reglab/statecodes huggingface dataset:
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.100 - Filing of Claims, MO HealthNet Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment changes the claim form
				  requirements for providers filing Pharmacy Claims, Professional Services
				  Claims, and Dental Claims.
(1) Claim forms used for filing MO HealthNet
				services as appropriate to the provider of services are-
(A) Nursing Home Claim-electronic claim
				submission or individualized provider software when authorized by the state's
				fiscal agent;
(B) Pharmacy
				Claim-Point-of-Service (POS), on-line claim format-National Council for
				Prescription Drug Programs (NCPDP) current version, or electronic claim
				submission;
(C) Outpatient Hospital
				Claim-UB-04 CMS-1450 or electronic claim submission;
(D) Professional Services Claim- CMS-1500
				form (02-12) version or electronic claim submission;
(E) Dental Claim-American Dental Association
				(ADA) 2019 revision, Dental Form, or electronic claim submission; or
(F) Inpatient Hospital Claim-UB-04 CMS-1450
				or electronic claim submission.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.110 - Second Opinion Requirement Before Nonemergency Elective Surgical Operations

Current through Register Vol. 49, No. 14, July 15, 2024
(Rescinded June 30, 2011)
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.130

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.153, RSMo 1967, amended 1967,
					 1973, 1989, 1990, 1991, 2007; 208.165, RSMo 1982; and 208.201, RSMo 1987,
					 amended 2007.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.140 - Direct Deposit of Provider Reimbursement

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This proposed amendment reflects changes
				  whereby the Missouri Medicaid Audit and Compliance Unit (MMAC) processes
				  provider direct deposit applications and updates instead of a MO HealthNet
				  Division unit.
PURPOSE: This rule requires the direct deposit of MO
				  HealthNet provider payments and describes the procedure by which those payments
				  will be made.
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) Enrolled providers must have their MO
				HealthNet payments automatically deposited into an authorized bank
				account.
(2) Unless otherwise
				agreed upon by the Department of Social Services, MO HealthNet providers must
				complete the Electronic Funds Transfer (EFT) Authorization Agreement, which is
				incorporated by reference and made a part of this rule as published by the
				Missouri Medicaid Audit and Compliance Unit (MMAC), 205 Jefferson Street, 2nd
				Floor, Jefferson City, MO 65102, and available on the MMAC website at
				https://mmac.mo.gov/providers/provider-enrollment/new-providers/provider-enrollment-forms/,
				August 27, 2021. This rule does not incorporate any subsequent amendments or
				additions.
(A) The completed application
				authorizes the Office of Administration to deposit MO HealthNet payments into
				an authorized checking or savings account.
(B) A provider's account may only be debited
				when an error has occurred resulting in an erroneous payment to the
				provider.
(C) Direct deposit will
				begin following:
1. Submission of a properly
				completed application form to the Department of Social Services, MO HealthNet
				Division;
2. Successful processing
				of a test transaction through the banking system; and
3. Authorization to make payment using the
				direct deposit option by the MO Health-Net Division.
(D) The state will conduct direct deposit
				through the automated clearing house system, utilizing an originating
				depository financial institution. The rules of the National Automated Clearing
				House Association and its member local Automated Clearing House Associations
				shall apply, as limited or modified by law.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.150 - Authorization To Receive Payment for Medicaid Services

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes who may receive
				  payment for services furnished to a recipient of medical assistance by a
				  provider who is subject to either the Federal Reimbursement Allowance (FRA) or
				  the Nursing Facility Reimbursement Allowance (NFRA). This rule is necessary to
				  comply with the terms and conditions required by the Health Care Financing
				  Administration for approval of Missouri's 111 5 Demonstration
				  Waiver.
(1) Authorization To
				Receive Payment. Payment for any services covered by the Missouri Medicaid
				program to a recipient eligible for medical assistance by an enrolled Medicaid
				provider who is subject to either the Federal Reimbursement Allowance (FRA) or
				the Nursing Facility Reimbursement Allowance (NFRA) shall be-
(A) By direct deposit to the provider's
				account at a bank or other financial institution;
(B) To a person or entity affiliated with the
				enrolled provider; or
(C) To a
				business agent, or to a government agency or a recipient specified by a court
				order, as permitted under federal regulations at 42
Code of Federal
				Regulations
section 447.10(e) and (f).
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.160 - Electronic Submission of MO HealthNet Claims and Electronic Remittance Advices

