reglab/statecodes huggingface dataset:
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.070 - Inpatient Psychiatric Services for Individuals Under Age Twenty-One

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment provides reimbursement to
				  psychiatric residential treatment providers for days when the participant is
				  temporarily away from the facility.
(1) Pursuant to provisions of section
				208.161,
				RSMo, MO HealthNet coverage will be afforded to eligible individuals under age
				twenty-one (21) for inpatient psychiatric services provided under the following
				conditions:
(A) Under the direction of a
				physician; and
(B) In a psychiatric
				hospital facility or an inpatient psychiatric program in a hospital, either of
				which is accredited by a national organization whose psychiatric hospital
				accrediting program has been approved by Centers for Medicare & Medicaid
				Services (CMS) or is licensed by the hospital licensing authority of Missouri;
				or
(C) In a psychiatric residential
				treatment facility (PRTF) that is operated as a public institution by the
				Missouri Department of Mental Health (DMH) and is exempt from the hospital
				licensing law, that is accredited by the Joint Commission, and is certified as
				complying with the requirements at
				42 CFR
				441 subpart D and the condition of
				participation at 42 CFR
				483 subpart G by the designated state agency
				for which such authority has been authorized; or
(D) In a privately operated PRTF that is
				accredited by the Joint Commission, the Council on Accreditation, the
				Commission on Accreditation of Rehabilitation Facilities, Det Norske Veritas
				(DNV), or equivalent organization, and is certified as complying with the
				requirements at 42 CFR
				441 subpart D and the condition of
				participation at 42 CFR
				483 subpart G by the designated state agency
				for which such authority has been authorized; and
(E) For claimants under the age of twenty-one
				(21) or, if receiving the services immediately before attaining the age of
				twenty-one (21), not to extend beyond the earlier of the date-
1. Services are no longer required;
				or
2. Individual reaches the age of
				twenty-two (22).
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.080 - Payment Method for General Relief Recipient Hospital Outpatient Services

Current through Register Vol. 49, No. 14, July 15, 2024
(Rescinded December 30, 2005)
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.090

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.153, RSMo 1967, amended 1973,
					 1989, 1990, 1991 and 208.201, RSMo 1987.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.150

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.153, RSMo 1967, amended 1973,
					 1989, 1990, 1991; and 208.201, RSMo
					 1987.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.170 - Enhanced Disproportionate Share Payment to Trauma Hospitals for the Cost of Care to the Uninsured Provided by Physicians Not Employed by the Hospital

Current through Register Vol. 49, No. 14, July 15, 2024
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.190 - Out-of-State Hospital Services Reimbursement Plan

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the method of
				  reimbursing out-of-state hospitals for inpatient or outpatient care provided to
				  any recipients of Missouri Medicaid, whether they are under age twenty-one (21)
				  or age twenty-one (21) and over.
(1) Covered inpatient hospital services
				include those items and services allowed by the Medicaid State Plan including
				medically necessary care in a semi-private room. If prior authorized Missouri
				Medicaid may reimburse for a private room if it is certified medically
				necessary by a physician to avoid jeopardizing the health of the patient or to
				protect the health and safety of other patients. No payment will be made for
				any portion of the room charge when the recipient requests and is provided a
				private room when the private room is not medically necessary.
(2) Payment for authorized inpatient hospital
				services shall be made on a prospective per diem basis for services provided
				outside Missouri if the services are covered by the Missouri Medical Assistance
				(Medicaid) Program. To be reimbursed for furnishing services to Missouri
				Medicaid recipients, out-of-state providers must complete a Missouri Medical
				Assistance Program Provider Participation Application and have the application
				approved by the Missouri Department of Social Services, Division of Medical
				Services.
(3) Determination of
				Payment. The payment for inpatient hospital services provided by an
				out-of-state provider shall be the lowest of:
(A) At the out-of-state hospital's election,
				the prospective inpatient payment may be based on information from the
				hospital's Medicare base year cost report and all financial documentation
				required by Missouri regulations for hospitals operating in Missouri with
				inflationary increases as granted by the Missouri General Assembly or the
				out-of-state hospital may be exempt from the cost report filing requirements if
				the hospital accepts the projected statewide average per diem rate for Missouri
				hospitals as calculated by the Department of Social Services, Division of
				Medical Services for the state fiscal year in which the service was provided.
				The effective date for any increase above the statewide average per diem rate
				for Missouri hospitals shall be the first day of the month following the
				Division of Medical Services determination of per diem rate based on
				information from the hospital's Medicare base year cost report and all
				financial documentation required by Missouri regulation for hospitals operating
				in Missouri;
(B) The amount of
				total charges billed by the hospital. The provider's billed charges must be
				their usual and customary charges for services; or
(C) The Medicare deductible or coinsurance,
				if applicable, up to the amount allowed by the Missouri Medicaid
				program.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.200 - Payment Policy for a Preventable Serious Adverse Event or Hospital or Ambulatory Surgical Center-Acquired Condition

