MAGI equivalent net income7

standard.8

(2) The department shall immediately seek any necessary9

waivers from the federal Department of Health and Human Services10

to implement the provisions of this subsection. The waivers11

shall:12

(a) Promote healthy behavior and reasonable requirements13

that patients take ownership of their health care by seeking14

early preventative care in appropriate settings, including no co-15

payments for preventive care services;16

(b) Require personal responsibility in the payment of17

health care by establishing appropriate co-payments based on18

family income that shall discourage the use of emergency room19

visits for non-emergent health situations and promote responsible20

use of other health care services;21

(c) Promote the adoption of healthier personal habits22

including limiting tobacco use or behaviors that lead to obesity;23

(d) Allow recipients to receive an annual cash incentive to24

promote responsible behavior and encourage efficient use of25

health care services; and26

(e) Allow health plans to offer a health savings account27

option.28


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(f) Include a request for an enhanced federal funding rate1

consistent with subsection 10 of this section for newly eligible2

participants.3

(3) If such waivers and enhanced federal funding rate are4

not granted by the federal government, the provisions of the5

show-me transformation act shall be null and void.6

4. Except for those individuals who meet the definition of7

medically frail, individuals eligible for MO HealthNet benefits8

under subsection 3 of this section shall receive only a package9

of alternative minimum benefits. The MO HealthNet division of10

the department of social services shall promulgate regulations to11

be effective January 1, 2014, that provide an alternative benefit12

package that complies with the requirements of federal law and13

subject to limitations as established in regulations of the MO14

HealthNet division.15

5. Except for those individuals who meet the definition of16

medically frail, individuals who qualify for coverage under17

subsections 2 and 3 of this section shall receive covered18

services through health plans authorized by the department under19

section 208.998.20

6. The department shall provide premium subsidy and other21

cost supports for individuals eligible for MO HealthNet under22

subsections 2 and 3 of this section to enroll in23

employer-provided health plans or other private health plans24

based on cost-effective principles determined by the department.25

7. Individuals eligible for MO HealthNet benefits under26

subsections 2 and 3 of this section who meet the definition of27

medically frail shall receive all benefits they are eligible to28


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34

receive under sections 208.152, 208.900, 208.903, 208.909, and1

208.930.2

8. The department shall establish a screening process in3

conjunction with the department of mental health and department4

of health and senior services for determining whether an5

individual is medically frail and shall enroll all eligible6

individuals who meet the definition of medically frail and whose7

care management would benefit from being assigned a health home8

into the health home program or other care coordination as9

established by the department. All eligible individuals may opt10

out of the health home program.11

9. The department or appropriate divisions of the12

department shall promulgate rules to implement the provisions of13

this section. Any rule or portion of a rule, as the term is14

defined in section 536.010, that is created under the authority15

delegated in this section shall become effective only if it16

complies with and is subject to all of the provisions of chapter17

536 and, if applicable, section 536.028. This section and chapter18

536 are nonseverable and if any of the powers vested with the19

general assembly pursuant to chapter 536 to review, to delay the20

effective date or to disapprove and annul a rule are subsequently21

held unconstitutional, then the grant of rulemaking authority and22

any rule proposed or adopted after August 28, 2013, shall be23

invalid and void.24

10. The department shall submit such state plan amendments25

and waivers to the Centers for Medicare and Medicaid Services of26

the federal Department of Health and Human Services as the27

department determines are necessary to implement the provisions28


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of this section. The department shall request of the federal1

government an enhanced federal funding rate for persons newly2

eligible under subsection 3 of this section whereby the federal3

government agrees to pay the percentages specified in Section4

2001 of PL 111-148, as that section existed on March 23, 2010.5

The provisions of subsections 3 to 8 of this section shall not be6

implemented unless such waivers and enhanced federal funding7

rates are granted by the federal government.8

11. If the federal funds at the disposal of the state for9

payments of money benefits to or on behalf of any persons under10

this section shall at any time become less than ninety percent of11

the funds necessary or are not appropriated to pay the12

percentages specified in Section 2001 of Public Law 111-148, as13

that section existed on March 23, 2010, subsections 3 to 8 of14

this section shall no longer be effective for the individuals15

whose benefits are no longer matchable at the specified16

percentages.17

208.997. 1. The MO HealthNet division shall develop and18

implement the "Health Care Homes Program" as a provider-directed19

care coordination program for MO HealthNet recipients who are not20

enrolled in a prepaid MO HealthNet benefits option and who are21

receiving services on a fee-for-service basis. The health care22

homes program shall provide payment to primary care clinics for23

care coordination for people who have complex and chronic medical24

conditions. Clinics shall meet certain criteria, including but25

not limited to the following:26

(1) The capacity to develop care plans;27

(2) Have a dedicated care coordinator; and28


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(3) Have an adequate number of clients, evaluation1

