13 CSR — Department of Social Services

Division 5 Office of the Director

Chapter 1 Public Records

13 CSR 5-1.030 Access for Inspection of Public Records and Fees for Copying of JASONKANDER(1/30/16) {#sec-13-csr-5-1.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 5-1.030}

SOCIAL SERVICES

13 CSR 5-1.030 Access for Inspection of Public Records and Fees for Copying of Public Records {#sec-13-csr-5-1.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 5-1.030}

PURPOSE: This rule supplements the requirements of Chapter 610 RSMo and prescribes requirements for individuals and organizations to gain access to public records of the department and the fees for copying of those public records.

(1) In this section the following words shall mean:

(A) The “department” shall mean the Missouri Department of Social Services including any division, subdivision, center, unit, or

part thereof; and (B) The remainder of the terms used in this

rule shall have the same meaning as that set forth in Chapter 610, RSMo.

(2) For requests for public records made under

Chapter 610, RSMo, the Communications Director of the Department of Social Services shall be the custodian of records. All requests for access to, or copying of, public records made to the department under Chapter 610, RSMo, shall be directed to the Communications Director. Such requests may be made in person, by telephone, electronic mail, facsimile, internet, postal mail, or by any other convenient means to the department’s Custodian of Records at the following address: Communications Director, Department of Social Services, PO Box 1527, Jefferson City, MO 65102.

(3) Copies of public records shall be provided by the department and shall be subject to the collection of search and copy fees and shipping charges as set forth herein. Requesters may avoid shipping charges by picking up their requested documents at the Office of the Director, Missouri Department of Social Services, 221 W. High, Room 240, Jefferson City, MO 65101. Requesters shall request to pick up their requested records at the time of their initial request. Copies of public records will be provided by the department subject to the copy and search fees set forth in section 610.026, RSMo.

(4) Fees for duplicating other types of records and other formats including electronic data shall be based on the actual cost of search and duplication, or as otherwise provided by section 610.026, RSMo.

(5) In accordance with section 610.026, RSMo, the department may furnish copies without charge or at a reduced charge when the department determines that waiver or reduction of the fee is in the public interest because it is likely to contribute significantly to public understanding of the operations or activities of the department and is not primarily in the commercial interest of the requester.

section 660.017, RSMo 2000.* Original rule filed July 29, 2015, effective Feb. 29, 2016. *Original authority: 610.010, RSMo 1973, amended 1977, 1978, 1982, 1987, 1993, 1998, 2004; 610.011, RSMo 1987, amended 2004; 610.015, RSMo 1973, amended 1987, 1993, 1998, 2004, 2013; 610.020, RSMo 1973, amended 1982, 1987, 1993, 1998, 2004; 610.021, RSMo 1987, 1993, 1995, 1998, 2002, 2004, 2008, 2009, 2013; 610.022, RSMo 1987, amended 1993, 1998, 2004; 610.023, RSMo 1987, amended 1998, 2004; 610.024, RSMo 1993; 610.025, RSMo 2004; 610.026, RSMo 1987, amended 1998, 2004; 610.027, RSMo 1982, amended 1987, 1990, 1998, 2004; 610.028, RSMo 1982, amended 1987, 2004; 610.029, RSMo 1993, amended 1998, 2004, 2014; 610.030, RSMo 1973, amended 1982, 1998; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 610.010–610.030, RSMo 2000, Supp. 2013, and Supp. 2014, and

Chapter 2 State Technical Assistance Program

13 CSR 5-2.010 Organization and Operation {#sec-13-csr-5-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 5-2.010}

PURPOSE: This rule describes the general organization and function of the State Technical Assistance Team including its responsibilities in providing technical assistance to the multidisciplinary child protection members of the Child Fatality Review Program (CFRP) panels in investigating and prosecuting cases involving child abuse, child neglect, child sexual abuse, child exploitation, or child fatality review. This rule also establishes and describes the functions of local (county)

CFRP panels, as well as the state CFRP panel in this child protective services process.

(1) General Provisions and Authority. This

rule is promulgated under the rulemaking

(2) Definition.

(A) Child fatality means the death of a child under the age of eighteen years, as a result of any natural, intentional, or unintentional act.

(3) State Technical Assistance Team.

(A) The State Technical Assistance Team shall assist in the investigation of child abuse, child neglect, child sexual abuse, child exploitation, child pornography, or child fatality cases upon the request of:

1. A federal, state, or local law enforcement agency;

2. A county, state, or federal prosecutor;

3. Children’s Division staff;

4. A representative of the family courts;

5. Medical examiner;

6. Coroner; or 7. Juvenile officer.

(B) Upon being requested to assist in an investigation, the State Technical Assistance Team shall notify all parties specified in sub-

section (3)(A) of STAT’s involvement in the investigation via email or personal contact.

(C) Where STAT’s assistance has been requested, STAT investigators, licensed as peace officers by the director of the Department of Public Safety pursuant to Chapter 590, RSMo, shall be deemed to be peace officers within the state of Missouri. The power of arrest of a STAT investigator, acting as a peace officer, shall be limited to offenses involving child abuse, child neglect, child sexual abuse, child exploitation, child pornography, or child fatality or in situations of imminent danger to the investigator or another person. STAT investigators are authorized to carry firearms as noted in

Chapter 571.030, RSMo, both on or off duty.

(D) STAT shall assist county multidisciplinary teams in the development and implementation of protocols for the investigation and prosecution of child abuse, child neglect, child sexual abuse, child exploitation, child pornography, or child fatality cases.

(E) All reports and records made and maintained by the STAT or local law enforcement relating to criminal investigations conducted pursuant to this section, including arrests, shall be available in the same manner as law enforcement records, as set forth in sections 610.100 to 610.200, RSMo, and to the individuals identified in subdivision (13) of subsection 2 of section 210.150, RSMo.

(F) An individual identified in subdivision (13) of subsection 2 of section 210.150, RSMo, is a person who is a tenure-track or full-time research faculty member at an accredited institution of higher education engaged in scholarly research and who has the permission of the director of the Department of Social Services. Prior to the release of any identifying information the director of the DSS shall require the researcher to present a plan for maintaining the confidentiality of the identifying information. The researcher shall be prohibited from releasing the identifying information of individual cases.

(G) All other records shall be available in the same manner as provided in section 210.150, RSMo. Nothing in this section shall preclude the release of findings or information about cases which resulted in a child fatality or near fatality. Such release is at the sole discretion of the director of the Department of Social Services, based upon the review of the potential harm to other children with the immediate family.

(4) Local (County) Child Fatality Review Program (CFRP) Panels.

(A) The prosecuting attorney, or circuit attorney, or upon vacancy of the CFRP chairpersonship, shall convene a local CFRP panel in each of the state’s one hundred fourteen (114) counties and St. Louis City to review suspicious child deaths.

(B) The Department of Social Services (DSS) shall convene a state CFRP panel appointed by the director of DSS to identify systemic problems and submit findings and recommendations on ways to prevent further child deaths.

(C) The local CFRP panel will review all deaths of children less than eighteen (18) years of age at the time of their death where one or more of the following factors are present:

1. Sudden, unexplained death of a child under age one (1) year;

2. Unexplained/undetermined manner;

3. Children’s Division reports on decedent or other persons in the residence;

4. Decedent in Children’s Division or Division of Youth Services’ custody;

5. Possible inadequate supervision of the decedent;

6. Possible malnutrition or delay in seeking medical care;

7. Possible suicide;

8. Possible inflicted injury;

9. Firearm injury;

10. Injury not witnessed by person in charge of child at time of injury;

11. Confinement;

12. Suspicious/criminal activity;

13. Drowning;

14. Suffocation or strangulation;

15. Poison/chemical/drug ingestion;

16. Severe unexplained injury;

17. Pedestrian/bicycle/driveway injury;

18. Vehicular injury;

19. Suspected sexual assault;

20. Fire injury;

21. Autopsy by certified child death pathologist;

22. Panel discretion;

23. Other suspicious findings (injuries such as electrocution, crush or fall);

24. Other suspicious child deaths in family/household; or 25. Animal-related death.

(D) The local CFRP panel at least shall review the following information on all suspicious deaths:

1. Findings from interviews, history, or death-scene investigation;

2. Physical evidence at the scene of injury, death, or both;

3. Findings from physical and medical examinations;

4. Findings from autopsy, radiological examination, and laboratory evaluation;

5. Reports of investigation/evaluation;

6. Relevant past history/agency involvement;

7. Community services that may be offered to the family and/or community; and 8. Prevention actions or best practices to prevent future deaths.

(E) The Children’s Division shall appoint regional coordinators to serve as resources to local CFRP panels. The regional coordinators will provide the following services:

1. Consultation and technical assistance;

2. Provide recommendations on procedures developed by local panels.

(F) Initially, all panel members will be appointed by the prosecuting attorney. Subsequent appointments will be made by the chairperson and require majority approval of the core panel members. All members who represent a governmental agency defined as mandatory in this section will serve as long as they hold the position which made them eligible for appointment to the local CFRP panel. All other members shall serve a term which is defined in the procedures developed by the local panel. The local procedures shall also define the selection and removal processes for non-core members. The chairperson shall be elected by the review panel.

The chairperson and all other members may be reappointed for consecutive terms. The local CFRP panel shall include, but not be limited to, the following core members:

1. The prosecuting or circuit attorney;

2. Medical examiner/coroner;

3. A law enforcement officer;

4. A representative of the Children’s Division;

5. A provider of public health services;

6. A representative of the juvenile court;

7. A representative of emergency medical services.

Optional panel members may also serve either temporarily, based upon their knowledge or expertise in the type of child death being reviewed; or regularly, as other professionals or citizens with special interest in child abuse and neglect, based upon continued approval of the core panel members.

(G) If the county of residence, illness/injury/event, or death are different, the CFRP panel in the county where the illness/injury/event occurred shall review the death.

1. The activated review panel may communicate with the chairperson of the CFRP panel in the county of residence and death, if different, to request necessary information.

2. The review panel in the county of death, residence, or both, may choose to review the death.

3. The national center for fatality review and prevention Internet-based case reporting system - case report, must be completed on all children ages birth through seventeen (0- 17) who die in Missouri, regardless of state of residence.

4. Children injured out of state, who die in Missouri, may be reviewed at the sole discretion of the county panel, regardless of state of residence.

(H) The panel members will hold all information obtained in the course of a review in the strictest confidence and will not discuss or disclose any information regarding any case, except as permitted by applicable statutes.

(I) STAT will not reimburse or compensate a county CFRP panel for expenses associated with review panel business. Expenses may be reimbursed consistent with state travel rules and limitations for required participation of STAT panel members for review and panel training purposes. STAT will be responsible for payment of expenses, subject to state travel rules and limitations, and compensation for its employees who are members of a review panel.

(J) The following process will be followed by the county CFRP panels:

1. Any police officer, sheriff, law enforcement officer or official, physician, coroner/medical examiner, funeral director, hospital personnel, or any person having knowledge that a person less than eighteen (18) years of age has died, shall notify the coroner or medical examiner immediately in the county of death.

A. If the coroner or medical examiner in the county of death or residence is notified of a death, s/he shall notify the coroner or medical examiner immediately in the county of illness/injury/event, if different.

B. If the coroner or medical examiner in the county of illness/injury/event determines that the death of the person under age eighteen (18) does not exhibit any suspicious circumstances as described in this section, the coroner/medical examiner will be responsible for notifying the panel chairperson of the death within seventy-two (72) hours and completing the appropriate sections of the national center for fatality review and prevention Internet-based case reporting system case report and circumstances. If the chairperson disagrees with the coroner or medical examiner regarding the nature of the death and desires a review, the review panel can be activated.

C. The coroner or medical examiner in the county of illness/injury/event shall notify a certified child death pathologist to determine the need for an autopsy. If there is disagreement, the certified child death pathologist shall make the determination, unless the CFRP panel, within twenty-four (24) hours, decides against the certified child death pathologist.

D. If the coroner or medical examiner determines that the child died from natural causes while under medical care, such coroner or medical examiner shall notify Children’s Division (Central Registry Unit, “Child Abuse/Neglect Hotline”—800-392- 3738 or by online system for reporting child abuse and neglect). In all other cases, the medical examiner or coroner shall immediately notify the Children’s Division of the child’s death, as required by section 58.452, RSMo;

2. The coroner or medical examiner in the county of illness/injury/event shall notify the chairperson of the CFRP panel immediately if the death is suspicious;

3. Upon notification, the chairperson will activate the review panel within seventytwo (72) hours and schedule a meeting to review the death.

A. Each member of the panel shall share information and records available to that panel member.

B. Each review panel shall operate the 4CODE OF STATE REGULATIONS (2/28/19) JOHNR. ASHCROFT review based on procedures developed by the panel and based on guidelines and protocols developed by the DSS;

4. The review panel shall determine, at a minimum:

A. The place where the injury/illness causing a death occurred;

B. The manner and circumstances of the death;

C. Actions taken by the agencies/persons involved with the child and his/her family;

D. The identification of any siblings or other children in the home of the deceased child and whether they require protection;

E. The identification of services that can be provided to the family and/or community;

F. The identification of prevention actions and/or best practices that can prevent future child deaths; and G. The identification of local systemic issues or policies which enhance or detract from efforts to assist in the investigation, treatment, or prevention of fatalities; and 5. The chairperson of the local CFRP panel will review, update, and complete the national center for fatality review and prevention Internet-based case reporting system case report that was initiated by the coroner or medical examiner, within sixty (60) days of the date of death, or within thirty (30) days of receipt of autopsy report, if child was autopsied.

(K) Final Report.

1. In all cases reviewed by a CFRP panel, the CFRP shall, after completing the review, prepare a Final Report which shall consist of a summary of prevention conclusions and recommendations. The Final Report shall be submitted on a form referred to as the Child Fatality Review Panel Final Report (or Final Report). Pursuant to section 210.192.3, RSMo, the Final Report issued by the panel is a public record and may be obtained by submitting a written request to the following address: State Technical Assistance Team, PO Box 208, Jefferson City, MO 65102-0208.

2. The CFRP panel’s Final Report will be forwarded directly to the State Technical Assistance Team, within ten (10) days of the final CFRP panel review, except in cases where criminal charges are being considered or pending. In those cases, the final report of the panel will be due within ten (10) days after a criminal indictment or information is filed in the case, or the local panel chair is notified of the prosecutor’s decision not to file charges.

3. STAT will be a direct liaison with all CFRP panels, in providing prevention resource guidance and facilitation in the implementation of appropriate prevention strategies and responses.

4. Separate from data collected, STAT will track the effectiveness of various prevention responses to specific risks, and will make this information available to the state CFRP panel and appropriate supporting agencies.

(5) State Child Fatality Review Panel.

(A) The state CFRP panel shall be composed of a minimum of seven (7) members.

All members will be appointed by the director of the DSS.

1. Members mandated by this rule to be members of this panel may serve as long as they hold the position which made them eligible for appointment.

2. The DSS shall establish procedures which define the terms for all members, reasons for the removal of members from the panel and how members will be appointed in the future.

3. The chairperson and all members may be reappointed for consecutive terms.

(B) The director of DSS shall appoint the following persons to serve on the state CFRP panel:

1. A prosecuting attorney or circuit attorney;

2. A coroner or medical examiner;

3. A law enforcement officer or official;

4. A representative from the Children’s Division;

5. A provider of public health care services;

6. A representative from the Department of Health and Senior Services;

7. A representative of the juvenile court;

8. A representative of emergency medical services.

(C) Other members of the state CFRP panel may include persons from the following agencies/groups:

1. Division of Youth Services;

2. Attorney General;

3. Missouri Juvenile Justice Association;

4. A physician experienced in examining and treating abused/neglected children;

5. Department of Mental Health;

6. Department of Public Safety;

7. Department of Elementary and Secondary Education;

8. Department of Corrections; and 9. Any other professionals or citizens with special interest in child abuse and neglect.

(D) The state CFRP panel will meet at least biannually. STAT may reimburse the members who are not division employees for reasonable expenses, consistent with state travel rules and limitations for expenses associated with review panel business held outside their county of residence, but will not provide for any other compensation. Children’s Division will be responsible for the reimbursement of expenses, subject to state travel rules and limitations, and compensation for its employees on the panel.

(E) The state CFRP panel shall review and discuss all relevant materials submitted by the state CFRP panel members, the local CFRP panels, and STAT. The purpose of the review will be to:

1. Review the findings of the county CFRP panels to determine the frequency and cause of child fatalities throughout the state;

2. Identify the appropriateness and comprehensiveness of cur rent statutes, policies, and procedures relevant to the management of fatal abuse/neglect cases;

3. Review data collected by the DSS, STAT to determine the accuracy of identification of fatally abused and neglected children;

4. Review reports on the status of the operations of the county CFRP panels; and 5. Recommend prevention strategies after reviewing statewide trends and actions suggested by local panels.

(F) The panel members will hold all information obtained in the course of a review in the strictest confidence and will not discuss or disclose any information regarding any case, except as permitted by applicable statutes.

(G) DSS and the state CFRP panel annually shall evaluate the following factors related to the work of the local CFRP panels:

1. Number of reviews;

2. Geographic area of reviews;

3. Results of reviews; and 4. Necessary amendments to the rules.

(H) The state CFRP panel shall submit findings and recommendations to the director of DSS, the governor, the speaker of the house of representatives, the president pro tempore of the senate, and the children’s services commission, juvenile officers, and chairperson of the local CFRP panels. At a minimum, the findings shall address the following issues:

1. The number of child fatality cases reviewed by county panels;

2. Non-identifying characteristics for perpetrators;

3. Non-identifying characteristics for deceased children;

4. The number of fatalities by cause(s) of death and whether death was attributable to child abuse/neglect;

5. Effectiveness of local panels; and 6. Systemic issues which need to be addressed through changes in policy, procedures, or statute.

Emergency rule filed Dec. 19, 2000, effective Jan. 1, 2001, expired June 29, 2001. Original

rule filed Dec. 19, 2000, effective June 30, 2001. Moved to 13 CSR 5-2.010 and amended: Filed Aug. 8, 2018, effective March 30, 2019. *Original authority: 210.192, RSMo 1991, amended 1991, 1994, 2000, 2014; 210.194, RSMo 1991, amended 1993, 1994, 1995; 210.195, RSMo 1991, amended 1994, 2000; 210.196, RSMo 1991, amended 1993, 1994, 1995, 2014; 660.017, RSMo 1993, amended 1995; 660.520, RSMo 1990, amended 2000, 2004; 660.523, RSMo 1990, amended 2014; 660.525, RSMo 1990, amended 2014; 660.526, RSMo 1994, amended 2014; and 660.528, RSMo 2000.

6CODE OF STATE REGULATIONS

(2/28/19) JOHNR. ASHCROFT

History

• authority granted to the Department of Social Services (DSS) pursuant to section 660.017, RSMo. Pursuant to Article IV, Section 37 of the Missouri Constitution, the director of the Department of Social Services is charged with promoting improved health and other social services to the citizens of the state as provided by law. Section 660.010.2, RSMo, authorizes the DSS director to coordinate the state’s programs devoted to those who are unable to provide for themselves and for victims of social disadvantage. Section 660.012.2, RSMo, also entrusts the DSS director with the duty to use the resources allocated to the department to provide comprehensive programs and leadership in order to improve services and economical operations. To that end, the DSS director has determined that the State Technical Assistance Team (STAT) under the Office of the Director (OD) improves the efficiency and economical operations of resources and maximizes services to the citizens of this state. This rule recognizes that STAT also provides a mechanism for the promulgation of procedures setting forth the function, general organization, and operation of the State Technical Assistance Team. As a unit of the Office of the Director, STAT is responsible for performing its duties related to child fatality review pursuant to sections 210.192 to 210.196, RSMo and its duties related to providing assistance to multidisciplinary teams and law enforcement agencies in investigating and prosecuting cases involving child abuse, child neglect, child sexual abuse, child exploitation, child pornography, or child fatality as prescribed in sections 660.520 to 660.527, RSMo. In performing its CFRP mission, STAT is responsible for providing training, expertise, and assistance to county CFRP panels for the review of child fatalities including establishing procedures for the collection and data entry into the national child death review Internet-based case reporting system, and preparation and submission of a Final Report by CFRP panels as reflected in subsection (4)(K) of this rule.
• AUTHORITY: sections 210.192–210.196, 660.017, and 660.520–660.528, RSMo 2016. This rule originally filed as 13 CSR 45-2.010.

Division 10 Division of Finance and Administrative Services

Chapter 1 Financial Services

13 CSR 10-1.015 Direct Deposit of Payments {#sec-13-csr-10-1.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-1.015}

(Rescinded August 30, 2018)

2014. Original rule filed April 22, 2015, effective Oct. 30, 2015. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: section 660.010, RSMo Supp.

Chapter 3 Tax Credits

13 CSR 10-3.010 Residential Treatment Agency Tax Credit 135.1150, RSMo, Residential Treatment Agency Tax Credit Act. {#sec-13-csr-10-3.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-3.010}

(1) A qualified residential treatment agency may apply for tax credits on behalf of taxpayers who make cash donations to the agency.

The amount of total credits available to any qualified residential treatment agency cannot exceed the total funds received from the Department of Social Services in the preceding twelve (12) months. Those who donate to qualifying providers are eligible to receive a tax credit up to fifty percent (50%) of their donation. Qualified residential treatment agencies that accept these donations are required to remit payments equivalent to the amount of the tax credit to the state of Missouri.

(2) Definitions.

(A) “Director” means the director of the (B) “Qualified residential treatment agency,” for the purpose of the Residential Treatment Agency Tax Credit, means a residential care facility that meets the definition stated in

section 135.1150, RSMo.

(3) Qualified residential treatment agencies must apply for the tax credit on behalf of the taxpayers. Required information includes:

(A) A complete and accurate Residential Treatment Agency Tax Credit Application.

Applications may be obtained at the Department of Social Services website: www.dss.mo.gov or by writing to— Attention: Residential Treatment Agency Tax Credit (B) Verification of accreditation status;

(C) A statement attesting to the receipt of 1. Taxpayer type and supporting documentation, when applicable;

2. Taxpayer’s name;

3. Taxpayer’s identification number;

4. Amount of the eligible donation and supporting documentation, when applicable;

5. Amount of anticipated tax credit;

6. Date the donation was received by the agency; and 7. Signature of the executive director;

(D) Payment from the qualified residential treatment agency equal to the value of the tax credit for which the application is being submitted. Checks must be made payable to the Department of Social Services; and (E) Verifying documentation must be on the type of donation. Required documen- 1. Cash—legible receipt from the residential treatment agency which indicates the name and address of the organization; name, tributor; amount and date the contribution was received; and signature of a representative of the residential treatment agency receiving the contribution;

2. Check—photocopy of the canceled the residential treatment agency including the same information required of a cash donation as described in paragraph (3)(E)1. of this

rule;

3. Credit card—legible transaction receipt with the name and address of the residential treatment agency; contributor’s name, address, and telephone number; the residential treatment agency receiving the contribution. Receipts should have the credit card account number blacked out;

4. Money order or cashier’s check—legname and address of the residential treatment agency; contributor’s name, address, and telephone number; amount and date the contribution was received; and signature of a representative of the residential treatment agency receiving the contribution;

5. Regarding contributions of stocks and 6. The value of contributions of real estate is the fair market value of the real estate within three (3) months of the date of the donation. The fair market value is the lower of at least two (2) qualified independent appraisals for commercial, vacant, or residential property that has been determined to have a value of over fifty thousand dollars ($50,000). Commercial, vacant, or residential property having a value of fifty thousand dollars ($50,000) or less will require only one (1) appraisal. The appraisals will be conducted by two (2) different licensed real estate appraisers; and 7. Contributions that include a benefit to that is needed in paragraphs (3) (E)1.–6., the residential treatment agency must provide written documentation of the type of function or event from which the benefit was received, description of the benefit received (if an auction item, identify the item received), gross (4) All applications and payments must be submitted within twelve (12) months from the taxpayer. Tax credit applications submitted more than one (1) year following the date of the contribution will be void and the right to the tax credit will be forfeited.

(5) Information required in section (3) of this

rule, must be submitted to the address refer- (6) Total tax credits issued for any qualified residential treatment agency cannot exceed the total payments made by the Department of Social Services to the qualified residential treatment agency in the twelve (12) months preceding the month the application for the tax credit was received. In the event the total credits exceed the total payments made to a qualified residential treatment agency by the Department of Social Services, the application and payment will be returned to the qualified residential treatment agency and may be resubmitted by the agency within thirty (30) days of the date the application was returned or within twelve (12) months from the date the donation was received by the agency, whichever is later.

(7) Upon receipt of the information required in subsection (3)(C) the Department of Social Services will verify with the Department of Revenue any outstanding balances due from (8) Upon verification of the information required in section (3) of this rule, the Department of Social Services will issue a certificate to the taxpayer indicating the amount of tax credit that was approved.

(A) Certificates will be mailed to the taxtion submitted by the qualified residential treatment agency.

(B) The Department of Social Services will not provide information regarding taxpayers’ state tax liability to unauthorized individuals.

(C) In the event a taxpayer’s tax credit is refund will not be issued to the qualified residential treatment agency.

(9) Approved tax credit certificates will be qualified residential treatment agency.

(10) When a certificate is assigned, transferred, sold, or otherwise conveyed, a notarized endorsement must be submitted to the (30) days of the date of the transaction. Information submitted must include:

(A) A complete and accurate Tax Credit Transfer Form found at the Department of Social Services website: www.dss.mo.gov.

Forms may also be obtained by writing to the address provided in subsection (3)(A).

Amended: Filed Feb. 25, 2013, effective Aug. 30, 2013. Moved to 13 CSR 10-3.010 and amended: Filed July 19, 2018, effective March 30, 2019. *Original authority: 135.1150, RSMo 2006, amended 2007, 2012, 2015 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 135.1150 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 35-100.010. Emergency rule filed Sept. 18, 2006, effective Oct. 1, 2006, expired March 29, 2007. Original rule filed Sept. 18, 2006, effective March 30, 2007.

13 CSR 10-3.020 Pregnancy Resource Center Tax Credit 135.630, RSMo, Pregnancy Resource Center Tax Credit to reflect the requirements of HB 1485 (2006). {#sec-13-csr-10-3.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-3.020}

(1) A qualified pregnancy resource center may apply for tax credits on behalf of taxpayers who make contributions to the agency.

The amount of tax credit issued may be equivalent to up to fifty percent (50%) of the contribution to the agency. Credits shall not be less than fifty dollars ($50) and cannot exceed fifty thousand dollars ($50,000) to a taxpayer in a fiscal year. The total amount of tax credits issued under this rule cannot exceed the amount stated in section 135.630, RSMo in any fiscal year.

(2) Definitions.

(A) “Director” means the director of the (B) “Qualified Pregnancy resource center,” for the purpose of the Pregnancy Resource Center Tax Credit, means a pregnancy resource center that meets the definition stated in section 135.630, RSMo.

(3) The director will annually develop and maintain a list of centers which are qualified for the Pregnancy Resource Center Tax Credit. A copy of the pregnancy resource center listing is posted on the DSS website and will be made available to taxpayers upon request (4) Annually, the director will determine which facilities in Missouri may be classified as pregnancy resource centers for purposes of the Pregnancy Resource Center Tax Credit.

To be a qualified center for purpose of the Pregnancy Resource Center Tax Credit, a facility must meet the definition set forth in

section 135.630, RSMo.

(A) In order for the director to make such determinations, centers seeking eligibility must submit the following information:

1. A complete and accurate Pregnancy Resource Center Tax Credit Application for Agency Eligibility Verification. Applications may be obtained at the Department of Social Services website: www.dss.mo.gov or by writing to— Attn: Pregnancy Resource Center Tax Credit Program PO Box 863 Jefferson City, MO 65102-0863;

2. A copy of certificate of incorporation;

3. Verification of Internal Revenue Service (IRS) tax-exempt status;

4. A brief program description including the number and ages of women served annually and the capacity of the facility;

5. All information should be submitted (B) All pregnancy resource centers must establish their eligibility for the Pregnancy Resource Center Tax Credit on an annual

basis by submitting an application for eligibility along with the required documentation as stated in subsection (4)(A) of this rule no later than June 1.

(C) Within forty-five (45) days of receipt of the required information, the director will make a determination of eligibility and notify the pregnancy resource center of the determination in writing. Upon a determination of eligibility, a center will automatically be added to the pregnancy resource center listing.

(D) Qualified centers must contact the (30) days of any changes in business func- The department will review the agency’s eligibility for participation in the tax credit program and notify the agency of the determination in writing.

(5) The director shall apportion the total available tax credits equally among all qualified pregnancy resource centers and the apportionment will be effective the first day of each state fiscal year (FY).

(A) The director shall inform each qualified pregnancy resource center of its share of the apportioned credits no later than thirty (30) days following July 1 of each fiscal year.

(B) The director shall no less than quarterly review the amount of apportioned tax credits being utilized by each qualified pregnancy resource center. Upon request by the director, pregnancy resource centers will provide in writing the amount their agency plans to utilize in tax credits for the fiscal year. Pregnancy resource centers seeking additional apportionment must submit a request to the director in writing. If a pregnancy resource center fails to use all, or a portion of its available credits throughout the fiscal year, the director may reapportion these unused tax credits to maximize the amount of tax credits available to taxpayers.

(C) Within thirty (30) days of any reapportionment, the director shall notify those pregnancy resource centers that would be affected by the reapportioned tax credit. The director will consider comments the pregnancy resource centers submit concerning planned future uses of the agency’s tax credit allocation prior to the end of the thirty- (30-) day period. The director’s decision regarding reapportionment shall be final.

(D) The cumulative amount of tax credits that may be claimed by taxpayers contributing to the centers shall not exceed the amount stated in section 135.630, RSMo.

(6) A qualified pregnancy resource center shall report the receipt of any contribution it believes qualifies for the tax credit on a form (2/28/19) JOHN R. ASHCROFT provided by the director. This form is known as the Pregnancy Resource Center Tax Credit Application For Claiming Tax Credits.

(A) Pregnancy resource centers may request the tax credit application at the Department of Social Services website www.dss.mo.gov or by writing to the address referenced in paragraph (4)(A)1.

(B) Pregnancy resource centers are permitted to decline a contribution from a taxpayer.

(C) The tax credit application shall be submitted to the director, by the pregnancy resource center within one (1) calendar year of the receipt of the contribution. Tax credit void and the right to the tax credit will be forfeited.

(D) Verifying documentation must be submitted by the Pregnancy Resource Center.

The type of documentation required will depend on the type of donation. Required documentation includes the following:

1. Cash—legible receipt from the pregnancy resource center, which indicates the name and address of the organization; name, tributor; amount of the cash donation and the nature of a representative of the pregnancy resource center receiving the contribution;

2. Check—photocopy of the canceled the pregnancy resource center including the same information required of a cash donation as described in paragraph (6)(D)1. of this

rule;

3. Credit card—legible transaction pregnancy resource center; name, address, and telephone number of the contributor; received; and a signature of a representative of the pregnancy resource center receiving the contribution. Receipts should have the credit card account number blacked out;

4. Money order or cashier’s check—legname and address of the pregnancy resource center; name, address, and telephone number of the contributor; amount of the cash donation and the date the contribution was received; and a signature of a representative of the pregnancy resource center receiving the contribution;

5. Regarding contributions of stocks and 6. The value of a contribution of real estate shall be the fair market value of the real estate appraisers; and 7. Contributions that include a benefit to needed in paragraphs (6)(D)1.–6., the pregnancy resource center must provide written documentation of the type of function or event from which the benefit was received, description of the benefit received (if an auction item, identify the item received), gross (7) The director will verify with the Departshall be subject to the confidentiality and penalty provisions of section 32.057, RSMo, relating to the disclosure of tax information.

(8) Within forty-five (45) days of receipt of (A) Taxpayer (notification to the taxpayer (B) Missouri Department of Revenue. and section 135.630, RSMo Supp. 2018.* This rule originally filed as 13 CSR 35- 100.020. Emergency rule filed Sept. 18, 2006, effective Oct. 1, 2006, expired March 29, 2007. Original rule filed Sept. 18, 2006, effective March 30, 2007. Moved to 13 CSR 10-3.020 and amended: Filed July 19, 2018, effective March 30, 2019. *Original authority: 135.630, RSMo 2006, amended 2007, 2013, 2014, 2018 and 660.017, RSMo 1993, amended 1995.

13 CSR 10-3.030 Developmental Disability Care Provider Tax Credit 135.1180, RSMo (2012), Developmental Disability Care Provider Tax Credit Program, to reflect the requirements of HB 1172 (2012). {#sec-13-csr-10-3.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-3.030}

(1) A qualified developmental disability care provider may apply for tax credits on behalf of taxpayers who make donations to the provider as provided herein. Those who donate to qualifying providers are eligible to receive a tax credit up to fifty percent (50%) of their donation. Qualified developmental disability care providers that accept these donations are required to remit payments equivalent to the amount of the tax credit to the state of Missouri.

(2) Definitions.

(A) “Director” means the director of the (B) “Qualified developmental disability care provider,” for the purpose of the Developmental Disability Care Provider Tax Credit, means a care provider that meets the definition stated in section 135.1180, RSMo.

(3) Qualified developmental disability care providers must apply for the tax credit on behalf of the taxpayers. Acceptable applications for the tax credit require— (A) A complete and accurate Developmental Disability Care Provider Tax Credit Application. Applications may also be obtained at the Department of Social Services website www.dss.mo.gov or by writing to— Attn: Developmental Disability Care Provider Tax Credit (B) A statement attesting to the receipt of 1. Taxpayer type and supporting documentation, when applicable;

2. Taxpayer’s name;

3. Taxpayer’s identification number;

4. Amount of the eligible donation and supporting documentation, when applicable;

5. Amount of anticipated tax credit;

6. Date the donation was received by the agency; and 7. The signature of the executive director of the qualified developmental disability care provider;

(C) Payment from the qualified developmental disability care provider equal to the value of the tax credit for which the applica tion is being submitted. Checks must be made payable to the Department of Social Services; and (D) Verifying documentation must be on the type of donation. Required documen- 1. Cash—legible receipt from the developmental disability care provider which indicates the name and address of the organization; name, address, and telephone number of the contributor; and amount and date the contribution was received; signature of a representative of the developmental disability care provider receiving the contribution;

2. Check—photocopy of the canceled the developmental disability care provider including the same information required of a cash donation as described in paragraph (2)(D)1. of this rule;

3. Credit card—legible transaction developmental disability care provider; contributor’s name, address, and telephone number; amount and date the contribution was the developmental disability care provider receiving the contribution. Receipts should have the credit card account number blacked out;

4. Money order or cashier’s check—legname and address of the developmental disability care provider; contributor’s name, address, and telephone number; amount and date the contribution was received; and signature of a representative of the developmental disability care provider receiving the contribution;

5. Regarding contributions of stocks and 6. The value of contributions of real estate is the fair market value of the real estate appraisers; and 7. Contributions that include a benefit to needed in paragraphs (3)(D)1.–6., the developmental disability care provider must provide written documentation of the type of function or event from which the benefit was received, description of the benefit received (if an auction item, identify the item received), gross amount of the contribution, fair market value of the benefit, and how the fair market value of the benefit was determined.

(4) All applications and payments must be submitted within twelve (12) months from the the taxpayer. The date of submission will be determined by the date that the application and payment are postmarked. Tax credit void and the right to the tax credit will be forfeited.

(5) Information required in section (3) of this

rule, must be submitted to the address refer- (6) Upon receipt of the information required in subsection (3)(B), the Department of Social Services will verify with the Department of Revenue whether or not the taxpayer has any outstanding balances due from the (7) Upon verification of the information required in section (3) of this rule, the Department of Social Services will issue a certificate to the taxpayer indicating the amount of tax credit that is approved for the application.

(A) Certificates will be mailed to the taxtion submitted by the qualified developmental disability care provider.

(B) The Department of Social Services will not provide information regarding taxpayers’ state tax liability to unauthorized individuals.

(C) In the event a taxpayer’s tax credit is refund will not be issued to the qualified developmental disability care provider.

(8) Approved tax credit certificates will be qualified developmental disability care (9) The owner of a developmental disability care provider tax credit certificate must notify the Department of Social Services within thirty (30) days of the date of the transaction to assign, transfer, sell, or convey the credit.

Information submitted to effectuate such a transfer must include a complete and accurate Department of Social Services Tax Credit Transfer Form. Forms may be obtained by writing to the address provided in subsection (3)(A) of this rule or at the Department of Social Services website: www.dss.mo.gov.

Moved to 13 CSR 10-3.030 and amended:

Filed July 19, 2018, effective March 30, 2019. *Original authority: 135.1180, RSMo 2012, amended 2015 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 135.1180 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 35-100.030. Original rule filed Sept. 19, 2012, effective April 30, 2013.

13 CSR 10-3.040 Domestic Violence Shelter and Rape Crisis Center Tax Credit 135.550, RSMo, Domestic Violence Shelter and Rape Crisis Center Tax Credit, and to reflect the requirements of House Bill 430 (2021). {#sec-13-csr-10-3.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-3.040}

(1) This rule transfers oversight of the contributions to centers for victims of Domestic Violence Tax Credit Program from the Department of Public Safety to the Department of Social Services.

(2) Definition of Terms.

(A) “Director” means the director of the (B) “Facilities” means a qualified domestic violence shelter or rape crisis center, in the context of this rule.

(C) “Qualified facility for domestic violence” or “qualified facility,” for the purpose of the Domestic Violence Shelter and Rape Crisis Center Tax Credit, means a shelter for victims of domestic violence located in Missouri that meets the definition stated in section 455.220, RSMo, or a nonprofit organization established and operating exclusively for the purpose of supporting a shelter for victims of domestic violence operated by the state or one (1) of its political subdivisions.

(D) “Rape Crisis Center” means a community-based nonprofit rape crisis center, as defined in section 455.003, RSMo, located in Missouri and that provides the twenty-four- (24-) hour core services of hospital advocacy and crisis hotline support to survivors of rape and sexual assault.

(3) The director will, at least annually, develop and maintain a list of domestic violence shelters and rape crisis centers which are qualified for the tax credit.

(A) Information provided on the list available to taxpayers will be the domestic violence shelter or rape crisis center name and telephone number.

(B) A copy of the qualified facilities is posted on the DSS website and will be made available to taxpayers upon request to the address referenced in paragraph (4)(A)1.

(4) At least annually, the director will determine which facilities in Missouri may be classified as shelters for victims of domestic violence or rape crisis centers for purposes of the tax credit. In order to be an eligible facility for purposes of the tax credit, a facility must meet the definition as set forth in section 135.550, RSMo.

(A) In order for the director to make such determinations, applicants for eligibility must submit the following information:

1. A complete and accurate Domestic Violence Shelter or Rape Crisis Center Tax Credit Application for Agency Eligibility Verification. Applications are available at the Department of Social Services website www.dss.mo.gov or may be obtained by sending a request to— Attn: Domestic Violence Shelter or Rape Crisis Center Tax Credit Program PO Box 216 Jefferson City, MO 65102-0216;

2. A copy of the articles of incorpora- 3. Verification of Internal Revenue Service (IRS) tax exempt status;

3. A brief program description including the number of individuals served annually and the capacity of the facility; and 5. All information should be submitted (B) All domestic violence shelters or rape crisis centers must establish their eligibility on at least an annual basis. All facilities must submit the above information no later than June 1, or as requested by the Department of Social Services, to maintain their eligibility for the tax credit.

(C) Within forty-five (45) days of receipt of all the required documentation, the director will make a determination of eligibility and will notify the domestic violence shelters or rape crisis centers of the determination in writing. Upon a determination of eligibility, a facility will automatically be added to the facility listing.

(D) Qualified facilities must contact the (30) days of any changes in business func- Within thirty (30) days of notification, the department will review the agency’s eligibility for participation in this tax credit program and notify the agency of the determination in writing.

(5) For fiscal years ending on or before June 30, 2022, the director shall equally apportion the total available tax credits among all qualified facilities effective the first day of each state fiscal year (FY). Beginning July 1, 2022, no apportionment is necessary because there is no limit imposed on the cumulative amount of the tax credit.

(A) The director shall inform each qualified facility of its share of the apportioned credits no later than thirty (30) days following July 1 of each fiscal year.

(B) The director shall no less than quarterly review the cumulative amount of apporified facility. Upon request by the director, facilities will provide in writing the amount their facility plans to utilize in tax credits for the fiscal year. Domestic violence shelters or rape crisis centers seeking additional apportionment should submit requests to the director in writing. If a facility fails to use all or a portion of their available tax credits throughout the fiscal year, the director may reapportion these unused tax credits to maximize the amount of tax credits available to taxpayers.

(C) Within thirty (30) days of any reapportionment, the director shall notify in writing those facilities that would be affected by the reapportioned tax credit. The director will consider comments the domestic violence shelters or rape crisis centers submit concerning planned future uses of the agency’s tax credit allocation prior to the end of the thirty- (30-) day period. The director’s decision regarding reapportionment shall be final.

(D) The cumulative amount of credits which may be claimed per any one (1) fiscal year shall not exceed the amount stated in

section 135.550, RSMo.

(6) A qualified facility shall report the receipt of any contribution it believes qualifies for the tax credit on a form provided by the director. This form is known as the Domestic Violence Shelter or Rape Crisis Center Tax Credit Application for Claiming Tax Credits.

(A) Facilities may request the tax credit application at the Department of Social Services website www.dss.mo.gov or by writing (B) Facilities shall be permitted to decline a contribution from a taxpayer.

(C) The tax credit application shall be submitted to the director by the domestic violence shelter or rape crisis center within one (1) calendar year of the receipt of the contribution. Tax credit applications submitted more than one (1) year following the date of the contribution will be void and the right to the tax credit will be forfeited.

(D) Verifying documentation must be submitted by the domestic violence shelter or rape crisis center. The type of documentation required will depend on the type of donation.

Required documentation includes the following:

1. Cash—legible receipt from the ter which indicates the name and address of the organization; name, address, and telephone number of the contributor; amount and date the contribution was received; signature of a representative of the domestic violence shelter or rape crisis center receiving the contribution;

2. Check—photocopy of the canceled the domestic violence shelter or rape crisis center including the same information required of a cash donation as described in paragraph (6)(D)1. of this rule;

3. Credit card—legible transaction ter; contributor’s name, address, and telephone number; amount and date the contribution was received; signature of a representative of the facility receiving the contribution. Receipts should have the credit card account number blacked out;

4. Money order or cashier’s check—legname and address of the domestic violence shelter or rape crisis center; contributor’s name, address, and telephone number; received; signature of a representative of the facility receiving the contribution;

5. Regarding contributions of stocks and include the source and date the stock was donated and how the bond amount was determined. Stock value will be determined by calculating the average of the high and low prices for the stock on the date the facility received the stock, multiplied by the number of shares donated; and 6. The value of contributions of real estate shall be the fair market value of the real tial property having a value fifty thousand estate appraisers.

(E) Contributions that include a benefit to needed in paragraphs (6)(D)1.–6., the ter must provide written documentation of the type of function or event from which the benefit was received, description of the benefit received (if an auction item, identify the item received), gross amount of the contribution, fair market value of the benefit, and how the fair market value of the benefit was determined.

(7) Tax credits shall be issued in the order contributions are received.

(8) The director will verify with the Director of Revenue any outstanding balances due from taxpayer’s prior year’s state tax liability.

If a balance due is outstanding, the amount of tax credit issued under this rule will be reduced by that amount. The director shall be subject to the confidentiality and penalty provisions of section 32.057, RSMo, relating to the disclosure of tax information.

(9) Within forty-five (45) days of receipt of (A) Taxpayer (notification to the taxpayer (B) Missouri Director of Revenue. and section 135.550, RSMo Supp. 2021.* This rule originally filed as 13 CSR 40- 79.010. Emergency rule filed Sept. 18, 2006, effective Oct. 1, 2006, expired March 29, 2007. Original rule filed Sept. 18, 2006, effective March 30, 2007. Moved to 13 CSR 10-3.040 and amended: Filed July 19, 2018, effective March 30, 2019. Amended: Filed Aug. 20, 2021, effective March 30, 2022. *Original authority: 135.550, RSMo 1997, amended 1999, 2006, 2007, 2021, and 660.017, RSMo 1993, amended 1995.

13 CSR 10-3.050 Maternity Home Tax Credit 135.600, RSMo, Contributions to Maternity Homes Tax Credit. {#sec-13-csr-10-3.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-3.050}

(1) A maternity home may apply for tax credits on behalf of taxpayers who make contributions to the agency. For fiscal years ending on or before June 30, 2022, the amount of tax credit issued may be equivalent to up to fifty percent (50%) of the contribution to the agency. For fiscal years starting on or after July 1, 2022, the amount of tax credits issued may be equivalent to up to seventy percent (70%) of the contribution to the agency. Initial credits issued cannot be less than fifty dollars ($50).

The amount of credit claimed by a taxpayer cannot exceed the amount of the taxpayer’s state tax liability for the taxable year the credit is claimed and cannot exceed fifty thousand dollars ($50,000) per taxable year. The total amount of tax credits issued under this rule cannot exceed the amount stated in section 135.600, RSMo, in a fiscal year.

(2) Definitions.

(A) “Agency,” in the context of this rule, is a qualified maternity home.

(B) “Director,” means the director of the (C) “Qualified maternity home,” for the

purpose of the Maternity Home Tax Credit, means a maternity home that meets the definition stated in section 135.600, RSMo.

(3) The director will annually develop and maintain a list of centers which are qualified for the Maternity Home Tax Credit. A copy of the maternity home listing is posted on the Department of Social Services website: www.dss.mo.gov.

(4) Annually, the director of the Department of Social Services or the director’s designee will determine which facilities in Missouri may be classified as maternity homes for purposes of the Maternity Home Tax Credit.

(A) In order for the director of the Department of Social Services to make such determinations, maternity homes seeking qualification should submit the following information:

1. A complete and accurate application.

The process to be followed is found on the Maternity Home Tax Credit Application for Agency Eligibility Verification form available on the Department of Social Services website: www.dss.mo.gov or by writing to:

Attn: Maternity Home Tax Credit Program PO Box 626 Jefferson City, MO 65102-0626;

2. A copy of the articles of incorpora- 3. Verification of Internal Revenue Service (IRS) tax exempt status; and 4. A brief program description including the primary business function as it relates to the mission of helping pregnant women, number and ages of pregnant women served annually, facility capacity, and services provided.

(B) Facilities serving women under age eighteen (18) must provide proof of licensure with the Department of Social Services, Children’s Division (i.e. license certificate or letter of good standing).

(C) Facilities considered exempt from licensure as described in section 210.516, RSMo, must attest to that status.

(D) All information should be submitted to the address referenced in paragraph (4)(A)1.

(5) All maternity homes must establish their qualification for the Maternity Home Tax Credit Program on an annual basis.

(6) Prior to the beginning of each state fiscal year, maternity homes must submit an application for eligibility along with the documentation as stated in subsection (4)(A) of this

rule no later than June 1.

(7) Within forty-five (45) days of receipt of the necessary information, the director will make a determination of qualification and notify the maternity home of the determination in writing. Upon a determination of qualification, a maternity home will automatically be added to the maternity home listing.

(8) Qualified maternity homes must contact the (30) days of any changes in business functions that could impact their qualifying status. The department will review the agency’s eligibility for participation in this tax credit program and notify the agency of the determination in writing.

(9) A qualified maternity home shall report the receipt of any contribution it believes qualifies for the tax credit on a form provided by the Department of Social Services. This form is known as the Maternity Home Tax Credit Application for Claiming Tax Credits.

(A) Maternity homes may request the tax credit application at the Department of Social Services website www.dss.mo.gov or by writing to the address referenced in paragraph (4)(A)1. of this rule.

(B) Maternity homes are permitted to decline a contribution from a taxpayer.

(C) The tax credit application shall be submitted to the Department of Social Services, by the maternity home, within one (1) calendar year of the receipt of the contribution.

Tax credit applications submitted more than one (1) year following the date of the contribution will be void and the right to the tax credit will be forfeited.

(D) Verifying documentation must be submitted by the Maternity Home. The type of documentation necessary will depend on the type of donation. Necessary documentation includes:

1. Cash—legible receipt from the maternity home, which indicates the name and address of the maternity home; name, tributor; amount of the cash donation and the nature of a representative of the maternity home receiving the contribution;

2. Check—photocopy of the canceled the maternity home including the same information needed for a cash donation as described in paragraph (9)(D)1. of this sub-

section;

3. Credit card—legible transaction maternity home; name, address, and telephone number of the contributor; amount and nature of a representative of the maternity home receiving the contribution. Receipts should have the credit card account number blacked out;

4. Money order or cashier’s check—legname and address of the maternity home; name, address, and telephone number of the contributor; amount of the cash donation and the date the contribution was received; and a signature of a representative of the maternity home receiving the contribution;

5. Regarding contributions of stocks and the donation. Information needed when subinclude the source and date the stock was donated and how the bond amount was determined, and confirmation documentation of the transfer from the contributor’s account to the maternity home. The division shall directly determine the stock value by calculating the average of the high and low prices for the stock on the date the facility received the stock, multiplied by the number of shares donated; and 6. The value of contributions of real estate is the fair market value of the real ducted by two (2) different, licensed real estate appraisers.

(E) Contributions that include a benefit to the donor in addition to the documentation necessary in paragraphs (9)(D)1.–6., the maternity home should provide written documentation of the type of function or event from which the benefit was received, description of the benefit received (if an auction item, identify the item received), gross (10) The director will verify with the Departis subject to the confidentiality and penalty provisions of section 32.057, RSMo, relating to the disclosure of tax information.

(11) Within forty-five (45) days of receipt of (A) Taxpayer (notification to the taxpayer (B) Missouri Department of Revenue.

(12) For fiscal years ending on or before June 30, 2022, the director shall equally apportion the total available tax credits among all qualified maternity homes and the apportionment will be effective the first day of each state fiscal year (FY). Beginning July 1, 2022, no apportionment is necessary because there is no limit imposed on the cumulative amount on the tax credit.

(A) The director shall inform each qualified maternity home of its share of the apportioned credits no later than thirty (30) days following July 1 of each fiscal year.

(B) The director will no less than quarterly, review the cumulative amount of apporified maternity home. Upon request by the director, maternity homes will provide in writing the amount their agency plans to utilize in tax credits for the fiscal year along with supporting documentation. Maternity homes seeking additional apportionment should submit requests and supporting documentation to the director in writing. If a maternity home fails to use all or a portion of their available tax credits throughout the fiscal year, the director may reapportion any unused tax credits to maximize the amount of tax credits available to taxpayers.

(C) Within thirty (30) days of any reapportionment, the director shall notify those maternity homes in writing that would be affected by the reapportioned tax credit. The director will consider comments the maternity homes submit concerning planned future uses of the agency’s tax credit allocation prior to the end of the thirty- (30-) day period. The director’s decision regarding reapportionment shall be final. and section 135.600, RSMo Supp. 2021.* This rule previously filed as 13 CSR 40- 80.010. Emergency rule filed May 26, 1998, effective June 11, 1998, expired Feb. 25, 1999. Original rule filed May 26, 1998, effective Nov. 30, 1998. Amended: Filed Sept. 1, 1999, effective April 30, 2000.

Rescinded, moved, and readopted: Filed July 19, 2018, effective March 30, 2019. Amended: Filed Aug. 20, 2021, effective March 30, 2022. *Original authority: 135.600, RSMo 1997, amended 1999, 2007, 2014, 2018, 2021, and 660.017, RSMo 1993, amended 1995.

13 CSR 10-3.060 Diaper Bank Tax Credit 135.621, RSMo, Contributions to Diaper Bank Tax Credit. {#sec-13-csr-10-3.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-3.060}

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) A diaper bank may apply for tax credits on behalf of taxpayers who make contributions to the agency. The amount of tax credit issued may be equivalent to up to fifty percent (50%) of the contribution to the agency.

Initial credits issued cannot be less than fifty dollars ($50). The amount of credit claimed by a taxpayer cannot exceed the amount of the taxpayer's state tax liability for the taxable year the credit is claimed and cannot exceed fifty thousand dollars ($50,000) per taxable year. The total amount of tax credits issued under this rule cannot exceed the amount stated in section 135.621, RSMo. in a fiscal year.

(2) Definitions of terms.

(A) “Director,” means the director of the (B) “Qualified diaper bank,” for the purpose of the Diaper Bank Tax Credit, means a diaper bank that meets the definition stated in

section 135.621, RSMo.

(3) Beginning July 1, 2019, the director will annually develop and maintain a list of centers which are qualified for the Diaper Bank Tax Credit. A copy of the diaper bank listing will be posted annually after July 1, 2019, on the Department of Social Services website: www.dss.mo.gov.

(4) Annually, the director of the Department of Social Services will determine which facilities in Missouri may be classified as diaper banks for purposes of the Diaper Bank Tax Credit. To be a qualified diaper bank for the

purpose of the Diaper Bank Tax Credit, a facility must meet the definition set forth in

section 135.621, RSMo.

(A) In order for the director to make such determinations, diaper banks seeking qualification should submit the following information:

1. A complete and accurate application.

The process to be followed is found on the Diaper Bank Tax Credit Application for Agency Eligibility Verification form which is incorporated by reference and made a part of this rule as published by the Department of Social Services, Division of Finance and Administrative Services, 221 West High Street, Jefferson City, MO 65101, and is available on the DSS website at www.dss.mo.gov, or by writing to the address below. This does not incorporate any subsequent amendments or additions.

Attn: Diaper Bank Tax Credit Program 2. A copy of the articles of incorpora- 3. Verification of Internal Revenue Service (IRS) tax exempt status; and 4. A brief program description including the primary business function as it relates to the mission of helping persons in need of diapers and hygiene products for infants, children, and incontinent adults, the number served annually, and a list of the schools, health care facilities, governmental agencies, or other non-profit entities which received diapers and hygiene products from the diaper bank in the last calendar year.

(B) All information should be submitted to the address referenced in paragraph (4)(A)1. of this subsection.

(5) All diaper banks must establish their eligibility for the Diaper Bank Tax Credit Program on a prospective basis by submitting an application for eligibility along with the required documentation as stated in subsection (4)(A) of this rule no later than June 1.

(6) By August 1, the director will make a determination of qualification and notify the diaper bank of the determination in writing.

(7) Qualified diaper banks must contact the (30) days of any changes in business func- The department will review the agency's eligibility for participation in this tax credit program and notify the agency of the determination in writing.

(8) A qualified diaper bank shall report the receipt of any contribution it believes qualifies for the tax credit on a form provided by the Department of Social Services. This form is known as the Diaper Bank Tax Credit Application for Claiming Tax Credits.

(A) Diaper banks may request the tax credit application at the Department of Social Services website: www.dss.mo.gov or by writing (4)(A)1. of this rule.

(B) Diaper banks are permitted to decline a contribution from a taxpayer.

(C) The tax credit application shall be submitted to the Department of Social Services, by the diaper bank, within one (1) calendar year of the receipt of the contribution. Tax credit applications submitted more than one (1) year following the date of the contribution will be void and the right to the tax credit will be forfeited.

(D) Verifying documentation must be submitted by the diaper bank. The type of documentation necessary will depend on the type of donation. Necessary documentation includes the following:

1. Cash—legible receipt from the diaper bank, which indicates the name and address of the diaper bank; name, address, and telephone number of the contributor; amount of the cash donation and the date the contribution was received; and a signature of a representative of the diaper bank receiving the contribution;

2. Check—photocopy of the canceled the diaper bank including the same information needed for a cash donation as described in paragraph (8)(D)1.;

3. Credit card—legible transaction receipt with the name and address of the diaper bank; name, address, and telephone number of the contributor; amount and date the contribution was received; and a signature of a representative of the diaper bank receiving the contribution. Receipts should have the credit card account number redacted;

4. Money order or cashier’s check—legname and address of the diaper bank; name, tributor; amount of the cash donation, and the date the contribution was received; and a signature of a representative of the diaper bank receiving the contribution;

5. Stocks and bonds—the amount of the contribution is the fair market value of the item as of the date of the donation. Information needed when submitting applications for tax credit shall include the source, date, and number of shares of stock which was donated, and confirmation documentation of the transfer from the contributor's account to the diaper bank;

6. Real estate—the fair market value of the real estate within three (3) months prior to the date of the donation. The fair market value is the lower of at least two (2) qualified independent appraisals for commercial, vacant, or residential property that has been determined to have a value of over fifty thousand dollars ($50,000). Commercial, vacant, or residential property having a value of fifty thousand dollars ($50,000) or less will require only one (1) appraisal. The appraisals will be conducted by two (2) different, licensed real estate appraisers; and 7. Contributions that include a benefit to necessary in paragraphs (8)(D)1.-6., the diaper bank shall provide written documentation of the type of function or event from which the benefit was received, description of the benefit received (if an auction item, identify the item received), gross amount of the contribution, fair market value of the benefit, and how the fair market value of the benefit was determined.

(9) The director will verify with the Departis subject to the confidentiality and penalty provisions of section 32.057, RSMo, relating to the disclosure of tax information.

(10) Within forty-five (45) days of receipt of approve or deny the application to the following parties:

(A) Taxpayer (notification to the taxpayer (B) Missouri Department of Revenue.

(11) Each eligible diaper bank determination shall be final after receipt of written notice from the DSS, unless the diaper bank files a protest with the director setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the DSS to the diaper bank. If a timely protest is filed, the director shall reconsider the determination the diaper bank has so requested. The director shall issue a final decision within forty-five (45) days of protest from the diaper bank.

(12) The director shall equally apportion the total available tax credits among all qualified diaper banks, and the apportionment will be effective the first day of each state fiscal year (FY).

(A) The director shall inform each qualified diaper bank of its share of the apportioned credits no later than thirty (30) days following July 1 of each fiscal year.

(B) The director will, no less than quarterly, review the cumulative amount of apporified diaper bank. Upon request by the director, diaper banks will provide in writing the amount their agency plans to utilize in tax credits for the fiscal year along with supporting documentation. Diaper banks seeking additional apportionment shall submit requests and supporting documentation to the director in writing. If a diaper bank fails to use all or a portion of their available tax credits throughout the fiscal year, the director may reapportion any unused tax credits to maximize the amount of tax credits available to taxpayers.

(C) Within thirty (30) days of any reapportionment, the director shall notify those diaper banks in writing that would be affected by the reapportioned tax credit. The director will consider comments the diaper banks submit concerning planned future uses of the agency’s tax credit allocation prior to the end of the thirty (30) day period. The director’s decision regarding reapportionment shall be final. and section 135.621, RSMo Supp. 2018.* Original rule filed Feb. 1, 2019, effective Aug. 30, 2019. *Original authority: 135.621, RSMo 2018 and 660.017, RSMo 1993, amended 1995.

13 CSR 10-3.070 Unmet Health, Hunger, and Hygiene Needs of Children In School Tax Credit {#sec-13-csr-10-3.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-3.070}

PURPOSE: This rule describes procedures for the implementation of section 135.1125, RSMo, to provide a tax credit for funding for unmet health, hunger, and hygiene needs of children in school.

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) An eligible provider may apply for tax credits on behalf of taxpayers who make donations to the provider as provided herein.

Those who donate to qualifying providers are eligible to receive a tax credit up to fifty percent (50%) of their donation. Qualified health, hunger, and hygiene providers that accept these donations are required to remit payments equivalent to the amount of the tax credit to the state of Missouri.

(2) Definitions of terms.

(A) “Director,” means the director of the (B) “Eligible donation,” means a donation (C) “Eligible provider,” means a provider (D) “Taxpayer,” means a person or entity (3) An application for the Unmet Health, Hunger, and Hygiene Needs of Children In School Tax Credit must be submitted by an eligible provider on behalf of a taxpayer.

Acceptable applications for the tax credit require— (A) A complete and accurate Unmet Health, Hunger, and Hygiene Needs of Children In School Tax Credit Application.

Applications which are incorporated by reference and made a part of this rule as published by the Department of Social Services, Division of Finance and Administrative Services, 221 West High Street, Jefferson City, MO 65101, at its website: www.dss.mo.gov/dfas/taxcredit/index.htm, or by writing to the address below. This does not incorporate any subsequent amendments or additions.

Attn: Unmet Health, Hunger, and Hygiene Needs of Children In School Tax Credit (B) A statement attesting to the receipt of 1. Taxpayer type and supporting documentation;

2. Taxpayer’s name;

3. Taxpayer’s identification number;

4. Amount of the eligible donation and verifying documentation, when applicable;

5. Amount of anticipated tax credit;

6. Date the donation was received by the eligible provider; and 7. The signature of the executive director of the eligible provider;

(C) Payment from the eligible provider in an amount equal to fifty percent (50%) of the eligible donation for which the tax credit is being submitted. For example, if the donation was for one hundred dollars ($100) the payment is fifty dollars ($50). Checks from the eligible provider must be made payable to the Department of Social Services;

(D) Verifying documentation must be on the type of donation. Verifying documen- 1. Cash—legible receipt from the health, hunger, and hygiene provider which indicates the name and address of the organization; name, address, and telephone number of the contributor; and amount of the cash donation and date the contribution was received; signature of a representative of the health, hunger, and hygiene provider receiving the contribu- 2. Check—photocopy of the canceled the health, hunger, and hygiene provider including the same information required of a cash donation as described in paragraph (2)(D)1. of this rule;

3. Credit card—legible transaction health, hunger, and hygiene provider; contributor’s name, address, and telephone number; amount and date the contribution was the health, hunger, and hygiene provider receiving the contribution. Receipts should have the credit card account number redacted;

4. Money order or cashier’s check—legname and address of the health, hunger, and hygiene care provider; contributor’s name, address, and telephone number; amount and date the contribution was received; and signature of a representative of the health, hunger, and hygiene provider receiving the contribu- 5. Stocks and bonds—the amount of the contribution is the fair market value of the item as of the date of the donation. Information required when submitting applications for tax credit shall include the source, date, and the number of shares of the stock which was donated;

5. Real estate—the fair market value of the real estate within three (3) months prior to the date of the donation. The fair market value is the lower of at least two (2) qualified independent appraisals for commercial, vacant, or residential property that has been determined to have a value of over fifty thousand dollars ($50,000). Commercial, vacant, or residential property having a value of fifty thousand dollars ($50,000) or less will require only one (1) appraisal. The appraisals will be conducted by two (2) different licensed real estate appraisers; and 7. Contributions that include a benefit to needed in paragraphs (3)(D)1.–6., the eligible provider must provide written documentation of the type of function or event from which the benefit was received, description of the benefit received (if an auction item, identify the item received), gross amount of the contribution, fair market value of the benefit, and how the fair market value of the benefit was determined;

(E) A statement describing how the eligible provider provides funding for unmet health, hunger, and hygiene needs of children in school; and (F) Verification of the eligible provider’s federal tax-exempt status.

(4) All applications and payments must be submitted within twelve (12) months from the the taxpayer. The date of submission will be determined by the date that the application and payment are postmarked. Tax credit void, and the right to the tax credit will be forfeited.

(5) Information required in section (3) of this

rule must be submitted to the address refer- (6) Upon receipt of the information required in subsection (3)(B), the Department of Social Services will verify with the Department of Revenue whether or not the taxpayer has any outstanding balances due from the (7) Upon verification of the information required in section (3) of this rule, the DSS will issue a certificate to the taxpayer indicating the amount of tax credit that is approved for the application.

(A) Certificates will be mailed to the taxtion submitted by the qualified health, hunger, and hygiene provider.

(B) The DSS will not provide information regarding taxpayers’ state tax liability to unauthorized individuals.

(C) In the event a taxpayer’s tax credit is refund will not be issued to the health, hunger, and hygiene provider.

(8) Approved tax credit certificates will be qualified health, hunger, and hygiene (9) Each eligible unmet health, hunger, and hygiene needs provider determination shall be final after receipt of written notice from the DSS, unless the unmet health, hunger, and hygiene needs provider files a protest with the director setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the DSS to the unmet health, hunger, and hygiene needs provider. If a timely protest is filed, the director shall reconsider the determination the unmet health, hunger, and hygiene needs provider has so requested.

The director shall issue a final decision within forty-five (45) days of protest from the unmet health, hunger, and hygiene needs (10) The owner of a health, hunger, and hygiene provider tax credit certificate must notify the DSS within thirty (30) days of the date of the transaction to assign, transfer, sell, or convey the credit. Information submitted to effectuate such a transfer must include a complete and accurate DSS Tax Credit Transfer Form. Forms may be obtained by writing to the address provided in subsection (3)(A) of this rule or at the Department of Social Services website: www.dss.mo.gov/dfas/taxcredit/index.htm. and section 135.1125, RSMo Supp. 2018.* Original rule filed Feb. 1, 2019, effective Aug. 30, 2019. *Original authority: 135.1125, RSMo 2018 and 660.017, RSMo 1993, amended 1995.

Chapter 4 Abortions

13 CSR 10-4.010 Prohibition Against Expenditure of Appropriated Funds for SOCIAL SERVICES Administrative Services {#sec-13-csr-10-4.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-4.010}

13 CSR 10-4.010 Prohibition Against Expenditure of Appropriated Funds for Abortion Facilities {#sec-13-csr-10-4.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 10-4.010}

PURPOSE: This rule supplements the requirements of HB 2011, passed by the 99th General Assembly, effective for State Fiscal Year 2019 and prescribes requirements for the Department of Social Services, individuals, organizations, or other entities receiving funding or appropriated funds from the General Assembly.

(1) Definitions.

(A) “Abortion” shall be defined pursuant to section 188.015(1), RSMo.

(B) “Abortion facility” means any clinic, physician’s office, or any other place or facility in which abortions are performed or induced other than a hospital, or any affiliate or associate of any such clinic, physician’s office, or place or facility in which abortions are performed or induced other than a hospital.

(C) “Affiliate of an abortion facility.” Factors to be considered in making this determination include, but are not limited to: an organization or location that shares, or has in common, any resource with an abortion facility including, but not limited to: operating funds, bank accounts, facilities, employees, service contracts, equipment, mailing lists, trademarks, copyrights, service marks, brands, trade names, financial reporting, marketing, advertising, websites, information and education materials, or any other assets.

(D) “Associate of an abortion facility.”

Factors to be considered in making this determination include, but are not limited to: an organization or location that shares an organizational structure with an abortion facility including, but not limited to: parent, subsidiary, or sister organizations; or an organization or location with common or interlocking management, ownership, or governance with an abortion facility; or an organization or location with the public appearance of association with an abortion facility, such as a shared name, or part of a name; an alliance or federation with an organization or location that is commonly identified as an advocate for abortion; or that holds itself out, has held itself out, or refers to it itself publicly in a way that demonstrates a connection to an organization or location that is commonly identified as an abortion facility.

(E) “Counsels women to have an abortion” means encouraging a patient to have an abortion or referring a patient for an abortion when such abortion does not meet an exception required by federal law. Factors of abortion counseling include, but are not limited to: providing a patient with information encouraging an abortion, or directing a patient to an abortion facility when such abortion would not meet an exception required by federal law.

(F) “Department” means the Missouri Department of Social Services and all of its divisions, units, and programs.

(G) “Program” means any project, service, or activity administered by the department.

(2) The department shall not expend any funds on any program that performs abortions or provides abortion counseling other than the exceptions required by federal law.

(3) The department shall not expend any funds to an abortion facility or an affiliate or associate thereof as determined by the department in accordance with this regulation.

History

• AUTHORITY: sections 11.920 and 11.930 of HB 2011, First Regular Session, One Hundredth General Assembly, 2019, and sections 208.153, 208.201, and 660.017, RSMo 2016. Emergency rule filed July 5, 2018, effective July 15, 2018, expired Feb. 28, 2019. Original rule filed July 5, 2018, effective Feb. 28, 2019. Emergency amendment filed June 20, 2019, effective July 1, 2019, expired Dec. 26, 2019. Amended: Filed July 26, 2019, effective Feb. 29, 2020. Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

Division 15 Division of Aging

Chapter 1 * - moved to 19 CSR 15-1

13 CSR 15-1.010 Organization and Operation {#sec-13-csr-15-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-1.010}

(Moved to 19 CSR 15-1.010)

MATTBLUNT(3/31/02)

Chapter 2 * - moved to 19 CSR 15-2

13 CSR 15-2.010 Alzheimer’s Pilot Project Grants {#sec-13-csr-15-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-2.010}

(Moved to 19 CSR 15-2.010)

MATTBLUNT(3/31/02)

Chapter 3 * - moved to 19 CSR 15-3

13 CSR 15-3.010 Definitions {#sec-13-csr-15-3.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-3.010}

(Moved to 19 CSR 15-3.010)

13 CSR 15-3.020 Sponsoring Agencies {#sec-13-csr-15-3.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-3.020}

(Moved to 19 CSR 15-3.020)

13 CSR 15-3.030 Volunteers {#sec-13-csr-15-3.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-3.030}

(Moved to 19 CSR 15-3.030)

13 CSR 15-3.040 Service Credits {#sec-13-csr-15-3.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-3.040}

(Moved to 19 CSR 15-3.040)

13 CSR 15-3.050 Redemption of Credits {#sec-13-csr-15-3.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-3.050}

(Moved to 19 CSR 15-3.050)

MATTBLUNT(3/31/02)

Chapter 4 * - moved to 19 CSR 15-4

13 CSR 15-4.010 Definition of Terms {#sec-13-csr-15-4.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.010}

(Moved to 19 CSR 15-4.010) . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.020Administration of the Older Americans Act (Moved to 19 CSR 15-4.020) . . . . .3 13 CSR 15-4.030Governorís Advisory Council on Aging (Moved to 19 CSR 15-4.030) . . . . . . . .3 13 CSR 15-4.040State Plan (Moved to 19 CSR 15-4.040) . . . . . . . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.050Funding Formula and Fiscal Management (Moved to 19 CSR 15-4.050) . . . . . .3

13 CSR 15-4.060 State Long-Term Care Ombudsman Program {#sec-13-csr-15-4.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.060}

(Moved to 19 CSR 15-4.060) . . . .3 13 CSR 15-4.070Designation of Area Agencies on Aging (Moved to 19 CSR 15-4.070) . . . . . . . .3

13 CSR 15-4.080 Withdrawal of Designation {#sec-13-csr-15-4.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.080}

(Moved to 19 CSR 15-4.080) . . . . . . . . . . . . . . . .3

13 CSR 15-4.090 Appeal to the Assistant Secretary {#sec-13-csr-15-4.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.090}

(Moved to 19 CSR 15-4.090) . . . . . . . . . . . .3 13 CSR 15-4.100Area Agency Governing Body (Moved to 19 CSR 15-4.100) . . . . . . . . . . . . . .3 13 CSR 15-4.105Area Agency Election Procedures for Governing Body Membership (Moved to 19 CSR 15-4.105) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.110Area Agency Advisory Council (Moved to 19 CSR 15-4.110) . . . . . . . . . . . . .3 13 CSR 15-4.120Affirmative Action/Equal Employment Opportunity/Preference in Hiring (Moved to 19 CSR 15-4.120) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.130Area Agency Staff (Moved to 19 CSR 15-4.130) . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.135Area Agency Director (Moved to 19 CSR 15-4.135) . . . . . . . . . . . . . . . . . . .3

13 CSR 15-4.140 Area Agency Plan {#sec-13-csr-15-4.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.140}

(Moved to 19 CSR 15-4.140) . . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.150Waivers (Moved to 19 CSR 15-4.150) . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 2CODE OF STATE REGULATIONS (3/31/02) MATTBLUNT 13 CSR 15-4.160Review, Submission and Approval of Area Agency Area Plans and Plan Amendments (Moved to 19 CSR 15-4.160) . . . . . . . . . . . . . .3

13 CSR 15-4.170 Area Agency Fiscal Management {#sec-13-csr-15-4.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.170}

(Moved to 19 CSR 15-4.170) . . . . . . . . . . . .3

13 CSR 15-4.175 Funding Acquisition or Construction of Multipurpose Senior Centers {#sec-13-csr-15-4.175 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.175}

(Moved to 19 CSR 15-4.175) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.180Area Agency Advocacy Responsibility (Moved to 19 CSR 15-4.180) . . . . . . . . .3 13 CSR 15-4.190Area Agency Development of a Comprehensive and Coordinated Service Delivery System (Moved to 19 CSR 15-4.190) . . . . . . . . .3 13 CSR 15-4.200Area Agency Subgrants or Contracts (Moved to 19 CSR 15-4.200) . . . . . . . . . .3 13 CSR 15-4.210Area Agency Grievance Procedures (Moved to 19 CSR 15-4.210) . . . . . . . . . .3 13 CSR 15-4.220Area Agency Technical Assistance, Monitoring and Evaluation Responsibilities (Moved to 19 CSR 15-4.220) . . . . . . . . . . . . . . . .3

13 CSR 15-4.230 Multipurpose Senior Center {#sec-13-csr-15-4.230 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.230}

(Moved to 19 CSR 15-4.230) . . . . . . . . . . . . . . .3 13 CSR 15-4.240Nutrition Service Requirements (Moved to 19 CSR 15-4.240) . . . . . . . . . . . . .3 13 CSR 15-4.250Area Agency USDA (Moved to 19 CSR 15-4.250) . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.260Outreach Services (Moved to 19 CSR 15-4.260) . . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.270Legal Assistance (Moved to 19 CSR 15-4.270) . . . . . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.280Ombudsman Services (Moved to 19 CSR 15-4.280) . . . . . . . . . . . . . . . . . . .3 13 CSR 15-4.290Information and Assistance (Moved to 19 CSR 15-4.290) . . . . . . . . . . . . . . . .3 13 CSR 15-4.300Record Keeping and Confidentiality (Moved to 19 CSR 15-4.300) . . . . . . . . . .3 13 CSR 15-4.310Corporate Eldercare (Moved to 19 CSR 15-4.310) . . . . . . . . . . . . . . . . . . . .3 Title 13óDEPARTMENT OF SOCIAL SERVICES Division 15óDivision of Aging

Chapter 4óOlder Americans Act

13 CSR 15-4.010 Definition of Terms {#sec-13-csr-15-4.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.010}

(Moved to 19 CSR 15-4.010)

13 CSR 15-4.020 Administration of the Older Americans Act {#sec-13-csr-15-4.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.020}

(Moved to 19 CSR 15-4.020)

13 CSR 15-4.030 Governorís Advisory Council on Aging {#sec-13-csr-15-4.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.030}

(Moved to 19 CSR 15-4.030)

13 CSR 15-4.040 State Plan {#sec-13-csr-15-4.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.040}

(Moved to 19 CSR 15-4.040)

13 CSR 15-4.050 Funding Formula and Fiscal Management {#sec-13-csr-15-4.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.050}

(Moved to 19 CSR 15-4.050)

13 CSR 15-4.060 State Long-Term Care Ombudsman Program {#sec-13-csr-15-4.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.060}

(Moved to 19 CSR 15-4.060)

13 CSR 15-4.070 Designation of Area Agencies on Aging {#sec-13-csr-15-4.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.070}

(Moved to 19 CSR 15-4.070)

13 CSR 15-4.080 Withdrawal of Designation {#sec-13-csr-15-4.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.080}

(Moved to 19 CSR 15-4.080)

13 CSR 15-4.090 Appeal to the Assistant Secretary {#sec-13-csr-15-4.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.090}

(Moved to 19 CSR 15-4.090)

13 CSR 15-4.100 Area Agency Governing Body {#sec-13-csr-15-4.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.100}

(Moved to 19 CSR 15-4.100)

13 CSR 15-4.105 Area Agency Election Procedures for Governing Body Membership {#sec-13-csr-15-4.105 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.105}

(Moved to 19 CSR 15-4.105)

13 CSR 15-4.110 Area Agency Advisory Council {#sec-13-csr-15-4.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.110}

(Moved to 19 CSR 15-4.110)

13 CSR 15-4.120 Affirmative Action/Equal Employment Opportunity/Preference in Hiring {#sec-13-csr-15-4.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.120}

(Moved to 19 CSR 15-4.120)

13 CSR 15-4.130 Area Agency Staff {#sec-13-csr-15-4.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.130}

(Moved to 19 CSR 15-4.130)

13 CSR 15-4.135 Area Agency Director {#sec-13-csr-15-4.135 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.135}

(Moved to 19 CSR 15-4.135)

13 CSR 15-4.140 Area Agency Plan {#sec-13-csr-15-4.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.140}

(Moved to 19 CSR 15-4.140)

13 CSR 15-4.150 Waivers {#sec-13-csr-15-4.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.150}

(Moved to 19 CSR 15-4.150)

13 CSR 15-4.160 Review, Submission and Approval of Area Agency Area Plans and Plan Amendments {#sec-13-csr-15-4.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.160}

(Moved to 19 CSR 15-4.160)

13 CSR 15-4.170 Area Agency Fiscal Management {#sec-13-csr-15-4.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.170}

(Moved to 19 CSR 15-4.170)

13 CSR 15-4.175 Funding Acquisition or Construction of Multipurpose Senior Centers {#sec-13-csr-15-4.175 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.175}

(Moved to 19 CSR 15-4.175)

13 CSR 15-4.180 Area Agency Advocacy Responsibility {#sec-13-csr-15-4.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.180}

(Moved to 19 CSR 15-4.180)

13 CSR 15-4.190 Area Agency Development of a Comprehensive and Coordinated Service Delivery System {#sec-13-csr-15-4.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.190}

(Moved to 19 CSR 15-4.190)

13 CSR 15-4.200 Area Agency Subgrants or Contracts {#sec-13-csr-15-4.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.200}

(Moved to 19 CSR 15-4.200)

13 CSR 15-4.210 Area Agency Grievance Procedures {#sec-13-csr-15-4.210 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.210}

(Moved to 19 CSR 15-4.210)

13 CSR 15-4.220 Area Agency Technical Assistance, Monitoring and Evaluation Responsibilities {#sec-13-csr-15-4.220 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.220}

(Moved to 19 CSR 15-4.220)

13 CSR 15-4.230 Multipurpose Senior Center {#sec-13-csr-15-4.230 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.230}

(Moved to 19 CSR 15-4.230)

13 CSR 15-4.240 Nutrition Service Requirements {#sec-13-csr-15-4.240 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.240}

(Moved to 19 CSR 15-4.240)

13 CSR 15-4.250 Area Agency USDA {#sec-13-csr-15-4.250 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.250}

(Moved to 19 CSR 15-4.250)

13 CSR 15-4.260 Outreach Services {#sec-13-csr-15-4.260 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.260}

(Moved to 19 CSR 15-4.260)

13 CSR 15-4.270 Legal Assistance {#sec-13-csr-15-4.270 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.270}

(Moved to 19 CSR 15-4.270)

13 CSR 15-4.280 Ombudsman Services {#sec-13-csr-15-4.280 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.280}

(Moved to 19 CSR 15-4.280)

13 CSR 15-4.290 Information and Assistance {#sec-13-csr-15-4.290 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.290}

(Moved to 19 CSR 15-4.290)

13 CSR 15-4.300 Record Keeping and Confidentiality {#sec-13-csr-15-4.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.300}

(Moved to 19 CSR 15-4.300)

13 CSR 15-4.310 Corporate Eldercare {#sec-13-csr-15-4.310 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-4.310}

(Moved to 19 CSR 15-4.310)

MATTBLUNT(3/31/02)*

Chapter 4óOlder Americans Act13 CSR 15-4

Chapter 5 * - Title XX

13 CSR 15-5.010 Responsible Agency Jan. 9, 1976. Functions transferred by Sept. 28, 1979, expired Jan. 25, 1980. {#sec-13-csr-15-5.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-5.010}

Dec. 13, 1979. Rescinded: Filed Nov. 12,

13 CSR 15-5.020 Eligibility Criteria Jan. 9, 1976. Functions transferred by Sept. 28, 1979, expired Jan. 25, 1980. {#sec-13-csr-15-5.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-5.020}

Dec. 13, 1979. Rescinded: Filed Nov. 12,

13 CSR 15-5.030 Eligibility Determination Jan. 9, 1976. Functions transferred by Sept. 28, 1979, expired Jan. 25, 1980. {#sec-13-csr-15-5.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-5.030}

Dec. 13, 1979. Rescinded: Filed Nov. 12,

13 CSR 15-5.040 Available Services Jan. 9, 1976. Functions transferred by Sept. 28, 1979, expired Jan. 25, 1980. {#sec-13-csr-15-5.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-5.040}

Dec. 13, 1979. Rescinded: Filed Nov. 12,

13 CSR 15-5.050 Appeals Jan. 9, 1976. Functions transferred by Executive Order 79-9, to Division of Aging. {#sec-13-csr-15-5.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-5.050}

Sept. 28, 1979, expired Jan. 25, 1980.

Dec. 13, 1979. Rescinded: Filed Nov. 12, MATTBLUNT(12/31/01)

Chapter 6 * - moved to 19 CSR 15-6

13 CSR 15-6.005 Definition of Terms {#sec-13-csr-15-6.005 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.005}

13 CSR 15-6.010 Designation and Organization {#sec-13-csr-15-6.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.010}

13 CSR 15-6.015 Recordkeeping and Confidentiality {#sec-13-csr-15-6.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.015}

13 CSR 15-6.020 Division Medication Procedures {#sec-13-csr-15-6.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.020}

(Moved to 19 CSR 15-6.020)

13 CSR 15-6.025 Division Formal Hearings {#sec-13-csr-15-6.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.025}

(Moved to 19 CSR 15-6.025)

13 CSR 15-6.030 Governor’s Advisory Council on Aging {#sec-13-csr-15-6.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.030}

13 CSR 15-6.035 Title III State Plan {#sec-13-csr-15-6.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.035}

13 CSR 15-6.040 Designation of Planning and Service Areas {#sec-13-csr-15-6.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.040}

13 CSR 15-6.045 Designation of Area Agencies on Aging {#sec-13-csr-15-6.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.045}

13 CSR 15-6.050 Withdrawal of Designation {#sec-13-csr-15-6.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.050}

13 CSR 15-6.055 Appeal to the Commissioner {#sec-13-csr-15-6.055 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.055}

13 CSR 15-6.060 Division Responsibilities {#sec-13-csr-15-6.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.060}

13 CSR 15-6.065 Long-Term Care Ombudsman Program {#sec-13-csr-15-6.065 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.065}

13 CSR 15-6.070 Area Agency Governing Body {#sec-13-csr-15-6.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.070}

13 CSR 15-6.075 Affirmative Action/Equal Employment Opportunity/Preference in Hiring {#sec-13-csr-15-6.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.075}

13 CSR 15-6.080 Area Agency Staff {#sec-13-csr-15-6.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.080}

13 CSR 15-6.085 Area Agency Advisory Council {#sec-13-csr-15-6.085 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.085}

13 CSR 15-6.090 Area Agency Grievance Procedures {#sec-13-csr-15-6.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.090}

13 CSR 15-6.095 Area Agency Plan {#sec-13-csr-15-6.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.095}

13 CSR 15-6.100 Waivers {#sec-13-csr-15-6.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.100}

13 CSR 15-6.105 Area Agency Public Hearings {#sec-13-csr-15-6.105 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.105}

13 CSR 15-6.110 Review, Submission and Approval of Area Agency Area Plan {#sec-13-csr-15-6.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.110}

13 CSR 15-6.115 Area Agency Advocacy Responsibility {#sec-13-csr-15-6.115 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.115}

13 CSR 15-6.120 Area Agency Development of a Comprehensive and Coordinated Service Delivery System {#sec-13-csr-15-6.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.120}

13 CSR 15-6.125 Area Agency Subgrants or Contracts {#sec-13-csr-15-6.125 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.125}

13 CSR 15-6.130 Area Agency Technical Assistance, Monitoring and Evaluation Responsibility {#sec-13-csr-15-6.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.130}

13 CSR 15-6.135 General Requirements for All Services {#sec-13-csr-15-6.135 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.135}

13 CSR 15-6.140 Multipurpose Senior Center Facilities and Services {#sec-13-csr-15-6.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.140}

13 CSR 15-6.145 Nutrition Service Requirements {#sec-13-csr-15-6.145 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.145}

13 CSR 15-6.150 Area Agency USDA Commodity/Cash Requirements 4CODE OF STATE REGULATIONS (3/31/02) MATTBLUNT {#sec-13-csr-15-6.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.150}

13 CSR 15-6.155 Nutrition Service Standards {#sec-13-csr-15-6.155 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.155}

13 CSR 15-6.160 Transportation Services {#sec-13-csr-15-6.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.160}

13 CSR 15-6.165 Transportation Service Standards {#sec-13-csr-15-6.165 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.165}

13 CSR 15-6.170 In-Home Service Standards {#sec-13-csr-15-6.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.170}

13 CSR 15-6.175 Outreach Services {#sec-13-csr-15-6.175 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.175}

13 CSR 15-6.180 Legal Services {#sec-13-csr-15-6.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.180}

13 CSR 15-6.185 Ombudsman Services {#sec-13-csr-15-6.185 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.185}

13 CSR 15-6.190 Information and Referral Services {#sec-13-csr-15-6.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.190}

13 CSR 15-6.191 Information and Referral Services Standards {#sec-13-csr-15-6.191 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.191}

13 CSR 15-6.195 Division Fiscal Management of Title III Funds {#sec-13-csr-15-6.195 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.195}

13 CSR 15-6.200 Area Agency Fiscal Management of Title III Funds {#sec-13-csr-15-6.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-6.200}

Chapter 7 * - moved to 19 CSR 15-7

13 CSR 15-7.005 Definitions {#sec-13-csr-15-7.005 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.005}

(Moved to 19 CSR 15-7.005)

13 CSR 15-7.010 General Requirements for All Service Providers {#sec-13-csr-15-7.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.010}

(Moved to 19 CSR 15-7.010)

13 CSR 15-7.020 In-Home Advanced Personal Care Standards and 660.050, RSMo Supp. 1992. Original {#sec-13-csr-15-7.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.020}

rule filed May 12, 1983, effective Aug. 11, 1983. Emergency amendment filed June 13, 1984, effective July 1, 1984, expired Oct. 26, 1984. Amended: Filed June 13, 1984, effective Oct. 17, 1984. Emergency rescission and

rule filed Aug. 15, 1985, effective Sept. 1, 1985, expired Dec. 29, 1985. Rescinded:

Filed Sept. 3, 1985, effective Dec. 12, 1985.

Readopted: Filed Sept. 6, 1985, effective Dec. 12, 1985. Amended: Filed April 14, 1987, effective July 11. 1987. Emergency rescission and rule filed June 16, 1989, effective July 1, 1989, expired Oct. 27, 1989.

Rescinded and readopted: Filed June 16, 1989, effective Oct. 27, 1984. Emergency rescission and rule filed Aug. 4, 1992, effective Aug. 14, 1992, expired Dec. 11, 1992.

Emergency rescission and rule filed Dec. 14, 1992, effective Dec. 24, 1992, expired April 22, 1993. Emergency rule filed April 5, 1993, effective April 22, 1993, expired June 1, 1993. Rescinded and readopted: Filed Aug. 4, 1992, effective May 6, 1993. Emergency amendment filed Feb. 5, 1993, effective Feb. 15, 1993, expired April 22, 1993. Amended:

Filed Feb. 5, 1993, effective Aug. 9, 1993.

Amended: Filed July 15, 1993, effective Jan. 13, 1994. Rescinded: Filed Sept. 1, 1994, effective April 30, 1995.

13 CSR 15-7.021 In-Home Service Standards {#sec-13-csr-15-7.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.021}

(Moved to 19 CSR 15-7.021)

13 CSR 15-7.025 In-Home Respite Care and 660.050, RSMo Supp. 1992. Emergency {#sec-13-csr-15-7.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.025}

rule filed Aug. 4, 1992, effective Aug. 14, 1992, expired Dec. 11, 1992. Emergency rule filed Dec. 14, 1992, effective Dec. 24, 1992, expired April 22, 1993. Emergency rule filed April 5, 1993, effective April 22, 1993, expired June 1, 1993. Original rule filed Aug. 4, 1992, effective May 6, 1993.

Amended: Filed July 14, 1993, effective Jan. 13, 1994. Rescinded: Filed Sept. 1, 1994, effective April 30, 1995.

13 CSR 15-7.030 In-Home Personal Care and Homemaker Services Standards and 660.050, RSMo Supp. 1992. Original {#sec-13-csr-15-7.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.030}

rule filed May 12, 1983, effective Aug. 11, 1983. Emergency amendment filed June 13, 1984, effective July 1, 1984, expired Oct. 26, 1984. Amended: Filed June 13, 1984, effective Oct. 17, 1984. Emergency rescission and

rule filed Aug. 15, 1985, effective Sept. 1, 1985, expired Dec. 29, 1985. Rescinded:

Filed Sept. 3, 1985, effective Dec. 12, 1985.

Readopted: Filed Sept. 6, 1985, effective Dec. 12, 1985. Amended: Filed April 14, 1987, effective July 11, 1987. Emergency rescission and rule filed June 16, 1989, effective July 1, 1989, expired Oct. 27, 1989.

Rescinded and readopted: Filed June 16, 1989, effective Oct. 27, 1989. Emergency rescission and rule filed Aug. 4, 1992, effective Aug. 14, 1992, expired Dec. 11, 1992.

Emergency rescission and rule filed Dec. 14, 1992, effective Dec. 24, 1992, expired April 22, 1993. Rescinded and readopted: Filed Aug. 4, 1992, effective May 6, 1993.

Emergency amendment filed Feb. 5, 1993, effective Feb. 15, 1993, expired April 22, 1993. Emergency rule filed April 5, 1993, effective April 22, 1993, expired June 1, 1993. Amended: Filed Feb. 5, 1993, effective Aug. 9, 1993. Amended: Filed July 14, 1993, effective Jan. 13, 1994. Rescinded: Filed Sept. 1, 1994, effective April 30, 1995.

13 CSR 15-7.035 In-Home RN Visit Standards and 660.050, RSMo Supp. 1992. Emergency {#sec-13-csr-15-7.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.035}

rule filed June 16, 1989, effective July 1, 1989, expired Oct. 27, 1989. Original rule filed June 16, 1989, effective Oct. 27, 1989.

Emergency rescission and rule filed Aug. 4, 1992, effective Aug. 14, 1992, expired Dec. 11, 1992. Emergency rescission and rule filed Dec. 14, 1992, effective Dec. 24, 1992, expired April 22, 1993. Emergency rule filed April 5, 1993, effective April 22, 1993, expired June 1, 1993. Rescinded and readopted: Filed Aug. 4, 1992, effective May 6, 1993. Rescinded: Filed Sept. 1, 1994, effective April 30, 1995.

13 CSR 15-7.040 Transportation Service {#sec-13-csr-15-7.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.040}

(Moved to 19 CSR 15-7.040)

13 CSR 15-7.050 Information and Assistance Service Standards {#sec-13-csr-15-7.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.050}

(Moved to 19 CSR 15-7.050)

13 CSR 15-7.060 Nutrition Service {#sec-13-csr-15-7.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.060}

(Moved to 19 CSR 15-7.060)

13 CSR 15-7.070 Multipurpose Senior Center Program Standards {#sec-13-csr-15-7.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-7.070}

(Rescinded December 30, 1995)

Original rule filed Jan. 6, 1986, effective April 30, 1986. Amended: Filed Feb. 17, 1988, effective June 15, 1988. Amended:

Filed June 3, 1991, effective Oct. 31, 1991.

Rescinded: Filed June 20, 1995, effective Dec. 30, 1995.

MATTBLUNT(3/31/02)

History

• AUTHORITY: section 660.050, RSMo 1994.

Chapter 8 * - moved to 19 CSR 30-90

13 CSR 15-8.010 Definitions {#sec-13-csr-15-8.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.010}

(Moved to 19 CSR 30-90.010)

13 CSR 15-8.020 Licensure Requirements {#sec-13-csr-15-8.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.020}

(Moved to 19 CSR 30-90.020)

13 CSR 15-8.030 Participants’ Rights and Program Policies {#sec-13-csr-15-8.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.030}

(Moved to 19 CSR 30-90.030)

13 CSR 15-8.040 Staffing Requirements {#sec-13-csr-15-8.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.040}

(Moved to 19 CSR 30-90.040)

13 CSR 15-8.050 Program and Participant Care Requirements {#sec-13-csr-15-8.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.050}

(Moved to 19 CSR 30-90.050)

13 CSR 15-8.060 Recordkeeping Requirements {#sec-13-csr-15-8.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.060}

(Moved to 19 CSR 30-90.060)

13 CSR 15-8.070 Facility Physical Requirements {#sec-13-csr-15-8.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.070}

(Moved to 19 CSR 30-90.070)

13 CSR 15-8.080 Fire Safety Requirements {#sec-13-csr-15-8.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-8.080}

(Moved to 19 CSR 30-90.080)

MATTBLUNT(11/30/01)

Chapter 9 * - moved to 19 CSR 30-81

13 CSR 15-9.010 General Certification Requirements {#sec-13-csr-15-9.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-9.010}

(Moved to 19 CSR 30-81.010)

13 CSR 15-9.015 Resident Assessment Instrument {#sec-13-csr-15-9.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-9.015}

(Moved to 19 CSR 30-81.015)

13 CSR 15-9.020 Prelong-Term Care Screening {#sec-13-csr-15-9.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-9.020}

(Moved to 19 CSR 30-81.020)

13 CSR 15-9.030 Evaluation and Assessment Measures for Title XIX Recipients and Applicants in Long-Term Care Facilities {#sec-13-csr-15-9.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-9.030}

(Moved to 19 CSR 30-81.030)

MATTBLUNT(11/30/01)

Chapter 10 * - moved to 19 CSR 30-82

13 CSR 15-10.010 General Licensure Requirements {#sec-13-csr-15-10.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-10.010}

(Moved to 19 CSR 30-82.010)

13 CSR 15-10.020 Classification of Rules {#sec-13-csr-15-10.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-10.020}

(Moved to 19 CSR 30-82.020)

13 CSR 15-10.030 Assessment of Availability of Beds {#sec-13-csr-15-10.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-10.030}

(Moved to 19 CSR 30-82.030)

13 CSR 15-10.050 Transfer and Discharge Procedures {#sec-13-csr-15-10.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-10.050}

(Moved to 19 CSR 30-82.050)

13 CSR 15-10.060 Hiring Restrictions— Good Cause Waiver {#sec-13-csr-15-10.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-10.060}

(Moved to 19 CSR 30-82.060)

13 CSR 15-10.070 Alzheimer’s Demonstration Projects {#sec-13-csr-15-10.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-10.070}

(Moved to 19 CSR 30-82.070)

Chapter 11 * - moved to 19 CSR 30-83

13 CSR 15-11.010 Definition of Terms {#sec-13-csr-15-11.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-11.010}

(Moved to 19 CSR 30-83.010)

MATTBLUNT(11/30/01)*

Chapter 11óDefinition of Terms13 CSR 15-11

Chapter 12 * - Skilled Nursing Facility

13 CSR 15-12.010 Standards for New Skilled Nursing Facility and Additions {#sec-13-csr-15-12.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-12.010}

(Rescinded June 11, 1981)

1979. Emergency rule filed Sept. 7, 1979, effective Sept. 28, 1979, expired Jan. 24, 1980. Original rule filed Sept. 7, 1979, effective Jan. 12, 1980. Rescinded: Filed Dec. 10, 1980, effective June 11, 1981.

History

• AUTHORITY: section 198.079, RSMo Supp.

13 CSR 15-12.011 Standards for New and Existing Skilled Nursing Facilities {#sec-13-csr-15-12.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-12.011}

(Rescinded October 13, 1983)

1979. Original rule filed Dec. 10, 1980, effective June 11, 1981. Amended: Filed Dec. 7, 1981, effective May 11, 1982. Rescinded:

Filed July 13, 1983, effective Oct. 13, 1983.

MATTBLUNT(12/31/01)

History

• AUTHORITY: section 198.079, RSMo Supp.

Chapter 13 * - moved to 19 CSR 30-84

13 CSR 15-13.010 Nurse Assistant Training Program {#sec-13-csr-15-13.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-13.010}

(Moved to 19 CSR 30-84.010)

13 CSR 15-13.020 Certified Medication Technician Training Program {#sec-13-csr-15-13.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-13.020}

(Moved to 19 CSR 30-84.020)

13 CSR 15-13.030 Level I Medication Aide {#sec-13-csr-15-13.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-13.030}

(Moved to 19 CSR 30-84.030)

13 CSR 15-13.040 Insulin Administration Training Program {#sec-13-csr-15-13.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-13.040}

(Moved to 19 CSR 30-84.040)

MATTBLUNT(11/30/01)

Chapter 14 * - Intermediate Care and Skilled Nursing Facility

13 CSR 15-14.010 Construction Standards for New Intermediate Care Facilities and Additions to Intermediate Care Facilities 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effec- {#sec-13-csr-15-14.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.010}

13 CSR 15-14.011 Construction Standards for New Intermediate Care Facilities and Additions to Intermediate Care Facilities 1979. Original rule filed Dec. 10, 1980, Filed July 13, 1983, effective Oct. 13, 1998. {#sec-13-csr-15-14.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.011}

13 CSR 15-14.012 Construction Standards for New Intermediate Care and Skilled Nursing Facilities and Additions to and Major Remodeling of Intermediate Care {#sec-13-csr-15-14.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.012}

(Moved to 19 CSR 30-85.012)

13 CSR 15-14.020 Fire Safety Standards 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effec- {#sec-13-csr-15-14.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.020}

13 CSR 15-14.021 Fire Safety Standards 1979. Original rule filed Dec. 10, 1980, 7, 1981, effective May 13, 1982. Emergency amendment filed May 28, 1982, effective June 7, 1982, expired Oct. 5, 1982. {#sec-13-csr-15-14.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.021}

Amended: Filed June 2, 1982, effective Sept. 11, 1982. Rescinded: Filed July 13, 1983, effective Oct. 13, 1983.

13 CSR 15-14.022 Fire Safety Standards {#sec-13-csr-15-14.022 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.022}

(Moved to 19 CSR 30-85.022)

13 CSR 15-14.030 Construction Standards for Existing Intermediate Care Facilities 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effec- {#sec-13-csr-15-14.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.030}

13 CSR 15-14.031 Physical Plant Require- 1979. Original rule filed Dec. 10, 1980, {#sec-13-csr-15-14.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.031}

13 CSR 15-14.032 Physical Plant Require- Care and Skilled Nursing Facilities {#sec-13-csr-15-14.032 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.032}

(Moved to 19 CSR 30-85.032)

13 CSR 15-14.040 Administration Require- {#sec-13-csr-15-14.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.040}

1979. Emergency rule filed Sept. 7, 1979, effective Sept. 18, 1979, expired Jan. 24, 1980. Original rule filed Sept. 7, 1979, effec-

History

• AUTHORITY: section 198.079 RSMo Supp.

13 CSR 15-14.041 Sanitation Require- 1979. Original rule filed Dec. 10, 1980, {#sec-13-csr-15-14.041 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.041}

13 CSR 15-14.042 Administration and Resident Care Requirements for New and Existing Intermediate Care and Skilled Nursing Facilities {#sec-13-csr-15-14.042 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.042}

(Moved to 19 CSR 30-85.042)

13 CSR 15-14.050 Patient Care Require- 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effec- {#sec-13-csr-15-14.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.050}

13 CSR 15-14.051 Furniture, Room Care, Supplies and Equipment Requirements for New and Existing Intermediate Care 1979. Original rule filed Dec. 10, 1980, {#sec-13-csr-15-14.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.051}

13 CSR 15-14.052 Dietary Requirements {#sec-13-csr-15-14.052 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.052}

(Moved to 19 CSR 30-85.052)

13 CSR 15-14.060 Administration and Personnel Requirements for New and Existing Intermediate Care Facilities 1979. Original rule filed Dec. 10, 1980, effective June 11, 1981. Amended: FIled Dec. {#sec-13-csr-15-14.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.060}

13 CSR 15-14.070 Resident Care Require- 1979. Original rule filed Dec. 10, 1980, MATTBLUNT(11/30/01) 7, 1981, effective May 13, 1982. Emergency amendment filed May 3, 1982, effective May 13, 1982, expired Aug. 30, 1982. Amended: {#sec-13-csr-15-14.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.070}

Filed May 13, 1982, effective Aug. 13, 1982.

Emergency amendment filed May 28, 1982, effective June 7, 1982, expired Oct. 5, 1982.

Amended: Filed June 2, 1982, effective Sept. 11, 1982, Rescinded: Filed July 13, 1983, effective Oct. 13, 1983.

13 CSR 15-14.080 Residents’ Rights and Grievance Procedures for Intermediate 1979. Original rule filed Dec. 10, 1980, {#sec-13-csr-15-14.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.080}

13 CSR 15-14.090 Standards for Intermediate Care Facilities for Handling Personal Funds and Property of Resident 1979. Original rule filed Dec. 10, 1980, 4CODE OF STATE REGULATIONS (11/30/01) MATTBLUNT {#sec-13-csr-15-14.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-14.090}

Chapter 15 * - Residential Care Facilities I and II

13 CSR 15-15.010 Construction Standards for New Residential Care Facilities and Additions to Residential Care Facilities 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effective Jan. 12, 1980. Emergency rescission {#sec-13-csr-15-15.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.010}

13 CSR 15-15.011 Construction Standards for Newly Constructed and Newly Licensed Residential Care Facilities and Additions to and Major Remodeling of Existing Residential Care Facilities 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Amended: Filed Dec. 7, 1981, {#sec-13-csr-15-15.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.011}

13 CSR 15-15.012 Construction Standards Facilities II and Newly Licensed Residential Care Facilities I {#sec-13-csr-15-15.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.012}

(Moved to 19 CSR 30-86.012)

13 CSR 15-15.020 Fire Safety Standards 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule Sept. 7, 1979, effective Jan. 2, 1980. Emergency rescission filed June 12, 1980, effective July 11, 1980, expired Nov. 9, 1980. Rescinded: Filed June 12, 1980, effective Nov. 13, 1980. {#sec-13-csr-15-15.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.020}

13 CSR 15-15.021 Construction Standards for Existing Residential Care Facilities 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Amended: Filed Dec. 7, 1981, {#sec-13-csr-15-15.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.021}

13 CSR 15-15.022 Fire Safety Standards {#sec-13-csr-15-15.022 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.022}

(Moved to 19 CSR 30-86.022)

13 CSR 15-15.030 Construction Standards for Existing Residential Care Facilities 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effective Dec. 13, 1979. Emergency rescission {#sec-13-csr-15-15.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.030}

13 CSR 15-15.031 Fire Safety Standards 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Amended: Filed Dec. 7, 1981, {#sec-13-csr-15-15.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.031}

13 CSR 15-15.032 Physical Plant Require- Care Facilities I and II {#sec-13-csr-15-15.032 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.032}

(Moved to 19 CSR 30-86.032)

13 CSR 15-15.040 Administration Require- 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effective Jan. 12, 1980. Emergency amendment filed Jan. 15, 1980, effective Jan. 25, 1980, expired May 1, 1980. Amended: Filed Jan. 15, 1980, effective May 11, 1980. Emergency rescission filed June 12, 1980, effective July 11, 1980, expired Nov. 9, 1980. Rescinded: {#sec-13-csr-15-15.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.040}

Filed June 12, 1980, effective Nov. 13, 1980.

13 CSR 15-15.041 Physical Plant Requirements of New and Existing Residential 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Amended: Filed Dec. 7, 1981, {#sec-13-csr-15-15.041 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.041}

13 CSR 15-15.042 Administrative, Personnel and Resident Care Requirements for New and Existing Residential Care {#sec-13-csr-15-15.042 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.042}

(Moved to 19 CSR 30-86.042)

13 CSR 15-15.045 Standards and Requirements for Residential Care Facilities II Which Provide Services to Residents with Alzheimer’s Disease or Other Dementia {#sec-13-csr-15-15.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.045}

(Moved to 19 CSR 30-86.045)

13 CSR 15-15.050 Resident Care Require- 1979. Emergency rule filed Sept. 7, 1979, 1980. Original rule filed Sept. 7, 1979, effective Jan. 12, 1980. Emergency rescission {#sec-13-csr-15-15.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.050}

13 CSR 15-15.051 Sanitation Require- 1979. Emergency rule filed June 12, 1980, MATTBLUNT(11/30/01) {#sec-13-csr-15-15.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.051}

Nov. 13, 1980. Rescinded: Filed July 13,

13 CSR 15-15.052 Dietary Requirements {#sec-13-csr-15-15.052 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.052}

(Moved to 19 CSR 30-86.052)

13 CSR 15-15.060 Administrative and Personnel Requirements for New and Existing Residential Care Facilities {#sec-13-csr-15-15.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.060}

(Rescinded May 13, 1982)

1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Emergency Amendment filed June 18, 1980, effective July 11, 1980, expired Nov. 9, 1980. Emergency Amendment filed July 16, 1980, effective July 26, 1980, expired Nov. 9, 1980. Rescinded: Filed Dec. 7, 1981, effective May 13, 1982.

13 CSR 15-15.070 Furniture, Supplies and Room Care in New and Existing Residential Care Facilities 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Amended: Filed Dec. 7, 1981, {#sec-13-csr-15-15.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.070}

13 CSR 15-15.080 Administrative and Personal Care Requirements for New and Existing Residential Care Facilities 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Amended: Filed Dec. 7, 1981, {#sec-13-csr-15-15.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.080}

13 CSR 15-15.090 Resident Rights and Grievance Procedures for Residential Care 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Rescinded: Filed July 13, {#sec-13-csr-15-15.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.090}

13 CSR 15-15.095 Standards for Residential Care Facilities for Handling Personal Funds and Property of Residents 1979. Emergency rule filed June 12, 1980, Nov. 13, 1980. Rescinded: Filed July 13, 4CODE OF STATE REGULATIONS (11/30/01) MATTBLUNT {#sec-13-csr-15-15.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-15.095}

Chapter 16 * - Adult Boarding Facilities

13 CSR 15-16.010 Construction Standards for New Adult Boarding Facilities and Additions to Adult Boarding Facilities Sept. 28, 1979, expired Jan. 24, 1980. {#sec-13-csr-15-16.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.010}

Jan. 12, 1980. Emergency rescission filed

13 CSR 15-16.011 Construction Standards for Newly Constructed and Newly Licensed Adult Boarding Facilities and Additions to and Major Remodeling of Existing Adult Boarding Facilities 1980. Amended: Filed Dec. 7, 1981, effective {#sec-13-csr-15-16.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.011}

13 CSR 15-16.020 Fire Safety Standards for New and Existing Adult Boarding Sept. 28, 1979, expired Jan. 24, 1980. {#sec-13-csr-15-16.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.020}

Jan. 12, 1980. Emergency rescission filed

13 CSR 15-16.021 Fire Safety Standards for New and Existing Adult Boarding 1980. Amended: Filed Dec. 7, 1981, effective {#sec-13-csr-15-16.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.021}

13 CSR 15-16.030 Construction Standards For Existing Adult Boarding Facilities Sept. 28, 1979, expired Jan. 24, 1980. {#sec-13-csr-15-16.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.030}

13 CSR 15-16.031 Physical Plant Require- 1980. Amended: Filed Dec. 7, 1981, effective {#sec-13-csr-15-16.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.031}

13 CSR 15-16.040 Administration Require- Sept. 28, 1979, expired Jan. 24, 1980. {#sec-13-csr-15-16.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.040}

Jan. 12, 1980. Emergency amendment filed Jan. 15, 1980, effective Jan. 25, 1980, expired May 1, 1980. Amended: Filed Jan. 15, 1980, effective May 11, 1980. Emergency rescission filed June 12, 1980, effective July 11, 1980, expired Nov. 9, 1980. Rescinded:

Filed June 12, 1980, effective Nov. 13, 1980.

13 CSR 15-16.041 Sanitation Require- 1980. Amended: Filed Dec. 7, 1981, effective {#sec-13-csr-15-16.041 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.041}

13 CSR 15-16.050 Personal Care Require- {#sec-13-csr-15-16.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.050}

Sept. 28, 1979, expired Jan. 24, 1980.

Jan. 12, 1980. Emergency rescission filed

History

• AUTHORITY: 198.076 RSMo Supp. 1979.

13 CSR 15-16.051 Administrative and Personal Requirements for New and Existing Adult Boarding Facilities {#sec-13-csr-15-16.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.051}

(Rescinded May 13, 1982)

1980. Emergency amendment filed July 16, 1980, effective July 26, 1980, expired Nov. 9, 1980. Rescinded: Filed Dec. 7, 1981, effective May 13, 1982.

13 CSR 15-16.060 Furniture, Supplies and Room Care in New and Existing Adult Boarding Facilities 1980. Emergency amendment filed Feb. 9, 1981, effective Feb. 20, 1981, expired June 20, 1981. Amended: Filed Dec. 7, 1981, effective May 13, 1982. Rescinded: Filed July 13, 1983, effective Oct. 13, 1983. {#sec-13-csr-15-16.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.060}

13 CSR 15-16.070 Administrative and Personal Care Requirements for New and Existing Adult Boarding Facilities 1980. Amended: Filed Dec. 7, 1981, effective May 13, 1982. Emergency amendment filed May 3, 1982, effective May 13, 1982, expired Aug. 30, 1982. Amended: Filed May 13, 1982, effective Aug. 13, 1982. Rescinded: {#sec-13-csr-15-16.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.070}

Filed July 13, 1983, effective Oct. 13, 1983.

13 CSR 15-16.080 Resident Rights and Grievance Procedures for Adult Boarding MATTBLUNT(12/31/01) {#sec-13-csr-15-16.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.080}

1980. Amended: Filed Dec. 7, 1981, effective

13 CSR 15-16.090 Standards for Adult Boarding Facilities for Handling Personal Funds and Property of Residents 1980. Amended: Filed Dec. 7, 1981, effective 4CODE OF STATE REGULATIONS (12/31/01) MATTBLUNT {#sec-13-csr-15-16.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-16.090}

Chapter 17 * - moved to 19 CSR 30-87

13 CSR 15-17.010 Definitions {#sec-13-csr-15-17.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-17.010}

(Moved to 19 CSR 30-87.010)

13 CSR 15-17.020 General Sanitation Requirements for New and Existing Long- Term Care Facilities {#sec-13-csr-15-17.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-17.020}

(Moved to 19 CSR 30-87.020)

13 CSR 15-17.030 Sanitation Requirements for Food Service {#sec-13-csr-15-17.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-17.030}

(Moved to 19 CSR 30-87.030)

MATTBLUNT(11/30/01)

Chapter 18 * - moved to 19 CSR 30-88

13 CSR 15-18.010 Resident Rights {#sec-13-csr-15-18.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-18.010}

(Moved to 19 CSR 30-88.010)

13 CSR 15-18.020 Resident’s Funds and Property {#sec-13-csr-15-18.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-18.020}

(Moved to 19 CSR 30-88.020)

MATTBLUNT(11/30/01)

Property in Long-Term Care Facilities13 CSR 15-18

Chapter 19 * - Special Inspection Standards

13 CSR 15-19.010 Standards for Inspection of Facilities or Premises Funded by Federal Departments Other Than Health and Human Services {#sec-13-csr-15-19.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-19.010}

(Rescinded April 30, 2019)

1987. Emergency rule filed July 15, 1988, effective Aug. 13, 1988, expired Nov. 1, 1988. Original rule filed July 15, 1988, effective Nov. 11, 1988. Rescinded: Filed Aug. 28, 2018, effective April 30, 2019.

JOHNR. ASHCROFT(3/31/19)

History

• AUTHORITY: section 198.009, RSMo Supp.

Chapter 20 * - moved to 19 CSR 30-89

13 CSR 15-20.010 Pediatric Nursing Facilities {#sec-13-csr-15-20.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 15-20.010}

(Moved to 19 CSR 30-89.010)

MATTBLUNT(11/30/01)

Division 20 Division of Corrections

Chapter 1 Organization

13 CSR 20-1.010 Organization and Operation {#sec-13-csr-20-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-1.010}

(Rescinded September 11, 1978)

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Original rule filed May 3, 1976, effective Nov. 11, 1976. Rescinded: Filed June 14, 1978, effective Sept. 11, 1978.

13 CSR 20-1.011 Organization and Operation {#sec-13-csr-20-1.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-1.011}

(Rescinded June 15, 1984)

Filed Feb. 28, 1984, effective June 15, 1984.

MATTBLUNT(12/31/01)

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Original rule field June 14, 1978, effective Sept. 11, 1978. Rescinded:

Chapter 101 Director's Office

13 CSR 20-101.020 Rulemaking RSMo 1969. Original rule filed May 3, 1976, effective Nov. 11, 1976. Rescinded: Filed Feb. 28, 1984, effective June 15, 1984. {#sec-13-csr-20-101.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.020}

13 CSR 20-101.030 Purpose and Function of Each Institution {#sec-13-csr-20-101.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.030}

(Rescinded December 11, 1976)

Rescinded: Published Oct. 1, 1976, effective Dec. 11, 1976.

History

• AUTHORITY: section 216.115, RSMo 1969.

13 CSR 20-101.040 The Public’s Access to Institutions RSMo 1969. Original rule filed Dec. 31, {#sec-13-csr-20-101.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.040}

13 CSR 20-101.050 Visits by Family and Friends RSMo 1978. Original rule filed Dec. 31, {#sec-13-csr-20-101.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.050}

13 CSR 20-101.060 Interstate Corrections Compact RSMo 1969 and 222.250, RSMo 1975. {#sec-13-csr-20-101.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.060}

Rescinded: Published Aug. 2, 1976, effective Nov. 11, 1976.

13 CSR 20-101.070 Merit Time Emergency rule filed March 15, 1976, effective March 25, 1976, expired July 23, 1976. {#sec-13-csr-20-101.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.070}

Parrish v Wyrick589 SW2d 74 (Mo.App. 1979). Unlike statutory good time, the granting of pre-1979 Criminal Code merit time was under the constitutional commutation power of the governor, and so entirely within his discretion.

13 CSR 20-101.080 Team Classification {#sec-13-csr-20-101.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.080}

(Rescinded December 11, 1976)

Rescinded: Published Oct. 1, 1976, effective Dec. 11, 1976.

History

• AUTHORITY: section 216.115, RSMo 1969.

13 CSR 20-101.090 Personalized Plan {#sec-13-csr-20-101.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.090}

History

• AUTHORITY: sections 216.020 and 216, 115,

13 CSR 20-101.100 Inmate’s Readiness for Parole {#sec-13-csr-20-101.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.100}

13 CSR 20-101.110 Recreation {#sec-13-csr-20-101.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.110}

13 CSR 20-101.120 Inmate Grievances {#sec-13-csr-20-101.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.120}

13 CSR 20-101.130 Religious Programs and Activities RSMo 1978. Original rule filed Dec. 31, {#sec-13-csr-20-101.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.130}

13 CSR 20-101.140 Quarantining of Inmates MATTBLUNT(12/31/01) {#sec-13-csr-20-101.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-101.140}

Chapter 102 Classification and Assignment

13 CSR 20-102.010 Institutional Transfer {#sec-13-csr-20-102.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-102.010}

(Rescinded November 11, 1976)

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Rescinded: Published Aug. 2, 1976, effective Nov. 11, 1976.

13 CSR 20-102.020 Classification Files {#sec-13-csr-20-102.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-102.020}

(Rescinded December 11, 1976)

Rescinded: Published Oct. 1, 1976, effective Dec. 11, 1976.

MATTBLUNT(12/31/01)

History

• AUTHORITY: section 216.115, RSMo 1969.

Chapter 103 Community Services

13 CSR 20-103.010 Community Release Program {#sec-13-csr-20-103.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-103.010}

(Rescinded September 11, 1978) 1975, effective June 10, 1976. Rescinded:

Filed June 14, 1978, effective Sept. 11, 1978.

13 CSR 20-103.011 Community Release Program {#sec-13-csr-20-103.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-103.011}

Original rule filed June 14, 1978, effective Sept. 11, 1978. Rescinded: Filed Feb. 28, 1984, effective June 15, 1984.

History

• AUTHORITY: sections 216.020(7), RSMo 1969 and 216.221, RSMo Supp. 1973.

13 CSR 20-103.020 Temporary Release 1975, effective June 10, 1976. Amended: {#sec-13-csr-20-103.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-103.020}

Filed Dec. 21, 1976, effective June 11, 1977.

Rescinded: Filed Feb. 28, 1984, effective June 15, 1984.

13 CSR 20-103.030 Use of Volunteers 1975, effective June 10, 1976. Amended: {#sec-13-csr-20-103.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-103.030}

Filed Dec. 21, 1976, effective June 11, 1977.

Rescinded: Filed Feb. 28, 1984, effective June 15, 1984.

MATTBLUNT(12/31/01)

Chapter 104 Custodial Services

13 CSR 20-104.010 Inmate Discipline {#sec-13-csr-20-104.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.010}

13 CSR 20-104.020 Inmate Trips to Bedside and Funeral Dec. 11, 1976. {#sec-13-csr-20-104.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.020}

13 CSR 20-104.030 Outside Details {#sec-13-csr-20-104.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.030}

13 CSR 20-104.040 Inmate Mail Privileges 1975, effective Jan. 10, 1976. Amended: {#sec-13-csr-20-104.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.040}

Filed Oct. 4, 1976, effective Jan. 13, 1977.

Rescinded: Feb. 28, 1984, effective June 15, 1984.

13 CSR 20-104.050 Emergency Squad Dec. 11, 1976. {#sec-13-csr-20-104.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.050}

13 CSR 20-104.060 Inmate Organization Dec. 11, 1976. {#sec-13-csr-20-104.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.060}

13 CSR 20-104.070 Inmate Personal Appearance {#sec-13-csr-20-104.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.070}

13 CSR 20-104.080 Inmate Telephone Calls {#sec-13-csr-20-104.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.080}

Filed Feb. 28, 1984, effective June 15, 1984.

History

• AUTHORITY: sections 216.020 and 260.115, 1975, effective Jan. 10, 1976. Rescinded:

13 CSR 20-104.090 Confiscation of Money Found in Possession of Inmates {#sec-13-csr-20-104.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.090}

History

• AUTHORITY: sections 216.020, 216.115 and 216.315, RSMo 1969. Rescinded: Published Aug. 2, 1976, effective Nov. 11, 1976.

13 CSR 20-104.100 Inmate Driver’s License {#sec-13-csr-20-104.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.100}

Filed Dec. 14, 1976, effective June 11, 1977.

Rescinded: Filed Feb. 28, 1984, effective June 15, 1984.

History

• AUTHORITY: sections 216.020 and 260.115, 1975, effective Jan. 10, 1976. Amended:

13 CSR 20-104.110 Security, Custody, Control and Outcount {#sec-13-csr-20-104.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.110}

13 CSR 20-104.120 Reporting Escapes Dec. 11, 1976. {#sec-13-csr-20-104.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.120}

13 CSR 20-104.160 Use of Force RSMo 1969. Original rule filed June 14, 1978, effective Sept. 11, 1978. Rescinded: {#sec-13-csr-20-104.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-104.160}

Filed Feb. 28, 1984, effective June 15, 1984.

MATTBLUNT(12/31/01)

Chapter 106 Inmate Services

13 CSR 20-106.010 Inmate Education {#sec-13-csr-20-106.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-106.010}

(Rescinded June 15, 1984)

Filed Feb. 28, 1984, effective June 15, 1984.

MATTBLUNT(12/31/01)

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Original rule filed June 14, 1978, effective Sept. 11, 1978. Rescinded:

Chapter 109 Fire and Safety

13 CSR 20-109.010 Occupational Safety Standards {#sec-13-csr-20-109.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-109.010}

(Rescinded December 11, 1976)

Rescinded: Published Oct. 1, 1976, effective Dec. 11, 1976.

MATTBLUNT(12/31/01)

History

• AUTHORITY: section 216.115, RSMo 1969.

Chapter 110 Fiscal Management

13 CSR 20-110.010 Discharge Allowments {#sec-13-csr-20-110.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-110.010}

(Rescinded November 11, 1976)

History

• AUTHORITY: sections 216.020, 216.115 and 216.350, RSMo 1969. Rescinded: Published Aug. 2, 1976, effective Nov. 11, 1976.

13 CSR 20-110.020 Obtaining Federal Surplus {#sec-13-csr-20-110.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-110.020}

(Rescinded December 11, 1976)

Rescinded: Published Oct. 1, 1976, effective Dec. 11, 1976.

History

• AUTHORITY: section 216.115, RSMo 1969.

13 CSR 20-110.030 Acceptance of Gifts to the Division {#sec-13-csr-20-110.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-110.030}

(Rescinded June 15, 1984)

RSMo 1969. Original rule filed Dec. 31, 1975, effective Jan. 10, 1976. Rescinded:

Filed Feb. 28, 1984, effective June 15, 1984

13 CSR 20-110.040 Federal Grants {#sec-13-csr-20-110.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-110.040}

(Rescinded June 15, 1984)

RSMo 1969. Original rule filed Dec. 31, 1975, effective Jan. 10, 1976. Rescinded:

Filed Feb. 28, 1984, effective June 15, 1984.

13 CSR 20-110.050 Inmate Canteen Committee {#sec-13-csr-20-110.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-110.050}

(Rescinded November 11, 1976)

RSMo 1969. Rescinded: Published Aug. 2, 1976, effective Nov. 11, 1976.

MATTBLUNT(12/31/01)

Chapter 112 Health Services

13 CSR 20-112.010 Inmate Medical Care {#sec-13-csr-20-112.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-112.010}

(Rescinded September 11, 1978)

Filed June 14, 1978, effective Sept. 11, 1978.

History

• AUTHORITY: sections 216.020 and 216.115 1975, effective Jan. 10, 1976. Rescinded:

13 CSR 20-112.011 Inmate Medical Care {#sec-13-csr-20-112.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-112.011}

Filed Feb. 28, 1984, effective June 15, 1984.

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Original rule filed June 14, 1976, effective Sept. 11, 1978. Rescinded:

13 CSR 20-112.020 Serious or Critical Illness, or Death of Inmate by Natural Cause or by Acts of Violence {#sec-13-csr-20-112.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-112.020}

Filed June 14, 1978, effective Sept. 11, 1978.

Rescinded: FIled Feb. 28, 1984, effective June 15, 1984.

History

• AUTHORITY: sections 216.020 and 226.115, 1975, effective Jan. 10, 1976. Amended:

13 CSR 20-112.030 Autopsy {#sec-13-csr-20-112.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-112.030}

Filed Feb. 28, 1984, effective June 15, 1984.

MATTBLUNT(12/31/01)

History

• AUTHORITY: sections 216.020 and 216.115, 1975, effective Jan. 10, 1976. Rescinded:

Chapter 113 Legal Services

13 CSR 20-113.010 Preparation of Inmate Legal Papers {#sec-13-csr-20-113.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-113.010}

(Rescinded December 11, 1976)

Rescinded: Published Oct. 1, 1976, effective Dec. 11, 1976.

History

• AUTHORITY: section 216.115 RSMo 1969.

13 CSR 20-113.020 Photographs of Inmates {#sec-13-csr-20-113.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-113.020}

(Rescinded September 15, 1984)

Filed May 7, 1984, effective Sept. 15, 1984.

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Original rule filed Dec. 31, 1975, effective Jan. 10, 1976. Rescinded:

13 CSR 20-113.030 Domestic Relations {#sec-13-csr-20-113.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-113.030}

(Rescinded September 15, 1984)

Filed May 7, 1984, effective Sept. 15, 1984.

Op. Atty. Gen. No. 119, Blassie, 11-5-76. A marriage entered into by an inmate, while under sentence to the Missouri Department of Corrections, is valid if entered into pursuant to chapter 451, RSMo (1969) and may be dissolved in accordance with chapter 452, RSMo (Supp. 1975).

MATTBLUNT(12/31/01)

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Original rule filed Dec. 31, 1975, effective Jan. 10, 1976. Rescinded:

Chapter 114 Personnel Services

13 CSR 20-114.010 Personnel Identification Cards Dec. 11, 1976. {#sec-13-csr-20-114.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-114.010}

13 CSR 20-114.020 Hiring and Recruitment {#sec-13-csr-20-114.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-114.020}

(Rescinded September 15, 1984)

Filed May 7, 1984, effective Sept. 15, 1984.

History

• AUTHORITY: sections 216.020 and 216.115, RSMo 1969. Original rule filed Dec. 31, 1975, effective Jan. 10, 1976. Rescinded:

13 CSR 20-114.030 Intra-Divisional Promotions and Career Development Dec. 11, 1976. {#sec-13-csr-20-114.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-114.030}

13 CSR 20-114.040 Employee Conduct Dec. 11, 1976. {#sec-13-csr-20-114.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-114.040}

13 CSR 20-114.050 Employees Grievance Dec. 11, 1976. {#sec-13-csr-20-114.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-114.050}

MATTBLUNT(12/31/01)

Chapter 116 Staff Training

13 CSR 20-116.010 Staff Training and Development {#sec-13-csr-20-116.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 20-116.010}

(Rescinded December 11, 1976)

Rescinded: Published Oct. 1, 1976, effective Dec. 11, 1976.

MATTBLUNT(12/31/01)

History

• AUTHORITY: 216.115, RSMo 1969.

Division 30 Child Support Enforcement

Chapter 1 Organization

13 CSR 30-1.010 Organization and Operation {#sec-13-csr-30-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-1.010}

(Rescinded May 30, 2017)

Original rule filed Feb. 16, 1988, effective April 11, 1988. Emergency amendment filed Dec. 13, 1993, effective Dec. 23, 1993, expired April 21, 1994. Emergency amendment filed April 11, 1994, effective April 21, 1994, expired Aug. 18, 1994. Amended:

Filed Jan. 5, 1994, effective July 30, 1994.

Amended: Filed June 15, 1995, effective Dec. 30, 1995. Rescinded: Filed Sept. 21, 2016, effective May 30, 2017.

History

• AUTHORITY: section 454.400, RSMo 1994.

Chapter 2 Performance Measures

13 CSR 30-2.010 Prosecuting Attorneys’ Performance Standards {#sec-13-csr-30-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-2.010}

(Moved to 13 CSR 40-108.040)

13 CSR 30-2.020 Financial Performance Measures for Counties Under Contract With the Missouri Division of Child Support Enforcement for the Provision of Total Child Support Services in Local Jurisdictions (Level A Counties) {#sec-13-csr-30-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-2.020}

(Rescinded May 30, 2017)

1993. Original rule filed Oct. 18, 1988, effective Jan. 13, 1989. Rescinded: Filed Sept. 21, 2016, effective May 30, 2017.

13 CSR 30-2.030 Standard Procedures for Handling Cash Receipts in Circuit Clerks’ Offices Under Contract With the Missouri Division of Child Support Enforcement for the Provision of IV-D Services {#sec-13-csr-30-2.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-2.030}

(Rescinded November 30, 2018)

1993. Emergency rule filed Oct. 16, 1989, effective Oct. 26, 1989, expired Feb. 22, 1990. Original rule filed Oct. 16, 1989, effective Feb. 11, 1990. Rescinded: Filed April 18, 2018, effective Nov. 30, 2018.

13 CSR 30-2.040 Standard Procedures for Handling Cash Receipts in Prosecuting Attorneys’ Offices Under Contract With the Missouri Division of Child Support Enforcement for the Provision of IV-D Services {#sec-13-csr-30-2.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-2.040}

(Rescinded November 30, 2018)

1993. Emergency rule filed Oct. 16, 1989, effective Oct. 26, 1989, expired Feb. 22, 1990. Original rule filed Oct. 16, 1989, effective Feb. 11, 1990. Rescinded: Filed April 18, 2018, effective Nov. 30, 2018.

Chapter 3 County Reimbursement (Moved to 13 CSR 40-3)

13 CSR 30-3.010 Reimbursable Expenditures {#sec-13-csr-30-3.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-3.010}

(Moved to 13 CSR 40-3.010)

13 CSR 30-3.020 Minimum Recordkeeping Requirements for County Reimbursement and Standardization of Claims Submissions {#sec-13-csr-30-3.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-3.020}

(Moved to 13 CSR 40-3.020)

ROBINCARNAHAN(5/31/09)

Chapter 4 Income Withholding

13 CSR 30-4.010 Interstate Income Withholding Procedure {#sec-13-csr-30-4.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-4.010}

(Rescinded October 30, 2008)

1990. Emergency rule filed Sept. 17, 1986, effective Sept. 27, 1986, expired Jan. 25, 1987. Original rule filed Oct. 16, 1986, effective Jan. 30, 1987. Emergency rule filed Feb. 16, 1993, effective Feb. 26, 1993, expired June 25, 1993. Emergency amendment filed April 13, 1993, effective June 22, 1993, expired Oct. 19, 1993. Amended: Filed Feb. 16, 1993, effective Aug. 9, 1993.

Rescinded: Filed April 22, 2008, effective Oct. 30, 2008.

History

• AUTHORITY: section 454.400, RSMo Supp.

13 CSR 30-4.020 Immediate Income Withholding Exceptions for Child Support Orders {#sec-13-csr-30-4.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-4.020}

(Moved to 13 CSR 40-104.010)

JOHNR. ASHCROFT(2/28/19)

Chapter 5 Determining Child Support Obligation

13 CSR 30-5.020 Review and Modification of Child and/or Medical Support Orders SOCIAL SERVICES Support Obligations {#sec-13-csr-30-5.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-5.020}

13 CSR 30-5.010 Child Support Obligation Guidelines {#sec-13-csr-30-5.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-5.010}

(Moved to 13 CSR 40-102.010)

13 CSR 30-5.020 Review and Modification of Child and/or Medical Support Orders {#sec-13-csr-30-5.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-5.020}

(Moved to 13 CSR 40-106.010)

JOHNR. ASHCROFT(4/30/19)

Chapter 6 Credit Reporting

13 CSR 30-6.010 Reporting of Child Support Debts to Consumer Reporting Agencies {#sec-13-csr-30-6.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-6.010}

(Moved to 13 CSR 40-104.020)

JOHNR. ASHCROFT(4/30/19)

Chapter 7 Administrative Hearings

13 CSR 30-7.010 Administrative Hearings {#sec-13-csr-30-7.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-7.010}

(Moved to 13 CSR 40-100.020)

JOHNR. ASHCROFT(4/30/19)

Chapter 8 Cooperation Requirement

13 CSR 30-8.010 Cooperation Requirement {#sec-13-csr-30-8.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-8.010}

(Moved to 13 CSR 40-100.030)

JOHNR. ASHCROFT(3/31/19)

Chapter 9 Incentives

13 CSR 30-9.010 Incentives {#sec-13-csr-30-9.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-9.010}

(Moved to 13 CSR 40-108.030)

JOHNR. ASHCROFT(2/28/19)

Chapter 10 Fees

13 CSR 30-10.010 Annual Fee {#sec-13-csr-30-10.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 30-10.010}

(Moved to 13 CSR 40-110-040)

JOHNR. ASHCROFT(2/28/19)

Division 35 Children's Division

Chapter 20 Child Protective Services

13 CSR 35-20.010 Screening and Classification of Child Abuse/Neglect Hotline Reports SOCIAL SERVICES {#sec-13-csr-35-20.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-20.010}

13 CSR 35-20.010 Screening and Classification of Child Abuse/Neglect Hotline Reports {#sec-13-csr-35-20.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-20.010}

(Moved to 13 CSR 35-31.020)

JASONKANDER(10/31/16)

Chapter 30 Voluntary Placement Agreement

13 CSR 35-30.010 Voluntary Placement Agreement Solely for the Purpose of Accessing Mental Health Services and Treatment for Children Under Age Eighteen (18) {#sec-13-csr-35-30.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-30.010}

PURPOSE: This rule sets forth procedures to be followed to divert children from Children’s Division (CD) legal custody when a parent is unable to access or afford clinically indicated mental health services for their child and the child otherwise is not the subject of parental abuse, neglect or abandonment.

(1) Parents or legal guardians (parents) who are considering relinquishing custody solely for the purpose of accessing clinically indicated mental health services for their child or who otherwise cannot afford such services shall be referred by the Children’s Division (CD) or Juvenile Court to the Department of Mental Health (DMH) or their designee for an assessment of eligibility to enter into a Voluntary Placement Agreement (VPA).

(2) The Department of Social Services-Children’s Division (DSS-CD) and the DMH shall develop protocol, policy and procedure to assess the level and extent of services needed for such children and to develop criteria for determining whether a child may be appropriate for a VPA in accordance with

Chapter 536, RSMo.

(3) If DMH determines pursuant to the procedures, policies, and protocols as indicated in section (2) above, that the child requires services that cannot be provided in the home and the parent is currently unable to access or financially afford the clinically indicated care the child requires, the parent may enter into a VPA with the DSS-CD.

(A) A VPA means a written agreement between the DSS-CD and a parent, legal guardian, or custodian of a child under age eighteen (18) in need of out-of-home placement, solely because he/she is in need of mental health treatment and services.

(B) A VPA developed following a DMH assessment and certification of appropriateness authorizes the DSS-CD to administer the placement and care of a child while the parent, legal guardian, or custodian of the child retains legal custody.

(4) The DSS-CD will authorize the DMH to place the child, administer the placement, and provide care and treatment for the child while he/she is under the Voluntary Placement Agreement.

(5) The DMH shall ensure that a child’s placement, under the VPA, shall be in the most appropriate and least restrictive environment available for the shortest period of time as clinically indicated.

(6) The VPA shall be effective the date the child is placed. Voluntary Placement Agreements may be for as short a period as the parties may agree in the best interests of the child but under no circumstances shall the total period of time that a child shall remain in care under a VPA exceed one hundred eighty (180) days. Subsequent agreements may be entered into, but the total period of placement of the child under a single VPA or a series of VPAs shall not exceed one hundred eighty (180) days without the express authorization of the director of the Children’s Division or his/her designee.

(7) The parents, DMH and DSS-CD shall hold a family support team meeting to develop a permanency/treatment plan for the child either prior to or within seventy-two (72) hours of the date of placement of the child pursuant to a VPA. The permanency/treatment plan shall be completed and in place no later than sixty (60) days from the date that the child is placed according to the agreement.

(8) The parents, the DSS-CD and DMH shall hold a family support team meeting no later than one hundred (100) days from the date that the child is placed pursuant to a VPA to determine whether:

(A) The parties have exercised reasonable efforts to finalize the permanency plan; and (B) Whether it is in the best interests of the child to either terminate the VPA and reunite the child with the child’s parents or whether it is in the best interests of the child to continue the child in care beyond the expiration date of the VPA.

(9) The DSS-CD shall maintain responsibility for compliance with all Federal Title IV-E requirements. All Voluntary Placement Agreements shall be consistent with the requirements of sections 210.108 and 210.710, RSMo and Title IV-E of the Social Security Act and its implementing regulations, including, but not limited to 42 U.S.C.

section 672.

(10) DMH shall develop and submit to DSS- CD at prescribed intervals a report of services provided to any child served under a VPA. Such report shall include any information identified by DSS-CD as required for federal reporting purposes.

(11) The VPA may be terminated by the DSS- CD upon ten (10) days written notice to the parties.

(12) The parent(s) may terminate the VPA for any reason at any time by providing either oral or written notification to DSS-CD.

Upon receipt of such notice the VPA shall immediately terminate and the child shall be returned to the legal and physical custody of the parents.

(13) All VPAs shall be in writing and shall be on a form approved by the DSS-CD in consultation with the DMH.

Original rule filed Dec. 23, 2004, effective June 30, 2005. *Original authority: 210.108, RSMo 2004.

History

• AUTHORITY: section 210.108, RSMo Supp. 2004. Emergency rule filed Dec. 23, 2004, effective Jan. 2, 2005, expired June 30, 2005.

13 CSR 35-30.020 Immediate Safety Intervention Plan {#sec-13-csr-35-30.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-30.020}

PURPOSE: This rule governs the use of Immediate Safety Intervention Plans, which are used as part of Temporary Alternative Placement Agreements (TAPAs) under section 210.123, RSMo. An Immediate Safety Intervention Plan is a form for the relative caretaker of a child under a TAPA to use to notify medical care providers, educational institutions, and others that they have legal

(1) Purpose and Scope— (A) An Immediate Safety Intervention Plan is a voluntary, time limited agreement between the Children’s Division, a child’s parent(s) and/or legal guardian(s), and any other third parties to protect a child from one (1) or more identified, immediate threats to the child’s safety, health, and welfare in the short term. The purpose of the Immediate Safety Intervention Plan is to establish and document in writing a plan to keep a child safe with the goal of preventing or eliminating the need for the child to be involuntarily removed from the child’s home and/or brought under the authority of a juvenile or family court pursuant to Chapter 211, RSMo.

(B) The paramount consideration for developing, implementing, and monitoring an Immediate Safety Intervention Plan is to protect the safety, best interests, and welfare of the child.

(2) Definitions. For the purposes of this section the following definitions shall apply:

(A) The terms “Safety Plan” and “ISIP” mean Immediate Safety Intervention Plan;

(B) The word “relative” shall mean a grandparent or any other person related to another by blood or affinity or a person who is not so related to the child but has a close relationship with the child or the child’s family. The status of a grandparent shall not be affected by the death or the dissolution of the marriage of a son or daughter; and (C) The phrases “Temporary Alternative Placement Agreement” and “TAPA” shall mean Temporary Alternative Placement Agreements as defined in section 210.123, RSMo, and 13 CSR 35-30.030.

(3) Each Immediate Safety Intervention Plan will be reduced to writing and signed by the parties to the Immediate Safety Intervention Plan. It will— (A) Identify the danger or immediate safety threat(s) to the child;

(B) Identify the services that the division may offer to address the identified safety threat(s) to the child;

(C) Identify the specific actions that the child’s parent(s), guardian(s), and relative(s) will take to address the identified safety threat(s) to the child, and specify the time frames during which those actions will be completed;

(D) Identify any other people or agencies that are willing and available to support the child and the parent(s), guardian(s), and/or relative(s) in the implementation of the Immediate Safety Intervention Plan, and identify what actions they may take to implement the Immediate Safety Intervention Plan;

(E) Include a statement that the parent(s), guardian(s), and relative(s) agree to the Immediate Safety Intervention Plan, that they will participate in good faith with the services offered by the division, that they will cooperate with the division, and that they will implement the requirements of the Immediate Safety Intervention Plan;

(F) Specify the date on which the Immediate Safety Intervention Plan will terminate;

(G) Contain any other provisions that the parties may deem appropriate; and (H) Include a plan for monitoring the effectiveness of the Immediate Safety Intervention Plan.

(4) Placements. An Immediate Safety Intervention Plan may provide for the child to remain in the child’s own home while the plan is being implemented, or to temporarily reside with the non-offending parent. Any change in the residence of a child pursuant to an Immediate Safety Intervention Plan is and shall be accomplished solely pursuant to the legal authority of and voluntary consent of the child’s parent(s), legal custodian(s), or legal guardian(s). A change in the residence of a child pursuant to an Immediate Safety Intervention Plan is not intended to be and shall not be construed to be a custody order, modification of a custody order, or a placement of the child by the division.

(5) An Immediate Safety Intervention Plan is not a custody or visitation order or a parenting plan, as such terms as otherwise defined by law. An Immediate Safety Intervention Plan does not and cannot supersede a court order governing the care, custody, control, or support of a child.

(6) The parent(s), guardian(s), and relative(s) shall cooperate in good faith with the division to implement the Immediate Safety Intervention Plan. This includes, but is not limited to:

(A) Making the child available to meet with the division or its contractors or representatives in the State of Missouri in person, virtually, or by other means of communication upon request to enable the division to ensure the Immediate Safety Intervention Plan is being implemented and the child is safe and well cared for during the pendency of the Immediate Safety Intervention Plan;

(B) Allowing the division or its contractors or representatives to inspect the home at reasonable times (announced and unannounced) to ensure the Immediate Safety Intervention Plan is being implemented;

(C) Executing any consents and/or authorizations to release information to the division and/or to or from third parties the division determines necessary to obtain information to develop and/or monitor the implementation of the Immediate Safety Intervention Plan. This includes, but is not limited to, health care providers, schools, and other professionals providing services to the child and other parties;

(D) Participating in team decision making meetings that the division may convene pertaining to the child;

(E) Keeping the division informed of their current residence address, mailing address, telephone number, e-mail address, work address, and contact information; and any change in the residence of and contact information for the child; and (F) It shall be the duty of the parent(s), legal guardian(s), and relative(s) to promptly notify the division of any change in circumstances that may impact the care of the child and/or the implementation of the Immediate Safety Intervention Plan.

(7) Background checks.

(A) The division may conduct a background check of the parent, guardian, the relative, and any adult member of the parent, guardian, or relative’s household as part of its process to determine whether the parent, guardian, or relative is a suitable temporary placement provider for the child. The parent, relative, and other adult household members shall execute any consents or other documents necessary to complete any background checks, and submit to a fingerprint-based criminal background check if the division determines this to be necessary. If the parent, relative, or any adult member of the household declines to assist in background check process then the division may decide not to enter into an Immediate Safety Intervention Plan.

(B) Notwithstanding any other provision of this section, the division will not enter into an Immediate Safety Intervention Plan where the parent or guardian of the child places the child under an Immediate Safety Intervention Plan in the home of a non-offending/non-resident parent where the individual or any member of the individual’s household has pled guilty or been found guilty of any the following crimes when a child was the victim:

1. Section 565.020, RSMo (murder, 2. Section 565.021, RSMo (murder, second degree);

2. Section 565.023, RSMo (voluntary manslaughter);

3. Section 565.024, RSMo (involuntary manslaughter, first degree);

4. Section 565.050, RSMo (assault, first 6. Section 566.030, RSMo (rape, first 7. Section 566.031, RSMo (rape, second degree, or section 566.040, RSMo 8. Section 566.032, RSMo (statutory rape, first degree);

5. Section 566.060, RSMo (sodomy, 10. Section 566.061, RSMo (sodomy, second degree, or section 566.070, RSMo 11. Section 566.062, RSMo (statutory sodomy, first degree);

6. Section 566.064, RSMo (statutory sodomy, second degree);

7. Section 566.067, RSMo (child molestation, first degree);

8. Section 566.068, RSMo (child molestation, second degree);

9. Section 566.069, RSMo (child molestation, third degree);

10. Section 566.071, RSMo (child molestation, fourth degree);

11. Section 566.083, RSMo (sexual misconduct involving a child);

12. Section 566.100, RSMo (sexual abuse, first degree);

13. Section 566.101, RSMo (sexual abuse, second degree, or section 566.090, RSMo before Aug. 28, 2013);

14. Section 566.111, RSMo (sex with an animal);

15. Section 566.151, RSMo (enticement of a child, first degree);

16. Section 566.203, RSMo (abusing an individual through forced labor);

17. Section 566.206, RSMo (trafficking for the purpose of slavery, involuntary servitude, peonage, or forced labor);

18. Section 566.209, RSMo (trafficking for the purpose of sexual exploitation);

19. Section 566.210, RSMo (sexual trafficking of a child, first degree);

20. Section 566.211, RSMo (sexual trafficking of a child, second degree, or section 566.212, RSMo before Jan. 1, 2017);

21. Section 566.215, RSMo (contributing to human trafficking through the misuse of documentation);

22. Section 567.050, RSMo (promoting prostitution, first degree);

23. Section 568.080, RSMo (child used in sexual performance, if before Jan. 1, 2017);

24. Section 568.090, RSMo (promoting sexual performance by a child, if before Jan. 1, 2017);

25. Section 568.020, RSMo (incest);

26. Section 568.030, RSMo (child abandonment, first degree);

27. Section 568.060, RSMo (abuse or neglect of a child);

28. Section 568.065, RSMo (genital mutilation of a female child);

29. Section 568.175, RSMo (trafficking in children);

30. Section 573.023, RSMo (sexual exploitation of a minor);

31. Section 573.025, RSMo (promoting child pornography, first degree);

32. Section 573.035, RSMo (promoting child pornography, second degree);

33. Section 573.037, RSMo (possession of child pornography);

34. Section 573.200, RSMo (child used in sexual performance or section 568.080, RSMo before Jan. 1, 2017); or 41. Section 573.205, RSMo (promoting sexual performance by a child or section 568.090, RSMo before Jan. 1, 2017).

(C) Except as otherwise provided in subsection (7)(B), the division may, at its discretion, agree to enter into an Immediate Safety Intervention Plan in which the parent or guardian of the child places the child in the home of a non-offending/non-resident parent where the individual or any adult member of the individual’s household has been found guilty of any other crimes against persons, substantiated or significant child abuse/neglect

history, or drug and alcohol related offenses if the parent, guardian, and/or the relative satisfy the division that the placement is in the best interests of the child, that the parent or relative is a fit and suitable person to temporarily care for the child, and that the household where the child will temporarily reside is safe and appropriate for the child. In making this decision, the division may consider the following factors:

1. Whether the parent, guardian, and/or relative or household member has successfully completed the conditions of sentencing and/or probation without further incidents;

2. Whether the parent, guardian, and/or relative or household member has successfully completed any prescribed or required treatment;

3. The duration of time between the prior incident and the negotiation of the Immediate Safety Intervention Plan;

4. The written advice and recommendations of professionals with knowledge of the family;

5. Whether the prior incident of criminal conduct, while unlawful at the time of the incident, is no longer unlawful or proscribed at the time that the division is considering Immediate Safety Intervention Plan; and 6. Any other factor or information that may be relevant to making a decision about the best interests, care, and safety of the child.

(8) Enforcement of Immediate Safety Intervention Plans. The division does not have the

(A) Making referrals, with or without recommendations for further action, to the juvenile officer;

(B) Making referrals to law enforcement;

(C) Investigating reports of child abuse or neglect and conducting family assessments;

(D) Sharing a copy of the Immediate Safety Intervention Plan and other relevant information with the juvenile officer, law enforcement, medical care providers, guardians ad litem for the child, schools and school personnel, and any other person the division determines has a need to have the information for the care, safety, and best interests of the child; and (E) Negotiating a new Immediate Safety Intervention Plan or a TAPA.

(9) Relationship between Immediate Safety Intervention Plans and TAPAs. The division may recommend and enter into a Temporary Alternative Placement Agreement (TAPA), pursuant to section 210.123, RSMo, and 13 CSR 35-30.030. If the parent(s), guardian(s), or relative(s) decline to enter into a TAPA, upon recommendation of the division, the division shall refer the matter to the juvenile officer for appropriate action.

(10) An Immediate Safety Intervention Plan will terminate under the following circumstances:

(A) Immediate Safety Intervention Plans will automatically terminate without further notice ten (10) days after the date the last party signs the agreement. Each party is responsible for signing and dating the document.

1. The parties may extend an Immediate Safety Intervention Plan for no more than ten (10) days at a time. Every extension of the Immediate Safety Intervention Plan must be done in writing and signed by all parties. The extension must specify the date on which the plan shall terminate. The division should not terminate its involvement with the family while there is an Immediate Safety Intervention Plan in place;

(B) Immediate Safety Intervention Plans are voluntary. Any party to the Immediate Safety Intervention Plan may terminate his or her participation in the Immediate Safety Intervention Plan at any time with reasonable notice to the other participants. Any party wishing to terminate their participation in the Immediate Safety Intervention Plan shall notify the division, preferably in writing;

(C) An Immediate Safety Intervention Plan shall terminate upon the child being brought under the jurisdiction of a juvenile or family court pursuant to law, or upon the entry of an order of a court of competent jurisdiction; and (D) The division may not terminate its involvement with the family if there is an Immediate Safety Intervention Plan in place.

History

• authority to make day-to-day decisions for the child in their care.
• authority, acting on its own, to enforce the requirements of an Immediate Safety Intervention Plan. The division retains the authority to take any action, any time and without prior notice or consultation, that the division deems in its sole discretion appropriate to protect the safety, best interests, and welfare of any child covered by an Immediate Safety Intervention Plan. This includes, but is not limited to:
• AUTHORITY: sections 207.020.1(2) and 660.017, RSMo 2016, and section 210.123, RSMo Supp. 2021. Emergency rule filed May 20, 2021, effective Aug. 2, 2021, expired Feb. 24, 2022. Original rule filed May 20, 2021, effective Nov. 30, 2021. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.123, RSMo 2020; and 660.017, RSMo 1993, amended 1995.

13 CSR 35-30.030 Temporary Alternative Placement Agreements (TAPA) {#sec-13-csr-35-30.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-30.030}

PURPOSE: This regulation implements Temporary Alternative Placement Agreements as provided in section 210.123, RSMo.

(1) Purpose and Scope.

(A) This regulation implements TAPAs as provided in section 210.123, RSMo, for the purposes therein stated.

(B) The paramount consideration for developing, implementing, and monitoring a TAPA is to protect the safety, best interests, and welfare of the child.

(C) The Children’s Division has determined that it is redundant to reproduce the statutory requirements of TAPAs as set forth in section 210.123, RSMo, in this regulation.

In addition to the requirements of this regulation, all parties to a TAPA must fully comply with the requirements of section 210.123, RSMo, and other applicable law.

(2) Definitions. For the purposes of this regulation the following words and/or phrases are defined as follows:

(A) The division incorporates the definitions of the terms, words, and phrases set forth in section 210.123, RSMo, as the definition of the same terms, words, and phrases when used in this regulation;

(B) References to the “Children’s Division” or “the division” shall also refer to any contractors or representatives that the Children’s Division may retain or employ in reference to developing and implementing TAPAs;

(C) The word “parent” shall include the child’s legal parents and, when relevant, the child’s legal guardian or custodian;

(D) In cases where the child’s parents do not reside together in the same household the word “relative” and “parent” may also include the child’s adoptive or biological parent that the child is not residing with;

(E) “TAPA” shall mean “Temporary Alternative Placement Agreement” as that phrase is defined in section 210.123, RSMo; and (F) The phrases “Team Decision Making Meeting” or “TDM” for purposes of this regulation shall mean a group of individuals invited by the Children’s Division to form a team to meet to assist, support, and advise the division and the parties to the TAPA on making decisions involving the children and family with the goal of successfully implementing the TAPA.

1. Mandatory TDM Members. The members of the team for a TDM shall include representatives of the Children’s Division, the child’s parent, the relative, the child’s guardian ad litem if the child has a guardian ad litem, any other party to the TAPA, and the attorney for any of the parties to the TAPA, at the request of that party. A TDM meeting may still be held if all of the mandatory team members are not in attendance.

2. Optional TDM Members. The team may also include other relatives of the children and parents as well as school personnel, medical and mental health personnel, the juvenile officer if the juvenile officer requests to be present, service providers to the child and family, and any other individual who the parties to the TAPA agree may provide constructive advice, assistance, and support for the implementation of the TAPA.

3. Children’s Participation in TDM Meetings. Children twelve (12) years of age and older should attend TDM Meetings, if the child is willing and able to attend the meetings, and the division believes their attendance is in the child’s best interests.

(3) Negotiation and execution of a TAPA.

(A) TAPAs are voluntary, written agreements between the parent, the relative, and the Children’s Division. To be valid, the TAPA must be executed by the division, the parent, and the relative. The TAPA may be executed in writing or by electronic signature.

(B) The Children’s Division shall base its decision whether to execute a TAPA on what the division believes to be in the best interests of the child. This will be based upon the information made available to the Children’s Division within the applicable time periods for completing a TAPA, the applicable law, and the unique circumstances of each child and family.

(C) The Children’s Division will give first consideration to entering into a TAPA with the child’s other parent when the child and the child’s parents do not reside in the same household. If the division determines that the other parent is not a suitable relative for placement, the Children’s Division will give second consideration to enter into a TAPA with the child’s grandparent.

(D) In making the decision to enter into a TAPA and deciding what services the Children’s Division may be able to offer to assist the parties in implementing the plan, the Children’s Division may consider and balance— 1. The wishes of the parent and relative;

2. The wishes of the child;

3. The needs of the child for safe, frequent, continuing and meaningful relationship between the child and the child’s parent;

4. The ability and willingness of the parent and the relative to actively perform their functions for the needs of the child;

5. The interaction and interrelationship of the child with the child’s parent, siblings, grandparents, the relative, and any other person who may significantly affect the child’s best interests;

6. The child’s adjustment to their home, school, and community;

7. The mental and physical health of all individuals involved;

8. Any history of any abuse or neglect of any individual involved;

9. Any history of domestic violence;

10. Any special needs of the child, the child’s level of care, and the needs of the child’s parent, and the relative;

11. The financial and personal resources available to the parent and the relative to care for the child and implement the plan set out in the TAPA. This may include whether the child, the child’s parent and the relative may be eligible for benefits and services through other governmental and private organizations;

12. The resources and services available to the Children’s Division, including the availability of appropriated funds for the provision of resources and services;

13. The educational needs of the child;

14. The willingness and ability of the parent, the relative, the child, and the relative’s household members to work with the Children’s Division and each other to cooperatively develop and implement the TAPA;

15. Any history of criminal activity of any individual involved that may pose a safety risk to the child or impact the ability or willingness of any individual to implement 16. Any current or past history of conduct that may indicate substance use disorder by the child, the parent, the relative, other members of the relative’s household, or other persons;

16. The number of children in the home or to be placed in the home; and 18. Any other facts, information, or considerations that the division deems relevant to its decision.

(4) When the division, the parent, and the relative agree to enter into a TAPA, the child’s parent and the relative shall cooperate with the Children’s Division to develop, implement, and monitor the TAPA. This includes, but is not limited to:

(A) Making the child available to meet with the Children’s Division in person, virtually, or by other means of communication at least two (2) times each month to enable the division to monitor the implementation of the TAPA and to ensure that the TAPA is being safely implemented. At least one (1) visit each month shall be in the relative’s home at the discretion of the Children’s Division, and the other visit may be virtual or in the community;

(B) Allowing the Children’s Division to inspect the home of the relative where the child resides, including allowing the Children’s Division to meet with the child in-person in the home of the relative at least one (1) time a month and the home of the parent, at reasonable times (announced and unannounced), to monitor the implementation of the TAPA and ensure the child is safe and well cared for during the TAPA;

(C) Executing any consents and/or authorizations to release information to the Children’s Division and/or to or from third parties that the Children’s Division determines necessary for the Children’s Division to obtain information to develop and/or monitor implementation of the TAPA. This includes, but is not limited to, health care providers, schools, and school districts and other professionals providing services to the child and the parties to the TAPA;

(D) Participating in all TDMs that the Children’s Division may convene pertaining to the child;

(E) Keeping the division informed of their current residence address, mailing address, telephone number, e-mail address, work address and contact information, and any change in the residence of and contact information for the child;

(F) Promptly notifying the Children’s Division of any change in circumstances that may impact the care of the child and/or the implementation of the TAPA;

(G) Providing full, truthful, accurate, and complete information to the division and other members of the TDM;

(H) Ensuring the child resides in the state of Missouri for the duration of the TAPA unless the child requires medical treatment in another state that is not reasonably available within the state of Missouri. The child’s parent and the relative shall immediately notify the Children’s Division if the child requires medical care out of state; and (I) Participating in the services the parties identify as necessary to the TAPA.

(5) Team Decision Making Meetings.

(A) In all cases managed through a TAPA, the division shall schedule a TDM within ten (10) days of the execution of a TAPA, and at least once every month thereafter for the duration of the agreement as provided in this

regulation.

1. The division may schedule additional TDMs as the division determines may be necessary to support the implementation of the TAPA.

2. Parties to the TAPA may ask the division to schedule additional meetings. Parties to a TAPA are encouraged, but not required, to ask to schedule a TDM meeting before voluntarily terminating a TAPA to see if the team can help resolve any issues that may cause the party to consider withdrawing from the TAPA.

3. The division may schedule a TDM before the TAPA is scheduled to expire to discuss the successes and challenges of implementing the TAPA, whether a new TAPA may be necessary and to discuss whether any next steps may be appropriate.

(B) TDM meetings shall be informal, and shall be held at times and places that are reasonably convenient for as many of the participants as possible, with priority given to the schedules of the mandatory TDM members identified in paragraph (2)(F)1.

(C) TDM meetings may be held in person at the offices of the Children’s Division or at other mutually convenient locations. TDM meetings may also be held by conference call or other electronic means.

(D) The Children’s Division may exclude from any TDM meeting any person who is, or the division has reasonable cause to believe may become, disruptive to the orderly management of the case and/or meeting.

The division may exclude from the TDM any non-mandatory team member who becomes disruptive to the meetings and successful implementation of the TAPA.

(E) The failure of any party to a TAPA to attend and fully participate in TDM meetings in good faith may be grounds for the division to take appropriate action including, but not limited to, notifying the juvenile officer that the parties are not participating in the TAPA and/or terminating the TAPA.

(F) The Children’s Division shall maintain documentation of each TDM meeting.

(G) Any agreements reached during the TDM to revise the TAPA shall be reduced to writing and signed by all of the parties to the TAPA. The Children’s Division will provide the juvenile officer with a copy of the revised TAPA.

(H) The Children’s Division or the division’s designee shall facilitate the TDM meeting unless otherwise agreed between the parties.

(I) During each TDM meeting the agenda shall include:

1. A review of how the health, care, safety, and welfare of the child is being assured;

2. The progress so far in implementing 3. A discussion of any challenges in implementing the TAPA and how challenges may be addressed;

3. A discussion of what next steps are necessary to progress toward termination of 5. Any matters that any member of the TDM may wish to add to the agenda.

(J) Decisions shall be made by consensus of the members of the TDM. No party to the TAPA or the division is legally bound by any decision made at a TDM. All decisions shall be voluntary.

(6) Notice to Provider Form and Procedure.

(A) The division will provide the relative with a notice that the relative may use to notify schools, medical care providers, and others that the relative has the temporary authority to make day-to-day decisions, educational decisions, and medical decisions for the child for the duration of the TAPA on the “Official Notice of Temporary Placement of a Child”

(hereinafter “Official Notice”), that is attached hereto and included herein.

(B) The relative shall retain the original of the Official Notice, but may provide a copy of the form to any individual or institution with a need for a copy for their records.

(C) At the requests of the Children’s Division, the relative shall provide to the Children’s Division a list of the names, addresses, and contact information of any individual or institution to whom the relative has given a copy of the Official Notice.

(D) Upon termination of the TAPA the relative shall notify each individual or institution who has received an Official Notice that the TAPA has terminated.

(7) Background Checks.

(A) The Children’s Division may conduct a background check of the relative, and any adult member of the relative’s household as

part of its process to determine whether the relative is a suitable temporary placement provider for the child. The relative and other adult household members shall execute any consents or other documents necessary to complete any background checks and submit to a fingerprint based criminal background check if the division determines this to be necessary. If the relative or any adult member of the relative’s household declines to assist in the background check process, then the division may decide not to enter into a TAPA.

(B) Notwithstanding any other provision of this section, the division will not enter into an TAPA where the parent or guardian of the child places the child under a TAPA in the home of a relative where the individual or any member of the individual’s household has pled guilty or been found guilty of any the following crimes when a child was the victim:

1. Section 565.020, RSMo (murder, 2. Section 565.021, RSMo (murder, second degree);

2. Section 565.023, RSMo (voluntary manslaughter);

3. Section 565.024, RSMo (involuntary manslaughter, first degree);

4. Section 565.050, RSMo (assault, first 6. Section 566.030, RSMo (rape, first 7. Section 566.031, RSMo (rape, second degree, or section 566.040, RSMo 8. Section 566.032, RSMo (statutory rape, first degree);

5. Section 566.060, RSMo (sodomy, 10. Section 566.061, RSMo (sodomy, second degree, or section 566.070, RSMo 11. Section 566.062, RSMo (statutory sodomy, first degree);

6. Section 566.064, RSMo (statutory sodomy, second degree);

7. Section 566.067, RSMo (child molestation, first degree);

8. Section 566.068, RSMo (child molestation, second degree);

9. Section 566.069, RSMo (child molestation, third degree);

10. Section 566.071, RSMo (child molestation, fourth degree);

11. Section 566.083, RSMo (sexual misconduct involving a child);

12. Section 566.100, RSMo (sexual abuse, first degree);

13. Section 566.101, RSMo (sexual abuse, second degree, or section 566.090, RSMo before Aug. 28, 2013);

14. Section 566.111, RSMo (sex with an animal);

15. Section 566.151, RSMo (enticement of a child, first degree);

16. Section 566.203, RSMo (abusing an individual through forced labor);

17. Section 566.206, RSMo (trafficking for the purpose of slavery, involuntary servitude, peonage, or forced labor);

18. Section 566.209, RSMo (trafficking for the purpose of sexual exploitation);

19. Section 566.210, RSMo (sexual trafficking of a child, first degree);

20. Section 566.211, RSMo (sexual trafficking of a child, second degree, or section 566.212, RSMo before Jan. 1, 2017);

21. Section 566.215, RSMo (contributing to human trafficking through the misuse of documentation);

22. Section 567.050, RSMo (promoting prostitution, first degree);

23. Section 568.080, RSMo (child used in sexual performance, if before Jan. 1, 2017);

24. Section 568.090, RSMo (promoting sexual performance by a child, if before Jan. 1, 2017);

25. Section 568.020, RSMo (incest);

26. Section 568.030, RSMo (child abandonment, first degree);

27. Section 568.060, RSMo (abuse or neglect of a child);

28. Section 568.065, RSMo (genital mutilation of a female child);

29. Section 568.175, RSMo (trafficking in children);

30. Section 573.023, RSMo (sexual exploitation of a minor);

31. Section 573.025, RSMo (promoting child pornography, first degree);

32. Section 573.035, RSMo (promoting child pornography, second degree);

33. Section 573.037, RSMo (possession of child pornography);

34. Section 573.200, RSMo (child used in sexual performance or section 568.080, RSMo before Jan. 1, 2017); or 41. Section 573.205, RSMo (promoting sexual performance by a child or section 568.090, RSMo before Jan. 1, 2017).

(C) Except as otherwise provided in sub-

section (7)(B), the division may, at its discretion, agree to enter into a TAPA where the parent or guardian of the child places the child in the home of a relative where the individual or an adult member of the individual’s household has been found guilty of any other crimes against persons, drug or alcohol-related offenses, or has a history of substantiated or significant child abuse/neglect if the parent and the relative satisfy the Children’s Division that placement on a TAPA is in the best interests of the child, that the relative is a fit and suitable person to temporarily care for the child, and that the household where the child will temporarily reside is safe and appropriate for the child. In making this decision, the division may consider the following factors:

1. Whether the relative or household member has successfully completed the conditions of sentencing and/or probation without further incidents;

2. Whether the relative or household member has successfully completed any prescribed or required treatment;

3. The duration of time between the prior incident and the negotiation of the TAPA;

4. The written advice and recommendations of professionals, community members, clergy, relatives, and/or others with knowledge of the family;

5. Whether the prior incident of criminal conduct, while unlawful at the time of the incident, is no longer unlawful or proscribed at the time that the division is considering the TAPA; and 6. Any other factor or information that may be relevant to making a decision about the best interests, care, and safety of the child.

(8) TAPA Form. The Children’s Division may utilize any format or template for a TAPA, provided that it specifies that the document is a Temporary Alternative Placement Agreement pursuant to this rule and section 210.123, RSMo, and that it complies with the other requirements of this rule and section 210.123, RSMo.

(9) Termination of a TAPA.

(A) Once a TAPA has been executed it shall be effective until terminated as provided in this regulation.

(B) A TAPA shall terminate— 1. Ninety (90) days from the date of the last party to the TAPA to execute the TAPA;

2. Five (5) days after the delivery and receipt of a written notice of intent to terminate the TAPA to the Children’s Division and the relative executed by the parent or legal guardian;

3. Except in an emergency which is beyond the control of the relative, five (5) days after the delivery and receipt of a written notice of intent to terminate the TAPA to the Children’s Division to the child’s parent by the relative;

4. Five (5) days after successful completion of the plan set forth in the TAPA, provided that the Children’s Division shall be given sufficient time to complete and submit its report to the juvenile officer; or 5. Entry of an order of a court with statutory authority and jurisdiction over the child that conflicts with the provision of the TAPA.

(C) If the relative is no longer able to care for the child due to an emergency, the relative will notify the division immediately. The remaining parties to the TAPA will confer to determine whether a new TAPA is appropriate and, if so, then the parties will follow the procedures in section 210.123, RSMo, and this regulation to implement a new TAPA.

The division is to schedule an emergency TDM meeting to facilitate the meeting between the remaining parties to the TAPA.

(10) Notwithstanding any other provision of this regulation, the Children’s Division retains the right and authority without prior notice in its sole discretion to take any action authorized by law to protect the safety and welfare of any child served under a TAPA, including, but not limited to, conducting investigations and family assessments, making referrals to law enforcement, and referring the matter to the juvenile officer with a recommendation for further action.

History

• AUTHORITY: sections 207.020.1(2) and 660.017, RSMo 2016, and section 210.123, RSMo Supp. 2021. Emergency rule filed May 20, 2021, effective Aug. 2, 2021, expired Feb. 24, 2022. Original rule filed May 20, 2021, effective Nov. 30, 2021. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.123, RSMo 2020; and 660.017, RSMo 1993, amended 1995.

Chapter 31 Child Abuse

13 CSR 35-31.050 Consent to Termination of Parental Rights and/or Adoption. . . . . . . . . . . . 8 {#sec-13-csr-35-31.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.050}

13 CSR 35-31.100 Use and Dissemination of Information {#sec-13-csr-35-31.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.100}

13 CSR 35-31.010 Definitions {#sec-13-csr-35-31.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.010}

PURPOSE: This rule establishes definitions pertaining to investigations and assessments conducted pursuant to Chapter 210, RSMo.

(1) The Children’s Division shall use the definitions set forth below when conducting investigations and assessments pursuant to Chapter 210, RSMo.

(A) “Emotional abuse” is any injury to a child’s psychological capacity or emotional stability demonstrated by an observable or substantial change or impairment in the child’s behavior, emotional response, or cognition, which may include, but is not limited to: anxiety, depression, withdrawal, or aggressive behavior; and which may be established by either lay or expert witnesses.

(B) “Physical injury” includes any bruising, lacerations, hematomas, welts, permanent or temporary disfigurement; loss, or impairment of any bodily function or organ, which may be ac companied by physical pain, illness, or impairment of the child’s physical condition.

(C) “Proper or necessary support” includes adequate food, clothing, shelter, medical care, or other care and control nec essary to provide for the child’s physical, mental, or emotional health or development.

(D) “Sexual abuse” is any sexual or sexualized interaction with a child, except as otherwise provided in paragraph 2. below.

1. Sexual abuse shall include, but is not limited to:

A. Any touching of the genitals, anus or buttocks of a child, or the breast of a female child, or any such touching through the clothing; any act involving the genitals of a child and the hand, mouth, tongue, or anus of another person; or any sexual act involving the penetration, however slight, of a child’s mouth, penis, female genitalia, or anus by any body part of an other person, or by any instrument or object;

B. Any conduct that would constitute a violation, regardless of arrest or conviction, of Chapter 566, RSMo if the victim is less than eighteen (18) years of age, section 567.050, RSMo if the victim is less than eighteen (18) years of age, sections 568.020, 568.060, 568.080, or 568.090, RSMo, sections 573.025, 573.035, 573.037, or 573.040, RSMo, or an attempt to commit any of the preceding crimes;

C. Sexual exploitation of the child, which shall include:

(I) Allowing, permitting, or encouraging a child to engage in prostitution, as defined by state law; or (II) Allowing, permitting, encouraging, or engaging in the obscene or pornographic photographing, filming, or depicting of a child as those acts are defined by state law. This includes the storage or transmission of any data depicting said obscene or pornographic acts, images, or recordings.

2. Any reasonable interaction with a child, including touching a child’s body for the purpose of providing the proper or necessary care or support of the child, shall not be considered sexual abuse. The touching of a child’s body, including a child’s genitals, buttocks, anus, or breasts for reasonable, medical, child rearing, or child care purposes shall not be considered sexual abuse.

3. The division shall not be required to prove that the alleged perpetrator received sexual gratification or that there was an exchange or promise of anything of value as a result of the act of sexual abuse to establish sexual abuse under

Chapter 210 or 211, RSMo.

4. The use of force or coercion is not a necessary element for a finding of sexual abuse.

5. Sexual abuse may occur over or under the child’s clothes.

6. The division shall not be required to prove that the child suffered trauma or harm as a result of the act of sexual abuse.

7. A child cannot consent to a sexual or sexualized act or interaction with a person responsible for that child’s care, custody, and control.

History

• Authority: sections 207.020 and 210.145.20, RSMo Supp. 2014. Original rule filed May 26, 2015, effective Nov. 30, 2015. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 210.145, RSMo 1975, amended 1980, 1982, 1986, 1990, 1993, 1994, 2000, 2002, 2003, 2004, 2007, 2011, 2012, 2014.

13 CSR 35-31.015 Out-of-Home Investigation Unit {#sec-13-csr-35-31.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.015}

PURPOSE: This rule defines the investigation procedure used when the relationship of the subject of a report of child abuse or neglect to the Children’s Division is such that a conflict of interest may occur.

(1) Definitions. For the purpose of this regulation, the following terms shall be defined as follows:

(A) Family or Family Member. A person related to the alleged victim by blood, adoption, or affinity within the third degree, a current or past foster parent of the alleged victim, or a resident of the current or past foster parent’s home;

(B) Family Assessment. An approach to be developed by the children’s division which will provide for a prompt assessment of a child who has been reported to the division as a victim of abuse or neglect by a person responsible for that child’s care, custody, or control and of that child’s family, including risk of abuse and neglect and, if necessary, the provision of community-based services to reduce the risk and support the family;

(C) Investigation. The collection of physical and verbal evidence to determine if a child has been abused or neglected; and (D) Out-of-Home Investigation Unit. The unit of investigators responsible for investigating or assessing child abuse and neglect when the relationship between the child and the alleged perpetrator is established in an out-of-home setting.

(2) The Out-of-Home Investigation Unit will investigate or assess allegations of child abuse or neglect in— (A) Cases in which the alleged victim resides in a foster home;

(B) Cases in which the alleged perpetrator is an employee, contracted agent, or volunteer of an organization which provides care or services to children. Such organizations shall include, but are not limited to, residential treatment facilities, schools, child care facilities, hospitals, youth camps, or youth groups; or (C) Other cases as deemed necessary by the Children’s Division on a case-by-case basis.

rule originally filed as 13 CSR 40-31.011. Original rule filed March 7, 1984, effective June 11, 1984. Moved to 13 CSR 35-31.015 and amended: Filed July 29, 2015, effective Feb. 29, 2016. Amended:

Filed Aug. 8, 2018, effective March 30, 2019. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016. This

13 CSR 35-31.020 Screening and Classification of Child Abuse/ Neglect Hotline Reports {#sec-13-csr-35-31.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.020}

PURPOSE: This rule establishes the use of the Structured Decision Making (SDM) process in the screening and classification of calls at the Child Abuse/Neglect Hotline Unit (CANHU).

(1) The division shall utilize protocol based upon structured decision-making principles for classification purposes of all child abuse and neglect reports received by the Child Abuse/ Neglect Hotline Unit (“Hotline”). The protocols developed by the division shall obtain and classify information, and shall give priority to ensuring the safety and well-being of the child.

(2) All child abuse and neglect reports received by the Hotline shall be initiated within twenty-four (24) hours of receipt and shall be classified based upon the reported safety risk and injury to the child, including, but not limited to, the following factors:

(A) If there is serious physical abuse alleged and siblings remaining in the home;

(B) If there is a child fatality due to alleged abuse or neglect and siblings remain in the home;

(C) If there is alleged physical abuse currently occurring;

(D) If there are injuries or symptoms of injuries evident that require immediate medical care, or if the child is in need of immediate psychiatric care due to alleged abuse;

(E) If there were severe or inhumane measures used;

(F) Does the alleged perpetrator have access to the child in the next twenty-four (24) hours or is the child afraid to go home;

(G) Did the alleged abuse occur within the last thirty (30) days;

(H) If the child is currently in a protected environment;

(I) If the current situation is immediately dangerous;

(J) If there are prior non-harassment child abuse or neglect reports;

(K) If the allegation is one of educational neglect only;

(L) If the child is exhibiting severe emotional trauma or physical injury due to alleged sexual abuse;

(M) If the child appears seriously ill or injured or in need of immediate care;

(N) If the child has a chronic illness or injuries that require attention.

(3) In all cases, the division must have face-to-face contact with all children in the alleged victim’s household within seventytwo (72) hours.

(4) CA/N Screen-In Criteria—Criteria concerning whether a call is classified as a child abuse and neglect (CA/N) report or a documented call (DOC). If the call is screened-in, it will be accepted as a CA/N report and sent to the county office. If the call is screened out, the call will be documented and entered into the database, but no further action will be taken, unless the division, pursuant to policy decides to refer it for appropriate community service.

(5) Track Assignment Guidelines—Criteria designed to determine if the screened-in CA/N report will require the investigation response or family assessment response. After response assignment, the report is sent to the local division office for review. The local division office has the option to change the response assignment, given additional information or prior history with the family.

(6) Response Priority—Criteria to determine the time frame in which the family should be contacted. Each investigation will be classified as a three (3) hour, twenty-four (24) hour, or seventy-two (72) hour call, based upon information received by the hotline. Face-to-face contact can be made by members of the multidisciplinary team (mandated reporters such as juvenile officer, or law enforcement personnel). Initial contacts can include phone calls or contact with appropriate persons in an attempt to make a home visit. Each level will require faceto-face contact based upon the following:

(A) Three (3) hour—Face-to-face contact with victim(s) listed on the report must be made within three (3) hours from the receipt of the report. A face-to-face contact with all other children living in the household must be made within seventytwo (72) hours. Available resources shall be utilized to locate the children, including law enforcement assistance;

(B) Twenty-four (24) hour—Face-to-face contact with victim(s) listed on the report must be made within twenty-four (24) hours from receipt of the report. A face-to-face contact with other children residing in the home must occur within seventy-two (72) hours;

(C) Seventy-two (72) hour—Face-to-face contact with all children (victims and home residents) must be made within seventy-two (72) hours from receipt of the report.

History

• AUTHORITY: section 210.145, RSMo Supp. 2014. This rule previously filed as 13 CSR 35-20.010. Original rule filed Nov. 2, 2004, effective June 30, 2005. Moved to 13 CSR 35-31.020, effective Nov. 30, 2016. Original authority: 210.145, RSMo 1975, amended 1980, 1982, 1986, 1990, 1993, 1994, 2000, 2002, 2003, 2004, 2007, 2011, 2012, 2014.

13 CSR 35-31.025 Child Abuse and Neglect Review Process {#sec-13-csr-35-31.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.025}

PURPOSE: This rule establishes a process to review child abuse and neglect determinations when an alleged perpetrator disagrees with the division’s preliminary finding.

(1) Definitions.

(A) The definitions of terms set forth in section 210.110, RSMo, and 13 CSR 35-31.010 also apply to the terms used in this (B) “Address of Record” means the mailing address or electronic mailing address that the alleged perpetrator provides to the Children’s Division or the last known address of the alleged perpetrator discovered during the investigation or last known address contained in the information systems of the Department of Social Services.

(C) “Alleged perpetrator” means the person accused of having committed the act of abuse or neglect, or the person determined or found to have perpetrated the act of abuse or neglect.

(D) “CANRB” or “Board” means the child abuse and neglect review board as established in sections 210.152 and 210.153, (E) “Court adjudication” refers to instances where the division may add a person to the central registry without administrative review because a court has found the person— 1. Committed child abuse or neglect;

2. Judicial findings substantiate the division’s finding of child abuse or neglect; or 3. The person has pleaded guilty or been found guilty of a crime pursuant to sections 210.110 or 210.118, RSMo.

(F) “Division” means the Children’s Division of the Department of Social Services.

(G) “Pending criminal charge” means a criminal charge filed with the court by complaint, information, or indictment.

(H) “Preliminary finding” means the division’s initial investigative determination of abuse or neglect.

(I) “Unknown perpetrator” means the unidentified person or persons who abused or neglected a child.

(J) “Witness” means a person with knowledge material to the allegation of abuse or neglect.

(2) Notices.

(A) The division shall notify the alleged perpetrator of its preliminary finding at the conclusion of the child abuse or neglect investigation.

(B) The notice shall— 1. Summarize the division’s preliminary findings;

2. Provide instructions for obtaining a copy of the investigative report; and 3. State the alleged perpetrator’s right to either request administrative review of the division’s finding by the board, or, in the alternative, waive administrative review and instead file a petition in circuit court for direct judicial review of the division’s finding.

(C) The division may deliver notice of the preliminary finding personally or send the notice to the alleged perpetrator’s Address of Record. Service of notice to the alleged perpetrator’s Address of Record in person, by mail, or by electronic means shall be deemed sufficient service for all purposes under this (D) The alleged perpetrator shall promptly notify the division of any changes to the alleged perpetrator’s mailing address, telephone number, electronic mailing address, or other contact information throughout the investigation and administrative review process.

1. It shall remain the responsibility of the alleged perpetrator to immediately notify the division of any changes to his or her current contact information, including current mailing address, throughout the investigation and administrative review process.

2. The alleged perpetrator may elect to receive formal notices and communications electronically or by mail.

Notification of the election shall be in writing and provided to the division.

(E) If the alleged perpetrator requests an administrative review under section (3) of this rule, the division and board shall send all notices and correspondence to the alleged perpetrator unless the division receives a written entry of appearance by counsel. Legal counsel for an alleged perpetrator shall file an entry of appearance with the board, which shall include the legal counsel’s name, bar number, regular and electronic mailing addresses, and telephone and fax numbers. Upon receipt of an entry of appearance by legal counsel, the division shall send any subsequent notices and correspondence to the alleged perpetrator and the attorney of record. Alleged perpetrators may present their cases to the board with or without legal counsel.

(3) Requesting Administrative Review or Judicial Review. If the alleged perpetrator disagrees with the division’s preliminary finding, the alleged perpetrator may request either direct judicial review or administrative review of the finding, but not both.

(A) Direct Judicial Review Requests.

1. If the alleged perpetrator wishes to waive administrative review, the alleged perpetrator shall have thirty (30) days from the receipt of the notification of the division’s preliminary finding to file a petition for direct judicial review with the circuit court as provided in sections 210.152, 210.153, and 536.100, RSMo. Upon receipt of service of the petition for direct judicial review, the division shall list the alleged perpetrator’s name in the central registry pending further orders or judgment of the circuit court. The alleged perpetrator shall not be entitled to administrative review if the alleged perpetrator has petitioned any circuit court for direct judicial review.

(B) Administrative Review Requests.

1. To request administrative review, the alleged perpetrator shall submit a written request for review within sixty (60) days from the receipt of the notification of the division’s preliminary finding as provided in sections 210.152 and 210.153, RSMo, except as otherwise provided herein. The alleged perpetrator may include any additional relevant information that the alleged perpetrator would like the division or board to consider.

A. Upon receipt of a timely written request for administrative review, the division may review the request, the investigative report, and any other relevant materials before the board hearing. If the division concludes the preliminary finding should be reversed before the board hearing, the division shall notify the alleged perpetrator and the alleged perpetrator shall not be listed in the central registry for that finding.

B. If the division receives a request for administrative review within sixty (60) days of notification of the division’s preliminary finding, the division shall not list the alleged perpetrator as a perpetrator of child abuse or neglect in the central registry for the preliminary finding unless and until the finding is sustained by the board.

C. If the division does not receive a request for administrative review within sixty (60) days of notification of the division’s preliminary finding, the division shall list the alleged perpetrator as a perpetrator of child abuse or neglect in the central registry.

2. Pending Criminal Charges.

A. If criminal charges that arose from the investigation are pending when the alleged perpetrator receives notice of the division’s preliminary finding, the alleged perpetrator may either— (I) Request administrative review within sixty (60) days of receiving notice of the division’s preliminary finding; or (II) In the alternative, the alleged perpetrator may waive administrative review within sixty (60) days of notice and instead request administrative review within sixty (60) days of the court’s final disposition or dismissal of the criminal charges, as provided for in this subsection and section 210.152.4, B. If the alleged perpetrator with pending criminal charges submits a request within sixty (60) days of notification of the division’s preliminary finding, the division shall proceed with the administrative review and the division shall not list the alleged perpetrator in the central registry unless and until the finding is sustained by the board.

C. If the alleged perpetrator with pending criminal charges does not request review within sixty (60) days of notification of the division’s preliminary finding, the division shall list the alleged perpetrator as a perpetrator of child abuse or neglect in the central registry, and the alleged perpetrator shall remain listed in the central registry unless and until the division’s finding is subsequently reversed by the division, the board, or judicial action.

D. To request administrative review within sixty (60) days of the court’s final disposition or dismissal of criminal charges arising from the investigation, the alleged perpetrator shall submit a copy of the court’s final disposition or dismissal of the criminal charges with the written request for administrative review. If the division receives the written request and the copy of the court’s final disposition or dismissal of the criminal charges within sixty (60) days of the court’s final disposition or the dismissal, the division shall schedule a board hearing. Once listed, the alleged perpetrator shall remain listed in the central registry unless and until the division’s finding is subsequently reversed by the division, board, or judicial action.

3. The alleged perpetrator shall be entitled to no more than one (1) administrative review of any preliminary finding.

4. The division shall not conduct an administrative review if a finding has been substantiated through court adjudication pursuant to sections 210.153, 210.110 or 210.118, RSMo.

5. Death Pending Administrative Review. If the alleged perpetrator’s representative or next of kin provides proof that the alleged perpetrator died before the alleged perpetrator’s time to request review expired or before the requested board hearing occurred, the division shall retain the report and all information but shall not add the deceased alleged perpetrator to the central registry. The division shall retain and disclose information and findings in the same manner as the division retains and discloses reports involving unknown perpetrators and family assessments.

(4) Administration of the Child Abuse and Neglect Review Board.

(A) The division may establish more than one (1) board to assure timely and independent review of child abuse and neglect determinations.

(B) Each board shall be composed of nine (9) members from specified professions as required in section 210.153, RSMo. No member of the board shall be employed by the Department of Social Services. Members shall be appointed by the governor with the advice and consent of the senate.

(C) Initially, three (3) board members shall be appointed to serve for a term of three (3) years, three (3) board members shall be appointed to serve for a term of two (2) years, and three (3) board members shall be appointed to serve for a period of one (1) year.

1. Members of the board may continue serving after their terms expire until they are reconfirmed or replaced by confirmed appointees.

2. Members of each board shall designate a chairperson.

3. Members of the board shall complete a minimum of three (3) hours of training regarding child abuse and neglect annually, as approved by the division. The division shall notify the board of available training opportunities.

(D) The information presented to the board and the deliberations of the board are confidential and shall not be disclosed except as authorized by law.

(E) Members of the board shall meet regularly, and if needed, frequently, depending on the number of requests for review being filed. But a minimum of one (1) board shall meet a minimum of one (1) time per month.

(F) The division shall assign one (1) or more staff members to the board to handle administrative matters such as scheduling cases for hearing, administering correspondence for the board, and other appropriate matters. Administrative personnel, including the division’s liaison to the board, shall not participate in the deliberations of the board on the merits of cases.

(5) The purpose of a board hearing is to provide an independent review of the sufficiency of the division’s preliminary finding.

CANRB review is limited to whether or not the information presented to the board establishes by a preponderance of evidence that the alleged perpetrator is responsible for abuse, neglect, or both, as those terms are defined in 13 CSR 35-31.010 and section 210.110, RSMo.

(6) A member of the board shall recuse themself from any case in which the member determines the member cannot be fair or impartial.

(A) A member of the board shall recuse themself from any case in which the member— 1. Has an interest in the case;

2. Is related to the alleged perpetrator, alleged victim, any witness, or any family member of the alleged victim or perpetrator;

3. Has been legal counsel to the alleged perpetrator, alleged victim, or any family member of the alleged victim or perpetrator;

4. Personally provided care or services to the alleged perpetrator, alleged victim, or any family member of the alleged victim or perpetrator; or 5. Has personal knowledge of the facts and circumstances of the case, beyond what may be generally available to the public.

(B) Alleged perpetrators have no right to a change of board or a particular board member.

1. Any alleged perpetrator who has good cause to believe that a member or members of the board cannot act in a fair and impartial manner shall promptly notify the board in writing and shall specify in detail the nature of the concern.

2. The board shall then rule on the concern. If a board member recuses himself or herself or if the board grants the alleged perpetrator’s request to recuse, then the board may grant a continuance of the hearing if the recusal would result in the board failing to reach a quorum.

3. If the alleged perpetrator does not file an objection with the board prior to the commencement of the hearing, any objection to the impartiality of the board or members of the board shall have been waived.