Current through Register Vol. 49, No. 14, July 15, 2024
(Rescinded June 30, 2012)
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.230 - Supplemental Upper Payment Limit Methodology

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes a methodology for
				  determining Upper Payment Limit (UPL) payments provided to hospitals beginning
				  July 1, 2011. The regulation also establishes an additional UPL supplemental
				  payment for hospitals with a Low Income and Needy Care Collaboration
				  Agreement.
(1) General
				Principles.
(A) Hospital Upper Payment Limit
				(UPL) payments cannot exceed the Medicare Upper Payment Limit as authorized by
				federal law and included in Missouri's State Plan.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.010

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 207.020, RSMo 1945, amended 1961,
					 1965, 1977, 1981, 1982, 1986.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.030 - Drugs Covered by the MO HealthNet Pharmacy Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The purpose of this amendment is to update
				  the rule to reference the federal guidelines.
PURPOSE: This rule implements recent changes in drug
				  coverage as mandated by the Centers for Medicare & Medicaid Services
				  (CMS).
(1) Drugs covered
				under the MO HealthNet Pharmacy Program must meet the definition of a covered
				outpatient drug as defined in the Social Security Act, section 1927(k)(2) and
				section 1927(k)(3), as amended.
"Such term also does not include any such drug or product for
				  which a National Drug Code number is not required by the Food and Drug
				  Administration or a drug or biological used for a medical indication which is
				  not a medically accepted indication."
(2) Participating Manufacturers- The MO
				HealthNet Division identifies those manufacturers who have entered into a
				rebate agreement according to the Social Security Act, section 1927(a)(1), as
				amended. All products marketed by participating manufacturers are reimbursable,
				with the following exceptions: those products identified as Drug Efficacy Study
				Implementation (DESI) drugs by the federal Food and Drug Administration (FDA);
				products considered by the federal FDA to be similar, identical or related to a
				DESI product; products identified in
				13 CSR
				70-20.031; and products not meeting the definition of
				drug in sections 505, 506, and 507 of the federal Food, Drug and Cosmetic
				Act.
*Original authority: 208.152, RSMo 1967, amended 1969,
					 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993;
					 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991 and 208.201, RSMo
					 1987.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.032

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.153, RSMo 1967, amended 1967,
					 1973, 1989, 1990, 1991, 2007, 2012 and 208.201, RSMo 1987, amended
					 2007.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.033

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.152, RSMo 1967, amended 1969,
					 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993; 208.153, RSMo
					 1967, amended 1967, 1973, 1989, 1991; and 208.201, RSMo
					 1981.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.034

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.152, RSMo 1967, amended 1969,
					 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993,
					 2004, 2005, 2007; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991,
					 2007; and 208.201, RSMo 1987, amended
					 2007.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.040

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.153, RSMo 1967, amended 1973,
					 1989, 1990, 1991 and 208.201, RSMo 1987.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.042 - Automatic Refill Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The purpose of this amendment is to remove
				  all Medication Synchronization Program language and add clarification on
				  automatic refill.
PURPOSE: This rule establishes the regulatory basis
				  to prohibit automatic refill of prescriptions by providers for MO HealthNet
				  participants.
(1) Automatic
				Refill Program.
(A) MO HealthNet does not
				allow automatic refills or automatic shipments of medications, devices, or
				supplies. MO HealthNet does not pay for any prescription without an explicit
				request from a participant or the participant's responsible party, such as a
				caregiver, for each refilling event. Participants and providers cannot waive
				the explicit refill request requirement and enroll in an automatic refill
				program.
(B) This ban on automatic
				refills shall include all MO HealthNet participants, including dual eligible
				participants and participants with other primary insurance.
(C) A nurse or other authorized agent of the
				facility may initiate a request for a refill for a participant residing in a
				skilled nursing facility, group home, or assisted living arrangement.
1. Cycle filling for a participant residing
				in a skilled nursing facility, group home, or assisted living arrangement does
				not constitute an automatic refill program as long as the pharmacy and facility
				staff have a policy and procedure in place to prevent medication that is
				discontinued or otherwise unneeded from being billed to MO HealthNet.
				Cycle-fill medication that does not follow the policy and procedure between the
				pharmacy and facility may be subject to administrative action.
(D) Any prescription filled
				without a request from a participant or the participant's responsible party may
				be subject to recoupment. Any provider who pursues an automatic refill policy
				may be subject to administrative action.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.045 - Thirty-One-Day Supply Maximum Restriction on Pharmacy Services Reimbursed by the MO HealthNet Division