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule implements the requirement that
				  claims for reimbursement by the MO HealthNet program be submitted
				  electronically and remittance advices be retrieved
				  electronically.
(1)
				"Electronic claim" means a claim that is submitted via electronic
				media.
(2) Electronic submission of
				MO HealthNet claims for services rendered under the MO HealthNet program is
				required. A MO HealthNet claim may be paid only if submitted as an electronic
				claim for processing by the Medicaid Management Information System.
(A) To utilize the Internet for electronic
				claim submissions, the provider must apply online via the Application for MO
				HealthNet Internet Access Account link.
(B) Each user is required to complete this
				online application to obtain a user ID and password.
(C) The enrolled MO HealthNet provider shall
				be solely responsible for the accuracy and authenticity of said electronic
				media claims submitted, whether submitted directly or by an agent.
(D) The enrolled MO HealthNet provider shall
				agree that services described on the electronic media claim are true, accurate,
				and complete.
(E) The enrolled MO
				HealthNet provider certifies that services described on the electronic media
				claim are personally rendered by the provider.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.170

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.201, RSMo 1987, amended 2007;
					 208.431, RSMo 2005; and 208.435, RSMo
					 2005.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.190

Current through Register Vol. 49, No. 14, July 15, 2024
*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 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.200 - Ambulance Service Reimbursement Allowance

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment changes the tax base from
				  gross receipts to emergency transport mileage.
(1) Ambulance service reimbursement allowance
				shall be assessed as described in this section.
(A) Definitions.
1. Ambulance. Ambulance shall have the same
				meaning as such term is defined in section
				190.100, RSMo.
2. Department. Department of Social
				Services.
3. Director. Director of
				the Department of Social Services.
4. Division. MO HealthNet Division.
5. Emergency Transport Mileage. Emergency
				ambulance mileage from Medicare, Medicaid, insurance, and private payments
				received by an ambulance service licensed under section
				190.109, RSMo (or by its
				predecessor in interest following a change of ownership). Mileage from CPT Code
				A0427/A0425 ambulance service, advanced life support, emergency transport,
				level 1 (ALS1-emergency); CPT Code A0429/A0425 ambulance services, basic life
				support, emergency transport (BLS-emergency); and CPT Code A0433/A0425 advanced
				life support, level 2 (ALS2).
6.
				Engaging in the business of providing ambulance services. Accepting payment for
				ambulance services as such term is defined in section
				190.100, RSMo.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.210 - Electronic Retention of Records

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule advises MO HealthNet providers of
				  the opportunity to store records on an electronic medium to save resources when
				  storing records.
(1) Records
				required to be maintained by the Department of Social Services may be
				maintained in an electronic medium. Records means any books, papers, journals,
				charts, treatment histories, medical histories, tests and laboratory results,
				photographs, X rays, and any other recordings of data or information made by or
				caused to be made by a provider relating in any way to services provided to MO
				HealthNet participants and payments charged or received.
(2) Upon transfer of an original paper record
				to an electronic medium, the enrolled provider may destroy the original paper
				record after assuring that all information contained in the original record,
				including signatures, handwritten notations, or pictures, is contained in the
				durable medium.
(3) If the provider
				does not retain the original paper record, or if there was no original paper
				record, a duplicate or back-up system sufficient to permit reconstruction of
				the electronic records shall be established at a separate location.
(4) Nothing in this regulation shall be
				construed as requiring the utilization of any particular method of record
				retention by an enrolled provider. Records may be retained in any form that can
				be made available for review at the same site at which the service was provided
				or at the provider's address of record with the Department of Social Services.
				Copies of records must be provided upon request of the Department of Social
				Services, Department of Health and Senior Services, and/or Department of Mental
				Health or its authorized agents, regardless of the media in which they are
				kept. Failure to make these records available at the same site at which the
				services were rendered or at the provider's address of record with the
				Department of Social Services, or failure to provide copies when and as
				requested, or failure to keep and make available records which document the
				services and payments as required in
				13
				CSR 70-3.030 shall constitute a violation of this
				section and shall be a reason for sanction.
*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 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.230 - Payment Policy for Provider Preventable Conditions