(7) Reviews conducted by the board are not contested cases under Chapter 536, RSMo. The board shall adhere to the following procedures for notification, scheduling, and conducting child abuse and neglect reviews:

(A) The parties to a board hearing are the alleged perpetrator and the division;

(B) The division shall determine whether a board hearing shall be held in person or via teleconference or other electronic means;

(C) Record Requests— 1. There is no right to conduct formal discovery as set forth in the Rules of Civil Procedure for the Missouri Supreme Court and/or Chapter 536, RSMo. However, the alleged perpetrator may request that the division produce relevant investigative records;

2. Record requests shall be addressed to the division and not to the Board; and 3. If the alleged perpetrator makes a request for records, the division shall provide a copy of the child abuse and neglect investigative report completed by the division to the alleged perpetrator as allowed by law, with the exception of information which is privileged and/or confidential as otherwise provided by law, and information that could, in the sole discretion of the division, jeopardize a person’s life or safety if released. The division shall redact from any information provided to the perpetrator all confidential information, including, but not limited to, any information that may identify the reporter of the incident in question;

(D) The division and the alleged perpetrator shall submit any written documents or other evidence to the board no less than twenty-one (21) days before the hearing date to provide the board with sufficient time to review the information before the hearing. Documents or evidence submitted to the board less than twenty-one (21) days before the hearing date may be considered at the sole discretion of the board;

(E) The division’s liaison to the board shall notify the alleged victim or the alleged victim’s parent, guardian, or legal representative that a hearing has been scheduled and of the opportunity to participate as a witness;

(F) Board hearings shall be conducted in an informal manner.

The rules of evidence do not apply to board hearings including, but not limited to, the following:

1. Testimony from witnesses and parties shall not be provided under oath;

2. There is no right to cross examine witnesses;

3. Neither witnesses nor evidence are subject to subpoena;

4. Board hearings are not hearings on the record;

5. The board shall determine whether information, exhibits, or evidence are relevant; and 6. No official transcript of the hearing shall be prepared, provided, or retained;

(G) The board hearing shall be closed to all persons except the parties, their attorneys, and witnesses. At the review, the division shall have twenty (20) minutes to present evidence to the board. Upon conclusion of the division’s evidence, the alleged perpetrator shall have twenty (20) minutes to present evidence to the board. The division and the alleged perpetrator may reserve three (3) of their twenty (20) minutes for rebuttal.

During their respective presentations, the division and the alleged perpetrator may present witnesses to the board. An additional twenty (20) minutes, to be divided evenly among all witnesses, may be allotted for additional witnesses who wish to provide evidence on behalf of the alleged victim, but who were not called as witnesses by either the division or the alleged perpetrator. All witnesses will be heard at the board’s discretion.

1. The board may, in its sole discretion, approve extra time for any presentation, but may not extend the time for decision of the case.

2. The alleged perpetrator’s attendance is not mandatory for a review to be held.

3. The division’s liaison to the board shall notify the alleged perpetrator and his or her attorney of record, if applicable, whether the review shall be held in person or via teleconference or other electronic means, and the date, time, and location of the review. If the hearing is held in person, any party, attorney, representative, or witness may nonetheless participate in the hearing by conference call.

4. Alleged perpetrators may present their cases to the board pro se or through legal counsel.

5. Appropriate staff shall represent the division. The division may also be represented by legal counsel.

6. Nonparty witnesses, including witnesses on behalf of the alleged victim, shall only be allowed to participate in that portion of the review in which they are presenting information.

7. Either party who wishes to submit evidence in electronic format shall contact the liaison of the board at least twentyone (21) days prior to the scheduled hearing date to ascertain whether the board has equipment to review the evidence.

Neither the division nor the board shall be responsible for supplying equipment or for equipment failure. The party who wishes to present the information in electronic format shall be responsible for delivering the information to the board in a format which the board and its members can review;

(H) The board shall review and discuss all relevant materials and testimony, and all board members participating at the hearing shall have the right to vote on whether to uphold or reverse the division’s finding.

1. The board shall have a quorum of not less than five (5) members to hold a hearing. If a quorum cannot be reached, the board shall reschedule the hearing. If there are vacancies on the board, the board shall continue to operate in its usual manner, so long as a quorum can be met for each hearing. To ensure a quorum, members may serve on CANRB panels outside the specific board to which the member was appointed.

2. The board’s decision shall be based on a majority vote. In cases where the vote is tied, the board shall affirm the division’s finding.

3. The board’s decision shall be based solely on the information submitted in advance or presented to the board at the hearing.

4. The board shall make its decision on the day of the case’s review;

(I) The division, on behalf of the board, shall promptly notify the alleged perpetrator of the board’s decision in writing.

1. If the board upholds the division’s preliminary finding, the division shall send the decision to the alleged perpetrator’s Address of Record. Any properly addressed decisions under this rule that are returned as refused or unclaimed shall be deemed satisfactory notice. The division shall notify the parties and the alleged perpetrator’s attorney, if applicable, by regular or electronic mail. The division shall place the alleged perpetrator’s name on the central registry as allowed by law.

2. If the board reverses the division’s preliminary finding, the division shall notify all parties by regular or electronic mail and the division shall not list the alleged perpetrator as a perpetrator of child abuse or neglect in the central registry;

(J) If the alleged perpetrator requires reasonable accommodations pursuant to the Americans with Disabilities Act, the alleged perpetrator shall notify the board’s liaison at least ten (10) days before the hearing; and (K) The division may grant a continuance to the alleged perpetrator for good cause, but the number of continuances shall be restricted to ensure a timely review. Pending criminal charges arising out of the facts of the investigation shall not constitute good cause if the alleged perpetrator obtained or could have obtained his or her investigative report.

(8) The board shall expunge its files after one (1) year. The board shall keep a log documenting the board’s final decision. If the board upholds the division’s preliminary finding, the division may, at its discretion, retain the board’s voting slip, notification letter(s), and certified mailing receipt by paper or electronic means.

(9) Each board shall submit, no later than March 15 annually, a written report to the Department of Social Services containing a summary of activities of the board and recommendations to improve the child protection services system at the state and local levels.

rule filed Sept. 27, 2007, effective March 30, 2008. Amended: Filed April 12, 2021, effective Oct. 30, 2021. *Original authority: 210.153, RSMo 1994, amended 2004 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 210.153 and 660.017, RSMo 2016. Original

13 CSR 35-31.027 Juveniles with Problem Sexual Behaviors {#sec-13-csr-35-31.027 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.027}

PURPOSE: This rule addresses the procedures assessing juveniles with problem sexual behaviors as required by section 210.148, (1) The Children’s Division shall use the definitions set forth below when conducting juvenile reports pursuant to section 210.148, RSMo.

(A) “Family assessment and services approach” shall mean an approach by the Children’s Division which provides for a prompt assessment of a child who has been alleged to have engaged in problem sexual behavior and of the child’s family, including risk of abuse and neglect and, if necessary, the provision of community-based services to reduce the risk and support the family.

(B) “Juvenile with Problem Sexual Behavior” and “Juvenile” shall mean any person under fourteen (14) years of age who has allegedly committed sexual abuse against another child.

(C) “Juvenile Report” means a report of a child with problem sexual behaviors handled under section 210.148, RSMo, and this (D) “Juvenile Sexual abuse” by children under fourteen (14) years of age under section 210.148, RSMo, and for purposes of this regulation, shall mean any sexual or sexualized interaction with a child including, but not limited to, acts that are age or developmentally inappropriate and— 1. Involve force or threats of the use of force;

2. Are intrusive;

3. Are unwelcome;

4. Result in physical injury or cause emotional trauma to the victim child; or 5. Are coercive or manipulative.

(2) Juvenile Report Screen-In Criteria.

(A) Calls received by the Child Abuse/Neglect Hotline Unit (Hotline) involving concerns of a juvenile with problem sexual behavior will be accepted as a juvenile report when— 1. The reporter identifies concerns that a child has committed sexual abuse involving another child; and 2. The reporter identifies the juvenile as being under the age of fourteen (14) at the time of the call to the hotline.

(B) Reporters to the hotline must disclose the identity of the juvenile and victim child(ren) if known.

(C) Calls received by the Child Abuse/Neglect Hotline Unit (Hotline) will be not be accepted as a juvenile report when— 1. The allegations concern physical abuse or other non-sexual reports; or 2. The juvenile with alleged problem sexual behavior resides in another state.

(D) If the Children’s Division determines the juvenile had care, custody, or control of the victim child, the Children’s Division shall conduct both an investigation and a juvenile report.

(3) Family Assessment and Services Approach.

(A) In addition to conducting a family assessment and services approach of the juvenile with alleged problem sexual behaviors and of the child’s family, the Children’s Division shall also assess the needs of the victim and the victim’s family.

(B) The Children’s Division may provide services to the families of the juvenile with alleged problem sexual behaviors and of the victim as appropriate.

(C) Participation in services is voluntary.

(4) Referral to Juvenile Office.

(A) The Children’s Division may refer the juvenile with alleged problem sexual behaviors to the juvenile office under one (1) or more of the following circumstances:

1. Reports in which the child has committed an act of sexual abuse and caused serious physical injury and/or used a weapon;

2. When the parent/caregiver of the juvenile with alleged problem sexual behaviors does not engage in the assessment process or there is no evidence that the parent/caregiver is taking steps to prevent future problem sexual behavior;

3. When the juvenile does not engage in the assessment process;

4. When there is a repeated incident of problem sexual behavior by the child;

5. When the Children’s Division’s assessment reveals the child’s behaviors are of such severity that the child cannot be safely maintained in the home and/or community; or 6. Other situations as deemed appropriate by the Children’s Division on a case-by-case basis.

(5) Parental notification and consent to interview.

(A) The Children’s Division shall notify a parent and obtain his or her consent prior to interviewing the juvenile with alleged problem sexual behaviors.

(B) The Children’s Division shall notify a parent of the victim child prior to interviewing the child, but does not have to obtain the parent’s consent.

(C) The Children’s Division shall notify any known guardian ad litem of the juvenile with alleged problem sexual behaviors or victim children prior to interviewing the child, but does not need to obtain the guardian ad litem’s consent.

(D) Notification may be made either verbally or in writing.

(6) Retention of juvenile reports. Juvenile reports shall be retained on the same schedule as family assessments completed in response to a child abuse/neglect report as defined in section 210.152, RSMo.

History

• AUTHORITY: section 207.020, RSMo Supp. 2014, and section 210.148, RSMo Supp. 2015. Original rule filed Feb. 8, 2016, effective Aug. 30, 2016. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 210.148, RSMo 2015.

13 CSR 35-31.050 Consent to Termination of Parental Rights and/or Adoption {#sec-13-csr-35-31.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.050}

PURPOSE: This rule establishes two (2) consent forms for use by parents in termination of parental rights cases and/or in adoption cases, as required by section 453.030.7, RSMo.

(1) The “General Consent to Termination of Parental Rights and Adoption” form, included herein as MO 886-4591, for use in cases filed pursuant to sections 211.444 or 453.030, RSMo, when adoptive parents are not specified shall be used in accordance with the instructions contained in this rule. Parents consenting to the termination of their parental rights shall provide written consent utilizing this form.

(2) The “Specific Consent to Termination of Parental Rights and Adoption” form, included herein as MO 866-4592, for use in cases filed pursuant to sections 211.444 or 453.030, RSMo when the adoptive parents are specified shall be used in accordance with the instructions contained in this rule. Parents consenting to adoption by named individuals shall provide written consent utilizing this form.

rule filed Aug. 19, 2016, effective March 30, 2017. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 210.148, RSMo 2015.

History

• AUTHORITY: sections 207.020 and 210.148, RSMo 2016. Original

13 CSR 35-31.100 Use and Dissemination of Information from the Central Registry {#sec-13-csr-35-31.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-31.100}

PURPOSE: This rule establishes the use and dissemination of child abuse and neglect findings from the central registry by the Children’s Division.

(1) As defined in section 210.110, RSMo, the central registry is a registry of persons where the Children’s Division maintains records of final determinations by the division or a court that persons have committed child abuse or neglect or pleaded guilty to or have been found guilty of offenses enumerated in sections 210.110(3) or 210.118, RSMo.

(2) Pursuant to sections 210.110 and 210.152, RSMo, the Children’s Division shall retain records in the central registry in perpetuity, including for persons placed on the central registry prior to August 28, 2004.

(3) The Children’s Division shall not use or disseminate a finding in the central registry to conduct a background check for employment with a third party or to find a person ineligible for employment with a third party or presence at a residential care facility or child placement agency, unless and until the finding is final and— (A) The finding has been substantiated by court adjudication, by at least a preponderance of the evidence standard;

(B) The finding has been upheld by a preponderance of the evidence standard;

(C) The person has waived administrative review or judicial review; or (D) The person has been found guilty of or pleaded guilty to an offense enumerated in sections 210.110(3) or 210.118, RSMo.

(4) To the extent authorized by law, the Children’s Division may use and disseminate records in the central registry for any

purpose authorized or required by law, including— (A) To respond to child abuse and neglect reports;

(B) Conduct investigations and assessments;

(C) Assist child welfare and law enforcement agencies with the protection of children from abuse or neglect and the provision of child welfare services;

(D) Assist law enforcement and prosecuting attorneys in criminal or civil investigations or prosecutions;

(E) Determine the best interests of a child and make permanency decisions and recommendations;

(F) Assess a child’s health, safety, and well-being;

(G) Conduct research and statistical analysis; or (H) For all other related purposes authorized by law.

History

• AUTHORITY: sections 207.020, 210.118, and 660.017, RSMo 2016, and sections 210.110, 210.145, 210.150, 210.152, and 210.493, RSMo Supp. 2022. Original rule filed Nov. 4, 2022, effective May 30, 2023. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 210.148, RSMo 2015; 210.110, RSMo 1975, amended 1982, 1985, 1994, 2000, 2004, 2005, 2016, 2017, 2018, 2019; 210.118, RSMo 2016; 210.145, RSMo 1975, amended 1980, 1982, 1986, 1990, 1993, 1994, 2000, 2002, 2003, 2004, 2007, 2011, 2012, 2014, 2018, 2020; 210.150, RSMo 1975, amended 1980, 1982, 1985, 1986, 1988, 1991, 1994, 1997, 1999, 2000, 2004, 2020, 2021; 210.152, RSMo 1982, amended 1986, 1990, 1991, 2000, 2004, 2005, 2011, 2014, 2017, 2018; 210.493, RSMo 2021; and 660.017, RSMo 1993, amended 1995.

Chapter 32 Child Care

13 CSR 35-32.030 Contracted Foster Care Case Management Costs {#sec-13-csr-35-32.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.030}

13 CSR 35-32.060 Eligibility and Authorization for Child Care Subsidy {#sec-13-csr-35-32.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.060}

13 CSR 35-32.070 Registration Requirements for Child Care Providers Serving Four (4) or {#sec-13-csr-35-32.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.070}

13 CSR 35-32.090 Registration Requirements for Licensed Child Care Facilities to Contract {#sec-13-csr-35-32.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.090}

13 CSR 35-32.120 Regulatory and Contractual Violations of Registered Child Care Providers SOCIAL SERVICES {#sec-13-csr-35-32.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.120}

13 CSR 35-32.010 Basis of Payment {#sec-13-csr-35-32.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.010}

(Rescinded August 30, 2017)

Original rule filed June 15, 2007, effective Dec. 30, 2007. Rescinded: Filed Jan. 3, 2017, effective Aug. 30, 2017.

History

• AUTHORITY: section 207.020, RSMo 2000.

13 CSR 35-32.020 Foster Care Case Management Contracts {#sec-13-csr-35-32.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.020}

(Moved to 13 CSR 35-35.120)

13 CSR 35-32.030 Contracted Foster Care Case Management Costs {#sec-13-csr-35-32.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.030}

(Moved to 13 CSR 35-35.130)

13 CSR 35-32.040 Hand-Up Pilot Program {#sec-13-csr-35-32.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.040}

(Rescinded August 30, 2018)

2012. Original rule filed May 1, 2013, effective Nov. 30, 2013. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: section 208.053, RSMo Supp.

13 CSR 35-32.050 Definitions {#sec-13-csr-35-32.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.050}

(Moved to 5 CSR 25-200.050)

13 CSR 35-32.060 Eligibility and Authorization for Child Care Subsidy {#sec-13-csr-35-32.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.060}

(Moved to 5 CSR 25-200.060)

13 CSR 35-32.070 Registration Requirements for Child Care Providers Serving Four (4) or Less Unrelated Children {#sec-13-csr-35-32.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.070}

(Moved to 5 CSR 25-200.070)

13 CSR 35-32.090 Registration Requirements for Licensed Child Care Facilities to Contract for State or Federal Child Care Funds {#sec-13-csr-35-32.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.090}

(Moved to 5 CSR 25-200.090)

13 CSR 35-32.100 Participant Overpayments {#sec-13-csr-35-32.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.100}

(Moved to 5 CSR 25-200.100)

13 CSR 35-32.110 Child Care Provider Overpayments {#sec-13-csr-35-32.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.110}

(Moved to 5 CSR 25-200.110)

13 CSR 35-32.120 Regulatory and Contractual Violations of Registered Child Care Providers {#sec-13-csr-35-32.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.120}

(Moved to 5 CSR 25-200.120)

13 CSR 35-32.130 Recordkeeping {#sec-13-csr-35-32.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-32.130}

(Moved to 5 CSR 25-200.130)

Chapter 34 Homeless, Dependent and Neglected Children

13 CSR 35-34.080 Children’s Income Disbursement System (KIDS) {#sec-13-csr-35-34.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-34.080}

Denny Hoskins (3/31/26)

Neglected Children

13 CSR 35-34.080 Children’s Income Disbursement System (KIDS) {#sec-13-csr-35-34.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-34.080}

(Rescinded April 30, 2026)

rule filed Oct. 7, 2005, effective April 30, 2006. Amended: Filed Oct. 17, 2018, effective June 30, 2019. Emergency rescission filed Oct. 8, 2025, effective Oct. 23, 2025, expired April 20, 2026. Rescinded:

Filed Oct. 8, 2025, effective April 30, 2026.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016. Original

Chapter 35 Alternative Care

13 CSR 35-35.100 Response and Evaluation Process for Case Management of Children {#sec-13-csr-35-35.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.100}

13 CSR 35-35.050 Case Plan {#sec-13-csr-35-35.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.050}

PURPOSE: This rule requires the establishment of a case plan for every child in the custody of Children’s Division or receiving social services from the Children’s Division. It also provides a definition of a case plan as well as describing the required content and time periods for development and review of the case plan.

(1) Every child in the care and custody of, or receiving social services from, the division shall have a case plan developed for the purpose of preventing removal of the child from the care of the parents, reunifying a child separated from parent(s), or securing a permanent placement for a child if it is determined the child cannot be reunified with his/her parents.

(2) Every case plan must be developed within thirty (30) days from the date if it has been determined a child should receive protective services or from the date that a judicial determination has been made that the child should be placed in the care and custody of the division. Thereafter, each case plan shall be reviewed and modified, as necessary, every six (6) months. The

purpose of the review is to determine the extent of compliance with the case plan and determine what changes, if any, should be made.

(3) The term case plan means a written document which describes social and child welfare services and activities to be provided by the division and other local community agencies for the purpose of achieving a permanent familial relationship for the child.

(4) This case plan shall include, at a minimum, the following information:

(A) Identifying information about the child and his/her immediate and extended family;

(B) A description of the factors and conditions, including the psychological needs of the child, which caused the division to determine that protective or alternative care services were needed or a copy of the judicial determinations made regarding the child’s placement in the custody of the division;

(C) A description of what efforts were made to prevent removal from the custody of the parent(s), to reunify the family, or to achieve a permanent placement for the child;

(D) A statement of the intended plan for permanency for the child which shall consist of one (1) of the following:

1. Maintain the child with the biological parents;

2. Reunify the child with his/her biological family if a judicial determination has been made for the child to be removed from the custody of the parent(s) and placed in alternate care;

3. Place the child for the purpose of guardianship or adoption; or 4. Maintain the child in a long-term separation from his/ her biological parents with an agreed upon plan with the care provider. This provision applies only if a child is over sixteen (16) years of age;

(E) A description of how the plan is designed to maintain or reunify the child with his/her biological parent(s) or achieve a permanent substitute placement for the child including:

1. A description of the social services to be provided and a description of the services needed to carry out any requirements of a judicial determination proceeding or order with a designation of the responsible parties for the provision of any services:

2. A description of the responsibilities of the parent(s); and 3. A description of parental behaviors which determine that services are no longer necessary or that alternative care is no longer needed;

(F) A description of the appropriateness and necessity for placement away from the biological parents if the court has ordered placement, including at a minimum, the following:

1. The least restrictive characteristics of the alternate care placement facility correlated to the condition and best interests of the child;

2. The degree of proximity of the alternate care placement facility to the location of the biological parent(s)’ residence(s);

3. A description of how the needs of the child will be met while in placement; and 4. A parental visitation schedule including frequency, location, arrangements, and a method of documentation for actual visits; and (G) An evaluation of case plan achievement by all parties, including a time period for case plan achievement.

rule originally filed as 13 CSR 40-30.010. Original rule filed June 28, 1983, effective Nov. 11, 1983. Moved to 13 CSR 35-35.050 and amended: Filed Aug. 8, 2018, effective March 30, 2019. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016. This

13 CSR 35-35.070 Alternative Care Review Board {#sec-13-csr-35-35.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.070}

PURPOSE: This rule defines the Alternative Care Review Board, discusses the purpose of the board, and explains the process for requesting an alternative care review hearing.

(1) Definitions.

(A) “Alternative care review board” or “ACRB”—The board before whom the alternative care resource provider may appeal any decision made by the Children’s Division or its contractors regarding a case management decision involving a child who is, or has been, placed in foster care with the claimant.

(B) “Case management decision”—The activity of a case manager employed by the division or one of its contractors in assessing family problem(s), case planning, coordinating and linking services for children and families, monitoring service provisions and progress, and providing aftercare service. A case management decision shall not include a decision made by the family support team, adoption staffing team, a court of appropriate jurisdiction, or any matter that is the subject of litigation before a court of competent jurisdiction.

(C) “Resource provider” — A resource family providing care for children in state custody.

(2) This section establishes the process for providing a fair and impartial grievance process for review of case management decisions as required by section 210.566, RSMo.

(3) Alternative Care Review Board Composition. Each of the division’s administrative regions shall establish an alternative care review board composed of seven (7) members and two (2) alternates. Members and alternates for an ACRB shall be selected as follows:

(A) Two (2) resource providers, of which one (1) shall be a licensed resource provider;

(B) Two (2) division employees;

(C) Three (3) members and two (2) alternates from the following fields or professions:

1. Community representative who has knowledge of the provision of alternative care services;

2. Professional school employee;

3. Juvenile officer or professional employee of the Juvenile Office;

4. Licensed child or family psychologist or other qualified mental health professional;

5. Physician, nurse, or other qualified medical professional; or 6. Child welfare professional that provides services to families and/or children; and (D) A division regional director shall appoint the members of the ACRB in that director’s region. The regional director shall nominate the chairperson of the board and forward the nomination to the division’s director or director’s designee for approval.

(4) ACRB Terms of Office.

(A) Members and alternates shall be appointed for two- (2-) year terms.

(B) The members of the ACRB shall have at least one (1) annual meeting regardless if any requests are filed. The members of the ACRB shall also meet at least one (1) time per month depending on the number of requests being filed. Other than the annual meeting, meetings are not required if there are no pending reviews.

(C) The members of the ACRB will receive payment for reasonable expenses associated with ACRB business, but will not receive compensation for the performance of their duties.

If a member cannot attend, an alternate shall be notified and asked to attend.

(D) A quorum at any ACRB meeting will be three (3) members, of whom one (1) will be a resource provider and one (1) will be a division employee.

(E) A division regional director may remove and/or replace a member of an ACRB for the following reasons:

1. Death;

2. Resignation;

3. Mental or physical incapacitation that limits the member from actively serving; or 4. For good cause as determined by the division director.

(F) The information and deliberations of the ACRB shall be confidential and protected from disclosure to the extent permitted by law.

(5) Process for Requesting an ACRB Review.

(A) The resource provider shall email a written request for review of a case management decision to cd.acrb@dss.mo.gov, or mail such request to Program Development Specialist, Resource Licensing, Missouri Children’s Division Central Office, PO Box 88, 205 Jefferson St., 10th Floor, Jefferson City, MO 65101, within ten (10) business days of being notified of the case management decision. The request for review shall specify the decision that is being contested and the basis of the grievance.

(B) Except as provided in this regulation, upon receipt of the grievance, division or contracted staff shall take no action to implement the decision being reviewed until the matter is resolved through the grievance process. The implementation of the following decisions, however, shall not be stayed pending resolution of the grievance:

1. Decisions that, in the division’s or contracted staff’s judgment, require immediate action to protect the health, safety, or well-being of the child in care; or 2. Decisions whose implementation has been ordered by a court of competent authority.

(C) Within ten (10) business days of receipt of the grievance, the division or contracted staff shall schedule an informal meeting/ review with the resource provider to attempt to resolve the matter. In cases concerning a case management decision made by the division, the attendees of the informal meeting shall include the resource provider, the resource provider’s attorney (if available), a regional division representative, and one (1) or more circuit division representatives. In cases concerning a case management decision made by a contracted agency, the attendees of the informal meeting shall include the resource provider, the resource provider’s attorney (if available), an agency manager, and a manager representing the contract holder. Within five (5) business days of the informal review, the division or contracted management staff shall notify the resource provider in writing of its decision to uphold or reverse the case management decision and, if the decision is upheld, shall advise the resource provider of the resource provider’s right to proceed with a request for an ACRB hearing.

(D) If the resource provider chooses to proceed with the ACRB hearing, the resource provider shall email a completed hearing request form or other written request for an ACRB hearing, including all pertinent information and records, to cd.acrb@ dss.mo.gov, or mail such written request, information, and records to Program Development Specialist, Resource Licensing, Missouri Children’s Division Central Office, PO Box 88, 205 Jefferson St., 10th Floor, Jefferson City, MO 65101, within five (5) business days of the division’s or contracted management staff’s written decision. The division may extend the time frame for submitting information for good cause shown. The division will notify the resource provider of the date scheduled for the ACRB hearing within five (5) business days of receiving the resource provider’s written request.

(E) The division or contracted staff shall submit all pertinent information and records to the resource provider’s regional ACRB within five (5) business days of receiving the request for the review. The division may extend the time frame for submitting information for good cause shown.

(F) The review should be scheduled to occur at the next scheduled ACRB meeting. The review may be continued if there is insufficient time for board members to prepare for the review.

(G) The review proceedings described in this subsection are informal and administrative in nature and are not subject to the Missouri Rules of Civil Procedure. The review proceedings are also not subject to common law or statutory evidentiary standards, apart from those regarding relevancy. The review proceedings shall not be governed by the procedures set forth in Chapter 536, RSMo, but shall instead be governed by the following procedures:

1. The division or contracted staff shall first present its case management decision and the rationale thereof. Division or contracted staff may participate in the review proceeding in person, telephonically, or virtually with or without legal counsel;

2. The resource provider and/or the provider’s counsel shall next present a summary of the resource provider’s grievance.

The resource provider and/or the provider’s counsel’s presence is not mandatory for a review to be held. The provider or provider’s counsel may submit a written statement and/ or participate in the review telephonically or virtually if equipment is available;

3. The resource provider and the division or contracted staff may provide information at the review through the use of witnesses. Witness testimony will not be taken under oath; however, the parties may submit information by written statement. No party to the review proceeding, including the ACRB, shall have the power to compel the appearance of any witness through the use of a subpoena or other means;

4. The review hearing may, at the election of either party, be recorded through the use of a recording device or a court reporter. However, the review hearing shall not be a hearing on the record. All expenses associated with the recording of the hearing shall be the sole responsibility of the party desiring them; and 5. The information provided to the ACRB, and the ACRB’s deliberations, shall be confidential and protected from disclosure to the extent permitted by law. The ACRB shall review and discuss all relevant materials and information and vote individually on whether to uphold, modify, or reverse the division or contracted staff’s finding and/or decision.

The ACRB shall prepare a written summary of its findings and recommended decision and present it to the division’s deputy director for permanency within seven (7) business days of the ACRB hearing. The deputy director shall discuss the recommendation with the division’s director. The division’s director shall provide the final written decision to all parties within thirty (30) calendar days of receipt of the ACRB’s recommendation. The division director’s decision shall be the final decision of the division.

(6) If at any time the grievance pending before the ACRB becomes the subject of a motion or other proceeding before a court of competent authority, the ACRB proceedings shall be stayed pending the resolution of the issue before the court.

In the event that the matter is decided by the court, the ACRB proceedings shall be dismissed by the ACRB.

History

• AUTHORITY: section 207.020, RSMo 2016, and section 210.566, RSMo Supp. 2023. The material covered in this rule was previously covered in 13 CSR 35-36.010. Original rule filed Oct. 24, 2023, effective May 30, 2024. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014, and 210.566, RSMo 2002, amended 2007, 2020.

13 CSR 35-35.100 Response and Evaluation Process for Case Management of Children in Foster Care {#sec-13-csr-35-35.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.100}

PURPOSE: This rule implements House Bill 1414 (2020), which amended section 210.112, RSMo. The purpose of this rule is to regulate the response and evaluation process for case management services that are identified in the amended statute.

(1) Purpose and Scope.

(A) The purpose of this regulation is to implement the amendments to section 210.112, RSMo, that were enacted into law in HB 1414 of the 2020 regular session of the Missouri General Assembly. This regulation applies to case management services, whether provided by employees of the Children’s Division (hereinafter the “division”) or by Foster Care Case Management Contractors (FCCMs).

(B) In implementing this regulation, the safety and welfare of children shall be the paramount consideration.

(2) Definitions. For the purposes of this section the following definitions shall apply:

(A) “Accrediting body” shall refer to the Council on Accreditation of Services for Children and Families, Inc., the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities;

(B) “CFSR” shall mean the Child and Family Services Review process, standards, goals, and measures established by the Administration of Children and Families of the United States Department of Health and Human Services;

(C) “CFSR-OSRI” shall refer to the CFSR On-Site Review Instrument utilized by the Administration of Children and Families of the United States Department of Health and Human Services;

(D) “Case management services” shall include assessments, case planning, placement services, service planning, and concurrent planning for children. These services include, but are not limited to:

1. Coordinating and facilitating the provision of services necessary to ensure the safety and well-being of the child, to meet the needs of the child’s parent(s) or caretaker, and to promote timely permanency;

2. Facilitation of family support team meetings;

3. Facilitation and/or supervision of visits between children and their family members;

4. Preparation of court reports;

5. Attending and participating in court hearings; and 6. Coordination of services and provisions in compliance with federal and state law, and directed by Children’s Division policy and regulation;

(E) “Child” or “Children” shall mean any individual who has been placed under the supervision of the division or in the legal or physical custody of the division by judgment or order of a juvenile or family court;

(F) “Direct Service Providers” means any person or entity who is providing case management services to children and families of children who are under the jurisdiction of the juvenile court and who are either placed under the supervision of the division or placed in the legal or physical custody of the division. This applies to alternative care Children’s Division Case Managers and their supervisors, and to FCCMs;

(G) “Foster Care Case Management Contractors,” “FCCM,” or “FCCMs” shall mean any individual or entity which has a contract with the children’s division to provide case management services for children. It also shall mean any contractor or subcontractor of an FCCM which provides case management services. It does not mean individual employees of the FCCM;

(H) “Large Contractor” shall mean any FCCM which is contracted to provide case management services for one hundred (100) or more children. It shall also refer to the lead FCCM contractor and their sub-contracted partner agencies;

(I) A “near fatality” means any physical injury or illness of a child caused by suspected or substantiated child abuse or neglect that, as certified by a physician, places the child in serious or critical condition;

(J) “Provider” shall mean the Children’s Division and FCCM, but shall not mean individual employees of the division or FCCMs;

(K) “Response and Evaluation Team” or “the R&E Team” shall refer to the Response and Evaluation Team established pursuant to 210.112.3, RSMo;

(L) “Sentinel events” shall mean any critical incident as described in 13 CSR 35-71.070, any unusual event as described in

13 CSR 35-73.050 and— 1. A child fatality or near fatality; {#sec-13-csr-35-73.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.050}

2. An incident that causes serious emotional harm or serious bodily injury to a child. For purposes of this regulation a serious emotional or physical injury occurs when it is medically reasonable or necessary for a child to obtain professional medical intervention as a result of something that happens to the child while placed with the individual or organization;

3. A child elopes from his or her placement;

4. A fire in a location routinely occupied by children, which requires the fire department to be called;

5. A report of child physical abuse, emotional abuse, sexual abuse, or neglect pertaining to a child; and 6. Whenever a child attempts to harm him/herself or others, including suicide attempts;

(M) The term “serious bodily injury” means bodily injury which involves substantial risk of death, extreme physical pain, protracted and obvious disfigurement, or protracted loss or impairment of the function of a bodily member, organ, or mental faculty; and (N) Children with “Special Needs” shall include children who have physical, behavioral, or mental health conditions that require specialized care.

(3) Evaluation Tool and Metrics.

(A) The division shall establish and implement a uniform evaluation tool, metrics, and performance outcome goals for providers to evaluate the quality of case management services.

Performance outcome goals, but not metrics, may be adjusted regionally to account for regional differences in the availability of services, provided that the same performance outcome goals apply to all providers in the same region; provided that the performance outcome goals that apply to the division shall be adjusted to take into consideration the factors set forth in subsection (3)(F). The division shall establish the tool in conjunction with the R&E Team and other appropriate individuals.

The division may establish and implement the evaluation tool in phases as described elsewhere in this regulation. The evaluation tool may draw from the following sources of data and information:

1. Data contained in the information system of the division, including Family and Children Electronic System (FACES);

2. Data from surveys;

3. Detailed case reviews of individual cases of children as described below;

4. Data and information from federal CSFR reviews;

5. External audits and program reviews;

6. Reports from an accrediting body; and 7. Other sources of information as may be necessary.

(B) The division will publish the proposed tool for Phase I on its website by April 1, 2022, and solicit comments from providers, stakeholders, and the public. Providers may recommend alternative metrics based on the best interests of the child. In making such recommendations the providers shall explain, in writing, how the alternative metrics are in the best interests of the child and promote the safety and welfare of children.

The division and the R&E Team will review the comments, and the R&E Team will submit recommendations based upon the comments within thirty (30) days of receipt of the comments.

The division will consider the public comments and recommendations of the R&E Team and publish final evaluation tools and metrics for Phase I on or before July 31, 2022. The final, Phase I evaluation tools, metrics, and performance outcome goals shall be implemented by and applicable to all effective October 1, 2022.

(C) The evaluation tool shall include selected metrics and performance outcome goals from the CFSR and the CFSR-OSRI.

(D) By October 1, 2022, the division, in conjunction with the R&E Team and following the procedures set forth in subsection (3)(B), shall implement and all providers are required to utilize and implement a uniform, standardized stakeholder feedback tool. This tool will collect data from stakeholders pertaining to the quantity, quality, and effectiveness of case management services that the division and FCCMs provide.

1. The tools may be surveys and will also provide space for stakeholders to provide narrative feedback and comments.

2. Separate stakeholder feedback tools shall be designed for and provided to each of the following categories of stakeholders: children twelve (12) years of age or older, parents or legal guardians of children, foster parents or resource providers, juvenile officers, and judges of juvenile and family courts.

3. Stakeholder feedback tools shall be submitted on the following schedule:

A. Children twelve (12) years of age or older: annually and at the conclusion of the time the child is in care;

B. Foster parents and resource parents annually;

C. Parents or legal guardians of children in care, annually;

D. Juvenile officers, annually; and E. Judges of the juvenile and/or family courts who preside over proceedings under Chapter 211, RSMo–annually.

(E) The evaluation tool for providers shall include metrics and performance outcome goals for the following domains listed below. The division may implement these in phases, but it shall implement at least one metric and performance outcome goals for each domain in Phase I no later than October 1, 2022; implement additional metrics and performance goals in Phase II no later than October 1, 2023; and implement all remaining metrics and performance goals in Phase III no later than October 1, 2024. The division may implement additional performance outcome goals and metrics or make amendments to any domain, performance outcome, goal, or metric in conjunction with the Response and Evaluation Team following the process set forth in subsection (9)(B) of this regulation as may be necessary and appropriate. Some metrics and performance outcome measures may apply to more than one (1) domain. To the maximum extent possible, the metrics and performance outcome measures shall be based upon, and preferably mirror, the federal CSFR and Program Improvement Plan (PIP) metrics, measures, and goals. The achievement of the deadlines specified in this regulation are contingent on the availability of information processing capability and the availability of funds that are necessary for implementation. The division, with the permission of the Department of Social Services, may extend the deadlines for implementation of a goal or metric if it is not technically feasible or if there are insufficient funds to implement by the deadline. The domains are— 1. Safety Domain. The purpose of the Safety Domain metrics and performance outcome goals is to ensure, to the maximum extent possible, that children are kept safe from the risk of abuse and/or neglect for the duration of their experience within the child welfare system. Metrics and performance outcome goals will be developed and implemented to address the following:

A. Worker/child visits;

B. Reports of abuse and/or neglect of a child;

C. Sentinel events; and D. Any other metrics and outcome goals that may be required by law or that the division may decide are appropriate;

2. Well-Being Domain. The purpose of the Well-Being Domain metrics and performance outcome goals is to ensure, to the maximum extent possible, that children receive the necessary care and services for them to grow, develop, and thrive for the duration of their experience within the child welfare system. Metrics and performance outcome goals will be developed and implemented to address the following:

A. Parent/child visits to the extent that they are not contrary to the orders of the court;

B. Healthy Child and Youth program compliance (i.e. compliance with federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements and standards). This will include timely completion of Healthy Children and Youth (HCY)/EPSDT screenings and also timely compliance with diagnosed and prescribed treatment;

C. Residential–Placement of a child in a residential or institutional setting shall be in compliance with the requirements of federal and state law;

D. Education–such as achievement of identified, developmentally, and age appropriate educational milestones;

E. All case managers and supervisors successfully complete training in providing trauma informed and trauma based services; and F. Any other metrics and outcome goals that may be required by law or that the division may decide are appropriate;

3. Permanency Domain. The purpose of the Permanency Domain metrics and performance outcome goals is to ensure, to the maximum extent possible, that children achieve permanency and are discharged to a safe and appropriate placement from the care and supervision of the child welfare system in a timely manner. Metrics and performance outcome goals will be developed and implemented to address the following:

A. Worker/parent visits;

B. Re-entries into foster care;

C. Timely achievement of the child’s court approved permanency plan;

D. Stability of placements;

E. Provision of services to meet the needs of older youth;

F. Timely development and effective implementation of a primary and concurrent permanency plan for each child;

G. Development and implementation of a social service plan to address the reasons why the child is in care; and H. Any other metrics and outcome goals that may be required by law or that the division may decide are appropriate; and 4. Service Domain. The purpose of the Service Domain metrics and performance outcome goals is to ensure that providers are effectively and efficiently managing the services that they are providing. Metrics and performance outcome goals will be developed and implemented to address the following:

A. Caseloads–including caseloads per case manager and the number of changes in case manager that a child may experience while a child is in care;

B. Effective ratio of supervisors to supervision of case managers;

C. Timely reporting of sentinel events;

D. Cases returned to the division due to catastrophic costs or court order for case management by Foster Care Case Management agencies; and E. Any other metrics and outcome goals that may be required by law or that the division may decide are appropriate.

(F) All metrics and performance outcome goals for the division shall be designed to take into consideration the following factors:

1. The fact that caseloads of FCCM case managers are capped; and 2. The fact that FCCMs may return cases to the division due to catastrophic costs or court order for case management.

(G) The division, in conjunction with the R&E Team, shall develop objective standards and criteria to identify cases which a provider may feel are anomalous and should not be considered in developing the case management tool. The standards and criteria shall be implemented following the process and deadlines established in subsection (3)(B) of this regulation.

(H) To calculate the performance and outcome scores, the division will calculate for each provider the percentage of the performance outcome goal for each item in each domain being scored under 13 CSR 35-35.100 that each provider actually achieved for that item during the phase for the period. The percentage achieved for each item under each domain shall then be multiplied by the weight factor (if any) assigned to each item. The net sum of the weighted percentages will be the total score for each provider for the period. The performance outcome goals for the period and the weights to be assigned to each item will be established by the division, in conjunction with the Research and Evaluation team and other individuals, following the procedures specified in this regulation.

(4) Collection of Data.

(A) Effective October 1, 2022, the division and FCCMs shall implement policies and procedures to require their staffs to timely record all of the necessary data in the information system. Information shall be timely posted if it is posted no later than the fifteenth day of each calendar month for the preceding calendar month or sooner as may be required by policy of the division.

(B) The division and each FCCM shall develop and implement a system to track the timely and accurate recording of data in the information system by October 1, 2022; this may include implementing a system to send reminders to staff or prohibit completion of data entries when mandatory data fields are not timely completed.

(C) The division will publish a list on its website describing the specific items of data that providers will be responsible for recording and reporting. The division will publish its first list of data items on or before April 1, 2022, to be effective July 1, 2022.

The division shall send a notice by e-mail to all providers notifying them when a change has been made in the data points at least one (1) quarter prior to the effective date of the list to ensure that providers have notice and an opportunity to prepare.

(D) Detailed Case Reviews.

1. The division and the R&E Team will utilize the information and findings from individual case reviews from the federally required, statewide CFSR process.

2. In addition to the CFSR process, the division, in conjunction with the R&E Team, may develop and implement a detailed case review process if necessary to supplement the CFSR process and/or to ensure the quality of data that is being reported and utilized for calculating metrics and performance outcome goals and measures. The division and the R&E Team may also utilize detailed case reviews as part of the process of identifying and providing technical assistance to providers who are having difficulty meeting performance outcome goals and measures, and for other purposes as provided in the contract.

3. When a case has been selected for a detailed individual case review, the provider providing case management services will be given the opportunity to propose different evaluation metrics if the case may have circumstances far beyond those which would be expected.

A. The division, in conjunction with the R&E Team and other stakeholders, shall develop and implement objective standards and criteria for identifying cases which will be evaluated on different evaluation metrics. The division shall utilize the process described in subsection (3)(B) for developing, publishing, and implementing the standards and criteria.

B. The provider shall make the request to apply different evaluation metrics in writing within ten (10) days of the date that the division identified the case for a detailed review. The request shall include:

(I) A detailed explanation for why the generally applicable criteria and metrics for conducting case reviews cannot be reasonably and appropriately applied to the case and why the case may have circumstances far beyond those that would be expected; and (II) Explain in detail what performance measures and metrics the provider proposes that the division and the R&E Team apply to the review of the case.

C. The provider shall have the burden of proving that the case falls far beyond what is expected and what alternative metrics should be applied by clear and convincing evidence.

D. The division and/or the R&E Team shall conduct a full case review of each and every case that a provider identifies as a case that should be evaluated using different evaluation metrics.

(E) The division will collect data and all providers will provide data on a monthly basis provided that Detailed Case Reviews will be conducted when necessary to supplement other data sources as determined by the division in conjunction with the R&E Team.

(F) Providers shall make available all data, files, records, and information pertaining to each and every case to the division and the R&E Team to perform their duties under section 210.112, RSMo, and this regulation. This includes information maintained in physical and electronic formats. Providers shall direct their staffs to provide true, complete, accurate, and timely information to the division and the R&E Team members when performing their duties under this regulation. Providers shall make their employees and subcontractors available for interviews when conducting detailed case reviews.

(G) Providers shall ensure that staff are trained and have the opportunity to enter data into the information system in a timely manner to ensure that the data retrieved from the information system is timely and accurate. Data for the preceding calendar month shall be entered into the information system no later than the fifteenth day of the following calendar month or sooner as may be required by policy of the division.

(H) The data and metrics shall be analyzed and reported in the aggregate across the whole system, and then by judicial circuit, county (or city within a county), and provider.

(5) The division and the R&E Team will develop, propose, and implement a system for reviewing and working with providers who request assistance or who show signs of performance weakness. Performance weakness shall be defined and measured with reference to the metrics and performance outcome goals as discussed in this regulation, in addition to other provisions in the contract.

(A) The division, in conjunction with the R&E Team, will identify objective performance measures and standards based on the metrics and performance goal outcome scores as calculated in subsection (3)(H) to identify providers who are showing areas in weakness of performance. This may be done in phases so as to be consistent with the phased implementation of the evaluation tool and metrics and performance outcome goals.

The division will give the public and stakeholders thirty (30) days to submit comments and suggestions. The division will consider the comments and then publish the operational performance measures and standards on the division’s website consistent with the phased implementation deadlines.

(6) Data Reporting.

(A) The division, in conjunction with the R&E Team, shall develop and implement a standardized format for analyzing and reporting the data and lessons learned from the data. This will ensure that data is analyzed and reported in a consistent and comparable manner from quarter to quarter. The division will follow the procedures specified in this regulation for developing and implementing the reporting tools.

(B) All measures, metrics, and performance measures shall be designed to take into consideration the following factors:

1. The fact that case loads of FCCM case managers are capped; and 2. The fact that FCCMs may return cases to the division due to catastrophic costs or court order for case management.

(C) The division will publish the report quarterly on its website. The report for the preceding quarter shall be published on or before the last day of the end of the last month of the subsequent calendar quarter. The initial report shall be published no later than March 31, 2023, for the October 1, 2022, through December 31, 2022, quarter.

(D) In developing the standardized format for reporting, the R&E Team shall be responsible for determining how to aggregate cases for the division and large contractors; so that performance and outcomes may be compared effectively while also protecting confidentiality.

(7) Conflicts of Interest.

(A) Private Providers shall not participate in conducting detailed case reviews under this regulation when they or one (1) of their officers, employees, or subcontractors have a conflict of interest. It shall be considered a conflict of interest— 1. For an officer or employee of a FCCM or private provider to conduct a case review of a case managed by the FCCM or private provider which employs them; and/or 2. For an officer or employee of a FCCM or private provider to conduct a case review of a case managed by a subcontractor of the FCCM or private provider which employs them; and 3. Where the provider or the employee of the provider has any interest in the underlying case.

(B) Division staff shall not conduct detailed case reviews of cases under this regulation arising from the circuit where the division staff member conducting the review is assigned. The division may assign special staff not affiliated with any one (1) particular circuit or region to conduct case reviews.

(C) No person shall conduct a detailed case review of a case in which he or she participated as a case manager or supervisor.

(8) All members of the R&E Team shall maintain the confidentiality of all information, documents, and data that they receive in the performance of their duties as members of the R&E Team to the same extent that the information, documents, and data is confidential in the hands of the division, its employees, and contractors. R&E Team members shall submit requests for access to information and data to the division for review.

(9) Review and Evaluation of the Evaluation Tools, Metrics, and Reporting Format.

(A) The R&E Team shall review the evaluation tool and report format established under this section at least twice each year and submit a report to the division making any recommendations for changes in the tool. The reports shall be due each year on or before July 1 and January 1 with the first report being due July 1, 2023.

(B) The division may amend the evaluation tool, metrics, and report formats as may be necessary to ensure that information is collected and reported in an accurate, efficient, and useful way. The division will utilize the following process to amend the evaluation tool and report format:

1. The proposed amendments will be submitted to the R&E Team for review and comment. The R&E Team will have thirty (30) days to provide comments;

2. The division will then publish an announcement of the proposed amendments to all providers and to the public by an announcement on the division’s website. The announcement will give providers and the public thirty (30) days to submit written comments;

3. The division may, but is not required to, hold one (1) or more public hearings to solicit comments. These public hearings may be held in person, virtually, or by telephone conference; and 4. The division will consider the comments from the R&E Team and other sources and publish the final amendments on the division’s website. The amendments shall be effective on the first day of the calendar quarter following the publication of the amendment; provided however, that the effective date of the amendment shall not be less than thirty (30) days from the date of publication.

(C) Twenty-four (24) months after the first publication of the tools and metrics established under this regulation the R&E Team and the division shall conduct a comprehensive review of the tools and metrics established pursuant to the process established in section 210.112, RSMo, and this regulation. The division shall publish a report on its evaluation within six (6) months of commencing the review.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016, and section 210.112.8, RSMo Supp. 2021. Emergency rule filed June 11, 2021, effective July 1, 2021, expired Feb. 24, 2022. Original rule filed June 11, 2021, effective Jan. 30, 2022. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.112, RSMo 2004, amended 2005, 2011, 2018, 2020; and 660.017, RSMo 1993, amended 1995.

13 CSR 35-35.120 Foster Care Case Management Contracts {#sec-13-csr-35-35.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.120}

PURPOSE: This rule establishes the governing provisions for foster care case management contracts to provide a comprehensive system of service delivery for children and their families as set forth in section 210.112, RSMo.

(1) This rule shall apply to the foster care case management contracts for the provision of case management services for youth placed in the custody or under the supervision of the Children’s Division (CD) as provided in section 210.112, RSMo, as well as govern the work of contractors and their subcontractors, officers, agents, and employees pursuant to those contracts. This regulation shall apply to any subcontractors of the contractor which provide foster care case management services. The safety and welfare of the children served under these contracts shall be the paramount consideration in all matters pertaining to these contracts.

(2) When providing case management services pursuant to the foster care case management contract with the Children’s Division, the contractor shall fully implement and comply with all requirements of federal and state law which apply to permanency planning and shall fully implement and comply with all written policies of the Children’s Division which do not conflict with those federal and state laws. This includes, but is not limited to, all regulations promulgated by the Children’s Division. The Children’s Division, in collaboration with the contractors, shall develop a mechanism for contractors to provide input and feedback regarding pending Children’s Division policy prior to implementation when such policy could have financial or programmatic impact on the contractor. Policy of the Children’s Division, laws, and regulations shall supersede any policy of the contractor when they conflict.

(3) Contractors shall provide a range of child welfare services including case management services for children in out-ofhome placements, family-centered services for parents and legal guardians from whose care the child was removed, and community resource development. Family-centered services shall be defined as the family-focused intervention method utilized by the Children’s Division when working with families to assist them in identifying their strengths and needs and to develop a family plan for change.

(A) Case management services shall include assessments, case planning, placement services, service planning, permanency planning, and concurrent planning. The contractor shall have ongoing contact with the child; the child’s out-of-home care provider; the parents or the guardian of the child in care, if parental/guardianship rights have not been terminated; the children remaining in the home; the court; and the members of the child’s Family Support Team as defined in the Children’s Division’s written policies. The contractor must provide case management services that respect the culture, ethnicity, and religious practices of the children and that of his/her family.

The contractor shall document all case management services provided in the case record as well as in the automated case management system within the timeframes outlined in the contract and in the policies of the Children’s Division.

1. Assessments shall be defined as the consideration of all social, psychological, medical, educational, and other factors to determine diagnostic data to be used as a basis for the case plan.

2. Case planning is a process of negotiation between the family case manager, the parent(s) or guardian(s) from whom the child was removed, and the juvenile officer, which describes the services and activities necessary for the purpose of achieving a permanent familial relationship for the child.

The case plan shall include the permanency plan as defined in paragraph (3)(A)5. below, the concurrent plan as defined in paragraph (3)(A)6. below, the service plan as defined in paragraph (3)(A)4. below, the timeframes in which services will be delivered, and the timeframes for obtaining reports from service providers, when applicable.

A. Contractors shall develop a case plan no later than thirty (30) days after referral of the child’s case to the contractor by the Children’s Division. The contractor shall submit case plans to the court in accordance with local court procedures.

B. The case plan shall be developed in accordance with the written policies of the Children’s Division and applicable federal and state law. In the event that the policies of the Children’s Division conflict with applicable federal and state law, federal and state law shall prevail.

C. The contractor’s case manager shall give careful consideration to the unique needs of each child and family when developing the case plan.

D. As necessary to effectuate the best interests of the subject child, the case plan may be amended from time-totime.

3. Placement services is the selection of, and placement with, the most appropriate resource for children in out-ofhome care based on the assessment of the child’s unique needs and personality and the out-of-home care provider’s capacity and skills in meeting those needs.

A. The contractor’s case manager must utilize the least restrictive out-of-home placement for a child.

(I) The best interests of the child in care shall govern all placement decisions. When the placement would not be contrary to the best interest of the child, the contractor must give relatives of the child in care preference and first consideration to serve as the child’s out-of-home care provider. As required by applicable federal and state law, the contractor must conduct an immediate search to locate, contact, and, where appropriate, place the child in care with his/her grandparent(s).

Therefore, grandparents of the child in care shall be given first consideration for placement before other relatives of the child in care are considered. Whenever the contractor decides that relative placement is contrary to the best interests of the child, the contractor shall document the reasons for this decision in the case plan.

(II) Placements in residential treatment shall be based on an individualized, independent assessment of each child’s needs in the manner required by law, regulation, and CD policy.

Such placements shall be considered for children in care who need structured and therapeutic intervention. Placement in a residential treatment facility must be of a limited duration and treatment during this time must be focused on enabling the child in care to transition to family and/or community-based care as soon as possible. The contractor shall prioritize methods of reducing or eliminating a child’s need for residential treatment through community-based services and supports.

(III) In coordination with the child in care’s Family Support Team, the contractor shall periodically reassess the placement of the child to determine whether the placement is consistent with the child’s permanency plan and is meeting the child’s needs.

(IV) As required by the written policies of the Children’s Division, the contractor shall convene Family Support Team meetings to discuss any change in placement.

B. The contractor shall exercise reasonable and continuing efforts to preserve, foster, and encourage the relationships between siblings of children under case management with the contractor unless it is contrary to the safety or welfare of one (1) or more of the siblings to do so.

(I) Whenever reasonably possible, the contractor shall place a child in out-of-home care with any siblings who are also removed from their home. The contractor shall make reasonable efforts to place siblings in the same placement unless doing so would be contrary to the safety or welfare of any of the siblings.

(II) The contractor must make arrangements for regular, frequent, and continuing visitation between siblings who are not in the same placement unless it is contrary to the safety or welfare of one (1) or more of the siblings to do so.

(III) Unless it is contrary to the safety or welfare of one (1) or more of the siblings to do so, the contractor shall reunite siblings at the earliest time possible when circumstances change and different caregivers are no longer required.

(IV) The contractor shall document in the case file its efforts to place siblings in the same home and, if not placed in the same home, its efforts to maintain the sibling relationship.

If the contractor determines that placement of siblings in the same placement or visitation between the siblings is contrary to the safety or welfare of the siblings, the contractor shall document the reasons therefore in the case file.

C. When an appropriate placement is available and it is in the best interests of the child to do so, placements of children in care shall be made in the child’s home community.

D. Unless otherwise ordered or authorized by the court, placement of children in care shall be with a licensed out-ofhome care provider.

E. The contractor’s case manager shall not place a child in a home in which any person residing in the home has been found guilty of, or pled guilty to, any crimes identified in section 210.117, RSMo.

4. Service planning is the provision of any services indicated and identified as needed through an assessment and case plan, or ordered by the juvenile court.

5. Permanency planning is determining the permanent plan which best meets the needs of the child in care and which complies with the applicable requirements of federal law.

Contractors shall provide ninety (90) calendar days of services to the child and family after a child is reunified with their parent(s) to assure a continued successful outcome as defined in the contract. Contractors shall provide ninety (90) calendar days of services to the child and family after a child is reunified with their legal guardian(s), from whom they were removed, to assure a continued successful outcome as defined in the contract. The permanency plan shall consider— A. The child’s need for a continuing relationship with his/her parent(s) or legal guardian(s) prior to the child’s removal from the home;

B. The ability and willingness of the child’s parent(s) or legal guardian(s) to actively perform their functions as the child’s caregiver with regards to the needs of the child;

C. The interaction and interrelationship of a child with the child’s parent(s) or legal guardian(s) from whom they were removed, the child’s out-of-home care provider, siblings, and any other person who may have a significant impact upon the child’s best interest;

D. The child’s adjustment to his/her out-of-home placement, school, and community;

E. The mental and physical health of all individuals involved, including any history of abuse of or by any individuals involved; and F. Any other information and factors that may be relevant to the care, safety, and welfare of each child.

6. A permanency plan shall include an individualized primary permanency plan and a concurrent permanency plan for each child. Concurrent permanency planning is a process of pursuing a primary permanency goal for a child in care, such as reunification, while simultaneously establishing and implementing an alternative permanency plan for that child.

The contractor shall make active, reasonable efforts to finalize the primary and concurrent permanency plan and shall document those efforts in the case file. The permanency plan shall be developed at the earliest possible opportunity and in no case later than thirty (30) days after case referral. The plan shall be submitted to the court in the manner prescribed by law or as otherwise ordered by the court. As required by Children’s Division written policies, the permanency plan shall be periodically reviewed and, where appropriate, may be modified if modification is in the best interests of the child as recommended by the child’s Family Support Team or as ordered by the court.

(B) Community resource development is the recruitment, assessment, training, maintenance, and retention of out-ofhome care providers. It shall also include the development of those services which shall best meet the needs of the child and family.

1. The contractor shall conduct community resource development activities to obtain appropriate out-of-home resource providers to enable the contractor to perform its duties under 2. Unless such policies conflict with applicable state law, the contractor shall ensure background investigations are conducted on all out-of-home care providers as required by law,

regulation, and the written policies of the Children’s Division.

3. The contractor shall utilize a training curriculum which meets or exceeds the resource development standards set forth in the written policies of the Children’s Division. The contractor shall obtain approval from the Children’s Division designee prior to finalizing the curriculum and content for the training sessions.

(C) The contractor may directly provide or contract for the services required by this rule in accordance with the proposal submitted in response to the Request for Proposal or Invitation for Bid for the contract awarded for such services. However, any subcontractors employed by the contractor must comply with all requirements of this regulation.

(4) The contractor shall ensure that all children under the age of ten (10) years old referred to the contractor receive a Healthy Children and Youth assessment within thirty (30) days of entering care, as often as necessary for the provision of follow-up care and treatment, and at least annually thereafter. Such assessments will be utilized to determine treatment services which will meet the child’s psychological and social needs.

When the assessment indicates intensive twenty-four- (24-) hour treatment services, appropriate services will be provided.

A written report of the assessments and documentation that the prescribed treatment has been timely provided to the child (or good cause why the treatment was delayed or not provided) shall be documented and maintained in the case file.

(5) The contractor shall deliver all services through qualified professionals who have substantial, current and relevant training, education, and experience and who are competent to deliver case management services. The contractor’s personnel must meet or exceed all of the applicable accreditation, licensing, and/or certification requirements of their profession set by the state of Missouri, if such licensure or certification is required by their profession for the performance of their specific job function. The contractor’s personnel must meet the education and experience expectations outlined in the most current child placing rules set forth at 13 CSR 40-73.035.

(A) The contractor shall maintain a personnel file for each employee which shall be accessible to the Children’s Division upon request for the purpose of verifying compliance with this regulation and the requirements of its contract with the Children’s Division. At a minimum, the file must include complete and current criminal record checks, background investigations, resumes, degrees or diplomas, date of employment, training records, performance appraisals, commendations, disciplinary actions, and other related actions. Background checks, including fingerprint-based criminal background checks, shall be periodically updated as requested by the Children’s Division or otherwise required by law. Contractors shall immediately notify the Children’s Division of any act or occurrence which may impact their employee’s ability, qualifications, or certification to provide services under the contract.

(6) The contractors shall deliver all services through professionals who have substantial and relevant training. The contractor’s personnel providing case management services or direct supervision of case management services must successfully complete the same training curriculum as the Children’s Division’s personnel which provide case management services or direct supervision of case management services. This applies to both pre-service and in-service training as required by the Children’s Division. Contractors may provide or require additional training as they deem appropriate, provided that the additional training is consistent with the Children’s Division’s regulations, policies, and procedures. Contractor’s personnel attending Children’s Division pre-service training will be scheduled for the first available session with openings.

(A) The contractor’s personnel who recruit, train, and assess foster parents serving children with elevated needs, or who provide ongoing support to such foster parents, must successfully complete specific training which is designed for the elevated needs program. Elevated needs shall be defined as provided in 13 CSR 35-60.070. Training for elevated needs providers must be provided by the Children’s Division or by the contractor’s staff utilizing curriculum which has been previously approved by the Children’s Division.

(B) The contractor’s personnel who train staff who are tasked to recruit, train, and assess foster parents serving children with elevated needs must successfully complete a Train-the-Trainer session provided by the Children’s Division or by another entity approved to provide such training by the Children’s Division.

(7) The contractor must submit all required information to the family care safety registry on behalf of all professional personnel assigned to provide services under the contract prior to such personnel providing service to children in care. Such information shall be updated on an annual basis thereafter. Any personnel who reside in another state and work in the state of Missouri, or who have relocated to the state of Missouri within the last five (5) years, shall provide documentation of background screening(s) from their state of origin to include, but not limited to, child abuse/neglect and criminal background screening check(s), prior to such personnel providing service.

If the employee continues to reside in another state while performing case management services for the contractor, the out-of-state check shall be done annually. The contractor’s professional personnel assigned to the contract must have background investigations, including fingerprint-based criminal background checks, submitted to the Children’s Division via a form provided by the Children’s Division prior to such professional personnel providing services under the contract.

(A) The form shall be submitted no later than fifteen (15) calendar days after the effective date of the contract for all professional personnel.

(B) The form shall be submitted for each new or anticipated professional personnel assigned to provide services under the contract prior to such personnel providing services.

(C) When child abuse/neglect or criminal activity is discovered through the background investigation of any professional personnel assigned to provide services under the contract, the contractor must review the information to determine the relevance of such finding to the provision of case management services.

1. The contractor shall not allow individuals to perform case management duties when his/her background investigation reveals that he/she has been found guilty, pled guilty, or has been convicted of— A. A felony conviction for child abuse or neglect or spousal abuse;

B. A felony or misdemeanor conviction for any crime in which a child was a victim or a crime against children, to include, but not limited to, any offense involving child pornography;

C. Any crime involving violence and/or sexual offenses, including, but not limited to, rape, domestic violence, domestic assault, armed criminal action, sexual assault, or homicide;

D. Failure to report suspected child abuse to the child abuse and neglect hotline as required by section 210.115, RSMo;

E. A felony conviction for physical assault, battery, or a drug-related offense within the past five (5) years; or F. Any other crime listed in section 210.117, RSMo.

2. The contractor must submit a written request to the Children’s Division designee when the contractor desires to hire an individual with a history of child abuse/neglect or criminal activity which does not meet the criteria identified in paragraph (7)(C)1. above. The Children’s Division designee shall review the request and provide a written response indicating if the individual may provide case management services.

A. The contractor or the individual or both may request an administrative review no later than thirty (30) days from the date of Children’s Division decision if they dispute such decision. If the Children’s Division does not receive a timely request for administrative review the Children’s Division’s decision shall be final.

B. The request for an administrative review shall be in writing and generally set out the reasons for the request.

C. The Children’s Division shall schedule an administrative review within five (5) business days of receipt of the request. The administrative review shall take place before the Children’s Division designee. The Children’s Division shall notify the contractor and/or the individual of the date and time of the review. The review may be continued at the request of the contractor or the individual, but the employment exclusion shall remain in effect pending the administrative review.

D. The review shall be informal, the rules of evidence shall not apply, and both the contractor and the Children’s Division may submit any information relevant to the appealed decision. The purpose of the review will be to determine the potential employee’s suitability for employment under the contract.

(I) The contractor’s personnel application must include an authorization for the Children’s Division to release information which directly relates the employee’s suitability for employment under the contract.

(II) Upon completion of the administrative hearing, the Children’s Division designee will submit a recommendation to the director of the Children’s Division. The director may affirm or reverse the initial decision. Such decision shall be final.

(D) The contractor must submit a written request to the Children’s Division designee when the contractor desires to hire a current or former child welfare employee of the Children’s Division. The Children’s Division will review the request and provide a written response indicating if the individual may provide the case management services. The administrative review process described in paragraph (7)(C)2. above shall be utilized when the contractor disputes the decision.

1. The administrative review process described in paragraph (7)(C)2. above shall not apply when the contractor does not have a signed, written authorization for the Children’s Division to release information to the contractor.

(E) The contractor’s personnel may be dismissed at the discretion of the contractor. However, an employee of the contractor shall be dismissed if required pursuant to section 207.085, RSMo.

(F) Except for employment and workers’ compensation matters, the contractor must disclose any relevant litigation within the past five (5) years involving the contractor, the contractor’s employees, officers, agents, and/or subcontractors within five (5) business days from the date the contractor receives a demand or is served with process, whichever takes place first. Individuals and entities who submit a response to an Request for Proposals (RFP) or Invitation for Bid (IFB) shall also disclose this information during the procurement process. The contractor shall disclose the names of the parties (initials may be used in lieu of party name for minors); the court and case number in which the case was filed; and a brief description of the claims or criminal charges brought. The contractor shall include a copy of the complaint or petition if requested by the Department of Social Services or the division.

1. Relevant litigation under this agreement is defined as any civil claims, judgments, or out-of-court settlements and/ or criminal charges which are pending or have been disposed of by a finding or plea of guilt, an Alford plea, or a plea of nolo contendere regarding the following:

A. Allegations of child abuse or neglect;

B. Personal injury to a client;

C. Violent acts, including but not limited to, domestic violence and other crimes against persons;

D. Acts against the family, which include, but are not limited to Orders of Protection, and criminal charges denominated as offenses against the family;

E. Fraud and/or misrepresentation;

F. Sexual offenses, including pornography, and any registration on a sexual offender registry;

G. Weapons offenses;

H. Controlled substance offenses; or I. Any other claims or charges which relate to the delivery of foster care case management services to children.

2. The contractor must also disclose any pending investigation or assessment or “substantiated finding” of any contractor’s employee, officer, agent, and/or subcontractor within five (5) business days from the date of notification.

3. Substantiated finding is defined as a court adjudication, or determination by the state agency or any court of a probable cause and/or preponderance of the evidence finding, or substantially similar findings in this state or any other.

4. Failure of the contractor to disclose relevant litigation, pending investigations, assessment, or “substantiated finding” as specified herein, shall be considered a breach of the contract and subject to appropriate and available remedies by the State of Missouri.

5. The Children’s Division may share information about any disclosed litigation, pending investigations, assessments, or “substantiated findings” with all state and federal agencies, law enforcement agencies, state and federal auditors, children and families, Family Support Team (FST), and any courts, in the sole discretion of the Children’s Division on a need to know

basis as determined by the state agency and consistent with applicable state law.

(8) Contractors shall have a proven record of providing quality child welfare services within the state of Missouri.

(A) Contracts shall be awarded through a competitive bid process to— 1. Children’s services providers and agencies contracted with the state of Missouri on or before July 1, 2005, to provide a comprehensive system of service delivery for children and their families; or 2. Public and private not-for-profit or limited liability corporations owned exclusively by not-for-profit children’s services providers and agencies with a proven record of providing child welfare services within the state of Missouri.

(B) The contractor and/or contractor’s subcontractors performing case management and resource development services must be licensed as a child placing agency by the state of Missouri.

(C) The contractor’s case management program must be accredited by one (1) or more of the following national accrediting bodies: the Council on Accreditation (COA); the Joint Commission; or the Commission on Accreditation of Rehabilitation Facilities. The Children’s Division will accept proof of accreditation in good standing as prima facie evidence of completion of the requirements for licensure under sections 210.481 to 210.511, RSMo, only as provided in 13 CSR 35-35.140.

(D) The contractor must have personnel available to the Children’s Division, out-of-home care providers, juvenile court personnel, guardians ad litems, and children in out-of-home care twenty-four (24) hours a day, seven (7) days a week.

1. The contractor’s case manager must provide services after normal working hours and on weekends as necessary.

(E) A case manager’s caseload may not exceed COA standards.

(F) The contractor’s supervisor-to-worker ratio may not exceed COA standards.

(9) Children’s Division shall award contracts through a competitive bid process, subject to appropriation.

(10) Subject to appropriation, the Children’s Division shall continue to offer contracts in areas of the state where eligible providers are capable of providing a broad range of services.

Subject to appropriation, the Children’s Division may consider expansion of the contracts to areas of the state where Children’s Division’s staff caseloads exceed COA standards.

(11) The contract may not result in the loss of federal funding.

The contractor shall therefore comply with and implement the requirements of all relevant federal and state laws, regulations, and policies including, but not limited to, those listed below which pertain to the child under case management by the contractor. In the event of a discrepancy between the policies of the Children’s Division and federal or state law, the contractor shall comply with the federal or state law– (A) Missouri rules and regulations governing child placing agencies;

(B) Missouri laws pertaining to the services described in the contract;

(C) The rules of procedure for the juvenile courts;

(D) Any court order pertaining to an assigned case;

(E) Interstate Compact on the Placement of Children/Juveniles;

(F) The Indian Child Welfare Act;

(G) Multi-Ethnic Placement Act of 1994;

(H) Children’s Division written policies pertaining to the services described in the contract;

(I) Children’s Division policy directives to provide services through best child welfare practices;

(J) Children’s Division Federal Program Improvement Plan;

(K) Federal laws, rules, and regulations including, but not limited to, Title IV-E of the Social Security Act, as amended, and the Health Insurance Portability and Accountability Act, as amended;

(L) All federal and state laws and all policies and resolutions of the Missouri Department of Social Services regarding disclosure of confidential information and statements to the public and news media about any case assigned under the terms of 1. The contractor’s policies and procedures shall be open to the public upon request.

2. The contractor is not prohibited from making public statements about the contractor, general policies and procedures of the contractor, and other issues of public importance not otherwise prohibited by law, regulation, or policy; and (M) Local initiatives pertaining to services which a case manager provides to children in out-of-home placements and their families which have been approved by the Children’s Division state office.

(12) All contracts and contractors shall be subject to oversight and inspection by the Missouri Department of Social Services and/or the Children’s Division to assure compliance with standards which shall be consistent with applicable federal standards, but not less than the standards and policies utilized by the Children’s Division. The contractor shall allow reasonable and timely site visits by the Missouri Department of Social Services and/or the Children’s Division.

(A) The contractor shall maintain adequate, legible, genuine, current, and complete records of services rendered under the terms of the contract which are not part of the child’s record for a period of five (5) calendar years following the expiration of the contract. This shall include, but is not limited to, resource records, expenditures, invoices, and other documentation pertaining to payments made under the terms of the contract.

(B) Adequate and complete documentation shall mean the contractor’s records are such that an orderly examination by a reasonable person is possible and can be conducted without the use of information extrinsic to the records and that such an examination can readily determine the contractor’s reported services were, in fact, provided; to whom the services were provided; and the extent and duration of such services. At a minimum, the required records shall consist of service authorization forms and copies of invoices submitted to the Children’s Division for payment.

(C) The contractor’s failure to maintain adequate, legible, genuine, current, and complete records of services rendered under the terms of the contract for a period of five (5) calendar years shall be deemed a material breach of the contract and the contractor shall repay to the Children’s Division all amounts received for any services which are not adequately verified and fully documented by the contractor’s records.

(D) The contractor shall indemnify and hold harmless the state of Missouri, the Missouri Department of Social Services and its agents, officers, and employees from any and all liability, loss, damages, or expenses which the Missouri Department of Social Services, the Children’s Division, or the state of Missouri may sustain, incur, or be required to pay by reason of any person’s injury, death, property loss, or damage sustained and/or suffered because of any act or omission by the contractor, its employees, or subcontractors that results from violation of a law, regulation, or policy of the Missouri Department of Social Services or the Children’s Division. This includes, but is not limited to, court costs and attorney fees incurred by or charged to the Missouri Department of Social Services or the Children’s Division as the result of such act or omission by the contractor, its officers, employees, agents, representatives, or subcontractors.

(E) In the event the court finds the contractor liable for sanctions or otherwise holds the contractor in contempt as a result of the contractor’s violation of any law, rule, court order, or procedure or policy of Missouri Department of Social Services or the Children’s Division, the contractor shall be solely responsible for the payment of any fines, penalties, or sanctions, including attorney fees and costs, that arise under any such action.

Additionally, the contractor shall save, indemnify, and hold the state of Missouri harmless, including its agencies, employees, and assigns, from every expense, liability, or payment arising out of such sanction, fine, or penalty assessed against the contractor or against the Missouri Department of Social Services, the Children’s Division, or the department’s Division of Legal Services as a result of the actions of the contractor, including court costs, attorney fees, and litigation expenses.

(13) The Children’s Division shall monitor and evaluate contractors based on objective, consistent, and performance-based criteria as provided in both 13 CSR 35-35.100 and the contract.

In the event of a conflict between 13 CSR 35-35.100 and the contract, the regulation shall prevail over the contract.

(A) A percentage of children under the jurisdiction of the juvenile court and in the care of the contractor must achieve permanency within a twelve (12)-month period as specified in the contract. For purposes of this section, permanency shall be defined as reunification with the child’s parent(s), reunification with the child’s guardian(s), a finalized adoption, or the establishment of a legal guardianship for the child.

(B) A percentage of children under the jurisdiction of the juvenile court and in the care of the contractor must not have substantiated child abuse/neglect reports with the out-of-home care provider listed as the perpetrator within a twelve (12)month period as specified in the contract.

(C) A percentage of children under the jurisdiction of the juvenile court and in the care of the contractor must not reenter Children’s Division custody or supervision within twelve (12) months of their previous exit from such custody or within twelve (12) months of the date of reunification as specified in (D) Children in the custody of, or under the supervision of, the Children’s Division and whose cases are being managed by the contractor must receive comprehensive and quality services as measured by the evaluation tool set forth in 13 CSR 35-35.100.

(14) The contractor shall participate and cooperate with any program evaluation and improvement plan, including on-going record keeping, evaluation, and reporting in accordance with the program evaluation design, and preparation for, and participation in, the federal Child and Family Service Review, or any other performance initiative required of, or by, the Children’s Division. Any program evaluation will include the same outcome measures for the contractors and the Children’s Division within a specified region.

(15) If the contractor does not comply with its obligations under this regulation, or breaches its contract with the Children’s Division, or the Children’s Division has reasonable cause to suspect that any child or children’s safety or welfare may be at risk the Children’s Division shall have the discretion to halt new referrals of cases to the contractor, transfer cases to other performing providers, terminate the contract, and seek any remedies which may be available in law and equity for breach of contract. The Children’s Division may take immediate action as the Children’s Division in its discretion may deem necessary to ensure the safety, welfare, and best interests of children served by the contractor. If the Children’s Division determines that the contractor has failed to meet the outcome measures specified in the contract, the Children’s Division may reduce the contractor’s caseload or cancel the contract in its entirety.

The contractor shall be allowed an opportunity to review the outcomes prior to the development of the final outcomes report. The contractor shall be responsible for any updates in the automated case management system which are necessary to correct the outcomes. The Children’s Division shall correct any programming errors identified by the contractor.

(16) In addition to those measures authorized in section (15) above, if the contractor does not meet the performance and/or outcome goals specified in the contract and in 13 CSR 35-35.100, or otherwise fails to comply with this regulation, any other laws or regulations, or the contract, the Children’s Division may elect to require the contractor to implement a corrective action plan to remedy any deficiencies in performance. Failure of the contractor to take action as indicated in the practice improvement plan within ninety (90) calendar days, or the number of days specified in the practice improvement plan, shall be considered a breach of contract. Thereafter, the Children’s Division may terminate the contract or pursue any other remedies in law or equity available to the Children’s Division. The written corrective action plan shall address— (A) Reasons why the goal was not achieved;

(B) Steps taken to meet the goal;

(C) Individual(s) responsible for necessary action; and (D) Timeframe for meeting the defined goal.

(17) All contractors, whether accredited, licensed or not, shall fully comply with the information sharing requirements set forth in 13 CSR 35-35.140(5).

rule filed Feb. 28, 2011, effective Oct. 30, 2011. Emergency amendment filed June 11, 2021, effective July 1, 2021, expired Feb. 24, 2022. Moved to 13 CSR 35-35.120 and amended: Filed June 11, 2021, effective Jan. 30, 2022. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.112, RSMo 2004, amended 2005, 2011, 2018, 2020; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016, section 210.112.8, RSMo Supp. 2021, and Young v. Children’s Division, State of Missouri Department of Social Services, 284 S.W.3d 553 (Mo. 2009). This rule originally filed as 13 CSR 35-32.020. Original

13 CSR 35-35.130 Contracted Foster Care Case Management Costs {#sec-13-csr-35-35.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.130}

PURPOSE: This rule establishes the methodology for the provision of reasonable cost for foster care case management contracted services as set forth in section 210.112.4.(6), RSMo.

(1) Payment to individuals and entities providing foster care case management services pursuant to section 210.112, RSMo, and 13 CSR 35-35.120 (hereinafter referred to as “contractors”) contracted by the Children’s Division of the Department of Social Services (hereinafter referred to as the “division” or “CD”) shall be based on the reasonable cost of services as determined through the competitive procurement process. Contractors and prospective contractors (hereinafter referred to as “contractor” or “contractors”) shall certify their bid covers all reasonable costs at a firm fixed price unless otherwise provided by law.

(A) Upon request by CD, the contractor shall submit a written explanation and supporting documentation detailing how the contractor calculated the reasonable costs of services. The CD may not award a contract to any contractor which fails to submit such information when requested by CD.

(B) CD, in its sole discretion, may reject any bid where CD determines that the bid amount for a service or services exceeds the reasonable cost of the service or services. The Department of Social Services shall apply the cost principles set forth in 2 CFR Part 200 as applicable in the approval, evaluation, and audit of bids and contracts. CD shall use federal Uniform Guidance, pursuant to 2 CFR 200.404, to define reasonable costs as follows:

1. Reasonable costs. A cost is reasonable if, in its nature or amount, it does not exceed that which would be incurred by a prudent person under the circumstances prevailing at the time the decision was made to incur the cost. The question of the reasonableness is particularly important when the contractor is predominantly federally funded. In determining the reasonableness of a given cost, consideration shall be given to— A. Whether the cost is of a type generally recognized as ordinary and necessary for the operation of the contractor or the proper and efficient performance of the contract;

B. The restraints or requirements imposed by such factors as sound business practices; arm’s-length bargaining; federal, state, local, tribal, and other laws and regulations; the terms and conditions of the federal award of monies to the state, generally-accepted sound business practices, and terms and conditions of the contract;

C. Market prices for comparable goods or services for the geographic area;

D. Whether the individuals concerned acted with prudence in the circumstances, considering their responsibilities to the contractor, its members, employees, and clients, the public at large, and the state and federal government; and E. Whether the contractor significantly deviates from the established practices of the division or the contractor, which may unjustifiably increase the contract costs.

(2) CD may, in its sole discretion, establish a cap on the highest amount that CD will pay for the reasonable cost of services identified in the Request for Proposal (RFP) or Invitation for Bid (IFB). CD will announce the cap for services in the RFP or IFB.

CD shall utilize one (1) or more of the following methods to establish the cap as part of the competitive procurement process:

(A) Industry cost reports for the previous three (3) calendar years which demonstrate the costs to the contractor to deliver the services identified in the RFP or IFB. Such reports shall include costs for case management services, community resource development, treatment services, special expenses, crisis expenses, administrative costs, and any other cost incurred to provide the services identified in the RFP or IFB. Upon request by CD, case management contractors or prospective case management contractors who submit a proposal or bid for a contract shall provide CD with cost reports and supporting documentation, if and when required by the RFP or IFB.

The format for submission of cost report information shall be included in the RFP or IFB.

1. Cost for case management services shall include all costs associated with assessments, case planning, placement services, service planning, permanency planning, and concurrent planning. Such costs shall include salaries and benefits for required staff.

A. Assessments shall be defined as the consideration of all social, psychological, medical, educational, and other factors to determine diagnostic data to be used as a basis for the case plan.

B. Case planning is a process of negotiation between the family case manager, parent(s) or guardian(s) from whom the child was removed, and the juvenile officer which describes the services and activities necessary for the purpose of achieving a permanent familial relationship for the child.

C. Placement services is the selection of the most appropriate placement resource for children in out-of-home care based on the assessment of the child’s unique needs and personality and the out-of-home care contractor’s capacity and skills in meeting those needs.

D. Service planning is the provision of any services indicated and identified as needed through an assessment and case plan or ordered by the juvenile court.

E. Permanency planning is determining the permanent plan which best meets the needs of the child.

F. Concurrent planning is a process of pursuing a primary permanency goal for children in out-of-home care, such as reunification, while simultaneously establishing and implementing an alternative permanency plan for that child.

2. Cost for community resource development shall include all costs associated with the recruitment, assessment, training, and maintenance and retention of out-of-home care contractors. It shall also include the development of those services which shall best meet the needs of the child and his/her family.

3. Cost for treatment services shall include all services designed to meet the service and treatment needs of an individual.

4. Cost for special expenses shall include all costs associated with needs of children which are not designed to meet a service or treatment need. These costs would not be included in the foster care maintenance payment to the placement contractor. An example is a clothing allowance.

5. Cost for crisis expenses shall include all reasonably necessary costs incurred to address the critical financial and resource needs of families. Crisis funds are utilized to purchase specific items family members need to alleviate a crisis. An example is payment to have utilities restored so that a child may be returned home.

6. Administrative costs are those which are incurred to deliver the case management services defined in the RFP or IFB which are not included above in paragraphs (2)(A)1., (2)(A)2., (2)

(A)3., (2)(A)4., or (2)(A)5. Such costs include expenses for general administrative functions and overhead.

7. Contractor costs shall be determined and validated by a third-party contractor retained by CD or the Department of Social Services for that purpose. The contractor shall submit any and all information that CD, the Department of Social Services, or the third-party contractor may require to validate the cost report. The contractor shall certify such information is truthful, accurate, and complete.

8. Contractor costs shall include any applicable credits or payments received through federal or state funding sources or private contributions.

9. Industry cost reports shall include any audited financial statements for the applicable time period under review;

(B) Cost to CD for the three (3) previous calendar years for similar services identified in the RFP or IFB;

(C) Historical expenditures of agencies contracted to provide the services identified in the RFP or IFB for up to three (3) previous calendar years. These expenditures shall include any payments the contractor has made on behalf of the children and families receiving services identified in the RFP or IFB;

(D) Historical expenditures of the CD for up to three (3) previous calendar years for all services identified in the RFP or IFB which have been provided to children placed in out-of-home care in the regions to be served by the foster care case management contractors. CD expenditures shall only be utilized in conjunction with industry cost reports and/or historical expenditures of agencies contracted to provide the services identified in the RFP or IFB; and (E) CD shall consider all applicable state and federal laws and regulations when a cap is established.

(3) Contracts shall be made to the lowest and best qualified bidder(s), subject to applicable procurement law and available appropriation. A qualified bidder is a contractor which meets all of the requirements in law, regulation, and policy related to the services identified in the RFP or IFB. A qualified bidder must also meet the qualifications outlined in the RFP or IFB.

(4) The number of bids, contracts, and cases awarded to any given contractor are subject to available appropriation.

(5) The contract shall specify the monthly amount which is to be paid to the contractor based on the number of cases awarded unless payment has been reduced for reasons specified in this regulation. The contract may include a provision that the parties to the contract may amend the contract to increase or decrease the rate if authorized by statute or appropriation.

(A) CD shall refer the number of cases in the Notice of Award to the contractor when cases are available. CD shall refer additional cases, when available, throughout the contract year with the intention of replacing cases which are expected to move to permanency each month based on the percentage of children who are to achieve permanency as identified in the contract.

CD reserves the right to increase the number of referrals during subsequent renewal periods when the number of children entering CD’s custody increases in the geographic region served by the contractor with the agreement of the contractor. CD will decrease the number of referrals in a region when CD cannot replace cases on a one-for-one basis. The provider’s base case award shall be decreased, which shall be effectuated through a contract amendment. CD in its discretion may shift case allocations to another region where there is a greater need and may increase another provider’s base caseload, which shall be effectuated through a contract amendment. CD and the contractor will mutually agree upon the implementation period when necessary to meet service needs or address emergency circumstances. Implementation periods identified within the applicable contract amendment for increases or decreases to a contractor's base case award will generally range from thirty (30) to ninety (90) days, depending upon operational needs, staffing considerations, provider capacity, and regional service demands of both CD and the contractor.

(B) The contractor may return cases to CD when children have been placed with their parent, or legal guardian from whom they were removed, for more than ninety (90) days only with the prior, written permission of the CD.

1. The contractor shall return cases to CD when an adoption has been finalized, the courts have awarded a legal guardianship, and when the juvenile court has terminated jurisdiction over the child. CD may replace such cases on a one-for-one basis. When the one-for-one case replacement methodology is utilized, CD shall replace cases in the following order of preference if cases are available:

A. The next child and any sibling who enter care no more than ten (10) calendar days prior to, and no later than ten (10) calendar days following, a permanency achievement or an exit from court jurisdiction. These cases will be replaced in the county where the previous child exited when possible;

B. A child and any sibling currently case managed by CD in the county where the case was returned with services being provided by a supervisor or coworker due to the extended absence of the assigned worker;

C. A child and any sibling who entered care within thirty (30) calendar days in the county where the case was returned which is case managed by CD;

D. A child and any sibling from a county other than the one where the case was returned which is served by the contractor and meets the criteria set forth in subparagraph (5)(B)1.A., (5)(B)1.B., or (5)(B)1.C. above, when agreeable to the contractor.

2. In the event the contractor is assigned more active cases than awarded in an effort to keep one (1) worker assigned to a sibling group, cases shall not be replaced until such a time when the contractor is serving the number of active cases awarded. Active cases do not include— A. Cases where the child has been placed for ninety (90) days with their parent, or legal guardian from whom they were removed, when CD has assigned a replacement case upon the contractor’s request;

B. Children who have been adopted;

C. Those situations where the courts have awarded a legal guardianship;

D. Situations where the juvenile court has terminated jurisdiction over the child; or E. Reentries into care unless they meet the criteria specified in subparagraph (5)(C)4.A. below or the rate or number of reentries into care within twelve (12) months has not exceeded the allowable rate or allowable number as defined in paragraph (5)(C)5. below.

3. The contractor shall not be assigned a sibling group which would increase the number of cases awarded by more than two percent (2%).

(C) The contractor shall be paid for the number of cases awarded except in the following situations:

1. CD shall reduce the payment by the number of cases disenrolled and not replaced, when CD determines it is in the best interest of a child to reassign the case to CD staff;

2. CD shall reduce payment when the contractor is placed on referral hold as the result of the contractor’s staff involvement with an unacceptable, egregious situation. Payment shall be reduced by the number of cases which CD is unable to refer while the contractor is on referral hold due to an unacceptable, egregious situation. Unacceptable, egregious situations include any situation which seriously impacts the delivery of services to a child or family assigned to the contractor, including a material breach of the contract with the division, and shall include, but is not limited to, the following:

A. Court contempt order;

B. Violating the condition(s) of a court order;

C. Unsafe environments or inappropriate out-of-home placements by the contractor as evidenced by the following:

(I) Placement in unlicensed foster homes or facilities unless approved by the court;

(II) Placements by a contractor without conducting a background screening;

(III) Placements by a contractor with a failed background screening as defined in the CD Child Welfare Manual;

(IV) Placements without full compliance with the requirements of the Interstate Compact on the Placement of Children (section 210.620, RSMo);

(V) Placements without court approval where court approval is required; and (VI) Any other circumstances where CD determines that placement of a child by the contractor will compromise child safety;

D. Breaches of confidentiality as defined in the contract;

E. Intentionally, recklessly, knowingly, or negligently entering false data in CD’s automated case management system;

F. Failure to comply with the requirement to report suspected child abuse and neglect, child injuries, child fatalities, or other critical incidents as required by contract and/or as required by section 210.115, RSMo; and G. Other violations of federal or state law;

3. Payment shall be reduced in the following month, and subsequent months, during the contract year, and subsequent renewal periods to correspond with the number of cases which could not be assigned when the counties have no case which meets any of the criteria identified in subparagraph (5)(B)1.A., (5)(B)1.B., (5)(B)1.C., or (5)(B)1.D. above;

4. The contractor shall not invoice for reentries into care within twelve (12) months of previous exit except under those circumstances described below:

A. The contractor shall be paid for reentries into care whereby the number of cases replacing those which are expected to move to permanency each month shall be reduced to correspond with the number of reentries when— (I) The contractor does not have an opportunity to serve the case, such as when emergency protective custody is allowed to expire, or the court terminates jurisdiction and there is clear and convincing documentation to support the contractor was against the release of jurisdiction; or (II) A youth between the ages of eighteen (18) and twenty-one (21) has elected to return to care pursuant to 211.036, RSMo;

5. CD shall set an allowable rate of reentries or the allowable number of reentries into care within twelve (12) months of previous exit, which shall not include the reentries defined above in parts (5)(C)4.A.(I) and (5)(C)4.A.(II). CD, at its sole discretion, may adjust this rate or number based on mitigating factors. The contract shall set forth that after the rate or number is exceeded, the contractor shall not be paid for cases exceeding the allowable rate or the allowable number of reentries set forth in the contract.

(D) When CD assumes the cost of foster care or residential treatment, or when the cost of the child’s placement is covered by a waiver, the contractor’s monthly case rate shall be reduced to remove the foster care and residential treatment costs.

(E) CD reserves the right in its sole discretion to reduce the number of cases assigned in subsequent contract years with payment reduced to correspond when the contractor fails to exceed the permanency expectation defined in the contract. CD also reserves the right to terminate the contract. In the event the contractor fails to exceed the permanency expectation and the number of cases is reduced in subsequent contract years, CD may reduce the number of cases awarded as follows:

1. CD may request the return of active cases; and/or 2. CD may not replace cases which are closed by the contractor.

(F) CD will reduce payment to correspond with the number of active cases served.

(6) The contract shall provide for the payment of incentives to recognize accomplishment of case goals and corresponding cost savings to the state, subject to the availability of appropriated funds. In the event that sufficient funds are not available to pay the full incentives, as adjusted, and calculated pursuant to this section, the Department of Social Services shall reduce the payment to each contractor eligible to receive an incentive payment pro rata on the basis of the proportion of cases that the eligible contractor handled during the period to the total number of cases handled by foster care case management contractors eligible to receive an incentive payment during the period.

(A) For the purpose of this regulation, “permanency” is defined as reunification with the child’s parent, or legal guardian from whom they were removed, a finalized adoption, or establishment of a legal guardianship. Reunification shall include a child who has been placed with their parent, or legal guardian from whom they were removed, for more than ninety (90) days.

(B) Incentive for Exceeding Permanency Expectations. Subject to available appropriation, the contractor can qualify for fifty percent (50%) of the possible incentive payment calculated as provided in this subsection. CD shall pay an incentive for the sum of the monthly differences between the number of children who are expected to achieve permanency as provided in the contract and the number of children who do achieve permanency when the one-for-one case replacement methodology is utilized. The following provisions shall apply to the administration of the permanency incentive:

1. The percentage of children who are to achieve permanency in a twelve- (12-) month contract period shall be based on one (1) of the following percentages, whichever number is higher:

A. The percentage of children CD serves who move to permanency within a geographic region as defined in the contract, utilizing an average for all counties served within the region; or B. The percentage of children contractors serve who move to permanency within a geographic region as defined in the contract, utilizing an average of the performance of contractors serving the region;

2. The contractor shall exceed the regional permanency expectations as defined in the contract to qualify for an incentive payment;

3. The incentive for permanency shall be a one- (1-) time payment for the number of children who exceeded the permanency expectation during the contract year.

(C) Incentive based on 13 CSR 35-35.100 Performance Goals.

If the contractor qualifies for an incentive by exceeding the permanency performance expectation for the geographic region as provided in subsection (6)(B) of this regulation, then the contractor will qualify to be eligible for the remaining fifty percent (50%) of the possible incentive payment as provided in this subsection. To earn the remaining fifty percent (50%) of the incentive payment, the contractor must meet or exceed the performance goals and outcomes established or subsequently amended pursuant to 13 CSR 35-35.100 as they are phased in, and as further provided in this subsection. Any incentive payment is subject to available appropriation.

1. The CD shall establish relative weights to be given to each item in the Safety, Well-Being, and Service Domains and the additional requirements of the Permanency Domain as they are phased in as provided in 13 CSR 35-35.100. The incentive payment shall be reduced as provided in paragraph (6)(C)2. of this regulation if the contractor fails to meet the performance goals established of 13 CSR 35-35.100 and the evaluation tool therein.

2. The remaining fifty percent (50%) of the incentive payment shall be calculated as follows:

A. Tier 1 Incentive: A contractor will be eligible for a performance-based incentive payment if a contractor achieves a score of equal to or greater than sixty percent (60%) of the weighted performance and outcome score after calculating the aggregate score of all weighted metrics specified in 13 CSR 35-35.100. If eligible for a performance-based incentive, the contractor shall receive an incentive payout equal to their aggregate weighted score, rounded up to the nearest whole number, not to exceed one hundred percent (100%) of the available incentive amount. For example, if a contracted provider has an aggregate weighted score of sixty-nine and a half percent (69.5%) at the end of a contract year, that number will be rounded up to seventy percent (70%) (the nearest whole number) and the contract provider would be eligible for a Tier 1 performance-based incentive payment of seventy percent (70%) of the total remaining incentive payment;

B. Tier 2 Incentive: Except as provided in parts (6)(C)2.B.(I)- (II) below, if a contractor is not eligible for a performance-based incentive payment, then the contractor will be eligible for an improvement-based incentive payment if the contractor’s aggregate weighted score is an improvement from the same contractor’s aggregate weighted score for the previous contract year. The incentive awarded shall be equal to the percentage of improvement of the contractor’s performance score when compared to their prior-year score, not to exceed fifteen percent (15%) of the total remaining incentive. For example, if a contracted provider had an aggregate weighted score of forty percent (40%) during the previous contract year and improved their aggregate weighted score to fifty percent (50%) the following contract year, the contracted provider would be eligible for a Tier 2 improvement-based incentive payment of ten percent (10%) of the total remaining incentive payment.

(I) For the first year of the contract effective October 1, 2026, or thereafter, contracted providers are not eligible for a Tier 2 improvement-based incentive payment and are only eligible for a Tier 1 performance-based incentive payment.

(II) New contracted providers with no previous performance baseline established are not eligible for a Tier 2 improvement-based incentive payment until such time as the contracted provider has two (2) consecutive years of aggregate weighted scores to compare;

C. If a contractor qualifies for a performance-based incentive payment, the contractor will not be eligible for an improvement-based incentive payment;

D. If a contractor fails to qualify for a performance-based incentive payment and fails to qualify for an improvementbased incentive payment, the contractor shall not receive an incentive payment under subsection (6)(C).

3. To calculate the performance and outcome score specified in paragraph (6)(C)2. of this regulation, the division will calculate for each contractor the percentage of the performance outcome goal for each item in each domain being scored under

13 CSR 35-35.100 that each contractor actually achieved for that item during the phase for the period. The percentage achieved for each item under each domain shall then be multiplied by the weight factor (if any) assigned to each item. The aggregate weighted score of the weighted percentages will be the final score for each contractor for the period. The performance outcome goals for the period and the weights to be assigned to each item will be established by the division, in conjunction with the Research and Evaluation team and other individuals, following the procedures specified in 13 CSR 35-35.100. {#sec-13-csr-35-35.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.100}

4. The final scores shall be rounded up to the nearest whole number.

5. The scores for each contractor shall be published on the division’s website.

(7) Changes to reimbursements for services in addition to the contracted amounts will be based upon available increased or decreased appropriations for services specifically included in the case management contract. Increases or decreases will be allocated to both the state agency and private contractors of such services. Any increase or decrease will result in an increase or decrease to the monthly case rate paid to the contractor. The allocation shall be calculated using a numerator equal to the contractor’s base case award and a denominator equal to the total number of cases served statewide at the point in time the calculation is performed. The resulting proportion shall determine the contractor’s share of the increased or decreased appropriation. The division shall be allocated the residual amount of the appropriation after contractor allocations are calculated, such that the total sum of all allocations equals the total available appropriation. Any increase or decrease in appropriations will only be expended for the purposes specified by the General Assembly. The proportional methodology described in this section shall not apply when the General Assembly directs a different methodology through bill language, budget language, or other instruction. Under no circumstances shall the Department of Social Services and the Children’s Division’s aggregate, total expenditure for foster care case management services contracts exceed the amount appropriated by the General Assembly for that purpose nor shall it exceed the funds available.

rule filed Feb. 28, 2011, effective Oct. 30, 2011. Emergency amendment filed June 11, 2021, effective July 1, 2021, expired Feb. 24, 2022. Moved to 13 CSR 35-35.130 and amended: Filed June 11, 2021, effective Jan. 30, 2022. Amended: Filed March 12, 2026, effective Sept. 30, 2026. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.112, RSMo 2004, amended 2005, 2011, 2018, 2020, 2025; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016, section 210.112.8, RSMo Supp. 2025, and Young v. Children’s Division, State of Missouri Department of Social Services, 284 S.W.3d 553 (Mo. 2009). This rule originally filed as 13 CSR 35-32.030. Original

13 CSR 35-35.140 Accreditation as Evidence for Meeting Licensing Requirements {#sec-13-csr-35-35.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-35.140}

PURPOSE: This rule establishes the procedures to be followed in order for an organization to qualify for a license under sections 210.481 through 210.511, RSMo, by the agency being accredited by Council on Accreditation of Services for Children and Families, Inc., the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities (accreditation bodies).

(1) Purpose and Scope. This regulation applies to Licenses issued to individuals or organizations which are accredited by an accrediting body.

(2) Definitions. For the purpose of this regulation, the definitions set forth in section 210.481, RSMo, and the following definitions shall apply:

(A) “Accrediting body” shall mean the Council on Accreditation of Services for Children and Families, Inc., the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities;

(B) “Individual or organization” shall mean any adult person, corporation, partnership, religious denomination, religious organization, or organized group of human beings; and (C) “Prima facie evidence” means evidence that will establish a fact or sustain a decision unless contradictory evidence is produced.

(3) The Children’s Division shall accept accreditation by an accrediting body as prima facie evidence that the individual or organization meets the requirements for a license to operate a foster home, residential care facility, or child placing agency in accordance with the applicable provisions of sections 210.481 to 210.511, RSMo. The division will accept accreditation for purposes of documenting eligibility for license or relicensure.

However, any individual or organization whose license is based upon accreditation must still fully comply with all of the requirements of licensure (including full compliance with all federal, state, and local health and safety codes) as if not accredited for the duration of the license to maintain the license.

The safety and welfare of children served by the individual or organization shall be the paramount consideration in all licensing decisions. If a service or program, including, but not limited to, child placing, maternity, infant/toddler, residential treatment, and intensive residential treatment in residential child care, is not accredited by the accrediting body, then the organization must apply for and meet all licensing requirements as for the unaccredited program or service.

(4) Application and Reapplication for License for Accredited Individual or Organizations.

(A) The individual or organization applying for licensure as an accredited individual or organization shall present to the division with its application for licensure or relicensure all of the following:

1. A copy of the individual or organization’s official final accreditation report and accreditation certificate from the accrediting body establishing that the individual or organization is accredited in good standing for the period of time covered by the license;

2. A list of operating sites which includes the capacity served, the gender served, and the ages served by that organization. This list shall be updated if there is a change in operating sites by the individual or organization;

3. A copy of the accrediting body’s official standards and policies for accreditation;

4. A copy of any corrective action documents or other notices from the accrediting body regarding areas of non-compliance or required improvement or monitoring;

5. Any documentation required at initial licensure or re-licensure as stated in chapters 13 CSR 35-71 (for residential treatment agencies) and 13 CSR 35-73 (for child placing agencies), including, but not limited to, agency policies, procedures, organizational charts, budgets, staff training records, and personnel records verifying compliance with background check requirements; and 6. Any and all other information and documentation that the division may determine is reasonably necessary to verify that the individual or organization is accredited in good standing and otherwise meets all of the requirements for licensure.

(B) The division in its discretion may conduct on-site visits to verify compliance with licensure requirements before a license is issued.

(C) The division shall examine the areas that the organization is applying for a license. The division then may issue a corresponding license for those areas in which the organization is accredited. The license shall be valid for the period of time up to two (2) years (or such other time as may be specifically authorized or required by statute), or when the organization’s accreditation expires, whichever is shorter.

(D) If the individual or organization’s accreditation expires during the term of the license, the division may issue a provisional license pursuant to section 210.486, RSMo, for a period of time not to exceed six (6) months upon the individual or organization showing that— 1. The individual or organization is still in good standing with the accrediting body, the re-accreditation process is being diligently pursued, and accreditation is expected within six (6) months of the date the accreditation expired. The division may, at its discretion, request a letter of good standing from the accrediting body;

2. The individual or organization otherwise demonstrates the potential capacity to meet full requirements for licensure; and 3. The division director is satisfied that the operation of the foster home, residential care facility, or child placing agency provisionally licensed is not detrimental to the health and safety of the children being served.

(E) The division may deny the issuance of a license to, or may suspend or revoke the license of, any individual or organization which fails to provide information that the division may require to establish eligibility for licensure.

(F) The individual or organization seeking licensure under this section shall have the responsibility to apply for accreditation and/or re-accreditation in a timely manner to ensure compliance with all deadlines set out in this section and other applicable laws.

(5) Information Sharing.

(A) The individual or organization shall notify the division immediately of any sentinel event, any critical incident as required in 13 CSR 35-71.070, any unusual event as required in 13 CSR 35-73.050, and of any suspension, limitation, including but not limited to required corrective action or monitoring, or revocation of accreditation. The procedures and requirements for reporting shall be the same for non-accredited, licensed individuals, and organizations as provided in chapters 13 CSR 35-71 and 13 CSR 35-73.

(B) Sentinel events are those events which the accrediting body requires the individual or organization to report to the accrediting body as a condition of accreditation, but shall at a minimum include the following:

1. A death of a child in one (1) of the individual’s or organization’s facilities;

2. A serious emotional or physical injury of a child in one (1) of the individual’s or organization’s facilities. For purposes of this regulation, a serious emotional or physical injury occurs when it is medically reasonable or necessary for a child to obtain professional medical intervention as a result of something that happens to the child while placed with the individual or organization;

3. A child elopes from the individual’s or organization’s facility;

4. A fire in a location routinely occupied by children, which requires the fire department to be called;

5. An allegation or report of physical abuse, sexual abuse, emotional abuse, or neglect of a child pertaining to the individual or organization, or an employee, contractor, subcontractor, volunteer, or officer of the individual or organization;

6. An employee is terminated from employment in relation to the safety and care of children;

7. There is any change in the chief executive officer;

8. There is a lawsuit filed against the individual or organization by or on behalf of a person who is or was in the individual’s or organization’s care;

9. Any known criminal charges are filed against the individual, facility, organization, any resident of the facility, or any employee or volunteer of the individual or organization who has contact with children;

10. When the individual or organization is not in compliance with any of the criteria for accreditation, including maintaining the required level of services and staffing levels, for more than three (3) consecutive days; or 11. Whenever a child attempts to harm him/herself or others, including suicide attempts.

(C) The individual or organization shall notify the division of the entrance, exit, and any performance review meetings of the accrediting body which are held in conjunction with the accreditation of the organization. The division has a right to attend any or all of these meetings between the organization and the accrediting body.

(6) The division may make such inspections and investigations as it deems necessary to ensure that the individual or organization continues to meet the requirements of licensure, for investigative purposes involving reports of alleged child abuse or neglect, and to address a complaint concerning the health and safety of children which the individual or organization serves.

(7) Any individual or organization who is aggrieved by a decision of the division to deny, revoke, or suspend a license based upon an organization’s accreditation standing under this section may either— (A) Seek administrative review following the procedures set forth in 13 CSR 35-71.030 for residential treatment agencies or

13 CSR 35-73.017 for child placing agencies; or (B) Apply for licensure as an unaccredited individual or organization. {#sec-13-csr-35-73.017 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.017}

History

• AUTHORITY: sections 207.020, 210.506, and 660.017, RSMo 2016, and section 210.112.8, RSMo Supp. 2021. This rule originally filed as 13 CSR 35-50.010. Emergency rule filed Dec. 23, 2004, effective Jan. 2, 2005, expired June 30, 2005. Original rule filed Dec. 23, 2004, effective June 30, 2005. Emergency amendment filed June 11, 2021, effective July 1, 2021, expired Feb. 24, 2022. Moved to 13 CSR 35-35.140 and amended: Filed June 11, 2021, effective Jan. 30, 2022. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.112, RSMo 2004, amended 2005, 2011, 2018, 2020; 210.506, RSMo 1982, amended 1993, 1995; and 660.017, RSMo 1993, amended 1995.

Chapter 36 Alternative Care Review Board

13 CSR 35-36.010 Alternative Care Review Board {#sec-13-csr-35-36.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-36.010}

(Rescinded May 30, 2024)

Material covered in this rule is now covered in 13 CSR 35-35.070.

History

• AUTHORITY: section 207.020, RSMo 2000, and section 210.566.6, RSMo Supp. 2013. Original rule filed Oct. 29, 2013, effective April 30, 2014. Rescinded: Filed Oct. 23, 2023, effective May 30, 2024.

Chapter 38 Adoption and Guardianship Subsidy

13 CSR 35-38.010 Adoption and Guardianship Subsidy {#sec-13-csr-35-38.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-38.010}

PURPOSE: This rule is to define the Adoption and Guardianship Subsidy Program.

(1) Definitions. For purposes of this section, the following terms shall mean— (A) Division. The Missouri Department of Social Services, Children’s Division;

(B) Child or Youth. A person within the state who is under the age of eighteen (18), or in the custody of the Children’s Division, who is in need of medical, dental, educational, mental, or other related health services and treatment, or who belongs to a racial or ethnic minority, who is five (5) years of age or older, or who is a member of a sibling group, and for whom an adoptive home is not readily available. A child or youth is also a person covered by an 18+ adoption subsidy agreement as set forth in section (13) of this regulation;

(C) Subsidy Agreement. The agreement between the adoptive parent(s) or the legal guardian(s) and the Children’s Division to delineate services which the Children’s Division will provide to the child at the time of adoption or guardianship until such time as the subsidy agreement ends;

(D) Maintenance Payments. The amount that the division will contribute to cover the cost of food, clothing, shelter, daily supervision, school supplies, a child’s personal incidentals, and liability insurance with respect to a child;

(E) Nonrecurring Expenses. One (1)-time expenses directly related to the adoption or legal guardianship of a special needs child. Nonrecurring expenses include, but are not limited to, the following: legal fees, private agency fees, and nonrecurring placement-related expenses including, but not limited to, pre-placement transportation, lodging and meal expenses, expenses for adoption studies, health and psychological examinations, and supervision of the adoptive placement prior to the finalization of the adoption up to a maximum amount provided in this regulation;

(F) Youth with Elevated Needs. A child meeting the criteria set forth in 13 CSR 35-60.070;

(G) Medical Foster Care. A licensed foster home utilized to meet the needs of a child with extraordinary medical needs.

Medical foster parents must have a foster parent license and must receive specific training from qualified medical care providers specific to the unique medical needs of the child and meet the requirements set out in 13 CSR 35-60.070;

(H) Respite. The provision of periodic and/or intermittent, temporary substitute care of children who are in the care and custody of the Children’s Division and placed in a licensed foster, relative, or kinship resource home. Respite services may be approved as part of an adoption or guardianship agreement;

(I) Intensive In-Home Services (IIS). A short-term, intensive, home-based, crisis intervention program that combines skillbased interventions with maximum flexibility so that services will be available to families according to their individual needs. The goal of IIS is to offer families in crisis the alternative of remaining together safely, averting out-of-home placement of children whenever possible. IIS are, however, offered solely to families that have a child or children at imminent risk of removal from the home due to neglect, abuse, family violence, mental illness, delinquency, or other circumstances when approved by the Children’s Division. Services provided assist with crisis management and restoration of the family to an acceptable level of functioning;

(J) Residential Care. A facility providing twenty-four (24) hour care in a group setting to children who are unrelated to the person operating the facility and who are unattended by a parent or guardian;

(K) Relative. A grandparent or any other person related to another by blood or affinity or a person who is not so related to the child but has a close relationship with the child or the child's family. A foster parent or kinship caregiver with whom a child has resided for nine (9) months or more is a person who has a close relationship with the child. The status of a grandparent shall not be affected by the death or the dissolution of the marriage of a son or daughter.

(L) Licensed Foster Family. A private residence of one (1) or more family members providing twenty-four- (24-) hour care to one (1) or more but less than seven (7) children who are unattended by a parent or guardian and unrelated to either foster parent by blood, marriage, or adoption and licensed through the Children’s Division.

(2) Eligibility Criteria for Adoption/Legal Guardianship Subsidy.

(A) In order for a child to qualify for an adoption or guardianship subsidy, the child shall meet the following eligibility criteria:

1. The child must be under the age of eighteen (18) at the time of adoptive or guardianship placement; and 2. At the time of planning for adoption or legal guardianship, the child must meet one (1) of the following circumstances:

A. Be in the custody of the Children’s Division; or B. Children placed in Missouri through a private child-placing agency that are Title IV-E eligible are eligible for Missouri adoption subsidy per Title 42 U.S.C. Section 673(c)

(2008). The applicant for the adoption subsidy shall provide sufficient information to the division to determine that the child is Title IV-E eligible; or C. Be in the custody of a child-placing agency licensed in accordance with sections 210.481 through 210.531, RSMo, the Division of Youth Services (DYS), or the Department of Mental Health (DMH); and a “child with special needs” as defined by the characteristics listed below:

(I) The child cannot or should not be returned to the home of his or her parents. If the division has determined that the child cannot or should not return home, and the child meets the statutory definition of special needs with regard to specific factors or conditions, then the division shall ask whether the prospective adoptive parent(s) are willing to adopt without subsidy. If the adoptive parent(s) say they cannot adopt the child without adoption subsidy, the requirement for a reasonable, but unsuccessful, effort to place the child without providing adoption subsidy under Title 42 U.S.C. Section 673(c) (2008) shall be satisfied;

(II) The division determines, with respect to the child, that a specific condition or conditions of the child exists, because of which it is reasonable to conclude that such child cannot be placed with adoptive parent(s) or guardian(s) without providing subsidy. A child to be determined as previously unadoptable and eligible for subsidy shall meet one (1) or more of the following conditions:

(a) Physical Handicap. Any physical abnormality or condition, whether congenital or not, which requires or is likely to require treatment or the purchase of special equipment or services;

(b) Intellectual impairment. Mental development below an IQ of eighty (80) or other intellectual dysfunction as documented by psychological testing;

(c) Racial or Ethnic Minority. The child’s ancestry is not Caucasian; and (d) Other Conditions.

I. Age. The child is five (5) years old or older and has not reached the age of eighteen (18) years or twenty-one (21) years if the child’s condition requires extraordinary treatment or rehabilitative services.

II. Member of a sibling group. Two (2) or more children who are siblings and are being placed with the same family.

III. Developmental disability. Any documented physical or mental condition not otherwise listed which prevents the child from functioning at the normal level for his or her age.

IV. A mental or emotional disturbance. A diagnosed and documented condition which impairs the child’s mental functioning, including learning dysfunctions.

V. Social maladjustment. A severe behavioral condition or inadequate social development which interferes with the child’s ability to form satisfactory relationships with others.

(III) The child has a history, which includes circumstances such as long-term out-of-home care, incest, or social or genetic complication in the family background, which provides other impediments to adoption.

(B) Children who have a subsequent adoption or guardianship because of the dissolution of their adoption or guardianship or the death of their adoptive parent(s) or guardian(s) continue to be eligible for assistance under Title IV-E or Missouri funded subsidy in a subsequent adoption if they were previously eligible.

(C) Unless specifically authorized by federal law, there shall be no income eligibility requirement (means test) for the prospective adoptive parent(s) or guardian(s) in determining eligibility for an adoption or guardianship subsidy.

(3) Ineligible Children for Missouri Adoption and Legal Guardianship Subsidy—The following children shall not be eligible for adoption or guardianship subsidy:

(A) Children being adopted internationally or children adopted from other states who are not Title IV-E eligible and are in the custody of a private child-placing agency;

(B) Children in the custody of Missouri juvenile courts, even though they may receive a payment while in other types of out-of-home care; or (C) Children being adopted by a stepparent or biological parent whose rights were previously terminated.

(4) Ineligible Placements for Missouri Adoption and Legal Guardianship Subsidy—The following prospective adoptive parent(s) or guardian(s) shall not be eligible to receive an adoption or guardianship subsidy:

(A) Felony convictions—Any person who has a felony conviction for child abuse or neglect, spousal abuse, a crime against children (including child pornography), or a crime involving violence, including rape, sexual assault, or homicide, but not including other physical assault or battery; and (B) Any person who in the past five (5) years has had a felony conviction for physical assault, battery, or a drug-related offense.

(5) Application Process.

(A) Any prospective adoptive parent(s) or legal guardian(s) who believe that he or she may be eligible to receive a subsidy on behalf of a qualified child shall complete an application on a form approved by the division.

(B) The division may require the prospective adoptive parent(s) or legal guardian(s) to provide any documents or other materials necessary to verify any information necessary to complete the application process. The application shall be supplemented with such additional information and documentation as the division may require or the applicant for the subsidy may choose to submit for consideration. All information furnished by an applicant for a subsidy shall be complete, accurate, and truthful. The division may reject an application or reject renewal of an adoption subsidy or guardianship agreement if the division determines that the applicant for the subsidy has failed to provide complete, accurate, or truthful information.

(C) For initial applications, the burden of proof shall be on the applicant to establish eligibility for the subsidy and that they are qualified to receive requested services.

(6) General Regulation Governing All Adoption and Guardianship Subsidy Agreements—The following provisions will govern all agreements for adoption and guardianship subsidy:

(A) Agreements approved to age eighteen (18) will continue until the last day of the month of the child’s eighteenth birthday unless previously terminated in the manner provided by law;

(B) All adoption and guardianship subsidy agreements shall be in writing on a form provided by the division. The division shall not be obligated to provide or pay for any services, maintenance payments, or non-recurring expenses which are not expressly and specifically set out in the agreement. The agreement will not be effective unless and until it is signed by the director of the Children’s Division or the director’s authorized designee and the adoptive parent(s) or legal guardian(s);

(C) Unless otherwise required by law, the Children’s Division will not approve or pay for any service through an adoptive or guardianship subsidy agreement which is otherwise paid for or reasonably available at no cost or at reasonable cost through any other sources and which the child or the adoptive parent(s) or guardian(s) may be eligible to receive. Examples of other sources include, but are not limited to, the following: any other governmental programs, programs offered by schools and school districts, private insurance, any public insurance programs (including Medicaid (MO HealthNet) programs), other community-based services, and services and programs provided by not-for-profit organizations;

(D) Under no circumstances will the division or the state of Missouri pay for any services which exceed the authorized amount for the service as set forth in the service section of the agreement. Any amounts which may be due to a provider which exceed the amount that the division is obligated to pay under the agreement shall be the sole responsibility of the adoptive parent(s) or guardian(s). The adoptive parent(s) or guardian(s) shall pay, be responsible for, and indemnify the state of Missouri, the Department of Social Services, and the Children’s Division for any amounts which the division may be required to pay in excess of the amounts set forth in the agreement;

(E) Except as otherwise provided in subsection (6)(F) of this

regulation, the division is not obligated to make payments to a provider for services authorized through a subsidy agreement, unless the division has a currently active contract with the provider. The division shall not be obligated to pay for any service provided by the service provider, unless the service provider provides an invoice satisfactory to the division itemizing the date the service was provided, describing the nature of the service provided, and stating the amount for the service. The division will pay services directly to the provider.

The use of contracted providers is required when a contract may be established. All receipts submitted for reimbursement must be submitted within one hundred eighty (180) days of the service being provided. The division shall not be responsible for paying for any service billed or invoiced to the department later than one hundred eighty (180) days from the date that the service was provided.

(F) The division shall reimburse the adoptive parent(s) or guardian(s) for payments made directly by the adoptive parent(s) or guardian(s) to the provider where the provider of the service does not have a contract with the division only if the division agrees in writing before the service is provided to make the payment and if all of the following conditions are met:

1. The service is one (1) which the division has expressly agreed to pay in the subsidy agreement;

2. The adoptive parent(s) or guardian(s) establishes that there is no service provider having a contract with the division who is reasonably available to provide the service. In cases where the adoptive parent(s) or guardian(s) identifies an appropriate provider who does not have a contract with the division or the state, the division may decide, in its sole discretion, whether or not to enter into a contract with the provider and pay for the services directly, or whether to agree to reimburse the adoptive parent(s) or guardian(s) under this paragraph;

3. The adoptive parent(s) or guardian(s) provides timely documentation satisfactory to the division that the service has actually been provided and that it was provided by a qualified provider of the service. Documentation satisfactory to the division includes providing an invoice and a receipt prepared by the provider; and 4. The adoptive parent(s) or guardian(s) shall provide the invoice and paid receipt to the division no later than thirty (30) days from the date that the service was provided and paid for by the adoptive parent(s) or guardian(s), but under no circumstances shall the division be obligated to reimburse the adoptive parent(s) or guardian(s) for services provided later than ninety (90) days from the date that the services were provided; and (G) Payment for nonrecurring adoption or guardianship expenses shall be made only after the adoption or guardianship is final. The division will not pay for any nonrecurring adoption or guardianship expenses which are not expressly set out in writing in the adoption or guardianship subsidy agreement or in a separate document executed by the adoptive parent(s) or guardian(s) and by the director of the Children’s Division or his/ her designee. Under no circumstances shall the division or the state of Missouri be obligated to pay any nonrecurring adoption or guardianship expenses, based on any oral representations made by an employee of the Children’s Division or the Department of Social Services. These expenses are not eligible for payment if applied for after final adoption or guardianship.

All expenses paid under the guardianship subsidy agreement will only be paid after legal guardianship has been granted by the probate court to a qualified relative in the manner authorized by law.

1. Under no circumstances will an adoption or guardianship subsidy agreement or payment be made to reimburse the adoptive parent(s) or guardian(s) for payment for services provided by the adoptive parent(s) or guardian(s), or member of the adoptive parent(s) or guardian(s) household.

2. The division will not pay for services that are a duplication of other available services.

3. The parties to the agreement may by mutual written agreement amend the terms of the subsidy to better meet the needs of the adoptive child. Under no circumstances shall a subsidy agreement be amended without the consent of the adoptive parent(s) or legal guardian(s), or amended in any manner which may be a violation of federal law. Adoptive parent(s) or guardian(s) who wish to request that a subsidy agreement be amended shall submit a written request to amend the agreement. The burden of proof to amend the agreement shall be on the party seeking to amend the agreement. The request shall include the following information: a copy of the agreement, the specific provisions of the agreement they are seeking to amend, a detailed statement of the factual basis for the request for amendment, and include all documentation to support the request to amend the agreement.

4. Overpayments—Any amounts paid to the adoptive parent(s) or guardian(s) in excess of what is required by the subsidy agreement shall be an overpayment which is and shall be immediately due and payable to the division. The adoptive parent(s) or guardian(s) have the duty to notify the division within ten (10) days when he or she receives any information which would lead a reasonable person to believe that an overpayment has been made. The adoptive parent(s) or guardian(s) must promptly repay any overpayment and shall fully cooperate and promptly provide any and all information that the division may require to investigate and ascertain whether an overpayment has been made. If the division determines that an overpayment has been made, the division shall notify the adoptive parent(s) or guardian(s), in writing, specifying the amount of the overpayment, the factual basis for the assessment of the overpayment, and the specific provisions of the subsidy agreement, regulation, or law upon which the assessment is based.

(7) Maintenance Payment.

(A) Each adoption or guardianship subsidy may provide for a maintenance payment. The maintenance payment may be— 1. A continuous monthly payment for a sum certain through the termination of the agreement; or 2. A continuous monthly payment towards the child’s care which periodically diminishes over a period of not longer than four (4) years at which time it ceases; or 3. A continuous monthly payment for a sum certain towards the child’s care for a period of more than four (4) years; or 4. A monthly payment for a sum certain which is continued for a limited time after legal adoption, not exceeding four (4) years. This payment is to aid the adoptive parent(s) in integrating the care of the new child in their home.

(B) There shall be three (3) maintenance rates for subsidy agreements: standard rate, medical rate, and rate for Youth with Elevated Needs Level A.

1. The standard rate is the default rate and shall not exceed the standard foster care maintenance rate subject to appropriations. At the time of placement, no payment may exceed the maintenance rate paid if the child had remained in out-of-home care, even when used in combination with other benefits available to the child.

2. A child shall qualify to receive the medical foster care rate or Youth with Elevated Needs Level A rate only if the adoptive parent(s) or the legal guardians(s) and child meet the qualifications for the Youth with Elevated Needs regulations as set forth in rule 13 CSR 35-60.070.

3. In order to qualify for the medical foster care rate the adoptive parent(s) or guardian(s) must have the same qualifications as a licensed medical foster parent as set forth in rule 13 CSR 35-60.070.

(8) Request for Medical Rate or Youth with Elevated Needs Level A Rate.

(A) In accordance with the procedures set forth below, any adoptive parent(s) or guardian(s) may request an increase from the standard rate to the Medical or Youth with Elevated Needs Level A maintenance rate.

(B) The adoptive parent(s) or guardian(s) shall submit a written request to increase the rate. In the request, the adoptive parent(s) or guardian(s) shall specifically describe the medical condition or behavior of the child which the adoptive parent(s) or guardian(s) believe qualifies the child for the higher maintenance rate. The adoptive parent(s) or guardian(s) shall provide any and all information and documentation to the Children’s Division necessary to process the request for the higher maintenance rate, including, but not limited to— 1. The names and full contact information and reports for all medical care providers for the child for all relevant times, including all physicians, hospitals, and clinics which have provided care, diagnosis, or treatment for the child;

2. The names and full contact information and reports for all mental and behavioral health care providers for the child for all relevant times, including all therapists, licensed clinical social workers, psychologists, hospitals, and clinics which have provided care, diagnosis, and treatment for the child;

3. The names, addresses, and full contact information and reports for all schools and educational institutions which provided educational services and/or assessments for the child;

4. The names, addresses, and full contact information and reports for any other person who may have information necessary to assess the medical, behavioral, and/or developmental needs of the child;

5. The adoptive parent(s) or guardian(s) shall provide the Children’s Division with any written authorizations to release information which the division determines is necessary and convenient to process the request; and 6. The adoptive parent(s) or guardian(s) shall have the burden to establish by a preponderance of the evidence that the child meets the eligibility requirements of Medical Level or Youth with Elevated Needs Level A.

(C) In order to qualify as a Youth with Elevated Needs, the child must meet the same criteria as a child in alternative care as required in 13 CSR 35-60.070, and the adoptive parent(s) or guardian(s) shall meet the training requirements set forth in 13 CSR 35-60.070. However, if the adoptive parent(s) or guardian(s) reside out of state or were not licensed foster families with the Missouri Children’s Division— 1. They shall have completed at least eighteen (18) hours of equivalent training specific to the needs of the adopted child which has been approved by the Children’s Division;

2. The adoptive parent(s) or guardian(s) shall provide the Children’s Division with the name and the address of the provider of the training program and a copy of the training curriculum;

3. Once the training has been approved, the division may reimburse the out-of-state adoptive parent(s) or guardian(s) for training up to ninety dollars ($90) per hour if there is a charge.

A receipt must be provided to the division by the adoptive parent(s) or guardian(s) prior to payment; and 4. The adoptive parent(s) or guardian(s) must provide documentation of successful completion of the program.

(D) Adoptive parent(s) or guardian(s) of children receiving the medical maintenance—In order to qualify to receive the medical maintenance rate, the adoptive parent(s) or guardian(s) shall receive individualized medical training provided by the child’s health care provider or other provider and approved by the division to enable the adoptive parent(s) or guardian(s) to meet the specialized medical needs of the child.

1. The training shall be individualized to the child’s specific health care needs.

2. The adoptive parent(s) or guardian(s) must provide documentation of successful completion of the program.

(E) Subsidy agreements or amendments to subsidy agreements which include maintenance payments at the medical or Youth with Elevated Needs Level A shall be written to be reviewed every two (2) years or to age eighteen (18) due to their condition being such that they are not expected to improve.

The Children’s Division shall fully review the needs of the child in cooperation with the adoptive parent(s) or guardian(s). The Children’s Division shall review and consider any and all information that the adoptive parent(s) or guardian(s) may submit for review and shall request information from all professionals who have provided diagnostic care or treatment for the child.

In the event that the child’s needs are such that the child no longer qualifies as a Youth with Elevated Needs, the standard maintenance rate shall apply. However, the burden shall be on the Children’s Division to establish by a preponderance of the evidence that there has been a substantial and continuing change in the medical or behavioral needs of the child such that the child no longer meets the criteria of a Youth with Elevated Needs. Nothing in this subsection shall apply to any adoption subsidy agreement entered before the effective date of this regulation without the consent of the adoptive parent(s) or guardian(s).

(F) At the time of placement, the amount paid is determined by information obtained from the adoptive parent(s) or guardian(s) as to what financial assistance they need to meet the needs of the child and the resources available to the child such as OASDI, VA, SSI, etc.

(9) Medical and Dental Care.

(A) A child eligible for adoption subsidy or guardianship subsidy shall be eligible to receive MO HealthNet benefits to the extent authorized by law.

(B) The Children’s Division shall not pay for any services which are covered by the MO HealthNet program. Notwithstanding any provision of an adoption subsidy agreement, any services paid for by the MO HealthNet program shall constitute payment in full for those services, and the Children’s Division shall not be responsible for or liable to pay for any amounts in excess of the amount paid by MO HealthNet. Services covered by MO HealthNet do not require special approval by the Children’s Division in the service section of the agreement; however, nothing in this subsection shall be construed to supersede the requirements of the MO HealthNet program, and the requirements of the MO HealthNet program for preapproval of services shall apply for any services administered by the MO HealthNet program.

1. Adoptive parent(s) or guardian(s) are encouraged, but not required, to add their adopted child or ward to their private insurance. Payment for an insurance deductible as prescribed by their private health insurance plan is the responsibility of the adoptive parent(s) or guardian(s). If an adoptive parent(s) or guardian(s) has added the adopted child or ward to their private health insurance, they must use their private health insurance, if the child is covered in their policy, before using MO HealthNet. However, the adoptive parent(s) or guardian(s) must indicate to the provider that the child is also eligible for MO HealthNet coverage.

2. The Children’s Division will not pay for any medical or dental services in whole or in part received from non-MO HealthNet providers without prior approval by signature of the director of the Children’s Division to the subsidy amendment.

3. The Children’s Division may agree to pay for orthodontic services through adoption or guardianship subsidy when the services are determined to be medically necessary by the MO HealthNet Division according to eligibility criteria of the MO HealthNet program, but only if a MO HealthNet provider is not located within one hundred (100) miles round-trip of the residence of the child. The Children’s Division will not pay any amounts in excess of the MO HealthNet rates for orthodontic services under this section. The Children’s Division will not be responsible for payment of orthodontic services without prior written approval of the division. The adoptive parent(s) or guardian(s) will be responsible for any costs for orthodontic care obtained prior to written approval from the division.

(10) Childcare.

(A) Eligibility for subsidized childcare shall be determined by Department of Elementary and Secondary Education (DESE) and governed by the regulations of DESE.

(B) The division or child-placing agency may provide referrals to DESE or DESE’s authorized representatives to apply for subsidized childcare.

(11) Nonrecurring Adoption or Legal Guardianship Expenses.

(A) The Children’s Division may include in an adoption or guardianship subsidy agreement a provision to pay reasonable nonrecurring adoption or legal guardianship expenses. The expenses that the division will pay shall be listed specifically in the agreement. The division will not pay for any expenses which are not specifically provided for in the agreement. All receipts submitted for reimbursement must be submitted within one hundred eighty (180) days of service completion.

Any nonrecurring adoption or guardianship expenses, including, but not limited to, attorney fees, court costs, and litigation expenses incurred by the adoptive parent(s) or guardian(s) in excess of the amount set forth in the agreement shall be the sole responsibility of the adoptive parent(s) or guardian(s).

Nonrecurring adoption or legal guardianship expenses which may be covered are the following:

1. Nonrecurring placement-related expenses may be reimbursed up to one thousand dollars ($1,000) and are limited to— A. Pre-placement transportation: This expense is paid at the current customary rate established by the Children’s Division for use of a personal automobile or the charge of air or ground transportation; and B. Lodging and food: Reimbursed using division travel guidelines for both in-state and out-of-state travel;

2. Legal fees include attorney’s fees, court costs, publication expenses, and Guardian Ad Litem (GAL) costs for the adoptive parent(s) or guardian(s) in adoption or the guardianship case filed in a court of competent jurisdiction.

A. Attorney’s fees will be reimbursed at a rate not to exceed one hundred dollars ($100) per hour to a maximum of one thousand five hundred dollars ($1,500) in non-contested adoption cases and up to three thousand dollars ($3,000) in a contested case. Legal fees for guardianship subsidies may be reimbursed up to one hundred dollars ($100) per hour to a maximum of five hundred dollars ($500) in non-contested guardianship cases and up to one thousand five hundred dollars ($1,500) if the guardianship is contested.

B. The attorney’s fees, court costs, and litigation expenses which the Children’s Division may agree to cover under a subsidy agreement shall only include those fees, costs, and litigation expenses which are reasonably necessary to pay for the adoption count of the adoption petition. Nothing in this

regulation shall be construed to require the division to pay for attorney’s fees, costs, or litigation expenses related to the termination of parental rights or other portions of any legal proceedings involving the child. Nothing in this regulation shall be construed to require the division to pay for the attorney’s fees, litigation expenses, and court costs for any other person, including the natural or legal parent(s) to defend the petition for adoption or guardianship petition;

3. Private agency fee reimbursement up to three thousand five hundred dollars ($3,500). Such costs may include the adoption study, including health and psychological examination, and supervision of the placement prior to adoption finalization; and 4. Payment for nonrecurring expenses shall not include those paid for or provided through resources available to the adoptive parent(s) or guardian(s), court, or the agency facilitating the placement. Examples of these resources include— A. A private agency waives the cost of the family assessment (home study) or the placement support services;

B. The adoptive parent(s) claimed the Missouri adoption tax credit for nonrecurring adoption expenses;

C. The adoptive parent(s) or guardian(s) has private insurance providing payment for certain services included in an adoption/guardianship; and D. A service provider has waived the cost for the service.

(12) Additional Services—An adoption or guardianship subsidy agreement may include provisions for the Children’s Division to provide the following:

(A) The division may offer available Intensive In-Home Services (IIS) or other services to the adoptive parent or guardian for the family who is in need of intervention that may reduce the risk of the child entering out-of-home care;

(B) For all existing adoption and guardianship subsidy agreements amended on or after June 25, 2024, and for all adoption and guardianship subsidy agreements executed or amended on or after June 25, 2024, payment for care and treatment of a child in a residential setting (hereinafter referred to in this regulation as “residential treatment”) (all levels) may be included in a subsidy agreement or added to the subsidy agreement through an amendment only as provided in this subsection.

The amendment must be approved and signed by the authorized signature of the Department of Social Services before payment for such services is made.

1. The division may approve payment, in whole or in part, for residential treatment of a child in a subsidy agreement only if all of the following criteria and conditions are met:

A. The division has determined that care and treatment of the child out of the home in a residential setting is the least restrictive setting and the program is necessary and appropriate to meet the child’s needs. The division may require that the child and family exhaust all reasonably available, less restrictive treatment modalities for the child before entering into an agreement to pay for residential treatment;

B. The division has determined that it is necessary for the child to receive treatment at a particular level of care in a residential setting;

C. The child has been accepted for treatment by a residential facility that is licensed by the state to provide the treatment, and the facility is either an enrolled MO HealthNet provider, an enrolled provider of the Medicaid program in the state in which the child is located, or a facility contracted with the state of Missouri for payment for the services;

D. Except as provided in subparagraph (12)(B)1.G. below, the child has received an approved prior authorization for treatment in the identified residential treatment facility. The approved prior authorization must be in writing and include a determination that the child requires residential treatment at a particular level of care to a reasonable degree of professional certainty according to the eligibility standards specified in this

regulation.

(I) For children covered by a subsidy agreement, who are residents of the State of Missouri and are participants in the MO HealthNet program, the prior authorization must be provided by the MO HealthNet Division or the provider contracted with the MO HealthNet Division to make those determinations.

(II) For children covered by a subsidy agreement who are not residents of the state of Missouri, but who are participants in the MO HealthNet program, then the prior authorization must be provided by the MO HealthNet Division or the managed care provider contracted with the MO HealthNet Division to make those determinations.

(III) For children who are not residents of the state of Missouri, who are not current participants in the MO HealthNet program, and are participants in another state’s Medicaid program, prior authorization shall be provided by the Medicaid program from the other state.

(IV) For children who are not residents of the state of Missouri, who are not current participants in the MO HealthNet program, and are either not participants in another state’s Medicaid program or the other state’s Medicaid program does not pay for residential treatment, then the division will use the exception procedure in subparagraph (12)(B)1.G. below to determine eligibility for subsidized residential treatment;

E. Every child receiving payment for residential treatment through a subsidy agreement shall have a current written plan of care;

F. The division will only enter into a subsidy agreement to pay for residential treatment if the facility is the closest available facility to the child’s home that provides the array of services that the division determines are necessary for the child at a contract price for those services agreeable to the division;

G. In exceptional, extraordinary, and unusual circumstances, the division may, in its discretion, waive the requirement in subparagraph (12)(B)1.D. of this regulation that the child has received prior authorization for payment through a subsidy agreement for residential treatment, but only if all of the following criteria are met:

(I) All of the other criteria for eligibility for payment for treatment in a residential care facility have been met;

(II) Either the adoptive parent or guardian has filed an appeal of the denial of prior authorization, or the child is a resident of a state whose Medicaid program does not include payment for the necessary residential treatment;

(III) The child’s treating or examining, psychiatrist, psychologist, physician, advanced practice psychiatric nurse, marital and family therapist, nurse practitioner, licensed professional counselor, or licensed clinical social worker certifies to a reasonable degree of medical certainty in writing that treatment in a residential facility at the indicated level of care is necessary. The division may at any time, in its discretion, require the child to be examined and the certification and child’s records reviewed by other licensed medical professionals for an independent assessment of the necessity for residential treatment. The division will determine what weight shall be given to conflicting opinions of medical experts;

(IV) The division determines that funds are available to pay for the treatment in a residential facility;

(V) The duration of the waiver shall be determined as follows:

(a) In the case where the waiver was triggered by a request for administrative review of the denial of a request to approve residential treatment, the waiver shall extend until the appeal has been decided on administrative review. The division may extend the waiver period if there is a request for judicial review of the administrative decision; or (b) In the case where the waiver was necessary because the child is a resident of a state whose Medicaid program does not include payment for the necessary residential treatment, the waiver shall be subject to the continuing care reviews as provided in this regulation; or (c) The division determines that treatment in a residential facility is no longer necessary, such as where the child is discharged from residential treatment; and (VI) The division determines that the child may be a danger to self or others.

2. Responsibilities of the adoptive parent or guardian. The implementation of a subsidy agreement to subsidize payment for residential treatment does not and shall not absolve the adoptive parent or guardian of any and all of the duties and responsibilities that they may have toward the child under law.

The fact that the division has entered into a subsidy agreement for payment for residential treatment does not mean that the child is or has been placed in the legal or physical custody of the division.

A. The adoptive parent or guardian shall be responsible for researching and exhausting all reasonably available, less restrictive, community-based care and treatment modalities before the division will approve subsidized residential treatment.

The division may provide referrals and information to support the adoptive parent or guardian in that effort.

B. The adoptive parent or guardian shall remain responsible for the support of the child throughout the child’s residential treatment and making arrangements for the physical care, custody, and placement of the child when treatment in a residential care facility is no longer necessary. This duty of support shall include both financial support and exercising all duties of a parent or guardian, including but not limited to making decisions for the child, visiting the child, actively participating with the provider in all aspects of the management of the child’s care and treatment, and engaging in active efforts to enable the child to return home.

C. If the adoptive parent or guardian is unable or unwilling to exercise these efforts or does not actively demonstrate a desire for the child to be returned to their home, then the division may take one (1) or more of the following actions:

(I) Decline to authorize payment for residential treatment under a subsidy agreement;

(II) Institute any available remedy for the modification or termination of the subsidy agreement, in whole or in part;

(III) Take any other action authorized by law, including a referral to the juvenile officer or the child welfare authorities of another state for investigation, assessment or other appropriate action.

D. The adoptive parent or guardian shall provide all required documentation necessary for determining eligibility, and continuing eligibility, for residential treatment to MO HealthNet or MO HealthNet’s contracted Managed Care provider, the Residential Treatment Provider, and the division.

This includes but is not limited to executing Health Insurance Portability and Accountability Act (HIPAA) and Family Education Rights and Privacy Act (FERPA) compliant consents to authorize the release of all information and records deemed necessary.

3. Residential treatment that is eligible for payment under a subsidy agreement.

A. The subsidy agreement may include payment on behalf of a child who is the subject of a subsidy agreement in a residential treatment facility for— (I) The reasonable and necessary cost for room and board for the child at the rate specified in the contract between the division and the provider of residential treatment;

(II) If the division has granted a waiver as provided in subparagraph (12)(B)1.G., then the division will pay the provider the agreed-upon amount for necessary residential treatment specified in the contract between the division and the provider of residential treatment; or (III) Discharge planning. The division may, but is not required to, pay for residential treatment for a limited period of time specified in the subsidy agreement to allow the family to establish and implement the necessary in-home or community-based treatment for the child, provided that the parent and guardian exercise diligent and active efforts to implement and complete the discharge plan within the time specified in the subsidy agreement. Discharge planning extensions shall be reviewed monthly or more frequently as necessary.

B. The subsidy agreement shall not include, and the division is not required to pay through a subsidy agreement for, any one (1) or more of the following:

(I) Residential treatment and other services that are covered by MO HealthNet or the Medicaid program of any state;

(II) Residential treatment that is covered by any policy of insurance that provides coverage for the child;

(III) Residential treatment that is not necessary;

(IV) Residential treatment that is beyond the scope of the participant’s plan of care or discharge plan;

(V) Residential treatment that is available to the child through other government or privately funded programs, including but not limited to schools and school districts, community-based services, and services provided by not-for-profit and religious organizations;

(VI) Residential treatment provided after the approved length of stay or after the child is discharged from the facility;

(VII) Residential treatment on behalf of a child to a provider who does not have a contract to provide the service with the state of Missouri; or (VIII) Residential treatment and other services that are provided by a provider who is not qualified and licensed to provide the treatment in the location where the treatment is provided.

4. Payments for residential treatment shall be made directly to the provider of the residential treatment pursuant to a contract between the state of Missouri and the provider. The adoptive parent or guardian and child shall not be a party or be a third-party beneficiary of the contract between the state of Missouri and the provider. No payments shall be made to a provider that is not currently licensed in good standing to provide the care and treatment. No payments shall be made directly to the adoptive parent or guardian. No payments shall be made to a provider who is either not an enrolled Medicaid provider or who does not have a contract with the state of Missouri to provide the service. The laws and regulations governing contracting with the state of Missouri shall govern all contracts for services under this regulation.

5. For the division to determine that residential treatment at a specific level of care is necessary, all of the criteria in subparagraphs (12)(B)5.A.-H. must be met, subject to the definition of “medical condition” specified in subparagraph (12)(B)5.I.

A. The child’s medical condition must satisfy all of the eligibility requirements of 13 CSR 35-38.010(12)(B).

B. The child must have one (1) or more current diagnosed medical condition(s), injury, or illness. The diagnosis may be final or provisional.

C. The diagnosis must have been made by a medical professional who is licensed and qualified by law to make that diagnosis.

D. Care and treatment in a residential facility for the child’s diagnosis meets the generally accepted standard for care and treatment for the child’s diagnosed condition.

E. Care and treatment in a residential setting is not experimental and is not mainly prescribed for the convenience of the child or the child’s parents or guardian.

F. Care and treatment in a residential setting is reasonably necessary to protect the life, safety, and health of the child.

G. The care and treatment is not optional or for purely cosmetic purposes.

H. Treatment at home or in a lower level of care for the medical condition has been ruled out by a medical professional who is licensed and qualified to determine whether the treatment is medically inappropriate.

I. In this regulation the phrase “medical condition” includes a diagnosed physical, psychiatric, psychological, and/or developmental condition.

6. The following documentation shall be submitted to determine whether residential treatment is necessary:

A. A report of a full assessment by a licensed and qualified health care professional using the most recent version of the Daily Living Activities (DLA-20) assessment process and tool. If a DLA-20 assessment process and tool is not available, the division may, in its discretion, accept an assessment using an equivalent, current assessment tool, provided that the assessment and tool is evidence-based, objective, generally accepted, and actually used in the medical community as a tool used for assessments for care and treatment in residential facilities. The assessment must be completed by a clinician licensed in the state in which the tool is administered who is trained and qualified to use the tool. The assessment and tool must be the most recent version of the tool as of the date of the assessment. Other tools that may be used when a DLA- 20 assessment is not available may include the Level of Care Utilization System (LOCUS) for youth over age eighteen (18), the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) for children aged six to eighteen (6-18), and the Early Childhood Service Intensity Instrument (ESCII) for children aged zero to five (0-5);

B. Any relevant child/youth psychiatric/behavioral health diagnoses;

C. The most recent psychiatric evaluation completed by a psychiatrist, psychologist, or advanced practice nurse, if one is available;

D. A statement detailing the rationale for residential treatment at the requested level of care;

E. Documentation of previous treatment history and outcome of treatment, if applicable and available;

F. Documentation of the name, address, telephone number, email address, and all other contact information for the adoptive parent or legal guardian of the child;

G. A discharge plan when available. Discharge planning shall start at admission and shall be continuously developed and evaluated throughout the child’s stay in residential treatment;

H. The child’s parent or guardian shall complete and submit a Residential Treatment Referral, CS-9, to the best of their ability in cooperation with the assigned subsidy worker.

The adoptive parent or guardian shall sign the form and certify that the information that they have provided is true, complete, and accurate to the best of their personal knowledge, information, and belief.

7. The adoptive parent or guardian shall have the burden of proof to establish by a preponderance of the evidence that the child is eligible for both initial and continuing treatment in a residential care facility at a particular level of care.

8. Except as otherwise provided elsewhere in these regulations, the division shall not approve payment for residential treatment in a residential care facility in a subsidy agreement for more than six (6) consecutive months. The division may enter into subsequent amended subsidy agreements that include payment for treatment in a residential setting following the continuing stay review procedures.

9. Continuing stay reviews. All subsidy agreements that include residential treatment services shall be subject to continuing stay reviews. The purpose of the continuing stay review is to determine whether ongoing residential treatment is necessary. All continuing stay reviews must include evidence that clearly supports the need for ongoing treatment at the requested level of care and must clearly identify why the child’s treatment needs can’t be treated at a lower level of care. The same procedures, standards, and criteria for initial approval of residential treatment services shall apply to continuing stay reviews.

A. The division may accept the continuing stay review decision of the primary payer for the purpose of approving continued subsidized residential treatment if all other eligibility requirements of this regulation are met.

B. When the division approves a prior authorization waiver, the division will conduct the continuing stay review to determine continued eligibility for subsidized residential treatment services.

(I) The division will conduct a continuing stay review within thirty (30) days prior to the expiration of the approved residential treatment services, and more frequently as the division determines necessary.

(II) Documentation. The child’s adoptive parent or guardian shall be responsible for providing all of the documentation to determine whether ongoing residential treatment of the child is necessary at a specified level of care. The adoptive parent or guardian may request the division to provide assistance in gathering the required documentation, provided that the request is made in a timely manner and the adoptive parent or guardian executes any required authorizations for the release of information. The documentation shall be the most current available information and shall include— (a) The child’s plan of care since last review; and (b) Treatment progress notes, to include any progress notes from the child’s treating psychiatrist, psychologist, physician, and/or therapists; and (c) Family therapy progress notes since last review, or detailed documentation to establish whether family therapy sessions are not occurring or have been excused; and (d) Any updates to the child’s diagnoses and prognosis; and (e) Medications prescribed to the child, including any changes to medications; and (f) The child’s discharge plan to include any details currently available including any established outpatient providers, appointment dates and times, recommended treatment level of care; and (g) The efforts that the adoptive family or guardian have engaged in to participate in the child’s care, treatment, and discharge plan; and (h) A new DLA-20, or equivalent assessment of whether treatment in a residential setting is necessary by a clinician trained and qualified to perform the assessment, if requested by the residential treatment provider, the payer of coverage for residential treatment, the adoptive parent or guardian, or the division.

10. Residential referral process. The procedures in this sub-

section shall govern all requests for payment for services, care, and treatment in a residential setting through an adoption or guardianship subsidy agreement.

A. At any time, the adoptive parent or guardian may request residential services. The division may refer the case to an IIS provider. If the division determines that IIS is appropriate, the division may provide IIS rather than residential services.

B. Community resources are to be researched by the adoptive parent or guardian, with the assistance of their division caseworker and the child’s care manager (if applicable), and efforts documented prior to making a residential treatment referral.

C. In the event that IIS is ineffective in remedying the situation and other community resources have not produced the necessary change in the family unit and/or adoptive parent or guardian are reasonably unable to access alternative resources to prevent placement in residential care, the adoptive parent or guardian must provide information necessary to evaluate the needs of the child to determine eligibility for placement in residential care.

D. The adoptive parent or guardian shall obtain the necessary documentation regarding the child's condition from appropriate professionals (psychological, psychiatric, etc.).

E. The adoptive parent or guardian shall make diligent efforts to place the child in close proximity to their home to allow involvement by the adoptive parent or guardian in the child's treatment.

F. The adoptive parent or guardian are responsible for making arrangements for actual placement into the residential facility.

11. Any adoptive parent or guardian who believes that they are aggrieved by an adverse decision regarding or prior authorization that is made by the MO Health Division, the managed care provider contracted with the MO HealthNet Division to make that decision, or the Medicaid program of another state shall first exhaust his or her administrative and judicial remedies under that program;

(C) The provisions of this subsection shall apply to all adoption and guardianship subsidy agreements executed prior to June 25, 2024.

1. Residential care services (all levels) may be included in a subsidy agreement or added to the subsidy agreement through an amendment, but only if residential care is the least restrictive treatment setting and program appropriate to meet the child’s needs. The amendment must be signed by the director of the Children’s Division before payment for such services may begin. All amendments and proposed amendments covering residential care and treatment services to adoption and guardianship subsidy agreements existing prior to June 25, 2024, are governed by subsection (12)(B) above and not this subsection.

2. Residential referral process.

A. At any time, the adoptive parent or guardian may request residential services. The division may refer the case to an IIS provider. If the division determines that IIS is appropriate, the division may provide IIS rather than residential services.

B. Community resources are to be researched by the adoptive parent or guardian, with the assistance of their division caseworker, and efforts documented prior to making a residential treatment referral.

C. In the event that IIS is ineffective in remedying the situation and other community resources have not produced the necessary change in the family unit or the adoptive parent or guardian is unwilling to utilize alternative resources to prevent placement in residential care, the adoptive parent or guardian must provide information necessary to evaluate the needs of the child to determine eligibility for placement in residential care.

D. The adoptive parent or guardian shall obtain the necessary documentation regarding the child’s condition from appropriate professionals (for example, psychological or psychiatric).

E. Efforts shall be made to place the child in close proximity to their home to allow involvement by the adoptive parent or guardian in the child’s treatment.

F. The adoptive parent or guardian is responsible for making arrangements for actual placement into the residential facility.

G. Once a child has been approved for residential treatment, the adoptive parent or guardian shall be referred to the out-of-home care program. A Family Centered Services (FCS) case may be opened to provide services to work toward reintegration.

H. If the adoptive parent or guardian is unwilling to be a

part of this process and has no desire for the child to be returned to their home, residential treatment may not be authorized through subsidy, and other permanency options shall be discussed with the family. If the child enters the custody of the Children’s Division, the division will pursue child support from the adoptive parent or guardian.

3. The Children’s Division will not pay for residential services at a more intensive treatment level and at a higher rate unless the director of the Children’s Division agrees in writing to pay for the more intensive treatment level. To request approval to pay at a higher rate for a more intensive treatment level in the residential setting— A. The adoptive parent or guardian shall submit a written request and state in detail the reasons that it is necessary for the child to be placed at a more intensive treatment level.

The adoptive parent or guardian shall provide any and all documentation that the division may require to ascertain whether the more intensive treatment level is necessary; and B. The documentation submitted must include current records and reports no more than ninety (90) days old and include an estimated discharge date and prognosis, monthly treatment summary, explanation of a continued need for residential treatment, and a description of parental involvement with the facility’s treatment plan;

(D) Youth with Elevated Needs Level B—A child may be placed in a Youth with Elevated Needs Level B Home if this service is determined necessary for the child by the Children’s Division in conformity with the procedures and eligibility criteria set forth in 13 CSR 35-60.070 and a Level B Home is available and has accepted the child for placement. The Elevated Needs Level B Home is for the purpose of treating a child’s behavioral issues so they may be successfully reintegrated into the adoptive or guardianship home.

1. The adoptive parent or guardian is to be referred to the out-of-home care program, a voluntary case is to be opened, and services are to be offered in order to work towards reintegration into the adoptive or guardianship home.

2. Youth with Elevated Needs Level B placements may be authorized for only six (6) months at a time. Upon the sixth month, the need for placement and level of care must be reviewed in a Family Support Team (FST) meeting.

3. An amendment requesting funding for Youth with Elevated Needs Level B placements shall be submitted to the division for approval. The amendment must be signed by the director of the Children’s Division before Youth with Elevated Needs Level B services may begin and payment for such services made.

4. With regard to agency liability of an adopted or guardianship child voluntarily placed in a Youth with Elevated Needs Level B placement, any legally recognized parent (biological or adoptive parent or guardian) is liable for the actions of his/her child as long as that adoptive parent or guardian has not been relieved of legal custody. If the division does not have legal custody of a child, the division is not liable for the child;

(E) Respite. Adoptive parent or guardian may receive respite as a special service on a case-by-case basis through subsidy when a documented need exists to age eighteen (18).

Respite care shall be provided according to any regulations promulgated by the division governing respite care.

1. The adoptive parent or guardian shall provide a letter requesting this service describing in detail the child’s need for respite.

2. All paid receipts submitted for reimbursement must be submitted within one hundred eighty (180) days of the service being provided.

3. Respite shall be approved in accordance with maintenance approval; if a child receives traditional maintenance to age eighteen (18), respite may be approved to age eighteen (18) as well. If a child receives medical or Youth with Elevated Needs Level A maintenance to age eighteen (18) due to their condition being such that they are not expected to improve, respite may also be approved to age eighteen (18).

However, if medical or Youth with Elevated Needs Level A maintenance is only approved for a two- (2-) year time period, respite should only be approved for two (2) years; and (F) If the child has a disabling condition as defined by the Americans with Disabilities Act, the Children’s Division within its discretion may include in an adoption or guardianship subsidy agreement a provision to pay for minor modifications of the residence of the child or vehicle used to transport the child under the following conditions:

1. The modification must be necessary for the child to effectively function in the home or vehicle;

2. The adoptive parent or guardian must be unable to acquire these services independent of the subsidy and have exhausted all available private and public community resources;

3. All expenses, modifications, and services shall be approved for payment pursuant to procurement laws and regulations including but not limited to 1 CSR 40-1.010 through 1 CSR 40-1.090; and 4. The division will pay for the least expensive, appropriate alternative to meet the needs of the child.

(13) 18+ Adoption Subsidy Agreement. The Children’s Division may approve an adoption subsidy to continue beyond the age of eighteen (18) up to the age of twenty-one (21) when the child has an extraordinary documented physical, dental, or mental health need that requires care beyond the age of eighteen (18).

These 18+ Adoption Subsidy Agreements are negotiated on an annual basis with the adoptive parent(s) according to the youth’s current needs and with the intent of transitioning the youth from subsidy services to adult community services to ensure all necessary services are in place for the youth’s success when subsidy is no longer available.

(A) Six (6) months prior to a youth covered by an adoption subsidy agreement’s eighteenth birthday, the adoptive parent(s) may make a request in writing to the Children’s Division for the division to assess whether or not the child is eligible for an 18+ adoption subsidy agreement. The division will make a determination as to whether or not the youth has an extraordinary documented physical, dental, or mental health need that requires care through a subsidy agreement beyond the age of eighteen (18). Documentation of need from the youth’s physician, psychiatrist, psychologist, or dentist shall be obtained and submitted as supporting documentation of need.

(B) The adoptive parent(s) shall be made aware of the need to transition the youth from adoption subsidy to adult community services to meet the youth’s needs and provide referral information and assistance with obtaining these services as needed. The adoptive parent(s) shall be advised they are required to apply for and participate in all such programs and services as may be reasonably necessary to meet the needs of the youth as indicated in the contract.

(C) The Children’s Division will not approve an 18+ adoption subsidy agreement for any child whose mental, physical, or dental needs may be met or otherwise paid for or reasonably available at no cost or at reasonable cost through any other services and which the child or the adoptive parent(s) or guardian(s) may be eligible to receive on behalf of the child.

(14) Termination of an adoption or legal guardianship subsidy agreement shall take place if any of the following events occur:

(A) The child has attained the age of eighteen (18) and there is no 18+ adoption subsidy agreement or the maximum age of twenty-one (21) if there has been an 18+ agreement in effect; or (B) The division determines that the adoptive parent(s) or guardian(s) are no longer legally responsible for support of the child; or (C) The division determines that the adoptive parent(s) are no longer providing any support to the child; or (D) The adoption subsidy agreement expires.

(15) Administrative and Judicial Review.

(A) Scope and Purpose. This establishes the procedures for the resolution of disputes involving the delay, overpayment, denial, amount, or type of adoption or guardianship subsidy for applicants for or participants in the adoption and/or guardianship subsidy program.

(B) Notice of Case Action. The division shall provide a written notice of case action to an applicant or participant of any decision on an application for subsidy and any decisions relating to an existing subsidy agreement to delay, deny, and/or modify the amount or type of the subsidy. The notice shall state the date of the decision and— 1. State generally the factual and legal basis for the division’s action;

2. State the effective date of the action, if applicable; and 3. Notify the applicant or the subsidy participant of his or her right to administrative review. Attaching a copy of this regulation to the division’s notice of case action shall be sufficient notice to comply with this subsection.

(C) Right to Administrative Review. Any person who believes that he or she is aggrieved by any delay in the adoption or guardianship subsidy process, or believes that he or she is aggrieved by the division’s decision regarding the denial, amount, or type of adoption or guardianship subsidy program shall have the right to request administrative review following the procedures set forth in this regulation.

(D) Standard of Review and Burden of Proof. The decision shall be based on competent and substantial evidence on the whole record as in administrative hearings in contested cases.

The preponderance of evidence standard shall apply. For initial applications and for requests for amendments to existing subsidy agreements, the burden of proof shall be on the applicant for subsidy or amendment to the subsidy agreement.

(E) Process for Administrative Review.

1. Requests for Administrative Review. A request for administrative review must be received by the division no later than thirty (30) days from the date of the division’s decision. The request for administrative review shall be in writing and shall set out, generally, the reasons why the applicant or participant believes he or she is aggrieved by the decision. If there is a current adoption subsidy agreement in place, at the request of the adoptive parents, the division shall stay implementing its decision and keep the existing agreement in place until a final decision on the request for administrative review has been made. If the division’s decision is finally affirmed, the division may seek reimbursement for any amounts overpaid to the adoptive parents pending the final decision.

2. First Level Review. Within thirty (30) days of the receipt of a request for administrative review, the division shall convene a panel of three (3) persons who are employees of the division, at least one (1) of whom is not responsible for the case management of, or the delivery of services to, either the child, the adoptive parent(s) or the prospective adoptive parent(s), guardian(s), or the prospective guardian(s). The panel shall review the request for administrative review, the materials submitted with the request, the division’s file, and any written materials submitted by the division. At the request of the person seeking administrative review, the panel may convene an informal meeting which shall be open to participation by the applicant, the child, and/or the child’s adoptive parents. The meeting shall be an informal settlement conference, the rules of evidence shall not apply, and no record of the meeting shall be kept. The panel may affirm, reverse, or modify the initial agency decision, or it may refer the case to a formal administrative hearing. If the person(s) requesting the hearing is not satisfied by the first level review, they may request in writing, within thirty (30) days of the decision of the panel, the referral of the case for an administrative hearing.

3. Administrative Hearing. In the event that the request for review is not resolved at the first level of review, the person requesting the review may request a hearing before a hearing officer of the Division of Legal Services of the Department of Social Services. The hearing shall be on the record and the rules of evidence shall apply as in administrative hearings in contested cases. The parties shall be afforded the right to adduce relevant evidence, to call witnesses, and to compel the attendance of witnesses by subpoena.

4. Hearing decision and right to judicial review. The hearing officer shall issue a written decision setting forth his or her findings of fact, conclusions of law, and decision after hearing, which shall be the final decision of the division. The written decision shall notify the parties of their right to request judicial review pursuant to section 536.100, RSMo.

Emergency amendment filed June 10, 2024, effective June 25, 2024, expired Feb. 27, 2025. Amended: Filed June 10, 2024, effective Jan. 30, 2025. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 453.073, RSMo 1973, amended 1978, 1981, 1982, 1985, 1997, 2001, 2005, 2008, 2014; 453.074, RSMo 1985, amended 2014; 536.010, RSMo 1945, amended 1957, 1976, 2004, 2005, 2006; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020.1(5), 453.073, 453.074, 536.010(6), and 660.017, RSMo 2016, and Young v. Children’s Division, State of Missouri Department of Social Services, 284 S.W.3d 553 (Mo. 2009). Original rule filed March 1, 2010, effective Oct. 30, 2010.

13 CSR 35-38.011 Definition of Guardianship Services {#sec-13-csr-35-38.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-38.011}

PURPOSE: This rule defines guardianship services.

(1) Guardianship services are defined as assessment and evaluation of the child and his/her needs; arrangements for care of the child prior to guardianship placement; placement of the child with an approved guardianship provider; placement support activities until the guardianship is legally completed; pre- and post-guardianship counseling to the natural parent and the guardian(s) regarding the guardianship arrangement; legal services associated with completing a guardianship; medical, dental, psychiatric, or psychological services for the child as needed; and subsidized guardianship.

History

• AUTHORITY: section 453.072, RSMo Supp. 2009. Original rule filed May 27, 2010, effective Nov. 30, 2010. Original authority: 453.072, RSMo 1999, amended 2001, 2005, 2008.

13 CSR 35-38.021 Provision of Guardianship Services {#sec-13-csr-35-38.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-38.021}

PURPOSE: This rule sets criteria for provision of guardianship services.

(1) The Children’s Division shall accept home assessments from families having an approved family assessment completed by the division, or other licensed child-placing agencies; registration of children designated as available for placement; and will cooperate with other state, regional, and national exchanges in the registration of children with special needs.

(2) The Children’s Division shall provide subsidized guardianship services to children who are considered to have special needs and who have no other financial resources or limited financial resources.

(3) In order for a child to be determined eligible for subsidized guardianship services, he/she shall meet one (1) or more of the following conditions:

(A) Physical Handicap. Any physical abnormality or condition, whether congenital or not, which requires or is likely to require treatment or the purchase of special equipment or services;

(B) Intellectual Impairment. Mental development below an IQ of eighty (80) or other intellectual dysfunction as documented by psychological testing;

(C) Racial or Ethnic Minority. The child’s ancestry is not Caucasian; and (D) Other Conditions.

1. Age. The child is five (5) years old or older and has not reached the age of eighteen (18).

2. Member of a sibling group. Two (2) or more children who are siblings and are being placed with the same guardian.

3. Developmental disability. Any documented physical or mental condition not otherwise listed which prevents the child from functioning at the normal level for his/her age.

4. Mental or emotional disturbance. A diagnosed and documented condition which impairs the child’s mental functioning, including learning dysfunctions.

5. Social maladjustment. A severe behavioral condition or inadequate social development which interferes with the child’s ability to form satisfactory relationships with others.

(4) In order for a guardian to be eligible for subsidy, he/she shall be a grandparent or great-grandparent, aunt or great-aunt, uncle or great-uncle, adult sibling, or adult first cousin of the child who has been approved as a guardianship placement by the Children’s Division, a licensed or approved child-placing agency; or for a family residing outside Missouri, a governmental child-placing agency or a licensed or approved child-placing agency in that state; and shall cooperate in providing information for the division to reach an agreement with the guardian regarding the amount of services, length of time of services, and types of services for which the division will make a subsidy payment and shall sign an agreement specifying the terms of the guardianship subsidy.

History

• AUTHORITY: section 453.072, RSMo Supp. 2009. Original rule filed May 27, 2010, effective Nov. 30, 2010. Original authority: 453.072, RSMo 1999, amended 2001, 2005, 2008.

13 CSR 35-38.030 Definition of Adoption Services {#sec-13-csr-35-38.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-38.030}

PURPOSE: This rule defines adoption services.

(1) Adoption services are defined as assessment and evaluation of the child and his/her needs; arrangements for care of the child prior to adoptive placement; placement of the child with an approved adoptive family; placement support activities until the adoption is legally completed; pre- and post-adoptive counseling to natural and adoptive parents regarding adoption; legal services associated with freeing a child for adoption; recruitment, assessment, approval, and selection of appropriate adoptive family resources; medical, dental, psychiatric, or psychological services for the child as needed; subsidized adoption; and cooperation with other state, regional, and national adoption exchanges or photo-listing services for the

purpose of assuring permanent care of children.

History

• AUTHORITY: section 207.020, RSMo 2000. This rule was previously filed as 13 CSR 40-38.010. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed June 28, 1983, effective Nov. 11, 1983. Moved and amended: Filed May 27, 2010, effective Nov. 30, 2010. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993.

13 CSR 35-38.040 Provision of Adoption Services {#sec-13-csr-35-38.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-38.040}

PURPOSE: This rule sets criteria for provision of adoption services.

(1) The Children’s Division shall accept home assessments from families having an approved adoptive family assessment completed by the division, or other licensed child-placing agencies; registration of children designated as available for adoptive placement; and will cooperate with other state, regional, and national exchanges in the registration of children with special needs.

(2) The Children’s Division shall provide subsidized adoption services to children who are considered to have special needs and who have no other financial resources or limited financial resources.

(3) In order for a child to be determined eligible for subsidized adoption services, he/she shall meet one (1) or more of the following conditions:

(A) Physical Handicap. Any physical abnormality or condition, whether congenital or not, which requires or is likely to require treatment or the purchase of special equipment or services;

(B) Intellectual Impairment. Mental development below an IQ of eighty (80) or other intellectual dysfunction as documented by psychological testing;

(C) Racial or Ethnic Minority. The child’s ancestry is not Caucasian; and (D) Other Conditions.

1. Age. The child is five (5) years old or older and has not reached the age of eighteen (18) years or twenty-one (21) years if the child’s condition requires extraordinary treatment or rehabilitative services.

2. Member of a sibling group. Two (2) or more children who are siblings and are being placed with the same family.

3. Developmental disability. Any documented physical or mental condition not otherwise listed which prevents the child from functioning at the normal level for his/her age.

4. A mental or emotional disturbance. A diagnosed and documented condition which impairs the child’s mental functioning, including learning dysfunctions.

5. Social maladjustment. A severe behavioral condition or inadequate social development which interferes with the child’s ability to form satisfactory relationships with others.

(4) In order for a family to be eligible for subsidy, they shall be approved for adoptive placement by the Missouri Children’s Division, a licensed or approved child-placing agency; or for a family residing outside Missouri, a governmental child-placing agency or a licensed or approved child-placing agency in that state; and shall cooperate in providing information for the division to reach an agreement with the family regarding the amount of services, length of time of services, and the types of services for which the division will make a subsidy payment; and shall sign an agreement specifying the terms of the adoption subsidy.

Amended: Filed June 28, 1983, effective Nov. 11, 1983. Moved and amended: Filed May 27, 2010, effective Nov. 30, 2010. *Original authority: 207.020 RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993.

History

• AUTHORITY: section 207.020, RSMo 2000. This rule was previously filed as 13 CSR 40-38.020. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed Aug. 18, 1977, effective Dec. 11, 1977. Emergency amendment filed Oct. 2, 1981, effective Oct. 12, 1981, expired Jan. 13, 1982. Amended: Filed Oct. 2, 1981, effective Jan. 14, 1982. Amended: Filed Jan. 10, 1983, effective April 11, 1983.

Chapter 50 Licensing

13 CSR 35-50.010 Accreditation as Evidence for Meeting Licensing Requirements SOCIAL SERVICES {#sec-13-csr-35-50.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-50.010}

13 CSR 35-50.010 Accreditation as Evidence for Meeting Licensing Requirements {#sec-13-csr-35-50.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-50.010}

(Moved to 13 CSR 35-35.140)

Chapter 60 Licensing of Foster Family Homes

13 CSR 35-60.120 Criminal Background Check Screening due to Coronavirus-Related Denny Hoskins (3/31/26) {#sec-13-csr-35-60.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.120}

13 CSR 35-60.010 Family Homes Offering Foster Care {#sec-13-csr-35-60.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.010}

PURPOSE: The principles of this rule are to support the licensing of family homes that are resilient, safe, healthy, and economically secure and where the household members are committed to the parental protecting and nurturing of foster youth placed in the family home.

(1) For the purpose of this regulation, the following terms shall be defined as follows:

(A) Foster Parent. A resource provider licensed under these regulations who operates a foster family home, or relatives of a child in foster care who are licensed to provide relative care;

(B) Relative. A relative is a person related to another by blood, adoption, or affinity within the third degree;

(C) Relative Care. Care provided by persons related to the foster youth in any of the following ways by blood, marriage, or adoption: grandparent, brother, sister, half-brother, half-sister, stepparent, stepbrother, stepsister, uncle, aunt, or first cousin;

(D) Traditional Foster Family Home. A private residence of one (1) or more family members providing twenty-four- (24-) hour care to one (1) or more, but less than six (6) children who are unattended by parent or guardian and unrelated to either foster parent by blood, marriage, or adoption;

(E) Foster Youth or Foster Child. A person in the custody of the Children’s Division to a maximum age of twenty-one (21) years of age;

(F) Family Support Team (FST). The group of individuals assembled to participate in a Family Support Team Meeting, a meeting convened by the division or another children’s services provider on behalf of the family and/or child for the purpose of determining service and treatment needs, determining the need for placement, developing a plan for reunification or other permanency options, determining the appropriate placement of the child, evaluating case progress, and establishing and revising the case plan;

(G) Waiver. Authorization by the Children’s Division to excuse certain relative care providers from specifically identified nonsafety licensing standards;

(H) Foster Family Home Applicant. One (1) or two (2) primary adult individual(s) who live in the same household and complete and submit a prescribed application to provide foster care services as parent substitutes to foster youth placed in the home. When two (2) individuals are applying— 1. Both individuals must be assessed separately as if they were applying as a single individual;

2. If either applicant cannot be approved, the application shall be denied; and 3. If both applicants are approved, a single license certificate shall be granted listing the names of both applicants;

(I) Resource Provider. Licensed foster parent as required by 13 CSR 35-60; and (J) Administrative Hold. License status of a foster parent that is operating under a provisional status due to licensing concerns, an investigation or assessment of abuse or neglect in the home, or other reasons as identified in Children’s Division policy.

(2) Process for applying for a license, or for the renewal of a license, as a foster family home.

(A) As required in sections 210.481–210.536, RSMo, any individual(s) planning to offer twenty-four- (24-) hour care to one (1) or more foster children must submit a signed copy of the application form approved by the Children’s Division.

(B) The applicant for the license renewal shall have the burden to establish by a preponderance of evidence that the applicant satisfies all of the qualification requirements for a license.

(C) The applicant for a license or the renewal of a license shall provide any and all documentation and shall execute such authorizations to release information that the Children’s Division may determine to be necessary or convenient to obtain information about the applicant and members of the applicant’s household. If the applicant, or any member of the applicant’s household, fails without good cause to provide the information or fails to execute an authorization to release the information, the division may deny the license.

(D) Any applicant, any household member age eighteen (18) and older, and any child less than eighteen (18) who has been certified as an adult for the commission of a crime, or has been convicted or pled guilty or nolo contendere to any crime, shall register with the Family Care Safety Registry (FCSR) and submit signed release forms and fingerprints for the purpose of obtaining background screening for child abuse or neglect, criminal, and circuit court records.

1. Fingerprints shall be sent to the Missouri State Highway Patrol for criminal background checks.

2. Subject to appropriation, the total cost of fingerprinting required by section 210.487, RSMo, may be paid by the state, including reimbursement of persons incurring the cost of fingerprinting under this subsection.

(E) Upon compliance with licensing law and regulations, the director shall authorize issuance of a license for a term not to exceed two (2) years, subject to renewal on expiration.

1. The license is not transferable and applies only to the foster family home to whom it is issued. Upon approval, a single license listing the individual(s) shall be issued. Only one (1) license can be issued per household. All adults age eighteen (18) and older in the household who will have child care responsibility will be required to attend state-approved foster parent training.

2. The license is the property of the division, not the licensee, and is subject to revocation upon failure of the individual(s) to comply with the licensing requirements. A licensee does not have a right to renewal of his or her license.

3. The license shall be kept on the premises of the home.

The license is a public record and shall, upon request, be made available for inspection.

4. The number, sex, and age range of foster children the home is authorized to accept for care shall be specified on the license and shall not be exceeded except for the temporary placement of sibling or mother and child family groups.

The foster family shall be able to indicate age and gender preference.

5. There shall be no fee for the license or investigations conducted by the personnel of the division or providers contracted by the division.

6. An identification card shall be issued to each foster parent at the time of initial licensure or renewal, verifying current licensing status.

(F) The division shall maintain a file on each applicant for a foster care license. The file shall contain any and all information pertinent to the licensing process including, but not limited to, the application for license and renewals of license and all supporting documentation. Except as otherwise provided herein or otherwise required by law, information contained (3/31/26) Denny Hoskins in a foster care licensing file that may be confidential and not disclosed to the public includes, but is not limited to— 1. Information which is confidential under the Missouri Sunshine Law, section 610.010 et seq., RSMo;

2. Protected health information of the applicant and household members as provided in HIPAA, 45 CFR Parts 160 and 164;

3. Information regarding foster children placed in the home;

4. Information relating to substance abuse diagnosis, care, and treatment, which is confidential pursuant to 42 CFR Part 2.1 and other applicable federal law;

5. Identifying information, addresses, and contact information, the release of which may put the health or safety of foster children, foster parents, or household members at risk; and 6. Other information as may be ordered by a court of competent jurisdiction. Notwithstanding, any provision in these rules to the contrary, parents and legal guardians may have access to information pertaining to foster parents as provided in section 210.498, RSMo.

(G) License Supervision.

1. Licensing staff of the division or its contractor may inspect the foster family home at reasonable times to verify compliance with the licensing rules.

2. The licensee shall cooperate with such inspections.

Notwithstanding, any provision in these rules to the contrary, parents and legal guardians may have access to information pertaining to such inspections as provided in section 210.498, RSMo.

Emergency rule filed July 18, 2006, effective Aug. 4, 2006, expired Jan. 30, 2007. Original rule filed July 18, 2006, effective Jan. 30, 2007. Amended: Filed Sept. 15, 2015, effective March 30, 2016.

Emergency amendment filed Oct. 8, 2025, effective Oct. 23, 2025, expired April 20, 2026. Amended: Filed Oct. 8, 2025, effective April 30, 2026. 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; and 660.017, RSMo 1993,

13 CSR 35-60.020 Capacity of Foster Homes {#sec-13-csr-35-60.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.020}

PURPOSE: This rule tells the ages and number of children to be kept in a foster home. It also lists the exceptions.

(1) The maximum number of children in a foster home shall not exceed six (6). Each foster child shall be counted as one (1) placement. The children of the foster parent are counted within the maximum number of children in the foster home until they reach the age of eighteen (18) years. The Children’s Division may waive the maximum number of children who may be placed in the same foster home to permit the placement of foster children sibling groups and placement of a minor parent and his/her child(ren).

(2) Foster parent(s) shall not provide care for more than two (2) children under age two (2) and no more than four (4) children under the age of five (5) unless necessary to accommodate a sibling group on a temporary basis.

(3) The maximum capacity of homes providing care for youth with elevated needs as defined in 13 CSR 35-60.070 and youth with elevated medical needs as defined in 13 CSR 35-60.100 shall not exceed four (4) placements with no more than two (2) placements of youth with elevated needs. The children of the foster parent are counted within the maximum until they reach the age of eighteen (18) years.

(4) The number of children placed in a foster family home may, at the discretion of the division, exceed the numerical limitation in section (1) of this rule for the following reasons:

(A) To allow a child in foster care who is also the parent of a child to remain together in a foster family home;

(B) To allow siblings to remain together;

(C) To allow a child with an established meaningful relationship with the family to remain with the family; or (D) To allow a family with special training or skills, as determined by the division, to provide care to a child who has a severe disability. Severe disability shall mean the same as a youth with elevated medical needs, as defined in 13 CSR 35-60.100 Foster Care Services for Youth with Elevated Medical Needs.

(5) Foster parents shall notify the division of all contracts for the care of children held at the time of application for an initial license. Foster parents shall notify the division of all contracts for the care of children entered into, terminated, or suspended after licensure.

(6) If a licensed foster parent is also licensed or registered as an in-home child care provider, no foster child under the age of seven (7) may be placed in the foster parent’s home unless necessary to accommodate a sibling group on a temporary

basis. The number of foster children placed at the foster parent’s home shall not cause the licensed or registered child care provider to exceed the number of children for which the provider is licensed or registered.

Original rule filed July 18, 2006, effective Jan. 30, 2007. Amended:

Filed Sept. 15, 2015, effective March 30, 2016. Amended: Filed July 1, 2020, effective Jan. 30, 2021. 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; and 660.017, RSMo 1993,

13 CSR 35-60.030 Minimum Qualifications of Foster Parent(s) {#sec-13-csr-35-60.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.030}

PURPOSE: This rule explains who can qualify to be a foster parent.

It gives the health requirements, standards of living, and personal information required.

(1) Age of Foster Parent(s). Applicant(s) shall not receive a license when one (1) or both are younger than twenty-one (21) except as provided for relative care in section 210.565, RSMo.

(2) Citizenship Status of Foster Parent(s). Applicant(s) who provide foster care must be a citizen of the United States, either through birth or naturalization, or be able to verify lawful immigration status.

(3) Personal Qualifications Required of Foster Parent(s).

(A) Foster parent(s) must be able to acquire skills and demonstrate performance-based competence in the care of children including but not limited to— 1. Understanding trauma and trauma-informed parenting;

2. Supporting families and maintaining children’s connections;

3. Understanding the child welfare system and the social, emotional, and physical impact it has on children and families;

4. Understanding the importance of cultural identity in foster care and adoption; and 5. Understanding children’s mental health issues and how substance use can impact children.

(B) Foster parent(s) shall cooperate with the division in all inquiries involving the care of the foster children. The foster parents’ ability to meet these competencies shall be reevaluated at each re-licensure.

(C) Foster parent(s) shall be responsible, mature individual(s) of reputable character who exercise sound judgment, display the capacity to provide good care for children, and display the motivation to foster.

(4) Health of Foster Family.

(A) Applicant(s) and all proposed foster family members must be determined by a physician to be in good physical and mental health. The physician shall complete a form provided by the licensing agency for each family member that verifies that the individual poses no risk to the health and safety of a foster child. If there is any question about the physical or mental health of any proposed foster family member, the licensing agency may require additional examinations or evaluations.

(5) Foster Parent Training.

(A) Pre-service Training. Prior to licensure, each adult with parenting responsibilities is required to successfully complete a competency based training approved by the Children’s Division.

(B) In-Service Training. To maintain a foster home license each foster parent shall meet performance based criteria as

part of a professional family development plan and complete a prescribed number of foster parent training hours as approved by the licensing authority during each two- (2-) year licensure period. The subject of training shall be directly tied to the foster parent professional development plan and related to the needs and ages of children in their care.

(6) Personal information elicited in the home assessment shall include, but not be limited to— (A) Family size and household composition of the foster family;

(B) Ethnic and racial background of the foster family;

(C) Religious preferences and practices of the foster family;

(D) Lifestyles and practices of the foster parents;

(E) Educational practices of the foster family; and (F) Employment of the foster parents.

(7) Parenting Skills Information Elicited in the Home Assessment.

(A) Foster parent structures environment so that it is safe and healthy for the child.

(B) Foster parent expresses positive feelings toward the child verbally and physically.

(C) Foster parent recognizes and responds appropriately to the child’s verbal and physical expressions of needs and wants.

(D) Foster parent consistently uses basic behavior management techniques in dealing with the child.

(E) Foster parent consistently uses appropriate techniques to discipline the child and does not use or will not use corporal punishment on any child in the custody of the division.

(F) Foster parent guides the child toward increasing independence.

(G) Foster parent behaves in a way that recognizes the developmental stage of the child.

(8) All information which is collected by the division in the licensing study will be condensed to comprise a foster home profile which will be available to team members when children are placed into the care of the division, in order for placement decisions to be made in the best interests of the child. The profile will not contain any protected health information, financial information, or information on biological or adopted children of the foster family.

rule filed July 18, 2006, effective Aug. 4, 2006, expired Jan. 30, 2007. Original rule filed July 18, 2006, effective Jan. 30, 2007.

Amended: Filed Sept. 15, 2015, effective March 30, 2016. Amended:

Filed Oct. 1, 2018, effective May 30, 2019. Amended: Filed Sept. 6, 2023, effective April 30, 2024. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014, and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016. Emergency

13 CSR 35-60.040 Physical and Environmental Standards {#sec-13-csr-35-60.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.040}

PURPOSE: This rule explains what physical and environmental conditions are required for licensing and further describes sleeping arrangements and fire and safety requirements.

(1) Conditions of the Home.

(A) The foster home shall be so located that a foster child has access to schools, recreational, religious, and other community resources.

(B) The home, grounds, and all structures on the grounds must be properly maintained in a clean, safe, and sanitary condition and in a reasonable state of repair within community standards.

(C) The home shall be of size and space and shall have furnishings and equipment to accommodate comfortably the foster parent(s) and all household members.

(D) The interior and exterior must be free from dangerous objects and conditions (meaning that any danger presented from such objects or conditions must be mitigated).

(E) The home shall have space for indoor play and access to outdoor play space. The outdoor play space shall be fenced when in the judgment of the division, nearby street traffic, railroad tracks, lakes, rivers, creeks, streams, swimming pools, or other potential hazards suggest the necessity for such fencing.

(F) The division may require inspection of the home by fire, health, sanitation, safety, or other officials, when in the agency’s judgment such inspection is needed to assist the division in making a decision about the safety of the home. The home must comply with all local, county, and state ordinances.

(G) The home shall have heating and/or cooling as required by the geographic area, consistent with accepted community standards and in safe operating condition.

(H) The home’s private water supply shall be adequate and safe for human consumption. The home’s water supply may be required to be tested at the time of licensing, and the cost of testing will be covered by the applicant. If the private water supply is found to be unsafe for human consumption, an alternative source for drinking water shall be made available.

The home’s water heater shall be set in accordance with the manufacturer’s recommended temperature setting.

(I) The interior of the home shall be free from an accumulation of visible dirt or any vermin, insect, or rodent infestation. The division may excuse compliance with this regulation with respect to a temporary infestation that the foster parent has taken appropriate steps to address.

(J) The home shall have adequate lighting, ventilation, and proper trash and recycling disposal, if recycling is available.

Windows and doors shall be screened as needed unless the area is air conditioned.

(K) All interior doors shall be designed to permit the opening of a locked door from the outside in an emergency.

(L) The home shall have a properly operating kitchen with a sink, refrigerator, stove, and oven.

(M) The home shall have at least one (1) toilet, sink, and tub or shower in operating condition.

(N) Mobile Homes.

1. There shall be an exit at each end of the home.

2. The mobile home shall be skirted with latticed or solid skirting and securely anchored by cable to the ground.

(O) Household swimming pools shall include the following safety requirements:

1. A barrier on all sides. For the purpose of this regulation, the exterior non-climbable surface of an above-ground pool that is at least four feet (4') tall may constitute a barrier;

2. Methods of access through the barrier must be equipped with a safety device, such as a bolt lock;

3. Swimming pools must be equipped with a life saving device, such as a ring buoy; and 4. If the swimming pool cannot be emptied after each use, the pool must have a working pump and filtering system.

(P) Hot tubs and spas must have safety covers that are locked when not in use.

(2) Hazardous Materials and Substances.

(A) All flammable liquids, matches, cleaning supplies, poisonous materials, alcoholic beverages, marijuana, medication, or other hazardous items shall be stored so as to restrict access by children to such items, to the extent such restrictions are appropriate for the age and development of the children in the household.

(B) For the purposes of this regulation, the terms “consumer,”

“qualifying patient,” “marijuana,” “marijuana infused products,” “medical use,” and “primary caregiver” shall have the same definitions set forth in 19 CSR 100-1.010.

(C) Foster parents and household members shall not use or possess substances that they are not permitted to use or possess by law.

(D) Foster parents and household members who use, possess, purchase, or cultivate marijuana must follow all rules and procedures set forth by the Department of Health and Senior Services (DHSS) in 19 CSR 100-1.010 through 19 CSR 100-1.050.

(E) Foster parents shall not use prescription and nonprescription medications, alcohol, or marijuana to the extent that such use would leave the foster parent in an impaired physical or mental state and prevent the foster parent from parenting the child.

(F) Foster parents, household members, and guests shall not use marijuana, tobacco, or nicotine products that emit smoke or vapor, including e-cigarettes, vape pens, or vaporizers, in— 1. The foster home when a child in division custody is placed in the home;

2. A vehicle when transporting a child in division custody; or 3. The presence of a child in division custody.

(G) Foster parents and household members who are qualifying patients, primary caregivers, and/or authorized by DHSS to cultivate marijuana must obtain identification cards from the DHSS. All foster parents and household members shall, upon request, provide the division with a copy of their identification cards as applicable.

(H) All consumer, qualifying patient, and primary caregiver cultivation shall take place in an enclosed, locked facility, as defined in 19 CSR 100-1.010 and with the plant specifications set forth in 19 CSR 100-1.040.

(3) Sleeping Arrangements.

(A) Foster parents must provide a safe and comfortable sleeping space including sleeping supplies, such as a mattress and linens, for each individual child, as appropriate for the child’s needs and age and similar to other household members.

(B) A foster child shall not be permitted to sleep in any building, apartment, or other structure which is separate from the foster family home; nor shall any foster child be permitted to sleep in an unfinished attic, in an unfinished basement, or in a hall or any other room which is normally used for a purpose other than sleeping.

(C) A foster child shall not be permitted to sleep in finished basement bedrooms or in bedrooms above the second floor of a single family dwelling unless suitable provision has been made for heating, ventilation, and humidity control and all exits from these bedrooms have been approved by the division.

(D) At night a responsible adult shall sleep within calling distance of the foster child.

(E) Foster children of the opposite sex, who are six (6) years of age or older, shall not sleep in the same room.

(F) A foster child shall not sleep in the bedroom of an adult age twenty-one (21) years and older except that foster children two (2) years of age or younger may sleep in the bedroom of a foster parent, and foster children two (2) years of age or older may sleep in the bedroom of the foster parents for special temporary care, such as during a child’s illness.

(G) A foster child, including infants, shall never co-sleep or bed-share with foster parents.

(H) Each bed or crib shall be of a size as to ensure comfort of the foster child, shall have a firm mattress or an orthopedic supportive surface, in good, clean condition with waterproof covering, if needed, and suitable covers adequate to the season. All sleeping environments and practices for infants shall be consistent with safe sleep practices as determined by the division.

(I) Each foster child over the age of two (2) shall have bed space equivalent to one-half (1/2) of a full-size bed. Each foster child under the age of two (2) shall have a separate bed. The abuse and neglect history of each child should be taken into consideration before allowing a child to share a bed with another child.

(J) Separate and accessible drawer space for personal belongings and closet space for clothing shall be available for each foster child.

(K) There shall be no surveillance cameras in areas of the home that violate the privacy of the foster child, including but not limited to bathrooms and dressing areas.

(4) Emergency Preparedness, Fire and Safety Requirements, and Evacuation Plans.

(A) All foster homes shall have a working phone or access to a working phone in close walking proximity.

(B) The foster parent(s) shall maintain a comprehensive list of emergency telephone numbers, including fire department, police, doctor, ambulance, and poison control, which shall be posted in a prominent place.

(C) The foster family shall have a written emergency evacuation plan, in case of fire or other emergencies. A foster child shall be instructed in the evacuation plan. The plan shall be posted in a prominent place in the home.

(D) Every room used for sleeping, living, or dining purposes shall have at least two (2) means of exit, at least one (1) of which shall be a door or stairway providing a means of unobstructed travel to the outside. An operable window will be considered as one (1) means of exit.

(E) No room or space shall be occupied for living or sleeping purposes which is accessible only by a ladder, folding stairs, or through a trap door.

(F) In apartment buildings where the foster family residence is on the second floor or above there shall be an exit stairway.

(G) The foster home shall have at least one (1) smoke detector on each level of occupancy of the home and at least one (1) near all sleeping areas.

(H) The foster home shall have at least one (1) carbon monoxide detector on each level of occupancy of the home and at least one (1) near all sleeping areas.

(I) The foster home shall have a charged portable ABC fire extinguisher of at least five- (5-) pound capacity located near the kitchen area.