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The purpose of this amendment is to update
				  "recipient" and "patient" to "participant," which is the current standard
				  language. This amendment also adds an additional exemption to the thirty-one-
				  (31-) day restriction to allow for a new ninety- (90-) day supply program
				  identified in proposed rule 13 CSR 70-20.047 Ninety-Day Supply Requirement for
				  Select Medications. The amendment also makes grammatical corrections by adding
				  hyphens to the terms "thirty-one (31) days" or "ninety (90) days" when those
				  terms are used as adjectives.
PURPOSE: This rule establishes a thirty-one- (31-)
				  day supply maximum restriction per dispensing on pharmacy services reimbursed
				  by the MO HealthNet Division on behalf of participants eligible for any of the
				  fee-for-service programs.
(1)
				The maximum days' supply of medication that may be provided per dispensing on
				behalf of a participant eligible for any of the fee-for-service programs is
				thirty-one (31) days, except for those drugs and/or categories under the
				provisions of this rule. Medication may be dispensed in quantities less than a
				thirty-one- (31-) day supply, if so ordered by the prescriber, except as
				specified elsewhere in this rule.
(2) Drugs and/or categories of medications
				that are exempt from the thirty-one- (31-) day supply limitation and therefore
				may be dispensed in quantities exceeding a thirty-one- (31-) day supply are
				made available in the MO HealthNet Pharmacy Manual, section 13.6.D(1). The MO
				HealthNet Pharmacy Manual is incorporated by reference in this rule as
				published by the Department of Social Services, MO HealthNet Division, 615
				Howerton Court, Jefferson City, MO 65109, at its website
				http://manuals.momed.com/manuals/, October 2, 2020. This rule does not
				incorporate any subsequent amendments or additions. The division reserves the
				right to effectuate changes in the list of drugs and/or categories of
				medications that are exempt from the thirty-one- (31-) day supply limitation by
				amending this rule.
(3) All spend
				down participants are exempt from the MO HealthNet thirty-one- (31-) day supply
				maximum restriction on pharmacy services.
(4) Exemptions from the thirty-one- (31-) day
				supply limitation may be given with prior authorization by the MO HealthNet
				Division to prevent a higher level of care.
(5) Drugs and/or categories of medications
				identified by 13 CSR 70-20.047 are exempt from the thirty-one- (31-) day supply
				limitation.
*Original authority: 208.152, RSMo 1967, amended 1969,
					 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993;
					 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; and 208.201, RSMo
					 1987.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.047 - Ninety-Day Supply Requirement for Select Medications

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes a ninety- (90-) day
				  supply requirement per dispensing on select medications reimbursed by the MO
				  HealthNet Division on behalf of participants eligible for any of the
				  fee-for-service programs.
PUBLISHER'S NOTE: The secretary of state has
				  determined that the publication of the entire text of the material which is
				  incorporated by reference as a portion of this rule would be unduly cumbersome
				  or expensive. This material as incorporated by reference in this rule shall be
				  maintained by the agency at its headquarters and shall be made available to the
				  public for inspection and copying at no more than the actual cost of
				  reproduction. This note applies only to the reference material. The entire text
				  of the rule is printed here.
(1) MO HealthNet participating pharmacies
				shall dispense a ninety-(90-) day supply of select medications to a participant
				eligible for any of the fee-for-service programs. Drugs and/or categories of
				medications that are subject to this ninety- (90-) day supply requirement are
				identified in the 90-Day Supply Medication List, which is incorporated by
				reference and made part of this rule as published by the Department of Social
				Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109,
				at its website at https://dss.mo.gov/mhd/cs/pharmacy/pages/frequpdat.htm,
				October 22, 2020. This rule does not incorporate any subsequent amendments or
				additions.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.050 - Return of Drugs

