Text of MO SB 49 (2023)

FIRST REGULAR SESSION SENATE BILL NO. 49 102ND GENERAL ASSEMBLY INTRODUCED BY SENATOR MOON. 0202S.01I KRISTINA MARTIN, Secretary AN ACT To amend chapter 191, RSMo, by adding thereto one new section relating to gender transition procedures. Be it enacted by the General Assembly of the State of Missouri, as follows: Section A. Chapter 191, RSMo, is amended by adding thereto 1 one new section, to be known as section 191.1720, to read as 2 follows: 3 191.1720. 1. This section shall be known and may be 1 cited as the "Missouri Save Adolescents from Experimentation 2 (SAFE) Act". 3 2. For purposes of this section, the following terms 4 mean: 5 (1) "Biological sex", the biological indication of 6 male or female in the context of reproductive potential or 7 capacity, such as sex chromosomes, naturally occurring sex 8 hormones, gonads, and nonambiguous internal and external 9 genitalia present at birth, without regard to an 10 individual's psychological, chosen, or subjective experience 11 of gender; 12 (2) "Cross-sex hormones": 13 (a) Testosterone or other androgens given to 14 biological sex females in amounts that are larger or more 15 potent than would normally occur naturally in healthy 16 biological sex females; and 17 (b) Estrogen given to biological sex males in amounts 18 that are larger or more potent than would normally occur 19 naturally in healthy biological sex males; 20 SB 49 2 (3) "Gender", the psychological, behavioral, social, 21 and cultural aspects of being male or female; 22 (4) "Gender reassignment surgery", any medical or 23 surgical service that seeks to surgically alter or remove 24 healthy physical or anatomical characteristics or features 25 that are typical for the individual's biological sex in 26 order to instill or create physiological or anatomical 27 characteristics that resemble a sex different from the 28 individual's biological sex, including, but not limited to, 29 genital or nongenital gender reassignment surgery performed 30 for the purpose of assisting an individual with a gender 31 transition; 32 (5) "Gender transition", the process in which an 33 individual transitions from identifying with and living as a 34 gender that corresponds to his or her biological sex to 35 identifying and living as a gender different from his or her 36 biological sex, and may involve social, legal, or physical 37 changes; 38 (6) "Gender transition procedures": 39 (a) Any medical or surgical service, including, but 40 not limited to, physician's services, inpatient and 41 outpatient hospital services, or prescribed drugs, related 42 to gender transition that seeks to: 43 a. Alter or remove physical or anatomical 44 characteristics or features that are typical for the 45 individual's biological sex; or 46 b. Instill or create physiological or anatomical 47 characteristics that resemble a sex different from the 48 individual's biological sex, including, but not limited to: 49 (i) Medical services that provide puberty-blocking 50 drugs, cross-sex hormones, or other mechanisms to promote 51 SB 49 3 the development of feminizing or masculinizing features in 52 the opposite biological sex; or 53 (ii) Genital or nongenital gender reassignment surgery 54 performed for the purpose of assisting an individual with a 55 gender transition; 56 (b) The term "gender transition procedures" shall not 57 include: 58 a. Services to individuals born with a medically- 59 verifiable disorder of sex development, including, but not 60 limited to, an individual with external biological sex 61 characteristics that are irresolvably ambiguous, such as 62 those born with forty-six XX chromosomes with virilization, 63 forty-six XY chromosomes with undervirilization, or having 64 both ovarian and testicular tissue; 65 b. Services provided when a physician has otherwise 66 diagnosed an individual with a disorder of sexual 67 development and determined through genetic or biochemical 68 testing that the individual does not have normal sex 69 chromosome structure, sex steroid hormone production, or sex 70 steroid hormone action; 71 c. The treatment of any infection, injury, disease, or 72 disorder that has been caused by or exacerbated by the 73 performance of gender transition procedures regardless of 74 whether the gender transition procedure was performed in 75 accordance with state and federal law; or 76 d. Any procedure undertaken because the individual 77 suffers from a physical disorder, physical injury, or 78 physical illness that would, as certified by a physician, 79 place the individual in imminent danger of death or 80 impairment of a major bodily function unless surgery is 81 performed; 82 SB 49 4 (7) "Genital gender reassignment surgery", a medical 83 procedure performed for the purpose of assisting an 84 individual with a gender transition, including, but not 85 limited to: 86 (a) Surgical procedures such as penectomy, 87 orchiectomy, vaginoplasty, clitoroplasty, or vulvoplasty for 88 biologically male patients or hysterectomy or ovariectomy 89 for biologically female patients; 90 (b) Reconstruction of the fixed part of the urethra 91 with or without a metoidioplasty; or 92 (c) Phalloplasty, vaginectomy, scrotoplasty, or 93 implantation of erection or testicular prostheses for 94 biologically female patients; 95 (8) "Health care provider", an individual who is 96 licensed, certified, or otherwise authorized by the laws of 97 this state to administer health care in the ordinary course 98 of the practice of his or her profession; 99 (9) "Nongenital gender reassignment surgery", medical 100 procedures performed for the purpose of assisting an 101 individual with a gender transition, including, but not 102 limited to: 103 (a) Surgical procedures for biologically male 104 patients, such as augmentation mammoplasty, facial 105 feminization surgery, liposuction, lipofilling, voice 106 surgery, thyroid cartilage reduction, gluteal augmentation, 107 hair reconstruction, or various aesthetic procedures; or 108 (b) Surgical procedures for biologically female 109 patients, such as subcutaneous mastectomy, voice surgery, 110 liposuction, lipofilling, pectoral implants, or various 111 aesthetic procedures; 112 (10) "Physician", an individual who is licensed under 113 chapter 334; 114 SB 49 5 (11) "Puberty-blocking drugs", gonadotropin-releasing 115 hormone analogues or other synthetic drugs used in 116 biological sex males to stop luteinizing hormone secretion 117 and therefore testosterone secretion, or synthetic drugs 118 used in biological sex females that stop the production of 119 estrogens and progesterone, when used to delay or suppress 120 pubertal development in children for the purpose of 121 assisting an individual with a gender transition. 