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates the list of Medicare
				  Hospital Acquired Conditions which are incorporated by
				  reference.
(1) Definitions.
(A) "Provider Preventable Conditions (PPC) "
				is an umbrella term for hospital and non-hospital acquired conditions
				identified by the state for nonpayment to ensure the high quality of Medicaid
				services. PPCs include two (2) distinct categories, Health Care-Acquired
				Conditions (HCAC) and Other Provider-Preventable Conditions (OPPC).
(B) "Health Care-Acquired Conditions (HCAC)"
				means conditions that occurred during a Medicaid inpatient hospital stay. HCACs
				are set forth in the most current list of Medicare Hospital Acquired
				Conditions, with the exception of Deep Vein Thrombosis/Pulmonary Embolism
				following total knee replacement or hip replacement in pediatric and obstetric
				patients, as the minimum requirements for states' PPC nonpayment
				program.
(C) "Other
				Provider-Preventable Conditions (OPPC)" means conditions occurring in any
				health care setting that include, at a minimum, wrong surgical or other
				invasive procedure performed on a patient; surgical or other invasive procedure
				performed on the wrong body part; surgical or other invasive procedure
				performed on the wrong patient pursuant to
				42 CFR
				447.26(b).
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.250 - Payment Policy for Early Elective Delivery

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the MO HealthNet payment
				  policy for early elective delivery provided in any setting. The goal of this
				  payment policy is to improve health outcomes for both the mother and
				  child.
(1) The following definition(s)
				will be used in administering this rule:
(A)
				Early Elective Delivery-a delivery by induction of labor without medical
				necessity followed by vaginal or Caesarean section delivery or a delivery by
				Cesarean section before thirty-nine (39) weeks gestation without medical
				necessity.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability › Section 13 CSR 70-3.280 - Home and Community-Based Services Waiver Definitions

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule defines terms used in 13 CSR
				  70-3.290, which implements federal regulatory requirements promulgated by the
				  United States Department of Health and Human Services, Centers for Medicare and
				  Medicaid Services at
				  42 CFR
				  441.301(c)(4). These
				  requirements must be met for settings in which home and community-based
				  services are provided under a 1915(c) HCBS Waiver Program.
(1) "Enroll/Enrollment" is the process that
				Missouri Medicaid Audit and Compliance (MMAC) uses to establish eligibility to
				receive a Medicaid billing number and/or Medicaid billing privileges. The
				process includes-
(A) Identification of a
				provider;
(B) Validation of the
				provider's eligibility to provide items or services to Medicaid
				beneficiaries;
(C) Identification
				and confirmation of the provider's practice location(s) and owner(s);
				and
(D) Granting the provider
				Medicaid billing privileges and/or a Medicaid billing number.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.050

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.152, RSMo 1967, amended 1969,
					 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004
					 and 208.201, RSMo 1987.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.051

Current through Register Vol. 49, No. 14, July 15, 2024
*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 1967, 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 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.060 - Required Reporting of Injuries Received by MO HealthNet Participants