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes that pharmacies must
				  give the MO HealthNet Division credit for any unused portion of the drug that
				  is reusable in accordance with applicable federal or state law.
(1) The return and reuse of drugs must
				follow guidelines set by the State Board of Pharmacy in
				20 CSR
				2220-3.040, as amended.
(2) The pharmacy must give the MO HealthNet Division
				credit for all reusable items (any unused portion) not taken by the MO
				HealthNet participant. In instances in which charges have been submitted prior
				to the return of an item, the pharmacy shall file an adjustment prorated to the
				quantity of the drug used by the MO HealthNet participant.
*Original authority: 208.201, RSMo 1987, amended
					 2007.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.060 - Professional Dispensing Fee

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The purpose of this amendment is to update
				  the amount of the professional dispensing fee reimbursable for the dispensing
				  of MO HealthNet covered prescriptions by a pharmacy provider in line with the
				  most recent cost of dispensing survey.
PURPOSE: The MO HealthNet Division establishes the
				  amount of the fee reimbursable for the professional dispensing of each MO
				  HealthNet covered prescription by a pharmacy provider.
(1) Between April 1, 2017 and January 31,
				2021, a professional dispensing fee shall be added to the MO HealthNet maximum
				allowable payment for MO HealthNet reimbursable prescriptions filled or
				refilled by a pharmacy provider as follows:
(A) Out-of-state pharmacy providers receive a
				professional dispensing fee of nine dollars fifty-five cents ($9.55);
(B) In-state pharmacy providers receive a
				professional dispensing fee of fourteen dollars thirty-seven cents
				($14.37);
(C) In-state pharmacy
				providers receive a preferred generic product incentive fee of five dollars
				zero cents ($5.00); and
(D) The
				professional dispensing fees as provided in this rule shall not be included in
				the computation of the MO HealthNet maximum allowable drug payment for
				participant cost-sharing purposes.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.070 - Drug Reimbursement Methodology

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the basis and the
				  method for pricing all drug claims in Missouri under the Title XIX Medicaid
				  pro- gram. The purchase of a computer-generated tape, with weekly updates, will
				  make it possi- ble to utilize the computer for review purpos- es, which greatly
				  increases the speed with which claims can be paid.
(1) The MO HealthNet Division will obtain, by
				contract with a rep- utable medical publishing company, a weekly
				computer-generated tape which will provide the information needed to price all
				fee-for- service Medicaid drug claims. The tape will contain National Drug Code
				(NDC), drug name, drug strength, dosage form, pac kage size, the prices set by
				direct-selling manufacturers (direct prices), Wholesaler Acquisition Cost
				(WAC), federal Health and Human Services upper limits for specified multiple
				source drugs (FUL), and National Ave rage Drug Acquisition Cost (NADAC). A
				multiple source drug is defined as a drug marketed or sold by two (2) or more
				manufacturers or labelers, or a drug marketed or sold by the same manufacturer
				or labeler under two (2) or more different proprietary names or both under a
				proprietary name and without that name.
(2) The MO HealthNet Division will add the
				Missouri Maximum Allowable Cost (MMAC) limits, for multiple source drugs as
				defined, to the data shown on the tape described in section (1) of this rule.
(3) Effective December 16, 2018,
				reimbursement for covered drugs will be determined by applying the following
				hierarchy method:
(A) National Average Drug
				Acquisition Cost (NADAC); if there is no NADAC;
(B) Missouri Maximum Allowed Cost (MAC); if
				no NADAC or MAC;
(C) Wholesale
				Acquisition Cost (WAC); or
(D) The
				usual and customary (U&C) charge submitted by the provider if it is lower
				than the chosen price (NADAC, MAC, or WAC).
1.
				 U&C is defined as the provider's charge to the general public
				that reflects all discounts or programs such as, but not limited to, dis- count
				programs, membership programs, price matching programs, or any other program
				offered by the provider to initiate a reduced price for product costs available
				to the general public, a special population, or an inclusive category of
				customers, on the date of service
2.
				 General public is defined as those patients that pay for their
				prescriptions and the prescription is not processed by a third-party which
				includes both governmental and non-governmental payers.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.071