122 3. A physician or other health care provider shall not 123 provide gender transition procedures to any individual under 124 eighteen years of age and shall not refer any individual 125 under eighteen years of age to any health care provider for 126 gender transition procedures. 127 4. Any referral for or provision of gender transition 128 procedures to an individual under eighteen years of age 129 shall be considered unprofessional conduct and any health 130 care provider doing so may be subject to discipline by the 131 appropriate licensing entity or disciplinary review board 132 with competent jurisdiction in this state. 133 5. The provision of gender transition procedures to an 134 individual under eighteen years of age in violation of the 135 provisions of this section shall be considered grounds for a 136 cause of action against the health care provider for 137 personal injury or death under chapter 538 and such cause of 138 action shall be governed by the provisions of such chapter. 139 An individual under eighteen years of age upon whom gender 140 transition procedures were performed in violation of this 141 section may bring the cause of action either through a next 142 friend or his or her own name, subject to the provisions of 143 section 516.105. 144 

FIRST REGULAR SESSION [TRULY AGREED TO AND FINALLY PASSED] SENATE SUBSTITUTE NO. 2 FOR SENATE COMMITTEE SUBSTITUTE FOR SENATE BILLS NOS. 49, 236 & 164 102ND GENERAL ASSEMBLY 2023 0202S.20T AN ACT To repeal sections 208.152, 217.230, and 221.120, RSMo, and to enact in lieu thereof four new sections relating to gender transition procedures. Be it enacted by the General Assembly of the State of Missouri, as follows: Section A. Sections 208.152, 217.230, and 221.120, RSMo, 1 are repealed and four new sections enacted in lieu thereof, to 2 be known as sections 191.1720, 208.152, 217.230, and 221.120, 3 to read as follows: 4 191.1720. 1. This section shall be known and may be 1 cited as the "Missouri Save Adolescents from Experimentation 2 (SAFE) Act". 3 2. For purposes of this section, the following terms 4 mean: 5 (1) "Biological sex", the biological indication of 6 male or female in the context of reproductive potential or 7 capacity, such as sex chromosomes, naturally occurring sex 8 hormones, gonads, and nonambiguous internal and external 9 genitalia present at birth, without regard to an 10 individual's psychological, chosen, or subjective experience 11 of gender; 12 SS#2 SCS SBs 49, 2 236 & 164 (2) "Cross-sex hormones", testosterone, estrogen, or 13 other androgens given to an individual in amounts that are 14 greater or more potent than would normally occur naturally 15 in a healthy individual of the same age and sex; 16 (3) "Gender", the psychological, behavioral, social, 17 and cultural aspects of being male or female; 18 (4) "Gender transition", the process in which an 19 individual transitions from identifying with and living as a 20 gender that corresponds to his or her biological sex to 21 identifying with and living as a gender different from his 22 or her biological sex, and may involve social, legal, or 23 physical changes; 24 (5) "Gender transition surgery", a surgical procedure 25 performed for the purpose of assisting an individual with a 26 gender transition, including, but not limited to: 27 (a) Surgical procedures that sterilize, including, but 28 not limited to, castration, vasectomy, hysterectomy, 29 oophorectomy, orchiectomy, or penectomy; 30 (b) Surgical procedures that artificially construct 31 tissue with the appearance of genitalia that differs from 32 the individual's biological sex, including, but not limited 33 to, metoidioplasty, phalloplasty, or vaginoplasty; or 34 (c) Augmentation mammoplasty or subcutaneous 35 mastectomy; 36 (6) "Health care provider", an individual who is 37 licensed, certified, or otherwise authorized by the laws of 38 this state to administer health care in the ordinary course 39 of the practice of his or her profession; 40 (7) "Puberty-blocking drugs", gonadotropin-releasing 41 hormone analogues or other synthetic drugs used to stop 42 luteinizing hormone secretion and follicle stimulating 43 hormone secretion, synthetic antiandrogen drugs to block the 44 SS#2 SCS SBs 49, 3 236 & 164 androgen receptor, or any other drug used to delay or 45 suppress pubertal development in children for the purpose of 46 assisting an individual with a gender transition. 47 3. A health care provider shall not knowingly perform 48 a gender transition surgery on any individual under eighteen 49 years of age. 50 4. (1) A health care provider shall not knowingly 51 prescribe or administer cross-sex hormones or puberty- 52 blocking drugs for the purpose of a gender transition for 53 any individual under eighteen years of age. 54 (2) The provisions of this subsection shall not apply 55 to the prescription or administration of cross-sex hormones 56 or puberty-blocking drugs for any individual under eighteen 57 years of age who was prescribed or administered such 58 hormones or drugs prior to August 28, 2023, for the purpose 59 of assisting the individual with a gender transition. 60 (3) The provisions of this subsection shall expire on 61 August 28, 2027. 62 5. The performance of a gender transition surgery or 63 the prescription or administration of cross-sex hormones or 64 puberty-blocking drugs to an individual under eighteen years 65 of age in violation of this section shall be considered 66 unprofessional conduct and any health care provider doing so 67 shall have his or her license to practice revoked by the 68 appropriate licensing entity or disciplinary review board 69 with competent jurisdiction in this state. 70 6. (1) The prescription or administration of cross- 71 sex hormones or puberty-blocking drugs to an individual 72 under eighteen years of age for the purpose of a gender 73 transition shall be considered grounds for a cause of action 74 against the health care provider. The provisions of chapter 75 SS#2 SCS SBs 49, 4 236 & 164 538 shall not apply to any action brought under this 76 subsection. 