(J) The foster home shall be free of obvious fire hazards, such as defective heating equipment or improperly stored flammable materials.

(K) Fireplaces, wood stoves, heaters, radiators, or floor furnaces shall have all protective features required by the fire inspector.

(L) The foster family shall maintain first-aid supplies.

(5) Firearms Requirements.

(A) Any and all firearms and ammunition not being carried on one’s person shall be stored in locked areas or cabinets using keys or other locking mechanisms so as to be inaccessible to children.

(B) Firearms and ammunition on one’s person in the presence of a foster child shall be held in a secured holster and not accessible to children subject to the following:

1. No firearms shall be present in any vehicle transporting a foster child unless the firearms are— A. In a locked glove box;

B. In a locked container; or C. In a secure holster inaccessible to children, when carried or concealed on a person possessing a concealed carry permit; and 2. An exception to subparagraphs (5)(B)1.A. through C. of this rule will be made for any governmental law enforcement employee transporting a foster child who must carry firearms and ammunition as part of their job responsibilities.

(C) No firearms possessed in violation of a state or federal law or a local government ordinance shall be present at any time in the foster home, on any household member, or in any vehicle in which a foster child is riding.

(D) Firearms and ammunition storage shall be made available for external viewing by Children’s Division staff to assure firearms and ammunition are inaccessible to children.

External viewing by Children’s Division shall occur upon reasonable notice during reasonable hours for the purpose of foster home licensure, re-licensure, and quarterly visits. This

rule shall not prohibit or hinder the Children’s Division’s ability to assure the safety and wellbeing of children and children’s living conditions. Firearms and ammunition storage shall be available for external viewing without prior notice as part of the periodic visits to the foster child’s home by the foster child’s legal custodian or if— 1. There is a reasonable basis to believe there is a violation of subsections (5)(A) through (C) of this rule; or 2. There are allegations of child abuse or neglect.

Original rule filed July 18, 2006, effective Jan. 30, 2007. Amended:

Filed Sept. 15, 2015, effective March 30, 2016. Amended: Filed June 22, 2020, effective Jan. 30, 2021. Rescinded and readopted:

Filed Feb. 2, 2024, effective Aug. 30, 2024. Emergency amendment filed April 21, 2025, effective May 5, 2025, expired Feb. 11, 2026.

Amended: Filed April 21, 2025, effective Nov. 30, 2025. 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; and 660.017, RSMo 1993,

13 CSR 35-60.050 Care of Children {#sec-13-csr-35-60.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.050}

PURPOSE: This rule sets forth the duties of foster parents to cooperate with Children’s Division and to provide physical care to a foster child. The rule further lists the division’s expectations concerning education and training, moral and religious training, discipline, chores and work, recreation and leisure, earning and spending money, supervision, and transportation.

(1) Duties of Foster Parent(s) to Cooperate with Children’s Division.

(A) As used in this regulation, the term “division” shall refer to Children’s Division or its foster care case management contractor, as applicable.

(B) The foster parent(s) shall cooperate in the division’s delivery of social services to the foster child’s family.

(C) The foster parent(s) shall actively participate in family support team meetings either through attendance or, in lieu of physical attendance, written or oral input.

(D) The foster parent(s) shall notify the division at least two (2) weeks prior to any change in family situation including, but not limited to— 1. A change in address;

2. Telephone number;

3. Employment;

4. Household composition; or 5. Marital status.

(E) Except in family emergencies, the foster parent(s) shall notify the division within two (2) weeks of any intended addition to household membership so that any required background checks may be completed and results obtained and approved prior to the individual joining the household. In cases of family emergency, the foster parent(s) shall immediately notify the division of any additions to the household membership so that background checks may be completed immediately thereafter.

(F) The foster parent(s) shall notify the division if any member of the household is arrested for, pleads guilty to, or is convicted of a criminal offense.

(G) The foster parent(s) shall consult with the division regarding any decisions concerning the child’s care besides routine day-to-day care and decisions relating to extracurricular, enrichment, cultural, and social activities that are governed by the reasonable and prudent parenting standard set forth in

section 210.665, RSMo.

(H) The foster parent(s) shall inform the division before allowing the foster child to go on visits to the foster child’s relatives.

(I) The foster parent(s) shall notify the division immediately of any emergencies involving the foster child. This includes serious illness, or injury requiring medical treatment, or other situations in which sound judgment dictates that the division be notified. This requirement does not relieve the foster parent(s) from first taking action, such as obtaining emergency medical treatment for the child before notifying the division.

(J) If the foster parent(s) discover that the child is missing, the foster parent(s) shall notify the division immediately. Within two (2) hours of discovering that the child is missing, the foster parent(s) shall also file a missing child complaint with the law enforcement agency having jurisdiction, and inform the National Center for Missing and Exploited Children that the child is missing.

(K) The foster parent(s) shall allow the division a reasonable period of time in which to make suitable plans for the foster child when the foster parent(s) have requested the child’s removal. The foster parent(s) shall give the division two (2) weeks’ advance written notice when requesting removal of a child unless there is an emergency. The advance written notice must include an explanation of the reason why the foster parent(s) is requesting the child’s removal.

(L) Foster children shall not be permitted to use or be known by the foster parent(s) surname, unless the child, child’s parent(s), and the division give their consent in writing.

(M) The foster parent(s) shall notify the division at least thirty (30) days prior to moving out of state.

(2) Physical Care.

(A) The foster parent(s) shall work with the division to provide all necessary medical and dental care for each child.

1. The foster parent(s) shall obtain medical and dental examinations for the child immediately following placement and at least annually thereafter in cooperation with the division.

2. The foster parent(s) shall keep the division informed of any health needs of the child.

3. The foster parent(s) shall respond to emergency medical needs in accordance with division policies and procedures and local legal requirements.

4. The foster parent(s) shall not disclose confidential medical information.

5. The foster parent(s) shall maintain a medical file on each foster child placed in the home. The file shall follow the child in the event of removal from the foster home.

(B) The foster parent(s) shall provide a routine for foster children for the establishment of good personal hygiene.

(C) The foster parent(s) shall provide food of quality and quantity sufficient to meet the nutritional requirements of the foster child according to his/her age and activities. All foods shall be prepared, served, and stored under sanitary conditions.

(D) The foster parent(s) shall provide clothing appropriate to the foster child’s age and of quality and quantity similar to other children in the community. Where it is appropriate and possible, foster children shall be allowed to participate in the selection of their own clothing. The possessions and clothing of the foster child shall follow the child in the event of removal from the foster home.

(E) Care of foster children shall not be combined with regular part- or full-time care of other children, unrelated aged individuals, or with any other service or business conducted in the home without the written approval of the division.

(3) Education and Training.

(A) The educational and vocational plan for the foster child shall be determined by the family support team.

(B) The division and Juvenile Office shall be informed of any educational plan other than education in a traditional public school setting.

(C) The foster parent(s) shall comply with the attendance requirements set forth in the educational plan and state law.

(D) The foster parent(s) may “act as the parent” on behalf of the foster child in the development of an Individual Education Plan (IEP). The foster parent acting as the parent may represent a child in all matters relating to the identification, evaluation, educational placement, and the provision of a free, appropriate, public education for the child.

(E) The foster parent(s) shall maintain a school file for the foster child that includes materials obtained through the school, such as child-specific documentation, report cards, photographs, awards, certificates, or mementos. The file is to follow the child in the event of removal from the home.

(4) Moral and Religious Training.

(A) The foster parent(s) shall provide for the moral training of foster children and shall make opportunities available for religious education and attendance of services compatible with the child’s religious heritage, provided that this training would not be injurious to the foster child’s physical, mental, or emotional health.

(B) The foster parent(s) shall support a foster child’s cultural identity and individuality in foster care.

(5) Discipline.

(A) Discipline shall be used in a constructive, fair, and consistent manner. The foster parent(s) shall not subject a foster child to corporal or degrading punishment.

(B) No foster child shall be subjected to verbal abuse, threats of corporal punishment, derogatory remarks about him/herself or members of his/her family, threats to withhold family visits, threats to expel the child from the foster home, or the withholding of food, shelter, or clothing.

(C) No foster child shall be subjected to abuse or neglect as defined in section 210.110, RSMo.

(D) One (1) child shall not be permitted to discipline another child in a foster home.

(E) No foster child shall be deprived of mail or family visits as a form of discipline.

(6) Chores and Work.

(A) No foster child shall be used for soliciting funds or in any other manner exploited by the foster parent(s).

(B) The foster parent(s) shall provide work and chore experience for the foster child that is appropriate to the age, health, and abilities of each individual child. Chores and work shall not interfere with the foster child’s time for school, study periods, play, sleep, normal community contacts, or visits with his/her family.

(C) The foster parent(s) shall differentiate between chores which a foster child is expected to perform as their share in family living and specific work assignments or opportunities as a means of earning money either in or outside the foster family.

(D) The foster parent(s) shall not require or permit work which requires the foster child to operate dangerous or hazardous equipment or machinery unless adequate safety equipment and proper adult supervision are provided.

(E) A foster child shall not be required to perform chores or work that is different in amount and type from the community standard for other children.

(7) Recreation and Leisure.

(A) The foster parent(s) shall provide opportunities for social and physical development through recreation and leisure time activities.

(8) Earning and Spending Money.

(A) The foster parent(s) shall make every reasonable effort to provide opportunities for experience in earning, spending, and saving money based on age and individual requirements of each foster child.

(B) The foster parent(s) shall not require an employed foster child to pay room and board.

(9) Supervision.

(A) The foster parent(s) will adhere to the reasonable and prudent parent standard when making decisions involving the child’s participation in extracurricular, enrichment, cultural, and social activities. In making such decisions, the foster parent(s) shall consider— 1. The child’s age, maturity, and developmental level;

2. The overall health and safety of the child;

3. Potential risk factors and appropriateness of the activity;

4. The best interests of the child;

5. Promoting, where safe and as appropriate, normal childhood experiences; and 6. Any other relevant factors based on the caregiver’s knowledge of the child.

(B) The foster parent(s) shall provide and ensure safe and adequate supervision at all times appropriate to the foster child’s age and individual needs.

(C) The foster parent(s) shall not permit foster children to own or operate firearms without written authorization from the division and proper training.

(D) The foster parent(s) shall comply with all family support team recommendations and court orders regarding visitation plans; any exceptions require prior approval from the division.

(10) Transportation.

(A) The foster parent(s) must ensure that the family has reliable, legal, and safe transportation. Reliable transportation includes a properly maintained vehicle with safety standards within the minimum requirements of the law or access to reliable public transportation.

(B) The foster parent(s) shall cooperate with the division in providing transportation as indicated by the individual needs of each foster child including but not limited to medical and dental appointments, educational or training programs, and counseling.

(C) The foster parent(s) shall not permit a foster child to drive any vehicle without insurance coverage and a proper driver’s license or permit.

(D) If a privately owned vehicle owned by the foster parent(s), their family members, or their friends is used to transport the foster child— 1. The operator of the vehicle must have a valid driver’s license or permit;

2. The vehicle must be insured as required by law;

3. The vehicle must be registered as required by law; and 4. All children in the vehicle shall be secured by car seats or seat belts as required by law.

(E) Reimbursement of mileage allowed per division policy is not a guaranteed payment and is subject to the same restraints as provided in the Department of Social Services Administrative Manual travel policy for state employees.

rule filed July 18, 2006, effective Jan. 30, 2007. Amended: Filed Sept. 15, 2015, effective March 30, 2016. Rescinded and readopted:

Filed Jan. 18, 2024, effective Aug. 30, 2024. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014, and 210.506, RSMo 1982, amended 1993, 1995.

History

• AUTHORITY: sections 207.020 and 210.506, RSMo 2016. Original

13 CSR 35-60.060 Records and Reports {#sec-13-csr-35-60.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.060}

PURPOSE: This rule requires that foster parents keep records on children placed in their care. The division’s assistance is required in this matter. The record’s contents are listed in this rule.

(1) General. A record shall be developed by the division on each foster child and given to the foster parents at the time of placement. As additional information is available, it shall be given to foster parent(s). This record shall be maintained by the foster parent(s) throughout the placement and shall follow the child in the event of removal from the foster home.

(2) Contents.

(A) Foster child’s name, birth date, date of placement, county of original jurisdiction, placement county, case manager’s name and office telephone number, and an after-hours telephone number for the case manager.

(B) Full name and address of the biological and/or legal parent(s) and other interested and responsible relatives where appropriate.

(C) All medical and dental information, including but not limited to diseases, surgical history, allergies, immunizations, psychosocial history, and mental health history.

(D) The foster child’s school records, rewards, pictures, church records, or any special items that will help to document the child’s background.

History

• AUTHORITY: section 207.020, RSMo Supp. 2014, and section 210.506, RSMo 2000. Original rule filed July 18, 2006, effective Jan. 30, 2007. Amended: Filed Sept. 15, 2015, effective March 30, 2016. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 210.506, RSMo 1982, amended 1993, 1995.

13 CSR 35-60.070 Foster Care Services for Youth with Elevated Needs {#sec-13-csr-35-60.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.070}

PURPOSE: This rule defines Foster Care Services for Youth with Elevated Needs.

(1) Definitions for the purpose of this regulation:

(A) Family support team (FST)—The group of individuals assembled to participate in a family support team meeting, a meeting convened by the division or children’s services provider on behalf of the family and/or child for the purpose of determining service and treatment needs, determining the need for placement and developing a plan for reunification or other permanency options, determining the appropriate placement of the child, evaluating case progress, and establishing and revising the case plan;

(B) Foster Youth with Elevated Needs—A program designed for youth with identifiable and documented moderate or serious emotional and/or behavioral needs requiring intensive and individualized intervention to succeed in a communitybased family setting and to achieve their goal of permanency.

There are two (2) levels available to meet the child-specific needs: Level A and Level B;

(C) Psychiatric hospital—A hospital which provides diagnostic and treatment services consistent with the needs of the child.

This is the most restrictive placement option utilized by the Children’s Division;

(D) Medical foster care—A licensed foster home utilized to meet the needs of a child with extraordinary medical needs.

Medical foster parents shall have a foster parent license and receive training from qualified medical care providers specific to the unique medical needs of the child;

(E) Residential care facility—A facility providing twenty-four (24) hour care in a group setting to children who are unrelated to the person operating the facility and unattended by a parent or guardian;

(F) Traditional foster home—A private residence of one (1) or more family members providing twenty-four (24) hour care to one (1) or more, but less than seven (7), children who are unattended by a parent or guardian and unrelated to either foster parent by blood, marriage, or adoption;

(G) Selection/screening team—A team constituted to evaluate a youth’s appropriateness for a higher level placement. The composition of the team shall be determined by the Children’s Division and shall take into consideration the type of expertise necessary to assess the unique needs of the youth being assessed. The team shall include the following individuals: case manager, supervisor, and the circuit or regional specialist or designated facilitator; and (H) “Youth” or “child”—A person within the state who is under the age of eighteen (18), or in the custody of the Children’s Division to a maximum age of twenty-one (21).

(2) Process for Determining Youth with Elevated Needs.

(A) Children in need of foster care will be placed in the least restrictive setting in a traditional foster home. In the event that the child’s condition or behaviors indicate that the child requires a higher level of care, the Children’s Division will assess the youth’s needs to determine which is the least restrictive, but most appropriate, placement to meet the needs of the particular youth based on available resources. The Children’s Division may conduct an elevated needs assessment on the recommendation of the child’s family support team, any member of the family support team, or at the written request of the child’s resource provider.

(B) The elevated needs assessment shall be conducted by the selection/screening team which will decide if the youth is an appropriate candidate for the program by considering the individual needs of the youth, the presenting behaviors of the youth, and the impact such behaviors have in the placement setting. Youth eligible for elevated needs should have more than one (1) presenting problem as listed in Presenting Problems Displayed By the Youth with Elevated Needs—Level A and Presenting Problems Displayed By the Youth with Elevated Needs—Level B sections of this regulation.

(C) Upon evaluation, the selection/screening team shall conclude— 1. That the youth is not appropriate for the Youth with Elevated Needs Program;

2. That the youth is appropriate, but a compatible home is not available in the county of origin or nearby counties; or 3. The youth is appropriate and there is a compatible home.

(3) Payment will be made for the least restrictive level of care found to be appropriate for the youth as determined by the screening team. The resource provider will only receive payment for one (1) level of care for the youth. The division will not make multiple payments for the same level of care to the same provider for the same youth.

(4) Characteristics of a Youth with Elevated Needs—Level A.

(A) Youth with Level A Elevated Needs require significantly greater structure and supervision and are significantly less able to assume responsibility for their daily care than youth in traditional foster care. These youth typically, but not always, have experienced multiple out-of-home placements. Youth appropriate for Level A fall into one (1) of two (2) categories— 1. Youth presently in a residential setting who may be moved to a less restrictive setting, but are not reasonably able to effectively function in a traditional foster home or in their parents’ home; or 2. Youth lacking a viable placement in a traditional foster family home or in their family home, and who, because of their presenting problems, would be placed in a residential setting unless an available Level A foster home can be found.

(5) Characteristics of a Youth with Elevated Needs—Level B.

(A) Youth with Level B Elevated Needs have significantly serious emotional and/or behavioral problems that require the twenty-four (24) hour availability of a highly-skilled Level B resource parent. These youth— 1. Because of their presenting problems, would be placed in a level III or above residential treatment facility or psychiatric hospital; and 2. Have been discharged from a residential treatment facility or psychiatric hospital and are unable to function effectively in a traditional foster home.

(6) Presenting Problems Displayed By the Youth with Elevated Needs—Level A. Level A children have a documented history of presenting behaviors which render the child unable to effectively function outside of a highly structured setting.

Examples of behaviors which the Children’s Division may consider include, but are not limited to:

(A) Significant behaviors which, if not modified, could result in the youth being designated as a status offender/juvenile delinquent;

(B) History of irresponsible or inappropriate sexual behavior, which has resulted in the need for extraordinary supervision;

(C) Significant, extraordinary, threatening, intimidating, or destructive behavior which is demonstrated by multiple incidents over a period of time;

(D) Significant and extraordinary oppositional and/or defiant behaviors when dealing with authority figures which pose a significant risk to the health and safety of the child or to others;

(E) Significant and extraordinary problems with peer-to-peer interactions which pose a significant risk to the health and safety of the child and/or his or her peers;

(F) Significant and extraordinary behavioral and academic problems at school that affect academic achievement or social adjustment;

(G) Significant and extraordinary conduct problems with lying, stealing, or manipulating;

(H) Significant and extraordinary problems with his or her ability to control and/or appropriately express anger;

(I) Significant problems with the abuse of alcohol and controlled substances;

(J) Oppositional behavior which contributes to placement disruptions and the inability to function productively with peers, parent figures, birth family, etc.;

(K) Any of the above behaviors, coupled with medical problems; or (L) Any of the above behaviors displayed by one (1) or more youth within a sibling group, qualifying the entire sibling group for placement together, if appropriate. However, not all of the youth within the sibling group would be eligible for the Level A maintenance rate.

(7) Presenting Problems Displayed By the Youth with Elevated Needs—Level B. Level B children have a documented history of presenting behaviors or diagnoses which render the child unable to effectively function outside of a highly structured setting. Examples of behaviors or diagnoses which the Children’s Division may consider include, but are not limited to:

(A) History of suicide or currently having suicidal thoughts, statements, and/or gestures;

(B) Affective disorders;

(C) Attention Deficit Disorder;

(D) Post-Traumatic Stress Disorder;

(E) Eating disorders;

(F) Panic disorders;

(G) Fears/phobias;

(H) Obsessive/Compulsive Disorders;

(I) Oppositional Defiant Disorders;

(J) Depression/withdrawal;

(K) Dissociative behaviors, black out, pass out, seizure;

(L) Anger/rage;

(M) History of fire setting;

(N) Destruction of property;

(O) Failure to form emotional attachments; and (P) Multiple short-term placements.

(8) Youth Who May Not be Appropriate for Level A. Youth who may not be appropriate for Level A may include, but are not limited to, the following:

(A) Children who may function successfully in a traditional foster home or adoptive or guardianship placement;

(B) Youth who qualify for a higher level of care and meet the criteria for Youth with Elevated Needs Level B;

(C) Children under the age of three (3) who cannot be treated effectively through the behavior modification treatment model;

(D) Youth who exhibit severe psychiatric behavior, as diagnosed by a psychiatrist/psychologist, such as an obvious lack of emotional contact, affect disturbances, and/or severe thought distortions;

(E) Youth with a recent history of extreme or dangerous physical aggression;

(F) Youth with a recent history of fire setting;

(G) Youth who have recently attempted suicide and continue to have suicidal ideations;

(H) Youth with an IQ score below sixty-five (65);

(I) Youth who are medically diagnosed as chemically dependent;

(J) Youth with severe medical or physical handicaps which present barriers that the child cannot or will not overcome;

(K) Youth whose primary presenting problem, as diagnosed by a psychiatrist/psychologist, is sexual addiction and who need extremely structured treatment and unusually close supervision; or (L) Youth with personality disorders, as diagnosed by a psychiatrist/psychologist, who have severe problems forming attachments with caretakers and significant others.

(9) Youth Who May Not be Appropriate for Level B. Youth who may not be appropriate for Level B may include, but are not limited to, the following:

(A) Children who may function successfully in a traditional foster home or adoptive or guardianship placement;

(B) Youth who qualify for a lower level of care and meet the criteria for Youth with Elevated Needs Level A;

(C) Actively suicidal;

(D) Homicidal;

(E) Compulsive fire setter;

(F) Sexual abuse offender which might endanger other family members;

(G) Require around-the-clock awake supervision;

(H) Unable to function in school, and alternative program (day treatment) is not available; and (I) Youth who have demonstrated behaviors that pose a significant risk of harm to the youth or others which require professional treatment in a hospital or institutional or structured residential care setting.

(10) Working with Youth with Developmental Delays. Youth with developmental delays may, or may not, be appropriate for Level B Foster Care. Appropriateness for Level B Foster Care should be based on the selection/screening team and/or the family support team (FST) evaluation of all the circumstances surrounding that particular youth. Youth should not be ruled out for Level B based solely on the singular characteristic of an IQ score falling below sixty-five (65). Instead, the team should consider a variety of information including, but not limited to, the following:

(A) Youth’s functioning level;

(B) Severity of developmental delays;

(C) Ability for self-care;

(D) Type of behavior problems;

(E) Level of physical aggressions;

(F) Age;

(G) Compliance; and (H) Need for supervision.

(11) Level A Resource Provider Training Requirements. In order to qualify as a Level A resource provider, the resource provider shall complete all required hours of pre-service training in addition to successful completion of eighteen (18) hours of specialized training workshops from the following topics:

(A) Team and relationship building;

(B) Communication skills;

(C) Behavior management techniques;

(D) Discipline and punishment procedure;

(E) Management of behavior crisis situations;

(F) Development of an individual treatment plan;

(G) De-escalation skills;

(H) Negotiation;

(I) Positive reinforcement technique; or (J) Professional skills for foster parents.

(12) Level B Resource Training Requirements. In order to qualify as a Level B resource provider, the resource provider shall complete all required hours of pre-service training, complete eighteen (18) hours of Level A specialized training, and participate in the following nine (9) hours of specialized training and practicum designed specifically for Level B resource providers:

(A) Crisis Intervention—Two (2) hours;

(B) Behavior Management—Two (2) hours;

(C) Suicide Management—Two (2) hours;

(D) Medication Management—Two (2) hours; and (E) Family Orientation—One (1) hour (training shall include how the severely emotionally disturbed or behavior disordered child may impact the resource provider’s family).

(13) Reviews. The Children’s Division will conduct reviews to ensure that progress is being made toward permanency throughout the Level A or Level B placement. The division shall conduct reviews as often as the division determines is necessary to assess the needs of the child. However, the division shall convene the selection/screening team to assess the child’s placement at least every one hundred eighty (180)

days. Children covered by an adoption subsidy or guardianship subsidy agreement will be reviewed at least every two (2) years. The division will seek a less restrictive setting once the youth’s presenting problems have been replaced with appropriate coping behaviors. The decision to terminate the child’s placement in a Level A or B setting shall be made solely by the Children’s Division. In making the decision, the division shall consult with and consider the recommendation of the FS T.

History

• AUTHORITY: section 453.073, RSMo Supp. 2009, sections 207.020, 210.506, and 453.074, RSMo 2000, and Young v. Children’s Division, State of Missouri Department of Social Services, 284 S.W.3d 553 (Mo. 2009). Original rule filed Feb. 23, 2010, effective Oct. 30, 2010. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993; 210.506, RSMo 1982, amended 1993, 1995; 453.073, RSMo 1973, amended 1978, 1981, 1982, 1985, 1997, 2001, 2005, 2008; and 453.074, RSMo 1985.

13 CSR 35-60.075 Treatment Foster Care {#sec-13-csr-35-60.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.075}

PURPOSE: This rule establishes conditions for providing foster family homes for children with significant emotional or behavioral needs, who can reside in a family setting with the benefit of intensive and individualized therapeutic intervention.

(1) Definitions. For the purpose of this regulation, the following terms shall be defined as follows:

(A) “Treatment foster care” or “TFC”—A specialized program for children between the ages of six (6) and twenty (20) with significant emotional or behavioral needs who, with intensive and individualized therapeutic intervention, can remain in a family setting and achieve positive growth and development;

(B) “Treatment foster home”—A home where the child’s caregiver(s) have fulfilled the requirements to provide treatment foster care and are responsible for providing intensive, individualized therapeutic interventions and daily care for one (1) to two (2) children with significant medical, developmental, emotional, or behavioral needs; and (C) “Level 2 Treatment Foster Care” or “Level 2 TFC” – A level of treatment foster care for children whose needs and/ or behaviors are so persistent and severe that they require the coordination of multiple services and interventions, including therapeutic and community-based services for the child who could not otherwise be served in a community setting without that level of individualized intervention.

(2) Treatment Foster Care.

(A) TFC exists to serve children whose special needs are so severe that they are at risk of being placed in restrictive congregate care settings such as hospitals, psychiatric centers, correctional facilities, or residential treatment programs. TFC services are provided by agencies contracted with the division to develop and oversee treatment foster homes. Each treatment foster home is assigned a TFC worker who is primarily responsible for the development of treatment plans. The TFC worker trains and supports the TFC parent(s) to implement key elements of treatment in the context of family and community life while promoting the goals of permanency planning for the child. The TFC worker also provides support and consultation to children enrolled in the TFC and their families. The TFC worker collaborates with other team members and coordinates activities to ensure children and families receive needed services according to their treatment plan. The TFC agency provides, at a minimum, weekly consultation to the TFC home and in-person contact every two (2) weeks.

(3) Process for Determining a Child’s Eligibility for Treatment Foster Care.

(A) A child’s eligibility for treatment foster care is identified through one (1) of the following triggering events:

1. The selection/screening team for the division’s Youth with Elevated Needs Program has recommended treatment foster care;

2. An independent assessor has recommended treatment foster care;

3. The child’s family support team has recommended treatment foster care; or 4. A clinician, such as a primary care physician or psychologist, who has examined or evaluated the child, has recommended treatment foster care.

(B) A division designee shall review the recommendation from one (1) of the parties above, using an agency-approved assessment tool, and supporting documentation such as the child’s current mental health evaluations, medical reports, therapy/counseling reports, and school records.

(C) The division designee shall evaluate the child’s condition and make a determination if treatment foster care is medically necessary, appropriate for the child, and the least restrictive placement in a community-based family setting.

(D) The division designee will determine an initial treatment period of up to nine (9) months in duration. The initial treatment period may be extended upon review and approval by division designee.

(E) The division designee shall have the final authority to determine if a child qualifies for treatment foster care and, if so, when a child’s placement in a treatment foster care home will end.

(F) Children who demonstrate one (1) or more of the following needs or behaviors may be eligible for Level 2 Treatment Foster Care.

1. Need for safety measures within the home, including, but not limited to:

A. Alarm system;

B. Locks;

C. Cameras; or D. Physical separation from other children.

2. Need for one-on-one supervision by the TFC parent at least seventy-five percent (75%) of the time, including both waking and sleeping hours (exception to this requirement to allow for a substitute care provider during times that the TFC parent is unavailable).

3. Chronic elopement.

4. Need for treatment of current substance abuse.

5. Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of autism spectrum disorder (per DSM, Level 2 and 3 of autism spectrum disorder require substantial to very substantial support).

6. DSM diagnosis of intellectual disability (IQ 70 or below, onset before 18, DSM 5 onset during developmental periods).

7. DSM diagnoses of scatolia (feces smearing), incontinence, or enuresis.

8. Need for additional supervision and services due to homicidal threats.

9. Known or suspected history of child human trafficking.

10. Dissociative behaviors.

11. Periods of unconsciousness (blacking out, epilepsy, seizure).

12. History of fire setting.

13. Multiple short-term placements (taking into consideration number and types of placements in placement

history).

14. Medical condition requiring daily monitoring, dependence on mechanical support for mobility, or an appliance for breathing, feeding, or drainage, including, but not limited to:

A. G-tube;

B. Trach;

C. Wheelchair;

D. Epilepsy;

E. Diabetes requiring insulin;

F. Medical condition requiring a lift; or G. Medical condition requiring assistance with bathing and toileting.

15. Nonverbal.

16. Self-harm with suicidal ideation or self-harm resulting in injury that requires medical attention, including cutting and swallowing harmful objects or substances.

17. Frequent utilization of 24/7 crisis intervention or acute hospitalization.

18. Involvement with the juvenile justice system.

19. Need for frequent respite above and beyond the approved level of respite.

20. Inability to maintain traditional school setting, including, but not limited to:

A. Homebound school;

B. Day treatment;

C. Non-traditional school setting;

D. Specialized school transportation; or E. Extra-ordinary educational support.

(4) Qualifications of Foster Parents in Treatment Foster Care Homes.

(A) Qualifications. To be eligible to become TFC foster parents, applicants must meet one (1) of the following criteria:

1. Have one (1) year full-time experience in the care of a child, which may include a combination of any of the following:

A. Experience as a licensed foster parent in good standing;

B. Professional experience in the care/treatment of a child;

C. Volunteer experience in the care/treatment of children; and D. Experience providing care for a child with special needs; or 2. Have graduated from a four- (4-) year college with a degree in child and family development, special education, psychology, sociology, or another closely related area; or 3. The division may allow an exception to be made to the eligibility requirements set forth above if the applicant is a relative of the foster child.

(5) Training Requirements.

(A) Pre-Service Training. Applicants must complete the following pre-service training requirements to qualify as a foster parent in a treatment foster care home:

1. Successfully complete a competency based pre-service training approved by the division as provided in 13 CSR 35- 60.030(5);

2. Complete a minimum of twenty-seven (27) hours of specialized foster care training approved by the division that includes the following areas:

A. Effective communication and relationship building techniques;

B. Positive reinforcement, discipline, and behavior management techniques;

C. Crisis management and de-escalation techniques;

D. Self-harming and suicide intervention and management;

E. Running behaviors, prevention and management;

F. Cultural competence and culturally responsive services; and 3. Relative caregivers who wish to become TFC foster parents will have up to ninety (90) days to complete nine (9) hours of pre-service relative training and will have up to six (6) months from the date on which the child is approved for relative TFC placement to complete the mandatory twentyseven (27) hours of pre-service training set forth in paragraph (5)(A)2. above.

(B) In-Service Training.

1. In addition to the in-service training required of all foster parents pursuant to 13 CSR 35-60.030, TFC foster parents must complete five (5) additional hours of annual in-service training relating to the rehabilitative treatment and care of the foster child. As part of this ongoing training, the foster parent shall meet performance-based criteria as part of a professional family development plan.

2. The division may allow an exception to be made to the five- (5-) hour annual training requirement if the primary caretaker in a treatment foster care home is a relative of the foster child.

3. In addition to the requirements set forth in paragraph 1, Level 2 TFC foster parents must complete five (5) additional hours of annual in-service training relating to the rehabilitative treatment and care of the foster child.

(6) Competency Requirements.

(A) In order to be licensed as TFC foster parents, applicants must demonstrate competency in the following subject matter areas, which will be covered in the pre-service and in-service trainings:

1. Understanding trauma, grief, loss, and separation and the impact on child development;

2. Promoting successful transition into the family and the community;

3. Using trauma-informed strategies to meet the needs of children with exceptional care needs;

4. Assessing crisis situations and utilizing proper crisis intervention and regulation;

5. Recognizing and implementing positive approaches to challenging behaviors;

6. Understanding the importance of and advocating for permanency, family, and cultural connections; and 7. Understanding the importance of attachment, relationship building, connections, and creating a support system.

(7) Treatment Foster Care Parent Responsibilities. Foster parents in treatment foster care homes shall be responsible for the following duties:

(A) Complying with all foster home licensing requirements set forth in this chapter;

(B) Providing therapeutic interventions in the home and acting as a liaison with clinical personnel;

(C) Assisting the child in understanding treatment goals, objectives, and interventions, and helping the child to achieve success;

(D) Complying with all requests from the division for visits, training, and meeting participation, including participation in treatment plan meetings and treatment foster care support group meetings;

(E) Ensuring routine transportation for each foster child, including transportation for the child to/from treatment team meetings, court appearances, medical, and counseling appointments; and (F) Working closely with all necessary parties, including the child’s parents, visiting resources, and case managers to achieve permanency for the child, in accordance with the treatment plan.

History

• AUTHORITY: section 207.020, RSMo 2016. Original rule filed Dec. 15, 2022, effective July 30, 2023. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014.

13 CSR 35-60.080 Licensing Standard Waivers for Relative Resource Providers {#sec-13-csr-35-60.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.080}

PURPOSE: This rule describes the waiver of certain non-safety foster home licensing standards to be granted on a case-by-case

basis for relatives to become licensed as relative resource providers.

(1) A relative care provider shall meet all licensing requirements to be licensed as a foster home. Notwithstanding the other provisions of this rule, the Children’s Division may grant a waiver of non-safety licensure standards on a case-by-case

basis. The Children’s Division will grant a waiver of non-safety foster home licensing standards only if the relative provider establishes the safety and well being of the relative foster child(ren) can be assured if the waiver is granted.

(2) Only the following licensing non-safety standards may be waived to license a relative resource provider under this

regulation:

(A) The requirements of 13 CSR 35-60.020(1), (2), and (3);

(B) The requirements of 13 CSR 35-60.030(1), (4)(A), and (5)(B); and/or (C) The requirements of 13 CSR 35-60.040(2)(D) through (F), and (2)(J).

History

• AUTHORITY: sections 207.020, 210.506, and 660.017, RSMo 2016, and section 210.565, RSMo Supp. 2020. Original rule filed Sept. 15, 2015, effective March 30, 2016. Amended: Filed June 22, 2020, effective Jan. 30, 2021. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; 210.565, RSMo 1990, amended 1994, 2004, 2009, 2011, 2017, 2019; and 660.017, RSMo 1993, amended 1995.

13 CSR 35-60.090 Denial or Revocation of License {#sec-13-csr-35-60.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.090}

PURPOSE: This rule addresses the procedures for license denial or revocation and the right for a hearing for a foster parent who is aggrieved by denial or revocation of his/her license, as required by

section 210.526, RSMo.

(1) The division may deny a license to an applicant, or may revoke the license of a licensee, if the applicant or anyone in the applicant’s household— (A) Fails consistently to comply with the applicable provisions of sections 208.400 to 208.535, RSMo, and the rules of the Children’s Division promulgated thereunder;

(B) Violates any of the provisions of its license;

(C) Violates state laws and/or rules relating to the protection of children;

(D) Furnishes or makes any misleading or false statements or reports to the division;

(E) Refuses to submit to the division any reports or refuses to make available to the division any records required by the division in conducting an investigation;

(F) Fails or refuses to admit authorized representatives of the division into his/her home at any reasonable time for the

purpose of investigation;

(G) Fails or refuses to submit to an investigation by the division;

(H) Fails to provide, maintain, equip, and keep in safe and sanitary condition the premises established or used for the care of children being served, as required by law, rule, or ordinance applicable to the location of the foster home;

(I) Fails to provide financial resources adequate for the satisfactory care of and service to children being served and the upkeep of the premises; or (J) Abuses or neglects children, or is the subject of reports of child abuse or neglect which upon investigation result in a court adjudicated, probable cause and/or preponderance of evidence finding, or is found guilty, pleads guilty to, or pleads nolo contedere to felony crimes against a person to include, but not limited to, felony possession, distribution, or manufacturing of controlled substance crimes as specified in Chapters 195, 565, 566, 567, 568, and 573, RSMo, or a substantially similar offense if committed in another state or country. The division may also deny or revoke a license to any person(s) who are on the respective Department of Health and Senior Services and/or the Department of Mental Health lists that exclude child or adult care employment and/or licensure.

(2) The division shall provide written notice of denial or revocation of a license. The notice shall— (A) Inform the applicant or licensee of the nature of the decision;

(B) State generally the factual and legal basis for the division’s decision;

(C) State the effective date of the application, if applicable; and (D) Notify the licensee of his/her right to seek administrative review.

(3) At any time during the denial or revocation process, the division may issue an amended notice of denial or revocation if additional, relevant information is discovered.

(4) Any notice for revocation shall be given ten (10) days prior to the effective date of the action.

(5) The licensee or applicant may not reapply for licensure within one (1) year from the date of denial or revocation.

If a licensee or applicant for license has previously had an application for foster parent license denied or revoked by the State of Missouri or any other state or country, the applicant shall fully disclose the reasons for the denial or revocation and shall establish by preponderance of the evidence that the reasons for the license denial or revocation have been cured or no longer exist.

(6) The Children’s Division will retain the option not to renew a foster home license in cases where a licensed foster home has not accepted a placement over a two- (2-) year period.

(7) Hearing on Administrative Review.

(A) The applicant/licensee who is aggrieved by the decision of the division to deny a license application, deny license renewal, or revoke an existing license shall have the right to a hearing on administrative review of the division’s decision.

(B) The licensee or applicant for a license may appeal the decision of the division to deny or revoke the license by filing a written request for administrative review with the division within thirty (30) days after the date of the notice of denial or revocation. The request for administrative review shall set forth the basis of the applicant/licensee’s objection to the division’s decision.

(C) The division may attempt to resolve the issue with the aggrieved party with an informal meeting prior to the hearing.

(D) If renewal of a license is denied and an administrative review hearing is properly requested, the applicant’s current license shall be placed on administrative hold pending the entry of an order after the administrative review hearing.

(E) If an existing license is revoked and an administrative review hearing is properly requested, the license shall be placed on administrative hold pending the entry of an order after the administrative review hearing.

(F) If the licensee or applicant for a license requests an administrative review hearing, the division shall hold said hearing following the procedures for an administrative review hearing in contested cases as set forth in Chapter 536, RSMo.

The Administrative Hearings Unit of the Division of Legal Services of the Department of Social Services (Administrative Hearings Unit) shall hold all hearings. The Administrative Hearings Unit shall be authorized to issue subpoenas and subpoenas duces tecum pursuant to section 536.077, RSMo.

(G) After the hearing, the Administrative Hearings Unit shall issue a written decision and, except in default cases or cases disposed of by stipulation, consent order, or agreed settlement, the decision, including orders refusing licenses, shall include or be accompanied by, findings of fact and conclusions of law. The findings of fact shall be stated separately from the conclusions of law and shall include a concise statement of the findings on which the agency bases its order. Immediately upon deciding any contested case, the agency shall give written notice of its decision by delivering or mailing such notice to each party, or his/her attorney of record, and shall upon request furnish him/ her with a copy of the decision, order and findings of fact and conclusions of law.

(H) The decision of the Administrative Hearings Unit shall be the final decision of the division. Any person aggrieved by a final decision of the division shall be entitled to judicial review as provided in sections 210.526 and 536.100 through 536.140, RSMo.

History

• AUTHORITY: section 207.020, RSMo Supp. 2014, section 210.565, RSMo Supp. 2013, and section 210.506, RSMo 2000. Original rule filed Sept. 15, 2015, effective March 30, 2016. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; and 210.565, RSMo 1990, amended 1994, 2004, 2009, 2011.

13 CSR 35-60.100 Foster Care Services for Youth with Elevated Medical Needs {#sec-13-csr-35-60.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.100}

PURPOSE: This rule defines foster care services for youth with elevated medical needs.

(1) Definitions for the purpose of this regulation.

(A) Youth with Elevated Medical Needs—a youth or child with medically diagnosed extraordinary medical condition(s) and or physical or mental disabilities as set forth in section (3) of this regulation.

(B) Resource provider—a foster parent who has a current license issued pursuant to 13 CSR 35-60.010–13 CSR 35-60.110.

(C) All other terms used in this regulation shall be defined consistent with 13 CSR 35-60.070.

(2) Process for identifying Youth with Elevated Medical Needs.

(A) The Children’s Division may conduct a medical needs assessment on the recommendation of the youth’s family support team, any member of the family support team, at the written request of the youth’s resource provider, or if ordered to do so by the court.

(B) The written request shall include: a completed assessment tool on a form provided by the division and all supporting medical documentation. The medical documentation shall include, at a minimum, the name and address of each of the youth’s physicians. Any person submitting a request shall provide any additional documentation as requested by the Children’s Division to process the request. The person submitting the request shall have the burden to prove by a preponderance of the evidence that the youth meets the criteria for a youth with elevated medical needs as set forth in this regulation.

(C) Upon receipt of the request, assessment tool, and all supporting documentation, the division will determine whether or not the youth is a youth with elevated medical needs as specified in this regulation. The Children’s Division will provide written notification of its decision to the person submitting the request.

(3) Characteristics of a Youth with Elevated Medical Needs.

In order to qualify as a youth with elevated medical needs, the youth must have a diagnosed medical or mental health condition that requires twenty-four- (24-) hour availability of a resource provider specifically trained to meet the elevated medical needs in order to successfully function in a foster family home setting and does not require placement in an institutional setting such as residential care or a hospital. A youth with elevated medical needs must meet the criteria outlined in subsection (A) or (B) below:

(A) Youth with elevated medical needs will have at least one (1) of the following diagnosed conditions and that condition significantly and substantially impairs the youth’s ability to function on a daily basis:

1. Down Syndrome;

2. Trisomy 18 (Edward’s Syndrome);

3. Triple-X Syndrome;

4. Pierre Robin Syndrome;

5. Cystic Fibrosis;

6. Cancer;

7. Autism Spectrum Disorders;

8. Cri-du-Chat Syndrome;

9. Trisomy 13 (Patau’s Syndrome);

10. Fragile X Syndrome;

11. Epilepsy/Seizure Disorder;

12. Cerebral Palsy;

13. HIV positive status;

14. Fetal Alcohol Syndrome;

15. Klinefelter’s Syndrome;

16. Turner’s Syndrome;

17. Prader-Willi Syndrome;

18. Spina Bifida;

19. Sickle Cell Disease;

20. PKU (phenylketonuria);

21. Systemic Lupus Erythamatosus;

22. Hypoxic-Ischemic Encephalopathy (HIE) and at term (36 weeks gestation or more);

23. Short Gut Syndrome with Dependence on Parenteral Nutrition;

24. Visual Impairment which meets the following criteria:

A. A medical diagnosis of visual acuity 20/70 or less in the better eye with maximum correction; or B. A very limited field of vision (20 degrees at its widest point); or C. A progressive disease leading to either of the above;

25. Congenital viruses/bacteria, herpes, syphilis, cytomegalovirus, toxoplasmosis, and rubella;

26. Cranio-facial anomalies (i.e., cleft palate, etc.);

27. Hearing impairments, which meets the following criteria:

A. For children below five (5) years of age, inability to hear air conduction thresholds at an average of forty (40) decibels (db) hearing level or greater in the better ear; or B. For children five (5) years of age and above:

(I) Inability to hear air conduction thresholds at an average of seventy (70) decibels (db) or greater in the better ear; or (II) Speech discrimination scores at forty percent (40%) or less in the better ear; or (III) Inability to hear air conduction thresholds at an average of forty (40) decibels (db) or greater in the better ear, and a speech and language disorder which significantly affects the clarity and content of the speech and is attributable to the hearing impairment;

28. Diabetes Mellitus Type I or Type II requiring daily glucose monitoring;

29. Hydrocephalus with Ventriculo-Peritoneal Shunt;

30. Cyanotic Congenital Heart Disease;

31. Developmental delays in at least one (1) area severe enough to qualify for First Steps of Missouri early intervention program as provided in 34 CFR 303.322:

A. Cognitive development;

B. Communication development;

C. Adaptive development;

D. Physical development, including vision, and hearing; or E. Social or emotional development;

32. Immobility;

33. Requires wheelchair and is dependent on mechanical support to be mobile; or 34. Has appliance for breathing, feeding or drainage (i.e., catheter, colostomy, gastrostomy tube, or tracheostomy).

(B) Submission of written certification from the treating physician of a diagnosed serious or chronic medical condition that significantly and substantially impairs the foster youth’s ability to function on a daily basis in a foster family home setting.

(4) Medical resource provider requirements for placement of youth with elevated medical needs. In order to qualify to receive the medical maintenance rate from the division, the resource provider shall— (A) Be licensed as required in 13 CSR 35-60.010–13 CSR 35- 60.110;

(B) Enter into a contract with the Children’s Division to provide medical foster care;

(C) Successfully complete and provide documentation of the completion of individualized medical training specific to the needs of the youth provided by the youth’s health care provider or other provider and approved by the division; and (D) Be currently providing placement for a youth who meets the criteria of a youth with elevated medical needs.

(5) Reviews. After a youth has been identified as a youth with elevated medical needs, the Children’s Division shall periodically review the status of the youth to determine whether the youth continues to meet the criteria for youth with elevated medical needs. The division shall conduct reviews as often as the division determines is necessary to assess the elevated medical needs of the youth, however, the division shall review the elevated medical needs at least annually.

(6) Termination.

(A) The Children’s Division may terminate the youth’s status as a youth with elevated medical needs when the Children’s Division determines that the youth no longer meets the criteria as set forth in this regulation.

(B) The Children’s Division will terminate the payment of medical rate maintenance to the resource provider when the youth no longer meets the criteria as set forth in this regulation or the criteria in section (5) are no longer met.

History

• AUTHORITY: sections 207.020, 453.073, and 453.074, RSMo Supp. 2014, and section 210.506, RSMo 2000. Original rule filed Sept. 15, 2015, effective March 30, 2016. 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; 453.073, RSMo 1973, amended 1978, 1981, 1982, 1985, 1997, 2001, 2005, 2008, 2014; and 453.074, RSMo 1985, amended 2014.

13 CSR 35-60.110 Removal of a Parent from a Foster Family License {#sec-13-csr-35-60.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.110}

PURPOSE: This rule explains the process to remove one (1) foster parent from a foster family home license.

(1) If a licensee who was approved for a two- (2-) parent foster family home license moves away from the foster family home, both persons listed on the license shall notify the division in writing two (2) weeks prior to this change, or within two (2) weeks after its occurrence if the change in residence was unplanned.

(A) Each licensee on the two- (2-) parent license who desires to continue providing foster care services shall be re-assessed by the division as a single foster parent family home.

(B) Each licensee who fails to notify the division within the time frame identified herein will be in violation of their license and the division shall commence the revocation process as outlined in 13 CSR 35-60.090.

(2) If a licensee who was approved for a two- (2-) parent foster family home license dies, the surviving licensee shall notify the division in writing within two (2) weeks of the death.

(A) If the surviving licensee desires to continue providing foster care services, he or she shall be re-assessed by the division as a single parent foster family home.

(B) If the surviving licensee fails to notify the division within the time frame identified herein, he or she will be in violation of their license and the division shall commence the revocation process as outlined in 13 CSR 35-60.090.

History

• AUTHORITY: sections 207.020, 453.073, and 453.074, RSMo Supp. 2014, and section 210.506, RSMo 2000. Original rule filed Sept. 15, 2015, effective March 30, 2016. 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; 453.073, RSMo 1973, amended 1978, 1981, 1982, 1985, 1997, 2001, 2005, 2008, 2014; and 453.074, RSMo 1985, amended 2014.

13 CSR 35-60.120 Criminal Background Check Screening due to Coronavirus-Related Closures {#sec-13-csr-35-60.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-60.120}

PURPOSE: This rule will allow for an alternate criminal history background check process and timeframe for foster parent applicants due to coronavirus-related closures of fingerprinting locations.

(1) Notwithstanding any other regulations to the contrary, beginning April 17, 2020, any applicant, any household member age seventeen (17) and older, and any child less than seventeen (17) who has been certified as an adult for the commission of a crime, or has been convicted or pled guilty or nolo contendere to any crime, shall register with the Family Care Safety Registry (FCSR) and submit signed release forms and fingerprints for the

purpose of obtaining background screening for child abuse or neglect, criminal, and circuit court records.

(A) Fingerprints shall be sent to the Missouri State Highway Patrol for criminal background checks. Subject to geographic availability, as determined by the Children’s Division, fingerprinting shall be completed prior to issuance of a license.

(B) In the event fingerprinting is not available due to closures of fingerprinting locations in the applicant’s geographic region, a name-based criminal background check utilizing the individual’s name, date of birth, social security number, sex, and race is satisfactory for licensure provided that fingerprints are submitted to the Missouri State Highway Patrol for positive identification as soon as possible, but no later than one hundred eighty (180) calendar days from the date of the preliminary name-based background check, or ninety (90) calendar days from the expiration of the state’s emergency declaration, whichever occurs sooner.

(2) The failure to follow all requirements and timeframes for criminal background checks, including fingerprints, shall be grounds for license revocation in accordance with 13 CSR 35- 60.090.

rule filed May 6, 2020, effective May 21, 2020, expired Feb. 25, 2021. Original rule filed May 6, 2020, effective Nov. 30, 2020. 1986, 1993, 2014; 210.486, RSMo 1982, amended 1993; 210.487, RSMo 2004, amended 2007, 2013, 2018; 210.506, RSMo 1982, amended 1993, 1995; and 660.017, RSMo 1993,

History

• AUTHORITY: sections 207.020, 210.486, 210.506, and 660.017, RSMo 2016, and section 210.487, RSMo Supp. 2020. Emergency

Chapter 71 Rules for Residential Care Facilities for Children

13 CSR 35-71.015 Background Checks for Personnel of Residential Care Facilities {#sec-13-csr-35-71.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.015}

13 CSR 35-71.025 Exemption of Religious Residential Treatment for Children and {#sec-13-csr-35-71.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.025}

13 CSR 35-71.100 Specific Rules for Basic Care Agencies Providing Care for Infant, {#sec-13-csr-35-71.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.100}

13 CSR 35-71.120 Specific Rules for Residential Treatment Agencies for Children and {#sec-13-csr-35-71.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.120}

13 CSR 35-71.130 Specialized Standards—Residential Treatment for Children and {#sec-13-csr-35-71.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.130}

13 CSR 35-71.140 Specialized Standards For Intensive Residential Treatment {#sec-13-csr-35-71.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.140}

13 CSR 35-71.300 Notification Requirements for License-Exempt Residential Care for Children {#sec-13-csr-35-71.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.300}

13 CSR 35-71.010 Definitions and Principles Generally Applicable to this Chapter {#sec-13-csr-35-71.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.010}

PURPOSE: This rule clarifies the terms used in the licensing rules for residential treatment agencies for children and youth.

(1) The following principles shall apply to all decisions made pursuant to this chapter:

(A) The safety and welfare of children is paramount;

(B) All providers of direct services to children and their families will be evaluated in a uniform, transparent, objective, and consistent basis;

(C) Services to children and their families which are provided by the division and licensed residential care facilities shall be provided in a timely manner to maximize the opportunity for successful outcomes, and such services shall be tracked and routinely evaluated through a quality assurance program;

(D) Any provider of direct services to children and families shall have the appropriate and relevant training, education, and expertise to provide the highest quality of services possible which shall be consistent with federal and state standards;

(E) Resources and efforts of the division and licensed residential care facilities shall be committed to pursue the best possible opportunity for a successful outcome for each child. In the case of children and youth who are in the foster care system, successful outcomes may include preparing youth for a productive and successful life as an adult outside the foster care system, such as independent living. For those providers that work with children requiring intensive twenty-four- (24-) hour treatment services, successful outcomes shall be based on the least restrictive alternative possible based on the child’s needs as well as the quality of care received; and (F) All licensed service providers shall prioritize methods of reducing or eliminating a child’s need for residential treatment through community-based services and supports.

(2) For the purpose of all regulations in 13 CSR Chapter 71, unless otherwise specified or unless the context clearly requires otherwise, the definitions of terms specified in sections 210.110, 210.481, 210.1253, RSMo, and 13 CSR 35-71.015 shall apply to all of the regulations in this chapter. The singular includes the plural and plural includes the singular. In addition, the following terms are defined as follows:

(A) “Agency” in the context of regulations governing licensed residential care facilities shall mean the same as licensed residential care facility or LRCF;

(B) “Background check” means a background check which complies with the requirements of 210.493, RSMo, and 13 CSR 35-71.015;

(C) “Chemical restraints” are drugs which are prescribed or administered to temporarily restrain a child who presents a likelihood of serious physical harm to him/herself or others;

(D) A “critical incident” is an incident involving a child in the care of the agency, in which the child or another person directly involved with the child is placed at significant risk of death, serious physical, mental, or sexual harm. A critical incident may involve conduct of the child, other children, and/or acts or omissions of staff of the agency. Examples of critical incidents include, but are not limited to: injury of a child during physical restraint; serious physical or sexual aggression by or toward the child; significant physical injuries requiring medical attention; allegations of sexual abuse; criminal conduct involving the child; elopement; attempted suicide; fire setting; child death; and information which must be reported to the child abuse and neglect hotline pursuant to 210.115, RSMo. A “critical incident report” is a report documenting a critical incident;

(E) “Director” is the director of the Children’s Division;

(F) “Division” is the Children’s Division of the Department of Social Services of Missouri as defined in section 210.481(3), (G) “Elopement” is when a child leaves a facility or designated area off the campus of a LRCF without permission and places the child out of sight and sound of direct supervision;

(H) “Family Care Safety Registry” means the family care safety registry administered by the Department of Health and Senior Services;

(I) “Good standing” refers to a licensed residential treatment agency for children and youth in substantial compliance with Chapter 71 of the Children’s Division residential treatment agencies for children and youth rules and is not under involuntary intake suspension, license denial, license suspension, and/or license revocation;

(J) “Intensive residential treatment” for children and youth is provided in a living unit of an agency for gravely, emotionally dysregulated youth that has the capability of providing a highly structured and secure environment to prevent runaway behavior, address the likelihood of rage and physical aggression, and minimize the likelihood of youth injuring themselves or others. Intensive residential treatment for children and youth may be achieved through a combination of staffing patterns, architectural design of the operating site, electronic monitoring of the operating site and its exits, or other means necessary to assure safety;

(K) “Mechanical restraints” are any device, instrument, or physical object used to confine or limit a child’s freedom of movement, except when necessary for orthopedic, surgical, and other medical purposes, or when necessary, to transport a child that may abscond or cause injury during transportation.

Support devices used in normal situations to achieve proper body position and balance are not mechanical restraints;

(L) “Medical examination” is a thorough physical examination conducted by a licensed physician, certified nurse practitioner, advanced practice nurse in a collaborative practice agreement with a licensed physician, or a registered nurse who is under the supervision of a licensed physician. It may include a variety of tests, depending on the age, sex, and health of the person being examined, that includes tests for communicable diseases including, but not limited to, tuberculosis and hepatitis, when recommended by a licensed physician. It should also include a statement of the patient’s mental state as determined by a licensed physician;

(M) “Operating site” is any building or campus of a licensed agency in which children receive care;

(N) “Physical restraint” is physical holding involving restriction of a child’s voluntary movement to temporarily restrain an agitated, violent, or aggressive child who presents a likelihood of serious physical harm to him/herself or others;

(O) “Professional staff” of residential care facility are staff or contractors of the residential care facility who are qualified and required by law to be licensed in good standing to provide services for children to provide the services which they are providing. Examples of professional staff include, but are not limited to, physicians, nurses, physician assistants, teachers, licensed professional counselors, physical therapists, and occupational therapists;

(P) “Social services” are planned psycho-social interventions that are intended to lead to increased individual and family self-sufficiency and empowerment, and will support the child’s transition from the placement into the family or community.

Social services shall include, but shall not necessarily be limited to, individual, family, or group therapy that is provided in conjunction with other age and developmentally appropriate expressive, experiential, and adjunct activities;

(Q) “Transitional living services” are services provided to older adolescents that combine life skills training with opportunities to practice same. The goal of such services is to prepare the youth for successful adult living in the community upon their discharge from residential treatment for children and youth;

(R) “Variance” is a minor, time limited, deviation from a rule that may be requested by a licensed residential treatment for children and youth agency on a form prescribed by the division and approved or denied by the division. Approval may be granted by the division when a variance does not negatively impact child health and safety and is not under the purview of another regulatory entity. Examples include, but are not limited to, time limited deviations in licensed capacity and age range; and (S) “Well-known religious order, church, and religious organization” are defined as follows:

1. A church, synagogue, or mosque;

2. An entity that would qualify for federal tax exempt status as a not-for-profit religious organization under section 501(c) of the Internal Revenue Code of 1954; or 3. An entity where the real property on which the residential treatment for children and youth operating site is located is exempt from local taxation because it is used for religious purposes. and sections 210.493 and 210.1286, RSMo Supp. 2021.* This rule originally filed as 13 CSR 40-71.010. Original rule filed May 9, 1956, effective May 19, 1956. Refiled March 12, 1976. Rescinded and readopted: Filed Nov. 8, 1978, effective Feb. 11, 1979. Rescinded and readopted: Filed Oct. 13, 1982, effective Jan. 13, 1983. Amended:

Filed Oct. 7, 1987, effective March 25, 1988. Emergency rescission and emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rescission and emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. expired Jan. 30, 2009. Moved to 13 CSR 35-71.010 and amended:

Filed Sept. 17, 2021, effective March 30, 2022. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.493, RSMo 2021; 210.506, RSMo 1982, amended 1993, 1995; 210.1286, RSMo 2021; and 660.017, RSMo 1993, amended 1995.

13 CSR 35-71.015 Background Checks for Personnel of Residential Care Facilities and Child Placing Agencies {#sec-13-csr-35-71.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.015}

PURPOSE: This rule establishes the processes and procedures for conducting background checks for personnel of child placing agencies, licensed residential care facilities, and residential care facilities subject to the notification requirements under sections 210.1250 to 210.1286, RSMo, as provided and authorized by section 210.493, RSMo.

(1) Definitions. For the purpose of this regulation, unless otherwise specified in this section or unless the context clearly requires otherwise, the definitions of terms specified in sections 210.110, 210.481, and 210.1253, RSMo, shall apply to this

regulation. The singular includes the plural and plural includes the singular. In addition, the following terms are defined as follows:

(A) “Applicant” means any individual who applies or is required to successfully complete the background check requirements for employment or presence at the Licensed Residential Care Facility (LRCF), License-Exempt Residential Care Facility (LERCF), or Child Placing Agency (CPA) by

section 210.493, RSMo. For the purposes of background checks conducted by the Missouri State Highway Patrol of the Missouri Department of Public Safety, the term “applicant” is further defined as specified in section 43.539, RSMo.

1. Except as otherwise provided in this regulation, applicants for LRCFs, LERCFs, and CPAs who are required to complete the background check process include contractors with unsupervised access to children; volunteers with unsupervised access to children; employees; owners of LRCFs and LERCFs that will have access to the facilities; and owners of LERCF, LRCF, and CPA that will have access to children.

2. Except as otherwise provided in this regulation, applicants for LERCFs who are required to complete a background check also include any applicant as defined in section 43.539, RSMo, who has unsupervised contact with a resident of the LERCF. The following individuals or classes of individuals who may have unsupervised contact with a child who is a resident of an LERCF are not deemed to be applicants and are not required to submit to background checks as provided in this subsection unless otherwise required by law or court order:

A. Legal parents, step-parents, grandparents, siblings, legal guardians, and prospective adoptive parents who do not reside on or at the LERCF but who have contact or visits with a child who resides on the property of an LERCF;

B. Licensed or other lawfully qualified individuals who do not reside at or on the property of an LERCF, who are not employees, volunteers, staff, and who provide occasional emergency professional services within the scope of their employment pertaining to a child who resides at or on the property of the LERCF, such as licensed physicians, licensed nurses, licensed emergency medical technicians, POST certified law enforcement officers, juvenile officers, division employees, prosecuting attorneys, court-appointed special advocates (CASA) assigned by a court to a child who resides at an LERCF, attorneys, and court-appointed guardians ad litem for children who reside at an LERCF; and/or C. Licensed or other lawfully qualified individuals who do not reside at or on the property of an LERCF, who are not employees, volunteers, staff, and who provide reasonably necessary, professional services, maintenance in an emergency when it is necessary to protect the health and safety of individuals at the facility and background checks are not reasonably possible under the circumstances, or government inspections on the premises of an LERCF to ensure the health and safety of the residents such as fire, health, and safety inspectors, and nationally recognized accrediting agencies, heating, construction, electrical, and plumbing contractors;

(B) “Boarding school” includes any educational institution in which some or all of the children who attend the institution reside during their attendance at the institution. Boarding schools include facilities where the children lodge in dorms, in private homes whose owners are contracted with, associated or affiliated with the institution, or in homes owned or operated by the institution regardless of whether or not the child’s residence is located on or off the institution’s campus;

(C) The “department” or the “division” shall refer to the Children’s Division of the Missouri Department of Social Services;

(D) “Employee” is any individual who works in the service of a LERCF, LRCF, or CPA under an express or implied contract for hire, whether written or unwritten, full time or part time, under which the LERCF, LRCF, or CPA has the right to control the details of work performance in whole or in part. For purposes of this regulation and any regulations implementing the background check process requirements prescribed by

section 210.493, RSMo, employees of an LERCF, LRCF, or CPA who neither work in nor perform services in Missouri, nor have access to children in Missouri, nor have access to a residential care facility in Missouri, and who are not otherwise required to successfully complete the background check process, are not required to complete the background check process requirements in their capacities as employees;

(E) “Licensed Residential Care Facility” or “LRCF” means a facility providing twenty-four- (24-) hour care in a group setting to children who are unrelated to the person operating the facility and who are unattended by a parent or guardian, and which is required to have a license to operate as a Residential Care Facility under section 210.516, RSMo. LRCFs do not include licensed foster family homes or unlicensed kinship placements made pursuant to a juvenile or family court order;

(F) “License-Exempt Residential Care Facility” or “LERCF” means a place, facility, or home that provides children with supervision, care, lodging, and maintenance for twenty-four (24) hours a day, with or without transfer of custody; is not required to be licensed under section 210.516, RSMo; and either receives children unrelated to the operator or receives the children of parents or guardians who are not residents of the residential care facility. Unless exempted as provided below, LERCFs include but are not limited to boarding schools, juvenile detention facilities, license-exempt foster homes as defined in section 210.516, RSMo, and other congregate care facilities. LERCFs do not include— 1. Hospitals, sanitariums, and clinics operated to provide medical care and treatment and operating pursuant to a valid license issued by the Missouri Department of Health and Senior Services (DHSS), the Missouri Department of Mental Health (DMH), the United States (such as Veterans’ Administration Hospitals and hospitals administered by the armed forces of the United States);

2. Boarding schools operated by the Missouri Department of Elementary and Secondary Education (DESE), provided DESE requires background checks equivalent or more stringent than the requirements of section 210.493, RSMo;

3. Foster homes and congregate care facilities or homes licensed or certified by the DMH, provided DMH requires background checks equivalent or more stringent than the requirements of section 210.493, RSMo;

4. Juvenile corrections programs operated by the Department of Social Services, Division of Youth Services, or juvenile detention facilities operated by juvenile officers or juvenile courts that are subject to the Prison Rape Elimination Act (PREA) standards and auditing;

5. Facilities operated by the Missouri Department of Corrections and county or local jails;

6. Residences where any individual (but not a corporation, partnership, organization, or association) receives on a voluntary basis the child of close, personal friends or relatives as an occasional and personal guest in their personal home or the home of the child’s parent, guardian, or legal custodian, who is otherwise unaffiliated with an LRCF or LERCF and who receives custody of or provides care of no other child unrelated by consanguinity, adoption, or affinity;

7. Residences where any individual (but not a corporation, partnership, organization, or association) otherwise unaffiliated with an LRCF or LERCF receives legal custody or guardianship of a child or sibling group pursuant to a judgment or order of a court of competent jurisdiction in cases where a state or local government is not a party and in cases where the judgment or order is entered by a court outside the state of Missouri, and all of the requirements of the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA), the Interstate Compact on the Placement of Children (ICPC), or the Interstate Compact on Juveniles (ICJ) have been fully satisfied; and 8. Any camp which is not a boarding school, which is operated solely during certain months of the year, not to exceed four (4) months, which is conducted in good faith primarily to provide recreation or religious instruction for children, in which the children do not spend more than thirty (30) consecutive overnight periods during any twelve- (12-) month period, and not for ongoing residential or treatment purposes;

(G) “Missouri State Highway Patrol” or “MSHP” shall mean the Missouri State Highway Patrol of the Missouri Department of Public Safety;

(H) “Owner” of an LERCF, LRCF, or CPA is any individual who holds an equity interest in the LERCF, LRCF, or CPA;

(I) “Sponsoring organization” shall mean the entity that sponsors the LERCF, LRCF, or CPA including but not limited to the sponsoring church or religious organization; and (J) “Volunteer” of an LERCF, LRCF, or CPA is any individual who performs a service for or on behalf of the LERCF, LRCF, or CPA of their own free will without obligation, or without any expectation of reward or compensation.

(2) The background checks conducted pursuant to this

regulation shall consist of the following:

(A) A fingerprint-based background check of open and closed criminal history conducted in conjunction with the MSHP pursuant to section (3) of this regulation; and (B) A search of the national sex offender registry conducted by the division; and (C) A search of the following registries, repositories, or databases in Missouri, the state where the applicant resides, and each state where the applicant resided during the preceding five (5) years conducted by the division:

1. The state sex offender registry or repository (in Missouri this is a search of the MSHP Sex Offender Registry); and 2. The state family care safety registry (in Missouri this is a search of the family care safety registry); and 3. The state-based child abuse and neglect registry and database (in Missouri this is a search of the Central Registry of the division).

(3) All of the fingerprint-based background checks of closed criminal history conducted under this regulation shall be performed in conjunction with the MSHP solely through the

History Service (MOVECHS) and the National Child Protection Act, Public Law 103-209, as amended. No fingerprint-based, criminal background checks of federal records or closed criminal history shall be conducted under this regulation on clients, patients, and students of the LERCF or LRCF unless the fingerprint-based background check of closed criminal history is authorized by federal and state law and that individual is also an employee, staff, or volunteer of the LERCF or LRCF. The background checks conducted in conjunction with the MSHP will be conducted pursuant to the law, statutes, regulations, and policies governing the MSHP and will include a fingerprint background check and a state open records check as provided in this section.

(A) Fingerprint background check is a state and FBI background check required for any person who is actively employed by or seeks employment with, actively licensed or seeks licensure with, actively volunteers or seeks to volunteer with, actively contracted with or seeks to contract with, an owner or operator of a Licensed Residential Care Facility, a License-Exempt Residential Care Facility, or a Child Placing Agency after the phase-in period.

1. The fingerprint background check will be conducted through the Missouri VECHS Program, pursuant to the National Child Protection Act, as amended.

2. Criminal history record information will consist of complete Missouri criminal history (open and closed) records, and criminal history from the Federal Bureau of Investigation.

Criminal history will include convictions, arrests within thirty (30) days, pending charges and suspended imposition of sentence (SIS) during probation, not guilty findings, charges nolle prossed, or dismissed cases, SIS cases after probation is completed, and arrests after thirty (30) days where no charges have yet been filed or reported by the prosecuting attorney, and will include a search of the state sex offender registry.

(B) State open records check is required for any person that is not an employee, volunteer, contractor, or owner/operator, who is eighteen (18) years of age or older, who resides at or on the property, or who has or may have unsupervised access to children for whom a Licensed-Exempt Residential Care Facility provides care. A state open record check consists of convictions, arrests within thirty (30) days, pending charges, suspended imposition of sentence (SIS) during probation, and will include a search of the state sex offender registry.

(4) Application of this Regulation. This regulation applies to CPAs, LRCFs, and LERCFs which are subject to the notification requirements of sections 210.1250 to 210.1286, RSMo.

(A) Phase-in Period. Every LRCF, LERCF, and Child Placing Agency operating on the date that section 210.493, RSMo, and this regulation became effective shall have until March 31, 2022, for all applicants to complete background checks. The division may extend this deadline for any individual LRCF, LERCF, and Child Placing Agency, due to unusual, compelling, and extenuating circumstances beyond the control of the LRCF, LERCF, or Child Placing Agency. The request for an extension shall be in writing and shall explain the reasons for the request for an extension. Any applicant who does not complete the background check process as specified in this regulation shall be ineligible for employment, service, or presence with an LRCF, LERCF, or Child Placing Agency.

(B) Any applicant who commences employment, service, or presence with a LRCF, LERCF, or Child Placing Agency after the effective date of the phase-in period shall complete the background check process as specified in this regulation in order to be eligible for employment, service, or presence with an LRCF, LERCF, or Child Placing Agency.

(5) Designation of Authority. The Department of Social Services hereby designates the Children’s Division of the Department of Social Services to be the division within the Department of Social Services to administer background checks as required by section 210.493, RSMo. The Department of Social Services hereby designates the Administrative Hearings Unit within the Division of Legal Services of the Department of Social Services to process and decide all appeals of applicants as provided in this regulation.

(6) Application Process.

(A) The applicant shall apply for background screening through the division’s online portal on forms promulgated by the division. The application forms and instructions are incorporated by reference and made a part of this rule as published by the Department of Social Services, Children’s Division, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, MO 65102, at its website at https://dss.mo.gov/providerservices/children/residential-program/background-checks/, April 23, 2024. This rule does not incorporate any subsequent amendments or additions. The applicant shall submit the completed application form and upload any supporting or supplemental forms and documentation through the division’s online portal. The application must be signed by the applicant (e-signature is acceptable).

1. The applicant may apply to the division for permission to file the application and supporting documentation by mail or private delivery service rather than through the online portal when there are unusual, compelling, and extenuating circumstances which make filing the application through the online portal impossible. The applicant shall apply for permission to file the application form, supporting, or supplemental materials with the division in writing, and shall explain why the applicant cannot submit the application through the online portal. A copy of the application forms for use in submitting application by mail is incorporated by reference and made a part of this rule as published by the Department of Social Services, Children’s Division, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, MO 65102, at its website at https://dss.mo.gov/provider-services/children/ residential-program/background-checks/, April 23, 2024. This

rule does not incorporate any subsequent amendments or additions. Applicants may download a copy of the forms.

The applicant shall attach all documentation that may be necessary to complete the required application. If the division grants permission under this section, the applicant may submit the form with supporting materials by mail, by private delivery service, or in person to the offices of the division at Children’s Division, Attn: Background Screening Team, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, Missouri 65102; or by email at CDScreen@dss.mo.gov.

(B) The application shall contain all of the following information:

1. The applicant’s current, full legal name, residence address, mailing address, business address, telephone number, and email address. The applicant’s mailing address and email addresses shall be the applicant’s address of record for purposes of this regulation;

2. The applicant’s date of birth and full Social Security number;

3. Any other names or aliases that the applicant has used or been known by during the five- (5-) year period preceding the application;

4. Any other residence address, mailing address, county and state of residence, business address, telephone number, and email address that the applicant has had during the five- (5-) year period preceding the application;

5. Whether the applicant is registered, or is required to be registered, on a state sex offender registry or repository or in the National Sex Offender Registry. If the applicant is so registered or required to be registered, the applicant shall provide the following additional information:

A. The national, federal, state, or local jurisdiction in which the applicant is registered or required to be registered;

B. The specific crime or offense for which the applicant is registered or required to be registered including— (I) The date or approximate date that the crime or offense was committed;

(II) The statute or section number of the crime or offense;

(III) The name and address of the court where the case was adjudicated;

(IV) The case number; and (V) The date of the plea, finding, judgment, or sentence;

6. Whether the applicant is listed as a perpetrator of child abuse or neglect under sections 210.109 to 210.183, RSMo, or any other finding of child abuse or neglect based on any other state’s registry or database. In states where the official registry of substantiated findings of child abuse or neglect are made or kept by a county, this information must also be disclosed. If the applicant is listed, the applicant shall also provide— A. The state or county registry or database in which the applicant is listed; and B. The specific finding(s) of the state or county agency and the conduct for which the applicant is listed, including— (I) The date(s) of the conduct;

(II) The date the applicant was listed; and (III) The name and address of the state or local government entity that maintains the list;

7. Whether the applicant has ever been found guilty of or pled guilty or nolo contendere to any crime or offense listed in section 210.493, RSMo. If the applicant has ever been found guilty of or pled guilty or nolo contendere to any such crime or offense, the applicant shall also provide— A. The national, federal, state, or local jurisdiction where the applicant was found guilty of or pled guilty or nolo contendere;

B. The specific crime or offense for which the applicant is registered or required to be registered, including— (I) The date or approximate date that the crime or offense was committed;

(II) The statute or section number of the crime or offense;

(III) The name and address of the court where the case was adjudicated;

(IV) The case number; and (V) The date of the plea, finding, judgment, or sentence;

8. Whether the applicant consents to the division notifying the LRCF, LERCF, or CPA of its decision on eligibility or ineligibility and/or sending a copy of its eligibility or ineligibility finding to the LRCF, LERCF, or CPA;

9. Whether the person is requesting a response and notice of final decision by first-class mail or by email;

10. The name and address of any LRCF, LERCF, or CPA that the applicant wishes the division to send a finding of eligibility or ineligibility to upon the completion of the background check process;

11. A fully completed and signed MOVECHS Waiver Agreement and Statement (SHP-981G) form. The completed and signed waiver form must be submitted with the application;

12. Acknowledgment and certification by the applicant, under penalty of perjury that all submitted information is true, accurate, and complete to the best of the applicant’s knowledge, and the applicant understands that a knowing violation of section 210.493, RSMo, may constitute a criminal offense and knowingly making a materially false statement in connection with a background check shall render the applicant ineligible;

13. Any other information and documents that the applicant wishes the division to consider in making its decision about eligibility; and 14. An explanation of why the applicant is unable to provide any of the information that must be provided to support the application.

(C) The applicant shall register with the Family Care Safety Registry and execute any documents necessary for the division to access the applicant’s results in the Family Care Safety Registry.

(D) The applicant shall execute any authorizations necessary to obtain information from state, local, and federal registries.

(E) The applicant shall submit fingerprint cards and any required fees to the Missouri State Highway Patrol’s central repository and follow all of the Missouri State Highway Patrol’s procedures for requesting a fingerprint-based criminal background check. The applicant shall further execute any documents and consents necessary for the Missouri State Highway Patrol to complete the fingerprint-based criminal background check and to notify the division of any criminal

history record, or lack of criminal history record information discovered on the applicant as required by law.

(F) The applicant must submit a completed MOVECHS Waiver Agreement and Statement (SHP-981G) to the division with the application form to the division before reporting to be fingerprinted.

(G) The application will not be complete until the division receives a fully completed application form, MOVECHS Waiver Agreement and Statement (SHP-981G) and the results of the fingerprint-based criminal background check from the Missouri State Highway Patrol, and the applicant has registered for the Family Care Safety Registry and executed any authorizations necessary to obtain information from any registries.

(H) Eligibility.

1. Preliminary Eligibility.

A. Upon receipt and review of a complete application and MOVECHS Waiver Agreement and Statement, the division may grant the applicant preliminary eligibility to commence employment, service, or presence at a LRCF, LERCF, or CPA for a period of thirty (30) days.

B. Within this thirty- (30-) day period, the division shall provide the applicant with a notice of withdrawal, provisional eligibility, final eligibility, or ineligibility.

C. Applicants granted preliminary eligibility shall be ineligible for employment, presence, or service after the thirty- (30-) day period unless they have received a notice of provisional or final eligibility.

D. Applicants granted preliminary eligibility shall not have access to children prior to receiving notice of provisional or final eligibility.

E. The division shall provide a notice of preliminary eligibility to the applicant and any LRCF, LERCF, or CPA designated by the applicant.

2. Provisional Eligibility.

A. Upon receipt and review of a complete application and MOVECHS Waiver Agreement and Statement, the division may grant the applicant provisional eligibility to commence employment, service, or presence at a LRCF, LERCF, or CPA if the applicant has complied with all steps necessary for the division to obtain background check results, but— (I) The division is still awaiting results from a state child abuse and neglect registry and database;

(II) The applicant is unable to timely register with the Family Care Safety Registry due to no fault of the applicant; or (III) The division cannot timely complete the background check process for other reasons beyond the control of the applicant.

3. Final Eligibility.

A. Upon receipt and review of a complete application, MOVECHS Waiver Agreement and Statement and the applicant’s complete background check results, the division will notify the applicant of eligibility or ineligibility.

B. The final eligibility notice will indicate whether the applicant is eligible or ineligible for employment, service, or presence at the LRCF, LERCF, or CPA.

C. The final eligibility notice will advise the applicant of the applicant’s right to request administrative appeal of the decision and the process for requesting administrative appeal.

D. The final eligibility notice will advise the applicant of the applicant’s responsibility to notify the division, LRCF, LERCF, or CPA of any event which would impact the applicant’s eligibility as provided in this regulation.

(I) If the division finds the applicant eligible, the division shall forward a copy of the finding to any LRCF, LERCF, or Child Placing Agency indicated by the applicant. If the division finds the applicant ineligible, the division shall not send a copy of the notice to any indicated LRCF, LERCF, or Child Placing Agency, until the division determines the applicant has exhausted the applicant’s administrative remedies and the division has received a written consent from the applicant authorizing the division to disclose such information.

(7) Fees and Costs. The applicant, LRCF, LERCF, or Child Placing Agency shall be responsible for the payment of any and all required fees for processing the application, including any fees for the fingerprint-based background check and the Family Care Safety Registry.

(8) Notice and Communications. The division will send all communications and notices pertaining to an application and request for administrative appeal by first-class mail unless the applicant or entity requesting administrative appeal affirmatively notifies the division, in writing, that the applicant or person would like to receive communications by email and provides the division with the email address. It is the responsibility of the applicant or person to notify the division of any change in the applicant’s or person’s contact information.

All notices shall be sent to the address or email address of record, and all correspondence sent to that address shall be deemed received and sufficient service for all purposes.

(9) The division shall not reveal any information pertaining to any disqualifying crime, offense, or other related information regarding the applicant to the LRCF, LERCF, or Child Placing Agency except as may be otherwise required by law.

(10) Continuing Obligation to Notify and Expiration of Determination.

(A) The division’s decision of eligibility or ineligibility shall be based upon the information that the division receives through the background check process, and any additional information that may be made available to the division during administrative appeal.

(B) The division’s finding is only valid through the date of the decision and only for the LRCF, LERCF, or Child Placing Agency indicated by the applicant on the application. The applicant may designate more than one LRCF, LERCF, or Child Placing Agency on a single application.

(C) The applicant shall be responsible for notifying the division of any change in circumstance which may render the applicant ineligible and shall submit a new application based upon the subsequent information.

(D) The applicant’s fingerprint-based background check is valid for five (5) years from the date the fingerprints were taken, or until there is any change in the circumstances of the applicant which would render the applicant ineligible under the statute, whichever occurs first. It is the responsibility of the applicant to track the expiration date of the fingerprints and submit an application for a new background check.

(E) The division’s finding automatically expires thirty (30) days from the date of the division’s decision. It is the responsibility of the applicant to submit a new application for a new determination and fingerprint-based criminal background check following the procedures specified in this regulation.

(11) In determining whether an applicant is eligible or ineligible under section 210.493, RSMo, and this regulation, the division shall not consider the manner, content, or the religious curriculum of the program, or ministry of a school or of a facility sponsored by a church or religious organization.

(12) Administrative Review and Appeal Procedure.

(A) The decision of the division shall be final unless the applicant or person who is aggrieved by a decision of the division under this regulation files a request for administrative review of the decision within fourteen (14) days of the mailing of the decision. Any request for administrative review that the division receives after the deadline is untimely and will not be subject to further administrative review or appeal.

(B) Administrative Review.

1. A request for administrative review shall be made in writing, either on a form provided by the division or by letter.

The division will publish a form on its website. The request for administrative review shall— A. Include the name, address, telephone number, and email address of the person requesting administrative review;

B. State whether the division should provide the response and notice of final decision by first-class mail or by email;

C. Identify the decision the requestor wishes to be reviewed, the specific reasons the requestor believes the division’s decision is erroneous, and why the requestor is aggrieved by the decision;

D. Include copies of any relevant documents, materials, or information that the requestor wishes to submit in support of the administrative review request; and E. State whether the person requests that the review be considered on the basis of the materials submitted or whether the person requests a conference. If the person requests a review conference, then the person shall also provide dates and times within the next thirty (30) days when the person may be available and the reasons why the administrative review cannot be processed on the basis of the materials presented.

2. The request for administrative review shall be submitted to the division by certified first-class mail through the United States Postal Service return receipt requested to the address specified on the notice of ineligibility or submitted electronically by email to the division to the email address specified in the notice of ineligibility.

3. The administrative review shall be conducted and decided based upon the written materials submitted to the division and any information and materials presented at a review conference. The division will provide a review conference upon written request.

4. The review conference may take place by telephone conference call, video conference, or in-person meeting.

5. The administrative review process shall be informal. The rules of evidence shall not apply. There is no right to conduct discovery. There shall be no right to compel the production of witnesses or evidence by subpoena or otherwise.

6. The administrative review shall be conducted by an individual designated by the director of the department or the division, who may be an employee of the division or the department. However, the individual shall not have been involved in making the decision which is subject to review.

7. The individual conducting the administrative review shall conduct the administrative review and render a written decision no later than thirty (30) days from the date that the division received the request for administrative review.

8. The decision upon administrative review shall be the final decision of the department as to any person that is not an applicant.

(C) Appeal.

1. Any applicant who is aggrieved by a decision upon administrative review shall have the right to appeal the decision to the Administrative Hearings Unit of the Division of Legal Services of the Department of Social Services. The applicant shall submit a notice of appeal to the division, within fourteen (14) days of the date of the administrative review decision, by certified first-class mail through the United States Postal Service return receipt requested to the address specified on the notice of ineligibility or submitted electronically by email to the division to the email address specified in the notice of decision upon administrative review. The division must receive the notice of appeal within fourteen (14) days of the date of the decision. Any notice of appeal that is received after the deadline is untimely and the appeal will be dismissed.

Completion of the administrative review process is a condition precedent to the applicant’s right to appeal.

2. The parties to the appeal shall be the division and the applicant.

3. All appeals shall be processed and decided by a hearing officer from the Administrative Hearings Unit of the Division of Legal Services of the Department of Social Services. The decision of the hearing officer shall be the final decision of the department.

4. The following evidence shall be admitted and considered by the hearing officer on appeal as provided in this section without further foundation:

A. A copy of the application form and all supporting documentation;

B. A copy of the record of the court establishing that the applicant pled guilty or nolo contendere or has been found guilty of a crime or offense listed in section 210.493, RSMo;

C. A copy of a letter or official communication from the applicable state, county, or local government agency stating that the applicant is listed as a perpetrator of child abuse or neglect in the state, county, or local government agency’s registry or database of perpetrators of child abuse or neglect;

D. A copy of the report of the fingerprint-based background check conducted pursuant to section (3) of this

regulation; and E. A copy of a letter, official communication, or a print out of the applicable page of the National Sex Offender Registry or state sex offender registry.

5. The applicant or division may object to the hearing officer considering the information outlined in this regulation.

The burden shall be on the objecting party to establish that the items of evidence shall not be considered by the hearing officer.

6. The hearings held under this section shall be informal, but they shall be held on the record and testimony will be adduced under oath. The rules of evidence do not apply. The applicant may be represented by an attorney.

7. Upon written request the division will provide the applicant with a copy of the fingerprint-based state and FBI background check.

8. The hearing shall not be an opportunity to collaterally attack or relitigate the validity of the underlying plea of guilt, plea of nolo contendere, or the underlying finding of child abuse, neglect, or maltreatment by the applicable state or local agency, or the accuracy of information in the federal, state, or local registry or repository.

9. The hearing shall be based upon the written submissions of the parties unless the applicant or the division requests a hearing by video or teleconference. The hearing officer may hold an in-person hearing only upon a showing that an inperson hearing is necessary to accommodate a special need of an applicant or the division.

10. The hearing officer shall issue a decision in writing, which will be sent by first-class mail (or by email at the election of the applicant) to the applicant at the applicant’s address of record. If the applicant is represented by an attorney, the decision will be sent to the applicant’s attorney. The written decision of the hearing officer shall be the final decision of the department.

(D) Judicial Review.

1. Any applicant aggrieved by the final decision of the department after appeal may seek judicial review as provided in section 536.150, RSMo.

2. Any person who is not an applicant who is aggrieved by the final decision of the department after administrative review may seek judicial review as provided in section 536.150, RSMo.

rule filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Original rule filed Sept. 17, 2021, effective March 30, 2022.

Emergency amendment filed May 30, 2023, effective June 13, 2023, expired Dec. 9, 2023. Amended: Filed May 30, 2023, effective Dec. 30, 2023. Amended: Filed April 23, 2024, effective Nov. 30, 2024.

Emergency amendment filed Oct. 24, 2024, effective Nov. 7, 2024, expired May 5, 2025. Amended: Filed Nov. 21, 2024, effective June 30, 2025. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.493, RSMo 2021, amended 2023; 210.1286, RSMo 2021; and 660.017, RSMo 1993, amended 1995.

History

• authority of the Missouri Volunteer and Employee Criminal
• AUTHORITY: sections 207.020 and 660.017, RSMo 2016, and sections 210.493 and 210.1286, RSMo Supp. 2024. Emergency

13 CSR 35-71.020 License Application, Renewal, and Monitoring {#sec-13-csr-35-71.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.020}

PURPOSE: This rule sets forth the process through which a residential care facility may obtain and renew a license and the division’s authority to monitor a facility’s compliance with the rules in this chapter through on-site visits and record reviews.

(1) Licensing Authority. Any person who establishes, maintains, or operates a residential care facility, other than persons exempt from licensure requirements under section 210.516, RSMo, must apply for and receive a license from the division prior to accepting any child for care.

(2) Application Procedures.

(A) The applicant facility shall complete an application with the division on forms available on the division’s website.

(B) The application shall be signed by an individual with the express authority to sign on behalf of the facility.

(C) In addition to the required application, the facility shall submit the following information in support of the application on forms provided by the division or as separate attachments:

1. Articles of incorporation or organization, bylaws, and a list of any board officers with such officers’ contact information;

2. Signed and dated copy of the division’s civil rights agreement;

3. Proposed budget for a period of not less than one (1) year, including sources of income;

4. Documentation of professional and commercial liability insurance, worker’s compensation insurance, fire and disaster insurance, and insurance for any vehicles operated by the facility (coverage must include personal injury protection for passengers);

5. Document setting forth the authority and responsibilities delegated to the executive director by the board of directors;

6. Chart depicting facility’s organizational structure;

7. Personnel manual;

8. Job titles and job descriptions for all staff;

9. Name, phone number, and email address of the designated caregiver authorized by the facility to use the reasonable and prudent parent standard pursuant to section 210.665, RSMo, if applicable;

10. Projected staffing plan for the anticipated capacity;

11. Staff training plan;

12. Certification that all individuals required to complete a background check and to be found eligible for employment or presence at the facility pursuant to 13 CSR 35-71.015 have completed the required background check and have been found eligible for employment or presence by the division;

13. Verification of the education, licensing credentials, and experience of all professional staff;

14. Résumés for all professional and administrative staff;

15. Evidence of compliance with local building and zoning requirements;

16. Floor plan of the facility that identifies the specific use of each room;

17. Evidence of compliance with the fire safety requirements required by the State Fire Marshal;

18. Local health department inspection certificates.

A. The facility shall submit local health department inspection certificates for food service and water/sewer, if applicable, for all counties, cities, and towns that require such certificates in which the facility operates.

B. If the facility is unable, after exercising diligent efforts, to obtain a local inspection certificate, then the facility shall submit a statement describing the efforts made to obtain the certificate(s) and the reason why it was unable to obtain the certificate. The facility shall attach copies of any correspondence to or from any local health departments declining to conduct an inspection or to provide a certificate;

19. Documentation that any pool on the grounds is operated in accordance with all applicable ordinances;

20. Program and/or policy manual for the facility that contains the following materials:

A. Description of specific program models, including methods of treatment;

B. Description of the recreational program;

C. Document outlining the respective educational responsibilities of the facility and any local education authority, as applicable;

D. Personnel health verification policy;

E. Intake policy;

F. Health and sick care protocol for residents;

G. Medication policy, including psychotropic medications;

H. Medical record retention policy for residents;

I. Confidentiality policy;

J. Visitation policy;

K. Critical incident reporting policy;

L. Child abuse and neglect reporting policy;

M. Discipline policy for residents;

N. Restraint policy using a recognized and approved physical restraint program;

O. Locked isolation policy; and P. Volunteer policy; and 21. Description of facility’s religious requirements and practices, if applicable.

(D) The application will be complete when the residential care facility submits a completed application with all of the required supporting documents and information, including all required inspection certificates.

(E) Upon receipt of the completed application form and supporting documentation, the division will send a request to the State Fire Marshal to conduct a fire and safety inspection and provide the residential care facility and the division with a copy of the approved fire and safety inspection.

(3) Licensing Assessment. When the application is complete, the division will conduct a thorough assessment of the residential care facility to determine whether the facility meets all of the requirements for licensure set forth in the applicable rules.

(4) The License.

(A) Upon determination of compliance with the applicable rules, the director shall issue a license for a period not to exceed two (2) years.

(B) The license shall be posted in a conspicuous place on the premises of the operating site.

(C) The number, sex, and age range of children a facility is authorized to accept for care shall be specified on the license and shall not be exceeded.

(D) The license shall not be transferable.

(E) A licensed residential care facility (LRCF) may request a temporary variance from one (1) or more of the licensing requirements for a specified period of time on a form prescribed by the division. The division will only approve a variance when the division determines that the variance will not negatively impact child health and safety. No variances will be granted for required third-party inspections, such as fire and safety inspections.

(5) License Amendment.

(A) A LRCF shall file an application to amend its license with the division on a form prescribed by the division at least forty-five (45) days prior to any of the following non-temporary changes:

1. Change in the name of the LRCF;

2. Relocation and/or address change;

3. Addition of new operating site;

4. Change in the capacity, gender served, and/or age range of children; or 5. Any major change in the program.

(B) These changes shall be approved by the division prior to amending the license.

(C) Approval for any temporary changes to paragraphs 1. through 5. in subsection (A) above should be requested through the variance process.

(6) Licensing Renewal.

(A) A LRCF shall submit a completed application for license renewal to the division at least ninety (90) days prior to the expiration of its current license. The LRCF shall use forms provided by the division to apply for renewal. The application form shall be signed by the director of the LRCF or the director’s legally authorized designee.

(B) In addition to the completed application form, a LRCF shall submit the following documents with its application for license renewal:

1. Current list of any board officers with such officers’ contact information;

2. Documentation of professional and commercial liability insurance, worker’s compensation insurance, fire and disaster insurance, and insurance for vehicles operated by the facility (must include passenger liability);

3. Summary of any significant changes to programs since the last application or renewal and copies of any resulting policies or policy changes;

4. Current personnel and/or program manual if there have been changes since last submitted to the licensing unit;

5. Current organization chart, if changes have been made since the last application or renewal;

6. Form prescribed by the division evidencing— A. That all persons required to submit to a background check pursuant to 13 CSR 35-71.015 have completed their background checks and have been found eligible by the division for employment or presence at the LRCF;

B. The annual results of a check of the family care safety registry (FCSR) for all staff, interns, contractors, and volunteers;

C. The annual results of a check of the child abuse and neglect registry and criminal records for those staff, interns, contractors, and volunteers that do not reside in Missouri;

7. Document outlining the respective educational responsibilities of the facility and any local education authority, if applicable;

8. Annual staff training plan;

9. Résumés for all administrative and professional staff not previously submitted to the licensing unit;

10. A record of monthly drills for fire and emergency evacuations;

11. Local health department inspection certificates for food service and water/sewer, if applicable, for all counties and cities in which the facility operates, that require such certificates;

12. Evidence of compliance with the fire safety requirements required by the State Fire Marshal;

13. Documentation evidencing that any swimming pool on the grounds is operated and maintained in accordance with all applicable local ordinances; and 14. Name, phone number, and email address of the designated caregiver authorized by the facility to use the reasonable and prudent parent standard pursuant to section 210.665, RSMo, if the facility will provide care to Missouri foster children.

(C) Upon determination of compliance with the licensing law and applicable rules, the director shall issue a license for a period not to exceed two (2) years.

(7) License Monitoring.

(A) Division licensing consultants may make scheduled or unscheduled visits to a facility to determine the facility’s compliance with the licensing rules.

(B) Division licensing consultants may review personnel files including criminal/child abuse/neglect/family care safety registry background screening documentation during on-site reviews.

(C) Division licensing consultant may review resident records during on-site reviews.

(D) Division licensing consultant may review a facility’s business records during on-site reviews. and sections 210.493 and 210.1286, RSMo Supp. 2023.* This rule originally filed as 13 CSR 40-71.020. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Rescinded: Filed Oct. 13, 1982, effective Jan. 13, 1983. Emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. Readopted: Filed Nov. 1, 1993, effective June 6, 1994. Emergency amendment filed July 25, 2008, effective Aug. 4, 2008, expired Jan. 30, 2009. Moved to 13 CSR 35-71.020 and amended: Filed July 25, 2008, effective Jan. 30, 2009. Amended: Filed Dec. 16, 2013, effective June 30, 2014.

Emergency amendment filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Amended: Filed Sept. 17, 2021, effective March 30, 2022. Rescinded and readopted: Filed Jan. 18, 2024, effective Aug. 30, 2024. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.493, RSMo 2021, amended 2023; 210.506, RSMo 1982, amended 1993, 1995; 210.1286, RSMo 2021; and 660.017, RSMo 1993, amended 1995.

13 CSR 35-71.025 Exemption of Religious Residential Treatment for Children and Youth Operating Sites {#sec-13-csr-35-71.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.025}

PURPOSE: This rule sets forth the requirement that residential treatment for children and youth operating sites must be under the exclusive control of a religious organization in order to qualify for exemption under sections 210.211(5) or 210.516.1(5), RSMo.

When a nonreligious organization, having as its principal

purpose the provision of residential treatment for children and youth services, enters into an arrangement with a religious organization to provide continuing assistance in the maintenance or operation of a residential treatment for children and youth operating site, the operating site is not under the exclusive control of the religious organization and does not qualify for exemption from licensure under sections 210.211(5) or 210.516.1(5), RSMo.

Moved to 13 CSR 35-71.025, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014. *Original authority: 210.481, RSMo (1982), amended 1985; 210.486 and 210.506, RSMo (1982), amended 1993; and 210.516, RSMo (1982).

History

• AUTHORITY: sections 210.481, 210.486, 210.506, and 210.516, RSMo 2000. This rule originally filed as 13 CSR 40-71.025. Original rule filed Oct. 7, 1987, effective March 25, 1988. Emergency rescission and emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rescission and emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994.

13 CSR 35-71.030 Hearings and Judicial Review {#sec-13-csr-35-71.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.030}

PURPOSE: This rule addresses the procedures for license denial, revocation, suspension, or suspension of intake and the right for an administrative hearing and judicial review for an agency aggrieved by a final decision of the director.

(1) License Denial or License Revocation.

(A) The division may refuse to issue a license to an applicant, or may deny or revoke the license of a licensee, who— 1. Fails consistently to comply with the applicable provisions of sections 210.481–210.536, and 210.1250–210.1286, RSMo, and the applicable corresponding rules;

2. Violates any of the provisions of its license;

3. Violates federal or state laws or rules relating to the protection of children;

4. Abuses or neglects children, or is the subject of multiple or serious reports of child abuse or neglect which upon investigation results in a substantiated finding of child abuse or neglect; or is found guilty, pleads guilty, or pleads no contest to any crime which would render an individual ineligible for employment or presence at the Licensed Residential Care Facility (LRCF) pursuant to section 210.493, RSMo;

5. Employs persons who the division has found ineligible for employment or presence at the LRCF pursuant to section 210.493, RSMo, and 13 CSR 35-71.015, or who abuses or neglects children;

6. Furnishes or makes any misleading or false statements or reports to the division;

7. Refuses to submit any reports or refuses to make available to the division any records required in making an investigation;

8. Fails or refuses to submit to an investigation by an authorized and identified representative of the division at any reasonable time;

9. Fails to provide, maintain, equip, and keep in safe and sanitary condition the premises established or used for the care of children as required by law, rule, or ordinance applicable to the location of a facility;

10. Fails to provide adequate financial resources for the satisfactory care of children being served, or the upkeep of the premises, or both;

11. Fails to satisfactorily comply with all fire, safety, health, and sanitation inspections as may be required by state law or local ordinance and required under section 210.252, RSMo; or 12. Is a health or safety concern for the children at the LRCF.

(B) The division shall provide written notice of denial or revocation of licensure to the agency, which shall include the reason(s) for the denial or revocation. Upon receipt of the notice of denial or revocation, the agency shall cease operation within ten (10) business days unless stayed by an appropriate administrative or judicial order, or a request for an administrative hearing is made before the expiration of the ten (10) business days from the date of the notice.

(C) The agency may appeal the decision of the division to deny or revoke the license by filing a request for appeal with the division within ten (10) days after receipt of the notice of denial or revocation.

(D) Any person aggrieved by a decision of the division to deny or revoke a license shall be entitled to a hearing on administrative review under section (5) of this rule.

(E) An agency may not reapply for licensure within one (1) year from the date of denial or revocation.

(2) License Suspension.

(A) The division shall have the authority to suspend the license of an agency when— 1. The division determines that the suspension of the license is necessary to protect the health, safety, and welfare of children who are or may be placed at the operating site; and 2. The division determines that noncompliance with one (1) or more of the criteria set out in sections 210.496 and 210.1250–210.1286, RSMo, and/or subsection (1)(A) of this rule may exist; and 3. The division has reasonable cause to believe that the agency will be able to develop and effectively implement a corrective action plan to resolve the concerns which gave rise to the suspension of the license.

(B) The agency shall cease operations within ten (10) business days of the date the division issues an order suspending the license of the agency unless— 1. The agency files a written request for administrative review within ten (10) business days of the date of the order; or 2. The order is stayed by an appropriate administrative or judicial order.

(C) The order for suspension of the license shall be in writing.

The order shall include:

1. The factual and legal basis for the order; and 2. Notification of the right of the agency to administrative review. The division may extend the order if there has been no substantial change in the circumstances since the entry of the original order or if there are new grounds for extension of the order.

(D) The division may reinstate a suspended license on its own motion or upon written application by the agency. The division may reinstate that license if the division determines that— 1. The agency has developed and successfully implemented a corrective action plan approved by the division to remedy the concerns which resulted in the license suspension; and 2. The agency meets all of the criteria for licensing; and 3. The division determines that suspension of the license is no longer necessary to protect the health, safety, and welfare of the children involved.

(3) Suspension of Intake.

(A) The division shall have the authority to suspend the authorization of the agency to admit additional children into placement during time periods proscribed by the division when the division determines that the agency is not in compliance with the requirements of sections 210.493, 210.496, and 210.1250–210.1286, RSMo, and/or subsection (1)(A) of this

rule and— 1. The addition of additional children to the agency is not in the best interests of the children already placed within the agency or who may be placed with the agency; and 2. Allowing the placement of additional children with the agency may pose a risk to the health, safety, and welfare of children already placed with the agency or who may be placed with the agency.

(B) The order for suspension of intake shall be in writing. The order shall include— 1. The factual and legal basis for the order; and 2. Notification of the right of the agency to administrative review. The division may extend the order if there has been no substantial change in the circumstances since the entry of the original order or if there are new grounds for extension of the order. A suspension of intake shall proscribe the number of additional children which the agency is authorized to accept for placement, if any, but it shall not include a requirement that children currently placed with the agency shall be removed.

(C) If the division finds that suspension of intake prior to the opportunity for a hearing on administrative review is necessary to protect the health, safety, and welfare of children then the division has the option to make the order to suspend intake effective immediately upon delivery to the agency; otherwise the order shall be effective ten (10) business days from the date of the entry of the order unless— 1. The agency files a written request for administrative review within ten (10) business days of the date of the order; or 2. The order is stayed by an appropriate administrative or judicial order.

(D) If the division issues an order to immediately suspend intake the division shall schedule an informal meeting to review the decision with the agency as soon as practicable.

The meeting shall take place before the director or his/her designee. The division shall notify the agency of the date and time for the meeting. The meeting may be continued at the request of the agency, but the order shall remain in effect pending the meeting. The meeting shall be informal, the rules of evidence shall not apply, and both the agency and the division may submit any information relevant to the issues in the case. The purpose of the meeting will be— 1. For the division to determine whether there is probable cause to find that a suspension of intake is necessary to protect the best interests of the children placed with the agency or who may be placed with the agency pending a fair hearing on administrative review pursuant to section (4), below; and 2. To afford the agency an opportunity to informally provide information relevant to the division’s decision and to request relief from the entry of the order.

(E) If the division finds after the meeting that there is probable cause to continue the suspension of intake pending hearing on administrative review the division shall expedite the hearing on administrative review; otherwise the suspension of intake shall be stayed pending hearing on administrative review.

(F) The division may rescind the order suspending intake on its own motion or upon written application by the agency. The division may reinstate the intake if the division determines that— 1. The agency has developed and successfully implemented a corrective action plan approved by the division to remedy the concerns which resulted in the suspension of intake; and 2. The agency meets all of the criteria for licensing; and 3. The division determines that the suspension of intake is no longer necessary to protect the health, safety, and welfare of the children.

(4) Emergency Order Against an Existing License.

(A) The division may issue an order immediately suspending a license prior to a hearing on administrative review when the division finds that there is probable cause to believe that— 1. There is an imminent risk of immediate and significant harm to the health, safety, or welfare of children who are placed or who may be placed with the agency; and 2. The risk is such that the health, safety, or welfare of the children may be at risk if the division’s emergency action does not become effective before the agency is afforded an opportunity for a hearing.

(B) The division’s findings under this section must be made in writing and set out in the order. The order shall notify the agency of its right to request administrative review and of its right to an informal meeting.

(C) If the division issues an emergency order against a license under this section the division shall schedule an informal meeting to review the decision with the agency as soon as practicable. The meeting shall take place before the director or his/her designee. The division shall notify the agency of the date and time for the meeting. The meeting may be continued at the request of the agency, but the order shall remain in effect pending the meeting. The meeting shall be informal, the rules of evidence shall not apply, and both the agency and the division may submit any information relevant to the issues in the case. The purpose of the meeting will be— 1. For the division to determine whether there is probable cause to find that an emergency exists which requires continuation of the division’s action pending a hearing on administrative review pursuant to section (5) below; and 2. To afford the agency an opportunity to informally provide information relevant to the division’s decision and to request relief from the entry of the order.

(D) If the division finds after the meeting that there is probable cause for the emergency action and continues the suspension in effect the division shall refer the matter for a hearing on administrative review; otherwise the suspension of the license shall be stayed pending hearing on administrative (5) Hearing on Administrative Review.

(A) The agency which is aggrieved by the decision of the division, (including, but not limited to, a decision to deny a variance, to suspend intake, suspend a license, deny a license application, or revoke an existing license) shall have the right to a hearing on administrative review of the division’s decision.

(B) The division shall provide written notice to the agency of its adverse action against the license of an agency. The notice shall— 1. Inform the agency of the nature of the decision;

2. State the factual and legal basis for the division’s action;

3. State the effective date of the action, if applicable; and 4. Notify the agency of its right to seek administrative (C) To request a hearing the agency shall submit a written request for administrative review within ten (10) business days of the decision of the division. The request for administrative review shall set forth the basis of the agency’s objection to the division’s decision.

(D) Unless otherwise provided in this rule, the division’s action shall be stayed pending the entry of an order after hearing on administrative review if the agency request administrative review of the division’s decision within ten (10) business days of the date of the notice of the division’s action.

(E) If the agency requests a hearing the division shall hold an administrative hearing. The hearing shall be held by the director or the director’s designee.

(F) Upon receipt of the final decision of the division, the agency can decide to accept the final decision or file petition for judicial review pursuant to sections 210.526 and 536.100 through 536.140, RSMo.

Filed Sept. 17, 2021, effective March 30, 2022. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.493, RSMo 2021; 210.506, RSMo 1982, amended 1993, 1995; 210.526, RSMo 1982; 210.1286, RSMo 2021; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020, 210.506, 210.526, and 660.017, RSMo 2016, and sections 210.493 and 210.1286, RSMo Supp. 2021. This rule originally filed as 13 CSR 40-71.030. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and expired Jan. 30, 2009. Moved to 13 CSR 35-71.030 and amended:

13 CSR 35-71.035 Court Review and Dispositional Hearing {#sec-13-csr-35-71.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.035}

PURPOSE: This rule defines the provisions for judicial review and disposition of the child(ren).

The agency shall comply with all applicable requirements of

section 210.710 or 210.720, RSMo, pertaining to judicial review of the status of the child.

This rule originally filed as 13 CSR 40-71.035. Emergency rule June 6, 1994. Moved to 13 CSR 35-71.035, effective Oct. 30, 2008.

13 CSR 35-71.040 Organization and Administration {#sec-13-csr-35-71.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.040}

PURPOSE: This rule sets forth the requirements for the incorporation, administration, and financing of an agency.

(1) Each agency shall be incorporated and shall submit to the division its articles of incorporation and certificate of incorporation.

(2) An agency shall have a governing body responsible for establishing its policies, determining its programs, guiding its development, and providing its leadership. A list of the names, addresses, and place of employment of the current members of the governing board shall be kept on file at the agency and available for review.

(3) Voting members of the board of directors shall not be employed by and/or do not receive financial compensation from the agency. Any employee who serves as a member of the board of directors shall sign a statement acknowledging his/her understanding of and agreement with this rule. Such statement shall be part of the personnel file.

(4) The governing body shall be responsible for— (A) Developing and maintaining a program of orientation and training for all new members of the governing body;

(B) Determining the size, selection, function, and organization of the governing body;

(C) Keeping minutes of each meeting of the governing body, which shall reflect its actions pertaining to and affecting the care and safety of children;

(D) Meeting as often as necessary, but at least four (4) times a year, to conduct the business of the agency, at least one (1) of which shall be held at an operating site;

(E) Conducting an on site visit to each operating site annually by at least a committee of the governing body;

(F) Ensuring an agency’s continuous compliance with Missouri law and applicable licensing rules;

(G) Ensuring the agency’s continuous compliance with all applicable federal, state, or local laws or regulations governing the operation of the agency;

(H) Ensuring that an agency’s standards of practice shall be professional, ethical, and responsive to client needs;

(I) Appointing the executive director and delegating responsibility to the director to administer the agency in all of its activities, functions, and services;

(J) Performing and retaining a written evaluation of the executive director on an annual basis;

(K) Providing the division a written statement which sets forth the kind and extent of authority delegated to the executive director;

(L) Ensuring that all operating sites are maintained, staffed, and equipped to implement the agency’s program effectively;

(M) Making available for review by the division the written policies and procedures of the agency, and evaluating the policies and procedures biennially to determine that the interests of children and families are being served;

(N) Meeting with division staff when requested;

(O) Providing written notification to the division within five (5) working days when there is a change of executive directors, board president, or the organizational structure of the agency;

(P) Reporting a criminal act of an employee in the performance of employment duties to law enforcement and/or the prosecuting attorney and providing immediate oral report followed by a written report to the division five (5) working days after the occurrence of the criminal act that specifies the agency’s corrective action plan; and (Q) Ensuring that no unrelated business is established at the licensed agency operating site without providing the division with a written request and receiving written permission from (5) Financial Management.

(A) The governing body shall approve an annual budget which shall be on file at the agency and submitted to the licensing unit;

(B) If an agency has annual gross revenues of five hundred thousand dollars ($500,000) or more, the agency shall be audited annually by an independent certified public accountant and a copy shall be submitted to the division. Agencies with an annual gross income of less than five hundred thousand dollars ($500,000) shall provide documentation of an annual financial review;

(C) The treasurer, administrator, and any other persons handling funds shall be bonded, as determined by the governing body;

(D) The governing body shall ensure that insurance for public liability, worker’s compensation, fire and disaster insurance on the property, and agency vehicles is maintained; and (E) The governing body shall be responsible for providing and maintaining adequate funds for the operation of the agency.

History

• AUTHORITY: section 210.506, RSMo 2000. This rule originally filed as 13 CSR 40-71.040. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rescission and emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. Rescinded and readopted: Filed Nov. 1, 1993, effective June 6, 1994. Emergency amendment filed July 25, 2008, effective Aug. 4, 2008, expired Jan. 30, 2009. Moved to 13 CSR 35-71.040 and amended: Filed July 25, 2008, effective Jan. 30, 2009. Amended: Filed Dec. 16, 2013, effective June 30, 2014. Original authority: 210.506, RSMo 1982, amended 1993, 1995.

13 CSR 35-71.045 Personnel {#sec-13-csr-35-71.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.045}

PURPOSE: This rule sets forth the requirements for child abuse/neglect and criminal background screenings, medical examinations, personnel records, job descriptions, and staff orientation and training.

(1) Pre-Employment Requirements.

(A) The licensed residential care facility (LRCF) shall require all professional staff to provide a copy of their official college transcript or college diploma and shall keep such transcripts or diplomas on file pursuant to the requirements set forth in subsection (4)(A) of this rule. The LRCF shall require any person employed in a position requiring a general educational development certificate or high school diploma to provide a copy of such certificate or diploma to the LRCF, which the LRCF shall keep on file pursuant to the requirements set forth in subsection (4)(A) of this rule.

(B) The LRCF shall require prospective employees to submit at least three (3) character references from unrelated persons.

At least one (1) reference shall be from a previous employer, supervisor, teacher, or professor. The LRCF shall contact all references and maintain documentation of the reference checks in the LRCF’s employee records pursuant to the requirements set forth in subsection (4)(A) of this rule. Documentation of the contact shall include the date, person making the contact, and the content of the contact.

(C) The LRCF shall establish a written job description for each position, which shall be given to staff at the time of employment.

Each description shall describe the duties and responsibilities of the position, address supervision, required knowledge, skills, and abilities, minimum experience, educational requirements, and shall include examples of work performed.

(2) Annual Requirements.

(A) The LRCF shall conduct an annual check of the family care safety registry (FCSR) for all employees and contractors and those owners and volunteers who have access to children.

The LRCF shall maintain documentation of the FCSR checks in its personnel records.

(B) The LRCF shall conduct an annual background check for employees, contractors, owners, and volunteers with access to children who reside outside of Missouri by searching the criminal records database and child abuse and neglect registry of the states where such persons reside. If the LRCF is not legally permitted to search such databases and registries, such employees, contractors, owners, and volunteers shall conduct a background check on themselves in such databases and registries and provide the results to the LRCF.

(C) The LRCF shall require an annual driver record check for any employees, interns, volunteers, or contract personnel who transport residents. No individual with a suspended or revoked driver's license or record of driving while under the influence of alcohol or any other intoxicating substance within the last five (5) years shall transport residents.

(3) Health Verification.

(A) All staff, employees, interns, volunteers, and contracted personnel shall be free of symptoms of communicable disease or other evidence of ill health that poses a threat to children.

(B) If the division has reason to question the capabilities of any individual working directly with children served by the LRCF, the division may require the individual to submit to a medical examination and obtain a report of an appropriate medical professional that the individual is medically fit to perform the services for the LRCF without reasonable risk to the children.

(4) Personnel Records. The LRCF shall maintain personnel records for each staff member, employee, intern, volunteer, and contracted employee as indicated below. The LRCF shall maintain the records on site and shall keep the records for at least three (3) years following the date of separation from the LRCF.

(A) For staff members and employees, the personnel record shall include— 1. Verification of education and experience, and a copy of professional license, if applicable;

2. Verification of the names of three (3) persons, unrelated to the staff member, who can provide character or professional references;

3. Results of annual checks of the family care safety registry;

4. Documentation that the individual has completed the background checks and that the division has found the individual eligible for employment or presence at the LRCF pursuant to section 210.493, RSMo, and 13 CSR 35-71.015;

5. Documentation that employees who reside outside of Missouri have completed an annual background check of a criminal records database and child abuse and neglect registry of the state in which such employees reside;

6. The date that employment commenced;

7. Copies of annual performance evaluations;

8. Results of an annual driver record check for any employee, intern, volunteer, and any contracted personnel who transport residents;

9. A copy of the following documents signed and dated by the employee:

A. Job description;

B. Confidentiality policy;

C. Discipline policy;

D. Child abuse/neglect reporting policy;

E. Critical incident reporting policy;

F. Acknowledgment of receipt of program policy;

G. Acknowledgment of personnel policy; and H. Acknowledgment of completed agency orientation;

10. Documentation that the staff member has successfully completed all required training;

11. Documentation of current first aid/cardiopulmonary resuscitation training and certification for applicable staff;

12. Documentation of current medication aide certification, when applicable; and 13. Documentation of current physical restraint training certification, when applicable.

(B) For interns, volunteers, and contracted employees who have direct contact with children, the personnel record shall include— 1. Copy of professional credentials, if applicable;

2. Results of annual checks of the family care safety registry and documentation that the individual has completed the background check process and been found eligible for service as provided in section 210.493, RSMo, and 13 CSR 35- 71.015;

3. Results of annual checks of the out-of-state criminal records database and child abuse and neglect registry for those interns, volunteers, and contracted employees who reside outside of Missouri;

4. A copy of the following documents signed and dated by the intern, volunteer, or contracted employee:

A. The contract or any agreement outlining purpose of presence on site;

B. The confidentiality policy;

C. The discipline policy;

D. The child abuse/neglect reporting policy;

E. The critical incident reporting policy;

F. Acknowledgment of receipt of program policy, if applicable;

G. Acknowledgment of receipt of manuals or policies related to the agreement/contract, if applicable; and H. Acknowledgment of completed facility orientation, if applicable.

(5) Staff Orientation.

(A) The LRCF shall have a written statement of personnel practices that is provided to all staff at the time of employment.

(B) Within thirty (30) days following appointment, employees, interns, volunteers, and contracted personnel shall be oriented to the facility’s programs, practices, and the duties of their positions. The orientation program shall include instruction in the following areas with respect to the facility:

1. Program model;

2. Policies;

3. Staff roles;

4. Health and safety procedures;

5. Crisis intervention procedures;

6. Recordkeeping requirements;

7. Separation and attachment issues;

8. Confidentiality;

9. Recognition of suicidal tendencies and appropriate intervention;

10. Procedure for identifying and reporting child abuse or neglect, or both, in accordance with sections 210.110-210.165, 11. Procedure for identifying and reporting the abuse of youth eighteen (18) years or older who are “eligible adults” under sections 192.2400–192.2505, RSMo, if applicable;

11. Basic information on the child welfare and juvenile justice systems, including the legal rights of children and their families; and 13. Procedures to follow in an emergency.

(6) Staff Training.

(A) A facility shall prepare a written plan of training each year for all employees and contracted personnel.

1. Employees and contracted personnel that work directly with children shall have twenty-five (25) hours of training annually.

2. Direct care staff and immediate supervisors must maintain certification in a certified medication training program unless all medication is managed through on-site medical personnel.

3. Direct care staff and immediate supervisors must maintain certification in a current recognized and approved physical restraint program (where applicable), first aid, and cardiopulmonary resuscitation.

4. Employees and contracted personnel that do not work directly with children shall receive job-appropriate training.

(B) All training must be documented on a training database/ training log with the dates, location, subject, number of hours earned, and person(s) who conducted the training.

(C) The training may include short-term courses, seminars, institutes, workshops, and in-service training provided on site by qualified professionals. Activities related to supervision of the staff member’s routine tasks shall not be considered training for the purpose of this rule.

(D) The training plan shall include training in the following areas for employees and contracted personnel who work directly with children:

1. Developmental needs of children;

2. For those facilities licensed to provide residential treatment and intensive residential treatment, training related specifically to treatment issues with emotionally disturbed, mentally ill, behaviorally disordered, medically fragile, physically disabled, and/or developmentally delayed children, as defined by the facility’s program;

3. Prenatal and parenting skills, including safe sleep, for facilities licensed for infant/toddler/preschool and maternity;

4. Basic group dynamics;

5. Trauma-informed care;

6. Cultural sensitivity;

7. Critical incident reporting;

8. Appropriate discipline, crisis intervention, de-escalation techniques, and behavior management techniques;

9. The role of direct care and professional staff at the operating site, including maintaining appropriate boundaries;

10. Proper, safe methods and techniques of physical restraint, if applicable;

11. Fire prevention and reporting fires;

12. Emergency evacuations;

13. First aid and cardiopulmonary resuscitation training, including infant CPR for facilities with an infant/toddler preschool license;

14. Medication training and/or certification, including training to identify changes in a child’s appearance or behavior that may be related to the use or disuse of any medication, including psychotropic medications;

15. Substance abuse;

16. Suicide prevention;

17. Human trafficking;

18. Legal rights of children and their families, including basic information on the constitutional rights of children and their families while children are in care and basic information on the Missouri juvenile justice system; and 19. Water safety for those agencies allowing water activities. and sections 210.493 and 210.1286, RSMo Supp. 2024.* This rule originally filed as 13 CSR 40-71.045. Emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency

rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. Original rule filed Nov. 1, 1993, effective June 6, 1994. expired Jan. 30, 2009. Moved to 13 CSR 35-71.045 and amended:

Filed Sept. 17, 2021, effective March 30, 2022. Amended: Filed Oct. 1, 2024, effective April 30, 2025. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.493, RSMo 2021, amended 2023; 210.506, RSMo 1982, amended 1993, 1995; 210.1286, RSMo 2021; and 660.017, RSMo 1993, amended 1995.

13 CSR 35-71.050 Staff Qualifications and Requirements {#sec-13-csr-35-71.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.050}

PURPOSE: This rule sets forth the requirements for personnel practices, including staff qualifications, staff/child ratios, staff training, and nonpaid staff.

(1) Employee Qualifications. The facility shall employ staff who are qualified by education, training, and experience for their assigned responsibilities.

(2) Administrative and Supervisory Personnel.

(A) The facility shall employ staff to perform administrative, supervisory, service, and direct care functions which may be combined only upon the approval of the division. Staff members who perform combined functions must meet the requirements for each function.

(B) The facility shall employ an administrator or executive director to manage the facility’s operations and direct its activities.

(C) When the position of administrator or executive director is vacated, the facility shall appoint an acting administrator or executive director and notify the division’s licensing unit of the change in personnel within five (5) working days. The facility shall notify the division’s licensing unit immediately after a new executive director is appointed.

(3) Qualifications of Administrator or Executive Director and Program Director.

(A) A facility’s administrator or executive director must be at least twenty-five (25) years of age and have one (1) of the following:

1. A master’s degree or higher in social work, counseling, social work administration, or a related human service degree, from an accredited school, and two (2) years experience in the management or supervision of child care personnel and programs;

2. A bachelor’s degree in social work or a related human service area of study from an accredited school and four (4) years experience in the management or supervision of residential treatment personnel and programs; or 3. A bachelor’s degree from an accredited school and two (2) years experience in the management or supervision of child care personnel and programs. In such cases, the facility shall employ a program director to directly oversee the facility’s programs and services who meets the qualifications set forth in subsection (3)(C).

(B) The administrator/executive director shall designate in writing a qualified staff to be in charge when he or she is absent.

(C) The program director shall have one (1) of the following:

1. A master’s degree in social work or a related human service area of study from an accredited school; or 2. A bachelor’s degree in social work or a related human service area or study from an accredited school plus two (2) years experience in residential treatment for children and youth services or other child welfare related field.

(4) Professional Personnel.

(A) A facility shall obtain any professional services required for the implementation of the individual service plan of a child when these services are not available from staff.

(B) Professional staff who perform casework, group work tasks, or planning of services for children and their families will have at least a bachelor’s degree or higher in social work, psychology, counseling, or a related field from an accredited college or university. Unless otherwise required by law, professional staff without a bachelor’s degree or higher described in this section may perform casework, group work tasks, or planning of services for children and their families if such person— 1. Has four (4) years professional experience in caseworkrelated tasks; and 2. Works under the close supervision and guidance of professional staff who have a bachelor’s degree or higher as described in subsection (4)(B) and are licensed as required in subsection (4)(C) and who will be responsible for the professional work performed by staff who lack a bachelor’s degree or higher.

(C) Full- or part-time professional staff including psychologists, psychiatrists, social workers, counselors, physicians, teachers, and nurses shall meet the licensing or certification requirements of their profession in Missouri.

(D) The facility shall have at least one (1) professional staff for every twenty (20) children in care.

(E) The facility shall designate a supervisor for professional staff when six (6) or more staff are employed. The supervisor shall have a master’s degree or higher in social work, psychology, counseling, or related human service field of study and at least two (2) years clinical experience.

(F) Facilities who, by mission, serve a medically fragile and/or drug and alcohol affected population shall employ or contract with and schedule a licensed or registered nurse qualified to dispense medication and supervise medication management for not less than twenty (20) hours per week. At least one (1) staff shall be present at all times who is trained in infant/child cardiopulmonary resuscitation.

(5) Direct Care Staff—Staff/Child Ratios.

(A) Direct care staff shall be responsible, mature individuals of reputable character who exercise sound judgment, display the capacity to provide good care and supervision of children and must demonstrate competence in their duties in the following areas:

1. Protecting and nurturing children;

2. Meeting child developmental needs and addressing child developmental delays;

3. Supporting relationships between children and families;

4. Working as a member of a professional team; and 5. Supporting children with lifetime relationships.

(B) Direct care staff shall be at least twenty (20) years of age and shall have at least a high school diploma or high school equivalency certificate.

1. A facility may seek a variance from the division pursuant to 13 CSR 35-71.020(4)(E) to place staff under twenty (20) years of age in a direct care role for educational, internship, or work study opportunities when— A. The intern or student under twenty (20) years of age is working at the facility as part of an educational program of an accredited institution of higher education; and B. The intern or student under twenty (20) years of age is supervised by an employee of the facility who is qualified without variance as provided in subsection (5)(B) while serving in a direct care role.

2. In no circumstances shall— A. Any individual less than eighteen (18) years of age be placed in a direct care role, regardless of participation in an (1/29/26) Denny Hoskins educational program or level of supervision; or B. The division grant any variance for any direct care staff that do not meet the intern or student requirements described in paragraph (5)(B)1.

(C) Direct care staff shall record and maintain shift notes in sufficient detail to ensure consistency of care across all staff who provide care to a child, which shall include any activities, needs, medication management, or problems that may be specific to the child.

(D) The ratio of direct care staff to children shall be consistent with the minimum ratios represented on the reference chart in this subsection unless the division requires a higher ratio pursuant to subsection (I) of this section or unless a higher staff ratio is required by 13 CSR 35-71.130 or 13 CSR 35-71.140.

The ratio of direct care staff to children shall be dependent on the needs of the children.

Age Range Level of Care Direct Care Staff to Resident Ratio AwakeAsleep Birth to six (6) four (4) children One (1) staff per six (6) children. Staff must remain awake ..

Six to eight (6-8) six (6) children One (1) staff per ten (10) children (If the staff is on duty, but also sleeping).

OR One (1) staff per twelve (12) children (If staff on duty remain awake).

Over eight (8) ten (10) children One (1) staff per ten (10) children (If the staff is on duty, but also sleeping).

OR One (1) staff per twelve (12) children (If staff on duty remain awake).

(E) Facilities must have a minimum of two (2) staff available on-site at all times, even if their staff/child ratio is lower than required above. One (1) staff may be sleeping, but available for emergency situations. When a facility has multiple cottages/ units on campus or in a large congregate care setting, roving staff may serve the purpose of maintaining the required staff/ child ratio by maintaining a presence in the cottages/units on a rotating, regular, and timely basis.

(F) Appropriate staff/child ratios must be maintained at all times on campus and during off-grounds group activities.

However, transportation of a child to an appointment may be made by one (1) staff as long as the staff can adequately supervise the child without compromising the safety of each child or the staff. The safety needs of each child during transportation shall be assessed individually.

(G) Any children of live-in staff shall be included in the required staff/child ratios.

(H) The division may require a higher staff/child ratio if onsite review indicates a need for more supervision to maintain control, discipline, and adequate care, or the division may approve a lower staff/child ratio if on-site review indicates adequate care, discipline, and control can be maintained at a lower staff/child ratio.

(I) Facilities employing twelve (12) or more direct care staff shall designate staff to be primarily responsible for supervising, evaluating, and monitoring the daily work and progress of the direct care workers. Such direct care supervisory staff shall meet the minimum qualifications set forth in subsection (5)(B) and two (2) years of direct care experience.

(6) Relief Staff. The facility shall provide planned relief for direct care staff and shall have qualified relief staff to substitute for direct care staff during sick leave, vacation, relief time, and other absences from the facility as well as breaks or other temporary absences during shifts.

(7) Interns, Students, Work Study Participants. All interns, students, and work study participants at the facility shall be subject to the general personnel policies of the facility, but shall not be considered or used as substitutes for qualified and employed staff.

(8) Educational Staff. A facility operating an on-grounds school shall— (A) Be fully accredited in good standing by the Missouri Department of Elementary and Secondary Education to provide educational services or be administered and supervised by a fully accredited educational institution; and (B) All personnel providing educational services shall comply with the training and licensure requirements of the Missouri Department of Elementary and Secondary Education.

(9) Recreational and Activity Staff. The facility shall develop and coordinate recreational and activity programs and shall assign recreational/activity staff on basis of experience, education, and/or training in working with groups of children whose recreational needs and interests vary. Additional training shall be provided for this staff to enhance his/her ability to perform his/her assigned duties.

(10) Clerical Staff. Clerical staff shall be employed as needed for general clerical duties such as typing, recordkeeping, bookkeeping, and filing. Clerical staff shall not supervise or assist in the care of children without being qualified according to these rules.

(11) Other Staff. A facility shall employ, as needed, cooks, kitchen helpers, maintenance, custodial, and other support staff to perform housekeeping and maintenance functions.

Such other staff shall not supervise or assist in the care of children without being qualified according to these rules.

(12) Volunteers. If a facility uses volunteers as part of its program of services, the facility shall have written policies, subject to review and approval by the division, which include— (A) A clear description of the facility’s purposes and goals;

(B) A clear job description for the individual tasked with overseeing volunteers and for each category of volunteers;

(C) A clear differentiation of functions and activities appropriate for paid staff members and volunteers in policymaking, advocacy, administrative, and direct service roles. If volunteers are counted toward the staff/child ratio, a facility supervisory employee must be present and available at the operating site;

(D) A process for screening and selecting volunteers, who have direct contact with children consistent with section 210.493, RSMo, and 13 CSR 35-71.015;

(E) A defined line of supervision, with clear written expectations of the supervisor and the volunteers;

(F) Orientation, preservice, and in-service training activities in the volunteers’ specified roles;

(G) Procedures for monitoring and evaluating volunteer activities and contributions;

(H) Procedures for observing professional ethics and confidentiality; and (I) Procedures for handling conflicts between paid staff members and volunteers.

History

• AUTHORITY: sections 207.020, 210.506, 210.511, and 660.017, RSMo 2016. This rule originally filed as 13 CSR 40-71.050. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and Moved to 13 CSR 35-71.050, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014. Amended: Filed Aug. 12, 2025, effective Feb. 28, 2026. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.506, RSMo 1982, amended 1993, 1995; 210.511, RSMo 1982; and 660.017, RSMo 1993, amended 1995.

13 CSR 35-71.060 Social Services Program {#sec-13-csr-35-71.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.060}

PURPOSE: This rule sets forth the policies and procedure requirements for intake and admission, discharge, and social services.

(1) Intake and Admission.

(A) Intake Policies.

1. Intake policies shall be in writing and shall identify services and programs offered.

2. Admissions shall be limited to children for whom the agency’s services are appropriate, with consideration being given to a child’s physical, psychological and emotional needs, social development, interests and past educational history.

3. An agency shall not discriminate in its intake and services on the basis of race, religion, color, ethnic, or national origin.

4. When a child is self-referred, efforts shall be made to contact the child’s parent(s), guardian or legal custodian within twenty-four (24) hours. If the parent(s), guardian, or legal custodian cannot be contacted, the agency shall notify the appropriate public agency (division, juvenile court, police department) of the presence of the child. All efforts to notify the appropriate public agency, parent(s), or legal guardian shall be documented in the child’s case record.

5. Whenever possible, an agency shall arrange for one (1) or more preplacement visits by the child (except in emergency placements), and when appropriate, for at least one (1) or more preplacement visits by the child’s parent(s), guardian, or legal custodian.

(B) Admission Policies.

1. The agency shall have current, clearly written admission policies and criteria describing the age, sex, and emotional/ behavioral needs of child/ren served; and 2. A copy of the admission policies must be submitted to the licensing unit with the application for the initial license and at any time changes are made in the admission policies.

(C) Admission Procedures.

1. An admission assessment must be completed for each child indicating that the placement meets the child’s needs and best interests— A. For planned admissions, the admission assessment must be completed before a child is accepted for care;

B. For emergency admissions, the admission assessment must be completed within five (5) days of admission; and C. If the assessment of the child indicates a need for a more restrictive environment, the agency shall contact the child’s treatment team, case manager, legal guardian, and/ or legal custodian to plan for the child’s placement in a more appropriate facility.

2. The admission assessment must be in writing and include specific information on— A. The circumstances which led to the child’s referral;

B. The immediate and long-range goals of placement;

C. The child’s family and his/her relationship with family members;

D. The child’s relationships with other adults and children;

E. The child’s behavior, including appropriate and maladaptive behavior;

F. The child’s medical history, including any current medical problems ensuring medical and all health related documentation is held in confidence consistent with applicable federal and state law;

G. The child’s developmental history and current level of functioning;

H. The child’s school history including current educational level, special achievements, and any school problems;

I. The history of any other placements outside the home, including the reasons for placement;

J. An evaluation of the child’s special needs and strengths in the following areas: physical, familial, educational, social and psychological;

K. The parent’s or legal guardian’s expectations for placement, family involvement, and the duration of the child’s stay in care; and L. The child’s understanding of placement.

3. Children must have a medical examination that includes tests for communicable diseases including, but not limited to, tuberculosis and hepatitis when recommended by a licensed physician, certified nurse practitioner, advanced practice nurse who is in a collaborative practice agreement with a licensed physician, or a registered nurse under the supervision of a licensed physician, within thirty (30) days before or ten (10) days after admission. A copy of the medical examination report and findings, signed and dated by the physician, must be in the child’s record.

4. Children must have a dental examination by a licensed dentist within one (1) year before admission or arrangements must be made for an examination within three (3) months after admission.

5. A written placement agreement between the agency and the child’s parent(s) or guardian must be completed at or before placement. A copy of the placement agreement must be in the child’s record. The placement agreement must include (1/29/26) Denny Hoskins authorization to care for the child and a medical consent form signed and dated by a child’s parent(s) or legal guardian authorized to give consent.

6. Information about the agency must be discussed with the child’s parent(s) or guardian at or before admission.

Written material about the agency must be given to the child’s parent(s) or guardian and child when age appropriate. The following information must be included in the discussion and in the written material:

A. Rules regarding visits, mail, gifts, and telephone calls;

B. Discipline policies;

C. Policies regarding religious training;

D. Rules regarding recreational activities;

E. Policy regarding participation in treatment planning;

F. A copy of the treatment plan;

G. Copies of all signed and dated releases of information;

H. Health Insurance Portability and Accountability Act.

(2) Evaluation and Planning.

(A) Treatment Plan.

1. A preliminary written treatment plan must be developed and documented in the child’s record within fifteen (15) days of admission for each child admitted on an emergency basis.

If the child remains in care beyond an initial thirty- (30-) day plan, the plan must be modified to indicate the need for continued placement. The plan must be based on the admission assessment.

2. A written treatment plan must be developed and documented in the child’s record within fifteen (15) days of admission for each child admitted by plan for placement.

The plan must be based on the admission assessment and observations of the child’s adjustment into care. When drafting the treatment plan the agency shall consult with and involve all individuals and institutions which are parties to a juvenile proceeding involving the child or who may be necessary in preparing a treatment plan for the child, including, but not limited to: the child’s legal custodian/ guardian, the child’s parent, the child (when appropriate), guardian ad litem, juvenile officer, children’s division case manager, court appointed special advocate, as applicable to the individual child, and staff members who provide direct care, social services, education, recreation, and health services in developing and implementing the treatment plan for the child and family.

3. The service plan must identify and include:

A. The child’s needs in addition to basic needs for food, shelter, clothing, routine care, and supervision;

B. Specific strategies and their frequencies to meet the child’s needs, including instructions to staff;

C. Specific strategies and frequencies for family involvement, including a defined plan for visitation and engaging the family in services for the child;

D. Specific strategies to meet the recreational and developmental needs of the child;

E. The estimated length of stay;

F. Time limited goals and preliminary plans for discharge, that address permanency related to family reunification, termination of parental rights and adoption, placement with a fit and willing relative, legal guardianship, or another planned permanent living arrangement; and G. The date and signature of the program director/ qualified professional staff and a signed and dated attendance sheet of all other participants. Invited participants shall include, but not be limited to:

(I) Legal custodian/guardian;

(II) Parent;

(III) Child, as age/developmentally appropriate; and (IV) Guardian ad litem/court appointed special advocate, as applicable to the individual child.

4. A copy or summary of the treatment plan must be given to the child, when appropriate, and to the child’s parents or legal guardian. If the plan is not shared with the child, the child’s record must reflect justification for this decision.

5. An agency shall provide and document in a child’s record, social services to each child at least two (2) times per month as required by treatment plan. Social services shall be provided to the child’s family for whom reunification is the permanency goal and shall begin at placement. The family’s participation or reasons for non-participation shall be documented.

6. The progress of a child and his/her family shall be evaluated at least every ninety (90) days from the date of admission, and the service plan shall be modified when appropriate. In crisis placement, an evaluation shall be conducted at least every thirty (30) days. Evaluations shall be made by professional staff in consultation with other staff who have significant contact with the child, the parent(s), guardian, or legal custodian.

(B) Treatment Plan Review.

1. The treatment plan review must include:

A. An evaluation of progress toward meeting the child’s needs;

B. An evaluation of progress toward the permanency goal;

C. Any needs identified since the plan was developed or last reviewed and strategies to meet the needs, including instructions to staff; and D. An update of the estimated length of stay and discharge plans, if changed.

2. The review of the treatment plan with the date and signature of the program director/qualified professional staff and a signed and dated attendance sheet of all other participants in the review must be documented in the child’s 3. Reports of the evaluations in summarized form shall be included in the child’s record, and shall be shared with the parent(s), guardian, or legal custodian.

(3) Discharge from Care.

(A) The following persons must be involved in planning a nonemergency discharge: the child; the child’s parent(s) or legal guardian and agency staff.

(B) The child may be released only to the parent(s) or legal guardian unless there is a court-authorized independent living arrangement.

(C) If a child is discharged because s/he is a danger to him/ herself or others, s/he must be accompanied by staff to the parent(s) or legal guardian or an appropriate placement resource.

(D) The date and circumstances of the child’s discharge must be documented in his/her record. The signature, address and relationship of the adult to whom the child is discharged must be included in the documentation.

(E) Except in emergency situations, an agency shall give at least thirty (30) days’ written notice to the parent(s), guardian, or legal custodian before discharging a child from care.

(F) The discharge plan must be tied to permanency goals related to family reunification, termination of parental rights and adoption, placement with a fit and willing relative, legal guardianship, or another planned permanent living arrangement.

(4) Discharge Summary. When a child in care is discharged, an agency shall complete a written discharge summary within thirty (30) days of the date of discharge. This summary shall be included in the child’s case record, and shall include:

(A) The name, address, telephone number, and relationship of the person(s) or agency to whom the child is discharged;

(B) A summary of services provided during care;

(C) A summary of growth and accomplishments during care;

(D) Reason for discharge; and (E) An identified aftercare plan which shall include cooperative efforts with the parent(s) or legal guardian to support the child’s transition from placement into the family or community.

This rule originally filed as 13 CSR 40-71.060. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and Moved to 13 CSR 35-71.060, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014. *Original authority 210.481, RSMo (1982).

13 CSR 35-71.070 Protection and Care of the Child {#sec-13-csr-35-71.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.070}

PURPOSE: This rule sets forth the provisions for protection of the child, including child abuse or neglect, or both, exploitation, confidentiality, discipline and control, physical restraint, fire safety/emergency preparedness procedures, transportation, work experience and allowances. Also, provision for the care of the child, including living arrangements, personal hygiene, clothing, food and nutrition, personal possessions, family identity, religious requirements, educational program, recreational and activity programs transitional living services, smoking policy, and prohibition of practices with negative impact on residents.

(1) Protecting the Child in Care. An agency shall submit an immediate oral report (within six (6) hours), to the division followed by a written report, within five (5) working days after the occurrence of an unusual incident, such as the death or serious injury of a child, alleged child abuse or neglect, loss of any electricity, gas, water, telephone, or any other conditions affecting the health and safety of children for a period of longer than twelve (12) hours or requires the removal of residents, or any emergency that requires summoning first responders.

(A) Protecting the Child in Care-Child Abuse or Neglect, or Both.

1. The agency shall require each staff person to read and sign a statement defining child abuse and neglect and outlining responsibilities to report all child abuse and neglect incidents as required by statute.

2. An agency shall have written procedures for any alleged incident of child abuse or neglect, or both, which shall include:

A. Reporting the alleged incident as required by the child abuse/neglect reporting law, sections 210.110-210.165, B. Conducting an internal investigation of the alleged incident; and C. Providing a written report to the licensing unit of the agency’s internal investigation of the alleged incident.

D. An internal investigation shall include, but not be limited to:

(I) Names of staff and residents involved;

(II) Date incident occurred;

(III) Date division notified;

(IV) A copy of the critical incident report including but not limited to: injury of a child during physical restraint; serious physical or sexual aggression by or toward the child; significant physical injuries requiring medical attention; and neglect hotline pursuant to section 210.115, RSMo;

(V) A summary of administrative interviews with staff and residents(s) to determine the situation;

(VI) Any action taken to protect the child(ren); and (VII) Any immediate corrective action of any licensing violations or agency policy.

E. An internal investigation should be completed by an objective third party not involved in the incident, so as to avoid any potential for conflict of interest.

3. If the safety of the children is threatened, as determined by the executive director, no person who is alleged as a perpetrator in an incident of child abuse or neglect, or both, shall work directly with children until an investigation is complete.

4. If the investigation results in an affirmative finding consistent with current statutory standard of proof the agency shall submit a written report to the licensing unit, outlining corrective action taken by the agency. If the agency fails to take appropriate action to prevent future abuse or neglect, or both, the division may deny, suspend, or revoke the license.

5. The agency shall create and maintain a centralized log of all critical incidents.

(B) Exploitation of Children.

1. Exploitation of children shall be prohibited.

2. As used in these rules, exploitation of children shall include, but not be limited to:

A. The use of a child or his/her picture or name for solicitation for funds without the written consent of the child’s parent(s), guardian or legal custodian;

B. The use of a child to advance an agency’s religious beliefs; and C. The placement of unreasonable demands for work upon a child.

(C) Confidentiality.

1. An agency shall have written procedures for the maintenance and security of clients’ records. This shall include a staff review of the procedures for confidentiality and a signed and dated statement indicating that staff have reviewed the procedures. The agency shall secure records against loss, tampering, or unauthorized use by— A. Protection of the confidentiality of records when in use and keeping them under lock when not in use;

B. Staff and professional consultants seeking access only to the records with which they are professionally involved;

C. Staff not disclosing or permitting the disclosure of any information concerning the child or his/her family, directly or indirectly, to any unauthorized person; and D. Staff being informed of the requirement that they must observe the procedures for protecting confidentiality after termination of employment.

2. Records shall be made available to the division or its authorized and identified agents, either upon written or verbal request. This includes division staff who are involved in child abuse/neglect reporting/investigation.

3. All requests for access to a child’s records shall be documented in the record providing the name of the individual making the request, the date, and the desired materials. If access was refused, the grounds for refusal shall be documented.

4. A consent for release form signed and dated by the parent(s), legal guardian, or legal custodian must be provided before a child’s records are released or a child’s photographs are displayed, or any video tape and/or audio recording of a child for the purpose of health, safety, welfare, enhanced supervision, and/or other therapeutic purpose pursuant to the child’s case plan is released, to any person other than those specified in these rules. The consent must specify what information may be released, to whom, for what purpose, and for what period of time.

(D) Discipline and Control.

1. An agency shall have written policies regarding discipline, supervision, and behavior management, which shall be explained and made available to a child’s parent(s), or guardian or legal custodian, or both, staff, and to the child. The procedures shall be within each child’s ability to understand and achieve.

2. The policies shall identify the type of children served, describe the anticipated behavioral problems, set forth acceptable methods of dealing with the behaviors, and detail the required qualifications and training of staff. All discipline shall be consistent with the treatment/safety plan developed for the resident.

3. All discipline shall be reasonable and appropriate to the child’s age and level of development. All discipline shall be limited to the least restrictive appropriate method and administered by appropriately trained staff.

4. Encouragement and praise of good behavior shall be used instead of focusing on unacceptable behavior.

5. The agency shall have written policies and procedures prohibiting discipline which may adversely affect a child’s health or physical or psychological well-being. A copy shall be given to all residents, families, staff and placing agencies. The following forms of discipline shall not be used:

A. Cruel and unusual punishment;

B. Excessive or inappropriate work;

C. Denial of meals, daily needs, and the program provided by the individual service plan;

D. Verbal abuse, ridicule, or humiliation;

E. Permission for a child to discipline another child;

F. Chemical restraints;

G. Mechanical restraints;

H. Denial of planned visits, telephone calls, or mail contacts with family shall not be used as a consequence for negative behaviors;

I. The use of foods intended to produce an adverse reaction;

J. Physical or emotional abuse;

K. Confinement in any space not designed for isolation and observation;

L. Requirement that a child remain silent for long periods of time or other unreasonable verbal restrictions;

M. Corporal punishment including, but not limited to, slapping, hitting, spanking, paddling, shaking, belting, marching, standing rigidly in one (1) spot, use of excessive physical exercises such as running laps or doing push-ups or any method which harms or endangers the child;

N. Locked isolation for the purpose of discipline;

O. Withholding of an opportunity for a minimum of eight (8) hours of sleep in a twenty-four- (24-) hour period;

P. Withholding of shelter, clothing, essential personal needs, essential program services; or Q. Withholding of meals, mail, allowances, or family visits.

(E) Physical Restraint.

1. All agencies using physical control techniques must have written policies defining the method of control utilizing a recognized physical restraint training program, approved by the division. The agency shall identify persons used in implementing these methods; and establish the training required for these persons. These policies shall address the use of crisis intervention, including techniques to be used prior to physical restraint and include:

A. The use of two (2) staff, one (1) of whom is fully qualified;

B. An immediate notice to the supervisor; and C. A written report to the administrator.

2. For agencies permitting the use of physical restraint, the administrator and/or program director shall review its usage at least quarterly.

3. The agency shall maintain a centralized record when physical restraint is used, which shall include:

A. The name of the child, the date and time the child was physically restrained;

B. The circumstances that led to the placement of the child in a physical restraint and the de-escalation attempts used to try to prevent the use of physical restraint;

C. The name of the staff person who initiated the physical restraint, the staff person(s) who assisted with the physical restraint, and any other staff and/or residents who witnessed the physical restraint;

D. The amount of time the child remained in the physical restraint, any changes in the staff participation, and the time of and reasons for release;

E. Documented behavioral observations of the child at each five- (5-) minute interval;

F. Specific notation of any extension of any physical restraints lasting longer than five (5) minutes including reasons for the extension;

G. Documentation of results of debriefing that includes recommendations of staff and resident for avoiding a similar situation; and H. Documentation of any medical care provided to the 4. Physical restraint shall include all efforts to minimize the possibility of injury to a child.

5. All instances of physical restraint shall be documented on incident reports and filed in the child’s record.

6. Physical restraint may be used as a management method after all other verbal de-escalation measures have been exhausted, never to replace other more positive measures of control. Physical restraint methods shall be used only to end disturbances that threaten physical injury to the child, physical injury to others, or to take from a child a dangerous object which the child has threatened to use against him/herself or against others.

7. An agency shall not use mechanical restraint.

8. Strap-boards, strait-jackets, or homemade restraint devices such as tape shall not be used.

9. Within twenty-four (24) hours of each physical restraint incident, treatment staff shall debrief the incident with the resident.

10. For agencies permitting the use of physical restraint, the administrator and/or program director shall review its usage at least quarterly.

11. If the agency does not meet all the requirements for the use of physical restraint, the division shall give written notice of specific deficiencies and the agency shall not use physical restraint until corrections are made and approved by (F) Fire Safety-Emergency Evacuation Procedure.

12. Each operating site shall be inspected biennially and shall be in compliance with the requirements of the State Fire Marshal.

13. Written instructions for fire and other emergency evacuations shall be posted in a conspicuous place in each operating site. Children shall be instructed in evacuation procedures at the time of admission. An evacuation drill shall be held at least monthly, and a record of all drills shall be on file at each agency.

14. The agency shall train staff in fire prevention and to report fires and shall teach children fire safety.

15. The agency shall establish emergency preparedness policy, to include but not to be limited to:

A. Emergency contact information;

B. Evacuation procedures; and C. Medication management during emergencies.

(G) Transportation.

1. General requirements.

A. The agency shall provide transportation as indicated by the individual needs of the children, for example, medical and dental appointments, educational or training programs, counseling, family therapy, and court proceedings. If the agency cannot, for any reason, transport a child to any required services, the agency shall work with the child’s treatment team members, legal guardian, and/or legal custodian to make appropriate and timely arrangements.

B. The agency shall be responsible for the care, safety, and supervision of children on field trips or at any time children are transported away from the operating site.

2. Vehicle and vehicle operator.

A. Staff transporting children shall have a valid driver’s license as required by Missouri law.

B. All vehicles used to transport children shall be licensed and operated in accordance with Missouri law.

C. Children shall not be transported in campers, trailers, or in the back of trucks.

3. Safety and supervision.

A. All children shall be seated in a permanent seat and restrained by seat belts or child restraint devices as required by Missouri law.

B. Staff/child ratios shall be maintained at any time the agency transports children away from the operating site.

C. Children shall be required to remain seated while the vehicle is in motion.

D. Doors shall be locked when the vehicle is moving.

E. Order shall be maintained when the vehicle is moving.

F. Children shall not be left unattended in a vehicle at any time.

G. Children shall enter and leave the vehicle from the curbside unless the vehicle is in a protected area or driveway.

H. Children shall be assisted, when necessary, while entering or leaving the vehicle.

I. Head counts shall be taken before leaving the operating site, after entering the vehicle, during a field trip, after taking the children to bathrooms, after returning to the vehicle and when back at the operating site.

J. When children leave the vehicle, the vehicle shall be inspected to ensure that no children are left on or under seats.

(H) Work Experience.

1. An agency shall provide the opportunity for work experiences for each child appropriate to the age, health, and abilities of the individual child.

2. Work experience shall not interfere with a child’s time for school, study periods, play, sleep, community contacts, or visits with his/her family, and shall be designed to serve the child’s interest.

3. If work experience is a part of the child’s treatment plan, it shall be identified in the treatment plan. A schedule shall be maintained for all children who work paying jobs for review by licensing staff.

4. Children shall not be used as substitutes for staff.

5. An agency shall differentiate between chores children are expected to perform, specific work assignments made as a means of earning money, and jobs performed in or out of the operating site to gain vocational training.

6. Work training programs and employment of children shall be approved by the executive director or designated staff when the child is employed outside the operating site.

7. Children shall be given some choice in their chores and work experiences, and duties shall be changed periodically to provide the child a variety of experience.

8. An agency shall limit the length of time children spend on regular nonpaid chores to one (1) hour a day during the school year and not more than two (2) hours a day during the summer months for all children.

9. An agency shall comply with the applicable child labor laws, sections 294.011-294.140, RSMo. Children working paying jobs shall receive pay in accordance with community rates.

10. A complete record of a child’s earnings and dispersals from this fund shall be maintained and made available upon request to the child, the parent(s), the guardian, or legal custodian and the licensing unit.

11. Children shall be provided proper supervision when working with, or in proximity to, power-driven machinery, upon scaffolding, in the operation of a motor vehicle, or in any other occupation which is dangerous to the life or health of a (I) Allowances and Money.

12. If a child does not work and earn his/her own spending money, each child shall receive a regular allowance. The child shall be allowed to use discretion in spending some of the allowance for items other than basic needs.

13. Money belonging to a child being discharged shall be transferred to the child, the parent(s), or the agency authorized to act as custodian.

14. Documentation of all deposits and withdrawals should be maintained and available for review upon request. At the time of discharge from the agency, documentation shall be made part of the child’s record.

(J) Critical Incident Report.

1. In the event that a critical incident occurs that includes, but is not limited to: injury of a child during physical restraint; serious physical or sexual aggression by or toward the child; significant physical injuries requiring medical attention; and neglect hotline pursuant to section 210.115, RSMo, a critical incident report is completed by the agency. When a child is not in Children’s Division custody, the agency shall then verbally notify, within six (6) hours, the regional licensing consultant, the child’s treatment team, case manager, parent, legal guardian, guardian ad litem, and legal custodian and provide them with a copy of the critical incident report within twenty-four (24) hours of the occurrence of the critical incident.

In the event a child is in Children’s Division custody, the agency contact, in addition to the regional licensing consultant, is the case manager. The agency contacts the regional licensing consultant and case manager within six (6) hours. The case manger then notifies the other pertinent team members. The agency then provides the regional licensing consultant and case manger with a copy of the critical incident report within twenty-four (24) hours of the occurrence of the critical incident.

(2) Care of the Child.

(A) Living Arrangements. Children shall be grouped by their age, level of development, and need for supervision.

(B) Personal Hygiene.

1. An agency shall provide each child with his/her own toiletry articles and with space for their storage.

2. An agency shall provide mirrors or unbreakable reflective surfaces in bathrooms at levels easily accessible to all children.

(C) Clothing.

1. An agency shall establish minimum clothing requirements for each child in care.

2. An agency shall assure that clothes are provided to each child. Clothes shall be individually selected and fitted, appropriate to the season and kept in a state of good repair and cleanliness. Each child’s clothing shall be identified as his/ her own.

3. An agency shall assure shoes are provided to each child which shall be kept in good repair.

4. When possible, children shall be permitted to participate in the selection and purchase of their own clothing.

5. Donated clothing shall be used only if it is in good condition.

6. Clothing belonging to and worn by a child while in residence shall be taken with him/her upon discharge.

(D) Food and Nutrition.

1. Nutritional requirements.

A. An agency shall provide nutritious, appetizing food which meets the daily nutritional requirements of the children in care.

B. Consideration shall be given when planning meals to the religious practices and cultural differences of the children.

C. An agency shall provide supplementary foods and modified diets for children with special dietary needs.

D. When a dietitian or nutritionist is not employed by an agency, consultation on menu planning shall be obtained as needed from a city, county, or state health agency or through a local resource.

E. Variations in the appetites of the children in care shall be recognized, and the children shall be encouraged, but not forced, to eat.

F. Children shall be encouraged to develop healthy eating habits.

G. All milk shall be pasteurized. Dry or powdered milk shall only be used in meal preparation and not utilized for drinking purposes.

2. Meal service.

A. An agency shall serve meals at recognized meal times, and at least three (3) times a day, unless children receive their noon meal at school.

B. Nutritious between-meal snacks shall be provided.

C. Staff and children who eat together shall be served the same food unless contraindicated for medical reasons.

(E) Personal Possessions. Each child shall be permitted to bring safe and appropriate personal possessions with him/her and to acquire belongings of his/her own while in residence.

A written inventory log of the child’s possessions at the time of admission and at the time of discharge shall be on file. The inventory log shall be updated during the stay, as needed.

(F) Family Identity and Relationships.

1. An agency shall develop written visitation policies.

2. An agency shall encourage and support contacts between a child and his/her family while the child is in care, unless the rights of the parent(s) to contact their child have been terminated or restricted by court order. The frequency of contact shall be determined by the child’s parent(s), guardian, or legal custodian in consultation with agency staff. An agency shall enable the family to visit and remain involved in their child’s care as well as actively participate in relationship building.

3. Privacy shall be provided for visits with family members, relatives, and friends, for telephone calls and for written communications unless otherwise indicated by the treatment plan.

4. Flexible visiting hours shall be provided for the parent(s) or legal guardian.

(G) Religious Requirements.

1. Prior to admission, an agency shall provide a written description of the agency’s religious requirements and practices, which shall be made available to the parent(s), guardian, or legal custodian, and, when appropriate, to the 2. Upon admission, if the agency requires mandatory religious observance or mandatory church attendance, consent of the parent(s), or guardian or legal custodian, or both, shall be obtained and explained to the child upon admission.

2. Opportunity for religious experience shall be made available to each child within the religious preference of his/ her family by treatment plan.

3. The child’s parent(s), guardian, or legal custodian shall provide written authorization regarding any change in religious affiliation by the child while s/he is in care.

4. Children shall be permitted to attend religious activities and services in the community by treatment plan.

(H) Educational Program. The agency shall be responsible for ensuring compliance with Missouri statutes pertaining to the children’s education.

1. An agency shall not admit a child unless an educational program appropriate to the child’s needs can be made available and provided.

2. The educational progress of a child shall be continually evaluated and the progress shall be included in the child’s three- (3-) month treatment plan review according to 13 CSR- 71.060(2)(B)1.A.

3. If the educational resources of the local community do not meet the needs of the children in care or if a child is excluded from school for behavioral or other reasons, the agency shall work closely with the local school district to provide an appropriate education plan pursuant to section 210.1050, RSMo.

4. An agency shall maintain contact and cooperation with involved school systems to provide a coordinated approach to meeting the educational needs of each child.

5. An agency shall provide appropriate space, adequate lighting, supervision for quiet study after school hours, and access to reference materials and school supplies.

6. Children shall be permitted and encouraged to participate in extracurricular activities such as sports, art and music, to the extent of their interests, abilities, and talents.

7. At the time of discharge, a copy of the child’s educational records/file shall follow the child.

8. Agency employees providing educational services shall meet the certification criteria established by the Department of Elementary and Secondary Education.

(I) Recreational and Activity Programs/Lei-sure Time.

1. An agency shall involve children in a variety of age and developmentally appropriate on site and community activities individually, and in groups, which meet the range of needs specified in their respective treatment plan.

2. An agency shall maintain a written plan and schedule for a recreational program of both general and physically challenging activities which promote health and physical development in accordance with the individual interests, ages, and needs of the children. This program shall include procedures by which a child’s involvement and progress shall be regularly reported.

3. An agency shall submit a list of general and physically challenging activities which they plan to use in their recreational program which includes a description of the activity, the purposes, and goals. This list shall be submitted to the division at initial licensure or license renewal.

4. An agency shall provide indoor and outdoor recreational facilities for quiet and active play.

5. Each child shall have some time to be alone if s/ he wishes, and places where the child reasonably will be undisturbed, while under the overall supervision of staff.

6. Recreational and leisure-time activities shall be included as a planned part of family interventions, provided these activities do not interfere with the safety or security of the child, family, or operating site.

7. Any water activity, including but not limited to, swimming, wading, fishing, or boating shall be permitted only when— A. An adult with a current lifeguard certificate, including cardio pulmonary resuscitation training is present; except B. An adult who has completed a course in basic water safety, which includes infant/child cardio pulmonary resuscitation training, may supervise children when a swimming pool containing a depth of less than twenty-four inches (24") of water is being used; and C. Other water activities such as fishing or boating shall require staff supervision at all times. The agency shall ensure the safety and supervision of the children and utilize appropriate equipment.

8. Agencies with on- or off-ground activity programs, which by their nature significantly alter the usual level of resident supervision, shall clearly describe each activity in their recreational plan. These include activities which could be described as physically or otherwise challenging, or those which utilize animals, or those which might involve a level of risk to children. The plan for each activity shall outline the qualifications of staff members involved, special equipment, supervision rules that will be used, and any changes in the usual behavioral rules for residents and staff required by the activity. At a minimum, the plan specifically shall address each of the following:

A. Special qualifications of staff.

(I) The agency will confirm in writing in each staff’s personnel file that the staff has specialized training, or extensive life experience in the recreational activity that qualify staff to supervise the activity.

(II) If the agency or specific staff is certified in a recognized activity area such as ROPES, Project Adventure, or Red Cross water safety instructor (WSI), these standards will be evidence of compliance;

B. Special safety equipment.

(I) All sports and outdoor equipment used in the program is selected on the basis of safety factors and is regularly checked or tested to insure it is up to the agency’s standards, which comply at a minimum with applicable national standards for the equipment in use.

(II) First aid and emergency response kits and other emergency supplies and medications needed by participants are under the control of the designated group leader at all (III) The agency provides for adequate shelter from the elements, safe and healthful food and water, appropriate clothing, and appropriate equipment required for the activities and the environment;

C. Special rules for staff and resident behavior.

(I) The agency has a written plan for coverage and supervision when groups are physically distant from the main location which includes delegation of authority.

(II) Personnel designated responsible for the group must have had first aid or first responder training and at least one (1) staff person with the group shall be certified to provide cardio pulmonary resuscitation; and D. Risk management.

(I) The agency shall have a written plan which describes unsafe conditions which would restrict or rule out this activity. Safety rules for staff and residents, appropriate clothing and equipment required, and necessary training for staff and residents prior to undertaking the activity shall be specified in the plan. Changes to this plan shall be submitted to the division.

(II) The agency shall include in its plan the level of administrative approval required to authorize the undertaking of any such activity.

(J) Transitional Living Services. Agencies serving an adolescent population shall develop and implement a transitional living services component which shall begin at the time of the initial assessment and shall be modified in accordance with the youth’s changing needs as new skills are developed. This component should compliment any other life skills program/ training in which the youth is involved. Group and individual counseling should include coping and adjustment issues relating to the youth’s transition from residential treatment.

The program shall include development of a planned program in which, at a minimum, residents may acquire skills and practice in the following areas developing:

1. Skills for independence;

2. Skills and knowledge of financial management;

3. Skills necessary for locating, obtaining, and maintaining a residence;

4. The basic skills for negotiating successfully with community institutions and systems;

5. A basic knowledge in substance abuse prevention, human sexuality, physical and sexual abuse, Human Immunodeficiency Virus prevention and other sexually transmitted diseases;

6. Daily life skills;

7. Skills for job preparation, maintenance, and retention;

8. Skills for developing positive peer relationships and a support system.

(K) Smoking Policy. Agencies shall develop a smoking policy for staff and residents that is consistent with Chapter 407, RSMo.

(L) Prohibition of Practices with Negative Impact on Residents.

Agencies shall develop policy that prohibits activities and media (music, movies, video games, television) that negatively impact children.

This rule originally filed as 13 CSR 40-71.070. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and Moved to 13 CSR 35-71.070, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014.

13 CSR 35-71.075 Health Care {#sec-13-csr-35-71.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.075}

PURPOSE: This rule sets forth the procedures for health care, emergency medical care, psychiatric and psychological care, including psychotropic medication.

(1) Health Care Procedure.

(A) The agency shall have a written health care program plan which shall address preventive medical, eye, hearing, and dental care.

(B) The agency’s health care program shall include admission examinations, subsequent examinations, nursing care, first-aid procedures, dispensing of medicine, basic remedial treatment and the training and implementation of the use of the universal health care precautions and the other basic principles of communicable disease prevention. The agency shall make provisions for the services of a licensed physician to be responsible for medical care, including on site or office visits.

(C) At admission, the agency shall obtain written authorization for each child from the parent(s), guardian, or legal custodian for emergency medical care, necessary immunizations, and for routine medical examinations and care.

(D) A complete medical examination by a licensed physician certified nurse practitioner, advanced practice nurse in a collaborative practice agreement with a licensed physician, or a registered nurse who is under the supervision of a licensed physician shall be given to each child within thirty (30) days prior to admission, or within ten (10) days after admission.

The findings of the examination shall be recorded on a form prescribed by the division, or one containing the equivalent information. Children shall receive physical examinations in accordance to the periodicity of the Missouri medicaid healthy children and youth schedule for medical and developmental examinations.

(E) If a child shows overt signs of highly infectious disease or other evidence of ill health, the agency shall make arrangements for an immediate examination by a licensed physician.

(F) Any child who has not received primary immunization prior to admission shall be immunized according to the Department of Health and Senior Services’s current guidelines.

(G) A current immunization history shall be maintained for each child.

(H) Booster shots shall be administered to children as needed, and at time intervals recommended by the agency physician or by the Department of Health and Senior Services’s current guidelines.

(I) Each child shall be given an annual eye examination and corrective treatment shall be provided as prescribed.

(J) Children must be tested for communicable diseases including, but not limited to, tuberculosis and hepatitis according to the recommendations of a licensed physician.

(K) Dental Care.

1. Children must have a dental examination by a licensed dentist within one (1) year before admission or within three (3) months after admission. A copy of the examination report and findings must be in the child’s record.

2. A child shall have a dental examination at least annually while in care.

(L) Any treatment or corrective measures required by the licensed physician or dentist shall be arranged by the agency, as approved by a parent, guardian, or legal custodian.

(M) Upon discharge, a copy or summary of the child’s health and dental records shall be provided to the child’s parent(s), guardian, or legal custodian.

(2) Emergency Medical Procedure.

(A) At least one (1) staff member shall be qualified/certified to administer first aid, including adult/child cardio pulmonary resuscitation, and shall be available within the agency at all (B) A first-aid kit shall be readily available.

(C) An agency shall contact a child’s parent(s), guardian, or legal custodian immediately, but no longer than twelve (12) hours when a serious illness, a serious injury, or hospitalization of the child occurs. This includes any visit to an emergency medical facility.

(D) In the event of the death of a child, the parent(s), guardian, legal custodian, and the division shall be notified immediately.

(3) Isolation for Illness. Provision shall be made for the medical isolation of any child with a highly communicable disease or other evidence of ill health which poses a serious threat to other children.

(4) Psychiatric and Psychological Care. When the agency’s treatment plan for a child indicates a need for professional care by a psychiatrist or a psychologist, the specialized treatment shall be provided, or arranged for, by the agency.

(5) Medicine and Drugs.

(A) All medication shall be prescribed by a licensed physician, and administered by a licensed nurse or staff who have successfully completed and maintained, at a minimum, the Level 1, Medication Aide Training Program or a recognized medication certification training program, approved by the division for children in residential treatment.

(B) All medicine and drugs shall be kept in a locked unit and shall only be accessible to and dispensed by the agency nurse or qualified/certified staff. Medications requiring refrigeration shall also be stored in a locked unit.

(C) All medication shall be labeled to indicate the name of the child, the type and dosage of medication, and shall be dated.

All administered, transferred, and/or destroyed medications shall be documented on a medication administration record.

(D) Medication prescribed for one (1) child shall not be administered to another.

(E) No child shall self-administer medication unless the practice is approved by a licensed physician, or a registered nurse with approval of a licensed physician. The approval shall be documented in the child’s medication record and treatment plan.

(F) When medications which are approved by a physician’s order are prescribed, continued, discontinued or changed, an entry shall be made in the child’s record. Entries shall be evaluated at least every thirty (30) days by a licensed nurse or staff that have successfully completed a recognized medication certification training program approved by the division for children in residential care.

(G) When medications are discontinued, they shall be destroyed within forty-eight (48) hours by staff as directed by a licensed physician or qualified pharmacist or a registered nurse.

(H) Upon discharge, all medication shall be transferred with the resident for whom it was prescribed. Medication must be given directly to a responsible adult/guardian/legal custodian or adult designee (such as a contracted transportation service) of the resident.

(6) Psychotropic Medication.

(A) Prescribing Psychotropic Medication.

1. An agency shall have written policies, which, upon request, shall be made available to the child’s parent(s), or guardian or legal custodian, or both, to staff and to the child, governing the use of psychotropic medication.

2. The prescribing physician shall provide a written medication order reflecting the reasons for prescribing the medication, the dosages and the frequency of administration.

3. When a written order for psychotropic medication is provided by a physician to be administered in an emergency situation in his/her absence, staff shall document all dosages of medication given. The physician shall fully document the justification for, and the expected results of, the medication order.

4. Psychotropic medication shall not be administered as a form of punishment, as a substitute for a program, or due to lack of staff.

5. Unless there is a court order to the contrary, the parent(s), guardian or legal custodian of a child shall give prior, informed, written consent to the use of medication. Consent may be given at the time of admission.

6. The parent(s), guardian or legal custodian shall be informed regarding any possible side-effects of medications to be administered. This shall be documented in the child’s (B) Administering and Monitoring of All Medications, Including Psychotropic Medication.

7. The following information shall be maintained in the case record of each child receiving medication:

A. The medication history of the child;

B. Documentation of all medication administered;

C. A description of any significant changes in the child’s appearance or behavior that may be related to the use of medication;

D. Any medication errors; and E. A record of each refusal of medication including the child’s name, the date, the time, the staff administering medication and the child’s reason for refusal.

(C) Staff Training Relating to Medication Management. An agency shall provide training for all staff who work directly with children to enable them to recognize changes in a child’s appearance or behavior that may be related to the use of any medication, including psychotropic.

This rule originally filed as 13 CSR 40-71.075. Emergency rule June 6, 1994. Moved to 13 CSR 35-71.075, effective Oct. 30, 2008.

13 CSR 35-71.080 Buildings, Grounds and Equipment {#sec-13-csr-35-71.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.080}

PURPOSE: This rule sets forth requirements for the physical plant, sanitation, safety and fire protection, space, and equipment.

(1) Physical Plant-General Requirements.

(A) Plans for additional buildings, or alterations which affect the structural strength, safety, sanitary conditions, and floor space of existing buildings, shall meet the requirements of state and local ordinances. The plans for these buildings or alterations shall be submitted for review by the residential licensing unit, the State Fire Marshal and the Department of Health and Senior Services.

(B) If construction is not started within one (1) year of the approval of plans, the plans and specifications shall be resubmitted to the same agencies prior to beginning construction.

(C) An agency shall maintain its buildings, grounds, furniture, and equipment in a clean, safe, and sanitary condition and in a good state of repair.

(D) Each operating site shall be effectively safeguarded against insects and rodents.

(E) Each operating site housing children shall include areas and specialized recreational space, and shall properly equip, supply, and maintain these areas so as to promote relaxation and varied opportunities for recreation.

(F) Telephone service shall be available in each operating site.

(G) An agency operating a swimming pool shall maintain a file to provide documentation that the pool is operated and maintained in accordance with all applicable local ordinances, state guidelines, or both.

(H) Heaters, floor furnaces, radiators, hot water heaters, or other equipment which pose a threat to children shall be separated from areas used by children by partitions, screens, or other barriers, as approved by the State Fire Marshal.

(I) Smoking shall be prohibited in child care, food preparation, and food service areas.

(J) Porches, decks, stairwells, or other areas having a significant drop-off from which children might fall and be injured shall have an approved railing or approved barrier.

(2) Administrative and Clerical Space. Adequate space shall be provided for administrative and clerical staff and for the storage of records.

(3) Interview and Consultation Area. A private area shall be provided for interviews and consultations.

(4) Sleeping Rooms and Areas.

(A) An agency licensed after the effective date of these rules (November 12, 1993) shall provide a sleeping space for each child of at least seventy (70) square feet.

(B) An agency licensed after (November 12, 1993) shall provide at least one (1) window to the outside of the operating site (effective the date of this amendment) in each sleeping room.

(C) No enclosed basement rooms or rooms that are more than one-third (1/3) below ground level on all four (4) sides shall be used. Each sleeping room, unless it has a door opening to the outside at ground level, shall have an exit access door leading directly to a corridor which leads to an exit. Exit doors shall comply with existing fire and safety requirements.

(D) Each child shall be provided with his/her own bed which shall be adequate in width and length for his/her height.

(E) Sleeping areas shall be designated and provided for boys and for girls to allow for maximum supervision and separation.

Programs providing care for children through age three (3) years are not required to separate children according to gender. Consideration for waiving the age limit may be given to programs providing less than seventy-two- (72-) hour care to enable programs to keep sibling groups together.

(F) An agency licensed, or buildings constructed, after the effective date of these rules (November 12, 1993), shall house no more than four (4) children in a single sleeping area.

(G) Single beds shall be provided and spaced appropriately to allow for maximum comfort of the children. Bunk beds may be used, if age-appropriate, and shall be constructed of safe, stable materials.

(H) Each bed shall have level, firm springs and a firm mattress or other comfortable, orthopedically supportive surface, protected by rubber sheeting or other covering, when necessary. A pillow, bed linen, and sufficient cover for comfort shall be provided.

(I) A complete change of bed linen shall be provided when soiled, but at least once a week.

(J) Children shall have sufficient closet and drawer space for clothing and personal belongings.

(5) Staff Quarters. When staff quarters are provided, they shall be located adjacent to the children’s bedrooms so that children can be supervised easily and staff can be available to any child, when needed.

(6) Bath and Toilet Facilities.

(A) A minimum of one (1) toilet and one (1) wash basin shall be provided for every four (4) children and one (1) tub or shower shall be provided for every six (6) children in residence.

In agencies licensed after the effective date of these rules (November 12, 1993), these accommodations shall be located on the same floor as the sleeping rooms. In agencies licensed after (effective the date of this amendment) the bath and toilet facilities shall be in a separate, distinct room.

(B) Separate and private bathroom accommodations shall be provided for boys and for girls ages six (6) years or older.

(C) Agencies licensed after (effective the date of this amendment) shall have a window to the outside of the operating site or other exhaust ventilation system in each bathroom.

(D) Hot water heating systems and water temperature shall be routinely monitored to ensure safety of children.

(7) Laundry and Utility Area. Laundry equipment shall be available in a well-lighted and well-ventilated area.

(8) Heating and Cooling. Each operating site shall be well ventilated and maintain indoor temperatures comfortable for children.

(9) Electrical Systems.

(A) Each operating site’s electrical system shall comply with all applicable local ordinances, state guidelines, or both.

(B) Artificial lighting shall be provided to meet the needs of the children and shall be safely and sufficiently shielded.

(C) The operating site shall have an adequate lighting source.

(10) Windows, Screens, and Glass Doors.

(A) Windows which are accessible from the outside shall be lockable and open easily from the inside. The manufacturer’s designed functions of windows shall not be altered without the approval of the State Fire Marshal.

(B) Open windows and doors shall be securely screened and barriers to prevent children from falling against windows or falling from window openings shall be provided as needed.

(C) Shatterproof safety glass shall be installed in high risk areas where children are active, and clear glass doors shall be marked plainly at varying heights to avoid impact.

(11) Dining and Kitchen Area.

(A) Each operating site shall have a kitchen which provides the following:

1. A refrigerator capable of maintaining foods at safe temperatures according to Department of Health and Senior Service’s standards and verified by thermometers located in each refrigerator and freezer;

2. A stove with a hood in operating condition;

3. A kitchen sink in operating condition with hot and cold running water;

4. Adequate provision for the sanitary disposal and temporary storage of food waste and refuse;

5. A supply of equipment to prepare meals, and dishes, glassware, and flatware for use at each meal. Utensils shall be free of chips, cracks, or other defects, and shall be thoroughly cleansed after each use;

6. Equipment used in the preparation and serving of food, including can openers, meat slicers, and cutting surfaces which shall be cleaned and sanitized after each use;

7. No smoking in food preparation and food service areas;

8. Dining areas equipped with tables and chairs appropriate to the children’s ages, and arranged so that children and staff can have their meals together;

9. Dishwashing facilities with water hot enough to sanitize utensils or other approved sanitization method;

10. A window or other adequate exhaust ventilation system in each kitchen;

11. Adequate space and light; and 12. Walls, floors, and ceilings made of materials that are easy to clean and maintain.

(12) Food Storage.

(A) Food and drink shall be stored, prepared, displayed, served and transported in a manner to protect it from contamination.

(B) Each operating site shall store and use food service areas, only sufficient poisonous and toxic materials required to maintain sanitary conditions. Toxic materials shall be properly labeled and stored in secure, locked, cabinets which are used for no other purpose.

(13) Water.

(A) If an operating site’s water supply is not an approved public source, each operating site shall have its water supply annually approved by the Department of Health and Senior Services or Department of Natural Resources.

(B) Each operating site shall provide cool, safe drinking water and single-serving cups or glasses for those unable to drink from fountains.

(14) Sewage Disposal.

(A) The agency shall utilize public sewage disposal systems when they are available.

(B) If the agency does not utilize public sewage disposal systems, facilities shall have their sewage disposal systems approved biennially by the Department of Health and Senior Services or Department of Natural Resources.

(15) Hazardous Materials. All flammable liquids, matches, poisonous materials, medicines, alcoholic beverages, hazardous personal care items, or other hazardous items shall be locked and inaccessible to children. Any lawful, authorized use of such materials would be under the approval of the executive director of the residential treatment agency for children and youth.

(16) Weapons.

(A) Ammunition, guns, hunting knives, bows and arrows or other weapons shall be stored in a locked cabinet or locked closet.

(B) All guns must have trigger locks installed.

(17) Animals.

(A) Agencies that have animals shall develop written policy and/or procedures that address the purpose and care of animals in therapeutic programming.

(B) Agencies that have animals shall adhere to local and state guidelines regarding care and public safety.

(C) Documentation of veterinarian visits and health records shall be made available, when requested.

(D) Appropriate pet containment systems shall be available to use, when necessary.

(18) Out Buildings. Any buildings used on campus for the storage of equipment or material shall be locked.

This rule originally filed as 13 CSR 40-71.080. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and Moved to 13 CSR 35-71.080, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014.

13 CSR 35-71.090 Record Keeping {#sec-13-csr-35-71.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.090}

PURPOSE: This rule sets forth the records, documents and reports, which an agency shall maintain and, upon request, submit to the residential licensing unit.

(1) The agency shall maintain a register of all children currently receiving care, including information concerning the child’s name, sex, birthdate and person or agency legally responsible for each child.

(2) Individual case records for all children accepted for care shall be maintained for at least five (5) years after a child is discharged from care and shall include:

(A) The child’s full name, date of birth, complete social

history including reason and date of placement and medical

history;

(B) Reports of any pre-placement visits and conferences;

(C) The admission assessment, including information concerning the religious, educational, economic and cultural background of the family; information about the child’s development, health history, personality, school placement and adjustment; previous placements; attitudes toward separations; family relationships;

(D) Documents pertinent to current legal custody and guardianship status;

(E) Written agreements with parent(s), guardian, or legal custodian;

(F) School reports for each semester, including the child’s grades, progress, and adjustment;

(G) The initial treatment plan and subsequent treatment plan reviews;

(H) Chronological case recording and progress summary completed at least monthly which identifies the child’s progress and services provided to the family;

(I) Plans for discharge, aftercare, and supervision;

(J) Reports from recreational and other adjunctive staff involved with the child and family. All recreational activity shall be documented separately in each child’s record;

(K) Copies of critical incident reports, which shall include, but not be limited to, injury of a child during physical restraint; serious physical or sexual aggression by or toward the child; significant physical injuries requiring medical attention; and neglect hotline pursuant to section 210.115, RSMo; and (L) Admission and periodic health, vision, and dental examination information, physician’s written instructions with regard to special dietary or health care, and record of all medications and treatments.

This rule originally filed as 13 CSR 40-71.090. Original rule filed Nov. 9, 1978, effective Feb. 11, 1979. Emergency rescission and Moved to 13 CSR 35-71.090, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014.

13 CSR 35-71.095 Exceptions for Transitional Living Services Programs {#sec-13-csr-35-71.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.095}

PURPOSE: The purpose of this rule is to set forth exceptions to the rules for residential treatment agencies with respect to transitional living services provided to the division through written agreement.

Youth who receive such services require more independent types of living arrangements than those otherwise provided by residential treatment agencies in order to make the transition from alternative care to self-sufficiency.

(1) This regulation only applies to agencies providing transitional living services to the division pursuant to a written transitional living services contract.

(2) Staffing Ratios. Notwithstanding any other provisions in this

chapter, agencies shall not be required to have two (2) on-site staff available at all times in the provision of transitional living services, provided that such agencies adhere to the staff ratios set forth in this chapter. In the event there is only one (1) on-site staff member, however, one (1) additional staff member must be on call who can promptly respond to emergencies.

(3) Treatment Plan. Notwithstanding any other provisions in this chapter, agencies shall have thirty (30) days to develop and document a written treatment plan for each child admitted to their transitional living program.

(4) Recreational and Activity Programs/Leisure Time. Agencies shall be exempt from the requirements set forth in 13 CSR 35-71.070(2)(I) but shall facilitate any recreational activities prescribed in a youth’s individual treatment plan.

(5) Allowances and Earnings Records. Notwithstanding any other provisions in this chapter, agencies shall not be required to provide an allowance to youth receiving transitional living services or to maintain a record of such youths’ earnings or disbursements.

(6) Hazardous Materials. Notwithstanding any other provisions in this chapter, hazardous materials that are needed to implement a youth’s treatment plan are not required to be locked up and kept inaccessible to the youth. Examples of such hazardous materials include but are not limited to personal care items, laundry soap, other cleaning products, and overthe-counter medications. The lawful, authorized use of such materials by a child in a transitional living services program shall not require the agency’s approval if permitted by the child’s treatment plan.

History

• AUTHORITY: section 210.506, RSMo 2016. Original rule filed Jan. 9, 2023, effective Aug. 30, 2023. Original authority: 210.506, RSMo 1982, amended 1993, 1995.

13 CSR 35-71.100 Specific Rules for Basic Care Agencies Providing Care for Infant, Toddler, or Preschool Age Children (Birth Through Age Six (6)) {#sec-13-csr-35-71.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.100}

PURPOSE: This rule sets forth the requirements for personnel, indoor and outdoor space, and equipment.

(1) Physical Requirements.

(A) General Requirements.

1. Stairways shall be well-lighted and free of obstructions.

Stairways having more than three (3) steps shall have a handrail the children can reach.

2. Porches, decks, stairwells, or other areas having a significant drop-off from which children might fall and be injured shall have an approved railing or approved barrier. The railing or barrier shall be constructed to prevent the child from crawling or falling through or becoming entrapped.

3. Approved safety gates at stairways and doors shall be provided and used as needed.

4. Protective outlet covers or twist-lock outlets shall be used in areas accessible to the children.

5. Heaters, floor furnaces, radiators, hot water heaters, or other equipment which pose a threat to children shall be separated from areas used by children by partitions, screens, or other approved barriers.

6. Smoking shall be prohibited in child care, food preparation, and food service areas.

(B) Indoor Space.

1. General requirements.

A. Open windows and doors shall be securely screened.

Barriers to prevent children from falling against windows or falling from windows shall be provided when windows are less than twenty-four inches (24") from the floor and not constructed of safety glass or other unbreakable material.

B. Walls, ceilings, and floors shall be finished with material which can be cleaned easily and shall be free of splinters, cracks, and chipping paint. Floor covering shall be in good condition. Lead-free paint shall be used for all painted surfaces.

C. Concrete floors in areas utilized for child care shall be covered with carpet, tile, linoleum, or other floor covering.

D. Floor surfaces under indoor equipment from which children might fall and be injured, shall be protected with pads or mats which will effectively cushion the fall of a child.

Carpeting alone is not an acceptable resilient surface under indoor equipment.

E. Toilet and handwashing facilities shall be in working order and convenient for the children’s use.

F. Paper towels, soap, and toilet paper shall be provided and easily accessible so the children can reach them without assistance.

G. Locks or latches shall not be used on bathroom or bathroom stall doors.

H. One (1) potty chair, junior commode, or toilet with an adaptor seat shall be provided for every four (4) children being toilet trained. Potty chairs shall be located in the bathroom and shall be emptied, cleaned, and disinfected after each use.

(C) Diapering Area.

1. A safe diapering table with a waterproof washable surface shall be used for changing diapers. The diapering table shall be located within or adjacent to the group space so staff using the diapering table can maintain supervision of his/her group of children at all times.

2. Operating sites shall have one (1) diapering table for every group of eight (8) infant/toddlers.

3. Diapering supplies, and a properly equipped hand washing sink with warm running water, soap, and a towel or other Department of Health and Senior Services approved hand sanitizing method shall be adjacent to the diapering area.

(D) Outdoor Space.

1. General requirements.

A. An outdoor play area shall be available on, or adjoining, the agency’s property. The area shall be located so it is convenient and the children can gain access to it without hazard. It shall be fenced when necessary for the protection of children from traffic, water, or other hazards.

B. The play area shall be safe for children’s activities, well-maintained, free of hazards such as poisonous plants, broken glass, rocks, or other debris and shall have good drainage.

C. The fall-zone area under and around outdoor equipment where children might fall and be injured shall be covered with impact-absorbing materials which will effectively cushion the fall of a child. This material may include sand, pea gravel, tanbark, shredded tires, wood chips, rubber matting, or other approved resilient material.

(E) Swimming and Wading Pools.

1. Swimming and wading pools used by children shall be constructed, maintained, and used in a manner which safeguards the lives and health of children.

2. Swimming and wading pools shall be fenced to prevent access by children. The fence shall be at least forty-eight inches (48") high with a self-closing, self-latching door that must be unlatched from the inside and should be constructed so that a four-inch (4") sphere could not be passed through the fence.

3. Children using swimming or wading pools shall be instructed in water safety and supervised by an adult at all 4. An adult with a current lifeguard training certificate, including infant/child cardio pulmonary resuscitation training, shall be on duty at all times when a swimming pool or other bodies of water containing a water depth of twenty-four inches (24") or more is being used.

4. An adult who has completed a course in basic water safety, which includes infant/child cardio pulmonary resuscitation, shall be on duty when a swimming pool containing less than twenty-four inches (24") of water is being used.

(F) Sleeping Equipment.

1. An individually assigned crib, portable crib, or playpen shall be provided for each infant and toddler. Stack cribs shall not be used.

2. Cribs and playpens shall have side rail spokes which conform to current United States Consumer Product Safety Commission standards.

3. The crib mattress or playpen pad shall be correctly sized to the crib or playpen, in good condition, waterproof, and kept clean and dry. Sheets and covers shall be changed immediately when soiled or wet.

(G) Tables and Seating Equipment.

1. Individual chairs and table space for the licensed capacity of the operating site shall be available for children twelve (12) months of age and older. Chairs shall be proportioned so children sit comfortably and securely.

2. Infants and toddlers who are unable to sit at a table shall have one (1) piece of mealtime feeding equipment for every four (4) infant/toddlers which may include feeding tables, high chairs, infant seats, or other safely designed infant seating equipment. Equipment shall be provided which will allow the child to sit comfortably and securely while being fed. Appropriate safety restraints shall be used according to manufacturer’s instructions.

(H) Indoor Play Equipment and Materials.

1. General requirements.

A. Play equipment and materials shall be clean, in good condition with all parts intact and accessible to children.

B. Play equipment and materials shall be replaced as needed to maintain the number of items required for the licensed capacity of the operating site.

2. Preschool and school-age children.

A. Children twenty-four (24) months of age and older shall have an ample variety of age-appropriate toys, books, creative materials and activities which provide fun, stimulation, development, and opportunities for individual choices.

B. The following shall be required:

(I) Blocks, construction, and transportation toys;

(II) Manipulatives;

(III) Creative arts;

(IV) Gross motor activities;

(V) Library and language activities;

(VI) Music and rhythm activities;

(VII) Dramatic and housekeeping play; and (VIII) Science activities or sensory experiences.

C. Infants and toddlers.

(I) Infants and toddlers shall have safe toys which shall be washed or sanitized at least weekly or when soiled. Toys, parts of toys, or other materials shall not be small enough to be swallowed. Toys and materials shall include, but not be limited to, each of the following:

(a) Push-pull toys;

(b) Balls or other gross motor equipment;

(c) Blocks, stacking toys, or other manipulatives;

(d) Cloth or plastic-coated books.

3. Outdoor equipment.

A. All outdoor equipment shall be safely constructed, in good condition and free of sharp, loose, or pointed parts. Only lead-free paint shall be used.

B. Outdoor equipment shall be provided for the ages and number of children in care to meet their physical and developmental needs.

C. Children shall be instructed in the safe use of outdoor equipment.

D. Stationary equipment such as swings, slides, and climbers shall be securely anchored, have no exposed footings, and be placed to avoid accidents or collisions.