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.153, RSMo 1967, amended 1973,
					 1989, 1990, 1991, 2007, 2012 and 208.201, RSMo 1987, amended
					 2007.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.075 - 340B Drug Pricing Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the payment
				  methodology for 340B covered entities as defined in section 1927(a)(5)(B) of
				  the Social Security Act that choose to carve-in Medicaid.
(1) 340B-covered entities that choose to
				carve-in Medicaid must pro- vide the Health Resources and Services
				Administration (HRSA) with their National Provider Identification (NPI) and
				their MO HealthNet Division (MHD) provider number for each site that carves in
				for inclusion in the HRSA Medicaid Exclusion File. The MHD requires the MO
				HealthNet provider number to be included on the Medicaid Exclusion File to
				identify providers that carve-in Medicaid and to prevent duplicate
				discounts.
(2) 340B covered
				entities are required to identify 340B purchased drugs at the claims level
				using the following codes:
(A) Point-of-sale
				pharmacy claims: Submission Clarification Code (SCC) 20; and
(B) Medical and outpatient claims: Modifier
				JG or TB.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.100 - Missouri Nonsteroidal Anti-Inflammatory Drug List

Current through Register Vol. 49, No. 14, July 15, 2024
(Rescinded September 30, 1991)
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.110 - Medicaid Program Coverage of Approved Drugs for Treatment of Acquired Immunodeficiency Syndrome (AIDS)

Current through Register Vol. 49, No. 14, July 15, 2024
(Rescinded September 30, 1991)
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.120 - Medicaid Program Coverage of Anti-Ulcer Preparations

Current through Register Vol. 49, No. 14, July 15, 2024
(Rescinded June 29, 1989)
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.200 - Drug Prior Authorization Process

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The purpose of this amendment is to
				  incorporate the functions of the Drug Prior Authorization Committee into the
				  Drug Utilization Review Board and to dissolve the Drug Prior Authorization
				  Committee.
(1) The following
				definitions shall be used in the interpretation and enforcement of this rule:
(A) "Clinical editing" shall be defined as
				that process which screens the use of specific medications on the basis of
				clinical appropriateness by requiring evidence of appropriate indications for
				use, and to achieve a cost savings, may require the initial use of less
				expensive agents ;
(B) "Fiscal
				editing" shall be defined as a process that screens the use of specific
				medications to reimburse based on the least expensive dosage forms in order to
				achieve a cost savings ;
(C) "Open
				access" shall be defined as the availability of a product without being
				subjected to prior authorization, clinical edits, or step therapy but shall not
				preclude fiscal and utilization edits ;
(D) "Preferred Drug List" shall be defined as
				a list of medications within a functional therapeutic class that are available
				via open access on the basis of supplemental rebate status and consideration of
				available evidence-based clinical review findings ;
(E) "Step therapy" shall be defined as a
				process that specifies the sequence in which different prescription drugs are
				to be reimbursed ; and
(F)
				"Utilization edits" are defined as prospective screening edits used to review
				the appropriate use of medication and may be advisory or preemptory.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.310 - Prospective Drug Use Review Process and Patient Counseling

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment adds more specific
				  incorporation by reference language and updates the rule to remove
				  duplication.
(1) Prospective
				Drug Use Review (DUR). This rule establishes a MO HealthNet prospective drug
				use review process within the Department of Social Services, MO HealthNet
				Division, as specified in section
				208.176,
				RSMo.
(2) Electronic Point-of-Sale
				Review. The MO HealthNet Division shall provide for electronic point-of-sale
				review before each prescription is dispensed to a MO HealthNet participant or
				MO HealthNet participant's caregiver on the date of service. The Missouri Drug
				Use Review Board will review and approve clinical modules, as outlined in
				42 CFR
				456.705, Prospective Drug Review as published
				on October 1, 2018 by the Office of the Federal Register National Archives and
				Records Administration, US Government Publishing Office US Superintendent of
				Documents, Washington, DC 20402 and is incorporated by reference and made a
				part of this rule, as published by the Department of Social Services, MO
				HealthNet Division, 615 Howerton Ct, Jefferson City, MO 65109, at its website
				at
https://dssruletracker.mo.gov/dss-proposed-rules/welcome.action
. This rule does not incorporate any subsequent amendments or additions. The MO
				HealthNet Division will provide electronic point-of-sale screening for
				potential drug therapy problems using the approved clinical modules on the date
				of service.
(3) Electronic
				Point-of-Sale Review Available for MO HealthNet Beneficiaries. The following
				reviews will be provided by the pharmacy point of service system:
(A) Drug Disease Contraindications.
1. Drug (actual) disease
				precaution.
2. Inferred Drug
				Disease precaution;
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.320 - Pharmacy Reimbursement Allowance