77 (2) An action brought pursuant to this subsection 78 shall be brought within fifteen years of the individual 79 injured attaining the age of twenty-one or of the date the 80 treatment of the injury at issue in the action by the 81 defendant has ceased, whichever is later. 82 (3) An individual bringing an action under this 83 subsection shall be entitled to a rebuttable presumption 84 that the individual was harmed if the individual is 85 infertile following the prescription or administration of 86 cross-sex hormones or puberty-blocking drugs and that the 87 harm was a direct result of the hormones or drugs prescribed 88 or administered by the health care provider. Such 89 presumption may be rebutted only by clear and convincing 90 evidence. 91 (4) In any action brought pursuant to this subsection, 92 a plaintiff may recover economic and noneconomic damages and 93 punitive damages, without limitation to the amount and no 94 less than five hundred thousand dollars in the aggregate. 95 The judgment against a defendant in an action brought 96 pursuant to this subsection shall be in an amount of three 97 times the amount of any economic and noneconomic damages or 98 punitive damages assessed. Any award of damages in an 99 action brought pursuant to this subsection to a prevailing 100 plaintiff shall include attorney's fees and court costs. 101 (5) An action brought pursuant to this subsection may 102 be brought in any circuit court of this state. 103 (6) No health care provider shall require a waiver of 104 the right to bring an action pursuant to this subsection as 105 a condition of services. The right to bring an action by or 106 SS#2 SCS SBs 49, 5 236 & 164 through an individual under the age of eighteen shall not be 107 waived by a parent or legal guardian. 108 (7) A plaintiff to an action brought under this 109 subsection may enter into a voluntary agreement of 110 settlement or compromise of the action, but no agreement 111 shall be valid until approved by the court. No agreement 112 allowed by the court shall include a provision regarding the 113 nondisclosure or confidentiality of the terms of such 114 agreement unless such provision was specifically requested 115 and agreed to by the plaintiff. 116 (8) If requested by the plaintiff, any pleadings, 117 attachments, or exhibits filed with the court in any action 118 brought pursuant to this subsection, as well as any 119 judgments issued by the court in such actions, shall not 120 include the personal identifying information of the 121 plaintiff. Such information shall be provided in a 122 confidential information filing sheet contemporaneously 123 filed with the court or entered by the court, which shall 124 not be subject to public inspection or availability. 125 7. The provisions of this section shall not apply to 126 any speech protected by the First Amendment of the United 127 States Constitution. 128 8. The provisions of this section shall not apply to 129 the following: 130 (1) Services to individuals born with a medically- 131 verifiable disorder of sex development, including, but not 132 limited to, an individual with external biological sex 133 characteristics that are irresolvably ambiguous, such as 134 those born with 46,XX chromosomes with virilization, 46,XY 135 chromosomes with undervirilization, or having both ovarian 136 and testicular tissue; 137 SS#2 SCS SBs 49, 6 236 & 164 (2) Services provided when a physician has otherwise 138 diagnosed an individual with a disorder of sex development 139 and determined through genetic or biochemical testing that 140 the individual does not have normal sex chromosome 141 structure, sex steroid hormone production, or sex steroid 142 hormone action; 143 (3) The treatment of any infection, injury, disease, 144 or disorder that has been caused by or exacerbated by the 145 performance of gender transition surgery or the prescription 146 or administration of cross-sex hormones or puberty-blocking 147 drugs regardless of whether the surgery was performed or the 148 hormones or drugs were prescribed or administered in 149 accordance with state and federal law; or 150 (4) Any procedure undertaken because the individual 151 suffers from a physical disorder, physical injury, or 152 physical illness that would, as certified by a physician, 153 place the individual in imminent danger of death or 154 impairment of a major bodily function unless surgery is 155 performed. 156 208.152. 1. MO HealthNet payments shall be made on 1 behalf of those eligible needy persons as described in 2 section 208.151 who are unable to provide for it in whole or 3 in part, with any payments to be made on the basis of the 4 reasonable cost of the care or reasonable charge for the 5 services as defined and determined by the MO HealthNet 6 division, unless otherwise hereinafter provided, for the 7 following: 8 (1) Inpatient hospital services, except to persons in 9 an institution for mental diseases who are under the age of 10 sixty-five years and over the age of twenty-one years; 11 provided that the MO HealthNet division shall provide 12 through rule and regulation an exception process for 13 SS#2 SCS SBs 49, 7 236 & 164 coverage of inpatient costs in those cases requiring 14 treatment beyond the seventy-fifth percentile professional 15 activities study (PAS) or the MO HealthNet children's 16 diagnosis length-of-stay schedule; and provided further that 17 the MO HealthNet division shall take into account through 18 its payment system for hospital services the situation of 19 hospitals which serve a disproportionate number of low- 20 income patients; 21 (2) All outpatient hospital services, payments 22 therefor to be in amounts which represent no more than 23 eighty percent of the lesser of reasonable costs or 24 customary charges for such services, determined in 25 accordance with the principles set forth in Title XVIII A 26 and B, Public Law 89-97, 1965 amendments to the federal 27 Social Security Act (42 U.S.C. Section 301, et seq.), but 28 the MO HealthNet division may evaluate outpatient hospital 29 services rendered under this section and deny payment for 30 services which are determined by the MO HealthNet division 31 not to be medically necessary, in accordance with federal 32 law and regulations; 33 (3) Laboratory and X-ray services; 34 (4) Nursing home services