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment replaces outdated language
				  throughout the regulation.
PURPOSE: Section 208.215.16, RSMo requires
				  participants receiving benefits as defined in Chapter 208, RSMo report injuries
				  to the Family Support Division or MO HealthNet Division.
(1) All participants receiving benefits
				provided for in Chapter 208, RSMo, within thirty (30) days of the date of
				benefit receipt, shall provide the Family Support Division or MO HealthNet
				Division with detailed information concerning any occurrences, other than an
				illness, routine medical service, or other medical treatment not related to a
				casualty, where medical treatment is given as a result of a casualty.
(2) "Casualty" as used in this regulation
				means an accident, event due to sudden unusual occurrence, misfortune, or
				mishap.
(3) "Participant" is
				defined as any person for whom medical benefits are provided for in Chapter
				208, RSMo.
(4) Failure to supply
				the information to the MO HealthNet Division within thirty (30) days of the
				occurrence, as determined by the Family Support Division, may be held as
				constituting participant failure to cooperate and result in loss of
				benefits.
(5) Loss of benefits
				resulting from a determination of a participant's failure to cooperate in
				accordance with the provisions of this rule shall not penalize nor deny
				reimbursement to a MO HealthNet provider who provided covered services to a
				participant presenting valid evidence of MO HealthNet eligibility as of the
				date service is provided, where the provider has advised the Family Support
				Division that the covered services rendered may have resulted from
				circumstances defined in this rule by completing the accident portion of the
				claim form or other written notice.
*Original authority: 207.020, RSMo 1945, amended 1961,
					 1965, 1977, 1981, 1982, 1986; 208.153, RSMo 1967, amended 1967, 1973, 1989,
					 1990, 1991; and 208.159, RSMo 1979.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.070

Current through Register Vol. 49, No. 14, July 15, 2024
*Original authority: 208.201, RSMo
					 1987.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.080 - State Children's Health Insurance Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes components of the
				  State Children's Health Insurance Program which will provide health care
				  coverage to uninsured, low income children pursuant to Senate Bill 632 enacted
				  by the 89th General Assembly, 1998 and reauthorized by Senate Bill 577 enacted
				  by the 94th General Assembly, 2007.
(1) Definitions.
(A) Children. Persons up to nineteen (19)
				years of age.
(B) Health insurance.
				Any hospital and medical expense incurred policy, nonprofit health care service
				for benefits other than through an insurer, nonprofit health care service plan
				contract, health maintenance organization subscriber contract, preferred
				provider arrangement or contract, or any other similar contract or agreement
				for the provision of health care benefits. The term "health insurance" does not
				include short-term, accident, fixed indemnity, limited benefit or credit
				insurance, coverage issued as a supplement to liability insurance, insurance
				arising out of a workers' compensation or similar law, automobile
				medical-payment insurance, or insurance under which benefits are payable with
				or without regard to fault and which is statutorily required to be contained in
				any liability insurance policy or equivalent self-insurance.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.100 - Preventing Medicaid Payment of Expenses Used to Meet Spenddown

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates a legal reference in
				  section (1) and outdated terminology throughout the rule. The amendment will
				  change the term "Division of Medical Services" to the "MO HealthNet Division"
				  and "recipients" to "participants."
(1) Aged persons (over sixty-five (65)
				years), blind persons, or people with disabilities with income above limits
				established under section 208.151.1(24), RSMo, for old age assistance benefits,
				permanent and total disability benefits, or aid to the blind benefits, as
				amended, are allowed to deduct from income incurred medical expenses (that is,
				spenddown) to become eligible.
(2)
				Spenddown eligibility shall be calculated on a monthly basis.
(3) The MO HealthNet program (Medicaid) will
				only reimburse enrolled Medicaid providers for covered medical expenses that
				exceed a recipient's spenddown amount. Medicaid does not pay the portion of a
				claim used to meet the applicant's spenddown obligation. For example, for the
				first day of coverage, the MO HealthNet Division denies or splits (partially
				pays) a claim or claims until the applicant's spenddown liability is reduced to
				zero (0).
(4) After the MO
				HealthNet Division has reduced the participant's liability to zero (0) for the
				first day of coverage, other claims submitted for that day of spenddown
				coverage and claims for the time remaining in the month are paid up to the
				Medicaid rate.
(5) Participants
				shall have the option to pay their monthly spenddown requirement to the MO
				HealthNet Division, much like a premium payment, in order to have continuous
				Medicaid coverage. Participants may also arrange to make the monthly spenddown
				payment through electronic funds transfer (EFT) from a bank account.
*Original authority 208.151, RSMo 1967, amended 1973, 1981,
					 1982, 1987, 1988, 1989, 1990, 1991, 1993, 1995, 2001; 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 5 - Nonemergency Medical Transportation (NEMT) Services › Section 13 CSR 70-5.010 - Nonemergency Medical Transportation (NEMT) Services