mechanisms, and quality improvement processes to qualify for2

reimbursement.3

2. For purposes of this section, "primary care clinic"4

means a medical clinic designated as the patient's first point of5

contact for medical care, available twenty-four hours a day,6

seven days a week, that provides or arranges the patient's7

comprehensive health care needs, and provides overall8

integration, coordination, and continuity over time and referrals9

for specialty care.10

3. The health care home for recipients of MO HealthNet11

services defined in paragraph (f) of subdivision (7) of12

subsection 1 of section 208.995 shall be the primary provider of13

home- and community-based services received by the recipient if14

such provider has a qualified, licensed designee to serve as the15

recipients care coordinator. The qualifications for such16

designees shall be defined by the department by rule.17

4. This section shall be implemented in such a way that it18

does not conflict with federal requirements for health care home19

participation by MO HealthNet participants.20

5. The department or appropriate divisions of the21

department may promulgate rules to implement the provisions of22

this section. Any rule or portion of a rule, as that term is23

defined in section 536.010, that is created under the authority24

delegated in this section shall become effective only if it25

complies with and is subject to all of the provisions of chapter26

536 and, if applicable, section 536.028. This section and27

chapter 536 are nonseverable and if any of the powers vested with28


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the general assembly pursuant to chapter 536 to review, to delay1

the effective date, or to disapprove and annul a rule are2

subsequently held unconstitutional, then the grant of rulemaking3

authority and any rule proposed or adopted after August 28, 2013,4

shall be invalid and void.5

208.998. 1. Except for individuals who meet the definition6

of medically frail, individuals who qualify for coverage under7

subsections 2 and 3 of section 208.995 shall receive covered8

services through health plans offered by managed care entities9

which are authorized by the department. Health plans authorized10

by the department:11

(1) Shall resemble commercially available health plans12

while complying with federal Medicaid requirements as authorized13

by federal law or through a federal waiver, and may include14

accountable care organizations;15

(2) Shall promote, to the greatest extent possible, the16

opportunity for children and their parents to be covered under17

the same plan;18

(3) Shall offer plans statewide;19

(4) Shall include cost-sharing for out-patient services to20

the maximum extent allowed by federal law;21

(5) May include other co-payments and provide incentives22

that encourage and reward the prudent use of the health benefit23

provided;24

(6) Shall encourage access to care through provider rates25

that include pay-for-performance and are comparable to commercial26

rates;27

(7) Shall provide incentives, including shared risk and28


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38

savings, to health plans and providers to encourage cost-1

effective delivery of care; and2

(8) May provide multiple plan options and reward3

participants for choosing a low-cost plan.4

2. The department may designate that certain health care5

services be excluded from such health plans if it is determined6

cost-effective by the department to provide such services through7

an administrative service organization.8

3. The department shall establish, in collaboration with9

plans and providers, uniform utilization review protocols to be10

used by all authorized health plans.11

4. The department shall follow the following process for12

contracting with managed care plans:13

(1) The department shall solicit capitated bids from14

interested bidders utilizing a competitive bidding process. The15

department shall solicit bids on a statewide basis.16

(2) The department shall provide bidders a single low-cost17

estimate per member per month, developed on an actuarially sound18

basis in conformance with 42 CFR 438.6(c), and bidders will19

submit their proposed discount of the low-cost estimate per20

member per month rate. The department shall provide bidders with21

the rate development factors to be applied to the low-cost22

estimate and bidders shall be required to agree to these factors23

as part of the bidding process. To assist the vendors in24

developing a competitive bid discount, the department shall25

develop a comprehensive, summary-level databook containing26

information on the populations and services to be included within27

this procurement. Bidders shall be permitted to submit questions28


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regarding the financial terms of this request for proposals and1