for participants, except to 35 persons with more than five hundred thousand dollars equity 36 in their home or except for persons in an institution for 37 mental diseases who are under the age of sixty-five years, 38 when residing in a hospital licensed by the department of 39 health and senior services or a nursing home licensed by the 40 department of health and senior services or appropriate 41 licensing authority of other states or government-owned and - 42 operated institutions which are determined to conform to 43 standards equivalent to licensing requirements in Title XIX 44 of the federal Social Security Act (42 U.S.C. Section 301, 45 SS#2 SCS SBs 49, 8 236 & 164 et seq.), as amended, for nursing facilities. The MO 46 HealthNet division may recognize through its payment 47 methodology for nursing facilities those nursing facilities 48 which serve a high volume of MO HealthNet patients. The MO 49 HealthNet division when determining the amount of the 50 benefit payments to be made on behalf of persons under the 51 age of twenty-one in a nursing facility may consider nursing 52 facilities furnishing care to persons under the age of 53 twenty-one as a classification separate from other nursing 54 facilities; 55 (5) Nursing home costs for participants receiving 56 benefit payments under subdivision (4) of this subsection 57 for those days, which shall not exceed twelve per any period 58 of six consecutive months, during which the participant is 59 on a temporary leave of absence from the hospital or nursing 60 home, provided that no such participant shall be allowed a 61 temporary leave of absence unless it is specifically 62 provided for in his plan of care. As used in this 63 subdivision, the term "temporary leave of absence" shall 64 include all periods of time during which a participant is 65 away from the hospital or nursing home overnight because he 66 is visiting a friend or relative; 67 (6) Physicians' services, whether furnished in the 68 office, home, hospital, nursing home, or elsewhere; 69 (7) Subject to appropriation, up to twenty visits per 70 year for services limited to examinations, diagnoses, 71 adjustments, and manipulations and treatments of 72 malpositioned articulations and structures of the body 73 provided by licensed chiropractic physicians practicing 74 within their scope of practice. Nothing in this subdivision 75 shall be interpreted to otherwise expand MO HealthNet 76 services; 77 SS#2 SCS SBs 49, 9 236 & 164 (8) Drugs and medicines when prescribed by a licensed 78 physician, dentist, podiatrist, or an advanced practice 79 registered nurse; except that no payment for drugs and 80 medicines prescribed on and after January 1, 2006, by a 81 licensed physician, dentist, podiatrist, or an advanced 82 practice registered nurse may be made on behalf of any 83 person who qualifies for prescription drug coverage under 84 the provisions of P.L. 108-173; 85 (9) Emergency ambulance services and, effective 86 January 1, 1990, medically necessary transportation to 87 scheduled, physician-prescribed nonelective treatments; 88 (10) Early and periodic screening and diagnosis of 89 individuals who are under the age of twenty-one to ascertain 90 their physical or mental defects, and health care, 91 treatment, and other measures to correct or ameliorate 92 defects and chronic conditions discovered thereby. Such 93 services shall be provided in accordance with the provisions 94 of Section 6403 of P.L. 101-239 and federal regulations 95 promulgated thereunder; 96 (11) Home health care services; 97 (12) Family planning as defined by federal rules and 98 regulations; provided, however, that such family planning 99 services shall not include abortions or any abortifacient 100 drug or device that is used for the purpose of inducing an 101 abortion unless such abortions are certified in writing by a 102 physician to the MO HealthNet agency that, in the 103 physician's professional judgment, the life of the mother 104 would be endangered if the fetus were carried to term; 105 (13) Inpatient psychiatric hospital services for 106 individuals under age twenty-one as defined in Title XIX of 107 the federal Social Security Act (42 U.S.C. Section 1396d, et 108 seq.); 109 SS#2 SCS SBs 49, 10 236 & 164 (14) Outpatient surgical procedures, including 110 presurgical diagnostic services performed in ambulatory 111 surgical facilities which are licensed by the department of 112 health and senior services of the state of Missouri; except, 113 that such outpatient surgical services shall not include 114 persons who are eligible for coverage under Part B of Title 115 XVIII, Public Law 89-97, 1965 amendments to the federal 116 Social Security Act, as amended, if exclusion of such 117 persons is permitted under Title XIX, Public Law 89-97, 1965 118 amendments to the federal Social Security Act, as amended; 119 (15) Personal care services which are medically 120 oriented tasks having to do with a person's physical 121 requirements, as opposed to housekeeping requirements, which 122 enable a person to be treated by his or her physician on an 123 outpatient rather than on an inpatient or residential basis 124 in a hospital, intermediate care facility, or skilled 125 nursing facility. Personal care services shall be rendered 126 by an individual not a member of the participant's family 127 who is qualified to provide such services where the services 128 are prescribed by a physician in accordance with a plan of 129 treatment and are supervised by a licensed nurse. Persons 130 eligible to receive personal care services shall be those 131 persons who would otherwise require placement in a hospital, 132 intermediate care facility, or skilled nursing facility. 