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates the tax rates for the
				  Pharmacy Reimbursement Allowance (PRA).
(1) Pharmacy Reimbursement Allowance (PRA).
				PRA shall be assessed as described in this section.
(A) Definitions.
1. Department-Department of Social
				Services.
2. Director-Director of
				Department of Social Services.
3.
				Division-MO HealthNet Division.
4.
				Gross retail prescription receipts- For ease of administration for the
				department as well as the industry, this shall be an annual amount. The basis
				of tax in any fiscal year will be the gross prescription sales of the last
				calendar year prior to the previous fiscal year.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.340 - National Drug Code Requirement

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The purpose of this amendment is to remove
				  duplicative information that is housed in the Pharmacy Provider Manual and to
				  simplify language for providers.
PURPOSE: This rule implements the National Drug Code
				  (NDC) requirement for all medications administered in the clinic or outpatient
				  hospital setting. The Deficit Reduction Act of 2005 (DRA) requires states to
				  collect rebates for certain physician-administered drugs.
(1) Drug charges submitted by providers on an
				electronic Professional or Institutional ASC X12 837 Health Care claim
				transaction or manually entered on a medical or outpatient claim into the MO
				HealthNet Division's (MHD) billing website eMOMED (
www.emomed.com
) must be billed with a valid
				Healthcare Common Procedure Coding System (HCPCS) procedure code and a valid
				NDC for all medications administered to MHD participants in the clinic or
				outpatient hospital setting. MHD must collect the eleven- (11-) digit NDC on
				all outpatient drug claims submitted to MHD from all providers for rebate
				purposes to receive federal financial participation. Providers can find the NDC
				on the medication's packaging, and must submit the NDC in the five (5) digit -
				four (4) digit - two (2) digit format. If the NDC does not appear in the five
				(5) digit - four (4) digit - two (2) digit format on the packaging, zero(s) (0)
				may be entered in front of the section that does not have the required number
				of digits. The MHD denies medical or outpatient claim lines submitted with a
				HCPCS procedure code without the corresponding NDC. For medical or outpatient
				claims correctly submitted with the appropriate HCPCS procedure code and the
				corresponding NDC, the system automatically generates a separate drug claim for
				the NDC to process as a pharmacy claim. It will appear as a separate claim on
				your Remittance Advice. The MHD will drop the corresponding line with the HCPCS
				procedure code and NDC from the medical or outpatient claim. If an NDC is not
				provided, the HCPCS procedure code will remain on the claim to report the
				denied line. All claims must be billed with the proper NDC quantities, not the
				HCPCS quantities. For drugs without a valid HCPCS procedure code, revenue code
				0250, "General Classification: Pharmacy," must be used with the appropriate
				NDC. Only drugs and items used during outpatient care in the hospital are
				covered. MHD does not cover take-home medications and supplies under the
				Hospital Program.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 25 - Physician Program › Section 13 CSR 70-25.100 - Abortions

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule complies with Federal Law and
				  rules relating to abortions and maintains compliance with the requirements of
				  the Title XIX program which provides funding for needy persons in the
				  state.
(1) No funds
				appropriated for the payment of medical claims shall be used to perform
				abortions except where the life of the mother would be endangered if the fetus
				were carried to term and a physician has found and certified in writing to the
				Medical Services Division that, on the basis of his/her professional judgment,
				the mother's life would be endangered if the fetus were carried to term. The
				certification shall set out the name, address and medical assistance number of
				the patient.
*Original authority: 207.020, RSMo 1945, amended 1961,
					 1965, 1977, 1981, 1982 and 1986.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 25 - Physician Program › Section 13 CSR 70-25.130 - Diabetes Prevention Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: The purpose of this rule is to establish the
				  Department of Social Services' MO HealthNet Division guidelines regarding
				  coverage and reimbursement for Diabetes Prevention Program services. The goal
				  of this policy is to improve health outcomes for the adult population at risk
				  for developing diabetes by managing obesity and associated
				  co-morbidities.
PUBLISHER'S NOTE: The secretary of state has
				  determined that the publication of the entire text of the material which is
				  incorporated by reference as a portion of this rule would be unduly cumbersome
				  or expensive. This material as incorporated by reference in this rule shall be
				  maintained by the agency at its headquarters and shall be made available to the
				  public for inspection and copying at no more than the actual cost of
				  reproduction. This note applies only to the reference material. The entire text
				  of the rule is printed here.
(1) Administration. The Diabetes Prevention
				Program (DPP) shall be administered by the MO HealthNet Division. The diabetes
				prevention program services covered and not covered, the limitations under
				which services are covered, and the maximum allowable fees for all covered
				services shall be determined by the MO HealthNet Division and shall be included
				in the MO HealthNet Physician Provider Manual, which is incorporated by
				reference and made part of this rule as published by the Department of Social
				Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109,
				at its website
http://manuals.momed.com/manuals/
,
				December 27, 2019. This rule does not incorporate any subsequent amendments or
				additions. Diabetes Prevention Program services covered by the MO HealthNet
				program shall include only those which are clearly shown to be medically
				necessary.
(A) In the administration of the
				rule, "Diabetes Prevention Program" or "DPP" means a structured, lifestyle
				change program specifically developed and recognized by the Centers for Disease
				Control and Prevention (CDC) to prevent type 2 diabetes. The program is
				intended for people who have prediabetes or are at risk for type 2 diabetes,
				but who do not already have diabetes, to promote lifestyle changes that
				decrease the progression to type 2 diabetes. The program services include group
				support and lifestyle changes such as eating healthier foods, reducing stress,
				and increasing physical activity.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 25 - Physician Program › Section 13 CSR 70-25.140 - Biopsychosocial Treatment of Obesity for Youth and Adults

