MHA Summary of Senate Bill 577 — MO HealthNet

The Missouri General Assembly's 2007 session ended Friday, May 18. One major piece of legislation passed was Senate Bill 577, also known as the Medicaid reform bill. The measure revamps state laws governing Medicaid and renames the program as “MO HealthNet.” The bill includes the following components.

Delivery Models and Program Implementation

• The Missouri Department of Social Services, with the approval of the MO HealthNet Oversight Committee, will create health improvement plans for MO HealthNet recipients. Each plan will be one of three models.

  • a risk-bearing coordinated care plan

  • an administrative services organization

  • a coordinated fee-for-service plan (§208.950)

• All MO HealthNet participants will be enrolled in a health improvement plan. Enrollment in health improvement plans will begin July 1, 2008, and be completed by July 1, 2011. (§208.950)

• Health improvement plans will provide MO HealthNet participants with a “health care home,” help enrollees receive care in the least restrictive environment, offer call centers and nurse help lines, and report participant and provider satisfaction annually. (§208.950)

• By July 1, 2008, health improvement plans will conduct a health risk assessment and develop a care plan for each participant. The plan will have health status goals appropriate for the participants’ age and health risk. (§208.950)

• Risk-bearing health plans and administrative services organizations will incur financial penalties if specified quality targets are not met. One target is the rate at which their enrollees seek to use hospital emergency departments for nonemergency medical conditions. (§208.950)

• Health improvement plans will be evaluated based on various factors. (§208.950)

• Aged, blind, or disabled MO HealthNet participants will not be required to enroll in a risk-bearing coordinated care plan. (§208.950)

• Health improvement plan contracts will be awarded based on competitive bid, with requests for proposals issued for at least six regions in the state. No vendor will be issued a single statewide contract, but this requirement will not void the state’s current contract for chronic care improvement services in place on August 28, 2007. Risk-bearing care coordination plans serving counties as of July 2007 will continue to serve their contractual enrollees.

• The Department of Social Services is to use a public process for designing and implementing standards for health improvement plans and for the MO HealthNet program generally. (§208.950)

Eligibility Standards

• A “premium offset” program is authorized. It would use state and federal funds to offset some of the cost of standardized private health insurance coverage for individuals who have been uninsured for one year and whose income does not exceed 185 percent of the federal poverty level. The offset would be available only if the employee or employer, or both, pay their required shares of the premium. An employee may directly enroll in the program if his or her employer does not participate. An employer may not participate for more than five years. Subject to MO HealthNet Oversight Committee approval, the program will be implemented in two regions, with one in an urban area and one in a rurual area. Unless reauthorized, the program will end June 30, 2011. The MO HealthNet Division will apply for federal waivers or plan amendments to implement the program. (§208.202)

• A “Ticket to Work Health Assurance Program” is created to extend MO HealthNet coverage to certain working disabled people. (§208.146)

• Subject to federal approval, participants in state drug court programs may receive a temporary extension of MO HealthNet coverage under certain circumstances. (§208.151)

• MO HealthNet coverage is extended to independent foster care adolescents between ages 18-21. (§208.151)

• New standards are established to determine whether a child is deemed to have access to affordable coverage, which is a criterion for coverage eligibility under the State Children’s Health Insurance Program. (§208.640)

• Income from employment at a sheltered workshop will not be considered in determining eligibility for coverage. (§208.152)

• Cost-of-living increases for Social Security will be disregarded until the federal poverty level for that year is implemented. (§208.153)

• Eligibility standards for the Uninsured Women’s Health Care program are revised to extend coverage to uninsured women with household incomes not exceeding 185 percent of the federal poverty level and assets of less than $250,000. The program provides women’s health services to participants. (§208.659)

• Spend-down expenditures may be carried forward under certain circumstances. (§208.153)

Covered Services

• Durable medical equipment is named as a covered MO HealthNet service, with a Web-based prior authorization system used to verify medical need. (§208.152)

• Hospice care is named as a covered MO HealthNet service. (§208.152)

• Subject to appropriations, optometric and dental services are named as covered MO HealthNet services, with a Web-based prior authorization system used to verify medical need. (§208.152)

• The MO HealthNet Division will cover services delivered through telehealth on the same basis as in-person contacts. The Department of Social Services will establish regulations governing the program’s standards for telehealth. Patient consent must be obtained before initiating telehealth services. (§208.670)

• The bill limits the MO HealthNet program’s ability to control access to psychotropic drugs covered under a fee-for-service health improvement plan. (§Section 2)

Provider Payment

• The MO HealthNet Division is to annually report on the status of provider reimbursement rates compared to Medicare rates. For dentists, the MO HealthNet payment rates will be compared to average third-party payor rates. The division is to develop a four-year plan to achieve parity with Medicare rates and third-party dental reimbursement rates. Implementation of the plan will be subject to appropriation, but the division is to include the funding needed to implement the plan in its annual budget request to the governor. (§208.152)

• Subject to appropriations, the MO HealthNet Division will implement a pay-for-performance system developed under the auspices of a professional services payment committee. Employers of physicians whose work generates a portion of an incentive payment will pass that portion, as defined by regulation, to the physician. (§208.153)