133 Benefits payable for personal care services shall not exceed 134 for any one participant one hundred percent of the average 135 statewide charge for care and treatment in an intermediate 136 care facility for a comparable period of time. Such 137 services, when delivered in a residential care facility or 138 assisted living facility licensed under chapter 198 shall be 139 authorized on a tier level based on the services the 140 resident requires and the frequency of the services. A 141 SS#2 SCS SBs 49, 11 236 & 164 resident of such facility who qualifies for assistance under 142 section 208.030 shall, at a minimum, if prescribed by a 143 physician, qualify for the tier level with the fewest 144 services. The rate paid to providers for each tier of 145 service shall be set subject to appropriations. Subject to 146 appropriations, each resident of such facility who qualifies 147 for assistance under section 208.030 and meets the level of 148 care required in this section shall, at a minimum, if 149 prescribed by a physician, be authorized up to one hour of 150 personal care services per day. Authorized units of 151 personal care services shall not be reduced or tier level 152 lowered unless an order approving such reduction or lowering 153 is obtained from the resident's personal physician. Such 154 authorized units of personal care services or tier level 155 shall be transferred with such resident if he or she 156 transfers to another such facility. Such provision shall 157 terminate upon receipt of relevant waivers from the federal 158 Department of Health and Human Services. If the Centers for 159 Medicare and Medicaid Services determines that such 160 provision does not comply with the state plan, this 161 provision shall be null and void. The MO HealthNet division 162 shall notify the revisor of statutes as to whether the 163 relevant waivers are approved or a determination of 164 noncompliance is made; 165 (16) Mental health services. The state plan for 166 providing medical assistance under Title XIX of the Social 167 Security Act, 42 U.S.C. Section 301, as amended, shall 168 include the following mental health services when such 169 services are provided by community mental health facilities 170 operated by the department of mental health or designated by 171 the department of mental health as a community mental health 172 facility or as an alcohol and drug abuse facility or as a 173 SS#2 SCS SBs 49, 12 236 & 164 child-serving agency within the comprehensive children's 174 mental health service system established in section 175 630.097. The department of mental health shall establish by 176 administrative rule the definition and criteria for 177 designation as a community mental health facility and for 178 designation as an alcohol and drug abuse facility. Such 179 mental health services shall include: 180 (a) Outpatient mental health services including 181 preventive, diagnostic, therapeutic, rehabilitative, and 182 palliative interventions rendered to individuals in an 183 individual or group setting by a mental health professional 184 in accordance with a plan of treatment appropriately 185 established, implemented, monitored, and revised under the 186 auspices of a therapeutic team as a part of client services 187 management; 188 (b) Clinic mental health services including 189 preventive, diagnostic, therapeutic, rehabilitative, and 190 palliative interventions rendered to individuals in an 191 individual or group setting by a mental health professional 192 in accordance with a plan of treatment appropriately 193 established, implemented, monitored, and revised under the 194 auspices of a therapeutic team as a part of client services 195 management; 196 (c) Rehabilitative mental health and alcohol and drug 197 abuse services including home and community-based 198 preventive, diagnostic, therapeutic, rehabilitative, and 199 palliative interventions rendered to individuals in an 200 individual or group setting by a mental health or alcohol 201 and drug abuse professional in accordance with a plan of 202 treatment appropriately established, implemented, monitored, 203 and revised under the auspices of a therapeutic team as a 204 part of client services management. As used in this 205 SS#2 SCS SBs 49, 13 236 & 164 section, mental health professional and alcohol and drug 206 abuse professional shall be defined by the department of 207 mental health pursuant to duly promulgated rules. With 208 respect to services established by this subdivision, the 209 department of social services, MO HealthNet division, shall 210 enter into an agreement with the department of mental 211 health. Matching funds for outpatient mental health 212 services, clinic mental health services, and rehabilitation 213 services for mental health and alcohol and drug abuse shall 214 be certified by the department of mental health to the MO 215 HealthNet division. The agreement shall establish a 216 mechanism for the joint implementation of the provisions of 217 this subdivision. In addition, the agreement shall 218 establish a mechanism by which rates for services may be 219 jointly developed; 220 (17) Such additional services as defined by the MO 221 HealthNet division to be furnished under waivers of federal 222 statutory requirements as provided for and authorized by the 223 federal Social Security Act (42 U.S.C. Section 301, et seq.) 224 subject to appropriation by the general assembly; 225 (18) The services of an advanced practice registered 226 nurse with a collaborative practice agreement to the extent 227 that such services are provided in accordance with chapters 228 334 and 335, and regulations promulgated thereunder; 229 (19) Nursing home costs for participants receiving 230 benefit payments under subdivision (4) of this subsection to 231 reserve a bed for the participant in the nursing home during 232 the time that the participant is absent due to admission to 233 a hospital for services which cannot be performed on an 234 outpatient basis, subject to the provisions of this 235 subdivision: 236 SS#2 SCS SBs 49, 14 236 & 164 (a) The provisions of this subdivision shall apply 237 only if: 238 a. The occupancy rate of the nursing home is at or 239 above ninety-seven percent of MO HealthNet certified 240 licensed beds, according to the most recent quarterly census 241 provided to the department of health and senior services 242 which was taken prior to when the participant is admitted to 243 the hospital; and 244 b. The patient is admitted to a hospital for a medical 245 condition with an anticipated stay of three days or less; 246 (b) The payment to be made under this subdivision 247 shall be provided for a maximum of three days per hospital 248 stay; 249 (c) For each day that nursing home costs are paid on 250 behalf of a participant under this subdivision during any 251 period of six consecutive months such participant shall, 252 during the same period of six consecutive months, be 253 ineligible for payment of nursing home costs of two 254 otherwise available temporary