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This proposed amendment will allow MO
				  HealthNet participants to receive transportation services to a pharmacy to
				  receive vaccinations during a scheduled appointment.
(1) The MO HealthNet Division (MHD) or its
				contractor shall reimburse eligible participants or nonemergency medical
				transportation (NEMT) providers for medically necessary transportation only if
				a participant does not have access to transportation services that are
				available free of charge.
(A) The participant
				must have an appointment for any medical treatment that is approved by
				MHD.
(B) MHD will not reimburse
				eligible participants or NEMT providers for nonemergency medical transportation
				to a pharmacy or to any location where the purpose of the nonemergency
				transportation is to fill a pharmaceutical prescription. MHD will reimburse
				eligible participants or NEMT providers for nonemergency medical transportation
				to a pharmacy for an MHD participant to receive a scheduled
				vaccination.
(C) Alternative
				transportation services that may be provided free of charge include but are not
				limited to private vehicles, volunteers, relatives, a designated legal
				representative, an individual involved in the resident's care, or
				transportation services provided by nursing facilities or other residential
				centers. Participants must not have access to free transportation in order to
				be eligible for reimbursement under this section.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 8 - Program of All-Inclusive Care for the Elderly › Section 13 CSR 70-8.010 - Program of All-Inclusive Care for the Elderly

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the requirements for
				  agencies contracting to provide services to eligible participants through the
				  MO HealthNet Division's (MHD) Program of All-Inclusive Care for the Elderly
				  (PACE).
(1) Purpose and
				Scope. This rule implements the Program of All-Inclusive Care for the Elderly
				(PACE). PACE provides comprehensive, community-based, acute, and long-term care
				services to participants who meet certain eligibility requirements, meet the
				criteria for level of care (LOC), and who can be served safely in the
				community. PACE is jointly funded and administered by the Centers for Medicare
				& Medicaid Services (CMS) and the state administering agency (SAA) as
				defined in section (2) of this rule.
(2) Definitions. For purposes of this
				regulation, the following words and phrases are defined as follows:
(A) "Interdisciplinary team" shall refer to
				the interdisciplinary team defined in
				42 CFR
				460.102 and in the program
				agreement;
(B) "Level of care
				(LOC)" shall refer to the level of care provided in a nursing facility, as
				established by the State of Missouri;
(C) "PACE organization (PO)" shall refer to
				the entity that provides services to participants under a PACE program
				agreement with CMS and the SAA;
(D)
				"Participant" shall refer to a person who receives services through the PACE
				organization;
(E) "Program
				agreement" shall refer to an agreement between a PACE organization, CMS, and
				the state administering agency for the operation of a PACE program;
				and
(F) "State administering agency
				(SAA)" shall refer to the Missouri Department of Social Services, MO HealthNet
				Division (MHD).
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.005 - Reasonable Cost-Related Reimbursement Plan for Long-Term Care

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes a payment plan for
				  nursing home care required by the
Code of Federal Regulations
( 42
				  CFR 447.273 - 447.316 ). The plan describes cost principles to be followed by
				  Title XIX nursing home providers in making financial reports and presents the
				  necessary procedures for setting rates, making adjustments and auditing of the
				  cost reports.
(1) Objectives.
(A) Uniform Plan. The provisions embodied in
				this rule define a system of reasonable cost-related reimbursement for
				long-term care (LTC) facilities participating in the Missouri Title XIX Medical
				Assistance Program that treats all providers of nursing care and services on a
				uniform basis.
(B) Adequacy of
				Reimbursement. Consistent with efficiency, economy and quality of care, the
				plan is to accomplish the purpose of adequate and reasonable reimbursement for
				services rendered to persons eligible for medical assistance under the Missouri
				Title XIX program.
(C) Improvement
				of Expenditure Forecasting. Capability of Title XIX management to forecast
				expenditures for LTC will be improved.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.016 - Global Per Diem Adjustments to Nursing Facility and HIV Nursing Facility Reimbursement Rates