E. Any hanging apparatus that might entrap, close, or tighten upon a child shall not be used.

F. Trampolines shall not be used. Mini-trampolines, aerobic bouncers, or other similar small jumping equipment may be used with close supervision.

This rule originally filed as 13 CSR 40-71.100. Emergency rule June 6, 1994. Moved to 13 CSR 35-71.100, effective Oct. 30, 2008.

13 CSR 35-71.110 Child Care Program {#sec-13-csr-35-71.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.110}

PURPOSE: This rule sets forth requirements for discipline, infant and toddler care, training and daily program.

(1) General Requirements.

(A) Staff shall provide frequent, direct contact, and supervision so children are not left unobserved on the premises.

(B) Children under three (3) shall be supervised and assisted while in the bathroom.

(C) Supervision shall be maintained while children are napping or sleeping and staff shall be able to see and hear the children if they have difficulty during napping or when they awaken.

(2) Discipline.

(A) The agency shall establish simple, understandable rules for children’s behavior and shall explain them to the children in a manner they can understand.

(B) Expectations for a child’s behavior shall be appropriate for the developmental level of the child.

(C) Only constructive, age-appropriate methods of discipline shall be used to help children develop self-control and assume responsibility for their own actions.

(D) Praise and encouragement of good behavior shall be used instead of focusing only upon unacceptable behavior.

(E) Firm, positive statements or redirection of behavior shall be used with infants and toddlers.

(3) Care of Infants and Toddlers.

(A) Infants and toddlers shall have constant care and supervision.

(B) Children shall be cared for by the same staff person on a regular basis.

(C) Staff shall be alert to various needs of the child such as thirst, hunger, diaper change, fear of or aggression by other children and the need for attention.

(4) Diapering and Toilet Training.

(A) Disposable tissues or wipes shall be used to cleanse the child at each time of diapering.

(B) The diapering table shall be cleaned thoroughly with a disinfectant or sanitizer after each use.

(C) The child shall not be left unattended at any time while on the diapering table.

(D) Diapers and wet clothing shall be changed promptly.

(E) Wet or soiled diapers shall be placed in an airtight disposal container located in the diaper change area. Diaper containers shall be plastic lined, contain only soiled diapers (no soiled clothes or linens) and kept clean and free of build-up of soil and odor.

(F) Staff changing diapers shall wash their hands with soap and running water or other Department of Health and Senior Services approved hand-sanitizing method each time after changing a child’s diaper before performing any other tasks.

(G) The diapering and hand washing area shall be separate from any food service area and any food-related materials.

(H) Children shall not be punished, berated, or shamed in any way for soiling their clothes.

(5) Daily Activities for Children.

(A) A daily schedule shall be established in written form which shall include activities for all ages of children in care.

(B) Daily activities for preschool and school-age children shall include, but not be limited to:

1. Developmentally appropriate play experiences and activities planned to meet the interests, needs, and desires of the children;

2. Individual attention and conversation with adults;

3. Indoor and outdoor play periods which provide a balance of quiet and active play, and individual and small group activities. Activities shall provide some free choice experiences;

4. Toileting and hand washing times;

5. Regular snack and meal times;

6. A supervised nap or rest period for preschool children after the noon meal;

7. A quiet time for school-age children after the noon meal with a cot or bed available for those who wish to nap or rest;

8. A study time for school-age children who choose to do homework, with a separate, quiet work space.

(C) Daily activities for infants and toddlers shall include, but not be limited to:

1. Developmental and exploratory play experiences and free choices of play appropriate to the interests, needs, and desires of infants and toddlers;

2. Regular snack and meal times according to each infant’s individual feeding schedule;

3. A supervised nap period. After awakening, an infant may remain in the crib for brief periods as long as s/he is content. Toddlers shall be taken out of bed for other activities when they awaken;

4. Individual attention and play with adults, including holding, cuddling, talking, and singing;

5. A plan for sensory stimulation which includes visual stimulation through pictures, books, toys, nonverbal communication, games, and the like; auditory stimulation through verbal communication, music, toys, games, and the like; tactile stimulation through surfaces, fabrics, toys, games, and the like;

6. Encouragement in the development of motor skills by providing opportunities for reaching, grasping, pulling up, creeping, crawling, and walking; and 7. Opportunity for outdoor play when weather permits.

This rule originally filed as 13 CSR 40-71.110. Emergency rule June 6, 1994. Moved to 13 CSR 35-71.110, effective Oct. 30, 2008.

13 CSR 35-71.120 Specific Rules for Residential Treatment Agencies for Children and Youth Providing Maternity Care {#sec-13-csr-35-71.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.120}

PURPOSE: This rule sets forth the requirements for agencies providing maternity care, including health care plan, program, and relinquishment of the infant.

(1) In addition to the rules for basic core agencies, an agency desiring to provide maternity care shall meet these additional general requirements— (A) A maternity residence upon request shall provide a written description of its program to the residents, parent(s), guardian, or legal custodian and to the division;

(B) Written financial policies and expectations shall be made available upon request to the division and to the parent(s), guardian, or legal custodian upon admission into the maternity residence;

(C) A training plan shall be developed to ensure that staff working with pregnant and parenting adolescents develop skills and knowledge regarding infant and adolescent care;

(D) Maternity residences shall be separate from other treatment programs; and (E) At least two (2) direct-care pursuant to 13 CSR 35-71.050(4)

(A)1.–5. and (B) trained pursuant to 13 CSR 35-71.045(5)(A)-(Q) and 13 CSR 35-71.045(6)(A)1. and 13 CSR 35-71.045(2)(B)1.–9., (C), and (D)1.–12. staff shall be on site at all times.

(2) Health Care.

(A) There shall be a written plan for all deliveries to take place in a licensed hospital.

(B) Physician’s Services.

1. Each resident shall receive the services of a licensed physician on a regular and continuing basis throughout pregnancy, delivery, and post-delivery checkups.

2. The maternity residence shall provide for consultation from a licensed obstetrician who shall be available in an emergency.

3. A licensed nurse shall be accessible on an as needed

basis for pre and post-natal care.

(C) Ambulance Service. Ambulance service shall be available for emergencies.

(D) Medical Records. The resident’s medical record shall include a medical consent form, the name of the health care provider, a schedule of appointments, documentation of pre and post-natal care, the expected date of delivery, and any special needs or problems.

(E) Medication. No prescription or nonprescription medication shall be administered without the specific documented approval of the physician providing obstetric care.

(3) Program.

(A) The maternity residence shall, at a minimum, provide a program to residents addressing prenatal care, labor, delivery, nutrition, general health and hygiene, postnatal care, family planning, sexually transmitted disease, and child-care techniques.

(B) Upon dismissal from the maternity residence, each resident shall be given written information regarding postnatal care.

(C) Professional staff shall be responsible for development of a long-term plan for the mother and infant. This plan shall be developed with the involvement of the mother and the legal guardian.

(4) Relinquishment of the Infant.

(A) The decision to keep or relinquish the infant shall be the right of the birth parent(s). This decision shall be made without undue pressure or influence.

(B) At the request of the resident, the professional staff shall arrange for referral to a licensed child-placing agency.

(5) Infant/Child Cardio Pulmonary Resuscitation.

(A) At least one (1) staff shall be present at all times who is trained in infant/child cardio pulmonary resuscitation.

This rule originally filed as 13 CSR 40-71.120. Emergency rule June 6, 1994. Moved to 13 CSR 35-71.120, effective Oct. 30, 2008.

13 CSR 35-71.130 Specialized Standards—Residential Treatment for Children and Youth {#sec-13-csr-35-71.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.130}

PURPOSE: This rule sets forth the requirements for specialized residential treatment, including program director, assessment staff, professional staff, staff/child ratios, training, treatment plan review, and locked isolation.

(1) In addition to rules for basic residential treatment for children and youth, an agency seeking to become licensed to provide residential treatment for children and youth, shall meet these additional requirements:

(A) Program Director. The program director must be a fulltime staff dedicated solely to the overall treatment program with at least the following minimum qualifications:

1. A master’s degree in social work or human service certified social worker; and 2. Two (2) years’ experience providing treatment services.

One (1) year of this experience must have been in a residential treatment setting;

(B) Assessment Staff. Staff responsible for developing initial assessment and treatment plan for each child must have at least the following minimum qualifications:

1. A master’s degree in social work or human service certified social worker; and 2. One (1) year of experience in a residential treatment setting;

(C) Professional Staff.

1. The agency must have sufficient, appropriately qualified professional staff available on a full-time, part-time, or continuing consultative basis, or any combination of these to address the needs of children in care.

2. The professional staffing plan must be in writing and implemented by the agency.

3. The program director shall document that the number, qualifications, and responsibilities of professional staff are appropriate to the agency’s size and the scope of its program.

(D) Staff/Child Ratios.

1. At least one (1) direct care staff for every four (4) children, birth to six (6) years of age, shall be on duty during waking hours.

2. Staff shall be awake during children’s sleeping hours, and maintain staff/child ratios of one (1) staff for every six (6) children from birth to six (6) years of age.

3. At least one (1) direct care staff for every six (6) children, age six (6) years and older shall be on duty during waking hours.

4. Staff shall be awake during children’s sleeping hours and maintain staff/child ratios of one (1) staff for every twelve (12) children age six (6) years and older.

5. An agency licensed, or buildings constructed after (effective the date of this amendment) shall have no more than two (2) children in a sleeping room.

(E) Training. All staff working with children must receive at least forty (40) hours annually of in-service training and meet the training requirements in accordance with 13 CSR 35-71.045.

At least ten (10) hours of the training must be related specifically to treatment issues with emotionally disturbed, mentally ill, behaviorally disordered, medically fragile, physically disabled, and/or developmentally delayed children. Professional staff providing sexual abuse treatment are required to have fifteen (15) hours of annual training in investigation, treatment, nature, extent, and causes of sexual abuse pursuant to section 660.526, RSMo;

(F) Treatment Plan Review.

1. Each child’s treatment plan shall be reviewed and updated at least every three (3) months.

2. If a child shows no progress toward achieving the goals and objectives in the treatment plan since the plan was developed or last reviewed, the reasons for continuing the child in the agency’s program must be included in the child’s 3. Appropriate information about the updated treatment plan shall be given to the child and the child’s parent(s), guardian, or legal custodian and documented in the child’s 4. A minimum of one (1) hour of individual, group, or family counseling sessions shall be provided to each child at least one (1) time a week with other sessions available as needed.

(G) Locked Isolation.

1. Prior to the implementation of a locked isolation room, the agency shall have approval of the State Fire Marshal and 2. Written policies for the use of locked isolation shall be made available to the child’s parent(s), or guardian or legal custodian, or both, and when appropriate, to the child.

2. Agencies utilizing locked isolation shall submit a plan for the emergency evacuation of isolated residents to the licensing unit including documentation that staff has included evacuating residents from locked isolation during fire drills.

3. Locked isolation may be used only as a management method after all other verbal de-escalation measures have been exhausted, and never to replace other more positive measures of control. Documentation of intervention methods used to prevent use of locked isolation must be in the resident’s 5. Locked isolation may be used only when a child presents a danger to him/herself or others.

4. Locked isolation shall be used in the shortest intervals possible until the child regains reasonable self-control.

5. The maximum time a child may remain in locked isolation is thirty (30) minutes, unless extensions are approved at the end of every thirty (30) minute period by the program director or a qualified designee. A child shall not remain in locked isolation more than a two (2) hour period. If the child has not regained control after two (2) hours, a medical order shall be obtained.

6. When a child is placed in locked isolation, staff shall physically monitor the child in at least five (5) minute intervals.

Staff shall remain in close proximity to the child in locked isolation with no more than one (1) locked door between the staff and the child. Close proximity means that staff are close enough to the child(ren) to be able to hear any sounds the child(ren) might make that would indicate a need for assistance.

9. Not more than one (1) child shall be in a locked isolation room. A locked isolation room shall not be utilized for any other purpose.

10. Within twenty-four (24) hours of each locked isolation incident, treatment staff shall debrief the incident with the resident.

11. The agency shall maintain a record when locked isolation is used, which shall include:

A. The name of the child, the date, and the time the child was placed in locked isolation;

B. The circumstances that led to the placement of the child in locked isolation and efforts to prevent the use of locked isolation;

C. The name of the staff person who requested placement of the child in locked isolation, the staff person who approved locked isolation, and the name of the staff person who monitored the child while in locked isolation;

D. The amount of time the child remained in locked isolation, the frequency of monitoring and the time of and reasons for release;

E. Documented behavioral observations of the child at each five (5) minute interval;

F. Specific notation of any extension of locked isolation including reasons for the extension and by whom approval for extension was given; and G. Documentation of results of debriefing that includes recommendations of staff and resident for avoiding similar situations.

12. For agencies permitting the use of locked isolation, the treatment team shall review its usage at least weekly and sign/ date the isolation report.

A. Written policies for the use of locked isolation shall be distributed to staff, and there shall be documented training Age Range Level of Care Direct Care Staff to Resident Ratio Awake Asleep Birth to six (6) years Residential Treatment One (1) staff per four (4) children One (1) staff per six (6) children. Staff must remain awake.

Age six (6) and older Residential Treatment One (1) staff per six (6) children One (1) staff per twelve (12) children.

Staff must remain awake. provided to staff in the policies and use of locked isolation, which shall include, but not be limited to:

(I) Directions for the removal of all dangerous items from the child, including but not limited to, belts, shoelaces, jewelry, items in pockets, matches, and any other items which represent a potential hazard during locked isolation; and (II) Proper written documentation of the use of locked isolation.

13. If the agency does not meet all requirements for the use of locked isolation, the division shall give written notice of the specific deficiencies and the agency shall not use locked isolation until corrections are made and approved by the division.

14. Locked isolation rooms shall be constructed and equipped so that control is maximized, but the risk of suicide or injury to children is minimized. The following shall apply:

A. An isolation room shall be constructed to allow for both visual and auditory supervision of a child;

B. An isolation room shall have one (1) approved lockingagainst-egress device which shall be used only when staff are immediately present, awake, and in possession of a key. There shall be a backup system which does not rely on a key, i.e., an electronic locking-release mechanism, as approved by the State Fire Marshal;

C. Potentially dangerous articles shall be removed from the child prior to placing the child in locked isolation, for example, belts, shoes, matches, and/or contents of pockets;

D. An isolation room shall have at least a seven and onehalf foot (7 1/2') ceiling and be of sufficient length and width for the comfort of the child;

E. All doors, ceilings, and walls shall be constructed of such strength and noncombustible material that harm to the child is minimized;

F. All switches controlling lights, ventilation, and the like, shall be on the outside of the room;

G. In order to prevent harm to the child, windows shall be secured and made of tempered material to prevent shattering;

H. No functional electrical outlets shall be allowed in the room;

I. Tamper-resistant, recessed ceiling lights shall be utilized, and steam or hot water radiators shall be enclosed in a tamper-resistant, protective casing;

J. The room shall be properly heated, cooled, and ventilated;

K. Normal toileting and bathing facilities shall be available during isolation; and L. The agency shall have a schedule for monthly routine maintenance of the locks.

This rule originally filed as 13 CSR 40-71.130. Emergency rule June 6, 1994. Moved to 13 CSR 35-71.130, effective Oct. 30, 2008.

13 CSR 35-71.140 Specialized Standards For Intensive Residential Treatment for Children and Youth {#sec-13-csr-35-71.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.140}

PURPOSE: This rule sets forth the standards for intensive residential treatment, including personnel requirements, staff/child ratios, training, treatment plan review, recreation, and safety procedures.

(1) In addition to the licensing rules for basic residential treatment for children and youth, an agency seeking to provide intensive residential treatment for children and youth shall meet these additional requirements— (A) Personnel.

1. Program director. The person responsible for the overall treatment program shall be full-time staff with at least the following minimum qualifications:

A. A master’s degree in social work or human service clinical social worker; and B. Two (2) years’ experience providing treatment services.

One (1) year of this experience must have been in a residential treatment setting.

2. Assessment staff. Staff responsible for developing an initial assessment and treatment plan for each child shall have at least the following minimum qualifications:

A. A master’s degree in social work or human service clinical social worker; and B. One (1) year of experience in a residential treatment setting.

3. Professional staff.

A. Agencies must have sufficient appropriately qualified professional staff available on a full-time, part-time, or continuing consultative basis, or any combination of these, to address the needs of children in care.

B. The professional staffing plan must be in writing and implemented by the agency.

C. The professional staff plan must document that the number, qualifications, and responsibilities of professional staff are appropriate to the agency’s size and the scope of its program;

(B) Nursing Personnel. The agency shall employ and schedule a licensed nurse for not less than twenty (20) hours per week;

(C) Staff/Child Ratios. Staff/child ratios shall be maintained at not less than a one to four (1:4) ratio for children ages birth to age six (6) years when children are awake and one to five (1:5) ratio when children ages birth to age six (6) years are asleep and one to five (1:5) ratio when children/youth ages six (6) to twenty-one (21) years are awake and one to six (1:6) ratio when children and youth ages six (6) to twenty-one (21) years are asleep. Staff shall remain awake on duty during children’s sleeping hours;

(D) Training. All staff working with children must receive at least forty (40) hours annually of in-service training at least ten (10) hours of the training must be specifically related to relevant intensive residential treatment issues;

(E) Treatment Plan Review.

1. Each child shall have an initial written treatment plan within ten (10) days of admission.

2. Each child’s treatment plan must be reviewed and updated at least every month.

3. If a child shows no progress toward achieving the goals and objectives in the treatment plan since the plan was developed or last reviewed, the reason(s) for continuing secure care shall be included in the child’s record.

4. Appropriate information about the updated treatment plan must be given to the child and the child’s parent(s), guardian, or legal custodian. This must be documented in the child’s record.

5. A minimum of one (1) hour of individual, group, or family counseling sessions shall be provided to each child at least two (2) times a week with other sessions available as needed.

6. If the assessment of a child indicates a need for treatment by a psychiatrist or if the child is currently under psychiatric care, the agency shall provide or arrange for appropriate consultation and treatment;

7. If the assessment of the child indicates a need for a more restrictive environment, the agency shall contact the child’s treatment team, case manager, legal guardian, and legal custodian to plan for the child’s placement in a more appropriate facility. Intensive residential treatment is not meant to replace the need for more restrictive settings such as psychiatric care or incarceration when indicated by psychological evaluation, psychiatric evaluation, or by physician or court order.

(F) Recreation. A recreation plan shall be developed by an individual with a degree in recreational therapy or a related field with at least one (1) year’s experience in working with children in a residential treatment setting;

(G) Safety-Emergency Evacuation Procedure. Locking hardware is permitted on children’s sleeping room doors if they are equipped with electronic locking-release mechanism approved by the State Fire Marshal or if staff are immediately present, awake, and in possession of a key for the locking device, or both. There shall be a backup system which does not rely on a key, i.e., an electronic release mechanism, as approved by the State Fire Marshal; and (H) Sleeping Area. An agency licensed, or buildings constructed after (effective the date of this amendment) shall house no more than one (1) child in a sleeping room.

Age Range Level of Care Direct Care Staff to Resident Ratio Awake Asleep Birth to age six (6)

Intensive Need A minimum of one (1) staff per four (4) children when children are awake and a minimum of one (1) staff per five (5) children when children are asleep. Staff shall remain awake on duty during children’s sleeping hours.

Age six (6) years and older Intensive Need A minimum of one (1) staff per five (5) children/youth when children/youth are awake and one (1) staff per six (6) children/youth when children/youth are asleep. Staff shall remain awake on duty during children’s/youth’s sleeping hours.

This rule originally filed as 13 CSR 40-71.140. Emergency rule June 6, 1994. Moved to 13 CSR 35-71.140, effective Oct. 30, 2008.

13 CSR 35-71.150 Designation Rules for Qualified Residential Treatment Programs {#sec-13-csr-35-71.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.150}

PURPOSE: This rule sets forth the requirements for the designation of a Qualified Residential Treatment Program (QRTP).

(1) A qualified residential treatment program (QRTP) means a program that has met all program requirements for designation as a QRTP, as determined herein.

(2) To qualify for designation as a QRTP, the agency shall meet the requirements set forth below. The designation shall not be considered a license issued by the Department of Social Services, Children’s Division.

(3) Designation Requirements.

(A) The agency shall be a residential treatment agency licensed by Children’s Division at the specialized standards for residential treatment or intensive residential treatment level in accordance with 13 CSR 35-71.

(B) The agency shall be accredited by any of the following independent, not-for-profit organizations:

1. The Commission on Accreditation of Rehabilitation Facilities (CARF);

2. The Joint Commission (JCO);

3. The Council on Accreditation (COA);

4. Educational Assessment Guidelines Leading Toward Excellence (EAGLE); or 5. The Teaching Family Association (TFA).

(C) The agency shall have a trauma-informed treatment model designed to address the needs of children in the program.

(D) The agency shall be equipped to meet the clinical needs, as appropriate, of children with serious emotional or behavioral disorders or disturbances, as appropriate for the agency’s residential treatment license.

(E) The agency shall be equipped to implement the treatment identified as necessary for the children in the program.

(F) The agency shall acquire the services of registered or licensed nursing staff who— 1. Provide care within the scope of their practice as defined by law;

2. Are available twenty-four (24) hours a day and seven (7) days a week; and 3. Are on-site according to the minimum standards set forth in 13 CSR 35-71.

(G) The agency shall acquire the services of licensed clinical staff to fulfill the clinical needs of children in the program.

(H) The agency shall designate lead personnel (one (1) or more individuals) involved in the implementation of the trauma-informed practices.

(I) The agency shall create a family engagement plan to explain how the requirements below will be met for each child— 1. To the extent appropriate, and in accordance with the child’s treatment plan, agencies shall facilitate the participation of family members in the child’s treatment program by— A. Facilitating outreach to the family members of the child, including siblings. The agency shall maintain documentation demonstrating how the outreach is made (including contact information), and shall maintain contact information for any known biological family and fictive kin of the child;

B. Documenting how family members are integrated into the treatment process for the child, including postdischarge, and how sibling connections are maintained; and C. Providing discharge planning and family-based aftercare support for at least six (6) months post-discharge. This service may be performed by the agency or a subcontractor of the agency. Any subcontracting agreements shall be in writing and provided to the division upon request.

(J) The agency shall create and follow a family engagement plan, as described in this section, for each child.

(4) Application.

(A) The agency shall submit written documentation to the division or the division’s designee to demonstrate the minimum qualifications identified in section (3) of this

regulation utilizing the Qualified Residential Treatment Provider Designation form (RPU-35), which is incorporated by reference and made part of this rule as published by the Department of Social Services at their website at https://dss.mo.gov/cd/info/ forms/pdf/rpu35.pdf, November 10, 2021. This rule does not incorporate any subsequent amendments or additions.

(B) The division or designee may conduct site visits, a review of records, and interviews with staff and residents to assess the application materials and qualifications of the agency in meeting the requirements herein.

(C) Upon receipt of all documents and information set forth herein, the division shall review and determine if all QRTP designation requirements are met.

(D) The division may request further supporting documentation or information to demonstrate the minimum qualifications herein.

(E) The division shall issue a written finding to either approve or deny the agency’s application for QRTP designation within forty-five (45) days of receipt of the agency’s complete application.

(F) In the event that the division denies the agency’s application for QRTP designation, the agency shall have the right to administrative review as stated in section (7) of this

regulation. The denial shall be in writing and shall provide the factual basis for the decision.

(5) Designation.

(A) The QRTP designation shall be valid for a period not to exceed six (6) years and shall be subject to periodic announced and unannounced monitoring, as determined by the division.

(B) The agency shall participate in all requests by the division to review records or documents, or contact agency personnel or residents, related to the trauma-informed model and QRTP designation.

(C) The agency shall provide written notice to the division within five (5) calendar days identifying a personnel change of the lead personnel of the trauma-informed practices and shall name a new individual to lead trauma-informed practices within thirty (30) calendar days of the change.

(D) The division shall have the authority to suspend, revoke, or deny the QRTP designation in the event the division determines the agency does not meet the requirements of 13 CSR 35-71.

(E) In the event of non-compliance with the requirements of 13 CSR 35-71, the division may suspend or revoke the QRTP designation. In the notice of suspension or revocation, the 1. Include the factual basis for the suspension or revocation;

2. In the event of a suspension, issue an immediate corrective action plan to mitigate the conditions related to the suspension; and 3. Notify the agency of the right to administrative review pursuant to 13 CSR 35-71.150(7).

(F) The agency may rescind the suspension on its own decision in the event that the division determines— 1. The agency has successfully implemented the corrective action plan requested by the division to remedy the concerns that resulted in the suspensions of the designation; and 2. The agency meets all criteria set forth in 13 CSR 35-71.150.

(G) The failure to correct areas of non-compliance as identified in any request for corrective action shall be grounds for designation revocation.

(H) In the event that an agency’s QRTP designation has been suspended, the agency shall have a maximum of three (3) months to correct the areas of non-compliance which led to the suspension action by the division. If the areas of non-compliance are not corrected after three (3) months, as determined by the division, or within any timeframes set by the division, the division shall have the right to revoke the designation.

(I) In the event that an agency’s QRTP designation has been revoked, the agency shall wait a period of not less than six (6) months prior to submitting the designation application again.

(6) Designation Renewal.

(A) The agency shall submit updated application materials as outlined in section (4) of this rule at least three (3) months prior but not more than six (6) months prior to the expiration date of the designation for designation renewal.

(B) The division shall issue a written finding to either approve or deny the agency’s renewal for QRTP designation within forty-five (45) days of receipt of the agency’s complete renewal application.

(C) The agency shall participate in all requests by the division to review records or documents, or contact agency personnel or residents, related to the trauma-informed model and QRTP designation, during the renewal application assessment.

(D) The designation shall be valid for a period not to exceed six (6) years.

(7) Administrative Review.

(A) The agency which is aggrieved by the decision of the division to deny, suspend, or revoke a QRTP designation shall have the right to a hearing on administrative review of the division’s decision.

(B) The division shall provide written notice to the agency of its adverse action against the QRTP designation of an agency.

The notice shall— 1. Inform the agency of the nature of the decision;

2. State the factual and legal basis for the division’s action;

3. State the effective date of the action, if applicable; and 4. Notify the agency of its right to seek administrative (C) To request a hearing, the agency shall submit a written request for administrative review within thirty (30) calendar days of the decision of the division. The request for administrative review shall set forth the basis of the agency’s objection to the division’s decision.

(D) If the agency requests a hearing, the division shall hold an administrative hearing. The hearing shall be held by the director or the director’s designee.

(E) The determination of the director or the director’s designee shall be the final agency decision.

rule filed Nov. 18, 2021, effective Dec. 6, 2021, expired June 3, 2022.

Original rule filed Nov. 18, 2021, effective June 30, 2022. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014, and 210.535, RSMo 2004.

History

• AUTHORITY: sections 207.020 and 210.535, RSMo 2016. Emergency

13 CSR 35-71.300 Notification Requirements for License- Exempt Residential Care Facilities {#sec-13-csr-35-71.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-71.300}

PURPOSE: This rule implements the notification requirements for License-Exempt Residential Care Facilities in Missouri as required by sections 210.1250 through 210.1286, RSMo, as enacted into law in HB 557 (2021).

(1) Definitions. For the purpose of this regulation, unless otherwise specified in this section or unless the context clearly requires otherwise, the definitions of terms specified in sections 210.110, 210.481, 210.1253, RSMo, and 13 CSR 35-71.010 and 13 CSR 35-71.015 shall apply to this regulation. The singular includes the plural and plural includes the singular. In addition, the following terms are defined as follows:

(A) “Residential Care Facility Notification Act” or “RCFNA” refers to sections 210.1250–210.1286, RSMo.

(2) Designation of Authority. The Department of Social Services hereby designates the Children’s Division of the Department of Social Services to be the division within the Department of Social Services to administer background checks as required by

section 210.493, RSMo, 13 CSR 35-71.015, and the RCFNA.

(3) Application and Purpose of this Regulation. This regulation implements the requirements of the RCFNA. It applies to License-Exempt Residential Care Facilities (LERCFs).

(4) All LERCFs shall notify the division of their operation within Missouri before they accept any children as provided in this

regulation and the RCFNA. LERCFs operating in Missouri and providing Residential Care Facility services to children on July 14, 2021, shall register with the division no later than Thursday, October 14, 2021.

(5) Notification Procedures.

(A) To notify with the division, the director of the LERCF, or his or her designee, shall file a notification using the division’s online portal, or as may be otherwise provided in this regulation.

1. The online notification form, instructions and filing the notification are incorporated by reference and made a part of this rule as published by the Department of Social Services, Children’s Division, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, MO 65102, at its website at https://www.dss. mo.gov/provider-services/children/residential-program/licenseexempt.htm, October 1, 2021. This rule does not incorporate any subsequent amendments or additions. The LERCF shall submit the completed notification form and upload any supporting or supplemental forms and documentation through this online portal. The LERCF shall attach all documentation that may be necessary to complete the required notification and upload the documentation with the notification form.

2. The LERCF may apply to the division for permission to file the notification and supporting documentation by mail or private delivery services rather than through the online portal when there are unusual, compelling, and extenuating circumstances which make filing the notification through the online portal impossible. The LERCF shall apply for permission to file the notification form, supporting or supplemental materials with the division in writing, and shall explain the circumstances why the LERCF cannot submit the notification through the online portal. A copy of the notification form for use in submitting notification by mail is incorporated by reference and made a part of this rule as published by the Department of Social Services, Children’s Division, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, MO 65102, at its website https://www.dss.mo.gov/provider-services/ children/residential-program/license-exempt.htm, October 1, 2021. LERCFs may download a copy of the form. The LERCF shall attach all documentation that may be necessary to complete the required notification. If the division grants permission under this subsection the LERCF may submit the form with supporting materials by mail, by private delivery service, or in person to the offices of the division at Residential Program Unit, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, Missouri 65102; or by email at CD.NotifyRPU@dss.mo.gov.

(B) The notification form shall be signed by the director of the LERCF, or his or her designee, attesting that the information contained in the notice and the supplemental materials are true, accurate, complete, and subject to penalties of perjury.

The division will accept e-signatures.

(C) The notification form shall designate the individual within the LERCF to be the point of contact between the LERCF and division. The point of contact between the division and the LERCF shall be the director unless otherwise specified by the LERCF. The notification form shall further indicate whether the LERCF prefers to receive communications by mail through the United States Postal Services or electronically by email.

(D) The notification shall contain the information required in this subsection and otherwise in this regulation.

1. The LERCF shall list its full name, street address, mailing addresses, email address, and phone number. The mailing and email addresses shall be the addresses of record of the LERCF and all official correspondence to the LERCF will be sent to the mailing or email address on record.

2. The LERCF shall identify the name of the director, owner, operator, all staff members, volunteers, and any individual eighteen (18) years of age or older who resides at or on the property of the LERCF. The LERCF shall provide the name, street address, physical and electronic mailing addresses, and phone number of the director or director’s designee who will serve as the point of contact between the division and the LERCF.

3. The LERCF shall provide a full description of the agency or organization operating the LERCF, including a statement as to whether the agency or organization is incorporated.

A. The description of the agency or organization shall specify the type of agency or organization.

B. If the agency or organization is incorporated then the LERCF shall provide the state in which the LERCF was incorporated and the corporate name of the LERCF.

4. The LERCF shall identify the name and address of the sponsoring organization of the residential care facility, if applicable.

5. The LERCF shall identify the school or schools attended by the children served by the residential care facility. The LERCF shall list the name and address of each school.

6. Fire and safety inspection certificates.

A. The LERCF shall include with the notification a copy of any and all fire and safety inspection certificates required by law in the jurisdiction where the LERCF operates, and shall indicate the date of the inspection and the date that each certificate expires, if any. If the LERCF operates in more than one (1) county or local jurisdiction then the LERCF shall submit the required certificates for each facility at each location. The LERCF shall indicate the date of the inspection and the date that each certificate expires, if applicable.

B. LERCFs operating in jurisdictions where there are no required fire and safety inspections shall include a statement to that effect in the notification form.

C. If the LERCF is unable, after exercising diligent efforts, and due to no fault of its own, to obtain fire and safety inspection certificates in jurisdictions where such certificates are required by state law or local ordinance, then the LERCF shall submit a statement describing the efforts made to obtain the certificate(s) and the reason why the LERCF was unable to obtain the certificate. The LERCF shall attach copies of any correspondence from any state, county, or local jurisdictions declining to conduct the inspection when available.

7. Local health department inspection certificates.

A. The LERCF shall include with the notification a copy of any and all state or local health department inspection certificates required in the jurisdiction in which the facility operates. If the LERCF operates in more than one (1) county or local jurisdiction, then the LERCF shall obtain the required certificates for each facility at each location. The LERCF shall indicate the date of the inspection and the date that each certificate expires, if any.

B. LERCFs operating in jurisdictions where there are no required local or county government health department inspections shall include a statement to that effect in the notification form.

C. If the LERCF is unable, after exercising diligent efforts, and due to no fault of its own, to obtain any required local health department inspection certificates in jurisdictions where such certificates are required by state law or local ordinance, then the LERCF shall submit a statement describing the efforts made to obtain the certificate(s) and the reason why the LERCF was unable to obtain the certificate. The LERCF shall attach copies of any correspondence from any state, county, or local jurisdictions declining to conduct the inspection when available.

8. Proof that medical records are maintained for each A. The division will accept a written attestation, made under oath, subject to penalty of perjury, and executed by the director of the LERCF, that the LERCF actually maintains medical records for each child served by the LERCF according to the written policy of the LERCF, which shall be attached to the attestation.

9. Background check completion/eligibility. The director of the LERCF, or his or her authorized designee, shall certify, under oath subject to the penalties of perjury that all individuals who are required to complete a background check have successfully completed the background check and have been found eligible for employment or presence at the LERCF pursuant to section 210.493, RSMo, and 13 CSR 35-71.015.

A. Phase-in period for LERCFs in operation as of July 14, 2021. For all original notifications submitted by LERCFs which were both in operation and had children in its facility as of July 14, 2021, the division will accept a written certification from the director of the LERCF that all individuals who are required to submit to a background check pursuant to section 210.493, RSMo, and 13 CSR 35-71.015 either have completed the background check requirements or will have successfully completed the background check by the end of the phase-in period.

Upon completion of this process the director or the director’s designee shall provide written or electronic notice to the division certifying that the background check process for these individuals has been successfully completed. The division may extend this period for up to an additional one hundred twenty (120) days if the LERCF establishes, in writing, that it is unable to successfully complete the process by the deadline.

(E) When the division is satisfied that the LERCF has complied with all of the requirements for notification, the division will issue a letter to the LERCF— 1. Confirming the receipt of the completed notification;

2. Informing the LERCF that the records of the division reflect that the LERCF has successfully completed all of the notification process as of the date of the letter, that the LERCF may accept children pursuant to section 210.1259, RSMo, and that the division will include the LERCF on the list of LERCFs as specified in section 210.1280, RSMo, and section (9) of this

regulation; and 3. Notifying the LERCF of the deadlines for submitting any supplemental notifications as provided in subsection (5)(F).

(F) Duty to Supplement. The LECRF shall have a continuing duty to submit a supplemental notification within fifteen (15) calendar days if or when— 1. The LERCF terminates its operations in Missouri;

2. The LERCF has any change in its physical address, mailing address, or email address, or other address on record; or 3. There is a change in the name, mailing address, email address, or other contact information for the director of the LERCF or designated point-of-contact of the LERCF.

3. The supplemental notification form shall be signed by the director of the LERCF or his or her designee attesting that the information contained in the form and the supplemental materials are true, accurate, and complete, and subject to penalties of perjury. The division will accept e-signatures.

(6) Nothing in this regulation shall give the division jurisdiction or authority to regulate or attempt to regulate, control, or influence the form, manner, or content of the religious curriculum, program, or ministry of the LERCF.

(7) When the department or the division is advised or has reason to believe that any LERCF is operating without proper notification in accordance with the RCFNA and the division’s implementing regulations, the division shall give the director of the LERCF written notice by certified mail that the director shall file notification in accordance with the RCFNA and the division’s implementing regulations, or the department may request a court injunction as provided under section 210.1271, RSMo, or take other action as may be authorized by law. The division shall send its written notice to the address of record of the LERCF when an address has been provided.

(A) The division may extend the time for the LERCF to comply with the notification requirements for up to sixty (60) days upon request of the LERCF and a showing by the LERCF that the LERCF has reasonable cause for the delay in completing the notification requirements and that the health and safety of the children will not be at risk.

(B) The division may further condition an extension of time upon the LERCF submitting a time-limited corrective action plan to complete the notification requirements that is mutually satisfactory to the LERCF and the division.

(8) Administrative Review and Judicial Review.

(A) Any LECRF which is aggrieved by a decision of the department or division under this regulation may file a request for administrative review of the decision within fourteen (14) days of the mailing of the decision as provided in this

regulation.

(B) Administrative Review.

1. A request for administrative review shall be made in writing, either on a form provided by the division or by letter or submitted electronically by email to the division to the email address specified in the division’s decision. The request for administrative review shall include the following information:

A. The name, address, telephone number, and email address of the LERCF making the request for administrative review;

B. Specify whether the LERCF is requesting a response and notice of final decision by first-class mail or by email;

C. Identify the division’s decision to be reviewed, and why the LERCF is aggrieved by the decision;

D. The LERCF shall include copies of any relevant documents, materials, or information that the LERCF wishes to submit in support of the request for administrative review; and E. Specify whether or not the LERCF requests that the review be considered on the basis of the materials submitted, or whether the LERCF requests an in-person review conference.

If the LERCF requests an in-person review conference then the LERCF shall also provide dates and times within the next thirty (30) days when the LERCF will be available and the reasons why the administrative review cannot be processed on the basis of the materials presented.

2. The LERCF may be represented by legal counsel.

3. The administrative review shall be conducted and decided based upon the written materials submitted to the division and any information and materials presented at an inperson review conference. If the LERCF establishes that there is a good reason to hold an in-person review conference then the division will hold an in-person review conference.

4. The in-person review conference may take place by telephone conference call, video conference, or in-person review conference at a date and time during regular working hours that are mutually convenient to the division and the LERCF requesting the conference.

5. The administrative review process and in-person review conference shall be informal. The rules of evidence shall not apply. There is no right to conduct discovery. There shall be no right to compel the production of witnesses or evidence by subpoena or otherwise.

6. The administrative review shall be conducted by an individual designated by the director of the department or division, who may be an employee of the division or the department. However, the individual shall not have been involved in making the decision which is subject to review.

7. The individual conducting the administrative review shall conduct the administrative review and render a written decision no later than thirty (30) days from the date that the division received the request for administrative review.

8. The decision upon administrative review shall be the final decision of the department.

(9) The division will maintain a list of all LERCFs which are in compliance with the requirements of sections 210.1250– 210.1286, RSMo, and this regulation.

(A) The list shall include the following information:

1. The name, physical address, and mailing address of the LERCF;

2. The name of the director of the LERCF; and 3. Whether the LERCF has submitted any fire and safety or health department certificates with the notification.

(B) The division will provide a copy of the list to anyone who asks, upon request submitted to the Children’s Division, Residential Program Unit, 205 Jefferson Street, PO Box 88, Jefferson City, MO 65102; or by email at CD.NotifyRPU@dss. mo.gov.

(C) The director of any LERCF may submit written request to correct any errors in the list or to supplement the list with updated information.

(D) The division will update the list when errors or updates are brought to its attention. Except in cases where there is a scrivener’s error, the division will provide notice and an opportunity to object making any changes about the LERCF on the list. The LERCF may seek administrative review of any changes in the list following the procedures specified in this

regulation.

rule filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Original rule filed Sept. 17, 2021, effective March 30, 2022.

Amended: Filed April 23, 2024, effective Oct. 30, 2024. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.493, RSMo 2021, amended 2023; 210.1286, RSMo 2021; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020 and 660.017, RSMo 2016, and sections 210.493 and 210.1286, RSMo Supp. 2023. Emergency

Chapter 73 Child Placing Agencies

13 CSR 35-73.010 Scope and Definitions {#sec-13-csr-35-73.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.010}

PURPOSE: This rule clarifies the terms used in the licensing rules for child placing agencies.

(1) The following principles shall apply to all decisions made pursuant to this chapter:

(A) The safety and welfare of children is paramount;

(B) All providers of direct services to children and their families will be evaluated in a uniform, transparent, objective, and consistent basis;

(C) Services to children and their families shall be provided in a timely manner to maximize the opportunity for successful outcomes, and such services shall be tracked and routinely evaluated through a quality assurance program;

(D) Any provider of direct services to children and families shall have the appropriate and relevant training, education, and expertise to provide the highest quality of services possible which shall be consistent with federal and state standards;

(E) Resources and efforts of the division and child placing agencies shall be committed to pursue the best possible opportunity for a successful outcome for each child. In the case of children and youth who are in the foster care system, successful outcomes may include preparing youth for a productive and successful life as an adult outside the foster care system, such as independent living. For those providers that work with children requiring intensive twenty-four- (24-) hour treatment services, successful outcomes shall be based on the least restrictive alternative possible based on the child’s needs as well as the quality of care received; and (F) All licensed service providers shall prioritize methods of reducing or eliminating a child’s need for residential treatment through community-based services and supports.

(2) Unless the context clearly requires otherwise, the definitions of terms specified in sections 210.110, 210.481, and 210.1253, RSMo, and 13 CSR 35-71.010 and 13 CSR 35-71.015 shall apply to all regulations in this chapter (13 CSR 35-73). The singular includes the plural and the plural includes the singular. In addition, the following terms are defined as:

(A) “Adoption” means the act of receiving a child into one’s family by choice and acquiring a parent-child relationship by legal process;

(B) “Adoption agency” means a licensed public or private organization whose purpose or parts of its purpose is to provide adoption services to children, adoptees, adoptive applicants, and birth and/or adoptive parents;

(C) “Adoption services” means the provision of pre-placement or foster care services to birth and/or adoptive parents, the completion of birth parent social and medical histories, the completion of adoptive family assessments, post-placement services to birth and/or adoptive parents, post-adoption services to birth and/or adoptive parents, or other related activities, including those requested by courts and other adoption agencies and organizations;

(D) “Adoptive applicant” means a prospective adoptive parent who has applied to adopt a child but who has not yet received a child for adoptive placement. It also includes an adoptive parent who has adopted one (1) or more children and who is requesting to adopt another child;

(E) “Adoptive parent” means a person with whom a child has been placed for adoption or who has adopted one (1) or more children;

(F) “Alternative care” means care provided a child in a foster home, a group home, residential treatment agency, child care institution, or any combination thereof;

(G) “Background check” means the background check required by section 210.493, RSMo, and 13 CSR 35-71.015;

(H) “Birth parent(s)” means the biological father and/or mother of a child;

(I) “Child” means any person under eighteen (18) years of age;

(J) “Child placing agency” means any person or organization, other than the parents, who places a child outside the home of the child’s parents or guardian, or advertises or holds him/herself forth as performing such services, but excluding the attorney, physician, or clergyman of the parents per section 453.014(4), RSMo;

(K) “Confidentiality” means complying with all federal and state laws governing the confidentiality of both identifying and nonidentifying information about clients, families, and other individuals receiving services from a licensed child placing agency;

(L) “Custody” means the right of care and control of a child and the duty to provide food, clothing, shelter, ordinary medical care, education, and discipline for a child.

Temporary custody of a child may be granted for a limited time only, usually pending further action or review by the court;

(M) “Director” means the director of the Children’s Division;

(N) “Division” means the Children’s Division of the Department of Social Services;

(O) “Facility” is any building of a licensed agency in which children reside;

(P) “Family Assessment” means a formal evaluation of the capacity and readiness of foster parent or adoptive applicants to receive a child, which includes a written report and recommendation;

(Q) “Finalization” means the issuance of a court order by an appropriate court which declares the child to be the child of adoptive petitioners as though born to them with full rights of inheritance;

(R) “Foster care,” see alternative care;

(S) “Foster Home” means a private residence of one (1) or more family members providing twenty-four- (24-) hour care to one (1) or more, but less than six (6) children who are unattended by parent or guardian and who are unrelated to either foster parent by blood, marriage, or adoption;

(T) “Foster parent” means a person of age twenty-one (21) or older who is licensed to provide twenty-four- (24-) hour care to one (1) or more, but less than six (6), children who are unattended by parent or guardian, and who is unrelated to the child(ren) by blood, marriage, or adoption;

(U) “Governing body” means the legal entity with ultimate authority and responsibility for the agency’s overall operation;

(V) “Home study,” see family assessment;

(W) “ICAMA” means the Interstate Compact on Adoption and Medical Assistance (ICAMA). A contract enacted into law among twenty-eight (28) states (as of May 1994) whereby medical assistance (Medicaid) may be granted to an adopted child in the state where the child lives, based upon certain criteria, one (1) of which is the provision of adoption subsidy through an agreement between an agency and the adoptive parents;

(X) “ICPC” means the Interstate Compact on the Placement of Children (ICPC). A contract enacted into law among the fifty (50) states, the District of Columbia, and the Virgin Islands whereby approval must be obtained from the receiving state ICPC office prior to the placement of a child across state lines for the purpose of adoption or certain other types of placement;

(Y) “ICWA” means the Indian Child Welfare Act (ICWA);

(Z) “Immediate family” means a person related within the third degree of blood, marriage, or adoption-parent, grandparent, brother, sister, half brothers, half sisters, stepparent, stepbrothers, stepsisters, uncle, aunt, or first cousin;

(AA) “Independent adoption” means the placement of a child with a prospective adoptive parent by a birth parent or some other person, acting as allowed by state law, as an intermediary. Also referred to as a private, identified, or designated adoption;

(BB) “International adoption” means the adoption of a child from a country other than the United States or of a child who is not a United States citizen by birth or naturaliza- (CC) “Legal father” is the husband of a natural mother at the time the child was conceived;

(DD) “MEPA” means Multi-Ethnic Placement Act (MEPA), Public Law 103-382 as amended;

(EE) “Office” means the place where business is transacted and where the functions of an agency are performed;

(FF) “Operating capital” means sufficient assets on hand to cover the initial start-up expenses for the initial period of licensure;

(GG) “Permanency plan” means moving children to permanent homes, birth or adoptive, in a purposeful and timely manner;

(HH) “Placement services” means any and all services offered to prospective adoptive children and families, ranging from selection of a particular family for a particular child through the physical arrival of the child in the adoptive home;

(II) “Post-legal adoption services” means any and all services offered to any party involved in an adoption after the adoption is granted or finalized by the appropriate court;

(JJ) “Post-placement services” means any and all services offered to any member of an adoptive family from the placement of the child to finalization of the adoption;

(KK) “Power of attorney” means an instrument authorizing another to act as one’s agent or attorney;

(LL) “Pre-placement services” means any and all services offered to birth parent(s) and child(ren) to evaluate and prepare them for an adoptive placement;

(MM) “Private adoption,” see independent adoption;

(NN) “Private agency adoption” means the services offered by a licensed agency in placing a child for adoption;

(OO) “Public agency adoption” means the services offered by a state public child welfare agency in placing a child for adoption;

(PP) “Social worker” means a professional person who possesses the qualifications and appropriate licensure to work directly with children, adoptees, birth and/or adoptive parents, and other relevant individuals. If the person is a contracted person of a licensed child placing agency, such person must possess a valid license from the Division of Professional Registration and must, at a minimum, possess either a Bachelor’s Degree or a Master’s Degree in Social Work from an accredited institution;

(QQ) “Subsidy/adoption assistance” means the provision of financial assistance to adoptive families who are adopting a child with special needs as defined in state and federal law; and (RR) “Termination of parental rights” (TPR) means a legal action which severs the parentchild relationship and allows the child to be adopted.

Filed Oct. 13, 1982, effective Jan. 13, 1983.

Amended: Filed Oct. 7, 1987, effective March 25, 1988. Rescinded and readopted:

Filed Jan. 14, 1997, effective July 30, 1997.

Moved to 13 CSR 35-73.010 and amended:

Filed Sept. 7, 2018, effective April 30, 2019.

Emergency amendment filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Amended: Filed Sept. 17, 2021, effective March 30, 2022.

History

• AUTHORITY sections 207.020, 210.506, and 660.017, RSMo 2016, and sections 210.493 and 210.1286, RSMo Supp. 2021. This rule originally filed as 13 CSR 40-73.010. Original rule filed Sept. 18, 1956, effective Sept. 28, 1956. Refiled: March 12, 1976. Rescinded and readopted: Filed Nov. 6, 1981, effective Feb. 11, 1982. Rescinded and readopted:

13 CSR 35-73.012 Basis for Licensure and Licensing Procedures {#sec-13-csr-35-73.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.012}

PURPOSE: This rule describes the procedures for application for licensure, the licensing investigation and provisions for continued licensing investigations after the initial license is granted.

(1) Licensing Authority.

(A) Section 210.486, RSMo, states it is unlawful for any person to operate a child placing agency without having a written license issued by the division, except for those persons specifically exempted by section 210.516, RSMo.

(B) Any person who desires to develop, establish, maintain, or operate a child placing agency, except for those persons exempt from licensing pursuant to section 210.516, RSMo, must file an Application for Licensure form with the division and must receive a license prior to accepting any clients for services.

(C) Before a license may be granted, an agency must be in compliance with sections 210.481–210.536, RSMo, and applicable rules promulgated and issued by the division.

(2) Application for Licensure.

(A) To apply for a license to operate a Child Placing Agency in Missouri, the individual legally authorized to act on behalf of the Child Placing Agency shall file an application with the division on forms provided by the division.

1. The application forms are published on the division’s website and are incorporated by reference and made a part of this rule as published by the Department of Social Services, Children’s Division, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, MO 65102, and on the web at https://www.dss.mo.gov/providerservices/children/residential-program/childplacing.htm, October 1, 2021. This rule does not incorporate any subsequent amendments or additions. The Child Placing Agency shall attach all additional supplementary materials and documentation that may be necessary to complete the required application. The Child Placing Agency shall submit the form with supplementary materials to the division by email at the following email address:

CD.CHILDPLACINGAPPS@dss.mo.gov.

2. The application form shall be signed by the legally authorized representative of the Child Placing Agency. The division will accept electronic signatures (e-signatures).

3. The Child Placing Agency may apply to the division for permission to submit its application and supporting documentation by mail or private delivery services rather than email when there are unusual, compelling, and extenuating circumstances which make submission by email impossible. The Child Placing Agency shall apply for permission to file the materials with the division in writing, and shall explain the circumstances why it cannot submit the materials by email. The Child Placing Agency shall attach all documentation that may be necessary to complete the required notification. If the division grants permission under this subsection the agency may submit the form with supporting materials by mail, by private delivery service, or in person to the offices of the division at Residential Program Unit, 205 Jefferson Street, 10th Floor, PO Box 88, Jefferson City, Missouri 65102; or by email to CD.CHILDPLACINGAPPS@dss.mo.gov.

(B) An agency shall submit the following documents to the division along with the application:

1. Documentation of the legal basis for operation;

2. A certified copy of the current Articles of Incorporation;

3. A copy of the current by-laws;

4. A list of the names and addresses of the current members of the governing board and a notarized letter of acceptance from each;

5. A completed personnel report on a form prescribed by the division;

6. Verification of the education, experience, and character of the administrator, all professional staff, and all contracted personnel;

7. Verification of a physical examination for all staff working directly with children, completed by a licensed physician or a registered nurse who is under the supervision of a licensed physician;

8. Certification that all individuals who are required to complete a background check are eligible for employment or presence at the Child Placing Agency as required in section 210.493, RSMo, and 13 CSR 35-71.015;

9. A chart depicting the agency’s organizational structure and lines of supervision;

10. A proposed budget for a period of not less than twelve (12) months duration which shows both anticipated expenses and income for the period;

11. An itemized schedule of all fees to be assessed to applicants;

12. Verification of availability of not less than ninety (90) days operating capital;

13. A copy of the Civil Rights Agreement signed by the president of the governing board or the agency director;

14. An outline of the agency’s proposed program and the specific geographic area to be served (this shall be directly related to the number of staff and the geographic area to which it can actually provide services);

15. A projected staffing plan for the anticipated capacity and programming of the agency;

16. A written statement clearly setting forth the authority and responsibilities delegated to a director, administrator, or supervisor, if other than the owner. When the responsibility for the operation of an agency rests with the governing board, that governing board shall establish written policies and procedures which clearly establish the lines of responsibility governing the operation of the agency. These shall include a statement of the kind and extent of authority delegated to the director employed to carry out the program;

17. A written description of intake policies which delineates the types of services to be provided, specific programs offered, and the methods of care and treatment to be provided;

18. Job title, job description, and minimum qualifications for all staff;

19. Written child abuse and neglect reporting policy;

20. Written personnel practices, including staff training and orientation;

21. Written discipline policy for children in care;

22. Written visitation policy for children in care;

23. Written health care policy for children in care which shall include preventive, medical, eye, hearing, and dental care;

24. A written statement of any religious practices or religious restrictions;

25. A written plan for all foster parent training; and 26. Proof of professional and commercial general liability insurance.

(C) The application shall be complete when the Child Placing Agency has submitted and the division has received a fully completed application form and all necessary supporting documentation.

(D) A new application shall be filed— 1. If the agency fails to follow through with completing the requirements for licensure within six (6) months of initial applica- 2. When an application for licensure has been withdrawn, and the agency seeks to reapply;

3. When there is a change of ownership or corporate status of the agency;

4. When the division has revoked or refused to renew a license, and a new license is sought; or 5. When a license or application has been voluntarily surrendered or withdrawn by the applicant.

(3) Licensing Assessment.

(A) After the application is complete the division will conduct a thorough assessment of the agency, including a review of the documents required in this rule and visits to the agency to determine compliance with the licensing law and applicable rules.

(B) If an applicant for licensure is determined not to be in compliance with the licensing law and applicable rules, and if compliance is not achieved within a six- (6-) month period, a new Application for Licensure must be filed if the agency desires to pursue licensure.

(4) The License.

(A) Upon determination of compliance with the licensing law and applicable rules, the director shall issue a license for an initial six- (6-) month probationary term.

(B) Following the probationary period, upon determination of continued compliance with Missouri statutes and applicable licensing rules, the director shall extend the term of the license for a period not to exceed two (2) years.

(C) The license shall be posted in a conspicuous place on the premises of the facility.

(D) The license shall reference specific category of service(s) the agency is authorized to provide.

(E) The license shall not be transferable and applies only to the agency to whom it is issued.

(5) License Amendment.

(A) An agency shall file an Application for Amendment with the division at least thirty (30) days prior to relocation, addition of a branch or operating site, change in the name of the agency, or significant change in the pro gram.

(B) An Application for Amendment shall be in the form of a letter from the executive director or board of directors and shall include the following information:

1. The type of change being requested;

2. The date the change will take effect;

3. Why the change is being requested;

4. Any specific location changes including full address and telephone number.

(C) These changes shall be approved by the division before implementation.

(6) Licensing Renewal.

(A) The Child Placing Agency shall complete and return the application to the division sixty (60) days prior to the expiration of the current license. The Child Placing Agency shall utilize the forms indicated in paragraph (2)(A)1. of this regulation to initiate the license renewal process. The Child Placing Agency shall attach all additional supplementary materials and documentation that may be necessary to complete the required application. The Child Placing Agencies shall submit the form with supplementary materials by email to the division to the following email address: CD.CHILDPLACIN- GAPPS@dss.mo.gov. The application form shall be signed by the Director of the Child Placing Agency or the director’s authorized designee. The division will accept electronic signatures.

(B) The division shall initiate action on the completed application prior to the expiration of the existing licensure period.

(C) When an agency has made timely and sufficient application for renewal of a license, and the division fails to render a decision on the application for renewal of the license prior to the expiration date on the license, the existing license shall continue in full force and effect for up to thirty (30) days until the final decision of the division has been made.

The division may further extend the period in which such decision must be made in individual cases for up to thirty (30) additional days, if good cause is shown.

(D) In addition to the completed renewal application, the Child Placing Agency shall submit the following documentation with the application:

1. Verification of a biennial physical examination, completed by a licensed physician, registered nurse who is under the supervision of a licensed physician, or an advanced practice nurse in a collaborative agreement with a licensed physician for all staff working directly with children (see 13 CSR 35- 73.030(3)(A));

2. A current governing board roster, with officers identified, including the addresses and a notarized letter of acceptance from each member;

3. A summary of any significant changes to programs and copies of any resulting policies or policy changes;

4. A copy of the current organizational chart;

5. A completed personnel report on a form prescribed by the division;

6. Certification that all individuals who are required to submit to a background check have completed their background checks and have been found eligible by the division for employment or presence at the Child Placing Agency as provided in section 210.493, RSMo, and 13 CSR 35-71.015;

7. Results of an annual check of the Child Abuse and Neglect CRU for all staff, contracted personnel, and volunteers working with children;

8. Results of the annual criminal records check for all staff, contracted personnel, and volunteers working with children;

9. A copy of a biennial financial audit and evaluation of the financial soundness of the operation conducted by a certified public accountant not employed by the agency;

10. A copy of the budget for the current calendar or fiscal year;

11. A statistical report on a form supplied by the division;

12. A list of the names and addresses of all current foster homes licensed by the agency;

13. An annual written plan for all foster parent training;

14. A written plan indicating how the agency will provide for the transfer of records on both open and closed cases in the event the agency closes;

15. An annual program evaluation;

16. An itemized schedule of all fees to be assessed to applicants; and 17. Copies of all written agreements (contracts) for the adoption process.

(E) When an agency has made timely and sufficient application for renewal of a license, and the division fails to render a decision on the application for renewal of the license prior to the expiration date on the license, the existing license shall continue in full force and effect for up to thirty (30) days until the final decision of the division has been made.

The division may further extend the period in which such decision must be made in individual cases for up to thirty (30) additional days, if good cause is shown.

(F) Upon determination of compliance with the licensing law and applicable rules, the director shall issue a license for a period not to exceed two (2) years.

Filed Sept. 17, 2021, effective March 30, 2022.

History

• AUTHORITY: sections 207.020, 210.506, 73.012. Original rule filed Feb. 6, 1997, 73.012 and amended: Filed Aug. 20, 2018, effective April 30, 2019. Emergency amendment filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Amended:

13 CSR 35-73.017 Hearings and Judicial Review {#sec-13-csr-35-73.017 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.017}

PURPOSE: This rule addresses the procedures for license denial, revocation, suspension, or suspension of intake and the right for an administrative hearing and judicial review for an agency aggrieved by a final decision of the director.

(1) License Denial, or Revocation.

(A) The division may refuse to issue a license to an applicant, or may deny or revoke the license of a licensee, who— 1. Fails consistently to comply with the applicable provisions of sections 210.481– 210.536 and Chapter 453, RSMo, if licensed as an adoption agency, and the applicable corresponding rules;

2. Violates any of the provisions of its license;

3. Violates state laws or rules relating to the protection of children;

4. Abuses or neglects children, or permits the abuse or neglect of children, or is the subject of multiple or serious reports of child abuse or neglect which upon investigation results in a finding of probable cause to suspect child abuse or neglect and fails to take corrective action acceptable to the division to ensure the safety of children;

5. Employs persons, utilizes volunteers, or utilizes contractors who the division has found ineligible for employment or presence at the Child Placing Agency pursuant to section 210.493, RSMo, and 13 CSR 35-71.015, or who abuse or neglect children, or are the subjects of multiple reports of child abuse or neglect which upon investigation results in a finding of preponderance of the evidence that the individual is responsible for child abuse or neglect and the agency fails to take corrective action acceptable to the division to ensure the safety of children;

6. Furnishes or makes any misleading or false statements or reports to the division;

7. Refuses to submit any reports or to make available to the division any records required in making an investigation;

8. Fails or refuses to submit to an investigation by an authorized and identified representative of the division at any reasonable time;

9. Fails to provide, maintain, equip, and keep in safe and sanitary condition the premises established or used for the care of children as required by law, rule, or ordinance applicable to the location of a facility; or 10. Fails to provide adequate financial resources for the satisfactory care of children being served.

(B) The division shall provide written notice within ten (10) days of denial or revocation of licensure to the agency, which shall include the reason(s) for the denial or revocation. Upon receipt of the notice of denial or revocation, the agency shall cease operation within five (5) working days unless the denial or revocation is stayed by an appropriate administrative or judicial order.

(C) The agency may appeal the decision of the division to deny or revoke the license by filing a request for appeal with the division within ten (10) days after receipt of the notice of denial or revocation.

(D) Any person aggrieved by a final decision of the division with regard to the denial or revocation of licensure shall be entitled to a hearing and review by the director or his/her designee as provided by section 210.526, RSMo.

(E) An agency shall not reapply for licensure within one (1) year from the date of denial or revocation.

(2) License Suspension and Suspension of Intake.

(A) The division shall have the authority to suspend the license of an agency when necessary to protect the health, safety, and welfare of children.

(B) The division shall provide written notice within ten (10) days of the suspension of license and the reason(s) for the suspension to the agency. Upon receipt of notice of suspension, the agency shall immediately cease operation pending review.

(C) The division shall have the authority to suspend the intake of children into placement during prescribed time periods in order to assure the health, safety, and welfare of children.

(D) The division shall have the authority to suspend the intake of birth parents and prospective adoptive parents during prescribed time periods in order to assure the health, safety, and welfare of clients.

(E) The division shall provide written notice within ten (10) days of the suspension of license and the reason(s) for the suspension to the agency. Upon receipt of notice of suspension, the agency shall immediately cease operation pending review.

(F) In the event that intake only is suspended, the division shall provide written notice within ten (10) days of the suspension and the reasons for the suspension, including time frames and limitations on intake.

(G) When the division suspends the license or the intake of an agency, the suspension shall be for a period not to exceed thirty (30) calendar days, or until there is an administrative review and decision by the director, whichever is first. The director can extend the suspension for an additional thirty (30) calendar days if the agency has failed to rectify the problem(s).

History

• AUTHORITY: sections 207.020, 210.506, and 660.017, RSMo 2016, and sections 210.493 and 210.1286, RSMo Supp. 2021. This rule originally filed as 13 CSR 40-73.017. Original rule filed Feb. 6, 1997, effective July 30, 1997. Moved to 13 CSR 35-73.017, effective June 30, 2018. Emergency amendment filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Amended: Filed Sept. 17, 2021, effective March 30, 2022.

13 CSR 35-73.020 Organization and Administration ments for the incorporation, administration and financing of the agency. {#sec-13-csr-35-73.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.020}

(1) Legal Basis for Operation. Agencies which are incorporated in the state of Missouri shall submit to the division their Articles of Incorporation and Certificate of Incorporation.

(2) An agency shall have a governing board, advisory board or designated individual responsible for establishing its policies, determining its programs, guiding its development and providing its leadership. The governing board, advisory board or designated individual shall be responsible for— (A) Developing and maintaining a program of orientation and training for all new members of the governing board or advisory board;

(B) Developing, maintaining and incorporating provisions for amending a set of bylaws regulating the size, method of selection, structure, function, organization, decision making and authority of the governing board or advisory board;

(C) Keeping minutes of each meeting of the governing board or advisory board which shall reflect its official actions;

(D) Meeting as often as necessary, but at least four (4) times a year to conduct the business of the agency;

(E) Continuing compliance with all applicable federal, state or local laws, or regulations governing the operation and services of the agency;

(F) Assuring that an agency’s standards of practice be professional, ethical and responsive to client’s needs;

(G) Appointing the administrator and delegating responsibility to that person to administer the agency in all of its activities, functions and services;

(H) Performing and retaining a written evaluation of the administrator on an annual

basis;

(I) Providing the division a written statement which sets forth the kind and extent of

(J) Assuring that all facilities are maintained, staffed and equipped to implement the agency’s program effectively;

(K) Evaluating the written policies, program, procedures, and fee structures annually to determine that the interests of children and families are being served, and submitting the evaluation in writing to the division;

(L) Meeting with division staff when requested;

(M) Providing written notification to the division within five (5) working days when there is a change of administrator, governing board president or the organizational structure of the agency;

(N) Adequately protecting the legal rights of children served by the agency;

(O) Informing the division in writing of any legal action brought against the agency which affects any child or children in care, personnel, or conduct of the agency; and (P) Maintaining a written list of the names, addresses, and title of each member of the governing board or advisory board which shall be provided upon request.

(3) The agency shall be responsible for financial management.

(A) The agency shall approve an annual budget which shall be on file at the agency and submitted to the licensing unit.

(B) The agency shall monitor the financial affairs of the agency and establish an accounting system capable of tracking income and expenditures.

(C) The agency shall be audited biennially by an independent certified public accountant and a copy shall be submitted to the division.

(D) The treasurer and all other persons authorized to handle funds of an agency shall furnish the agency fidelity bonds in amounts to be determined by the governing board. The expense of such bonds shall be borne by the (E) The agency shall develop written policy on management and security of client fees.

(4) The agency shall have a written policy covering conflict of interest, which shall include at a minimum the following provisions:

(A) Governing board members shall exempt themselves from voting on, or participating in, decisions that have or could have a monetary benefit or a benefit of any other nature upon them or their immediate family;

(B) The agency shall not use any business that is owned or operated by a governing board member or in which a governing board member has a financial interest, or shall not use the services of a governing board member unless the governing board can document that the goods or services were obtained at a competitive price;

(C) Governing board members seeking foster care or adoptive placement services from the agency shall resign from the governing board during the period(s) when such services are received. The requirements shall also apply when a person from a governing board member’s immediate family seeks agency services;

(D) The agency shall not require clients to use the consultant services of a governing board member or of a governing board member’s family;

(E) A governing board member shall not use a governing board position for personal benefit or for the benefit of family or friends who are seeking services from the governing board member’s agency;

(F) While employees or their spouses can be members of the governing board, such membership shall not comprise more than forty percent (40%) of the composition of the governing board; and (G) Any potential conflict of interest shall be declared by a governing board member and the minutes shall record declaration and abstention from the vote when a conflict exists.

(5) Agency Ethics.

(A) Agencies must not make or facilitate financial payments or offer other incentives for referrals.

(B) Agencies shall not influence decisions of clients by offering financial or other incentives.

(C) Agencies shall not coerce clients in any manner.

(D) All professional agency staff shall maintain the ethical codes of their respective professions.

History

• authority delegated to the administrator;
• AUTHORITY sections 210.481–210.536, (1994) and (Cum. Supp. 1996). This rule originally filed as 13 CSR 40-73.020. Original rule filed Sept. 18, 1956, effective Sept. 28, 1956. Refiled: March 12, 1976. Amended: Filed Nov. 6, 1981, effective Feb. 11, 1982. Rescinded: Filed Jan. 14, 1997, effective July 30, 1997. Readopted: Filed Feb. 6, 1997, effective July 30, 1997. Moved to 13 CSR 35-73.020, effective June 30, 2018. Original authority: Please see the Missouri Revised Statutes 1994 and Cumulative Supplement 1996.

13 CSR 35-73.030 Personnel Practices and Personnel ments for child abuse/neglect, medical examinations, personnel records, job descriptions and staff orientation. {#sec-13-csr-35-73.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.030}

(1) Personnel Practices.

(A) An agency shall have a written statement of personnel practices, approved by the governing board, which shall be furnished to all employees at the time of employment.

(B) The personnel policies shall be reviewed annually and updated as necessary by the agency.

1. Personnel policies will include, but not be limited to:

A. Hiring and termination procedures;

B. Description of employment benefits, including, but not limited to, paid vacation, sick leave, holidays, leaves of absence, retirement plans, insurance (malpractice, health, liability);

C. Provision of annual evaluations of work performance;

D. Provision for staff development through in-service training and continuing education;

E. Provision for addressing concerns, disagreements, and grievances of staff;

F. Probationary status;

G. Agency chain of command; and H. Employment outside the agency.

2. Job descriptions shall be established in writing for all positions.

(C) The agency shall investigate and evaluate employment application information carefully to determine whether employment of an applicant is in the best interests of the children and clients served.

1. No person who has served as a member of the governing board, administrator, or other officer of an agency that has failed to secure a license to operate as a child placing agency shall be employed by, licensed by, or associated with a licensed child placing agency for a period of two (2) years after termination or cessation of that illegal operation.

2. No person, administrator, or other officer of an agency which continued in operation after having knowledge of the revocation or suspension of the agency’s license shall be employed by or associated with a licensed agency for a period of two (2) years from cessation of the illegal operation.

3. The division may waive provisions of 13 CSR 35-73.030(1)(C)1. and 2. if it is shown that the person had no knowledge of or had no reason to know the operation was illegal. Such a waiver must take place before the employee is hired or a request for a waiver shall be submitted to the division within thirty (30) days after it is discovered that an ineligible person has been employed.

(D) The agency shall require that each individual associated with the agency who is required to submit to a background check pursuant to section 210.493, RSMo, 13 CSR 35-71.015, and 13 CSR 35-73.035 successfully complete the background check and be found eligible by the division for employment or presence at the licensed child placing (E) Prior to the employment of any person for a position requiring credit hours and/or a degree from an accredited college or university, a resume and an official college transcript, or a copy of the diploma, shall be on file at the agency.

(F) An agency shall secure the names of at least three (3) persons for each staff person, who are unrelated to the staff member, who can provide character references; employer references for each staff person from all previous employers within the last five (5) years, and a history of any previous employment in child placing or child caring settings. All references shall be documented by the agency with letters or verification in the record of verbal contacts, providing the date, person making the contact, and the content of the contact.

(2) Child Abuse and Neglect Central Registry Unit (CA/N CRU) Checks.

(A) After the background checks have been completed, the agency shall request from the division an annual check of the Family Care Safety Registry and the Child Abuse and Neglect Central Registry Unit to determine whether a child abuse and/or neglect report has been received on staff members, employees, contracted personnel, and volunteers working directly with children. Results of the checks shall be on file at the agency.

(B) The agency shall require each staff person to read and sign a statement defining child abuse and neglect and outlining responsibilities to report all child abuse and neglect incidents as required by Chapter 210, RSMo.

(3) Medical Examinations.

(A) All persons employed by an agency who work directly with children shall be free of signs of highly communicable disease or other evidence of ill health which poses a threat to children. This shall be verified by a physical examination by a licensed physician, certified nurse practitioner, advanced practice nurse in a collaborative agreement with a licensed physician, or a registered nurse who is under the supervision of a licensed physician before employment, or within ten (10) days following employment, and biennially thereafter.

(B) Medical examination reports shall include a tuberculin skin test, a chest x-ray, or appropriate followup of a previous examination that indicates the individual is free of contagion.

(C) Staff shall be free of any conditions which would adversely affect their ability to work with children or families or pose a threat to children.

(D) If the division has reason to question the capabilities of any person working directly with children, the division may require additional examinations.

(4) Personnel Records. Personnel records shall be maintained for each staff member and shall include:

(A) Verification of education and experience;

(B) Verification of character references from three (3) persons, unrelated to the staff member;

(C) Verification of employer references for the past five (5) years and a history of any previous employment in child care settings;

(D) A copy of the job description signed by the employee;

(E) Reports of initial and subsequent physical examinations;

(F) Results of annual checks of the CA/N CRU;

(G) The date of employment, date and reason(s) for termination of employment;

(H) Copies of an initial six- (6-) month performance evaluation and each subsequent annual evaluation;

(I) Results of the annual criminal records check;

(J) A signed and dated statement by the employee that written personnel policies were received and reviewed; and (K) Documentation of orientation and annual staff training.

(5) Job Descriptions. An agency shall establish a written job description for each position, which shall be made available to the employee at the time of employment. Each description shall describe the duties and responsibilities of the position, address supervision, required knowledge, skills, and abilities, minimum experience, educational requirements, and shall include examples of work performed.

(6) Staff Orientation. Immediately before or following appointment, a staff member shall be oriented to the agency’s programs, practices, and the duties and expectations of his/her position. The orientation program shall include, but not be limited to— (A) Agency philosophy and history;

(B) Agency policies;

(C) Agency staff roles;

(D) The family’s role in the child’s care and the worker’s role and responsibilities in relation to the family;

(E) Complete description of the agency’s program model;

(F) Record keeping requirements;

(G) The laws and procedures governing the confidentiality of information and records;

(H) The procedure for identifying and reporting child abuse or neglect, or both, in accordance with sections 210.110–210.165, RSMo; and (I) Review and discussion of state licensing (7) Staff Development.

(A) An agency shall establish and submit to the licensing unit an annual written plan for at least twenty (20) hours of training each year for the administrator and professional staff.

(B) All training must be documented with the dates, location, the subject and the name of the person(s) who conducted the training.

(C) The training may include, but not be limited to, short-term courses, seminars, institutes, workshops, and in-service training provided on-site by qualified professionals.

(D) Staffings and supervisory conferences will not count toward training hours.

(E) The training plan shall include, but not be limited to:

1. Developmental needs of children;

2. The direct care and professional staff roles in the facility;

3. Specific requirements of the applicable laws relating to adoption that effect the performance of their duties, as well as local court rules;

4. Trans-racial and cross-cultural place- 5. Cultural diversity;

5. Separation and attachment issues;

6. Conducting a family assessment;

7. Adoption-related training, if agency provides such service;

8. Interstate Compact for the Placement of Children (ICPC) and Interstate Compact on Adoption and Medical Assistance (ICAMA);

9. Adoption subsidy;

10. International adoptions;

11. Adoption search issues;

12. Adoption risk issues;

13. Post-placement services; and 15. Post-legal adoption services.

(8) The agency shall maintain, for a period of at least five (5) years, the personnel record of an employee who leaves the agency.

Filed Feb. 6, 1997, effective July 30, 1997.

Moved to 13 CSR 35-73.030 and amended:

Filed Aug. 20, 2018, effective April 30, 2019.

Emergency amendment filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Amended: Filed Sept. 17, 2021, effective March 30, 2022.

History

• AUTHORITY sections 207.020, 210.506, 73.030. Original rule filed Sept. 18, 1956, effective Sept. 28, 1956. Refiled: March 12, 1976. Amended: Filed Nov. 6, 1981, effective Feb. 11, 1982. Rescinded: Filed Jan. 14, 1997, effective July 30, 1997. Readopted:

13 CSR 35-73.035 Staff Qualifications and Requirements ments for personnel practices, including staff qualifications, contract personnel, caseload size, and nonpaid staff. {#sec-13-csr-35-73.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.035}

(1) Employee Qualifications. The agency shall employ staff who are qualified by education, training, and experience for their assigned responsibilities. A current employee who has qualified for a position under the previous rule and is serving in that position shall be exempt from meeting any increased requirements defined by these rules. Each individual associated with the agency who is required to submit to a background check pursuant to section 210.493, RSMo, and 13 CSR 35-71.015 must also successfully complete the background check and be found eligible by the division for employment or presence at the licensed child placing agency.

(2) Administrative Personnel.

(A) The agency shall employ staff to perform administrative, supervisory, social service, and direct care functions which may be combined only upon the approval of the governing board.

(B) Staff members shall meet the requirements for each function, for direct and nondirect care functions, when such functions are combined as approved by the governing board.

(C) The administrator shall be at least twenty-five (25) years of age and shall have one (1) of the following:

1. A master’s degree in social work, counseling, social work administration, or a related human service degree from an accredited school and three (3) years’ experience in the management or supervision of child placing or residential care personnel and programs; or 2. A bachelor’s degree in social work or a human service area of study from an accredited school and five (5) years’ experience in the management or supervision of child placing or residential care personnel and programs; or 3. If the administrator is responsible only for administrative functions such as personnel and fiscal matters and is not responsible for direct supervision of the programs and services of the agency, the agency may then employ an administrator who has a bachelor’s degree from an accredited school and two (2) years’ experience in child placing or residential care services. However, in this case, the agency shall employ a person, responsible for the direct supervision of the agency’s services, who meets the qualifications set forth in 13 CSR 35-73.035(2)(C)1. or 2.

(D) The administrator’s responsibilities 1. Developing, implementing, and maintaining policies and procedures for program and fiscal operation under the direction of the governing board and maintaining compliance with all applicable requirements of federal and state law, including the background check and eligibility requirements of section 210.493, RSMo, and 13 CSR 35-71.015;

2. Keeping the governing board informed of the program and management of the agency;

3. Interpreting and implementing recognized standards for child welfare services;

4. Ensuring that the agency achieves and maintains compliance with the requirements of the licensing rules;

5. Employing, evaluating, and discharging staff members, in accordance with the agency’s established personnel policies; and 6. Ensuring the maintenance of current client’s records and statistics.

(E) When the position of administrator is vacated, the governing board shall within five (5) working days submit a plan for interim management to the division for approval.

The plan is to include:

1. Provisions for recruitment of a permanent administrator;

2. The name of the designee and his/her qualifications; and 3. His/her responsibilities.

(F) The administrator shall designate in writing a qualified staff person to be in charge when s/he is absent.

(3) Supervisor of Placement Services.

(A) In an agency where the administrator operates primarily in an administrative capacity and is not directly involved in child placing activities, a person shall be employed as supervisor of placement services.

1. A supervisor of placement services employed after the effective date of these rules shall have one (1) of the following:

A. A master’s degree in social work or a human service area of study from an accredited school plus three (3) years experience in child placing services; or B. A bachelor’s degree in social work or a human service area of study from an accredited school plus five (5) years experience in child placing services and possess a current license as a clinical social worker in the state of Missouri.

2. A supervisor of placement services responsibilities include:

A. The supervision, management, training, and evaluation of all professional staff, students, and consultants involved in placement services;

B. The supervision of volunteers whose work involves direct contact with clients;

C. The approval of decisions regarding family and child eligibility for service, maternity and child care, transportation and placement arrangements, finalization, and any other changes in the child’s legal status;

D. The implementation of the agency’s adoption program(s) and services, and recommendations regarding changes to the program.

3. When the position of supervisor of placement services is vacated, the agency shall submit a plan within five (5) working days for interim supervision to the division.

The plan is to include:

A. Provisions for recruitment of a permanent supervisor of placement services;

B. The name of the designee and his/her qualifications; and C. His/her responsibilities.

(B) Supervisors of placement services are required to submit to background checks and be found eligible by the division for employment or presence at the licensed child placing agency pursuant to section 210.493, RSMo, and 13 CSR 35-71.015.

(4) Professional Personnel.

(A) An agency shall obtain any professional services required for the implementation of the individual service plan of a child when these services are not available from staff.

1. An agency shall arrange or make appropriate referrals for medical, legal, psychiatric, psychological, or other professional services to birth parents, children, or foster and adoptive parents, as necessary.

2. The agency shall not require clients to use medical, legal, psychological, psychiatric, or other consultants used by the agency.

The agency may use consultants and/or persons selected by agency clients. The agency can reserve the right to request a second opinion from a neutral source.

(B) Professional staff who perform social work tasks, counseling with children and their families, therapeutic services, or planning of services for children and their families, shall have a master’s degree in social work, psychology, counseling, or a closely related clinical field from an accredited college or university. Professional staff may have a bachelor’s degree in social work, psychology, counseling, or a related area of study from an accredited school if s/he is under the direct supervision of a qualified supervisor of placement services (13 CSR 35-73.035(3)).

(C) Full- or part-time professional staff including psychologists, psychiatrists, social workers, counselors, physicians, teachers, and nurses, shall meet the licensing or certification requirements of their profession in Missouri.

(D) The agency shall designate a supervisor for professional staff when six (6) or more professional staff are employed. The supervisor shall have at least three (3) years clinical experience. Supervision of contracted employees shall constitute part of the supervisor’s work load.

(E) Professional personnel are required to submit to background checks and be found eligible by the division for employment or presence at the licensed child placing agency pursuant to section 210.493, RSMo, and 13 CSR 35-71.015.

(5) Contracted Personnel.

(A) An agency assumes responsibility for work performed by a contracted person when such services are performed under the auspices of said agency.

(B) All official child placing activities and written documentation shall be processed through the child placing agency.

(C) All contracted personnel must meet the staff qualifications for the position they are being contracted to fill.

(D) Supervision of all contracted personnel must be provided by a qualified supervisor of placement services from that agency.

(E) A file shall be maintained for each contracted personnel which includes:

1. A copy of the signed contract;

2. Verification of education and experience;

3. Verification of character references from three (3) persons, unrelated to the staff member;

4. Verification of employer references for the past five (5) years and a history of any previous employment in child care settings;

5. A copy of the job description signed by the contractor;

6. Reports of initial and subsequent biennial physical examinations;

7. Results of annual checks of the Child Abuse and Neglect Central Registry Unit (CA/N CRU) checks;

8. Copies of an annual performance evaluation;

9. Documentation that each individual associated with the agency who is required to submit to a background check pursuant to

section 210.493, RSMo, and 13 CSR 35- 71.015 has successfully completed the background check and is found eligible by the division for employment or presence at the licensed child placing agency; and 10. Documentation of orientation and annual staff training.

(F) Caseload sizes shall be proportionate to the number of hours worked on a monthly

basis.

(G) Contracted personnel shall not collect fees from clients unless authorized by the contract with the agency.

(6) Students and Interns.

(A) Interns, graduate students, and students in a field work placement at the agency shall be subject to the general personnel policies of the agency, but shall not be considered or used as substitutes for employed staff. A written plan for using students will include:

1. A plan for the selection, orientation, training, assignment, and evaluation of students;

2. A description of what services the student is responsible for and what arrangement the agency has for supervising the students;

3. A signed statement of their understanding of confidentiality;

4. A copy of the written plan shall be given to each student, his/her school, and to the supervising staff members; and 5. A plan for coverage of caseload in student’s absence.

(B) Interns, graduate students, and students are required to submit to background checks and be found eligible by the division for employment or presence at the licensed child placing agency pursuant to section 210.493, RSMo, and 13 CSR 35-71.015.

(7) Clerical Staff.

(A) Clerical staff shall not supervise or assist in the care of children without being qualified according to these rules.

(B) Clerical staff shall sign a statement of their understanding of confidentiality.

(C) Clerical staff shall submit to background checks and be found eligible by the division for employment or presence at the licensed child placing agency pursuant to section 210.493, RSMo, and 13 CSR 35-71.015.

(8) An agency shall not be wholly dependent upon the use of volunteers to ensure the provision of services. If an agency uses volunteers as part of its program of services, the agency shall have written policies which (A) A description of the agency’s purposes and goals;

(B) A job description for the director of volunteers and for each category of volunteers;

(C) A differentiation of functions and activities appropriate for paid staff members and volunteers;

(D) A process for screening and selecting volunteers, who have direct contact with children similar to that used for paid staff members;

(E) A defined line of supervision, with written expectations of the supervisor and the volunteers;

(F) Orientation and training in the volunteers’ specified roles;

(G) Procedures for monitoring and evaluating volunteer activities;

(H) Maintaining a file for each volunteer, who works directly with children including applications, verification of CA/N CRU and background checks, and task assignments and annual evaluations;

(I) Procedures for observing professional ethics and confidentiality of records and information;

(J) Procedures for reimbursement of travel and other expenses; and (K) Procedures for handling conflicts between paid staff members and volunteers.

(9) Cases to be counted in the agency caseload are— (A) Children in agency custody including children for whom any court jurisdiction has been entered who are still waiting a final order;

(B) Children not in the custody of the agency, but who are being supervised in a foster or adoptive home, group home, or institution; and (C) The agency shall have at least one (1) professional staff for every— 1. Twenty (20) children in alternative care;

2. Thirty-five (35) children under postplacement supervision;

3. Thirty (30) active adoptive or birth families; or 4. A reasonable combination thereof.

Filed Sept. 17, 2021, effective March 30, 2022.

History

• AUTHORITY: sections 207.020, 210.506, 73.035. Original rule filed Feb. 6, 1997, 73.035 and amended: Filed Sept. 7, 2018, effective April 30, 2019. Emergency amendment filed Sept. 17, 2021, effective Oct. 1, 2021, expired March 29, 2022. Amended:

13 CSR 35-73.040 Operational Requirements ments for office space and equipment, fees and fiscal practices, record maintenance, and extraordinary events. {#sec-13-csr-35-73.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.040}

(1) Office Space and Equipment.

(A) An agency shall provide a bona fide office physically located within the state of Missouri which is accessible to the public and appropriate for the administrative program and supportive services;

(B) An agency shall maintain sufficient space to provide for the confidentiality of client interviews;

(C) An agency shall have adequate staff for that office;

(D) An agency shall provide and maintain sufficient equipment and supplies to assure delivery of services;

(E) An agency shall have Missouri telephone service or a toll-free number and be listed in the local directory;

(F) An agency shall ensure that the office is a safe, well-maintained environment for both clients and employees; and (G) An agency shall maintain adequate space to store all records of Missouri clients served in Missouri.

(2) Fees and Fiscal Practices.

(A) The agency shall prepare and maintain on file a written description of— 1. Policies describing financial responsibilities of the agency, the birth parent(s), and the adoptive parent(s), for the period prior to the placement of a child through the date that a decree of adoption is entered;

2. Procedures for the setting, collecting, waiving, nonpayment, and refunding of fees, along with guidelines for exceptions to these policies and procedures; and 3. Policies regarding making refunds to an eligible client no more than thirty (30) calendar days after receipt of a written request for such refunds from an agency client.

(B) The agency shall prepare and maintain on file a written schedule of all fees in each case and provide a copy of the schedule to an agency client before service delivery begins.

The client shall sign the schedule and a copy will be kept in each client’s record.

(C) The agency shall identify in writing for the birth parent(s) and the adoptive parent(s), the anticipated services which they must obtain for themselves, which are not provided by the agency.

(D) If the agency uses a sliding fee scale or subsidies, actual costs and costs as determined by the sliding fee scale or subsidies shall be available upon request by legal or licensing authorities. Nothing herein shall be construed to prevent agencies from using sliding fee scales or subsidies.

(E) If the agency uses a schedule for payments, the agency shall provide the client(s) with written information concerning initial payments and frequency and conditions for subsequent payments.

(F) The financial policies and practices, general financial records, and financial records of individual placement cases shall be made available by the agency to the division upon request.

(G) The agency shall not consider the clients’ willingness to donate money, goods, or services or to participate in agency fundraising efforts in determining their eligibility for services.

(H) The agency shall provide equal access to services to all eligible clients without regard to actual or potential donations of money, goods, time, or efforts.

(I) Adoption fees shall be reasonable and shall be established based on the cost of the individual adoption or based on the costs of the following services for the total adoption program:

1. Medical services to the birth mother and/or child;

2. Legal services for the placement and/or adoption of the child(ren);

3. Counseling services;

4. Family assessment services;

5. Child finding services;

6. Foster care services;

7. Pre- and post-placement social ser- 8. Transportation;

8. Contracted services, if applicable;

9. Any other services as may be reasonably foreseeable.

(J) Client fees relative to the above service components shall be kept in a separate trust account until such services have been provided.

(3) Records.

(A) An agency shall maintain a register of all children currently placed in foster or adoptive homes including the child’s name, sex, birthdate, dates of foster and adoptive placements, the person legally responsible for the child, and, if available a Social Security number.

(B) An agency shall record all case activities every thirty (30) days.

(C) Individual case records for all children placed in foster care shall be maintained for at least ten (10) years after the agency terminates service to the child.

(D) Adoption records shall be kept in a permanent file and shall not be destroyed.

(E) Missouri foster care and adoption records shall be kept and maintained in Missouri.

(F) Birth parent, child, and adoptive parent records shall be cross-referenced for identification purposes, in cases of adoption.

(G) The agency shall maintain permanent records for each adoptive family. The permanent record shall contain— 1. The adoptive family evaluation and supporting documents;

2. Copy of any written information given to adoptive parent(s) concerning the child;

3. Summaries of post-placement supervision and recommendations to the court;

4. Legal documents required for adop- 5. Progress notes and/or counseling;

5. Closing summary.

(H) The agency shall maintain a permanent adoption record of the child, which shall contain the following:

1. The child assessment summary as defined in 13 CSR 35-73.080(3)(A) and supporting documentation;

2. Summaries of post placement supervision and recommendations to the court;

3. Legal documents required for adoption; and 4. Closing summary.

(I) The agency shall maintain a permanent birth parent(s) record(s), which shall contain the following:

1. The birth parent evaluation and supporting documentation;

2. All agreements signed by the birth parents;

3. Legal documents required for adop- 4. Progress notes and/or counseling;

4. Closing summary.

(J) An applicant for initial or continuing licensure must submit a written plan indicating how the agency will provide for the transfer of records on both open and closed cases to a licensed Missouri child placing agency if the agency closes.

1. Plans for the transfer of open cases and case records must specify arrangements the agency will make to transfer clients to another licensed agency for continuation of services and to transfer the case record with the client.

2. Plans for the transfer of closed adoption records must be accompanied by a signed agreement or other documentation indicating that a licensed child placing agency has agreed to accept and maintain the agency’s closed case records and to provide followup services to affected clients.

(4) Extraordinary Events.

(A) The agency shall notify the division orally of any extraordinary changes or events within twenty-four (24) hours after the agency learns of their occurrence and shall submit written notification to the division within five (5) working days.

(B) This shall include, but not be limited to, the following:

1. Unanticipated permanent or temporary closing of the agency or any part thereof;

2. Any serious injury, endangerment or death of a child;

3. Any convictions of any staff member and volunteers involved in the agency, excluding minor traffic violations;

4. Legal action against the agency or a staff member which involves the operation of the agency or any child under the care of the agency, excluding any legal actions unrelated to agency business or child welfare;

5. Damage to agency facilities which substantially disrupts the program or the agency’s accessibility to clients; or 6. Knowledge of any child placement by any other party which the agency has reason to believe is not permitted by law or by these (5) An agency that plans to place a child with an out-of-state family or to receive a child from out-of-state for placement within the state or supervise a Missouri family who relocates to another state shall notify the Interstate Compact Unit of the division and shall comply with applicable regulations governing child placement in both states.

(6) Prior to adoptive placement, an agency shall comply with the requirements of the Federal Indian Child Welfare Act for placement of Native American or Native Alaskan children.

(7) Prior to adoptive placement, an agency shall comply with the requirement of the Multi-Ethnic Placement Act.

CSR 40-73.040. Original rule filed Sept. 18, Oct. 13, 1982, effective Jan. 13, 1983. 73.040 and amended: Filed Sept. 7, 2018,

13 CSR 35-73.050 Protection and Care of the Child {#sec-13-csr-35-73.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.050}

PURPOSE: This rule sets forth the provisions for protection of the child, including child abuse and/or neglect, exploitation, confidentiality, discipline and child management, clothing, family identity and relationships, religious requirements, and educational program.

(1) An agency shall make an oral report within twenty-four (24) hours to the division followed by a written report within five (5) working days after the occurrence of an unusual incident, such as the death or serious injury of a child, alleged child abuse or neglect, or both, a fire which required the services of the fire department, or any time the agency has been served with any adverse legal action.

(A) Protecting the Child in Care—Child Abuse or Neglect (CA/N).

1. An agency shall have written procedures for any alleged incident of child abuse or neglect, or both, which shall include:

A. Reporting the alleged incident as required by the CA/N reporting law, sections 210.110–210.165, RSMo;

B. Conducting an internal investigation of the alleged incident; and C. Providing a written report of the agency’s internal investigation to the division licensing unit.

2. No person who is alleged as a perpetrator in an incident of child abuse or neglect, or both, shall have direct contact with child(ren) until an investigation is complete unless the administrator determines that the safety of the child(ren) is not threatened.

3. If the investigation determines reason to suspect child abuse or neglect, or both, the agency shall submit a written report to the licensing unit outlining corrective action taken by the agency. If the agency fails to take timely appropriate action to prevent future abuse or neglect, or both, the division may revoke the license.

(B) Exploitation of Children.

1. Exploitation of children shall be prohibited.

2. Exploitation of children shall include, but not be limited to, the use of a child or his/her picture or name for solicitation for funds or publicity or the use of a child to advance an agency’s religious or political beliefs without the written consent of the child’s parent(s), guardian, or legal custodian and court order, if applicable.

(C) Confidentiality.

1. An agency shall have written procedures for the maintenance and security of client records. This shall include a staff review of the procedures for confidentiality and a signed statement indicating that staff have reviewed the procedures. The agency shall secure records against loss, tampering, or unauthorized use by— A. Protection of the confidentiality of records when in use and keeping them under lock when not in use;

B. Staff and professional consultants seeking access only to the records with which they are professionally involved;

C. Staff not disclosing or permitting the disclosure of any information concerning the child or his/her family, directly or indirectly, to any unauthorized person; and D. Staff being informed of the requirement that they must observe the procedures for protecting confidentiality after termination of employment.

2. Records shall be made available to the division or its authorized and identified agents, either upon written or verbal request.

This includes division staff who are involved in child abuse/neglect reporting/investigation.

3. A consent for release of information signed by the parent(s), guardian, or legal custodian must be provided before records are released to any person other than those specified in these rules. The consent must specify what information may be released, to whom, for what purpose and for what period of time.

4. All requests for access to a child’s records shall be documented in the record providing the name of the individual making the request, the date and the desired materials. If access was refused, the grounds for refusal shall be documented.

(D) Discipline and Child Management.

1. An agency shall have written policies regarding discipline and behavior management, which shall be explained and made available to a child’s parent(s), guardian, or legal custodian, or both, staff and to the child, if age appropriate.

2. The procedures shall be within each child’s ability to understand and achieve.

3. The policies shall identify the type of children served, describe anticipated behavioral problems, set forth acceptable methods of dealing with the behaviors, and detail the required qualifications and training of foster parents. All discipline shall be consistent with the service plan developed for the child.

4. All discipline shall be reasonable and appropriate to the child’s age and level of development. All discipline shall be limited to the least restrictive appropriate method and administered by appropriately trained care givers.

5. Encouragement and praise of good behavior shall be used instead of focusing on unacceptable behavior.

6. The agency shall have written policies and procedures prohibiting discipline which may adversely affect a child’s health or physical or psychological well-being. The following forms of discipline shall not be used:

A. Cruel or unusual punishment;

B. Excessive or inappropriate work;

C. Denial of meals, shelter, clothing, essential personal daily needs, and the program provided by the individual service plan;

D. Verbal abuse, ridicule, or humilia- E. Permission for a child to discipline another child;

F. Chemical restraints;

G. Mechanical restraints;

H. Denial of planned visits, telephone calls, or mail contacts with family;

I. The use of foods intended to produce an adverse reaction;

J. Physical or emotional abuse;

K. Confinement in any space not designed for detainment of human beings; or for long periods of time;

L. Requirement that a child remain silent for long periods of time or other unreasonable verbal restrictions;

M. Corporal punishment including, but not limited to slapping, hitting, spanking, paddling, shaking, belting, or marching;

N. Standing rigidly in one (1) spot or use of excessive physical exercises such as running laps or doing push-ups or any method which harms or endangers the child;

O. Locked isolation for the purpose of discipline;

P. Denial of opportunity for a minimum of eight (8) hours of sleep in a twentyfour- (24-) hour period; and Q. Withholding of meals, mail, allowances, or family visits.

7. The agency shall assure that children are appropriately supervised while in care.

(E) Clothing.

1. An agency shall establish minimum clothing requirements for each child in care.

2. An agency shall assure that clothes are provided to each child. Clothes shall be individually selected and fitted, appropriate to the season, and kept in a state of good repair and cleanliness. Each child’s clothing shall be identified as his/her own.

3. An agency shall assure shoes are provided to each child which shall be kept in good repair.

4. When possible, children shall be permitted to participate in the selection and purchase of their own clothing.

5. Donated clothing shall be used only if it is in good condition.

6. Possessions and clothing belonging to a child while in residence shall be released to him/her upon discharge.

(F) Family Identity and Relationships.

1. An agency shall develop written visitation policies.

2. An agency shall encourage and support contacts between a child and his/her family while the child is in care, unless the rights of the parent(s) to contact the child have been terminated, restricted by court order, or limited by parent. The frequency of contact shall be determined by the child’s parent(s), guardian, or legal custodian in consultation with agency staff. An agency shall enable the family to visit and remain involved in their child’s care as well as actively participate in relationship building.

3. Privacy shall be provided for visits with family members, relatives, and friends, for telephone calls and for written communications unless otherwise indicated by the service plan.

4. Flexible visiting hours shall be provided for the parent(s) or legal guardian.

(G) Religious Requirements.

1. Upon admission, an agency shall provide a written description of the agency’s religious requirements and practices, which shall be made available to the parent(s), guardian or legal custodian, and, when appropriate, to the child.

2. If the agency requires mandatory religious observance or mandatory church attendance, consent of the parent(s), or guardian or legal custodian, or both, shall be obtained and explained to the child upon admission.

3. Opportunity for religious experience and attendance at religious activities and services shall be made available to each child within the religious preference of his/her family and in agreement with any service plan.

4. The child’s parent(s), guardian, or legal custodian shall provide written authorization regarding any change in religious affiliation by the child while s/he is in care.

(H) Educational Program. The administrator shall be responsible for ensuring compliance with Missouri statutes pertaining to the child(ren)’s education.

1. An agency shall not admit a child unless an educational program appropriate to the child’s need can be obtained.

2. The educational progress of a child shall be continually evaluated and the progress shall be included in the child’s three (3) month service plan review according to 13 CSR 35-73.075(2)(A).

3. Children excluded from school shall be provided education, training, or work experience consistent with their needs and abilities.

4. An agency shall maintain contact and cooperation with a child’s school systems to provide a coordinated approach to meeting the educational needs of each child.

5. An agency shall provide appropriate space, adequate lighting, supervision for quiet study after school hours, and access to reference materials and school supplies.

6. Children shall be permitted and encouraged to participate in extracurricular activities such as sports, art, and music, to the extent of their interests, abilities, and talents.

CSR 40-73.050. Original rule filed Sept. 18, Oct. 13, 1982, effective Jan. 13, 1983. 73.050 and amended: Filed Sept. 7, 2018,

13 CSR 35-73.055 Health Care {#sec-13-csr-35-73.055 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.055}

PURPOSE: This rule sets forth the procedures for health care, emergency medical care, dental care, psychiatric and psychological care, and medicine and drugs.

(1) Health Care Procedure.

(A) The agency shall have a written health care plan which shall address preventive medical, eye, hearing and dental care for any child(ren) in the custody of the agency.

(B) The agency’s health care plan shall include examinations upon entering agency care, subsequent examinations, nursing care, first-aid procedures, dispensing of medicine and basic remedial treatment and the training of basic principles of communicable disease prevention.

(C) The agency shall obtain written authorization for each child from the parent(s), guardian or legal custodian for emergency medical care, emergency surgical care, necessary immunizations and general medical care upon entering care.

(D) A complete physical examination by a licensed physician, a certified nurse practitioner, advanced practice nurse in a collaborative agreement with a licensed physician or a registered nurse who is under the supervision of a licensed physician shall be given to each child under the age of three (3) within seventy-two (72) hours after entering care, unless being discharged directly from a medical facility. For any child over age three (3) the physical examination shall be given within thirty (30) days prior to placement, or within seventy-two (72) hours after entering care. The findings of the examination shall be recorded on a form prescribed by the division, or one containing the equivalent information. Children shall otherwise receive medical examinations in accordance to the periodicity of the Missouri Medicaid Healthy Children and Youth Schedule for Physical and Developmental Examinations available through the division.

(E) If a child shows overt signs of highly infectious disease or other evidence of ill health, the agency shall make arrangements for an immediate examination by a licensed physician.

(F) Any child who has not received primary immunizations prior to placement shall be immunized according to the Department of Health’s current guidelines.

(G) A current immunization history shall be maintained for each child.

(H) Booster shots shall be administered to children as needed, and at time intervals recommended by the agency physician or by the Department of Health’s current guidelines.

(I) Each child under twelve (12) years of age shall be given an annual eye examination.

Children twelve (12) years of age and older shall be given an eye examination on an asneeded basis. Corrective treatment shall be provided as prescribed.

(J) Upon discharge, a copy or summary of the child’s health and dental records shall be provided to the person or agency responsible for the future planning or care of the child.

(2) Emergency Medical Procedure.

(A) At least one (1) foster care provider shall be qualified/certified to administer first aid, including cardiopulmonary resuscitation (CPR).

(B) A first-aid kit shall be readily available.

(C) Authorization for nonemergency surgery, even though provided before admission, shall be used only when the parent(s), guardian or legal custodian is unavailable to reaffirm the authorization.

(D) An agency shall contact a child’s parent(s), guardian or legal custodian within twenty-four (24) hours when a serious illness, a serious injury or hospitalization of the child occurs.

(E) In the event of the death of a child, the parent(s), guardian or legal custodian and the division shall be notified immediately.

(3) Dental Care.

(A) An agency shall provide for annual dental examinations, and for reexaminations and treatment, as necessary.

(B) Upon transfer of the child, a copy or summary of the child’s dental record shall be provided to the person or agency responsible for the future planning for the child.

(4) Psychiatric and Psychological Care.

(A) When the agency’s service plan for a child indicates a need for professional care by a psychiatrist or a psychologist, the specialized treatment shall be provided, or arranged for, by the agency.

(B) Psychiatrists and psychologists shall be appropriately qualified, certified and/or licensed as appropriate to the nature of the service.

(5) Medicine and Drugs.

(A) All medication shall be prescribed by a licensed physician.

(B) All medicine and drugs shall be kept in a safe place and shall only be accessible to and dispensed by the care giver.

(C) All medication shall be labeled to indicate the name of the child, the type and dosage of medication and shall be dated.

(D) Medication prescribed for one (1) child shall not be administered to another.

(E) No child shall self-administer medication unless the practice is approved by a licensed physician, or a registered nurse with approval of a licensed physician, and the administrator. The approval shall be documented in the child’s medication record and social service plan.

(F) When medications which are approved by a physician’s order are prescribed, continued, discontinued or changed, an entry shall be made in the child’s records. Entries shall be evaluated at least every sixty (60) days to determine if medication shall be continued, discontinued or changed.

(G) When medications are discontinued, they shall be destroyed.

(H) Upon transfer of a child, medications which are prescribed shall be provided to the person responsible for the future planning or care of the child.

(6) All dietary changes for children under one (1) year should be approved by a licensed physician.

rule originally filed as 13 CSR 40-73.055.

Original rule filed Feb. 6, 1997, effective July 30, 1997. Moved to 13 CSR 35-73.055, effective June 30, 2018. *Original authority: Please see the Missouri Revised Statutes 1994 and Cumulative Supplement 1996.

History

• AUTHORITY: sections 210.481–210.536, RSMo (1994) and (Cum. Supp. 1996). This

13 CSR 35-73.060 Recommendation for Foster Home Licensing ments for an agency to recommend foster home rules for licensure, relicensure, revocation, and procedures for the handling of complaints. {#sec-13-csr-35-73.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.060}

(1) Initial Procedure.

(A) Prior to being licensed to recommend foster homes for licensure an agency shall— 1. Comply with rules as set forth by the division and demonstrate intent to comply with those rules where compliance can only be demonstrated after the agency has initiated operations;

2. Have a written statement of requirements for foster parents(s). These requirements shall be in compliance with foster home rules, 13 CSR 35-60.010 through 13 CSR 35-60.060 as set forth by the division;

3. Have written procedures for processing foster home inquiries and applications.

(2) Recommendation of Foster Homes.

(A) Licensing recommendations shall be submitted to the division on forms provided or approved by the division and in the manner prescribed by the division.

(B) An agency shall ensure that foster parent(s) are in compliance with these rules and foster home rules, 13 CSR 40-60.010 through 13 CSR 40-60.060.

(3) Foster Parent Qualifications.

(A) Applicants for foster parents must be at least twenty-one (21) years of age.

(B) Foster parents shall be responsible, mature individuals of reputable character, who exercise sound judgment, display the capacity to provide good care for children, and display the motivation to foster parent.

(4) Foster Parent Training.

(A) An agency shall establish and submit to the licensing unit an annual written plan for all foster parent training.

(B) All foster parents shall receive twelve (12) hours of pre-service training prior to licensure.

(C) When applicable, agencies may utilize division foster family training.

(D) A minimum of ten (10) additional hours in-service training per year is required.

(5) Foster Family Services.

(A) Before services are provided, the agency shall provide orientation to prospective foster parents to acquaint them with the agency’s policies and practices, grievance procedures, the approximate time the assessment will take, eligibility standards, and the types of children available so as to enable them to make an informed decision to proceed.

(B) An agency shall make available to prospective foster parents a verbal explanation of and a written agreement with the agency, describing specific services to be provided, reimbursement rates, and, rights and responsibilities of both parties. Said explanation and agreement shall include the following, if applicable:

1. Room and board payments;

2. Physician’s expenses;

3. Hospital and other medical expenses;

4. Counseling services;

5. Transportation;

6. Contracted services, if applicable;

7. Any other services as may be reasonably foreseeable.

(C) A written description of the foster care program will be provided to applicants upon request.

(6) Foster Family Assessment.

(A) The agency shall complete a foster family assessment of each eligible foster family prior to the placement of a child in the home.

1. The family assessment process shall consist of— A. An individual interview with each applicant;

B. A joint interview with co-applicants;

C. Interviews with all members of the applicants’ household; and D. A visit to the residence of the applicant(s) which includes a complete inspection of the home.

2. The written family assessment shall A. Identifying information on each member of the household including:

(I) Full name, including maiden if (II) Current address and phone number, and previous addresses if less than five (5) years at current address;

(III) Date and place of birth;

(IV) Citizenship;

(V) Social Security number;

(VI) Race and ethnic background;

(VII) Religion, if applicable;

(VIII) Veteran’s status, if applicable;

(IX) Education;

(X) Occupational history, place of employment, address and telephone numbers;

(XI) Any children not in the home;

(XII) Physical description;

B. A social history on each applicant which shall include:

(I) Description of the applicant’s family of origin, including type of family structure, values, child rearing, relationships past and present and discipline methods. If the family of origin was dysfunctional (for example, alcoholism, abuse) describe how the applicant has coped with the issues in his/her adult life;

(II) Educational history;

(III) Marital history and evaluation;

(IV) Interests and hobbies;

(V) Physical and mental health history including psychiatric, alcohol, and drug use;

(VI) Applicant’s personality, strengths and weaknesses, emotional stability, and maturity; and (VII) Religious beliefs and practices;

C. An assessment on the applicant(s) which includes:

(I) Motivation to foster parent;

(II) Awareness of foster parenting issues such as talking to the child about his/her foster care status, grief and loss, the goal of foster care, and the foster parent role in that process;

(III) Applicant’s readiness to seek family counseling, if needed;

(IV) For special needs foster parenting, awareness of the child’s special needs and appropriate ways to meet those needs;

(V) For trans-racial or trans-cultural foster parenting, the applicant’s awareness of and sensitivity to differences, how they plan to impact a positive identity and expose the child to his/her ethnic heritage;

(VI) Philosophies on child-rearing and discipline; agreement that corporal punishment is unacceptable;

(VII) Attitudes and acceptance of foster parenting by other family members and friends;

(VIII) Location and description of physical residence, including type of community and school district available;

(IX) If the family contains a school age child(ren), reports from school personnel regarding school adjustment;

(X) Child care arrangements, if (XI) Description of children and background factors the applicants can accept;

(XII) Financial status and manage- (XIII) A history of all previous contacts with the applicants; and (XIV) The applicant’s previous history/experience with other agencies, if applicable;

D. Supplemental documentation shall (I) A total of no less than six (6) reference letters; employment (for the last five (5) years), one (1) relative, and four (4) nonrelated personal references, one of whom could be the applicant’s clergyperson;

(II) Child abuse and neglect background screening check Child Abuse and Neglect Central Registry Unit (CA/N CRU), no more than one- (1-) year old;

(III) Criminal arrest records from a state law enforcement agency;

(IV) Criminal conviction records from a state law enforcement agency;

(V) Any findings on child abuse or criminal records shall be followed up by requesting a copy of the child abuse investigation report or the police report;

(VI) Written medical reports on all members of the household;

(VII) Verifications of marriage(s) and divorces, if applicable;

(VIII) Written documentation of income and financial resources, including a copy of the latest Federal Income Tax 1040 form verifying adjusted gross income;

(IX) Other family assessments and recommendations, if applicable; and (X) Birth and death certificates;

E. Impressions including a recommendation by the agency of the age, sex, or type of child(ren) that could best be served by the applicants.

(7) Renewal of Foster Home License.

(A) A minimum of one- (1-) home visit per year should be made to the foster home.

(B) Updated foster family assessments should be completed biennially. An update should also be completed if there is a significant change in the family situation (i.e., job change, address change). An assessment shall include at a minimum:

1. One (1) or more interviews with all members of the family;

2. Medical reports on all household members;

3. Child abuse/neglect reports (CA/N CRU) on all adults completed within the last thirty (30) days;

4. Arrest record check completed within the last thirty (30) days;

5. Evaluation of any previous placements; and 6. Continued compliance with the foster home rules, 13 CSR 35-60.010 through 13 CSR 35-60.060, and rules as set forth by the division.

(C) Prior to recommending a foster home for relicensure, an agency shall document the updated family assessment in the foster home case record.

(D) The agency will submit all necessary relicensure forms to the division at least ten (10) days prior to the expiration of the current license.

(8) Foster Home Licensing Violations.

(A) When an agency receives a complaint which may indicate possible violations of the foster home licensing rules, an agency shall— 1. Conduct an internal investigation to determine compliance with applicable rules;

2. Submit a written report of the investigation within five (5) working days to the licensing unit of the division, including a recommendation regarding the licensure of the foster home.

(B) Denial, Revocation, and Suspension.

1. When an agency recommends that a foster home license be denied, revoked, or suspended, the following documents shall be submitted to the division:

A. A copy of the investigation conducted by the agency;

B. Recommendation of the agency;

C. Other appropriate documents supporting the results of the investigation.

2. This information shall be submitted to the licensing unit within five (5) working days of the decision to recommend denial, revocation, or suspension.

(C) After an evaluation of the recommendation to deny, suspend, or revoke a license, and an evaluation of the documents provided by an agency, the division may take any or all of the following actions:

1. Request additional information or documentation;

2. Deny, suspend, or revoke the license of a foster home;

3. Issue a conditional license; or 4. Deny the recommendation of the (D) License Denial or Revocation.

4. The division shall provide written notice of denial or revocation of licensure to the agency and the foster home within ten (10) working days. Upon receipt of the notice of revocation or denial of licensure, the agency shall provide other living arrangements for any child(ren) in the foster home immediately.

5. The denial or revocation of licensure shall be effective immediately unless the order of denial or revocation is stayed by an appropriate administrative or judicial order.

6. The agency or foster parent(s) may appeal the decision of the division to deny or revoke licensure by filing a request for hearing with the division within ten (10) calendar days after receipt of the notice of denial or revocation of licensure.

7. Any person aggrieved by a final decision of the division with regard to the denial or revocation of licensure shall be entitled to a hearing and review by the director or his/her designee as provided by section 210.526, RSMo.

(E) License Suspension.

1. The division shall have the authority to suspend the license of a foster home when necessary to protect the health and welfare of children.

2. The division shall provide written notice of the suspension and the reason(s) for the suspension to the agency and the foster home within ten (10) working days. Upon receipt of notice of suspension, the foster home shall immediately cease operation, pending the review.

3. When the division suspends the license of a foster home, the suspension shall be for a period of time not to exceed thirty (30) working days, or until there is a review and decision by the director, whichever is first.

4. The agency and/or the foster parent(s) may appeal the decision of the division to suspend the license by requesting within five (5) days of the notice of suspension, a review by the division director or his/her designee.

The review shall be conducted no later than five (5) working days following receipt of the request for review. The agency and/or the foster parent(s) may be assisted by an attorney or other person in presenting their case for review.

(F) Change in Licensing Status. The agency shall notify the division within five (5) working days of any change in address or status for any foster home.

CSR 40-73.060. Original rule filed Sept. 18, March 12, 1976, Amended: Filed Nov. 6, 1981, effective Feb. 11, 1982. Rescinded:

Filed Jan. 14, 1997, effective July 30, 1997.

Readopted: Filed Feb. 6, 1997, effective July 30, 1997. Moved to 13 CSR 35-73.060 and amended: Filed Sept. 7, 2018, effective April 30, 2019.

13 CSR 35-73.070 Placement of Children in Foster Family Homes ments for an agency to place children in foster care. {#sec-13-csr-35-73.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.070}

(1) Initial Procedure.

(A) Prior to being licensed to receive children for placement in foster care, an agency shall— 1. Comply with rules 13 CSR 35-73.010 to 13 CSR 35-73.030 as set forth by the division or demonstrate intent to comply with those rules where compliance can only be demonstrated after the agency has initiated operations; and 2. Have a current written program statement which includes the types of foster care provided, the types of services provided to the children, their families, and their foster families, and which shall be available to agency foster parent(s), parent(s), and referring agencies.

(B) An agency shall place a child only in a licensed foster home, within the terms of the license.

(2) If an agency places a child in a home recommended for licensure through another agency, there shall be a written agreement for each child, and the placement shall be within the terms of the current foster home license.

(3) An agency shall have a signed written agreement for each child placed, outlining the expectations and responsibilities of both the agency and the foster parent(s) regarding the operation of the home, the social services to be provided, the financial arrangement, and the authority the foster parent(s) can exercise for the children placed in their home.

(4) Pre-Placement Assessment.

(A) An agency shall complete a pre-placement assessment to determine that removal from a child’s home is necessary.

(B) The pre-placement assessment shall document whether social services were offered or provided a child and his/her family and whether alternatives to placement were explored.

(5) Preparing the Child for Placement.

(A) Except in emergency placements, an agency shall arrange for one (1) or more preplacement visits by the child, when indicated and possible.

(B) Preparation for placement shall be appropriate to the child’s age, individual needs, and circumstances necessitating place- (C) An agency shall document the following in each child’s case record:

1. That placement counseling has been provided for each child; and 2. The reason(s) placing the child with a foster family is in the child’s best interest.

(D) The agency shall make reasonable efforts to place siblings together. When sibling placement is not a possibility the agency shall document— 1. Efforts made to place siblings together; or 2. Reasons that sibling placement is not in the child(ren)’s best interest.

(E) The agency shall make reasonable efforts to place in a foster home of similar racial or cultural background in compliance with Multi-Ethnic Placement Act (MEPA).

When such placement is not a possibility the agency shall document— 1. Efforts made to locate such a home;

2. Reasons why such a resource/place- (F) When more than one (1) agency is involved in a placement, both agencies shall share information and reach a mutual decision on the services to be provided.

(G) The agency shall provide the following information to foster parent(s) maintaining confidentiality:

1. Written history of the child including developmental and medical history;

2. Reason(s) the parent(s) made a foster plan; and 3. A synopsis of any professional evaluation and treatment recommendations for the child (for example, medical, educational, dental, psychological, psychiatric, etc.).

(6) At the time of initial placement into foster care and continuously thereafter, an agency shall maintain in the child’s case record documentation of the agency’s legal right to provide for the care of the child. This may be a court order or a signed agreement by the parent(s) or referring agency.

CSR 40-73.070. Original rule filed Sept. 18, Oct. 13, 1982, effective Jan. 13, 1983. 73.070 and amended: Filed Sept. 7, 2018,

13 CSR 35-73.075 Foster Care Services {#sec-13-csr-35-73.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.075}

PURPOSE: This rule sets forth the provisions for placement records, service plan, education, family relationships and visitation, agency supervision, termination of foster care, and birth parent case records.

(1) Placement Records.

(A) Within five (5) working days after the initial placement, the following shall be documented in the child’s record:

1. The circumstances leading to the need for foster care; and 2. Previous out-of-home placements.

(B) Within five (5) working days after initial placement, the following shall be documented on a face sheet in the child’s record:

1. Name, birthdate, sex, race, Social Security number, and other identifying physical information;

2. Date of placement;

3. Name, address, birthdate, race, sex, Social Security number, and marital status of parent(s);

4. Name and address of legal guardian or custodian, if any;

5. Name(s) and whereabouts of sibling(s);

6. Religious preference of the child’s family;

7. Name and location of foster parent(s);

8. The social worker(s) assigned to the child and parent(s).

(C) A preliminary written service plan must be developed and documented in the child’s record within seventy-two (72) hours of admission.

(D) If the child remains in care beyond an initial thirty- (30-) day plan, the written service plan must be modified to indicate the need for continued placement.

(E) The plan must be based on the admission assessment and observations of the child’s adjustment into care. The service plan must identify and include:

1. The child’s needs in addition to basic needs for food, shelter, clothing, routine care, and supervision;

2. Specific strategies and their frequencies to meet the child’s needs, including instructions to foster parents;

3. Specific strategies and frequencies for family involvement, including a defined plan for visitation and engaging the family in services for the child;

4. The estimated length of stay;

5. Time limited goals and preliminary plans or discharge, including plans for reintegration into family and community;

6. The person(s) responsible for providing each service;

7. The initial educational plan for the child; and 8. The date and signatures of all participants involved in the service plan including the parents and child, if applicable.

(F) If the only reason for foster placement is to place the child in a neutral setting prior to adoptive placement, the service plan requirement will be waived.

(2) Service Plan.

(A) The progress of a child and his/her family shall be evaluated at least every three (3) months, and the service plan shall be modified when appropriate. Evaluations shall be made by professional staff in consultation with foster parents, schools, medical practitioners, psychiatrists, psychologists, or others who have significant contact with the child(ren) or parent(s) and copies shall be provided to the parent(s), guardian and, if appropriate, the child.

(B) Written documentation of the service plan review shall be kept in the child’s record.

(3) Education.

(A) The agency shall be responsible for determining that the educational needs of each child in placement are met.

(B) An agency shall not place a child unless an educational program appropriate to the child’s needs can be provided.

(C) An agency shall ensure that all educational programs are in accordance with Missouri law.

(D) The educational progress of a child shall be continually evaluated, and such progress shall be included in the child’s three (3) months’ service plan review according to

section 13 CSR 35-73.075(2)(A) of these (E) Children excluded from school, or who are unable to benefit from usual school attendance, shall be provided education, training, or work experience consistent with their needs and abilities.

(F) A foster home shall provide appropriate space and supervision for quiet study after school hours, and shall ensure that a child has access to sufficient reference materials and school supplies.

(4) Family Relationships and Visitation.

(A) An agency shall develop written visitation policies which shall allow visits between parent(s) and children unless parental rights have been terminated or visits are prohibited by court order.

(B) Reasonable privacy shall be provided for visits with family members, relatives, and friends, for telephone calls and for written communications.

(C) If visitation is permitted, flexible visiting hours shall be provided for parent(s) who are unable to visit at designated times.

(5) Agency Supervision.

(A) Each child in care and the foster parent(s) shall be visited as often as is necessary to support the placement, but at least once a month. Documentation of supervisory visits shall be placed in the child’s record and shall include information on the child’s adjustment and development.

(B) At least one (1) visit each quarter shall be made in the foster home.

(C) A chronological record, noting significant events and contacts with the child and documentation of supervisory visits shall be provided by the agency.

(6) Termination of Parental Rights. When all efforts to restore a child to his/her family have failed, an agency shall initiate action to terminate parental rights.

(7) Termination of Foster Care.

(A) When foster care is terminated, an agency shall complete a written discharge summary within thirty (30) days of the date of termination of care. This summary shall be included in the child’s case record, and shall 1. The name, address, telephone number, and relationship of the person to whom the child is transferred or released;

2. A summary of services provided during care;

3. A summary of growth and accomplishments during care;

4. The assessed needs which remain to be met and alternate service possibilities which might meet those needs; and 5. A statement of an aftercare plan and identification of the person or agency responsible for follow-up services and aftercare.

(B) A copy of the discharge summary, or a summary of the services provided should be made available to the person or agency responsible for the future planning or care of the child, upon request.

(8) Birth Parent(s) Case Record. A record shall be maintained for the birth parent(s) of children in foster care which shall include:

(A) Names, addresses, home telephone numbers, and addresses and telephone numbers where the parent(s) can be contacted at any time;

(B) A record of all efforts put forth by the parent(s) to keep the child(ren) in their own home;

(C) The reason(s) why foster care was necessary to ensure the safety and welfare of the child;

(D) A signed agreement, including financial arrangements, for voluntary placements;

(E) Conditions for the return of the child(ren) to the home;

(F) A chronological record noting significant events and contacts with the child(ren), parent(s) and foster parents;

(G) A written summary of visits between the parent(s) and child(ren); and (H) A closing summary.

History

• AUTHORITY: sections 207.020 and 660.017, CSR 40-73.075. Original rule filed Feb. 6, 1997, effective July 30, 1997. Moved to 13 CSR 35-73.075 and amended: Filed Sept. 7, 2018, effective April 30, 2019.

13 CSR 35-73.080 Adoption Services {#sec-13-csr-35-73.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-73.080}

PURPOSE: Except as otherwise expressly set forth in this rule, this rule applies to child placing agencies licensed pursuant to sections 210.481 to 210.536, RSMo and to intermediaries as defined in section 453.014, RSMo (includes attorneys licensed pursuant to Chapter 484, RSMo; physicians licensed pursuant to Chapter 334, RSMo; or clergyman of the parents) and who, in the absence of a child placing agency representing the child, place a child outside the home of the child’s parent(s) or guardian, or who advertise or hold themselves out as performing such services (collectively), “adoption intermediaries.” This rule sets forth rules relating to birth parents, pre-placement and placement services to the child, adoptive family services, placement services, post-placement services to the family, adoption disruption services, and international placements. Only those rules which specify adoption intermediaries apply to adoption intermediaries. All rules apply to child placing agencies.

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) General Program Requirements.

(A) A child placing agency shall maintain and make available to its clients information on resources in the community which may be of use to foster or adoptive parents, birth parents, children and adult adoptees.

(B) A child placing agency shall ensure access to its services by eligible persons with disabilities.

(C) A child placing agency shall maintain and keep on file a grievance procedure for clients.

(D) A child placing agency or adoption intermediary shall be in compliance with all applicable laws including Interstate Compact on the Placement of Children (ICPC), Interstate Compact on Adoption and Medical Assistance (ICAMA), and Indian Child Welfare Act (ICWA).

(2) Services to Birth Parents.

(A) Before services are provided an agency shall provide a written description of its current program for birth parents, including information on the agency’s services, options available for birth parents and the adoption process.

(B) Before financial liability is incurred or care of the child is transferred by power of attorney or court order, an agency shall make available to birth parents a verbal explanation of and a written agreement with the agency, describing specific services to be provided, fees to be charged, and rights and responsibilities of both parties.

(C) When a child placing agency or adoption intermediary accepts or obtains the waiver of necessity of consent to future adoption or consent to termination of parental rights of a child, it can do so only after determining that the birth parents or legal guardians are not acting under duress. (Specifically, this waiver of consent may be taken on the “Consent to Termination of Parental Rights and Consent to Adoption” form developed by and made available through the local County Office of the Children’s Division, or Children’s Division Central Office, PO Box 88, Jefferson City, MO 65103, or the Court.)

1. The birth parent(s) shall not be required to sign a statement committing him/her to any definite plan for the unborn child in order to obtain services from the 2. The birth parent(s) shall not be required to waive the necessity of consent to future adoption or to consent to termination of parental rights for a child for adoption in order to receive medical services, maternity or residential care, or any other agency service.

2. A child placing agency that directly provides residential care, foster home care, and/or maternity home services to clients shall ensure that such facilities and/or homes meet applicable state licensing, certification, or local zoning requirements.

3. The birth mother shall be encouraged to identify all possible birth and/or legal fathers and reasonable efforts shall be made to locate them.

4. All birth and legal parents shall be informed of their options including parenting or making an adoption plan.

5. Appropriate legal authorities shall be notified when a birth parent is a minor or incompetent so that a guardian ad litem can be appointed as required by Chapter 453, RSMo.

6. Before placement of a child, it shall be documented that the birth parents were— A. Offered counseling by a child placing agency that fully explores alternative plans for the child, including, but not limited to, temporary foster care, day care, and care by relatives;

B. Informed by the child placing agency or adoption intermediary that their decision must be free, knowing, and voluntary regardless of their age;

C. Prepared by the child placing agency, along with the child, for placement and separation;

D. Referred to other community resources when the agency cannot provide needed services;

E. Informed of the existing laws regarding contact and disclosure of informa- F. Asked to submit complete medical and social information on forms prescribed or approved by the division (birth parent, social and medical history); and G. Asked to update and submit to the agency changes of address(es) and/or any significant medical information now and in the future.

8. A child placing agency and, as applicable, the adoption intermediary shall explain the significance of placement to the birth and legal parents and document acknowledgment of said explanations and take appropriate actions including the following:

A. The full terms of this understanding shall be delineated in writing, signed and dated by the birth parent(s) and agency, if applicable, and maintained on file;

B. The birth parent(s) shall be given the opportunity to state any preferences that s/he may have affecting the selection of the adoptive family;

C. A child placing agency or adoption intermediary shall act in the best interests of the child in recommending the adoptive family;

D. A child placing agency or the adoption intermediary shall not take a waiver of necessity of consent to future adoption, consent to termination of parental rights or Consent to Adoption before allowed by statute; and E. A child placing agency or the adoption intermediary shall document those parents who cannot read, fully understand the meaning of waiver of necessity of consent to future adoption or consent to termination of parental rights.

9. While the parent(s) has the legal right to resume custody, a child placing agency shall not delay returning a child solely because the parent(s) is unable to pay medical and/or other fees.

10. A child placing agency shall request the court to take appropriate action as necessary for the protection of the child.

11. After the child is placed for adoption, a child placing agency shall provide post-placement supportive services to the birth parent(s) to help them adjust to the placement and to deal with any concerns, including at least one (1) in-person contact if requested by the parent.

(3) Pre-Placement and Placement Services to the Child.

(A) Prior to adoptive placement, a comprehensive and documented assessment, as required pursuant to section 453.026, RSMo, of each child’s medical, psychological, and social development shall be completed on an age-appropriate basis by or at the direction of a child placing agency or adoption intermediary. In preparing this assessment, the agency or adoption intermediary shall have the duty to inquire and obtain reports and information into the following matters concerning the prospective adoptive child, if such report or information is appropriate given the age of the child:

1. A medical examination of the child within a reasonable period of time prior to placement, meaning at least within thirty (30) days prior to, or ten (10) days after, adoptive placement;

2. Medical, social, and cultural/ethnic background information about the child’s birth family;

3. Information on previous alternative care or adoptive placements, if applicable;

4. Any specialized evaluations, if applicable;

5. Assessment of the child’s needs by one who is authorized to make such an assessment under section 453.070.2, RSMo;

6. The child’s involvement in the adoption or reason(s) for not involving the child;

7. An evaluation of the feasibility of placement with birth sibling(s);

8. Developmental history of the prospective adoptive child— A. Birth and health history;

B. Early development— (I) Locomotor;

(II) Developmental milestones;

(III) Feeding;

(IV) Sleeping; and (V) Temperament;

C. Current development;

D. A written synopsis of any professional evaluation and treatment recommendations for the child, including medical, educational, dental, psychological, psychiatric, etc.;

E. Child’s experiences— (I) Maternal attitudes during pregnancy and early infancy including prenatal care and drug usage;

(II) Continuity of parental care and affection;

(III) Foster care placements;

(IV) Separation and attachment issues; and (V) Any history of abuse or neglect; and F. Language skills or education; and 9. Compliance with ICWA.

(B) A child placing agency that is unable to locate an appropriate adoptive family within ninety (90) calendar days of the date the child was legally freed for adoption shall— 1. Refer the child to the Adoption Resource Exchange, or any successor statewide exchange;

2. Refer the child to an interstate or national adoption exchange; and 3. A child placing agency may refer a child to any adoption exchange(s) earlier than is required.

(C) A child placing agency placing a special needs child shall document its efforts to facilitate an adoptive placement.

(D) Preparation for adoptive placement shall be done in cooperation with the primary caregiver to supply the adoptive family with all necessary social, physical, and developmental background.

1. The placement should include the temporary caregiver(s) in a meeting with the adoptive family.

2. Pre-placement visits should take place in length and frequency that is appropriate to the child’s age, his/her needs, and response and adjustment to the new family.

(E) For children over thirty-six (36) months, preparation for adoptive placement should include the primary caregiver(s) and private interviews with the child to discuss the placement plan, as age and developmentally appropriate.

1. The child’s understanding of and response to these pre-placement interviews shall be documented in the record.

2. Counseling should include exploration of the child’s understanding of what is taking place and the child’s feelings about adoption and separation and loss.

(F) The pre-placement services shall be recorded in the child’s record.

(4) Adoptive Family Services.

(A) Before services are provided, a child placing agency shall provide orientation to prospective adoptive parents to acquaint them with the agency’s policies and practices, fee schedules, grievance procedures, the approximate time the assessment will take, eligibility standards, adoption risk issues, availability of subsidy for special needs children, and the types of children available so as to enable them to make an informed decision to proceed.

(B) A child placing agency shall make available to prospective adoptive parents a verbal explanation of and a written agreement with the agency, describing specific services to be provided, fee ranges, and rights and responsibilities of both parties. Said explanation and agreement shall include the follow ing, if applicable:

1. Physician’s expenses;

2. Hospital and other medical expenses;

3. Court costs and fees for legal ser- 4. Agency fees or expenses— A. Counseling services;

B. Family assessment services;

C. Birth parent services;

D. Foster care services;

E. Pre- and post-placement social ser- F. Transportation;

G. Contracted services, if applicable;

H. Any other services as may be reasonably foreseeable; and I. Child-finding services.

(C) A written description of the adoption program shall be provided to applicants upon request.

(D) A child placing agency or adoption intermediary shall complete, or cause to be completed, an adoptive family assessment of each eligible adoptive family prior to the placement of a child in the home. This assessment shall be completed by a person or agency as stipulated in section 453.070.2, RSMo.

1. The family assessment process shall consist of— A. An individual interview with each applicant;

B. A joint interview with co-applicants;

C. Confidential interviews, with all members of the applicants’ household, as age appropriate; and D. A visit to the residence of the applicant(s) which includes a complete inspection of the home.

2. The family assessment process shall include a minimum of at least two (2) separate visits on nonconsecutive days.

3. The written family assessment shall A. Identifying information on each member of the household including:

(I) Full name(s), including maiden and aliases, if applicable;

(II) Current address and phone number; and previous addresses if less than five (5) years at current address;

(III) Date and place of birth;

(IV) Citizenship;

(V) Social Security number;

(VI) Race and ethnic background;

(VII) Religion, if applicable;

(VIII) Veteran’s status, if applicable;

(IX) Education;

(X) Place of employment, address, and telephone numbers;

(XI) Any children, including those not in the home; and (XII) Physical description;

B. A social history on each applicant which shall include:

(I) Description of the applicant’s family of origin, including type of family structure, values, child rearing, relationships past and present, and discipline methods. If the family of origin was dysfunctional (for example, alcoholism, abuse) describe how the applicant has coped with the issues in his/her adult life;

(II) Educational and occupational

history including current employment;

(III) Marital history and current relationships;

(IV) Interests and hobbies;

(V) Physical and mental health history including psychiatric treatment, if any, and extent of alcohol and drug use;

(VI) Applicant’s personality, including applicant’s perceived strengths and weaknesses, emotional stability and maturity; and (VII) Religious beliefs and practices;

C. Parenting background of the application(s) which shall include:

(I) Motivation to adopt;

(II) Awareness of adoption issues such as talking to the child about his/her adopted status, identity issues with adoptees, grief and loss in adoption, openness, search;

(III) Applicant’s readiness to seek family counseling if needed;

(IV) Philosophies on child rearing and discipline;

(V) Attitudes and acceptance of adoption by other significant family members and friends;

(VI) Location and description of physical residence, including type of community and school district available;

(VII) If the family contains school age child(ren), reports from school personnel regarding school adjustment;

(VIII) Child care arrangements;

(IX) Description of children and adopted children’s background factors the applicants can accept;

(X) Financial status and manage- (XI) For special needs adoption, awareness of the child’s special needs and appropriate ways to meet those needs; and (XII) For trans-racial or trans-cultural adoption, the applicant’s awareness of and sensitivity to differences, how they plan to impact a positive identity, and expose the child to his/her cultural/ethnic heritage;

D. Supplemental documentation shall (I) A total of no less than four (4) reference letters; including, but not limited to, one (1), employment related reference per applicant (if applicable) from one (1) who has worked with the person within the last five (5) years, one (1) relative, and one (1) nonrelated personal reference;

(II) Child abuse and neglect background screening check Child Abuse and Neglect Central Registry Unit (CA/N CRU), no more than six (6) months old;

(III) Criminal arrest records from a state law enforcement agency, no more than six (6) months old;

(IV) Criminal conviction records including a fingerprint search, from a state law enforcement agency;

(V) Any findings on child abuse or criminal records shall be followed up by requesting a copy of the child abuse investigation report or the police report;

(VI) Written medical reports, no more than twelve (12) months old, on all adult members of the household;

(VII) Verifications of marriage(s) and divorces if applicable;

(VIII) Written documentation of income and financial resources, including a copy of the latest Federal Income Tax 1040 form verifying adjusted gross income;

(IX) Other family assessments and recommendations, if applicable; and (X) Birth and death certificates;

E. Impressions and recommendations.

(E) Adoptive family assessments shall be updated annually. An update shall also be completed if there is a significant change in the family situation (for example, job change, address change). It shall include:

1. One (1) or more interviews with all members of the family;

2. Medical reports on all household members biennially unless otherwise indicated;

3. Child abuse/neglect reports on all adults completed within the last thirty (30) days;

4. Arrest record check completed within the last thirty (30) days;

5. Evaluation of any previous placements; and 6. A summary of additional children to be adopted.

(5) Placement Services.

(A) Prepare child and family for adoption, including discussion of— 1. Understanding and acceptance of the child’s background;

2. Separation from birth family;

3. Planning for continued contact, if 4. Meaning of and desire for adoption;

4. Placement with siblings, if planned;

5. Plans to encourage and preserve the child’s ethnic and cultural identity;

6. The adoption process, transfer of custody, period of supervision, and finalization;

7. Child’s needs and any special concerns.

(B) A child placing agency shall document the reason(s) placing the child with the adoptive family is in the child’s best interest.

(C) A child placing agency shall make reasonable efforts to place siblings together.

When sibling placement is not a possibility the agency or adoption intermediary shall document— 1. Efforts made to place siblings together;

2. Reasons why such a resource/place- 3. Plan for contact with siblings or reasons for no contact.

(D) A child placing agency shall make reasonable efforts to place in an adoptive home of similar racial or cultural background in compliance with the Multi-Ethnic Placement Act (MEPA). When such placement is not a possibility the agency shall document— 1. Efforts made to locate such a home;

2. Reasons why such a resource/place- (E) A child placing agency shall enter a written agreement with the adoptive parents specifying the rights and responsibilities of each regarding the child during the supervision period.

(F) When more than one (1) child placing agency is involved in a placement, both agencies shall share information and develop a mutual written agreement on the services to be provided by each.

(G) A child placing agency shall provide the following information, to adoptive parent(s) while maintaining confidentiality as appropriate:

1. Written history of the child including developmental and medical history;

2. Reason(s) the birth parent(s) made an adoption plan;

3. A written synopsis of any professional evaluation and treatment recommendations for the child (for example, medical, educational, dental, psychological, psychiatric, etc.); and 4. Any resources, which may be available to the adoptive families, such as— A. Missouri Adoption Subsidy Program (MASP);

B. Payment for nonrecurring adoption expenses only;

C. Missouri Adoption Tax Credit;

D. Supplemental Security Income;

E. Social Security benefits; and F. Laws relating to health insurance.

(6) Post-Placement Services to Family.

(A) A child placing agency shall provide education, training, and support to the family, to facilitate positive adjustment to the place- (B) A child placing agency shall maintain contact with the family during the supervision period.

1. For children thirty-six (36) months of age and under, the agency shall— A. Conduct, at a minimum, quarterly home visits until the adoption is final;

B. Conduct monthly telephone contacts between home visits; and C. Receive regular written reports from the child’s pediatri cian.

2. For children over thirty-six (36) months of age or children with special needs, the agency shall— A. Conduct one (1) home visit within the first ten (10) days of placement, then, at a minimum, quarterly until the adoption is finalized;

B. Conduct monthly telephone contacts between home visits;

C. Receive regular written reports from the child’s pediatri cian;

D. If the child is in school, receive one (1) report from the school personnel regarding the child’s progress every school quarter;

E. Interview the child privately to discuss the child’s feelings about the adoption during each supervisory visit.

(C) Document in the child’s record that all members of the adoptive family’s household were interviewed during supervision.

(D) Document in the child’s record that the following issues were discussed:

1. How the addition of this child into the family has changed marital and sibling relationships and how extended family and friends have reacted to the adoption;

2. What role each family member has assumed in child care;

3. How parents have coped with adjustments, additional responsibilities, discipline, physical, psychological, emotional, and financial stresses;

4. How family is imparting knowledge of child’s history, as age appropriate; and 5. The child’s adjustment including health, school, and family.

(E) Prior to finalization, the family will provide documentation to the child placing agency that provisions have been made to provide for the care of child in the event of the parents inability to provide care.

(7) Disruption of Placement.

(A) A child placing agency shall have and follow a written policy on procedures to be followed in the event of an adoptive placement disruption which shall include:

1. A thorough assessment of the reasons for the disruption;

2. Provision of counseling services to the adoptive family and child as needed; and 3. Provision for temporary care of the child until another permanent plan can be made.

(B) A child placing agency maintains responsibility for the health and welfare of a child. When it becomes necessary to remove a child from a placement the agency shall— 1. Take appropriate action to insure the child’s health and well being;

2. Seek an appropriate adoptive resource for the child; and 3. Advise the appropriate court(s) of placement changes.

(C) The division shall be notified in writing within three (3) working days of all disruptions.

(8) International Placements.

(A) Families being considered for the placement of a child from a foreign country shall meet all criteria for families adopting a child born in Missouri as specified in 13 CSR 35-73.080(4).

(B) Families residing in states other than Missouri, but adopting children from a Missouri resource, must also complete a criminal record check and child abuse and neglect screening in their state of residence.

(C) In countries where foreign government authorization or licensure of orphanages, lawyers, or others working in the field of adoption is required, agencies shall enter into agreements and working relationships regarding an adoption with those who meet the requirements of the foreign government.

(D) In countries where an agency based in Missouri is required to obtain a license or other authorization from that country, a copy of said license or authorization shall be filed with the division.

(E) In the event that the adoptive placement ends in a disruption, the same procedure as stated in 13 CSR 35-73.080(7) shall be followed.

1. If the disruption occurs prior to the finalization of the adoption, the placing agency shall be responsible for the care and replacement of the child, as discussed in 13 CSR 35-73.080(7).

2. If the child placing agency is an agency located in the state other than Missouri, applicable provisions of the ICPC shall be followed.

3. If the child placing agency is a Missouri agency and the child is placed in a state other than Missouri and the adoption disrupts, applicable provisions of the ICPC shall be followed.

(F) Pre-Placement Planning.

1. A child placing agency evaluating the prospective adoptive parents shall include in their discussion with and evaluation of the adoptive family:

A. Discussion of the family’s intent and ability to help the child maintain cultural/ethnic identity and familiarity with the country of origin;

B. Discussion of factors particular to child’s country of origin (such as, medical, developmental concerns);

C. Community resources available to assist the prospective adoptive parents with the adjustment following the placement of the child; and D. Coping with any language, cultural, or other barriers that may affect the place- 2. A child placing agency must evaluate the prospective adoptive parents for the placement of a child from a foreign country, including discussion about the child’s acceptance within the immediate and extended family, and the community at large.

3. For international placement situations where the prospective adoptive parents must travel to the foreign country, assistance from the placing agency should include assisting or preparing the family for such travel, assistance with passport and visa, any immuniza tions, or health concerns and preparation for travel within the foreign culture.

4. A child placing agency shall obtain and document all available infor mation about the birth parents.

(G) Post-placement services.

1. Post-placement services shall be provided in compliance with provisions of rule 13 CSR 35-73.080(6).

2. Attention shall be given to the child’s acceptance within the extended family and the community at large.

3. Discussion shall focus on any differences in appearance of the child from the family and how those differences are being addressed and resolved.

4. Health concerns relative to the child’s country of origin shall be noted and followed by a physician as needed and shall be discussed by the worker and the family.

5. Post-placement reports shall be completed and forwarded to the country of origin as required by that country.

6. The agency shall offer information to the family regarding recognition of foreign decree, transfer of custody, and adoption as needed.

7. Certified copies of the final decree of the adoption shall be kept in the case record and forwarded to the country of origin as needed. A translation of said decree shall be retained if applicable.

8. Families shall be encouraged to complete naturalization proceedings on their adopted child.

(9) A child placing agency that provides services for adoption must comply with all provisions of the licensing rules.

Filed Feb. 6, 1997, effective July 30, 1997.

Emergency amendment filed Jan. 15, 1998, effective Feb. 1, 1998, expired July 30, 1998.

Amended: Filed Jan. 15, 1998, effective July 30, 1998. Moved to 13 CSR 35-73.080 and amended: Filed Sept. 7, 2018, effective April 30, 2019. 1965, 1977, 1981, 1982, 1986, 1993, 2014.

History

• AUTHORITY section 207.020, RSMo 2016. 73.080. Original rule filed Sept. 18, 1956, effective Sept. 28, 1956. Refiled: March 12, 1976. Amended: Filed Nov. 6, 1981, effective Feb. 11, 1982. Rescinded: Filed Jan. 14, 1997, effective July 30, 1997. Readopted:

Chapter 80a Payment of Residential Facilities

13 CSR 35-80.010 Residential Foster Care Maintenance Methodology {#sec-13-csr-35-80.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-80.010}

PURPOSE: This rule establishes a methodology for determination of the costs associated with the provision of foster care maintenance based on the statutory criteria contained in 42 U.S.C. 672/675(4)(A) and related rates for residential care agencies.

(1) Objectives. This rule establishes a methodology for determination of the costs associated with the provision of foster care maintenance based on the statutory criteria contained in 42 U.S.C. 672/675(4)(A) and related rates for residential care agencies.

(2) General Principles.

(A) Four (4) child-specific foster care maintenance rates shall be determined in accordance with section (3) Residential Foster Care Maintenance Rate Methodology.

(B) Residential child caring agencies will be required to complete a cost report detailing their most recent fiscal yearís operating costs. Providers must also submit audited financial statements with their report for verification purposes.

(C) Foster care maintenance costs shall be obtained from residential care providers using the standard cost report completed in accordance with applicable instructions.

1. In order to be considered ìFoster Care Maintenance,î agency costs shall first meet the general definition as ascribed within federal regulation, accompanying clarification or audit finding and be allowable as defined within OMB Circular A-122, OMB Circular A-87, and the Child Welfare Policy Manual.

2. Reported agency costs shall be reasonable in nature as defined with OMB Circular A-122 and OMB Circular A-87.

3. Cost must be appropriately allocated to all benefiting programs or services offered by an agency.

4. The calculation of the foster care maintenance rate must consider any applicable credits or payments received either directly from federal or state funding sources or indirectly via contracted services or reimbursement.

(D) Statewide foster care maintenance costs shall be rebased every three (3) years.

(E) The Department of Social Services (DSS) will submit budget items for the General Assemblyís consideration to revise rates in accordance with the results of the rate setting methodology. Rates will be adjusted in accordance with the Truly Agreed and Finally Passed appropriation by the General Assembly subject to veto by the Governor.

(3) Residential Foster Care Maintenance Rate Methodology. The foster care maintenance rate will contain two (2) separate components. A statewide average room and board component and a child-specific daily supervision component.

(A) Room and Board Component.

1. Because the general cost of providing room and board will not vary based on a childís identified level of care or other programmatic considerations, a core, statewide, board rate will be calculated based on the average cost of all agencies providing such services.

2. The room and board component will be calculated by dividing the total net applicable room and board related costs for all agencies by the statewide total days of residential child caring services provided.

(B) Daily Supervision Component.

1. The daily supervision component will vary based upon required staffing ratios as defined within the Missouri Code of State RegulationsìRules of Department of Social Services, Division 40óDivision of Family Services, Chapter 71óLicensing Rules for Residential Care Agencies.î This document establishes basic expectations for staff/child ratios within residential care agencies as identified within Exhibit 1, Residential Child Care Agency Staff/Child Ratios.

Exhibit 1 2. Agencies will report days by type of service provided. To determine the child-specific daily supervision portion of the rate, agencies will be classified into one of four categories based upon the average level of supervision required by children in their care.

This classification will allow for adequate differentiation of cost incurred in the provision of daily supervision across each category and permit calculation of the related rate component. After categorization of agencies into each of the defined categories, the daily supervision rate will be calculated by dividing the total net applicable supervision costs for all agencies within a category by the total days of child caring services provided by those agencies.

A. Days of service provided under the basic core requirements regardless of payor source. Examples of services under this category reimbursed by DSS include the following categories:

(I) Emergency shelter;

(II) REHABóRT emergency crisis intervention;

(III) Maternity care; and (IV) Maternity care with infant.

B. Days of service provided under the infant/toddler/preschool requirements regardless of payor source. Examples of services under this category reimbursed by DSS include the following contract categories:

(I) Infant care; and (II) Toddler care.

C. Days of service provided under residential treatment requirements regardless of payor source. Examples of services under this category reimbursed by DSS include the following contract categories:

(I) Moderate need (Level II);

(II) REHABóRT moderate need (Level II);

(III) Severe need (Level III);

(IV) REHABóRT severe need (Level III); and (V) Family focused residential services.

D. Days of services provided under intensive residential care requirements regardless of payor source. Examples of services under this category reimbursed by DSS include the following contract categories:

(I) Intensive need (Level IV); and (II) REHABóRT intensive need (Level IV).

(4) Inflation/Trend Factor Adjustments.

(A) For the purpose of establishing base year costs, the room and board component will be adjusted based on the change in the USDA Expenditures on Children by Families.

For State Fiscal Year 2005, the adjustment will be three and thirty hundredths percent (3.30%). The child-specific daily supervision component will be adjusted based on the change in the Midwest Region Consumer Price Index for all Urban consumers (CPI- U). For State Fiscal Year 2005, the adjustment will be two and ninety-two hundredths percent (2.92%). The annual change in the Category Age Child Awake Child Asleep Basic Core Requirements Birthñ6 6ñ8 8ñ21 1:10 1:12 (staff asleep) 1:20 (staff awake)

Infant/Toddler/ Preschool Birthñ6 1:4 1:6 (staff awake)

Residential Treatment (DFS Levels II & III) 8ñ21 1:8 1:16 (staff awake)

Intensive Residential Care (DFS Level IV)

4CODE OF STATE REGULATIONS

USDA index two and twenty hundreths percent (2.20%) and CPI-U one and ninety-four hundreths percent (1.94%) was determined for the most recent calendar year and multiplied by a factor of 1.5 for the purpose of converting calendar year 2003 cost data to the State Fiscal Year 2005 rate period.

(B) For the purpose of interim inflation/trend factor adjustments until rates are rebased, the department will submit budget items for the General Assemblyís consideration to revise rates in accordance with the results of the rate setting methodology. The change in the USDA Expenditures on Children by Families will be used for the room and board component and the Midwest Region Consumer Price Index for all Urban consumers (CPI-U) will be used for the daily supervision component. Rates will be adjusted in accordance with the Truly Agreed and Finally Passed appropriation by the General Assembly subject to veto by the Governor.

History

• AUTHORITY: section 207.020, RSMo 2000. Emergency rule filed Jan. 16, 2004, effective Jan. 26, 2004, expired July 23, 2004. Original rule filed Jan. 16, 2004, effective Aug. 30, 2004. Emergency amendment filed Sept. 22, 2004, effective Oct. 2, 2004, expired March 30, 2005. Amended: Filed Sept. 22, 2004, effective March 30, 2005. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993.

13 CSR 35-80.020 Residential Care Agency Cost Reporting System {#sec-13-csr-35-80.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-80.020}

PURPOSE: This rule establishes a uniform cost reporting system to be used in reporting actual cost incurred in the operation of residential care agencies. The uniform cost reporting system provides the data necessary for the determination of the costs and rates associated with the provision of foster care maintenance.

(1) Objectives. This rule establishes a uniform cost reporting system to be used in reporting actual cost incurred in the operation of residential care agencies. The Residential Care Agency Cost Report included is one part of the two (2)-part process set forth by the State of Missouri Department of Social Services in fulfilling the requirements for identifying foster care maintenance related expenditures within residential care agencies. The other part of the process involves participation in either a time study or random moment sample to determine the portion of time direct care staff spend performing foster care maintenance related activities.

(2) General Cost Reporting Principles. Residential Care Agency Cost Report line specific reporting instructions are included as an

appendix to this rule included herein. The cost report must include all costs incurred by the residential care agency. Costs included in the report can be grouped/categorized in several different ways and are subject to certain guidelines or requirements:

(A) Costs directly attributable to a function or activity may be charged in their entirety to that function or activity. Example: A staff person working in a single function or activity may have one hundred percent (100%) of their time charged to that function or activity.

(B) Costs not attributable to a single function or activity must be distributed based on an appropriate allocation methodology.

Example: A staff person who spends a portion of their time working for several different functions or activities should have their related cost allocated across each program by some substantially documented methodology.

(C) Some staff will have their associated cost allocated through the application of activity-based time study or random moment sample (RMS) results: All agency staff responsible for the provision of direct daily supervision of children on a regular basis will be included in the activity based allocation time study process. Those staff that should NOT participate in the time study include:

1. Agency administration. It should be noted that, in some agencies, an agency administrator might perform a significant amount of direct care of residents. In these instances, the individual should participate in the time study process.

2. Staff involved in the provision of a single function such as the provision of counseling or therapy; medical service; food preparation; cleaning; or facility maintenance.

(D) Costs are either considered allowable or unallowable, based on federal definitions and guidelines, for inclusion in the calculation of the residential foster care maintenance rate.

(E) Costs must be net of applicable credits when determining the portion attributable to the residential foster care maintenance rate.

Any credits to reported costs will be applied as a function of the rate calculation process.

Examples of applicable credits may include, but are not limited to:

1. IV-E training payments;

2. USDA reimbursements;

3. Payments from school districts or the Department of Elementary and Secondary Education for the provision of educational services;

4. Reimbursements from the Department of Social Services (DSS), the Department of Mental Health (DMH) or other third party payors that offset reported costs such as, including but not limited to:

A. Reimbursements for the development of the initial treatment plan, quarterly updates to the initial treatment plan and other treatment planning services reimbursed by others;

B. Reimbursements for day treatment; and C. Reimbursements for counseling or other therapeutic services.

5. Reimbursements for medical and behavioral health services covered by the stateís Medicaid State Plan (either directly or indirectly through MC+Plans) including, but not limited to:

A. Physicianís services;

B. Pharmacy-related services;

C. Psychology and counseling services; and D. Targeted case management.

6. Other reimbursement from Medicaid or the MC+plans for the provision of other medically necessary services.

7. Reimbursements for medical and behavioral health services covered by other third party payors.

(3) Explanation of Common Terms. To facilitate the completion of the cost report costrelated terms used throughout the instructions are defined, and a brief explanation of their application is given.

(A) Reported Costs. For a cost to be included on the cost report it must meet the following general criteria:

1. Be reasonable for the performance of the activities of the agency;

2. Be accorded consistent treatment; and 3. Be adequately documented.

(B) Reasonable. A cost is reasonable if, in its nature or amount, it does not exceed that which would be incurred by a prudent person under the circumstances prevailing at the time the decision was made to incur the costs.

Reasonable costs are further defined in OMB Circular OMB A-87.

(C) Allowable. Allowable costs are those costs that are generally considered eligible for federal reimbursement based on the cost principles established in federal transmittals such as OMB Circular A-87 or A-122.

Appendix A gives a list of items that are generally considered to be allowable. This is not an all-inclusive list and other costs not listed may be allowable. Although a cost may be considered ineligible for inclusion in the foster care maintenance rate based upon federal rules, regulations, or guidelines. (See ìEligible Costî)

(D) Unallowable. A cost is unallowable for reimbursement under, or claim to, any federal program based on established cost principles. Appendix A includes a list of items considered to be unallowable. All costs should be included on the cost report. Costs that are not allowable based on the federal guidelines should be placed in the ìUnallowableî column on the cost report.

(E) Administrative Cost. Refers to those costs related to general operation and management of an agency or to those costs incurred in the support of multiple agency functions or programs. Examples of administrative costs include, but are not limited to:

1. Executive direction and supervision;

2. Bookkeeping and fiscal management;

3. Secretarial and clerical support;

4. Physical plant management;

5. Staff training (unless clearly related to a primary activity area); and 6. Related occupancy costs.

(F) Allocation Methodology. Documentation and/or description of the procedures/methods used to distribute costs to programs and to the direct service categories on the cost report. In general, costs should be allocated across the cost reportís direct service categories/activities if there is a clear delineation and documentation for the allocation. Documentation must be maintained recording the methodology and detailing the specific calculation used to distribute costs.

The use of estimates not based on a statistically sound methodology is unacceptable.

(G) Applicable Credits. The term applicable credits refers to those receipts, or reduction of expenditures which operate to offset or reduce expense items that are allocable to awards as direct or indirect costs. Typical examples of such transactions are: purchase discounts, rebates or allowances, recoveries or indemnities on losses, insurance refunds, and adjustments of overpayments or erroneous charges. To the extent that such credits accruing or received by the organization relate to allowable cost, they shall be credited to the federal government either as a cost reduction or cash refund, as appropriate. In some instances, the amounts received from the federal government to finance organizational activities or service operations should be treated as applicable credits. Specifically, the concept of netting such credit items against related expenditures should be applied by the organization in determining the rates or amounts to be charged to federal awards for services rendered whenever the facilities or other resources used in providing such services have been financed directly, in whole or in part, by federal funds. For rules covering program income (i.e., gross income earned from federally-supported activities) see Sec. 24 of Office of Management and Budget (OMB) Circular A-110, ìUniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education, Hospitals, and Other Non-Profit Organizations.î (H) Random Moment Sample (RMS)/Time Study. A time study or RMS is a statistically based process to gather information from direct service child care staff members on how they spend their time. The information collected will be used for distributing the cost of direct staff among various activities. The results of this study are used to determine the portion of the direct service providers cost related to foster care maintenance.

(I) Eligible Cost. For the purpose of determining the residential foster care maintenance rate, only those costs incurred in the provision of the following items/activities will be considered. The federal Department of Health and Human Services, Administration for Children and Families has published guidance in this regard in the Child Welfare Policy ManualSection 8.3.B.1. In general, this includes the cost of, and the cost of providing, the following:

1. Food;

2. Clothing;

3. Shelter;

4. Daily supervision;

5. School supplies;

6. Personal incidentals;

7. Liability insurance with respect to the child care;

8. Reasonable travel for the child for visitation as defined within the Child Welfare Policy Manual; and 9. Related administrative costs.

(4) Entities Covered by the Cost Report. The Missouri Residential Care Agency Cost Report is to be used in reporting actual costs incurred in the operation of residential care licensed under the Department of Social Services, Division 40óDivision of Family Services, Chapter 71óLicensing Rules for Residential Care Agencies. Each cost report establishes the portion of that agencyís cost attributable to the provision of foster care maintenance. Information from all reporting agencies will be used, in aggregate, to establish foster care maintenance rates for each of the following four (4) categories based upon Missouri licensing rules for residential care agencies:

(A) Basic Core Requirements;

(B) Infant/Toddler/Preschool;

(C) Residential Treatment (DFS Levels II and III); and (D) Intensive Residential Care (DFS Level IV).

(5) Reporting Period and Filing Requirements.

(A) The cost report must reflect actual audited costs incurred in the provision of residential child care and related services by an agency for the most recent fiscal year. Cost reports must be submitted in accordance with the applicable instructions and in the cost report format prescribed in Appendix A, included herein. Failure to provide cost reports may result in the residential care facilities exclusion from contracts with the Childrenís Division.

(B) An annual cost report for fiscal years ending after December 31, 2003 must be submitted within ninety (90) days of the close of the fiscal year. The division may grant an extension for submission of the annual cost report and/or audited financial statement.

Cost reports which have not been submitted for fiscal years ending in calendar year 2004 must be submitted by August 15, 2005 on the current report format contained in Appendix A. A wavier from filing a fiscal year 2004 cost report will be provided for providers that will submit a fiscal year 2005 cost report by August 15, 2005.

(C) Audited financial statements must be submitted with cost reports. An auditorís opinion does not have to be provided on the cost report. A preliminary fiscal year 2005 cost report may be submitted by August 15, 2005 without an audited financial statement.

A final report and audited financial statement must be submitted in accordance with sub-

section (5)(B).

(D) Providers must also participate in the statewide time study of direct care staff described in section (1).

(6) Record Retention. Records used in support of costs reported on the cost report must be retained for a minimum of three (3) years from the end of the rate year for which the report is applicable. Records include, but are not limited to, financial, programmatic, statistical, recipient records, and supporting documentation. If any litigation, administrative review, claim, negotiation, audit, or other action involving the records has been started before the expiration of the three (3)year period, the records shall be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular three (3)-year period, whichever is later. As part of the residential foster care maintenance rate calculation process, the state and/or its contracted representative may conduct reviews of the financial 6CODE OF STATE REGULATIONS and programmatic information used as the

basis for completion of an agencyís cost report. After completion of any such review, a written report will be completed addressing whether reported costs are adequately supported, allocated appropriately, and reasonable in nature. Documentation created while completing the cost report should be maintained recording the compilation of costs included in the report, and any methodologies or calculations used in the allocation of costs.

Appendix A 8CODE OF STATE REGULATIONS 10CODE OF STATE REGULATIONS 12CODE OF STATE REGULATIONS 14CODE OF STATE REGULATIONS 16CODE OF STATE REGULATIONS 18CODE OF STATE REGULATIONS

Chapter 100 Tax Credits

13 CSR 35-100.030 Developmental Disability Care Provider Tax Credit JOHNR. ASHCROFT(2/28/19) {#sec-13-csr-35-100.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-100.030}

SOCIAL SERVICES

13 CSR 35-100.010 Residential Treatment Agency Tax Credit {#sec-13-csr-35-100.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-100.010}

(Moved to 13 CSR 10-3.010)

13 CSR 35-100.020 Pregnancy Resource Center Tax Credit {#sec-13-csr-35-100.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-100.020}

(Moved to 13 CSR 10-3.020)

13 CSR 35-100.030 Developmental Disability Care Provider Tax Credit {#sec-13-csr-35-100.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 35-100.030}

(Moved to 13 CSR 10-3.030)

Division 40 Family Support Division

Chapter 1 Organization

13 CSR 40-1.010 Organization {#sec-13-csr-40-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-1.010}

PURPOSE:

In accordance with requirements in section 536.023, RSMo, this rule describes the functions and general organization of the Family Support Division of the Department of Social Services.

(1) General Function. The Family Support Division, hereinafter referred to as the division, was established by Executive Order 03– 02 to administer the income maintenance (IM) programs, the child support (CS) program, and rehabilitation services for the blind (RSB) programs for the state, as established by federal and state laws. The legal basis for establishing the division is provided in sections 207.010 and 454.400, RSMo.

(2) Central Office. The division’s central office is located at 615 Howerton Court, PO Box 2320, Jefferson City, MO 65102–2320; telephone: (573) 751–3221; TDD telephone: 1– 800–735–2966; online: www.dss.mo.gov/fsd.

The division director is located at the central office and is responsible for the division’s overall organization, management, policy formulation, and delivery of services, as set forth in federal and state laws and regulations.

(3) IM Programs. The location of each IM office, descriptions of IM services, and access to online services is provided for the public at www.dss.mo.gov and www.dss.mo.gov/fsd.

IM services include:

(A) Programs for food security— 1. Supplemental Nutrition Assistance Program (SNAP), known in Missouri as the Food Stamp Program; and 2. Food Distribution programs;

(B) Programs for children and families— 1. Temporary Assistance;

2. MO HealthNet for Kids;

3. MO HealthNet for Pregnant Women and Newborns;

4. MO HealthNet for Families;

5. Uninsured Women’s Health Service;

6. Child Care Services;

(C) Programs for the aged, blind, and persons with disabilities— 1. MO HealthNet;

2. Nursing Care;

3. Home and Community–Based Services;

4. Prevention of Spousal Impoverishment;

5. Supplemental Aid to the Blind;

6. Blind Pension;

7. Adult Supplemental Payments; and 8. Medicare Cost Savings Programs;

(D) Other income maintenance/self–sufficiency programs and services— 1. Community Services Block Grant (CSBG) Programs;

2. Low Income Home Energy Assistance Program (LIHEAP);

3. Emergency Solutions Grant/Homeless Services;

4. Refugee Resettlement;

5. Emergency management services;

6. Voter registration.

(4) CS Program. The location of each CS office, descriptions of CS services, and access to online services is provided for the public at www.dss.mo.gov and www.dss.mo.gov/cse.

CS services include:

(A) Locating parents;

(B) Paternity establishment for children born to unmarried parents;

(C) Child and medical support order establishment;

(D) Support order enforcement;

(E) Support order review and modification;

(F) Interstate and international child support services if a parent lives in another state or a reciprocating country; and (G) Payment processing through operation of Missouri’s state disbursement unit, the Family Support Payment Center.

(5) RSB Programs. The location of each RSB office, descriptions of RSB services, and information on accessing services is provided for the public at www.dss.mo.gov and www.dss.mo.gov/fsd/rsb. Services include:

(A) Vocational Rehabilitation;

(B) Independent Living Rehabilitation;

(C) Children’s Services;

(D) Older Blind Services;

(E) Transition Services;

(F) Business Enterprise Program; and (G) Prevention of Blindness.

Filed Sept. 21, 2016, effective May 30, 2017. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014.

JOHNR. ASHCROFT(4/30/17)

History

• AUTHORITY: sections 207.020 and 454.400, RSMo 2016. Original rule filed Sept. 2, 1976, effective Dec. 11, 1976. Amended:

Chapter 2 Income Maintenance

13 CSR 40-2.110 Persons Whose Expenses and Income Are Included in Determining {#sec-13-csr-40-2.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.110}

13 CSR 40-2.220 Families Deemed to be Receiving AFDC for Purposes of Title XIX {#sec-13-csr-40-2.220 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.220}

13 CSR 40-2.240 Medicaid Eligibility in General Relief Prior to Application {#sec-13-csr-40-2.240 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.240}

13 CSR 40-2.250 Resource Eligibility Standards for Title XIX Under the Poverty Level {#sec-13-csr-40-2.250 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.250}

13 CSR 40-2.290 Compensation for Legal Representation of General Relief Recipient in Successful Supplemental Security Income Appeal {#sec-13-csr-40-2.290 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.290}

13 CSR 40-2.300 Definitions Which Are Applicable for Benefit Programs Funded by the {#sec-13-csr-40-2.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.300}

13 CSR 40-2.305 Prohibition Against the Payment of Temporary Assistance to a Person {#sec-13-csr-40-2.305 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.305}

13 CSR 40-2.315 Work Activity and Work Requirements for Recipients of Temporary {#sec-13-csr-40-2.315 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.315}

13 CSR 40-2.320 Prohibition Against Displacing Existing Workers Through Work Activities {#sec-13-csr-40-2.320 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.320}

13 CSR 40-2.325 Prohibition Against Payment of Temporary Assistance to Families That {#sec-13-csr-40-2.325 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.325}

13 CSR 40-2.330 Reduction of Temporary Assistance for Noncooperation in Establishing {#sec-13-csr-40-2.330 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.330}

13 CSR 40-2.335 Assignment of Certain Support Rights as a Condition for the Receipt of {#sec-13-csr-40-2.335 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.335}

13 CSR 40-2.340 Prohibition Against Payment of Temporary Assistance to Teenage Parents {#sec-13-csr-40-2.340 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.340}

13 CSR 40-2.345 Prohibition Against Payment of Temporary Assistance to Teenage Parents {#sec-13-csr-40-2.345 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.345}

13 CSR 40-2.355 Prohibition Against Payment of Temporary Assistance Benefits to a Person Found to Have Fraudulently Misrepresented Residence in {#sec-13-csr-40-2.355 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.355}

13 CSR 40-2.360 Prohibition Against Payment of Temporary Assistance to Certain Persons {#sec-13-csr-40-2.360 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.360}

13 CSR 40-2.365 Prohibition Against Payment of Temporary Assistance on Behalf of Minor Children Who Are Absent from the Home for a Significant {#sec-13-csr-40-2.365 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.365}

13 CSR 40-2.370 Requirement that All Recipients for the Payment of Temporary Assistance Shall Complete an Assessment and May Be Required To Complete an {#sec-13-csr-40-2.370 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.370}

13 CSR 40-2.400 Definitions for the Screening and Testing for the Illegal Use of Controlled {#sec-13-csr-40-2.400 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.400}

13 CSR 40-2.410 Screening Temporary Assistance Applicants and Recipients for Illegal Use {#sec-13-csr-40-2.410 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.410}

13 CSR 40-2.420 Testing for the Illegal Use of a Controlled Substance by Applicants and {#sec-13-csr-40-2.420 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.420}

13 CSR 40-2.450 Assignment of a Protective Payee Over Temporary Assistance Benefits When the Head-of-Household is Declared Ineligible for Temporary SOCIAL SERVICES {#sec-13-csr-40-2.450 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.450}

13 CSR 40-2.010 General Application Procedures {#sec-13-csr-40-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.010}

PURPOSE: This rule defines the application procedures for Income Maintenance cases.

Any person shall have the right to file an application included herein for any type of assistance or service administered by the Family Support Division. The Family Support Division shall inform the applicant of the types of assistance and services which are available, the requirements of eligibility, and additional information necessary, if any, to determine eligibility.

(2)

Applications must be approved or denied in accordance with the timeframes established by federal and state law except when— (A) The application is incomplete or is missing information that is necessary to complete an eligibility determination; or (B) The division cannot reach a decision because the applicant or an examining physician delays or fails to provide the information necessary to make an eligibility determination.

(3) Failure to make a decision within the timeframes established by federal and state law does not result in an automatic determination that the applicant is eligible for any type of assistance or service.

(4) Applications submitted by mail, telephone, or any commonly available electronic means shall be accepted and treated the same as an in-person filing of an application.

(5) An application is not considered complete without a signature. Signature shall include electronic, telephonically recorded, and handwritten signatures.

(6) All information provided to the Family Support Division, shall be true, accurate, and complete.

(7) The participant and applicant shall disclose all information which may impact eligibility for any Income Maintenance program.

The participant and applicant have a continuing obligation to notify the division if any information specified in the application changes within ten (10) days of the change.

The continuing duty includes, but is not limited to, disclosing any changes in income of the participant or household member, changes in residence or mailing address, and the addition or removal of any individual from the household whose information is or was required to be submitted.

RSMo 2016.* This version filed March 24, 1976. Previous versions of this rule which were merged to form this rule: 1) Original rule filed Feb. 20, 1947, effective March 2, 1947;

2. Original rule filed Nov. 3, 1950, effective Nov. 13, 1950. Amended: June 20, 1951, effective June 30, 1951. Amended: Sept. 26, 1951, effective Oct. 6, 1951. Amended: June 13, 1974, effective June 23, 1974; 3) Original

rule filed Nov. 3, 1950, effective Nov. 13, 1950. Amended: June 15, 1967, effective June 25, 1967. Amended: June 6, 1968, effective June 16, 1968. Amended: July 1, 1968, effective July 10, 1968. Amended: June 1, 1971, effective June 10, 1971. Amended: June 13, 1974, effective June 23, 1974; and 4) Original

rule filed June 30, 1972, effective July 9, 1972. Amended: March 1, 1973, effective March 10, 1973. Amended: June 13, 1974, effective June 23, 1974. Emergency amendment filed Aug. 3, 1987, effective Aug. 13, 1987, expired Dec. 1, 1987. Amended: Filed Aug. 3, 1987, effective Jan. 14, 1988. Amended: Filed July 31, 2013, effective Feb. 28, 2014. Amended: Filed Sept. 27, 2018, effective May 30, 2019.

13 CSR 40-2.015 Authorized Representatives {#sec-13-csr-40-2.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.015}

PURPOSE: This rule defines the procedures for appointing authorized representatives for participants in MO HealthNet programs and the parameters of their powers and authority. 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) Scope. This regulation defines the procedures for the appointment of an authorized representative for participants in MO Health- Net programs and specifies the parameters of the authorized representative’s powers and

(2) For purposes of this rule, the following terms shall mean:

(A) “Attorney-in-fact” shall mean an individual or corporation appointed to act as agent of a principal in a written power of attorney that may be durable or not durable.

The written power of attorney shall comply with Chapter 404, RSMo;

(B) “Authorized representative” shall mean an individual person at least eighteen (18) years of age or an organization designated by the participant to act on behalf of the participant, the participant’s children, or any members of the MO HealthNet household at any time for any MO HealthNet program;

(C) “Conservator” or “Guardian” shall mean one appointed by a Missouri court under the authority of Chapter 475, RSMo, or if a foreign guardian or conservator is in compliance with the authority of Chapter 475, RSMo, to have the care and custody of the estate of a minor or a disabled person;

(D) “MO HealthNet programs” shall mean the MO HealthNet benefits provided to participants under the MO HealthNet programs including, but not limited to, MO HealthNet for the Aged, Blind, and Disabled (MHABD) program, MO HealthNet for Families (MHF) program, the Adult Expansion Group (AEG) pursuant to Article IV Section 39(c) of the Missouri Constitution, MO HealthNet for Kids (MHK) program, MO HealthNet for Pregnant Women (MPW) program, and Uninsured Women’s Health Services (UWHS) program. MO HealthNet programs also include presumptive eligibility for any of the above programs; and (E) “Participant” shall mean any adult, or emancipated minor individual who has applied for, or is receiving, or has been denied benefits from the MO HealthNet programs administered by the division.

(3) The appointment of an authorized representative shall comply with the following requirements:

(A) A participant must knowingly designate the appointment of an authorized representative;

(B) A participant is permitted at the time of application and at any other time to appoint an authorized representative;

(C) The participant may at any time designate a person or organization to serve as authorized representative by a document that complies with subsection (3)(D) submitted by mail, in-person, facsimile, or electronically.

The appointment of the authorized representative shall be signed by the participant. The appointment may, but is not required to be, on a form provided by the division. The participant’s signature can be handwritten, stamped, electronic, telephonically recorded, or by any other method accepted by the division; and (D) The designation of authorized representative under subsection (3)(C) shall include the following information:

1. The name of the person or organization designated to serve as the authorized representative;

2. The address of the authorized representative and the mailing address of the authorized representative (if different);

3. A phone number for the authorized representative; and 4. An attestation substantially in the following format: “In appointing my authorized representative, I understand that I will be legally bound and responsible for the actions of my appointed representative with respect to my application for or participation in the MO HealthNet program.” The attestation shall also contain or be accompanied by a signed authorization compliant with the Health Insurance Portability and Accountability Act (HIPAA) for the Department of Social Services to release protected health information to the authorized representative.

(4) The division shall not release participant information to an authorized representative until the division has received a HIPAA compliant authorization and designation of authorized representative. This section shall not apply to a request for release of participant information from the participant’s attorney, participant’s spouse, attorney-in-fact, guardian or conservator, or court appointed public administrator.

(5) The participant cannot designate an authorized representative if the participant is incompetent as determined by a court of competent jurisdiction or the participant’s cognitive function is impaired to the extent the participant lacks the ability to make a willful, knowing decision.

(6) An authorized representative designation is void to the extent its creation was induced by fraud, duress, or undue influence or at the time of creation, the participant was incompetent or impaired.

(7) The participant may designate more than one (1) individual or organization to serve as the authorized representative at any given time to assist with MO HealthNet programs.

(8) If the division receives conflicting instructions or information from more than one (1) authorized representative, the division will consult with the authorized representatives to resolve the conflict. The division may also consult directly with and request instructions from the participant or the participant’s court appointed legal guardian or conservator or attorney-in-fact. If the participant is represented by an attorney who has filed a written entry of appearance, the division will consult with the attorney first before consulting with the participant. The division may require the participant, the participant’s guardian or conservator, attorney-in-fact, and/or the authorized representatives to provide documentation, additional information and written confirmation of instructions. The division shall make the final decision resolving the conflict between the authorized representatives where consensus cannot be reached. The division shall issue written findings resolving any factual dispute and issue a written decision. If the individual/applicant is aggrieved by the decision, he/she may request administrative review pursuant to section 208.080, RSMo.

(9) The participant’s designation of an authorized representative by mail, telephone, or any commonly available electronic means, other than social media, shall be accepted and treated the same as an in-person designa tion as long as the designation complies with subsection (3)(D).

(10) A participant shall be bound and liable for all actions taken or facts submitted by any of the participant’s authorized representatives.

(11) The authorized representative shall not make a false statement or misrepresentation, willfully conceal information, or fail to report or disclose any fact or event required to be reported by any law, regulation, or rule of this state or the United States.

(12) If an organization is appointed as an authorized representative— (A) The organization shall provide in writing the name, address, and phone number of an individual within the organization who shall serve as a contact person for the division within ten (10) days of appointment of the organization as the authorized representative, if not provided by the participant. The organization shall notify the division in writing of any change in the name and contact information for the contact person within ten (10) days of the change;

(B) An organization shall provide within ten (10) days upon request by the division written verification that an individual purporting to be a member or employee of the organization acting as an authorized representative is acting within the authority of the organization. The verification shall be provided by another member or employee of the organization and cannot be provided by the individual who is the subject of the request by the division; and (C) As required by 42 CFR 435.923(e), the provider, staff member, or volunteer of the organization shall affirm and agree that, as a condition of serving as an authorized representative, he or she will adhere to section 208.155, RSMo, 42 CFR part 431, sub-

part F, and 45 CFR 155.260(f) (relating to confidentiality of information), 42 CFR 447.10 (relating to the prohibition against reassignment of provider claims as appropriate for a facility or an organization acting on the facility’s behalf), as well as other relevant state and federal laws concerning conflicts of interest and confidentiality of information.

(13) Department of Social Services employees may contact the participant to verify the appointment of an authorized representative, discuss with the participant information provided by the authorized representative, and for any other purposes and, notwithstanding the availability of the authorized representative, may communicate directly with the participant at any time the department deems appropriate.

(14) Subject to the requirements of section (3), the participant may revoke or modify the designation of an authorized representative and appoint another authorized representative to represent him or her at any time. The participant may modify the authority of the authorized representative to act at any time.

To revoke or modify the authority of an authorized representative the participant shall submit a signed and dated statement revoking or modifying the designation of the authorized representative or the authority to act to the division and the authorized representative. The revocation shall be effective on the date that it is received by the division.

(15) No authorized representative shall make willfully false statements, coerce, threaten, or harass any participant who wishes to revoke or modify the authority of the authorized representative in order to prevent or dissuade the individual from revoking or modifying the authorized representative relationship. The division will no longer accept the authorized representative as acting on behalf of the participant should the division determine this has occurred.

(16) The death of the participant shall terminate the authority of the authorized representative to act as of the day of the participant’s death. However, the death of the participant shall not stay the authority of the authorized representative to assist with an application filed with the family support division prior to the participant’s death until the application is approved or rejected and any hearing rights have expired. The death of the participant shall also not stay the authority of the authorized representative to assist with payment of MO HealthNet benefits owed prior to the participant’s death.

(17) An appointment as an authorized representative is non-transferrable and may not be delegated by the individual or the organization acting as an authorized representative to another individual or organization.

(18) A court-appointed legal guardian and/or conservator; a public administrator who has been appointed a participant’s legal guardian; participant’s spouse; an attorney-in-fact; and an attorney at law, authorized to practice in the state of Missouri, may represent a participant and receive information about the participant’s application for a MO HealthNet program or hearing at any stage of the application process without having to submit an authorized representative form, but shall— (A) Notify the division when the authority to represent the participant changes or terminates for any reason. The authority to act as the participant’s representative shall terminate upon death of the participant;

(B) Provide the division in writing a current address, phone number, and e-mail or facsimile number. An attorney shall provide his or her Missouri bar number;

(C) A court-appointed legal guardian or public administrator who has been appointed a participant’s legal guardian shall submit to the division a copy of his or her letters of appointment or a copy of the court order appointing him or her to act as the participant’s legal guardian;

(D) A participant who has a court-appointed guardian and/or conservator cannot revoke or limit the authority of the guardian and/or conservator absent a court order; and (E) An attorney-in-fact shall submit to the division the powers or authority of the attorney-in-fact to represent the participant or act as the authorized representative. An attorneyin-fact other than a durable power of attorney shall not represent the participant or serve as an authorized representative if the authority to so act is not included within the terms of his or her appointment.

(19) This rule hereby incorporates by reference the following provisions and definitions from the Code of Federal Regulations (CFR) listed below as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, DC 20408, and which is located on the website of the U.S. Government Publishing Office at https://www.govinfo.gov/app/collection/CFR.

This rule does not incorporate any subsequent amendments or additions:

(A) 42 CFR 435.923, October 20, 2021;

(B) 42 CFR 431 Subpart F, October 20, 2021;

(C) 45 CFR 155.260, October 20, 2021;

(D) 42 CFR 447.10, October 20, 2021.

History

• authority. This regulation shall only apply to MO HealthNet programs.
• AUTHORITY: sections 207.010, 207.022, 208.991, and 660.017, RSMo 2016. Original rule filed June 30, 2015, effective Dec. 30, 2015. Emergency amendment filed Oct. 5, 2021, effective Oct. 20, 2021, expired April 17, 2022. Amended: Filed Oct. 5, 2021, effective April 30, 2022. Original authority: 207.010, RSMo 1945, amended 1949, 1953, 1973, 2014; 207.022, RSMo 2014; 208.991, RSMo 2013; and 660.017, RSMo 1993, amended 1995.

13 CSR 40-2.020 General Reinvestigation Procedures {#sec-13-csr-40-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.020}

PURPOSE: This rule provides general guidelines for conducting annual reviews (reinvestigations) of a participant’s eligibility for programs administered by the Family Support Division.

(1) The Family Support Division shall reinvestigate all Temporary Assistance, Supplemental Aid to the Blind, Blind Pension, Supplemental Payments, MO HealthNet, and Supplemental Nursing Care cases at least once every twelve (12) months.

(A) The division shall conduct reinvestigations for MO HealthNet, Supplemental Aid to the Blind, Supplemental Payments, and Supplemental Nursing Care in compliance with section 208.990, RSMo and any other federal requirements relevant to these programs that are not referenced by that statute.

(B) Reinvestigations for Blind Pension and Temporary Assistance shall be supplemented by more frequent reinvestigations whenever deemed advisable.

(2) This rule does not apply to the Supplemental Nutrition Assistance Program (SNAP or Food Stamps); however, information obtained from a SNAP recertification, pursuant to 7 CFR 273.14 may be used to complete an annual review under this rule, subject to verification requirements specific to the program that is under review.

(3) Subject to subsection (1)(A) of this rule, and subject to other laws or rules governing the eligibility determination for Blind Pension or Temporary Assistance, if any, the division shall give a participant at least ten (10) days to comply with any request for verification, information, or documentation related to a reinvestigation. If a participant does not comply with such a request within the time period allotted, the division may take action to close the participant’s case.

RSMo 2016.* Original rule filed May 8, 1948, effective May 18, 1948. Amended:

Filed July 20, 1949, effective July 30, 1949.

Amended: Filed Nov. 3, 1950, effective Nov. 13, 1950. Amended: Filed Sept. 26, 1951, effective Oct. 6, 1951. Amended: Filed Nov. 4, 1954, effective Nov. 14, 1954. Amended:

Filed Feb. 27, 1974, effective March 9, 1974.

Amended: Filed Feb. 6, 1975, effective Feb. 16, 1975. Amended: Filed June 1, 1977, effective Sept. 11, 1977. Amended: Filed July 11, 1979, effective Oct. 11, 1979. Amended:

Filed Feb. 9, 1987, effective May 11, 1987.

Amended: Filed Sept. 27, 2018, effective RSMo 1993, amended 1995 .

13 CSR 40-2.030 Definitions Relating to Real and Personal Property {#sec-13-csr-40-2.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.030}

PURPOSE: This rule defines the real and personal property considered in determining eligibility for assistance and how the value of that property is determined.

(1) In determining eligibility for public assistance, the Family Support Division (FSD) shall consider property of any kind or character which the claimant owns or possesses or has an interest in, of which s/he is the record or beneficial owner, less encumbrances of record.

(2) For programs applying the Old Age Assistance (OAA), Permanent and Total Disability (PTD) criteria, and General Relief (GR) applicants and recipients, the home, as referenced in section 208.010, RSMo, is defined as the principal place of residence of the claimant. For town or city property, lots on which there is no dwelling and which adjoin the residence are considered a part of the home (regardless of the number of lots so long as they are in the same city block). For rural property, the acreage on which the home is located plus any adjoining acreage will be considered part of the home. (Property will be considered as adjoining even though a road may separate two (2) tracts.)

(3) In determining eligibility for public assistance and blind pension, the value of real property will be its current market value if sold on the open market. (Original rule filed Nov. 4, 1954, effective Nov. 14, 1954.)

(4) The value of a life insurance policy at any time shall be the cash surrender value of the policy, minus the amount of any lien, loan, accrued interest payments or assigned portion of the policy. (Original rule filed Feb. 20, 1947, effective March 2, 1947.)

(5) Personal property is defined as household goods, jewelry, farm surpluses, livestock, farm or business machinery or equipment, automobiles and trucks, and similar items.

(Original rule filed Feb. 20, 1947, effective March 2, 1947.)

(6) The total amount on deposit in a joint bank account of which the applicant is one of the owners is considered as available to the applicant unless there is verification that the money placed in the account or a definite portion of it belongs to the other joint owner, who is not applying for or receiving public assistance. When both or all the owners of a joint bank account are applying for or receiving assistance, each is considered as owning his/her proportionate share of the account. If the applicant states s/he has not deposited any portion of the money in the account and past circumstances of the applicant indicate that this is reasonable, the total amount on deposit will not be considered as available to the applicant. (Original rule filed Feb. 6, 1975, effective Feb. 16, 1975.)

(7) In those programs applying the OAA, PTD criteria, in GR cases, and in Aid to Families with Dependent Children (AFDC) cases, in certain instances as defined in sections (8)–(13) of this rule, the property will be considered as a resource which the applicant or recipient can and should use in meeting his/her needs and will not be eligible for public assistance. (Original rule filed Feb. 6, 1975, effective Feb. 16, 1975.) The eligibility factor of property as an available resource applies under the OAA criteria to an applicant, recipient, and spouse. In AFDC cases, the policy applies to a child and to a parent(s) or, as allowed by federal law or regulation, to stepparents or, if included in the grant, a needy nonparent caretaker relative or legal guardian with whom the child is living. In cases receiving GR, the policy applies to an applicant or recipient and spouse and children in the home under the age of twenty-one (21). If the GR applicant or recipient is under age twenty-one (21), it applies to his/her parent(s) in the home. In programs applying the PTD criteria, the policy applies to the applicant or recipient and spouse. (Original rule filed Nov. 3, 1950, effective Nov. 13, 1950.

Amended: Oct. 20, 1967, effective Oct. 30, 1967. Amended: July 8, 1969, effective July 18, 1969. Amended: Feb. 6, 1975, effective Feb. 16, 1975.)

(8) When an applicant or recipient of programs applying the OAA, PTD, or Aid to the Blind (AB) criteria, or the spouse with whom s/he lives owns real property which is not furnishing shelter for him/her, its current market value shall be considered an available asset and subject to the limits of section (12) of this regulation. When an applicant or recipient of programs applying the OAA, PTD, or AB criteria is under age eighteen (18) and the parent(s) with whom s/he lives owns real property which is not furnishing shelter for him/her, its current market value shall be considered an available asset and subject to the limits of section (12) of this

regulation. For GR, when an applicant or recipient or the spouse with whom s/he lives owns real property which is not furnishing shelter for him/her, its current market value shall be considered an available asset and subject to the limits of section (13) of this

regulation. When an applicant or recipient of GR is under age twenty-one (21) and the parent(s) with whom s/he lives owns real property which is not furnishing shelter for him/her, its current market value shall be considered an available asset and subject to the limits of section (13) of this regulation. In programs applying the OAA, PTD, AB criteria, or GR, the claimant will not be eligible for assistance on the basis of need; provided, all of the following criteria which apply are met (the value of an equity in a life estate and of burial lots shall be excluded from this computation). For AFDC cases, the limitation will be one thousand dollars ($1000), except that burial lots must be excluded from this computation. If the value of real property does not exceed the asset limits of section (12) or (13) of the rule, it shall be counted as a part of the combination of available resources in determining eligibility.