leave of absence days provided 255 under subdivision (5) of this subsection; and 256 (d) The provisions of this subdivision shall not apply 257 unless the nursing home receives notice from the participant 258 or the participant's responsible party that the participant 259 intends to return to the nursing home following the hospital 260 stay. If the nursing home receives such notification and 261 all other provisions of this subsection have been satisfied, 262 the nursing home shall provide notice to the participant or 263 the participant's responsible party prior to release of the 264 reserved bed; 265 (20) Prescribed medically necessary durable medical 266 equipment. An electronic web-based prior authorization 267 system using best medical evidence and care and treatment 268 SS#2 SCS SBs 49, 15 236 & 164 guidelines consistent with national standards shall be used 269 to verify medical need; 270 (21) Hospice care. As used in this subdivision, the 271 term "hospice care" means a coordinated program of active 272 professional medical attention within a home, outpatient and 273 inpatient care which treats the terminally ill patient and 274 family as a unit, employing a medically directed 275 interdisciplinary team. The program provides relief of 276 severe pain or other physical symptoms and supportive care 277 to meet the special needs arising out of physical, 278 psychological, spiritual, social, and economic stresses 279 which are experienced during the final stages of illness, 280 and during dying and bereavement and meets the Medicare 281 requirements for participation as a hospice as are provided 282 in 42 CFR Part 418. The rate of reimbursement paid by the 283 MO HealthNet division to the hospice provider for room and 284 board furnished by a nursing home to an eligible hospice 285 patient shall not be less than ninety-five percent of the 286 rate of reimbursement which would have been paid for 287 facility services in that nursing home facility for that 288 patient, in accordance with subsection (c) of Section 6408 289 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 290 (22) Prescribed medically necessary dental services. 291 Such services shall be subject to appropriations. An 292 electronic web-based prior authorization system using best 293 medical evidence and care and treatment guidelines 294 consistent with national standards shall be used to verify 295 medical need; 296 (23) Prescribed medically necessary optometric 297 services. Such services shall be subject to 298 appropriations. An electronic web-based prior authorization 299 system using best medical evidence and care and treatment 300 SS#2 SCS SBs 49, 16 236 & 164 guidelines consistent with national standards shall be used 301 to verify medical need; 302 (24) Blood clotting products-related services. For 303 persons diagnosed with a bleeding disorder, as defined in 304 section 338.400, reliant on blood clotting products, as 305 defined in section 338.400, such services include: 306 (a) Home delivery of blood clotting products and 307 ancillary infusion equipment and supplies, including the 308 emergency deliveries of the product when medically necessary; 309 (b) Medically necessary ancillary infusion equipment 310 and supplies required to administer the blood clotting 311 products; and 312 (c) Assessments conducted in the participant's home by 313 a pharmacist, nurse, or local home health care agency 314 trained in bleeding disorders when deemed necessary by the 315 participant's treating physician; 316 (25) The MO HealthNet division shall, by January 1, 317 2008, and annually thereafter, report the status of MO 318 HealthNet provider reimbursement rates as compared to one 319 hundred percent of the Medicare reimbursement rates and 320 compared to the average dental reimbursement rates paid by 321 third-party payors licensed by the state. The MO HealthNet 322 division shall, by July 1, 2008, provide to the general 323 assembly a four-year plan to achieve parity with Medicare 324 reimbursement rates and for third-party payor average dental 325 reimbursement rates. Such plan shall be subject to 326 appropriation and the division shall include in its annual 327 budget request to the governor the necessary funding needed 328 to complete the four-year plan developed under this 329 subdivision. 330 2. Additional benefit payments for medical assistance 331 shall be made on behalf of those eligible needy children, 332 SS#2 SCS SBs 49, 17 236 & 164 pregnant women and blind persons with any payments to be 333 made on the basis of the reasonable cost of the care or 334 reasonable charge for the services as defined and determined 335 by the MO HealthNet division, unless otherwise hereinafter 336 provided, for the following: 337 (1) Dental services; 338 (2) Services of podiatrists as defined in section 339 330.010; 340 (3) Optometric services as described in section 341 336.010; 342 (4) Orthopedic devices or other prosthetics, including 343 eye glasses, dentures, hearing aids, and wheelchairs; 344 (5) Hospice care. As used in this subdivision, the 345 term "hospice care" means a coordinated program of active 346 professional medical attention within a home, outpatient and 347 inpatient care which treats the terminally ill patient and 348 family as a unit, employing a medically directed 349 interdisciplinary team. The program provides relief of 350 severe pain or other physical symptoms and supportive care 351 to meet the special needs arising out of physical, 352 psychological, spiritual, social, and economic stresses 353 which are experienced during the final stages of illness, 354 and during dying and bereavement and meets the Medicare 355 requirements for participation as a hospice as are provided 356 in 42 CFR Part 418. The rate of reimbursement paid by the 357 MO HealthNet division to the hospice provider for room and 358 board furnished by a nursing home to an eligible hospice 359 patient shall not be less than ninety-five percent of the 360 rate of reimbursement which would have been paid for 361 facility services in that nursing home facility for that 362 patient, in accordance with subsection (c) of Section 6408 363 of P.L. 101-239 (Omnibus Budget Reconciliation Act of 1989); 364 SS#2 SCS SBs 49, 18 236 & 164 (6) Comprehensive day rehabilitation services 365 beginning early posttrauma as part of a coordinated system 366 of care for individuals with disabling impairments. 