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment provides for a per diem
				  increase to nursing facility and HIV nursing facility per diem reimbursement
				  rates of ten dollars and eighteen cents ($10.18), effective for dates of
				  service July 1, 2021 through June 30, 2022, for increases in costs associated
				  with staffing, supplies, social distancing standards, and other factors due to
				  the COVID-19 national emergency. This per diem adjustment corresponds to the
				  State Fiscal Year (SFY) 2022 appropriation for nursing facilities and is
				  approved by the Centers for Medicare and Medicaid Services
				  (CMS).
(1) Authority. This
				regulation is established pursuant to the authorization granted to the
				Department of Social Services (department), MO HealthNet Division (division),
				to promulgate rules and regulations.
(2) Purpose. This regulation sets forth the
				global per diem adjustments to be applied to nursing facility reimbursement
				rates, established in
				13 CSR
				70-10.015, and Human Immunodeficiency Virus (HIV)
				nursing facility reimbursement rates, established in 13 CSR 70-10.080. All
				principles and definitions set forth in
				13 CSR
				70-10.015 are applicable to nursing facilities, and
				all principles and definitions set forth in 13 CSR 70-10.080 are applicable to
				HIV nursing facilities. The terms "facility" or "facilities" as used in this
				regulation shall apply to both nursing facilities and HIV nursing
				facilities.
(3) Adjustments to the
				Reimbursement Rates. Subject to the limitations prescribed in
				13 CSR
				70-10.015, a nursing facility's reimbursement rate may
				be adjusted as described in this section. Subject to the limitations prescribed
				in 13 CSR 70-10.080, an HIV nursing facility's reimbursement rate may be
				adjusted as described in this section.
(A)
				Global Per Diem Rate Adjustments. A facility with either an interim rate or a
				prospective rate may qualify for the global per diem rate adjustments. Global
				per diem rate adjustments shall be added to the specified cost component
				ceiling.
1. FY-96 negotiated trend factor-
A. Facilities with either an interim rate or
				prospective rate in effect on October 1, 1995, shall be granted an increase to
				their per diem effective October 1, 1995, of four and six-tenths percent (4.6%)
				of the cost determined in paragraphs (11)(A)1., (11)(B)1., (11)(C)1., and the
				property insurance and property taxes detailed in subsection (11)(D) of
				13 CSR
				70-10.015; or
B. Facilities that were granted a prospective
				rate based on paragraph (12)(A)2. of
				13 CSR
				70-10.015 that is in effect on October 1, 1995, shall
				have their increase determined by subsection (3)(S) of
				13 CSR
				70-10.015.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.017 - Nursing Facility Invasive Ventilator Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule sets forth the requirements for
				  participation in the MO HealthNet
Invasive Ventilator Program and the per diem add-on
				  amounts to be applied to nursing facility reimbursement rates, established in
				  13
				  CSR 70-10.015 and
				  13
				  CSR 70-10.016. The services provided under the
				  Invasive Ventilator Program are in addition to the nursing facility services
				  already provided by the facility and as such are subject to all policies,
				  rules, regulations, and provider agreements applicable to providing nursing
				  facility services to MO HealthNet participants.
(1) The Invasive Ventilator Program is
				limited to-
(A) Nursing facilities licensed
				by the Department of Health and Senior Services (DHSS) and certified for
				participation in the MO HealthNet program and enrolled in the MO HealthNet
				Invasive Ventilator Program; and
(B) Services provided to adult MO HealthNet
				participants who are dependent on an invasive ventilator as a means of life
				support. An invasive ventilator generates breath delivered to the participant
				through an artificial airway positioned in the participant's trachea.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.030 - Prospective Reimbursement Plan for Nonstate-Operated Facilities for ICF/IID Services