the rate development process, and the department will make those2

questions and the corresponding answers available to all bidders3

registered for this request for proposals. In addition, the4

department shall conduct bidders conferences to answer questions5

about this request for proposals, the financial terms, and the6

rate development process. Bidders are cautioned that any oral7

answers provided during a bidders conference shall be considered8

non-binding and only those answers formally provided in writing9

by the designated procurement officer are binding. Bidders are10

cautioned that any communication with any department staff other11

than through the designated procurement officer shall be grounds12

for disqualification of their proposal.13

(3) Bidders shall submit bids with a percentage discount14

off the low-cost estimate per member per month set by the15

department. Only percentage discounts between zero and ten16

percent shall be considered by the department in the bid process.17

Any bid that proposes an increase to the low-cost estimate shall18

be deemed non-responsive and that bidders proposal shall be19

rejected in its entirety and eliminated from the evaluation20

process.21

(4) The department shall reserve the right to request best22

and final offers regarding bids, but may award bids after the23

first round of bidding.24

(5) The department shall select a minimum of three winning25

bids and may select up to a maximum number of bids equal to the26

quotient derived from dividing the total number of participants27

anticipated by the department in a region by one hundred28


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40

thousand.1

(6) The lowest conforming bid shall be accepted by the2

department. For determining other accepted bids, the department3

shall consider the following factors:4

(a) The cost to Missouri taxpayers;5

(b) The extent of the network of health care providers6

offering services within the bidders plan;7

(c) Additional services offered to recipients under the8

bidders plan;9

(d) The bidders history of providing managed care plans10

for similar populations in Missouri or other states;11

(e) Whether the bidder or an associated company offers an12

identical or substantially similar plan within a health care13

exchange in this state, whether federally facilitated, state-14

based, or operated on a partnership basis; and the bidder, if the15

bidder offers an identical or similar plan, or the bidder and the16

associated company, if the bidder has formed a partnership for17

purposes of its bid, has included a process in its bid by which18

MO HealthNet recipients who choose its plan will be automatically19

enrolled in the corresponding plan offered within the health care20

exchange if the recipients income increases resulting in the21

recipients ineligibility for MO HealthNet benefits; and22

(f) Any other criteria the department deems relevant to23

ensuring MO HealthNet benefits are provided to recipients in such24

manner as to save taxpayer money and improve health outcomes of25

recipients.26

5. (1) Participants enrolling in managed care plans under27

this section shall have the ability to choose their plan. In the28


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enrollment process, participants shall be provided a list of all1

plans available which includes the annual capitation rate per2

member. Participants shall be informed in the enrollment process3

that they will be eligible to receive a portion of the amount4

saved by Missouri taxpayers if the participant chooses the lowest5

cost plan offered in the participants region. The portion6

received by a participant shall be determined by the department7

according to the departments best judgment as to the portion8

which will bring the maximum savings to Missouri taxpayers.9

(2) If a participant fails or refuses to choose a plan as10

set forth in subdivision (1) of this subsection, the department11

shall determine rules for auto-assignment which shall include12

incentives for low-cost bids and improved health outcomes as13

determined by the department.14

6. Existing managed care contracts in effect as of January15

1, 2013, shall continue in effect through the duration of the16

previously contracted period.17

7. All MO HealthNet plans under this section shall provide18

coverage for the following services unless they are specifically19

excluded under subsection 2 of this section and instead provided20

by an administrative services organization:21

(1) Ambulatory patient services;22

(2) Emergency services;23

(3) Hospitalization;24

(4) Maternity and newborn care;25

(5) Mental health and substance abuse treatment, including26

behavioral health treatment;27

(6) Prescription drugs;28


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(7) Rehabilitative and habilitative services and devices;1