367 Rehabilitation services must be based on an individualized, 368 goal-oriented, comprehensive and coordinated treatment plan 369 developed, implemented, and monitored through an 370 interdisciplinary assessment designed to restore an 371 individual to optimal level of physical, cognitive, and 372 behavioral function. The MO HealthNet division shall 373 establish by administrative rule the definition and criteria 374 for designation of a comprehensive day rehabilitation 375 service facility, benefit limitations and payment 376 mechanism. Any rule or portion of a rule, as that term is 377 defined in section 536.010, that is created under the 378 authority delegated in this subdivision shall become 379 effective only if it complies with and is subject to all of 380 the provisions of chapter 536 and, if applicable, section 381 536.028. This section and chapter 536 are nonseverable and 382 if any of the powers vested with the general assembly 383 pursuant to chapter 536 to review, to delay the effective 384 date, or to disapprove and annul a rule are subsequently 385 held unconstitutional, then the grant of rulemaking 386 authority and any rule proposed or adopted after August 28, 387 2005, shall be invalid and void. 388 3. The MO HealthNet division may require any 389 participant receiving MO HealthNet benefits to pay part of 390 the charge or cost until July 1, 2008, and an additional 391 payment after July 1, 2008, as defined by rule duly 392 promulgated by the MO HealthNet division, for all covered 393 services except for those services covered under 394 subdivisions (15) and (16) of subsection 1 of this section 395 and sections 208.631 to 208.657 to the extent and in the 396 SS#2 SCS SBs 49, 19 236 & 164 manner authorized by Title XIX of the federal Social 397 Security Act (42 U.S.C. Section 1396, et seq.) and 398 regulations thereunder. When substitution of a generic drug 399 is permitted by the prescriber according to section 338.056, 400 and a generic drug is substituted for a name-brand drug, the 401 MO HealthNet division may not lower or delete the 402 requirement to make a co-payment pursuant to regulations of 403 Title XIX of the federal Social Security Act. A provider of 404 goods or services described under this section must collect 405 from all participants the additional payment that may be 406 required by the MO HealthNet division under authority 407 granted herein, if the division exercises that authority, to 408 remain eligible as a provider. Any payments made by 409 participants under this section shall be in addition to and 410 not in lieu of payments made by the state for goods or 411 services described herein except the participant portion of 412 the pharmacy professional dispensing fee shall be in 413 addition to and not in lieu of payments to pharmacists. A 414 provider may collect the co-payment at the time a service is 415 provided or at a later date. A provider shall not refuse to 416 provide a service if a participant is unable to pay a 417 required payment. If it is the routine business practice of 418 a provider to terminate future services to an individual 419 with an unclaimed debt, the provider may include uncollected 420 co-payments under this practice. Providers who elect not to 421 undertake the provision of services based on a history of 422 bad debt shall give participants advance notice and a 423 reasonable opportunity for payment. A provider, 424 representative, employee, independent contractor, or agent 425 of a pharmaceutical manufacturer shall not make co-payment 426 for a participant. This subsection shall not apply to other 427 qualified children, pregnant women, or blind persons. If 428 SS#2 SCS SBs 49, 20 236 & 164 the Centers for Medicare and Medicaid Services does not 429 approve the MO HealthNet state plan amendment submitted by 430 the department of social services that would allow a 431 provider to deny future services to an individual with 432 uncollected co-payments, the denial of services shall not be 433 allowed. The department of social services shall inform 434 providers regarding the acceptability of denying services as 435 the result of unpaid co-payments. 436 4. The MO HealthNet division shall have the right to 437 collect medication samples from participants in order to 438 maintain program integrity. 439 5. Reimbursement for obstetrical and pediatric 440 services under subdivision (6) of subsection 1 of this 441 section shall be timely and sufficient to enlist enough 442 health care providers so that care and services are 443 available under the state plan for MO HealthNet benefits at 444 least to the extent that such care and services are 445 available to the general population in the geographic area, 446 as required under subparagraph (a)(30)(A) of 42 U.S.C. 447 Section 1396a and federal regulations promulgated thereunder. 448 6. Beginning July 1, 1990, reimbursement for services 449 rendered in federally funded health centers shall be in 450 accordance with the provisions of subsection 6402(c) and 451 Section 6404 of P.L. 101-239 (Omnibus Budget Reconciliation 452 Act of 1989) and federal regulations promulgated thereunder. 453 7. Beginning July 1, 1990, the department of social 454 services shall provide notification and referral of children 455 below age five, and pregnant, breast-feeding, or postpartum 456 women who are determined to be eligible for MO HealthNet 457 benefits under section 208.151 to the special supplemental 458 food programs for women, infants and children administered 459 by the department of health and senior services. Such 460 SS#2 SCS SBs 49, 21 236 & 164 notification and referral shall conform to the requirements 461 of Section 6406 of P.L. 101-239 and regulations promulgated 462 thereunder. 463 8. Providers of long-term care services shall be 464 reimbursed for their costs in accordance with the provisions 465 of Section 1902 (a)(13)(A) of the Social Security Act, 42 466 U.S.C. Section 1396a, as amended, and regulations 467 promulgated thereunder. 468 9. Reimbursement rates to long-term care providers 469 with respect to a total change in ownership, at arm's 470 length, for any facility previously licensed and certified 471 for participation in the MO HealthNet program shall not 472 increase payments in excess of the increase that would 473 result from the application of Section 1902 (a)(13)(C) of 474 the Social Security Act, 42 U.S.C. Section 1396a (a)(13)(C). 