• Applications for Medicaid waivers may not seek to waive the services or payment standards for federally qualified health centers or rural health clinics except as authorized by the MO HealthNet Oversight Committee. (§208.151)

• Certified pediatric or family nurse practitioners must have collaborative practice arrangements with physicians to qualify as MO HealthNet providers. (§208.152)

• Current law requiring second opinions to authorize payment for surgery is repealed. (§208.152)

Cost-sharing

• After July 1, 2008, enrollee cost-sharing will be in the form of payments that will be in addition to rather than in lieu of the provider payment. (§208.152)

Program Administration

• A MO HealthNet Oversight Committee is created to oversee various aspects of the program’s development and implementation. (§208.955)

• A committee is created to advise the Department of Social Services about the development of a comprehensive entry point for long-term care. (§208.955)

• A legislative Joint Committee on MO HealthNet is created to assess the program’s need for resources to continue and improve the program. (§208.952)

• A Professional Services Payment Committee is established to develop and oversee the pay-for-performance guidelines authorized by the legislation. (§208.197)

• The Department of Social Services will commission an independent survey to assess health delivery system indicators, including provider availability in the MO HealthNet program compared to the general population. (§208.950)

• The General Assembly’s Legislative Budget Office will conduct an annual rolling five-year forecast for MO HealthNet budgets and enrollment. (§Section 1)

• The legislation modifies various standards governing the Department of Social Services’ rights of subrogation of third-party benefits available to enrollees. (§208.215, 208.217, 473.398)

Access to Providers

• Liability coverage under the State Legal Expense Fund is extended to various practitioners working in certain clinic settings, including physicians and dentists who provide care without compensation to patients referred for treatment by those clinics. (§105.711)

• Authorizes a capped amount of income tax credits for contributions of money or equipment to be used to improve access to health care services at practice settings in health professional shortage areas. Monetary contributions will generate state matching funds. (§135.575, 191.1050 to 191.1056)

• Health Access Incentives Fund monies may be appropriated to enhance MO HealthNet payments to psychologists, psychiatrists and other mental health providers in shortage areas. Also, psychiatrists and psychologists are specifically made eligible for the PRIMO program of state incentives to encourage practice in underserved areas. (§191.411)

Fraud

• Individuals reporting allegations of suspected Medicaid provider fraud may receive 10 percent of amounts subsequently recovered by the state attorney general under current Medicaid fraud statutes. (§191.907)

• The legislation modifies the definition of Medicaid fraud and increases some penalties for violating Medicaid fraud statutes. The fraud standards will apply to state employees, representatives and subcontractors. (§191.900, 191.905)

• With specified exceptions, employers may not discriminate against an employee who reports allegations of Medicaid fraud. (§191.908)

• Persons or facilities discovering fraud violations and reporting them voluntarily will not be subject to criminal prosecution. (§191.900)

• The attorney general’s office will annually report on Medicaid fraud investigations and recoveries. (§191.909)

• Recording-keeping requirements pertinent to Medicaid claims are established. (§191.910)

• Criminal penalties are established for intentionally filing a false allegation of fraud. (§191.914)

• The MO HealthNet Oversight committee will study whether to establish a state office of inspector general to promote program accountability and deter fraud in the MO HealthNet program. (§208.952)

• Medicaid fraud recoveries not otherwise allocated will be used to raise MO HealthNet provider reimbursement rates. (§191.900)

Technology

• The legislation creates a “Health Technology Fund” and standards for its use and administration. (§208.975, 208.978)

Long-Term Care

• Current law grants a state income tax deduction for 50 percent of unreimbursed long-term care insurance premiums that are not included in itemized deductions. This bill allows all such premiums to be deductible. (§135.096)

• Assisted living facilities are given deadlines for implementing physician orders for a resident discharged from a hospital or nursing home. (§198.069)

• New standards are created governing criminal penalties for individuals who assume responsibility for managing the funds of an elderly or disabled person who is a nursing home resident and fail to pay the facility. (§198.097)

• MO HealthNet coverage of nursing home care will not be available to those with more than $500,000 equity in a home. (§208.151)

• The legislation refashions current law creating a Long-Term Care Partnership program. In determining eligibility for coverage of long-term care services, the MO HealthNet program would disregard the value of assets equal to the value of a private long-term care insurance policy purchased by the applicant. (§208.690 to 208.698)

Personal Care

• Personal care services will be authorized based on a tiered system of care needs, subject to federal approval. (§208.152)

• Standards for assessing the value of a personal care contract and its effect on eligibility for an institutionalized individual are established. (§208.213)

• The expiration date of a law authorizing a consumer-directed personal care program is extended until 2019. (§208.930)

Other

• The legislation codifies in law an executive order that calls for the state to report on the employers who have 50 or more employees, employee spouses or dependents who are MO HealthNet enrollees. (§208.230)

• A Chronic Kidney Disease Task Force is created and will complete its work by August 30, 2008. (§192.632)

• A not-for-profit corporation may implement a family development account. (§208.750)

• The expiration dates on laws governing the SCHIP and the former Medicaid laws are repealed, and standards are established for the implementation of the SCHIP program as federal funds are available. (§208.631, 208.014)