(A) For real property in which the applicant or recipient has lived— 1. Twenty-four (24) months have elapsed since the last date on which either the claimant or spouse have occupied the dwelling except that the twenty-four (24)month rule will not apply to real property owned by a claimant, spouse, or both, who is a patient in a domiciliary, practical or skilled nursing home, an intermediate care facility (ICF), state hospital or medical institution; the value of this property shall be excluded in determining eligibility on the basis of available resources during the period of time the applicant or recipient is a patient in a nursing home or institution;

2. In the AFDC program, real property in which the applicant/recipient has lived will be counted as a resource the month after the month in which it is vacated for other than a temporary purpose, unless the spouse from whom the claimant is separated and the claimant own the home jointly and the spouse continues to remain in the home. In this case, the home and forty (40) adjoining acres will not be included in determining equity in resources as long as the spouse remains in the home. In the event of divorce, the equity in the property immediately must be considered a resource;

3. If a claimant or couple owns two (2) pieces of property, they shall be required to designate one (1) as their homestead and the other immediately shall be considered as an available resource. Also, when two (2) claimants marry and each owns a home in which s/he has been living, they will be required to designate one (1) of the properties as their homestead, the other immediately shall be considered as an available resource;

4. For programs applying the OAA, PTD criteria and GR applicants and recipients for town or city property, lots on which there is no dwelling and which adjoin the residence are considered a part of the home (regardless of the number of lots so long as they are in the same city block). For AFDC applicants and recipients, the land on which the home is located, up to forty (40) acres, is considered a part of the home so long as the land is adjoining, in the same city block, and there is no other dwelling on the forty (40) acres; or 5. For programs applying the OAA, PTD criteria and GR applicants and recipients, for rural property, the acreage on which the home is located plus any adjoining acreage which is a part of that farming acreage which is a part of that farming unit will be considered as part of the home. For AFDC applicants and recipients, the land on which the home is located, up to forty (40) acres, which is part of that farming unit will be considered as part of the home so long as the land is adjoining and there is no other dwelling on the forty (40) acres. (Property will be considered as adjoining even though a road may separate two (2) tracts, if the property is farmed as a single unit.)

(B) For all other real property—For programs applying the OAA, PTD criteria and GR applicants and recipients, the property is not being used directly by the claimant in the course of his/her business or employment or, if in use, is not producing an annual return consistent with its fair market value. For AFDC applicants and recipients, all other real property will be included in determining the one thousand dollar ($1000) limitation.

(Original rule filed Oct. 24, 1951, effective Nov. 3, 1951. Amended: Nov. 21, 1952, effective Dec. 1, 1952. Amended: July 29, 1959, effective Aug. 29, 1959. Amended: Oct. 19, 1959, effective Oct. 29, 1959. Amended: July 8, 1969, effective July 18, 1969. Amended:

July 23, 1970, effective Aug. 2, 1970.

Amended: Dec. 22, 1972, effective Jan. 1, 1973.)

(9) A single individual applying for or receiving assistance in programs applying the OAA or PTD criteria who owns insurance (over and above the first one thousand five hundred dollars ($1500) in face value) with a cash or loan value of one thousand dollars ($1000) or more through June 30, 2017, will not be considered eligible for assistance on the basis of available resources. Effective July 1, 2017, the cash or loan value in excess of the one thousand five hundred dollars ($1500) shall be considered an available asset and subject to the limits of section (12) of this regulation.

A husband or wife living together may own insurance (over and above the first one thousand five hundred dollars ($1500) each in face value) in any combination with a total cash or loan value up to and including two thousand dollars ($2000) through June 30, 2017. Effective July 1, 2017, the cash or loan value in excess of the one thousand five hundred dollars ($1500) for each spouse shall be considered an available asset and subject to the limits of section (12) of this regulation. In GR cases, the one thousand five hundred dollar ($1500) face value exemption will apply to each person included in the GR case.

When the claimant has deposited money with an individual, firm, or corporation as an advance payment for a funeral and the payment is safeguarded by burial insurance, trust fund, or joint bank account, the amount of money over one thousand five hundred dollars ($1500) deposited under such a plan will be considered a resource in the same manner as the cash or loan value of life insurance policies, if the contract is revocable. If the burial/funeral contract is irrevocable, the entire amount of money deposited will be excluded from available resources. If the claimant has both life insurance and prepaid burial (revocable or irrevocable), the one thousand five hundred dollar ($1500) exemption will apply to either or to any combination. The face value of an irrevocable burial contract will always be counted toward the one thousand five hundred dollar ($1500) exemption. If the cash or loan value of insurance is less than the amounts stated in this

section, it shall be counted as part of the combination of available resources in determining eligibility as stated in section (12) for OAA or PTD, or in section (13) for GR of this rule. An individual applying for or receiving assistance in programs applying the OAA or PTD criteria may designate separately identifiable funds as set aside for burial for the individual or spouse up to a maximum of one thousand five hundred dollars ($1500).

The amount of one thousand five hundred dollars ($1500) shall be reduced by—1) the total face value of insurance policies on the life of the individual or spouse which are owned by him/her or his/her spouse, the cash surrender value of which has been excluded in determining eligibility on available resources as provided in this section and in

section (12) for OAA or PTD, or in section (13) for GR of this rule and 2) the value of any burial/funeral contract on the life of the individual or spouse. When this fund has been designated and all or a portion is excluded in determining available resources eligibility as provided in this section and in section (12) for OAA or PTD, or section (13) for GR of this rule, the interest or appreciation to the excluded portion of this fund (if left to accumulate) also shall be excluded in determining available resources eligibility, starting with interest or appreciation accrued on or after the beginning date of Medicaid eligibility. In AFDC cases, there shall be disregarded any prearranged funeral or burial contract, or any two (2) or more contracts, which provides for the payment of one thousand five hundred dollars ($1500) or less per family member.

The face value of an irrevocable burial contract will always be counted toward the one thousand five hundred dollar ($1500) exemption. In AFDC cases, any family who owns revocable prepaid burials (over and above the first one thousand five hundred dollars ($1500) in equity value) or insurance with cash surrender value over one thousand dollars ($1000) will not be eligible for assistance. If the cash surrender value of revocable prepaid burials (over and above the first one thousand five hundred dollars ($1500) in equity value) or insurance is one thousand dollars ($1000) or less, it shall be counted as a part of the combination of available resources in determining eligibility as stated in section (13) of this rule. (Original rule filed Jan. 1, 1952, effective Jan. 10, 1952.

Amended: July 29, 1959, effective Aug. 29, 1959. Amended: Oct. 19, 1959, effective Oct. 29, 1959. Amended: July 8, 1969, effective July 18, 1969. Amended: July 23, 1970, effective Aug. 2, 1970. Amended: Dec. 22, 1972, effective Jan. 1, 1973.)

(10) In programs applying the OAA, PTD, or AB criteria, and GR cases, salable personal property, such as livestock, farm surplus, jewelry (except wedding and engagement rings owned by claimant or spouse), machinery, automobiles and trucks, and the like, shall be considered as an available resource when the following criteria are present:

(A) In programs applying the OAA, PTD, or AB criteria, and GR cases, the equity based on current market value is one thousand dollars ($1000) or more, or more than two thousand dollars ($2000) in the case of a married person living with spouse. In GR cases involving two (2) or more persons eligible for GR, the limitation is more than two thousand dollars ($2000). Effective July 1, 2017, the equity value for programs applying the OAA, PTD, or AB criteria shall be considered an available asset and subject to the limits of section (12) of this rule;

(B) If personal property is not being used by the claimant in the course of his/her business or employment or, if in use, is not producing an annual return consistent with its fair market value. An automobile or truck will not be considered as an available resource if it provides transportation for any of the following purposes: employment, marketing, school or church attendance, or obtaining medical care;

(C) Household furnishings shall not be considered as available resources unless they are not being used by the applicant, in which case they are subject to the limitations in section (12) for OAA, PTD, or AB criteria, and

section (13) for GR;

(D) Effective July 1, 2017, in programs applying the OAA, PTD, or AB criteria, the first five thousand dollars ($5000) of medical savings accounts and independent living accounts shall be limited to deposits of earned income and earnings on that income while the individual is a participant; and (E) If the value of the personal property is less than the amounts stated in subsections (10)(A)–(D), it shall be counted as a part of the combination of available resources in determining eligibility as stated in section (12) for OAA, PTD, or AB, or section (13) for GR of this rule. (Original rule filed Jan. 11, 1952, effective Jan. 21, 1952. Amended:

Dec. 3, 1952, effective Dec. 13, 1952.

Amended: July 29, 1959, effective Aug. 29, 1959. Amended: Oct. 19, 1959, effective Oct. 29, 1959. Amended: July 8, 1969, effective July 18, 1969. Amended: July 23, 1970, effective Aug. 2, 1970. Amended: Dec. 22, 1972, effective Jan. 1, 1973.)

(11) An AFDC applicant or recipient may not own personal property with equity greater than one thousand dollars ($1000). However the following personal property will not be included in this determination:

(A) Tools, supplies, livestock, farm surplus, and similar items being used by the claimant in the course of his/her business. This does not include business or farm machinery;

(B) Household furnishings, household goods, and personal effects used by the claimant;

(C) The first fifteen hundred dollar ($1500) equity in one (1) automobile; and (D) Wedding and engagement rings and jewelry of limited value.

(12) Any combination of available resources— real property, personal property, cash or securities, or cash surrender or loan value of life insurance (including money deposited in revocable prepaid burials) shall be considered in regards to the asset limits set below. The following asset limits apply to every MHABD program, except Blind Pension, the Breast and Cervical Cancer Treatment program, and the Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) programs:

(A) This subsection identifies the asset limits for MHABD before July 1, 2017.

1. A household that is applying for or receiving MHABD on the basis of being over age sixty-five (65) or permanently and totally disabled does not qualify for MHABD if— A. It is a one- (1-) person household, and the household has countable assets of one thousand dollars ($1,000) or more; or B. It is a two- (2-) person household, and the household has countable assets of two thousand dollars ($2,000) or more.

2. A household that is applying for or receiving MHABD on the basis of being blind does not qualify for MHABD if— A. It is a one- (1-) person household, and the household has countable assets of two thousand dollars ($2,000) or more; or B. It is a two- (2-) person household, and the household has countable assets of four thousand dollars ($4,000) or more;

(B) Effective July 1, 2017, a household is not eligible for MHABD, regardless of whether eligibility is determined based on age, blindness, or permanent and total disability, if it has countable assets at or in excess of the following limits:

(C) Effective July 1, 2021 (Fiscal Year 2022), the asset limit identified in section (5) of this rule shall increase every July thereafter at the same rate as the increase in the cost-of-living percentage of the Consumer Price Index for All Urban Consumers (CPI- U), or its successor, as determined by the U.S. Department of Labor. The asset limit shall be rounded to the nearest five cents (5¢).

1. The percentage increase shall be based on changes in the CPI-U between July of two (2) years prior to the year in which the current fiscal year begins, and July of the immediately preceding year.

A. Example: To determine the asset limit for Fiscal Year 2022 (FY22), the department shall measure the increase in the CPI-U between July 2019 and July 2020. If the CPI-U increased by one percent (1%) during that period, the asset limit for FY22 shall also increase by one percent (1%); and (D) Notwithstanding the provisions of this

section, a person is not eligible for QMB or SLMB if the person’s household has countable assets in excess of the maximum resource level applied for the applicable year under 42 U.S.C. section 1395w-114(a)(3)(D), pursuant to 42 U.S.C. section 1396d(p)(1)(C).

(13) In GR cases, any combination of one thousand dollars ($1000) or more for the applicant or recipient of GR would make that person ineligible (except that a husband and wife or two (2) or more persons in the household eligible for GR could have up to two thousand dollars ($2000) together). In AFDC cases, any combination of more than one thousand dollars ($1000) would make the family ineligible. (Original rule filed Jan. 11, 1952, effective Jan. 21, 1952. Amended: July 29, 1959, effective Aug. 29, 1959. Amended:

Oct. 19, 1959, effective Oct. 29, 1959.

Amended: July 8, 1969, effective July 18, 1969. Amended: July 23, 1970, effective Aug. 2, 1970.)

(14) Notwithstanding the previously mentioned eligibility requirements with respect to resources, the following will apply to individuals meeting the definition of institutionalized spouses who begin a period of continuous institutionalization on or after September 30, 1989:

(A) As used in this section, the definitions for the following terms shall apply:

1. Assessment shall mean a determination by the FSD of the total equity value of available resources (as stated in sections (6)- (13)) owned by the institutionalized spouse, the community spouse, or both, which may be requested at the beginning of a period of continuous institutionalization expected to last at least thirty (30) days or more;

2. Community spouse shall mean the husband or wife of an institutionalized spouse who does not reside in a medical hospital or a Medicaid-certified bed in a nursing facility (NF) and, if the institutionalized spouse is one who meets the definition in subparagraph (14)(A)3.C., the community spouse may not be one who meets those criteria;

3. Institutionalized spouse shall mean a claimant who resides in— A. A medical hospital;

B. A Medicaid-certified bed in an NF, with an expected stay of at least thirty (30) days; or C. His/her own home and is assessed by the Division of Disability and Senior Services as needing both an NF level-of-care as defined in 19 CSR 30-81.030 and home- and community-based waiver services and is assessed to need these services for at least thirty (30) days, and is married to a person who meets the definition of a community spouse in paragraph (14)(A)2.; and 4. Period of continuous institutionalization shall mean a stay in a medical hospital or Medicaid-certified bed in an NF or when the Division of Disability and Senior Services determines a need for home- and communitybased waiver services which is expected to last thirty (30) days or more; and (B) The following shall apply with regard to resource eligibility for institutionalized spouses who begin a period of continuous institutionalization on or after September 30, 1989:

1. When an individual meets the criteria in subparagraph (14)(A)3.C., his/her gross monthly income shall be compared to one thousand twelve dollars ($1,012). If his/her gross monthly income is equal to or less than one thousand twelve dollars ($1,012), the FSD shall complete an assessment of assets as defined in paragraph (14)(B)2. When his/her gross monthly income is greater than one thousand twelve dollars ($1,012), s/he is not eligible for an assessment of assets as defined in paragraph (14)(B)2. The one thousand twelve dollar ($1,012) income limit shall be increased each year effective January 1 in accordance with the Social Security costof-living adjustment (COLA), beginning in 'DWHV(IIHFWLYH 2QH SHUVRQ +RXVHKROG 7ZR SHUVRQ +RXVHKROG -XO\±-XQH -XO\±-XQH -XO\±-XQH -XO\±-XQH 2006;

2. At the beginning of the first period of continuous institutionalization, the institutionalized spouse, the community spouse, or a representative acting on behalf of either may request an assessment by the FSD of total equity in available resources owned by either or both in the month in which the period of institutionalization began or, in the case of an institutionalized spouse who meets the definition in subparagraph (14)(A)3.C. and who met that definition prior to January 1, 1993, January 1993 shall be substituted for the month in which the period of institutionalization began;

3. From this total, the FSD shall compute the spousal share, which shall be the greater of—1) twelve thousand dollars ($12,000) or 2) one-half (1/2) of the total, not to exceed sixty thousand dollars ($60,000). The twelve thousand dollar ($12,000) minimum and the sixty thousand dollar ($60,000) maximum shall be increased each January in accordance with the increase in the Consumer Price Index, beginning in 1990;

4. In determining initial Medicaid eligibility for the institutionalized spouse in this continuous period of institutionalization, the FSD again shall determine the total equity in available resources owned by the institutionalized spouse, the community spouse, or both, at the time of Medicaid request. From this total, the FSD shall deduct the amount of the spousal share as computed in paragraphs (14)(B)2. and 3. If the remainder is equal to or less than the appropriate resource maximum for a single person, the institutionalized individual, to the extent the individual expresses intent to transfer any excess resources to the community spouse, shall be initially eligible for Medicaid on the factor of available resources. Eligibility for Medicaid for individuals described in subparagraph (14)(A)3.C. who become resource eligible using the assessment described in paragraph (14)(B)2. cannot begin prior to the date the individual actually receives home- and community-based waiver services;

5. Any such individual who is determined initially eligible for Medicaid must transfer any resources above the appropriate resource maximum which are held in the individual’s name to the community spouse within ninety (90) days of notification of initial eligibility, unless good cause exists;

6. If good cause does not exist, the FSD shall consider any resources held in the name of the institutionalized spouse, including any jointly-owned resources, in determining continued Medicaid eligibility, effective ninety (90) days after notification of initial eligibility;

7. After the determination of initial eligibility for the institutionalized spouse, no resources of the community spouse not jointly owned with the institutionalized spouse shall be considered available to the institutionalized spouse in Medicaid determinations in that continuous period of institutionalization;

8. If either spouse establishes in a fair hearing that the spousal share (in relation to the amount of income generated by that amount) is inadequate to raise the community spouse’s own income to the amount determined in 13 CSR 40-2.200(5)(A), the spousal share may be adjusted to an amount adequate to provide the additional income. At the fair hearing the maximum amount of the institutionalized spouse’s income that may be made available to the community spouse under 42 U.S.C.1396r-5(d), shall be considered the community spouse’s own income;

9. If a court has entered an order against an institutionalized spouse for the support of the community spouse, the amount of the order shall be substituted for the spousal share.

RSMo 2016.* Filing dates for original rules are shown in the text of the rule. This version filed March 24, 1976. Amended: Filed Feb. 10, 1978, effective May 11, 1978. Emergency amendment filed Feb. 20, 1979, effective March 2, 1979, expired June 10, 1979.

Amended: Filed March 9, 1979, effective June 11, 1979. Emergency amendment filed May 12, 1982, effective May 22, 1982, expired Aug. 11, 1982. Amended: Filed May 12, 1982, effective Aug. 12, 1982. Amended:

Filed March 14, 1983, effective June 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Dec. 30, 1983, expired April 11, 1984. Emergency amendment filed Jan. 13, 1984, effective Jan. 23, 1984, expired April 11, 1984. Amended: Filed Jan. 13, 1984, effective April 12, 1984. Emergency amendment filed Oct. 3, 1984, effective Oct. 13, 1984, expired Jan. 11, 1985. Amended:

Filed Oct. 15, 1984, effective Jan. 12, 1985.

Emergency amendment filed Sept. 24, 1985, effective Oct. 4, 1985, expired Jan. 23, 1986.

Amended: Filed Sept. 24, 1985, effective Dec. 26, 1985. Amended: Filed Sept. 6, 1988, effective Dec. 11, 1988. Emergency amendment filed Sept. 19, 1989, effective Sept. 30, 1989, expired Jan. 27, 1990.

Amended: Filed Nov. 2, 1989, effective Jan. 26, 1990. Emergency amendment filed Dec. 18, 1992, effective Jan. 1, 1993, expired April 30, 1993. Emergency amendment filed Feb. 26, 1993, effective May 1, 1993, expired Aug. 28, 1993. Amended: Filed Dec. 18, 1992, effective June 7, 1993. Emergency amendment filed Dec. 13, 1993, effective Jan. 1, 1994, expired April 30, 1994.

Amended: Filed Dec. 13, 1993, effective July 10, 1994. Emergency amendment filed Dec. 29, 1994, effective Jan. 8, 1995, expired May 7, 1995. Amended: Filed Jan. 12, 1995, effective July 30, 1995. Amended: Filed Sept. 6, 2005, effective April 30, 2006. Emergency amendment filed June 20, 2017, effective July 1, 2017, expired Feb. 22, 2018. Amended:

Filed June 20, 2017, effective Jan. 30, 2018.

Estate of Pearl v. State Division of Welfare, 538 SW2d 922 (Mo. App. 1976). Old Age Assistance benefits were denied plaintiff based on finding of division that assets of recipient in the way of property not furnishing shelter to her were in excess of $2000 limit set by rule of the division. The court held the comparable sales used to determine the value of the property did not provide competent and substantial evidence upon the whole record to support the denial of benefits.

13 CSR 40-2.035 Transfer of Property Emergency rule filed April 10, 1981, effective April 20, 1981, expired June 30, 1981. {#sec-13-csr-40-2.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.035}

13 CSR 40-2.040 Definition of Abandonment of Residence {#sec-13-csr-40-2.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.040}

PURPOSE: This rule defines when a recipient of assistance becomes ineligible due to abandonment of Missouri residence.

(1) When it is known that a recipient of public assistance or Blind Pension has left the state, the Family Support Division shall determine the reason for the absence and, if it is established that the recipient has abandoned his/her Missouri residence, assistance will be discontinued.

RSMo 2016.* Original rule filed Nov. 4, 1954, effective Nov. 14, 1954. Amended:

Filed Sept. 27, 2018, effective

13 CSR 40-2.050 Definition of Earned Income {#sec-13-csr-40-2.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.050}

PURPOSE: This rule defines earned income in order to determine when earned income disregards apply in establishing the amount of payment for which the recipient is eligible.

(1) In applying the earned income exemptions, as stated in section 209.240, RSMo, to an applicant for, or a recipient of, Supplemental Aid to the Blind and as stated in section 208.010, RSMo for an applicant for or recipient of MO HealthNet for the Aged, Blind, and Disabled (MHABD), the following definition of earned income will be used:

(A) The term earned income encompasses income in cash or in kind earned by a needy individual through the receipt of wages, salary, commissions, or profit from activities in which s/he is engaged as a self-employed individual or an employee. The earned income may be derived from his/her own employment, such as business enterprise or farming, or derived from wages or salary received as an employee. It includes earnings over a period of time for which settlement is made at one (1) given time, as in the instance of sale of farm crops, livestock, or poultry. In considering income from farm operation, the option available for reporting under Social Security Disability Income, namely the cash receipts and disbursements method, that is, a record of actual gross, of expenses and of net, is an individual determination and is acceptable also for public assistance. With reference to commissions, wages, or salary, the term earned income means the total amount, irrespective of personal expenses, such as income tax deductions, lunches, and transportation to and from work. With respect to self-employment, the term earned income means the total profit from business enter prise, farming, and the like, resulting from a comparison of the gross income received with the business expenses, that is, total cost of the production of the income. Personal expenses, such as income tax payments, lunches, and transportation to and from work, are not classified as business expenses;

(B) The definition shall exclude the following from earned income: Returns from capital investment with respect to which the individual is not him/herself actively engaged, as in a business (for example, under most circumstances, dividends and interest would be excluded from earned income); and benefits (not in the nature of wages, salary or profit) accruing as compensation or reward for service or as compensation for lack of employment (for example, pensions and benefits such as United Mine Worker’s benefits or veterans benefits); and (C) With regard to the degree of activity, earned income is income produced as a result of the performance of services by a recipient; in other words, income which the individual earns by his/her own efforts, including managerial responsibilities, would be properly classified as earned income, such as management of capital investment in real estate.

Conversely, for example, in the instance of capital investment where the individual carries no specific responsibility, such as where rental properties are in the hands of rental agencies and the check is forwarded to the recipient, the income would not be classified as earned income. In households where a Supplemental Aid to Blind or MHABD claimant is entitled to an income exemption and where other persons are receiving other types of assistance, the exempted income also shall be disregarded in determining the need of the other persons for public assistance.

RSMo 2016.* Original rule filed Sept. 26, 1951, effective Oct. 6, 1951. Amended: Filed Sept. 19, 1961, effective Oct. 13, 1961.

Amended: Filed Oct. 1, 1965, effective Oct. 10, 1965. Amended: Filed Sept. 24, 1970, effective Oct. 4, 1970. Amended: Filed Aug. 8, 2018, effective March 30, 2019. Amended:

Filed Sept. 6, 2019, effective March 30, 2020.

13 CSR 40-2.060 Definitions Relating to AFDC {#sec-13-csr-40-2.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.060}

PURPOSE: This rule defines certain requirements in determining eligibility for Aid to Families with Dependent Children.

(1) Continued absence from the home is defined as absence resulting from any one (1) of the following reasons: divorce; desertion; separation; confinement in a penal, medical or custodial institution; physical restoration; or training program developed by vocational rehabilitation if the plan necessitates absence from the home of the parent.

(2) Home is interpreted to mean a family setting maintained or in the process of being established as evidenced by the assumption or continuance of responsibility for the child.

Usually the child shares the family household with the parent or relative. A home exists as long as the parent or relative takes responsibility for the care and control of the child, even though circumstances may require temporary absence of either the child or the parent (or relative) from the customary family setting. (Original rule filed Feb. 20, 1947, effective March 2, 1947.)

(3) The statement physical or mental defect, illness or disability exists which prevents the parent from performing any substantially gainful activity means that the incapacity is expected to last at least thirty (30) days and is of a debilitating nature as to substantially reduce or eliminate the parent’s ability to support or to care for the child considering the limited employment opportunities of handicapped individuals. This will be met under the following circumstances:

(A) Incapacitated parent working for an employer—the family is eligible if it can be ty, the parent is working substantially less time on the job than an able-bodied person would spend or that s/he is working for a substantially lower wage rate than the usual wage paid for the type of work being done;

(B) Incapacitated parent who is selfemployed—the family is eligible if it can be ty, s/he cannot perform the major activities which his/her job requires;

(C) Incapacitated parent who is unemployed—the family is eligible if it can be ty, s/he is prevented from engaging in fulltime employment on a regular basis at the normal wage rate for that employment; and (D) The parent is receiving Old Age Supplemental Disability Income or Supplemental Security Income benefits on the basis of disability or blindness. (Original rule filed Oct. 24, 1949, effective Nov. 3, 1949. Amended:

Feb. 6, 1975, effective Feb. 16, 1975.)

(4) The relative with whom a dependent child shall be living in order to be eligible for Aid to Dependent Children (ADC) assistance as set forth in section 208.040, RSMo shall be construed to include, in addition to the relatives specifically named in the act: stepfather or stepmother (but not their parents); adoptive father or adoptive mother; grandfatherin-law or grandmother-in-law (meaning the spouse of a second marriage of one the child’s natural grandparents); great-grandfather or great-grandmother; brother or sister of half blood; adoptive brother or adoptive sister; brother-in-law or sister-in-law; uncle or aunt of the half blood; uncle-in-law or aunt-in-law; great-uncle or great-aunt (including great-great-uncle or great-greataunt); and other relatives by adoption, in addition to those specifically mentioned here, may be considered eligible payees within the same degree of relationship as apply to blood relatives. The natural relatives of an adopted child also continue to be eligible payees. As provided in section 208.043, RSMo, a legal guardian of a child also may serve as a payee for ADC and if the legal guardian is otherwise eligible may be eligible for a cash payment. (Original rule filed Sept. 19, 1973, effective Sept. 29, 1973.)

(5) An unemployed parent as used in section 208.041, RSMo is defined as a natural or adoptive parent who meets all of the following criteria:

(A) The parent must be the principal earner. This can be determined by whichever parent, in a home in which both parents of that child are living, earned the greater amount of income in the twenty-four (24)-month period, the last month of which immediately precedes the month in which assistance is requested due to the unemployment of a parent.

1. If primary evidence of earnings for this period cannot be secured, the division shall designate the principal earner, using the best evidence available.

2. The earnings of each parent are considered in determining the principal earner regardless of when their relationship began.

3. The principal earner so defined remains the principal earner for each consecutive month for which the family receives the aid on the basis of application.

4. If both parents earned an identical amount of income (or earned no income) in the twenty-four (24)-month period, the division shall designate which parent shall be the principal earner;

(B) The parent must be employed less than one hundred (100) hours a month; or s/he can exceed that standard for a particular month if the work is intermittent and the excess is of a temporary nature as evidenced by the fact that s/he was under the one hundred (100)-hour standard for the prior two (2) months and is expected to be under the standard during the next month; and (C) The parent who is unemployed must not be unemployed as a result of participation in a strike. 24, 1976. Amended: Filed June 1, 1977, effective Sept. 11, 1977. Emergency amendment filed June 1, 1977, effective July 1, 1977, expired Oct. 31, 1977. Amended: Filed June 29, 1977, effective Oct. 13, 1977.

Emergency amendment filed Nov. 21, 1979, effective Dec. 1, 1979, expired March 12, 1980. Amended: Filed Nov. 21, 1979, effective March 13, 1980. Emergency amendment filed July 10, 1980, effective July 20, 1980, expired Oct. 10, 1980. Amended: Filed July 10, 1980, effective Oct. 11, 1980. Amended:

Filed Feb. 9, 1981, effective May 11, 1981.

Emergency amendment filed July 12, 1982, effective July 22, 1982, expired Oct. 10, 1982. Amended: Filed July 12, 1982, effective Oct. 11, 1982. Amended: Filed June 17, 1983, effective Oct. 13, 1983. Amended:

Filed Jan. 30, 1991, effective July 8, 1991.

Amended: Filed July 15, 1991, effective Nov. 31, 1991.

Rist v. Missouri State Division of Family Services, 595 SW2d (Mo. App. 1980). DFS Income Maintenance Manual required denial of benefits to recipient because she was attending school outside her district.

Since this guideline was inconsistent with pertinent provisions of the Social Security Act, the guideline must fall.

13 CSR 40-2.070 Definitions Relating to General Relief {#sec-13-csr-40-2.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.070}

(Rescinded March 30, 2020)

Part of original rule filed Feb. 20, 1947, effective March 2, 1947 and remaining part of original rule filed Dec. 2, 1971, effective Dec. 12, 1971. Amended: Nov. 22, 1972, effective Dec. 2, 1972. Amended: March 1, 1973, effective March 10, 1973. Amended:

Feb. 6, 1975, effective Feb. 16, 1975. This version filed March 24, 1976. Emergency amendment filed Feb. 20, 1979, effective March 2, 1979, expired June 10, 1979.

Amended: Filed March 9, 1979, effective June 11, 1979. Emergency amendment filed June 22, 1981, effective July 2, 1981, expired Oct. 10, 1981. Amended: Filed June 22, 1981, effective Oct. 11, 1981. Amended:

Filed Dec. 10, 1981, effective March 11, 1982. Amended: Filed Aug. 2, 1985, effective Oct. 26, 1985. Rescinded: Filed Sept. 6, 2019, effective March 30, 2020.

Emily v. Missouri State Division of Family Services, 570 SW2d 783 (Mo. App. 1978).

The transitory use by one relative (claimant) of the living quarters of another (her sister) does not itself render the claimant ineligible for general assistance, since no family support relationship is suggested and the sister cannot be viewed as a “resource” available to the claimant under section 208.010.1, RSMo.

13 CSR 40-2.080 Definitions Relating to Institutions {#sec-13-csr-40-2.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.080}

PURPOSE: This rule defines institutions for the purpose of establishing eligibility for Blind Pension pursuant to Chapter 209, RSMo, MO HealthNet pursuant to Chapter 208, RSMo, and Supplemental Payment programs pursuant to section 208.030, RSMo. 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) Definitions— (A) “Public institution” shall be defined according to the definition in 42 CFR section 435.1010;

(B) “Inmate or resident of a public institution” shall be defined according to the definition of “inmate of a public institution” in 42 CFR section 435.1010.

1. This definition includes, but is not limited to, an inmate serving time for a criminal offense, or who is being confined in a local, state, or federal prison, jail, detention facility, or other penal facility, regardless of adjudication status;

(C) “Patient” shall be defined according to the definition in 42 CFR section 435.1010;

(D) “Medical institution” shall be defined according to the definition in 42 CFR section 435.1010;

(E) “Maintained” shall mean, for purposes of this regulation, a blind person who is “maintained” in a private institution that provides food and shelter to four (4) or more persons unrelated to the proprietor; and (F) “Private institution” shall mean an “institution,” as defined in 42 CFR section 435.1010, that does not meet the definition of a public institution.

(2) Any claimant who is an inmate or resident of a public institution, except as a patient in a medical institution, shall not be eligible for Blind Pension, MO HealthNet, and Supplemental Payment programs.

(3) For purposes of Blind Pension only: Blind persons who are maintained in private or endowed institutions shall not be eligible for the Blind Pension cash payment; however, these persons may qualify for Mo HealthNet if they are otherwise eligible for Blind Pen- ( 4) The provisions and definitions cited by this

rule from the Code of Federal Regulations (CFR) are published on the Electronic Code of Federal Regulations (ECFR) website at https://www.ecfr.gov/cgi-bin/textidx?rgn=div5;node=42%3A4.0.1.1.6#se42 .4.435_11010 and are hereby incorporated by reference and made part of this rule as published by the office of Federal Register, National Archives and Records Administration, Washington, DC 20408, February 6, 2020. This rule does not incorporate any subsequent amendments or additions.

RSMo 2016.* Original rule filed May 13, 1948, effective May 23, 1948. Amended:

Filed Nov. 4, 1954, effective Nov. 14, 1954;

Original rule filed May 13, 1948, effective May 23, 1948. Amended: Filed Nov. 4, 1954, effective Nov. 14, 1954; Original rule filed Sept. 26, 1951, effective Oct. 6, 1951 and original rule filed Sept. 26, 1951, effective Oct. 6, 1951. Amended: Filed July 24, 1953, effective Oct. 4, 1953. Amended: Filed Nov. 20, 1967, effective Nov. 30, 1967. Combining these four (4) rules filed March 24, 1976.

Amended: Filed Sept. 22, 2017, effective May 30, 2018. Amended: Filed Feb. 7, 2020, effective Aug. 30, 2020.

13 CSR 40-2.090 Definitions Relating to Money Payments {#sec-13-csr-40-2.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.090}

(Rescinded March 30, 2019) 24, 1976. Amended: Filed Oct. 21, 1980, effective Feb. 12, 1981. Rescinded: Filed July 19, 2018, effective March 30, 2019.

13 CSR 40-2.100 Definitions Relating to PTD {#sec-13-csr-40-2.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.100}

PURPOSE: This rule defines permanently and totally disabled.

(1) Permanent and Total Disability (PTD) means that the individual has some physical or mental impairment, disease or loss from which recovery or substantial improvement cannot be expected and which substantially precludes him/her from engaging in any occupation within his/her competence, such as holding a job or homemaking.

RSMo 2016.* Original rule filed Nov. 1, 1950, effective Nov. 11, 1950. Amended:

Filed Aug. 8, 2018, effective March 30, 2019.

Crudup v. Missouri State Division of Family Services 600, SW2d 129 (Mo. App. 1980). In applying the definition of permanent and total disability found at 13 CSR 40-2.100, the agency must conform its decision to its own interpretation of a promulgated rule given effect as a policy. Also, this agency policy may be used to assist the reviewing court.

13 CSR 40-2.110 Persons Whose Expenses and Income Are Included in Determining Cash Payments {#sec-13-csr-40-2.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.110}

PURPOSE: This rule outlines those persons whose income and expenses must be included in determining the amount of the cash payment.

(1) The requirements of the following persons who are members of the household shall be included in the Aid to Families with Dependent Children (AFDC) grant: eligible children under the age of eighteen (18) or age eighteen (18) and in secondary school or the equivalent vocational or technical school if expected to graduate before or in the month the child turns nineteen (19), natural or adoptive parents of one (1) or more of the eligible children and any needy nonparent caretaker relative or related or unrelated guardian. The nonparent caretaker relative or the guardian, if found to be eligible for inclusion, has the option to be excluded from the assistance group. (Original rule filed April 12, 1948, effective April 22, 1948. Amended: Oct. 20, 1967, effective Oct. 30, 1967. Amended: Oct. 17, 1969, effective Oct. 27, 1969. Amended:

Feb. 6, 1975, effective Feb. 16, 1975.)

(A) When a person in an AFDC household meets eligibility requirements for AFDC and Supplemental Aid to the Blind (SAB) or Blind Pension (BP), the person must receive AFDC and will be ineligible for SAB or BP.

1. No special Aid to the Blind (AB) or BP expenses nor AB or BP income exemptions will be allowed in determining eligibility for AFDC.

2. If the AFDC household is determined to be ineligible, that person may apply as a single SAB or BP applicant and, if eligible, that person may receive SAB or BP only.

(2) The requirements of the following members of the household shall be included in the General Relief grant: applicant or recipient and his/her spouse and any children living in the home under age twenty-one (21). If the applicant or recipient is under twenty-one (21), the requirements of his/her parent(s) living in the home also shall be included.

April 22, 1948. Amended: Feb. 6, 1975, effective Feb. 16, 1975.)

(3) The requirements of the AB applicant or recipient only shall be included in the AB grant. (Original rule filed Sept. 26, 1951, effective Oct. 6, 1951. Amended: Oct. 20, March 19, 1969, effective March 29, 1969.) 24, 1976. Emergency amendment filed June 1, 1977, effective July 1, 1977, expired Oct. 31, 1977. Amended: Filed June 29, 1977, effective Oct. 13, 1977. Emergency amendment filed Feb. 20, 1979, effective March 2, 1979, expired June 10, 1979. Amended: Filed March 9, 1979, effective June 11, 1979.

Emergency amendment filed Feb. 19, 1982, effective March 1, 1982, expired June 10, 1982. Amended: Filed Feb. 19, 1982, effective June 11, 1982.

13 CSR 40-2.120 Methods Used to Determine the Amount of Cash Payments {#sec-13-csr-40-2.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.120}

PURPOSE: This rule outline the methods used to determine the correct amount of cash payments in the various assistance programs.

(1) The budgetary method is used in establishing eligibility for and the extent of need for public assistance. This requires the determination of the needs of the individual or groups of individuals who may be affected by the receipt of assistance, the determination of income and resources available to these persons and, if income and resources are not sufficient to provide a reasonable subsistence compatible with decency and health, the planning of assistance to meet the deficit.

April 22, 1948.)

(2) Consideration of Available Income.

(A) In Aid to Dependent Children (ADC) cases, all income of the following persons who are in the household shall be considered in determining whether the children (includ ing stepchild and adopted child) are in need and, if so, the amount of the need-eligible children; natural or adoptive parents of one (1) or more of the eligible children; any needy nonparent caretaker relative or related or unrelated guardian if they desire to be included in the assistance group and are eligible for inclusion; a stepparent, in accordance with

Section 402(a)(31) of the Social Security Act; and any blood or adoptive brother or sister of an eligible child, if that brother or sister meets the conditions described in clauses (1) and (2) of Section 406(a) of the Social Security Act and is living in the home. This income shall be included notwithstanding

Section 205(j) of the Social Security Act in the case of benefits provided under Title II.

With respect to an eligible child who is living with a parent or legal guardian who is under age nineteen (19), the income of this minor’s own parents or legal guardians who are living in the home shall be included to the same extent that the income of a stepparent is included in accordance with 402(a)(31) of the Social Security Act. Income of all other persons in the household will be considered in the amount made available to the household.

(B) In Aid to the Blind (AB) cases, all income of the applicant or recipient shall be considered in determining whether the applicant or recipient is in need, and, if so, the amount of that need. The income of any other person in the household will be considered only in the amount made available to the AB applicant or recipient.

(C) In computing the income of an applicant or recipient, or of the household of which s/he is a member, only that income which is available during the period under consideration shall be taken into account. To be considered as available, the income shall actually and presently exist (not to be a potential or remote income) and shall be sufficient to have some appreciable significance in meeting the immediate requirements of the applicant or recipient. The following will not be considered in determining eligibility: in Aid to Families with Dependent Children (AFDC) cases, the first fifty dollars ($50) of monthly child support payments; home produce raised or used by the applicant or recipient for consumption by the family, and loans made under conditions which preclude their use for meeting current living costs. (Original rule filed April 12, 1948, effective April 22, 1948. Amended: Feb. 6, 1975, effective Feb. 16, 1975.)

(3) Each budget shall include provision in an amount per month as established by the Family Support Division which represents the average of all individual need items formally budgeted (except day care expenses) for each size AFDC assistance group and for the Supplemental Aid to the Blind (SAB) need eligibility budget and will be referred to as the AFDC, and SAB Consolidated Standard.

(A) The Consolidated Standard for each size AFDC assistance group and for the SAB budget shall be as follows:

1. AFDC:

Assistance Consolidated Group Size Standard 1 $ 393.00 2 $ 678.00 3 $ 846.00 4 $ 990.00 5 $1123.00 6 $1247.00 7 $1372.00 8 $1489.00 9 $1606.00 10 $1722.00 11 $1839.00 12* $1956.00 *For any AFDC assistance group larger than twelve (12), add one hundred sixteen dollars ($116) per individual.

2. SAB: The Consolidated Standard of three hundred dollars ($300) implemented February 16, 1976 will be used as a base amount. Beginning January 1, 1985, but including the Old Age Supplemental Disability Income (OASDI) increases of July 1982 and January 1984, whenever OASDI benefits under Title II of the Social Security Act are increased, the SAB Consolidated Standard also shall be increased. The amount of the increase shall be determined by adding the same percentage increase to the last Consolidated Standard amount as was added to Title II benefits and rounding the result to the next highest dollar. When an SAB claimant is a member of Temporary Assistance to Needy Families (TANF) assistance group, there shall be added one hundred dollars ($100) to the TANF assistance group size Consolidated Standard. This amount represents the following special additional allowances: Food— twelve dollars ($12); clothing—eight dollars ($8); personal incidentals— eleven dollars ($11); shopping and errand expense—fifteen dollars ($15); laundry and dry cleaning expense—fifteen dollars ($15); household incidentals—ten dollars ($10); transportation—nine dollars ($9); preparation of food— five dollars ($5); and cost for a seeing eye dog or other guide—fifteen dollars ($15).

April 22, 1948. Amended: May 18, 1966, effective May 28, 1966. Amended: Oct. 20, Dec. 2, 1968, effective Dec. 12, 1968.

Amended: Dec. 22, 1975, effective Jan. 1, 1976.)

(4) Assistance recipients sixty-five (65) years of age or over will be expected to use fully the medical care benefits that are available to them through Title XVIII B of the federal Social Security law; however, the deductibles and coinsurance costs will be paid by the Family Support Division by means of vendor payments. Assistance recipients over age sixty-five (65) who have exhausted their Title XVIII benefits and eligible assistance recipients under age sixty-five (65) will be eligible for vendor payments on their behalf for the medical care benefits as specified in section 208.151, RSMo; this includes benefits for eligible recipients who are in a state mental institution or a state tuberculosis hospital.

April 22, 1948. Amended: May 18, 1966, effective May 28, 1966. Amended: Oct. 20, Sept. 24, 1970, effective Oct. 4, 1970.Amended: May 7, 1971, effective May 17, 1971. Amended: June 18, 1971, effective June 28, 1971. Amended: Feb. 6, 1975, effective Feb. 16, 1975. Amended: Dec. 22, 1975, effective Jan. 1, 1976.)

(5) In the payment of public assistance benefits, the amount shall be rounded to the nearest dollar interval. For all benefits other than AFDC, payment amounts ending in less than fifty cents (50¢) shall be lowered to the nearest dollar and amounts ending in fifty cents (50¢) or over shall be increased to the nearest dollar. In AFDC cases, payment amounts will always be lowered to the nearest dollar. If the determined need results in a grant of less than ten dollars ($10) in AFDC cases, no cash payment will be made. (Original rule filed April 12, 1948, effective April 22, 1948.)

(6) Earned Income Exemption—AFDC.

(A) In determining need and amount of grant for applicants or recipients of AFDC, the following earned income exemptions will apply and these amounts will be disregarded in determining the amount of income available to meet the family’s needs:

1. All of the earned income of any child receiving AFDC will be exempted if the child is a full-time student or is a part-time student who is not a full-time employee;

2. The first ninety dollars ($90) of the gross earned income will be disregarded from employment;

3. An amount equal to thirty dollars ($30) of the total of earned income not already disregarded in the preceding provisions of this subsection (6)(A), for an eight- (8-) month period following the fourth consecutive month of the disregard provided for in this paragraph, but excluding, for purposes of this subsection, earned income derived from participation on a project maintained under the programs established by Section 432(b)(2) and (3) of the Social Security Act;

4. An amount equal to the first thirty dollars ($30) of the total of earned income not already disregarded in the preceding provisions of paragraph (6)(A)3. plus one-third (1/3) of the remainder but excluding, for purposes of this subsection, earned income derived from participation on a project maintained under the programs established by

Section 432(b)(2) and (3) of the Social Security Act; and 5. An amount equal to expenditures for care in that month shall be disregarded from earned income for a dependent child, or an incapacitated individual living in the same home as the dependent child, receiving AFDC and requiring care for that month, to the extent that the amount for each dependent child or incapacitated individual does not exceed one hundred seventy-five dollars ($175) for children age two (2) and over or two hundred dollars ($200) for children under two (2) years of age.

(B) The disregards applied against earned income outlined in subsection (6)(A) shall not be applied to the earned income of any person who— 1. Terminated his/her employment or reduced his/her earned income without good cause within the period (of not less than thirty (30) days) preceding that month as may be prescribed by the secretary of the United States Department of Health and Human Services (HHS);

2. Refused without good cause, within the thirty- (30-) day period or longer period prescribed by the secretary of the United States Department of HHS, to accept employment in which s/he is able to engage which is offered through the public employment offices of the state, or is otherwise offered by an employer if the offer of the employer is determined by the Family Support Division or agency designated by the Family Support Division, after notification by the employer, to be a bona fide offer of employment; and 3. Failed without good cause to make a timely report to the Family Support Division of earned income received in that month.

(C) The disregard applied against earned income, as provided for— 1. In paragraph (6)(A)1., shall be applied when determining need for up to six (6) months within the calendar year of January through December and after that shall not be applied if the income without applying this need;

2. In paragraph (6)(A)3., shall not be applied if the income without applying this need unless the person received AFDC in one (1) or more of the four (4) months preceding that month and this disregard has not already been applied to his/her income for four (4) consecutive months while s/he was receiving AFDC. If this disregard provided for in paragraph (6)(A)3. has been applied for four (4) consecutive months, the disregard shall not be applied for as long as the person continues to receive AFDC and shall not apply until the expiration of a period of twelve (12) consecutive months during which the person is not a recipient of AFDC; and 3. In paragraph (6)(A)4., shall be available only for the eight- (8-) month period following the fourth consecutive month of the disregard provided for in paragraph (6)(A)3.

If the eight- (8-) month period for the disregard provided for in paragraph (6)(A)4. has expired, the disregard shall not be applied for as long as the person continues to receive AFDC and shall not apply until the expiration of a period of twelve (12) consecutive months during which the person is not a recipient of AFDC.

(7) No family shall be eligible for AFDC if, for that month, the total income of the family (other than AFDC benefits) without application of the earned income disregards provided for in paragraphs (6)(A)2.–5. and for up to six (6) months within the calendar year of January through December with application of the earned income disregard provided for in paragraph (6)(A)1. exceeds one hundred eighty-five percent (185%) of Missouri’s standard of need for a family of the same composition.

(8) A standard amount for expenses of producing earned income will be budgeted for each member of the SAB assistance group who has earned income to include allowances for all federal and state income tax and Retirement, Survivor’s, and Disability Insurance (RSDI) withholdings. An additional standard for costs of union dues, extra food, clothing, personal expense, transportation to and from work, and other employment connected personal incidental costs will also be budgeted for each member of the SAB assistance group who has earned income. The standard amounts, in direct relationship to varying increments of gross monthly earnings and number of dependents, will be budgeted.

If the actual expenses exceed the standard amount included for union dues, extra food, clothing, personal expense, transportation to and from work, or other employment connected personal incidental costs, the actual expenses will be used.

Pers. Exps. 35–40 2.66 2.66 2.66 2.66 2.66 2.66 2.66 2.66 2.66 4.00 40.01–45 2.99 2.99 2.99 2.99 2.99 2.99 2.99 2.99 2.99 4.50 45.01–50 3.33 3.33 3.33 3.33 3.33 3.33 3.33 3.33 3.33 5.00 50.01–55 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 3.66 5.50 55.01–60 3.99 3.99 3.99 3.99 3.99 3.99 3.99 3.99 3.99 6.00 60.01–65 4.32 4.32 4.32 4.32 4.32 4.32 4.32 4.32 4.32 6.50 65.01–70 4.66 4.66 4.66 4.66 4.66 4.66 4.66 4.66 4.66 7.00 70.01–75 4.99 4.99 4.99 4.99 4.99 4.99 4.99 4.99 4.99 7.50 75.01–80 5.32 5.32 5.32 5.32 5.32 5.32 5.32 5.32 5.32 8.00 80.01–85 5.65 5.65 5.65 5.65 5.65 5.65 5.65 5.65 5.65 8.50 85.01–90 5.99 5.99 5.99 5.99 5.99 5.99 5.99 5.99 5.99 9.00 90.01–95 6.32 6.32 6.32 6.32 6.32 6.32 6.32 6.32 6.32 9.50 95.01–100 6.65 6.65 6.65 6.65 6.65 6.65 6.65 6.65 6.65 10.00 100.01–105 6.98 6.98 6.98 6.98 6.98 6.98 6.98 6.98 6.98 10.50 105.01–110 7.32 7.32 7.32 7.32 7.32 7.32 7.32 7.32 7.32 11.00 110.01–115 7.65 7.65 7.65 7.65 7.65 7.65 7.65 7.65 7.65 11.50 115.01–120 7.98 7.98 7.98 7.98 7.98 7.98 7.98 7.98 7.98 12.00 120.01–125 8.31 8.31 8.31 8.31 8.31 8.31 8.31 8.31 8.31 12.50 125.01–130 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 8.65 13.00 130.01–135 8.98 8.98 8.98 8.98 8.98 8.98 8.98 8.98 8.98 13.50 135.01–140 9.31 9.31 9.31 9.31 9.31 9.31 9.31 9.31 9.31 14.00 140.01–145 9.64 9.64 9.64 9.64 9.64 9.64 9.64 9.64 9.64 14.50 145.01–150 9.98 9.98 9.98 9.98 9.98 9.98 9.98 9.98 9.98 15.00 150.01–155 10.31 10.31 10.31 10.31 10.31 10.31 10.31 10.31 10.31 15.50 155.01–160 10.64 10.64 10.64 10.64 10.64 10.64 10.64 10.64 10.64 16.00 160.01–165 10.97 10.97 10.97 10.97 10.97 10.97 10.97 10.97 10.97 16.50 165.01–170 11.31 11.31 11.31 11.31 11.31 11.31 11.31 11.31 11.31 17.00 170.01–175 11.64 11.64 11.64 11.64 11.64 11.64 11.64 11.64 11.64 17.50 175.01–180 11.97 11.97 11.97 11.97 11.97 11.97 11.97 11.97 11.97 18.00 180.01–185 12.30 12.30 12.30 12.30 12.30 12.30 12.30 12.30 12.30 18.50 185.01–190 12.64 12.64 12.64 12.64 12.64 12.64 12.64 12.64 12.64 19.00 190.01–195 12.97 12.97 12.97 12.97 12.97 12.97 12.97 12.97 12.97 19.50 195.01–200 13.40 13.30 13.30 13.30 13.30 13.30 13.30 13.30 13.30 20.00 200.01–205 14.34 13.64 13.64 13.64 13.64 13.64 13.64 13.64 13.64 20.50 205.01–210 15.26 13.96 13.96 13.96 13.96 13.96 13.96 13.96 13.96 21.00 210.01–215 16.20 14.30 14.30 14.30 14.30 14.30 14.30 14.30 14.30 21.50 215.01–220 17.73 14.63 14.63 14.63 14.63 14.63 14.63 14.63 14.63 22.00 220.01–225 18.66 14.96 14.96 14.96 14.96 14.96 14.96 14.96 14.96 22.50 225.01–230 19.60 15.30 15.30 15.30 15.30 15.30 15.30 15.30 15.30 23.00 230.01–235 20.53 15.63 15.63 15.63 15.63 15.63 15.63 15.63 15.63 23.50 235.01–240 22.36 15.96 15.96 15.96 15.96 15.96 15.96 15.96 15.96 24.00 240.01–245 22.69 16.29 16.29 16.29 16.29 16.29 16.29 16.29 16.29 24.50 245.01–250 24.23 16.63 16.63 16.63 16.63 16.63 16.63 16.63 16.63 25.00 250.01–255 24.56 16.96 16.96 16.96 16.96 16.96 16.96 16.96 16.96 25.50 255.01–260 26.09 17.29 17.29 17.29 17.29 17.29 17.29 17.29 17.29 26.00 260.01–265 27.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 17.62 26.50 265.01–270 27.95 17.95 17.95 17.95 17.95 17.95 17.95 17.95 17.95 27.00 270.01–275 29.49 18.29 18.29 18.29 18.29 18.29 18.29 18.29 18.29 27.50 275.01–280 31.02 18.62 18.62 18.62 18.62 18.62 18.62 18.62 18.62 28.00 280.01–285 31.35 18.95 18.95 18.95 18.95 18.95 18.95 18.95 18.95 28.50 285.01–290 32.89 20.39 19.29 19.29 19.29 19.29 19.29 19.29 19.29 29.00 290.01–295 33.21 20.71 19.61 19.61 19.61 19.61 19.61 19.61 19.61 29.50 295.01–300 34.75 22.25 19.95 19.95 19.95 19.95 19.95 19.95 19.95 30.00 Pers. Exps. 300.01–305 36.29 23.79 20.29 20.29 20.29 20.29 20.29 20.29 20.29 30.50 305.01–310 36.61 24.11 20.61 20.61 20.61 20.61 20.61 20.61 20.61 31.00 310.01–315 38.15 25.65 20.95 20.95 20.95 20.95 20.95 20.95 20.95 31.50 315.01–320 40.08 27.18 21.28 21.28 21.28 21.28 21.28 21.28 21.28 32.00 320.01–325 40.41 27.51 21.61 21.61 21.61 21.61 21.61 21.61 21.61 32.50 325.01–330 41.95 29.05 21.95 21.95 21.95 21.95 21.95 21.95 21.95 33.00 330.01–335 42.28 29.38 22.28 22.28 22.28 22.28 22.28 22.28 22.28 33.50 335.01–340 43.81 30.91 22.61 22.61 22.61 22.61 22.61 22.61 22.61 34.00 340.01–345 45.65 32.81 22.94 22.94 22.94 22.94 22.94 22.94 22.94 34.50 345.01–350 45.99 33.15 23.28 23.28 23.28 23.28 23.28 23.28 23.28 35.00 350.01–355 47.52 34.68 23.61 23.61 23.61 23.61 23.61 23.61 23.61 35.50 355.01–360 49.15 36.21 23.94 23.94 23.94 23.94 23.94 23.94 23.94 36.00 360.01–365 49.48 36.54 24.27 24.27 24.27 24.27 24.27 24.27 24.27 36.50 365.01–370 51.31 38.07 25.20 24.60 24.60 24.60 24.60 24.60 24.60 37.00 370.01–375 51.99 38.74 25.89 24.94 24.94 24.94 24.94 24.94 24.94 37.50 375.01–380 53.72 40.27 27.42 25.27 25.27 25.27 25.27 25.27 25.27 38.00 380.01–385 55.45 41.80 28.95 25.60 25.60 25.60 25.60 25.60 25.60 38.50 385.01–390 55.79 42.14 29.29 25.94 25.94 25.94 25.94 25.94 25.94 39.00 390.01–395 57.61 43.66 30.81 26.26 26.26 26.26 26.26 26.26 26.26 39.50 395.01–400 60.80 46.43 33.57 26.92 26.60 26.60 26.60 26.60 26.60 40.00 400.01–405 61.14 46.77 33.91 27.26 26.94 26.94 26.94 26.94 26.94 40.50 405.01–410 61.46 47.09 34.23 27.58 27.26 27.26 27.26 27.26 27.26 41.00 410.01–415 61.80 47.43 34.57 27.92 27.60 27.60 27.60 27.60 27.60 41.50 415.01–420 65.73 50.76 37.90 28.25 27.93 27.93 27.93 27.93 27.93 42.00 420.01–425 66.48 51.43 38.56 28.91 28.52 28.26 28.26 28.26 28.26 42.50 425.01–430 66.82 51.77 38.90 29.25 28.86 28.60 28.60 28.60 28.60 43.00 430.01–435 67.15 52.10 39.23 29.58 29.19 28.93 28.93 28.93 28.93 43.50 435.01–440 71.08 55.63 42.56 29.91 29.52 29.26 29.26 29.26 29.26 44.00 440.01–445 71.41 55.96 42.89 30.24 29.85 29.59 29.59 29.59 29.59 44.50 445.01–450 72.17 56.74 43.58 30.90 30.56 29.93 29.93 29.93 29.93 45.00 450.01–455 72.50 57.07 43.91 31.23 30.89 30.26 30.26 30.26 30.26 45.50 455.01–460 76.43 61.00 47.24 34.36 31.22 30.59 30.59 30.59 30.59 46.00 460.01–465 76.76 61.33 47.57 34.69 31.55 30.92 30.92 30.92 30.92 46.50 465.01–470 77.09 61.66 47.90 35.02 31.88 31.25 31.25 31.25 31.25 47.00 470.01–475 77.86 62.42 48.67 35.71 32.54 32.13 31.59 31.59 31.59 47.50 475.01–480 81.79 66.35 52.00 39.04 32.87 32.46 31.92 31.92 31.92 48.00 480.01–485 82.12 66.68 52.33 39.37 33.20 32.79 32.25 32.25 32.25 48.50 485.01–490 82.46 67.02 52.67 39.71 33.54 33.13 32.59 32.59 32.59 49.00 490.01–495 82.78 67.34 52.99 40.03 33.86 33.45 32.91 32.91 32.91 49.50 495.01–500 86.72 71.28 56.33 43.37 34.20 33.79 33.25 33.25 33.25 50.00 500.01–505 87.55 72.05 57.10 44.14 34.87 34.51 34.02 33.59 33.59 50.50 505.01–510 87.87 72.37 57.42 44.46 35.19 34.83 34.34 33.91 33.91 51.00 510.01–515 88.21 72.71 57.76 44.80 35.53 35.17 34.68 34.25 34.25 51.50 515.01–520 92.14 76.64 61.19 48.13 35.86 35.50 35.01 34.58 34.58 52.00 520.01–525 92.47 76.97 61.52 48.46 36.19 35.83 35.34 34.91 34.91 52.50 525.01–530 93.34 77.78 62.29 49.24 36.97 36.53 36.06 35.57 35.25 53.00 530.01–535 93.67 78.11 62.62 49.57 37.30 36.86 36.39 35.90 35.58 53.50 535.01–540 97.60 82.04 66.55 52.90 39.93 37.19 36.72 36.23 35.91 54.00 540.01–545 97.93 82.37 66.88 53.23 40.26 37.52 37.05 36.56 36.24 54.50 545.01–550 98.27 82.71 67.22 53.57 40.60 37.86 37.39 36.90 36.58 55.00 550.01–555 99.13 83.58 68.03 54.32 41.37 38.60 38.11 37.60 37.12 55.50 555.01–560 103.06 87.51 71.96 57.65 44.70 38.93 38.44 37.93 37.45 56.00 560.01–565 103.39 87.84 72.29 57.98 45.03 39.26 38.77 38.26 37.78 56.50 565.01–570 103.72 88.17 72.62 58.31 45.36 39.59 39.10 38.59 38.11 57.00 Pers. Exps. 570.01–575 104.06 88.51 72.96 58.65 45.70 39.93 39.44 38.93 38.45 57.50 575.01–580 108.52 92.97 77.41 62.47 49.46 40.69 40.23 39.67 39.16 58.00 580.01–585 108.85 93.30 77.74 62.80 49.79 41.02 40.56 40.00 39.49 58.50 585.01–590 109.19 93.64 78.08 63.14 50.13 41.36 40.90 40.34 39.83 59.00 590.01–595 109.51 93.96 78.40 63.46 50.45 41.68 41.22 40.66 40.15 59.50 595.01–600 115.25 99.70 84.14 68.60 55.29 42.32 41.56 41.00 40.49 60.00 600.01–605 116.18 100.57 85.02 69.47 56.12 43.10 42.34 41.80 41.23 60.50 605.01–610 116.50 100.89 85.34 69.79 56.44 43.42 42.66 42.12 41.55 61.00 610.01–615 116.84 101.23 85.68 70.13 56.78 43.76 43.00 42.46 41.89 61.50 615.01–620 117.16 101.55 86.00 70.45 57.10 44.08 43.32 42.78 42.21 62.00 620.01–625 117.50 101.89 86.34 70.79 57.44 44.42 43.66 43.12 42.55 62.50 625.01–630 117.84 102.23 86.68 71.13 57.78 44.76 44.00 43.46 42.89 63.00 630.01–635 118.81 103.15 87.55 71.99 58.63 45.56 44.75 44.29 43.64 63.50 635.01–640 126.64 110.68 95.08 79.52 64.96 51.89 45.08 44.62 43.97 64.00 640.01–645 126.97 111.01 95.41 79.85 65.29 52.22 45.41 44.95 44.30 64.50 645.01–650 127.31 111.35 95.75 80.19 65.63 52.56 45.75 45.29 44.64 65.00 650.01–655 127.64 111.68 96.08 80.52 65.96 52.89 46.08 45.62 44.97 65.50 655.01–660 128.62 112.65 97.00 81.38 66.92 53.77 46.88 46.39 45.82 66.00 660.01–665 128.95 112.98 97.33 81.71 67.15 54.10 47.21 46.72 46.15 66.50 665.01–670 129.28 113.31 97.66 82.04 67.48 54.43 47.54 47.05 46.48 67.00 670.01–675 129.62 113.65 98.00 82.38 67.82 54.77 47.88 47.39 46.82 67.50 675.01–680 138.35 121.18 105.53 89.91 74.35 61.10 48.21 47.72 47.15 68.00 680.01–685 139.29 122.14 106.48 90.82 75.23 61.96 49.09 48.50 47.99 68.50 685.01–690 139.63 122.48 106.82 91.16 75.57 62.30 49.43 48.84 48.33 69.00 690.01–695 139.95 122.80 107.14 91.48 75.89 62.62 49.75 49.16 48.65 69.50 695.01–700 140.29 123.14 107.48 91.82 76.23 62.96 50.09 49.50 48.99 70.00 700.01–705 140.63 123.48 107.82 92.16 76.57 63.30 50.43 49.84 49.33 70.50 705.01–710 141.63 124.44 108.78 93.12 77.46 64.17 51.28 50.71 50.14 71.00 710.01–715 141.97 124.78 109.12 93.46 77.80 64.51 51.62 51.05 50.48 71.50 715.01–720 150.70 132.51 116.65 100.99 85.33 70.84 57.75 51.38 50.81 72.00 720.01–725 151.03 132.84 116.98 101.32 85.66 71.17 58.08 51.71 51.14 72.50 725.01–730 151.37 133.18 117.32 101.66 86.00 71.51 58.42 52.05 51.48 73.00 730.01–735 152.39 134.20 118.28 102.62 86.96 72.40 59.31 52.93 52.34 73.50 735.01–740 152.72 134.53 118.61 102.95 87.29 72.73 59.64 53.26 52.67 74.00 740.01–745 153.05 134.86 118.94 103.28 87.62 73.06 59.97 53.59 53.00 74.50 745.01–750 153.39 135.20 119.28 103.62 87.96 73.40 60.31 53.93 53.34 75.00 750.01–755 153.72 135.53 119.61 103.95 88.29 73.73 60.64 54.26 53.67 75.50 755.01–760 162.45 144.26 127.14 111.48 95.82 80.16 66.97 54.59 54.00 76.00 760.01–765 163.50 145.31 128.19 112.45 96.79 81.12 67.87 55.45 54.87 76.50 765.01–770 163.83 145.64 128.52 112.78 97.12 81.45 68.20 55.78 55.20 77.00 770.01–775 164.17 145.98 128.86 113.12 97.46 81.79 68.54 56.12 55.54 77.50 775.01–780 164.50 146.31 129.19 113.45 97.79 82.12 68.87 56.45 55.87 78.00 780.01–785 164.83 146.64 129.52 113.78 98.12 82.45 69.20 56.78 56.20 78.50 785.01–790 165.86 147.70 130.58 114.81 99.11 83.45 70.17 57.71 57.09 79.00 790.01–795 166.18 148.02 130.90 115.13 99.43 83.77 70.49 58.03 57.41 79.50 795.01–800 174.92 156.76 138.54 122.67 106.97 91.31 76.83 63.67 57.75 80.00 800.01–805 175.26 157.10 138.88 123.01 107.31 91.65 77.17 64.01 58.09 80.50 805.01–810 175.58 157.42 139.20 123.33 107.63 91.97 77.49 64.33 58.41 81.00 810.01–815 176.68 158.46 140.26 124.43 108.66 92.95 78.49 65.32 59.32 81.50 815.01–820 177.01 158.79 140.59 124.76 108.99 93.28 78.82 65.65 59.65 82.00 820.01–825 177.34 159.12 140.92 125.09 109.32 93.61 79.15 65.98 59.98 82.50 825.01–830 177.68 159.46 141.26 125.43 109.66 93.95 79.49 66.32 60.32 83.00 830.01–835 178.01 159.79 141.59 125.76 109.99 94.28 79.82 66.65 60.65 83.50 835.01–840 187.55 169.28 151.04 134.02 118.25 102.48 86.78 73.62 61.63 84.00 Pers. Exps. 840.01–845 187.88 169.61 151.37 134.35 118.58 102.81 87.11 73.95 61.96 84.50 845.01–850 188.22 169.95 151.71 134.69 118.92 103.15 87.45 74.29 62.30 85.00 850.01–855 188.55 170.28 152.04 135.02 119.25 103.48 87.78 74.62 62.63 85.50 855.01–860 188.88 170.61 152.37 135.35 119.58 103.81 88.21 74.95 62.96 86.00 860.01–865 190.00 171.74 153.46 136.41 120.67 104.90 89.12 75.92 63.94 86.50 865.01–870 190.33 172.07 153.79 136.74 121.00 105.23 89.45 76.25 64.27 87.00 870.01–875 190.67 172.41 154.13 137.08 121.34 105.57 89.79 76.59 64.61 87.50 875.01–880 199.40 181.14 162.86 144.61 128.87 113.10 97.32 82.92 69.74 88.00 880.01–855 199.73 181.47 163.19 144.94 129.20 113.43 97.65 83.25 70.07 88.50 885.01–890 200.07 181.81 163.53 145.28 129.54 113.77 97.99 83.59 70.41 89.00 890.01–895 201.19 182.96 164.66 146.37 130.59 114.82 99.03 84.58 71.37 89.50 895.01–900 201.53 183.30 165.00 146.71 130.93 115.16 99.37 84.92 71.71 90.00 900.01–905 201.87 183.64 165.34 147.05 131.27 115.50 99.71 85.26 72.05 90.50 905.01–910 202.19 183.96 165.66 147.37 131.59 115.82 100.03 85.58 72.37 91.00 910.01–915 202.53 184.30 166.00 147.71 131.93 116.16 100.37 85.92 73.71 91.50 915.01–920 212.37 193.80 175.54 157.25 140.26 124.45 108.68 93.00 79.72 92.00 920.01–925 212.70 194.13 175.87 157.58 140.59 124.78 109.01 93.33 80.05 92.50 925.01–930 213.04 194.47 176.21 157.92 140.93 125.12 109.35 93.67 80.39 93.00 930.01–935 213.37 194.80 176.54 158.25 141.26 125.45 109.68 94.00 80.72 93.50 935.01–940 213.70 195.13 176.87 158.58 141.59 125.78 110.01 94.33 81.05 94.00 940.01–945 214.92 196.31 178.00 159.71 142.73 126.89 111.06 95.39 82.12 94.50 945.01–950 215.26 196.65 178.34 160.05 143.07 127.23 111.40 95.73 82.46 95.00 950.01–955 215.59 196.98 178.67 160.38 143.40 127.56 111.73 96.06 82.79 95.50 955.01–960 226.32 205.71 187.40 169.11 150.93 135.09 119.26 103.49 89.12 96.00 960.01–965 226.65 206.04 187.73 169.44 151.26 135.42 119.59 103.82 89.45 96.50 965.01–970 227.88 207.24 188.92 170.59 152.41 136.60 120.72 104.92 90.54 97.00 970.01–975 228.22 207.58 189.26 170.93 152.75 136.94 121.06 105.26 90.88 97.50 975.01–980 228.55 207.91 189.59 171.26 153.08 137.27 121.39 105.59 91.21 98.00 980.01–985 228.88 208.24 189.92 171.59 153.41 137.60 121.72 105.92 91.54 98.50 985.01–990 229.22 208.58 190.26 171.93 153.75 137.94 122.06 106.26 91.88 99.00 990.01–995 230.41 209.81 191.47 173.10 154.88 139.10 123.24 107.35 92.93 99.50 995.01–1000 241.15 218.75 200.21 181.84 163.52 146.64 130.78 114.89 99.27 100.00 1000.01–1005 241.49 219.09 200.55 182.18 163.86 146.98 131.12 115.23 99.61 100.50 1005.01–1010 241.81 219.41 200.87 182.50 164.18 147.30 131.44 115.55 99.93 101.00 1010.01–1015 242.15 219.75 201.21 182.84 164.52 147.64 131.78 115.89 100.27 101.50 1015.01–1020 242.48 220.08 201.54 183.17 164.85 147.97 132.11 116.22 100.60 102.00 1020.01–1025 243.70 221.29 202.76 184.43 166.05 149.11 133.28 117.40 101.72 102.50 1025.01–1030 244.04 221.63 203.10 184.77 166.39 149.45 133.62 117.74 102.06 103.00 1030.01–1035 244.37 221.96 203.43 185.10 166.72 149.78 133.95 118.07 102.39 103.50 1035.01–1040 255.10 232.69 212.16 193.83 175.45 157.31 141.48 125.60 109.72 104.00 1040.01–1045 255.43 233.02 212.49 194.16 175.78 157.64 141.81 125.93 110.05 104.50 1045.01–1050 256.68 234.27 213.72 195.38 177.02 158.85 143.01 127.12 111.23 105.00 1050.01–1055 257.01 234.60 214.05 195.71 177.35 159.18 143.34 127.45 111.56 105.50 1055.01–1060 257.34 234.93 214.38 196.04 177.68 159.51 143.67 127.78 111.89 106.00 1060.01–1065 257.67 235.26 214.71 196.37 178.01 159.84 144.00 128.11 112.22 106.50 1065.01–1070 258.00 235.59 215.04 196.70 178.34 160.17 144.33 128.44 112.55 107.00 1070.01–1075 259.21 236.82 216.23 197.89 179.55 161.38 145.50 129.59 113.71 107.50 1075.01–1080 269.94 247.55 224.96 206.62 188.28 169.91 153.03 137.12 121.24 108.00 1080.01–1085 270.27 247.88 225.29 206.95 188.61 170.24 153.36 137.45 121. 57 108.50 1085.01–1090 270.61 248.22 225.63 207.29 188.95 170.58 153.70 137.79 121.91 109.00 1090.01–1095 270.93 248.54 225.95 207.61 189.27 170.90 154.02 138.11 122.23 109.50 1095.01–1100 271.99 249.61 227.07 208.66 190.33 171.94 155.09 139.18 123.24 110.00 1100.01–1105 272.33 249.95 227.41 209.00 190.67 172.28 155.43 139.52 123.58 110.50 1105.01–1110 272.65 250.27 227.73 209.32 190.99 172.60 155.75 139.84 123.90 111.00 Pers. Exps. 1110.01–1115 272.99 250.61 228.07 209.66 191.33 172.94 156.09 140.18 124.24 111.50 1115.01–1120 283.72 261.34 238.80 218.39 200.06 181.67 163.62 147.71 131.77 112.00 1120.01–1125 284.77 262.39 239.89 219.47 201.05 182.71 164.63 148.77 132.81 112.50 1125.01–1130 285.11 262.73 240.23 219.81 201.39 183.05 164.97 149.11 133.15 113.00 1130.01–1135 285.44 263.06 240.56 220.14 201.72 183.38 165.30 149.44 133.48 113.50 1135.01–1140 285.77 263.39 240.89 220.47 202.05 183.71 165.63 149.77 133.81 114.00 1140.01–1145 286.10 263.72 241.22 220.80 202.38 184.04 165.96 150.10 134.14 114.50 1145.01–1150 286.44 264.06 241.56 221.14 202.72 184.38 166.30 150.44 134.48 115.00 1150.01–1155 287.49 265.11 242.63 222.24 203.83 185.43 173.33 151.49 135.55 115.50 1155.01–1160 298.22 275.84 253.36 230.97 212.56 194.16 175.76 159.02 143.08 116.00 1160.01–1165 298.55 276.17 253.69 231.30 212.89 194.49 176.09 159.35 143.41 116.50 1165.01–1170 298.88 276.50 255.02 231.63 213.22 194.82 176.42 159.68 143.74 117.00 1170.01–1175 299.22 276.84 255.36 231.97 213.56 195.16 176.76 160.02 144.08 117.50 1175.01–1180 300.32 277.89 255.38 233.07 214.64 196.23 177.81 161.04 145.17 118.00 1180.01–1185 300.65 278.22 255.71 233.40 214.97 196.56 178.14 161.37 145.50 118.50 1185.01–1190 300.99 278.56 256.05 233.74 215.31 196.90 178.48 161.71 145.84 119.00 1190.01–1195 301.31 278.88 256.37 234.06 215.63 197.22 178.80 162.03 146.16 119.50 1195.01–1200 312.05 289.62 267.11 244.60 224.37 205.96 187.54 169.57 153.70 120.00 (9) In determining the total income of Supplemental Nursing Care claimants, any income received from employment in a sheltered workshop and any income received from employment as a patient worker at subminimum wages in an institution, pursuant to the Fair Labor Standards Act, Section 14,

Regulation 29 CFR part 259. shall be excluded. (Original rule filed April 25, 1974, effective May 5, 1974.)

(10) In AFDC cases, the initial assistance payment benefit must be prorated when the case is approved in the same month as the filing of the application. The payment will be determined by multiplying the amount payable for a whole month by the ratio of the days in the month from the date of application to the end of the month to the number of days in a standard thirty- (30-) day month.

RSMo 2016.* Filing dates for original rules are shown in the text of the rule. This version filed March 24, 1976. Amended: Filed Dec. 23, 1976, effective April 11, 1977. Amended:

Filed June 1, 1977, effective Sept. 11, 1977.

Emergency amendment filed June 1, 1977, effective July 1, 1977, expired Oct. 31, 1977.

Amended: Filed June 29, 1977, effective Oct. 13, 1977. Emergency amendment filed Feb. 20, 1979, effective March 2, 1979, expired June 10, 1979. Amended: Filed March 9, 1979, effective June 11, 1979. Emergency amendment filed Jan. 30, 1980, effective Feb. 9, 1980, expired April 10, 1980. Amended:

Filed Jan. 30, 1980, effective May 11, 1980.

Emergency amendment filed June 22, 1981, effective July 2, 1981, expired Oct. 10, 1981.

Amended: Filed June 22, 1981, effective Oct. 11, 1981. Amended: Filed Aug. 12, 1981, effective Nov. 12, 1981. Emergency amendment filed Feb. 19, 1982, effective March 1, 1982, expired June 10, 1982. Amended: Filed Feb. 19, 1982, effective June 11, 1982.

Emergency amendment filed Oct. 8, 1982, effective Oct. 18, 1982, expired Jan. 12, 1983. Amended: Filed Oct. 8, 1982, effective Jan. 13, 1983. Emergency amendment filed Oct. 1, 1984, effective Oct. 11, 1984, expired Jan. 11, 1985. Amended: Filed Oct. 15, 1984, effective Jan. 12, 1985. Emergency amendment filed March 20, 1985, effective March 31, 1985, expired July 11, 1985.

Amended: Filed March 20, 1985, effective July 12, 1985. Amended: Filed July 17, 1989, effective Oct. 12, 1989. Emergency amendment filed June 2, 1993, effective July 1, 1993, expired Oct. 28, 1993. Amended:

Filed June 2, 1993, effective Jan. 31, 1994.

Amended: Filed Sept. 18, 2018, effective

13 CSR 40-2.130 Maximum Cash Payment Amounts {#sec-13-csr-40-2.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.130}

PURPOSE: This rule states the maximum payment amounts and exceptions to these amounts for the various assistance programs.

(1) When the appropriation for General Relief (GR) assistance payments is not sufficient to make full payments on the basis of maximum legal allowance, all GR payments (except for the types listed in this rule) will be subject to a percentage of reduction. An exception will be made for each GR person whose budget includes an allowance for intermediate or residential II nursing home care.

This type of case will be known as a Full Grant Case. No reduction will be applied to the GR payment made to that person. (Original rule filed May 13, 1948, effective May 23, 1948. Amended Sept. 1, 1972, effective Sept. 10, 1972.)

(2) Maximum Supplemental Aid to the Blind (SAB) Payments.

(A) For those persons who apply for Aid to the Blind (AB) on or after January 1, 1974, the maximum amount of payment they may receive is authorized in 209.040, RSMo; provided, however, that if the person is a resident of a residential care facility or an intermediate care or skilled nursing facility (ICF/SNF) and not eligible for Medicaid nursing care benefits; the maximum payment will be as authorized in section (7) of this rule.

(B) Persons who are eligible for vendor payments in their behalf for skilled nursing home care or ICF care will not be eligible for SAB payments.

(C) The amount of the SAB payment will be determined by subtracting the amount of any Supplemental Security Income (SSI) benefit from the amount of the maximum SAB payment, as described here. The amount of the SAB payment will be the remainder, rounded to the nearest dollar, except that if the remainder is one cent through forty-nine cents (1¢–49¢), the claimant will be eligible for an AB supplemental payment of one dollar ($1). (Original rule filed Nov. 29, 1973, effective Dec. 9, 1973. Amended Sept. 26, 1975, effective Oct. 6, 1975.)

(3) Persons who become ineligible for SSI due to an increase in other income may continue to be eligible for Missouri Supplemental Payment (SP). The amount of the Missouri SP, in these cases, will be determined by subtracting the current income from the December 1973 total income plus the Old Age Assistance (OAA), Permanent and Total Disability (PTD) or AB assistance grant that was legally received for the month of December 1973. The amount of the SP shall not be greater than an amount needed to provide total income at the December 1973 level; if the person’s income equals or exceeds the total amount, no Missouri SP shall be made.

These persons must continue to meet all eligibility requirements that were in effect for OAA, PTD or AB for the month of December 1973. (Original rule filed April 25, 1974, effective May 5, 1974.)

(4) Persons who are eligible for SSI (as a result of the conversion from OAA, PTD or AB in December 1973) but are not eligible for Missouri SP in January 1974, may become eligible for Missouri SP at a later time if their total income drops below the total income they received in December 1973. In those cases, the amount of the Missouri SP will be the difference between the present total income and the total income received in December 1973. (Original rule filed April 25, 1974, effective May 5, 1974.)

(5) The Division of Family Services will compute the Missouri SP in SSI-SP cases based on the amount of SSI for which the claimant is eligible and not the SSI payment which is actually received. (Original rule filed April 11, 1975, effective April 21, 1975.)

(6) No intermediate care or skilled nursing payment shall be made to a person residing in a licensed ICF or in a licensed SNF—unless the person has been determined by his/her own physician or doctor to medically need those services, subject to review and approval by the Department of Social Services, based upon the standards in 13 CSR 15-9.030(3) and (4). Residential care payments may be made to persons residing in a licensed intermediate care facility (ICF) or licensed skilled nursing facility (SNF), who do not meet this requirement and are otherwise eligible for supplemental nursing care.

(7) The maximum payment for eligible recipients of supplemental nursing care benefits will be one hundred forty-eight dollars ($148) if residing in a licensed residential care facility I, two hundred seventy-six dollars ($276) if residing in a licensed residential care facility II and three hundred sixty-eight dollars ($368) if residing in an ICF or SNF and not eligible for Medicaid nursing care benefits.

(8) In accordance with state law, section 208.030.5, RSMo, any person eligible to receive a cash nursing home grant, will also receive twenty-three dollars ($23) per month personal expense allowance. These funds are to be used by the claimant for his/her personal needs and MUST be treated as the claimant’s personal spending monies. These funds are not to be applied to the claimant’s monthly expenses associated with—room and board/rent, any contracted services provided through the facility, or both. Individuals who are provided funds for personal use by the Department of Mental Health will not be eligible to receive the twenty-three dollars ($23) personal needs funds through the Division of Family Services program. the text of the rule. This version of rule filed March 24, 1976. Amended: Filed June 1, 1977, effective Sept. 11, 1977. Amended:

Filed April 5, 1983, effective July 11, 1983.

Emergency amendment filed July 1, 1983, effective July 11, 1983, expired Oct. 12, 1983. Amended: Filed July 1, 1983, effective Oct. 13, 1983. Emergency amendment filed Oct. 9, 1986, effective Oct. 19, 1986, expired Feb. 6, 1987. Amended: Filed Oct. 9, 1986, effective Jan. 12, 1987. Amended: Filed March 22, 1988, effective July 11, 1988.

Amended: Filed Sept. 6, 1988, effective Dec. 11, 1988. Amended: Filed Oct. 16, 1989, effective Jan. 12, 1990. Emergency amendment filed June 27, 1990, expired Nov. 3, 1990, effective Jan. 12, 1990. Amended:

Filed June 27, 1990, effective Nov. 30, 1990.

13 CSR 40-2.140 Limitations on Amount of Cash Payments {#sec-13-csr-40-2.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.140}

PURPOSE: This rule outlines the restrictions or limitations placed on certain types of cash payments.

(1) Receipt of General Relief (GR) and Other Types of Assistance.

(A) Persons receiving Supplemental Payments (SPs), Supplemental Aid to the Blind (SAB) or Blind Pension (BP) will not be eligible for additional assistance from GR funds except that persons who were on the GR rolls in December 1973 may receive SPs if their total income was reduced because of the Supplemental Security Income (SSI) program.

Persons eligible for Aid to Dependent Children (ADC) must be transferred from GR to ADC immediately. Persons receiving Aid to Families with Dependent Children (AFDC)

Emergency Assistance will not be eligible for GR funds during the month in which they receive AFDC Emergency Assistance. (Original rule filed Sept. 26, 1951, effective Oct. 6, 1951. Amended: Nov. 29, 1973, effective Dec. 9, 1973.)

(2) To be eligible for GR, Aid to the Blind (AB) or BP, a GR, AB or BP claimant must apply for SSI benefits if it appears that s/he would be eligible for the benefits. Claimants for BP must be found ineligible for SSI benefits before they may be approved for BP. GR recipients who are subsequently approved or reinstated for SSI will have deducted from their initial SSI award, whether due to approval or reinstatement, an amount equal to the GR cash payments made pending the approval for or reinstatement of SSI in accordance with section 1631 of the Social Security Act. Refusal by a GR claimant to sign an agreement to have the amount deducted from his/her initial SSI award will create ineligibility for the GR claimant. (Original rule filed Nov. 29, 1973, effective Dec. 9, 1973.)

(3) Those persons who are eligible for state SPs, ADC, BP, GR or SAB payments will not be eligible for Supplemental Nursing Care (SNC) benefits. In addition, those persons who are eligible for vendor payments in their behalf for professional nursing home or intermediate care facility care under Title XIX will not be eligible for SNC benefits. (Original rule filed Nov. 29, 1973, effective Dec. 9, 1973.)

(4) Parents in the home or needy eligible caretaker relatives who are recipients of SSI shall not be eligible for AFDC or Title XIX.

Children who are under the age of eighteen (18) and who are recipients of SSI shall not be eligible for AFDC but shall be eligible for Title XIX. The expenses, income and resources of these SSI recipients will not be counted in determining AFDC eligibility of other members of an AFDC family. If a recipient of SSI makes income available to the AFDC household or pays any of the expenses of the AFDC household, the income will not be included on the AFDC budget. The person may elect to receive AFDC rather than SSI if the person meets all AFDC eligibility requirements. (Original

rule filed Jan. 2, 1974, effective Jan. 12, 1974. Amended: Feb. 6, 1975, effective Feb. 16, 1975.)

(5) Any person who is ineligible for SSI because his/her income exceeds the maximum allowable by the Social Security Administration (SSA) is ineligible for GR.

(A) Any person applying for SSI and GR will be eligible for GR, if otherwise eligible, pending certification of eligibility for SSI. If however, the applicant is obviously ineligible for SSI on the basis of income, the application will be held and rejected upon denial by the SSA. If the GR application is approved and the SSI application is later denied on the

basis of his/her income, his/her GR case must be closed.

(B) A determination of ineligibility for SSI on the basis of income must be made by the SSA district office. (Original rule filed July 7, 1975, effective July 17, 1975. Amended:

Nov. 4, 1975, effective Nov. 14, 1975.)

(6) All persons who meet the definition of a Temporary Assistance household must have their eligibility explored under Temporary Assistance before having their eligibility for GR explored. Any person whose eligibility has been explored under Temporary Assistance and is found to be ineligible for Temporary Assistance because of the following reasons shall be ineligible for GR:

(A) The person refuses to cooperate in establishing his/her eligibility for Temporary Assistance (this would include persons who refuse to apply for a Social Security number, refuse to participate in work activities, refuse to make an assignment of support rights, refuse to cooperate in the identification or location of absent parents, refuse to participant in self-sufficiency pact or an assessment pursuant to 13 CSR 40-2.370, and the like);

(B) Relationship to the payee who is not a legal guardian cannot be established for children under eighteen (18);

(C) The budget shows no need;

(D) The available resources exceed the maximum allowed;

(E) The children are not deprived of parental support;

(F) The person meets the prohibition in 13 CSR 40-2.305, 13 CSR 40-2.340, 13 CSR 40-2.345, 13 CSR 40-2.355, 13 CSR 40- 2.360, or 13 CSR 40-2.365; or (G) The person is ineligibile due to the lifetime limits outlined in 13 CSR 40-2.350.

(7) Persons wishing to withdraw or terminate their eligibility for SSI benefits may do so by contacting their nearest Social Security office. Persons voluntarily withdrawing from or terminating their SSI benefits will be ineligible for SP or any other category of public assistance administered by the Division of Family Services, except ADC. This ineligibility for public assistance benefits would be effective for the month in which the withdrawal or termination from SSI is effective.

(Original rule filed July 7, 1975, effective July 17, 1975.)

Amended: Filed June 28, 1978, effective Oct. 11, 1978. Amended: Filed June 19, 1980, effective Oct. 11, 1980. Emergency amendment filed June 22, 1981, effective July 2, 1981, expired Oct. 10, 1981. Amended: Filed June 22, 1981, effective Oct. 11, 1981.

Amended: Filed Dec. 10, 1981, effective March 11, 1982. Amended: Filed Feb. 23, 1989, effective May 25, 1989. Emergency amendment filed June 20, 2002, effective July 1, 2002, expired Dec. 27, 2002. Amended:

Filed June 20, 2002, effective Dec. 30, 2002. *Original authority: 207.020 RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993.

History

• AUTHORITY: section 207.020, RSMo 2000. 24, 1976. Amended: Filed June 1, 1977, effective Sept. 11, 1977. Emergency amendment filed June 1, 1977, effective July 1, 1977, expired Oct. 31, 1977. Amended: Filed June 29, 1977, effective Oct. 13, 1977.

13 CSR 40-2.150 Date Cash Payments Are Due and Payable {#sec-13-csr-40-2.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.150}

PURPOSE: This rule outlines when assistance payments are due and payable to eligible claimants.

(1) Scope. This rule governs the delivery of benefits for the following programs:

(A) The Temporary Assistance program, pursuant to section 208.040, RSMo, and Title IV-A of the Social Security Act;

(B) The Supplemental Nutrition Assistance Program (SNAP), formerly called Food Stamps, pursuant to 7 USC 2011-2036c;

(C) The Blind Pension program, pursuant to Chapter 209, RSMo; and (D) Supplemental Payments, Supplemental Aid to the Blind, and Supplemental Nursing Care, pursuant to section 208.030, RSMo.

(2) Temporary Assistance (TA) benefits shall be paid monthly in advance as follows:

(A) Newly-authorized TA benefits, issued for a portion of a month and not the entire month, shall be mailed, or issued electronically, within seven (7) calendar days from the (B) Ongoing TA benefits, or newly-authorized TA benefits being issued for an entire ly on a date that corresponds to the payee’s month of birth. Benefits that are mailed shall be mailed on the first business day following the monthly availability date, if the monthly availability date falls on a weekend or holiday.

(3) SNAP benefits shall be issued as follows:

(A) Newly-issued or supplemental SNAP benefits shall be due and payable pursuant to 7 CFR 274.2 and other relevant federal laws and rules; and (B) Pursuant to 7 CFR 274.2(d)(1), and except as otherwise provided under 7 CFR 274.7, ongoing SNAP benefits shall be issued by way of electronic benefits transfer (EBT) on a date that corresponds with the first letter of the payee’s last name and the payee’s month of birth.

(4) Blind Pension, Supplemental Payments, and Supplemental Aid to the Blind benefits shall be paid monthly in advance as follows:

(A) Newly-authorized benefits, issued for a portion of a month and not the entire ly within seven (7) calendar days from the (B) Ongoing benefits, or newly-authorized benefits being issued for an entire month, are due and payable on the tenth of each month and will be mailed or issued electronically on the tenth of the month, or on the first working day after the tenth, if the tenth falls on a weekend or a holiday.

(5) Supplemental Nursing Care (SNC) benefits shall be paid monthly in advance as follows:

(A) Newly-authorized benefits, issued for a portion of a month and not the entire ly within seven (7) calendar days from the (B) Ongoing benefits, or newly-authorized SNC benefits being issued for an entire month, are due and payable on the first day of each month and will be mailed or issued electronically on the first of the month, or on the first working day after the first, if the first falls on a weekend or a holiday.

(6) Claimants receiving payments by means of electronic benefits transfer (EBT) shall be required to use an EBT card on which there is a photographic identification of the payee for the benefits in order to gain access to the benefits. Good cause exemptions for requiring photographic identification on the electronic benefits transfer card may be allowed in the following circumstances:

(A) The payee for the benefits belongs to a religion which prohibits members being photographed;

(B) The payee for the benefits is housebound;

(C) The payee for the benefits already possesses a valid electronic benefits transfer card issued by the division for use in the TA or SNAP program;

(D) A direct deposit TA benefit has been returned by the receiving bank and a temporary EBT card is issued to allow the recipient access to the returned benefits;

(E) Lives in a remote area defined as more than a two- (2-) hour round trip from home to the Department of Revenue office;

(F) Unavailability of transportation; and (G) Circumstances beyond the member’s control such as, but not limited to, the inability of the division to generate the photographic identification, illness, or illness of another household member requiring the presence of the head of household.

RSMo 2016.* Original rule filed Nov. 3, 1950, effective Nov. 13, 1950. Amended:

Filed Feb. 27, 1974, effective March 9, 1974.

Amended: Filed Feb. 6, 1975, effective Feb. 16, 1975. Amended: Filed May 1, 1996, effective Nov. 30, 1996. Amended: Filed July 19, 2018, effective March 30, 2019.

13 CSR 40-2.160 State Hearing Procedures {#sec-13-csr-40-2.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.160}

PURPOSE: This rule outlines the procedure for appeals from county decisions and subsequent action to be taken on those appeals.

(1) This rule outlines the procedure for participant appeals resulting from the operation of the programs administered by the Missouri Department of Social Services pursuant to

section 208.080, RSMo. For anything in this

rule that conflicts with appeals of decisions regarding Temporary Assistance screening or testing for illegal controlled substances, the

regulation at 13 CSR 40-2.440 shall control.

For anything in this rule that conflicts with a federal or state law or regulation relevant to the program for which the appeal is made, the relevant federal or state law or regulation controls.

(2) Definitions.

(A) “Authorized Representative” means an individual or organization who a participant has legally authorized to act on behalf of the participant in the appeal process as provided for under 13 CSR 40-2.015. Participants shall designate an authorized representative in ways that are approved by the division and are authorized by state and federal law. If the participant is unable to reduce such authorization to writing or to a form approved by the division, the hearing officer, or other division employee may assist the participant in doing so as allowed by law.

(B) “Division” means the relevant division of the Department of Social Services to whom a participant is requesting an appeal.

Pursuant to section 208.080, RSMo, this shall be either the Family Support Division, Children’s Division, or MO HealthNet Divi- (C) “Electronic access account” means the use of available online application processes or other available electronic systems by participants to submit an application or otherwise conduct business with the division.

(D) “Good cause” means a mistake or conduct beyond the control of the participant that is not intentionally or recklessly designed to impede the hearing process. For purposes of this regulation, failure to advise the division of a current mailing address shall not constitute good cause.

(E) “Hearing” means a legal proceeding to provide documents and testimony for the division. The proceeding shall be conducted for the purpose of presenting evidence relevant to the participant’s appeal. The Hearing Officer may appear in person, by telephone, or other electronic means.

(F) “Hearing Notice” means a document, sent by the Division of Legal Services of the Department of Social Services, advising the participant of the time, date, and place of their hearing.

(G) “Participant” means an individual or vendor who has applied for, is receiving, or has been denied benefits or services provided by the Department of Social Services or by other applicable programs administered by the Department of Social Services.

(3) In addition to appeal rights conveyed by

section 208.080, RSMo, if an institutionalized spouse, a community spouse, or a representative of either has requested an assessment of countable resources for the month in which institutionalization begins, in accordance with 42 USC 1396r-5, upon the determination of the spousal share, the institutionalized spouse and the community spouse shall be notified in writing by the division of their rights to appeal to the director of the division.

This notice shall inform the institutionalized spouse and community spouse that appeal rights are effective upon application for applicable MO HealthNet benefits for the institutionalized spouse. Hearings regarding assessment issues shall be held within thirty (30) days of the date of the request for the hearing.

(4) Upon the determination of the community spouse monthly income allowance described in 42 USC 1396r-5, the division shall notify, in writing, the institutionalized spouse and the community spouse, of their rights to appeal to the director of the division.

(5) A participant may appeal any division decision that delays, denies, or adversely affects the participant’s benefits or services to the division director, pursuant to section 208.080, RSMo. This may include a failure of the division to act, as provided by law.

(A) A participant may request an appeal in person, by telephone, by mail, or through other commonly available electronic means that are used by the division, including email and facsimile transmission.

(B) Proper blank forms for requesting an appeal shall be available at local division offices and online through the division website.

(C) A request for an appeal shall include, at a minimum:

1. The name and Departmental Client Number (DCN), Social Security number, or date of birth of the participant for which the hearing has been requested, or the name and Departmental Vendor Number (DVN) of the vendor for which the hearing has been requested;

2. The name of the person requesting the hearing, if requested by someone other than the participant;

3. The current address and phone number of the participant, and the current address and phone number of the person requesting the hearing if requested by someone other than the participant; and 4. A brief description of the reason the appeal is being requested.

(D) An electronic signature shall serve as a valid signature for the purposes of requesting an appeal under this regulation.

(6) A participant may request an expedited hearing if the participant’s life, health, or ability to attain, maintain, or regain maximum function would be jeopardized by the time ordinarily permitted for a standard hearing, or as otherwise required by law.

(A) A health care provider may request an expedited hearing on behalf of the participant and in regards to the participant’s eligibility for benefits and services governed by section 208.080, RSMo, or alternatively, may submit documentation supporting the individual’s request for an expedited hearing.

(B) A request for an expedited hearing may be made in the same manner as any other request for a hearing, as set forth in paragraph (5)(C)2., above.

(C) If the hearing officer denies the request for an expedited hearing, the hearing officer shall notify the participant through electronic means or orally, and if orally, with written notice sent within two (2) calendar days of the denial.

(D) If the hearing officer denies the request for an expedited hearing, the denied request shall still serve as a valid request for an appeal under this regulation.

(7) The department shall send notice to the participant electronically at the participant’s last known electronic mail address, or by posting it to the participant’s electronic access account, at least ten (10) days before the date of the hearing, specifying the time, date, and location of the hearing. If the department determines that the participant has no electronic mail address on record and does not have an electronic access account, or has opted out of receiving electronic communications, the department shall send the notice by regular United States mail to the participant’s last known mailing address.

(A) The burden is on the participant to keep the division advised of his or her current mailing address and other pertinent contact information.

(B) Service of notice to the participant’s last known electronic or mailing address of record, pursuant to this section, shall be deemed proper service.

(C) If the department receives information prior to the scheduled hearing that the participant did not receive the notice, the department shall reset the scheduled hearing to a new hearing date and issue a new hearing notice to the participant’s updated contact location. If the participant’s updated contact location, or the contact location of his/her authorized representative or attorney, cannot be determined, the division shall take the appropriate action regarding the participant’s benefits or services as provided for by law for situations in which the division is unable to locate a participant.

(D) The department may use a shorter notice period if it is not prejudicial to the parties.

(E) A copy of the notice also will be sent to any attorney, legal guardian, and/or authorized representative who has notified the division that they are representing the participant.

(8) Procedure with reference to the hearings shall be informal with respect to the conduct of the hearings. The Missouri Administrative Procedure Act, as set forth in section 536.070, RSMo, shall apply to hearings pursuant to this regulation unless in conflict with another statute or federal regulation, or as otherwise set forth herein.

(A) Stipulations may be entered into prior to final disposition to— 1. Withdraw the application for a hearing;

2. Agree to a statement of facts; or 3. Agree to any other pertinent matter or order.

(B) An attorney shall not act as an advocate at a hearing in which the attorney is likely to be a necessary witness.

(C) Briefs setting forth written argument on the law and the facts may be filed in any case within a specified time designated by the hearing officer.

(D) In order to protect the integrity and fairness of the appeals process, the hearing officer requires all parties and persons acting in a representational capacity to comply with the following rules of conduct:

1. All individuals shall appear for the hearing and be ready to proceed no later than the starting time listed on the notice. A hearing officer may find a participant in default and dismiss the appeal if the participant or the participant’s representative does not appear within ten (10) minutes after the starting time. However, the hearing officer shall retain the authority to commence the hearing at a time appropriate to the circumstances;

2. All individuals shall comply with all directions given by a hearing officer during a hearing. If any individual fails to follow these directions, the hearing officer may exclude the individual from the hearing, or may adjourn the hearing.

(9) The department’s Division of Legal Services (DLS) has established hearing officer positions in order to comply with all pertinent federal and state law and regulations.

(A) Hearing officers shall be licensed to practice law in the State of Missouri at all times relevant herein.

(B) The hearing officers shall have authority to conduct state-level hearings of a pretermination or appeal nature. They shall serve as designees of the division director, as required by federal or state law.

(C) All decisions issued after state-level hearings conducted by the hearing officers shall be in the name of the division director or the director’s designee, as required by federal or state law.

(D) The hearing officers’ authority to conduct hearings shall be statewide.

(E) The authority of the hearing officers to conduct hearings arises under section 208.080, RSMo, and shall apply to all programs administered by the director of the department as set forth in section 208.080, RSMo.

(10) Any party shall be entitled to conduct depositions pursuant to section 536.073 RSMo, as amended, and the Missouri Rules of Civil Procedure. The costs of the depositions shall be borne by the party conducting the deposition unless otherwise agreed to by the parties or ordered by a court of competent jurisdiction.

(A) Pursuant to section 536.073, RSMo, no discovery shall be allowed for hearings conducted pursuant to this rule unless it is expressly identified herein.

(11) Subpoenas to compel the attendance of witnesses and subpoenas duces tecum to compel the production of records may be issued by the hearing officer upon a statement of necessity filed by the party requesting the issuance of the subpoena pursuant to section 536.077, RSMo.

(A) The witness shall be entitled to the same fees and, if compelled to travel more than forty (40) miles from his or her place of residence, shall be entitled to the same tender of fees for travel and attendance, and at the same time, as is now or may hereafter be provided for witnesses in civil actions in the circuit court, such fees to be paid by the party requesting the subpoena, except where the payment of such fees is otherwise provided for by law.

(B) Under no circumstances shall the department grant witness fees to parties to the case or their relatives.

(12) The hearing officer may, as allowed by state and federal law, keep the record of the administrative hearing open to a fixed day so as to order, and receive the results of, a physical or mental health examination, to allow the parties to submit additional evidence, or for other good cause.

(A) In cases in which the hearings unit keeps the record open to a fixed day in order to allow the parties to submit additional evidence, if the additional evidence is not received by the department by the fixed day and no requests have been made to extend the record (in which case the hearing officer may extend the record further), the hearing officer shall close the record and the director will issue a decision based on the record.

(B) A request for a continuance of the hearing date must be communicated to the hearing officer and any other parties to the hearing, if possible, at least five (5) days prior to the date of the scheduled hearing. Continuances will be granted only when the hearing officer determines from the request that extraordinary circumstances exist.

(13) For any time limit imposed by state or federal law under which the division must take final administrative action, starting with the date of the request for a hearing and ending on the date of the division’s action, and as allowed by federal and state law, the time limit is tolled for the length of any delay in the hearing process caused either by one (1) of the reasons identified in section (12) of this

rule, the claimant’s actions, or by the actions of, or at the request of, the claimant’s authorized representative, guardian, conservator, or attorney.

(A) If the record at an administrative hearing is held open at the request of a claimant under section (12) of this rule, the deadline for administrative action is extended by the number of calendar days between the date of the request for a hearing and the fixed day identified in section (12).

(B) Example: The division receives a request for a hearing regarding a person’s eligibility for MO HealthNet on the basis of disability on May 1, 2020. Under federal law, the division has ninety (90) days to take a final action on the outcome of the hearing.

The division must therefore take final administrative action on or before July 30, 2020.

The hearings unit sets a hearing date for May 15, 2020 (fourteen (14) days into the ninety- (90-) day timeline). The claimant then requests a continuance of the hearing date, and the hearing is rescheduled for May 31, 2020. The ninety- (90-) day count stops on May 15, 2020 at fourteen (14) days. It resumes on May 31, 2020. This results in an extension of the deadline for administrative action by sixteen (16) days to cover the continuance period of May 15 through May 31, 2020. The new deadline for administrative action becomes August 15, 2020.

(14) Any party may represent themselves, be represented by an authorized representative, by a licensed Missouri attorney, by a nonresident attorney appearing in compliance with Supreme Court Rule 9, or by an eligible law student complying with Missouri Supreme Court Rule 13.

(15) All persons who will be acting in a representative capacity on behalf of a party before the hearing officer shall file notice of their intent to represent the party as soon as possible after being retained or chosen. Nonattorneys shall file proof that they are authorized representatives of the participant pursuant to 13 CSR 40-2.015. Attorneys shall file an entry of appearance.

(16) The Hearings Unit shall dismiss an appeal under the following circumstances:

(A) The appeal was not timely requested;

(B) The division has not taken an action affording (or has not been inactive to such an extent as to afford) the participant a right to appeal; or (C) The participant, having been notified of the time, date, and place of the hearing, fails to appear at the hearing without good cause.

(17) If the participant dies prior to or at any time during the appeal, the participant’s attorney’s or authorized representative’s

(A) Upon being advised of the death of the participant, the hearing officer shall continue the hearing.

(B) Following the participant’s death, only the duly authorized personal representative of or legal counsel for the participant’s estate shall be allowed to represent the participant at the hearing.

(C) If the duly authorized personal representative of the participant’s estate does not enter an appearance with the hearing officer within thirty (30) days after the hearing date, the hearing officer will dismiss the appeal.

(D) This section shall not terminate an authorized representative’s authority to assist with an application for MO HealthNet benefits prior to the participant’s death, as allowed under 13 CSR 20-2.015(16).

(18) Within a reasonable time after the conclusion of a hearing, the division director or the director’s designee, as required by federal and state law, will render a decision in compliance with section 208.080.7, RSMo.

(A) A copy of the decision will be sent to the participant and to the participant’s legal guardian, attorney, and/or authorized representative by regular United States mail, or electronically if the participant so chooses and the department has the capability to send an electronic notice.

(B) A copy will also be sent to the divi- RSMo 2016.* Original section (1) filed separately Sept. 26, 1951, effective Oct. 6, 1951.

Original section (4) filed separately Feb. 20, 1947, effective March 2, 1947. Original sub-

section (5)(G) filed separately Feb 20, 1947, effective March 2, 1947. Original section (6) filed separately April 1, 1975, effective April 10, 1975. This version filed March 24, 1976.

Amended: Filed April 14, 1980, effective Aug. 11, 1980. Emergency amendment filed Sept. 19, 1989, effective Oct. 1, 1989, expired Jan. 28, 1990. Amended: Filed Nov. 2, 1989, effective Jan. 26, 1990. Amended:

Filed Jan. 10, 1990, effective April 12, 1990.

Amended: Filed April 29, 2020, effective Nov. 30, 2020. 660.017, RSMo 1993, amended 1995.

Connors v. Missouri Division of Family Services, 576 SW2d 578 (Mo. App. 1979).

Physician member of medical review team which denied claimant’s application was not present for cross-examination at the hearing.

Claimant’s failure to subpoena physician under 13 CSR 40-2.160(3)(C) precludes her from complaining on appeal of a deprivation of her right to cross-examine the physician.

History

• authority shall terminate.

13 CSR 40-2.170 Special Requirements for the AFDC Program {#sec-13-csr-40-2.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.170}

PURPOSE: This rule outlines special provisions for determining eligibility for Aid to Families with Dependent Children.

(1) In verification of age for children obviously under eighteen (18) years, assistance may be granted without proof of age but verification of the birth date must be obtained by the time of the next reinvestigation. (Original

rule filed Feb. 6, 1975, effective Feb. 16, 1975.)

(2) Effective January 2, 1974, aliens who have lawfully entered the United States and are considered a legal alien will be eligible for public assistance and aliens found to be in this country illegally will be ineligible. If an illegal alien is found to be on the Aid to Dependent Children (ADC) rolls, his/her case will be closed and if an applicant is found to be an illegal alien, this application will be rejected. (Original rule filed Jan. 2, 1974, effective Jan. 12, 1974.)

(3) Aid to Families with Dependent Children- Foster Care (AFDC-FC) payments may be granted to any child under the age of nineteen (19) who has been removed from the home of a parent or relative by court order and the child would have met AFDC eligibility standards in the home from which s/he was removed at the time of the court proceedings allowing the six (6) months previous to meet the living with a specified relative requirement and continues to be eligible for AFDC in his/her own right after the initial determination. Children under the age of twenty-one (21) whose placement in foster care is lawfully authorized who meet financial eligibility of the ADC program and for whom the Division of Family Services is financially responsible, in whole or in part, will be eligible for Title XIX. (Original rule filed Dec. 22, 1975, effective Jan. 1, 1976.) 24, 1976. Emergency amendment filed June 1, 1977, effective July 1, 1977, expired Oct. 31, 1977. Amended: Filed June 29, 1977, effective Oct. 13, 1977. Emergency amendment filed Feb. 19, 1982, effective March 1, 1982, expired June 10, 1982. Amended: Filed Feb. 19, 1982, effective June 11, 1982.

13 CSR 40-2.180 Confidentiality of Case Records {#sec-13-csr-40-2.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.180}

PURPOSE: This rule outlines the confidential nature of information contained in case records.

(1) Pursuant to sections 208.120 and 208.155, RSMo, the Family Support Division shall protect from public disclosure any information concerning an applicant or recipient of public assistance, and the file and record of an applicant or recipient shall be open to inspection only to those persons directly connected with the administration of the relevant assistance program. The division may disclose information that is protected by this rule if the specific type of disclosure is not otherwise prohibited by state or federal law and if— (A) The disclosure is of a specific kind that is authorized by state or federal law;

(B) The federal laws and regulations, if any, governing the program that is relevant to the information being disclosed allow for such a disclosure; or (C) The division has the written consent of the applicant or recipient, or the applicant or recipient’s legal guardian or conservator, to disclose the information.

RSMo 2016.* Original rule filed May 4, 1959, effective May 14, 1959. Amended:

Filed April 24, 2019, effective Nov. 30, 2019.

13 CSR 40-2.190 Procedure for Collection of Overpayments {#sec-13-csr-40-2.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.190}

PURPOSE: This rule outlines procedures for collection of payments made to claimants of assistance when claimants were ineligible for payments.

(1) Restitution and recovery may be required if at any time it is determined that a recipient has received benefits to which s/he was not entitled because of a state or federal statutory or regulatory requirement.

Original rule filed March 15, 1973, effective March 25, 1973. Emergency amendment filed Feb. 9, 1984, effective Feb. 19, 1984, expired May 10, 1984. Amended: Filed Feb. 9, 1984, effective May 11, 1984.

13 CSR 40-2.200 Determining Eligibility for Medical Assistance {#sec-13-csr-40-2.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.200}

PURPOSE: This rule provides that the decision on the factor of disability shall be made by a qualified medical consultant employed by the division except in cases involving disability-based Social Security Income or Retirement, Survivor’s and Disability Insurance, and establishes the principles used by county staff in determining eligibility for Medical Assistance only on the basis of income.

(1) The medical diagnosis and other medical information on Medical Assistance (MA), Supplemental Nursing Care (SNC), Aid to the Blind (AB) and Blind Pension (BP) cases shall be reviewed by a medical consultant employed by the Family Support Division, who shall certify eligibility or ineligibility on the basis of permanent and total disability or vision, except that this review will not be required to certify permanent and total disability when the claimant receives Supplemental Security Income (SSI) or Retirement, Survivor’s, and Disability Insurance (RSDI) based on his/her disability. In these cases, the verification of the receipt of disability-based SSI or RSDI benefits will be sufficient to establish permanent and total disability.

(2) If a single individual has an adjusted gross income per month that does not exceed the income limit and meets the other eligibility requirements, s/he will be eligible for MA. If eligibility is based on AB provisions, the income limit is one hundred percent (100%) of the federal poverty level (FPL). If eligibility is based on MO HealthNet for Aged, Blind, and Disabled (MHABD) or Permanent and Total Disability (PTD) provisions, the income limit is eighty-five percent (85%) of the FPL. For a married couple living together, the adjusted gross income limitation will be one hundred percent (100%) of the FPL for two (2) persons, if eligibility is based on AB provisions. For a married couple living together, the adjusted gross income limitation will be eighty-five percent (85%) of the FPL for two (2) persons, if eligibility is based on MHABD or PTD provisions. In determining adjusted gross income, the following exemptions will be applied to the gross income:

(A) If the income is earned or unearned, an amount of twenty dollars ($20) may be excluded from the gross. Payments for premiums for medical insurance, including Supplemental Medical Insurance (SMI) premium, may be excluded;

(B) The full amount of any SSI payment will be excluded; and (C) If the income is earned, the twentydollar ($20) exclusion in subsection (2)(A) will be applied plus the first sixty-five dollars ($65) and one-half (1/2) of the remainder of all earned income will be excluded. If a person is a student and is under the age of twenty-two (22), the amount of the school expense will be excluded from any earned income. If eligibility is based on AB provisions, any work-related expenses also will be excluded from earned income.

(3) If an individual qualifies for institutional vendor payments under the MA program, fifty dollars ($50) of the individual’s personal income shall be retained as his/her personal needs allowance. Federal regulation 42 CFR,

Section 435.733 provides that there shall be a minimum amount available to meet the clothing and other personal needs of the individual. In order to meet other of the individual’s basic personal needs, this amount shall not be exhausted to satisfy any guardianship fees, court costs, attorney’s fees, or other related legal or court costs, or any combination of these, resulting from the administration of a guardianship or conservatorship, or both that has been sought on behalf of the Medicaid recipient. The claimant’s personal needs allowance shall not be used for the provision of any medical or remedial services, or both, that are covered through the Missouri Medical Exception Process. Institutionalized individuals who participate in sheltered workshops are allowed a personal needs allowance of fifty dollars ($50) plus the sheltered workshop income.

(4) When an individual living in his/her home is assessed by Department of Health and Senior Services as needing both a nursing facility level-of-care as defined in 19 CSR 30- 81.030 and home- and community-based waiver services, his/her gross monthly income shall be compared to one thousand three hundred eleven dollars ($1,311) effective January 1, 2018, subject to adjustment by the Consumer Price Index beginning January 2019, if his/her gross monthly income is equal to or less than one thousand three hundred eleven dollars ($1,311), s/he shall be considered income eligible for Title XIX under the MA program. When his/her gross monthly income is greater than one thousand three hundred eleven dollars ($1,311), s/he must qualify for Title XIX in accordance with

section (2) of this rule.

(5) If an institutionalized spouse (as defined in 13 CSR 40-2.030) qualifies for institutional vendor payments under the MA program, in determining the amount the institutional ized spouse must pay to the medical institution or nursing facility for the cost of his/her care, the following amounts shall be disregarded:

(A) A community spouse monthly income allowance which shall be determined as follows:

1. The amount by which— A. The applicable percentage of the Federal Poverty Level for two (2) persons; plus B. The amount by which the community spouse’s shelter expenses exceed thirty percent (30%) of the applicable percentage of the Federal Poverty Level for two (2) persons; exceeds C. The community spouse’s own income;

2. The amount determined in subparagraphs (5)(A)1.A. and B. may not exceed one thousand five hundred dollars ($1,500), subject to adjustment by the Consumer Price Index beginning January 1990;

3. The amount of court-ordered support, if higher, may be substituted for the amount determined in paragraph (5)(A)1.;

4. The applicable percentages of the Federal Poverty Level specified in paragraph (5)(A)1. shall be as follows:

A. Effective September 30, 1989, one hundred twenty-two percent (122%);

B. Effective July 1, 1991, one hundred thirty-three percent (133%); and C. Effective July 1, 1992, one hundred fifty percent (150%);

5. Allowable shelter expenses for the community spouse shall include the following expenses incurred at the principal place of residence of the community spouse:

A. Mortgage payment or taxes, or both, and insurance;

B. Rent;

C. Maintenance fee for condominium or cooperative apartment; and D. The utility standard of the Food Stamp program in accordance with the Food Stamp Act of 1977, if the utility expenses are actually incurred and are not a part of the maintenance fee or rent previously allowed.

If the community spouse’s only utility is telephone, the standard used shall be the telephone standard of the Food Stamp program.

If the community spouse incurs any other type of utility, the standard used shall be the utility standard of the Food Stamp program;

6. If either spouse establishes in a fair hearing that the allowance as determined by the Family Support Division is insufficient (resulting in significant financial duress), an adequate amount may be substituted; and (B) An allowance for each family member equal to one-third (1/3) of the amount by which the amount described in subparagraph (5)(A)1.A. exceeds the monthly income of that family member. As used in this rule, the term family member shall mean minor or dependent children, dependent parents, or dependent siblings of either spouse who are residing with the community spouse. Dependent as used here means an individual who could be claimed as a dependent for federal income tax purposes.

(6) Pursuant to the determination of the Health Care Financing Administration of the United States Department of Health and Human Services, no amounts charged as guardianship or conservatorship fees, court costs, attorney’s fees, or other related or similar legal or court costs are properly classified as necessary medical or remedial care.

Therefore, no charges shall be recognized or allowed by this agency for the purpose of deducting those sums from an individual’s total income, when that individual qualifies for institutional vendor payments under the MA program established pursuant to Title XIX of the Social Security Act, 42 U.S.C. 1396.

(7) Persons who are eligible for MA only must meet the eligibility requirements, other than income, for Old Age Assistance, Permanent and Total Disability or AB that was in effect in January 1972, except that the Homemaker provision will not be applied to the determination of disability in these cases.

(8) Persons who receive SSI may receive MA if they meet the eligibility requirements, other than income, for General Relief that were in effect January 1972. However, in determining eligibility for MA, the eligibility requirements described in section (6) must be applied first.

RSMo 2016.* Original rule filed Sept. 26, 1951, effective Oct. 6, 1951. Amended: Filed Nov. 4, 1954, effective Nov. 14, 1954.

Amended: Filed Feb. 27, 1974, effective March 9, 1974. Amended: Filed April 25, 1974, effective May 5, 1974. Amended: Filed June 3, 1974, effective June 13, 1974.

Amended: Filed June 10, 1975, effective June 20, 1975. Amended: Filed July 8, 1977, effective Oct. 13, 1977. Amended: Filed March 13, 1978, effective June 11, 1978.

Amended: Filed April 17, 1987, effective Sept. 11, 1987. Amended: Filed Sept. 6, 1988, effective Dec. 11, 1988. Emergency amendment filed Sept. 19, 1989, effective Oct. 1, 1989, expired Jan. 28, 1990. Amended: Filed Nov. 2, 1989, effective Jan. 26, 1990. Emergency amendment filed Dec. 18, 1992, effective Jan. 1, 1993, expired April 30, 1993. Emergency amendment filed Feb. 26, 1993, effective May 1, 1993, expired Aug. 28, 1993. Amended: Filed Dec. 18, 1992, effective June 7, 1993. Emergency amendment filed Dec. 13, 1993, effective Jan. 1, 1994, expired April 30, 1994.

Amended: Filed Dec. 13, 1993, effective July 10, 1994. Emergency amendment filed Dec. 29, 1994, effective Jan. 8, 1995, expired May 7, 1995. Amended: Filed Jan. 12, 1995, effective July 30, 1995. Amended: Filed June 27, 2005, effective Jan. 30, 2006. Amended:

Filed Sept. 18, 2018, effective May 30, 2019.

Bell v. Missouri State Division of Family Services, 597 SW2d 699 (Mo. App. 1980). 13 CSR 40-2.200, insofar as it makes the Medical Review Team report controlling upon the director upon appeal, is inconsistent with

section 208.075, RSMo and to that extent is invalid.

13 CSR 40-2.210 State Emergency Assistance Program {#sec-13-csr-40-2.210 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.210}

(Rescinded November 30, 2020)

Emergency rule filed Dec. 17, 1979, effective Dec. 27, 1979, expired April 10, 1980. Original rule filed Dec. 17, 1979, effective April 11, 1980. Emergency amendment filed May 22, 1980, effective May 29, 1980, expired Sept. 11, 1980. Amended: Filed May 22, 1980, effective Sept. 12, 1980. Emergency amendment filed June 19, 1980, effective June 29, 1980, expired Oct. 10, 1980.

Amended: Filed June 19, 1980, effective Oct. 11, 1980. Emergency amendment filed Sept. 10, 1980, effective Sept. 20, 1980, expired Dec. 10, 1980. Amended: Filed Sept. 10, 1980, effective Dec. 11, 1980. Rescinded:

Filed May 13, 2020, effective Nov. 30, 2020.

13 CSR 40-2.220 Families Deemed to be Receiving AFDC for Purposes of Title XIX Emergency rule filed Oct. 3, 1984, effective Oct. 13, 1984, expired Jan. 11, 1985. Original rule filed Oct. 15, 1984, effective Jan. 12, 1985. Amended: Filed Feb. 17, 1988, effective June 11, 1988. Emergency amendment filed Dec. 30, 1988, effective Jan. 10, 1989, expired May 10, 1989. Amended: Filed Dec. 30, 1988, effective March 25, 1989. {#sec-13-csr-40-2.220 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.220}

Amended: Filed Jan. 17, 1990, effective April 12, 1990. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

13 CSR 40-2.230 Disposal of Excess Real Property {#sec-13-csr-40-2.230 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.230}

PURPOSE: This rule defines the requirements for disposal of excess real property in the Aid to Families with Dependent Children program as provided for in section 208.010, RSMo.

(1) In determining eligibility for Aid to Families with Dependent Children (AFDC) cash benefits, real property which the family is making a good faith effort to sell shall be excluded for a period not to exceed six (6) months, if the family agrees in writing with the Division of Family Services to sell this property and repay the amount of assistance received during that period from the net proceeds of the sale.

(2) If the property has not been sold within six (6) months from the effective date of the agreement, or if eligibility terminates for any other reason, the entire amount of assistance paid during that period shall be a debt due the state.

(3) The agreement shall specify— (A) Which property will be excluded and the market value;

(B) The disposal period of six (6) months;

(C) What good faith effort requires; and (D) The requirement to repay the assistance received during the disposal period.

(4) All owners of the property in the AFDC assistance group must sign the agreement. A spouse who is an owner and living in the home, but not in the AFDC assistance group, must also sign the agreement.

(5) A claimant must provide proof of good faith effort as requested by the Division of Family Services. Good faith effort to sell includes the following:

(A) Listing the real property with a reputable real estate agent and cooperating in marketing the property. Cooperation in marketing the property includes things such as showing the property and setting a realistic sales price;

(B) Publicly advertising the property for sale on no less than a weekly basis in a general newspaper, instead of listing the property with a reputable real estate agent;

(C) Accepting reasonable purchase offers, for example, reflecting a reasonable market value; and (D) Initiating any legal action necessary to force a sale when other owners, outside the AFDC assistance group, do not wish to sell.

Emergency rule filed Nov. 14, 1985, effective Nov. 24, 1985, expired March 24, 1986.

Original rule filed Nov. 14, 1985, effective Feb. 13, 1986.

13 CSR 40-2.240 Medicaid Eligibility in General Relief Prior to Application {#sec-13-csr-40-2.240 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.240}

(Rescinded December 30, 2005)

Original rule filed Aug. 3, 1987, effective Oct. 25, 1987. Rescinded: Filed June 8, 2005, effective Dec. 30, 2005.

13 CSR 40-2.250 Resource Eligibility Standards for Title XIX Under the Poverty Level {#sec-13-csr-40-2.250 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.250}

(Rescinded March 30, 2017)

Original rule filed Jan. 5, 1988, effective June 11, 1988. Rescinded: Filed Aug. 19, 2016, effective March 30, 2017.

13 CSR 40-2.260 Newborns Deemed to be Eligible for Title XIX {#sec-13-csr-40-2.260 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.260}

PURPOSE: This rule establishes that newborns will be deemed to be eligible for Title XIX when they are born to a woman eligible for and receiving Title XIX on the date the child is born.

(1) A child born to a woman eligible for and receiving Title XIX on the date her child is born is deemed to have filed an application and been found eligible for Title XIX on the date of the birth and to remain eligible for one (1) year; provided— (A) The child is living; and (B) The child remains a resident of Missouri.

1. When the child’s state of residence changes during the first year of life, MO HealthNet benefits shall be closed.

2. If the child’s state of residence changes back to Missouri during the first year of life, MO HealthNet benefits shall be reinstated until the child’s first birthday. An application and review of eligibility is not required.

(2) The child is not required to remain in the household of the biological mother to be eligible.

(3) The child’s birth must be reported to Family Support Division (FSD) prior to beginning MO HealthNet benefits. Report of the birth may be accepted from— (A) A legal adult member of the mother’s MO HealthNet household as defined in 13 CSR 40-7.010;

(B) The mother’s authorized representative;

(C) The hospital;

(D) A representative from the hospital; or (E) The mother’s managed care plan.

(4) Before beginning MO HealthNet benefits for newborns deemed eligible, FSD shall obtain all of the following:

(A) The mother’s Departmental Client Number (DCN);

(B) The child’s legal name, unless unavailable;

(C) The child’s date of birth; and (D) The child’s gender.

(5) Pursuant to section 208.151.1(17), RSMo, and 42 USC 1396b(x)(2)(D), identification and citizenship shall be verified when newborns are deemed eligible for Title XIX for the first year of life.

(6) MO HealthNet benefits shall end for newborns deemed eligible for Title XIX when— (A) The child is no longer a resident of Missouri;

(B) The child is deceased;

(C) The child’s MO HealthNet benefits are voluntarily closed by an adult member of the child’s household or an authorized representative, guardian, or conservator; or (D) The child begins receiving healthcare under another state agency or division.

RSMo 2016.* Emergency rule filed Dec. 19, 1988, effective Jan. 1, 1989, expired May 1, 1989. Original rule filed Dec. 19, 1988, effective March 25, 1989. Emergency amendment filed March 6, 1991, effective March 16, 1991, expired July 13, 1991. Amended:

Filed March 7, 1991, effective Aug. 30, 1991. Amended: Filed Sept. 20, 2018, effective May 30, 2019.

13 CSR 40-2.270 Determining Eligibility for Qualified Medicare Beneficiaries {#sec-13-csr-40-2.270 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.270}

PURPOSE: This rule establishes the principles used in determining eligibility for Qualified Medicare Beneficiary coverage on the

basis of income, resources and Part A Medicare entitlement. entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

Therefore, the material which is so incorporated is on file with the agency who filed this

rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

(1) An eligible Qualified Medicare Beneficiary shall— (A) Be entitled to and enrolled in Hospital Insurance under Part A of Medicare, as described in Section 1811 of the Social Security Act;

(B) Not possess available resources, as defined in 13 CSR 40-2.030, in excess of twice the individual resource maximum of the federal Supplemental Security Income (SSI) program for a single person or, if married and actually living with the spouse, the available resources of either the Qualified Medicare Beneficiary or the spouse, or both, shall not exceed twice the couple resource maximum of the federal SSI program, as cited at Section 1611(a)(3) of the Social Security Act;

(C) Not have adjusted gross income in excess of one hundred percent (100%) of the federal poverty level beginning January 1, 1991. For a single person, the adjusted gross income limitation shall be the applicable percentage of the poverty level for one (1) person. For a married couple living together, the adjusted gross income limitation shall be the applicable percentage of the poverty level for two (2) persons. For a married couple living together with an eligible dependent child, when one (1) of the parents is also eligible, the adjusted gross income limitation shall be the applicable percentage of the poverty level for three (3) persons. When an eligible dependent child lives with an ineligible parent(s), a portion of the income of the parent(s) shall be deemed to be the child’s and, in combination with the child’s own income, be compared to the adjusted gross income limitation for a single person. In determining adjusted gross income, the following exemptions will be applied to gross income:

1. If the income is earned or unearned, an amount of twenty dollars ($20) may be excluded from the gross;

2. The full amount of any SSI payment will be excluded; and 3. If the income is earned, the twenty dollar ($20) exclusion in paragraph (1)(C)1. will be applied, plus the first sixty-five dollars ($65) and one-half (1/2) of the remainder of all earned income will be excluded. If a person is a student and is under the age of twenty-two (22), the amount of the school expense will be excluded from any earned income;

(D) Not have transferred property without receiving fair and valuable consideration.

Transfers which occur prior to July 1, 1989 shall cause periods of ineligibility for assistance in accordance with section 208.010.2(1), RSMo. Transfers which occur after June 30, 1989 shall cause periods of ineligibility in accordance with section 208.010.6., RSMo; and (E) Not possess, prior to October 1, 1989, equity in total property in excess of the maximum set out in section 208.010.2(5), RSMo.

(2) Eligibility for Qualified Medicare Beneficiary assistance may not begin until the month following the month the Division of Family Services completes the determination of eligibility.

Emergency rule filed July 5, 1989, effective July 15, 1989, expired Nov. 12, 1989. Original rule filed July 5, 1989, effective Oct. 12, 1989. Emergency amendment filed Dec. 20, 1989, effective Dec. 30, 1989, expired April 29, 1990. Amended: Filed Feb. 15, 1990, effective May 11, 1990. Emergency amendment filed Dec. 18, 1990, effective Jan. 1, 1991, expired April 30, 1991. Amended:

Filed Jan. 25, 1991, effective July 8, 1991.

13 CSR 40-2.280 FUTURES Program {#sec-13-csr-40-2.280 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.280}

Original rule filed May 2, 1990, effective Sept. 28, 1990. Amended: Filed Aug. 11, 1994, effective Feb. 26, 1995. Emergency amendment filed June 15, 1995, effective June 25, 1995, expired Oct, 22, 1995.

Amended: Filed June 15, 1995, effective Nov. 30, 1995. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: section 207.020, RSMo 1994.

13 CSR 40-2.290 Compensation for Legal Representation of General Relief Recipient in Successful Supplemental Security Income Appeal Emergency rule filed Nov. 1, 1990, effective Nov. 11, 1990, expired March 11, 1991. {#sec-13-csr-40-2.290 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.290}

Original rule: Filed Nov. 1, 1990, effective April 29, 1991. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

13 CSR 40-2.300 Definitions Which Are Applicable for Benefit Programs Funded by the Temporary Assistance for Needy Families (TANF) Block Grant {#sec-13-csr-40-2.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.300}

PURPOSE: This rule provides the definition of terms which are applicable to the Temporary Assistance program funded by the Temporary Assistance for Needy Families (TANF)

Block Grant.

(1) Agent. Any entity acting on behalf of the division under a contract or memorandum of understanding.

(2) Assistance. Every form of support provided to participants and their families under the Temporary Assistance (TA) program, including child care, work subsidies, and allowances to meet living expenses. Assistance does not include the cash diversion program in 13 CSR 40-2.480; services that have no direct monetary value to an individual family and that do not involve implicit or explicit income support, such as counseling, case management, peer support, and employment services that do not involve subsidies or other forms of income support; or one- (1-) time, short-term assistance authorized by a representative of the Family Support Division as part of an Individual Employment Plan (IEP) under 13 CSR 40-2.370(2), including assistance to pay for automobile repairs to retain employment and avoid welfare receipt, and appliance repair to maintain living arrangements.

(3) Community service programs. Structured programs and embedded activities in which TA recipients perform work for the direct benefit of the community under the auspices of public or nonprofit organizations. Community service programs must be limited to projects that serve a useful community purpose in fields such as health, social service, environmental protection, education, urban and rural redevelopment, welfare, recreation, public facilities, public safety, and child care.

(4) Division. The Family Support Division of the Department of Social Services of the State of Missouri, or its agent.

(5) Household. A family that includes:

(A) Eligible children under the age of eighteen (18); or (B) Eligible children who are age eighteen (18) and in secondary school or the equivalent vocational or technical school, if they are expected to graduate before turning age nineteen (19); and (C) The natural or adoptive parents of one (1) or more of the eligible children; or (D) Any needy non-parent caretaker relative or unrelated guardian of one (1) or more of the eligible children, if there are no natural or adoptive parents in the home. The non-parent caretaker relative or the guardian, if found to be eligible for inclusion, may exclude themselves from the assistance group.

(6) Investigation. A review conducted by the division to determine that a participant is not cooperating with a work participation activity requirement. The investigation may include a telephone or personal contact with the participant at the discretion of the division.

(7) Participant. Any individual who has applied for, or is receiving, or has been denied, TA benefits or services administered by the Family Support Division.

(8) Temporary Assistance (TA). The division’s program for the provision of any public assistance funded in whole or part directly through the Temporary Assistance for Needy Families (TANF) Block Grant, section 603 of Title 42, United States Code and Parts 260– 284 of Title 45, Code of Federal Regulations.

(9) Satisfactory attendance at a secondary school, provided that the participant has not already completed secondary school. Regular attendance, in accordance with the requirements of the secondary school or course of study, at a secondary school or in a course of study leading to a certificate of general equivalence, in the case of a recipient who has not completed secondary school or received such a certificate. This activity must be supervised on an ongoing basis no less frequently than daily.

(10) Work activities that any participant seeking TA shall engage in unless exempt include:

(A) Unsubsidized employment;

(B) Subsidized private sector employment;

(C) Subsidized public sector employment;

(D) Work experience (including work associated with the refurbishing of publicly assisted housing) if sufficient private sector employment is not available;

(E) On-the-job training;

(F) Job search and job readiness assistance;

(G) Community service programs;

(H) Vocational educational training (not to exceed twelve (12) months with respect to any participant);

(I) Job skills training directly related to employment;

(J) Education directly related to employment for participants who have not received a high school diploma or a certificate of high school equivalency;

(K) Satisfactory attendance at a secondary school provided that the participant has not already completed secondary school; and (L) Providing child care services to a participant who is involved in a community service program.

(11) Subsidized Public Sector Employment.

Employment in the public sector for which the employer receives a subsidy from TA or other public funds to offset some, or all, of the wages and costs of employing a recipient.

(12) Subsidized Private Sector Employment.

Employment in the private sector for which the employer receives a subsidy from TA or other public funds to offset some, or all, of the wages and costs of employing a recipient.

(13) Vocational educational training. Organized educational programs that are directly related to the preparation of individuals for employment in current or emerging occupations requiring training other than a baccalaureate or advanced degree. Vocational educational training must be supervised on an ongoing

basis no less frequently than daily.

(14) Work Experience. A work activity, performed in return for TA, that provides an individual with an opportunity to acquire the general skills, training, knowledge, and work habits necessary to obtain employment.

(15) Unsubsidized employment. Full- or parttime employment in the public or private sector that is not subsidized by TA or any other public program. 2014, and section 208.026, RSMo Supp.

1998. Original rule filed Jan. 16, 1998, ment filed Aug. 18, 2015, effective Aug. 28, 2015, expired Feb. 23, 2016. Amended: Filed Aug. 28, 2015, effective April 30, 2016. *Original authority: 207.022, RSMo 2014 and 208.026, RSMo 2015.

13 CSR 40-2.305 Prohibition Against the Payment of Temporary Assistance to a Person Who Has Been Convicted of Certain Felony Drug Offenses of Temporary Assistance to a person who has been convicted of certain felony drug offenses. {#sec-13-csr-40-2.305 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.305}

(1) For the purpose of the administration of the Temporary Assistance Program the Diviassistance to or on behalf of an individual who has been convicted (under federal or state law) of any offense which is classified as a felony by the law of the jurisdiction involved and which has as an element the possession, use or distribution of a controlled substance (as defined in section 802(6) of Title 21, United States Code).

(2) The amount of assistance that would otherwise be required to be provided under the Temporary Assistance Program to the family members of an individual to whom section (1) applies shall be reduced by the amount which would have otherwise been made available to the individual who has been convicted of such an offense.

(3) For purposes of the administration of this

rule, the prohibition contained within this

rule shall not apply to convictions arising out of offenses occurring prior to the effective date of United States Public Law 104-193 on August 22, 1996.

(4) For purposes of the administration of this

rule, each individual applying for benefits under the Temporary Assistance Program shall be required in the application process to state, in writing, whether the individual, or any member of the household of the individual, has been convicted of a crime described in section (1) of this rule.

Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.310 Requirements as to Eligibility for Temporary Assistance {#sec-13-csr-40-2.310 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.310}

PURPOSE: This rule establishes the requirements for eligibility for Temporary Assistance (TA).

(1) All participants shall meet the eligibility requirements set forth in this rule to qualify for receipt of Temporary Assistance (TA):

(A) Each participant and each dependent child shall be a resident of the state of Missouri; and (B) A United States citizen; or (C) A qualified alien as defined in section 1641 of Title 8, United States Code, except as otherwise provided herein. Except as provided in section 1622(b) of Title 8, United States Code, a qualified alien who enters the United States on or after August 22, 1996, is not eligible for TA benefits for a period of five (5) years beginning on the date of the alien’s entry into the United States. Qualified aliens who have entered the United States on or after August 22, 1996, and who do not meet the time limit exception, may be eligible for TA after a period of five (5) years beginning on the date of the qualified alien’s entry into the United States. An alien who is not a qualified alien under sections 1641 or 1622(b) of Title 8, United States Code shall be ineligible to receive TA benefits. If an alien who is not eligible to receive TA benefits is found to be on the TA rolls, then his or her benefits will be terminated and his or her case will be closed. If a participant in the TA program is not a qualified alien or does not otherwise fall within the exception set forth in section 1622(b) of Title 8, United States Code, then the participant’s application for TA will be denied;

(D) A participant shall provide all Social Security numbers for each parent, caretaker, and child for whom benefits are being requested, and shall be required to cooperate with the division to obtain Social Security numbers;

(E) The participant shall use the assistance provided under the Temporary Assistance program for the benefit of the child or children;

(F) Any household member receiving Supplemental Security Income (SSI) shall not be eligible for TA for themselves. The income, expenses, and resources of the SSI recipient are excluded when determining the eligibility of the household. The individual shall be excluded for purposes of determining household size;

(G) The participant shall meet all other eligibility requirements contained in 13 CSR 40-2.300 through 13 CSR 40-2.370 and 13 CSR 40-2.400 through 13 CSR 40-2.450;

(H) Beginning August 28, 2015, any parent or caretaker who applies for TA under these regulations shall first complete a standardized orientation which informs participants of the program’s rules and requirements, available resources for work activities, and consequences if the program’s requirements are not satisfied. Any parent or caretaker who is applying for TA benefits for himself or herself shall sign a Personal Responsibility Plan in which he or she commits to participate in the program and specifies the work activities in which he or she will participate;

(I) Beginning August 28, 2015, any parent or caretaker whose TA case is closed due to work activity sanctions under these regulations shall first perform work activities for an average of thirty (30) hours per week in a one- (1-) month period before qualifying for TA again, unless such individual is otherwise exempt from work activities as provided for in these regulations; and (J) Beginning January 1, 2016, any parent or caretaker who applies for TA benefits under these regulations shall complete an online job registration before receiving any payment of TA.

(2) Application for benefits and timely determination of eligibility for benefits will comply with sections 208.060 and 208.070, RSMo, and 13 CSR 40-2.010. In TA cases where an eligible individual does not receive his or her first payment for the month in which the thirtieth day after application falls, a delayed payment will be made for that month and any later months that passed before the application was approved.

(3) A participant is not eligible for Temporary Assistance if his/her total countable resources exceeds one thousand dollars ($1,000). If the participant is participating in an Individual Employment Plan as defined in 13 CSR 40-2.370, the resource limit is five thousand dollars ($5,000). This policy applies to a child and to a parent(s), or to step-parents, or if included in the grant, a needy nonparent caretaker relative or legal guardian with whom the child is living. Resources considered in determining eligibility for TA, and how the value of those resources is determined, shall be as follows, unless otherwise defined in subparagraph (8)(B)1.D.:

(A) Property of any kind or character which the participant owns or possesses, or has an interest in, of which s/he is the record or beneficial owner, less encumbrances of record:

1. The value of a life insurance policy at any time shall be the cash surrender value of the policy, minus the amount of any lien, loan, accrued interest payments, or assigned portion of the policy;

2. The value of a qualified tuition program (as defined at section 529 of Title 26, United States Code) and Individual Development Account (as defined at section 604(h) of Title 42, United States Code) does not count toward a person’s eligibility for Temporary Assistance; and 3. The total amount on deposit in a joint bank account of which the participant is one (1) of the owners is considered as available to the participant, unless there is verification that the money placed in the account, or a definite portion of it, belongs to the other joint owner, who is not applying for or receiving TA.

When both or all the owners of a joint bank account are applying for or receiving assistance, each is considered as owning his/her proportionate share of the account. If the participant states s/he has not deposited any portion of the money in the account, and past circumstances of the participant indicate that this is reasonable, the total amount on deposit will not be considered as available to the participant;

(B) For purposes of the Temporary Assistance program, personal property is defined as household goods, jewelry, farm surpluses, livestock, farm or business machinery or equipment, automobiles, trucks, and similar items;

(C) Real Property:

1. When a participant owns real property that is not furnishing shelter for him/her, the property shall be considered a resource, subject to the exceptions in paragraph 2. of this subsection. The countable value of the property is its current market value less encumbrances of record. The value of countable real property shall be counted as part of the combination of available resources in determining eligibility for TA;

2. Real property in which the participant has lived will be counted as a resource the month after the month in which it is vacated for other than a temporary purpose, unless the spouse from whom the participant is separated and the participant own the home jointly and the spouse continues to remain in the home. In this case, the home and forty (40) acres adjoining will not be included in determining equity in resources as long as the spouse remains in the home. In the event of divorce, the equity in the property must be considered as a resource immediately;

3. If a participant or legally married couple owns more than one (1) piece of property, they shall be required to designate one (1) as their homestead, and the other real property shall be considered an available resource. Also, when two (2) participants marry and each owns a home in which s/he has been living, they will be required to designate one (1) of the properties as their homestead, and the other shall be considered as an available resource;

4. The land on which the home is located, up to forty (40) acres, is considered a part of the home as long as the land is adjoining, in the same city block, and there is no other dwelling on the forty (40) acres; or 5. The land on which the home is located up to forty (40) acres, which is part of a farming unit, will be considered as part of the home so long as the land is adjoining and there is no other dwelling on the forty (40) acres. Property will be considered as adjoining even though a road may separate two (2) tracts, if the property is farmed as a single unit; and 6. All other real property will be included in determining the one thousand dollar ($1,000) limitation for participants, or the five thousand dollar ($5,000) limitation for participants in Individual Employment Plans;

(D) There shall be disregarded any prearranged funeral or burial contract, or any two (2) or more contracts, which provide for the payment of one thousand, five hundred dollars ($1,500) or less per family member. The face value of an irrevocable burial contract is not a countable resource; however, it will always be counted toward the one thousand, five hundred dollar ($1,500) exemption. The face value of a revocable funeral or burial contract is a countable resource, minus the one thousand, five hundred dollar ($1,500) exemption. If the same household member is the beneficiary of both an irrevocable prearranged contract and one (1) or more revocable prearranged contracts, the one thousand, five hundred dollar ($1,500) exemption must be applied to the irrevocable contract first. If the irrevocable contract’s cash value is less than one thousand, five hundred dollars ($1,500), the remainder of the exemption can be applied to the revocable contracts;

(E) A participant may not own resources with equity greater than one thousand dollars ($1,000), and a participant in an Individual Employment Plan may not own resources with equity greater than five thousand dollars ($5,000); however, the following types of personal property will not be counted as a resource:

1. Tools, supplies, livestock, farm surplus, and similar items being used by the participant in the course of his/her business.

This does not include business or farm machinery;

2. Household furnishings, household goods, and personal effects used by the participant;

3. The first automobile shall be excluded, plus one thousand, five hundred dollars ($1,500) equity in a second automobile; and 4. For participants only, earned income retained in an individual development account (as defined at section 604(h) of Title 42, United States Code);

(F) Any combination of more than one thousand dollars ($1,000) for a household, and five thousand dollars ($5,000) for households in which participants have signed Individual Employment Plans, would make the family ineligible.

(4) In applying earned income exemptions the following definition of “earned income” will be used:

(A) The term “earned income” encompasses income in cash or in kind earned by a needy individual through the receipt of wages, salary, commissions, or profit from activities in which s/he is engaged as a self-employed individual or an employee. Such earned income may be derived from his/her own employment, such as a business enterprise or farming, or derived from wages or salary received as an employee. It includes earnings over a period of time for which settlement is made at one given time, as in the instance of sale of farm crops, livestock, or poultry. In considering income from a farm operation, the option available for reporting under Old Age Survivor’s and Disability Insurance (OASDI), namely the “cash receipts and disbursements” method, (i.e., a record of actual gross expenses and of net) is an individual determination and is acceptable also for Temporary Assistance. With reference to commissions, wages, or salary, the term “earned income” means the total amount, irrespective of personal expenses, such as income tax deductions, lunches, transportation to and from work. With respect to self-employment, the term “earned income” means the total profit from business enterprise, farming, etc., resulting from a comparison of the gross income received with the “business expenses” (i.e., total cost of the production of the income). Personal expenses, such as income tax payments, lunches, and transportation to and from work, are not classified as business expenses;

(B) The definition shall exclude the following from “earned income”:

1. Returns from capital investment with respect to which the individual is not him/herself actively engaged, as in a business (for example, under most circumstances, dividends and interest would be excluded from “earned income”); and 2. Benefits (not in the nature of wages, salary, or profit) accruing as compensation, or reward for service, or as compensation for lack of employment (for example, pensions and benefits, such as United Mine Workers’ benefits or Veterans benefits); and (C) With regard to the degree of activity, earned income is income produced as a result of the performance of services by a participant; in other words, income which the individual earns by his/her own efforts, including managerial responsibilities, would be properly classified as earned income, such as management of capital investment in real estate.

Conversely, for example, in the instance of capital investment wherein the individual carries no specific responsibility, such as where rental properties are in the hands of rental agencies and the check is forwarded to the participant, the income would not be classified as earned income.

(5) Temporary Assistance shall be granted on behalf of eligible child(ren) in otherwise eligible families. TA may be granted to the parents or other needy relatives caring for a child or children meeting all eligibility criteria, and who— (A) Are deprived of parental support or care for the following reasons:

1. Death;

2. Continued absence from, or never living in, the home;

3. Physical or mental incapacity of a parent when the incapacity is expected to last at least thirty (30) days and is of such a debilitating nature as to substantially reduce or eliminate the parent’s ability to support or to care for the child. Physical or mental incapacity shall be certified by a competent medical or other appropriate authority designated by the division. Such certification is declared to be competent evidence in any proceedings concerning the eligibility of the participant to receive TA. Physical or mental incapacity can also be verified by the parent’s receipt of Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI);

4. Divorce/separation;

5. Desertion;

6. Confinement in a penal, medical, or custodial institution;

7. A physical restoration or training program developed by vocational rehabilitation, if the plan necessitates absence of a parent from the home; or 8. Financial need due to a lack of adequate income to properly provide for the needs of the child(ren), as determined in sub-

section (8)(B) of this rule;

(B) Are not deprived of parental support due to the parent’s participation in a strike;

(C) Are living with a relative limited to the following: the child’s father, mother, grandfather, grandmother, brother, sister, stepfather, or stepmother (but not their parents), stepbrother, stepsister, uncle, aunt, first cousin, first cousin of a parent, nephew, niece, adoptive father, or adoptive mother, grandfatherin-law, or grandmother-in-law (meaning the spouse of a second marriage of one (1) of the child’s biological grandparents), great-grandfather, or great-grandmother (including greatgreat grandfather or great-great grandmother), brother or sister of half-blood; adoptive brother or adoptive sister, brother-in-law or sister-in-law, uncle or aunt of the half blood; uncle-in-law or aunt-in-law, great-uncle or great-aunt (including great-great uncle or great-great aunt). Relatives by adoption, in addition to those specifically mentioned here, may be considered eligible payees within the same degree of relationship as applies to blood relatives. The biological relatives of an adopted child also continue to be eligible payees. A legal guardian may also serve as a payee for TA, and if the legal guardian is otherwise eligible, may be eligible for a cash payment.

(6) Unless it is being used to refer to the physical dwelling owned by a participant, “home” shall be a family setting maintained or in the process of being established as evidenced by the assumption or continuance of responsibility for the child. A home exists as long as the parent or relative takes responsibility for the care and control of the child, even though circumstances may require temporary absence of either the child or the parent (or relative) from the customary family setting, subject to 13 CSR 40-2.365.

(7) For the purpose of the administration of Temporary Assistance, payments shall be defined as payments by electronic or other means made to the payee, at regular monthly intervals. TA benefits will be made available on the same schedule as indicated in 13 CSR 40-2.150.

(8) Determining the Amount of Cash Payments.

(A) The size and composition of the TA household is determined under the definition in 13 CSR 40-2.300.

(B) Consideration of available income to determine whether a need for TA exists— 1. In TA cases, all income of the following persons who are in the household, irrespective of subsection (8)(A), shall be considered in determining whether the children (including stepchild) are in need, and if so, the amount of that need:

A. Eligible children;

B. Parents of one (1) or more of the eligible children;

C. Any needy non-parent caretaker relative or related or unrelated guardian if they desire to be included in the assistance group and are eligible for inclusion;

D. New spouse and stepparent income:

(I) Upon the marriage of a TA recipient, the division will disregard the income and resources of the TA recipient’s new spouse for six (6) consecutive TA months.

Only months in which a TA benefit is paid to the recipient will be counted toward the six (6) consecutive months. The disregard begins the first day of the first month following the marriage date, in which benefits could possibly, but not necessarily, have been affected without application of this disregard. The TA recipient cannot receive this disregard again if he or she remarries. The TA recipient shall provide proof of a valid marriage to the division;

(II) Except as otherwise excluded in part D.(I) of this subparagraph, the income of a stepparent living in the same home as an eligible child counts toward the TA household’s eligibility, insofar as it exceeds the sum of— (a) The first ninety dollars ($90) of the stepparent’s earned income, for such month;

(b) The Standard of Need for a family of the same composition as the stepparent and those other individuals living in the same household as the dependent child, and claimed, or who could be claimed, by such stepparent as dependents for purposes of determining the stepparent’s federal personal income tax liability, but whose needs are not taken into account;

(c) Amounts paid by the stepparent to individuals not living in such household and claimed by him/her as dependents for purposes of determining the stepparent’s federal personal income tax liability; and (d) Payments by such stepparent of court-ordered alimony or child support with respect to individuals not living in such household;

(III) Dissolution of a marriage severs the legal relationship of the stepparent to the stepchild unless legal guardianship is established by the court;

E. The income of any biological or adoptive brother or sister of an eligible child, if such brother or sister meets the conditions described in 13 CSR 40-2.310(4) and 13 CSR 40-2.325(1)(A)1. and 2., and is living in the home;

F. With respect to a parent or legal guardian who is under age eighteen (18) with an eligible child, the income of such minor parent’s own parents who are living in the home shall be included to the same extent that the income of a stepparent is included (see part (8)(B)1.D.(II) above). The minor parent’s earned income shall be disregarded up to one hundred percent (100%) of the federal poverty level; and G. Income of all other persons in the household will be considered in the amount made available to the household;

2. In computing the income of a participant, or of the household of which s/he is a member, only that income which is available during the period under consideration shall be taken into account. To be considered as available, the income shall actually and presently exist (not to be a potential or remote income) and shall be sufficient to have some apprecia ble significance in meeting the immediate requirements of the participant.

(9) Earned Income Exemption.

(A) In determining need and amount of grant for participants of Temporary Assistance, the following earned income exemptions will apply, and these amounts will be disregarded in determining the amount of income available to meet the family’s needs:

1. All of the earned income of any child receiving Temporary Assistance will be exempted if the child is a full-time student or is a part-time student who is not a full-time employee;

2. The first ninety dollars ($90) of each participant’s gross earned income will be disregarded;

3. An amount equal to the first thirty dollars ($30) of the actual total of each participant’s earned income not already disregarded in the preceding provisions of this subsection (9)(A) plus one-third (1/3) of the remainder thereof for four (4) consecutive months;

4. An amount equal to thirty dollars ($30) of the total of each participant’s earned income not already disregarded in the preceding provisions of this subsection (10)(A), for an eight- (8-) month period following the fourth consecutive month of the disregard provided for in paragraph (10)(A)3.;

5. An amount equal to expenditures for care in such month shall be disregarded from earned income for an eligible child, or an incapacitated individual living in the same home as the child, receiving Temporary Assistance and requiring such care for such month, to the extent that such amount for each such child or incapacitated individual does not exceed one hundred seventy-five dollars ($175) for children age two (2) and over, or two hundred dollars ($200) for children under two (2) years of age; and 6. All of the earned income of a parent who is under the age of nineteen (19) and is a full-time student in a secondary school or equivalent program of education or training.

(B) The disregards applied against the earned income outlined in subsection (9)(A) shall not be applied to the earned income of any person who— 1. Terminated his/her employment or reduced his/her earned income without good cause within such period of not less than thirty (30) days preceding such month;

2. Refused without good cause, within such thirty- (30-) day period, to accept employment in which s/he is able to engage, which is offered through the public employment offices of the state or is otherwise offered by an employer, if the offer of the employer is determined by the division or agency designated by the division, after notification by the employer, to be a bona fide offer of employment; and 3. Failed without good cause to make a timely report to the division of earned income received in such month.

(C) The disregards applied against earned income as provided for in subsection (9)(A) are subject to the following requirements:

1. The exclusion of a child’s earned income in paragraph (9)(A)1. shall be applied when determining need for up to six (6) months within the calendar year of January through December, and thereafter shall not be applied if the income without applying this need;

2. The thirty dollar ($30) plus one-third (1/3) disregard in paragraph (9)(A)3. shall not be applied if the income without applying this disregard was in excess of the standard of need, unless the person received TA in one (1) or more of the four (4) preceding such months, and this disregard has not already been applied to his/her income for four (4) consecutive months while s/he was receiving TA. If this disregard provided for in paragraph (9)(A)3. has been applied for four (4) consecutive months, the disregard shall not be applied for as long as the person continues to receive TA, and shall not apply until the expiration of a period of twelve (12) consecutive months during which the person is not a recipient of TA; and 3. The thirty dollar ($30) disregard in paragraph (9)(A)4. shall be available only for the eight- (8-) month period following the fourth consecutive month of the disregard provided for in paragraph (9)(A)3. If the eight- (8-) month period for the disregard provided for in paragraph (9)(A)4. has expired, the disregard shall not be applied for as long as the person continues to receive TA, and shall not apply until the expiration of a period of twelve (12) consecutive months during which the person is not a recipient of TA.

(D) The division shall apply the two-thirds (2/3) earned income disregard, consistent with section 208.040.5(1), RSMo. The twothirds (2/3) disregard shall apply for no more than twelve (12) consecutive months. Once the two-thirds (2/3) disregard is applied for twelve (12) consecutive months, the individual is not eligible for the two-thirds (2/3) disregard until the individual does not receive TA for twelve (12) consecutive months. The two-thirds (2/3) disregard is applied prior to allowing the thirty dollars ($30) plus onethird (1/3) disregard as defined in paragraph (9)(A)3.

(10) 185% Test. No family shall be eligible for TA if for that month, the total income of the family (other than Temporary Assistance benefits), without application of the earned income disregards provided for in paragraphs (9)(A)2.–5. and for up to six (6) months within the calendar year of January through December with application of the earned income disregard provided for in paragraph (9)(A)1., equals or exceeds one hundred eighty-five percent (185%) of the Standard of Need for a family of the same composition.

(11) Standard of Need Test. No family shall be eligible for TA if, for that month, the total income of the family (other than TA benefits), without application of the earned income disregards provided for in paragraphs (9)(A)2.– 5., except paragraphs (9)(C)1. and 2. would have application, and for up to six (6) months within the calendar year of January through December with application of the earned income disregard provided for in paragraph (9)(A)1. equals or exceeds the Standard of Need for a family of the same composition.

(12) Percentage of Need Test. No family shall be eligible for TA if, for that month, the total income of the family (other than TA benefits), after application of the earned income disregards provided for in section (9), equals or exceeds 34.526% of the Standard of Need.

(13) When considering an application for TA, the income tests in sections (10), (11), and (12) must each indicate income below the respective standard. To be eligible, income shall be less than— (A) 185% of the Standard of Need when applying the 185% Test;

(B) The Standard of Need for the Standard of Need Test; and (C) 34.526% of the Standard of Need for the Percentage of Need Test.

If the household is determined eligible after application of the tests in sections (10), (11), and (12), the grant amount will be the deficit determined in the Percentage of Need Test.

The table below indicates the maximum grant amount by application of the Percentage of Need (34.526%) to the Standard of Need, according to household size.

No. of Persons: 1 2 3 4 5 6 7 8 9 10 11 Standard of Need: 393 678 846 990 1123 1247 1372 1489 1606 1722 1839 34.526% of Need: 136 234 292 342 388 431 474 514 554 595 635 No. of Persons: 12 13 14 15 16 17 18 19 20 21 22 Standard of Need: 1956 2072 2188 2304 2420 2536 2652 2768 2884 3000 3116 34.526% of Need: 675 715 755 795 835 875 915 955 995 1035 1075 (14) In the payment of TA benefits, the amount shall always be lowered to the nearest dollar interval. If the determined amount results in a grant of less than ten dollars ($10), no cash payment will be made.

(15) In TA cases, the initial assistance payment must be prorated when the case is approved in the same month as the filing of the application. The payment will be determined by multiplying the amount payable for a whole month by the ratio of the days in the month from the date of application to the end of the month to the number of days in a standard thirty- (30-) day month.

(16) Legal immigrants meeting the eligibility criteria for TA, who would be eligible for food stamps but for the passage of P.L. 104- 193, effective August 22, 1996, may be eligible for nutrition assistance calculated by use of the Food Stamp budgeting process set forth in section 2014 of Title 7, United States Code.

(17) Participants who meet the definition of a TA household must have their eligibility explored under TA (except under emergency situations when General Relief orders may be utilized) before having their eligibility for General Relief explored, if funds have been appropriated to the General Relief program.

Any participant whose eligibility has been explored under TA and is found to be ineligible for TA cash payments because of the following reasons shall be ineligible for General Relief:

(A) The person refuses to cooperate in establishing his/her eligibility for TA, including persons who refuse to apply for a Social Security number, refuse to participate in work activities, refuse to enter into an individual employment plan, refuse to make an assignment of support rights, refuse to cooperate in the identification of absent parents, and refusal to cooperate for any other reason;

(B) Relationship to the payee who is not a legal guardian cannot be established for children under eighteen (18);

(C) The budget shows no need;

(D) The available resources exceed the maximum allowed; or (E) The children are not deprived of parental support.

(18) A participant who is aggrieved by a deci- (19) The confidentiality provisions of 13 CSR 40-2.180 apply to the TA program.

(20) The provisions of 13 CSR 40-2.190, regarding the collection of overpayments, apply to the TA program.

(21) The provisions of 13 CSR 40-2.230, regarding the disposal of excess real property, apply to the TA program.

(22) By submitting information to the division, a participant is certifying that the information is true, accurate, and complete. 2014.* Emergency rule filed Feb. 18, 1998, 1998. Original rule filed Jan. 16, 1998, ment filed July 22, 2003, effective Aug. 1, 2003, expired Jan. 27, 2004. Amended: Filed Jan. 23, 2004, effective July 30, 2004.

Emergency amendment filed Aug. 18, 2015, effective Aug. 28, 2015, expired Feb. 23, 2016. Amended: Filed Aug. 28, 2015, effective April 30, 2016. *Original authority: 207.022, RSMo 2014.

13 CSR 40-2.315 Work Activity and Work Requirements for Recipients of Temporary Assistance {#sec-13-csr-40-2.315 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.315}

PURPOSE: This rule establishes the work activities and participation requirements for receipt of Temporary Assistance (TA) benefits.

(1) A participant in a single parent family engages in work activities if he or she participates in the work activities described in 13 CSR 40-2.300(11)(A) through (I) for at least thirty (30) hours per week, unless otherwise required by section 261.31(d) of Title 45, Code of Federal Regulations. After the first twenty (20) hours, the participant can also earn additional hours by participating in the work activities described in 13 CSR 40- 2.300(11)(J) through (L).

(2) A participant in a two- (2-) parent family with work eligible parents engages in work activities if he or she participates in a combined minimum of thirty-five (35) hours of work activities as described in 13 CSR 40- 2.300(10)(A) through (I), unless otherwise required by section 261.31(d) of Title 45, Code of Federal Regulations. After the first thirty (30) hours, the participant can earn additional hours by participating in work activities described in 13 CSR 40-2.300(10)(J) through (L).

(3) A work eligible, two- (2-) parent family that receives federally-funded child care assistance, and which includes an adult who is neither disabled nor caring for a severely disabled child, must engage in at least fifty-five (55) hours of work activities per week, unless otherwise required by section 261.31(d) of Title 45, Code of Federal Regulations. After the first fifty (50) hours, the participant can earn additional hours by participating in work activities described in 13 CSR 40- 2.300(10)(J) through (L).

(4) A participant who is married, or is a single parent head of household under twenty (20) years of age, who has one (1) or more children of any age, is deemed to be engaged in work activities, notwithstanding section (1) or (2) of this rule, if— (A) The participant maintains satisfactory monthly attendance in a secondary school or a course of study leading to a certificate of general equivalence; or (B) Participates in education directly related to employment for an average of at least twenty (20) hours per week each month.

(5) For a married participant, hours of engagement in the activities described in sub-

section (4)(A) or (4)(B) shall be reported as the greater of— (A) The actual hours of participation in these activities; or (B) Twenty (20) hours.

(6) A family with two (2) work-eligible parents under twenty (20) years of age will satisfy the work activities if both participate in the activities described in subsection (4)(A) or (4)(B).

(7) A single parent head of household or relative, as defined in 13 CSR 40-2.310(5)(C), who has a child under age six (6), shall be deemed to be meeting the work participation requirement if the parent head of household or relative engages in work activities for twenty (20) hours, notwithstanding section (1) of this

rule, unless otherwise required by section 261.31(d) of Title 45, Code of Federal Regulations.

(8) Notwithstanding the requirements of this

rule or any other rule governing the TA program, the job search and job assistance work participation activity set forth in 13 CSR 40- 2.300(10)(F) shall be limited as set forth in

section 261.34 of Title 45, Code of Federal Regulations.

(9) If the division determines, after an investigation, that a participant is not cooperating with a work activity requirement as provided for in 13 CSR 40-2.310 or this regulation, the division shall schedule a face-to-face meeting with the participant to explain potential sanctions and the requirements to avoid a sanction.

(A) The division shall send notice of the scheduled meeting to the participant at least ten (10) business days before the meeting date. The notice shall include the date, time, and place designated by the division for the participant to appear. If the participant is unable to attend the meeting, the participant must contact the division to reschedule the meeting prior to the scheduled meeting time, and request an alternative meeting date, time, or place. The meeting must occur prior to or during the same calendar week as the original meeting, unless good cause exists. When good cause exists, the participant may only request to schedule one (1) additional appointment which will be within a reasonable amount of time not to exceed ten (10) business days from the original meeting date.

(B) “Good cause” includes a mistake or conduct beyond the control of the TA participant that is not intentionally or recklessly designed to impede an eligibility determination under these or any other TA regulations.

Good cause includes, but is not limited to— 1. A court-required appearance or incarceration lasting less than thirty (30) days;

2. An emergency family crisis that renders the participant unable to meet at the scheduled place, date, or time; and 3. A breakdown in transportation arrangements with no readily accessible alternate means of transportation.

(C) The participant shall have six (6) weeks from the first business day of the week following the meeting with the division to comply with the work activity requirements, as required by the division. The participant’s TA benefits shall not be sanctioned during the six- (6-) week period.

(D) If the participant fails to appear for the scheduled face-to-face meeting and does not contact the division prior to the meeting to reschedule the meeting as described in this section, the participant shall have six (6) weeks from the first business day of the week following the most recent scheduled meeting with the division to comply with the work activity requirements, as required by the division. The participant’s TA benefits shall not be sanctioned during the six- (6-) week period.

(E) If the participant does not comply with the work activity requirements during the six- (6-) week period, as described in either sub-

section (C) or (D) of this section, the division shall apply a sanction terminating fifty percent (50%) of the full amount of TA benefit for which the participant and the participant’s family is otherwise eligible, for a period of no more than ten (10) weeks. If the participant complies with the work activity requirements during the six- (6-) week period, described in either subsection (C) or (D) of this section, the division will take no further action against the participant’s TA benefits.

(F) During this ten- (10-) week period, the participant shall remain in sanction status and the division shall attempt to schedule a second face-to-face meeting with the participant as provided for in this section. To end the sanction, the participant shall perform work activities for a minimum average of thirty (30) hours per week for one (1) month.

(G) Failure to complete the requirements in subsection (F) of this section shall result in the participant’s TA case being closed.

(H) A participant whose case is closed under subsection (G) of this section will attend a temporary assistance eligibility interview if the individual wishes to re-apply for TA. The individual shall complete a minimum average of thirty (30) hours of work activities per week within one (1) month of the temporary assistance eligibility interview. The completion of work activities is a pre-requisite for any further eligibility for TA.

(10) Individuals who are already sanctioned by the division for non-cooperation with work activities as of August 28, 2015, shall comply with the following:

(A) Attend a face-to-face meeting with the division as set forth in section (9);

(B) If the participant appears for the scheduled face-to-face meeting, the work requirement sanction in place prior to August 28, 2015, shall be ended. The participant shall have six (6) weeks from the first business day of the week following the meeting with the division to comply with the work participation activity requirements, as required by the division;

(C) If the participant fails to appear for the scheduled face-to-face meeting required by subsection (9)(A), and does not contact the division prior to the meeting to reschedule the meeting, the participant shall have six (6) weeks from the first business day of the week following the originally scheduled meeting with the division to comply with the work activity requirements, as required by the division. The participant’s TA benefits shall remain sanctioned at twenty-five percent (25%) during the six- (6-) week period;

(D) If the participant appears for the scheduled face-to-face meeting required by subsection (9)(A), and complies with the work activity requirements during the six- (6-) week period, no further action will be taken;

(E) If the participant does not comply with the work activity requirements during the six- (6-) week period, as described in either subsections (9)(C) or (9)(D), the division shall apply a sanction terminating a total of fifty percent (50%) of the TA benefit amount the household would otherwise receive. This sanction shall apply for a period of no more than ten (10) weeks. If the participant complies with the work activity requirements during the six- (6-) week period, described in either subsection (9)(C) or (9)(D), the division will take no further action against the participant’s TA benefits;

(F) During this ten- (10-) week period, the division shall attempt to schedule a second face-to-face meeting with the participant as provided for in subsection (9)(A). To end the sanction, the participant shall perform work activities for a minimum average of thirty (30) hours per week for one (1) month;

(G) Failure to complete the requirements in subsection (F) of this section shall result in the participant’s TA case being closed; and (H) If the participant re-applies for TA after his or her case was closed under subsection (G) of this section, the application cannot be approved until the applicant completes a minimum of thirty (30) hours of work activities per week with one (1) month of the TA application.

(11) The following TA participants are exempt from work activities, but may voluntarily participate in work activities:

(A) Participants who are permanently disabled, if they have been determined to be eligible for Social Security Old Age Survivor’s and Disability Insurance (OASDI), Supplemental Security Income (SSI), or employersponsored disability insurance. Participants are exempt from work activities while an application for any of the aforementioned is pending unless or until an unfavorable determination is made;

(B) A child who is under the age of eighteen (18), or a child under age nineteen (19) who is attending secondary school and is not a head of a household;

(C) Caretaker-payees sixty (60) years of age or older;

(D) A participant who is a single custodial parent caring for a child who has not attained twelve (12) weeks of age;

(E) A participant caring for a disabled family member living in the home, provided that there is medical documentation to support the need for the participant to remain in the home to care for the disabled family member;

(F) The division may temporarily exclude TA recipients from work participation if any of the following conditions prevents them from participating:

1. The participant is determined by a physician, psychiatrist, or psychologist to have a temporary disability. The temporary disability must be expected to persist for at least thirty (30) days, and at most six (6) months. The participant shall produce a copy of medical records and a written report from a licensed medical professional providing the medical diagnosis, along with any supporting medical tests and examinations that establish the existence of the medical condition and the timeframe of the medical statement. The temporary waiver is removed when the period expires;

2. The participant is a victim of domestic violence, or participation in work activities would place the participant or his or her family in an unsafe or unstable situation. The temporary waiver will be removed once the participant informs the division that he or she can return to participation. The division shall review the ongoing necessity of the temporary waiver after thirty (30) days, regardless of whether the participant has contacted the division;

3. The participant has an active case with the Department of Social Service’s Children’s Division (CD). The division shall contact CD to confirm if the participant has an active case, the anticipated duration of the active case, and whether the participant’s involvement in the case prevents the recipient from participating in work activities; and 4. The participant is unable to find child care or transportation. The participant shall be required to provide the division with documentation supporting the participant’s efforts to obtain childcare or transportation, including information such as dates, contacts, and outcomes. The division will review the ongoing necessity of this temporary waiver every thirty (30) days.

(G) A single custodial parent caring for a child less than six (6) years of age because— 1. Appropriate child care within a reasonable distance from the home or work site is unavailable; or 2. Informal child care by a relative or under other arrangements is unavailable or unsuitable; or 3. Appropriate and affordable formal child care arrangements are unavailable; or 4. As used in this subsection, “affordable formal child care arrangements” shall mean that no participant shall be required to accept child care if the only available child care requires the family to personally pay more than twenty percent (20%) of their gross household income (less medical insurance premiums) for child care. This twenty percent (20%) includes any sliding-scale fee or additional co-payment the family would be required to pay. This twenty percent (20%) does not include any federal, state, or local child care subsidy; or 5. As used in this subsection, “appropriate child care” shall mean an appropriate provider that is:

A. Licensed by the Missouri Department of Health and Senior Services; or B. If exempt from licensure, is registered by the Children’s’ Division; or 6. As used in this subsection, “unsuitability of informal care” shall mean that the participant believes the child is at risk of abuse or neglect while being cared for by the provider. A participant shall not be required to use a provider with whom the participant has reason to believe will abuse or neglect the child. If another adult is residing in the household, but the participant does not believe the other adult is suitable, the participant must provide a reasonable statement as to why the other adult(s) is unavailable, or why this adult places the child at risk of abuse or neglect; or 7. As used in this subsection, “reasonable distance” shall be determined by the following:

A. The availability of personal transportation;

B. The distance from a public transportation access point to a child care facility or work site; or C. What is considered to be a reasonable distance in the participant’s community;

(H) The division shall determine if there is good cause for not participating in work activities prior to imposing a sanction. Good cause may include:

1. Employment that would result in the family of the participant experiencing a net loss of cash income;

A. Net loss of cash income results if the family’s gross income, less necessary work-related expenses such as uniforms, background screenings, and personal protective equipment, is less than the cash assistance the individual was receiving at the time the offer of employment was made.

B. For the purposes of this paragraph, gross income includes, but is not limited to, earnings, unearned income, and cash assis tance;

2. A court-required appearance or incarceration that renders participation unreasonable;

3. A breakdown in transportation arrangements beyond the control of the participant, with no readily accessible alternate means of transportation;

4. A breakdown in a child care arrangement, or the unavailability of child care suited for the special needs of the child for whom it is intended;

5. A lack of identified social services necessary for participation as set forth in an individual employment plan referenced in 13 CSR 40-2.370;

6. The participant’s home is rendered unlivable by fire or other natural disaster;

7. A temporary disability that causes the participant to be unable to work;

8. The accidental injury of a child or other family member that requires the participant to remain at home to care for the child or family member, and that prevents the participant from being able to seek work or maintain present employment;

9. A job loss due to company layoff, downsizing, or closing; or 10. The participant or a family member is a victim of a felony, as defined in the Missouri criminal statutes.

(12) All information provided to the division by a participant as required by this regulation shall be true, accurate, and complete.

(13) A participant who is aggrieved by a deci- 2014, and section 208.026, RSMo Supp.

1998. Original rule filed Jan. 16, 1998, ment filed Aug. 18, 2015, effective Aug. 28, 2015, expired Feb. 23, 2016. Amended: Filed Aug. 28, 2015, effective April 30, 2016. *Original authority: 207.022, RSMo 2014 and 208.026, RSMo 2015.

13 CSR 40-2.320 Prohibition Against Displacing Existing Workers Through Work Activities Associated with the Temporary Assistance Program {#sec-13-csr-40-2.320 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.320}

PURPOSE: This rule prohibits displacing existing workers through work activities associated with the Temporary Assistance Program and creates a grievance procedure for workers who believe that they have been displaced.

(1) An adult receiving assistance through the administration of the Temporary Assistance Program may fill a vacant employment position in order to engage in work activities. An adult receiving assistance through the program, who fills a vacant employment position in order to engage in work activities, must be guaranteed wages and benefits comparable to employees in like positions.

(2) An adult receiving Temporary Assistance and participating in a wage supplementation program may only fill a new employment position.

(3) No adult in a work activity as part of the Temporary Assistance Program and described in these rules shall be employed or assigned to a work activity when— (A) Any other individual is on layoff from the same or any substantially equivalent job;

(B) The employer has terminated the employment of any regular employee, reduced the hours of such employee, or otherwise caused an involuntary reduction of its workforce in order to fill the vacancy so created with an individual described in section (1); or (C) The employment opportunity is created by a strike, lockout or other bona fide labor dispute.

(4) An individual who believes that s/he has been adversely affected by a violation of sections (2) and (3) or the organization that is duly authorized to represent the employee, shall be afforded an opportunity to grieve it.

The employee or the employee’s organization must first attempt to remedy the alleged violation through a meeting with the employer within thirty (30) days of the request for the meeting. If the complaint is not resolved to the satisfaction of the employee, the employee may appeal to the Division of Family Services in accordance with the provisions of 13 CSR 40-2.160. The division may make a recommendation to the employer that the employee be reinstated or receive retroactive pay and benefit. In addition, if it is found the employer violated the provisions in sections (2) and (3) above, the division shall terminate the wage supplementation contract with the employer.

(5) Nothing in this section shall preempt or supersede any provision of a collective bargaining agreement. If there is an existing grievance procedure in a collective bargaining agreement, it must be followed.

(6) Nothing in this section shall preempt or supersede any provision of state law that provides greater protection for employees from job displacement. terminated Aug. 10, 1998. Original rule file Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.325 Prohibition Against Payment of Temporary Assistance to Families That Do Not Include a Minor Child of Temporary Assistance to families that do not include a minor child. {#sec-13-csr-40-2.325 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.325}

For the purpose of the administration of the Temporary Assistance Program, the Family Support Division shall not provide assistance to or on behalf of a family— (A) Unless the family includes:

1. A child under the age of eighteen (18) who resides with a custodial parent or other adult caretaker relative of the minor child; or 2. A child under the age of nineteen (19) and a full-time student in a secondary school (or at the equivalent level of vocational or technical training), if the child may reasonably be expected to complete the program of the secondary school (or vocational or technical training); and (B) If the family includes an adult who has received public assistance through a program funded, in whole or part, through the Temporary Assistance for Needy Families (TANF)

Block Grant, section 603 of Title 42, United States Code (including the Temporary Assistance Program), for a total of forty-five (45) cumulative months, whether or not consecutive, unless an exception described in 13 CSR 40-2.350 applies. As used in this paragraph “assistance” is defined as set forth in 13 CSR 40-2.300, whether provided in Missouri or another state or territory, or whether provided before or after the effective date of these rules. 2014, and section 208.040.5, RSMo Supp.

1998. Original rule filed Jan. 16, 1998, effective Aug. 1, 1998. Amended: Filed Feb. 8, 2016, effective Aug. 30, 2016. 1994, 1999, 2001, 2009, 2015.

13 CSR 40-2.330 Reduction of Temporary Assistance for Noncooperation in Establishing Paternity or Obtaining Child Support {#sec-13-csr-40-2.330 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.330}

PURPOSE: This rule provides for the reduction of Temporary Assistance for noncooperation in establishing paternity or obtaining child support.

(1) If it is determined by the Division of Child Support Enforcement, or its designee, that an applicant for or a recipient of Temporary Assistance is not cooperating in establishing paternity or in establishing, modifying, or enforcing a support order with respect to a child, and the individual does not qualify for any good cause or other exception established by the Division of Child Support Enforcement, or its designee, pursuant to

section 654(29) of Title 42, United States Code, then the Division of Family Services— (A) Shall deduct from the assistance that would otherwise be provided to the family of the individual an amount equal to not less than twenty-five percent (25%) of the amount of such assistance.

(2) For purposes of the administration of section (1) of this rule, good cause for refusing to cooperate is deemed to exist in one (1) or more of the following circumstances:

(A) Cooperation by the applicant may reasonably be anticipated to result in— 1. Physical or emotional harm to a child;

2. Physical or emotional harm to the claimant of sufficient severity that it will reduce the applicant’s capacity to adequately care for a child; or 3. Physical or emotional harm to the claimant as a result of domestic violence; and (B) Establishing paternity or securing support will be detrimental to a child because— 1. The child was conceived as a result of incest or rape;

3. Legal proceedings for adopting the child are pending before a court; or 3. A public or private social agency is currently assisting the applicant to resolve the issue of whether to keep the child or to relinquish the child for adoption, and the discussions have not gone on for more than three (3) months.

Jan. 16, 1998, effective Aug. 1, 1998. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993 and 208.040.5, RSMo 1949, amended 1955, 1969, 1982, 1985.

13 CSR 40-2.335 Assignment of Certain Support Rights as a Condition for the Receipt of Temporary Assistance {#sec-13-csr-40-2.335 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.335}

PURPOSE: This rule provides for the assignment of certain support rights as a condition for the receipt of Temporary Assistance.

(1) For the purpose of the administration of the Temporary Assistance Program the Division of Family Services shall require, as a condition to eligibility for the receipt of assistance, that a member of the family assign to the Division of Family Services any rights the family member may have (on behalf of the family member or of any other person for whom the family member has applied for or is receiving such assistance) to support from any other person, not exceeding the total amount of assistance so provided to the family, which accrue (or have accrued) before the date the family leaves the program. Such assignment of support, on or after the date the family leaves the program, shall not apply with respect to any support (other than support collected pursuant to section 664 of Title 42, United States Code) which accrued before the family received such assistance and which the Division of Child Support Enforcement has not collected within the time limits set forth in section 608(a)(3)(i) and (ii) of Title 42, United States Code.

(2) The Division of Family Services shall not require, as a condition of providing Temporary Assistance to any family, that a member of the family assign any rights to support described in section (1) which accrue after the date the family leaves the program.

(3) For purposes of the administration of this

rule, an application or receipt of Temporary Assistance shall constitute an assignment of such support rights which shall take effect, by operation of law, upon a determination that the applicant is eligible for assistance.

Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.340 Prohibition Against Payment of Temporary Assistance to Teenage Parents Who Do Not Attend High School or Other Equivalent Training of Temporary Assistance to teenage parents who do not attend high school or other equivalent training program. {#sec-13-csr-40-2.340 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.340}

(1) For the purpose of the administration of assistance to an individual who has not attained eighteen (18) years of age, is not married, has a minor child at least twelve (12) weeks of age in his/her care, and has not successfully completed a high school education (or its equivalent), if the individual does not participate in — (A) Educational activities directed towards the attainment of a high school diploma or its equivalent; or (B) An alternative educational or training program that has been approved by the Division of Family Services.

Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.345 Prohibition Against Payment of Temporary Assistance to Teenage Parents Not Living in Adult Supervised Settings of Temporary Assistance to teenage parents not living in adult supervised settings. {#sec-13-csr-40-2.345 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.345}

(1) Except as provided in section (2), for the

purpose of the administration of the Temporary Assistance Program, the Division of Family Services shall not provide assistance to an individual who has not attained eighteen (18) years of age, is not married, and has a minor child in his/her care, if the individual and the minor child do not reside in a place of residence maintained by a parent, legal guardian, or other adult relative of the individual as such parent’s, guardian’s, or adult relative’s home.

(2) In the case of an individual described in

section (3) of this rule, the Division of Family Services shall provide, or assist the individual in locating a maternity home, or other appropriate adult-supervised supportive living arrangement, taking into consideration the needs and concerns of the individual, unless the Division of Family Services determines that the individual’s current living arrangement is appropriate, and thereafter shall require that the individual and the individual’s minor child reside in such living arrangement as a condition of the continued receipt of assistance or in an alternative appropriate arrangement should circumstances change and the current arrangement cease to be appropriate.

(3) For purposes of section (2) the “individual” means an individual who has not attained eighteen (18) years of age, is not married, and has a minor child in his/her care and— (A) The individual has no parent, legal guardian, or other appropriate adult relative described in subsection (3)(B) of his/her own who is living or whose whereabouts are known;

(B) No living parent, legal guardian, or other appropriate adult relative, who would otherwise meet applicable criteria to act as the individual’s legal guardian, of such individual allows the individual to live in the home of such parent, guardian, or relative; or (C) The Division of Family Services deter mines that— 1. The individual or the minor child referred to in section (1) is being or has been subjected to serious physical or emotional harm, sexual abuse, or exploitation in the residence of the individual’s parent or legal guardian;

2. Substantial evidence exists of an act or failure to act that presents an imminent or serious harm if the individual and the minor child lived in the same residence with the individual’s own parent or legal guardian; or 3. The Division of Family Services otherwise determines that it is in the best interest of the minor child to waive the requirement of

section (1) with respect to the individual or the minor child.

Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.350 Time Limit for Receipt of Temporary Assistance {#sec-13-csr-40-2.350 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.350}

PURPOSE: This rule establishes procedures for the implementation of the forty-five (45) month lifetime limit for the receipt of Temporary Assistance (TA), and exemptions to that limit beginning January 1, 2016, pursuant to

section 208.040.5, RSMo.

(1) For purposes of this rule, “assistance” shall be defined according to the definition in

section 260.31 of Title 45, Code of Federal Regulations.

(2) A family is not eligible for TA if the family includes an adult who has received assistance a cumulative total of forty-five (45) months, subject to the exemptions provided by this rule.

(A) This limit shall apply regardless of whether the family with an adult has received assistance in Missouri, another state, or territory, under the Temporary Assistance for Needy Families (TANF) Block Grant program authorized by sections 601–619 of Title 42, United States Code.

(B) This limit shall apply regardless of whether the adult has received Temporary Assistance before or after the effective date of these rules.

(C) The total cumulative months do not need to be consecutive.

(D) To determine the total cumulative lifetime limit, the division shall include all months in which the adult received TANF cash assistance in Missouri, on or after July 1, 1997. If TANF cash assistance was received in another state, the division shall include all months in which the adult received federal TANF cash assistance from the date that state’s TANF program commenced.

(3) The division shall not count any month of receipt of assistance by a participant towards the forty-five (45) cumulative month limit, as defined in section (2), when— (A) The participant was a minor and neither the head-of-household nor married to the head-of-household in the month the participant received assistance; or (B) The participant’s household includes a person who has been battered or subjected to extreme cruelty.

1. The participant has been battered or subject to extreme cruelty when the participant has suffered mental abuse, neglect, or a deprivation of medical care, or physical acts that resulted in, or threatened to result in, either physical injury, non-consensual sexual acts, or sexual abuse to the participant; or (C) The participant adult lived in Indian country (as defined in section 1151 of Title 18, United States Code) or in a Native Alaskan Village, if at least fifty percent (50%) of the adults living on the reservation or in the village were not employed.

(4) Pursuant to section 264.1(b)(2) of Title 45, Code of Federal Regulations, the division shall not count any month of receipt of assistance by a participant towards the forty-five (45) cumulative month limit, as defined in

section (2), when the participant is receiving assistance funded by certain separate state programs, as defined in section 270.2 of Title 45, Code of Federal Regulations. The exemption from the lifetime limit applies when— (A) The adult participant is age sixty (60) or over; or (B) The adult participant is permanently and totally disabled as defined by section 1382c(a)(3) of Title 42, United States Code, or is receiving employer-sponsored disability payments; or (C) The participant is a teen parent headof-household under the age of eighteen (18) and is attending a secondary school, or taking a course of study leading to a certificate of general equivalence; or (D) The adult participant is required to remain in the home to care for a disabled household member.

(5) Hardship Extension. The division, pursuant to section 208.040.5(5), RSMo, shall provide Temporary Assistance to the following adults, beyond the lifetime limit, if one (1) or more of the following conditions occur:

(A) Substance abuse. A participant has a substance abuse hardship when the participant has been— 1. Diagnosed by either a physician, licensed psychologist, or licensed clinical social worker with a substance abuse issue;

2. Is receiving treatment through residential care, day treatment, counseling, support groups, group education, group counseling, C-STAR, Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or other generally accepted substance abuse treatment methods;

3. This hardship will terminate upon completion of the substance abuse treatment, or upon the failure of the participant to cooperate with the treatment, unless there are circumstances beyond the participant’s control;

(B) Mental health crisis. A participant has a mental health crisis hardship when the participant is unable to work due to a mental health condition, and has also been— 1. Diagnosed with a mental disease or condition by either a physician or licensed psychologist or division medical team review;

2. Receiving services from Vocational Rehabilitation due to a mental health condi- 3. Receiving treatment through residential care, counseling, support groups, mental health case management with a community support worker, or targeted case management;

3. This hardship will terminate— A. Upon the failure of the participant to cooperate with treatment, unless there are circumstances beyond the participant’s control; or B. When the condition is no longer preventing the participant from working;

(C) The participant has an active case with the Children’s Division (CD) in family centered services, as defined in 13 CSR 35- 32.020(3), or alternative care, pursuant to

Chapter 211, RSMo.

1. To qualify for a hardship extension under this subsection, the participant must be actively working with and cooperating with CD, and is complying with the treatment and/or services plan. The division shall determine if the participant has a hardship as the result of an active case with CD, after the division contacts CD. The division shall confirm with CD— A. That the participant has an active CD case;

B. The anticipated duration of the active case; and C. Whether the termination of the participant’s TA creates a hardship for the participant. The participant must notify the division that the participant is involved with CD;

(D) If the division extends assistance to

part of its caseload as permitted under this

section; it will only determine whether or not the extension applies to a specific family once the adult claiming the hardship has received forty-five (45) cumulative months of assistance; and (E) The average monthly number of families receiving a hardship extension under this

section shall not exceed twenty percent (20%) of the average monthly number of families to which assistance is provided during the fiscal year or the immediately preceding fiscal year;

(6) All information provided to the division by the participant seeking a hardship exemption to the forty-five (45) cumulative month limit shall be true, accurate, and complete.

(7) A participant who is aggrieved by a deci- 2014, and section 208.040.5, RSMo Supp.

1998. Original rule filed Jan. 16, 1998, effective Aug. 1, 1998. Amended: Filed Feb. 8, 2016, effective Aug. 30, 2016. 1994, 1999, 2001, 2009, 2015.

13 CSR 40-2.355 Prohibition Against Payment of Temporary Assistance Benefits to a Person Found to Have Fraudulently Misrepresented Residence in Order to Obtain Assistance in Two or More States of Temporary Assistance to a person found to have fraudulently misrepresented residence in order to obtain assistance in two or more states. {#sec-13-csr-40-2.355 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.355}

(1) For the purpose of the administration of assistance to or on behalf of an individual during the ten (10)-year period that begins on the date the individual is convicted in federal or state court of having made a fraudulent statement or representation with respect to the place of residence of the individual in order to receive assistance simultaneously from two (2) or more states under programs that are funded under Title IV (42 United States Code section 601 et seq.), Title XIX (42 United States Code section 1396 et seq.), or the Food Stamp Act of 1977, or benefits in two (2) or more states under the Supplemental Security Income program under Title XVI (42 United States Code section 1381 et seq.).

The preceding sentence shall not apply with respect to a conviction of an individual, for any month beginning after the president of the United States grants a pardon with respect to the conduct which was the subject of the conviction.

Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.357 Temporary Assistance Diversion Program {#sec-13-csr-40-2.357 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.357}

PURPOSE: This rule provides the eligibility requirements for the Temporary Assistance (TA) Diversion program, pursuant to Senate Bill 24 (2015).

(1) Scope. This rule describes the requirements necessary to qualify for the TA Diversion program. The program provides an alternative to Temporary Assistance (TA) benefits received on a monthly basis. The program goes into effect January 1, 2016.

(2) For purposes of this rule, the following definitions shall apply:

(A) The terms “program” and “diversion program” shall mean the TA Diversion program, unless described otherwise; and (B) “Household” shall be defined according to the TA definition in 13 CSR 40- 2.300(6).