475 10. The MO HealthNet division may enroll qualified 476 residential care facilities and assisted living facilities, 477 as defined in chapter 198, as MO HealthNet personal care 478 providers. 479 11. Any income earned by individuals eligible for 480 certified extended employment at a sheltered workshop under 481 chapter 178 shall not be considered as income for purposes 482 of determining eligibility under this section. 483 12. If the Missouri Medicaid audit and compliance unit 484 changes any interpretation or application of the 485 requirements for reimbursement for MO HealthNet services 486 from the interpretation or application that has been applied 487 previously by the state in any audit of a MO HealthNet 488 provider, the Missouri Medicaid audit and compliance unit 489 shall notify all affected MO HealthNet providers five 490 business days before such change shall take effect. Failure 491 of the Missouri Medicaid audit and compliance unit to notify 492 SS#2 SCS SBs 49, 22 236 & 164 a provider of such change shall entitle the provider to 493 continue to receive and retain reimbursement until such 494 notification is provided and shall waive any liability of 495 such provider for recoupment or other loss of any payments 496 previously made prior to the five business days after such 497 notice has been sent. Each provider shall provide the 498 Missouri Medicaid audit and compliance unit a valid email 499 address and shall agree to receive communications 500 electronically. The notification required under this 501 section shall be delivered in writing by the United States 502 Postal Service or electronic mail to each provider. 503 13. Nothing in this section shall be construed to 504 abrogate or limit the department's statutory requirement to 505 promulgate rules under chapter 536. 506 14. Beginning July 1, 2016, and subject to 507 appropriations, providers of behavioral, social, and 508 psychophysiological services for the prevention, treatment, 509 or management of physical health problems shall be 510 reimbursed utilizing the behavior assessment and 511 intervention reimbursement codes 96150 to 96154 or their 512 successor codes under the Current Procedural Terminology 513 (CPT) coding system. Providers eligible for such 514 reimbursement shall include psychologists. 515 15. There shall be no payments made under this section 516 for gender transition surgeries, cross-sex hormones, or 517 puberty-blocking drugs, as such terms are defined in section 518 191.1720, for the purpose of a gender transition. 519 217.230. The director shall arrange for necessary 1 health care services for offenders confined in correctional 2 centers, which shall not include any gender transition 3 surgery, as defined in section 191.1720. 4 SS#2 SCS SBs 49, 23 236 & 164 221.120. 1. If any prisoner confined in the county 1 jail is sick and in the judgment of the jailer, requires the 2 attention of a physician, dental care, or medicine, the 3 jailer shall procure the necessary medicine, dental care or 4 medical attention necessary or proper to maintain the health 5 of the prisoner; provided, that this shall not include any 6 gender transition surgery, as defined in section 191.1720. 7 The costs of such medicine, dental care, or medical 8 attention shall be paid by the prisoner through any health 9 insurance policy as defined in subsection 3 of this section, 10 from which the prisoner is eligible to receive benefits. If 11 the prisoner is not eligible for such health insurance 12 benefits then the prisoner shall be liable for the payment 13 of such medical attention, dental care, or medicine, and the 14 assets of such prisoner may be subject to levy and execution 15 under court order to satisfy such expenses in accordance 16 with the provisions of section 221.070, and any other 17 applicable law. The county commission of the county may at 18 times authorize payment of certain medical costs that the 19 county commission determines to be necessary and 20 reasonable. As used in this section, the term "medical 21 costs" includes the actual costs of medicine, dental care or 22 other medical attention and necessary costs associated with 23 such medical care such as transportation, guards and 24 inpatient care. 25 2. The county commission may, in their discretion, 26 employ a physician by the year, to attend such prisoners, 27 and make such reasonable charge for his service and 28 medicine, when required, to be taxed and collected as 29 provided by law. 30 3. As used in this section, the following terms mean: 31 SS#2 SCS SBs 49, 24 236 & 164 (1) "Assets", property, tangible or intangible, real 32 or personal, belonging to or due a prisoner or a former 33 prisoner, including income or payments to such prisoner from 34 Social Security, workers' compensation, veterans' 35 compensation, pension benefits, previously earned salary or 36 wages, bonuses, annuities, retirement benefits, compensation 37 paid to the prisoner per work or services performed while a 38 prisoner or from any other source whatsoever, including any 39 of the following: 40 (a) Money or other tangible assets received by the 41 prisoner as a result of a settlement of a claim against the 42 state, any agency thereof, or any claim against an employee 43 or independent contractor arising from and in the scope of 44 the employee's or contractor's official duties on behalf of 45 the state or any agency thereof; 46 (b) A money judgment received by the prisoner from the 47 state as a result of a civil action in which the state, an 48 agency thereof or any state employee or independent 49 contractor where such judgment arose from a claim arising 50 from the conduct of official duties on behalf of the state 51 by the employee or subcontractor or for any agency of the 52 state; 53 (c) A current stream of income from any source 54 whatsoever, including a salary, wages, disability benefits, 55 retirement benefits, pension benefits, insurance or annuity 56 benefits, or similar payments; and 57 (2) "Health insurance policy", any group insurance 58 policy providing coverage on an expense-incurred basis, any 59 group service or indemnity contract issued by a not-for- 60 profit health services corporation or any self-insured group 61 health benefit plan of any type or description. 62 