(8) Laboratory services;2

(9) Preventive and wellness care, and chronic disease3

management;4

(10) Pediatric services, including oral and vision care;5

and6

(11) Any other service required by federal law.7

8. No MO HealthNet plan shall provide coverage for an8

abortion unless the abortion is certified in writing by a9

physician to the MO HealthNet agency that, in the physician's10

professional judgment, the life of the mother would be endangered11

if the fetus were carried to term.12

9. The MO HealthNet program shall provide a high deductible13

health plan option for uninsured adults nineteen years of age or14

older and under sixty-four years of age with incomes of less than15

one hundred percent of the federal poverty level. The high16

deductible health plan shall include:17

(1) High deductible coverage. After meeting a one thousand18

dollar deductible, individuals shall be covered for benefits as19

specified by rule of the department;20

(2) An account, funded by the department, of at least one21

thousand dollars per adult to pay medical costs for the initial22

deductible funded by the department;23

(3) Preventive care, as defined by the department by rule,24

that is not subject to the deductible and does not require a25

payment of moneys from the account described in subdivision (2)26

of this subsection;27

(4) A basic benefits package if annual medical costs exceed28


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one thousand dollars;1

(5) A minimum deductible of one thousand dollars;2

(6) As soon as practicable, the health plan shall establish3

and maintain a record-keeping system for each health care visit4

or service received by recipients under this subsection. The5

plan shall require that the recipient's prepaid card number be6

entered or electronic strip be swiped by the health care provider7

for purposes of maintaining a record of every health care visit8

or service received by the recipient from such provider,9

regardless of any balance on the recipient's card. Such10

information shall only include the date, provider name, and11

general description of the visit or service provided. The plan12

shall maintain a complete history of all health care visits and13

services for which the recipient's prepaid card is entered or14

swiped in accordance with this subdivision. If required under15

the federal Health Insurance Portability and Accountability Act16

(HIPAA) or other relevant state or federal law or regulation, a17

recipient shall, as a condition of participation in the prepaid18

card incentive, be required to provide a written waiver for19

disclosure of any information required under this subdivision;20

(7) To incentivize the appropriate use of taxpayer21

resources, the department shall, by rule, determine a proportion22

of the amount left in a participants account described in23

subdivision (2) of this subsection which the department shall pay24

to the participant for saving taxpayer money. The method of25

payment shall be determined by the department; and26

(8) To incentivize the purchase of private health plans,27

the department shall, by rule, determine a proportion of a28


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participants account described in subdivision (2) of this1

subsection which shall be used to subsidize premiums to2

facilitate a participants transition from health coverage under3

MO HealthNet to private health insurance based on cost-effective4

principles determined by the department.5

10. All participants with chronic conditions shall be6

included in an incentive program for MO HealthNet recipients who7

obtain specified primary care and preventive services, and who8

participate or refrain from participation in specified activities9

to improve the overall health of the recipient. Recipients who10

complete the requirements of the program shall be eligible to11

receive an annual cash payment for successful completion of the12

program. The department shall establish, by rule, the specific13

primary care and preventive services, activities to be included14

in the incentive program, and the amount of any annual cash15

payments to recipients.16

11. A MO HealthNet recipient shall be eligible for17

participation in only one of either the high deductible health18

plan under subsection 9 of this section or the incentive program19

under subsection 10 of this section.20

12. No cash payments, incentives, or credits paid to or on21

behalf of a MO HealthNet participant under a program established22

by the department under this section shall be deemed to be income23

to the participant in any means-tested benefit program unless24

otherwise specifically required by law or rule of the department.25

13. Managed care entities shall inform participants who26

choose the high deductible health plan under subsection 9 of this27

section that the participant may lose his or her payment if the28


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participant utilizes visits to the emergency department for1

nonemergent purposes. Such information shall be included on2

every electronic and paper correspondence between the managed3

care plan and the participant.4

14. The department shall seek all waivers and state plan5

amendments from the federal Department of Health and Human6

Services necessary to implement the provisions of this section.7

The provisions of this section shall not be implemented unless8

such waivers are granted. If this section is approved in part by9

the federal government, the department is authorized to proceed10

on those sections which approval has been granted; except that,11

any increase in eligibility shall be contingent upon the receipt12

of all necessary waivers and state plan amendments.13

15. The department may promulgate rules to implement the14

provisions of this section. Any rule or portion of a rule, as15

the term is defined in section 536.010, that is created under the16

authority delegated in this section shall become effective only17

if it complies with and is subject to all of the provisions of18

chapter 536 and, if applicable, section 536.028. This section and19

chapter 536 are nonseverable and if any of the powers vested with20

the general assembly pursuant to chapter 536 to review, to delay21

the effective date or to disapprove and annul a rule are22

subsequently held unconstitutional, then the grant of rulemaking23

authority and any rule proposed or adopted after August 28, 2013,24

shall be invalid and void.25

208.999. To the extent allowed by federal law, the26

department shall develop incentive programs to encourage the27

construction and operation of urgent care clinics which operate28


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outside normal business hours and are in or adjoining emergency1