(3) To qualify for a diversion payment, a participant must be determined eligible for TA.

(4) A participant is not eligible for this program if an adult in the participant’s household has reached his or her lifetime limit of monthly Temporary Assistance for Needy Families (TANF) payments pursuant to 13 CSR 40-2.350.

(A) Effective January 1, 2016, the lifetime limit for participation in the TA program is forty-five (45) cumulative (not necessarily consecutive) months in which an adult in the household has received assistance under the TANF block grant program, pursuant to sections 601-619 of Title 42, United States Code.

(B) Months in which a participant receives a payment under the TA Diversion program do not count toward the TA lifetime limit.

(C) A participant can only receive a total of five (5) diversion program payments in his or her lifetime as a parent, guardian, or caretaker relative in a TA household. This limit includes payments from diversion programs in other states or U.S. jurisdictions.

(5) A participant applying for this program is not required to comply with the TA recipient work activity requirements, as described in 13 CSR 40-2.315, subject to subsection (A) of this section. A partici pant applying for this program must demonstrate good cause as described in section (7) of this rule.

(A) A participant who is actively sanctioned for non-cooperation with the TA work activity requirements under 13 CSR 40- 2.315, or whose TA case has been closed due to non-cooperation with the work activity requirements, shall not qualify for a diversion payment until the sanction is ended in accordance with 13 CSR 40-2.315.

(6) An eligible participant shall not receive more than one (1) diversion program payment once during a twelve- (12-) month period.

(A) The first month in determining the twelve- (12-) month period is the month in which the diversion payment was issued.

(7) A participant requesting a diversion payment is eligible to receive a payment only if the participant establishes good cause for one (1) of the following reasons:

(A) An involuntary loss of employment, as demonstrated by a written notice from the TA participant’s previous employer, unless the division determines that the participant— 1. Voluntarily quit a job; or 2. Was terminated for poor job performance or for failure to meet a condition of employment; or (B) A catastrophic illness or accident that renders the participant unable to work temporarily or permanently, as demonstrated by a statement from a licensed medical professional. The participant shall produce a copy of medical records and a written report from a licensed medical professional, on letterhead, providing the medical diagnosis, along with any supporting medical tests and examinations that establish the existence of the medical condition and the probable duration of the medical condition. If the participant has been determined disabled by a state or federal disability determination process, a written notice from such agency shall be acceptable documenta- (C) The participant is a victim of an incident of domestic violence, as defined by section 455.010(5), RSMo, or of human trafficking, as defined by section 566.200(16), RSMo, that is documented by either a written self-attestation, police reports, ex parte order, or other orders or judgments issued by a court; or (D) An employed participant is unable to care for the basic needs of his or her family due to an emergency or other event, including but not limited to— 1. An involuntary reduction in wages, as documented through pay stubs or an employer statement, to the extent that the participant qualifies for TA even though he or she is still employed; or 2. The participant temporarily loses access to adequate transportation to work or school beyond the control of the participant with no readily accessible alternate means of transportation. The participant shall produce documentation of the loss of transportation by documents such as police reports, insurance claims, repair estimates, documentation of bus route changes, towing bills, or other evidence supporting this claim; or 3. The participant temporarily loses access to child care as documented through a statement from the childcare provider, or other evidence supporting this claim; or 4. The participant has temporarily been deprived of shelter, electricity, water, heating and/or cooling, or food due to circumstances beyond the control of the participant caused by intentional or negligent acts or due to a man-made or natural disaster. The participant shall produce documentation of the event by police reports, insurance claims, repair estimates, or other evidence supporting this claim; or 5. A temporary financial hardship caused by natural or accidental death or the catastrophic illness of a household member, or a parent or sibling of a household member, including half or step-siblings; or 6. Any other event that the division determines warrants good cause, and that is supported by documentation establishing the occurrence of the event.

(8) The participant shall agree to use a diversion payment to address an issue related to the purpose of the TANF program pursuant to

section 601 of Title 42, United States Code.

(A) The division shall issue a diversion payment directly to the participant by electronic benefits transfer (EBT).

(B) The participant is not eligible for TA in the month in which the diversion payment was issued.

(C) A TA payment shall not be issued to a household for any month for which a diversion payment was also issued, regardless of whether the head of household or the person receiving the payment changes.

(D) The participant is not eligible for TA for up to two (2) months following the month for which the diversion payment was approved, to the extent that the total diversion payment exceeds or equals the amount of TA for which the participant would otherwise qualify in those months. The diversion case is considered to be active during this period.

(9) The TA Diversion program is not included within the definition of “assistance” in 13 CSR 40-2.300(3).

(10) All information provided to the division by a participant in support of a request for a diversion payment shall be true, accurate, and complete.

(11) The participant shall disclose to the division all information which may impact eligibility for the diversion payment. The participant has a continuing obligation to notify the division if any information supporting the grant of the diversion payment changes within ten (10) days of the change.

(12) A participant who is aggrieved by a deci- 2014, and section 208.040.5(6), RSMo Supp. 2015.* Original rule filed Jan. 15, 2016, effective July 30, 2016. *Original authority: 207.022, RSMo 2014 and 208.040, RSMo 1939, amended 1941, 1949, 1951, 1953, 1955, 1957, 1973, 1977, 1982, 1983, 1984, 1987, 1994, 1999, 2001, 2009, 2015.

13 CSR 40-2.360 Prohibition Against Payment of Temporary Assistance to Certain Persons Fleeing to Avoid Prosecution, or Custody or Confinement After Conviction of Temporary Assistance to certain persons fleeing to avoid prosecution, or custody or confinement after conviction. {#sec-13-csr-40-2.360 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.360}

(1) For the purpose of the administration of assistance to or on behalf of any individual who is— (A) Fleeing to avoid prosecution, or custody or confinement after conviction, under the laws of the place from which the individual flees, for a crime, or an attempt to commit a crime, which is a felony under the laws of the place from which the individual flees, or which, in the case of the state of New Jersey, is a high misdemeanor under the laws of such state; or (B) Violating a condition of probation or parole imposed under federal or state law.

The preceding sentence shall not apply with respect to conduct of an individual, for any month beginning after the president of the United States grants a pardon with respect to the conduct.

Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.365 Prohibition Against Payment of Temporary Assistance on Behalf of Minor Children Who Are Absent from the Home for a Significant Period of Time of Temporary Assistance to minor children who are absent from the home for a significant period of time. {#sec-13-csr-40-2.365 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.365}

(1) For the purpose of the administration of assistance to or on behalf of— (A) A minor child who has been, or is expected by a parent (or other caretaker relative) of the child to be, temporarily absent from the home for a period exceeding ninety (90) consecutive days; or (B) An individual who is a parent (or other caretaker relative) of a minor child and who fails to notify the Division of Family Services of the absence of the minor child from the home for the period specified in or provided for pursuant to subsection (1)(A), by the end of the five (5)-day period that begins with the date that it becomes clear to the parent (or relative) that the minor child will be absent for such period so specified or provided for.

Jan. 16, 1998, effective Aug. 1, 1998.

13 CSR 40-2.370 Requirement that All Recipients for the Payment of Temporary Assistance Shall Complete an Assessment and May Be Required To Complete an Individual Employment Plan {#sec-13-csr-40-2.370 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.370}

PURPOSE: This rule requires that all applicants/recipients for the payment of Temporary Assistance shall complete an assessment and may be required to complete an individual responsibility plan which is termed an Individual Employment Plan (IEP).

(1) Initial Assessment.

(A) For the purpose of the administration of the Temporary Assistance Program, the Family Support Division shall make an initial assessment of the skills, prior work experience, and employability of each applicant/recipient of assistance under the program who is the head of household or second parent and— 1. Has attained eighteen (18) years of age; or 2. Has not completed high school or obtained a certificate of high school equivalency and is not attending secondary school.

(B) The assessment described in subsection (1)(A) shall be completed at application.

(C) On the basis of the assessment made under subsection (1)(A) with respect to an individual, the Family Support Division shall refer the recipient to the contracted service provider or its designee to negotiate an Individual Employment Plan (IEP) with the individual, unless the person meets an exclusion or exemption under 13 CSR 40-2.315(2)(C) and 13 CSR 40-2.315(2)(D).

(2) Individual Employment Plan.

(A) The contracted service provider or its designee shall develop with the individual an IEP which— 1. Sets forth an employment goal for the individual and a plan for moving the individual into employment as soon as possible and will include a requirement that the individual participate in an allowable/countable work activity for the minimum required hours outlined in 13 CSR 40-2.315;

2. To the greatest extent possible is designed to move the individual into whatever employment the individual is capable of handling as quickly as possible by establishing short- and long-term educational/occupational goals;

3. Assesses the individual’s barriers that may hinder the individual’s ability to seek and/or obtain employment. Those barriers may include (but are not limited to): substance abuse, legal issues, child care, healthcare, transportation, and education;

4. Identify available support services, such as subsidized child care, medical services, and transportation benefits, to help ensure that the family will become self-sustaining and will be less likely to return to public assistance;

5. Address circumstances creating barriers to self-sufficiency and may be updated and adjusted to identify and address the removal of these barriers; and 6. Ascertain the skills of the individual that will expand the individual’s opportunity to obtain employment.

(3) The Family Support Division shall encourage families who have an IEP to make full use of the federal earned income tax credit.

(4) If an individual in a family fails to cooperate in developing, or fails to comply with the requirements of, the IEP without good cause as defined in 13 CSR 40-2.315, the division shall sanction the individual as provided in 13 CSR 40-2.315.

Original rule filed Jan. 16, 1998, effective Aug. 1, 1998. Amended: Filed June 1, 2007, effective Dec. 30, 2007. Amended: Filed Sept. 21, 2010, effective April 30, 2011. 1994, 1999, 2001, 2009.

History

• AUTHORITY: section 207.020, RSMo 2000 and section 208.040.5, RSMo Supp. 2010. Emergency rule filed Feb. 18, 1998, effective March 1, 1998, terminated Aug. 10, 1998.

13 CSR 40-2.375 Medical Assistance for Families {#sec-13-csr-40-2.375 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.375}

(Rescinded March 30, 2019)

Filed June 7, 2004, effective Jan. 30, 2005.

Emergency amendment filed May 20, 2005, effective July 1, 2005, expired Dec. 27, 2005.

Amended: Filed May 20, 2005, effective Dec. 30, 2005. Rescinded: Filed July 19, 2018, effective March 30, 2019.

History

• AUTHORITY: sections 207.020 and 208.145, RSMo 2000. Emergency rule filed June 7, 2002, effective July 1, 2002, expired Dec. 27, 2002. Original rule filed June 11, 2002, effective Dec. 30, 2002. Emergency amendment filed June 7, 2004, effective July 1, 2004, expired Dec. 27, 2004. Amended:

13 CSR 40-2.380 Grandparents as Foster Parents {#sec-13-csr-40-2.380 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.380}

(Rescinded December 30, 2005)

2003. Emergency rule filed July 11, 2003, effective Aug. 1, 2003, expired Jan. 27, 2004. Original rule filed Jan. 23, 2004, effective July 30, 2004. Rescinded: Filed June 8, 2005, effective Dec. 30, 2005.

History

• AUTHORITY: sections 207.020, RSMo 2000 and 453.322 and 453.325, RSMo Supp.

13 CSR 40-2.390 Transitional Employment Benefit {#sec-13-csr-40-2.390 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.390}

PURPOSE: This rule establishes the Transitional Employment Benefit. This rule also establishes the circumstances when a family is eligible for the Transitional Employment Benefit payment and the length of time a family qualifies for the Transitional Employment Benefit payment.

(1) The Family Support Division shall make payable a fifty-dollar ($50) Transitional Employment Benefit payment to families with earned income who are no longer eligible for Temporary Assistance benefits as defined in

13 CSR 40-2.300 through 13 CSR 40-2.370 due to an increase in income, removal of an earnings disregard or an allowable expense deduction, or a household composition change which causes ineligibility due to income guidelines for Temporary Assistance provided— (A) The family received Temporary Assistance cash benefits for at least one (1) month; {#sec-13-csr-40-2.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.300}

(B) There is a work-eligible individual, as defined in 45 CFR 261.10, included in the family;

(C) Work-eligible individuals in the family continue to meet the minimum work participation hours as outlined in 42 USC 607.

1. Transitional Employment Benefit work participation hours must be met through employment only.

2. Work participation hours must be reported and verified within ten (10) days of the Temporary Assistance case closing or change in employment;

(D) The family continues to meet all other eligibility requirements contained in 13 CSR 40-2.300 through 13 CSR 40-2.370 with the exception of income; and (E) The family was eligible for and received Temporary Assistance in October 2008 or later.

(2) The family is eligible to receive the fiftydollar ($50) Transitional Employment Benefit payment for up to six (6) consecutive months as long as the family meets the requirements in subsections (1)(B) and (1)(C).

(3) There is no limit on the number of times a family may receive Transitional Employment Benefit payments as long as the family loses eligibility for Temporary Assistance as outlined in section (1).

(A) The Transitional Employment Benefit is not included in the sixty (60)-month lifetime limit for Temporary Assistance as referenced in 42 USC 608.

(4) Families who receive Transitional Employment Benefits shall not assign to the Family Support Division on behalf of the state any rights to support from any other person on behalf of any member of the family.

History

• AUTHORITY: section 207.020, RSMo 2000 and section 208.040.5, RSMo Supp. 2008. Emergency rule filed Sept. 23, 2008, effective Oct. 3, 2008, expired March 31, 2009. Original rule filed Sept. 23, 2008, effective May 30, 2009. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993 and 208.040, RSMo 1939, amended 1941, 1949, 1951, 1953, 1955, 1957, 1973, 1977, 1982, 1983, 1984, 1987, 1994, 1999, 2001.

13 CSR 40-2.395 Spend Down Program {#sec-13-csr-40-2.395 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.395}

PURPOSE: This rule establishes terminology as well as provides definition of terms for the spend down program and defines valid verification of incurred medical expenses.

(1) Spend down is a program created for persons with disabilities and persons aged sixtyfive (65) and older who have income that exceeds the Medicaid qualification limits.

Such individuals may qualify for Medicaid benefits when they spend down their income that exceeds the Medicaid eligibility limit.

Medicaid coverage begins when the individual’s incurred medical expenses equal the monthly spend down requirement.

(2) Definitions.

(A) “Incurred medical expenses” means expenses incurred by the individual or financially responsible relatives for necessary medical and remedial services that are recognized under state law and are not subject to payment by a third party, unless the third party is a public program of a state or political subdivision of a state. Incurred medical expenses include Medicare and other health insurance deductibles and co-insurance charges, and co-payments or deductibles imposed under 42 C.F.R. Section 447.51 or

Section 447.53. The term incurred medical expenses includes expenses incurred by an individual’s spouse whose income is included in the Medicaid eligibility determination.

(B) “Individual” means aged persons (over sixty-five (65) years), blind persons, or people with disabilities with income above limits established under section 208.151, RSMo, for MO HealthNet for the Aged, Blind, and Disabled, permanent and total disability benefits, or aid to the blind benefits.

(C) “Third party” means a Medicare, private health insurance, or other health care payer.

(3) How spend down amount is calculated.

The monthly spend down amount is calculated as the difference between the individual’s monthly net income and the Medicaid eligibility limits. The net income is calculated according to the provisions of 13 CSR 40- 2.200.

(4) Spend down may be met in one (1) of the following ways:

(A) Incurred Costs Method. Spend down participants using this method must provide documentation of medical expenses they have incurred.

1. Incurred medical expenses that can be applied to spend down must be either— A. Incurred within the month MO HealthNet coverage is requested and bills are submitted to the Family Support Division; or B. Incurred within the three (3) months prior to the month for which MO HealthNet coverage is requested and bills are submitted to the Family Support Division for those eligible for MO HealthNet Aged, Blind, and Disabled spend down program;

C. Incurred medical expenses can be applied to future months limited to a maximum of three (3) months from the current month in which MO HealthNet coverage is requested when— (I) The bills were incurred while the participant was eligible for MO Health- Net spend down;

(II) The bills were not paid and will not be paid by MO HealthNet;

(III) The bills are currently owed or paid by the participant;

(IV) The bills were not previously applied in any month to meet spend down, including use of out-of-pocket expenses; and (V) The bills were incurred no earlier than three (3) months prior to the current month;

D. Allowable medical expenses include those specified in section 208.152, RSMo; and E. Proof of incurred costs does not require proof of payment of the incurred costs.

2. In order for an individual to claim that an incurred medical expense should be credited to the individual’s spend down obligation, the individual shall provide documentation of the incurred medical expense within one (1) year of the date of the medical service.

3. No credit for incurred medical expenses shall be given without documentation that the individual has incurred, and is legally obligated to pay the expense, and has not previously used the expense for spend down. Documentation of an incurred medical expense shall be submitted in either one (1) of the following methods:

A. An invoice, billing statement, or receipt from the provider that contains the following information:

(I) Name of patient;

(II) Date of service;

(III) Type of service provided and/or description of the service;

(IV) Identification of the portion of the total charges that are billed to a third party and the portion of the total charges that are the patient’s responsibility to pay; and (V) To document incurred costs of mileage of medically necessary, nonemergency transportation, the individual shall certify the miles traveled and the purpose. Travel expenses required to obtain a medical item or service shall be determined at the State Employee Reimbursement rates established by the state of Missouri Office of Administration pursuant to 1 CSR 10-11.010 and 1 CSR 10-11.030 as of the date of travel; or B. A Family Support Division Provider form signed and completed by the provider containing the information set out in subparagraph (4)(A)3.A. of this regulation.

4. The provider shall, upon request, provide any additional information required by the Family Support Division to establish that the individual has incurred the medical expense.

5. When it is known that the individual has coverage by a third party and the portion subject to payment by the third party cannot be identified, the Family Support Division shall— A. For individuals with private health insurance or coverage by another healthcare payer, estimate the amount of the individual’s incurred cost based upon the provisions of coverage; and B. For individuals with Medicare Part A and/or B coverage and who do not have Qualified Medicare Beneficiary coverage, estimate the amount of the individual’s incurred medical cost to be— (I) One hundred percent (100%) of the Medicare reimbursement rate up to the individual’s Medicare deductible, if the deductible has not been met; and thereafter (II) Twenty percent (20%) of the Medicare allowable reimbursement once the deductible has been met.

6. Individuals receiving Qualified Medicare Beneficiary coverage cannot use incurred medical expenses covered by Medicare towards meeting spend down.

7. If a provider provides a direct medical service based on an “ability-to-pay” or “sliding” fee scale, only the amount the individual is legally obligated to pay the provider is an incurred medical expense;

(B) Pay-in Method. An individual may pay their spend down amount to the state. The monthly spend down requirement may be paid by the individual, their spouse, a financially responsible relative, or a public program of a state or political subdivision of a state; and (C) Combination Method. An individual may use a combination of the incurred costs method and the pay-in methods to satisfy the monthly spend down amount to the state.

(5) Any individual who disagrees with the FSD’s decision shall have the right to request administrative review pursuant to 208.080, RSMo, and 13 CSR 40-2.160.

RSMo 2016.* Original rule filed March 1, 2012, effective Oct. 30, 2012. Amended:

Filed Sept. 27, 2018, effective

13 CSR 40-2.400 Definitions for the Screening and Testing for the Illegal Use of Controlled Substances by Temporary Assistance Applicants and Recipients {#sec-13-csr-40-2.400 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.400}

PURPOSE: This rule establishes the definitions that will govern the use of certain terms used to establish the procedures for the screening and testing for illegal use of controlled substances by Temporary Assistance applicants and recipients.

(1) Applicant—A person who has applied for Temporary Assistance benefits in accordance with Temporary Assistance eligibility regulations, but has not yet been determined eligible for benefits.

(2) Appropriate substance abuse treatment program—A substance abuse treatment program that the Department of Mental Health has approved and— (A) Is certified as an alcohol and drug abuse treatment program by the Department of Mental Health; and (B) Is contracted with the Department of Mental Health to provide Comprehensive Substance Treatment and Rehabilitation (CSTAR) services.

(3) Drug test—The urine dipstick five- (5-) panel test.

(4) Entry into the substance abuse treatment program—A recipient shall be considered to have entered into a substance abuse treatment program when the recipient has been enrolled in the Department of Mental Health’s consumer information system by an appropriate treatment provider.

(5) Controlled substance—a drug, substance, or immediate precursor in Schedules I through V listed in sections 195.005 to 195.425, RSMo.

(6) Head-of-household—The individual who is registered as the applicant or recipient for Temporary Assistance benefits with the divi- (7) Individual—A person who is either an applicant or recipient for Temporary Assistance benefits with the Family Support Divi- (8) Misdemeanor or felony drug offense— Any arrests or convictions for violating any federal or Missouri state statutes relating to any illegal use, possession, trafficking, delivery, distribution, registration, creation, production, or manufacturing of any drugs, narcotics, controlled substances, controlled substance analogues, imitation controlled substances, drug paraphernalia, counterfeit substances, or immediate precursor shall constitute the misdemeanor or felony drug offenses that shall be screened for by a search of the records of the Missouri Highway Patrol.

(9) Protective payee—An individual appointed by the Family Support Division to act on behalf of the Temporary Assistance household with regard to Temporary Assistance benefits.

(10) Reasonable cause—Reasonable cause exists when there is reasonable suspicion that there is an articulable individualized basis for suspecting that the Temporary Assistance applicant or recipient is engaging in the illegal use of controlled substances. Reasonable suspicion shall be deemed to exist based on the response to the screening tool or when a search of the law enforcement records of the Missouri Highway Patrol establishes that the individual has been arrested or convicted of a misdemeanor or felony drug offense within the last twelve (12) months.

(11) Recipient—A person who receives public assistance benefits in accordance with Temporary Assistance eligibility regulations.

(12) Successful completion of substance abuse treatment program—A recipient referred under section 208.027, RSMo, has successfully completed a substance abuse program when a letter or other official notice is issued from the appropriate substance abuse treatment program verifying the recipient has made satisfactory progress toward the criteria outlined in 9 CSR 30-3.130(8)(A) and if the recipient has not tested positive in accordance with 13 CSR 40-2.420.

(13) Temporary Assistance (TA)—Missouri’s Temporary Assistance for Needy Families program that provides temporary cash assistance to families as set forth in sections 208.040, RSMo, et seq. and 13 CSR 40- 2.300 to 13 CSR 40-2.370.

(14) Temporary Assistance for Needy Families (TANF)—The federal program under which Missouri’s Temporary Assistance benefits are distributed as set forth in 42 U.S.C.

section 601, et seq. and 42 CFR 260.10, et seq.

(15) Treatment provider—Is an individual or entity that operates a substance abuse treatment program that the Department of Mental Health has approved and— (A) Is certified as an alcohol and drug abuse treatment program by the Department of Mental Health; and (B) Is contracted with the Department of Mental Health to provide Comprehensive Substance Treatment and Rehabilitation (CSTAR) services.

(16) Urine dipstick five- (5-) panel test—A test that will analyze an individual’s urine sample to determine whether an individual has used the following controlled substances:

(A) Amphetamines/Methamphetamines;

(B) Cannabinoids (THC);

(C) Cocaine;

(D) Opiates; and (E) Phencyclidine (PCP).

13 CSR 40-2.410 Screening Temporary Assistance Applicants and Recipients for Illegal Use of a Controlled Substance that all applicants or recipients for the payment of Temporary Assistance who are age eighteen (18) or older and are the head-ofhousehold complete a screening for illegal use of a controlled substance. {#sec-13-csr-40-2.410 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.410}

This rule also establishes the individual’s eligibility due to the screening and consequences when the individual fails to comply with the screening requirement and when the screening provides reasonable cause for illegal use of a controlled substance.

The Family Support Division shall conduct a screening to determine illegal use of a controlled substance for all Temporary Assistance applicants and recipients who are age eighteen (18) or older, are the head-of-the-household, and are otherwise eligible for Temporary Assistance benefits as defined in 13 CSR 40- 2.300 through 13 CSR 40-2.370.

(A) The individual must cooperate with the screening process.

1. The individual must agree to complete the screening process.

2. The individual must answer all questions.

(B)

Screening shall consist of the following two (2) processes:

1. The individual shall submit answers to a screening tool administrated by the Family Support Division at the time of application;

2. The Family Support Division shall conduct a periodic match of Temporary Assistance recipients with the Missouri State Highway Patrol law enforcement records for individuals that have an arrest, suspended imposition of sentence, or conviction for a misdemeanor or felony drug offense upon implementation of the screening process.

(C) The individual may request referral to and then must successfully complete an appropriate substance abuse treatment program as set forth in 13 CSR 40-2.430 in lieu of a drug test as set forth in 13 CSR 40-2.420.

(D) The division shall not provide Temporary Assistance to or on behalf of an individual who refuses to cooperate with the screening process. The individual is ineligible for Temporary Assistance for a period of three (3) years from the date of a refusal to cooperate with the screening process or an administrative hearing decision if a hearing is requested and the division is affirmed. The hearing process is set forth in 13 CSR 40-2.440.

(2) The individual shall submit to a urine dipstick five- (5-) panel drug test, as set forth in

13 CSR 40-2.420 if— (A) The individual’s response to the screening tool gives rise to reasonable suspicion the individual engages in the illegal use of a controlled substance; or (B) An individual has an arrest or conviction for a misdemeanor or felony drug offense from the match with the Missouri Highway Patrol within the preceding twelve (12) months of the date of the match with the Missouri Highway Patrol. {#sec-13-csr-40-2.420 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.420}

13 CSR 40-2.420 Testing for the Illegal Use of a Controlled Substance by Applicants and Recipients of Temporary Assistance that applicants for Temporary Assistance and recipients for the payment of Temporary Assistance who are age eighteen (18) or older and are the head-of-household whose screening for illegal use of a controlled substance establishes reasonable cause to believe the individual engages in the illegal use of a controlled substance must submit to a urine dipstick five- (5-) panel drug test. {#sec-13-csr-40-2.420 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.420}

This rule also establishes the individual’s ineligibility for Temporary Assistance pursuant to the drug testing requirement.

(1) The Family Support Division shall require an individual to submit to a urine dipstick five- (5-) panel drug test when the Family Support Division determines there is reasonable cause to believe the individual is engaging in the illegal use of a controlled substance. The determination of reasonable cause shall be based upon the screening process set forth in 13 CSR 40-2.410.

(A) The division or its designee shall notify the individual in writing, at the individual’s last known address as contained within the division records, of the reasonable cause determination that requires the individual to submit to a urine dipstick five- (5-) panel drug test.

(B) The division or its designee shall notify the individual in writing of the location of the test and the date by which the test must be completed and of the drug testing process.

(C) The division or its designee shall make the test available either within the individual’s county of residence as known to the division or in an adjacent county if the testing location is within twenty-five (25) miles of the individual’s residence, whichever is closer.

(D) The individual must provide verification of identity when submitting to the drug test. Acceptable forms of identity verification include: U.S. passport; driver’s license issued by the state or U.S. territory with a photograph or other identifying information; certificate of degree of Indian blood; school identification card; U.S. military card or draft card with photograph; identification card issued by federal, state, or local government; Native American tribal document.

(2) Drug Testing Protocols.

(A) All urine samples collected under this program shall be collected and analyzed by a qualified contractor of the state of Missouri with laboratory facilities that comply with the standards of the National Institute on Drug Abuse/Substance Abuse and Mental Health Service Administration of the U.S. Department of Health and Human Services or other appropriate accrediting institution. The collection and analysis shall include the initial screening of the urine dipstick five- (5-) panel test and when necessary a confirmation test analyzed by a laboratory that complies with the standards of the Substance Abuse and Mental Health Service Administration of the U.S. Department of Health and Human Services. All samples confirmed by the laboratory as non-negative shall be interpreted as positive or negative by a medical review officer licensed by the American Association of Medical Review Officers, American College of Occupational and Environmental Medicine, Medical Review Officer Certification Council, or American Society of Addiction Medicine.

(B) The laboratory must screen and test for the substances set forth in 13 CSR 40- 2.400(16). Said testing must screen, at a minimum, for the levels of such substances as provid ed by 1 CSR 30-7.010(5), as may be amended from time-to-time.

(3) The division shall not provide Temporary Assistance to or on behalf of an individual who is required to submit to a drug test and who refuses to cooperate with any part of the drug testing process.

(A) A refusal to cooperate with the testing process shall include one (1) or more of the following:

1. Failure to provide a sample for drug testing within the required time frame;

2. Failure to fully comply with the drug testing process as directed by the Family Support Division or its designee;

3. Failure to appear for drug testing at the designated location and time;

4. Failure to contact or cooperate with any medical review process;

5. Failure to provide verification of identity;

6. Failure to complete any documents or consent forms required by the Family Support Division or its designee, the drug testing provider, the Department of Mental Health, or the substance abuse treatment provider;

7. Failure to provide a sufficient amount of urine for testing; or 8. Failure to provide a urine sample at the correct temperature.

(B) The individual is ineligible for Temporary Assistance for a period of three (3) years from the date of a positive test, test refusal, or an administrative hearing decision if a hearing is requested and the division is affirmed. The hearing process is set forth in 13 CSR 40- 2.440.

(4) The division shall not provide Temporary Assistance to or on behalf of an individual who tests positive for illegal use of a controlled substance and fails to enter, participate, and successfully complete an appropriate substance abuse treatment program as set forth in 13 CSR 40-2.430. The individual is ineligible for Temporary Assistance for a period of three (3) years from the date of a positive test or an administrative hearing decision if a hearing is requested and the division is affirmed. The hearing process is set forth in 13 CSR 40-2.440.

(5) An individual subject to drug testing who has a positive drug result may, at his or her expense, have the positive drug test result confirmed. The individual must make this request for testing within ten (10) days from notification of the positive test result.

(6) The division may require a urine dipstick five- (5-) panel drug test six (6) months after the date the recipient entered the substance abuse treatment program as defined in 13 CSR 40-2.430. If the individual tests posi tive, the individual is ineligible for Temporary Assistance for a period of three (3) years from the date of a positive test or an administrative hearing decision if a hearing is requested and the division is affirmed. The hearing process is set forth in 13 CSR 40-2.440.

(7) The amount of assistance that would otherwise be required to be provided under the Temporary Assistance Program to the family members of an individual to whom sections (3), (4), and (6) apply shall be reduced by the amount which would have otherwise been made available to the individual who has been declared ineligible.

(8) The division shall add an otherwise eligible individual who has been declared ineligible for Temporary Assistance as set forth in

13 CSR 40-2.400 through 13 CSR 40-2.430 to the Temporary Assistance household after the three- (3-) year period of ineligibility has elapsed. The individual is subject to the rules as set forth in 13 CSR 40-2.400 through 13 CSR 40-2.450. {#sec-13-csr-40-2.400 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.400}

13 CSR 40-2.430 Substance Abuse Treatment Program for Temporary Assistance Recipients {#sec-13-csr-40-2.430 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.430}

PURPOSE: This rule explains the referral and treatment process for recipients of Temporary Assistance benefits who are required to enter and complete a substance abuse treatment program as a result of 13 CSR 40- 2.420.

(1) The Family Support Division shall refer recipients of Temporary Assistance benefits who are determined to have tested positive for the illegal use of a controlled substance under the provisions of section 208.027, RSMo, to an appropriate substance abuse treatment program approved by the Department of Mental Health, as set forth in 13 CSR 40-2.400.

(2) Recipients referred to an approved substance abuse treatment program as set forth in these rules shall receive a comprehensive assessment to determine the appropriate level of care and to develop an initial treatment plan. Treatment services shall be delivered in accordance with all rules applicable to certified programs as defined in 9 CSR 30-3.032.

(3) Active participation in the substance abuse treatment program by recipients referred as provided in section 208.027, RSMo, shall be demonstrated by— (A) Completion of comprehensive assessment as set forth in section (2);

(B) Enrollment in an appropriate substance abuse treatment program;

(C) Consent to communication between and among the treatment provider, Family Support Division, and Department of Mental Health personnel about participation and progress in substance abuse treatment; and (D) Participation in the development of an individualized treatment plan and satisfactory progress toward treatment goals.

(4) The Department of Mental Health or the treatment provider shall inform the Family Support Division in writing within five (5) days of the following:

(A) The date the recipient enters into the substance abuse treatment program; and (B) The date upon which the recipient successfully completed the substance abuse treatment program; and (C) The date the recipient did not successfully complete the substance abuse treatment program.

(5) The written notice(s) required in section (4) shall be signed by the treatment provider.

The original, signed notice(s) shall be selfauthenticating and shall be admissible into evidence without further foundation at any hearing conducted under 13 CSR 40-2.440. The hearing officer may authorize a substitution of the original with a copy for the record. If the division or the recipient objects to the introduction of the notice(s) into evidence, the party making the objection shall have the burden to establish that the notice(s) is not authentic and should not be admitted into evi dence. The recipient or the division may request that the hearing officer issue a subpoena to the treatment provider for examination or cross-examination on the record.

13 CSR 40-2.440 Hearings for Proceedings under 13 CSR 40-2.400 through 13 CSR 40-2.450 that all applicants or recipients for Temporary Assistance benefits who are age eighteen (18) or older and are the head-of-household who refuses or fails to cooperate with the screening process, who refuses to submit to a drug test, or who tests positive for the illegal use of controlled substances and fails to participate in a substance abuse treatment program will have a hearing. {#sec-13-csr-40-2.440 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.440}

This rule establishes the procedures to be followed in the hearing.

(1) Eligibility for Hearing.

(A) Any applicant for or recipient of Temporary Assistance may request the Director of the Family Support Division to provide an administrative hearing before the Director of the Family Support Division or his/her designee when he/she— 1. Refuses to cooperate with the screening process;

2. Refuses to submit to a drug test; or 3. Tests positive for the illegal use of controlled substances; and 4. Does not participate in an appropriate substance abuse treatment program; or 5. Fails to successfully complete an appropriate substance abuse treatment program.

(2) Notification of Adverse Action and Hearings.

(A) Notice. The Family Support Division shall notify the individual in writing of any action affecting his/her Temporary Assistance benefit(s) as set forth in section (1). The notification shall be sent by mail to his/her address of record at least ten (10) days before the date the action becomes effective. The individual has the duty to notify the Family Support Division of any change in his/her residence address, mailing address, and other contact information. The notice for administrative hearings shall meet the requirements set out in section 208.080, RSMo, the hearing requirements in 45 CFR 205.10, this regulation, and any other applicable federal statutes or regulations. The individual shall have ninety (90) days from the date of the notice of the action affecting his/her Temporary Assistance benefit(s) in which to request an appeal to the Director of the Family Support Division.

(B) Hearings. The administrative hearings shall be conducted pursuant to procedures set forth in section 208.080, RSMo, the hearing requirements in 45 CFR 205.10, this regulation, and any other applicable federal statutes or regulations by administrative hearing officers designated by the Director of the Family Support Division.

(3) Hearing Procedure. The following procedure shall apply to administrative hearings required by section (1).

(A) Notice. The hearing officer shall mail a notice of the hearing to the Family Support Division, the individual at his/her address of record, and if appropriate, to the individual’s attorney or designated representative. The notice shall include any information required by either Chapter 208, RSMo, 45 CFR 205.10, or any other federal statutes or regulations that are applicable to the hearing being conducted under the authority of section (1). In addition, the following information shall be included in every hearing notice:

1. The caption and number of the case;

2. The time and place of the hearing;

3. The subject of the hearing;

4. That an order will be entered in accordance with the adverse action notice if the individual fails to appear and participate at the hearing;

5. Information on how to contact the hearing officer to request an in-person hearing if the individual has a need for a special accommodation due to a disability; and 6. That the individual may represent him/herself or the individual may authorize another individual, such as legal counsel or a relative, to act as a representative.

(B) No answer or responsive pleading shall be required to respond to any notice affecting his/her Temporary Assistance benefit(s) mailed by the Family Support Division or notice of an administrative hearing provided for under this regulation.

(C) The hearing officer shall set the date and time for the hearing. The hearing may be continued once on request of the individual or the Family Support Division.

(D) The hearing shall be conducted by telephone if the individual agrees, or at the local office of the Family Support Division.

(E) The Family Support Division shall have the burden to establish by a preponderance of the evidence that the individual— 1. Tested positive for the illegal use of a controlled substance;

2. Refused to cooperate or submit to the screening as set forth in 13 CSR 40-2.410;

3. Refused to cooperate or submit to the test for illegal use of a controlled substance as required by 13 CSR 40-2.420;

4. Failed or refused to participate in an appropriate substance abuse treatment program as set forth in 13 CSR 40-2.420; or 5. Failed or refused to successfully complete substance abuse treatment as set forth in 13 CSR 40-2.440.

(F) Affirmative Defenses. The individual shall have the burden of proving any of the affirmative defenses set forth below. Failure to comply with any of the requirements of subsection (3)(F) shall be considered a waiver of the affirmative defenses set forth below.

1. The individual was prescribed drugs by a licensed physician that resulted in the positive test for the illegal use of controlled substances. It shall be presumed that the ingestion of medication prescribed to someone other than the individual subject to the test for illegal use of controlled substances required under section 208.027, RSMo, will not constitute an affirmative defense to excuse or negate the positive test result for the illegal use of a controlled substance.

2. The individual has a medical condition that prevented the individual from submitting a sample for testing for illegal use of controlled substances or from completing an appropriate substance abuse treatment program. The assertion of this affirmative defense shall be governed by the following rule:

A. The individual must produce a copy of medical records and a written report from the individual’s physician providing the medical diagnosis along with any supporting medical tests and examinations that establish the existence of the medical condition that the individual asserts prevented compliance with the testing for illegal use of controlled substances or from completing an appropriate substance abuse treatment program.

(G) Evidence at the Hearing.

1. Written medical reports, medical results, treatment records from an appropriate substance abuse treatment program, laboratory reports and results, affidavits, and the contents of the aforementioned documents submitted by the individual or the Family Support Division at the hearing are declared to be competent evidence and admissible into evidence at the hearing to be considered by the hearing officer along with any other evidence or testimony submitted.

2. Written medical reports, medical results, treatment records from an appropriate substance abuse treatment program, laborato ry reports and results, affidavits, and the contents of the aforementioned documents purporting to be executed and signed by the medical doctor or other appropriate authority, its agents or employees accompanied by a business record affidavit that meets the requirements of section 490.692, RSMo, shall be prima facie evidence of it being properly executed and signed without further proof of identification.

3. Written medical reports, medical results, treatment records from an appropriate substance abuse treatment program, laboratory reports and results, affidavits, and the contents of the aforementioned documents reporting a positive drug test result shall create a rebuttable presumption that the individual has tested positive for the illegal use of a controlled substance in violation of section 208.027, RSMo, or has failed to successfully complete an appropriate substance abuse treatment program.

The entry of the written medical reports, medical records, reports of medical review officers, chain of custody documentation, drug test results, treatment records from an appropriate substance abuse treatment program, laboratory reports and results, affidavits, and the contents of the aforementioned documents reporting a positive drug test result or the failure to successfully complete an appropriate substance abuse treatment program into evidence at the administrative hearing required by section (1) shall shift the burden of proof to the individual to refute the presumption.

(H) The hearing shall be on the record.

(4) The hearing officer in an administrative hearing requested under section (1) shall make specific written findings of fact and conclusions of law pertinent to the questions in issue. The findings of fact and conclusions of law shall be based solely upon the evidence introduced into the record at the hearing.

Copies of the decision of the hearing officer shall be mailed to the individual and their attorney at law or legal guardian and the Family Support Division.

(5) Judicial Review.

(A) Any applicant for or recipient of Temporary Assistance who may request the director provide an administrative hearing under

section (1) may obtain judicial review pursuant to section 208.100, RSMo.

13 CSR 40-2.450 Assignment of a Protective Payee Over Temporary Assistance Benefits When the Head-of-Household is Declared Ineligible for Temporary Assistance Pursuant to 13 CSR 40-2.400 through 13 CSR 40-2.440 that all recipients for Temporary Assistance benefits who are age eighteen (18) or older and are the head-of-household and who become ineligible as set forth in 13 CSR 40- 2.400 through 13 CSR 40-2.440 will have a protective payee assigned to administer the Temporary Assistance benefit. {#sec-13-csr-40-2.450 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.450}

(1) The Family Support Division shall require the assignment of a protective payee any time the Temporary Assistance head-ofhousehold refuses to complete the screening process as set forth in 13 CSR 40-2.410.

(2) The Family Support Division shall require the assignment of a protective payee any time the Temporary Assistance head-of-household refuses to submit to a drug test for the illegal use of a controlled substance as set forth in 13 CSR 40-2.420.

(3) The Family Support Division shall require the assignment of a protective payee any time the Temporary Assistance head-ofhousehold tests positive for the illegal use of a controlled substance and does not enter or successfully complete a substance abuse treatment program as set forth in 13 CSR 40- 2.430.

(4) The Family Support Division shall designate the protective payee, within forty-five (45) days of the administrative hearing decision that affirms the division as outlined in 13 CSR 40-2.440, or when a new protective payee must be designated.

(A) The Temporary Assistance head-ofhousehold may nominate an individual to be their protective payee.

(B) A relative, friend, clergy person, or other qualified adult may be designated as the protective payee.

(C) The protective payee shall certify to the division he/she meets the following qualifications before being appointed to be a protective payee:

1. Over the age of twenty-one (21);

2. Able to read, write, and willing and able to act in a fiduciary capacity to handle funds on behalf of another person;

3. Has the ability to keep his/her current residence and mailing address on file at all times with the Family Support Division and keep the individual and other household members informed of his/her current address and contact information;

4. Able to maintain records and account for the use of funds as provided in this regulation;

5. The Department of Social Services has not established a claim against him/her for fraud or misuse arising from any program administered by the Department of Social Services;

6. Has not been convicted, pled guilty incarceration actually occurred) of any felony;

7. Has not been convicted, pled guilty demeanor set forth in Chapter 570, RSMo;

8. Has not been convicted, pled guilty demeanor involving the use and/or possession of controlled substances;

9. Has not been convicted, pled guilty demeanor involving the ineligible individual or a family member that is in the Temporary Assistance household;

10. Has not been placed on the central registry maintained by the Department of Social Services for any actions or inaction involving the ineligible individual or a family member that is in the Temporary Assistance household; and 11. Has no civil or criminal court order that hinders the ability of the protective payee to perform any duties as provided in this regulation.

(D) The protective payee has an affirmative obligation to notify the division of any changes in circumstances that would affect his/her qualifications to serve as protective payee as set forth in section (4) including changes in his/her address or contact information within ten (10) days of the change.

(5) A person shall not be qualified to serve as a protective payee under the following circumstances:

(A) The person does not meet the qualifications set out in section (4) of this regula- (B) The person makes any false statements in the certification as set out in section (4) of this regulation.

(6) Responsibilities of the protective payee include:

(A) Acting in a fiduciary capacity on behalf of the members of the Temporary Assistance household when receiving and using the Temporary Assistance benefits under this regulation;

(B) Keeping receipts and other records necessary and appropriate to document how he or she has spent or otherwise utilized the Temporary Assistance benefits paid to the protective payee under this regulation;

(C) Providing an accounting to the individual, to other household members, or their legal representative and/or the Family Support Division for the receipt and expenditure of all Temporary Assistance benefits paid under this regulation; and (D) Providing copies of the receipts and other documents to the individual or the division upon request.

(7) The protective payee must use the Temporary Assistance benefits as follows:

(A) To meet the needs of the Temporary Assistance household. Approved uses may include, but are not limited to, the following examples: clothing, food, household supplies such as cleaning supplies and sanitary supplies, medicine, school supplies for children in the household, utility payments, rent, and activities for the children;

(B) Shall not be used to meet the needs of the protective payee or to compensate the protective payee for managing the Temporary Assistance benefits;

(C) Shall not be given to or used in any way to benefit the ineligible individual, or an individual or entity that does not provide a need for the Temporary Assistance household;

(D) Shall not be utilized to purchase controlled substances without a prescription from a licensed health care professional; and (E) Any payments made to the protective payee that are utilized in violation of this regulation shall be considered a misuse of Temporary Assistance benefits.

(8) The Family Support Division may remove and designate a new protective payee when— (A) The protective payee fails to use the benefits as set out in section (7) of this regulation;

(B) The protective payee fails to meet the qualifications in section (4); and (C) A protective payee who has been previously removed shall be disqualified from serving as a protective payee under this regulation.

(9) The Family Support Division may remove the protective payee at such time when the head-of-household is no longer ineligible for Temporary Assistance benefits as set forth in

13 CSR 40-2.400 through 13 CSR 40-2.440. {#sec-13-csr-40-2.400 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-2.400}

Chapter 3 County Reimbursement (moved to 13 CSR 40-108)

13 CSR 40-3.010 Reimbursable Expenditures {#sec-13-csr-40-3.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-3.010}

(Moved to 13 CSR 40-108.010)

13 CSR 40-3.020 Minimum Record-Keeping Requirements for County Reimbursement and Standardization of Claims Submissions {#sec-13-csr-40-3.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-3.020}

(Moved to 13 CSR 40-108.020)

Chapter 7 Family Healthcare

13 CSR 40-7.015 Application Procedure for Family MO HealthNet Programs and the SOCIAL SERVICES {#sec-13-csr-40-7.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.015}

13 CSR 40-7.010 Scope and Definitions define terms that are used in determining eligibility for Family MO HealthNet programs and the Children’s Health Insurance Program (CHIP). {#sec-13-csr-40-7.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.010}

(1) Definitions.

(A) “Applicant” is a participant as listed in

13 CSR 40-7.015 who completes and submits an application for a Family MO HealthNet Program or CHIP program, whether for themselves or on behalf of someone else. {#sec-13-csr-40-7.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.015}

(B) “Authorized Representative” means an individual as defined in 13 CSR 40- 2.015(2)(B).

(C) “Child” or “Children” means a person or persons who are under nineteen (19) years of age.

(D) “Children’s Health Insurance Program” or “CHIP” means the health assistance provided to uninsured, low income children under Title XXI of the Social Security Act and established in sections 208.631 through 208.658, RSMo.

(E) “Deductions” means an allowable amount that is deducted from earned income and claimed on the participant’s federal income taxes.

(F) “Division” means the Family Support Division, Department of Social Services.

(G) “Earned Income” means— 1. Wages, salaries, tips, commissions, and other taxable employee pay;

2. Union strike benefits;

3. Long-term disability benefits received prior to minimum retirement age;

4. Net earnings from self-employment if— A. The participant or household member owns or oper ates a business or a farm;

B. The participant or household member is a minister or member of a religious order; or C. The participant or household member meets the definition of a “statutory employee” under section 3121(d) of the Internal Revenue Code and has income;

5. Compensation in lieu of wages/bartering.

(H) “Electronic data hub” means any electronic service established by the Secretary of the United States Department of Health and Human Services, through which the division may verify certain information with, or obtain such information from, federal agencies and other data sources.

(I) “Emancipated minor” means a minor who— 1. Has been declared emancipated by a court of competent jurisdiction; or 2. Meets all of the following criteria:

A. The minor is sixteen (16) or seventeen (17) years of age; and B. The minor is self-supporting, such that the minor is without the physical or financial support of a parent or legal guardian; and C. The minor’s parent or legal guardian has consented to the minor living independent of the parents’ or guardians’ control. Consent may be expressed or implied, such that— (I) Expressed consent is any verbal or written statement made by the parent(s) or guardian(s) of the minor displaying approval or agreement that the minor may live independently of the parent’s or guardian’s control;

(II) Implied consent is any action made by the parent or guardian of the minor that indicates the parent or guardian is unwilling or unable to adequately care for the minor. Such actions may include, but are not limited to:

(a) Barring the minor from the home or otherwise indicating that the minor is not welcome to stay;

(b) Refusing to provide any or all financial support for the minor; or (c) Abusing or neglecting the minor, as defined in section 210.110, RSMo, or committing an act or acts of domestic violence against the minor, as defined in section 455.010, RSMo.

(J) “Family member” means a person who meets the following relationship criteria: father, mother, grandfather, grandmother, brother, sister, stepfather or stepmother (but not step-grandparents), stepbrother, stepsister, uncle, aunt, first cousin, first cousin of a parent, nephew, niece, adoptive father or adoptive mother, grandfather-in-law or grandmother-in-law (meaning the spouse of a second marriage of one (1) of the child’s biological grandparents), great-grandfather or great-grandmother (including great-great grandfather or great-great grandmother), brother or sister of half-blood, adoptive brother or adoptive sister, brother-in-law or sister-in-law, uncle or aunt of the half-blood, uncle-in-law or aunt-in-law, great-uncle, or great-aunt (including great-great uncle or great-great aunt). Relatives by adoption not specifically mentioned in this subsection are treated in the same way as blood relatives.

(K) “Family MO HealthNet programs” means MO HealthNet benefits provided to participants under the MO HealthNet for Families (MHF) program, the Adult Expansion Group (AEG) pursuant to Article IV,

Section 36(c) of the Missouri Constitution, MO HealthNet for Kids (MHK) program, MO HealthNet for Pregnant Women (MPW) program, and Uninsured Women’s Health Services (UWHS) program. Family MO HealthNet programs also include presumptive eligibility for any of the above programs.

(L) “Household” means individuals who make up an eligibility group under 42 CFR 45.603(f) and 13 CSR 40-7.020.

(M) “Non-custodial parent” means the parent who does not have physical custody of the child.

1. If physical custody is questioned, a court order, judgment, decree, or any legally enforceable separation, divorce, or custody agreement establishing which party has physical custody shall control who is the custodial parent.

2. If there is no such order or agreement, or the order or agreement is silent, or in the event of joint custody, the custodial parent is the parent with whom the child expects to spend more than fifty percent (50%) of his or her overnight visits in the year for which eligibility is being determined.

3. In the case of true joint physical custody where the child spends an equal amount of overnight visits with both parents, the noncustodial parent is the parent who does not claim the child as part of their tax household.

(N) “Non-Filer” means an individual who is not expected to file a tax return or be claimed as a tax-dependent.

(O) “Parent” means a natural or biological, adopted, or stepparent.

(P) “Participant” means any individual who has applied for, is receiving, or has been denied Family MO HealthNet benefits or CHIP benefits.

(Q) “Sibling” means a natural or biological, adopted, half, or step sibling.

(R) “Reasonable Compatibility” means the information received by the division, is not in conflict with other information known by the division. Income information is “reasonably compatible” if the sources of information are above or both are at or below the applicable income standard or other relevant income threshold limit, or the difference between the sources of the income information is ten percent (10%) or less and the sources of income are similar.

(S) “Tax Dependent” means an individual for whom another individual claims a deduction for a personal exemption under Internal Revenue Code, section 151 for a taxable year.

(T) “Taxpayer” means an individual who expects to file a tax return for the taxable year in which an initial determination or renewal of eligibility is being made and who does not expect to be claimed as a tax dependent by another individual.

(U) “Unearned Income” means— 1. Pay received for work while an inmate is in a penal institution;

2. Interest and dividends;

3. Retirement income;

4. Social Security;

5. Unemployment benefits;

6. Alimony; and 7. Child support.

RSMo 2016.* Original rule filed July 31, 2013, effective Feb. 28, 2014. Amended: Filed Oct. 1, 2018, effective May 30, 2019. Emergency amendment filed Oct. 5, 2021, effective Oct. 20, 2021, expired April 17, 2022.

Amended: Filed Oct. 5, 2021, effective April 30, 2022. *Original authority: 207.022, RSMo 2014, and 660.017,

13 CSR 40-7.015 Application Procedure for Family MO HealthNet Programs and the Children’s Health Insurance Program (CHIP) {#sec-13-csr-40-7.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.015}

PURPOSE: This rule defines the application procedures for Family MO HealthNet programs or the Children’s Health Insurance Program (CHIP).

(1) General application procedures for programs administered by the Family Support Division are found at 13 CSR 40-2.010. For anything in this section conflicting with the general application procedures, this regulation controls for the application procedures for Family MO HealthNet programs or the Children’s Health Insurance Program (CHIP).

(2) An application for Family MO HealthNet programs or the Children’s Health Insurance Program (CHIP) may be obtained by contacting one (1) of the following sources:

(A) An insurance exchange, whether federally facilitated, state based, or operated on a partnership basis;

(B) The Family Support Division Contact Center;

(C) A Family Support Division office; or (D) Accessing the Department of Social Services website www.dss.mo.gov.

(3) An application for Family MO HealthNet program or the Children’s Health Insurance Program (CHIP) shall be accepted by mail, telephone, or in person at any Family Support office, or via the department’s Internet website found at www.dss.mo.gov. The division shall also accept applications through providers who the division contracts with in order to facilitate eligibility decisions.

(4) The following individuals may apply for Family MO HealthNet or the Children’s Health Insurance Program (CHIP) on behalf of a participant:

(A) The participant, as defined under 13 CSR 40-7.010;

(B) An adult who is in the participant’s household. For purposes of this subsection, “household” shall have the same definition as in 42 CFR section 435.603(f)(1);

(C) A member of the participant’s family, as defined in 26 U.S.C section 36B(d)(1);

(D) An authorized representative of the participant;

(E) An individual with a valid power of attorney to act on behalf of the participant;

(F) If the participant is an incapacitated person as defined under 475.010, RSMo— 1. A parent, spouse, and other close adult relative;

2. An authorized representative; or 3. A guardian or conservator; or 4. A public administrator; or 5. Other person appointed by a court of competent jurisdiction.

(G) If the participant is a minor under age eighteen (18), an application may be submitted by the following:

1. The minor on behalf of him/herself, if any of the following conditions apply:

A. The minor is pregnant;

B. The minor has been lawfully married;

C. The minor is a parent;

D. The minor is a victim of domestic violence, as defined by section 455.010, RSMo, or meets all the criteria in section 431.056, RSMo;

E. Is a victim of trafficking offenses under section 566.203, 566.206, 566.209, 566.210, or 566.211, RSMo; or F. The minor is emancipated.

2. For other minors not in the custody, care, or control of a parent or guardian, someone acting responsibly for the applicant.

This shall include a person age eighteen (18) or over who has the capacity to enter into a contract, has primary custody, care, or control of the minor and who— A. Is related to the applicant by blood, marriage, or adoption; or B. Is a person who— (I) The division reasonably determines has sufficient knowledge of the applicant’s circumstances to accurately complete the application; and (II) Has an obligation to act in the best interests of the applicant as per 13 CSR 40-2.015.

(5) The applicant shall provide and attest to the following information when making an application for Family MO HealthNet benefits or CHIP benefits:

(A) The name of each individual who resides with the participant;

(B) The name of each individual who the participant claims or intends to claim on his or her federal income tax returns;

(C) The name of any person who claims or intends to claim the participant as a dependent on his or her federal tax forms; and (D) For the participant, and each person listed in subsections (5)(A), (5)(B), or (5)(C), the applicant shall provide the following information:

1. Relationship to the applicant;

2. Physical Address;

3. Mailing address, if different from physical address;

4. Date of Birth;

5. Gender;

6. Social Security Number, in accordance with section (6) of this rule;

7. Intent to file taxes or be claimed as a tax dependent on someone else’s taxes;

8. Whether the participant is pregnant;

9. Any physical, mental, or emotional health condition that causes limitations in activities of daily living;

10. Residence in a medical facility or nursing home;

11. Citizenship or immigration status;

12. Race (optional);

13. Employment status, employer name and address, hours employed, and rate of pay;

14. Any and all sources of income and amounts;

15. Any federal tax deductions entitled for alimony paid or student loan interest;

16. Enrollment in any health care coverage, name of insurer, policy number, and any limitations on the coverage;

17. If he or she or anyone in their family is American Indian or Alaska Native. If any person is, information about tribe affiliation, services, and income received from benefits must be disclosed;

18. Details concerning any health coverage which is available to him or her through a job. This includes coverage that is offered through someone else’s job, such as a parent or spouse; and 19. If a participant is a child, the name and address of any parent living outside the home.

(6) Subject to the exceptions recognized in 42 CFR 435.910(h), Social Security numbers are requested of every person for whom coverage is being requested, pursuant to subsections (5)(A), (5)(B), or (5)(C).

(A) If the person is a participant in MO HealthNet, the person’s Social Security number shall be included.

(B) If the person is not a participant in MO HealthNet, the inclusion of the Social Security number is voluntary.

(C) Social Security numbers are to be used only for the purpose of determining a participant’s eligibility for MO HealthNet or for a

purpose directly connected to the administration of MO HealthNet.

(7) The applicant shall sign an assignment of rights to the MO HealthNet Division to pursue and recover money owed for medical expenses from any applicable insurance policies, legal settlements or judgments, or other liable or potentially liable third parties.

(8) The applicant shall sign an assignment of rights to pursue and obtain medical support from a parent or spouse who owes such a duty.

(9) The participant and applicant shall disclose all information which may impact eligibility for any MO HealthNet program. The participant and applicant have a continuing obligation to notify the division if any information specified in the application changes within ten (10) days of the change. The continuing duty includes, but is not limited to disclosing any changes in income of the participant or household member, changes in residence or mailing address, and the addition or removal of any individual from the household whose information is or was required to be submitted.

(10) The applications shall be signed under penalty of perjury, attesting to the information provided as true, accurate, and complete.

Amended: Filed April 18, 2018, effective Nov. 30, 2018. *Original authority: 207.022, RSMo 2014; 208.991, RSMo 2013; and 660.017, RSMo 1995.

History

• AUTHORITY: sections 207.022, 208.991, and 660.017, RSMo 2016. Original rule filed July 31, 2013, effective Feb. 28, 2014.

13 CSR 40-7.020 Household Composition explain the Household Composition Standard for Family MO HealthNet programs and the Children’s Health Insurance Program (CHIP). {#sec-13-csr-40-7.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.020}

(1) A household shall include the taxpayer, or in the case of a joint return, taxpayers, and all tax dependents.

(A) In the case of a married couple living together, each spouse shall be included in the household of the other spouse regardless of whether they expect to file jointly or whether one (1) spouse is expected to be declared as a tax dependent of the other spouse.

(B) In determining the household size of a pregnant woman, the division shall count the pregnant woman plus the number of unborn children she is expecting to deliver. In determining the household size of other individuals who have a pregnant woman in the household the pregnant woman is considered as one (1) person.

(C) If a taxpayer cannot reasonably establish that another individual is a tax dependent for the tax year for which eligibility is sought, the inclusion of such individual in the household shall be determined in accordance with section (3) of this rule.

(D) In the case of a participant taxpayer under age nineteen (19), who resides with his or her parents, the household shall be determined in accordance with section (3) of this

rule.

(2) In the case of a participant who expects to be claimed as a tax dependent by another taxpayer for the taxable year in which an initial determination or renewal of eligibility is being made, the participant’s household is the household of the taxpayer claiming such individual as a tax dependent with the following exceptions:

(A) Family members and unrelated individuals claimed as a tax dependent by a taxpayer other than a parent or spouse;

(B) Children claimed as a tax dependent by the non-custodial parent; or (C) Children who expect to be claimed by one (1) parent as a tax dependent and are living with both parents, but whose parents do not expect to file a joint tax return.

(3) For participants who do not expect to file a tax return, who do not intend to be claimed as a tax dependent, or tax dependents that fall into an exception under subsections (2)(A), (2)(B), or (2)(C) of this rule, the household shall consist of— (A) The participant;

(B) The spouse of the participant if living with the participant;

(C) Children of the participant if living with the participant; and (D) For participants who are children— 1. The participant’s parents who live with the participant;

2. Any siblings, who are also dependent children, who live with the participant.

(4) This rule shall be effective for all eligibility decisions made on January 1, 2014, and RSMo 2016.* Original rule filed July 31, 2013, effective Feb. 28, 2014. Amended: Filed Aug. 8, 2018, effective March 30, 2019. *Original authority: 207.022, RSMo 2014 and 660.017,

13 CSR 40-7.030 Calculation of Modified Adjusted Gross Income (MAGI) explain how Modified Adjusted Gross Income (MAGI) is calculated for the Family MO HealthNet programs and the Children’s Health Insurance Program (CHIP). {#sec-13-csr-40-7.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.030}

(1) Modified Adjusted Gross Income (MAGI) based income means income calculated using the same financial methodologies used to determine modified adjusted gross income as defined in section 36B(d)(2)(B) of the Internal Revenue Code, with the exceptions listed below.

(A) Any lump sum gift or income is included as income only in the month in which it is received.

(B) Scholarships and grants which are used for educational purposes, and not for living expenses are excluded from income.

(C) The following Alaskan Native and American Indian benefits and distributions are excluded from income:

1. Distributions from Alaska Native Corporations and Settlement Trusts;

2. Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior;

3. Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resources extraction and harvest from— A. Rights of ownership or possession in any lands described in paragraph (1)(C)2. of this rule; or B. Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources;

4. Distributions resulting from real property ownership interests related to natural resources and improvements:

A. Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or B. Resulting from the exercise of federally-protected rights relating to such real property ownership interests;

5. Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable Tribal Law or custom; and 6. Student financial assistance provided under the Bureau of Indian Affairs education programs.

(2) Eligibility determinations for participants for Family MO HealthNet programs and CHIP shall be based on a household’s current monthly income and household size. A house hold’s income is the sum of the Modified Adjusted Gross Income (MAGI) based income as defined above of every individual included in the participant’s household.

(A) The division shall take into consideration reasonable anticipated changes in income that exist at initial determination such as seasonal or time based employment sources and periods, or the known ending period of employment or an income source.

(B) Income of a child shall not be included in the household if the child is not required to file a tax return under the Internal Revenue Code, section 6012(a)(1) for the taxable year in which eligibility is being determined, regardless if the child expects to or actually filed a tax return.

(3) This rule shall be effective for all eligibility decisions made on January 1, 2014, or

History

• AUTHORITY: section 207.020, RSMo 2000, and section 208.991, RSMo Supp. 2013. Original rule filed July 31, 2013, effective Feb. 28, 2014. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993 and 208.991, RSMo 2013.

13 CSR 40-7.035 Participant Verification {#sec-13-csr-40-7.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.035}

PURPOSE: This rule outlines how the Department of Social Services will verify participant information in order to administer the Family MO HealthNet programs and Children’s Health Insurance Program (CHIP).

(1) Scope: This regulation specifies how the Department of Social Services shall verify participant information in order to administer the Family MO HealthNet programs and CHIP to prevent fraud and insure the integrity of the Family MO HealthNet programs and CHIP.

(2) The “Federally Facilitated Marketplace” is created under section 1321(c)(1) of the Patient Protection and Affordable Care Act of 2010 (Public Law No. 111-148) as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152).

(3) The Department of Social Services shall access the electronic data hub, as defined in 13 CSR 40-7.010, to verify information provided by the participant as part of the application process for Family MO HealthNet programs and CHIP. The department shall only verify the following:

(A) Citizenship;

(B) Immigration status;

(C) Income using Internal Revenue Service information;

(D) Income from Title II benefits information from the Social Security Administration;

(E) The number of work quarters from Social Security Administration;

(F) Employment information; and (G) Confirm current enrollment in a MO HealthNet program.

(4) The Department of Social Services shall also use the electronic data hub to send information on participants who are not eligible for Family MO HealthNet programs and CHIP to the Federal Facilitated Marketplace to verify if the participants qualify for advance payment of premium tax credit; cost-sharing reductions or qualified health plans. The Federally Facilitated Marketplace will use the electronic data hub to send information to the Department of Social Services to verify if participants qualify for Family MO HealthNet programs or CHIP or to verify if a participant is already enrolled in Family MO HealthNet programs or CHIP.

(5) The Department of Social Services will not use, duplicate, or disclose any information used or obtained under this rule to any individual, organization, state or federal agency for any purpose not related to the public assistance benefits administered in whole or in part by the Department of Social Services as that phrase is defined in section 205.967.1(1), RSMo. All applicable state and federal laws and regulations governing the confidentiality of public assistance programs, health information, and taxpayer information shall govern the use or disclosure of information shared with or obtained from the electronic data hub.

(6) All information used or obtained under this

rule, unless otherwise prohibited by this rule, shall be destroyed in accordance with section 208.125, RSMo, unless otherwise required by law.

History

• AUTHORITY: section 208.990, RSMo Supp. 2013. Original rule filed April 8, 2014, effective Oct. 30, 2014. Original authority: 208.990, RSMo 2013.

13 CSR 40-7.040 Verification Procedures explain what Verification Procedures the Family Support Division will use when determining eligibility for Family MO HealthNet programs and the Children’s Health Insurance Program (CHIP). {#sec-13-csr-40-7.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.040}

(1) The division shall verify all eligibility factors, through available means, including information obtained through the electronic data hub, a participant’s statements, or other information the division has obtained. Verification shall occur upon application and recertification, and at any other time necessary to verify continued eligibility.

(A) The division shall verify eligibility information of a participant through the electronic data hub.

(B) If the information obtained through the electronic data hub is reasonably compatible with information provided by or on behalf of the participant, the division shall use the participant’s information as verification for eligibility.

(C) If reasonably compatible standards are not met, secondary verification is required.

Secondary verification may include the following:

1. Other electronic data sources available;

2. Other information, including paper documentation; or 3. A written statement which reasonably explains the discrepancy.

(2) If verification cannot be obtained by the division through the electronic data hub, or if the information is not reasonably compatible with other information provided, the division shall ask for any additional information from or on behalf of the participant needed in order to verify the information.

(A) The participant shall provide the required verification within ten (10) days from the date that the division requests the information in writing.

(B) A participant may request additional time to provide the information. The additional time shall be granted if the participant is making a reasonable effort to obtain the information.

(C) If a participant fails to provide the requested verification within ten (10) days from the date of the written request or fails to obtain additional time to provide the information, the division shall issue an adverse action notice to the participant notifying them that their coverage is denied or their coverage shall terminate ten (10) days from the date of the adverse action notice.

(D) The participant shall be given the right to request a hearing on the issue pursuant to

section 208.080, RSMo. Failure on the part of the participant to request a hearing shall result in termination of coverage upon expiration of the adverse action notice.

(3) This rule shall be effective for all eligibility decisions made on January 1, 2014, and

History

• AUTHORITY: section 207.020, RSMo 2000, and section 208.991, RSMo Supp. 2013. Original rule filed July 31, 2013, effective Feb. 28, 2014. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993 and 208.991, RSMo 2013.

13 CSR 40-7.050 Presumptive Eligibility establish the conditions under which MO HealthNet eligibility will be temporarily available to certain categories of participants based on preliminary determinations by certain categories of providers. {#sec-13-csr-40-7.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.050}

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) The department shall provide MO Health- Net benefits to individuals during a period of presumptive eligibility for individuals who have been determined eligible for MO Health- Net benefits on the basis of preliminary information by a presumptive eligibility qualified entity in accordance with this rule, and pursuant to sections 435.1100, 435.1101, 435.1102, 435.1103, and 435.1110 of Title 42, Code of Federal Regulations, which is incorporated by reference and made part of this rule as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, D.C. 20408, and available at its website (https://www.ecfr.gov/current/title- 42/chapter-IV/subchapter-C/part-435?toc=1), October 20, 2021. This rule does not incorporate any subsequent amendments or additions.

(2) For the purposes of this rule— (A) “Presumptive eligibility” means temporary MO HealthNet benefits for children under the age of nineteen (19) (pursuant to 42 U.S.C. sections 1396a(47) and 1396r-1a and 42 CFR sections 435.1102 and 435.1110), parents and other caretaker relatives (pursuant to 42 CFR sections 435.1103 and 435.1110), former foster care children (pursuant to 42 CFR sections 435.1103 and 435.1110), pregnant women (pursuant to 42 U.S.C. sections 1396a(47) and 1396r-1 and 42 CFR sections 435.1103 and 435.1110), individuals with breast cancer or cervical cancer (pursuant to 42 U.S.C. sections 1396a(47) and 1396r-1b and 42 CFR sections 435.1103 and 435.1110), and adults between ages nineteen (19) and sixty-four (64) (pursuant to 42 CFR 435.1110), allowing them to receive MO HealthNet benefits before they have applied for MO HealthNet benefits through the division;

(B) “Qualifying hospital” has the same meaning as in 42 CFR 435.1110(b);

(C) “Federally qualified health center” has the same meaning as in 42 U.S.C. section 1396(l)(2)(B);

(D) “Rural health clinic” has the same meaning as in 42 U.S.C. section 1395x(aa)(2);

(E) “Presumptive eligibility qualified entity” means a MO HealthNet provider organization responsible for screening individuals/families regarding presumptive eligibility for MO HealthNet benefits.

1. For presumptive eligibility determinations for children under the age of nineteen (19), “presumptive eligibility qualified entity” means a federally qualified health center, rural health clinic, or qualifying hospital that meets the requirements for a “qualified entity” in 42 U.S.C. section 1396r–1a(b)(3)(A).

2. For presumptive eligibility determinations for pregnant women, “presumptive eligibility qualified entity” means a county health department, federally qualified health center, rural health clinic, or qualifying hospital that meets the requirements for a “qualified provider” in 42 U.S.C. section 1396r– 1(b)(2).

3. For presumptive eligibility determinations for parents and caretaker relatives, “presumptive eligibility qualified entity” means a qualifying hospital as provided in

section 42 CFR 435.1110.

4. For presumptive eligibility determinations for breast and cervical cancer treatment, “presumptive eligibility qualified entity” means a Show-Me Healthy Women provider which has a participation agreement with the Missouri Department of Health and Senior Services that meets the requirements for a “qualified entity” in 42 U.S.C. section 1396r–1b(b)(2).

5. For presumptive eligibility determinations for former foster care children, “presumptive eligibility qualified entity” means a qualifying hospital.

6. For presumptive eligibility determinations for adults between ages nineteen (19) and sixty-four (64), “presumptive eligibility qualified entity” means a qualifying hospital.

(3) In order to be eligible to be a presumptive eligibility qualified entity, a MO HealthNet provider must first— (A) Apply to be a presumptive eligibility qualified entity in a manner prescribed by the division which shall include the following information:

1. The name and mailing address of the MO HealthNet provider applying to be a presumptive eligibility qualified entity;

2. The state in which the provider is licensed, registered, or incorporated;

3. The national provider identifier (NPI) number of the provider;

4. The MO HealthNet programs for which the provider intends to be a presumptive eligibility qualified entity; and 5. The name, mailing address, telephone number, and email address of the individual who will serve as principal contact between the qualified entity and the division with respect to presumptive eligibility determinations;

(B) Be approved as a presumptive eligibility qualified entity by the division;

(C) Through representatives, attend and successfully complete all training required by the division for presumptive eligibility qualified entities;

(D) Comply with section 208.155, RSMo and shall execute agreements, as required by the division, relating to security, confidentiality, and computer access; and (E) Post an informational poster regarding the availability of MO HealthNet benefits in its facility reception area or in some other appropriate area of the facility if requested to do so by the division.

(4) A presumptive eligibility qualified entity shall make presumptive eligibility determinations subject to the requirements listed below:

(A) Designated staff or other representatives of the presumptive eligibility qualified entity will offer interested individuals/families the opportunity to apply for and receive benefits based on a presumptive eligibility determination;

(B) Designated staff or other representatives of the presumptive eligibility qualified entity will determine presumptive eligibility for the program;

(C) The presumptive eligibility qualified entity shall provide applicable MO HealthNet application forms to individuals, parents, and caretakers pursuant to 13 CSR 40-7.015 and assist such persons in completing and filing such forms, or shall assist individuals, parents, and caretakers to apply at mydss.mo.gov;

(D) The presumptive eligibility qualified entity shall notify the individual, parent, or caretaker of the presumptive eligibility determination in writing at the time the determination is made on a form provided or approved by the division;

(E) The presumptive eligibility qualified entity shall notify the division that the participant is presumptively eligible within five (5) working days after the date of a presumptive eligibility determination;

(F) Where a determination of presumptive eligibility is made, the presumptive eligibility qualified entity shall notify the individual, parent, or caretaker in writing on a form provided or approved by the division, that— 1. If a MO HealthNet application is not filed by the last day of the month following the month in which the presumptive eligibility determination is made, the period of presumptive eligibility will end on that last day;

2. If a MO HealthNet application is filed by the last day of the month following the month in which the presumptive eligibility determination is made, the period of presumptive eligibility will end on the day a decision is made on the MO HealthNet application;

(G) Where a determination is made that the individual is not presumptively eligible, the presumptive eligibility qualified entity shall notify the individual, parent, or caretaker in writing on a form provided or approved by the division, at the time the determination is made, of the reason for the determination and that the individual, parent, or caretaker may file an application for MO HealthNet benefits pursuant to 13 CSR 40-7.015;

(H) In making a presumptive eligibility determination, the presumptive eligibility qualified entity shall apply preliminary eligibility criteria established by applicable law and regulation, using forms provided by the division, and shall approve an application for presumptive eligibility only if the following requirements are met:

1. For children under the age of nineteen (19)— A. The child must meet the same Medicaid coverage for children under nineteen (19); and B. There can be no more than one (1)

2. For parents and caretaker relatives— A. Individuals must be parents or other caretaker relatives (as defined in 42 CFR 435.4), including pregnant women, of a dependent child (as defined in 42 CFR 435.4) under age eighteen (18);

B. The individual must meet the same Medicaid coverage for parents; and C. There can be no more than one (1)

3. For pregnant women— A. The individual must be pregnant;

B. The woman must meet the same Medicaid coverage for pregnant women or for coverage under the Show-Me Healthy Baby program; and C. The individual must not have already received benefits under a MO Health- Net presumptive eligibility program during the current pregnancy;

4. For breast and cervical cancer treatment— A. The individual must be diagnosed with breast or cervical cancer by a Show-Me Healthy Women provider unless the participant is diagnosed by a MO HealthNet provider while currently receiving MO HealthNet benefits;

B. The woman must meet the same coverage under the Breast and Cervical Cancer Coverage program; and C. There can be no more than one (1)

5. For former foster care children— A. The individual must be in foster care under the responsibility of the state of Missouri as of their eighteenth birthday or within thirty (30) days prior to their eighteenth birthday;

B. The individual must be under the age of twenty-six (26) years old;

C. The individual must not be eligible for another MO HealthNet benefits group;

D. The individual must have been covered by MO HealthNet while they were in foster care;

E. The individual must be a Missouri resident; and F. There can be no more than one (1) bility period; and 6. For adults between ages nineteen (19) and sixty-four (64)— A. The adult must meet the requirements for income and United States and Missouri residency required for regular Medicaid coverage for adults between ages nineteen (19) and sixty-four (64) pursuant to 42 CFR 435.1103 and 435.1110; and B. There can be no more than one (1)

(I) The presumptive eligibility qualified entity shall verify with the division that prospective participants are not currently covered by MO HealthNet or have not already had a period of presumptive eligibility during the past twelve (12) months or, if applicable, during the current pregnancy;

(J) The presumptive eligibility qualified entity shall adhere to the following application processing procedures established by the division:

1. The presumptive eligibility qualified entity shall date stamp the presumptive eligibility applications and MO HealthNet applications on the same day received if paper applications are used;

2. In connection with presumptive eligibility determinations, the division will provide to presumptive eligibility qualified entity only the applicant’s or participant’s Departmental Client Numbers (DCN), dates of MO HealthNet coverage, correct spelling of names, correct type of assistance, and level of care. All other requests for applicant or participant information from the presumptive eligibility qualified entity to the division shall be accompanied by an appropriate authorization for release of information; and 3. To the extent it receives a completed MO HealthNet application, the presumptive eligibility qualified entity shall transmit MO HealthNet applications to the division for final processing so they are received by the division within five (5) business days of the applicant’s or participant’s signature;

(K) The presumptive eligibility qualified entity shall maintain written or electronic records of all presumptive eligibility applications and determinations along with any related supporting documentation for a period of five (5) years from the date of the determination or application unless litigation or an audit by the department, State Auditor’s Office, or the Center for Medicare and Medicaid Services relating to the records has been started prior to the sixth year, then records must be maintained until the litigation or audit is resolved. These records shall be made available to the department, at its request, for the purposes of determining whether the presumptive eligibility qualified entity is in compliance with this rule;

(L) The presumptive eligibility qualified entity’s staff that are, or will be, involved in making presumptive eligibility determinations shall attend or otherwise receive and satisfactorily complete training from the division in the manner prescribed by the division;

(M) The presumptive eligibility qualified entity shall keep up-to-date the identity and contact information of the person who will be the primary contact between the division and the presumptive eligibility qualified entity under paragraph (3)(A)5. of this rule;

(N) The presumptive eligibility qualified entity shall not delegate or subcontract the

(5) MO HealthNet benefits begin on the date the presumptive eligibility qualified entity determines that the individual is presumptively eligible. The presumptive eligibility period shall end on the date a decision is made on the individual’s MO HealthNet application or, in the event no regular application is filed, on the last day of the month following the month in which the presumptive eligibility determination was made.

(6) After a determination of presumptive eligibility is made, MO HealthNet providers shall provide applicable services during the period the presumptive eligibility determination remains in effect.

(7) In order to remain a presumptive eligibility qualified entity, a presumptive eligibility qualified entity must meet the following performance standards with respect to its presumptive eligibility determinations:

(A) The presumptive eligibility qualified entity must make, and be capable of making, presumptive eligibility determinations in accordance with this rule, including compliance with quality assurance and on-site monitoring efforts by the division;

(B) The division must receive a regular MO HealthNet application for the appropriate program before the end of the presumptive eligibility period with respect to ninety percent (90%) of the participants determined to be presumptively eligible by the presumptive eligibility qualified entity in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility;

(C) Ninety-five percent (95%) or more of the applications actually received by the division from participants determined to be presumptively eligible by the presumptive eligibility qualified entity must be approved as eligible for MO HealthNet benefits by the division in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility. However, applications denied because the applicant failed to meet eligibility criteria that are not listed in subsection (4)(H) of this rule will not count against the presumptive eligibility qualified entity for the purposes of this performance standard;

(D) The presumptive eligibility qualified entity is required by subsection (4)(I) of this

rule to check whether the applicant already has current MO HealthNet coverage. The presumptive eligibility qualified entity shall make this determination of prior coverage accurately with respect to ninety percent (90%) or more of its presumptive eligibility determinations, whether presumptive eligibility is approved or denied, in the aggregate, for each calendar year, and for any shorter review period designated by the division.

This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility;

(E) The presumptive eligibility qualified entity is required by subsection (4)(I) of this

rule to check whether the applicant has received MO HealthNet benefits under presumptive eligibility in the past twelve (12) months or, for pregnancy determinations, during the current pregnancy. The presumptive eligibility qualified entity shall make this determination correctly with respect to ninety-eight percent (98%) or more of its presumptive eligibility applicants, whether presumptive eligibility is approved or denied, in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility;

(F)

The presumptive eligibility qualified entity shall make an accurate presumptive eligibility determination based on the information provided from the applicant on the presumptive eligibility application on ninety percent (90%) of its presumptive eligibility applicants, whether presumptive eligibility is approved or denied, in the aggregate, for each calendar year, and for any shorter review period designated by the division.

This standard shall be effective twelve (12) months from the date that the division approves the qualified entity’s application to determine presumptive eligibility;

(G) In the event a presumptive eligibility qualified entity fails to meet any of the standards set forth in subsections (7)(A) through (7)(F), the presumptive eligibility qualified entity, upon notification by the division that it has not met the standard(s), shall submit to the division a corrective action plan to ensure future compliance with subsections (7)(A) through (7)(F). The presumptive eligibility qualified entity must amend the corrective action plan as required by the division. Once the division has approved the corrective action plan, the qualified entity must implement and satisfactorily complete the corrective action plan within the time frames set forth in the plan. The division shall monitor the qualified entity’s performance on the corrective action plan at least every three (3) months until the division determines that the corrective action plan has been successfully completed; and (H) In the event the presumptive eligibility qualified entity does not submit a corrective action plan acceptable to the division or again fails to meet the performance standards set forth in subsections (7)(A) through (7)(F) after approval by the division of a corrective action plan, the division may disqualify the provider as a presumptive eligibility qualified entity.

1. The qualified entity shall receive thirty (30) days prior notice of its disqualification as a presumptive eligibility qualified entity.

2. The presumptive eligibility qualified entity shall have ten (10) calendar days after receipt of a notice of disqualification to submit a request that the department director reconsider the decision to disqualify. Any such request for reconsideration shall include a detailed explanation of the reasons why the presumptive eligibility qualified entity should not be disqualified for failing to meet performance standards and shall contain any documentation the presumptive eligibility quali fied entity wishes the director to consider. It is entirely within the discretion of the department director whether to reconsider the disqualification decision.

3. Disqualification shall be for a minimum of a three- (3-) year period. At the conclusion of the disqualification period, the presumptive eligibility qualified entity may reapply and shall successfully complete training required by the department director in order to be reinstated.

(8) Applicants and participants may not appeal the presumptive eligibility determination made by a presumptive eligibility qualified entity under this rule. However, nothing in this rule limits the ability of an applicant or participant to appeal the final determination of eligibility for MO HealthNet benefits made by the division as otherwise provided by law.

(9) Upon the effective date of this rule, any existing agreements regarding presumptive eligibility between the division and MO Health- Net providers, including providers designated as “qualified providers” or “qualified entities” in such agreements, shall terminate and shall be superseded by this rule, except as follows:

(A) Any provider that is party to such an agreement that notifies the division within thirty (30) days of the effective date of this

rule that it intends to continue as a presumptive eligibility qualified entity will not be required to be approved as a presumptive eligibility qualified entity under subsection (3)(B) of this rule with respect to the MO HealthNet program for which it was previously authorized by contract to make presumptive eligibility determinations; and (B) Any provider who notifies the division under subsection (9)(A) of its intention to continue as a presumptive eligibility qualified entity shall remain subject to all other requirements of this rule, including the requirement to submit the information specified in subsection (3)(A).

RSMo 2016, and section 208.151.1(22), RSMo Supp. 2021.* Original rule filed March 31, 2016, effective Sept. 30, 2016. Emergency amendment filed Oct. 5, 2021, effective Oct. 20, 2021, expired April 17, 2022. Amended:

Filed Oct. 5, 2021, effective April 30, 2022. *Original authority: 207.022, RSMo 2014; 208.151, RSMo 1967, amended 1973, 1981, 1982, 1987, 1988, 1989, 1990, 1991, 1993, 1995, 2001, 2005, 2007, 2011, 2013, 2018, 2019, 2020; and 660.017, RSMo 1993, amended 1995.

History

• authority to determine presumptive eligibility to another entity. However, they may implement their presumptive eligibility program with the support of third party contractors.

13 CSR 40-7.060 Show-Me Healthy Babies Program {#sec-13-csr-40-7.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.060}

PURPOSE: This rule establishes the eligibility requirements for the Show-Me Healthy Babies Program, in accordance with section 208.662, RSMo.

(1) Scope. This rule describes the eligibility requirements and coverage for the Show-Me Healthy Babies Program.

(2) For purposes of this section, the following definitions shall apply:

(A) “Affordable insurance” or “affordable health care coverage” shall mean a health insurance plan (employer-sponsored or otherwise) that covers the pregnancy and that requires monthly premiums equal to the amounts described in section 208.640, RSMo and section 1397cc(e)(3)(B) of Title 42, United States Code;

(B) “Household” shall have the same definition that appears in 13 CSR 40-7.020;

(C) “Modified adjusted gross income (MAGI)” shall mean income calculated using the same financial methodologies used to determine modified adjusted gross income as defined in section 36B(d)(2)(B), Internal Revenue Code, pursuant to the rules and exceptions in 13 CSR 40-7.030;

(D) “Participant” shall mean any individual who has applied for, or is receiving, or has been denied, income maintenance benefits or services through an income maintenance program administered by the Family Support Division (hereinafter, “division”), including an unborn child;

(E) “Post-partum” shall mean healthcare coverage continues until the last day of the month containing the sixtieth day after the termination of pregnancy; and (F) “Program” shall mean the Show-Me Healthy Babies program, unless described otherwise.

(3) To be eligible for the program, a participant— (A) Must be the unborn child of a pregnant woman. The pregnancy is verified upon the mother’s (or her representative’s) attestation that she is pregnant. The division may request more verification if information is not reasonably compatible with the participant’s attestation in accordance with section 457.380(e) of Title 42, Code of Federal Regulations;

(B) Must not be eligible for any other non- Children’s Health Insurance Program (CHIP), MO HealthNet program that covers the pregnancy and does not require a premium or a spend-down in exchange for coverage;

(C) Must not have insurance that covers the same pregnancy-related services as this program;

(D) If not insured, does not have access to affordable insurance that covers the same pregnancy-related services as this program;

(E) Must be in a household with a modified adjusted gross income no greater than three hundred percent (300%) of the federal poverty level, subject to the rules and exceptions in 13 CSR 40-7.030 and the verification requirements in 13 CSR 40-7.040.

(4) Coverage.

(A) This program provides to unborn children and their mothers the same coverage afforded to pregnant women under section 1397ll(d)(1) of Title 42, United States Code.

This coverage includes, but is not limited to— 1. Coverage effective no earlier than the month of conception;

2. Post-partum coverage for the mother that continues through the end of the month, in which the sixtieth day after the termination of pregnancy occurs, provided the mother applied for services in the program while pregnant with the child.

(B) Participants in this program are not eligible for automatic, extended women’s health services pursuant to 13 CSR 70-4.090.

(C) Children born to participants covered under this program are eligible for continuing coverage for one (1) year after the birth, under the applicable CHIP level of care. During this period, no premium shall be applied, regardless of the level of care.

(D) There is no waiting period for participants to receive coverage once they are determined eligible for the program, regardless of the household’s level of income.

History

• AUTHORITY: sections 207.022 and 208.662, RSMo Supp. 2014. Original rule filed Dec. 23, 2015, effective June 30, 2016. Original authority: 207.022, RSMo 2014 and 208.662, RSMo 2014.

13 CSR 40-7.070 MO HealthNet for Families establish the conditions under which MO HealthNet for Families eligibility will be available to participants. {#sec-13-csr-40-7.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.070}

(1) The Department of Social Services shall provide MO HealthNet benefits to individuals who are determined eligible for MO Health- Net for Families in accordance with this rule.

(2) Definitions.

(A) “Eligible child” means a child who— 1. May or may not be applying for or receiving MO HealthNet for Families benefits;

2. Meets all applicable eligibility criteria under section 208.151, RSMo; and 3. Is one (1) of the following:

A. A child under the age of eighteen (18) who resides with a custodial parent or other adult caretaker relative of the minor child; or B. A child under the age of nineteen (19) and a full-time student in a secondary school (or at the equivalent level of vocational or technical training), if the child may reasonably be expected to complete the program of the secondary school (or vocational or technical training).

(B) “Parent or caretaker relative” is an individual who is a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care, and who is one (1) of the following:

1. The child’s father, mother, grandfather, grandmother, brother (including half), sister (including half), stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece; or 2. The spouse of such parent or relative, even after the marriage is terminated by death, separation, or divorce.

(3) To initially qualify for MO HealthNet for Families eligibility, participants must meet the following criteria:

(A) The Family Support Division shall not provide MO HealthNet for Families coverage to or on behalf of a household (as defined in the Internal Revenue Code 26 CFR 1.36B-1), unless the household includes an eligible child; and (B) Countable family income for the household size does not exceed the Modified Adjusted Gross Income (MAGI) equivalent standard based on the July 16, 1996 Aid to Families with Dependent Children (AFDC)

(current Temporary Assistance) income limits.

RSMo 2016.* Original rule filed July 19, 2018, effective March 30, 2019. *Original authority: 207.022, RSMo 2014 and 660.017,

13 CSR 40-7.080 MO HealthNet for Former Foster Care Children {#sec-13-csr-40-7.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-7.080}

PURPOSE: This rule implements Senate Bill 514 (2019), which amended paragraph 208.151.1(26), RSMo, governing how and when foster care recipients who turn age eighteen (18) can receive MO HealthNet coverage until they reach age twenty-six (26).

(1) A person is eligible for MO HealthNet under paragraph 208.151.1(26), RSMo, if— (A) The person was in foster care under the responsibility of Missouri when the person turned age eighteen (18), or within the thirty (30) days preceding the person’s eighteenth birthday, or;

(B) The person was in foster care under the responsibility of any other United States state, territory, tribe, or the District of Columbia, when the person turned age eighteen (18), or within the thirty (30) days preceding the person’s eighteenth birthday, received foster care for at least six (6) months in the other state, territory, tribe, or the District of Columbia, and is currently residing in Missouri, and;

(C) The person identified in subsection (A) or (B) meets the requirements of subparagraphs (a), (b), and (c) of paragraph 208.151.1(26), RSMo.

RSMo 2016, and section 208.151.2, RSMo Supp. 2020.* Original rule filed Nov. 13, 2020, effective May 30, 2021. *Original authority: 207.022, RSMo 2014; 208.151, RSMo 1967, amended 1973, 1981, 1982, 1987, 1988, 1989, 1990, 1991, 1993, 1995, 2001, 2005, 2007, 2011, 2013, 2018, 2019, 2020; and 660.017, RSMo 1993, amended 1995.

Chapter 8 MO HealthNet for the Aged, Blind, and Disabled

13 CSR 40-8.020 Ways of Treating Income and Assets {#sec-13-csr-40-8.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-8.020}

PURPOSE: This rule defines the asset limits, the ways in which assets are treated, in determining eligibility for MO HealthNet for the Aged, Blind, and Disabled (MHABD), and programs with which MHABD coverage is provided.

(1) Scope. This rule describes the general requirements related to how assets affect eligibility for MHABD. This regulation does not apply to the Blind Pension program pursuant to Chapter 209, RSMo 2016, unless noted otherwise. Any provisions in this rule control over similar provisions in 13 CSR 40- 2.030, including, but not limited to, the asset limits defined in that rule.

(2) The division shall treat income and assets in a way that is no more restrictive than the way income and assets are treated for the Supplemental Security Income (SSI) program, with the exception of the asset limits described in section (4) of this rule, and as provided for in the Medicaid State Plan.

(3) In determining eligibility for MHABD, the division shall consider— (A) Any kind of asset that is owned by a household member, or in the name of someone on behalf of the household member;

(B) Any kind of asset that is owned by a trust or any other entity, but which a household member, or someone acting on behalf of a household member, has the legal power to use for the general benefit of the household; or (C) Any kind of asset that is owned by a self-settled trust, as defined in, determined by, and subject to the rules of 42 U.S.C. section 1396p(d).

(4) The following asset limits apply to every MHABD program, except Blind Pension, the Breast and Cervical Cancer Treatment program, and the Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) programs:

(A) This subsection identifies the asset limits for MHABD before July 1, 2017.

1. A household that is applying for or receiving MHABD on the basis of being over age sixty-five (65) or permanently and totally disabled does not qualify for MHABD if— A. It is a one- (1-) person household, and the household has countable assets of one thousand dollars ($1,000) or more; or B. It is a two- (2-) person household, and the household has countable assets of two thousand dollars ($2,000) or more.

2. A household that is applying for or receiving MHABD on the basis of being blind does not qualify for MHABD if— A. It is a one- (1-) person household, and the household has countable assets of two thousand dollars ($2,000) or more; or B. It is a two- (2-) person household, and the household has countable assets of four thousand dollars ($4,000) or more;

(B) Effective July 1, 2017, a household is not eligible for MHABD, regardless of whether eligibility is determined based on age, blindness, or permanent and total disability, if it has countable assets at or in excess of the following limits:

(C) Effective July 1, 2021 (Fiscal Year 2022), the asset limit identified in section (4) of this rule shall increase every July thereafter at the same rate as the increase in the cost-of-living percentage of the Consumer Price Index for All Urban Consumers (CPI- U), or its successor, as determined by the U.S. Department of Labor. The asset limit shall be rounded to the nearest five cents (5¢).

1. The percentage increase shall be based on changes in the CPI-U between July of two (2) years prior to the year in which the current fiscal year begins and July of the immediately preceding year.

A. Example: To determine the asset limit for Fiscal Year 2022 (FY22), the department shall measure the increase in the CPI-U between July 2019 and July 2020. If the CPI-U increased by one percent (1%) during that period, the asset limit for FY22 shall also increase by one percent (1%);

(D) Notwithstanding the provisions of this

section, a person is not eligible for QMB or SLMB if the person’s household has countable assets in excess of the maximum resource level applied for the applicable year under 42 U.S.C. section 1395w- 114(a)(3)(D), pursuant to 42 U.S.C. section 1396d(p)(1)(C).

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History

• AUTHORITY: sections 207.022 and 660.017, RSMo 2016. Emergency rule filed June 20, 2017, effective July 1, 2017, expired Feb. 22, 2018. Original rule filed June 20, 2017, effective Jan. 30, 2018. Original authority: 207.022, RSMo 2014 and 660.017, RSMo 1993, amended 1995.

Chapter 13 Blind Pension

13 CSR 40-13.010 Scope and Definitions {#sec-13-csr-40-13.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-13.010}

PURPOSE: This rule states the definition of terms which are applicable to the blind pension program.

(1) Scope: This rule establishes the definitions and terms which are applicable to blind pension payments and eligibility for blind pension (state funded) MO HealthNet pursuant to RSMo, 208.151.1(3), notwithstanding any other provision of the Code of State Regulations to the contrary. This rule applies to the blind pension program and does not apply to the Supplemental Aid to the Blind (SAB) program, unless stated otherwise.

(2) Definitions.

(A) “Adjusted Gross Income” means the gross income less any health insurance premiums and court ordered child support payments made by the sighted spouse.

(B) “Applicant” means the adult that applied for blind pension benefits whose signature, or whose signature as written by the adult’s guardian, conservator, or attorney-infact, is on the application for blind pension.

(C) “Application Date” means the day on which the division receives a completed and signed application.

(D) “Asset” or “Resource” means a liquid resource, personal property, or real property, as defined in this rule.

(E) “Authorized Representative” means a person or organization designated by the participant to act responsibly on the participant’s behalf. Notwithstanding any other regulations to the contrary, a participant or applicant may appoint an authorized representative pursuant to 13 CSR 40-2.015.

(F) “Blind.” A person is blind if his or her vision cannot be corrected to better than five two-hundredths (5/200), in the better eye, or if his or her visual field is less than or equal to five (5) degrees as tested with five millimeter (5 mm) target on perimeter in the better eye, for a period that lasted or is expected to last at least twelve (12) months.

(G) “Division” means the Family Support Division of the Department of Social Services of the state of Missouri.

(H) “Household” or “Household Member” means:

1. A person applying for, receiving, or appealing an adverse decision in regard to assistance from the blind pension program; and 2. The spouse of the participant, if the spouse is living with the participant or in a dwelling on the same parcel of land as the participant, or is a community spouse, as defined in 13 CSR 40-2.030, including situations when one (1) spouse is away from the home for work, education, or medical purposes, but would otherwise be living with the participant.

(I) “Liquid Resource” or “Liquid Asset” means cash or other property which can be converted to cash within twenty (20) business days. Examples of a liquid resource include, but are not limited to:

1. Money in a checking, savings, money market, certificate of deposit, nursing home patient account, or other bank account;

2. The cash surrender value of a life insurance policy, minus the amount of any lien, loan, accrued interest payments, or assigned portion of the policy;

3. Securities, as defined in section 409.1-101, RSMo, including mutual funds and retirement accounts;

4. The cash surrender value of an annuity;

5. The income stream of an irrevocable annuity, pursuant to section 208.212, RSMo;

6. A burial plan, pre-need funeral contract, or personal funeral trust account;

7. A promissory note, mortgage, contract for deed, or other loan instrument; or 8. An instrument similar to those identified in this subsection that the division has determined to be of value to the household.

(J) “Motor Vehicle” means any self-propelled vehicle not operated exclusively upon tracks or private roads.

(K) “Participant” means any individual who has applied for, is receiving, or has been denied blind pension benefits or services administered by the division.

(L) “Personal Property” means anything that is neither a liquid resource, nor real property. This includes, but is not limited to:

1. Household goods and personal effects;

2. Farm surpluses, livestock, farm or business machinery, or equipment;

3. Automobiles, trucks, and similar items; or 4. Anything that does not meet the definition of a liquid resource or real property.

(M) “Real Property” means land, and any interest, buildings, or any permanent structures attached to the land, including, but not limited to, mobile homes and trailers.

(N) “Reasonable Support” means the sighted spouse’s annual income is equal to or greater than five hundred percent (500%) of that year’s Federal Poverty Limit for the applicant’s household size of two (2) (as the term “household size” is used when determining Federal Poverty Guidelines).

(O) “Residence.” In order to establish residency, the participant must show physical personal presence in the state of Missouri with the intention to remain permanently or for an indefinite time, without any fixed or certain purpose to return to a former place of abode outside of Missouri. The participant must be a resident of Missouri for the continuous twelve (12) months immediately preceding the date of application. The division may require documentation to verify Missouri residency.

(P) “Sighted Spouse” means a person who has vision better than the requirement to receive blind pension as defined by 13 CSR 40-13.015, who is married to a recipient of blind pension.

(Q) “Trust” is defined pursuant to Chapter 456, RSMo.

RSMo 2016.* Original rule filed March 12, 2019, effective Sept. 30, 2019. *Orignal authority: 207.022, RSMo 2014 and 660.017,

13 CSR 40-13.015 Eligibility for Blind Pension {#sec-13-csr-40-13.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-13.015}

PURPOSE: The purpose of this rule is to establish the eligibility requirements for blind pension payments and blind pension MO HealthNet benefits, pursuant to Chapter 209, RSMo.

(1) Scope: This rule only applies to blind pension and does not apply to the Supplemental Aid to the Blind (SAB) program, unless stated otherwise.

(2) In order to qualify for blind pension benefits, the applicant must, at the time of application and until notifying the agency otherwise, meet the vision requirements in their better eye set forth in section 209.040, RSMo, and this rule:

(A) Each applicant must complete a vision exam, certified by an ophthalmologist, a physician skilled in diseases of the eye, or an optometrist, that consists of all of the following seven (7) components: 1.Visual Acuity;

2. Extraocular Motility and Alignment;

3. Pupils Exam;

4. Tonometry;

5. Slit-Lamp Examination;

6. Fundoscopy (indirect or direct ophthalmoscopy); and 7. Humphrey 24-2 Visual Field Exam (or equivalent).

(3) A person can apply for and receive a blind pension separately from MO HealthNet coverage. Individuals who are receiving a blind pension separately, and who want MO HealthNet coverage pursuant to section 208.151, RSMo, shall submit a new application for MO HealthNet.

(A) If a blind pension participant wants to qualify for federally-funded Medicaid services, including, but not limited to, services provided by the SAB program or the Home and Community-Based waiver services (HCB) program, the household must also qualify under all federal and state eligibility requirements relevant to those programs.

(B) A person who is receiving or applying for MO HealthNet coverage and also wants to receive a blind pension shall submit a separate application for blind pension.

(4) For the applicant and each household member, the applicant shall provide the following information that the division shall use in order to determine the applicant’s eligibility for blind pension benefits:

(A) Relationship to the applicant;

(B) Physical address;

(C) Mailing address, if different from physical address;

(D) Date of birth;

(E) Social Security number (for applicant only);

(F) Citizenship or immigration status (for applicant only);

(G) Employment status, employer name and location, hours employed;

(H) Any and all sources of income to determine the reasonable support of the sighted spouse;

(I) Itemization of any real or personal property owned or held in trust by the applicant and/or any household members and the fair market value thereof;

(J) Itemization of any liquid assets owned by the applicant or a household member, or a trust created by a household member; and (K) Itemization of any transfers of the type of assets listed in paragraphs (I) and (J) of this subsection by a household member, by a trust created by a household member, or by someone’s action on the household member’s behalf or behest, for an amount less than the asset’s fair market value.

(5) In order to qualify for a blind pension, an applicant shall be eighteen (18) years of age or older and— (A) Be a continuous resident of Missouri since the applicant went blind; or (B) Be a resident of Missouri for twelve (12) months immediately preceding the date of application; and (C) Be of good moral character.

1. Individuals convicted of a felony within the ten (10) years preceding the date of application are not of good moral character for purposes of this rule.

2. For purposes of this subsection, a suspended imposition of sentence (SIS) is not a conviction, and a suspended execution of sentence (SES) is a conviction; and 3. Any blind pension recipient who intentionally or knowingly submits, or causes to be submitted, false information to the division shall not be deemed a person of good moral character and shall not be eligible for a blind pension pursuant to section 209.030, RSMo; and (D) The applicant’s qualifying visual impairment has lasted or is expected to last at least twelve (12) months.

(6) A person is not eligible for blind pension if that person’s household owns property or has an interest in property as defined in 13 CSR 40-13.010, the value of which is over thirty thousand dollars ($30,000).

(A) In determining eligibility for blind pension, the division shall consider as property:

1. Any kind of asset that is owned by a household member or held on behalf of the household member;

2. Any kind of asset that is owned by a trust or any other entity, but which a household member or someone acting on behalf of a household member, has the legal power to use for the general benefit of the household; or 3. Any kind of asset that is owned by a self-settled trust, as defined in, determined by, and subject to 42 U.S.C. section 1396p(d).

(B) The division shall treat real property as— 1. For real property deemed commercial property or residential property located in Missouri, the fair market value shall be the current market value of the property, as determined by the assessor in the county in which the property is located, before applying the level of assessment pursuant to section 137.115, RSMo.

2. For real property deemed agricultural, the pensioner or applicant shall provide, upon request, an estimate of the property’s current market value from a knowledgeable source. The division may reject the assessment of a particular knowledgeable source if there is reason to believe that the source has a conflict of interest regarding the property or a close relationship with the applicant, and the division may request to see any applicable credentials or other information regarding the selected source at the discretion of the division.

A. Knowledgeable sources include, but are not limited to the following:

(I) Licensed real estate brokers;

(II) The local office of the Farmer’s Home Administration (for rural land);

(III) The local office of the Agricultural Stabilization and Conservation Service (for rural land);

(IV) Banks, savings and loan associations, mortgage companies, and similar lending institutions;

(V) The Assessor;

(VI) The County Agricultural Extension Service; or (VII) An appraisal from a qualified appraiser of agricultural property.

B. If the division determines that the agricultural property has no market value, or the household believes that the assessed market value is inaccurate, the division may require the household to provide one (1) or more of the items identified in paragraph (6)(B)2. of this rule.

3. For the division to determine the fair market value of real property located outside the state of Missouri, the household shall provide one (1) or more of the following:

A. An appraisal of the property that is less than twelve (12) months old, that shows the fair market value, and is completed by an appraiser who is licensed to do appraisals in the jurisdiction in which the property is located;

B. A bill of sale on the property from the last twelve (12) months that shows the amount for which the property was purchased;

C. A written statement attesting to the value from a real estate professional licensed in the jurisdiction in which the property is located; or D. Convincing evidence that the household is barred by law from selling the property, in which case the property will be deemed as having no fair market value.

4. If the household does not provide the information from at least one (1) category identified in this subsection, after being given at least ten (10) days to provide it, the division may deny eligibility to the household or determine the value of the property based on the information that is available to the division.

5. If the applicant or a household member owns a portion of real property jointly or in common with people who are not household members, the value of the household (5/31/20) JOHN R. ASHCROFT member’s share shall be the property’s fair market value, multiplied by the percentage of ownership held by the household member.

(C) In determining eligibility for blind pension, the division shall not consider as property the primary residence of the participant and the first one hundred thousand dollars ($100,000) held in an Achieving a Better Life Experience (ABLE) account.

(7) A person is not eligible for blind pension payments if— (A) The person has a spouse who: is a resident of the state, and can provide reasonable support to the applicant as defined in 13 CSR 40-13.010;

(B) The person publicly asks or begs for money by any means anywhere in the state;

(C) The person is maintained in a private or public institution as outlined in 13 CSR 40-2.080, unless the person is a patient in a public medical institution; or (D) The person has a driver’s license and does not relinquish the license to the Missouri Department of Revenue or to the issuing

(8) Individuals will be disqualified from receiving blind pension benefits for a period of two (2) years for their first sanction, four (4) years for their second sanction, and permanently disqualified for their third (3) sanction if they— (A) Obtain or renew a driver license from any state while receiving blind pension; or (B) Operate a motor vehicle (as defined in 13 CSR 40-13.010) while receiving blind pension.

(9) Any person shall permanently forfeit all of his or her rights to future blind pension benefits, if the division determines that the person— (A) Willfully and fraudulently provided information that is false in order to qualify for blind pension; or (B) Transferred ownership or an interest in property in order to become wholly or in part qualified for a blind pension.

RSMo 2016.* Original rule filed March 12, 2019, effective Sept. 30, 2019. ** *Orignal authority: 207.022, RSMo 2014 and 660.017, **Pursuant to Executive Order 21-09, 13 CSR 40-13.015, section (8) and subsection (9)(B) was suspended from March 25, 2020 through December 31, 2021.

History

• authority in the state or jurisdiction from which the license was issued within sixty (60) days of approval for blind pension. Each applicant has a one- (1-) time sixty- (60-) day grace period to surrender their license and will not be given another sixty- (60-) day period if they must reapply due to any issue, regardless of reason, with an earlier application.

13 CSR 40-13.020 Vision Re-examination {#sec-13-csr-40-13.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-13.020}

PURPOSE: This rule establishes the requirements to determine whether an individual previously eligible for a blind pension is required to submit to a re-examination of the individual's vision less often than every five (5) years, and whether the division can waive future re-examinations.

(1) Scope: This rule specifies how and when an individual eligible for a blind pension is required to submit to a re-examination of the individual’s vision less often than every five (5) years, whether the division can waive future re-examinations, and the reporting responsibilities for all blind pension recipients concerning changes in vision or other circumstances.

(2) An individual has “no usable vision” when— (A) One (1) or both of the following two (2) conditions are met:

1. The individual has no vision or only light perception in their better eye; or 2. The individual's vision, with or without proper adjusted glasses, or assistive technology, is determined to be up to, but not including, five two hundredths (5/200) in their better eye, or whose best visual field is five (5) degrees as tested with five (5) millimeter target or perimeter in their better eye; and (B) The individual's vision loss is permanent; or is medically unlikely to return or improve, with or without assistive technology.

(3) Applicants for blind pension and recipients of blind pension may apply to the division for a waiver of the requirement that they submit to a re-examination of their vision every five (5) years as authorized in section 209.040, RSMo. To qualify for the waiver, the individual shall have no usable vision in the better eye as certified by an ophthalmologist, a physician skilled in diseases of the eye, or an optometrist designated or approved by the division and that condition can reasonably be expected to persist for five (5) years. The certification required by this section shall be in writing and submitted to the division on a form provided by the division or in a letter on the provider’s letterhead. Such certification must be provided within ninety (90) days of the examination conducted to determine if the individual has no usable vision. The health care provider conducting the examination shall personally sign the form. The form or letter shall include the following information:

(A) The name and license number of the ophthalmologist, physician skilled in diseases of the eye, or optometrist who conducted the examination;

(B) The name of the individual examined and the date of the examination;

(C) The ophthalmologist, physician skilled in diseases of the eye, or optometrist who conducted the examination shall state whether— 1. The individual has no usable vision in the better eye; or 2. The individual's vision, with or without proper adjusted glasses, is up to, but not including, five two hundredths (5/200) in their better eye, or his/her best visual field is five (5) degrees or less as tested with a five (5) millimeter target or perimeter in their better eye; and (D) The ophthalmologist, physician skilled in diseases of the eye, or optometrist who conducted the examination shall state whether the individual's vision loss is— 1. Permanent; or 2. Is medically unlikely to return or improve, with or without glasses or assistive technology.

(4) The ophthalmologist, physician skilled in diseases of the eye, or optometrist who conducted the vision examination may indicate that a re-examination should be performed in less than five (5) years. This shall be sufficient evidence to give the division reasonable belief that an individual’s vision will improve.

(5) The Family Support Division shall grant the waiver to applicants for blind pension and blind pension recipients upon receipt of the certification required in section (3).

(A) FSD may terminate the waiver for any blind pension recipient based on review of available technological advances and said blind pension recipient’s circumstances.

(6) Blind pension recipients shall notify the division if they have or obtain a valid driver’s license or experience any improvement in their vision, with or without assistive technology, within ten (10) days of change in circumstances.

(7) Blind pension recipients who have been granted a waiver of the vision re-examination shall certify that their vision has not improved at the time of their annual eligibility redetermination. The individual shall provide the following information when making the written certification:

(A) The name of the individual making the certification;

(B) The individual's current physical address;

(C) Mailing address, if different from physical address;

(D) The individual's department client number or Social Security number;

(E) A statement that the recipient certifies, subject to penalty of perjury, that his or her vision has not improved, with or without glasses or assistive technology; and (F) The certification shall be signed by the blind pension recipient or the recipient’s authorized representative.

(8) Whenever the blind pension recipient reports that his or her vision has improved or the division has reasonable cause to believe that a blind pension recipient's vision no longer meets the vision requirement to receive blind pension, the division shall require the blind pension recipient to submit to a vision re-examination to determine whether the individual is still qualified for the waiver or for blind pension benefits. The blind pension recipient shall promptly submit to an eye re-examination or visual determination made by an ophthalmologist, a physician skilled in diseases of the eye, or an optometrist, designated or approved by the Family Support Division when requested to do so by the division.

(9) The division shall deny or terminate the blind pension recipient’s benefits at any time the division determines that a blind pension recipient— (A) Is not blind;

(B) Is not eligible for the benefit;

(C) Has failed to timely notify the division that he or she may no longer meet the visual or other requirements for the blind pension program;

(D) Fails to submit to a re-examination under section (7) or (8); or (E) Who otherwise fails to comply with his or her responsibilities under this section.

(10) Any blind pension payment made to a recipient who was not qualified for blind pension benefits shall be a debt immediately due to the state and collected as overpayment.

The blind pension recipient shall repay the sum of the blind pension payments that the individual was not entitled to receive, and any MO HealthNet benefits received while not eligible.

(11) Certifications submitted by mail or any commonly available electronic means such as fax or e-mail, shall be accepted and treated the same as an in-person filing of a certification. A blind pension recipient who submits a certification by electronic transmission certifies under penalty of perjury that the certification and the information contained therein is true, accurate, and authentic. The blind pension recipient shall retain and provide the original certification to the division upon request.

(12) Any blind pension recipient who intentionally or knowingly submits, or causes to be submitted, false information to the division shall not be deemed a person of good moral character and shall not be eligible for a blind pension pursuant to section 209.030, RSMo.

(13) All information provided to the Missouri Department of Social Services, Family Support Division in the certification shall be true, accurate, and complete.

(14) A blind pension recipient who is aggrieved by a decision of the division under this regulation may appeal the division's decision pursuant to section 209.110, RSMo.

RSMo 2016.* Original rule filed Jan. 12, 2015, effective July 30, 2015. Amended: Filed March 12, 2019, effective Sept. 30, 2019. ** *Original authority: 207.022, RSMo 2014 and 660.017, **Pursuant to Executive Order 21-09, 13 CSR 40-13.020, section (9) was suspended from March 25, 2020 through December 31, 2021.

13 CSR 40-13.030 Adjustment of Blind Pension Payments {#sec-13-csr-40-13.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-13.030}

(Rescinded August 30, 2015)

Filed Jan. 27, 2015, effective Aug. 30, 2015.

History

• AUTHORITY: sections 207.020.1(5) and 209.040.2, RSMo Supp. 2014, and section 660.017, RSMo 2000. Emergency rule filed Oct. 8, 2014, effective Oct. 18, 2014, expired April 15, 2015. Original rule filed July 28, 2014, effective Jan. 30, 2015. Rescinded:

13 CSR 40-13.040 Blind Pension Prescription Drug Coverage {#sec-13-csr-40-13.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-13.040}

PURPOSE: This rule establishes the basis on which Medicare-eligible blind pension participants will receive prescription drug coverage.

(1) For purposes of this rule, the following definitions shall apply:

(A) “Benchmark plan” means a prescription drug plan with premiums at or below the lowincome benchmark premium amount established for the Missouri region annually by the Centers for Medicare and Medicaid Services (CMS) as set forth in 42 CFR section 423.780, including de minimis plans as contemplated in 42 CFR section 423.780(f).

(B) “Covered outpatient drug” has the same meaning as that term is defined in section 1927(k) of the Social Security Act.

(C) “Creditable prescription drug coverage” means non-Medicare coverage as defined in 42 CFR section 423.56, where the actuarial value of that coverage equals or exceeds the actuarial value of defined standard prescription drug coverage under Medicare Part D in effect at the start of each plan year.

(D) “Department” means the Missouri Department of Social Services.

(E) “Prescription drug plan” or “PDP” means prescription drug coverage that is offered under a policy, contract, or plan that has been approved as specified in 42 CFR section 423.272 and that is offered by a PDP sponsor that has a contract with CMS that meets the contract requirements under subpart K of Part 423 of Title 42 of the Code of Federal Regulations.

(F) “Participant” means an individual under

section 208.151.1(3), RSMo, who is receiving medical assistance by reason of receiving blind pension benefits and who is eligible for Medicare Part D as set forth in 42 CFR section 423.30, who is not otherwise eligible for Medicaid benefits under Title XIX of the Social Security Act.

(2) All participants shall receive prescription drug coverage through a benchmark plan unless they otherwise demonstrate to the department that they receive creditable prescription drug coverage.

(A) Participants shall be responsible for initial and subsequent enrollment in a benchmark plan as set forth in 42 CFR section 423.32.

(B) Participants shall provide the department with notice of enrollment in a benchmark plan by December 15th of each year.

Notice of enrollment may be made in writing on a form made available by the department, or by phone, email, facsimile, or other commonly available electronic means, and shall include, at a minimum:

1. The participant’s name, Departmental Client Number (DCN), and Medicare Health Insurance Claim (HIC) number; and 2. The name and Plan ID number of the benchmark plan.

(C) A participant may authorize the department to act on the participant’s behalf to enroll him or her in a benchmark plan selected by the department by providing written authorization (2/28/22) JOHN R. ASHCROFT and any information necessary for the department to do so no later than the midpoint of the annual open enrollment period.

(D) Participants shall provide the department with written notice of disenrollment from a benchmark plan for any reason within fifteen (15) days of the participant receiving notice of disenrollment from the benchmark plan. A participant who voluntarily disenrolls from a benchmark plan and is not able to, or elects not to, reenroll in a benchmark plan shall be responsible for any late enrollment penalty that results from his or her voluntarily disenrollment.

(E) Participants receiving creditable prescription drug coverage shall notify the department in writing of such coverage with sufficient information to identify the entity providing creditable prescription drug coverage, including the participant’s policy number and the insuring entity’s name.

(F) A participant receiving creditable prescription drug coverage, who involuntarily loses such coverage, shall notify the department in writing or by phone, email, facsimile, or other commonly available electronic means of his or her loss of creditable prescription drug coverage within thirty (30) days of receiving notice of loss of creditable prescription drug coverage.

(3) The department shall notify a participant prior to the open enrollment period if the participant’s PDP will not be considered a benchmark plan for the upcoming plan year.

Participants affected by a change in benchmark plan status shall enroll in a benchmark plan for the upcoming plan year.

(A) Participants affected by a change in benchmark plan status shall notify the department by the midpoint of the annual open enroll ment period, in writing or by phone, email, facsimile, or other commonly available electronic means, of an intention to enroll in a benchmark plan.

(B) A participant may authorize the department to act on the participant’s behalf to enroll him or her in a benchmark plan selected by the department as set out in subsection (2)(C) above.

(C) If a participant has not notified the department of an intention to enroll in a benchmark plan by the midpoint of the annual open enrollment period, the department may act on the participant’s behalf to enroll him or her in a benchmark plan for the upcoming plan year. Participants so enrolled shall be notified promptly of the enrollment and— 1. The procedures by which the participant may disenroll from the benchmark plan and enroll in a different benchmark plan;

2. The existence of alternative benchmark plans; and 3. The manner in which the participant may change his or her enrollment to an alternative benchmark plan, or obtain assistance in doing so.

(4) The department shall pay all premiums, deductibles, copayments, and coinsurance associated with a participant’s prescription drug coverage under his or her benchmark plan.

(A) The department may pay the prescription drug costs incurred by a participant for covered outpatient drugs that are not part of his or her benchmark plan’s formulary or are obtained from a pharmacy that is not in his or her benchmark plan’s network. Such payments will comply with the MO HealthNet Division’s Pharmacy program set out in

Chapter 20 of Division 70 of Title 13 of the Code of State Regulations.

(B) The department will not pay any costs associated with a participant’s enrollment in a PDP that is not a benchmark plan.

(5) The procedures set forth in subpart M of

Part 423 of Title 42 of the Code of Federal Regulations shall be the participant’s exclusive remedies for grievances, coverage determinations, redeterminations, and reconsiderations regarding prescription drug coverage under this section, except that payment determinations made under subsection (4)(A) above shall be afforded administrative hearing rights under section 208.080, RSMo.

History

• AUTHORITY: sections 207.020 and 209.010, RSMo Supp. 2014. Original rule filed Oct. 8, 2014, effective May 30, 2015. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014 and 209.010, RSMo 1939, amended 2014.

Chapter 15 Supplemental Nutrition Assistance Program (Food Stamps)

13 CSR 40-15.455 Eligibility for Individuals with a Drug Felony Conviction {#sec-13-csr-40-15.455 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-15.455}

PURPOSE: This rule establishes the requirements to determine whether a participant who has pled guilty or nolo contendere to or is found guilty under federal or state law of a felony involving possession or use of a controlled substance can be eligible for Food Stamp benefits.

(1) Scope. This rule specifies how the division shall implement the authority granted in

section 208.247, RSMo, to determine whether a participant is eligible for Food Stamps if he or she has pled guilty or nolo contendereto or is found guilty under federal or state law of a felony involving possession or use of a controlled substance.

(2) Definitions. For purposes of this rule, the following terms shall mean:

(A) Participant: Any individual who is currently eligible for food stamp benefits, who has applied for food stamp benefits, who has received food stamp benefits, or who currently receives food stamp benefits, administered by the division;

(B) Custody: A participant is considered in custody when the individual has been remanded to the custody of the Missouri Department of Corrections, United States Bureau of Prisons, or a state penal institution in any other state, to serve a sentence of imprisonment imposed by a court of one (1) year or more.

Custody shall not mean pre-trial detention;

(C) Food Stamp benefits: The Supplemental Nutrition Assistance Program (SNAP) operated by the United States Department of Agriculture (USDA) Food and Nutrition Services, pursuant to 7 U.S.C. chapter 51, and in conjunction with the division to provide benefits to low-income individuals who are in need of aid to purchase food; and (D) Approved substance abuse treatment program: An alcohol and drug abuse treatment program or provider certified by the Department of Mental Health, Division of Behavioral Health.

(3) Any participant may request a determination of eligibility for the exemption from Food Stamp eligibility disqualification set forth in

section 208.247, RSMo. The request for a determination of section 208.247, RSMo, exemption shall be submitted in writing to the division or, if available, electronically through the division’s website. The participant shall provide the following information in order to establish eligibility for the exemption:

(A) The participant’s name;

(B) A list of the participant’s felony crimes involving the use or possession of controlled substances to which the participant has pled guilty or nolo contendere, or has been found guilty of committing, the dates of the guilty plea or finding of guilt, and the court involved; and (C) The participant’s certification that the participant, after August 28, 2014— 1. Has not pled guilty or nolo contendereto or been found guilty of an additional controlled substance misdemeanor or felony offense within one (1) year after the participant’s release from custody; or 2. Has not pled guilty or nolo contendereto or been found guilty of an additional controlled substance misdemeanor or felony offense within one (1) year after the date of conviction if the participant was not committed to custody;

(D) A participant who has been released from custody or pled guilty or nolo contendereto a controlled substance misdemeanor or felony offense less than three (3) years prior to the request for a determination of section 208.247, RSMo exemption shall provide a statement either on a form provided by the division or on an official document of the Division of Probation and Parole, Division of Behavioral Health, or the court that the participant has complied with all obligations imposed by court, by the Division of Probation and Parole, and by the Division of Behavioral Health. A participant will be considered to have complied with all obligations imposed by a court or the Division of Probation and Parole if the Missouri Board of Probation and Parole has not taken action to revoke the participant’s probation or parole;

(E) The participant shall also submit with the request for determination a signed written statement from an approved substance abuse treatment program to establish compliance with the substance abuse treatment requirements set forth in section 208.247.1(1)(a) to (1)(d), RSMo. Directories containing lists of approved substance abuse treatment programs can be found on the Department of Mental Health’s website. The statement shall either be on a form provided by the division or shall be on an official document of the approved substance abuse treatment program. The statement shall be accompanied by documentation of the name, mailing address, and telephone number of the approved substance abuse treatment program and the name and telephone number of the person, designee, or agent that is verifying the provider’s statements to the division. The statement shall certify that the participant— 1. Is currently successfully participating in a substance abuse treatment program approved by the Division of Behavioral Health; or 2. Is currently enrolled in and accepted for treatment and participation in a substance abuse treatment program approved by the Division of Behavioral Health, but is subject to a waiting list to receive available treatment, and the participant remains enrolled in the program and will enter the treatment program at the first available opportunity; or 3. Has satisfactorily completed a substance abuse treatment program approved by the Division of Behavioral Health; or 4. Was determined by a Division of Behavioral Health certified treatment provider not to need substance abuse treatment; and (F) The participant shall attest that s/he has demonstrated sobriety through voluntary urinalysis testing. The participant shall be responsible for any fees incurred for the voluntary urinalysis testing. The participant shall satisfy this requirement by providing the division the written test results of a urinalysis, provided by an official licensed drug testing vendor/facility, which shows the participant tested negative for illegal controlled substances, as defined in 21 USC section 802(6), other than those legally prescribed to the participant, at the time of the test. The test shall be completed following the participant’s last plea of guilty or nolo contendereto or finding of guilt for a controlled substance misdemeanor or felony offense involving possession or use of a controlled substance. The participant shall not use any self-administered test process to satisfy this requirement.

(4) Any participant who has pled guilty or nolo contendereto or been found guilty of two (2) subsequent felony offenses involving possession or use of a controlled substance after the date of the first controlled substance felony conviction shall not be eligible for section 208.247, RSMo exemption.

(5) Any participant who, after August 28, 2014, has pled guilty or nolo contendereto or is found guilty under federal or state law of an additional controlled substance misdemeanor or felony offense within one (1) year after release from custody or, if not committed to custody, within one (1) year after the date of conviction shall not be eligible for

section 208.247, RSMo exemption.

JOHNR. ASHCROFT(4/30/17)

(6) The participant’s request for a determination of a drug conviction exemption submitted by the participant shall be true, accurate, and complete.

(7) Food stamp benefits received by a participant for him or herself during a period in which the participant did not qualify for the exemption shall be a debt due to the state and collected as overpayment.

(8) Any participant aggrieved by a decision of the division under this regulation may request a hearing pursuant to section 208.080, RSMo. The following procedure shall apply to all administrative hearings requested under this section:

(A) Copies or printouts of case.net information, business record affidavits, written reports, letters or documents from the Missouri Board of Probation and Parole, Division of Probation and Parole, Division of Behavioral Health, or any state or federal court or parole or probation office, and the contents of the aforementioned documents submitted by the individual or the division at the hearing are declared to be competent evidence and admissible into evidence at the hearing to be considered by the hearing officer along with any other evidence or testimony submitted;

(B) A business record affidavit that meets the requirements of section 490.692, RSMo shall be prima facieevidence of it being properly executed and signed without the need for further proof of identification;

(C) Copies or printouts of case.net information, business record affidavits, written reports, letters, or documents from the Missouri Board of Probation and Parole, Division of Probation and Parole, Division of Behavioral Health, or any state or federal court or parole or probation office and the contents of the aforementioned documents reporting that the participant has failed to meet any of the requirements for the drug conviction exemption as set forth in this regulation shall create a rebuttable presumption that the participant has failed to meet the requirements of this

regulation and shall shift the burden of proof to the participant to refute the presumption.

4CODE OF STATE REGULATIONS

(4/30/17) JOHNR. ASHCROFT

History

• AUTHORITY: sections 207.022, 208.247, and 454.400, RSMo 2016. Original rule filed Sept. 21, 2016, effective May 30, 2017. Original authority: 207.022, RSMo 2014; 208.247, RSMo 2014; and 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014.

Chapter 19 Energy Assistance

13 CSR 40-19.010 Utilicare Program {#sec-13-csr-40-19.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-19.010}

(Rescinded May 30, 2017)

Emergency rule filed Nov. 9, 1979, effective Nov. 19, 1979, expired Feb. 10, 1980. Original rule filed Nov. 9, 1979, effective Feb. 11, 1980. Emergency amendment filed Dec. 11, 1979, effective Dec. 21, 1979, expired Feb. 10, 1980. Amended: Filed Feb. 8, 1980, effective May 11, 1980. Emergency amendment filed Nov. 26, 1980, effective Dec. 6, 1980, expired March 11, 1981. Amended:

Filed Nov. 26, 1980, effective March 12, 1981. Emergency amendment filed Nov. 19, 1981, effective Dec. 1, 1981, expired March 10, 1982. Amended: Filed Nov. 19, 1981, effective March 11, 1982. Emergency amendment filed Oct. 29, 1982, effective Nov. 15, 1982, expired Feb. 10, 1983. Amended: Filed Oct. 29, 1982, effective Feb. 11, 1983.

Rescinded: Filed Sept. 21, 2016, effective May 30, 2017.

History

• AUTHORITY: section 207.022, RSMo 1994.

13 CSR 40-19.020 Low Income Home Energy Assistance Program (LIHEAP) and Utilicare {#sec-13-csr-40-19.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-19.020}

PURPOSE: This rule establishes the basic policies and procedures to determine eligibility and amount of benefits to be paid under Missouri’s Utilicare and Low Income Home Energy Assistance Program (collectively known as “LIHEAP”). This program is designed to assist eligible, low income individuals, particularly those with the lowest income who pay a high proportion of household income for home energy, in meeting their immediate energy needs.

(1) Scope: This rule establishes procedures for the implementation of the Low Income Home Energy Assistance Program and Utilicare, collectively referred to in this rule as “LIHEAP”. This rule establishes the requirements governing the eligibility of households under the program, pursuant to 42 U.S.C. sections 8621-8630 and sections 660.100- 660.136, RSMo.

(2) Definitions.

(A) “Applicant” shall be defined as the individual whose signature, or whose signature as written by the individual’s guardian/conservator or power of attorney, is on the application.

(B) “Crisis” shall be defined as any of the following:

1. The receipt of a termination or disconnect notice indicating a specific disconnect date;

2. The issuance of a final billing statement advising the account has been terminated;

3. A situation in which a propane tank is filled at less than twenty-percent (20%) capacity;

4. A situation in which the customer is a cash on delivery (COD) customer; or 5. A situation in which a pre-paid electric customer indicates their pre-paid usage is about to run out.

(C) “Disabled” shall be defined as an individual who is totally and permanently disabled or blind and is receiving one (1) or more of the following: Civil Service Disability, Medical Assistance, Railroad Retirement Disability Benefits, Social Security Disability Benefits, State Aid to the Blind, State Blind Pension, State Supplemental Payments, Supplemental Security Income Program, or Veterans Administration Disability Benefits.

(D) “Elderly” shall be defined as sixty-five (65) years of age or older to receive the LIHEAP income deduction, as established in

section (3) of this rule, and sixty (60) years of age or older for federal reporting purposes, as required under 45 CFR section 96.82.

(E) “Fuel source” shall be defined as the fuel consumed in the operation of an appliance manufactured and used for the purpose of heating or cooling a household.

(F) “Home energy supplier” shall be defined as a public or private business engaged in the retail sale of home heating and cooling fuel, including public or private investor owned utilities, municipally owned utilities, rural electric cooperatives, and privately owned distributorships.

(G) “Household” shall be defined as an individual(s) living in private living quarters (a space with a private entrance) for which residential heat is purchased in common.

(H) “Income” shall be defined as monthly revenue obtained that is either earned or unearned.

(I) A “landlord household” shall be defined as a household in which the landlord sends the household a separate bill to cover the heating and cooling costs. Landlord households may receive both Energy Assistance (EA) and Energy Crisis Intervention Program (ECIP) benefits.

(J) “LIHEAP fiscal year” shall be defined as the federal fiscal year, October 1–September 30.

(K) “Live-in-attendant” shall be defined as an individual living in the household who receives wages to provide medical/child care and who is not responsible for any household expenses. A relative, as defined in this rule, cannot be considered a live-in-attendant.

(L) “Roomer/boarder” shall be defined as an individual who pays a household for lodging and/or food expenses only, and who is not responsible for any other household expenses. A relative, as defined in this rule, cannot be considered a roomer/boarder.

(M) A “renter household” shall be defined as a household in which heating and/or cooling costs are included in the rent. Renter households may receive EA benefits, but cannot receive ECIP benefits.

(N) “Resources” shall be defined as any assets that are available to an individual, including, but not limited to, annuities, bonds, certificates of deposit, deposits in banks, savings and loan companies, credit unions, and other financial institutions, individual retirement accounts, Keogh’s and deferred compensation plans, money markets, mutual funds, and stocks. Resources will be considered available unless documented by the institution holding the resources that they are restricted or inaccessible.

(O) “Participating home energy suppliers” shall be defined as suppliers that sign an agreement with the department.

(P) “Account” shall be defined as a customer account established with a home energy supplier for residential heating and cooling.

(Q) “Relative” shall be defined as an individual who is related to the household member as father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, father-in-law, daughterin-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, half-brother, or half-sister.

(R) “Address of record” shall be defined as the most recent mailing address that the applicant/participant provided to the division.

(3) Federal funds, pursuant to 42 U.S.C. sections 8621–8630, and state funds, pursuant to RSMo 660.100–660.136, may be expended for— (A) Energy Assistance (EA), which provides a direct one (1) time lump sum payment of utility costs incurred for home heating by qualified Missouri residents continuing so long as funds remain available for this purpose. EA may include additional supplemental payments as determined necessary by the department; or (B) The Energy Crisis Intervention Program (ECIP), which provides direct payment of utility costs incurred for home heating and cooling by qualified Missouri residents experiencing a crisis, as defined in this rule, so long as funds remain available for this pur pose.

(4) Not more than one (1) LIHEAP qualified EA benefit will be paid for each qualified individual eligible household, with the exception of a possible additional supplemental payment, during any LIHEAP fiscal year.

(A) Only one (1) individual on a multiple named fuel bill account will be eligible to receive LIHEAP benefits.

(B) If the fuel bill account is in the name of an individual under the age of eighteen (18) and there is another household member that is age eighteen (18) or older, the account name must be changed to an adult household member’s name. If the oldest individual in the household is under the age of eighteen (18), that individual may be considered the account holder only with division approval.

(5) ECIP benefits must not exceed the amount needed to resolve the energy crisis, up to the maximum amount of eight hundred dollars ($800) for winter assistance for the months of November through May, and three hundred dollars ($300) for summer assistance for the months of June through September, so long as funds remain available for this purpose.

(6) LIHEAP qualified households must meet all of the following criteria to be eligible for benefits under the program:

(A) All household members must be a citizen of the United States or be a legal permanent resident admitted to the United States for permanent residence status and a current resident of Missouri;

(B) Each household’s resources may not exceed three thousand dollars ($3,000);

(C) Each household must establish that they have an account in their name or meet the definition of a renter/landlord household, pursuant to this rule, and are incurring heating/cooling costs; and (D) Each household must meet the specified income guidelines based on their household size, as established in section (14) of this

rule.

1. Households with applicants or their spouses who are elderly or disabled shall be entitled to a one hundred dollar- ($100-) deduction for medical expenses when determining income eligibility;

(E) All ineligible and eligible LIHEAP applicants will receive written notification by mail to the address of record. Applicants may choose to receive notification by electronic mail or text message, if the division has established a policy that gives applicants and/or participants this option. The notification shall advise them of their right to request a fair hearing regarding the decision made on their application. LIHEAP applicants can request a hearing for denial of their applica tion, a lack of timeliness, or as otherwise provided for in

section 208.080, RSMo.

(7) A household meeting any of the following conditions will not be eligible to receive LIHEAP benefits:

(A) A household that is located outside the State of Missouri. This does not include a household that has a mailing address of another state, but that is physically located in Missouri;

(B) A household which resides in a professional, practical, or domiciliary nursing or boarding home and does not pay a home energy supplier or landlord directly for heating/cooling costs;

(C) A household which resides in a hotel, motel, dormitory, or temporary shelter, and does not pay a home energy supplier or landlord directly for heating/cooling costs;

(D) A household which resides in government subsidized housing, unless they are paying a home energy supplier or are billed by the landlord/housing authority for any out-ofpocket heating/cooling costs;

(E) A household in a transitional living situation that has its heating/cooling paid for by the Department of Mental Health;

(F) A household that has a credit balance with its fuel supplier that is in excess of fivehundred dollars ($500), with the exception of households who pre-pay for their fuel;

(G) A household that cuts its own wood, when wood is the household’s primary source of heating; and (H) A household residing in a recreational vehicle (RV), travel trailer, tent, shed, or other dwelling residing at the same address as, and sharing the same meter or source of power with, a household that has already received EA in the current LIHEAP fiscal year. (One (1) Meter + One (1) Bill= One (1) Household).

(8) Individuals meeting any of the following conditions shall not be included in a LIHEAP household:

(A) Individuals that are not citizens of the United States or a legal permanent resident;

(B) Individuals that are not living in the home at the time of application, unless the individual(s) was temporarily out of their home due to service termination;

(C) Individuals that are incarcerated;

(D) Individuals defined as roomers, boarders, or live-in-attendants;

(E) Deceased individuals, unless determined eligible prior to their date of death, and surviving household members exist; and (F) Individuals that have been approved in a Missouri EA case or individuals moving into a household that has previously received EA in the current LIHEAP fiscal year at the same address. Eligibility will not be affected for individuals who have received LIHEAP benefits from another state in the same program year. Individuals that have been approved for EA in another household but require a new application due to change in address or supplier, may be eligible for ECIP only benefits as long as all other LIHEAP eligibility requirements have been met.

(9) Applicants shall use form EA-1 to apply for LIHEAP benefits. General application procedures for programs administered by the division are found in 13 CSR 40-2.010. For anything in this rule conflicting with the general application procedures in 13 CSR 40- 2.010, this regulation controls for the application procedures for LIHEAP.

(A) The application form for LIHEAP benefits may be obtained by contacting the division or by accessing the department website (www.dss.mo.gov).

(B) The applicant shall provide and attest to the following information when making an application for LIHEAP benefits:

1. Applicant’s contact information, including a home address and a mailing address, if different from the home address;

2. Applicant’s and all other household member’s identifying information, including name, Social Security number, date of birth, relationship to applicant, and citizenship status;

3. Utility and household information, including whether or not the applicant owns or plans on buying his/her home, whether or not the home has been weatherized by the local weatherization program, whether or not the home is all electric, the primary/main form of energy and secondary/other form of energy, if any, used to heat the home, and energy supplier information including supplier name, city, name on the account, and account number;

4. Landlord information, if applicable, including whether the applicant has an account with an energy supplier in his/her landlord’s name and is billed by the landlord, whether or not the applicant lives in subsidized housing and the heating and cooling costs are included in the rent, and the landlord’s name, address, and phone number;

5. For each household member that received income from a job in the calendar month preceding the month in which the application is submitted to the division, include the member’s name, employer name and address, how often the individual is paid, gross pay, current employment status, and provide all income documentation for that month on everyone in the household that works. This 4CODE OF STATE REGULATIONS (4/30/17) JOHNR. ASHCROFT documentation includes, but is not limited to, wages (regular pay), vacation, sick leave, bonuses, and tips;

6. If anyone in the household receives income from self-employment, the applicant must provide a copy of the most recent Federal Income Tax Form 1040, and any accompanying schedules and other relevant forms, for each household member who is selfemployed;

7. If anyone in the household pays court ordered Child Support, provide the amount paid in the last month and the eight- (8-) digit Child Support Case Number;

8. Any and all income received by any household member from sources other than a job or business, including the amount received and how often; and 9. Any and all resources, as defined in this rule.

(C) By submitting information to the division, an applicant or household member is certifying that the information is true, accurate, and complete.

(D) Applicants must provide additional application documentation as requested by the division, pursuant to Chapter 208, RSMo.

(E) The division will begin accepting applications on October 1, and processing applications on November 1, for households that include members who are elderly or disabled, as defined in this rule. The division will begin accepting all other household applications on November 1, and will begin processing those applications starting on December 1. If an acceptance or processing date falls on a weekend or holiday, the division will begin accepting/processing applications on the following work day.

(F) The applicant and anyone acting on their behalf have a continuing obligation to notify the division if any information specified in the application changes within ten (10) days of the change. Failure to do so may result in an adverse effect on the account, including, but not limited to, termination of LIHEAP benefits.

(G) Any notices will be sent to the address of record, and service by first class mail to the last known address of record in the department’s system shall be good service for all notices for all purposes.

(10) Amounts paid by the department above the amount that the household was eligible to receive shall be an overpayment and may be collected as a debt due the state.

(11) In addition to any remedies authorized by law, the division may recover outstanding EA overpayments made in a prior year’s programs by deducting the overpayment from the current year’s EA benefit payment.

(12) Any LIHEAP eligible household whose home energy supplier does not participate in the program, or declines to provide service to the household, qualifies for a direct LIHEAP EA payment, to be paid to the applicant in an amount as determined under section (14) of this rule.

(13) A LIHEAP eligible renter household whose home heating costs are included as a

part of their regular monthly rental charge will receive a one- (1-) time Energy Assistance (EA) direct cash payment equal to no more than eight percent (8%) of their annual rental charge not to exceed the maximum EA benefit payment.

(14) EA payments are determined by household size, income range, and fuel source, using metrics established by the division.

Monthly Income Federal Poverty ranges are A: 0-25% of the Federal Poverty Level, as set by the U.S. Department of Health and Human Services each year, B: 26-50%, C: 51-75%, D: 76-100%, E: 101-125% and F: 126-135%.

Payment Levels for Missouri Primary Fuel Monthly Income Federal Poverty Level Fuel Type A B C D E F Natural Gas $296 $278 $259 $240 $221 $203 Tank Propane $450 $413 $375 $338 $300 $263 Electric $289 $270 $251 $233 $214 $195 Fuel Oil $296 $278 $259 $240 $221 $203 Wood $199 $180 $161 $143 $124 $105 Kerosene $139 $120 $101 $ 83 $ 64 $ 45 Cylinder Propane $161 $143 $124 $105 $ 86 $ 68 6CODE OF STATE REGULATIONS (4/30/17) JOHNR. ASHCROFT

Amended: Filed Oct. 29, 1982, effective Feb. 11, 1983. Emergency amendment filed Oct. 5, 1983, effective Nov. 1, 1983, expired Jan. 12, 1984. Amended: Filed Oct. 5, 1983, effective Jan. 13, 1984. Emergency amendment filed Sept. 7, 1984, effective Oct. 15, 1984, expired Jan. 15, 1985. Emergency amendment filed Oct. 4, 1985, effective Oct. 15, 1985, expired Feb. 1, 1986. Amended: Filed Oct. 4, 1985, effective Feb. 14, 1986. Emergency rescission and rule filed Sept. 16, 1986, effective Sept. 26, 1986, expired Jan. 14, 1987. Rescinded and readopted: Filed Sept. 16, 1986, effective Jan. 12, 1987.

Emergency amendment filed Sept. 1, 1987, effective Sept. 11, 1987, expired Jan. 9, 1988. Amended: Filed Sept. 1, 1987, effective Nov. 23, 1987. Emergency amendment filed Sept. 28, 1988, effective Nov. 1, 1988, expired March 1, 1989. Amended: Filed Sept. 28, 1988, effective Dec. 29, 1988. Emergency amendment filed Sept. 27, 1989, effective Nov. 1, 1989, expired Feb. 28, 1990. Amended: Filed Sept. 27, 1989, effective Jan. 12, 1990. Emergency amendment filed Aug. 30, 1990, effective Nov. 1, 1990, expired March 1, 1991. Amended: Filed Aug. 30, 1990, effective Feb. 14, 1991. Emergency amendment filed Aug. 30, 1991, effective Nov. 1, 1991, expired Feb. 28, 1992. Amended: Filed Aug. 30, 1991, effective Jan. 13, 1992.

Emergency amendment filed Oct. 8, 1992, effective Nov. 1, 1992, expired Feb. 28, 1993.

Emergency amendment filed Dec. 2, 1992, effective Feb. 28, 1993, expired June 27, 1993. Amended: Filed Oct. 8, 1992, effective April 8, 1993. Emergency amendment filed Oct. 15, 1993, effective Nov. 1, 1993, expired Feb. 28, 1994. Emergency amendment filed Feb. 4, 1994, effective March 1, 1994, expired June 28, 1994. Amended: Filed Oct. 15, 1993, effective April 9, 1994. Emergency amendment filed Oct. 13, 1994, effective Nov. 1, 1994, expired Feb. 9, 1995. Emergency amendment filed Jan. 17, 1995, effective Feb. 10, 1995, expired June 9, 1995.

Amended: Filed Oct. 13, 1994, effective March 30, 1995. Emergency amendment filed Sept. 20, 1995, effective Oct. 1, 1995, expired March 28, 1996. Amended: Filed Sept. 20, 1995, effective Feb. 25, 1996.

Emergency amendment filed Sept. 10, 1996, effective Oct. 1, 1996, expired March 29, 1997. Emergency amendment filed Sept. 23, 1997, effective Oct. 3, 1997, expired March 31, 1998. Amended: Filed Sept. 23, 1997, effective March 30, 1998. Emergency amendment filed Sept. 4, 1998, effective Oct. 1, 1998, expired March 29, 1999. Amended:

Filed Sept. 4, 1998, effective March 30, 1999. Emergency amendment filed Sept. 2, 1999, effective Oct. 1, 1999, expired March 28, 2000. Amended: Filed Sept. 2, 1999, effective April 30, 2000. Emergency amendment filed Aug. 31, 2000, effective Oct. 1, 2000, expired March 28, 2001. Amended:

Filed Aug. 31, 2000, effective Feb. 28, 2001.

Emergency amendment filed Sept. 21, 2001, effective Oct. 1, 2001, expired March 29, 2002. Amended: Filed Sept. 21, 2001, effective April 30, 2002. Emergency amendment filed Sept. 19, 2002, effective Oct. 3, 2002, expired March 31, 2003. Amended: Filed Sept. 19, 2002, effective March 30, 2003.

Emergency amendment filed Sept. 19, 2003, effective Oct. 1, 2003, expired March 28, 2004. Emergency amendment filed Sept. 24, 2004, effective Oct. 4, 2004, expired April 1, 2005. Amended: Filed Sept. 19, 2003, effective May 30, 2004. Amended: Filed Sept. 21, 2016, effective May 30, 2017. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993.

History

• AUTHORITY: section 207.022, RSMo 2016. Emergency rule filed Nov. 26, 1980, effective Dec. 6, 1980, expired March 11, 1981. Original rule filed Nov. 26, 1980, effective March 12, 1981. Emergency amendment filed Nov. 19, 1981, effective Dec. 1, 1981, expired March 10, 1982. Amended: Filed Nov. 19, 1981, effective March 11, 1982. Emergency amendment filed Oct. 29, 1982, effective Nov. 15, 1982, expired Feb. 10, 1983.

13 CSR 40-19.030 Summer Electric Utility Service {#sec-13-csr-40-19.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-19.030}

(Rescinded May 30, 2017)

Emergency rule filed Dec. 15, 1980, effective Dec. 15, 1980, expired March 11, 1981.

Original rule filed Dec. 5, 1980, effective March 12, 1981. Rescinded: Filed Sept. 21, 2016, effective May 30, 2017.

History

• AUTHORITY: section 207.020, RSMo 1994.

Chapter 20 Child Support Enforcement

13 CSR 40-20.010 Scale and Formula for Determining Support Obligations {#sec-13-csr-40-20.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-20.010}

(Rescinded April 11, 1988)

Original rule filed Oct. 1, 1982, effective Dec. 11, 1982. Rescinded: Filed Feb. 2, 1988, effective April 11, 1988.

MATTBLUNT(12/31/01)

History

• AUTHORITY: section 207.020.1(5), RSMo 1978 and 454.480, RSMo Supp. 1982.

Chapter 24 Community Programs

13 CSR 40-24.080 Formula for the Distribution of Community Service Block Grant Funds to Community Action Agencies Support Division (division) will distribute Community Service Block Grant (CSBG) mandatory funds to Community Action Agencies (CAA). {#sec-13-csr-40-24.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-24.080}

(1) Definitions.

(A) “Community Action Agency” or “CAA” means a private, not-for-profit agency within the state of Missouri designated by the governor of the state of Missouri as an eligible entity as defined by 42 U.S.C. section 9909.

(B) “CSBG” means Community Service Block Grant program established by 42 U.S.C.

section 9901 et seq and section 660.370 et seq, RSMo.

(C) “Mandatory funds” means at least ninety percent (90%) of the total amount of CSBG funds required to be allocated to CAAs from the CSBG grant annually awarded to the state of Missouri by the United States Department of Health and Human Services, Office of Community Support, for the administration of the CSBG program.

(2) The division shall allocate the mandatory funds on the basis of federal fiscal years beginning October 1 as follows:

(A) A portion of the mandatory funds shall be distributed such that each CAA shall receive a base amount of two hundred thousand dollars ($200,000);

(B) The portion of mandatory funds remaining after deducting the sum of the base amount awarded to CAAs shall be distributed based on the CAA’s poverty population relative to the state’s total poverty population utilizing the following formula:

((Total mandatory funds) – ($200,000 x # of CAAs)) x (poverty population of the CAA/total state poverty population) = CAA poverty population allocation 1. Total state poverty population shall be the total poverty population according to the most recent data published annually by the American Community Survey of the United States Census Bureau.

2. The poverty population of the designated geographic area served by a CAA shall be the total poverty population within the area as determined by the most recent data published by the American Community Survey of the United States Census Bureau.

(3) Allocations of mandatory funds to CAAs shall be based on the most recent information on availability and amounts of CSBG funding to be awarded to Missouri by the U.S.

Department of Health and Human Services, Office of Community Services as of the date that the Family Support Division issues the award. Any and all distributions to CAAs are contingent on the availability of CSBG funds for that fiscal year. The division may increase or decrease the funds awarded to a CAA during the grant term depending on the availability of CSBG funds awarded to the state of Missouri by the United States Department of Health and Human Services, Office of Community Services, for the administration of the CSBG program. Any increase or decrease in the amount awarded to a CAA shall be based upon the formula set forth in subsection (2)(B) of this rule.

(4) The division shall issue a Notice of Award to the CAA. The Notice of Award shall specify the amount of the grant and the basis for the Family Support Division’s Calculation.

The Notice of Award shall be issued electronically.

(5) If a CAA has its CSBG funding terminated or reduced below the proportional share of funding the entity received in the previous fiscal year then that CAA may request a hearing on the record to the director of the Family Support Division pursuant to 42 U.S.C. section 9908(b)(8). The request for hearing shall be in writing and served on the director of the Family Support Division no later than thirty (30) days from the date of the Notice of Award. The request for hearing shall specify in detail the legal and factual basis for the CAA’s request for hearing and shall include any factual documentation in support of the CAA’s position. The hearing shall be held before the director of the Family Support Division or his/her designee. The final decision of the director shall be subject to review by the secretary of the U.S. Department of Health and Human Services as provided in 42 U.S.C. section 9915(b).

13 CSR 40-24.090 Supplemental Funding Formula for CommunityAction Agencies to Administer the CSBG Program Support Division (division) will supplement Community Service Block Grant (CSBG) funds for those Community Action Agencies (CAAs) that will be receiving less than the proportional share the CAA received in federal fiscal year 2013. {#sec-13-csr-40-24.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-24.090}

(1) The definitions set forth in 13 CSR 40- 24.080 shall apply to this rule.

(2) Beginning in federal fiscal year 2014, the division shall distribute Community Service Block Grant (CSBG) mandatory funds to all Community Action Agencies (CAAs) based on the funding formula set forth in 13 CSR 40-24.080. Over a period of five (5) years, the division shall provide supplemental funding for any CAA that will be receiving less than the proportional share the CAA received in federal fiscal year 2013 as a result of the funding formula set forth in 13 CSR 40- 24.080 as follows:

(A) For federal fiscal year 2014, the diviequal to eighty percent (80%) of the difference between the proportional share the CAA (B) For federal fiscal year 2015, the diviequal to sixty percent (60%) of the difference between the proportional share the CAA (C) For federal fiscal year 2016, the diviequal to forty percent (40%) of the difference between the proportional share the CAA (D) For federal fiscal year 2017, the diviequal to twenty percent (20%) of the difference between the proportional share the CAA (E) For federal fiscal year 2018 thereafter, the division shall cease providing supplemental funding to those CAAs that will be receiving less than the proportional share the CAA received in federal fiscal year 2013 and all CAAs shall receive funding based entirely on the funding formula set forth in 13 CSR 40- 24.080.

(3) The division may distribute CSBG discretionary grant funds, as defined in 13 CSR 40- 24.080, to comply with the requirements of this rule.

(4) Any and all distributions to CAAs are contingent on the amount of the CSBG grant annually awarded to the state of Missouri by the United States Department of Health and Human Services, Office of Community Services.

(5) Supplemental funding is contingent on sufficient funds that are appropriated by the legislature for such purpose.

13 CSR 40-24.100 Use of Community Service Block Grant Discretionary Funds Support Division (division) will use discretionary funds that are awarded to the Family Support Division by the U.S. Department of Health and Human Services for the administration of the Community Service Block Grant (CSBG) program. {#sec-13-csr-40-24.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-24.100}

(1) The definitions set forth in 13 CSR 40- 24.080 shall apply to this rule.

(A) “Discretionary grant funds” means no more than ten percent (10%) of the total amount of the CSBG grant annually awarded to the state of Missouri by the United States Department of Health and Human Services, Office of Community Support, for the administration of the CSBG program that may be reserved and/or distributed at the discretion of the division.

(2) The division shall use discretionary grant funds for purposes outlined in 42 U.S.C. section 9907(b). The division may use no more than five percent (5%) of the total annual amount of CSBG funds awarded to the state of Missouri by the United States Department of Health and Human Services, Office of Community Services, for administrative expenses, including monitoring activities.

Any unused CSBG funds may be used by the division for other discretionary uses pursuant to this section.

(3) Subject to the availability of discretionary grant funds, discretionary grant funds may be used for the following purposes consistent with those identified in 42 U.S.C. section 9907(b):

(A) Address a priority need identified by the division related to the causes and conditions of poverty or a specific target population impacted by these same causes and conditions;

(B) Training and technical assistance to increase the capacity and sustainability of eligible entities and/or discretionary funded providers, as well as improve the quality of their services;

(C) Responses to natural or man-made disasters; and (D) Evidence-based, innovative, and/or demonstration projects that improve the causes and conditions of poverty for low-income individuals, families, and communities, including specific target populations, and support efforts that reduce poverty; revitalize lowincome communities; and empower lowincome families and individuals to become fully self-sufficient.

(4) Any non-profit entity or local unit of government seeking funding from the discretionary grant funds from the division may contact the division to inquire regarding the availability of discretionary funds. In order to be considered for funding for the following fiscal year, non-profit entities or local units of government must submit applications from July 15 to August 15. An exception to the application time frame may be made due to extenuating circumstances as determined by the division. The application must contain the following:

(A) Description of need including information regarding the proposed use of funds including demographic and other relevant data to support need;

(B) Proposed target population;

(C) Organization and governance including information on the applicant’s organization and governance structure, a description of the agency’s history, vision and mission, services provided, and number and roles of current staff. The applicant must provide information on the applicant’s board of directors, by-laws, and a list of current board members;

(D) Coordination of services including a description of how the applicant will ensure services support or complement, but not duplicate, services being provided by other related agencies;

1. The applicant must provide a description of any proposed coalition(s), partnerships, organizations, cooperating entities, consultants, or any other entities or individuals with which the applicant may be contracting or collaborating. The applicant must include a letter of commitment from entities that have identified roles in the use of CSBG discretionary funds;

(E) Implementation plan that addresses the program or project goal(s), action steps, person(s) responsible for the completion of the goals, timeline for completion, and evaluation measures;

(F) Personnel information including the educational background and work experience of project and management staff. The applicant must include an organizational chart showing the lines of personnel authority. The organizational chart shall include:

1. The relationship of project staff to management and support staff;

2. The names of employees and their titles; and 3. The existence of sub-contractors;

(G) Management including a description of how services of the grant agreement will be managed, controlled, and supervised in order to ensure satisfactory grant agreement performance; and (H) Itemized budget and budget narrative.

(5) In addition to providing the information set forth in section (6), a non-profit entity submitting an application to receive discretionary grant funds must provide the following information and documentation:

(A) Certified copy of the non-profit entity’s articles of incorporation;

(B) Certified documents showing that the organization is in good standing;

(C) A copy of the most recent audit showing that the non-profit entity is compliant with the American Institute of Certified Public Accountants Standards;

(D) Documentation establishing that the non-profit entity is designated as a non-profit organization by the Internal Revenue Service under 26 U.S.C. section 501(c)(3); and (E) Any other documents that the division may request from time-to-time to establish the continued good standing of the organization.

(6) A non-profit entity or local unit of government shall fully cooperate with the division including providing all records, documents, and information requested during the application process and at any time upon granting funding to the non-profit entity or local government.

(7) Upon review of the application, the division shall issue a determination to the entity.

The determination is subject to the division’s discretion.

(8) Any previous discretionary funded nonprofit entity or local unit of government is not entitled to discretionary funding awards and must reapply annually.

(9) Any unused discretionary grant funds may be carried over into the following federal fiscal year to be used for purposes consistent 4CODE OF STATE REGULATIONS (5/31/14) JASONKANDER with this section and for the purposes for which the funds were awarded.

Chapter 30 Permanency Planning for Children

13 CSR 40-30.030 Attorney Fees and Guardian Ad LitemFees in Subsidized Adoption SOCIAL SERVICES Children {#sec-13-csr-40-30.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-30.030}

13 CSR 40-30.010 Case Plan {#sec-13-csr-40-30.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-30.010}

(Moved to 13 CSR 35-35.050)

13 CSR 40-30.020 Attorney Fees in Termination of Parental Rights Cases {#sec-13-csr-40-30.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-30.020}

PURPOSE: The purpose of this rule is to establish fees for attorneys and guardians ad litemwho provide services in termination of parental rights cases.

(1) If permanency for the children requires parental rights be terminated to enable children to be permanently placed or adopted, the children’s parents shall be provided representation in such cases which shall include counsel, investigative, expert and other services to ensure adequate representation. This includes the appointment of a guardian ad litemfor the children. Representation shall be provided for financially eligible persons. A person is considered financially eligible when it appears from all of the circumstances of the case including the person’s income, the number of individuals dependent on the person for support, and the person’s financial assets and liabilities, that the person does not have the means available to obtain counsel and is indigent. Upon motion and/or application by any party, the court in which the case is pending shall have the authority to determine, based on a finding of indigency, whether the Division of Family Services should pay for counsel for a particular parent. The motion and/or application for and determination of indigency may be made at any time by the court. If the court finds the parent is not indigent, the Division of Family Services shall discontinue paying for counsel on behalf of such parent. Counsel furnishing representation under the plan shall be selected from a panel of attorneys designated or approved by the court, or from a bar association or other organization of attorneys willing to furnish representation of parents in termination of parental rights cases. A person for whom counsel is appointed shall be represented at every stage of the termination of parental rights proceeding, from his or her initial appearance after the filing of the termination of parental rights petition is filed through appeal, including ancillary matters appropriate to the proceedings. In the interest of justice, one counsel may be substituted for another at any stage of the proceedings.

(2) After the filing of a termination of parental rights petition pursuant to Chapter 211, RSMo, or if a combined termination of parental rights and transfer of custody and/or adoption petition was filed, as permitted by

Chapter 453, RSMo, then after the initiation of the termination of parental rights phase of that case payment for attorney representation shall be made as provided below:

(A) Hourly Rate. Any attorney shall, at the conclusion of the representation (i.e., the conclusion of trial or at the conclusion of any appeal, or both at the conclusion of trial and at the conclusion of appeal), be compensated at a rate not exceeding one hundred dollars ($100) per hour. Attorneys may be reimbursed, at the conclusion of the representation (i.e., the conclusion of trial or at the conclusion of any appeal, or both at the conclusion of trial and at the conclusion of appeal), for expenses reasonably incurred, including the costs of transcripts authorized by the court except that if a termination of parental rights petition was filed in a separate proceeding and a duplicative termination of parental rights petition or the transfer of custody and/or adoption petition or the combined termination of parental rights and transfer of custody and/or adoption petition was filed prior to the court’s ordering of termination of parental rights in that separate proceeding, reimbursement for attorneys fees and/or expenses will not be reimbursed if those fees and/or expenses are duplicative of fees and/or expenses reimbursed in the separate termination of parental rights proceeding;

(B) Maximum Amounts. The compensation to be paid for representation at trial shall not exceed one thousand dollars ($1,000) for uncontested matters and seven thousand dollars ($7,000) for contested matters. For representation in an appellate court, the compensation shall not exceed three thousand five hundred dollars ($3,500) at one hundred dollars ($100) per hour;

(C) Cost of Extraordinary Expenses. The cost of extraordinary expenses must be approved in advance by the court but shall be reimbursed at the conclusion of the representation (i.e., the conclusion of trial or at the conclusion of any appeal, or both at the conclusion of trial and at the conclusion of appeal). Such extraordinary expenses include:

1. Psychiatric/psychological/medical evaluations;

2. Expert witnesses; and 3. Deposition of witnesses;

(D) Waiving Maximum Amounts. Payment in excess of any maximum amount provided in subsection (2)(B) may be made for extended or complex representation whenever the court in which the representation was rendered certifies that the amount of the excess payment is necessary to provide fair compensation and the payment is approved by the court. At any time an attorney believes that the cost of representation will surpass the limits provided for in subsection (2)(B), they must provide notice to the Division of Family Services, that they may exceed the current maximum fee;

(E) Disclosure of Fees. The amounts paid to particular attorneys or groups of attorneys shall be available as public records. However, the identity of parties, including parents, children, foster parents and anyone whose confidentiality is established in Chapter 210 or 211, RSMo, shall not be publicly available;

(F) Filing Claims. A separate claim for compensation and reimbursement shall be made to the Division of Family Services for each case. Each claim shall be supported by a sworn written statement specifying the time expended, services rendered, and expenses incurred while the case was pending before the court, and the compensation and reimbursement applied for or received in the same case from any other source. The Division of Family Services may agree to the claim, may negotiate the claim with the applying attorney, or may deny the claim in which case the attorney shall apply to the court to determine the compensation and reimbursement to be paid to the attorney;

(G) New Trials. For purposes of compensation and other payments authorized by this

section, an order by a trial or appellate court granting a new trial shall be deemed to initiate a new case;

(H) Receipt of Other Payments. Whenever the Division of Family Services or the court finds that funds are available for payment from or on behalf of a person furnished representation, it may authorize or direct that such funds be paid to the appointed attorney.

JOHNR. ASHCROFT(2/28/19)

History

• AUTHORITY: section 207.020, RSMo 2000. Emergency rule filed Feb. 14, 2002, effective Feb. 24, 2002, expired Aug. 22, 2002. Original rule filed Feb. 14, 2002, effective July 30, 2002. Emergency amendment filed Dec. 4, 2002, effective Dec. 14, 2002, expired June 11, 2003. Amended: Filed Dec. 4, 2002, effective June 30, 2003. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993.

13 CSR 40-30.030 Attorney Fees and Guardian Ad LitemFees in Subsidized Adoption and Guardianship Cases Emergency rule filed June 13, 2002, effective June 24, 2002, expired Dec. 20, 2002. {#sec-13-csr-40-30.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-30.030}

4CODE OF STATE REGULATIONS

(2/28/19) JOHNR. ASHCROFT

Chapter 31 Child Abuse

13 CSR 40-31.010 Perpetrator Employed by Division of Family Services {#sec-13-csr-40-31.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.010}

(Rescinded June 11, 1984)

Jan. 9, 1976. Amendment filed May 20, 1977, effective Sept. 11, 1977. Rescinded:

Filed March 7, 1984, effective June 11, 1984.

13 CSR 40-31.011 Investigations Involving a Conflict of Interest {#sec-13-csr-40-31.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.011}

(Moved to 13 CSR 35-31.015)

13 CSR 40-31.012 Definition of Sexual Exploitation {#sec-13-csr-40-31.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.012}

(Rescinded February 29, 2016)

Original rule filed Jan. 9, 1984, effective April 12, 1984. Rescinded: Filed July 29, 2015, effective Feb. 29, 2016.

History

• AUTHORITY: section 207.020, RSMo 1986.

13 CSR 40-31.020 Information Released to Subject of a Report Jan. 9, 1976. Rescinded: Filed Aug. 6, 1982, effective Nov. 11, 1982. {#sec-13-csr-40-31.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.020}

State ex rel. Gladfelter v. Lewis, 595 SW2d 788 (Mo. App. 1980). Mandamus will not lie to challenge the validity of 13 CSR 40- 31.020, RSMo since an adequate remedy for that purpose is found at section 536.050(1) and (2), RSMo (1978).

13 CSR 40-31.021 Definitions {#sec-13-csr-40-31.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.021}

(Rescinded February 11, 1983)

rule filed Aug. 6, 1982, effective Nov. 11, 1982. Emergency rescission filed Nov. 1, 1982, effective Nov. 11, 1982, expired Feb. 10, 1983. Rescinded: Filed Nov. 1, 1982, effective Feb. 11, 1983.

History

• AUTHORITY: sections 207.020, RSMo 1978 and 210.506, RSMo Supp. 1982. Original

13 CSR 40-31.025 Child Abuse and Neglect Review Process {#sec-13-csr-40-31.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.025}

(Rescinded March 30, 2008)

Original rule filed June 30, 1988, effective Sept. 29, 1988. Amended: Filed Sept. 26, 1989, effective Dec. 28, 1989. Amended:

Filed June 14, 1996, effective Dec. 30, 1996.

Rescinded: Filed Sept. 27, 2007, effective March 30, 2008.

History

• AUTHORITY: section 207.020, RSMo 1994.

13 CSR 40-31.030 Retention of Unsubstantiated Reports Jan. 9, 1976. Amended: Filed Aug. 11, 1978, effective Nov. 11, 1978. Rescinded: Filed Aug. 6, 1982, effective Nov. 11, 1982. {#sec-13-csr-40-31.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.030}

13 CSR 40-31.040 Retention of Substantiated Reports Jan. 9, 1976. Amended: Filed Aug. 18, 1977, effective Dec. 11, 1977. Filed Aug. 11, 1978, effective Nov. 11, 1978. Rescinded: Filed Aug. 6, 1982, effective Nov. 11, 1982. {#sec-13-csr-40-31.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.040}

13 CSR 40-31.050 Child Fatality Review Process {#sec-13-csr-40-31.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-31.050}

(Rescinded June 30, 2001)

Original rule filed June 15, 1989, effective Jan. 1, 1990. Emergency rescission and emergency rule filed Dec. 20, 1991, effective Jan. 1, 1992, expired April 29, 1992. Emergency rescission and emergency rule filed April 16, 1992, effective April 26, 1992, expired Aug. 23, 1992. Rescinded and readopted: Filed Jan. 3, 1992, effective Aug. 6, 1992. Emergency rescission filed Dec. 19, 2000, effective Jan. 1, 2001, expired June 29, 2001. Rescinded: Filed Dec. 19, 2000, effective June 30, 2001.

JASONKANDER(1/30/16)

History

• AUTHORITY: section 207.020, RSMo 1986.

Chapter 32 Child Care

13 CSR 40-32.010 Basis of Payment {#sec-13-csr-40-32.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-32.010}

(Rescinded December 30, 2007)

Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed Aug. 18, 1977, effective Dec. 11, 1977. Emergency amendment filed Jan. 15, 1980, effective Feb. 1, 1980, expired April 10, 1980. Amended:

Filed Jan. 15, 1980, effective April 11, 1980.

Emergency amendment filed Feb. 20, 1980, effective March 1, 1980, expired June 11, 1980. Amended: Filed Feb. 20, 1980, effective June 12, 1980. Emergency rescission filed May 14, 1980, effective May 24, 1980, expired June 12, 1980. Rescinded: Filed May 14, 1980, effective Aug. 11, 1980. Emergency

rule filed July 15, 1980, effective July 25, 1980, expired Oct. 10, 1980. Readopted:

Filed July 15, 1980, effective Oct. 11, 1980.

Emergency amendment filed Oct. 5, 1981, effective Oct. 14, 1981, expired Jan. 13, 1982. Amended: Filed Oct. 5, 1981, effective Jan. 14, 1982. Amended: Filed June 28, 1983, effective Nov. 11, 1983. Emergency amendment filed March 22, 1990, effective April 1, 1990, expired July 29, 1990.

Amended: Filed April 18, 1990, effective June 28, 1990. Emergency rescission and

rule filed Oct. 22, 1991, effective Nov. 1, 1991, expired Feb. 28, 1992. Rescinded and readopted: Filed Nov. 13, 1991, effective March 9, 1992. Emergency amendment filed March 22, 2007, effective April 1, 2007, expired Sept. 27, 2007. Rescinded: Filed June 15, 2007, effective Dec. 30, 2007.

History

• AUTHORITY: section 207.020, RSMo 1986.

13 CSR 40-32.020 Processing of Applications for State and Federal Funds for Providing Child Care Services {#sec-13-csr-40-32.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-32.020}

(Rescinded April 30, 2019)

Emergency rule filed Dec. 19, 2000, effective Jan. 1, 2001, expired June 29, 2001. Original

rule filed Dec. 19, 2000, effective June 30, 2001. Rescinded: Filed Aug. 20, 2018, effective April 30, 2019.

History

• AUTHORITY: section 210.025, RSMo 2000.

Chapter 33 WIN

13 CSR 40-33.010 Service to Participants {#sec-13-csr-40-33.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-33.010}

(Rescinded November 11, 1983)

Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983.

Matt Blunt (12/31/01)

History

• AUTHORITY: section 207.020, RSMo 1978.

Chapter 34 Homeless, Dependent and Neglected Children

13 CSR 40-34.010 Foster Family Home {#sec-13-csr-40-34.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.010}

(Rescinded November 11, 1982)

Jan. 9, 1976. Rescinded: Filed Aug. 6, 1982, effective Nov. 11, 1982.

13 CSR 40-34.011 Foster Care Definitions {#sec-13-csr-40-34.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.011}

(Rescinded February 11, 1983)

rule filed Aug. 6, 1982, effective Nov. 11, 1982. Emergency rescission filed Nov. 1, 1982, effective Nov. 11, 1982, expired Feb. 10, 1983. Rescinded: Filed Nov. 1, 1982, effective Feb. 11, 1983.

History

• AUTHORITY: section 207.020, RSMo 1985 and 210.506, RSMo Supp. 1982. Original

13 CSR 40-34.012 Rates for Foster Care {#sec-13-csr-40-34.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.012}

(Rescinded January 30, 2019)

Original rule filed June 28, 1983, effective Nov. 11, 1983. Rescinded: Filed June 8, 2018, effective Jan. 30, 2019.

History

• AUTHORITY: section 207.020, RSMo 1986.

13 CSR 40-34.020 Eligibility Jan. 9, 1976. Amended: Filed Aug. 18, 1977, effective Dec. 11, 1977. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983. {#sec-13-csr-40-34.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.020}

13 CSR 40-34.030 Reimbursement for Clothing Jan. 9, 1976. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983. {#sec-13-csr-40-34.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.030}

13 CSR 40-34.040 Rates for Foster Care {#sec-13-csr-40-34.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.040}

History

• AUTHORITY: section 207.020, RSMo. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983.

13 CSR 40-34.050 Vietnamese and Cambodian Refugees Jan. 9, 1976. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983. {#sec-13-csr-40-34.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.050}

13 CSR 40-34.060 Parental Support {#sec-13-csr-40-34.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.060}

(Rescinded May 30, 2019)

Original rule filed Aug. 6, 1982, effective Nov. 11, 1982. Rescinded: Filed Sept. 27, 2018, effective May 30, 2019.

History

• AUTHORITY: section 207.020, RSMo 1986.

13 CSR 40-34.070 Payment to School Districts for Special Education Services for Children in the Custody of the Division of Family Services and Placed in Residential Treatment Facilities {#sec-13-csr-40-34.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.070}

(Rescinded May 30, 2018)

History

• AUTHORITY: sections 162.970 and 207.020, RSMo 1986. This rule was previously filed as

13 CSR 40-34.020. Original rule filed Sept. 6, 1989, effective Dec. 28, 1989. Rescinded: {#sec-13-csr-40-34.020. omnilex-key=us-mo-regs-official--title-13--13 CSR 40-34.020.}

Filed Sept. 22, 2017, effective May 30, 2018.

JOHNR. ASHCROFT(4/30/19)

Chapter 35 Medical Assistance

13 CSR 40-35.010 Expenditures for Medical Expenses {#sec-13-csr-40-35.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-35.010}

(Rescinded November 11, 1983)

Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983.

MATTBLUNT(12/31/01)

History

• AUTHORITY: section 207.020, RSMo 1978.

Chapter 36 Alternative Care Grievance Process

13 CSR 40-36.001 Foster/Relative/Adoptive Parent Grievance Procedure {#sec-13-csr-40-36.001 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-36.001}

(Rescinded April 30, 2019)

Original rule filed July 6, 1988, effective Sept. 29, 1988. Amended: Filed June 15, 1994, effective Jan. 29, 1995. Rescinded:

Filed Aug. 20, 2018, effective April 30, 2019.

History

• AUTHORITY: section 210.526, RSMo 1986.

13 CSR 40-36.010 Eligibility Criteria {#sec-13-csr-40-36.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-36.010}

(Rescinded November 11, 1983)

Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed Aug. 18, 1977, effective Dec. 11, 1977. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983.

History

• AUTHORITY: section 207.020, RSMo 1978.

Chapter 37 Early Periodic Screening, Diagnosis and Treatment

13 CSR 40-37.010 Basis for Provision {#sec-13-csr-40-37.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-37.010}

(Rescinded March 30, 2023)

History

• AUTHORITY: section 207.020 RSMo 1986. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed May 10, 1978, effective Aug. 11, 1978. Emergency amendment filed Aug. 16, 1979, effective Oct. 1, 1979, expired Nov. 10, 1979. Published: Sept 4, 1979, effective Nov. 11, 1979. Rescinded: Filed Aug. 30, 2022, effective March 30, 2023.

Chapter 38 Adoption - moved to 13 CSR 35-38

13 CSR 40-38.010 Definition of Adoption Services {#sec-13-csr-40-38.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-38.010}

(Moved to 13 CSR 35-38.030)

13 CSR 40-38.020 Provision of Services {#sec-13-csr-40-38.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-38.020}

(Moved to 13 CSR 35-38.040)

ROBINCARNAHAN(10/31/10)

Chapter 39 Interstate Compact

13 CSR 40-39.010 Administrator of Interstate Compact {#sec-13-csr-40-39.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-39.010}

(Rescinded November 11, 1983)

Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983.

History

• AUTHORITY: section 207.020, RSMo 1978.

13 CSR 40-39.020 Placement of Children {#sec-13-csr-40-39.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-39.020}

(Rescinded November 11, 1983)

Original rule filed Aug. 18, 1977, effective Dec. 11, 1977. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983.

MATTBLUNT(12/31/01)

History

• AUTHORITY: section 207.020, RSMo 1978.

Chapter 40 Title XX

13 CSR 40-40.010 Responsible Agency Jan. 9, 1976. Rescinded: Filed June 28, {#sec-13-csr-40-40.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-40.010}

13 CSR 40-40.020 Eligibility Criteria Jan. 9, 1976. Amended: Filed Aug. 18, 1977, effective Dec. 11, 1977. Amended: Filed Sept. 26, 1978, effective Jan. 13, 1979. Amended: {#sec-13-csr-40-40.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-40.020}

Filed June 29, 1979, effective Oct. 11, 1979.

Amended: Filed Jan. 14, 1980, effective April 11, 1980. Rescinded: Filed June 28, 1983, effective Nov. 11, 1983.

13 CSR 40-40.030 Eligibility Determinations Jan. 9, 1976. Rescinded: Filed June 28, {#sec-13-csr-40-40.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-40.030}

13 CSR 40-40.040 Appeals Jan. 9, 1976. Rescinded: Filed June 28, {#sec-13-csr-40-40.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-40.040}

13 CSR 40-40.050 Matching Funds Jan. 9, 1976. Rescinded: Filed June 28, {#sec-13-csr-40-40.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-40.050}

13 CSR 40-40.060 Administrative Fees Jan. 9, 1976. Rescinded: Filed June 28, MATTBLUNT(12/31/01) {#sec-13-csr-40-40.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-40.060}

Chapter 50 Licensing of Foster/Adoptive Homes

13 CSR 40-50.010 Family Homes Offering Foster/Adoptive Care {#sec-13-csr-40-50.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-50.010}

(Rescinded May 30, 2019)

Original rule filed Dec. 14, 1987, effective March 25, 1988. Rescinded: Filed Sept. 20, 2018, effective May 30, 2019.

JOHNR. ASHCROFT(4/30/19)

History

• AUTHORITY: section 207.020, RSMo 1986.

Chapter 59 Criminal Record Reviews

13 CSR 40-59.010 Screening Procedures for Child Care Providers and Child Care {#sec-13-csr-40-59.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.010}

13 CSR 40-59.030 Criminal and Child Abuse/Neglect Central Registry Checks for Foster, {#sec-13-csr-40-59.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.030}

13 CSR 40-59.050 Child Abuse/Neglect Central Registry Checks for Child JOHNR. ASHCROFT(8/31/18) {#sec-13-csr-40-59.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.050}

SOCIAL SERVICES

13 CSR 40-59.010 Screening Procedures for Child Care Providers and Child Care Employees {#sec-13-csr-40-59.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.010}

(Rescinded October 13, 1988)

Chapter 536, RSMo, sections 210.830 and 210.850, RSMo 1978, and S.B. 401, 83rd General Assembly. Emergency rule filed July 15, 1985, effective July 25, 1985, expired Nov. 8, 1985. Amended: Filed July 15, 1985, effective Oct. 1, 1985. Rescinded: Filed July 7, 1988, effective Oct. 13, 1988.

History

• AUTHORITY: section 207.020, RSMo 1986,

13 CSR 40-59.020 Definitions {#sec-13-csr-40-59.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.020}

(Rescinded August 30, 2018)

Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: sections 207.020 and 210.486, RSMo 1986. Original rule filed March 22, 1990, effective June 28, 1990. Rescinded:

13 CSR 40-59.030 Criminal and Child Abuse/Neglect Central Registry Checks for Foster, Adoptive and Relative Care Providers {#sec-13-csr-40-59.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.030}

(Rescinded August 30, 2018)

Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: sections 207.020 and 210.486, RSMo 1986. Original rule filed March 22, 1990, effective June 28, 1990. Rescinded:

13 CSR 40-59.040 Definitions in Release of Information {#sec-13-csr-40-59.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.040}

(Rescinded September 30, 2018)

rule filed March 22, 1990, effective June 28, 1990. Rescinded: Filed Feb. 20, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: sections 207.020, RSMo 1986 and 210.150, RSMo Supp. 1991. Original

13 CSR 40-59.050 Child Abuse/Neglect Central Registry Checks for Child Care Employees and Volunteers {#sec-13-csr-40-59.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-59.050}

(Rescinded September 30, 2018)

Filed May 13, 1993, effective Dec. 9, 1993.

Rescinded: Filed Feb. 20, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: sections 207.020, RSMo 1986, 210.145, RSMo 1990 and 210.150, RSMo Supp. 1991. Original rule filed March 22, 1990, effective June 28, 1990. Amended:

Chapter 60 Licensing of Foster Family Homes

13 CSR 40-60.010 Family Homes Offering Foster Care Filed June 28, 1983, effective Nov. 11, 1983. {#sec-13-csr-40-60.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-60.010}

Amended: Filed July 6, 1988, effective Sept. 29, 1988. Emergency rescission filed July 18, 2006, effective Aug. 4, 2006, expired Jan. 30, 2007. Rescinded: Filed July 18, 2006, effective Jan. 30, 2007.

13 CSR 40-60.020 Number of Children Filed June 28, 1983, effective Nov. 11, 1983. {#sec-13-csr-40-60.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-60.020}

13 CSR 40-60.030 Minimum Qualifications of Foster Parent(s) {#sec-13-csr-40-60.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-60.030}

Filed Dec. 14, 1982, effective March 11, 1983. Amended: Filed June 28, 1983, effective Nov. 11, 1983. Emergency amendment filed Dec. 19, 1984, effective Dec. 29, 1984, expired April 19, 1985. Amended: Filed Dec. 19, 1984, effective April 11, 1985. Amended:

Filed June 2, 1988, effective Aug. 25, 1988.

Emergency rescission filed July 18, 2006, effective Aug. 4, 2006, expired Jan. 30, 2007.

13 CSR 40-60.040 Physical Standards for Foster Homes {#sec-13-csr-40-60.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-60.040}

Sept. 11, 1978. Amended: Filed June 28, 1983, effective Nov. 11, 1983. Rescinded:

Filed July 18, 2006, effective Jan. 30, 2007.

History

• AUTHORITY: section 210.221, RSMo 1986.

13 CSR 40-60.050 Care of Children {#sec-13-csr-40-60.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-60.050}

Sept. 11, 1978. Amended: Filed June 28, 1983, effective Nov. 11, 1983. Amended:

Filed Jan. 8, 2002, effective July 30, 2002.

History

• AUTHORITY: section 210.221, RSMo 2000.

13 CSR 40-60.060 Records and Reports {#sec-13-csr-40-60.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-60.060}

Sept. 11, 1978. Rescinded: Filed July 18, 2006, effective Jan. 30, 2007.

History

• AUTHORITY: section 210.221, RSMo 1986.

Chapter 61 Licensing Rules for Family Day Care Homes

13 CSR 40-61.085 Physical Requirements of the Family Day Care Home {#sec-13-csr-40-61.085 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.085}

13 CSR 40-61.090 The Day Care Provider and Other Day Care Personnel 2CODE OF STATE REGULATIONS (8/31/18) JOHNR. ASHCROFT {#sec-13-csr-40-61.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.090}

13 CSR 40-61.105 The Day Care Provider and Other Day Care Personnel JOHNR. ASHCROFT(8/31/18) {#sec-13-csr-40-61.105 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.105}

SOCIAL SERVICES

Day Care Homes

13 CSR 40-61.010 Definitions {#sec-13-csr-40-61.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.010}

(Moved to 19 CSR 40-61.010)

13 CSR 40-61.015 Exemption of Day Care Facilities {#sec-13-csr-40-61.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.015}

(Moved to 19 CSR 40-61.015)

13 CSR 40-61.020 Initial Licensing In-formation Original rule filed in 1956. Amended: Filed Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-61.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.020}

Amended: Filed July 6, 1976, effective Oct. 11, 1976. Amended: Filed Dec. 6, 1978, effective March 11, 1979. Rescinded: Filed April 13, 1982, effective Aug. 31, 1982.

Readopted: Filed April 13, 1982, effective Sept. 1, 1982. Rescinded: Filed March 29,

13 CSR 40-61.025 Organization and Administration {#sec-13-csr-40-61.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.025}

(Moved to 19 CSR 40-61.025)

13 CSR 40-61.030 Hearings and Judicial {#sec-13-csr-40-61.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.030}

(Rescinded August 31, 1982)

Original rule filed Dec. 19, 1975, effective Jan. 1, 1976. Rescinded: Filed April 13, 1982, effective Aug. 31, 1982.

History

• AUTHORITY: section 210.221, RSMo 1978.

13 CSR 40-61.031 Licensing Renewal Information Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.031}

13 CSR 40-61.035 Exemption of Religious Child Care Facilities {#sec-13-csr-40-61.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.035}

rule filed Oct. 7, 1987, effective March 25, 1988. Rescinded: Filed March 20, 1991, effective Oct. 31, 1991.

History

• AUTHORITY: sections 210.211, 210.221, 210.486 and 210.506, RSMo 1986. Original

13 CSR 40-61.040 Day Care Licensing Review Board Sept. 1, 1982. Amended: Filed April 2, 1986, effective July 26, 1986. Rescinded: Filed {#sec-13-csr-40-61.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.040}

13 CSR 40-61.045 Initial Licensing Information {#sec-13-csr-40-61.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.045}

(Moved to 19 CSR 40-61.045)

13 CSR 40-61.050 Hearings and Judicial Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.050}

13 CSR 40-61.055 License Renewal {#sec-13-csr-40-61.055 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.055}

(Moved to 19 CSR 40-61.055)

13 CSR 40-61.060 Organization and Administration {#sec-13-csr-40-61.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.060}

Sept. 1, 1982. Rescinded: Filed March 29,

History

• AUTHORITY: section 210.211, RSMo 1986.

13 CSR 40-61.065 Child Care Licensing Review Board {#sec-13-csr-40-61.065 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.065}

(Rescinded September 30, 2018)

1987. This rule was previously filed as 13 CSR 40-61.040. Original rule filed March 29, 1991, effective Oct. 31, 1991. Rescinded:

Filed Feb. 20, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: section 210.221, RSMo Supp.

13 CSR 40-61.070 Physical Requirements of the Home Sept. 1, 1982. Amended: Filed Nov. 12, 1982, effective Feb. 11, 1983. Rescinded: {#sec-13-csr-40-61.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.070}

Filed March 29, 1991, effective Oct. 31,

13 CSR 40-61.075 Hearings and Judicial {#sec-13-csr-40-61.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.075}

(Rescinded September 30, 2018)

This rule was previously filed as 13 CSR 40- 61.050. Original rule filed March 29, 1991, effective Oct. 31, 1991. Rescinded: Filed March 2, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: section 210.221, RSMo 1987.

13 CSR 40-61.080 Furniture, Equipment and Materials Sept. 1, 1982. Amended: Filed Nov. 12, 1982, effective Feb. 11, 1983. Rescinded: {#sec-13-csr-40-61.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.080}

Filed March 29, 1991, effective Oct. 31,

13 CSR 40-61.085 Physical Requirements of the Family Day Care Home {#sec-13-csr-40-61.085 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.085}

(Moved to 19 CSR 40-61.085)

13 CSR 40-61.090 The Day Care Provider and Other Day Care Personnel Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.090}

13 CSR 40-61.095 Furniture, Equipment and Materials {#sec-13-csr-40-61.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.095}

(Moved to 19 CSR 40-61.095)

13 CSR 40-61.100 Day Care Family and Household {#sec-13-csr-40-61.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.100}

Sept. 1, 1982. Amended: Filed April 2, 1986, effective July 26, 1986. Rescinded: Filed

History

• AUTHORITY: section 210.211, RSMo 1986.

13 CSR 40-61.105 The Day Care Provider and Other Day Care Personnel {#sec-13-csr-40-61.105 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.105}

(Moved to 19 CSR 40-61.105)

13 CSR 40-61.110 Medical Examination Reports Sept. 1, 1982. Amended: Filed Nov. 12, 1982, effective Feb. 11, 1983. Rescinded: Filed {#sec-13-csr-40-61.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.110}

13 CSR 40-61.115 Day Care Family and Household {#sec-13-csr-40-61.115 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.115}

(Moved to 19 CSR 40-61.115)

13 CSR 40-61.120 Admission Policies and Procedures Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.120}

13 CSR 40-61.125 Medical Examination Reports {#sec-13-csr-40-61.125 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.125}

(Moved to 19 CSR 40-61.125)

13 CSR 40-61.130 Evening and Nighttime Care Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.130}

13 CSR 40-61.135 Admission Policies and Procedures {#sec-13-csr-40-61.135 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.135}

(Moved to 19 CSR 40-61.135)

13 CSR 40-61.140 Overlap Care of Children Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.140}

13 CSR 40-61.145 Nighttime Care {#sec-13-csr-40-61.145 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.145}

(Moved to 19 CSR 40-61.145)

13 CSR 40-61.150 Emergency School Closings Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.150}

13 CSR 40-61.155 Overlap Care of Children {#sec-13-csr-40-61.155 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.155}

(Moved to 19 CSR 40-61.155)

13 CSR 40-61.160 Daily Activities and Care of the Child Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.160}

13 CSR 40-61.165 Emergency School Closings {#sec-13-csr-40-61.165 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.165}

(Moved to 19 CSR 40-61.165)

13 CSR 40-61.170 Nutrition and Food Service Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.170}

13 CSR 40-61.175 Child Care Program {#sec-13-csr-40-61.175 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.175}

(Moved to 19 CSR 40-61.175)

13 CSR 40-61.180 Records and Reports Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-61.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.180}

13 CSR 40-61.185 Health Care {#sec-13-csr-40-61.185 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.185}

(Moved to 19 CSR 40-61.185)

13 CSR 40-61.190 Nutrition and Food Service {#sec-13-csr-40-61.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.190}

(Moved to 19 CSR 40-61.190)

13 CSR 40-61.200 Transportation and Field Trips {#sec-13-csr-40-61.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.200}

(Moved to 19 CSR 40-61.200)

13 CSR 40-61.210 Records and Reports {#sec-13-csr-40-61.210 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-61.210}

(Moved to 19 CSR 40-61.210)

4CODE OF STATE REGULATIONS

(8/31/18) JOHNR. ASHCROFT

Chapter 62 Licensing Rules for Group Day Care Homes and Child Day Care Centers

13 CSR 40-62.040 The Day Care Provider and Other Child Care Personnel 2CODE OF STATE REGULATIONS (8/31/18) JOHNR. ASHCROFT {#sec-13-csr-40-62.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.040}

13 CSR 40-62.082 Physical Requirements of Group Day Care Homes and Day Care Centers SOCIAL SERVICES Day Care Homes and Child Day Care Centers {#sec-13-csr-40-62.082 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.082}

13 CSR 40-62.010 Definitions {#sec-13-csr-40-62.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.010}

(Moved to 19 CSR 40-62.010)

13 CSR 40-62.020 Physical Requirements of the Home Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.020}

Aug. 31, 1982.