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the MO HealthNet
				  payment policy for the biopsychosocial treatment of obesity for youth and adult
				  participants. The goal of this policy is to improve health outcomes for both
				  the youth and adult population by managing obesity and associated
				  co-morbidities.
PUBLISHER'S NOTE: The secretary of state has
				  determined that the publication of the entire text of the material which is
				  incorporated by reference as a portion of this rule would be unduly cumbersome
				  or expensive. This material as incorporated by reference in this rule shall be
				  maintained by the agency at its headquarters and shall be made available to the
				  public for inspection and copying at no more than the actual cost of
				  reproduction. This note applies only to the reference material. The entire text
				  of the rule is printed here.
(1) Administration. The MO HealthNet
				Division, Department of Social Services, shall administer Biopsychosocial
				Treatment of Obesity for Youth and Adult participants. Biopsychosocial
				treatment of obesity services covered and not covered, the limitations under
				which services are covered, and the maximum allowable fees for all covered
				services shall be determined by the MO HealthNet Division and shall be included
				in the MO HealthNet Physician Provider Manual and Behavioral Health Services
				Manual, which are incorporated by reference and made part of this rule as
				published by the Department of Social Services, MO HealthNet Division, 615
				Howerton Court, Jefferson City, MO 65109, at its website at,
http://manuals.momed.com/manuals
,
				December 27, 2019. This rule does not incorporate any subsequent amendments or
				additions. Biopsychosocial treatment of obesity services covered by the MO
				HealthNet program shall include only those which are shown to be medically
				necessary.
(A) In the administration of the
				rule, the following definitions are used:
1.
				"Biopsychosocial Treatment of Obesity" means using a combination of obesity
				screenings, Medical Nutrition Therapy (MNT), and Intensive Behavioral Therapy
				(IBT) to promote life style changes leading to weight loss in adult and youth
				participants.
A. "Adult Intensive Behavioral
				Therapy (IBT)" means obesity management by utilizing intensive multicomponent,
				behavior-based weight loss interventions that promote and sustain weight loss
				in adult participants.
B. "Youth
				Intensive Behavioral Therapy (IBT)" means obesity management by utilizing
				comprehensive, intensive behavior-based weight loss interventions that can
				include multi-component family-based behavioral treatment (FBT) interventions
				tailored to participant needs targeting both the parent/guardian and the
				youth;
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 25 - Physician Program › Section 13 CSR 70-25.150 - Payment Policy for Asthma Education and In-Home Environmental Assessments