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment provides for ICF/IID
				  reimbursement rates to be recalculated (i.e., rebased) using a more recent base
				  year, which allows the division to pay rates that reflect more current costs
				  incurred by ICF/IID providers.
(1) Objectives. This rule establishes a
				payment plan for nonstate-operated intermediate care facility for individuals
				with intellectual disabilities (ICF/IID) services.
(2) General Principles.
(A) The MO HealthNet program shall reimburse
				qualified providers of ICF/IID services based solely on the individual MO
				HealthNet participant's days of care (within benefit limitations) multiplied by
				the facility's Title XIX per diem rate less any payments made by
				participants.
(B) Effective
				November 1, 1986, the Title XIX per diem rate for all ICF/IID facilities
				participating on or after October 31, 1986, shall be the lower of-
1. The Medicare per diem rate, if applicable;
				or
2. The reimbursement rate as
				determined in accordance with this regulation.
(C) This plan has an effective date of
				November 1, 1986, at which time prospective per diem rates shall be calculated
				for the remainder of the state's FY-87 and future fiscal years. Per diem rates
				established by updating facilities' base years to FY-85 may be subject to
				retroactive and prospective adjustment based on audit of the facilities' new
				base year period.
(D) The Title XIX
				per diem rates as determined by this plan shall apply only to services
				furnished on or after November 1, 1986.
(E) All illustrations and examples provided
				throughout this rule are for illustration purposes only and are not meant to be
				actual calculations.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.110 - Nursing Facility Reimbursement Allowance

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This regulation is necessary to outline the
				  provisions allowed in House Bill 1362.
PURPOSE: This amendment provides for a change in the
				  Nursing Facility Reimbursement Allowance (NFRA) rate to twelve dollars and
				  ninety-three cents ($12.93) effective July 1, 2018.
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) Nursing Facility Reimbursement Allowance
				(NFRA). NFRA shall be assessed as described in this section.
(A) Definitions.
1. Nursing facility. An institution or a
				distinct part of an institution which-
A. Is
				primarily engaged in providing to residents-
(I) Skilled nursing care and related services
				for residents who require medical or nursing care; or
(II) Rehabilitation services for the
				rehabilitation of injured, disabled, or sick persons; or
(III) On a regular basis, health-care and
				services to individuals who, because of their mental or physical condition,
				require care and services (above the level of room and board) which can be made
				available to them only through institutional facilities and is not primarily
				for the care and treatment of mental diseases; and
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.160 - Public/Private Long-Term Care Services and Supports Partnership Supplemental Payment to Nursing Facilities

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment allows supplement payments to public
				  nursing facilities that have qualified IGT agreements with the Department of
				  Social Services.
(1) Effective for
				dates of service on or after April 1, 2012, through June 30, 2013, supplemental
				payments will be made as set forth in subsections (1)(A)-(1)(D) in each
				following calendar quarter from the Long-Term Support Upper Payment Limit (UPL)
				Fund to qualifying private and public nursing facilities for services rendered
				during the quarter on or after April 1, 2012 through June 30, 2013. Maximum
				payments to all qualifying private and public nursing facilities shall not
				exceed the upper payment limit defined in
				42 CFR
				447.272 in each state fiscal year.
(2) Effective for dates of service beginning
				July 1, 2013, Nursing Facility UPL Payments shall be made as set forth below in
				subsections (2)(A)-(2)(C). Maximum aggregate payments to all qualifying nursing
				facilities shall not exceed the upper payment limit defined in
				42 CFR
				447.272 in each state fiscal year.
(A) An annual UPL Payment shall be made at
				the end of each state fiscal year (SFY) to qualifying nursing facilities.
(B) Qualifying Criteria. Public
				nursing facilities that have executed an agreement with the department are
				eligible for a UPL Payment and shall be referred to as qualifying nursing
				facilities. In addition, to qualify for the UPL Payment, each nursing facility
				must be enrolled in the Medicaid program at the time the UPL payments are
				calculated and made.
(C)
				Reimbursement Methodology. The annual UPL Payment will be made to qualifying
				nursing facilities based on each facility's unreimbursed costs determined from
				the facility's second prior year Medicaid cost report, subject to the Medicare
				Upper Payment Limit.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.010 - Inpatient Hospital Services Reimbursement Methodology