13 CSR 40-62.021 Initial Licensing Information Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.021}

13 CSR 40-62.022 Exemption of Day Care Facilities {#sec-13-csr-40-62.022 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.022}

(Moved to 19 CSR 40-62.022)

13 CSR 40-62.030 Furniture, Equipment Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.030}

Aug. 31, 1982.

13 CSR 40-62.031 Licensing Renewal Information Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.031}

13 CSR 40-62.032 Organization and Administration {#sec-13-csr-40-62.032 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.032}

(Moved to 19 CSR 40-62.032)

13 CSR 40-62.035 Exemption of Religious Child Care Facilities {#sec-13-csr-40-62.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.035}

rule filed Oct. 7, 1987, effective March 25, 1988. Rescinded: Filed March 29, 1991, effective Oct. 31, 1991.

History

• AUTHORITY: sections 210.211, 210.221, 210.486 and 210.506, RSMo 1986. Original

13 CSR 40-62.040 The Day Care Provider and Other Child Care Personnel Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.040}

Aug. 31, 1982.

13 CSR 40-62.041 Day Care Licensing Review Board Sept. 1, 1982. Amended: Filed April 2, 1986, effective July 26, 1986. Rescinded: Filed {#sec-13-csr-40-62.041 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.041}

13 CSR 40-62.042 Initial Licensing Information {#sec-13-csr-40-62.042 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.042}

(Moved to 19 CSR 40-62.042)

13 CSR 40-62.050 The Day Care Family and Household Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.050}

Aug. 31, 1982.

13 CSR 40-62.051 Hearings and Judicial Review Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.051}

13 CSR 40-62.052 License Renewal {#sec-13-csr-40-62.052 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.052}

(Moved to 19 CSR 40-62.052)

13 CSR 40-62.060 Health Examinations Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.060}

March 11, 1977. Amended: Filed March 14, 1978, effective June 11, 1978. Rescinded:

Filed April 13, 1982, effective Aug. 31, 1982.

13 CSR 40-62.061 Organization and Administration Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.061 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.061}

13 CSR 40-62.062 Child Care Licensing Review Board {#sec-13-csr-40-62.062 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.062}

(Rescinded September 30, 2018)

1987. This rule was previously filed as 13 CSR 40-62.041. Emergency rescission filed Aug. 18, 1993, effective Aug. 28, 1993, expired Dec. 25, 1993. Original rule filed Rescinded: Filed March 2, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: section 210.221, RSMo Supp.

13 CSR 40-62.070 Admission Policies and Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.070}

Aug. 31, 1982.

13 CSR 40-62.071 Physical Requirements of the Center Sept. 1, 1982. Amended: Filed Nov. 12, {#sec-13-csr-40-62.071 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.071}

13 CSR 40-62.072 Hearings and Judicial Review {#sec-13-csr-40-62.072 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.072}

(Rescinded September 30, 2018)

1987. This rule was previously filed as 13 CSR 40-62.051. Emergency rescission filed Aug. 18, 1993, effective Aug. 28, 1993, expired Dec. 25, 1993. Original rule filed Rescinded: Filed March 2, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: section 210.221, RSMo Supp.

13 CSR 40-62.080 Daily Activities and Care of the Child Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.080}

March 11, 1977. Rescinded: Filed April 13, 1982, effective Aug. 31, 1982.

13 CSR 40-62.081 Furniture, Equipment {#sec-13-csr-40-62.081 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.081}

Sept. 1, 1982. Amended: Filed Nov. 12,

History

• AUTHORITY: section 210.221, RSMo 1996.

13 CSR 40-62.082 Physical Requirements of Group Day Care Homes and Day Care Centers {#sec-13-csr-40-62.082 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.082}

(Moved to 19 CSR 40-62.082)

13 CSR 40-62.090 Nutrition and Food Services Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.090}

March 11, 1977. Rescinded: Filed April 13, 1982, effective Aug. 31, 1982.

13 CSR 40-62.091 Personnel Sept. 1, 1982. Amended: Filed April 2, 1986, effective July 26, 1986. Rescinded: Filed {#sec-13-csr-40-62.091 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.091}

13 CSR 40-62.092 Furniture, Equipment {#sec-13-csr-40-62.092 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.092}

(Moved to 19 CSR 40-62.092)

13 CSR 40-62.095 Records and Reports Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-62.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.095}

Aug. 31, 1982.

13 CSR 40-62.100 Child Care Staff/Child Ratio Sept. 1, 1982. Amended: Filed Nov. 12, {#sec-13-csr-40-62.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.100}

13 CSR 40-62.102 Personnel {#sec-13-csr-40-62.102 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.102}

(Moved to 19 CSR 40-62.102)

13 CSR 40-62.110 Medical Examination Reports Sept. 1, 1982. Amended: Filed Nov. 12, {#sec-13-csr-40-62.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.110}

13 CSR 40-62.112 Staff/Child Ratios {#sec-13-csr-40-62.112 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.112}

(Moved to 19 CSR 40-62.112)

13 CSR 40-62.120 Admission Policies and Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.120}

13 CSR 40-62.122 Medical Examination Reports {#sec-13-csr-40-62.122 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.122}

(Moved to 19 CSR 40-62.122)

13 CSR 40-62.130 Evening and Nighttime Care Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.130}

13 CSR 40-62.132 Admission Policies and {#sec-13-csr-40-62.132 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.132}

(Moved to 19 CSR 40-62.132)

13 CSR 40-62.140 Hourly Care Centers Sept. 1, 1982. Amended: Filed Nov. 12, {#sec-13-csr-40-62.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.140}

13 CSR 40-62.142 Nighttime Care {#sec-13-csr-40-62.142 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.142}

(Moved to 19 CSR 40-62.142)

13 CSR 40-62.150 Overlap Care of Children Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.150}

13 CSR 40-62.152 Hourly Care Facilities {#sec-13-csr-40-62.152 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.152}

(Moved to 19 CSR 40-62.152)

13 CSR 40-62.160 Emergency School Closings Sept. 1, 1982. Rescinded: Filed March 29, {#sec-13-csr-40-62.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.160}

13 CSR 40-62.162 Overlap Care of Children {#sec-13-csr-40-62.162 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.162}

(Moved to 19 CSR 40-62.162)

13 CSR 40-62.170 Daily Activities and Care of the Child 6CODE OF STATE REGULATIONS (8/31/18) JOHNR. ASHCROFT Sept. 1, 1982. Amended: Filed Nov. 12, {#sec-13-csr-40-62.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.170}

13 CSR 40-62.172 Emergency School Closings {#sec-13-csr-40-62.172 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.172}

(Moved to 19 CSR 40-62.172)

13 CSR 40-62.180 Nutrition and Food Service Sept. 1, 1982. Amended: Filed Nov. 12, {#sec-13-csr-40-62.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.180}

13 CSR 40-62.182 Child Care Program {#sec-13-csr-40-62.182 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.182}

(Moved to 19 CSR 40-62.182)

13 CSR 40-62.190 Records and Reports {#sec-13-csr-40-62.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.190}

Sept. 1, 1982. Amended: Filed Nov. 12, 1982, effective Feb. 11, 1982. Rescinded:

History

• AUTHORITY: sections 210.221, RSMo 1986.

13 CSR 40-62.192 Health Care {#sec-13-csr-40-62.192 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.192}

(Moved to 19 CSR 40-62.192)

13 CSR 40-62.202 Nutrition and Food Service {#sec-13-csr-40-62.202 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.202}

(Moved to 19 CSR 40-62.202)

13 CSR 40-62.212 Transportation and Field Trips {#sec-13-csr-40-62.212 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.212}

(Moved to 19 CSR 40-62.212)

13 CSR 40-62.222 Records and Reports {#sec-13-csr-40-62.222 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-62.222}

(Moved to 19 CSR 40-62.222)

Chapter 63 Licensing of Day Care Centers

13 CSR 40-63.010 Definitions and Licensing Information Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.010}

Aug. 31, 1982.

13 CSR 40-63.020 Organization and Administration Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.020}

Aug. 31, 1982.

13 CSR 40-63.030 Admission Policies and Procedures Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.030}

Aug. 31, 1982.

13 CSR 40-63.040 Physical Plant Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.040}

13 CSR 40-63.050 Furniture, Equipment and Materials Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.050}

Aug. 31, 1982.

13 CSR 40-63.060 Personnel Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.060}

Aug. 31, 1982.

13 CSR 40-63.070 Health Examinations Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.070}

Amended: Filed March 14, 1978, effective June 11, 1978. Rescinded: Filed April 13,

13 CSR 40-63.080 Daily Activities and Care of the Child Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.080}

13 CSR 40-63.090 Nutrition and Food Service Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.090}

13 CSR 40-63.095 Records and Reports Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.095}

Aug. 31, 1982.

13 CSR 40-63.098 Special Services Dec. 19, 1975, effective Jan. 1, 1976. {#sec-13-csr-40-63.098 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-63.098}

Aug. 31, 1982.

MATTBLUNT(12/31/01)

Chapter 64 Infant and Toddler Day Care Centers

13 CSR 40-64.010 Definitions and Licensing Information Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.010}

13 CSR 40-64.020 Organization and Administration Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.020}

13 CSR 40-64.030 Admission Policies and Procedures Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.030}

13 CSR 40-64.040 The Physical Plant Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.040}

13 CSR 40-64.050 Furniture, Equipment and Materials Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.050}

13 CSR 40-64.060 Personnel Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.060}

13 CSR 40-64.070 Health Examinations Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.070}

13 CSR 40-64.080 Nutrition and Food Service Jan. 1, 1976. Amended: Filed March 14, {#sec-13-csr-40-64.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.080}

13 CSR 40-64.090 Daily Activities and Care of the Child Jan. 1, 1976. Amended: Filed March 14, MATTBLUNT(12/31/01) {#sec-13-csr-40-64.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-64.090}

Chapter 65 Evening and Nighttime Care Centers

13 CSR 40-65.010 Definitions and Licensing Information Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-65.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-65.010}

13 CSR 40-65.020 Admission Policies and Procedures Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-65.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-65.020}

13 CSR 40-65.030 Furniture, Equipment and Materials Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-65.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-65.030}

13 CSR 40-65.040 Personnel Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-65.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-65.040}

13 CSR 40-65.050 Program of Activities Jan. 1, 1976. Rescinded: Filed April 13, MATTBLUNT(12/31/01) {#sec-13-csr-40-65.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-65.050}

Chapter 66 Hourly Care Centers

13 CSR 40-66.010 Definitions and Licensing Information Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-66.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-66.010}

13 CSR 40-66.020 Admission Policies and Procedures Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-66.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-66.020}

13 CSR 40-66.030 Physical Plant Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-66.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-66.030}

13 CSR 40-66.040 Health Examinations Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-66.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-66.040}

13 CSR 40-66.050 Nutrition and Food Service Jan. 1, 1976. Rescinded: Filed April 13, {#sec-13-csr-40-66.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-66.050}

13 CSR 40-66.060 Records and Reports Jan. 1, 1976. Rescinded: Filed April 13, MATTBLUNT(12/31/01) {#sec-13-csr-40-66.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-66.060}

Chapter 67 Summer School Age Day Care

13 CSR 40-67.010 Definitions and Licensing Information {#sec-13-csr-40-67.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.010}

13 CSR 40-67.020 Organization and Administration {#sec-13-csr-40-67.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.020}

13 CSR 40-67.030 Admission Policies and Procedures {#sec-13-csr-40-67.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.030}

13 CSR 40-67.040 The Physical Plant and/or Site {#sec-13-csr-40-67.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.040}

13 CSR 40-67.050 Equipment and Materials {#sec-13-csr-40-67.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.050}

13 CSR 40-67.060 Nutrition and Food Service {#sec-13-csr-40-67.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.060}

13 CSR 40-67.070 Program of Daily Activities {#sec-13-csr-40-67.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.070}

13 CSR 40-67.080 Personnel {#sec-13-csr-40-67.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.080}

13 CSR 40-67.090 Health Examinations {#sec-13-csr-40-67.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.090}

13 CSR 40-67.095 Records and Reports MATTBLUNT(12/31/01) {#sec-13-csr-40-67.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-67.095}

Chapter 71 Licensing Rules for Residential Care Agencies

13 CSR 40-71.010 Definitions {#sec-13-csr-40-71.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.010}

(Moved to 13 CSR 35-71.010)

13 CSR 40-71.020 Basic Residential Care Core Requirements (Applicable To All Agencies)—Basis for Licensure and Licensing Procedures {#sec-13-csr-40-71.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.020}

(Moved to 13 CSR 35-71.020)

13 CSR 40-71.025 Exemption of Religious Child Care Facilities {#sec-13-csr-40-71.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.025}

(Moved to 13 CSR 35-71.025)

13 CSR 40-71.030 Hearings and Judicial Review {#sec-13-csr-40-71.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.030}

(Moved to 13 CSR 35-71.030)

13 CSR 40-71.035 Court Review and Dispositional Hearing {#sec-13-csr-40-71.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.035}

(Moved to 13 CSR 35-71.035)

13 CSR 40-71.040 Organization and Administration {#sec-13-csr-40-71.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.040}

(Moved to 13 CSR 35-71.040)

13 CSR 40-71.045 Personnel {#sec-13-csr-40-71.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.045}

(Moved to 13 CSR 35-71.045)

13 CSR 40-71.050 Staff Qualifications and Requirements {#sec-13-csr-40-71.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.050}

(Moved to 13 CSR 35-71.050)

13 CSR 40-71.060 Social Services Program {#sec-13-csr-40-71.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.060}

(Moved to 13 CSR 35-71.060)

13 CSR 40-71.070 Protection and Care of the Child {#sec-13-csr-40-71.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.070}

(Moved to 13 CSR 35-71.070)

13 CSR 40-71.075 Health Care {#sec-13-csr-40-71.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.075}

(Moved to 13 CSR 35-71.075)

13 CSR 40-71.080 Buildings, Grounds and Equipment {#sec-13-csr-40-71.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.080}

(Moved to 13 CSR 35-71.080)

13 CSR 40-71.090 Record Keeping {#sec-13-csr-40-71.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.090}

(Moved to 13 CSR 35-71.090)

13 CSR 40-71.100 Specific Rules for Basic Care Agencies Providing Care for Infant, Toddler or Preschool Age Children (Birth Through Age Six) {#sec-13-csr-40-71.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.100}

(Moved to 13 CSR 35-71.100)

13 CSR 40-71.110 Child Care Program {#sec-13-csr-40-71.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.110}

(Moved to 13 CSR 35-71.110)

13 CSR 40-71.120 Specific Rules for Residential Care Agencies Providing Maternity Care {#sec-13-csr-40-71.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.120}

(Moved to 13 CSR 35-71.120)

13 CSR 40-71.130 Specialized Standards— Residential Treatment {#sec-13-csr-40-71.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.130}

(Moved to 13 CSR 35-71.130)

13 CSR 40-71.140 Specialized Standards For Intensive Residential Treatment {#sec-13-csr-40-71.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-71.140}

(Moved to 13 CSR 35-71.140)

ROBINCARNAHAN(12/31/08)

Chapter 72 Group Homes Facilities

13 CSR 40-72.010 Group Homes Offering Residential Care {#sec-13-csr-40-72.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-72.010}

PURPOSE: Section 210.246, RSMo makes it unlawful for any person to establish or operate a residential care facility without having in full force a written license granted by the Missouri Division of Family Services. This

rule establishes requirements which a group home must meet in order to qualify for a license. Group homes are small residential programs caring for twelve or less children.

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.

Therefore, the material which is so incorporated is on file with the agency who filed this

rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

(1) Legal Basis for Licensing. The Division of Family Services has responsibility for licensing those persons offering care to groups of children. The primary purpose of licensure is the protection of children.

Sections 210.481–210.536, RSMo provide for the defining, licensing, inspection and

regulation of group care for children. The law directs the division to publish rules for the licensing of residential facilities and to assist the agencies, groups or individuals subject to licensing in meeting these requirements for group child care.

(A) Definitions.

1. Child means an individual who is under the age of eighteen (18) and the word children means more than one (1) such individual.

2. Person is any individual, corporation, partnership, association, firm, agency or institution acting in concert regardless of the name used.

3. Director is the director of the Division of Family Services.

4. Division is the Division of Family Services.

5. License is a legal document issued for a maximum of two (2) years to a person authorizing him/her to provide care for children, subject to his/her compliance with the law and applicable rules published by the division.

6. Provisional license means the nonrenewable legal document issued by the division, for a maximum of six (6) months, to a group home which is not currently meeting requirements for full licensure in accordance with sections 210.481–210.536, RSMo and applicable rules promulgated and issued by the division.

7. Foster parent(s) are individuals who provide twenty-four (24)-hour care in their home to a group of children not related to them by blood, marriage or adoption.

8. Child care staff means persons employed to provide care and supervision for the children in the group home.

9. Staff means full- and part-time employees other than foster parents and child care staff.

10. Well-known religious order, church and religious organization are defined as follows:

A. A church, synagogue or mosque;

B. An entity that would qualify for federal tax exempt status as a not-for-profit religious organization under Section 501(c) of the Internal Revenue Code of 1954; or C. An entity where the real property on which the child care facility is located is exempt from local taxation because it is used for religious purposes.

11. Types of care are— A. Foster family group home. A private home of foster parents who provide twenty-four (24)-hour care for seven to twelve (7–12) children under the custody and supervision of the division only. This type of care is not recommended for any child under the age of six (6) years;

B. Independent foster family group home. A private home, independent of any agency auspices, of foster parents who provide twenty-four (24)-hour care for seven to twelve (7–12) children in the custody of parents, relatives, guardian or agencies. This type of care is not recommended for any child under the age of six (6) years;

C. Satellite group home. A group home operated by a licensed child caring or child placing agency in a single dwelling or apartment owned, rented or leased by the agency. Child care staff are employed by the parent agency to provide twenty-four (24)hour care for twelve (12) children or less.

This type of care is not recommended for any child under the age of six (6) years; and D. Independent group home. A group home privately operated by a person in a single dwelling or apartment which is owned, rented or leased by the person. Child care staff are employed to provide twenty-four (24)-hour care for twelve (12) children or less. This type of care is not recommended for any child under the age of six (6) years.

(B) When a nonreligious organization, having as its principal purpose the provision of child care services, enters into an arrangement with a religious organization to provide continuing assistance in the maintenance or operation of a child care facility, the facility is not under the exclusive control of the religious organization and does not qualify for exemption from licensure under sections 210.211(5) or 210.516.1(5).

(2) Rules for Foster Family and Independent Foster Family Group Homes.

(A) Basic Requirements for Foster Families.

1. Foster parents shall have personal characteristics and have experienced relationships which will make it possible for them to perform the responsibilities entailed in caring for children. Foster parents shall be individuals who demonstrate affection, an ability to care for children and to be responsive to their needs, who can enjoy being foster parents; who can accept the individuality of each child; who give of themselves without expecting immediate returns; who have satisfactory interpersonal relationships; who have emotional stability and are able to function in relation to family responsibilities and employment; who have maturity and good physical health to enable them to provide appropriate care for children; who have a reputable character, values and ethical standards conducive to the well-being of children; who show flexibility in their ability to change their expectations, attitudes and behavior in relation to the needs and problems of children; who show ability to help in meeting problems of family living; to recognize the need for and who have the ability to accept a child’s relationship with his/her parents or a social agency or both.

2. The foster parent-child ratio shall be at least one to six (1:6).

3. Relationships between all members of the foster family shall be such as to assure a favorable influence and atmosphere for the children accepted for care.

4. There shall be agreement among the members of the foster family as to the advisability of the sharing of their home for twenty-four (24)-hour care with a group of children not related to the family.

5. The foster family shall be economically self-sufficient.

6. At least three (3) nonrelated references shall attest to the characteristics, motivations and abilities of the foster family offering twenty-four (24)-hour care to children.

7. Health of foster family group home members.

A. All members of the foster family and employed staff shall pass a complete physical examination within six (6) months prior to application. Their physician shall provide a statement that each employee or member of the family is free from communicable disease. A tuberculin test and/or chest X ray shall be completed if recommended by the physician.

B. All members of the foster family and employed staff must be determined by a physician to be in good physical and mental health. The licensing agency shall review the examination reports.

C. After initial licensure, a physical examination is required every two (2) years.

If the licensing agency has reason to question the physical or mental health of any member of the foster family or employed staff, the agency may require a mental or physical examination more frequently.

8. A foster family shall care for a maximum of twelve (12) children, including any children of the foster family. The number of children in residence at any given time shall not exceed the number for which it is licensed.

9. At least one (1) foster parent shall not be gainfully employed.

(B) Care of the Child in the Group Home.

1. Provision for any indicated services shall be made available to the children in the group home. Services include: family counseling; preventive and therapeutic medical services; psychological services; psychiatric services; remedial education; vocational counseling; recreation; and any other indicated social services.

2. Physical care.

A. Responsibility for medical and dental care shall be negotiated between the placing agency and group facility before admission of the child to the group facility.

(I) Provision shall be made for the services of licensed physician.

(II) Provision shall be made for hospital care when recommended by a physician.

(III) Provision shall be made for the correction or treatment of all remedial defects.

(IV) Children shall have a complete physical examination, including any necessary tests or inoculations, immediately before admission and at least annually thereafter.

Results of the physical examinations shall be on file in the group home.

(V) Children shall have annual dental examinations and any necessary correction of teeth or mouth shall be begun.

(VI) First-aid equipment shall be readily available and foster parents shall be knowledgeable of its use.

B. Hygiene. A routine shall be established to insure good hygiene.

C. Nutrition.

(I) Food of good quality and quantity shall be served and meet Department of Health’s dietary standards.

(II) All foods shall be from sources approved by the Department of Health. All milk shall be pasteurized.

(III) Nourishing between meal snacks shall be provided and may be part of the daily food needs.

(IV) A regular meal schedule shall be established.

(V) At all times food shall be prepared, served and stored under the conditions acceptable to Department of Health’s rules.

D. Clothing.

(I) Clothing provided to children shall be of good quality and quantity.

(II) Clothing worn by children in group homes shall be similar to that worn by children in average homes in the community.

(III) Children should be allowed to participate in the selection of their own clothing.

3. Education.

A. The group home shall observe the legal requirements regarding school attendance and child labor.

B. Educational experience or appropriate training opportunities, or both, shall be made available to all children in group homes.

4. Moral and religious training. Children shall be given the opportunity to attend the church of their choice, subject to parental approval of the biological parents.

5. Discipline.

A. Discipline shall be used in a constructive, fair and consistent manner.

B. All discipline shall be reasonable and related to the individual needs and behavior of the child.

C. No cruel or unusual forms of punishment shall be used; for example, no child shall be confined in any dark spaces.

D. Corporal punishment shall be not used.

E. Children shall not be deprived of meals as punishment.

6. Recreation and leisure. The group home shall provide for leisure time programs and activities.

7. Earning and spending money.

A. Children shall be provided with opportunities for experience in earning or spending money or both based on age and individual requirements.

B. Allowances shall be provided when opportunities to earn money are not available.

8. Supervision.

A. Adult supervision shall be available at all times. When there are more than six (6) children in residence with only one (1) foster parent, there shall be a plan for an assistant to be on call if there is an emergency.

B. It is recommended that the foster parents provide for relief help in order that they may have some time away from the children and for themselves alone. Meeting the constant demands in daily care in a group of children can be an exhausting and exacting business. Time off allows for rest and the ability to remain alert and responsive.

9. Transportation. If children are transported in the foster family car, provision shall be made for proper insurance coverage.

Safety locks on doors and a seat belt for each child should be provided.

(C) Physical Facility.

1. General requirements.

A. The group home shall be in a neighborhood that is readily accessible to school, recreational, religious and other community resources. Suitable indoor and outdoor play space shall be available to children of the appropriate age.

B. All buildings and immediate surroundings used in whole or in part as a group home shall comply with all applicable state and local building, sanitation, zoning, fire and safety regulations.

C. The group home shall be large enough to provide living accommodations for all residents and shall be suitably furnished and equipped.

D. The group home shall be kept in sanitary condition and good repair.

E. Safe water supply and sewage facilities shall be provided and shall comply with Department of Health’s requirements.

F. The home shall be effectively safeguarded against insects and rodents.

G. Heating, electrical, ventilating and other mechanical systems, home appliances and outlets shall be designed and maintained so that under normal conditions of use danger to the health and safety of the children from that equipment will be held to a minimum.

H. All rooms shall be well-lighted and ventilated.

4CODE OF STATE REGULATIONS

(12/31/01) MATTBLUNT

I. There shall be a minimum of two (2) toilets for the children and one (1) tub or shower for each six (6) children. Separate bathing and toilet facilities should be provided for boys and girls where practical.

J. Dining facilities shall be provided with space and equipment to serve all residents at the same time.

K. The kitchen shall be equipped to provide for food preparation, storage and service.

L. A telephone shall be provided with emergency instructions posted nearby for fire, police and medical assistance.

M. The foster family shall have a plan for evacuation of the group home in case of fire. Written instructions for evacuation should be posted in a conspicuous place and fire drills shall be held monthly to assure efficient evacuation of the facility in case of emergency. Children shall be instructed in the evacuation plan at time of admission.

2. Sleeping rooms.

A. Children of different sex shall not sleep in the same room.

B. All sleeping rooms shall be outside rooms and shall be above the lowest level of the ground.

C. Each child shall have a separate bed with a space of at least three feet (3') on all sides of the bed except where it touches the wall.

D. Third floor level sleeping quarters shall be prohibited.

E. Sleeping rooms shall be so located that night supervision will be available at all times.

F. Separate, accessible drawer space for personal belongings and closet space for clothing shall be available for each child.

(D) Records and Reports.

1. Records shall be kept to identify each child and to enable communication with the parents or person responsible for the child in the foster family group home and in an emergency situation. These shall include: child’s name, birth date and the date of admission; full name of both parents, or person or agency responsible for the child, family’s home address, work addresses, hours of work and telephone numbers; a written plan which outlines the steps necessary to obtain emergency care for the child and a written consent from the parent, person or agency responsible for the child giving permission to proceed with any routine and ordinary medical care; instructions for reaching the parent(s), guardian or agency; name, address and telephone number of the child’s or family’s physician or both; financial arrangements with the parents or others, including the rate of pay for care; record of all physical examinations, immunizations and other pertinent health information; record of any accidents, illnesses or unusual situation.

2. Reports to the division shall be submitted as required.

(3) Rules for Independent and Satellite Group Homes.

(A) Incorporation and Bylaws. The group home or its parent body shall be incorporated. Bylaws shall be written and usually include the following:

1. General function of the organization as stated in the articles of incorporation;

2. Frequency, time and place of meetings, requirements regarding board members’ attendance at meetings and number necessary for a quorum;

3. Size, selection, duties and organization of the board of directors;

4. Appointment and duties of committees and staff; and 5. Provision for changes in the bylaws.

(B) The Board of Directors.

1. Every independent group home or parent agency of a satellite group home shall have a governing board which is representative of the community. The sources of an independent group home or satellite group home’s financing, the geographical area it encompasses and the groups that it serves determine to some extend the desirable composition of its board.

2. The board shall meet as often as necessary to conduct the business of the agency, but at least three (3) times annually.

3. Functions of the board shall include:

A. Selection and appointment of a well-qualified administrator to provide a program for children according to policies set forth by the board.

B. Responsibility for funding a quality program;

C. Responsibility for formulating and reviewing the general program plans and policies of the group home: operating procedures such as intake, release and day-to-day operations of the group home; job descriptions and responsibilities of all staff; personnel policies which include action to be taken regarding hiring, suspension, termination and any appeal procedures available; and D. Good public relations through presentation and interpretation of the group home’s services.

(C) Finances.

1. There shall be financial resources which will provide a quality program of services for the group home.

2. Annual financial statements prepared by a certified public accountant shall be made available to the division upon request. The division shall hold all these statements confidential.

3. A budgetary estimate for each year shall be prepared and approved by the board before the beginning of each year.

(D) Personnel and Personnel Practices.

Administration shall establish personnel policies and practices in compliance with the following guidelines:

1. Administrator or project director.

When an administrator or project director is appointed by the board of directors, s/he shall— A. Be qualified by education, training or experience or both in the child care field;

B. Have administrative ability and be in full charge of management of the group home in accordance with policies and procedures established by the board;

C. Be a person of sound judgment;

D. Be temperamentally adapted to work with children;

E. Attend board meetings, participate in the formulation of policies and procedures and make reports regularly to the board;

F. Assume responsibility for interpretation to the board of all appropriate state laws and rules for child caring facilities;

G. Provide opportunity for the continued education and professional growth of staff; and H. Be responsible for establishing and maintaining good working relationships with other social agencies and, along with the board members, provide interpretation of the group home’s program to the community;

2. Social work staff.

A. The group home or parent agency shall have the responsibility to see that social services are provided to each child in care and his/her family.

B. If a social worker is employed by the group home, s/he, as a minimum, shall have graduated from an accredited four (4)year college or university. Supervision or consultation shall be provided by an individual who has achieved a graduate degree in social work or related behavioral sciences;

3. Child care staff. In the recruitment and selection of child care staff, careful consideration shall be given tot he implications of having staff’s biological children living in the group home.

A. Desirable qualifications are—a genuine liking for young people and some understanding of their problems; practical experience in working with children; the ability to give of themselves without demanding a warm response from the children; good physical health with no disqualifying physical or mental handicaps; emotional maturity; flexibility; a sense of humor; commitment to helping problem youth; the ability to tolerate demanding and sometimes annoying behavior; the ability to set limits and have reasonable expectations of the children; the ability to work with the administrator or project director and other staff members to understand and evaluate the children to make plans for the child’s treatment or living program, and to carry out these plans; and the ability to communicate effectively with the children’s parents and community groups.

B. Child care staff shall be at least twenty-one (21) years of age.

C. Child care staff shall have at least two (2) work days off during each seven (7)day period;

4. Staff/child ratio. Provision shall be made for no less than one (1) staff member for each six (6) children in care and for at least one (1) adult to be available at all times;

5. Staff development.

A. Regularly scheduled inservice training sessions shall be established for staff and volunteers.

B. Additional learning experiences should be made available through various resources such as workshops, seminars and child care associations;

6. Personnel policies and records.

A. Written minimum qualifications as outlined in subsection (3)(D) for each staff position shall be established and maintained on file.

B. Each staff member shall receive a written job description.

C. Personnel records shall be maintained on each staff member and shall include job application; reports from references and former employer; the required annual health report; and an annual evaluation prepared by the immediate supervisor;

7. Volunteers.

A. Services to be provided by the volunteers shall be specifically defined.

B. Volunteers shall receive training and supervision from a qualified staff member; and 8. Health requirements for staff.

A. Any person who is suffering from a communicable disease shall not be employed.

B. All staff members having direct contact with children shall have a physical examination before employment and annually thereafter. A statement regarding the health status of each such employee shall be signed by a licensed physician and be on file.

C. Each staff member shall have a yearly tuberculin skin or chest X ray, tests for venereal diseases and any other indicated laboratory procedures.

(E) Program.

1. Intake policies.

A. Intake policies and procedures shall be written and shall include acceptable referral sources, admission criteria and other forms or reports necessary before a child is considered for placement. Admission procedures, policies and planning shall include preparation of the child and parents as appropriate with preadmission visits planned for both parent and child whenever possible.

B. The division shall review the criteria for admission for its appropriateness to the program of the group home.

C.Criteria for admission to a group home shall include the following:

(I) The appropriate age range and sex for the facility in question;

(II) Able to benefit from and contribute to a group living experience;

(III) Able to attend school or be employed in the community, able to utilize community resources and to move about the community freely with a minimum of supervision;

(IV) Preschool age children shall not be admitted except on an emergency basis not to exceed a period of thirty (30) days, unless the children are members of a sibling group and it is considered to be in their best interest to remain together.

D. The number of children in residence at any given time shall not exceed the number for which the facility is licensed.

E. Written provision for medical care shall be required from the person legally responsibility for the child.

F. Visitation policy shall be clearly written and available to both parent and child before or at time of admission.

G. Information shall not be released on the child without permission from the person legally responsible for the child.

2. Plan of services for the child and family. The group home shall collaborate with the child, parent, referring agency or parent agency in preparing a written plan for services for the child and family. This plan for services shall include:

A. A statement of goals and objections for providing services to the child and family including social work services on a regular basis for each child; responsibilities assumed by parents, agency and court and tentative plans for discharge;

B. Provision for services needed by the child and family where indicated including: family counseling; preventive and therapeutic medical services; psychological services; psychiatric services; remedial education; vocational counseling, recreation; and any other indicated social services;

C. Regular review of plans for the services for the child and family at least every six (6) months;

D. Release of a child shall be part of a well-planned, individualized program with the decision being made in a conference with appropriate staff or other group home representative, the referring or parent agency and the child’s family; and E. The group home should make arrangement with the referring agency to assure aftercare services to the child in his/her new environment.

3. Records and reports.

A. Care records.

(I) Every group home shall keep on file a record of each child’s birth date, correct name, names of parents and relatives and name of the contact person with the referring agency.

(II) The record shall also provide a health history of the child, including immunizations and an account of any illness or injury suffered while in care of the group home.

(III) The record shall include a statement regarding plan of services for the child and his/her family.

(IV) There shall be a school record.

(V) There shall be information in the record concerning the child’s release.

This should include the date of discharge, the name, address and relationship of the person(s) taking him/her and the circumstances of release.

(VI) The records shall be confidential.

B. Every group home shall keep accurate listings of children in care and statistical reports that give the complete scope of the services provided.

C. All records and reports shall be available upon request to any authorized licensing agent of the division. Records may be destroyed three (3) years after the date of the child’s discharge.

(F) Care in the Group Home.

1. Physical care.

A. Responsibility for medical and dental care shall be negotiated between the placing agency and group facility before admission of the child to the group facility.

(I) Provision shall be made for the services of a qualified physician licensed in the state of Missouri.

(II) Provision shall be made for hospital care when recommended by a physician.

(III) Provision shall be made for the correction or treatment for remediation of defects.

6CODE OF STATE REGULATIONS

(12/31/01) MATTBLUNT

(IV) Provision shall be made for a physical examination, tests or inoculations for each child immediately before admission and at least annually thereafter. Results of the physical examination shall be on record in the group home for these children and for any child placed by a parent agency.

(V) Provision shall be made for an annual dental examination for each child.

(VI) First-aid equipment shall be readily available and child care and other staff shall be knowledgeable of its use.

(VII) Health education and preventative medical care should be a major part of the health services.

B. Hygiene. A routine shall be established to insure good personnel hygiene.

C. Nutrition.

(I) Food of good quality shall be served and meet Department of Health’s standards.

(II) All foods shall be from sources approved by the Department of Health. All milk shall be pasteurized.

(III) Nourishing between-meal snacks shall be provided and may be part of the daily food needs.

(IV) A regular meal schedule shall be established.

(V) At all times food shall be prepared, served and stored under conditions acceptable to Department of Health’s rules.

D. Clothing.

(I) Clothing provided to children shall be of good quality and quantity.

(II) Clothing shall be similar to that worn by children in average homes in the community.

(III) Children should be allowed to participate in the selection of their own clothing.

2. Education.

A. The group home shall observe the legal requirements regarding school attendance and child labor.

B. Educational experience or appropriate training opportunities or both shall be made available.

3. Moral and religious training.

Children shall be given the opportunity to attend the church of their choice, subject to parental approval.

4. Discipline.

A. Discipline shall be used in a constructive, fair and consistent manner.

B. All discipline shall be reasonable and related to the individual needs of the child.

C. No cruel or unusual forms of punishment shall be used, for example, no child shall be confined in any dark spaces.

D. Corporal punishment shall not be used.

E. Children shall not be deprived of meals as punishment.

5. Recreation and leisure. The group home shall provide leisure time activities.

6. Earning and spending money.

A. Children shall be provided with opportunities for experience in earning or spending money or both based on age and individual requirements.

B. Allowances shall be provided when opportunities to earn money are not available.

(G) Physical Facility.

1. General requirements.

A. The group home shall be in a neighborhood that is readily accessible to school, recreational, religious and other community resources.

B. All buildings and immediate surroundings used in whole or in part as a group home shall comply with all applicable state and local building, sanitation, zoning, fire and safety regulations.

C. The facility shall be of a size to provide living accommodations for all residents, including separate and comfortable quarters for child care staff. The facility shall be suitably furnished and equipped.

D. The facility shall be kept in sanitary condition and good repair.

E. Safe water supply and sewage facilities shall be provided and shall comply with Department of Health’s requirements.

F. The home shall be effectively safeguarded against insects and rodents.

G. Heating, electrical, ventilating and other mechanical systems, home appliances and outlets shall be designed and maintained so that under normal conditions of use, danger to the health and safety of the children from that equipment will be held to a minimum.

H. All rooms shall be well-lighted and ventilated.

I. There shall be minimum of one (1) toilet for every four (4) children and one (1) tub or shower for each six (6) children.

Separate bathing and toilet facilities should be provided for boys and girls where practical. There should also be separate toilet facilities for child care staff.

J. Dining facilities shall be provided with space and equipment to serve all residents.

K. The kitchen shall be equipped to provide for food preparation, storage and service.

L. A telephone shall be provided with emergency instructions posted nearby for fire, police and medical assistance.

M. Written fire drill procedures should be posted in a conspicuous place. Fire drills shall be held monthly. Children shall be instructed in the evacuation plan at time of admission.

2. Sleeping rooms.

A. Children of different sex shall not sleep in the same room.

B. All sleeping rooms shall be outside rooms and shall be above the lowest level of the ground.

C. Each child shall have a separate bed with a space of at least three feet (3') on all sides of the bed except where it touches the wall.

D. Third floor level sleeping quarters shall be prohibited.

E. Sleeping rooms shall be so located that night supervision will be available at all times.

F. Separate, accessible drawer space for personal belongings and closet space for clothing shall be available for each child.

(H) Hearing and Judicial Review.

1. Entitlement to a hearing and review.

Any person or organization aggrieved by a final decision of the division with regard to the license issuance, license revocation or license denial shall be entitled to a hearing and review by the director or his/her designee.

2. Written notice and request for hearing. Ten (10) days’ written notice, specifying reason for proposed revocation shall be given an agency before a revocation occurs. If a request for a hearing, either written or verbal is received within the ten (10)-day period, revocation shall not occur until the decision of the director is issued.

3. Appeal of administrative decision.

Any agency wishing to appeal the administrative decision of the director shall be entitled to judicial review as provided in Chapter 536, RSMo.

March 12, 1976. Amended: Filed Oct. 13, 1982, effective Jan. 13, 1983. Amended:

Filed Oct. 7, 1987, effective March 25, 1988. Amended: Filed Sept. 11, 1989, effective Dec. 28, 1989. *Original authority: 210.481–210.536, see Missouri Revised Statutes.

History

• AUTHORITY: sections 210.481–210.536, RSMo 1986. Original rule filed Dec. 17, 1975, effective Dec. 27, 1975. Refiled:

Chapter 73 Licensing of Child Placing Agencies

13 CSR 40-73.015 Exemption of Child Placing Agencies From Licensure {#sec-13-csr-40-73.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.015}

13 CSR 40-73.060 Recommendation for Foster Homes Licensing {#sec-13-csr-40-73.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.060}

13 CSR 40-73.070 Placement of Children in Foster Family Homes JOHNR. ASHCROFT(3/31/19) {#sec-13-csr-40-73.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.070}

SOCIAL SERVICES

Placing Agencies

13 CSR 40-73.010 Definitions {#sec-13-csr-40-73.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.010}

(Moved to 13 CSR 35-73.010)

13 CSR 40-73.012 Basis for Licensure and Licensing Procedures {#sec-13-csr-40-73.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.012}

(Moved to 13 CSR 35-73.012)

13 CSR 40-73.015 Exemption of Child Placing Agencies From Licensure {#sec-13-csr-40-73.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.015}

(Rescinded April 30, 2019)

Filed Aug. 20, 2018, effective April 30, 2019.

History

• AUTHORITY sections 210.481–210.536, RSMo (1994) and (Cum. Supp. 1996). Original rule filed Oct. 7, 1987, effective March 25, 1988. Rescinded: Filed Jan. 14, 1997, effective July 30, 1997. Readopted: Filed Feb. 6, 1997, effective July 30, 1997. Rescinded:

13 CSR 40-73.017 Hearings and Judicial Review {#sec-13-csr-40-73.017 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.017}

(Moved to 13 CSR 35-73.017)

13 CSR 40-73.018 Court Review and Dispositional Hearing {#sec-13-csr-40-73.018 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.018}

(Rescinded April 30, 2019)

History

• AUTHORITY: sections 210.481–210.536, RSMo (1994) and (Cum. Supp. 1996). Original rule filed Feb. 6, 1997, effective July 30, 1997. Rescinded: Filed Aug. 20, 2018, effective April 30, 2019.

13 CSR 40-73.020 Organization and Administration {#sec-13-csr-40-73.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.020}

(Moved to 13 CSR 35-73.020)

13 CSR 40-73.030 Personnel Practices and Personnel {#sec-13-csr-40-73.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.030}

(Moved to 13 CSR 35-73.030)

13 CSR 40-73.035 Staff Qualifications and Requirements {#sec-13-csr-40-73.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.035}

(Moved to 13 CSR 35-73.035)

13 CSR 40-73.040 Operational Requirements {#sec-13-csr-40-73.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.040}

(Moved to 13 CSR 35-73.040)

13 CSR 40-73.050 Protection and Care of the Child {#sec-13-csr-40-73.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.050}

(Moved to 13 CSR 35-73.050)

13 CSR 40-73.055 Health Care {#sec-13-csr-40-73.055 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.055}

(Moved to 13 CSR 35-73.055)

13 CSR 40-73.060 Recommendation for Foster Homes Licensing {#sec-13-csr-40-73.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.060}

(Moved to 13 CSR 35-73.060)

13 CSR 40-73.070 Placement of Children in Foster Family Homes {#sec-13-csr-40-73.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.070}

(Moved to 13 CSR 35-73.070)

13 CSR 40-73.075 Foster Care Services {#sec-13-csr-40-73.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.075}

(Moved to 13 CSR 35-73.075)

13 CSR 40-73.080 Adoption Services {#sec-13-csr-40-73.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.080}

(Moved to 13 CSR 35-73.080)

13 CSR 40-73.090 Hearing and Judicial Review {#sec-13-csr-40-73.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-73.090}

(Rescinded July 30, 1997)

March 12, 1976. Amended: Filed Nov. 6, 1981, effective Feb. 11, 1982. Rescinded:

Filed Jan. 14, 1997, effective July 30, 1997.

History

• AUTHORITY sections 210.201–210.245, RSMo 1986. Original rule filed Sept. 18, 1956, effective Sept. 28, 1956. Refiled:

Chapter 79 Domestic Violence Shelter Tax Credit

13 CSR 40-79.010 Domestic Violence Shelter Tax Credit {#sec-13-csr-40-79.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-79.010}

(Moved to 13 CSR 10-3.040)

Chapter 80 Maternity Home Tax Credit

13 CSR 40-80.010 Maternity Home Tax Credit {#sec-13-csr-40-80.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-80.010}

(Rescinded March 30, 2019)

rule filed May 26, 1998, effective June 11, 1998, expired Feb. 25, 1999. Original rule filed May 26, 1998, effective Nov. 30, 1998.

Amended: Filed Sept. 1, 1999, effective April 30, 2000. Rule currently filed as 13 CSR 10- 3.050. Rescinded: Filed July 19, 2018, effective March 30, 2019.

History

• AUTHORITY: sections 135.600, RSMo Supp. 1998 and 207.020, RSMo 1994. Emergency

Chapter 81 Vendor Payment for Medical Care Services

13 CSR 40-81.012 Five Prescription Limit Per Month Per Recipient {#sec-13-csr-40-81.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.012}

(Moved to 13 CSR 70-20.040). 5

13 CSR 40-81.013 Missouri Nonsteridal Anti-Inflammatory Drug List {#sec-13-csr-40-81.013 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.013}

(Moved to 13 CSR 70-20.100)

13 CSR 40-81.014 Medicaid Program Coverage of Approved Drugs for Treatment of Acquired Immunodeficiency Syndrome(AIDS) {#sec-13-csr-40-81.014 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.014}

(Moved to 13 CSR 70-20.110) ...............

13 CSR 40-81.015 Payment for Early Periodic Screening, Diagnosis and Treatment Program Services {#sec-13-csr-40-81.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.015}

(Moved to 13 CSR 70-25.110). ....................................... .

13 CSR 40-81.020 Method of Filing Claim for Drug Payment {#sec-13-csr-40-81.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.020}

(Rescinded February 11, 1980) ........

13 CSR 40-81.030 Labeling of Medicaid Prescriptions {#sec-13-csr-40-81.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.030}

(Moved to 13 CSR 70-20.080).

13 CSR 40-81.035 Medicaid Program Benefits for Human Organ and Bone Marrow Transplants and Related Medical Services {#sec-13-csr-40-81.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.035}

(Moved to 13 CSR 70-2.200) ......................... 13 CSR /10-81.040 Dental Benefits and Limitations, Medicaid Program 13 CSR 70-35.010)

13 CSR 40-81.045 Medicaid Program Benefits for Nurse-Midwife Services {#sec-13-csr-40-81.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.045}

(Moved to 13 CSR 7055.010)

13 CSR 40-81.050 Inpatient Hospital Services Reimbursement Plan; Outpatient Hospital Services Reimbursement Methodology {#sec-13-csr-40-81.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.050}

(Moved to 13 CSR 70-15.010). ............

13 CSR 40-81.051 Limitations on Payment for Inpatient Hospital Care 13 CSR 70-15.030) {#sec-13-csr-40-81.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.051}

13 CSR 40-81.052 Second Opinion Requirement Before Nonemergency Elective Surgical Operations {#sec-13-csr-40-81.052 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.052}

(Moved to 13 CSR 70-3.1 IO).. ., _. . . . . .5

13 CSR 40-81.053 Inpatient ‘Hospital Psychiatric Services for Individuals Under Age Twenty-One {#sec-13-csr-40-81.053 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.053}

(Moved to 13 CSR 70-15.070)

13 CSR 40-81.054 Copayment and Coinsurance for Certain Medicaid-Covered Services {#sec-13-csr-40-81.054 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.054}

(Moved to 13 CSR 70-4.050).

13 CSR 40-81.055 Copayment for Pharmacy Services {#sec-13-csr-40-81.055 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.055}

(Moved to 13 CSR 70-4.051) ....................

13 CSR 40-81.056 Home Health Care Services {#sec-13-csr-40-81.056 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.056}

(Moved to 13 CSR 70-90.010). ..........................

13 CSR 40-81.057 Home Health Care Services Reinbursement {#sec-13-csr-40-81.057 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.057}

(Moved to 13 CSR 70-90.020). .......

13 CSR 40-81.060 Obtaining Information From Providers of Medical Services {#sec-13-csr-40-81.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.060}

(Moved to 13 CSR 70-3.050).

13 CSR 40-81.070 Length of Time for Submitting Claims {#sec-13-csr-40-81.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.070}

(Rescinded April 11, 1980).

13 CSR 40-81.071 Timely Filing and Processing of Claims, Medicaid Program {#sec-13-csr-40-81.071 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.071}

(Moved to 13 CSR 70-3.100).

13 CSR 40-81.080 Reasonable Cost-Related Reimbursement Plan for Long-Term Care {#sec-13-csr-40-81.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.080}

(Moved to 13 CSR 70-10.005) ............................................................. .5

13 CSR 40-81.081 Prospective Reimbursement Plan for Long-Term Care {#sec-13-csr-40-81.081 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.081}

(Moved to 13 CSR 70-10.010)

13 CSR 40-81.082 Limitation on Allowable Capital Cost Overruns for New Institutional Health Services in Title XIX Reimbursement Rate Setting {#sec-13-csr-40-81.082 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.082}

(Moved to 13 CSR 70-10.100)

13 CSR 40-81.083 Prospective Reimbursement Plan for Nonstate Operated Facilities for ICF/MR Services {#sec-13-csr-40-81.083 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.083}

(Moved to 13 CSR 70-10.030). .................................

13 CSR 40-81.084 Evaluation and Assessment Measures for Title XIX Residents in Long-Term Care Facilities {#sec-13-csr-40-81.084 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.084}

(Moved to 13 CSR 15-9.030) .......................... .5

13 CSR 40-81.085 Prospective Reimbursement System for Long-Term Care {#sec-13-csr-40-81.085 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.085}

(Rescinded August 11, 1984). ............................................................... .

13 CSR 40-81.086 Preadmission Screening {#sec-13-csr-40-81.086 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.086}

(Moved to 13 CSR 15-9.020) .................................

13 CSR 40-81.090 Duty of Medicaid Participating Hospitals and Other Vendors to Assist in Recovering Third Party Payments {#sec-13-csr-40-81.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.090}

(Moved to 13 CSR 70-3.040) ................. .5

13 CSR 40-81.092 Required Reporting of Injuries Received by Title XIX Recipients {#sec-13-csr-40-81.092 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.092}

(Moved to 13 CSR 70-4.060).

13 CSR 40-81.100 Abortions ........................................................................................ ;.,, {#sec-13-csr-40-81.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.100}

13 CSR 40-81.101 Abortions {#sec-13-csr-40-81.101 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.101}

(Moved to 13 CSR 70.2,5.100) .................................................

13 CSR 40-81.110 Quality Standards for Approving Manufacturers for the Medicaid Drug Program {#sec-13-csr-40-81.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.110}

(Rescinded January 12, 1980). ..................................................

13 CSR 40-81.120 Hearing Aid Program {#sec-13-csr-40-81.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.120}

(Moved to 13 CSR 70-45.010) .................................. .6

13 CSR 40-81.125 Personal Care Program {#sec-13-csr-40-81.125 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.125}

(Moved to 13 CSR 70-91.010). ................................

13 CSR 40-81.126 Adult Day Health Care Program {#sec-13-csr-40-81.126 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.126}

(Moved to 13 CSR 70-92.010) .....................

13 CSR 40-81.130

Podiatric Services Program (Moved to 13 CSR 70-30.010). ...........................

13 CSR 40-81.140 Procedures for Medical Services Provider Hearings {#sec-13-csr-40-81.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.140}

(Moved to 13 CSR 70-4.030) 6

13 CSR 40-81.141 Eligibility Corrective Action Recipient Payment {#sec-13-csr-40-81.141 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.141}

(Moved to 13 CSR 70-4.040) .... .6

13 CSR 40-81.150 Computer-Generated Drug Pricing Tape {#sec-13-csr-40-81.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.150}

(Moved to 13 CSR 70-20.070) ............

CSR 40-81.160 Sanctions for False or Fraudulent Claims for Title XIX Services Surgical Operations (Moved to 13 CSR 70-3.030) .....................................

13 CSR 40-81.161 Computation of Provider Overpayment by Statistical Sampling 13 CSR 70-3.130). ............................................................... {#sec-13-csr-40-81.161 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.161}

13 CSR 40-81.162 Procedures for Evaluation of Appropriate Hospital Admissions and Continued Days of Stay {#sec-13-csr-40-81.162 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.162}

(Moved to 13 CSR 70-15.090) ...............................

13 CSR 40-81.165 Title XIX Provider Enrollment {#sec-13-csr-40-81.165 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.165}

(Moved to 13 CSR 70-3.020). ........................

13 CSR 40-81.170 Optical Care Benefits and Limitations, Medicaid Program 13 CSR 70-40.010) {#sec-13-csr-40-81.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.170}

13 CSR 40-81.180 Payment Method for General Relief Recipient Hospital Outpatient Services 13 CSR 70-15.080) {#sec-13-csr-40-81.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.180}

13 CSR 40-81.181 Scope of Medical Services for General Relief Recipients 13 CSR 70-2.020). {#sec-13-csr-40-81.181 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.181}

13 CSR 40-81.190 Limitations on Payment of Out-of-State Nonemergency Medical Services 1~3 CSR 70-3.120). {#sec-13-csr-40-81.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.190}

13 CSR 40-81.195 Title XIX Procedure of Exception to Medical Care Services Limitations ,.--- 13 CSR 70-2.100). {#sec-13-csr-40-81.195 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.195}

13 CSR 40-81.200 Title XIX Recipient Lock-In Program {#sec-13-csr-40-81.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.200}

(Moved to 13 CSR 70-4.070) _. _. .6 CODE OF STATE REGULATKINS

Chapter El-Vendor Payment for Medical Care Services 13 CSR 40-81 Title 13-DEPARTMENT OF SOCIAL SERVICES Division 40-Division of Family Services

Chapter Sl-Vendok Payment for Medical Care Services . .

13 CSR 40-81.005 Organization and Description {#sec-13-csr-40-81.005 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.005}

(Moved fo 13 CSR 70-1.010)

13 CSR 40-81.010 List of Drugs Covered by Medicaid {#sec-13-csr-40-81.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.010}

(Moved to 13 CSR 70-20.030)

13 CSR 40-81.011 Participating Drug Vendors {#sec-13-csr-40-81.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.011}

(Moved to 13 CSR 70-20.010)

13 CSR 40-81.012 Five Prescription Limit Per Month Per Recipient {#sec-13-csr-40-81.012 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.012}

(Moved to 13 CSR 70-20.040)

13 CSR 40-82.013

Mi~issouri Nonsteroidal Anti-Inflammatory Drug List (Moved to 13 CSR 70-20.100)

13 CSR 40-81.014 Medicaid Program Coverage of Approved Drugs for lkeatment of Acquired lmmunodeficiency Syndrome (AIDS) {#sec-13-csr-40-81.014 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.014}

(Moved to 13 CSR 70-20.110)

13 CSR 40-81.015 Payment for Early Peri- _, odic Screenixg, Diagnosis and Treatment Program Services {#sec-13-csr-40-81.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.015}

(Moved to :3 CSR 70-25.110) 13 CSR 4L,-81.020 Method of Filing Claim for Drug .!?ayment (Rescinde,J February II, 1980)

13 CSR 40-81.030 Labeling of Medicaid Prescriptions {#sec-13-csr-40-81.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.030}

(Moved to 13 CSR 70-20.080)

13 CSR 40-81.035 Medicaid Program Benefits for Human Organ and Bone Marrow Transplants and Related Medical Services {#sec-13-csr-40-81.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.035}

(Moved to 13 CSR 70-2.200)

13 CSR 40-81.040 Dental Benefits and Limitations, Medicaid Program {#sec-13-csr-40-81.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.040}

(Moved to 13 CSR 70-35.010)

13 CSR 40-81.045 Medicaid Program Benefits for Nurse-Midwife Services {#sec-13-csr-40-81.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.045}

(Moved to 13 CSR 70-55.010)

13 CSR 40-81.050 Inpatient Hospital Services Reimbunement Plan; Outpatient Hospital Services Reimbursement Methodology {#sec-13-csr-40-81.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.050}

(Moved to 13 CSR 70-15.010)

13 CSR 40-81.051 Limitations on Payment for Inpatient Hospital Care {#sec-13-csr-40-81.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.051}

(Moved to 13 CSR 70-15.030)

13 CSR 40-81.052 Second Opinion Requirement Before Nonemergency Eke. tive Surgical Operations {#sec-13-csr-40-81.052 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.052}

(Moved to 13 CSR 70-3.110)

13 CSR 40-81.053 Inpatient Hospital Psychiatric Services for Individuals Under Age Twenty-One {#sec-13-csr-40-81.053 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.053}

(Moved to 13 CSR 70-15.070)

13 CSR 40-81.054. Copayment and Coinsurance for Certain Medicaid-Covered Services {#sec-13-csr-40-81.054. omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.054.}

(Moved to 13 CSR 70-4.050)

13 CSR 40-81.055 Copayment for Phannacy Services {#sec-13-csr-40-81.055 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.055}

(Moved to 13 CSR 70-4.051)

13 CSR 40-81.056 Home Health Care Se,.vices {#sec-13-csr-40-81.056 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.056}

(Moved to 13 CSR 70-90.010)

13 CSR 40-81.057 Home Health Care Services Reimbursement {#sec-13-csr-40-81.057 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.057}

(Moved to 13 CSR 70-90.020)

13 CSR 40-81.060 Obtaining Information From Providers of Medical Servicces {#sec-13-csr-40-81.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.060}

(Moved to 13 CSR 70-3.050)

13 CSR 40-81.070 Length of Time for Submitting Claims {#sec-13-csr-40-81.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.070}

(Rescinded April 11, 1980)

13 CSR 40-81.071 lamely Filing and Processing of Claims, Medicaid Program {#sec-13-csr-40-81.071 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.071}

(Moved to 13 CSR 70-3.100)

13 CSR 40-81.080 Reasonable Cost-Related Reimbursement Plan for Long-Term Cal2 {#sec-13-csr-40-81.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.080}

(Moved to 13 CSR 70-10.005)

13 CSR 40-81.081 Prospective Reimbursement Plan for Long-Term Care {#sec-13-csr-40-81.081 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.081}

(Moved to 13 CSR 70-10.010)

13 CSR 40-81.082 Limitation on Allowable Capital Cost Overruns for New Institutional Health Services in litle XIX Reimbursement Rate Setting {#sec-13-csr-40-81.082 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.082}

(Moved to 13 CSR 70-10.100)

13 CSR 40-81.083 Prospective Reimbursement PIan for Nonstate Operated Facilities for ICFIMR Services {#sec-13-csr-40-81.083 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.083}

(Moved to 13 CSR 70-10.030)

13 CSR 40-81.084 Evaluation and Assessment Measures for Title XIX Residents in Long-Term Care Facilities {#sec-13-csr-40-81.084 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.084}

(Moved to 13 CSR 15-9.030)

13 CSR 40-81.085 Prospective Reimbursement System for Long-Term Care {#sec-13-csr-40-81.085 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.085}

(Rescinded August 11, 1984)

13 CSR 40-81.086 Preadmission Screening {#sec-13-csr-40-81.086 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.086}

(Moved to 13 CSR 15-9.020)

13 CSR 40-81.090 Duty of Medicaid Participating Hospital and Other Vendon to Assist in Recovering Third party Payments {#sec-13-csr-40-81.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.090}

(Moved to 13 CSR 70-3.040)

13 CSR 40-81.092 Required Reporting of In&ies Received by Title XIX Recipients {#sec-13-csr-40-81.092 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.092}

(Moved to 13 CSR 70-4.060)

13 CSR 40-81.100 Abortions Emwency ndefiled July 7. 1977, effecdve July 17, 1977, expired Ocr. 15, I977 {#sec-13-csr-40-81.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.100}

13 CSR 40-81.101 Abortions {#sec-13-csr-40-81.101 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.101}

(Moved to 13 CSR 70-25.100)

Rebecca McDowell Cook (‘2,419,) seerefmy Of state a 13CSR40-81-SOCIALSERVICES Division 4LDivision of Family Services

13 CSR 40-81.110 Quality Standards for Approving Manufacturers for the Medicaid Drug Program {#sec-13-csr-40-81.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.110}

(Rescinded January 12, 1980)

13 CSR 40-81.120 Hearing Aid Program {#sec-13-csr-40-81.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.120}

(Moved to 13 CSR 70-45.010)

13 CSR 40-81.125 Personal Care Program {#sec-13-csr-40-81.125 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.125}

(Moved to 13 CSR 70-91.010)

13 CSR 40-81.126 Adult Day He&h Care Program {#sec-13-csr-40-81.126 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.126}

(Moved to 13 CSR 70-92.010)

13 CSR 40-81.130 Podiatric Services Prog=m {#sec-13-csr-40-81.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.130}

(Moved to 13 CSR 70-30.010)

13 CSR 40-81.140 Procedures for Medical Services Provider Hearings {#sec-13-csr-40-81.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.140}

(Moved to 13 CSR 70-4.030)

13 CSR 40-81.180 Payment Method for General Relief Recipient Hospital Outpa dent Services {#sec-13-csr-40-81.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.180}

(Moved to 13 CSR 70-15.080)

13 CSR 40-81.181 Scope of Medical Services for General Relief Recipients {#sec-13-csr-40-81.181 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.181}

(Moved fo 13 CSR 70-2.020)

13 CSR 40-81.190 Limitations on Payment of Out-of-State Nonemergency Medical SePiWS {#sec-13-csr-40-81.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.190}

(Moved to 13 CSR 70-3.120)

13 CSR 40-81.195 Title XIX Procedure of Exception to Medical Care Services Limitations {#sec-13-csr-40-81.195 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.195}

(Moved to 13 CSR 70-2.100)

13 CSR 40-81.200 Title XIX Recipient Lock-in Program {#sec-13-csr-40-81.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.200}

(Moved to 13 CSR 70-4.070)

13 CSR 40-81.141 Eligibility Corrective {#sec-13-csr-40-81.141 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.141}

Section Recipient Payments (Moved to 13 CSR 70-4.040)

13 CSR 40-51.150 Computer-Generated Drug Pricing Tape {#sec-13-csr-40-51.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-51.150}

(Moved to 13 CSR 70-20.070)

13 CSR 40-81.160 Sanctions for False or Fraudulent Claims for Title XIX Services {#sec-13-csr-40-81.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.160}

(Moved to 13 CSR 70-3.030)

13 CSR 40-81.161 Computation of Provider Overpayment by Statistical Sampling {#sec-13-csr-40-81.161 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.161}

(Moved to 13 CSR 70-3.130)

13 CSR 40-81.162 Procedures for Evaluation of Appropriate Hospital Admissions and Continued Days of Stay {#sec-13-csr-40-81.162 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.162}

(Moved to 13 CSR 70-15.090)

13 CSR 40-81.165 Title XIX Provider Enrollment {#sec-13-csr-40-81.165 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.165}

(Moved to 13 CSR 70-3.020)

13 CSR 40-81.170 Optical Care Benefits and Limitations, Medicaid Program {#sec-13-csr-40-81.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-81.170}

(Moved to 13 CSR 7040.010)

(214191)’ Rebecca McDowell Cook

Chapter 91 Rehabilitation Services for the Blind (RSB)

13 CSR 40-91.010 Business Enterprise for the Blind {#sec-13-csr-40-91.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-91.010}

PURPOSE: This rule establishes the guidelines for administration of the Business Enterprise Program of the Family Support Division, Bureau for the Blind, as mandated by the Randolph-Sheppard Act, as amended through 1974, 34 CFR 395, sections 8.051 and 8.700–8.745, RSMo.

(1) Legal Authority. The Business Enterprise Program (BEP) of the Family Support Division/Rehabilitation Services for the Blind is administered according to the Randolph-Sheppard Act, as amended through 1974, 34 CFR 361.50, 34 CFR 395, sections 8.051 and 8.700—8.745, RSMo. The Family Support Division/ Rehabilitation Services for the Blind administers the Business Enterprise Program according to the terms of this rule.

(2) Definitions.

(A) “Administrative fee” means an assessment against the operating income from direct sales in vending facilities, including income from manager-serviced vending machines and from commissions that vending companies pay on proceeds from vending machines located in facilities in which there is an on-site manager.

(B) “Assigned income” means income from commissions that vending companies pay to the nominee on proceeds from vending machines in vending facilities in which there is an on-site manager. The nominee disburses this income to the manager, according to subsection (15)(C).

(C) “Blind person” is a person whose central visual acuity is no more than twenty/two hundred (20/200) in the better eye with best correction or whose field of vision in the better eye is restricted to a degree that its widest diameter subtends an angle no greater than twenty degrees (20°).

(D) “Rehabilitation Services for the Blind” is the unit within the Family Support Division that administers the Business Enterprise Program. Rehabilitation Services for the Blind is referred to in this rule as RSB.

(E) “Business Enterprise Program” means the total vending facility program within the Family Support Division/ Rehabilitation Services for the Blind. The Business Enterprise Program is referred to in this rule as the BEP.

(F) “Cafeteria” means a full-line food service facility in which the food is prepared on-site.

(G) “Certificate of Training” means the certificate that RSB presents to a blind person who successfully completes vending facility manager training. The certificate indicates the level of the training which a blind person has completed and the level at which the state licensing agency (SLA) may license the blind person, as stated in subsection (2)(T).

(H) “Change fund loan” means an interest-free loan from the nominee to be used for the manager’s initial operating funds.

(I) “Convenience store” means a vending facility that has over-the-counter sales but does not have on-site food preparation that requires the manager to handle unpackaged products, except for hot and cold beverages.

(J) “Creditable service” means only those periods when a manager is employed as a full-time contracted BEP manager.

(K) “Deputy director” means the person in the Family Support Division/Rehabilitation Services for the Blind who directs the administration of all service programs of RSB and who is referred to in this rule as deputy director.

(L) “Direct competition” means the presence and operation of a vending machine or a vending facility operated by an entity other than a blind manager on the same premises as a vending facility operated by a blind manager. Vending machines or vending facilities operated in areas serving employees, the majority of whom normally do not have direct access, in terms of uninterrupted ease of approach and the amount of time required to patronize the vending facility, to the vending facility operated by a blind manager shall not be considered to be in direct competition with the vending facility that is operated by a blind manager.

(M) “Family Support Division” is the state licensing agency that is designated by the Secretary of the United States Department of Education to issue licenses to blind persons for the operation of vending facilities on federal, state, and other property. The Family Support Division is referred to in this rule as the SLA.

(N) “Equipment” means occupational fixtures, furnishings, machinery, tools, and accessories that are required in the operation of a vending facility. Equipment has a life of at least one (1) year and can be used repeatedly.

(O) “Executive committee of blind vendors” is the executive body that is elected by the Blind Vendors of Missouri, as discussed in section (6). Blind Vendors of Missouri is referred to in this rule as BVM.

(P) “Fair minimum return” means the amount RSB establishes as the minimum level of net income that a manager derives from a vending facility.

(Q) “Federal property” means any building, land, or other real property owned, leased, or occupied by any department, agency, or instrumentality of the United States, including General Services Administration, the Department of Defense, the Department of Energy, and the United States Postal Service, or any other instrumentality wholly owned by the United States.

(R) “Individual location,” “installation,” or “facility” means a single building or a self-contained group of buildings. In order for RSB to consider two (2) or more buildings to be a self-contained group of buildings, the buildings must be located in close proximity to each other and a majority of the employees housed in any of the buildings must move regularly from one (1) building to another in the course of official business during normal workdays.

(S) “Initial inventory” means the marketable merchandise and consumable supplies that RSB determines is necessary for a manager to begin operation of a new or substantially altered vending facility.

(T) “License” means the written instrument the SLA issues to a blind person and that confirms that person’s eligibility to operate a vending facility on federal, state, or other property.

A Level 1 license is for the management of vending machine banks in which all income is derived from commissions. A Level 2 license is for the management of convenience stores. A Level 2.5 license is for the management of a manager-serviced vending machine route or a convenience store. A manager-serviced vending machine bank requires a Level 2.5 license. A Level 3 license is for the management of vending machine banks, convenience stores, and snacks bars. A Level 4 license is for the management of vending machine banks, convenience stores, snack bars, and cafeterias. A Level 5 license is for the management of military dining. The SLA shall issue a license only to those blind persons who are citizens of the United States, whom RSB certifies, as defined in subsection (2)(G), as qualified to operate a vending facility, who have successfully completed a six- (6-) month probationary period as an active facility manager, and who are in need of employment.

(U) “Licensee” means a blind person to whom the SLA has issued a license to operate a vending facility on federal, state, or other property.

(V) “Management services” means supervision, inspection, quality control, consultation, accounting, regulating, in-service training, and other related services provided on a systematic basis to support and improve vending facilities operated by blind vendors. Management services do not include those services or costs that pertain to the ongoing operation of an individual vending facility after the initial establishment period.

(W) “Manager-serviced vending machines” means vending machines for which the manager is responsible for purchase of product, filling, and maintenance of the machines. The manager receives all revenue, less administrative fees, from sales and pays all operational expenses except for repair of vending machines.

(X) “Net income” means operating income plus income from commissions, less administration.

(Y) “Nominee” means a nonprofit corporation which, through a written agreement with the SLA, acts as the agent of the SLA in providing services to vending facility managers in the BEP.

(Z) “Normal working hours” means an eight- (8-) hour work period between the approximate hours of 6:00 a.m. to 6:00 p.m., Monday through Friday.

(AA) “Operating income” means income from operations, less operating expenses.

(BB) “Other property” means property which is not federal property or state property and on which the SLA establishes or operates vending facilities by the use of any funds derived in whole or in part, directly or indirectly, from the operation of vending facilities on federal or state property.

(CC) “Over-the-counter sales,” including “manager-serviced vending machines,” mean any transaction in which a customer purchases products which a manager has procured for the purpose of resale within the vending facility.

(DD) “Probationary period” means the first six (6) months of active facility management by a certified graduate of the BEP training program.

(EE) “Property management” means a person or instrumentality that grants a permit, contract, or agreement to the SLA for the operation of a vending facility at a specific location.

(FF) “Set-aside funds” means funds which accrue to the nominee from all unassigned income from vending machines located on federal property and from the administrative fee that the nominee assesses against the operating income from direct sales in all vending facilities and from the administrative fee that the nominee assesses against commissions paid by vending companies on vending machine proceeds in all vending facilities in which there is a manager on-site.

(GG) “Snack bar” means a vending facility with limited onsite food preparation and over-the-counter sales.

(HH) “State property” means all real property, or part of real property, that is owned, leased, rented, or otherwise controlled or occupied by any department, agency or body of the state of Missouri, including roadside rest areas, except property of Department of Mental Health. State property does not include a building in which less than one hundred (100) state employees are, or will be, located during normal working hours; a building in which less than fifteen thousand (15,000) square feet of interior floor space is to be used for state government purposes or in which services are to be provided to the public; or a building that state government employees are to occupy for less than three (3) years.

(II) “Supplies” means items that are expendable, necessary to carry out the day-to-day operation of a vending facility, and that are used on the premises.

(JJ) “Unassigned income” means income that accrues to the nominee from commissions that vending companies pay on proceeds from vending machines on federal, state, and other property in which there is no on-site manager. The nominee uses these funds for manager and program benefits according to subsection (15)(D).

(KK) “Vending facility” means a business that the SLA establishes for the sale of products. It may consist, exclusively or in combination, of automatic vending machines, convenience stores, snack bars, or cafeterias. A vending facility may consist of only a portion of a building, it may be comprised of one (1) or more locations within a building, and it may encompass more than one (1) building.

(LL) “Vending facility manager” means a blind person who has been licensed by the SLA and who has a Vending Facility Manager’s Agreement. Vending facility manager is referred to in this rule as manager.

(MM) “Vending Facility Manager’s Agreement” means a written document, entered into by the licensee, the SLA and the nominee that states the terms and conditions for the licensee to be on-site to operate a vending facility at a specific location.

Vending Facility Manager’s Agreement, a copy of which follows this rule, is referred to in this rule as manager’s agreement.

(NN) “Vending machine bank” means one (1) or more coin-operated or electronic transfer of funds vending machines that dispense articles or services and that are located in one (1) or more locations in one (1) or more buildings that RSB designates as a vending facility. Vending machine bank does not mean those machines that are operated by the United States Postal Services for the sale of postage stamps or other postal products and services, or machines located on federal property that provides services of a recreational nature.

(OO) “Vending machine income” means proceeds from vending machine operations on federal, state, or other property where the machines are operated, serviced, or maintained by, or with the approval of, a department, agency, or instrumentality of the United States, Missouri, or other public or private entity. Vending machine income also includes commissions that a commercial vending company pays to the nominee on proceeds from vending machines that the commercial vending company operates, services, and maintains on federal, state, or other property for, or with the approval of, a department, agency, or instrumentality of the United States, the state of Missouri, or other public or private entity.

(3) Nondiscrimination. The SLA and RSB shall administer the BEP without regard to race; color; religion; sex; national origin; veteran; secondary handicap; marital status; age; or political beliefs of blind persons who are manager applicants, trainees, licensees, or managers. The SLA and RSB shall administer the BEP without regard to race; color; religion; sex; national origin; veteran; handicap; marital status; age; or political beliefs of SLA or nominee employees and of contractors that provide goods or services to vending facilities.

(4) Responsibilities of RSB. RSB, as designated by the SLA, shall carry out the following activities in the administration of the BEP:

(A) RSB shall establish vending facilities on federal, state or other property. The Randolph-Sheppard Act, as amended through 1974, authorizes RSB to establish vending facilities on federal property. Sections 8.051 and 8.700–8.745, RSMo authorize RSB to establish vending facilities on state property.

RSB establishes vending facilities on other public or private property at the request of the public or private entity responsible for management of the property;

(B) RSB shall provide to each manager consultation and advice for developing sales techniques, merchandising and general operating of the vending facility, purchasing procedures, managerial methods or procedures to promote financial success, appearance and sanitation of the vending facility and required reporting procedures;

(C) RSB may act as liaison between the manager and property management, suppliers and patrons;

(D) RSB shall provide to each manager a copy of 34 CFR 395, 34 CFR 361.50, sections 8.051 and 8.700–8.745, RSMo and this

rule;

(E) RSB shall provide to each manager a written description of the arrangements for providing services and the manager’s agreement. If the facility is on federal property, RSB shall provide to the manager a copy of the permit that covers the operation of the vending facility. If the vending facility is not on federal property, RSB shall provide to the manager written documentation of the responsibilities of the manager, the SLA and property management in relation to operation of the vending facility. At the request of a manager, RSB shall arrange a convenient time to explain these documents to each manager;

(F) RSB shall provide to each manager access to all program and financial data of the SLA and the nominee that is relevant to the operation of the BEP. The data shall include monthly and annual financial reports; provided that this disclosure does not violate applicable federal or state laws pertaining to the disclosure of confidential information. To the extent possible, RSB shall provide these data to each manager in the manager’s preferred reading medium. At the request of a manager, RSB shall arrange a convenient time to assist in the interpretation of the data;

(G) RSB shall provide the Blind Vendors of Missouri (BVM) executive committee with advance written notice of matters that the executive committee will consider and of meetings that the executive committee or other managers should attend; and (H) RSB, through the authority designated to it by the SLA, shall have the ultimate responsibility for the administration of the BEP, including the expenditure of all federal and state funds, funds that are paid to the nominee by vending facility managers and funds that accrue to the nominee from commissions that vending companies pay on vending machine proceeds. RSB shall consult with the executive committee regarding program issues. If RSB does not adopt the recommendations of the executive committee, RSB shall notify the executive committee in writing of the decision RSB reaches and the reason(s) for the decision.

(5) Responsibilities of the Blind Vendors of Missouri. All active managers in the BEP are members of the Blind Vendors of Missouri, an organization whose membership is limited to managers in the BEP. This organization, which meets at least one (1) time and no more than two (2) times each year, nominates individuals from its membership to serve on the executive committee of blind venders, which is referred to in this

rule as the executive committee. The executive committee, to the extent possible, is representative of all managers in the BEP and functions throughout the year in behalf of all managers.

(A) Meeting(s) of BVM. A quorum at any meeting of this organization shall consist of one-third (1/3) of the membership; provided, two (2) officers are present. The meeting held annually in June is referred to as the annual meeting of the organization.

All meetings of the BVM shall be conducted under Robert’s Rules of Order.

(B) Nomination of Executive Committee Members. RSB shall provide that, prior to the annual meeting of the BVM, a nomination ballot is sent to each manager that contains the names of all managers in the BEP who are eligible for election to positions on the executive committee that become vacant at the time of the annual meeting. To be eligible a person must be a licensed contract manager in good standing. After receipt of all nomination ballots, RSB shall compile an election ballot that contains for each position the names of the two (2) managers who received the most nominative votes. If there is a three- (3-) way tie, a run-off election will be held at the annual meeting, prior to the general election, to establish the top two (2) candidates.

(C) Election of Executive Committee Members. At the annual meeting of the BVM, RSB shall provide for the managers in attendance to elect, by secret ballot, a manager to fill each vacant position on the executive committee. The manager who receives the most votes for each position assumes the elective office at the conclusion of the annual meeting. Each of the five (5) members and one (1) alternate shall serve a term of two (2) years and shall not be eligible for election to the same office for more than two (2) consecutive terms.

(D) Any executive committee member who misses two (2) consecutive executive committee meetings (unless due to a personal or family emergency) will be dropped from the committee. The alternate board member shall succeed to active board member status until the next annual meeting of the BVM is held. The executive committee will function without an alternate until the annual election. If the exiting member held an officer position, the members of the executive committee shall elect, from the committee, an individual to function in that officer position until the next annual meeting when the general membership will vote for a replacement to fill the unexpired term.

(6) Responsibilities of the Executive Committee of Blind Vendors of Missouri. The committee shall meet as often as is necessary, as determined by RSB and the executive committee, to carry out the following responsibilities:

(A) To participate actively with RSB in major administrative, policy and program decisions that affect the overall administration of the BEP;

(B) To participate actively with RSB in the development and administration of a system for the selection, transfer and promotion of managers;

(C) To participate actively with RSB in developing training and retraining programs for managers;

(D) To receive and transmit grievances from managers to RSB;

(E) To serve as advocates for managers in grievance proceedings;

(F) To sponsor, with the assistance of RSB and the nominee, meetings and instructional conferences for managers;

(G) To designate, as necessary, subcommittees or individual members to carry on the functions of the executive committee between meetings of the entire executive committee;

(H) All meetings of the executive committee shall be conducted under Robert’s Rules of Order.

(7) Responsibilities of the Nominee. The SLA may enter into a written agreement with a nominee to act as its agent in the administration of the BEP. The responsibilities of the nominee include:

(A) The nominee shall collect from each manager and promptly deposit in a designated bank an administrative fee, as defined in subsection (2)(A);

(B) The nominee shall collect and promptly deposit in designated banks all commissions paid on vending machine proceeds. The nominee shall maintain separate accounts for the restricted and unrestricted fund revenue;

(C) As funds are available, the nominee shall disburse setaside funds at the direction of RSB and for the purposes stated in subsection (12(B);

(D) As funds are available, the nominee shall disburse unassigned income from vending machines located on nonfederal property at the direction of RSB and for the purposes stated in subsection (15)(D); and (E) The nominee shall maintain records which accurately reflect all transactions of the nominee and shall make available all records that are required for audits that may be conducted by federal or state auditors or private auditors that the nominee retains to conduct annual or special audits.

(8) Vending Facility Manager Training. RSB shall train a vending facility manager through the following procedures:

(A) Application for Training. Any person who is a vocational rehabilitation client of RSB may request a determination of eligibility to enter manager training. RSB shall meet the cost of manager training with vocational rehabilitation case service funds, within the guidelines stated in 13 CSR 40-91.020;

(B) Criteria for Acceptance for Manager Training. A vocational rehabilitation client who is accepted for manager training shall undergo a criminal background check and shall meet the following criteria:

1. Is legally blind; and 2. Is a citizen of the United States;

(C) Responsibilities of the Manager Trainee.

1. Trainees are expected to be punctual, present a clean, well-groomed appearance, be attentive, and conduct themselves in a professional manner.

2. If the trainee displays any of the following behaviors, training may be suspended immediately, with the recommendation to the training director and vocational rehabilitation counselor for termination to be effected as soon as possible:

A. Insubordination;

B. Inability to control temper or emotional outbursts;

C. Abuse of alcohol or use of illegal drugs;

D. Embezzlement of training funds or property;

E. Absenteeism;

F. Tardiness;

G. Not completing assignments in a timely manner; and H. Lack of personal hygiene (must maintain a clean and well-groomed appearance).

3. If problems arise causing the trainee to fall behind the training schedule, for example, illness, personal problems, previously undetected skill deficiencies, attitude, etc. the trainee will be given written notice of the areas of unacceptable performance. The trainee will, if requested, be given one (1) week to correct the problem(s). After this week, the training director, with advice of the trainer, will determine if training will continue or be terminated.

4. If training is terminated, the trainee may reapply for training after the reasons for termination have been corrected.

This person would then be placed on the training list as of the date of reapplication. If the trainee left the training program due to illness or family problems and re-enters within twelve (12) months from the date training was terminated, the trainee may be credited with training previously completed. Credit will be given if a one- (1-) week evaluation conducted prior to resuming training demonstrates an acceptable level of retention of initial instruction; and (D) Manager Training Requirements. Training for a Level 1 license consists of orientation to the BEP and on-the-job training. Training for a Level 2, Level 3, or Level 4 license consists of orientation to the BEP, academic course work, and on-the-job training. Training for a Level 5 license consists of a customized training for any Level 4 manager who has recently been awarded a military dining location, on all aspects of contract management for military dining. The manager who provides on-the-job training for a trainee shall complete a Trainee Evaluation Report, a copy of which follows this rule.

1. The deputy director, with the concurrence of the executive committee, may waive a portion of training for those persons who have prior education, training, or experience in food service operations. Regardless of prior education, training, or experience, all Level 1 trainees shall have a minimum of two (2) weeks BEP training and all Level 2, Level 3, or Level 4 trainees shall have a minimum of four (4) weeks BEP training.

If the deputy director does not waive a portion of the training, Level 1 training is a minimum of eight (8) weeks, Level 2 is a minimum of sixteen (16) weeks, Level 3 training is a minimum of eighteen (18) weeks, and Level 4 training is a minimum of twenty-six (26) weeks.

2. When a trainee successfully completes all training, RSB will award to the trainee a Certificate of Training that certifies the person is qualified to be licensed as a vending facility manager. The Certificate of Training states the level for which the trainee is eligible to be licensed. Level 2, Level 3, and Level 4 trainees must attain a minimum score of seventy-two percent (72%) on the final exam to be eligible for licensure.

3. A certified graduate, upon assuming management of a facility, shall begin a six- (6-) month probationary period.

During the probationary period, the probationary manager will receive insurance benefits normally associated with the BEP, but shall not be licensed until the probationary period has been completed. During the probationary period, a bond will be secured through established BEP procedures. If bondability cannot be achieved, the probationary manager will be terminated from the program. When the probationary period has been successfully completed and bond has been secured, the probationary manager will be issued a license. The license shall be retroactive, to include the probationary period and will establish eligibility for full benefits.

4. The deputy director may require an evaluation or additional training, or both, for any active manager whom RSB determines is not performing at a satisfactory level. The deputy director may require the manager to undergo comprehensive assessment of compensatory skills, and, or medical examinations, including visual and psychological, that the deputy director considers necessary in order to determine the manager’s ability to continue management of a vending facility.

(9) Licensing of a Manager. The SLA shall issue a license only to a person who is legally blind, is a citizen of the United States, is certified by RSB as qualified to manage a vending facility, and has successfully completed a six- (6-) month probationary period as an active facility manager.

(A) The license issued by the SLA shall state the level of facility the licensee is qualified to manage.

(B) If the SLA has licensed a person as a vending facility manager but that person has not actively participated in the BEP through management of a facility or bidding on a facility, for three (3) years or more, the SLA may terminate the manager’s license. The SLA, upon the deputy director’s recommendation, may grant as extension of licensure beyond the three (3) year period of nonparticipation in the BEP.

(10) Selection and Appointment of a Vending Facility Manager.

RSB shall use the following procedures to select and appoint each manager:

(A) RSB shall send written notification of each vending facility management opening to all licensees. In order for RSB to consider an applicant, a written application must be post-marked within twelve (12) calendar days of the date of written notification of the opening. In order for the application of any manager to be considered, the manager must be current in submitting Manager’s Weekly Reports, must be current in payment of administrative fees and, if applicable, must be current in all payments due the nominee. The applicant must be appropriately certified or licensed and have current National Restaurant Association’s Applied Food Service Sanitation Course certification as required in subsection (11)(D);

(B) An applicant for the position of vending facility manager must sign a “Release of Information” form, allowing a review of the applicant’s records. The executive committee shall review and evaluate each application on the basis of the information the applicant provides in the application, on information RSB provides regarding the applicant’s performance as a trainee or manager and on the results of a personal interview that the executive committee conducts with each applicant. RSB retains the right to acquire any additional information, such as verification of payment to purveyors, considered relevant to an applicant’s qualifications for appointment as a manager.

The executive committee shall give the deputy director the committee’s recommendation regarding appointment of a manager. The executive committee may recommend that none of the applicants be appointed;

(C) If the deputy director agrees with the executive committee, the deputy director shall appoint or reject each applicant, as recommended by the executive committee. If the deputy director does not agree with the recommendation of the executive committee, the deputy director, after consultation with the executive committee, may appoint another qualified applicant as manager of the vending facility;

(D) The deputy director shall send written notification of the results of the selection process to each applicant; and (E) The SLA, the nominee, and the manager will sign a manager’s agreement, which is dated the day that the manager assumes management of the vending facility.

(11) Operation of a Vending Facility. The SLA, RSB, nominee, and each manager shall follow these procedures regarding the operation of a vending facility.

(A) Each manager agrees to enter his/her facility at his/her own risk. Responsibility for injuries received and all related expenses thereto will be assumed by the vending facility manager. Each manager may, at his/her own expense, purchase Workers’ Compensation insurance coverage for his/herself.

(B) Each manager is responsible for having the vending facility open for business on the days and during the hours specified in the permit, contract, or agreement, a copy of which will be given to the manager. The manager shall not subcontract or make other arrangements that will relieve the manager from active, personal management of the facility, unless RSB has given prior written approval. Active, personal management for the purposes of this rule shall mean the manager shall be physically present in the vending facility at least five (5) hours per day, five (5) days per week. At least half of this time must be during hours that the facility is open to the public.

(C) Each manager will notify RSB in advance and within a reasonable time period before taking any voluntary leave from the vending facility, and as soon as possible in the event of involuntary leave (for example, illness). The manager will provide for substitute operation of the vending facility as may be necessitated by the manager’s absence due to illness, vacation, etc. The salary of the person who substitutes for the facility manager, or that of other emergency or temporary help, shall be paid by the vending facility manager. If a manager is absent from the vending facility for more than thirty (30) successive days due to illness, RSB may request all medical information regarding the manager’s health condition. If the medical information indicates the manager will be absent from the vending facility for as much as six (6) months, the SLA may terminate the manager’s agreement.

(D) Any person who is licensed as a Level 2, Level 3, Level 4, or Level 5 manager after July 1, 1990, shall obtain recertification in the Applied Food Service Sanitation course every five (5) years. Any person who manages a Level 2, Level 3, Level 4, or Level 5 facility in a municipality that requires certification in the Applied Food Service Sanitation course shall obtain recertification every five (5) years, regardless of the date the SLA licensed the person.

(E) Each manager shall maintain the facility according to the standards stated in state and local health laws and regulations and the terms stated in the permit, contract, or agreement with property management. The manager and all vending facility employees shall maintain high standards of personal hygiene and grooming. They will maintain a neat, business-like appearance while working at the facility and will operate the facility in an orderly business-like manner.

(F) Children of the manager or facility employees shall not be present in the facility for the purpose of child care during the normal hours of operation.

(G) RSB shall conduct a bimonthly on-site inspection of each vending facility to insure it is being managed according to the requirements of 34 CFR 395, section 8.051, RSMo, sections 8.700–8.745, RSMo, and this rule. The findings of the inspection shall be recorded on the Review of Facility (ROF) form, a copy of which follows this rule. A score of less than two point seven-five (2.75) on the ROF may require remedial training.

(H) Each manager shall maintain product liability, general liability and Workers’ Compensation insurance for his/her vending facility. The nominee shall be named as the “additional insured.” The nominee, with consultation from the executive committee and as directed by RSB, shall obtain the insurance and shall bill the manager his/her proportionate share of the premium on each monthly statement. The amount charged will be adjusted annually based on prevailing rates and the annual insurance audits.

(I) RSB, in consultation with the manager, shall determine and provide equipment for each vending facility. The manager shall not purchase, transfer, modify, or dispose of any vending facility equipment unless RSB has given prior written authorization. When equipment is delivered to a vending facility, the manager shall sign the invoice noting any obvious damage, potential for concealed damage, or shortage, and deliver it to RSB. If the equipment cannot be inspected at the time of delivery, it should be signed for “subject to inspection.” RSB will inspect the equipment to ensure that it is not damaged and that it meets the required specifications. The manager shall ensure appropriate care of all equipment and shall be responsible for training all vending facility employees in the proper and safe use of equipment. RSB shall maintain vending facility equipment in good repair and attractive condition.

When the manager becomes aware of the need for equipment repair or replacement, the manager shall notify RSB promptly in writing. If the manager considers that repair or replacement is needed immediately, the manager may inform RSB orally of the need and shall confirm the request in writing within (5) workdays. RSB, in consultation with the manager, shall decide whether repair or replacement is needed. If emergency repair or replacement is needed, RSB shall provide oral authorization and shall confirm the authorization in writing within one (1) workday. If the manager discovers the need for emergency repair or replacement on a day when RSB offices are closed, the manager may make arrangements for repair or replacement and shall notify RSB on the first day that RSB offices are open following the discovery. The manager shall pay for any equipment repair that RSB did not authorize. The manager also shall pay the cost of repair that is needed due to negligence or abuse by the manager or vending facility employees and for expense resulting from failure to determine a minor repair such as unit not plugged in, reset button not pushed, or circuit breaker tripped. The right, title to, and interest in equipment that the SLA or the nominee purchases shall be vested in the name of the primary purchaser. The nominee shall take necessary steps to defend and maintain the SLA’s paramount right, title to, and interest in all equipment.

(J) RSB shall provide an initial inventory adequate for the manager to begin operation at each new or substantially altered vending facility. Each manager will be provided with a written copy of the initial inventory and its value computed on wholesale prices at the time of purchase. On the date of the manager’s termination as manager, for whatever cause, RSB shall take an inventory of all readily marketable merchandise and consumable supplies in the vending facility. The value of the inventory shall be computed on current wholesale prices.

RSB shall deduct the value of the inventory plus any cash advances or other sums that the manager owes to RSB or the nominee. The difference is the amount due and it shall be paid to the manager or the manager’s estate within ninety (90) days from the date the inventory was taken. Failure to pay the amount due within the required ninety- (90-) day period will result in a penalty to RSB of one and one-half percent (1 1/2%) of the balance, to be paid monthly until the account is settled. If the manager or the manager’s estate owes money to RSB or the nominee, RSB or the nominee shall notify the manager or the manager’s estate in writing of the amount that is owed. The manager shall pay the amount owed to RSB or the nominee within ninety (90) days from the date of the notification letter.

If a manager’s estate owes money to RSB or the nominee, RSB or the nominee shall file a claim against the manager’s estate for the amount of the debt that is owed. RSB or the nominee shall assess a penalty of one and one-half percent (1 1/2%) per month of the balance that the manager of the manger’s estate owes to RSB or the nominee, until the account is settled. Each manager shall maintain an inventory of equal or greater value than the initial inventory in order to insure continuation of services and maintenance of a viable business operation.

(K) If a manager is unable to furnish a change fund for the facility, the nominee may make an interest-free loan to the manager in an amount that RSB, after consultation with the manager, determines is sufficient. The manager shall repay this loan in ten (10) equal monthly installments beginning no later than ninety (90) days from the date of the loan or upon the manager’s resignation or termination as manager of the facility, whichever date occurs first. When the nominee makes an interest-free loan to a manager, the manager shall sign a promissory note, a copy of which follows this rule.

(L) Each manager shall set prices for items to be sold based on market value. If a manager refuses to set prices based on market value or if a dispute arises between two (2) or more managers, RSB may establish the price at which product(s) will be sold.

(M) Each manager shall operate the vending facility business on a cash basis except for such credit accounts as may be established or authorized by RSB. The manager may sell only the types of merchandise stated in the permit, contract, or agreement with property management. Merchandise types may not be added or deleted without the approval of RSB and the consent of property management. Merchandise that is purchased for the vending facility and reported on the manager’s weekly report shall not be removed from the facility unless sold. Each manager is accountable to RSB for the proceeds of the business and will handle the proceeds, including payments to suppliers and deposits of funds, in accordance with instructions from RSB. Each manager who has employees shall make required federal tax deposits at a federal reserve bank.

Deposits will include employee withholdings for income taxes and Social Security and employer matching withholding for Social Security. Each manager shall collect all applicable sales taxes on gross sales and shall remit the taxes to the nominee, in the amount shown on the monthly statement. The nominee shall submit tax forms and monthly payments for all managers to the Missouri Department of Revenue and when appropriate to county and city governments. The manager shall maintain a business account which is separate from any personal account(s). The manager is liable for all debts s/he incurs in the operation of the vending facility. RSB may, with reasonable cause, require verification that a manager has paid all legal debt incurred in the operation of the vending facility and that federal tax deposits are current.

(N) Subject to applicable laws, regulations, and this rule each manager shall make all personnel decisions, including hiring and termination, employee wages, benefits, and working conditions. Employee wages must be within the prevailing wage range for the job classification in the area where the facility is located. If the wage/salary exceeds the prevailing wage, the manager may be required to provide RSB with written justification. A manager may consult with RSB regarding the number of employees s/he will hire. First, preference shall be given to blind persons in need of employment. Second, preference shall be given to other disabled persons. Each manager and all vending facility employees will strive at all times to maintain a positive working relationship with management and customers of the vending facility.

(O) Each manager shall submit all reports or records that RSB or the nominee requests. These reports or records shall include, but not be limited to, daily and weekly reports. The daily report shall include opening cash-on-hand, the amount of sales, the amount of pay outs, and cash-on-hand at the close of the business day. The manager’s weekly report and payroll report must include completed Manager’s Weekly Report and Vending Facility Payroll Report forms, copies of which follow this rule.

In addition, supporting documentation including cash register “Z 2” tapes and all paid invoices for the week the report covers must be included. All required reports shall be postmarked no later than the fourth day following the closing date of the period the report covers.

(P) At the end of each month, the nominee shall furnish to the manager a Monthly Operating Statement for the manager’s vending facility. The report will reflect the facility’s sales and expenses and the amount the manager must submit to the nominee for administrative fees, sales taxes, and insurance.

The manager is responsible for personal income tax deposits due the Internal Revenue Service. A copy of the Monthly Operating Statement follows this rule.

(Q) The manager shall send to the nominee the amount owed, as shown on the monthly statement with postmark no later than the twenty-fifth day of the month. If payment is delinquent, a penalty of one and one-half percent (1 1/2%) per month shall be assessed on the balance owed. If a manager is two (2) months delinquent in paying to the nominee the amounts due, the SLA may terminate the manager’s agreement or license, or both. If the manager submits any check which does not clear the bank, the nominee shall assess a penalty charge in the same amount that the bank assesses the nominee. If a manager submits two (2) checks within a twelve- (12-) month period that fail to clear the bank, the nominee shall give written notification to the manager that all future payments must be made by certified check or money order.

(R) RSB shall ensure that each manager has a fair minimum return, within the following limitations. A manager may apply in writing to the nominee for an interest-free subsidy for any month during which the net income from the manager’s vending facility is less than seven hundred dollars ($700). The subsidy for one (1) month cannot exceed seven hundred dollars ($700) or the difference between seven hundred dollars ($700) and the amount of the manager’s net income from the vending facility for the month, whichever is less. The manager may apply for this interest-free subsidy no more than three (3) times. The manager must pay all amounts s/he owes to RSB or the nominee before s/he is eligible to apply for a subsidy.

After a maximum of three (3) subsidies, the manager may reestablish eligibility for interest-free subsidies by repaying the full amount of all previous fair minimum return subsidies. The manager may repay the subsidies at any rate selected by the manager. The nominee does not require the manager to repay the subsidies, but failure to repay the subsidies will result in ineligibility to receive additional fair minimum return subsidies.

(S) RSB shall select vending facility locations that require payments of rent or other fees only when a manager’s net income from that location is expected to justify that expense. When payments of rent or other fees are necessary, the manager shall make these payments.

(T) Before beginning operation of a vending facility, the manager shall obtain and pay for all necessary state, county and city licenses and permits. These licenses and permits shall be kept current by the manager for the duration of the manager’s agreement.

(U) The nominee shall pay all initial charges for purchase, installation and connecting or disconnecting telephone for the vending facility.

(V) If the majority of the population in a building which houses a vending facility is transferred from that building to another on either a temporary or permanent basis, the SLA may transfer the vending facility and manager to the new building without placing the new facility on competitive bid.

(W) Each manager shall maintain minimum levels of net profit from sales of nineteen percent (19%) for a Level 2 facility, fourteen percent (14%) for a Level 3 facility, and ten percent (10%) for a Level 4 facility. The maximum percent of merchandise costs shall not exceed seventy-two percent (72%) for a Level 2 facility, fifty-eight percent (58%) for a Level 3 facility, and fifty-two percent (52%) for a Level 4 facility.

(X) Failure to operate a vending facility in accordance with acceptable operating standards as outlined in this section may result in the SLA placing the manager on probation for a period of time deemed sufficient to correct noted management deficiencies. The SLA may require additional training during this period. If correction is not achieved within this probationary period, the SLA may terminate the manager’s agreement or license or both according to subsection (16)(A).

(12) Administrative Fees and Set-Aside Funds. RSB and the managers shall establish policies regarding set-aside funds.

Set-aside funds accrue to the nominee from all commissions on vending machine proceeds in vending facilities located on federal property in which there is no manager on-site, from administrative fees that the nominee assesses against all operating income from vending facilities and administrative fee that the nominee assess on commissions on vending machine proceeds in vending facilities in which there is a manager on-site.

(A) Each manager shall pay to the nominee a fee in the amount of thirteen percent (13%) of the income from net proceeds. This fee is referred to as the administrative fee and is included in the set aside funds. The nominee shall record on the manager’s monthly statement the amount of the administrative fee that the manager owes on that month’s sales. The nominee shall deduct a thirteen percent (13%) administrative fee from all commissions that vending machine companies pay on vending machine proceeds in vending facilities in which there is a manager on-site.

(B) As set-aside funds are available, the nominee shall use setaside funds solely for the purposes of a fair minimum return for managers, maintenance, and replacement of vending facility equipment, purchase of new vending facility equipment, management services, and the establishment and maintenance of retirement or pension funds, including group life insurance, health insurance and contributions, and provision for paid vacation time for managers and nominee employees.

(13) Seniority. A manager earns or loses seniority credit according to the following guidelines:

(A) A full-time manager in the BEP shall earn one (1) month of seniority for each full month that the manager worked and paid all fees, as required by this rule, except that a licensee who works as a temporary manager shall earn only one-half (1/2) month seniority for each month that the temporary manager worked. A manager shall not accrue seniority for any month in which payment of fees or loans are delinquent;

(B) A full-time manager in the BEP who resigns from a facility in good standing shall lose fifty percent (50%) of the manager’s accumulated seniority at the time the manager resigns. After an absence from the BEP of three (3) years, the manager shall lose all seniority;

(C) When the SLA terminates a manager’s agreement due to the manager’s failure to adhere to the terms of this rule, the manager shall lose all seniority immediately;

(D) If the SLA closes a vending facility for a reason other than the manager’s failure to adhere to the terms of this rule, the manager shall retain all seniority the manager had accumulated at the time the SLA closed the vending facility. After an absence from the BEP of three (3) years, the manager shall lose all seniority; and (E) Seniority is a factor in the vacation pay schedule and all other factors being equal may be considered in making a facility award or recommendation for award.

(14) Fringe Benefits. As set-aside funds are available, the nominee shall use set-aside funds, as discussed in section (12), to meet the cost of the following benefits for managers:

(A) Paid Vacation. Effective January 1, 1996, a manager shall earn vacation and the nominee shall pay the manager for earned vacation, according to the following:

1. After one (1) full year of creditable service as a BEP manager, a manager shall earn one (1) week of paid vacation. A manager is not eligible for vacation pay unless s/he is current in submitting required reports and payments of administrative fees and loans from the nominee;

2. A manager will be eligible to receive vacation pay on the anniversary date of employment as a full-time contract manager. A manager who is ineligible for vacation pay on this date will not become eligible to receive vacation pay until his/ her next anniversary of employment date. Vacation pay shall not accumulate beyond the twelve- (12-) month period.;

3. The nominee shall compute the week of earned vacation as equal to one fifty-second (1/52) of the manager’s net income for the immediately preceding twelve- (12-) month period; and 4. If a manager who is eligible for vacation pay dies, resigns from a vending facility, or, if the SLA terminates the manager’s agreement or license, RSB shall prorate the vacation pay for the number of weeks of creditable service the manager has accrued since the last anniversary date of the manager’s employment. This prorated amount shall be applied toward any debt to the SLA or nominee and any balance remaining shall go to the manager and/or to his/her estate;

(B) Health Insurance and Life Insurance Coverage. RSB, with consultation from the executive committee, shall select an insurance carrier to provide health insurance and group life insurance for managers and their dependents.

1. The nominee shall pay the premiums for health insurance coverage and for a maximum of five thousand dollars ($5000) of group life insurance coverage for each manager.

The manager shall pay the premiums on insurance coverage for the manager’s dependents and for any additional insurance for the manager.

2. Upon the request of a manager who resigns from the BEP or whose contract has been terminated by the SLA, the nominee may continue health and life insurance coverage for that individual and the individual’s dependents through the nominee’s insurance carrier, if allowed by the carrier, for a period not to exceed thirty (30) days. The individual must submit to the nominee prepayment of the total amount of the premium for the thirty- (30-) day extended period of coverage for the individual and the individual’s dependents; and (C) Retirement Benefits. RSB, with consultation from the executive committee, shall select a provider with which managers may invest in an individual retirement account (IRA). The manager may invest in an IRA, within the limitations stated in federal law except that payments will only be matched on a calendar year basis, for example, contributions must be made by December 31 of each year to be applied to that tax year. For each tax year, the nominee shall use income from vending machines located on nonfederal property to match each dollar a manager invests in an IRA, up to a maximum of five hundred dollars ($500) per year. In order to be eligible to participate in the IRA program, a manager’s administrative fees and change fund loan payments must be current.

(15) Collection and Distribution of Income From Vending Machines.

(A) Income From Vending Machines.

1. Federal property. Vending machines on federal property may be the responsibility of the federal government agency, through direct operation of the machines or through a contractual arrangement with a commercial vending company.

In other situations, the state of Missouri, on behalf of the nominee, contracts with a vending company to provide vending services.

A. When the vending operation is the responsibility of the federal government agency, a property management official shall be responsible for the collection of, and accounting for, the income from vending machines.

B. When the state of Missouri contracts with a vending company to provide vending services, the vending company shall submit commissions and documentation on vending machine proceeds to the nominee.

(B) Collection of Income From Vending Machines.

1. Federal property. When the vending operation is the responsibility of the federal government agency, at least once each quarter the property management official shall collect vending machine income and forward it to the nominee, as follows:

A. One hundred percent (100%) of income from all vending machines that are in direct competition with a vending facility that is operated by a manager who is on-site, as determined by property management, with RSB’s concurrence;

B. Fifty percent (50%) of all income from all vending machines that are not in direct competition with a vending facility that is operated by a manager who is on-site; and C. Thirty percent (30%) of all income from all vending machines on federal property at which fifty percent (50%) or more of the total hours worked on the premises occurs during a period other than normal working hours.

(C) Distribution of Income From Vending Machines.

1. Federal property.

A. Vending machine income from vending machines on federal property which has been disbursed to the state licensing agency by a property managing department, agency, or instrumentality of the United States under section 395.32, shall accrue to each blind vendor operating a vending facility on such federal property in each state in an amount not to exceed the average net income of the total number of blind vendors within such state, as determined each fiscal year on the basis of each prior year’s operation, except that vending machine income shall not accrue to any blind vendor in any amount exceeding the average net income of the total number of blind vendors in the United States. No blind vendor shall receive less vending machine income than s/he was receiving during the calendar year prior to January 1, 1974, as a direct result of any limitation imposed on such income under this paragraph.

No limitation shall be imposed on income from vending machines, combined to create a vending facility, when such facility is maintained, serviced, or operated by a blind vendor.

Vending machine income disbursed by a property managing department, agency, or instrumentality of the United States to a state licensing agency in excess of the amounts eligible to accrue to blind vendors in accordance with this paragraph shall be retained by the appropriate state licensing agency.

B. The state licensing agency shall disburse vending machine income less the administrative fee, to blind vendors within the state on at least a quarterly basis.

C. Federal property in which Missouri contracts with a vending machine company to provide vending service, a manager is on-site to operate a vending facility, and there are one (1) or more vending machine banks in the building at which there is no manager on-site. The nominee shall distribute to the manager all of the assigned income, less the administrative fee. The nominee also shall distribute to the manager the unassigned income, less the administrative fee, up to, but not exceeding, the average income of the total number of managers in Missouri, as determined each federal fiscal year on the basis of the prior year’s operation of the BEP, or the average income of the total number of vending facility managers in the United States, whichever is less.

The nominee shall not impose a limitation on income from vending machines combined to create a vending facility when a manager services, maintains, or operates the facility. If there is a balance of unassigned income after the nominee pays the appropriate amount to the manager, the balance shall accrue to the nominee.

D. On federal property in which there is no manager on-site. all commissions on vending machine proceeds shall accrue to the nominee.

2. Nonfederal property.

A. Nonfederal property in which Missouri contracts with a vending company to provide vending service and a manager is on-site. On a monthly basis, the nominee shall distribute to the manager commissions from proceeds, less administrative fee, from vending machines that are listed in RSB’s contract to operate that vending facility.

(I) For any facility that is of the type discussed in this subparagraph and in which a manager assumed management of the facility after July 8, 1991, the amount of income that the nominee distributes to the manager shall not exceed one hundred fifty percent (150%) of the average income of the total number of managers in Missouri, as determined each federal fiscal year on the basis of the prior year’s operation of the BEP, or the average income of the total number of vending facility managers in the United States, whichever is more.

(II) If there is a balance of vending machine income after the nominee pays the appropriate amount to the manager, the balance shall accrue to the nominee.

B. All income from commissions on vending proceeds from machines located on nonfederal property in which there is no manager on-site to operate a vending facility shall accrue to the nominee.

(D) Use of Unassigned Vending Machine Income That the Nominee Retains.

1. Federal property.

A. If approved by a majority vote of all managers, the nominee shall use unassigned income that accrues to it from vending machines located on federal property for the establishment and maintenance of retirement or pension plans, for health insurance contributions, and for the provision of paid vacation time for all managers.

B. The nominee shall use any vending machine income not needed to meet the cost of benefits stated in subparagraph (15)(D)1.A. for the maintenance and replacement of equipment, the purchase of new equipment, management services and assuring a fair minimum return to managers.

C. The nominee shall reduce the administrative fee charged to managers pro rata in an amount equal to the total vending machine income that remains after the nominee meets the cost of manager benefits stated in subparagraph (15)

(D)1.A.

2. Nonfederal property. In consultation with the executive committee, the nominee shall use unassigned income that accrues to it from vending machine proceeds located on nonfederal property to meet the cost of the following: establishment and maintenance of retirement or pension plans, health insurance contributions, the provision of paid vacation time for all managers, maintenance and replacement of equipment, purchase of new equipment, management services, assuring a fair minimum return to managers, and other costs that RSB determines are necessary for program growth and efficient administration of the BEP. The primary purpose of unassigned income from proceeds of vending machines located on nonfederal property shall be to develop and enhance the BEP.

(16) Termination of License or Manager’s Agreement. The SLA may terminate a license or manager’s agreement.

(A) Reasons for Termination of License or Manager’s Agreement. Any of the following situations is sufficient reason for the SLA to terminate a manager’s license or manager’s agreement:

1. Willful or malicious destruction of, or failure to exercise reasonable and necessary care of, vending facility equipment;

2. Failure to operate the vending facility according to federal, state, or municipal law, this rule, or the terms of any permit or contract that governs the operation of the vending facility;

3. Falsification of reports or documents that are required by RSB;

4. Failure to report all sales and vending revenues on the Manager’s Weekly Report;

5. Failure to provide all sales and cost documentation, weekly, as required by RSB;

6. Failure to maintain a minimum acceptable rating of two point seven-five (2.75), as established by the executive committee and RSB, on the Review of Facility Report, a copy of which follows this rule;

7. Abandonment of vending facility, which occurs when the manager is absent from a vending facility without arranging for the ongoing operation of the vending facility;

8. Failure to pay a legally enforceable debt of the manager that arises from the operation of the vending facility;

9. Failure to pay the amount owed to the SLA and the nominee, as stated in subsection (11)(Q);

10. Failure to comply with the nondiscrimination policy that is stated in section (3);

11. Loss of visual eligibility to participate in the BEP. The licensee shall notify RSB when there is a change in the licensee’s vision that may affect eligibility to participate in the BEP.

In order to verify a licensee’s continued eligibility, RSB may require a manager to have periodic examinations by an eye care specialist that RSB selects. The cost of these examinations will be borne by the BEP;

12. Use of or being under the influence of an intoxicant or illegal drug while in a vending facility;

13. Conviction of a felony;

14. RSB determines that, due to mismanagement, a manager is not operating a vending facility profitably;

15. Failure to make or provide proof of having made the required deposits when due for employee withholdings for income taxes and Social Security and employer matching withholdings for Social Security;

16. Failure to provide thirty (30) days written advance notification of termination, unless RSB agrees to a shorter notification; and 17. In addition to the reasons stated in paragraphs (16)(A)1.– 16., the SLA may terminate a manager’s agreement if problems exist between a manager and property management; RSB, manager, and property management are unable to resolve the problems; the manager does not resign from managing the facility, and the SLA considers it to be in the best interest of that facility and the BEP for the manager to be removed as manager of the facility.

(B) SLA Procedures for Termination of License or Manager’s Agreement.

1. RSB shall give at least ten (10) days written notice to the licensee or manager that states the reason(s) for termination of the license or manager’s agreement and the effective date of the termination. RSB is not required to give ten (10) days written notice if the reasons for termination involve a risk of danger to public health or safety, if RSB considers there is an immediate threat of loss of BEP funds, inventory, or other property or if the manager’s continued operation of the facility would substantially damage economically the operation of the BEP.

2. RSB shall inform the licensee or manager of the right to present a grievance before the executive committee and to request grievance reviews according to section (17).

3. A manager shall relinquish the vending facility on the date that the termination becomes effective except, if the manager appeals the termination, in writing, prior to the effective date, the manager may continue to manage the vending facility until the hearing process is concluded. This exception does not apply if RSB considers there exists a danger to public health or safety or an immediate threat of loss of BEP funds, inventory, or other property.

4. RSB or the nominee shall assume management of any vending facility on the same day that the manager of the vending facility relinquishes management of the vending facility.

5. If a licensee or manager whose license or manager’s agreement has been terminated has not initiated the grievance procedure prior to the date of termination, the licensee or manager has an additional twenty (20) days after the date of termination to transmit a grievance to the executive committee.

6. If, at any time during the grievance procedure, the SLA’s decision to terminate the manager’s license or manager’s agreement is reversed, the nominee shall pay to the manager a proportionate amount of the vending facility’s average monthly net income during the twelve- (12-) month period immediately preceding the manager’s termination. The nominee shall hold in escrow all net income generated by the vending facility until the grievance process is completed.

(C) Automatic Termination of a License or Manager’s Agreement. The death of a manager results in automatic termination of the individual’s license and manager’s agreement.

(17) Grievance Procedures. A licensee who is dissatisfied with any action regarding the operation or administration of the BEP has access to the following grievance procedures:

(A) If a licensee wishes, s/he may make a written request directly to the deputy director for an administrative review. If the licensee does not wish to appeal directly to the deputy director, s/he shall follow each level of the grievance procedures stated in section (17);

(B) Review by Executive Committee. A licensee may present a grievance before the executive committee. The executive committee shall ensure that the licensee is provided guidance in seeking a remedy of the grievance. Within ten (10) days after hearing a licensee’s grievance, the executive committee shall transmit the grievance to RSB, with a written statement regarding the executive committee’s support or lack of support for the licensee’s grievance, and shall send a copy of the statement to the licensee;

(C) Administrative Review. Within fifteen (15) workdays after the date of the executive committee’s report to RSB, the licensee may make a written request to the deputy director for an administrative review. Within ten (10) workdays after the receipt of the licensee’s request, the deputy director or the deputy director’s designee shall contact the licensee regarding the licensee’s request and shall provide the following information in writing to the licensee:

1. The date, time, and place of the administrative review.

If possible, the administrative review shall be held within fifteen (15) workdays of the receipt of the written request for an administrative review, within regular working hours and at RSB district office that is nearest to the licensee’s vending facility. If agreed to by the licensee and the deputy director or the deputy director’s designee, the administrative review may be held on a date, at a time, and place different than specified in this paragraph;

2. The nominee shall pay necessary costs of transportation, lodging, and meals that a licensee needs in conjunction with the grievance process;

3. The nominee shall pay all costs, including travel expenses, of an interpreter or a reader when a licensee needs interpreter or reader service in conjunction with the grievance process;

4. The licensee and RSB may present written or oral evidence relevant to the grievance;

5. The licensee may be represented by counsel of the licensee’s choice, at the licensee’s expense;

6. RSB shall tape record the review proceedings;

7. Within fifteen (15) workdays after the date of the administrative review, the deputy director or the deputy director’s designee shall notify the licensee in writing of the decision.

The notification shall inform the licensee of the licensee’s right to a full evidentiary hearing, referred to in this rule as a fair hearing;

(D) Fair Hearing. If the licensee is dissatisfied with the results of the administrative review, the licensee may request a fair hearing. The following guidelines govern the fair hearing process:

1. The licensee must make a written request for a fair hearing to the director of the SLA within fifteen (15) workdays after the date of the decision of the deputy director or the deputy director’s designee;

2. The director of the SLA shall designate to conduct the fair hearing an impartial official who has no involvement either with the action that is at issue in the hearing or with the administration or operation of the BEP;

3. The hearing will be conducted during normal work hours in Jefferson City, Missouri unless the hearing officer decides to hold the hearing in another location;

4. The provisions of paragraphs (17)(C)2.—6. apply to the fair hearing;

5. Within twenty (20) workdays after the date of the fair hearing, the hearing officer shall notify the licensee and the SLA in writing of the decision; and 6. The director of the SLA shall have the right to review the decision of the hearing officer and shall make the final decision regarding the fair hearing.

A. Within twenty (20) workdays of the mailing of the decision of the hearing officer, the director of the SLA shall notify the licensee whether the director intends to review the decision of the hearing officer. If the director fails to notify the licensee of the intent to review the decision, the decision of the hearing officer becomes a final decision.

B. Within thirty (30) calendar days of notifying the licensee of the intent to review the decision of the hearing officer, the director shall notify the licensee of the final decision, including a full report of the findings and the basis for the decision;

(E) Arbitration Panel. If the licensee is dissatisfied with the decision from the fair hearing, the licensee may file a written complaint with the secretary of the United States Department of Education. The licensee shall include with the written complaint all available supporting documents, including a statement of the decision of the hearing officer or director of the SLA and the basis for the decision. The secretary of the United States Department of Education shall convene an ad hoc arbitration panel to conduct a hearing and render a decision regarding the manager’s complaint; and (F) A licensee who is dissatisfied with the results of the fair hearing shall have the right to invoke the Randolph-Sheppard arbitration process. If still dissatisfied, the vendor may then seek judicial review in a federal district court.

(18) Confidentiality of Information. The provisions of 13 CSR 40- 91.020(25) apply to the administration of the BEP.

History

• AUTHORITY: sections 8.051, 8.700–8.745, 207.010, 207.022, 209.010, 209.020, and 660.017, RSMo 2016. Original rule filed Oct. 6, 1977, effective Jan. 13, 1978. Rescinded and readopted: Filed Aug. 4, 1988, effective Oct. 15, 1988. Rescinded and readopted: Filed Feb. 15, 1991, effective July 8, 1991. Amended: Filed May 11, 1995, effective Nov. 30, 1995. Amended: Filed Oct. 1, 2018, effective May 30, 2019. Original authority: 8.051, RSMo 1990; 8.700, RSMo 1981, amended 2014; 8.705, RSMo 1981, amended 1985; 8.710–8.745, see the Missouri Revised Statutes; 207.010, RSMo 1945, amended 1949, 1953, 1973; 207.022, RSMo 2014; 209.010, RSMo 1939, amended 2014; 209.020, RSMo 1939, amended 2014; and 660.017, RSMo 1993, amended 1995.

13 CSR 40-91.020 Vocational Rehabilitation for the Blind {#sec-13-csr-40-91.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-91.020}

PURPOSE: This rule establishes the guidelines for provision of vocational rehabilitation services to applicants and eligible clients as mandated by the Rehabilitation Act of 1973 (P.L. 93–112), as amended through 2020, 34 CFR 361 and 34 CFR 363. These services are authorized by sections 207.010, 209.010, and 209.020, RSMo.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) The program of vocational rehabilitation for the blind (VR) is administered pursuant to the Rehabilitation Act of 1973 as amended, Chapter 16 of Title 29, United States Code, and Chapter 209, RSMo. Federal law requires Rehabilitation Services for the Blind (RSB) to develop policies that govern the administration of the vocational rehabilitation program and allows RSB to develop limitations within which it administers some areas of the program. Therefore, except as otherwise provided and as allowed by federal law, this rule hereby incorporates by reference the provisions and definitions from the Code of Federal Regulations (CFR) listed below as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, DC 20408, and which is located on the website of the U.S. Government Publishing Office at https:// www.govinfo.gov/content/pkg/CFR-2019-title34-vol2/pdf/CFR- 2019-title34-vol2-subtitleB-chapIII.pdf. This rule does not incorporate any subsequent amendments or additions.

(A) 34 CFR 361.5, July 1, 2019.

(B) 34 CFR 361.13, July 1, 2019.

(C) 34 CFR 361.36, July 1, 2019.

(D) 34 CFR 361.42, July 1, 2019.

(E) 34 CFR 361.43, July 1, 2019.

(F) 34 CFR 361.44, July 1, 2019.

(G) 34 CFR 361.45, July 1, 2019.

(H) 34 CFR 361.46, July 1, 2019.

(I) 34 CFR 361.47, July 1, 2019.

(J) 34 CFR 361.48, July 1, 2019.

(K) 34 CFR 361.49, July 1, 2019.

(L) 34 CFR 361.51, July 1, 2019.

(M) 34 CFR 361.53, July 1, 2019.

(N) 34 CFR 361.56, July 1, 2019.

(O) 34 CFR 361.57, July 1, 2019.

(P) 34 CFR 363.1, July 1, 2019.

(Q) 34 CFR 397.20, July 1, 2019.

(R) 34 CFR 397.30, July 1, 2019.

(S) 34 CFR 397.40, July 1, 2019.

(2) Definitions.

(A) This section includes all definitions in 34 CFR 361.5.

(B) “Applicant” means an individual who has applied for vocational rehabilitation services and whose eligibility for services has not been determined.

(C) “Client” means an individual who meets the requirements to receive vocational rehabilitation services under the terms of an Individualized Plan for Employment (IPE). A client also is an individual who meets the requirements to receive vocational rehabilitation services during a period of trial work in order to determine the individual’s rehabilitation potential.

(D) “Client assistance program” means a federally-funded, statewide program that is available to advise all applicants and clients of all services available from RSB and to assist applicants and clients in their relationships with RSB and other providers of vocational rehabilitation services, including appropriate remedies to ensure the protection of applicant and client rights.

(E) “Deputy director” means the person in the Family Support Division/RSB who is the state unit director referred to in 34 CFR 361.13(b). The state unit director is referred to in this

rule as the deputy director.

(F) “Family Support Division” is the sole state agency referred to in 34 CFR 361.13(a)(1)(ii). The sole state agency is referred to in this rule as the division.

(G) “Individual with a most significant disability” means an eligible individual with a significant disability who additionally has a severe physical or mental impairment that seriously limits three (3) or more functional capacities (i.e., mobility, communication, self-care, self-direction, interpersonal skills, work tolerance, or work skills) in terms of an employment outcome.

(H) “Maintenance” means limited monetary support provided to an individual for expenses, such as food, shelter, clothing, and other necessary subsistence items (i.e. personal toiletries) that are in excess of the individual’s normal expenses and that are necessitated by the individual’s participation in an assessment for determining eligibility and vocational rehabilitation needs or the individual’s receipt of vocational rehabilitation services under an individualized plan for employment.

(I) “Multilevel marketing” is a business model that involves unsalaried, hierarchical sales teams selling products directly to consumers in conjunction with recruiting additional company sales representatives.

(J) “Rehabilitation Services for the Blind” or “RSB” is the unit within the Family Support Division that is the “designated state unit” identified in 34 CFR 361.5(c)(13).

(3) Eligibility for Vocational Rehabilitation Services.

(A) Basic Conditions of Eligibility. An individual’s eligibility for vocational rehabilitation for the blind services shall be based only upon the following criteria:

1. The individual meets the eligibility requirements contained within 34 CFR 361.42(a)(1), and the individual has— A. A nonprogressive eye disease with a central visual acuity of twenty/two hundred (20/200) or less in the better eye with best correction; or, if the central visual acuity with best correction is more than twenty/two hundred (20/200) in the better eye, there is a visual field defect in which the widest diameter of the visual field subtends an angle distance no greater than twenty degrees (20°), or has a visual efficiency that does not exceed twenty percent (20%);

B. A progressive eye disease with a central visual acuity of twenty/seventy (20/70) or worse in the better eye with best correction, or has a visual efficiency that does not exceed sixtyfour percent (64%), or has near vision that is decreased to the extent that the individual cannot read print that is smaller than Jaeger nine (J9) with best correction; or C. A visual impairment which results in a substantial impediment to employment for the individual because the individual functions at the level of someone who meets the visual disability standards in subparagraph (3)(A)1.A. or B. Such eligibility determination shall be made by the deputy director or designee.

(B) Prohibited Factors— 1. RSB shall ensure prohibited factors, as set forth in 34 CFR 361.42(c), are not imposed in determining eligibility.

(C) Assessment for Determining Eligibility for Services. RSB shall carry out a comprehensive diagnostic study of each applicant for vocational rehabilitation services. The purposes of the comprehensive diagnostic study are to determine whether the applicant meets the basic conditions of eligibility stated in subsections (A)-(B) of this section. If RSB is unable to determine whether the applicant will benefit from vocational rehabilitation services in terms of an employment outcome due to the severity of the applicant’s disability, RSB shall carry out an assessment of the applicant’s capacity for work, as provided in

section (6) of this rule.

(D) Presumptive Eligibility for Social Security recipients and beneficiaries shall be pursuant to 34 CFR 361.42.

(E) RSB and the Missouri Division of Vocational Rehabilitation may consult with each other regarding individuals for whom there is a question as to which agency should provide vocational rehabilitation services to the individuals.

(4) Comparable Services and Benefits. RSB shall utilize the requirements of 34 CFR 361.53(a)-(c) when determining whether comparable services and benefits are available under any other program.

(5) Authorization of Services.

(A) RSB shall not pay for any vocational rehabilitation service unless RSB has issued an authorization and dated the authorization for services on/before the initiation of services.

1. In cases of emergency medical services, where prior authorization is needed by the provider but, due to the urgent nature of the emergency, the authorization cannot be issued immediately, the RSB staff may provide their approval.

2. Any request for services after the service start date will require an approval signature by the deputy director or designee.

(B) RSB shall not issue payments to an applicant or eligible individual for goods or services not yet procured, such as a cash advance.

(6) Trial Work Period. RSB shall provide vocational rehabilitation services to an applicant during a Trial Work Period under the following circumstances:

(A) If an applicant has a mental or physical disability(ies) that, for the applicant, constitutes or results in a substantial impediment to employment but RSB cannot determine, from information obtained during the comprehensive diagnostic study described in subsection (3)(C) that the applicant will benefit in terms of employability from the provision of vocational rehabilitation services;

(B) RSB shall provide only those services that the client must have so that RSB can determine the individual’s eligibility for vocational rehabilitation services;

(C) The Trial Work Period shall begin on the date that RSB approves a written plan and certifies the applicant for a Trial Work Period, as discussed in subsection (7)(B);

(D) RSB shall make a thorough assessment of the client’s progress as often as necessary but at least once every ninety (90) days from the date of the certification for trial work services. This assessment shall include periodic reports from each rehabilitation facility or person who is providing services to the client;

(E) RSB shall end the provision of services when RSB is able to determine whether the client is eligible for vocational rehabilitation services;

(F) RSB shall not certify more than one (1) Trial Work Period during the time the client’s case is opened; and (G) If RSB closes a client’s case and the individual reapplies for vocational rehabilitation services, RSB may provide another period of trial work services if the individual needs to receive extended services in order for RSB to determine the individual’s vocational potential.

(7) Certification.

(A) Certification of Eligibility. If RSB determines that an applicant is eligible for vocational rehabilitation services, RSB shall complete a certification of eligibility. The certification shall include the statement that the applicant meets the basic conditions of eligibility stated in subsection (3)(A).

(B) Certification for Trial Work Period. If RSB determines that an applicant meets the requirements stated in subsection (6)

(A), and a Trial Work plan has been developed, RSB shall complete, sign, and date a certification for Trial Work Experience.

(C) Certification of Ineligibility. When RSB determines that the applicant or client is not eligible for vocational rehabilitation services, an appropriate RSB staff member shall complete, sign, and date a certification of ineligibility. RSB shall assure that the certification states the reasons for the ineligibility determination. RSB shall carry out all activities stated in subsections (16)(B) and (C).

(8) Vocational Rehabilitation Services for the Individual. As appropriate to the vocational rehabilitation needs of each applicant or client, RSB shall make available the vocational rehabilitation services that are listed in this section. To the extent possible, within the limitations that are relevant to this

section in federal law, Chapter 34, RSMo, available appropriations, and this rule, the applicant or client may select the vendor(s) to provide each service. RSB shall provide services in the most cost-effective manner in order to prepare the client for securing, retaining, advancing in, or regaining an employment outcome that is consistent with the individual’s strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice. This rule establishes the procedures for the provision of the following services and the limitations on the provision of certain services:

(A) Pre-Employment Transition Services listed in 34 CFR 361.48(a) may be provided only to students with disabilities, as defined in subsection (2)(A) of this rule, who can receive these services either as full VR clients under an IPE, or prior to signing an application for vocational rehabilitation services; and (B) Vocational Rehabilitation Services that may be available to applicants, as defined under subsection (2)(B) of this rule, or clients, as defined under subsection (2)(C) of this rule— 1. Assessment – Services provided and activities performed to determine an individual’s eligibility for VR services and/or to determine the nature and scope of VR services to be included in the IPE;

2. Diagnosis and Treatment of Impairments—As provided in section (11) of this rule;

3. Vocational Rehabilitation Counseling and Guidance, including personal adjustment counseling, to maintain a counseling relationship with the applicant or client throughout the program of services, to help the applicant or client secure needed services from other agencies, and to advise the applicant or client about the client assistance program;

4. Job Search Assistance—Job search activities that support and assist an individual in searching for an appropriate job.

Job search assistance may include help in resume preparation, identifying appropriate job opportunities, developing interview skills, and making contacts with companies on behalf of the client;

5. Job Placement Assistance—A referral to a specific job resulting in an interview, whether or not the individual obtained the job;

6. Short Term Job Supports—Support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job retention. Such services include short-term job coaching for persons who do not have a supported employment goal consistent with the employment goal on the IPE;

7. Supported Employment Services—On-going support services and other appropriate services needed to support and maintain an individual with a most significant disability in supported employment for a period of time generally not to exceed twenty-four (24) months. Services, such as job coaching, are for individuals who have supported employment and long-term supports identified on the IPEs. On-the-job support services with a supported employment goal are funded using Title VI and Title I funds;

8. Information and Referral Services—Services provided as needed to assist the applicant or eligible individual in securing needed goods and services not available through Rehabilitation Services for the Blind from other agencies or programs, including other components of the statewide workforce development system and the Client Assistance Program;

9. Benefits Counseling—Involves an analysis of an individual’s current benefits, such as Social Security Disability Income (SSDI) and Supplemental Security Income (SSI), the individual’s financial situation, and the effect different income levels from work will have on the individual’s future financial situation.

This service is intended to provide the individual an opportunity to make an informed choice regarding the pursuit of employment, but it does not include providing legal advice;

10. Customized Employment Services—The flexible strategies leading to a customized employment outcome; includes job exploration by the individual or working with an employer to facilitate placement;

11. Extended Services—Ongoing support services and other appropriate services needed to support and maintain an individual with a most significant disability in supported employment, as outlined in section (13) of this rule;

12. Graduate College or University Training—As provided in subsection (10)(A) of this rule;

13. Four- (4-) Year College or University Training—As provided in subsection (10)(A) of this rule;

14. Junior or Community College Training—As provided in subsection (10)(A) of this rule;

15. Occupational or Vocational Training—As provided in subsection (10)(A) of this rule;

16. On-the-job Training;

17. Registered Apprenticeship Training;

18. Basic Academic Remedial or Literacy Training;

19. Job Readiness Training;

20. Disability-Related Skills Training;

21. Business Enterprise Program (BEP) Training;

22. Customized Training—Training designed to meet an employer’s special requirements where the employer has entered into an agreement to hire individuals trained to meet their specific needs;

23. Miscellaneous Training—Any training not covered in the other training categories in paragraphs (8)(B)12.–(8)(B)22.;

24. Transportation—As provided in subsection (12)(A);

25. Maintenance—As provided in subsection (12)(B), monetary support provided for those expenses such as food, shelter, and clothing that are in excess of the normal expenses of the individual, and that are necessitated by the individual’s participation in an assessment for determining eligibility and VR needs or while receiving services under an IPE;

26. Rehabilitation Technology—As defined under subsection (2)(A), with guidance as provided in subsection (12)(C) of this rule;

27. Personal Assistance Services;

28. Technical Assistance Services—Services, as provided in subsection (12)(D), provided to eligible individuals who are pursuing a vocational goal of self-employment, telecommuting, or establishing a small business operation, including the development of business plans, marketing analyses, and resource development;

29. Reader Services—As provided in subsection (12)(F);

30. Interpreter Services—As provided in subsection (12)(G);

31. Services to members of an applicant’s or client’s family—As provided in subsection (12)(H);

32. Post-employment services—Services necessary to maintain or regain other suitable employment; and 33. Other goods and services not already identified in this

rule and pursuant to 34 CFR 361.48(b), subject to the restrictions governing the purchasing of goods in subsection (12)(C) of this

rule.

(9) Vocational Planning and the Individualized Plan for Employment.

(A) The individualized plan for employment will be developed pursuant to 34 CFR 361.45.

(B) If a client seeks multiple sources of employment, RSB will support the employment goal that will result in providing the individual’s greatest source of earned income.

(10) Training Costs. RSB provides training to an eligible client when the client needs training in order to achieve a vocational goal that is recorded in the client’s IPE. Training includes the areas of personal and vocational adjustment, academic training, and vocational training.

(A) Tuition, fees, books, and supplies that the client incurs, that are necessary to participate in the training program. RSB applies the following limitations to payment of tuition, fees, books, and supplies:

1. RSB may pay tuition and fees at state or other public colleges and universities in Missouri, vocational schools, or rehabilitation facilities at current verified rates;

2. RSB may pay tuition and fees at private colleges or universities in Missouri and at colleges or universities outside Missouri up to but not to exceed the in-state resident rate for courses at the University of Missouri–Columbia (MU) for students at a comparable academic level. If there is no comparable rate available at the University of Missouri– Columbia, the lowest cost of the rates within the University of Missouri System shall be used. If there is no comparable rate available within the University of Missouri System, the lowest cost rate at a public college within Missouri shall be used. If a deaf-blind client attends Gallaudet University, RSB may pay the full cost of tuition and fees at Gallaudet University;

3. RSB limits payment of tuition, fees, books, and supplies for academic and vocational training to a client’s completion of the academic or training curriculum that the client needs in order to obtain employment in the occupational area that the client selects, as recorded in the client’s IPE;

4. Comparable services and benefits must also be considered and applied for appropriately. For postsecondary educational programming, this means the student is required to apply for the Pell Grant and each year provide the counselor with a copy of their Free Application for Federal Student Aid (FAFSA) Submission Summary. RSB sponsorship may not be provided to students who do not apply for the Pell Grant and/ or do not supply RSB the FAFSA Submission Summary;

5. RSB may pay tuition and fees at private colleges or universities in Missouri and at colleges or universities outside of Missouri at a rate higher than that established by paragraph (10)(A)2. if there are no public institutions in Missouri offering comparable degrees and/or outcomes and such degree/ outcome is necessary for the client to achieve a vocational goal that is recorded in the client’s IPE. The granting of such requests requires approval by the deputy director or designee.

6. After the client’s first term, prior to authorization of funds for subsequent terms, the student shall provide RSB with grade reports;

7. The student is to register and complete a full course load each term. Full course loads are defined by the institution and/ or training program. Payment of any fees for dropping courses shall be the student’s responsibility. RSB may recoup the funds that RSB paid for a course that the student drops. RSB shall not pay for the same course twice. RSB may approve less than a full course load if the student can demonstrate that a less than full course load is necessary for the successful continuation of the student’s education that is required to achieve a vocational goal recorded in the student’s IPE. The student shall bear the burden of proof of justifying approval of a less than full course load. The granting of requests for part-time course loads require approval by the deputy director or designee;

8. The student is to maintain acceptable academic standing of at least a 2.0 GPA each term, or will meet the requirements of the particular training program in which the student is participating in cases where the standard is higher or the standard GPA is not used; and 9. If the student fails to maintain the standards in paragraphs (10)(A)7.-8., the student is required to meet with RSB staff to determine if RSB sponsorship will continue into the next term. If the student subsequently fails to meet the standards in paragraphs (10)(A)7.-8., RSB sponsorship will be withdrawn until the client meets those standards for one (1) term.

(11) Physical and Mental Restoration.

(A) General Provisions. Within the limitations that are relevant to this section in federal law, Chapter 34, RSMo, and this rule, and subject to appropriation, RSB may provide the physical and mental restoration services stated in this rule to a vocational rehabilitation client, to correct or substantially modify a physical or mental condition that is stable or slowly progressive and which contributes to the client’s impediments to employment. All costs and fees paid for physical and/or mental restoration must be for medically necessary services as certified by a qualified and licensed medical professional.

(B) Types of Physical or Mental Restoration— 1. Medical or corrective surgical treatment;

2. Diagnosis and treatment for mental or emotional disorders;

3. Dentistry;

4. Nursing services;

5. Inpatient or outpatient hospitalization needed in connection with surgery or treatment and clinic services;

6. Drugs and medical supplies;

7. Prescription of prosthetic and/or orthotics related to the individual’s diagnosed disability and essential to the achievement of the employment outcome;

8. Prescription of eyeglasses and visual services, including visual training, and the examination and services necessary for the prescription of eyeglasses, contact lenses, microscopic lenses, telescopic lenses, and other special visual aids that are prescribed by a physician skilled in diseases of the eye or by an optometrist, whichever the client may select;

9. Podiatry;

10. Physical, occupational, speech or hearing therapy;

11. Mental health services;

12. Medical or medically related social work services;

13. Treatment of either acute or chronic medical complications and emergencies which are associated with or arise out of the provision of physical and mental restoration services or which are inherent in the condition under treatment;

14. Special services for the treatment of end-stage renal disease, including transplantation, dialysis, artificial kidneys, and supplies; and 15. Other medical or medically related rehabilitation services.

(C) Payment for Physical or Mental Restoration. All comparable services and benefits that are available from any source to meet, in whole or in part, the cost of a client’s physical or mental restoration shall be utilized, unless to utilize these services or benefits would delay the provision of vocational rehabilitation services to any client who is at extreme medical risk as defined in subsection (2)(A). A determination of extreme medical risk shall be based upon medical evidence provided by a qualified licensed medical professional. Comparable benefits and services shall include, but not be limited to, Title XVIII (Medicare), Title XIX (Medicaid), public or private health insurance, Veterans Administration medical benefits, and Worker’s Compensation.

1. RSB may pay for other medical services, including hospital facility fees, physician services, laboratory and X-ray fees, anesthesia services, and hospital outpatient care, at a rate that is determined by the Department of Social Services to be reasonable, not to exceed rates established by the Centers for Medicare & Medicaid Services’ Physician Fee Schedule.

2. RSB may pay for medical services received outside Missouri at the rates paid by the vocational rehabilitation agency in that state, unless the provider participates in the Missouri Title XIX program, in which case RSB limits payment to Missouri Title XIX rates.

3. Selection of provider. To the extent possible, RSB shall purchase physical and mental restoration services (including medically necessary dental services) for clients who are eligible for Title XIX benefits from Title XIX providers who are located in Missouri.

4. Dental fee schedule. Authorized dental services shall be paid at the fiftieth percentile of the national rate as set forth in a national publication analyzing dental fees current as of the date of the provision of services.

(12) Support Services. RSB may pay the reasonable cost of necessary support services to or on behalf of an applicant or client undergoing assessment(s) to determine eligibility and the nature and scope of services. Additionally, pursuant to the individual’s rehabilitation plan, RSB may pay the cost of support services to or on behalf of a client in order for the client to benefit from physical or mental restoration, academic, vocational, and other training, or job-related services (such as job search, job placement, and job retention).

Comparable services and benefits must be considered and applied appropriately, as outlined within section (4) of this rule.

Support services are the following:

(A) Transportation. RSB shall pay the cost of the most economical source of transportation that meets the applicant or client’s rehabilitation service needs. RSB pays the cost of mileage traveled by private automobile at the rate per mile currently allowed state employees by the Department of Social Services; bus fare and train fare at actual charges; and cab fare, only when other methods of transportation are not available, at actual charges. When a client must travel by plane, air travel shall not exceed the cost of coach fare for the most direct available route.

1. Physical or mental restoration. RSB may pay the reasonable and necessary costs of transportation that a client needs in order to obtain physical or mental restoration that is prescribed by a provider who meets the standards in subsection (17)(D).

2. Personal and vocational adjustment training. RSB may pay the reasonable and necessary costs of transportation that a client needs in order to participate in personal and vocational adjustment evaluation or training at a rehabilitation facility that meets the standards in subsections (17)(A) and (B).

A. When a client stays in rehabilitation facility residential quarters, RSB shall limit payment to the necessary trips the client makes between the client’s home and the rehabilitation facility during the time the client is in evaluation or training activities at the facility. The decision regarding the number of trips that are necessary is made by RSB, the rehabilitation facility, and the client.

B. When a client lives at home and commutes, the total monthly payment for transportation shall not exceed the reasonable and necessary cost of room and board that is available at or in conjunction with the rehabilitation facility, as described in subparagraph (12)(B)4.C.

3. Academic training and vocational training. RSB may pay costs of reasonable and necessary transportation that a client needs in order to participate in academic training or vocational training.

A. If a client lives at home and commutes to campus, the total monthly payment for transportation to and from campus shall not exceed the lowest cost of double occupancy dormitory charges with maximum meal plan at the University of Missouri–Columbia, as described in subparagraph (12)(B)4.A.

B. If a client commutes to campus and RSB is providing maintenance in support of their academic or vocational training, the total monthly payment for transportation to and from campus and maintenance combined shall not exceed the lowest cost of double occupancy dormitory charges with maximum meal plan at the University of Missouri–Columbia, as described in subparagraph (12)(B)4.A.

4. Job-related services. RSB may pay reasonable and necessary costs of transportation that a client needs in order to participate in job-related services, including to seek 5. Relocation expenses. RSB may pay the reasonable and necessary costs of transportation that a client needs in order to relocate after obtaining employment. Payment of these transportation expenses is limited to payment of moving expenses from the client’s home locale to the location of the client’s employment;

(B) Maintenance, as defined by subsection (2)(H) of this rule, is not based on an individual’s economic or financial situation.

1. The amount of maintenance shall be based on the individual’s specific circumstances.

2. Lodging and meals not covered under a contract or otherwise limited by this rule will be paid at the maximum state rate, per the department’s travel policy utilized for Missouri state employees.

3. For other subsistence items that are additional expenses in excess of normal living expenses necessitated by participation in an assessment or IPE, the maximum total for all items combined shall not exceed one hundred twenty dollars ($120) per month.

4. Maintenance to support academic and vocational training received on campus.

A. For in-state public institutions, the maximum payment shall not exceed the lowest cost of a double occupancy dormitory charge with maximum meal plan at the state university’s lowest rate.

B. For private and out-of-state institutions, and in-state public institutions that have no dormitories, the maximum payment shall not exceed the lowest cost of double occupancy dormitory charge with maximum meal plan at the University of Missouri–Columbia (MU) unless the deputy director or designee determines a comparable academic or vocational program is not offered at in-state public institutions, in which case RSB’s payment shall be reasonable (i.e., the least expensive goods and services to meet the recipient’s needs) and shall not exceed actual costs.

C. For Personal and Vocational Adjustment to Blindness (PVA) training at a contracted Community Rehabilitation Program (CRP), maintenance will be paid at the contract rate.

Those maintenance costs not covered by a PVA contract will be paid in accordance with paragraphs (12)(B)1. and (12)(B)2. above.

D. Maintenance for academic or vocational training is contingent on maintaining acceptable academic standing, as provided in paragraphs (10)(A)7.-8. of this rule, and maintaining full-time status as dictated by the institution.

E. RSB may pay continuous maintenance during school breaks to an eligible individual if the eligible individual is attending consecutive semesters and the term between semesters is less than six (6) weeks.

5. Maintenance to support job-related services.

A. RSB may pay maintenance in support of reasonable and necessary job-related services (such as job search) in accordance with paragraphs (12)(B)1. and (12)(B)2.

B. RSB may pay the necessary costs of establishing a new living arrangement in order for an eligible individual to accept employment. Payment for housing will be limited to expenses actually incurred for no more than two (2) weeks prior to the start date of the employment, and may continue until the eligible individual has been employed for one (1) full calendar month, or one thousand three hundred dollars ($1,300) total for the same time period, whichever is less;

(C) Assistive Technology Devices, Other Equipment, Tools, and Supplies. RSB may pay for reasonable and necessary assistive technology devices as well as other reasonable and necessary equipment, tools, and supplies that the eligible individual needs to participate in academic, vocational, or other training, and to perform required job duties following employment. RSB may recover equipment at any time prior to case closure when the purpose for its issuance no longer exists and/or when it is no longer needed to achieve the client’s vocational goal;

(D) Start-up costs for small businesses. RSB may pay no more than seventy-five percent (75%) or a total of seventeen thousand five hundred dollars ($17,500), whichever is less, of a client’s start-up costs for establishing a small business. Payments for start-up costs shall be made only for six (6) months, starting from the date of the initial payment. Start-up costs for establishing a small business include, but are not limited to, rent, utilities, and supplies. RSB cannot provide start-up support for a multilevel marketing business, a business prohibited by law, or a business that sells products prohibited by law.

This subsection does not apply to start-up costs for vending facilities that RSB supervises according to 13 CSR 40-91.010. SSI/ SSDI beneficiaries are not required to participate in the cost to fund start-up businesses, but the seventeen thousand five hundred dollar ($17,500) limit, the six- (6-) month limitation, and the prohibition on a multilevel–marketing business, a business prohibited by law, or a business that sells products prohibited by law do apply to them;

(E) Home Modification. Home modification is an allowable expense under the following circumstances:

1. It is essential in order for the eligible individual to achieve an established vocational goal;

2. The eligible individual is in an active status (Note:

This service cannot be provided prior to development of an IPE or if the case record indicates the client’s plan has been interrupted);

3. The home being modified is owned or being purchased by the eligible individual or the eligible individual’s immediate family and is the eligible individual’s place of residence;

4. If the eligible individual resides in rental property, the only modification allowed will be ramping or a lift; and 5. When a ramp or lift is being provided for rental property, there must be written permission from the landlord in the case file prior to the service being authorized;

(F) Reader Service. RSB may provide reader service that a client needs in order to participate in a rehabilitation program, including orientation to employment. RSB will pay the cost of reader service for an eligible individual who is in post-secondary training using funds that are available from the State Reader’s Fund as matching funds, as authorized in sections 178.160 and 178.180, RSMo;

(G) Language/Sign/Tactile Interpreting Services. RSB applicants and clients shall utilize state-contracted language interpreting services whenever possible. RSB may pay the cost of interpreting services when an individual needs interpreting services in order to participate in a rehabilitation program including orientation to employment when services are not available under a state contract. RSB may pay the rate that is charged by a qualified interpreter who is available to an individual;

(H) Services to Family Members. RSB may provide services to members of a client’s family, when the provision of such services is necessary in order for the client to become rehabilitated; and (I) Other Support Services that are necessary to participate in VR services include, but are not limited to, additional costs incurred for child care and personal assistance services for individuals with most significant disabilities.

(13) Supported Employment. RSB shall provide vocational rehabilitation services that will lead to supported employment for individuals with the most significant disabilities who are eligible for these services, pursuant to 34 CFR 363.1.

(A) RSB provides supported employment to youth with the most significant disabilities, as defined in subsection (2)(A) of this rule.

(B) The approval of the deputy director or designee is required for job supports (i.e., job coaching) services exceeding nine hundred sixty (960) hours or lasting beyond nine (9) months, whichever occurs first. RSB will only approve this service if the client establishes that the client will lose their employment without ongoing job supports.

(C) RSB may provide the following services only to youth with the most significant disabilities seeking a supported employment outcome in competitive-integrated employment:

1. Extended services. Funds may be used to provide extended services only to youth with the most significant disabilities.

A. Extended services shall not exceed four (4) years or until such time that a client no longer meets the definition of a youth with a disability under 34 CFR 361.5(c)(58), whichever occurs first.

(14) Transition Services. RSB shall provide transition services, as needed by a client to promote the client’s movement from school to post-secondary education, vocational training, or suitable employment. RSB shall provide transition services through cooperative efforts with the Department of Elementary and Secondary Education, the Missouri School for the Blind, and local education agencies.

(15) Extended Employment. Vocational goals for working in extended employment do not meet the requirement for competitive-integrated employment outcomes and thus cannot be supported under the vocational rehabilitation program. The individual seeking extended employment must first obtain documentation that activities as provided in 34 CFR 397.20, 34 CFR 397.30, 34 CFR 397.40, and this section were completed prior to entering extended employment.

(A) RSB shall inform the applicant or eligible individual that Vocational Rehabilitation Services are available should the individual wish to pursue competitive-integrated employment.

(B) If the individual, exercising their informed choice, persists in pursuing extended employment, RSB and the individual shall follow requirements set forth in 34 CFR 397.20, 34 CFR 397.30, and 34 CFR 397.40 to secure documentation necessary for the individual to enter extended employment, and to ensure the client is offered the required services of these sections at the necessary intervals for the duration of their employment at subminimum wage.

(C) Students with a disability seeking subminimum wage 1. Upon being notified that a student with a disability is seeking subminimum wage employment, the following must take place:

A. RSB shall explain to the student that RSB cannot provide vocational rehabilitation services to obtain subminimum wage employment;

B. RSB shall explain to the student that Vocational Rehabilitative services are intended to achieve an employment outcome in a competitive-integrated employment setting;

C. RSB shall explain that Vocational Rehabilitation Services are available, should the applicant wish to pursue competitive-integrated employment; and D. RSB shall provide information regarding Pre- Employment Transition Services (PETS).

(16) Case Closure. RSB shall close an applicant’s or client’s vocational rehabilitation case at any time in the vocational rehabilitation process when—RSB has determined that an applicant is not eligible for vocational rehabilitation services; the client has completed vocational rehabilitation services that RSB planned to provide, and additional vocational rehabilitation services are either unnecessary or inappropriate, except services that RSB may provide as post-employment services; or an applicant or client is not available to receive vocational rehabilitation services. Prior to RSB closing any case for the reason that the individual is not available, RSB shall contact the individual at their last known address, notifying them to contact RSB within ten (10) calendar days of the date of the notice. RSB may close the case if the individual does not cooperate with the notice, or if the post office returns agency mail directed to the individual indicating no forwarding address.

(A) Case Closure Without an Eligibility Determination. RSB shall close an applicant’s case without a determination of eligibility when the applicant does not, or is unavailable to complete an evaluation of vocational rehabilitation potential and RSB has made reasonable efforts to contact the applicant or, as appropriate, the applicant’s representative, and to encourage the applicant’s participation.

(B) Case Closure Due to a Determination of Ineligibility Before IPE Development. When RSB determines that an applicant does not meet one (1) or more of the basic conditions of eligibility for vocational rehabilitation services or that a client no longer meets one (1) or more of the basic conditions of eligibility, RSB shall close the applicant’s or client’s case. RSB shall carry out the following activities in regard to case closure:

1. RSB shall make the ineligibility determination only after full consultation with the applicant or client or, as appropriate, the applicant’s or client’s parent, guardian, legal custodian, or other representative, or after giving a clear opportunity for such consultation; and 2. RSB shall complete a certification of ineligibility which indicates the reasons the applicant or client is ineligible for vocational rehabilitation services.

(C) Case Closure Due to a Determination of Ineligibility After IPE Development. When RSB decides to terminate vocational rehabilitation services that RSB is providing to a client because of a determination that the client is no longer eligible, RSB shall close the individual’s case. RSB shall make the ineligibility determination only after full consultation with the client or, as appropriate, the client’s parent, guardian, legal custodian, or other representative, or after giving an opportunity for such consultation, except under the following circumstances: the client has refused to participate, the client is no longer present in Missouri, the client’s whereabouts are unknown, or the client’s medical condition is rapidly progressive or terminal.

When the client or, as appropriate, the client’s parent, guardian, or other representative has consulted with RSB, RSB shall record the views of the individual regarding the decision.

(D) Annual Review of Certain Case Closures. When RSB determines an applicant or client is ineligible for vocational rehabilitation services because the applicant or client cannot be expected to achieve a vocational goal, RSB shall review the ineligibility decision pursuant to 34 CFR 361.43(e).

(E) Case Closure as Successfully Rehabilitated. RSB shall close a client’s case if RSB determines the client to be successfully rehabilitated, as set forth in 34 CFR 361.56. RSB shall conduct post-exit follow up after the case is closed to verify continued (F) RSB shall notify the client in writing of case closure. The notification shall include information regarding the client’s appeal rights and the assistance that is available from the client assistance program. RSB does not need to send written notification to the client when the client is deceased, the address is unknown, or the client cannot be located.

(17) Standards for Facilities and Other Providers of Services. RSB requires providers from which RSB purchases vocational rehabilitation services to meet the standards stated in this section of this rule and 34 CFR 361.51.

(A) Rehabilitation Facilities. A rehabilitation facility is a facility that is operated for the purpose of providing vocational rehabilitation services to clients and applicants. A rehabilitation facility must have the capability to provide, singly or in combination, one (1) or more of the following vocational rehabilitation services:

1. Vocational rehabilitation services, including under one (1) management: medical, psychiatric, psychological, social, and vocational services;

2. Testing, fitting, or training in the use of prosthetic or orthotic devices;

3. Prevocational conditioning or recreational therapy;

4. Physical and occupational therapy;

5. Speech and hearing therapy;

6. Psychiatric, psychological, and social services;

7. Evaluation of rehabilitation potential;

8. Personal and work adjustment;

9. Vocational training with a view toward career advancement, which is provided in combination with other rehabilitation services;

10. Evaluation or control of specific disabilities;

11. Orientation and mobility services and other adjustment services to blind individuals;

12. Transitional or extended employment for those individuals with disabilities who cannot be absorbed readily into the competitive labor market;

13. Psychosocial rehabilitation services for clients and applicants with chronic mental illness; and 14. Rehabilitation technology services.

(B) Rehabilitation Facility Accreditation. A rehabilitation facility must comply with the rehabilitation facility standards specified by RSB. These standards include, but are not limited to, those of the Commission on the Accreditation of Rehabilitation Facilities (CARF) and the Joint Committee on the Accreditation of Hospitals (JCAH), or other national accreditation body, if the standards of the entities referred to in this subsection are approved pursuant to 42 USC 1395bb.

(C) Academic or Vocational Training Accreditation. An agency or institution that provides academic or vocational training services must be accredited or licensed by the accrediting or licensing agency that is appropriate to the training curriculum that the agency or institution provides.

(D) Physical or Mental Restoration Provider Accreditation. A physician or any other health care provider must be certified or accredited to perform the specific service that the applicant or client requires and must be licensed to perform the service in the state in which the service is performed.

(18) Pursuant to 34 CFR 361.49, RSB shall manage a Center for Braille and Narration Production (CBNP) for the purposes of providing access to information for individuals who are blind, including but not limited to Braille, narration, large print, and special electronic formats. Current RSB clients may access these services at no cost. CBNP may provide transcription, narration, and other services required to produce accessible informational materials for a fee set by RSB.

(19) Order of Selection. If RSB is unable to provide vocational rehabilitation services to all eligible individuals who apply for services, RSB will implement an order of selection pursuant to 34 CFR 361.36 to ensure that those individuals with the most severe disabilities are provided services.

(A) An eligible individual’s assigned category may be changed at any time based on information that clarifies the severity of the individual’s disability or if there is a change in the severity of disability.

(B) The implementation of an order of selection shall not affect the provision of diagnostic and evaluation services necessary to determine eligibility.

(C) While under an order of selection, RSB shall develop an individualized plan for employment (IPE) only for those eligible individuals who are in the priority categories currently being served.

(D) RSB shall continue to provide all needed services to any eligible individual who has begun to receive services under an IPE prior to the effective date of the order of selection, regardless of the eligible individual’s assigned category.

(E) Eligible individuals will be served under the categories of priority defined in paragraphs (19)(E)1.-3. In accordance with these categories, individuals with the most significant disabilities (Priority I) will be selected first for the provision of vocational rehabilitation services. In the event that all Priority I individuals can be served with available resources, Priority II and then Priority III cases (in that order) will be opened for provision of vocational rehabilitation services.

1. Priority III: Individual with a disability, as defined in subsection (2)(A) of this rule.

2. Priority II: Individual with a significant disability, as defined in subsection (2)(A) of this rule.

3. Priority I: Individual with a most significant disability, as defined in subsection (2)(G) of this rule.

(F) While RSB is operating under the order of selection, all RSB-eligible individuals who are in priority categories that are not being served will be placed on a waiting list prior to IPE development and will remain on the waiting list in that status until approval is given to serve individuals in their assigned priority category. When approval to serve a priority category that has been on the waiting list is given, individuals will be served in the order of their application date.

(20) Exceptions to rule. Except as otherwise provided in this

regulation, any other exceptions to the limitations on services defined by this rule must be approved by an administrative review team designated by the deputy director to determine

rule exceptions. Exceptions to this rule shall not be in conflict with the provisions of the vocational rehabilitation program as set forth in state and federal law.

(21) Review Procedures. Pursuant to 34 CFR 361.57, an applicant for or recipient of services through RSB’s vocational rehabilitation program has the right to obtain the review of any determination regarding the furnishing or denial of services. One (1) or more of the options for review set forth in this section can be used, which provide the individual and RSB the opportunity to submit additional evidence and information.

(A) Administrative Review. An administrative review is an informal process for resolving a request for review without mediation or a due process hearing.

1. The applicant or eligible individual or, as appropriate, the individual’s guardian or representative, may request an administrative review by submitting a written request to the deputy director or designee.

2. The deputy director or designee will conduct an informal review within thirty (30) days from receipt of the request unless both parties agree to an extension of time.

3. The applicant or eligible individual or, as appropriate, the individual’s guardian or representative, will be informed of the results of their informal review in writing and the right to a due process hearing or mediation.

(B) Due Process Hearing. An applicant or eligible individual may request a due process hearing with or without an administrative review.

1. The applicant or eligible individual must request a due process hearing in writing submitted to the deputy director or designee.

2. The hearing officer shall be selected from a list of qualified impartial hearing officers maintained by Rehabilitation Services for the Blind. Selection of hearing officer is by agreement between deputy director or designee and the applicant or eligible individual or, as appropriate, the individual’s guardian or other representative. If the deputy director or designee and the applicant or eligible individual or that person’s guardian or representative cannot agree on the choice of a hearing officer, RSB shall select at random a hearing officer from the aforementioned list of qualified impartial hearing officers.

3. The fair hearing shall be held within sixty (60) calendar days from the date RSB receives the eligible individual’s request for review of a decision, unless informal resolution or a mediation agreement is achieved prior to the sixtieth day or the parties agree to a specific extension of time.

4. The fair hearing shall be held during normal working hours, at the RSB district office where the eligible individual’s case record is located.

5. The applicant or eligible individual or, as appropriate, the individual’s guardian or representative, shall be given the opportunity to present and examine witnesses, additional evidence, and relevant sources of information during the due process hearing or if the hearing officer holds the record open to admit additional evidence.

6. The hearing officer will make a determination based on the facts and applicable law. The hearing officer shall render a decision in writing. The decision must specify the findings of fact, conclusions of law, and decision of the hearing officer. The hearing decision must be based solely on the facts adduced to the hearing officer at the hearing. The written decision will be served on the deputy director and the individual or applicant, or that person’s representative.

7. Within twenty (20) calendar days of the date of the hearing officer’s written decision, either party may request in writing a review of the written decision by the director of Family Support Division or their designee. The director of Family Support Division may not delegate the responsibility for reviewing the written decision of the hearing officer to any Family Support Division staff.

8. The director of Family Support Division or designee shall provide the opportunity for submission of additional evidence and information relevant to a final decision concerning the matter under review.

9. The director of Family Support Division or designee may overturn or modify the hearing officer’s decision, or part of the decision supporting the position of the applicant or eligible individual, if it is determined, based on clear and convincing evidence, that the decision of the impartial hearing officer is clearly erroneous on the basis of being contrary to the federal act and/or regulations, or appropriate state law and/or regulations.

10. The director of Family Support Division or designee shall provide an independent, final decision in writing, including the statutory and regulatory findings for the decision, to the applicant or eligible individual or, as appropriate, the individual’s representative and to Rehabilitation Services for the Blind within thirty (30) days of the request for the administrative review.

(C) Mediation. Applicants and eligible individuals shall have the right to pursue mediation with respect to disputes involving any determinations that affect the provision of vocational rehabilitation services.

1. Mediation shall be voluntary on the part of the individual and RSB; not be used to deny or delay the rights of an individual to a due process hearing or deny any other rights; and be conducted by a qualified and impartial mediator who is selected from a list of qualified and impartial mediators maintained by RSB.

2. RSB shall bear the reasonable costs of the mediation process.

3. An applicant or eligible individual may request mediation by writing the deputy director of RSB and stating the issue(s) to be mediated. If mediation is agreed upon by both RSB and the applicant or eligible individual, a qualified mediator will then be selected by the individual. The mediator will be informed of the request and will assist parties in selecting a mutually agreeable time and place.

4. An applicant or eligible individual may be represented in the mediation session by an authorized representative or licensed attorney, at the individual’s expense.

5. The mediation will be held within sixty (60) days unless both parties agree to an extension. Mediation sessions are held at a time and location mutually agreed upon by both parties.

6. An agreement reached by the parties to the dispute in the mediation process shall be set forth in a written mediation agreement, and provided to the applicant or eligible individual or, if appropriate, the individual’s guardian or representative and the deputy director of RSB within thirty (30) days of completion of the mediation session.

7. Discussions that occur during the mediation process shall be confidential and not used as evidence in any subsequent due process hearing or civil proceeding. Both parties may be required to sign a confidentiality pledge prior to the commencement of such process.

8. Nothing in this section shall be construed to preclude the parties to such a dispute from informally resolving the dispute prior to mediation proceedings. Mediation will not be used to deny or delay an individual’s due process hearing.

Filed Nov. 5, 1979, effective Feb. 11, 1980. Amended: Filed Dec. 10, 1980, effective March 12, 1981. Emergency amendment filed Feb. 23, 1982, effective March 8, 1982, expired June 10, 1982. Amended:

Filed Feb. 23, 1982, effective June 11, 1982. Emergency amendment filed July 13, 1982, effective Aug. 1, 1982, expired Oct. 10, 1982.

Amended: Filed July 13, 1982, effective Oct. 11, 1982. Emergency amendment filed Jan. 15, 1985, effective Feb. 1, 1985, expired May 14, 1985. Amended: Filed Jan. 15, 1985, effective April 11, 1985.

Emergency amendment filed Jan. 15, 1986, effective Jan. 25, 1986, expired May 15, 1986. Amended: Filed Jan. 15, 1986, effective June 12, 1986. Emergency rescission and emergency rule filed Jan. 21, 1987, effective Jan. 31, 1987, expired May 21, 1987. Rescinded and readopted: Filed Jan. 21, 1987, effective May 11, 1987. Emergency amendment filed July 8, 1987, effective July 18, 1987, expired Nov. 15, 1987. Amended: Filed July 8, 1987, effective Oct. 11, 1987.

Amended: Filed Nov. 4, 1988, effective Jan. 27, 1989. Amended:

Filed April 3, 1989, effective July 1, 1989. Rescinded and readopted:

Filed June 6, 1991, effective Oct. 31, 1991. Emergency amendment filed Oct. 18, 1991, effective Oct. 31, 1991, expired Feb. 27, 1992.

Amended: Filed Sept. 13, 1994, effective March 30, 1995. Amended:

Filed Jan. 27, 2021, effective July 30, 2021. Amended: Filed Oct. 8, 2025, effective April 30, 2026. *Original authority: 207.022, RSMo 2014; 209.010, RSMo 1939, amended 2014; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.022, 209.010, and 660.017, RSMo 2016. Original rule filed Aug. 11, 1978, effective Nov. 11, 1978. Amended:

13 CSR 40-91.030 Prevention of Blindness Program {#sec-13-csr-40-91.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-91.030}

PURPOSE: This rule establishes the guidelines for provision of services to visually impaired persons through the Prevention of Blindness Program. Provision of these services is authorized by sections 207.010, 207.020, 209.010 and 209.020, RSMo.

(1) Prevention of Blindness Program. This program meets the cost of eye care for Missouri residents of all ages who meet visual eligibility requirements outlined in subsection (1)(A) and financial eligibility requirements outlined in subsection (1)(B).

(A) Visual Eligibility Requirements. Visual eligibility for Prevention of Blindness services is based on examination by an eye-care specialist that establishes one (1) of the following conditions: a progressive eye disease, a malformation or malfunction of all or part of an eye, or central visual acuity without correction of twenty/two hundred (20/200) or less in one (1) eye.

(B) Financial Eligibility Requirements. Financial eligibility for services is based on financial need as determined by Rehabilitation Services for the Blind.

(C) Priority of Services. When necessary, due to limitation of Prevention of Blindness funds, Rehabilitation Services for the Blind may initiate a priority of services plan, with those persons in need of emergency eye care or surgical procedures receiving priority.

(D) Prior authorization must be given for any service involving expenditure of Prevention of Blindness funds.

(E) Fees for Service. Total payment or eye care authorized by Prevention of Blindness will not exceed fees established by the Family Support Division.

(F) Similar Benefits. Prevention of Blindness funds will be used to pay for eye care only after payment available from other sources has been determined. Other sources include, but are not limited to: Title XVIII (Medicare), Title XIX (Medicaid), vocational rehabilitation programs, and other public or private health care programs.

rule filed Aug. 11, 1978, effective Nov. 11, 1978. Amended: Filed Jan. 10, 1985, effective April 11, 1985. Emergency amendment filed Oct. 17, 1985, effective Oct. 27, 1985, expired Feb. 14, 1986. Amended:

Filed Oct. 17, 1985, effective Feb. 13, 1986. Emergency amendment filed Aug. 17, 1992, effective Sept. 1, 1992, expired Dec. 29, 1992.

Amended: Filed Aug. 17, 1992, effective April 8, 1993. Amended:

Filed Aug. 15, 2000, effective Feb. 28, 2001. Amended: Filed Sept. 18, 2018, effective May 30, 2019. *Original authority: 207.022, RSMo 2014 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.022 and 660.017, RSMo 2016. Original

13 CSR 40-91.040 Payments for Vision Examinations {#sec-13-csr-40-91.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-91.040}

(Rescinded June 30, 2018)

rule originally filed as 19 CSR 40-11.010. Emergency rule filed Jan. 9, 2009, effective Jan. 19, 2009, expired July 17, 2009. Original rule filed Jan. 9, 2009, effective Aug. 30, 2009. Moved and amended:

Filed Sept. 13, 2010, effective March 30, 2011. Rescinded: Filed Nov. 3, 2017, effective June 30, 2018.

History

• AUTHORITY: sections 167.195 and 192.935, RSMo Supp. 2010. This

Chapter 100 Child Support Program, General Administration

13 CSR 40-100.020 Administrative Hearings {#sec-13-csr-40-100.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-100.020}

PURPOSE: This rule sets forth procedures by which the Family Support Division conducts hearings before its designated hearing officers to resolve disputes between the division and persons from whom the division is seeking to establish or modify an obligation for support or collect an established obligation.

(1) Definitions.

(A) “Obligor” means any person who owes or is alleged to owe a duty of support.

(B) “Administrative hearing” means a hearing to dispute an action taken by the division on a child support matter that is heard by the Administrative Hearings Section of the Division of Legal Services, Department of Social Services.

(C) “Case” means a matter before the Administrative Hearings

Section.

(D) “Child support case” means an official record comprised of an obligee or payee and dependent child(ren), associated with a particular obligor, receiving services pursuant to section 454.400, RSMo.

(E) “Obligee or payee” means a person to whom payments are or will be required to be made pursuant to a support order.

(F) “Division” means the Family Support Division and its employees.

(G) “Hearing request” means a request made by a party to the action, who personally or through a representative, requests a hearing according to the procedures set forth under this rule and applicable federal or Missouri statutes and regulations.

(H) “Administrative hearing officer” means a person designated by the Missouri Department of Social Services to resolve child support issues in compliance with all federal and state laws and regulations. The administrative hearing officers have the authority to conduct child support hearings on behalf of the Family Support Division on child support matters.

(I) “Administrative hearing packet” means a packet containing documents from the child support case record and submitted by the division to the Administrative Hearing Section to be offered as evidence in an administrative hearing on a child support case.

(2) Administrative Hearing Procedures.

(A) All administrative hearings on child support cases will be conducted by an administrative hearing officer designated by the Director of the Department of Social Services pursuant to section 454.475.1, RSMo. Any hearing officer employed by the Department of Social Services, and appointed to the Administrative Hearings Section as a hearing officer to handle child support matters is deemed to have been designated by the Director of the Department of Social Services. The designation by the Director of the Department of Social Services shall expire when employment with the Department of Social Services, Division of Legal Services, ceases or at such time as the hearing officer’s duties no longer include responsibility for conducting child support hearings.

(B) Ex parte communication with the administrative hearing officer from the parties, the division or its employees, or any attorney representing any party to the case is prohibited.

Ex parte communication includes any written or verbal communication with the administrative hearing officer, before or after the hearing, without the presence of all parties about a pending case. Ex parte communication also includes any written communication that has not been provided to all parties prior to any decision being rendered by the hearing officer on the document. This shall not prevent the parties from submitting hearing exhibits so long as all exhibits are provided to all parties to the case.

(C) Hearings held by the Administrative Hearings Section will be held by telephone or other electronic means. Any party may request to attend the hearing in-person at the Administrative Hearings Section’s office in Jefferson City. Any request to attend a hearing in-person with the hearing officer shall be made at least seven (7) days before the scheduled hearing. Any request to attend a hearing in-person made to the Administrative Hearings Section less than seven (7) days before the scheduled hearing shall be granted at the discretion of the Administrative Hearings Section or the administrative hearing officer. The Administrative Hearings Section will not provide transportation to any party to attend a hearing held by telephone, other electronic means, or in-person. All parties participating in the hearing will pay the party’s own costs.

1. If a party intends to participate by telephone, the party will need to provide the Administrative Hearings Section with a valid telephone number where the party can be reached on the day and at the time of the hearing.

2. If a party is incarcerated at the time of the hearing, it shall be the party’s obligation to make arrangements with the correctional institution to attend the hearing by telephone and to provide evidence or exhibits for the hearing. The incarcerated party may either provide a telephone number where the party can be reached on the day and time of the hearing or the party may call the Administrative Hearings Section on the day and at the time of the hearing at the telephone number provided for the hearing on the notification letter sent by the Administrative Hearings Section.

(D) All exhibits to be submitted as hearing exhibits in an administrative hearing, including the division’s administrative hearing packet(s), shall be submitted to the Administrative Hearings Section, the division, and all parties within five (5) days prior to the hearing. If hearing exhibits are not received five (5) days prior to the hearing, admission of exhibits as evidence any time thereafter shall be at the discretion of the hearing officer. The hearing officer shall have the discretion to leave the hearing record open for the submission of exhibits as evidence as long as copies of all exhibits are provided to the division and all parties, with the opportunity for the division or any party to submit rebutting evidence.

(3) Request for Continuance.

(A) In any administrative hearing under this rule, continuances may be granted only by the Administrative Hearings

Section. The Administrative Hearings Section, at its discretion, may grant a continuance freely upon the first request for a continuance from any party.

(B) If a party requesting a continuance was granted a prior continuance, the Administrative Hearings Section shall grant an additional continuance only upon a clear and present showing that substantive rights of a party in interest will be severely prejudiced by the denial of the request for continuance or for good cause shown as determined by the Administrative Hearings Section.

(C) All requests for continuances filed prior to the hearing date must be in writing, must contain a clear explanation as to why the continuance is needed, and all parties must be notified of the request. If notification to one (1) of the parties (12/31/24) John R. Ashcroft is not possible, the request for continuance filed with the Administrative Hearings Section must explain why notification to the parties is not possible. Any request for continuance must provide available dates for the resetting of the hearing date. If necessary, a party may request a continuance at the time of the hearing for good cause as determined by the Administrative Hearings Section.

(4) Default Administrative Decision.

(A) In any proceeding under this rule, the administrative hearing officer may enter a decision in default against any party who has failed to appear at the hearing. All parties shall appear for the hearing and be ready to proceed no later than the starting time listed on the notice. A hearing officer may find a party in default if the party or the party’s attorney does not appear within ten (10) minutes after the starting time. However, the hearing officer shall retain the

(B) All individuals shall comply with all directions given by a hearing officer during a hearing. If any individual fails to follow these directions, the hearing officer may exclude the individual from the hearing or may adjourn the hearing.

(C) The valid entry of a decision in default by the administrative hearing officer may be made in all cases, subject to the defaulting party’s right to move that the decision in default be set aside for good cause, but only if the defaulting party gives notice of the good cause to the administrative hearing officer in writing within ten (10) calendar days after the default decision is mailed to all parties. Nothing in this subsection abrogates the rights of the parties under section 454.475, RSMo, to file a motion for correction or motion to vacate with the Administrative Hearings Section.

(D) Any notice mailed to the last-known address of any party in interest will be deemed valid delivery of that notice.

(5) Hearing Requests.

(A) If the parties are entitled to a hearing under federal or state law or regulation or the division has notified the party of the right to a hearing due to an action taken by the division in the administration of the child support program, the division will provide, upon request, a hearing as set forth in section 454.475, RSMo. Any request for hearing must comply with any request procedure as set out in the law or regulation authorizing the hearing. For Missouri tax refund offset hearings for the obligor or nonobligated spouse, the notice to contest the tax offset is deemed received ten (10) calendar days after the date on the notice, unless refuted by competent evidence to the contrary. If the parties are entitled to a hearing, but federal or state law or regulation does not provide specific procedures or timelines for when the hearing requests must be made, then the parties to the child support case have thirty (30) calendar days from the date of the notice of the division’s action to request a hearing. The hearing request, unless it is for a federal tax refund offset, must be in writing and provided to the division, unless the authorizing law or regulation requires otherwise. Hearing requests on federal tax refund offsets may be verbal or in writing. The division will review the hearing request and may contact the party requesting the hearing in an effort to resolve the issues raised by the hearing request. The division will notify the parties in writing if the hearing request is granted, resolved, or denied and the reason for the denial.

If the request for hearing is granted, the division will forward the hearing request and administrative hearing packet to the Administrative Hearings Section. The Administrative Hearings

Section will schedule a hearing and send notice to the parties.

The administrative hearing notice shall state the date and time of the hearing, the procedures for participating in the hearing, and state the action or actions that the administrative hearing will address. The division may deny a request for an administrative hearing for any one (1) of the following reasons:

1. The party’s hearing request is based solely on issues that have previously been litigated and decided by a court of law;

2. The hearing request was untimely as set forth in either federal or state law or regulation; or 3. The party’s request for administrative hearing is based solely on issues which cannot be decided in an administrative hearing including but not limited to visitation, legal custody, and nonpaternity.

(B) An administrative hearing need not be held if all disputed matters are resolved before the hearing.

(C) If the Administrative Hearings Section receives multiple hearing requests from the same parties on the same child support case, the Administrative Hearings Section may combine the hearing requests into one (1) hearing if the hearing requests are for similar administrative actions.

(6) Administrative Hearings Procedures for License Suspension.

(A) The Administrative Hearings Section shall use procedures contained in this section to conduct hearings to determine whether suspension of a license is appropriate when the director has issued a notice of intent to suspend a license pursuant to section 454.1003, RSMo, on a child support case when an obligor is not making child support payments in accordance with a support order. The obligor may request an administrative hearing on the notice of intent to suspend a license the division issued on the obligor’s child support case. The suspension of the license shall be stayed pursuant to section 454.1005.3, RSMo, until the Administrative Hearings Section issues a decision containing written findings of facts and conclusions of law on the factors enumerated within section 454.1005, RSMo, determining whether the license suspension is appropriate. As used in section 454.1005.3, RSMo, “the director shall stay suspension of the license pending the outcome of the hearing” means that the director’s action to suspend the obligor’s license on the child support case shall be stayed pending the hearing decision and no order suspending the license on the child support case shall be issued by the director to the license authority until a decision is entered and an order is issued pursuant to section 454.1005.6, RSMo.

(B) The hearing officer shall have thirty (30) days to issue written findings of facts and conclusions of law after the hearing has ended and the hearing record has closed.

(C) In determining whether license suspension is appropriate, the hearing officer shall consider relevant factors presented by the obligor, the obligee, the division, and other witnesses that may be received by testimony, exhibits submitted prior to hearing, and exhibits admitted by the discretion of the hearing officer before the hearing record is closed. The obligor shall bear the burden of production and persuasion to show cause why suspension of a license is not appropriate under the totality of the obligor’s circumstances enumerated in section 454.1005.4, RSMo, and that the obligor failed to comply with the child support payment obligation for good cause as set forth in section 454.1005.5, RSMo. In providing evidence regarding license suspension, the obligor will submit such documentation or supporting evidence as requested by the hearing officer if the documentation or supporting evidence has not been submitted by the obligor prior to the hearing.

1. When considering the relevant factors regarding payments, “payments” mean any amount or amounts ordered to be paid pursuant to a “support order” as defined by section 454.1000(13), RSMo.

2. When considering the relevant factors regarding payments, “arrearage” means arrearage as defined by section 454.1000(1), RSMo.

3. When considering the relevant factor of payments that are in arrearage, the hearing officer at the hearing officer’s discretion and the circumstances of the child support case may limit the hearing officer’s consideration to a time frame less than the entire lifetime of the child support obligation.

4. When considering the relevant factor of transportation, “extracurricular activities” means an activity related to a school, job, or profession, but outside of the regular curriculum of the school or outside of the usual duties of the job or profession.

(D) If the hearing officer finds that the obligor failed with good cause to comply with the child support payment obligation and an arrearage exists in excess of two thousand five hundred dollars ($2,500) or the obligor owes an arrearage greater than or equal to three (3) months support payments, the hearing officer shall not issue an order suspending the obligor’s license on the child support case.

(E) After the issuance of a decision not to suspend a license, the director may issue a new notice of intent to suspend a license pursuant to section 454.1003, RSMo, if the obligor fails to make payments on the child support case and accumulates an additional arrearage in an amount greater than or equal to three (3) months support payments or two thousand five hundred dollars ($2,500), whichever is less, as of the date of service of the new notice of intent to suspend the license.

(F) Pursuant to section 454.1005.6, RSMo, the director shall issue an order suspending the obligor’s license on the child support case when the hearing officer finds that the obligor has failed without good cause to comply with any of the requirements in section 454.1005.4, RSMo. In section 454.1005.6, RSMo, “to comply with any of the requirements in subsection 4 of this section” means that the obligor failed to comply with the child support payment obligation and an arrearage exists in excess of two thousand five hundred dollars ($2,500) or the obligor owes an arrearage greater than or equal to three (3) months support payments. In section 454.1005.6, RSMo, “without good cause” means that the obligor did not present sufficient evidence on any of the relevant factors enumerated in section 454.1005.4, RSMo, or the relevant good cause considerations in section 454.1005.5, RSMo, for the hearing officer to find that the suspension of the license is inappropriate.

Amended: Filed Sept. 15, 1992, effective April 8, 1993. Emergency amendment filed June 2, 1995, effective July 15, 1995, expired Nov. 11, 1995. Amended: Filed June 2, 1995, effective Sept. 30, 1995.

Moved to 13 CSR 40-100.020 and amended: Filed Sept. 27, 2018, effective May 30, 2019. Amended: Filed June 12, 2024, effective Jan. 30, 2025. *Original authority: 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014, and 660.017, RSMo 1993, amended 1995.

History

• authority to commence the hearing at a time appropriate to the circumstances. It shall be the parties’ responsibility to provide the division and the Administrative Hearings Section with a current mailing address for notices issued by the Administrative Hearings Section including but not limited to hearing notices, continuance notices, and hearing decisions and/or orders, or proposed modification decisions and orders.
• AUTHORITY: sections 454.400 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-7.010. Original rule filed May 2, 1989, effective Aug. 25, 1989. Amended: Filed Dec. 13, 1989, effective April 26, 1990. Emergency amendment filed Sept. 15, 1992, effective Sept. 25, 1992, expired Jan. 22, 1993. Emergency amendment filed Jan. 7, 1993, effective Jan. 23, 1993, expired May 22, 1993.

13 CSR 40-100.030 Cooperation Requirement {#sec-13-csr-40-100.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-100.030}

PURPOSE: This rule sets forth the requirement for individuals who are applicants for or recipients of public assistance benefits (applicants/recipients) to cooperate with the Family Support Division in its efforts to establish paternity and establish, modify, and enforce child support orders.

(1) Definitions. For the purposes of this rule the following definitions are applicable:

(A) “Division” means the Family Support Division;

(B) “Good cause” means the circumstances under which cooperation is not in the best interest of the child or custodian who has applied for or is receiving public assistance benefits;

(C) “Cooperation” means the duty of applicants/recipients to provide, within their ability to do so, all requested information and assistance to the division to enable it to establish paternity and establish, modify, and enforce child support and medical support orders;

(D) “Public assistance” means any benefits from a program funded pursuant to Part A or Part E of Title IV of the Social Security Act, Title XIX of the Social Security Act, or the Food Stamp Act;

(E) “Applicant/recipient” is a person who has applied for or is receiving public assistance;

(F) “NCP” means noncustodial parent;

(G) “AF” means alleged father;

(H) “Genetic Testing” means testing for paternity using blood cells, other tissue, or fluid.

(2) Cooperation Requirements. If it is determined by the Division’s Child Support Program that an applicant/recipient is not cooperating in establishing paternity, establishing a medical support order with respect to a child, or in establishing, modifying, or enforcing a support order, and the applicant/recipient does not qualify for a good cause or other exceptions established by the Division, the Division’s Child Support Program shall notify the Division’s Income Maintenance Program, who shall impose sanctions. Cooperation requirements include, but are not limited to, providing to the Division’s Child Support Program the following information pertaining to the noncustodial parent (NCP) or alleged father (AF) and assistance to establish paternity and establish, modify, and enforce support orders:

(A) Information relating to the NCP or AF includes, but is not limited to:

1. The name;

2. Date of birth or approximate age;

3. Social Security number;

4. Known address or last known address;

5. Past or present employer and usual occupation;

6. Name of high school, college, university, vocational school/expected graduation date;

7. Names of friends or relatives who may have information;

8. Names of clubs or union memberships;

9. Driver’s license information;

10. Physical description;

11. Make, model, or license plate of any vehicles owned;

12. Any information regarding any other property owned; and 13. Any other pertinent information relevant to locating (12/31/24) John R. Ashcroft the NCP/AF;

(B) Assistance required from the applicant/recipient— 1. Providing financial and income information, education, and work history of the applicant/recipient;

2. Providing and updating the street and mailing address of the applicant/recipient;

3. Appearing at and cooperating with the Division’s Child Support Program or prosecuting attorney’s offices and supplying written documentary evidence;

4. Appearing as a witness at judicial or administrative hearings;

5. Completing a notarized affidavit attesting to a lack of relevant requested information regarding the NCP or AF; and 6. All other assistance requested by the Division’s Child Support Program to establish paternity including, but not limited to, keeping appointments for genetic testing and participating in genetic testing.

(3) Good Cause for Noncooperation.

(A) An applicant/recipient may refuse to cooperate with the Division’s Child Support Program based upon good cause. Each applicant/recipient will be informed by the division about the duty to cooperate and the right to claim good cause. Each applicant/recipient will also be provided information regarding good cause, including its definition and how good cause can be claimed and what evidence is needed to support such a claim.

(B) If the applicant/recipient claims good cause to the Division’s Income Maintenance Program, the Division’s Income Maintenance Program may make the good cause determination in compliance with this regulation.

(C) The applicant/recipient shall be provided a written copy of the requirement to cooperate and the right to claim good cause for refusal to cooperate with the Division’s Child Support Program. It is the responsibility of the applicant/recipient to specify the circumstances under which good cause is claimed and provide corroborative evidence. Good cause for refusing to cooperate is deemed to exist in one (1) or more of the following circumstances, but may not be limited to these circumstances:

1. Physical or emotional harm to a child;

2. Physical or emotional harm to the applicant/recipient of sufficient severity that it would reduce the applicant/recipient’s capacity to adequately care for a child;

3. Physical or emotional harm to the applicant/recipient as a result of domestic violence;

4. The child for whom support is sought was conceived as a result of incest or rape; or 5. Legal proceeding for the adoption of the child is pending before a court.

(4) The documentation will be submitted to the Division’s Income Maintenance Program which will review it to determine if there is sufficient evidence to establish a claim of good cause. A claim of good cause may be verified by one of the following:

(A) Birth certificate or medical or law enforcement records that indicate that a child was conceived as the result of incest or forcible rape. Acceptable medical records shall include records reflecting the judgment of a disinterested third party including, but not limited to, counselors, therapists, or any other medical or psychological health professional that conception is the result of rape;

(B) Court documents or other records that indicate that legal proceedings for adoption are pending before a court of competent jurisdiction;

(C) Court, medical, criminal, child protective services, social service, psychological, or law enforcement records that indicate the NCP/AF might inflict physical or emotional harm on the child or applicant/recipient;

(D) Medical records regarding the emotional health history and present emotional health status of the applicant/recipient or the child for whom support would be sought that indicate emotional harm would result from cooperation, or written statements from a mental health professional indicating such results;

(E) A written statement from a public or licensed private social agency that the applicant/recipient is being assisted by the agency to resolve the issue of whether to keep the child or relinquish him or her for adoption; or (F) When none of the items listed above is present or conclusive, a sworn statement from the applicant/recipient, and at least one other individual with knowledge of the circumstances that provide the basis for the claim of good cause may be submitted.

(5) Due Process Rights.

(A) Upon application, the applicant/recipient will be given, in writing, notice of the cooperation requirements. These requirements will be explained along with what sanctions can be applied when the applicant/recipient fails to cooperate with the Division’s Child Support Program. If the applicant/recipient claims good cause, he/she will have twenty (20) calendar days to provide evidence to support the claim of good cause. The twenty (20) days may be extended, in the case of difficulty in obtaining the evidence, for a period of time not to exceed forty-five (45) days as determined by the Division’s Income Maintenance Program.

(B) Review and Determination. If the applicant/recipient claims good cause, the Division’s Income Maintenance Program will review the information provided and make the final determination as to whether there is good cause for noncooperation.

(C) Notification of Final Determination. The Division’s Income Maintenance Program will notify the applicant/recipient of its decision in writing. If the division finds that there is good cause for noncooperation, the division will give the applicant/ recipient the option to have child support services stopped or be continued. If the division finds that there is no good cause to refuse to cooperate, the division will give the applicant/recipient an opportunity to cooperate, withdraw the request for assistance, or terminate assistance.

History

• AUTHORITY: sections 454.400 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-8.010. Original rule filed March 30, 2000, effective Oct. 30, 2000. Moved to 13 CSR 40-100.030 and amended: Filed Aug. 28, 2018, effective April 30, 2019. Original authority: 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997 and 660.017, RSMo 1993, amended 1995.