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the MO HealthNet
				  payment policy for Asthma Education and In-Home Environmental Assessments to
				  improve the health of MO HealthNet's youth participants that have uncontrolled
				  asthma.
PUBLISHER'S NOTE: The secretary of state has
				  determined that the publication of the entire text of the material which is
				  incorporated by reference as a portion of this rule would be unduly cumbersome
				  or expensive. This material as incorporated by reference in this rule shall be
				  maintained by the agency at its headquarters and shall be made available to the
				  public for inspection and copying at no more than the actual cost of
				  reproduction. This note applies only to the reference material. The entire text
				  of the rule is printed here.
(1) Administration. Asthma Education and
				In-Home Environmental Assessment services shall be administered by the MO
				HealthNet Division. Asthma education and in-home environmental assessments
				services covered and not covered, the limitations under which services are
				covered, and the maximum allowable fees for all covered services shall be
				determined by the MO HealthNet Division and shall be included in the MO
				HealthNet Physician Provider Manual, which is incorporated by reference and
				made part of this rule as published by the Department of Social Services, MO
				HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its
				website at http://manuals.momed.com/manuals/, May 14, 2021. This rule does not
				incorporate any subsequent amendments or additions. Asthma Education and
				In-Home Environmental Assessment services covered by the MO HealthNet program
				shall include only those which are clearly shown to be medically necessary.
(A) The following definition(s) will be used
				in administering this rule:
1. "Asthma
				Education" means direct training of the patient and family by qualified asthma
				education provider in areas including, but not limited to, avoiding triggers,
				medication compliance, proper use of inhalers, and use of durable medical
				equipment;
2. "In-Home
				Environmental Assessment" means thorough and detailed analysis of the home
				environment by a qualified environmental assessment provider evaluating for
				asthma triggers including, but not limited to, rodent excrement, mites, animal
				dander, insects, dust, mold with recommendations for remedial actions.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 30 - Podiatry Program › Section 13 CSR 70-30.010 - Podiatric Services Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment makes current the rule's
				  incorporation by reference.
(1) Persons Eligible for Podiatric Services.
				Any person who is eligible for Title XIX benefits from the Family Support
				Division and who is found to be in need of podiatric services in accordance
				with the procedures described in this rule.
(2) Payment will be made for services by
				podiatrists who have an agreement with the MO HealthNet Division to the extent
				that those services are covered under the guidelines established by the MO
				HealthNet Division through-
(A) MO HealthNet
				provider manuals, which are incorporated by reference and made a part of this
				rule as published by the Department of Social Services, MO HealthNet Division,
				615 Howerton Court, Jefferson City, MO 65109, at its website at
				http://manuals.momed.com/manuals/, September 27, 2018; or
(B) Provider Bulletins, which are
				incorporated by reference and made a part of this rule as published by the
				Department of Social Services, MO HealthNet Division, 615 Howerton Court,
				Jefferson City, MO 65109, at its website at
				https://dss.mo.gov/mhd/providers/pages/bulletins.htm, September 27, 2018. This
				rule does not incorporate any subsequent amendments or
				additions.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 50 - Hospice Services Program › Section 13 CSR 70-50.010 - Hospice Services Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This proposed amendment updates the
				  publication information of the MO HealthNet Hospice Manual, and increases the
				  document retention period to six (6) years.
PURPOSE: This rule establishes the MO HealthNet
				  payment policy for the Hospice Program. The goal of the Hospice Program is to
				  meet the needs of participants with life-limiting illnesses and to help their
				  families cope with related problems. Hospice care is an approach to treatment
				  that recognizes that the impending death of an individual warrants a change in
				  focus from curative care to palliative care.
(1) Administration. The Hospice Program shall
				be administered by the Department of Social Services, MO HealthNet Division.
				The medical services covered and not covered, the program limitations under
				which services are covered, and the maximum allowable fees for all covered
				services shall be determined by the MO HealthNet Division and shall be included
				in the MO HealthNet Hospice Provider Manual, which is incorporated by reference
				and made part of this rule as published by the Department of Social Services,
				MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its
				website at
http://manu-als.momed.com/collections/collection_hos/print.pdf
,
				November 25, 2020. This rule does not incorporate any subsequent amendments or
				additions. Hospice services covered by the MO HealthNet program shall include
				only those that are clearly shown to be medically necessary. The division
				reserves the right to affect changes in services, limitations, and fees with
				proper notification to MO HealthNet hospice providers.
(2) Persons Eligible. Participants eligible
				for medical assistance benefits from the Department of Social Services are
				certified by a physician to be terminally ill with a medical prognosis of life
				expectancy of six (6) months or less if the illness runs its normal course and
				who elects hospice benefits is eligible. The individual must agree to seek only
				palliative care for the duration of the hospice enrollment with the following
				exception:
(A) Hospice services for a child
				under twenty-one (21) years of age may be concurrent with the care related to
				curative treatment of the condition for which a diagnosis of a terminal illness
				has been made.