room facilities which receive a high proportion of patients who2

are participating in MO HealthNet.3

376.961. 1. There is hereby created a nonprofit entity to4

be known as the "Missouri Health Insurance Pool". All insurers5

issuing health insurance in this state and insurance arrangements6

providing health plan benefits in this state shall be members of7

the pool.8

2. Beginning January 1, 2007, the board of directors shall9

consist of the director of the department of insurance, financial10

institutions and professional registration or the director's11

designee, and eight members appointed by the director. Of the12

initial eight members appointed, three shall serve a three-year13

term, three shall serve a two-year term, and two shall serve a14

one-year term. All subsequent appointments to the board shall be15

for three-year terms. Members of the board shall have a16

background and experience in health insurance plans or health17

maintenance organization plans, in health care finance, or as a18

health care provider or a member of the general public; except19

that, the director shall not be required to appoint members from20

each of the categories listed. The director may reappoint21

members of the board. The director shall fill vacancies on the22

board in the same manner as appointments are made at the23

expiration of a member's term and may remove any member of the24

board for neglect of duty, misfeasance, malfeasance, or25

nonfeasance in office.26

3. Beginning August 28, 2007, the board of directors shall27

consist of fourteen members. The board shall consist of the28


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director and the eight members described in subsection 2 of this1

section and shall consist of the following additional five2

members:3

(1) One member from a hospital located in Missouri,4

appointed by the governor, with the advice and consent of the5

senate;6

(2) Two members of the senate, with one member from the7

majority party appointed by the president pro tem of the senate8

and one member of the minority party appointed by the president9

pro tem of the senate with the concurrence of the minority floor10

leader of the senate; and11

(3) Two members of the house of representatives, with one12

member from the majority party appointed by the speaker of the13

house of representatives and one member of the minority party14

appointed by the speaker of the house of representatives with the15

concurrence of the minority floor leader of the house of16

representatives.17

4. The members appointed under subsection 3 of this section18

shall serve in an ex officio capacity. The terms of the members19

of the board of directors appointed under subsection 3 of this20

section shall expire on December 31, 2009. On such date, the21

membership of the board shall revert back to nine members as22

provided for in subsection 2 of this section.23

5. Beginning on August 28, 2013, the board of directors on24

behalf of the pool, the executive director, and any other25

employees of the pool shall have the authority to provide26

assistance or resources to any department, agency, public27

official, employee, or agent of the federal government for the28


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specific purpose of transitioning individuals enrolled in the1

pool to coverage outside of the pool beginning on or before2

January 1, 2014. Such authority does not extend to authorizing3

the pool to implement, establish, create, administer, or4

otherwise operate a state-based exchange.5

376.962. 1. The board of directors on behalf of the pool6

shall submit to the director a plan of operation for the pool and7

any amendments thereto necessary or suitable to assure the fair,8

reasonable and equitable administration of the pool. After9

notice and hearing, the director shall approve the plan of10

operation, provided it is determined to be suitable to assure the11

fair, reasonable and equitable administration of the pool, and it12

provides for the sharing of pool gains or losses on an equitable13

proportionate basis. The plan of operation shall become14

effective upon approval in writing by the director consistent15

with the date on which the coverage under sections 376.960 to16

376.989 becomes available. If the pool fails to submit a17

suitable plan of operation within one hundred eighty days after18

the appointment of the board of directors, or at any time19

thereafter fails to submit suitable amendments to the plan, the20

director shall, after notice and hearing, adopt and promulgate21

such reasonable rules as are necessary or advisable to effectuate22

the provisions of this section. Such rules shall continue in23

force until modified by the director or superseded by a plan24

submitted by the pool and approved by the director.25

2. In its plan, the board of directors of the pool shall:26

(1) Establish procedures for the handling and accounting of27

assets and moneys of the pool;28


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(2) Select an administering insurer or third-party1

administrator in accordance with section 376.968;2

(3) Establish procedures for filling vacancies on the board3

of directors; and4

(4) Establish procedures for the collection of assessments5

from all members to provide for claims paid under the plan and6

for administrative expenses incurred or estimated to be incurred7

during the period for which the assessment is made. The level of8

payments shall be established by the board pursuant to the9

provisions of se

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