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This proposed amendment adds a new
				  supplemental payment paid to hospitals.
(1) General Reimbursement Principles.
(A) For inpatient hospital services provided
				for an individual entitled to Medicare Part A inpatient hospital benefits and
				eligible for MO HealthNet, reimbursement from the MO HealthNet Program will be
				available only when MO HealthNet's applicable payment schedule amount exceeds
				the amount paid by Medicare. MO HealthNet's payment will be limited to the
				lower of the deductible and coinsurance amounts or the amount the MO HealthNet
				applicable payment schedule amount exceeds the Medicare payments. For all other
				MO HealthNet participants, unless otherwise limited by rule, reimbursement will
				be based solely on the individual participant's days of care (within benefit
				limitations) multiplied by the individual hospital's Title XIX per diem
				rate.
(B) The Title XIX
				reimbursement for hospitals, excluding those located outside Missouri, shall
				include the payments as outlined below. Reimbursement shall be subject to
				availability of federal financial participation (FFP).
1. Inpatient per diem reimbursement is
				established in accordance with sections (4) and (5).
2. Outpatient reimbursement is established in
				accordance with 13 CSR 70-15.160.
3. Acuity adjustment payment (AAP) is
				established in accordance with section (6).
4. Poison control (PC) payment is established
				in accordance with section (7).
5.
				Stop loss payment (SLP) is established in accordance with section
				(8).
6. Disproportionate share
				hospital (DSH) payment is established in accordance with
				13 CSR
				70-15.220.
7. Graduate medical education (GME) payment
				is established in accordance with section (9).
8. Upper payment limit (UPL) payment is
				established in accordance with
				13 CSR
				70-15.230.
9. Children's outlier (CO) payment is
				established in accordance with section (10).
10. Psych adjustment (PA) payment is
				established in accordance with section (11).
(C) The Title XIX reimbursement for hospitals
				located outside Missouri will be established in accordance with 13 CSR
				7015.190.
Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.030 - Payment and Payment Limitations for Inpatient Hospital Care

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates the incorporation by
				  reference language and the link for the MO HealthNet exempt diagnosis
				  table
.
(1) For inpatient
				hospital admissions that do not require certification as specified in
				13 CSR
				70-15.020, the number of days which MO HealthNet will
				cover for each admission is included in the MO HealthNet exempt diagnosis
				table, which is 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/pdf/Exempt-Diagnosis-Table.pdf
,
				November 9, 2021. All other admissions require certification per
				13 CSR
				70-15.020. This rule does not incorporate any
				subsequent amendments or additions.
(A) The
				MO HealthNet program shall be administered by the Department of Social
				Services, MO HealthNet Division. The 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 division and shall be
				included in the 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,
				and at its website at
https://dss.mo.gov/mhd/
, November 9,
				2021. 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 15 - Hospital Program › Section 13 CSR 70-15.040 - Hospital Outpatient Settlements

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment deletes or clarifies outdated
				  terms, language, and provisions regarding hospital inpatient and outpatient
				  settlements. The division is removing the provisions governing inpatient
				  settlements entirely, since the practice of calculating settlements for those
				  services has ceased.
PURPOSE: This regulation defines the specific
				  procedures used to calculate the final outpatient settlements for hospital
				  providers.
(1) General. This
				regulation defines the specific procedures used to calculate outpatient
				settlements for Missouri instate hospitals participating in the Missouri
				Medicaid program. Outpatient settlements are only determined for new hospitals
				and nominal charge providers.
(A) The
				hospital's settlement will be determined after the division receives a Medicare
				cost report with a Notice of Provider Reimbursement (NPR). The cost report used
				for the settlement shall be the one with the latest NPR at the time the
				settlement is calculated. The data used, except for Medicaid data, shall be as
				reported in the cost report unless adjusted by this regulation. The current
				version of the cost report is Centers for Medicare and Medicaid Services (CMS)
				2552-10, and references in this regulation are from this cost report. However,
				the division will use the version of the report received from the fiscal
				intermediary, which may change the references.
(B) The Medicaid charges used to determine
				the cost, and the payments used to determine the final settlement, will be from
				the division's paid claims data for reimbursable services paid on a percentage
				basis under 13 CSR
				70-15.160(1)-(2). This data includes
				only claims on which Medicaid made payment.
(C) Pursuant to
				13 CSR
				70-15.160(5), effective for dates of
				service beginning July 20, 2021, payment for outpatient hospital services will
				be final, with no cost settlement.