13 CSR 40-100.040 State Directory of New Hires {#sec-13-csr-40-100.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-100.040}

PURPOSE: For new hire reporting purposes under section 285.300, RSMo, this rule defines “newly hired employee” in accordance with The Trade Adjustment Assistance Extension Act of 2011 (Public Law 112–40) amendment to section 453A(a)(2) of the Social Security Act.

(1) “Newly hired employee” means an employee who— (A) Has not previously been employed by the employer; or (B) Was previously employed by the employer but has been separated from such prior employment for at least sixty (60) consecutive days.

Original rule filed Sept. 16, 2013, effective Feb. 28, 2014. *Original authority: 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997.

History

• AUTHORITY: section 454.400.2(5), RSMo 2000. Emergency rule filed Sept. 16, 2013, effective Sept. 26, 2013, expired March 24, 2014.

Chapter 102 Child Support Program, Establishment

13 CSR 40-102.010 Child Support Obligation Guidelines {#sec-13-csr-40-102.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-102.010}

PURPOSE: This rule sets forth the guidelines to be followed by the Family Support Division to determine the current amount of support due when establishing or modifying child support obligations.

(1) General Provisions.

(A) Definitions—as used in this rule:

1. “Director” means the director of the Family Support Division or his/her designee;

2. “Division” means the Family Support Division; and 3. “Form 14” means Missouri Supreme Court Civil Procedure Rule Form 14 and accompanying Schedule of Basic Child Support Obligations.

(B) The division shall follow, as its Child Support Obligation Guidelines, Missouri Supreme Court Civil Procedure Rule 88.01 and Missouri Supreme Court Rule Civil Procedure Form 14 and the accompanying Schedule of Basic Child Support Obligations.

(2) Specific Provisions.

(A) Determining and Imputing Income.

1. The division will generally include overtime, secondary employment, and bonus income when determining gross income.

2. For a parent incarcerated in a federal or state prison, the division will use actual income, which may be the monetary compensation the incarcerated parent receives for engaging in work or education programs while incarcerated.

3. Past earnings information may be used to impute income. Information on previous earnings may be obtained from the following sources, including, but not limited to, Division of Employment Security computer screens, Internal Revenue Service, past employers, tax returns, and wage stubs.

4. When income information is not available, and information regarding the parent’s normal occupation or educational level is known, or special skills which qualify him/her to maintain specific jobs, income may be imputed based on probable earnings levels for his/her usual occupation, qualifications, and prevailing job opportunities and wages in the parent’s community. This information may be obtained from sources including, but not limited to, the Department of Labor and Industrial Relations, local unions, or employers in the area.

5. Income may be imputed to a parent who is unemployed or underemployed based on the determination of the parent’s potential to earn income. A parent whose actual income cannot be determined or who has no income will be imputed income as follows:

A. A parent who is not currently employed, whether or not he/she has a work

history, and is now disabled and unable to work, or has a child at home whose condition or circumstance requires a parent’s presence in the home, will be imputed zero income;

B. A parent who has no work history and has a child in the home under the age of six (6) years will be imputed zero income;

C. A parent who has no work history and has a child at home between the ages of six (6) and twelve (12) years, will be imputed part-time (twenty (20) hours per week) at federal minimum wage or minimum wage in the state where the party resides, whichever is higher; or D. A parent with no work history, and no children under age thirteen (13), will be imputed income (up to forty (40) hours per week) at federal minimum wage or the minimum wage in the state where the party resides, whichever is higher.

(B) The parents must provide information (court orders, pay records, previous Form 14s, check stubs, etc.) regarding other child support obligations, spousal obligations, insurance, and child care, for credit on the Form 14.

(C) Neither parent will be considered the moving party if the division or a non-parent caretaker relative initiates the modification.

Both parents will be given credit for any other court or administrative order of child or spousal support or for other natural or adopted children not subject to this proceeding.

(D) To include extraordinary medical or child-rearing costs, it must be ordered by the court or an agreement in writing of the amount of any extraordinary medical or child rearing costs to be included on the Form 14 must be signed by both parents and provided to the division.

(E) For adjustments for periods of overnight visitation, the division will follow the Form 14 Directions, Comments For Use and Examples for Completion of Form No.

14. Adjustment for periods of overnight visitation will be given up to the amount of visitation that has been court-ordered. If the noncustodial parent visits the child less than the amount granted in the court order, he/she will only receive credit for the overnight visits actually exercised. The parents must provide evidence concerning the amount of time actually exercised in court-ordered visitations. In determining the number of overnight visits the parent paying support exercises, the division will:

15. If the parent receiving support and parent paying support agree on the number of overnights, use the agreed number of overnights;

16. If only one (1) of the parents provide information, use the information provided;

17. If neither parent responds, use the total number of overnights awarded by the court; or 4. If the parent receiving support and the parent paying support disagree on the number of overnights and the conflict cannot be resolved, use the information provided that will give the parent paying support the largest adjustment without exceeding the court ordered visitation.

(3) Deviations.

(A) If it is determined the presumed child support amount is unjust and inappropriate, the division may deviate based on the relevant factors set forth in the Civil Procedure Form No. 14 Directions, Comments for Use and Examples or for any of the following reasons:

1. A parent is under a Chapter 13 Bankruptcy plan;

2. The Children’s Division determines that in a foster care case the child support amount is not in the best interest of the child.

The Children’s Division staff must provide the reason in writing; or 3. The parent obligated to pay support claims to the division an inability to pay the presumed child support amount because the parent’s reasonable shelter expenses, or half of the shelter expenses if another person resides with the parent and assists in these expenses, and the child support total is sixty percent (60%) or more of the parent’s gross monthly income. The parent to whom support is due claims the child support amount is too low and that parent’s share of the total child support and his/her reasonable shelter expenses, or half of the shelter expenses if another person resides with and assists in these expenses, minus the presumed child support of the parent obligated to pay support equals sixty percent (60%) or more of his/her gross income.

(B) The division may deviate to adjust the presumed child support amount up to twentyfive percent (25%) if any of the factors in (A) above exist or if a deviation reason from the Civil Procedure Form No. 14 Directions, Comments for Use and Examples exist.

(C) If the total amount of children on the order exceeds six (6), the division will add to the amount determined by the guidelines for six (6) children, the difference between the JOHNR. ASHCROFT(3/31/19) amount for five (5) children and six (6) children and add that amount for each additional child.

(D) If the parent receiving support and parent paying support have multiple children and the support obligations for the children are in different orders (i.e., multiple judicial orders or a combination of judicial and administrative orders) and a modification review is requested, the division may deviate upward or downward so that when all of the obligations are added together, the obligation equals the presumed amount the parent paying support should pay for all of his/her children.

(E) If a judicial support obligation exists between the parent receiving support and parent paying support for their children, and the same parent receiving support and parent paying support have an additional child(ren) not included in previously entered judicial order(s), the division may deviate so that the amount the parent paying support pays for the additional child(ren) is the difference between the presumed support amount for all of the children and the amount in the parents’ existing orders. If the presumed amount for all the children is less than the existing order(s), the division may enter an order for zero (0) for the additional child(ren).

Amended: Filed Dec. 13, 1989, effective April 26, 1990. Emergency rescission and emergency rule filed March 14, 1994, effective April 1, 1994, expired July 29, 1994.

Emergency rescission and emergency rule filed July 27, 1994, effective Aug. 6, 1994, expired Dec. 3, 1994. Rescinded and readopted: Filed March 14, 1994, effective Oct. 30, 1994. Amended; Filed June 15, 1995, effective Dec. 30, 1995. Rescinded: Filed Nov. 9, 2000, effective May 30, 2001. Readopted: Filed May 17, 2000, effective Dec. 30, 2000. Moved to 13 CSR 40-102.010 and amended: Filed Aug. 28, 2018, effective April 30, 2019. *Original authority: 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014 and 660.017, RSMo 1993, amended 1995.

4CODE OF STATE REGULATIONS

(3/31/19) JOHNR. ASHCROFT

History

• AUTHORITY: sections 454.400 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-5.010. Original rule filed Feb. 2, 1988, effective April 11, 1988. Emergency amendment filed Dec. 13, 1989, effective Dec. 23, 1989, expired April 11, 1990. Emergency amendment filed Jan. 17, 1990, effective Jan. 27, 1990, expired Feb. 25, 1990.

Chapter 104 Child Support Program, Enforcement

13 CSR 40-104.010 Immediate Income Withholding Exceptions for Child Support Orders {#sec-13-csr-40-104.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-104.010}

PURPOSE: This rule establishes and sets forth the procedures for allowing exceptions from immediate income withholding when child support orders are entered or modified by the Family Support Division pursuant to sections 454.460–454.520, RSMo.

(1) Definitions— (A) “Division” means the Family Support Division;

(B) “Director” means the director of the Family Support Division or his/her designee;

(C) “Temporary Assistance for Needy Families (TANF)” means a financial assistance program for families with children, also known as Title IV-A of the Social Security Act;

(D) “Obligor” means any person who owes a duty of support as determined by a court or administrative agency of competent jurisdiction;

(E) “Obligee” means a person to whom a duty of support is owed as determined by a court or administrative agency of competent jurisdiction;

(F) “Arrearage” means past-due child support owed under a child support order;

(G) “Assignee” means a state agency to which an obligee relinquishes the right to receive child support, either by agreement or by operation of law;

(H) “Bond” means a cashier’s check or money order payable to the division to ensure the payment of child support under a child support order;

(I) “Current support” means the periodic child support obligation, imposed by a child support order;

(J) “Good cause” means the circumstances under which the director will not impose an immediate order to withhold income upon entry of an order for child support;

(K) “Income withholding” means the withholding of any form of payment to an individual regardless of source, including, but not limited to, wages, salary, commissions, compensation as an independent contractor, Workers’ Compensation, disability, annuity, and retirement benefits, and any other payments made by any person, private entity, federal or state government, any unit of local government, school district, or any entity created by public law or ordinance;

(L) “Notice and finding of financial responsibility” means a written allegation as to the parent’s responsibility to support his/her child(ren), which precedes the establishment of an administrative child support order for support pursuant to Chapter 454, RSMo of the Missouri Revised Statutes;

(M) “Written agreement” means an agreement in writing between the obligor and the obligee, and in cases in which there is an assignment of support rights, an agreement between the obligor and the assignee, which provides for an alternative arrangement for payment of support to the Family Support Payment Center and is signed by each party to the agreement; and (N) “Family Support Payment Center” means the state disbursement unit established by the division pursuant to section 454.530, RSMo, for the receipt and disbursement of payments made pursuant to support orders.

(2) Immediate Income Withholding When Initial Order is Entered.

(A) The director shall issue an immediate withholding order to the obligor’s employer or other payor on the entry date of the child support order, unless the director determines that good cause exists not to do so or unless there is a written agreement as defined in this

rule.

(B) Good cause exists for not effecting immediate income withholding if— 1. The obligor posts a bond with the division equal to two (2) months’ current support at the time the child support order is entered;

2. The obligor agrees to notify the division of his/her current employer’s name and address as long as the child support order is in effect; and 3. The obligor provides proof that he/she has obtained or applied for medical insurance for the child(ren) named in the notice and finding of financial responsibility, unless the obligee has medical insurance for the obligor’s child(ren) other than Medicaid.

(C) The division shall hold the bond in escrow. The bond will not accrue interest while held by the division. If no arrearage is owed to the obligee, the division shall refund any remaining balance to the obligor within sixty (60) days of— 1. The date the division is notified by the obligee that the child(ren) no longer meet requirements for continued support under 452.340, RSMo, or a court order or administrative order finds that the child(ren) are no longer eligible for continued support; or 2. The date the obligee stops receiving child support enforcement services from the division.

(D) If the obligor misses a scheduled child support payment and an arrearage equal to or greater than one (1) month’s current support amount has accrued, the director will— 1. Apply the bond to the obligor’s child support arrearage and pay to the obligee, or the current assignee of support rights, the amount of the accrued arrearage, up to the remaining bond amount; and 2. Issue an income withholding order to the obligor’s employer or other payor, if known.

(3) Immediate Income Withholding When Child Support Orders Are Modified.

(A) The director shall issue an immediate income withholding order to the obligor’s employer or other payor on the entry date of the modification of any child support order modified under sections 454.496, and 454.500, RSMo, unless the director determines that good cause exists not to do so or unless there is a written agreement as defined in this rule.

(B) Good cause exists for not effecting immediate income withholding if the obligor provides to the division— 1. A written request that immediate income withholding not be implemented;

2. Trusteeship records showing that an arrearage did not exist on the child support order prior to its modification;

3. Trusteeship records showing that all payments on the child support order were made on or before the due date;

4. Proof that he/she has obtained or applied for medical insurance for the child(ren) named in the order, unless the obligee has medical insurance other than Medicaid for the obligor’s child(ren); and 5. A written agreement to notify the division of the name and address of his/her current employer as long as the child support order is in effect.

(C) Notwithstanding the fact that good cause exists under subsection (3)(B) of this

rule, an income withholding shall be effected if any one (1) of the following occurs:

1. The obligor misses any scheduled payments on the child support order and an arrearage exists equal to at least one (1) month’s current support;

2. The obligor requests that income withholding begin;

3. The obligee requests that income withholding begin and the Family Support Payment Center received at least one (1) scheduled payment after its due date;

4. The obligor does not provide the division with his/her new employer’s name and address; or 5. The obligor terminates medical insurance coverage for the child(ren) named in a child support order that includes medical support, unless the termination is done with the consent of the obligee or assignee.

(4) Written Agreement.

(A) As assignee of support rights, the director will not enter into a written agreement not to impose immediate income withholding if the person owed support for the obligor’s child(ren) is receiving TANF on the date the notice and finding of financial responsibility is issued.

(B) If the obligee is not receiving TANF when the notice and finding of financial responsibility is issued, the director shall notify the obligor and the obligee that immediate income withholding will be initiated on the entry date of the order unless— 1. The obligee and the obligor each sign and within twenty (20) calendar days return to the division a written agreement allowing the obligor to make child support payments directly to the Family Support Payment Center;

2. The obligor agrees to notify the division of his/her current employer’s name and address as long as the child support order is in effect; and 3. The obligor provides proof that he/she has obtained or applied for medical insurance for the child(ren) named in the notice and finding of financial responsibility, unless the obligee has medical insurance for the obligor’s child(ren) other than Medicaid.

(C) The written agreement shall be invalid and the director shall initiate an income withholding order to the obligor’s employer or other payor without prior notice to either party if — 1. The obligor misses any scheduled payments on the child support order and an arrearage exists equal to at least one (1) month’s current support;

2. The obligor requests that income withholding begin;

3. The obligee requests that income withholding begin and the Family Support Payment Center received at least one (1) scheduled payment after its due date;

4. The obligor does not provide the division with his/her new employer’s name and address; or 5. The obligor terminates medical insurance coverage for the child(ren) named in a child support order that includes medical support, unless it is terminated with the consent of the obligee or assignee.

(D) If the legal custody of the child(ren) has been placed with the Children’s Division, a written agreement not to impose immediate income withholding may be obtained between the obligor and the Children’s Division caseworker assigned to the child(ren)’s alternative care case. The agreement shall be in accordance with the terms and requirements of subsections (4)(B) and (C) of this rule.

History

• AUTHORITY: sections 454.400 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-4.020. Original rule filed Dec. 24, 1990, effective June 10, 1991. Moved to 13 CSR 40-104.010 and amended: Filed Aug. 8, 2018, effective March 30, 2019. Original authority 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014 and 660.017, RSMo 1993, amended 1995.

13 CSR 40-104.020 Reporting of Child Support Debts to Consumer Reporting Agencies {#sec-13-csr-40-104.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-104.020}

PURPOSE:

The purpose of this rule is to establish procedures where a consumer reporting agency may request debt information from the Family Support Division (FSD). It also contains procedures for FSD to report an obligor who has an arrearage of $1000 or more to consumer reporting agencies. This

rule references 13 CSR 40-100.020, regarding procedures where an obligor, whose debt is to be reported to a consumer reporting agency, may request and receive an administrative hearing regarding the report. The information given to consumer reporting agencies will be used to update individual consumer records.

(1) Definitions.

(A) “Consumer reporting agency” (CRA), or a credit bureau, is any person, corporation, association, partnership, or other entity which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly engages in assembling and/or evaluating consumer credit information or other information on consumers for the purpose of furnishing credit reports to third parties, and which uses any means or facility of interstate commerce for the purpose of preparing or furnishing consumer reports.

(B) “Division” means the Missouri Family Support Division (FSD) and its employees.

(C) “Arrearage” means an amount of money owed for past-due child support, spousal support, or a state debt arising from Temporary Assistance for Needy Families (TANF), which includes, but is not limited to, a cash grant, funds expended for medical services, and alternative care payments.

(D) “Obligor” means any person who is ordered to pay support by a court or administrative authority.

(2) Division (IV-D) Responsibilities.

(A) If an obligor— 1. Is at least two (2) months delinquent in the payment of support and the arrearage is one thousand dollars ($1,000) or more, the division shall periodically report to consumer reporting agencies an obligor’s name and other identifying information specified in subsection (2)(D) and may continue to do so after the arrearage is less than one thousand dollars ($1000); or 2. Has an arrearage of one thousand dollars (1,000) or more and is not two (2) months delinquent in the payment of support, the division may periodically report to consumer reporting agencies the obligor’s name and other identifying information specified in subsection (2)(D), and may continue to do so after the arrearage is less than one thousand dollars ($1,000).

(B) A CRA may request information on an obligor from the division. The request must always be in writing, signed by a CRA’s managerial officer and sent to the division at its main office address contained in 13 CSR 40- 1.010. The officer must possess authority to make the request and that authority must be cited in the request. If the obligor already has been referred to a CRA, the division must provide the information within a reasonable time. If a referral has never been made to a CRA, and the obligor is at least two (2) months delinquent in the payment of support, the division must send advance notice to the obligor as provided in subsection (2)(C), prior to providing the CRA with the requested information.

(C) Prior to the referral to a CRA under subsection (2)(A) or (2)(B), the division must provide notice to the obligor that consists of the arrearage information the division intends to give the CRA and the obligor’s right to contest the accuracy of that information. The advance notice to the obligor will be sent by first class mail. The advance notice must contain—a statement that the division intends to report the obligor’s arrearage to one (1) or more CRAs; the date the CRA(s) will be sent the arrearage information; the arrearage amount as calculated by the division; identifying information specified in subsection (2)(D); a statement that the obligor may contest the arrearage amount by requesting an administrative hearing within twenty (20) calendar days after the notice is mailed; and the name, address, and telephone number of the person from whom the obligor can request a hearing. The division shall not refer an obligor’s name and other identifying information to a CRA under this rule while the request for hearing is pending.

(D) The division will generate a monthly 4CODE OF STATE REGULATIONS (4/30/19) JOHNR. ASHCROFT file of all obligors meeting the criteria under subsection (2)(A) and electronically transmit the file to each CRA. The file shall include, but not be limited to, the obligor’s name, Social Security number, current arrearage figure, and other identifying information as determined necessary by the division.

(E) Nonwithstanding the provisions of subsections (2)(A) and (2)(B) to the contrary, the division shall not make information available to— 1. A consumer reporting agency which the division determines does not have sufficient capability to systematically and timely make accurate use of such information; or 2. An entity which has not furnished evidence satisfactory to the division that the entity is a consumer reporting agency.

(3) CRA Responsibilities.

(A) Each CRA must agree to the following provisions. The CRA must develop a computer program which will allow the division’s electronic information to be entered in its records in a systematic and timely manner, agree to use information provided by the division in a lawful manner and safeguard information received from the division in accordance with federal and state confidentiality requirements.

(4) Fees. The division shall not charge the credit bureau a fee.

(5) Disputing Arrearage Amounts on File with the CRA.

(A) An obligor may seek to contest arrearage figures on file with a CRA. If the obligor contacts the division, s/he must do so in writing and clearly state the grounds on which the arrearage figure is being contested.

An administrative hearing will not be held, but the division will review the case and respond to the obligor regarding the results of the review.

(B) If the arrearage figure does change, the CRA will be notified on the next monthly electronic file listing. If the CRA representative contacts the division to verify the accuracy of information which is disputed by the obligor, the division will then review the case for accuracy in the same manner as if contacted directly by the obligor.

Filed June 2, 1995, effective Sept. 30, 1995.

Moved to 13 CSR 40-104.020 and amended:

Filed Oct. 1, 2018, effective May 30, 2019. *Original authority: 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 454.400 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-6.010. Original rule filed Dec. 13, 1989, effective April 26, 1990. Emergency amendment filed June 2, 1995, effective July 15, 1995, expired Nov. 11, 1995. Amended:

Chapter 106 Child Support, Modification

13 CSR 40-106.010 Review and Modification of Child and/or Medical Support Orders {#sec-13-csr-40-106.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-106.010}

PURPOSE: This rule sets forth the Family Support Division’s procedures for review and modification of existing child and/or medical support orders in accordance with sections 454.400, 454.496, and 454.500, RSMo, and 42 U.S.C. 666.

(1) Definitions.

(A) “Administrative order” means a child and/or medical support order established through the administrative process in accordance with sections 454.470–454.520, RSMo.

(B) “Temporary Assistance for Needy Families (TANF) case” means a case in which an applicant for or recipient of assistance has assigned to the state his/her rights to support as a condition of eligibility for public assistance under Title IV-A of the Social Security Act.

(C) “Division” means the Missouri Family Support Division.

(D) “Medicaid case” means a case in which a custodial parent or custodian has assigned to the state his/her rights to medical support to receive public assistance, but has not assigned to the state his/her rights to child support.

(E) “Review” means an objective evaluation of complete, accurate, up-to-date information necessary for application of the child support guidelines and criteria for support set forth in Missouri Supreme Court Rule 88.01 and other applicable law.

(2) Review.

(A) The division shall review the following cases, at its own request:

1. TANF cases with child and/or medical support orders, but the review will occur no less frequently than once every thirty-six (36) months from the date the order was established, last reviewed, or modified; and 2. Medicaid cases with child support orders that lack medical support provisions if the obligated parent has health insurance available through an employer, union, or group affiliation.

(B) A review shall be conducted after thirty-six (36) months from the date the order was established, last reviewed, or modified, or the date a review terminated pursuant to subsection (5)(B) of this rule, when the review is being conducted at the request of either the obligated parent or the person or agency having custody of the dependent child subject to the order. A review may be conducted earlier than thirty-six (36) months at the request of the obligated parent or the person or agency having custody of the dependent child subject to the order, or the division in a TANF or Medicaid case, if— 1. A child should be added to an administrative order;

2. A child should be removed from a general order, whether administrative or judicial;

3. The requesting party submits information that shows, or a sworn statement that alleges, there has been a fifty percent (50%) or more increase or involuntary decrease in income of either party to the order, and the division determines that the circumstances that caused the change have existed for at least three (3) months, and that it is reasonably likely they will remain unchanged for another six (6) months or longer;

4. The requesting party submits information that shows, or a sworn statement that alleges there has been a fifty percent (50%) or more voluntary decrease in income of either party to the order, and the division determines that the circumstances that caused the change have existed for at least six (6) months, and that it is reasonably likely they will remain unchanged for another six (6) months or longer;

5. A health insurance provision should be added to an administrative or judicial order;

6. The obligated parent will be incarcerated for more than one hundred eighty (180) calendar days; or 7. A child support obligation should be added to an administrative or judicial order, and— A. The order only addresses a health insurance obligation; or B. The order specifically states that no child support is ordered; or C. The court specifically reserved or retained jurisdiction of the child support issue in the order.

(3) Financial Information.

(A) Both parents subject to the order to be reviewed shall provide financial information and verification of income within ten (10) calendar days after the date the division mails a written request for the information. Documents verifying income shall include, but not be limited to, the following: copies of federal and state income tax returns, W-2 statements, pay stubs or a signed statement from an employer, or other source of income. If the division is unable to obtain financial information concerning the nonrequesting parent, it may request the other party to provide the financial information if that party is able to do so. If a requesting parent fails to provide financial information, the division may terminate the review.

(B) The division may use all other resources normally accessed to obtain the parents’ financial information.

(4) Denying Requests. A request for review by the obligated parent or the person or agency having custody of the dependent child subject to the order may be denied for the following reasons:

(A) The location of the nonrequesting party is unknown at the time the request is made;

(B) It has been less than thirty-six (36) months since the entry date of the support order or most recent modification, or last completed review, whichever is later, or it has been less than thirty-six (36) months since a review or modification action was terminated pursuant to subsection (5)(B) of this rule.

However, a review may be conducted earlier than thirty-six (36) months if the case meets criteria for earlier review set forth in subsection (2)(B) of this rule;

(C) The division is not providing services with respect to the order for which the review has been requested;

(D) The request is for the purpose of modifying custody or visitation rights;

(E) The request is for the sole purpose of modifying the amount of delinquent support that has accrued under a support order;

(F) The request is for the purpose of modifying the amount of spousal support under a support order; or (G) The request is for the review of a temporary support order.

(5) Withdrawing a Request by a Party.

(A) The division will consider the written withdrawal of the party who requested a review pursuant to subsection (2)(B) of this

rule if the withdrawal is submitted after the division acknowledged the request for review, but no later than— 1. Thirty (30) calendar days after service of process is achieved on a motion to modify filed pursuant to sections 454.496 and 454.500, RSMo, if neither party requested an administrative hearing; or 2. The date of the administrative hearing if either party requested an administrative hearing within thirty (30) calendar days after service of process was achieved on a motion to modify filed pursuant to sections 454.496 JOHNR. ASHCROFT(4/30/19) and 454.500, RSMo.

(B) Upon receiving a withdrawal pursuant to subsection (5)(A) of this rule, the division will notify the nonrequesting party of the withdrawal. The nonrequesting party will have ten (10) calendar days from the date of notice to contact the division in writing— 1. If the nonrequesting party protests the withdrawal, the division will notify the requesting party of the protest and will continue the review or modification of the order; or 2. If the nonrequesting party agrees to the withdrawal, either in writing or by his/her failure to contact the division in writing within ten (10) calendar days, the division will terminate all actions to review or modify the order.

(C) If the division terminates a review or modification action pursuant to subsection (5)(A) of this rule, the division will not accept from either party a request to review the order earlier than thirty-six (36) months from the date the action was terminated, unless the case meets criteria for earlier review set forth in subsection (2)(B) of this

rule.

(6) Withdrawing a Division Request.

(A) If the child(ren) of the order stop receiving TANF and/or Medicaid after the division has initiated a review, the division may withdraw from the review and modification.

(B) Upon withdrawing, the division will notify both parties of the withdrawal. The parties will have ten (10) calendar days from the date of notice to contact the division in writing— 1. If one (1) of the parties protests the withdrawal, the division will notify the other party of the protest and will continue the review or modification of the order; or 2. If both parties agree to the withdrawal, either in writing or by his/her failure to contact the division in writing within ten (10) calendar days, the division will terminate all actions to review or modify the order.

(C) If the division terminates a review or modification action pursuant to subsection (5)(B) of this rule, the division will not accept from either party a request to review the order earlier than thirty-six (36) months from the date the action was terminated, unless the case meets criteria for earlier review set forth in subsection (2)(B) of this rule.

(7) Modifications.

(A) The division will seek a modification if the review indicates that:

1. The case meets the modification threshold requirements of section 452.370 or 454.500, RSMo;

2. The child support obligation does not contain a provision for health insurance coverage by the obligated parent, and the children are not covered under a health benefit plan, other than Medicaid, by the custodial parent/custodian;

3. A child should be added to an administrative order; or 4. A child should be removed from a general order, whether administrative or judicial.

(B) If the obligated parent agrees to the modification, the division will send the order to the obligated parent to sign.

1. The obligated parent must return the signed and notarized order to the division in ten (10) calendar days.

2. Upon receipt of a signed and notarized order, the division will send the order to the person or agency having custody of the dependent child for signature. The person or agency having custody of the dependent child must return the signed and notarized order to the division in ten (10) calendar days.

(C) If the obligated parent and the person or agency having custody of the dependent child fail to return the signed and notarized order, the division will enter a default order.

(8) Modification Inappropriate.

(A) If the review of the order reveals a modification is inappropriate, the division will notify the parties in writing that the division will not modify the order.

(B) The parties will have thirty (30) calendar days from the date of the written notice to rebut in writing the division’s decision not to proceed with a modification of the order.

Filed Dec. 2, 1991, effective April 9, 1992.

Emergency amendment filed May 14, 1993, effective May 24, 1993, expired Sept. 20, 1993. Emergency amendment filed July 28, 1993, effective Sept. 21, 1993, expired Jan. 18, 1994. Amended: Filed May 14, 1993, effective Nov. 8, 1993. Emergency amendment filed Dec. 13, 1993, effective Dec. 23, 1993, expired April 21, 1994. Emergency amendment filed April 11, 1994, effective April 21, 1994, expired Aug. 18, 1994. Emergency amendment filed May 26, 1994, effective June 6, 1994, expired Oct. 2, 1994.

Amended: Filed Dec. 13, 1993, effective July 30, 1994. Emergency amendment filed May 26, 1994, effective June 5, 1994, expired Oct. 2, 1994. Amended: Filed May 26, 1994, effective Nov. 30, 1994. Amended: Filed June 15, 1995, effective Dec. 30, 1995. Amended:

Filed Nov. 30, 1995, effective May 30, 1996.

Moved to 13 CSR 40-106.010 and amended:

Filed Oct. 1, 2018, effective May 30, 2019. *Original authority: 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014 and 660.017, RSMo 1993, amended 1995.

4CODE OF STATE REGULATIONS

(4/30/19) JOHNR. ASHCROFT

History

• AUTHORITY: sections 454.400 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-5.020. Original rule filed Dec. 24, 1990, effective June 10, 1991. Emergency amendment filed Dec. 2, 1991, effective Dec. 16, 1991, expired April 13, 1992. Amended:

Chapter 108 Child Support Program, Counties under Cooperative Agreement

13 CSR 40-108.010 Reimbursable Expenditures {#sec-13-csr-40-108.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-108.010}

PURPOSE: The purpose of this rule is to define those expenditures for which the Family Support Division will provide federal financial participation through reimbursement and also to provide, in certain instances, criteria or prerequisites for claiming that reimbursement.

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) Definitions.

(A) “Division” means the Family Support (B) “State agency” means the Missouri Department of Social Services.

(C) “Director” means the person serving as director of the Missouri Family Support (2) Cooperative Agreements. To qualify for federal financial participation, a city or county must have entered into a cooperative agreement with the state agency and must submit a budget for approval from the director or his/her designee. Under section 454.405, RSMo, the director shall offer cooperative agreements to city or county governing bodies or officers, including, but not necessarily limited to, circuit courts, circuit clerks, and prosecuting attorneys. Federal financial participation shall be available for costs incurred as of the first day of the calendar quarter in which a cooperative agreement or amendment is signed by all parties, provided the party claiming reimbursement files timely and proper claims. The division shall set the standards where claims that the county submits for reimbursement are deemed timely and properly filed. Cooperative agreements shall provide, at a minimum, for— (A) The governing body of the city or county to hire additional investigative, clerical, and/or secretarial staff needed to fulfill its responsibilities assumed under the agreement or, if the city or county is a participant in a multiple-county agreement, to participate in the cost of this additional staff;

(B) The city or county, upon the prosecuting attorney’s recommendation, to hire additional assistant prosecuting attorneys needed to fulfill its responsibilities assumed under the agreement or, if the city or county is a participant in a multiple-county agreement, to participate in the cost of attorneys retained for that purpose;

(C) The city or county to furnish office space and other administrative requirements needed to fulfill its responsibilities assumed under the agreement or, if the city or county is a participant in a multiple-county agreement, to participate in the costs of office space and other administrative requirements;

(D) The division to reimburse the county at the applicable federal rate from monies received from the federal government for reasonable and necessary costs, as determined by the director or his/her designee, associated with the establishment and enforcement of support obligations by the city or county or, if applicable, the multiple-county unit; and (E) The city or county or, if applicable, the multiple-county unit to maintain financial and performance records required by federal regulation. The city or county or multiple-county unit is required to make these records available for inspection to representatives of the state agency, the state auditor, or the United States Department of Health and Human Services.

(3) Activities for Which Federal Funds are Available. Federal funds are available at the applicable rate for reasonable and necessary costs, as determined by the director or his/her designee, for the following activities:

(A) Establishment of paternity upon referral from the division. Reimbursable activities include reasonable and necessary attempts to determine the identity of the child’s father, such as investigation; the development of evidence, including the use of genetic tests; pretrial discovery; court proceedings or other actions necessary to establish paternity under procedures established by state statutes or regulations having the effect of law; and referral of cases to other states’ child support enforcement agencies to establish paternity, when necessary;

(B) Establishment and enforcement of support obligations upon referral from the division. These activities include investigation, development of evidence, and, when appropriate, bringing court actions; determination of child support obligation amounts, including the development of information that is needed for financial assessments; establishment of medical support obligations when they will not reduce the obligor’s abilities to pay current child support; referral of cases to other states’ child support enforcement agencies to establish or modify child support obligations when necessary; enforcement of child and spousal support obligations, including those activities associated with collection and enforcement of court orders, issuance of warrants, income withholding, or other civil or criminal actions, as necessary; and investigation and prosecution of fraud related to child and spousal support;

(C) Establishment and maintenance of case records as required by federal regulations and the division;

(D) Activities related to requests for certification of collection of support delinquencies by the secretary of the treasury under 45 CFR 303.71;

(E) Reasonable and essential short-term training of court and law enforcement staff assigned on a full- or part-time basis to child support enforcement activities, provided that prior written approval is obtained from the director or his/her designee;

(F) Necessary travel expenses relating to the performance of reimbursable child support enforcement activities, if permitted under federal regulation, provided that prior approval for out-of-state travel is obtained from the director or his/her designee. The same spending limitations that the division imposes on its employees for subsistence and other expenses will apply to county and court staff claims;

(G) Expenses related to indirect costs, as provided in the Office of Management and Budget Circular A-87;

(H) Activities directly related to the successful completion of referred cases; and (I) Activities that have received prior approval for reimbursement by the division.

(4) Activities for Which Federal Funds Are Not Available. Federal funds are not available for the following activities:

(A) Service of process fees, court filing fees, and other court costs unless the court or law enforcement agency normally would be required to pay these costs. These costs include deposits or other filing fees, court fees, library fees, fees for making copies of documents, fees for certified copies of documents, guardian ad litem fees, and fees for appointed counsel;

(B) Compensation costs (salary and fringe benefits) for judges;

(C) Travel and training costs that judges incur, if related to the judicial determination process;

(D) Office-related costs, such as space, equipment, furnishings, and supplies, that judges incur;

(E) Compensation (salary and fringe benefits), travel and training, and office-related costs that judges’ administrative and support staffs incur;

(F) Costs associated with otherwise reimbursable activities in the absence of adequate documentation as required by the division or by federal regulations;

(G) Costs of arrest and incarceration when no purchase of service agreement exists;

(H) Costs associated with construction and major renovations;

(I) Costs of space rental in publicly owned buildings;

(J) Personnel expenses for employees whose wages or salaries are paid for with other federal funds not eligible as match for IV-D funds; and (K) Educational and training programs and educational expenditures, except direct costs of short-term training as allowed by federal regulations and with the division’s prior approval.

(5) Additional Criteria or Prerequisites for Claiming Certain Reimbursable Expenses.

(A) Rent. The director’s or his/her designee’s written approval shall be required for participation in the cost of rent in the private sector. Counties can claim these costs only if public space is unavailable; the county actually incurs the expense by the actual expenditure of county general revenue; the county also participates in the rent costs for private space in which other public work is conducted; and rental costs claimed do not exceed the market value established in the community by competitive bid. When rent is paid to a county official, the county shall provide documentation of compliance with sections 105.454(2) and (3), RSMo.

(B) Genetic Testing Costs. Costs of genetic tests used to establish paternity are reimbursable at the applicable rate for federal financial participation. The prosecuting attorney may seek recovery of genetic testing costs from the putative or alleged parent. When collected, the prosecutor must remit the recovered costs by check to the director.

(C) Travel and Subsistence. In those instances where county subsistence maximums are less than state maximums, only these costs actually incurred by the county can be claimed, up to the state maximum.

(D) Equipment Purchases. Equipment, for the purpose of this rule, is nonexpendable personal property with an initial cost of two thousand five hundred dollars ($2,500).

Reimbursement for equipment shall be available only through straight-line depreciation.

The depreciation claimed will be based on the Internal Revenue Service’s Table of Class Lives and Recovery Periods set forth in Publication 946, How to Depreciate Property, dated 2019, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, Child Support Program 615 Howerton Court Jefferson City, MO 65102, at its website at https://dssruletracker.mo.gov/dss-proposedrules/welcome.action on June 1, 2020. This

rule does not incorporate any subsequent amendments or additions. To claim depreciation in the purchase of equipment with at least an initial cost of two thousand five hundred dollars ($2,500) or more, the county must request and receive (in writing) the director’s or his/her designee’s prior approval for federal financial participation in the cost of equipment. Retroactive approval will not be granted. The county will claim depreciation annually after the first full year of use.

(E) Clerical Staff Time. For any clerical employee who is compensated for both IV-D and non-IV-D related activities, the clerical employee must maintain detailed daily time records supporting personnel costs claimed, including IV-D case name, actual time, and specific activity.

(F) Reimbursable Activities in Prosecutors’ Offices. Activities eligible for reimbursement for county employees who are compensated for both IV-D- and non-IV-Drelated activities are those activities directly related to establishment or enforcement of orders for payment of child support in Title IV-D cases. Review of the case file is reimbursable only when—1) As a result of the review, some establishment or enforcement action is taken and time claimed for those actions is claimed concurrent with the time claimed for review; or 2) It is determined by the prosecuting attorney that no action should be taken and the case is returned to the division. The review shall be claimed in the same month the resulting establishment or enforcement action is taken or in the same month the case is returned to the division.

(G) Timely Claims for Reimbursement.

All reimbursement claims must be submitted for payment no later than ninety (90) calendar days after the close of the calendar month for which IV-D reimbursement is claimed.

Untimely claims submitted shall not be paid unless written waiver is granted by the director or his/her designee. This waiver may not extend the time for filing initial primary (regular) claims for more than thirty (30) calendar days.

(H) Supplemental claims for overhead and operating costs may be submitted beyond ninety (90) days provided the original primary (regular) claim for the month for which the supplemental is claimed was filed within the required time frame.

RSMo 2016.* This rule previously filed as 13 CSR 30-3.010 and 13 CSR 40-3.010. Original

rule filed Oct. 18, 1988, effective Jan. 13, 1989. Amended: Filed Nov. 2, 1989, effective Feb. 11, 1990. Amended: Filed May 17, 2000, effective Dec. 30, 2000. Moved to 13 CSR 40-3.010 and amended: Filed Nov. 26, 2008, effective June 30, 2009. Moved to 13 CSR 40-108.010 and amended: Filed June 1, 2020, effective Nov. 30, 2020.

13 CSR 40-108.020 Minimum Record- Keeping Requirements for County Reimbursement and Standardization of Claims Submissions {#sec-13-csr-40-108.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-108.020}

PURPOSE: The purpose of this rule is to establish minimum record-keeping requirements to document reimbursement claims received from county and city governing bodies under cooperative agreement with the Family Support Division (IV-D) and to standardize claims submissions.

(1) County government units which enter into cooperative agreements to provide child support enforcement (IV-D) services under section 454.405, RSMo, and federal regulations and which submit reimbursement claims under those agreements, will maintain records, available for audit, for five (5) years from the date the claims are presented to the Family Support Division for payment. If any litigation, claim, negotiation, audit, or other action involving the records is started before the end of the five- (5-) year period, the county will keep the records until the action is completed and all issues which arise from it are resolved, or until the end of the regular five- (5-) year period, whichever is later. For documentation, the records will include at a minimum:

(A) All receipts or vouchers for expenses claimed under operating and overhead (direct and indirect costs);

(B) Any employee who is compensated for both IV-D- and non-IV-D-related activities must maintain detailed daily time records supporting personnel costs claimed, including actual time and date, IV-D case name, and case activity. In place of this requirement, a county may request permission from the division to sample personnel time using a method prescribed by the division. If approved by the division, these sampling results may be used to allocate IV-D personnel costs on a quarterly basis; and (C) All records required by this rule must be available and adequate to verify expenditures. When documentation is not adequate, reimbursement may be denied or recovered if already paid. For the purpose of this rule, the term adequate records means that the required documents are legible, and that the information they contain can be readily discerned through reasonably careful examination without resort to extrinsic sources of data or special explanations not contained in the documents.

(2) Counties must submit and document claims in a manner prescribed by, and on forms provided by, the division.

RSMo 2016.* This rule originally filed as 13 CSR 30-3.020 and 13 CSR 40-3.020. Original rule filed Oct. 18, 1988, effective Jan. 13, 1989. Moved to 13 CSR 40-3.020 and amended: Filed Nov. 26, 2008, effective June 30, 2009. Moved to 13 CSR 40-108.020 and amended: Filed Aug. 8, 2018, effective March 30, 2019.

13 CSR 40-108.030 Incentives {#sec-13-csr-40-108.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-108.030}

PURPOSE: This rule defines how the Family Support Division will share available federal incentive funds with counties for allowable expenses not to exceed one hundred percent (100%) of counties’ reasonable and necessary costs.

(1) Definitions.

(A) “Division” means the Family Support (B) “Director” means the director of the Family Support Division.

(C) “Formula” means the amount otherwise payable to a state as federal incentives under Section 458A of the Social Security Act.

(D) “Counties” means all counties and all cities not located within a county.

(E) “Allowable expenses” means expenses that may be claimed pursuant to 13 CSR 40- 108.010.

(F) “TANF” means temporary assistance for needy families.

(G) “County incentives” means the total amount of money counties are entitled to receive from the federal incentives received by the state as set forth in Section 458A of the Social Security Act. County incentives are equal to six percent (6%) of their counties’ TANF collections plus six percent (6%) of their counties’ non-TANF collections (not to exceed the six percent (6%) of TANF collections). Level A and B counties will receive six percent (6%) of their counties’ TANF collections plus six percent (6%) of non-TANF collections (up to one hundred fifteen percent (115%) of their counties’ TANF collections).

The incentives are subject to availability of federal funding and shall only be paid from federal incentive funds.

(2) Payments to be Received by Counties.

Incentive payments to counties shall not exceed one hundred percent (100%) of the counties’ allowable expenses which have not been reimbursed pursuant to 13 CSR 40- 108.010. If the funds received by the county do not equal one hundred percent (100%) of the counties’ non-reimbursed allowable expenses, the division may, at the sole discretion of the director, allocate additional funds up to one hundred percent (100%) of nonreimbursed allowable expenses, if federal funds are available after all other counties have received their county incentives. If the total federal funds received by the state, which have not been paid to counties, are not sufficient to cover counties’ cost that have not been reimbursed pursuant to 13 CSR 40- 108.010, or that have not been covered by incentives, the counties will share the incentives on a pro rata share based on the percent of the counties’ total IV-D collections. If at any time federal incentives received by the state are insufficient to pay county incentives, then the federal incentives shall be distributed to the counties pro rata based on collections in IV-D cases. If the total federal funds received by the state exceed the amount necessary to pay all counties allowable costs after reimbursement pursuant to 13 CSR 40- 108.010, and receipt of all incentives to which they are entitled, the state shall retain these incentives for use as appropriate.

(3) The division will initially use a county’s first calendar year under a cooperative agreement with the Department of Social Services for child support services as the starting base year to determine the amount of allowable expenses for each county. The base year will include expenses of the counties that are normal and usual yearly expenses for the counties’ operations. The division will exclude from the base year any one- (1-) time expenses not related to normal and usual expenses.

After the first base year is established, then each year thereafter the previously approved year’s expenses will be used as the base year.

If a county does not utilize all of its base year allotment for expenses, the next year’s base year expense amount may be decreased by the amount not utilized by the county in the previous year. The counties may request additional funding over the base amount from the director in writing. These requests must be received by the director on or before the first day of July. Additional requests may be submitted as needed throughout the year.

Requests may be made for increases to the base year or for a one- (1-) time expense. The director may approve the request, deny the request, or approve for reimbursement pursuant to 13 CSR 40-108.010. The director has sole discretion to approve, deny, or modify any requests for funds under this regulation. The director may not approve any requests for funds if funding is unavailable.

Availability of funds will be determined by the director.

(4) Incentives received by counties must be reinvested into the IV-D program.

(5) Performance Audits. Counties must pass performance audits conducted by the division pursuant to 13 CSR 40-108.010 or submit corrective action plans approved by the director to receive full allotment. Counties that fail to successfully comply with approved corrective action plans shall be subject to reductions of their allotment. These reductions will be at four percent (4%) of the previous base year’s expenses for the first failure, eight percent (8%) for the second consecutive failure, and sixteen percent (16%) for the third consecutive failure and subsequent failures; these reductions will begin upon failure to achieve corrective action plans.

RSMo 2016.* This rule originally filed as 13 CSR 30-9.010. Original rule filed Feb. 3, 2000, effective Sept. 30, 2000. Moved to 13 CSR 40-108.030 and amended: Filed Aug. 8, 2018, effective March 30, 2019.

13 CSR 40-108.040 Prosecuting Attorneys’ Performance Standards {#sec-13-csr-40-108.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-108.040}

PURPOSE: This rule establishes additional standards by which the performance of the office of each county prosecuting attorney will be evaluated in determining whether sanctions affecting cooperative agreements between the county and the Missouri Family Support Division shall be imposed.

(1) Definitions.

(A) “Prosecuting attorney” means the person elected as the prosecuting attorney for any county or the City of St. Louis, or any assistant prosecuting attorney duly appointed by a prosecuting attorney, or any person employed by the prosecuting attorney, or any person acting on behalf of the prosecuting attorney with actual or apparent authority.

(B) “Division” means the Family Support (C) “Director” means the person serving as director of the Missouri Family Support (D) “State agency” means the Missouri Department of Social Services.

(E) “Case” means a matter in which the state agency or the division has initiated or will initiate an action to collect funds arising from a child support matter, including the case record maintained under 45 CFR 302.33 and 45 CFR 303.2.

(F) “Referral” means a case sent to a prosecuting attorney on behalf of the division.

(G) “Successful completion” of an action means that a referral has been determined by the division or the prosecuting attorney to require no further action by the prosecuting attorney. In cases where judicial proceedings are determined necessary by the prosecuting attorney, a case is completed successfully if the necessary documentation has been submitted to the clerk for filing and service of process has been completed or an unsuccessful attempt to serve process has been documented by the prosecuting attorney, and the prosecuting attorney is proceeding with due diligence. If the initial attempt at service of process is unsuccessful, then the prosecuting attorney shall proceed with diligent efforts to serve process as defined in subsection (1)(M).

(H) “Adequate documentation” means written or electronically stored records, the accuracy and authenticity of which specifically are adopted by the prosecuting attorney, and from which a reasonable person, by normal and reasonable review, can determine what actions were taken by the prosecuting attorney and the outcome of those actions.

Adequate documentation and adequate records shall have the same meaning. Documentation includes all case file records and all other records pertaining to referrals. For purposes of service of process, adequate documentation shall be a copy of the return of service from the process server or documentation in the case file of the contents of the return of service. No documentation shall be deemed adequate if it fails to meet the requirements of 45 CFR 303.2.

(I) “Requested action” means any act by the prosecuting attorney requested to be performed by the division including, but not limited to, the initiating of correspondence on a case, the researching of legal issues and/or investigation, the filing or preparation of legal documents or other correspondence, or the obtaining and forwarding to the division or the state agency data and information related to a referral(s). A requested action shall include all requirements of the cooperative agreement and any training or cooperation with federal or state agency auditors, as may be asked of the prosecuting attorney by the division.

(J) “A Level A county” means a county in which the prosecuting attorney has sole responsibility for the operation of the IV-D program in that county, for cases assigned by the division, and also performs specific legal functions on referrals sent to him/her by the division.

(K) “A Level B county” means a county in which the prosecuting attorney has sole responsibility for a specific portion of the IV- D program in that county, for cases assigned by the division, and also performs specific legal functions on referrals sent to him/her by the division.

(L) “A Level C county” means a county in which the division has sole responsibility for the entire operation of the IV-D program in that county and the prosecuting attorney performs specific legal functions on referrals sent to him/her by the division.

(M) “Diligent efforts” to serve process means efforts which, in the sound discretion of the prosecuting attorney, are designed reasonably, under the particular circumstances of the case, to ensure accomplishment of personal service, taking into account the potential cost of the service and the risk of personal safety of the person attempting service.

The prosecuting attorney shall provide adequate documentation to explain the failure of service. In cases where previous attempts to serve process failed and adequate identifying and other information exists, the prosecuting attorney, within ninety (90) days of the last attempt at service, shall reattempt service of process in the event that there is a likelihood of successful service of process.

(2) Performance Requirements Standards for All Counties on Cases Referred by the Division.

(A) The county shall complete all necessary actions and achieve successful completion of all requested actions as defined by subsections (1)(G), (1)(I), and (1)(M) of this

rule within sixty (60) calendar days after the county accepts any referral from the division.

A failure to comply with the terms contained in subsections (1)(G), (1)(I), or (1)(M) shall be deemed a failure to comply with this sub-

section (2)(A) only.

(B) In all cases needing support order establishment, regardless of whether paternity has been established, the county shall complete action to establish support orders from the date of service of process to the time of disposition within one (1) year. The term “disposition,” as used herein, shall include an order of support or genetic exclusion of all alleged fathers referred.

(C) The time frames contained in subsection (2)(A) of this rule shall be tolled for those time periods during which the prosecuting attorney has requested information from the division that is essential to the successful completion of the requested action; or time periods in which the custodian does not cooperate with the prosecuting attorney and the custodian’s cooperation is essential to the successful completion of the requested action, provided the prosecuting attorney has documented the date the noncooperation occurred and the reason for determination of noncooperation in the automated child support system. Tolling due to noncooperation shall terminate only upon the custodian’s affirmative action that is essential to the successful completion of the requested action.

The prosecuting attorney (PA) shall document the date the affirmative action occurred and the reason for determination of cooperation in the automated child support system.

(D) If a support order needs to be established in a case and an order is established in accordance with Missouri Supreme Court

Rule 88.01 during the audit period, the county will be considered to have taken appropriate action in that case for audit purposes regardless of whether the requirements of subsection (A) of this section have been met.

(E) If the requested action is an enforcement action and an action is taken, in addition to a federal and state income tax refund offset, which results in a collection during the audit period, the county will be considered to have taken appropriate action in the case for audit purposes regardless of whether the requirements of subsection (A) of this section have been met.

(F) In all petitions filed with the court for the establishment of child support orders, the prosecuting attorney shall request an order for medical support.

(G) If a prosecuting attorney determines that no appropriate legal remedy is available on a case, and documents in the automated child support system the reason for return or rejection, that case shall be dropped from the audit sample of a compliance review conducted based on the requirements of 13 CSR 30-2.010(2).

(H) The prosecuting attorney shall notify the division of the conclusion of all requested actions by documenting the conclusion in the automated child support system and sending to the division any supporting documentation that provides information regarding the disposition of the referral within twenty (20) calendar days of the supporting documentation being received by the PA.

(3) Performance Standards for Level A and Level B Counties for Cases in Their Own Caseload. The prosecuting attorney shall— (A) Make applications for child support enforcement services readily accessible to the public;

(B) Maintain records of all persons applying for IV-D services. The records shall include documentation that applications are being provided to the applicants in conformance with 45 CFR 303.2(a)(2);

(C) For all cases referred to the division or applying for services, the prosecuting attorney shall attempt to locate all noncustodial parents or alleged fathers, the location of noncustodial parents’ or alleged fathers’ employers, or other sources of income and/or assets when location is necessary to take necessary action. The location attempts shall be in full compliance with 45 CFR 303.3(b)(1)– (3);

(D) In all cases where previous attempts to locate noncustodial parents or alleged fathers, employers, or sources of income and/or assets have failed, but adequate identifying or other information exists to meet requirements for submittal for location, the prosecuting attorney shall comply fully with all requirements of 45 CFR 303.3(b)(5) and (6);

(E) The prosecuting attorney shall refer all appropriate cases to the IV-D agency of any other state in full compliance with the requirements of 45 CFR 303.7;

(F) The prosecuting attorney, within ninety (90) calendar days of locating the noncustodial parent or alleged father, regardless of whether paternity has been established, shall establish an order for support, or complete service of process necessary to begin proceedings to establish an order for support, or complete service of process necessary to begin proceedings to establish a court order, and if necessary, paternity, or document unsuccessful attempts to serve process in accordance with subsection (1)(M) of this

rule. In all cases needing support order establishment, regardless of whether paternity has been established— 1. The prosecuting attorney shall complete action to establish support orders from the date of service of process to the time of disposition within the following time frames:

A. Seventy-five percent (75%) in six (6) months; and B. Ninety percent (90%) in twelve (12) months;

2. In cases where the prosecuting attorney uses long-arm jurisdiction and disposition occurs within twelve (12) months of service of process on the noncustodial parent or alleged father, the case may be counted as a success within the six- (6-) month tier of the time frame regardless of when disposition occurs in the twelve- (12-) month period following service of process;

3. In all cases in which the court or administrative authority dismisses a petition for a support order without prejudice, the prosecuting attorney, at the time of the dismissal, shall examine the reasons for dismissal and determine when it would be appropriate to seek an order in the future;

4. In all cases in which the prosecuting attorney is seeking to establish a support obligation, the prosecuting attorney shall apply the child support guidelines as set forth in Supreme Court Rule 88.01. The prosecuting attorney shall notify the division of any deviation from the guidelines by documenting the deviation in the automated child support system;

(G) For all cases assigned to the prosecuting attorney in which paternity has not been established, the prosecuting attorney shall— 1. File for paternity establishment, or complete service of process to establish paternity or document unsuccessful attempts to serve process in accordance with subsection (1)(M) of this rule, within no more than ninety (90) calendar days of locating the alleged father;

2. Establish paternity or exclude the alleged father as a result of genetic tests and/or legal process within the time frames set out in paragraphs (3)(F)1. and 2. of this

rule; and 3. Meet the requirements set forth in paragraphs (3)(G)1. and 2. of this rule for all alleged fathers, in any case where an alleged father is excluded, but more than one (1) alleged father has been identified;

(H) For all cases assigned to the prosecuting attorney in which a child support order has been established, the prosecuting attorney shall maintain and use an effective system to— 1. Monitor compliance with the support obligation;

2. Identify on the date the parent owing a duty of support failed to make payments in an amount equal to the support payable for one (1) month;

3. Enforce the obligation in full compliance with the requirements of 45 CFR 303.6(c)(1)–(3); and 4. In cases in which enforcement attempts have failed, the prosecuting attorneys should examine the reason the attempt failed and determine when it would be appropriate to take enforcement action in the future. When appropriate, the prosecuting attorney shall take action in full compliance with the requirements of 45 CFR 303.6(c)(1)–(3);

(I) The prosecuting attorney shall comply with the system developed by the division for case assessment and prioritization;

(J) The prosecuting attorney shall comply with the system developed by the division for case closure;

(K) The prosecuting attorney shall comply with the provisions of 13 CSR 40-102.010;

(L) Notwithstanding the time frames contained in— 1. Subsection (3)(F) of this rule, if a support order needs to be established in a case and an order is established in accordance with Missouri Supreme Court Rule 88.01 during the audit period, the prosecuting attorney will be considered to have taken appropriate action in that case for audit purposes;

2. Paragraph (3)(H)3. of this rule, if the requested action is an enforcement action and an action is taken, in addition to federal and state income tax refund offset, which results in a collection received during the audit period, the prosecuting attorney will be considered to have taken appropriate action in the case for audit purposes.

(4) Performance Requirements.

(A) The following are mandatory requirements by which prosecuting attorneys’ actions on referred cases shall be evaluated:

1. The county shall provide services on referred cases according to federal and state statutes and regulations and cooperative agreement requirements, including those related to financial reimbursement for services provided on referred cases. Failure to do so shall be deemed failure to comply with this rule and this provision. Waivers of this provision may be granted by the division director but are not effective unless granted in writing and are not effective retroactively unless specifically set forth by the director as being permissibly applied retroactively for a specified time period;

2. The county shall cooperate with compliance reviews conducted by the division pursuant to the requirements of 13 CSR 40- 108.040(2), which will occur no more frequently than semi-annually. Upon completion of the compliance review, the division shall submit a draft compliance review results summary to the county. The county shall have the right to submit written rebuttals of this review to the manager of the division compliance review section within thirty (30) days of receiving the review results. The division shall then have sixty (60) days in which to submit, in writing, its decision on each and every case rebutted to the county. The county shall then have fifteen (15) days to submit, in writing, the division’s rebuttal decisions for review de novo by the division’s deputy director. After review de novo, the final decision of the division shall be issued within sixty (60) days. The county may request in writing an extension of the timeframes contained herein. The division will notify the county if an extension of the division’s timeframes are necessary;

3. The division will otherwise retain

The division will also retain the authority to discuss with the prosecuting attorney the actions taken in all cases that have been referred to the county and take other action as set forth in the cooperative agreement between the state agency and the prosecuting attorney; and 4. The county shall achieve substantial compliance with the performance requirements set forth in this regulation concerning actions taken on referred cases and meeting time requirements in so doing. Substantial compliance means that the county has achieved the same case quality standards for those activities for which it is responsible, as are required by the division of its child support offices set forth by federal statutes, federal regulations, and federal IV-D policy.

(5) Sanctions by the Division.

(A) Upon determining that a prosecuting attorney has not complied with the requirements of this rule or is not complying with the requirements of this rule, the division may send notice that it has determined one (1) of the following conditions to exist:

1. That the prosecuting attorney is in significant noncompliance with this rule and that a written corrective action plan addressing all aspects of noncompliance as described in the division’s notice must be submitted to the division within thirty (30) calendar days after the division sends the notice of significant noncompliance. The division shall approve or disapprove each corrective action plan within twenty (20) calendar days after it is sent to the division by the prosecuting attorney. The prosecuting attorney shall have twenty (20) calendar days from the date the division sends a disapproval to resubmit a new corrective action plan. Failure to submit a new plan timely may be determined by the division to constitute substantial noncompliance;

A. To be approved by the division, a corrective action plan, at a minimum, must contain the following: 1) an overall completion date of no more than twelve (12) calendar months from the date of division approval, 2) a statement of planned correction addressing each item of noncompliance as set forth in the division’s notice of significant noncompliance, 3) an individual completion date for each item of noncompliance contained in the division’s notice of significant noncompliance, 4) a statement that during the plan of correction, no part of the prosecuting attorney’s performance will become out of compliance during the plan of correction period, and 5) a statement that the prosecuting attorney will attend such training as deemed necessary by the division. The division’s notice of significant noncompliance shall contain the following: 1) a listing of specific items of this rule with which the division alleges the prosecuting attorney is not in compliance, 2) an explanation of the method used by the division to determine noncompliance, 3) a statement that the division’s determination is final and that a corrective action plan will be required, and 4) the date the corrective action plan is due; or B. That the prosecuting attorney is in substantial noncompliance with this rule and that the cooperative agreement with the county of the prosecuting attorney will be cancelled. A notice of substantial noncompliance shall set forth, in addition to the information required for a notice of significant noncompliance, a description of the findings, facts, and circumstances giving rise to the notice of substantial noncompliance and shall specify a date certain upon which the cooperative agreement will no longer be of any force and effect. The division may issue a notice of substantial noncompliance to a prosecuting attorney only when—1) there is no corrective action plan in effect for the office of the prosecuting attorney to which the notice is issued, 2) a review or audit of the prosecuting attorney’s child support enforcement procedures and/or records has been conducted and issued as a final report, and 3) a notice of significant noncompliance has been previously issued to the prosecuting attorney and has not been successfully completed, or a notice of significant noncompliance has been issued and no corrective action plan has been approved by the division within ninety (90) calendar days from the date of the division’s notice of significant noncompliance.

(B) By issuing or failing to issue any notice of noncompliance, the division does not alter, waive, or otherwise substitute this rule for any of the division’s rights or benefits agreed to in the cooperative agreement by the county of the prosecuting attorney.

(6) Waivers for Counties. The director may waive any requirement of this rule for any county if all of the following conditions have been met by that county prior to the waiver being granted:

(A) The prosecuting attorney has requested a waiver in writing, whenever possible, identifying the specific cases to which the waiver will apply;

(B) The prosecuting attorney has assured the director in writing that the waiver will not permit or cause a failure to achieve successful completion of a case; and (C) The waiver does not violate any state or federal law or rule.

(7) All timeliness requirements of this rule that are calculated from the date the division sends a document, notice, or request, except those requirements found in paragraphs (4)(A)1.–4., upon request of the prosecuting attorney, shall be calculated from the date the prosecuting attorney actually received the notice, document, or request. This request shall be granted if the prosecuting attorney has a reasonably accurate and reliable procedure to verify the actual date of receipt.

Amended: Filed Dec. 3, 1990, effective June 10, 1991. Amended: Filed Oct. 2, 1991, effective Feb. 6, 1992. Emergency amendment filed April 11, 1994, effective April 21, 1994, expired Aug. 18, 1994. Emergency amendment filed July 27, 1994, effective Aug. 19, 1994, expired Dec. 16, 1994. Amended:

Filed April 11, 1994, effective Nov. 30, 1994.

Amended: Filed April 26, 1995, effective Oct. 30, 1995. Amended: Filed April 12, 2001, effective Oct. 30, 2001. Amended: Filed Oct. 15, 2010, effective April 30, 2011. Moved to

History

• authority to conduct special audits and take appropriate action based on the special audit.
• AUTHORITY: sections 454.400.2(5) and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-2.010. Original rule filed Oct. 18, 1988, effective Jan. 13, 1989.

13 CSR 40-108.040 and amended: Filed Aug. 8, 2018, effective March 30, 2019. {#sec-13-csr-40-108.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-108.040}

Chapter 110 Fees

13 CSR 40-110.020 Federal Income Tax Refund Offset Fee {#sec-13-csr-40-110.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-110.020}

(Rescinded September 30, 2005)

Filed March 17, 2005, effective Sept. 30, 2005. 13 CSR 40–110.030 Annual Thirty–Five Dollar ($35) Fee

PURPOSE: This rule defines how the Family Support Division will assess and collect an annual thirty-five dollar ($35) fee as required by section 454(6)(B)(ii) of Title IV-D of the Social Security Act as amended by the Bipartisan Budget Act of 2018, Pub. L. 115-123.

(1) Definitions.

(A) “Case” means an official record comprised of an obligee or payee and dependent child(ren), associated with a particular obligor.

(B) “Obligee or Payee” means an individual to whom a duty of support is owed.

(C) “Division” means the Family Support Division.

(D) “Federal fiscal year” means the period from October 1 to September 30.

(E) “IV-D” means part IV-D of the Social Security Act.

(F) “IV-D, Never-Assistance Case” means a case in which the obligee or payee is receiving services pursuant to section 454.400, RSMo, but has never received Aid to Families with Dependent Children or Temporary Assistance for Needy Families benefits on behalf of the child(ren) associated with the case.

(G) “Obligor” means a person who owes a duty of support as determined by a court or administrative agency of competent jurisdiction.

(H) “Support” means any financial support collected for the support or maintenance of a child or the obligee or payee of a child or a spouse or ex-spouse based upon a judicial or administrative order.

(2) Assessing an Annual Thirty-Five Dollar ($35) Fee. In a IV-D, never-assistance case in which the division has disbursed to the obligee or payee at least five hundred fifty dollars ($550) of support in the federal fiscal year, the division shall assess an annual fee of thirty-five dollars ($35).

(A) If an obligee or payee or an obligor is associated to more than one (1) IV-D, neverassistance case, the division shall assess the fee on each case in which at least five hundred fifty dollars ($550) of support has been disbursed to the obligee or payee in the federal fiscal year.

(B) The division shall assess the fee in each federal fiscal year after the first five hundred fifty dollars ($550) of support has been disbursed to the obligee or payee.

(C) The division shall not assess a fee in cases excluded by federal law or regulation.

(3) Collecting the Annual Thirty-Five Dollar ($35) Fee. The division will collect seventeen dollars and fifty cents ($17.50) of the thirtyfive dollar ($35) assessed fee from the obligee or payee and collect seventeen dollars and fifty cents ($17.50) of the thirty-five dollar ($35) assessed fee from the obligor on each assessed case.

(A) The division shall deduct the obligee’s or payee’s seventeen dollars and fifty cents ($17.50) fee from support payments collected on behalf of the obligee or payee, in excess of the five hundred fifty dollar ($550) threshold, prior to disbursing payments to the obligee or payee. The obligor shall receive credit toward his or her obligation for the entire support payment. The division will notify obligees or payees of the state’s annual fee for IV–D services.

(B) If the obligee or payee does not satisfy the seventeen dollar and fifty cent ($17.50) fee by the end of the federal fiscal year in which the division assessed the thirty-five dollar ($35) fee, the balance remains due, and the division will deduct the unpaid fee from any future support payments received for the obligee or payee until the entire fee is satisfied.

(C) The division shall provide notice to the obligor of his/her seventeen dollar and fifty cent ($17.50) fee. The notice shall provide instructions to the obligor for satisfying the fee. The division may collect the fee from the obligor utilizing enforcement mechanisms provided by law.

(D) If the obligor does not satisfy the fee by the end of the federal fiscal year in which it is assessed, the balance remains due.

(E) Any fee assessed to the obligor under this regulation that is not satisfied prior to the amendment remains due.

Amended: Filed April 8, 2019, effective Oct. 30, 2019. *Original authority: 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: section 454.400.2(5), RSMo 2000. Original rule filed Sept. 10, 2004, effective March 30, 2005. Emergency rescission filed March 17, 2005, effective March 30, 2005, expired Sept. 25, 2005. Rescinded:
• AUTHORITY: sections 454.400.2(5) and 660.017, RSMo 2016. Original rule filed Aug. 20, 2007, effective Feb. 29, 2008.

13 CSR 40-110.040 Annual Fee {#sec-13-csr-40-110.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-110.040}

PURPOSE: The purpose of this rule is to define how the Family Support Division will collect an annual processing fee from an obligee on a non-IV-D case who receives support payments that are processed by the Family Support Payment Center.

(1) Definitions. For the purposes of this rule, the following definitions are applicable:

(A) “Division” means the Family Support Division;

(B) “Payment Center” means the Family Support Payment Center;

(C) “Support” means any financial support due for the support or maintenance of a child, or the custodian of a child, or a spouse or exspouse based upon a judicial or administrative order;

(D) “Case” means a family, as used in section 454.425, RSMo, associated with a particular support order(s). A case includes a collection of people, generally, an obligee, and dependent(s) associated with an obligor;

(E) “Obligor” means a person who owes a duty of support as determined by a court or administrative agency of competent jurisdiction;

(F) “Obligee” means a person to whom a duty of support is owed as determined by a court or administrative agency of competent jurisdiction; and (G) “Non-IV-D case” is a case as defined above which is not currently receiving child support services pursuant to section 454.400, RSMo.

(2) Annual Fees. The division will collect an annual processing fee of ten dollars ($10) on each order associated with a non-IV-D case in which payments are being received by and processed through the Payment Center for all or any part of a calendar year. If an order is associated to more than one (1) case, all cases must be non-IV-D cases.

(A) The obligor will receive credit against the support obligation for the entire payment received by the Payment Center. The fee will be collected from the obligee.

(B) The fee will be deducted from the first support payment received in each calendar year by the Payment Center prior to disbursement of the payment to the obligee. If the first support payment processed for the calendar year by the Payment Center does not satisfy the annual fee, the balance remains due and will be collected from subsequent support payments received for that calendar year until the entire fee is satisfied. If the fee is not satisfied by the end of a calendar year, the uncollected fee for that year will not accrue into the next calendar year.

(C) An annual fee will be charged in a former TANF or Medicaid case if all arrearages owed to the state have been paid and child support services pursuant to section 454.400, RSMo, are not currently being provided.

(9/30/19) JOHN R. ASHCROFT

History

• AUTHORITY: sections 454.400 and 660.017, RSMo 2016. This rule originally filed as 13 CSR 30-10.010. Original rule filed July 17, 2001, effective Jan. 30, 2002. Moved to 13 CSR 40-110.040 and amended: Filed Aug. 8, 2018, effective March 30, 2019. Original authority: 454.400, RSMo 1959, amended 1982, 1993, 1995, 1997, 2014 and 660.017, RSMo 1993, amended 1995.

Chapter 112 Child Support Program, Medical Support

13 CSR 40-112.010 Establishing or Modifying to Include Medical Support Obligations {#sec-13-csr-40-112.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 40-112.010}

PURPOSE: This rule sets forth the Family Support Division’s procedures for establishing medical support obligations or modifying existing orders to include medical support obligations in accordance with sections 454.600 and 454.603, RSMo.

(1) For purposes of this rule, the following terms will be defined as:

(A) “Gross Income” means the amount of money earned prior to tax deductions and other mandatory or voluntary deductions;

(B) “Parent Seeking Support” means the person or state agency that will be entitled to receive support after the entry of a support order;

(C) “Parent Not Seeking Support” means the person who will be obligated to pay support after the entry of a support order;

(D) “Private Health Benefit Plan” means any benefit plan or combination of plans, other than public assistance programs, providing medical or dental care or benefits through insurance or otherwise, including, but not limited to, health service corporations, as defined in section 354.010, RSMo; prepaid dental plans, as defined in

section 354.700, RSMo; health maintenance organization plans, as defined in section 354.400, RSMo; and self-insurance plans, to the extent allowed by federal law; and (E) “Public Health Benefit Plan” means any benefit plan or combination of plans, providing medical or dental care that is funded under Title XIX or Title XXI of the Social Security Act.

(2) A health benefit plan through an employer or union will be considered reasonable if the cost of dependent coverage does not increase the current premiums of the parent who is to provide such coverage by more than five percent (5%) of that parent’s gross income. In applying the five percent (5%) standard for the cost of health benefit plan coverage, the cost will be the difference between self–only coverage and family coverage, or the cost of adding the dependent(s) to existing coverage, whichever is applicable given the individual’s available plan options.

If the child(ren) is already covered by private health benefit plan coverage, the five percent (5%) standard does not apply.

(3) A private health benefit plan is accessible if the plan does not limit coverage to a specific geographical area; or the plan limits coverage to a geographical area and the child(ren) reside(s) within that geographical area.

(4) The parent seeking support and the parent not seeking support will cooperate with the division by providing necessary information to determine if health benefit plan coverage through an employer or union is reasonable and accessible. The parent seeking support and the parent not seeking support must provide information within thirty (30) days of the date of the request from the division. If only one (1) parent provides information, then the division will use the information provided by that parent or information from other sources.

(5) When establishing or modifying a medical support obligation, the division will— (A) Determine if the parent not seeking support has the child(ren) covered by a private health benefit plan, and if so, the division will order that parent to provide health benefit plan coverage;

(B) If the parent not seeking support does not have the child(ren) covered by a private health benefit plan, the division will determine if the parent seeking support has the child(ren) covered under a private health benefit plan. If the parent seeking support does have the child(ren) covered and wants to maintain such coverage, the division will order that parent to provide health benefit plan coverage;

(C) If neither parent maintains private health benefit plan coverage for the child(ren), the division will determine if the parent not seeking support has private health benefit plan coverage available at a reasonable cost. If the parent not seeking support has private health benefit plan coverage available at a reasonable cost that is accessible to the child(ren), the division will order that parent to provide health benefit plan coverage;

(D) If the parent not seeking support does not have private health benefit plan coverage available at reasonable cost, the division will determine if the parent seeking support has private health benefit plan coverage at a reasonable cost. If the parent seeking support has private health benefit plan coverage available at a reasonable cost that is accessible to the child(ren), the division will order that parent to provide health benefit plan coverage;

(E) If neither parent has private health benefit plan coverage available at a reasonable cost that is accessible to the child(ren) and the parent seeking support has the child(ren) on public health benefit plan coverage, the division will order the parent not seeking support to pay a percentage of uncovered costs of the child(ren)’s necessary medical care. The percentage will be determined by using that parent’s percentage as set forth in line 4 of the Form 14 calculated by the division or if the division does not calculate a Form 14 then the division will order fifty percent (50%). If the parent not seeking support does not pay the percentage of the reasonable costs of the child(ren)’s necessary medical care as ordered, and a court has entered a sum–certain judgment regarding the amount the parent owes for the child(ren)’s necessary medical care, the division will collect the judgment amount; and (F) If neither parent has private health benefit plan coverage available at a reasonable cost that is accessible to the child(ren) and the child(ren) are not enrolled in public health benefit plan, the division will order the parent not seeking support to pay a percentage of reasonable costs of the child(ren)’s necessary medical care. The percentage will be determined by using that parent’s percentage as set forth in line 4 of the Form 14 calculated by the division or if the division does not calculate a Form 14 then the division will order fifty percent (50%). If the parent not seeking support does not pay the percentage of the reasonable costs of the child(ren)’s necessary medical care as ordered, and a court has entered a sum–certain judgment regarding the amount the parent owes for the child(ren)’s necessary medical care, the division will collect the judgment amount.

History

• AUTHORITY: sections 207.022, 454.400, and 660.017, RSMo 2016. Original rule filed Feb. 7, 2020, effective Aug. 30, 2020. Original authority: 207.022, RSMo 2014; 454.400, RSMo 1982, amended 1985, 1986, 1990, 1993, 1995, 1997, 2014; and 660.017, RSMo 1993, amended 1995.

Division 45 Division of Legal Services

Chapter 2 State Technical Assistance Team (Moved to 13 CSR 5-2.010)

13 CSR 45-2.010 Organization and Operation {#sec-13-csr-45-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 45-2.010}

(Moved to 13 CSR 5-2.010)

Division 50 Division of Health

Chapter 1 Organization (rescinded)

13 CSR 50-1.010 General Organization— Division of Health {#sec-13-csr-50-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-1.010}

(Rescinded August 25, 1988)

rule filed Sept. 27, 1976, effective Jan. 13, 1977. Rescinded: Published June 17, 1988, effective Aug. 25, 1988.

MATTBLUNT(7/31/02)

History

• AUTHORITY: sections 207.10, 207.20, 209.10, and 209.20, RSMo 1978. Original

Chapter 20 * - Hospitals - moved to 19 CSR 30

13 CSR 50-20.010 Construction Standards for New Hospitals {#sec-13-csr-50-20.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.010}

13 CSR 50-20.011 Definitions Relating to Hospitals {#sec-13-csr-50-20.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.011}

(Moved to 19 CSR 30-20.011)

13 CSR 50-20.015 Administration of the Hospital Licensing Program {#sec-13-csr-50-20.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.015}

(Moved to 19 CSR 30-20.015)

13 CSR 50-20.020 Standards for Physical Facilities for Existing Hospitals {#sec-13-csr-50-20.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.020}

13 CSR 50-20.021 Organization and Management for Hospitals {#sec-13-csr-50-20.021 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.021}

(Moved to 19 CSR 30-20.030)

13 CSR 50-20.030 Administration {#sec-13-csr-50-20.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.030}

13 CSR 50-20.031 Construction Standards for New Hospitals {#sec-13-csr-50-20.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.031}

(Moved to 19 CSR 30-20.030)

13 CSR 50-20.040 Definitions Relating to Long-Term Care Units in Hospitals {#sec-13-csr-50-20.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.040}

(Moved to 19 CSR 30-20.040)

13 CSR 50-20.050 Standards for the Operation of Long-Term Care Units {#sec-13-csr-50-20.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.050}

(Moved to 19 CSR 30-20.050)

13 CSR 50-20.060 Construction Standards for New Long-Term Care Units in Hospitals {#sec-13-csr-50-20.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-20.060}

(Moved to 19 CSR 30-20.060)

Rebecca McDowell Cook (9/30/97)

Chapter 22 * - Rehabilitation Hospitals - moved to 19 CSR 30

13 CSR 50-22.010 General Design and Constructon Standards for Rehabilitation Hospitals {#sec-13-csr-50-22.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-22.010}

(Moved to 19 CSR 30-22.010)

13 CSR 50-22.020 Administration {#sec-13-csr-50-22.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-22.020}

(Moved to 19 CSR 30-22.020)

Rebecca McDowell Cook (9/30/97)

Chapter 24 * - Psychiatric Hospitals - moved to 19 CSR 30

13 CSR 50-24.010 General Design and Construction Standards for Psychiatric Hospitals {#sec-13-csr-50-24.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-24.010}

(Moved to 19 CSR 30-24.010)

13 CSR 50-24.020 Administration {#sec-13-csr-50-24.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-24.020}

(Moved to 19 CSR 30-24.020)

13 CSR 50-24.030 Preparation of Plans and Specifications For Psychiatric Hospitals {#sec-13-csr-50-24.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-24.030}

(Moved to 19 CSR 30-24.030)

Rebecca McDowell Cook (9/30/97)

Chapter 25SN * - Special Notice

13 CSR 50-25 030Home Health Aide Basic Course In a resolution dated February 4, 1986, the Joint Committee of Administrative Rules took “the position that any rule promulgated pursuant to section 197.445, RSMo was not valid for failure to comply with Section 3.” The secretary of state has removed these rules from the Code of State Regulations. {#sec-13-csr-50-25 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-25}

Chapter 30 * - Ambulatory Surgical Centers - moved to 19 CSR 30

13 CSR 50-30.010 Definitions and Procedure for Licensing for Ambulatory Surgical Centers {#sec-13-csr-50-30.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-30.010}

(Moved to 19 CSR 30-30.010)

13 CSR 50-30.020 Administration {#sec-13-csr-50-30.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-30.020}

(Moved to 19 CSR 30-30.020)

13 CSR 50-30.030 General Design and Construction Standards for Ambulatory Surgical Centers {#sec-13-csr-50-30.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-30.030}

(Moved to 19 CSR 30-30.030)

13 CSR 50-30.040 Preparation of Plans and Specifications for Ambulatory Surgical Centers {#sec-13-csr-50-30.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-30.040}

(Moved to 19 CSR 30-30.040)

Rebecca McDowell Cook (9/30/97)

Chapter 40 * - Ambulance Regulations - moved to 19 CSR 30

13 CSR 50-40.005 Abbreviations {#sec-13-csr-50-40.005 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.005}

(Moved to 19 CSR 30-40.005)

13 CSR 50-40.010 Staffing {#sec-13-csr-50-40.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.010}

(Moved to 19 CSR 30-40.010)

13 CSR 50-40.020 Ambulance Vehicle Configuration Equipment Requirements for Licensure {#sec-13-csr-50-40.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.020}

(Moved to 19 CSR 30-40.020)

13 CSR 50-40.025 Ambulance Markings {#sec-13-csr-50-40.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.025}

(Moved to 19 CSR 30-40.025)

13 CSR 50-40.030 Insurance Required for Ambulance Licensure {#sec-13-csr-50-40.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.030}

(Moved to 19 CSR 30-40.030)

13 CSR 50-40.040 Patient-Care Equipment {#sec-13-csr-50-40.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.040}

(Moved to 19 CSR 30-40.040)

13 CSR 50-40.050 Mobile Emergency Medical Technicians {#sec-13-csr-50-40.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.050}

(Moved to 19 CSR 30-40.050)

13 CSR 50-40.070 Hearings {#sec-13-csr-50-40.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.070}

(Moved to 19 CSR 30-40.070)

13 CSR 50-40.080 Records and Forms {#sec-13-csr-50-40.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.080}

(Moved to 19 CSR 30-40.080)

13 CSR 50-40.090 Examination Procedures {#sec-13-csr-50-40.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.090}

(Moved to 19 CSR 30-40.090)

13 CSR 50-40.100 Relicensure Procedures {#sec-13-csr-50-40.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.100}

(Moved to 19 CSR 30-40.100)

13 CSR 50-40.110 Procedures for EMS Course Approvals {#sec-13-csr-50-40.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.110}

(Moved to 19 CSR 30-40.110)

13 CSR 50-40.120 Instructor Qualifications for EMT Courses {#sec-13-csr-50-40.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.120}

(Moved to 19 CSR 30-40.120)

13 CSR 50-40.130 Use of Obturators by EMTs {#sec-13-csr-50-40.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.130}

(Moved to 19 CSR 30-40.130)

13 CSR 50-40.140 Licensure Action {#sec-13-csr-50-40.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.140}

History

• Authority for Gross Negligence in Patient Care by Ambulance Personnel (Moved to 19 CSR 30-40.140)

13 CSR 50-40.150 Restriction on Licensure Actions Without Thorough Investigation and Administrative Review {#sec-13-csr-50-40.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.150}

(Moved to 19 CSR 30-40.150)

13 CSR 50-40.160 Physician Medical Advisor Required for All Ambulance Services {#sec-13-csr-50-40.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.160}

(Moved to 19 CSR 30-40.160)

13 CSR 50-40.170 Misrepresenting the Level of Ambulance Service or Training, a Violation of Law {#sec-13-csr-50-40.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.170}

(Moved to 19 CSR 30-40.170)

13 CSR 50-40.180 Use of Pneumatic Counter Pressure Device by EMTs {#sec-13-csr-50-40.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.180}

(Moved to 19 CSR 30-40.180)

13 CSR 50-40.190 Exceptions to the Requirements for Maintenance of Voice Contact or Telemetry in Regard to Mobile Emergency Medical Technician Advanced Life-Support Procedures {#sec-13-csr-50-40.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-40.190}

(Moved to 19 CSR 30-40.190)

Rebecca McDowell Cook (9/30/97)

Chapter 61 * - Food Service Sanitation - moved to 19 CSR 20

13 CSR 50-61.010 Sanitation of Food-Service Establishments {#sec-13-csr-50-61.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-61.010}

(Moved to 19 CSR 20-1.010)

Rebecca McDowell Cook (9/30/97)

Chapter 63 * - Frozen Desserts - moved to 19 CSR 20

13 CSR 50-63.010 Sanitation and Production Standards for Frozen Desserts {#sec-13-csr-50-63.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-63.010}

(Moved to 19 CSR 20-1.030)

Rebecca McDowell Cook (9/30/97)

Chapter 66 * - Sanitation of Tourist Camps, Cabins and Resorts - moved to 19 CSR 20

13 CSR 50-66.010 Sanitation of Tourist Courts, Cabins and Resorts {#sec-13-csr-50-66.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-66.010}

(Moved to 19 CSR 20-3.050)

Rebecca McDowell Cook (9/30/97)

Chapter 70 * - The Inspection of Manufacturing and Sale of Foods - moved to 19 CSR 20

13 CSR 50-70.010 Inspection and Sale of Foods {#sec-13-csr-50-70.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-70.010}

(Moved to 19 CSR 20-1.040)

Rebecca McDowell Cook (9/30/97)

Chapter 71 * - Inspection of Manufacturing and Sale of Drugs and Devices - moved to 19 CSR 20

13 CSR 50-71.010 Inspection of Manufacturing and Sale of Drugs and Devices {#sec-13-csr-50-71.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-71.010}

(Moved to 19 CSR 20-2.010)

Rebecca McDowell Cook (9/30/97)

Chapter 72 * - Inspection of Manufacturing and Sale of Cosmetics - moved to 19 CSR 20

13 CSR 50-72.010 Inspection and Sale of Cosmetics {#sec-13-csr-50-72.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-72.010}

(Moved to 19 CSR 20-2.020)

Rebecca McDowell Cook (9/30/97)

Chapter 73 * - Return and Resale of Drugs and Medicines - moved to 19 CSR 20

13 CSR 50-73.010 The Return and Resale of Drugs and Medicines {#sec-13-csr-50-73.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-73.010}

(Moved to 19 CSR 20-2.030)

Rebecca McDowell Cook (9/30/97)

Chapter 74 * - Sanitation Standards for the Manufacture of Soft Drinks and Beverages - moved to 19 CSR 20

13 CSR 50-74.010 Sanitation Standards for the Manufacture of Soft Drinks and Beverages {#sec-13-csr-50-74.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-74.010}

(Moved to 19 CSR 20-1.050)

Rebecca McDowell Cook (9/30/97)

Chapter 75 * - Licensing of Beverage Manufacturers and Distributors and the Collection of Beverage Inspection Fees - moved to 19 CSR 20

13 CSR 50-75.010 Licensing of Beverage Manufacturers and Distributors and the Collection of Inspection Fees {#sec-13-csr-50-75.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-75.010}

(Moved to 19 CSR 20-1.060)

Rebecca McDowell Cook (9/30/97) of Beverage Inspection Fees13 CSR 50-75

Chapter 77 * - Construction of Water Supply Wells - moved to 19 CSR 20

13 CSR 50-77.010 The Construction of Water Supply Wells {#sec-13-csr-50-77.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-77.010}

(Moved to 19 CSR 20-3.010)

Rebecca McDowell Cook (9/30/97)

Chapter 79 * - Preparation Rooms of Funeral Establishments - moved to 19 CSR 20

13 CSR 50-79.010 Sanitation of Preparation Rooms in Funeral Establishments {#sec-13-csr-50-79.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-79.010}

(Moved to 19 CSR 20-3.030)

Rebecca McDowell Cook (9/30/97)

Chapter 82 * - Sanitation of Public Bathing Places - moved to 19 CSR 20

13 CSR 50-82.010 Sanitation of Public Bathing Places {#sec-13-csr-50-82.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-82.010}

(Moved to 19 CSR 20-3.020)

Rebecca McDowell Cook (9/30/97)

Chapter 83 * - Environmental Health - moved to 19 CSR 20

13 CSR 50-83.010 Environmental Health Rules for the Control of Communicable Diseases {#sec-13-csr-50-83.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-83.010}

(Moved to 19 CSR 20-3.040)

Rebecca McDowell Cook (9/30/97)

Chapter 90 * - Protection Against Ionizing Radiation - moved to 19 CSR 20

13 CSR 50-90.010 Definitions {#sec-13-csr-50-90.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.010}

(Moved to 19 CSR 20-10.010)

13 CSR 50-90.020 Exemptions {#sec-13-csr-50-90.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.020}

(Moved to 19 CSR 20-10.020)

13 CSR 50-90.030 Registration {#sec-13-csr-50-90.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.030}

(Moved to 19 CSR 20-10.030)

13 CSR 50-90.040 Maximum Permissible Exposure Limits {#sec-13-csr-50-90.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.040}

(Moved to 19 CSR 20-10.040)

13 CSR 50-90.050 Personnel Monitoring and Radiation Surveys {#sec-13-csr-50-90.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.050}

(Moved to 19 CSR 20-10.050)

13 CSR 50-90.060 Radiation Exposure Records and Reports {#sec-13-csr-50-90.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.060}

(Moved to 19 CSR 20-10.060)

13 CSR 50-90.070 Storage of Radioactive Materials {#sec-13-csr-50-90.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.070}

(Moved to 19 CSR 20-10.070)

13 CSR 50-90.080 Control of Radioactive Contamination {#sec-13-csr-50-90.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.080}

(Moved to 19 CSR 20-10.080)

13 CSR 50-90.090 Disposal of Radioactive Wastes {#sec-13-csr-50-90.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.090}

(Moved to 19 CSR 20-10.090)

13 CSR 50-90.100 Radiation Labeling {#sec-13-csr-50-90.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.100}

(Moved to 19 CSR 20-10.100)

13 CSR 50-90.110 Relative Biological Effectiveness Values {#sec-13-csr-50-90.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.110}

(Moved to 19 CSR 20-10.110)

13 CSR 50-90.120 General Requirements for Diagnostic X-ray Equipment {#sec-13-csr-50-90.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.120}

(Moved to 19 CSR 20-10.120)

13 CSR 50-90.130 Special Requirements for Medical Fluoroscopic Installations {#sec-13-csr-50-90.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.130}

(Moved to 19 CSR 20-10.130)

13 CSR 50-90.140 Special Requirements for Medical Radiographic Installations {#sec-13-csr-50-90.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.140}

(Moved to 19 CSR 20-10.140)

13 CSR 50-90.150 Special Requirements for Dental Radiographic Installations {#sec-13-csr-50-90.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.150}

(Moved to 19 CSR 20-10.150)

13 CSR 50-90.160 Special Requirements for Mobile Medical Radiographic Installations {#sec-13-csr-50-90.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.160}

(Moved to 19 CSR 20-10.160)

13 CSR 50-90.170 Special Requirements for Photo-fluorographic Installations {#sec-13-csr-50-90.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.170}

(Moved to 19 CSR 20-10.170)

13 CSR 50-90.180 Requirements for Radiation Therapy Installations {#sec-13-csr-50-90.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.180}

(Moved to 19 CSR 20-10.180)

13 CSR 50-90.190 Requirements for Room Shielding {#sec-13-csr-50-90.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.190}

(Moved to 19 CSR 20-10.190)

13 CSR 50-90.200 Shoe-Fitting Devices {#sec-13-csr-50-90.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-90.200}

(Moved to 19 CSR 20-10.200)

Rebecca McDowell Cook (9/30/97)

Chapter 101 * - Communicable Diseases - moved to 19 CSR 20

13 CSR 50-101.010 Definitions Relating to Communicable Diseases {#sec-13-csr-50-101.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.010}

(Moved to 19 CSR 20-20.010)

13 CSR 50-101.020 Diseases to be Reported {#sec-13-csr-50-101.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.020}

(Moved to 19 CSR 20-20.020)

13 CSR 50-101.030 When Reports are to be Made by Whom and How {#sec-13-csr-50-101.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.030}

(Rescinded October 11, 1986)

Aug. 1, 1986, effective Oct. 11, 1986.

13 CSR 50-101.040 When No Physician is in Attendance Dec. 11, 1981, effective May 13, 1982. {#sec-13-csr-50-101.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.040}

13 CSR 50-101.041 Exclusion From School and Readmission {#sec-13-csr-50-101.041 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.041}

(Moved to 19 CSR 20-20.030)

13 CSR 50-101.050 Communicable Disease Control Measures {#sec-13-csr-50-101.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.050}

(Moved to 19 CSR 20-20.040)

13 CSR 50-101.060 Duties of Physician Dec. 11, 1981, effective May 13, 1982. {#sec-13-csr-50-101.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.060}

13 CSR 50-101.061 Quarantine or Isolation Practices and Closing of Schools and Places of Public and Private Assembly {#sec-13-csr-50-101.061 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.061}

(Moved to 19 CSR 20-20.050)

13 CSR 50-101.070 Duties of a Health Officer Dec. 11, 1981, effective May 13, 1982. {#sec-13-csr-50-101.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.070}

13 CSR 50-101.071 Control Measures for Food Handlers {#sec-13-csr-50-101.071 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.071}

(Moved to 19 CSR 20-20.060)

13 CSR 50-101.080 Duties of City and County Health Department {#sec-13-csr-50-101.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.080}

(Moved to 19 CSR 20-20.070)

13 CSR 50-101.090 Duties of Laboratories {#sec-13-csr-50-101.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.090}

(Moved to 19 CSR 20-20.080)

13 CSR 50-101.100 Moving Persons Infected with Communicable Diseases Dec. 11, 1981, effective May 13, 1982. {#sec-13-csr-50-101.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.100}

13 CSR 50-101.110 Measures to Prevent Entrance and Limit Spread of Poliomyelitis Within the State Emergency rule filed June 13, 1979, effective June 23, 1979, expired Sept. 13, 1979. {#sec-13-csr-50-101.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-101.110}

Rebecca McDowell Cook (9/30/97)

Chapter 103 * - Typhoid and Paratyphoid Carriers - moved to 19 CSR 20

13 CSR 50-103.010 Supervision of Typhoid and Paratyphoid Carriers {#sec-13-csr-50-103.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-103.010}

(Moved to 19 CSR 20-22.010)

Rebecca McDowell Cook (9/30/97)

Chapter 105 * - Dead Bodies Infected With a Communicable Disease - moved to 19 CSR 20 - 24

13 CSR 50-105.010 Procedures To Be Followed When a Person Dies While Infected With a Communicable Disease {#sec-13-csr-50-105.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-105.010}

(Moved to 19 CSR 20-24.010)

Rebecca McDowell Cook (9/30/97)

Chapter 107 * - Venereal Diseases - moved to 19 CSR 20

13 CSR 50-107.010 Prevention of Blindness {#sec-13-csr-50-107.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-107.010}

(Moved to 19 CSR 20-26.010)

Rebecca McDowell Cook (9/30/97)

Chapter 110 * - Immunization - moved to 19 CSR 20

13 CSR 50-110.010 Immunization Requirements for School Children {#sec-13-csr-50-110.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-110.010}

(Moved to 19 CSR 20-28.010)

Rebecca McDowell Cook (9/30/97)

Chapter 115 * - Chronic Diseases - moved to 19 CSR 70

13 CSR 50-115.010 Reporting of Cancer Cases {#sec-13-csr-50-115.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-115.010}

(Moved to 19 CSR 70-21.010)

Rebecca McDowell Cook (9/30/97)

Chapter 130 * - Controlled Substances Schedules - moved to 19 CSR 30

13 CSR 50-130.010 Schedules of Controlled Substances {#sec-13-csr-50-130.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-130.010}

(Moved to 19 CSR 30-1.010)

13 CSR 50-130.020 List of Excepted Substances {#sec-13-csr-50-130.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-130.020}

(Moved to 19 CSR 30-1.020)

Rebecca McDowell Cook (9/30/97)

Chapter 131 * - Controlled Substances Registration - moved to 19 CSR 30

13 CSR 50-131.010 Requirements for Controlled Substances Registration {#sec-13-csr-50-131.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-131.010}

(Moved to 19 CSR 30-1.030)

Rebecca McDowell Cook (9/30/97)

Chapter 132 * - Dispensing to Controlled Substances - moved to 19 CSR 30

13 CSR 50-132.010 Dispensing and Distribution of Controlled Substances in Certain Situations {#sec-13-csr-50-132.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-132.010}

(Moved to 19 CSR 30-1.040)

Rebecca McDowell Cook (9/30/97)

Chapter 140 * - Rules for Determination of Blood Alcohol by Blood, Breath, Saliva and Urine Analysis - moved to 19 CSR 20

13 CSR 50-140.010 Definitions {#sec-13-csr-50-140.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-140.010}

(Moved to 19 CSR 20-30.010)

13 CSR 50-140.020 Permits {#sec-13-csr-50-140.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-140.020}

(Moved to 19 CSR 20-30.020)

13 CSR 50-140.030 Qualification for Permits {#sec-13-csr-50-140.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-140.030}

(Moved to 19 CSR 20-30.030)

13 CSR 50-140.040 Duties and Responsibilities of Permittees {#sec-13-csr-50-140.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-140.040}

(Moved to 19 CSR 20-30.040)

13 CSR 50-140.050 Approved Breath Analyzers, Chemical Test Reagents and Standards {#sec-13-csr-50-140.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-140.050}

(Moved to 19 CSR 20-30.050)

13 CSR 50-140.060 Operating Procedures for Breath Analyzers {#sec-13-csr-50-140.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-140.060}

(Moved to 19 CSR 20-30.060)

Rebecca McDowell Cook (9/30/97) by Blood, Breath, Saliva and Urine Analysis13 CSR 50-140

Chapter 141 * - Milk-Testing Laboratories - moved to 19 CSR 20

13 CSR 50-141.010 State Approval of Milk- Testing Laboratories {#sec-13-csr-50-141.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-141.010}

(Moved to 19 CSR 20-32.010)

Rebecca McDowell Cook (9/30/97)

Chapter 142 * - Laboratories for Serologic Tests for Syphilis - moved to 19 CSR 20

13 CSR 50-142.010 Approval of Laboratories for the Performance of Serologic Tests for Syphilis on Prenatal Blood {#sec-13-csr-50-142.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-142.010}

(Moved to 19 CSR 20-34.010)

Rebecca McDowell Cook (9/30/97)

Chapter 143 * - Testing for Metabolic Diseases - moved to 19 CSR 20

13 CSR 50-143.010 Testing for Phenylketonuria (PKU) and Primary Hypothyroidism {#sec-13-csr-50-143.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-143.010}

(Moved to 19 CSR 20-36.010)

Rebecca McDowell Cook (9/30/97)

Chapter 144 * - Laboratory Fees - moved to 19 CSR 20

13 CSR 50-144.010 Laboratory Handling Fees {#sec-13-csr-50-144.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-144.010}

(Moved to 19 CSR 20-38.010)

Rebecca McDowell Cook (9/30/97)

Chapter 150 * - Vital Records - moved to 19 CSR 30

13 CSR 50-150.010 Birth Registration {#sec-13-csr-50-150.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-150.010}

(Moved to 19 CSR 30-10.010)

13 CSR 50-150.020 Vital Records Certification {#sec-13-csr-50-150.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-150.020}

(Moved to 19 CSR 30-10.020)

13 CSR 50-150.030 Filing a Delayed Birth Certificate {#sec-13-csr-50-150.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-150.030}

(Moved to 19 CSR 30-10.030)

13 CSR 50-150.040 Filing a Live Birth Certificate {#sec-13-csr-50-150.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-150.040}

(Moved to 19 CSR 30-10.040)

13 CSR 50-150.050 Death Certificate Form {#sec-13-csr-50-150.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-150.050}

(Moved to 19 CSR 30-10.050)

13 CSR 50-150.060 Fetal Death Certificate Form {#sec-13-csr-50-150.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-150.060}

(Moved to 19 CSR 30-10.060)

Rebecca McDowell Cook (9/30/97)

Chapter 151 * - Abortions - moved to 19 CSR 30

13 CSR 50-151.010 Report of Induced Termination of Pregnancy {#sec-13-csr-50-151.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-151.010}

(Moved to 19 CSR 30-15.010)

13 CSR 50-151.020 Complication Report for Post-Abortion Care {#sec-13-csr-50-151.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-151.020}

(Moved to 19 CSR 30-15.020)

13 CSR 50-151.030 Content and Filing of Tissue Report {#sec-13-csr-50-151.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-151.030}

(Moved to 19 CSR 30-15.030)

13 CSR 50-151.040 Induced Termination of Pregnancy Consent Form {#sec-13-csr-50-151.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-151.040}

(Moved to 19 CSR 30-15.040)

Rebecca McDowell Cook (9/30/97)

Chapter 155 * - The Sudden Infant Death Syndrome Program - moved to 19 CSR 40

13 CSR 50-155.010 Administration of the Program {#sec-13-csr-50-155.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-155.010}

(Moved to 19 CSR 40-3.010)

Rebecca McDowell Cook (9/30/97)

Chapter 156 * - The Hemophilia Program - moved to 19 CSR 40

13 CSR 50-156.010 Requirements for Participating in the Hemophilia Program {#sec-13-csr-50-156.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-156.010}

(Moved to 19 CSR 40-2.010)

Rebecca McDowell Cook (9/30/97)

Chapter 157 * - Early Periodic Screening, Diagnosis and Treatment - moved to 19 CSR 40

13 CSR 50-157.010 Basis for Provisions of EPSDT {#sec-13-csr-50-157.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-157.010}

(Moved to 19 CSR 40-4.010)

Rebecca McDowell Cook (9/30/97)

Chapter 160 * - Missouri Crippled Children's Service (MCCS) - moved to 19 CSR 40

13 CSR 50-160.010 Definitions Relating to the Missouri Crippled Children’s Service (MCCS) {#sec-13-csr-50-160.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.010}

(Moved to 19 CSR 40-1.010)

13 CSR 50-160.020 Program Eligibility {#sec-13-csr-50-160.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.020}

(Moved to 19 CSR 40-1.020)

13 CSR 50-160.030 Categories of Care {#sec-13-csr-50-160.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.030}

(Moved to 19 CSR 40-1.030)

13 CSR 50-160.040 Financial Eligibility Categories {#sec-13-csr-50-160.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.040}

(Moved to 19 CSR 40-1.040)

13 CSR 50-160.050 Client Responsibilities {#sec-13-csr-50-160.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.050}

(Moved to 19 CSR 40-1.050)

13 CSR 50-160.060 Organization and Management {#sec-13-csr-50-160.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.060}

(Moved to 19 CSR 40-1.060)

13 CSR 50-160.070 Service Providers {#sec-13-csr-50-160.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.070}

(Moved to 19 CSR 40-1.070)

13 CSR 50-160.080 Sanctions {#sec-13-csr-50-160.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-160.080}

(Moved to 19 CSR 40-1.080)

Rebecca McDowell Cook (9/30/97)

Chapter 170 * - Financial Aid for Medical Students - moved to 19 CSR 50

13 CSR 50-170.010 Loan Program for Medical Students {#sec-13-csr-50-170.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-170.010}

(Moved to 19 CSR 50-1.010)

Rebecca McDowell Cook (9/30/97)

Chapter 171 * - Programs to Increases Family Physician Training Opportunities in Missouri - moved to 19 CSR 50

13 CSR 50-171.010 Funding of the Programs {#sec-13-csr-50-171.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 50-171.010}

(Moved to 19 CSR 50-1.020)

Rebecca McDowell Cook (9/30/97)

Division 65 Missouri Medicaid Audit and Compliance

Chapter 2 Medicaid

13 CSR 65-2.010 Definitions {#sec-13-csr-65-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 65-2.010}

PURPOSE: This rule implements federal reg- 457, defining the terms used in the rules of the Missouri Medicaid Audit and Compliance Unit.

(1) Affiliates means persons having an overt, covert, or conspiratorial relationship so that any one (1) of them directly or indirectly controls or has the power to control another.

(2) Agent means any person who has been delegated the authority to obligate or act on behalf of a provider.

(3) Application shall include:

(A) Enrollment application to become a MO HealthNet Program provider;

(B) Revalidation application to remain a MO HealthNet Program provider;

(C) New practice location application;

(D) Provider direct deposit application;

(E) Change of ownership application;

(F) Hardship waiver request; or (G) Other information Missouri Medicaid Audit and Compliance (MMAC) needs, under applicable federal or state laws and regulations as they pertain to the Medicaid program, in order to enroll a MO HealthNet Program provider.

(4) Application fee means a fee required to be paid by a MO HealthNet Program institutional provider at the time of— (A) Initial application;

(B) Revalidation application;

(C) Change of ownership application; or (D) New practice location application.

(5) Applying provider means any person submitting an application as defined in section (3) above.

(6) Approve/approval as to a billing provider means the billing provider has been determined to be eligible under Medicaid rules and regulations to receive a Medicaid billing number and be granted Medicaid billing privileges.

(7) Approve/approval as to a performing provider means the performing provider has been determined to be eligible under Medicaid rules and regulations to receive a non-billing Medicaid number.

(8) Best interests of the MO HealthNet Program shall include consideration of the following factors:

(A) Ensuring reasonable access to MO HealthNet Program services;

(B) Promoting health, safety, and welfare of participants;

(C) The provider’s history of compliance with applicable rules and regulations related to the MO HealthNet Program; and (D) Any other factors related to MO HealthNet Program integrity.

(9) Billing provider means a provider or supplier who is authorized to bill the MO HealthNet Program for items or services provided to Medicaid participants. Billing provider includes providers who are authorized to bill Medicaid for items or services provided by performing providers.

(10) Closed-end provider agreement means an agreement which is for a specific period of time not to exceed twenty-four (24) months and which must be renewed in order for the provider to continue to participate in the Missouri Medicaid Program.

(11) Conviction or convicted means that— (A) A judgment of conviction has been entered by a federal, state, or local court, regardless of whether an appeal from that judgment is pending;

(B) A person has pled guilty to a criminal offense; or (C) A person is serving any period of probation or parole, regardless of any suspended imposition of sentence or suspended execution of sentence resulting from that offense.

(12) Deactivate means that the provider’s participation in the MO HealthNet program is stopped.

(13) Deny/denial means the applying provider has been determined to be ineligible under Medicaid rules and regulations to participate in the MO HealthNet program.

(14) Department means the Department of Social Services or its designated divisions or units.

(15) Enroll/enrollment means the process that MMAC uses to establish eligibility to participate as a provider in the MO HealthNet program. The process includes:

(A) Identification of a provider and any owners;

(B) Validation of the provider’s qualifications to meet program requirements;

(C) Screening the provider and owners through all required federal and state databases;

(D) Identification and confirmation of the provider’s practice location(s) and owner(s);

(E) Granting the provider a MO HealthNet number.

(16) Enrollment application means a MMAC approved paper enrollment application or a MMAC approved electronic enrollment process.

(17) Exclusion from participation in a federal health care program (e.g., Medicare and Medicaid) is a penalty imposed on a provider by the Office of Inspector General (OIG) under section 1128 or 1128A of the Social Security Act. States may also exclude providers from their Medicaid Programs under state law or pursuant to 42 CFR section 1002.2.

(18) Federal health care program means a program as defined in section 1128B(f) of the Social Security Act.

(19) Fiscal agent means an organization under contract to the state of Missouri for providing services related to the administration of the MO HealthNet Program.

(20) Hardship means a financial condition in which paying the application fee would impose a significant financial burden on the provider, and the provider is otherwise eligible to be a MO HealthNet Program provider.

Other factors which may indicate that a hardship exists include:

(A) Considerable bad debt expenses incurred by the provider;

(B) Considerable amount of charity care/financial assistance furnished to patients;

(C) Presence of substantive partnerships (whereby clinical, financial integration are present) with those who furnish medical care to a disproportionately low-income population;

(D) Whether an institutional provider receives considerable amounts of funding through disproportionate share hospital payments; or (E) Whether the provider is enrolling in a geographic area that is a presidentially declared disaster area under the Robert T.

Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. sections 5121- 5206 (Stafford Act).

(21) Hardship waiver request means a request submitted to MMAC (defined below) along with the provider application requesting that the application fee be waived due to hardship, detailing the hardship, and providing any documentation in support of the hardship waiver request.

(22) Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity.

This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

(23) Limited provider agreement means an agreement with an applying provider which has been accepted as a MO HealthNet Program provider by MMAC (defined below) conditional upon the applying provider performing services, delivering supplies, or otherwise participating in the program only in adherence to, or subject to, specially set out conditions agreed to by the applying provider prior to enrollment.

(24) Managed care entity means managed care organizations (MCOs), pre-paid inpatient health plans (PIHPs), pre-paid ambulatory health plans (PAHPs), primary care case management (PCCMs), and health improvement organizations (HIOs) or any similar managed care program type created by the state Medicaid agency.

(25) Managing employee means an owner, member, partner, director, general manager, business manager, administrator, school district superintendent, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider, either under contract or through some other arrangement, whether or not the individual is a W–2 employee of the provider.

(26) Medicaid agency or the agency means the single state agency administering or supervising the administration of the state Medicaid plan.

(27) Missouri Medicaid Audit and Compliance Unit (MMAC) means the unit within the Department of Social Services that is responsible for program integrity and compliance in the Medicaid Title XIX, CHIP Title XXI, and Waiver Programs in Missouri, which includes the enrollment and auditing of MO HealthNet providers and Medicaid participants through the lock-in program.

MMAC is charged with the responsibility of detecting, investigating, and preventing fraud, waste, and abuse of the Missouri Medicaid Title XIX, CHIP Title XXI, and Waiver Programs.

(28) Medical assistance benefits means those benefits authorized to be provided by Chapter 208, RSMo.

(29) MO HealthNet Program means programs operated pursuant to Title XIX of the Social Security Act, Title XXI of the Social Security Act, and/or waiver programs authorized by the United States Department of Health and Human Services.

(30) MO HealthNet means the division within the department, pursuant to sections 208.001 and 208.201, RSMo, that administers the Medicaid Title XIX, CHIP Title XXI, and waiver programs, approves claims from MO HealthNet providers for services or merchandise provided to eligible Medicaid participants, and authorizes and disburses payment for those services or merchandise accordingly.

(31) The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use NPIs in administrative and financial transactions adopted under HIPAA.

(32) Network Provider means any provider, group of providers, or entity that has a network provider agreement with a MCO, or a subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of the state’s contract with an MCO. A network provider is not a subcontractor by virtue of the network provider agreement.

(33) Open-end provider agreement means an agreement that has no specific termination date and continues in force as long as it is agreeable to both the state Medicaid agency and the enrolled provider.

(34) Organizational provider is a non-corporeal provider. Individual physicians or other individually licensed practitioners are not institutional providers. Organizational provider includes, but is not limited to:

(A) Ambulance service suppliers, health clinics, hospitals, pharmacies, and skilled nursing facilities;

(B) Other organizational entities that bill the MO HealthNet Program on a fee-for-service basis, such as personal care agencies, nonemergency transportation providers, residential care facilities, adult day care facilities, assisted living facilities, residential treatment centers, providers billing under the Consumer Directed Services Program or entities established under sections 205.968- 205.973, RSMo; and (C) Any other types of non-corporeal MO HealthNet Program providers consistent with the state plan, the Waiver Program, and CHIP Title XXI.

(35) Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII, or XX of the Act. This includes:

(A) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization (meaning all MCOs) that participates in Medicare (Title XVIII);

(B) Any Medicare intermediary or carrier;

(C) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under Title V or Title XX of the Act.

(36) Participant means a person who is eligible to receive benefits allocated through the department as part of the MO HealthNet Program.

(37) Participation means the ability and

(38) Performing provider means a provider or supplier who provides items or services to Medicaid participants, but who does not directly bill or receive payment from the MO HealthNet Program. Performing provider can also include referring, ordering, prescribing, and/or attending physicians, and non-physician practitioners.

(39) Person means any corporeal person or individual; or any legal or commercial entity, including but not limited to, any partnership, corporation, not-for-profit, professional corporation, business trust, estate, trust, limited liability company, association, joint venture, governmental agency, or public corporation.

(40) Person with an ownership or control interest, as defined in sections 1124 and 1124A(a) of the Social Security Act, means a person or corporation that— (A) Has an ownership interest totaling five percent (5%) or more in a disclosing entity;

(B) Has an indirect ownership interest equal to five percent (5%) or more in a disclosing entity;

(2/28/22) JOHN R. ASHCROFT

(C) Has a combination of direct and indirect ownership interests equal to five percent (5%) or more in a disclosing entity;

(D) Owns an interest of five percent (5%) or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent (5%) of the value of the property or assets of the disclosing entity;

(E) Is an officer or director of a disclosing entity that is organized as a corporation;

(F) Is a partner in a disclosing entity that is organized as a partnership; or (G) Is a managing employee.

(41) Practitioner means a physician or other individual licensed under state law to practice his or her profession.

(42) Provider means billing and performing providers and includes any person that enters into a contract or provider agreement with MMAC for the purpose of providing items or services to Missouri Medicaid participants.

Provider includes ordering, referring, prescribing, and/or attending physicians, and non-physician practitioners.

(43) Provider agreement means an agreement with MMAC which authorizes a provider to furnish items or services to eligible Missouri Medicaid participants.

(44) Provider application means the MMAC approved application and supplemental forms required to be submitted for the purpose of becoming a MO HealthNet Program provider, containing information and documentation requested by MMAC.

(45) Provider direct deposit means a form specified by MMAC and submitted by a provider of Medicaid Title XIX, CHIP Title XXI, or Waiver Program services for the purpose of having Missouri Medicaid checks automatically deposited to an authorized bank account.

(46) Reject/rejected means that the provider’s enrollment application was not approved due to incomplete or incorrect information, failure to submit an application fee, or the applying provider is not eligible to participate in the MO HealthNet Program.

(47) Revalidation means the requirement that all existing providers must go through an application process to verify their enrollment information is current, and they are still eligible to participate in the MO HealthNet Program.

(48) Revalidation application means an approved MMAC revalidation application and supplemental forms which are required to be submitted by all existing providers, containing all information and documentation requested by MMAC under applicable federal or state laws and regulations, and submitted at the time revalidation is required pursuant to this rule.

(49) Site visit may include any or all of the following:

(A) Physical visit to, and inspection of, the premises of the provider or a beneficiary’s home if the provider has no central operational facility;

(B) Obtaining photographs of the provider or the provider’s business for inclusion in the provider’s enrollment file;

(C) Full documentation of observations made at the provider’s premises including such facts as:

1. The facility was vacant and free of all furniture;

2. A notice of eviction or similar documentation is posted at the facility; and 3. The premises are not occupied by the provider, but by another person;

(D) A written report of the findings regarding each site visit;

(E) Verification that the facility is operational, open for business, and staff is present;

(F) Verification that customers are present at the facility where appropriate for the provider type;

(G) Acceptance of attestation with documentation when deemed appropriate by MMAC and consistent with applicable federal or state laws and regulations; or (H) Acceptance of proof of a recent site visit under the Medicare program or other state Medicaid program when deemed appropriate by MMAC and consistent with applicable federal or state laws and regulations.

(50) State plan means a document completed by the state of Missouri to tell the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) how the state will administer the MO HealthNet Program according to federal laws and regulations.

(51) Subcontractor means— (A) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or (B) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.

(52) Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).

(53) Suspension from participation means a provider is not authorized to provide MO HealthNet Program services for a specified or indefinite period of time.

(54) Suspension of payments means withholding of MO HealthNet Program payments otherwise due to a provider for a specified or indefinite period of time.

(55) Termination means the department’s discontinuation of a provider’s participation in the MO HealthNet program.

(56) Voluntary termination means that a provider submits written confirmation to MMAC of its decision to discontinue participation in the MO HealthNet Program.

(57) Waiver program means programs authorized in section 1915 of the Social Security Act (or other waiver programs authorized by federal law).

(58) Written notice means a notice to the address of the provider as listed in MMAC’s system, in writing, transmitted via the US mail, other public or private service for the delivery of correspondence, packages, or other things, facsimile, e-mail, or any other method/mode of transmittal that is deemed by MMAC to be an efficient, cost-effective, verifiable, and reliable method/mode of communication with the provider or applying provider.

Aug. 20, 2021, effective March 30, 2022.

History

• authority to provide services or merchandise to eligible MO HealthNet participants.

13 CSR 65-2.020 Provider Enrollment and Application {#sec-13-csr-65-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 65-2.020}

PURPOSE: This rule implements federal reg- 457, establishing the basis on which providers under the MO HealthNet Program may be approved or denied as a new provider and/or as a revalidating provider, establishing the

basis on which a new practice location may be approved or denied, establishing a revalidation requirement for all providers and establishing application and periodic screening requirements.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) Enrollment.

(A) All persons are required to enroll with MMAC as a billing or performing provider in the MO HealthNet Program if the services or items they provide will be billed to the MO HealthNet Program.

(B) For any person to receive payment from the MO HealthNet Program for items or services other than out-of-state emergency services, the billing providers and the performing providers of such items or services must be enrolled providers in the MO HealthNet Program on the date the items or services are provided unless applicable rules or manuals permit enrollment as of an earlier date, up to a maximum of three hundred sixty-five (365) days prior to the actual enrollment date.

(C) All claims for payment for items and services that were ordered, prescribed, or referred must contain the National Provider Identifier (NPI) of the provider who ordered, prescribed, or referred such items or services.

(D) All persons enrolled as MO HealthNet providers shall abide by the policies and procedures set forth in the MO HealthNet provider manual(s) applicable to the provider’s provider type(s). The MO HealthNet provider manuals 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 available at http://manuals.momed.com/manuals/, August 20, 2021. This rule does not incorporate any subsequent amendments or additions. A MO HealthNet provider’s breach of any MO HealthNet provider manual may result in imposition of sanctions, including but not limited to termination.

(2) Applications.

(A) All applying providers shall have a valid email address and shall submit a MMAC-approved application and any supplemental forms, information, and documentation required by MMAC for the appropriate provider type for which the person is applying.

(B) All information and documentation requested in the application and supplemental forms must be provided to MMAC prior to the application being approved.

(C) Specific application instructions are modified as necessary for efficient and effective administration of the MO HealthNet Program as required by federal or state laws and regulations. Providers applying on or after the promulgation of this rule should refer to the appropriate MMAC application filing instructions, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, Missouri Medicaid Audit and Compliance Unit, 205 Jefferson Street, Second Floor, Jefferson City, MO 65109, at its website mmac.mo.gov, August 20, 2021. This rule does not incorporate any subsequent amendments or additions.

(D) The application shall include all information required in the mandatory disclosures pursuant to section (3) of this rule. Upon submission of any application(s), supplemental form(s), information and documentation requested in the application(s) and supplemental form(s), MMAC may, at its discretion, request additional or supplemental information and documentation from the applying provider prior to considering the application and/or conducting screening pursuant to this rule in order to clarify any information previously submitted and to verify that the provider meets all applicable requirements of state or federal laws and regulations.

(3) All providers, fiscal agents, managed care entities, and persons with an ownership or control interest in the provider are required to disclose as follows:

(A) The following disclosures are mandatory:

1. The name and address of the applying provider and any person(s) with ownership in the provider. The address must include the provider’s primary business address, each additional practice location(s), and any corresponding PO Box addresses;

2. Dates of birth and Social Security numbers (in the case of a corporeal person);

3. Other tax identification number(s) of any person with ownership in the provider or in any subcontractor in which the provider has a five percent (5%) or more interest;

4. Whether any person with ownership in the applying provider is related to another person with ownership in the provider as a spouse, parent, child, or sibling;

5. Whether any person with ownership in any subcontractor in which the provider has a five percent (5%) or more interest is related to another person with ownership in the provider as a spouse, parent, child, or sibling;

6. The name of any other provider(s) in which an owner of the applying or enrolled provider has ownership; and 7. The name, address, date of birth, and Social Security number of any managing employee of the provider;

(B) Disclosures from any provider are due at the following times, and must be updated within thirty (30) days of any changes in information required to be disclosed:

1. Upon initial enrollment, reenrollment, or revalidation; and 2. Upon request of MMAC;

(C) Disclosures from fiscal agents are due at the following times:

1. Upon the fiscal agent submitting a proposal;

2. Upon request of MMAC;

3. Ninety (90) days prior to renewal or extension of a contract; and 4. Within thirty (30) days after any change in ownership of the fiscal agent;

(D) Disclosures from managed care entities (managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, and health insuring organizations), except primary care case management programs, are due at the following times:

1. Upon the managed care entity submitting a proposal;

2. Upon request of MMAC;

3. Ninety (90) days prior to renewal or extension of the contract; and 4. Within thirty (30) days after any change in ownership;

(E) Disclosures from Primary Care Case Management Programs (PCCM). PCCMs will comply with disclosure requirements under subsection (B) of this section;

(F) All disclosures must be provided to MMAC. Disclosures not made to MMAC will be deemed non-disclosed and not in compliance with this section; and (G) Administrative action(s) for failure to provide required disclosures.

1. Any person’s failure to provide, or timely provide, disclosures pursuant to this

section may result in deactivation, denial, rejection, suspension, or termination of the provider’s participation in the MO HealthNet program. If the failure is inadvertent or merely technical, MMAC may choose not to impose administrative actions if, after notice, the provider promptly corrects the failure.

(4) Provider Revalidation.

(A) All providers shall revalidate their enrollment with the MO HealthNet Division at least every five (5) calendar years from the effective date of the provider’s most recently executed provider agreement, in order to remain a MO HealthNet provider. For example, a provider whose initial or revalidated provider agreement was effective on March 1, 2020, is required to revalidate their enrollment no later than March 1, 2025. MMAC may request that the provider revalidate on an off-cycle revalidation period.

(B) The MMAC-approved revalidation application, supplemental forms, information, and documentation requested by MMAC, along with the application fee and/or hardship waiver request, if applicable, shall be submitted no later than one hundred twenty (120) days prior to the expiration of the effective provider agreement.

(C) Revalidating providers must comply with the requirements of this rule and will be subject to the screening process noted in this

rule in order to have their applications for revalidation approved.

(5) Application Fee.

(A) An application fee, hardship waiver request, and/or an exemption reason provided in this rule must accompany every organizational provider’s application.

(B) The application fee must be in the form of a cashier’s check, money order, or an electronic payment acceptable to MMAC and for the correct application fee amount in effect as of the date of receipt by MMAC.

(C) Failure to submit the application fee in an acceptable form and/or for the correct amount may result in the return of the fee to the provider and rejection of the application.

(D) Applying and revalidating providers must submit an application fee, determined as follows:

1. As of the effective date of this rule for calendar year 2021, five hundred ninety-nine dollars ($599.00); and 2. For calendar year 2022 and subsequent years— A. The amount of the application fee shall be the amount for the preceding year adjusted by the percentage change in the consumer price index for all urban consumers for the twelve- (12-) month period ending with June of the previous year as published by the Bureau of Labor Statistics of the United States Department of Labor.

(E) If MMAC determines that a person is an organizational provider, that person is required to pay the application fee.

(F) Exemptions from Application Fee.

MMAC may waive the application fee under the following conditions:

1. Providers who are enrolled in and paid the application fee required by CMS for Medicare or another state’s Title XIX or Title XXI program within two (2) years of the date the application to enroll as a MO HealthNet Provider shall be exempt from paying an application fee;

2. MMAC, in consultation with other state of Missouri departments, divisions, and units, determines that imposition of the application fee would impede Missouri Medicaid participants’ access to care;

3. A provider is submitting a provider application as a result of a national or state public health emergency situation as lawfully declared by a federal or state authority; and 4. The provider is owned and operated by the state of Missouri or an agency of the state of Missouri.

(G) Providers seeking an exemption from the application fee are responsible for notifying MMAC, in writing, that they qualify for exemption and for providing proof of such qualification.

(6) Hardship Waiver Request.

(A) Providers can request a hardship waiver of the application fee from the Centers for Medicare and Medicaid (CMS) when submitting their initial enrollment application or a revalidation application, but the request must be received by MMAC before the application will be processed by MMAC. A hardship waiver request will not be considered if it is received by MMAC after MMAC approves the application or revalidation. If CMS approves the hardship waiver, MMAC will refund the application fee to the provider.

(B) A provider that requests a hardship waiver must submit a letter and supporting documentation that describes the hardship and why the hardship justifies an exception, including providing comprehensive documentation (which may include, but is not limited to, historical cost reports, recent financial statements such as balance sheets and income statements, cash flow statements, or tax returns).

(C) Factors that may suggest a hardship exception is appropriate include but are not limited to the following:

1. Considerable bad debt expenses;

2. Significant amount of charity care/financial assistance furnished to patients;

3. Presence of substantive partnerships with those who furnish care to a disproportionately low-income population;

4. Whether an institutional provider receives considerable amounts of funding through disproportionate share hospital payments; or 5. Whether the provider is enrolling in a geographic area that is a presidentially declared disaster area under the Robert T.

Stafford Disaster Relief and Emergency Assistance Act.

(D) Upon receipt of a hardship waiver request with an application, MMAC will send the request and all accompanying documentation to CMS. CMS will determine if the request should be approved. CMS will communicate its decision to the institutional provider and MMAC via letter.

(7) Appeal of the Denial of a Hardship Waiver Request. A provider may file a written reconsideration request with CMS within sixty (60) calendar days from the date of the notice of initial determination. The request must be signed by the individual provider, a legal representative, or any authorized official within the entity. The procedures for submitting an appeal will be provided on the denial letter from CMS.

(8) MMAC shall use the application fee to offset the costs associated with the provider screening program in its entirety. This includes but is not limited to the following:

(A) Implementation and augmentation of MMAC’s provider enrollment system; and (B) Any other administrative costs related to the provider screening program, which include costs associated with processing fingerprints and conducting criminal background checks. The application fee does not cover the cost associated with capturing fingerprints and a provider may be charged additional costs for this purpose in addition to the application fee.

(9) Refund of the Application Fee.

(A) If an institutional provider is granted a hardship exception pursuant to this rule or if the application is rejected because it was not properly signed or is missing other information required to be provided on the application itself, and an application fee was included with the application and the hardship waiver request, the application fee shall be returned to the applying provider.

(B) Once the screening process has begun, regardless whether the application goes through part or all of the screening process, the application fee is non-refundable.

(10) Screening.

(A) The screening requirements contained in this section apply to all applying providers and to all persons disclosed, or required to be disclosed, in the application.

(B) MMAC shall conduct pre-enrollment screening and post-enrollment monthly screenings. Screenings may include the following:

1. Screening pursuant to 42 CFR sections 455.410(a) and (b), 42 CFR 455.412, 42 CFR 455.432, 42 CFR 455.436, and 42 CFR 455.452;

2. Screening to ensure that the providers meet all enrollment criteria for their provider type;

3. Announced or unannounced pre- and post-approval site visits; and 4. For screening purposes, utilization of databases and other sources of information to prevent enrollment of fictitious providers, to ensure that spurious applications are not processed, and to prevent fraud, waste, and abuse in the MO HealthNet Program.

(C) The screening procedures and requirements are applicable to all enrolled or applying providers. All providers are required to revalidate their MO HealthNet enrollment(s) at least every five (5) years.

(D) The following screening categories are established for MO HealthNet providers, as required by federal law and regulation for Medicare and Medicaid providers under 42 CFR section 424.518 and section 1902(kk)(1) of the Social Security Act. There are three (3) levels of screening: limited, moderate, and high. Each provider type is assigned to one (1) of these screening levels.

If a provider could fit within more than one (1) screening level described in this section, the highest risk category of screening is applicable.

1. Limited Risk Category.

A. The following providers pose a limited risk of fraud, waste, and abuse to the MO HealthNet Program and are subjected to limited category screening:

(I) Physicians or non-physician practitioners (except as otherwise listed in another risk category) and medical groups or clinics;

(II) Ambulatory surgical centers (ASCs);

(III) Competitive acquisition program/Part B vendors;

(IV) End-stage renal disease (ESRD) facilities;

(V) Federally qualified health centers (FQHCs);

(VI) Histocompatibility laboratories;

(VII) Home infusion therapy suppliers;

(VIII) Hospitals, including critical access hospitals (CAHs);

(IX) Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act;

(X) Mammography screening centers;

(XI) Mass immunization roster billers;

(XII) Opioid treatment programs (if 42 CFR 424.67(b)(3)(ii) applies);

(XIII) Organ procurement organizations (OPOs);

(XIV) Pharmacies;

(XV) Radiation therapy centers (RTCs);

(XVI) Religious nonmedical health care institutions (RNHCIs);

(XVII) Rural health clinics (RHCs);

(XVIII) Skilled nursing facilities (SNFs).

B. The providers in the limited category are subject to the following screening requirements:

(I) Verification that the applying provider, and all persons disclosed or required to be disclosed, meet all applicable federal regulations and MO HealthNet Program requirements for the provider type;

(II) Verification that the applying provider, and all persons disclosed, have a valid license, operating certificate, or certification if required for the provider type, and that there are no current limitations on such licensure, operating certificate, or certification which would preclude enrollment;

(III) Verification that the applying provider’s, and that of all persons disclosed, license(s) held in any other state has/have not expired and that there is/are no current limitations on such license(s) which would preclude enrollment;

(IV) Confirmation of the identity of the applying provider and determination of the exclusion status of the applying provider and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of the following federal databases:

(a) Social Security Administration’s Death Master File;

(b) National Plan and Provider Enumeration System;

(c) List of Excluded Individuals/Entities;

(d) The Excluded Parties List System;

(e) Medicare Exclusion Database;

(f) Any such other databases as the Secretary of the United States Department of Health and Human Services has prescribed as of September 30, 2021, pursuant to section 455.436 of Title 42, Code of Federal Regulations, which is incorporated by reference and made part of this rule as published by the Office of the Federal Register, 7 G Street NW, Suite A-734, Washington, DC 20401, and available at its website https://www.ecfr.gov/current/title- 42/chapter-IV/subchapter-C/part-455/sub-

part-E/section-455.436. This rule does not incorporate any subsequent amendments and additions.

(V) Database check of the National Sex Offender Public Website;

(VI) The information from these databases shall be used to determine eligibility of the MO HealthNet provider and for verification of the identity of the applying person, the Social Security number, the National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, and any exclusion by the Department of Health and Human Services, Office of Inspector General; and (VII) MMAC may conduct preapproval site visits prior to acceptance of an applying provider’s application.

2. Moderate Risk Category.

A. The following providers pose a moderate risk of fraud, waste, and abuse to the MO HealthNet Program and are subject to moderate screening requirements:

(I) Adult Day Care providers (ADCs);

(II) Ambulance service suppliers;

(III) Community Mental Health Centers (CMHCs);

(IV) Comprehensive outpatient rehabilitation facilities (CORFs);

(V) Entities established under sections 205.968-205.973, RSMo;

(VI) Hospice organizations;

(VII) Independent clinical laboratories (ICLs);

(VIII) Independent diagnostic testing facilities (IDTFs);

(IX) Non-emergency transportation providers (NEMTs);

(X) Personal care providers, including providers billing under the Consumer Directed Services program;

(XI) Physical therapists including physical therapy groups;

(XII) Portable X-ray suppliers (PXSs);

(XIII) Revalidating Diabetes Prevention Program providers (DPPs);

(XIV) Revalidating durable medical equipment suppliers (DMEPOS);

(XV) Revalidating home health agencies (HHAs); and (XVI) Revalidating opioid treatment programs.

B. In addition to the screening requirements for the limited risk category in paragraph (10)(D)1., the providers in the moderate risk category shall be subject to site visits prior to acceptance of an applying provider’s application and are additionally subject to unannounced post-enrollment site visits.

3. High Risk Category.

A. The following providers pose a high risk of fraud, waste, and abuse to the MO HealthNet Program and are subject to high risk screening requirements:

(I) Newly enrolling or reenrolling home health agencies;

(II) Newly enrolling or reenrolling Durable Medical Equipment, Prosthetic, Orthotic, and Supplies (DMEPOS) suppliers;

(III) Newly enrolling or reenrolling DPP suppliers; and (IV) Newly enrolling or reenrolling opioid treatment programs that have not been fully and continuously certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) since October 23, 2018.

B. In addition to the screening requirements for the limited and moderate risk categories in paragraphs (10)(D)1. and 2. of this rule, the providers and their owners must submit to a fingerprint-based criminal

history report check of the Federal Bureau of Investigations (FBI) Integrated Automated Fingerprint Identification System— (I) A revalidating provider who has already submitted fingerprints once will not be required to submit fingerprints a second time unless required by FBI protocols;

(II) Pursuant to 42 CFR section 455.434(b), the provider is responsible for the cost of supplying the fingerprints and the state and federal government will share the cost of the processing of the fingerprints and the background check; and (III) This fingerprint-based criminal history report check applies to all persons in this risk category applying to be a provider (whether as a billing or performing provider), or an individual with a five percent (5%) or greater direct or indirect ownership interest in such provider, or a managing employee.

(E) MMAC must adjust the categorical risk level from “limited” or “moderate” to “high” when any of the following occurs:

1. MMAC imposes a payment suspension on a provider based on a credible allegation of fraud, waste, or abuse by the provider; the provider has an existing Medicaid overpayment; or the provider has been excluded by the Department of Health and Human Services, Office of Inspector General or another state’s Medicaid program within the previous ten (10) years. The upward adjustment of the provider’s categorical risk level for a payment suspension or overpayment shall continue only so long as the payment suspension or overpayment continues; or 2. MMAC or CMS in the previous six (6) months lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider at any time within six (6) months from the date the moratorium was lifted.

(F) If a person has been screened by Medicare or by another state Medicaid agency and paid Medicare or another state Medicaid agency’s application fee, within two (2) years of the date of the application to MMAC, such person will not be subject to the screening requirements or application fee provided for by this rule except those screening requirements and application fee imposed pursuant to subsection (E) of this section.

(G) Any MO HealthNet Program provider not categorized by this regulation as within the limited, moderate or high risk category shall be a considered moderate risk and screened as a moderate risk.

(H) MMAC may request and consider additional information or documentation related to the eligibility criteria, if at any time during the application process it appears that the enrollment application or supporting documentation is inaccurate, incomplete, or misleading; or it appears the applying person may be ineligible to become a MO HealthNet provider.

(11) The provider shall advise MMAC, in writing, on enrollment forms specified by MMAC, of any changes affecting the provider’s enrollment records within ninety (90) days of the change, with the exception of change of ownership or control of any provider which must be reported within thirty (30) days.

(A) The Provider Enrollment Unit within MMAC is responsible for determining whether a current MO HealthNet provider record shall be updated or a new MO HealthNet provider record is created. A new MO HealthNet provider record is not created for any changes, including but not limited to change of ownership, change of operator, tax identification change, merger, bankruptcy, name change, address change, payment address change, Medicare number change, National Provider Identifier (NPI) change, or facilities/offices that have been closed and reopened at the same or different locations.

This includes replacement facilities, whether they are at the same location or a different location, and whether the Medicare number is retained or if a new Medicare number is issued. A provider may be subject to administrative action if information is withheld at the time of application that results in a new provider number being created in error. The division shall issue payments to the entity identified in the current MO HealthNet provider enrollment application. Regardless of changes in control or ownership, MMAC shall recover from the entity identified in the current MO HealthNet provider enrollment application liabilities, sanctions, and penalties pertaining to the MO HealthNet program, regardless of when the services were rendered.

(12) MO HealthNet provider identifiers shall not be released to any non-governmental entity, except the enrolled provider, by the MO HealthNet Division or its agents.

(13) The provisions of this rule are declared severable. If any provision of this rule is held invalid by a court of competent jurisdiction, the remaining provisions of this rule shall remain in full force and effect, unless otherwise determined by a court of competent jurisdiction to be invalid.

(14) Except to the extent inconsistent with this rule, the requirements of 13 CSR 70- 3.030 remain in force, including any provisions regarding denial of applications and termination, until those provisions are rescinded.

May 26, 2015, effective Nov. 30, 2015. ** Emergency amendment filed March 11, 2022, effective March 30, 2022, expired Sept. 26, 2022. Amended: Filed March 11, 2022, effective Oct. 30, 2022. **Pursuant to Executive Order 21-07, 13 CSR 65-2.020, section (5) and subsections (9)(B) and (9)(F) was suspended from March 19, 2020 through April 13, 2021.

13 CSR 65-2.030 Denial or Limitations of Applying Provider {#sec-13-csr-65-2.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 65-2.030}

PURPOSE: This rule implements federal reg 457, establishing the bases on which enrollment, revalidation, and establishment of a new practice location may be approved, limited, or denied.

(1) Missouri Medicaid Audit Compliance (MMAC) may terminate the provider’s enrollment or deny enrollment— (A) Where the provider did not submit timely and accurate information or did not cooperate with screening methods required under applicable statutes and regulations unless the provider cures the failure to comply with this subsection within thirty (30) days of MMAC’s notice that it intends to terminate the provider or deny enrollment;

(B) Where the provider or any person with convicted of or pled guilty to a criminal offense, including any suspended imposition of sentence, any suspended execution of sentence, or any period of probation or parole, related to their involvement with the Medicare, Medicaid, or Title XXI program in the last ten (10) years, unless MMAC determines that denial or termination of enrollment is not in the best interests of the MO HealthNet Program and MMAC docu- (C) Where the provider or any person with convicted of or pled guilty to a misdemeanor or felony charge, including any suspended imposition of sentence, any suspended execution of sentence, or any period of probation or parole relating to:

1. Endangering the welfare of a child;

2. Abusing or neglecting a resident, patient, or client;

3. Misappropriating funds or property belonging to a resident, patient, or client; or 4. Falsifying documentation verifying delivery of services to a personal care assistance services consumer;

(D) Where the provider or any person with placed on the Family Care Safety Registry as mandated by sections 210.900–210.936, RSMo; or been placed on the Missouri Sex Offender Registry as mandated by sections 589.400–589.425 and 43.650, RSMo;

(E) Where the provider is terminated under Title XVIII of the Social Security Act or under the Medicaid Program or Children’s Health Insurance Program (CHIP) of any other state unless MMAC determines that the termination was not for cause, which may include, but is not limited to, fraud, integrity, or quality. Termination or denial of enrollment will not be required if MMAC determines it would not be in the best interests of the MO HealthNet Program and MMAC receives a waiver from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services pursuant to 42 U.S.C. 1320a-7;

(F) Where the provider or a person with an ownership or control interest or who is an agent or managing employee of the provider fails to submit timely or accurate information, unless MMAC determines that termination or denial of enrollment is not in the best interests of the MO HealthNet Program, and MMAC documents that determination in writing;

(G) Where the provider, or any person with ownership or control interest, fails to submit fingerprints in a form and manner to be determined by MMAC within thirty (30) days of a request by Centers for Medicare and Medicaid Services (CMS) or MMAC, unless MMAC determines that termination or denial of enrollment is not in the best interests of the MO HealthNet Program, and MMAC docu- (H) Where the provider fails to permit access to provider locations for any site visits under 13 CSR 65-2.020, unless MMAC determines that termination or denial of enrollment is not in the best interests of the MO HealthNet Program, and MMAC docu- (I) Where the provider fails to complete an application for provider direct deposit as required by 13 CSR 70-3.140;

(J) Where the provider or a person with an ownership or control interest submitted false information to MMAC; or (K) Where the identity of any provider or person with an ownership or control interest cannot be verified.

(2) Denial of enrollment shall preclude any provider or person from submitting claims for payment, either personally or through claims submitted by any clinic, group, corporation, affiliate, partner, or any other association to the single state agency or its fiscal agents for any services or supplies delivered under the MO HealthNet program whose enrollment as a MO HealthNet provider has been denied. Any claims submitted by a nonprovider through any clinic, group, corporation, affiliate, partner, or any other association and paid shall constitute overpayments.

(3) No clinic, group, corporation, partnership, affiliate, or other association may submit claims for payment to the MO HealthNet Division or its fiscal agent for any services or supplies provided by a provider or person within each association who has been denied enrollment in the MO HealthNet program.

Any claims for payment submitted and paid under these circumstances shall constitute overpayments.

(4) Except to the extent inconsistent with this

rule, the requirements of 13 CSR 70-3.030 remain in force, including any provisions regarding denial of applications and termination, until those provisions are rescinded.

(5) The provisions of this rule are declared severable. If any provision of this rule is held invalid by a court of competent jurisdiction, the remaining provisions of this rule shall remain in full force and effect, unless otherwise determined by a court of competent jurisdiction to be invalid.

Aug. 20, 2021, effective March 30, 2022.

Chapter 3 Providers and Participants—General Provider and Participant Policies

13 CSR 65-3.010 Participant Lock-In Program {#sec-13-csr-65-3.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 65-3.010}

PURPOSE: This rule establishes a process to safeguard against unnecessary or inappropriate utilization of care and services by MO HealthNet participants by identifying excessive use patterns in order to rectify overutilization practices of participants.

(1) Definitions applicable to the administration of this program are as follows:

(A) “Lock-In” means limiting or restricting a participant’s ability to access services to a single physician and/or a single pharmacy to reduce excessive MO HealthNet benefits usage;

(B) “Medically necessary” means health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine;

(C) “Misutilization” or “misuse” means overusing, underusing, or using MO HealthNet services in a way that is harmful, wasteful, and uncoordinated or using services provided under the MO HealthNet program in an improper or incorrect manner, whether that use is intentional or unintentional;

(D) “Overlap” means at least one (1) day of overlapping dispensing of prescriptions written by two (2) or more different prescribers; and (E) “Therapeutic class” means a class of medications that are used to treat similar medical conditions.

(F) “MMAC approved pharmacy” means a licensed pharmacy that is currently enrolled with MO HealthNet and is not currently sanctioned or under investigation by any federal or state authority.

(G) “MMAC approved physician” means a licensed physician that is currently enrolled with MO HealthNet and is not currently sanctioned or under investigation by any federal or state authority.

(2) Unless a participant shows that the service or product provided to the participant was otherwise medically necessary, the Missouri Medicaid Audit and Compliance Unit (MMAC) may place the participant in the Lock-In Program if the participant’s utilization of benefits exceeds one (1) or more of the following parameters during a three- (3-) month period:

(A) Use of three (3) or more drugs in the same therapeutic class such that the prescriptions of such drugs overlap;

(B) Use of three (3) or more pharmacies;

(C) Use of sixteen (16) or more prescriptions for therapeutic classes such as, but not limited to, analgesics, anticonvulsants, skeletal muscle relaxants, anxiolytics, or other potential drugs of misuse;

(D) Use of three (3) or more providers that specialize in a same or similar service or product;

(E) Use of three (3) or more different emergency departments; or (F) Use by referral, review, or other analysis that indicates possible overutilization or that identifies a patient safety issue.

(3) Placement in the Lock-In Program.

(A) The decision to place a participant in the Lock-In Program is at MMAC’s discretion. MMAC is to consider the following factors when deciding whether to place the participant in the Lock-In Program:

1. Seriousness of the findings – MMAC will consider the seriousness of the findings including, but not limited to, overlaps of the same therapeutic class of prescription medications, the use of multiple pharmacies, the prescription of the same therapeutic class of prescription medications by multiple, like, or different prescribers, emergency department visits for non-emergent services, the use of multiple emergency departments in different locations, and the use of multiple primary care clinics;

2. Extent of Inappropriate Utilization of Services – MMAC will consider the extent as measured by, but not limited to, the number of overlapping prescriptions within the same therapeutic class prescribed by different prescribers and the number of emergency department visits and locations for diagnoses that are non-emergent such as back pain, lumbago, pain in limb, or toothache;

3. Prior History of Action Taken by the Lock-In Section – MMAC will consider whether or not the participant has been given prior education by the Lock-In Section which includes any education letters, warning letters, or previous placement in the Lock-In Program.

(4) A participant shall be placed in the Lock- In Program if the participant’s utilization of benefits was misused by any of the following methods:

(A) Lending or giving the participant’s Medicaid ID card to ineligible individuals who are not eligible for Medicaid;

(B) Submitting, or causing to be submitted, forged documents to providers for medical benefits or services;

(C) Refusing to submit to, or failing to have predicted, urine or blood levels following testing for medications prescribed to the participant and covered by the MO HealthNet program while engaged in a pain management or substance use disorder treatment program; or (D) Paying cash for prescribed medications covered by the MO HealthNet program.

(5) Once MMAC identifies a participant that falls under subsection (2) or (3) of this rule and notifies the participant of its decision to place the participant in the Lock-In Program, the participant is to provide MMAC with the following:

(A) Notification within twenty (20) days of the participant’s selection of a single physician and a single pharmacy that must be approved by MMAC. In the event the participant fails to select an MMAC approved physician and pharmacy, MMAC will select a single physician and a single pharmacy on behalf of the participant;

(B) Notification if the participant requires more than one (1) physician or pharmacy for the purposes of specialized medical treatment. MMAC may permit a participant to select more than one (1) physician or pharmacy upon showing of such need; and (C) Notification of any request to change a selected physician and/or pharmacy. A participant may not request to change selection of physician and/or pharmacy more than once within a three (3) consecutive month period unless additional provider changes within that three (3) consecutive month period are approved upon verification of just cause. A participant may only change a selected physician and/or pharmacy if any of the following occur:

1. The physician or pharmacy moves, retires, dies, discontinues MO HealthNet participation, or refuses to provide care to the participant; or 2. The participant moves from the physician’s service area.

(6) A participant who is subject to the Lock- In Program may not select a single physician and single pharmacy if the single physician and/or single pharmacy decline to serve as the participant’s single physician or pharmacy.

(7) A participant who is subject to the Lock- In Program may only receive services from a provider who is not the designated physician and/or a pharmacy that is not the designated pharmacy in the following circumstances:

(A) Documented medical emergencies;

(B) Upon referral by the participant’s designated Lock-In provider; or (C) As otherwise authorized by MMAC.

(8) A participant who is placed in the Lock- In Program will be subject to Lock-In for a minimum of twenty-four (24) months. If after twenty-four (24) months, MMAC determines that the participant is continuing to misuse the MO HealthNet program as set forth in this rule, MMAC may impose an additional Lock-In period for up to twenty-four (24) additional months.

(9) Any participant who is aggrieved by a decision made under this regulation may seek administrative review under section 208.080, RSMo.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original rule filed July 19, 2018, effective Feb. 28, 2019. Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.

13 CSR 65-3.050 Electronic Signatures for Mo HealthNet Program {#sec-13-csr-65-3.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 65-3.050}

PURPOSE: This rule establishes the basis on which Health Care Providers and participants under Missouri Medicaid Title XIX Programs may utilize electronic signatures when validating services rendered and received.

(1) As used in this rule, the following terms shall mean:

(A) “Electronic Medical Record” means a record from which symptoms, conditions, diagnosis, treatments, prognosis, and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty. Electronic Medical Records may be referred to as “Electronic Health Records;”

(B) “Electronic Record” means an electronic record of health-related information on an individual, from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty;

(C) “Electronic Signature” means a computer data compilation of any symbol or series of symbols executed, adopted, or authorized by an individual with the intent to be the legally binding equivalent of the individual’s handwritten signature. The use of biometrics does not constitute an electronic signature; however, biometrics may be used as part of electronic signature verification. A signature stamp does not constitute an electronic signature;

(D) “Participant” means any individual who is a participant in the Missouri Medicaid Title XIX or Title XXI programs;

(E) “Provider” means any health care provider that participates or provides services under Title XIX and under Title XXI of the federal Social Security Act.

(2) This rule applies to any Electronic Record, Electronic Health Record or Electronic Medical Record, or Electronic Signature, as defined herein.

(3) If a law or regulation requires a record to be in writing, an electronic record shall satisfy such law for MO HealthNet purposes. If a law or regulation requires a signature to be in writing, an electronic signature shall satisfy such law for MO HealthNet purposes.

(4) An electronic signature has the same legal effect and can be enforced in the same manner as a written signature.

(5) Electronic records and electronic medical records are subject to the retention requirements set forth in 13 CSR 70-3.030 and 13 CSR 70-3.210.

(6) Nothing herein shall require a provider to conduct business electronically, but if a provider chooses to conduct business electronically, the following requirements shall apply:

(A) Only employees or agents designated by the provider may make entries in a participant’s electronic record or electronic medical record;

(B) All entries in a participant’s electronic record or electronic medical record must be authenticated with a method established to identify the author. The method utilized may include computer keys/codes or biometric identification systems that utilize a personal identification number (PIN). When computer key/code(s), biometric identification systems, or other codes are used, these methods must be under the sole control of the employee or agent using them. Providers must be able to demonstrate that adequate safeguards are maintained to protect against improper or unauthorized use of these methods;

(C) A provider shall have a process in place to deactivate and disable an employee’s or an agent’s access to electronic records and electronic medical records upon suspension or termination of an employee’s or agent’s employment or agency relationship;

(D) Providers’ electronic records and electronic medical records systems shall maintain an activity tracking system to monitor and record user activity for all documents in a participant’s record that are viewed, created, updated, or modified. The tracking system must record the following for each activity:

1. User log-in and log-out dates and times;

2. User identification;

3. Device identification, such as a Media Assigned Control (MAC) address; and 4. Dates and times when records are viewed, created, updated, or modified; and (E) Providers shall ensure measures are in place to assure that the signer cannot deny having signed the record.

(7) Electronic medical records shall contain the following:

(A) The name, title, and electronic signature of the MO HealthNet enrolled provider delivering the service; and (B) The date the electronic signature was executed.

(8) The process of affixing an electronic signature shall require at least two (2) distinct identification components, such as an identification code and a password.

(9) When a change is made to an electronic record or electronic health record, the following requirements apply:

(A) All original records shall be maintained; and (B) Any edits or changes to the record shall be saved, and the record shall contain the date of the edit or change, the reason for the edit or change, and the author of the edit or change.

History

• AUTHORITY: sections 208.159 and 660.017, RSMo 2016. Original rule filed April 6, 2017, effective Nov. 30, 2017. Original authority: 208.159, RSMo 1979 and 660.017, RSMo 1993, amended 1995.

13 CSR 65-3.060 Computation of Provider Overpayment by Statistical Sampling {#sec-13-csr-65-3.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 65-3.060}

PURPOSE: This rule establishes a statistical methodology where the billing forms or claims for payment submitted by Medicaid providers may be examined to determine compliance with Title XIX (Medicaid) Program requirements and proper payment, and this

rule also sets forth the manner in which providers may challenge the results.

(1) The following definitions will be used in administering this rule:

(A) “Claim for payment” or “claim” means the Internal Control Number (ICN) and the associated data submitted to the 4CODE OF STATE REGULATIONS (3/31/19) JOHNR. ASHCROFT Medicaid agency for the purpose of obtaining payment by the Title XIX Medicaid Program;

(B) “Disproportionate Stratified Random Sampling Technique” means a sampling method in which the size of the sample drawn from a particular stratum is not proportional to the relative size of that stratum;

(C) “Medicaid agency” or “the agency” means the single state agency administering or supervising the administration of the state Medicaid plan;

(D) “Overpayment” means an amount of money paid to a provider by the Medicaid agency to which the provider was not entitled by reason of improper billing, error, fraud, abuse, lack of verification, or insufficient medical necessity;

(E) “Provider” means any person, partnership, corporation, not-for-profit corporation, professional corporation, or other business entity that enters into a contract or provider agreement with the Medicaid agency for the

purpose of providing services to Medicaideligible persons and obtaining from the Medicaid agency reimbursement for services;

(F) “Sampling Unit” means one (1) of the units into which an aggregate (e.g. total paid on claims) is divided for the purpose of sampling. For example a sampling unit may be ICNs, a specific procedure code or codes, or participant DCNs (Document Control Numbers);

(G) “Stratum” refers to a sampling method in which the universe is divided into nonoverlapping subgroups. Each of the subgroups is called a stratum, and two (2) or more subgroups are called strata; and (H) “Universe” means all claims for payment or all claims relating to a specific service or a specific item or merchandise submitted by a provider between two (2) certain dates.

(2) The Medicaid agency may use a Disproportionate Stratified Random Sampling Technique to establish provider overpayments. This technique is an extrapolation of a statistical sampling of claims used to determine the total overpayment for recoupment.

(3) When a total overpayment has been computed by statistical sampling, the Medicaid agency may proceed to recover the full amount of the overpayment from the provider as an amount due. Recovery of the overpayment shall be accomplished according to the provisions of 13 CSR 70-3.030(6), except that in cases where the amount due was computed by statistical sampling, the notice informing the provider of the amount due required by 13 CSR 70-3.030(6)(A) and (B) shall also contain the following information:

(A) The dates of service and total paid for the Universe;

(B) Definition of the sampling unit;

(C) The number of claims in the statistical sample; and (D) A generally summarized description of the reasons for the overpayment determinations with all claims in the statistical sample identified as to which overpayment description applies to each.

(4) The extrapolated overpayment is a final decision regarding administration of the state Medicaid plan and is subject to appeal in accordance with section 208.156, RSMo.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original rule filed Aug. 28, 2018, effective April 30, 2019. Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.

Division 70 Mo Healthnet Division

Chapter 1 Organization

13 CSR 70-1.010 Organization and Description {#sec-13-csr-70-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-1.010}

PURPOSE: This rule states the function and general organization of the MO HealthNet Division to comply with the requirements of

section 536.023, RSMo.

(1) General Authority and Purpose.

(A) The MO HealthNet Division (MHD) was created within the Department of Social Services by executive order of the governor on February 27, 1985. The Missouri General Assembly granted statutory authority to the division by adding section 208.201, RSMo, effective September 28, 1987. MHD operates under the provisions of Chapter 208, RSMo, and Title XIX of the federal Social Security Act.

(B) MHD is responsible for the administration of the medical assistance program in Missouri except for the determination of participant eligibility for the program, which shall be the responsibility of the Family Support Division.

(2) Organization and Operations. The MHD is located in Jefferson City at 615 Howerton Court. MHD can be contacted by writing to the division at PO Box 6500, Jefferson City, MO 65102-6500. MHD is divided into five (5) major organizational components—administration and four (4) sections—finance; information services; operations; and clinical review, development, and performance.

(A) Administration. The director’s office provides the overall guidance and direction for the division and is responsible for establishing the agency’s goals, objectives, policies, and procedures. The director’s office is also responsible for providing legislative guidance on Medicaid and health care related issues, overseeing the distribution of federal and state resources, planning, analyzing and evaluating the provision of Medicaid services for eligible Missourians, and final review of the budget. In Missouri, “MO HealthNet” can be described as “Medicaid,” “Title XIX,” or “medical assistance.”

1. Transformation. The Transformation program is a combination of initiatives with the goal of transforming Missouri’s Medicaid program. The initiatives are wide-ranging, and include operational improvements as well as larger more transformational changes.

(B) Finance. The Finance section is divided into the following units:

1. Budget, Financial Services, Rate Development, and Premium Collections.

A. Budget. This unit is responsible for developing and tracking the division’s annual budget request and subsequent appropriations. The unit is responsible for preparation of quarterly estimates and expenditure reports required by the Centers for Medicare & Medicaid Services (CMS). During the legislative session, the unit is also responsible for reviewing all bills affecting the division, preparing fiscal notes, and attending hearings as assigned.

B. Financial Services. This unit is responsible for managing the financial procedures and reporting of the Medicaid claims processing system, creating expenditure reports for management and budget purposes, coordinating the production and mailing of provider remittance advices, checks and automatic deposits, and reviewing and approving provider 1099 information. The unit is also responsible for processing adjustments to Medicaid claims, receiving and depositing payments, and managing provider account receivables.

C. Rate Development. This unit is responsible for developing the capitation rates for the Medicaid Managed Care Program, the Nonemergency Medical Transportation Program, and the Program of All-Inclusive Care for the Elderly (PACE). The group works closely with the contracted actuary in evaluating Medicaid fee-for-service expenditures to determine the financial impact of implementing policy alternatives and evaluating the cost effectiveness of Managed Care and PACE;

D. Premium Collections. This group is responsible for managing the lock box, automatic withdrawals, and cash deposits for the State Children’s Health Insurance Program premium cases and spenddown pay-in cases. The group manages the financial procedures and reporting for these programs in the state’s computer system and in the electronic Medicaid Management Information System (eMMIS) to ensure the collection accurately establishes the Medicaid eligibility record and to ensure that client notices are accurate and timely;

2. Institutional Reimbursement. This unit is divided into the following groups:

A. Federally Qualified Health Center (FQHC) and Independent Rural Health Clinic (IRHC) Reimbursements.

This group is responsible for the audit of the FQHC and IRHC cost reports including the calculation of final settlements relating to those cost reports and the review and processing of Managed Care Supplemental Interim Payments for FQHCs and IRHCs. The group is also responsible for the administration of state regulations, state plan amendments, and responses to inquiries regarding reimbursement issues relative to these programs; and B. Nursing Home Policy and Reimbursement. This group is responsible for determining and carrying out the policy and reimbursement functions of the MO HealthNet nursing facility program and the Nursing Facility Reimbursement Allowance (NFRA) provider tax program. The nursing facility duties include overseeing audits of nursing facility cost reports, determining reimbursement rates, analyzing nursing facility data, determining and establishing reimbursement methodologies, and overseeing the preparation of the nursing facility Upper Payment Limit (UPL) demonstration. The NFRA duties include determining and collecting the NFRA, preparing various NFRA reports, and reconciling the NFRA fund balance. The group is also responsible for the review and analysis of proposed bills and preparation of fiscal notes, the administration of state regulations and state plan amendments, representing the division in litigation, and responding to inquiries regarding nursing facility reimbursement and NFRA issues. The group oversees and monitors contractors to ensure nursing facility cost report audits and the nursing facility UPL demonstration are completed in a timely manner and in accordance with state and federal rules. The group works closely with the contractors in developing audit plans, evaluating nursing facility reimbursement issues, collecting and preparing data for the UPL demonstration, and implementing any changes to these processes;

3. Hospital Reimbursement Unit. This unit is divided into the following groups:

A. Hospital Policy and Reimbursement. This group is responsible for determining and carrying out the policy and reimbursement function of the MO HealthNet program for hospitals. This includes the day-to-day activities of hospital reimbursement such as overseeing the hospital cost report audits, overseeing the Disproportionate Share Hospital (DSH) audits, calculating hospital per diem rates, updating the hospital per diem rates in the eMMIS, calculating hospital payments (i.e., supplemental payments, DSH payments, and Graduate Medical Education (GME) payments), calculating Federal Reimbursement Allowance (FRA) hospital provider tax, processing the hospital payments and tax each financial cycle, providing litigation support, conducting FRA program tracking, and handling hospital rate adjustment requests.

The group is also responsible for the administration of state regulations, state plan amendments, and responses to inquiries regarding hospital reimbursement issues; and B. Children’s Outliers and Provider Based Rural Health Clinic (PBRHC) Reimbursements and Settlements. This group is responsible for calculating children’s outlier payments for hospitals, calculating the PBRHC reimbursement rate, updating the PBRHC reimbursement payment rate in eMMIS, and calculating and processing the final settlements for PBRHCs. The group is also responsible for the administration of state regulations, state plan amendments, and responses to inquiries regarding reimbursement and settlement issues; and 4. The Cost Containment and Audit Compliance unit is divided into the following groups: Medicare Savings Program, Recoveries, and Pharmacy Rebate.

A. Medicare Savings Program: This group is responsible for ensuring that Medicare funds are utilized whenever possible in providing medical services to Medicaid clients. This is accomplished by the identification of those recipients who are, or who might be, Medicare eligible, the recovery of funds paid as Medicaid services for these clients, and the administration of Medicare Part A and B premiums.

B. Recoveries: This group ensures that all potential, legally liable payers of medical services pay up to their liability to offset Medicaid expenditures. This is accomplished through cost avoidance and post-payment recovery (pay-and-chase or cash recovery).

(I) Cost avoidance occurs when the group receives information that a third-party payer is responsible for payment prior to Medicaid payment. The Third Party Liability (TPL) unit verifies commercial health insurance after receiving the information from multiple sources. The insurance data is entered into participant eligibility files, which are connected to the Medicaid claims payment processing system, and serve as a source of editing to determine claim payment or denial.

Cost avoidance also occurs through the Health Insurance Premium Payment (HIPP) program. If a participant has access to employer-sponsored health insurance, Medicaid will purchase the commercial health insurance if it is determined to be cost effective.

(II) Post-payment recovery occurs when the unit determines that a third-party payer is potentially responsible for payment when a participant receives medical services. Data matches and the Medicaid claims processing system determine potential recovery sources. TPL personnel are responsible for the following recovery activities: burial plans, personal funds, estates, and trauma (includes personal injury, product liability, malpractice, traffic accidents, worker’s compensation, and wrongful death). A contractor is primarily responsible for recovery of commercial health insurance payments.

(III) These activities ensure that Medicaid funds are used only after all other potential resources available to pay have been exhausted.

C. Pharmacy Rebate: This group is responsible for the collection of rebates from pharmaceutical manufacturers contracted with CMS to participate in the Medicaid Drug Rebate Program, and for collection of supplemental rebates from manufacturers participating in the state’s Supplemental Rebate Program. The group invoices manufacturers quarterly for products dispensed during the period. As payments are received, disputes are identified and the unit researches any product disputed by the manufacturer. Disputes are resolved with the manufacturer to collect the greatest rebate possible.

This unit is also responsible for collecting rebates for the Missouri Rx Program.

(C) Information Services. This section is responsible for managing the operations, development, and implementation of the information system that the division uses to administer MO HealthNet programs. This includes the various components of the eMMIS which are hosted, developed, operated, and maintained by multiple information technology vendors and multiple vendor systems and services related to health information exchange. The Information Services Unit is also responsible for managing quality, integrity, and use of the MO HealthNet program data. The information services unit is also responsible for securing enhanced federal funding related to allowable system implementation and operation costs. The Information Services section is divided into the following units: Project Management Office, Business Systems, Data Management Office, Information Services Funding, and Health Information Technology Programs.

1. Project Management Office. This unit is responsible for managing procurement and implementation of the more advanced modifications to the eMMIS and of new eMMIS solutions. The implementation of a replacement enterprise data warehouse and business intelligence solutions is an example of a new eMMIS solution. The unit ensures that a structured approach is used so as not to disrupt the automated Medicaid claims processing and the information retrieval system currently in place.

2. Business Systems. This unit is responsible for oversight and monitoring of the operations of the eMMIS and management of the contracts with the information technology vendors responsible for hosting, developing, operating and maintaining the eMMIS systems. The unit is responsible for maintaining the claims processing system by reviewing claims payment issues, establishing corrective action plans, and designating specific tasks to the system vendors.

3. Data Management Office. This unit is responsible for managing the quality of the data contained in the enterprise data warehouse and establishing governance over the MO HealthNet data by determining information ownership, establishing data standard option processes, establishing and enforcing data integrity, and managing the data architecture and usage. This unit is also responsible for managing all data requests and data reporting and analysis.

4. Information Services Funding. This unit is responsible for creating and managing requests for federal funding related to eMMIS system operations, enhancements, and implementations, and maximizing federal participation in system costs.

This unit is also responsible for processing invoices received from information technology vendors, ensuring the invoices are coded to the correct federal funding request, and tracking the budget to actual system costs.

5. Health Information Technology Programs. This unit is responsible for managing all federal programs and projects related to Health Information Technology and Health Information Exchange. This unit is also responsible for managing contracts with health information networks providing health information exchange services for MO HealthNet.

(D) Operations. The Operations section is divided into the following units: Home and Community-Based, School-Based, and Waiver Services; Medical Programs and Policy; and Managed Care, Constituent Services, and the Program of All- Inclusive Care for the Elderly (PACE).

1. Home and Community-Based, School-Based, and Waiver Services: This unit has the following three (3) groups:

A. Home and Community-Based In-Home Services Group. This group works closely with the Department of Health and Senior Services (DHSS) and CMS regarding several Home and Community-Based Services (HCBS) 1915(c) waivers and state plan programs to ensure state and federal requirements are met. This group develops, amends, and renews HCBS waiver applications, and performs quality oversight activities, analysis, and reporting for those programs. This group is also responsible for administration of state regulations and state plan amendments, along with research, program development, policy implementation, and program communications;

B. Home and Community-Based and School-Based Services Group. This group works closely with the Department of Mental Health (DMH) and CMS regarding several HCBS 1915(c) waivers and state plan programs to ensure state and federal requirements are met. The group develops, amends, and renews HCBS waiver applications, and performs quality oversight activities, analysis, and reporting for those programs. This group is responsible for coordination of state plan amendments, policy implementation, and regulations drafted to reflect program changes. In addition, this group administers the School-Based Service programs including invoice processing, program compliance activities, federal reporting, and contract oversight;

C. Show Me Home Group: The Show Me Home program was designed to reduce reliance on Skilled Nursing Facilities (SNF) and Intermediate Care Facilities (ICF/MR) for individuals who are aged or those who have a disability, while providing resources for individuals wishing to transition to a quality community-based long-term care setting. The Show Me Home group works closely with DHSS, DMH, and CMS to ensure that federal Show Me Home program requirements are met. This group is responsible for oversight and coordination of Show Me Home program implementation across the three (3) state agencies, formulating a program budget each calendar year, evaluating the program on a semi-annual basis, marketing, and continually looking for best practices for improvement.

2. Medical Programs and Policy: This unit divides the responsibilities for MHD’s medical programs and their policies among three (3) areas dedicated to each’s assigned programs.

The first group focuses primarily on hospital providers; the second group focuses primarily on physicians, clinics, and hospice providers; and the third group focuses primarily on nursing facilities, durable medical equipment, and nonemergency medical transportation. Programs and policies regarding all other enrolled medical providers are also managed by one (1) of the three (3) groups.

A. The unit is responsible for research, analysis, development, implementation, and monitoring various benefit programs within the division, including the prior authorization process for approval of medically necessary items. Personnel in this unit also interact with advisory committees to obtain guidance regarding complicated health care issues, coordinate and assist in the development of training packages, write and revise program manuals and bulletins pertaining to program policy, procedure, and operations, and monitor and evaluate program effectiveness by tracking utilization patterns.

B. The unit is responsible for researching state and federal regulations, CMS directives and rulings, and reviewing Medicaid programs implemented by other states. The group analyzes data and legislation, coordinates special projects, and works with other state agencies and groups within the division to implement new Medicaid programs including the development of new manuals and procedures. The group also aids in the implementation of major changes to existing MHD programs. This unit is also responsible for policy implementation, program communication, oversight of contracts with outside vendors, certain clinical program enhancement activities, and implementation of those program enhancements. Documents such as state plan amendments and state regulations are drafted to reflect program changes.

C. This unit also researches and gathers information for program development and provides procedural support for systems changes and claims processing issues such as medical procedures and equipment prior authorization, and durable medical equipment special pricing. The unit serves as the liaison with eMMIS and other units within the division to facilitate program enhancement activities.

3. Managed Care, Constituent Services, and PACE.

A. Managed Care. Managed Care is responsible for administration of the Managed Care Program, which operates under a 1915(b) Freedom of Choice Waiver. This program provides Medicaid Managed Care services to participants in four (4) broad groups: Medical Assistance for Families, Medicaid for Children, Medicaid for Pregnant Women, and children in state custody. This group is also responsible for developing new policies and procedures for the Managed Care Program. This unit is divided into the following groups:

Managed Care Policy, Contract Development, and Compliance; and Quality Assessment.

(I) Managed Care Policy, Contract Development, and Compliance. This group is responsible for monitoring contracts.

Personnel monitor the Managed Care and the Beneficiary Support System contracts to ensure providers are adhering to the terms and conditions of their agreements. The group ensures that the Managed Care Organizations (MCOs) adhere to service access guidelines, verify provider networks, and handle complaints against MCOs. The group also works with the Department of Commerce and Insurance to assure MCOs are in compliance with state insurance rules and regulations.

Premium collections is also a responsibility of this group. The group is responsible for answering phones and correspondence regarding the State Children’s Health Insurance Program (CHIP) and Ticket-to-Work Health Assurance (TTWHA) program premium cases as well as spend-down pay-in cases, answering questions regarding program rules, and receipt of payments.

(II) Quality Assessment. This group performs research and data analysis to address monitoring and oversight requirements established by the CMS. The group utilizes a collaborative process to develop and implement strategies to improve the health status of Medicaid participants. This process entails coordination with advisory groups, other state agencies, managed care organizations, external quality review organizations, providers, and the public. The group is also responsible for researching, assessing, evaluating, and reporting information regarding the quality of care provided to Managed Care members.

B. Education and Training. This group is responsible for training and educating providers, participants, division personnel, and outside entities regarding the division’s policies and procedures. The group also assists providers with the submission of Medicaid claims through provider training sessions. Additionally, this group assists with outreach to members and oversees a member forum for input.

(I) Provider Communication. This group is responsible for responding to provider inquiries and concerns. Much of this communication is handled via a provider hotline. Written responses to provider inquiries are also handled by this group.

The group explains difficult and complex Medicaid rules, regulations, policies, and procedures to providers.

C. Constituent Services. This group aids the fiscal agent’s Participant Services Unit by acting as liaison with other groups within the division and handling more complex inquiries from participants. The division maintains a toll-free hotline for participants and is responsible for the Medicaid Participant Reimbursement program and handles all prior authorizations of out-of-state services. This group also handles requests for appeals from MHD participants who have had adverse actions regarding service denials or closures.

D. PACE. This group is responsible for the implementation and oversight of the PACE program. The group is responsible for coordinating PACE, developing state regulations, facilitating audits and focused reviews, and reviewing participant eligibility and enrollment. The group maintains regular communications with PACE organizations and works with the Missouri Medicaid Audit and Compliance Unit (MMAC) on program integrity.

(E) Clinical Review, Development, and Performance: This

section includes the offices of the Medical Director and Assistant Medical Director, and Registered Nurse Specialists;

Durable Medical Equipment Review and Approval; Medical Program Development, Support, and Evaluation; Exceptions Management and Review; Primary Care Health Home Management; the Quality Program; the Behavioral Health Program; and the Pharmacy Program.

1. Medical Director, Assistant Medical Director, and Registered Nurse Specialists. The Medical Director oversees the unit, approves decisions, reviews medical documentation for clinical accuracy and appropriateness, participates in state fair hearings, and reviews transplant requests and prior authorization requests.

2. Medical Program Development, Support, and Evaluation.

The unit provides support for both the Fee-for-Service and Managed Care programs, including the PACE program, and provides recommendations to develop evidence-based clinical guidelines to advance quality in the programs. The unit assists contractors with their medical reviews and decision-making when necessary, and reviews individual medical decisions that have been referred for state fair hearings. The unit also provides responses to legislative and other external inquiries and provides medical subject-matter support to MHD personnel.

A. Subject-matter support for the Fee-for-Service program includes, but is not limited to, determining medical necessity of requested equipment or services, making program recommendations that follow best practices and evidence-based approaches, and providing guidance regarding federal and state program requirements.

B. Subject-matter support for the Managed Care program includes, but is not limited to, determining medical necessity of requested equipment or services, making program recommendations that follow best practices and evidence-based approaches, providing guidance regarding federal and state program requirements, reviewing clinical information related to quality outcomes, reviewing the health plans’ care management programs, reviewing claims and benefit denials as needed, and coordinating with other state agencies regarding shared population health mandates.

3. Exceptions Management and Review. An administrative exception may be made on a case-by-case basis to limitations and restrictions. The unit provides oversight of these reviews which may be of a routine or an emergency nature.

4. Primary Care Health Home Management. The unit is responsible for oversight of all aspects of this program including internal systems, program expansion, collaboration with the managed care unit and the contracted health plans, data collection, and analysis.

5. Durable Medical Equipment (DME) Review and Approval.

This group evaluates all requests and has a call center for DME, optical, and alternative therapies for pain management and approves or denies these requests. It also responds to inquiries from providers, medical consultants, and public officials related to MHD policies and procedures. It also evaluates possible program abuse, suspected fraud, dual services, and helps to improve program efficiency.

6. Quality Program. This group is responsible for a variety of data analyses relating to various grants and initiatives throughout MHD, including those related to Health Home, women and infant health, and asthma. Annual and quarterly quality data from the Managed Care Organizations are processed by this group, which also produces a series of reports and graphs from that data, and it also prepares and disseminates reports for distribution to the MCOs regarding immunizations, members with special needs, lead screenings, etc.

Annual CMS Core Set measures are calculated and reported by this group. It also responds to numerous ad hoc data requests throughout the year from administrators, managers, the legislature, and assorted outside interests.

7. Behavioral Health Program. This group is responsible for overseeing the purchase and delivery of behavioral health services on behalf of MHD fee-for-service and managed care participants. It is responsible for research, analysis, development, implementation, and monitoring of behavioral health services covered by MHD, including the precertification process for approval of individual, family, and group psychotherapy for feefor-service participants. This unit researches evidence-based and best practices to inform policy revision. Personnel in this unit participate in annual clinical reviews of managed care health plans and monitor compliance with mental health and substance use disorder parity standards. They also interact with community advisors for input on complex behavioral health care issues, coordinate and assist in the development of provider training, and provide clinical and policy consultation to other Department of Social Services (DSS) divisions and to other state agencies. This unit is responsible for provider bulletins and manuals as well as state plan amendments and state regulations related to behavioral health services changes.

This unit is responsible for providing clinical input regarding behavioral health conditions and services as related to various MHD and managed care initiatives. It is responsible for researching state and federal regulations, CMS directives and rulings, and other state Medicaid programs and services.

8. Pharmacy Program. The Pharmacy Program includes Pharmacy Operations, Pharmacy Reviews and Hearings, and the Pharmacy Clinical group.

A. Pharmacy Operations. The pharmacy operations group maintains the listing of payable drug products and management of the drug pricing methodology for the pharmacy department to ensure proper drug claim payment.

The group houses the pharmacy administration helpdesk which communicates with providers on issues processing drug claims, including drug pricing. Pharmacy Operations also processes pharmacy provider bulletins, hot tips, regulations, provider manuals, and state plan amendments. In addition, the unit reviews requests for compounded prescriptions, medically necessary over-the-counter drugs, non-reference diabetic supplies, and medication requests for participants enrolled in hospice to determine whether the medication is related to the terminal illness.

B. Pharmacy Reviews and Hearings. The unit provides clinical review for pharmacy prior authorizations when necessary and utilizes physician consultants when additional clinical review or peer-to-peer consultation is needed or requested.

C. Pharmacy Clinical Group. This group operates a tollfree hotline for providers to request overrides on drug products with restricted access due to clinical or fiscal edits and prior authorization. The hotline staff in this unit process requests for drug products which have been denied through the usual claims processing system.

(I) The group is responsible for the implementation and maintenance of clinical pharmacy cost saving initiatives.

This unit is responsible for the review, implementation, and maintenance of the Preferred Drug List (PDL) and all clinical and fiscal edits. It also oversees the prior authorization of all new drug products and monitoring of the drug pipeline.

All clinical drug information and pharmacoeconomic evidence-based reviews are organized for presentation to the Drug Use Review Board (DUR). Online point-of-sale clinical edits are established to assure cost effective and appropriate drug usage.

(II) Internal clinical management for fee-for-service patients is performed, including identification and monitoring of drug regimens outside normal parameters, and working with patients’ healthcare providers to reach desired outcomes.

D. Missouri Rx Plan. This group is responsible for the ongoing operations of the Missouri Rx Plan, which pays fifty percent (50%) of the member’s out-of-pocket cost for prescription drugs covered by the Medicare Prescription Drug Program and by the member’s Medicare Part D Plan formulary for dual eligible participants.

rule was previously filed as 13 CSR 40-81.005. Emergency rule filed Sept. 15, 1987, effective Sept. 28, 1987, expired Jan. 25, 1988.

Original rule filed Oct. 1, 1987, effective Jan. 29, 1988. Amended:

Filed July 2, 1992, effective Feb. 26, 1993. Amended: Filed April 14, 2006, effective Oct. 30, 2006. Amended: Filed Aug. 23, 2021, effective March 30, 2022. Amended: Filed June 17, 2024, effective Dec. 30, 2024. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. This

13 CSR 70-1.020 Standards for Privacy of Individually Identifiable Health Information {#sec-13-csr-70-1.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-1.020}

PURPOSE: The state of Missouri, Department of Social Services, MO HealthNet Division, is committed to protecting the confidentiality of protected health information of applicants and participants of the Medical Assistance MO HealthNet Program. This

rule describes how health care information about MO HealthNet applicants and participants may be used and disclosed and how MO HealthNet participants can get access to their personal health information.

(1) General Authority. There are many state and federal laws and regulations that safe guard applicants’ and participants’ protected health information.

(A) Section 1902(a)(7) of the federal Social Security Act requires that a state plan for medical assistance must provide safeguards which restrict the use or disclo sure of information concerning applicants and participants to purposes directly connected with the administration of the plan.

(B) The Health Insurance Portability and Accountabil ity Act (HIPAA) represents the first compre hensive federal protection of patient privacy (45 Code of Federal Regulations, parts 160- 164). Passed by the United States Congress in 1996, HIPAA sets national standards to protect personal health information, reduces health care fraud, and makes health coverage more portable. The entire health care industry must implement HIPAA, including state governments.

(C) The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. Subtitle D of the HITECH Act, Sections 13400-13424 of Public Law 111-5, codified at 42 U.S.C. 300jj et seq.; 17901 et seq., addresses the privacy and security concerns associated with the electronic transmission of health information, in part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules. The U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) issued a final rule that implements a number of provisions of the HITECH Act, to strengthen the privacy and security protections for health information established under the HIPAA for individual’s health information maintained in electronic health records and other formats at 45 CFR Parts 160 and 164, Vol. 78, No. 17.

(2) Definitions.

(A) Breach. The unauthorized acquisition, access, use, or disclosure of Protected Health Information which compromises the security or privacy of such information, except as provided in 42 U.S.C. section 17921.

(B) Business Associate. An individual or business who carries out a function or activity, involving the use or disclosure of individually identifiable health information, on behalf of the Department of Social Services and its divisions.

(C) Covered Entity. A health plan, a healthcare clearinghouse, and a healthcare provider who transmits any health information in electronic form in connection with a covered transaction. The Department of Social Services is a Health Plan, as defined in HIPAA.

(D) Health Information Network. A group of hospitals and medical professionals, and its related infrastructure, who have an agreement to exchange protected health information as defined by HIPAA.

(E) Health Information Technology for Economic and Clinical Health (HITECH) Act. Subtitle D of the HITECH Act, addresses privacy and security concerns associated with the electronic transmission of health information, in part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules, including business associate liability, enforcement, and breach notification.

(F) Health Insurance Portability and Accountability Act of 1996 (HIPAA). This law established “portability” requirements, allowing employees to “take their coverage with them” when they changed jobs. The “Administrative Simplification” section of the law deals with privacy, security of health care information, and standardized formats for electronic health care transactions (such as submission of health care claims).

(G) MO HealthNet. In Missouri, the medical assistance program on behalf of needy persons, Title XIX, Public Law 89- 97, 1965 amendments to the federal Social Security Act, 42 U.S.C. Section 301, et seq., shall be known as “MO HealthNet.”

Medicaid shall also mean “MO HealthNet” whenever it appears throughout Missouri Revised Statues.

(H) Protected Health Information. A term established under the HIPAA privacy rules, it refers to individually identifiable health information, in whatever medium it is trans mitted or maintained (e.g., paper, electronic, or even oral), including demographic infor mation, that is created or received by a health care provider, health plan, employer, or health care clearinghouse, and that relates to the past, present, or future physical or men tal health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.

(I) Treatment, Payment, and Health Care Operations (TPO) includes all of the following:

1. Treatment means the provision, coor dination, or management of health care and related services, consultation between providers relating to an individual, referral of an individual to another provider for health care, and the necessary sharing of information through a health information network for treatment purposes.

2. Payment means activities undertaken by a health plan to obtain premiums or determine/fulfill responsibility for coverage or provision of benefits, or by a provider or health plan to obtain or provide reimburse ment for health care, including determinations of eligibility or coverage, billing, collections activities, medical necessity determinations, and utilization review.

3. Health care operations includes func tions such as quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, case management and care coordination, reviewing competence or qualifications of health care professionals, conducting training programs, licensing and credentialing activities, under writing, premium rating, conducting or arranging for medical review, legal services and auditing functions, business planning and development, and general business and administrative activities (including activities relating to the sale, transfer, or merger of the covered entity).

(3) Disclosures of Protected Health Information Required or Allowed by Law.

(A) The Depart ment of Social Services, the single state MO HealthNet agency, and its divisions, may use an applicant’s or participant’s individually identifi able health information for treatment, pay ment, or health care operations. For example, individually identifiable health information may be used to determine disability for a pub lic assistance program; when reviewing a request from the treating physician for a MO HealthNet service that requires a prior approval; when sharing information through a health information network for treatment purposes; and when processing claims and other requests for medical care payments. The Department of Social Services, MO HealthNet Division may also report informa tion for research purposes and matters con cerning organ donations. The research must be for helping the MO HealthNet program.

(B) The Department of Social Services, MO HealthNet Division shall provide information— 1. To public health authorities to report contagious and reportable diseases, including, but not limited to, those defined by 19 CSR 20-20.020, birth defects, cancer, or other information for public health purposes;

2. Reporting of certain types of wounds or other physical injuries;

3. Regarding reactions to problems with medicines;

4. To the police when required by law;

5. For court and administrative proceedings, when ordered;

6. To health oversight authorities to review how Department of Social Services programs are working;

7. To a provider or other insurance company who needs to know if a participant is enrolled in one of the Department of Social Services programs;

8. To Workers’ Compensation for work related injuries;

9. Birth, death, and immunization infor mation;

10. To the federal government to protect our country, the president, and other government workers;

11. When reporting information about victims of abuse, neglect, or domestic violence to a government authority to the extent the disclosure is required by law;

12. For Medical eligibility when that information is used for a governmental function, such as local public health agency using eligibility information to determine eligibility for local health programs;

13. To funeral directors, coroners, or medical examiners; and 14. To another government agency administering a government program providing public benefits if the programs serve the same or similar populations and the disclosure of protected health information is necessary to coordinate the covered functions of such programs or to improve administration and management relating to the covered functions of such programs.

(4) Disclosure of Protected Health Information to Business Associates and Other Covered Entities. The Department of Social Services, and its divisions, may disclose, at its discretion, a participant’s protected health information to designated business associates in accordance with and as authorized by HIPAA, as amended by the HITECH Act, and all regulations promulgated pursuant to authority granted therein. Examples of how a participant’s protected health information may be disclosed, include, but are not limited to:

(A) Treatment of a Participant. Includes activities such as, providing, coordinating, or managing health care delivery and related services; consultation between providers relating to a participant; referral of a participant to another provider for health care; and necessary sharing of information through a health information network for treatment purposes;

(B) Payment. Payment activities may include obtaining premiums or determining/fulfilling responsibility for coverage or provision of benefits by a provider or health plan to obtain or provide reimbursement for health care; providing reimbursement for health care services provided to the participant, which may include eligibility determinations, medical necessity or appropriateness; utilization management activities; claims management; billing; and collection activities; and (C) Health Care Operations. Includes functions such as quality assessment and improvement activities; population-based activities relating to improving health or reducing health care costs; protocol development; wellness and risk assessments; quality assessments and improvement, case management and care coordination; contacting of health care providers and patients with information about treatment alternatives; conducting training programs; licensing and credentialing activities; underwriting, premium rating, conducting or arranging for medical review; legal services and auditing functions; business planning and development; customer service; and general business and administrative activities (including activities relating to the sale, transfer, or merger of the covered entity).

(5) Restrictions of Allowable Disclosures by a Participant. In accordance with HIPAA, a participant may request Department of Social Services to restrict allowable disclosures of the participant’s protected health information. Such requests must be made in writing to the Department of Social Services Privacy Officer. The Department of Social Services Privacy Review Board shall consider the request and assess the impact on ensuring delivery of safe and quality health care to the participant, timely and accurate payment for services provided to the participant, and for the accurate review and audit of public funds used to provide health care to the participant. Decisions of the Department of Social Services Privacy Review Board may be appealed to the Department of Social Services Director for affirmation or reversal.

(6) Protected Health Information Available Through Health Information Networks. Protected health information may be made available for the treatment of a participant, review of health care services for payment of medical expenses, and health care operations, including case management and care coordination for a participant, upon request from authorized business associates through a health information network or by other electronic means provided directly by the department, if such disclosures are made in accordance with HIPAA and for the purposes stated herein.

(7) Other Uses and Disclosures Require the Applicant’s or Participant’s Written Autho rization. For other situations, the Department of Social Services will ask for the applicant’s, or participant’s, or their representative’s writ ten authorization before using or disclosing information. The applicant, or participant, or their representative may cancel this authorization at any time in writing. The Department of Social Services cannot take back any uses or disclosures already made with the applicant’s, or participant’s, or their representative’s authorization.

(8) Applicant or Participant Rights to Restrict or Request Protected Health Information. An applicant, or participant, or their representa tive has the right to— (A) Receive private information from the Department of Social Services by other means or at another place;

(B) Have their doctor see their health infor mation, unless it is psychotherapy notes taken by a mental health provider that are kept sep arate from the rest of the individual’s medical record;

(C) Request a change of their medical information if they think some of the information is wrong; and (D) Request a list of medical information the Department of Social Services shared that was not for treatment, payment, or health care operations or as required by federal law. An applicant, or par ticipant, or their representative can get a list of where their health information has been sent, unless it was sent for treatment, payment, health care operations; such as checking to make sure they received quality care, or to make sure the laws are being followed, on forms prepared by the Department of Social Services.

1. If the individual requests a copy of the protected health information or agrees to a summary or explanation of such informa tion, the covered entity may impose a reason able, cost-based fee, provided that the fee includes only the cost of— A. Copying, including the cost of supplies for and labor of copying, the protected health information requested by the individual;

B. Postage, when the individual has requested the copy, or summary or explana tion, be mailed;

C. Preparing an explanation or sum mary of the protected health information; and D. Requests for information in other formats such as compact disks (CDs) or flash drives, will be invoiced at the rate the agency actually paid for the format used.

Filed Oct. 12, 2007, effective April 30, 2008. Amended: Filed March 12, 2014, effective Oct. 30, 2014. *Original authority: 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: sections 208.001 and 208.201, RSMo Supp. 2013. Original rule filed Feb. 3, 2003, effective Sept. 30, 2003. Amended:

Chapter 2 General Scope of Medical Service Coverage

13 CSR 70-2.020 Scope of Medical Services for General Relief Recipients 13 CSR 70-2.100 {#sec-13-csr-70-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-2.020}

13 CSR 70-2.200 MO HealthNet Program Benefits for Human Organ and Bone Coverage {#sec-13-csr-70-2.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-2.200}

13 CSR 70-2.020 Scope of Medical Services for General Relief Recipients {#sec-13-csr-70-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-2.020}

(Rescinded December 30, 2005)

History

• AUTHORITY: section 207.020, RSMo 1986. This rule was previously filed as 13 CSR 40-81.181. Emergency rule filed July 15, 1981, effective Aug. 1, 1981, expired Oct. 10, 1981. Original rule filed July 15, 1981, effective Oct. 11, 1981. Amended: Filed April 17, 1987, effective Sept. 11, 1987. Emergency rescission filed June 7, 2005, effective July 1, 2005, expired Dec. 27, 2005. Rescinded: Filed June 15, 2005, effective Dec. 30, 2005.

13 CSR 70-2.100 Title XIX Procedure of Exception to Medical Care Services Limitations {#sec-13-csr-70-2.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-2.100}

PURPOSE: This rule establishes the basis, procedure, and criteria where the state Medicaid agency may grant an exception to benefit limitations otherwise imposed by the state’s Medicaid program.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) Under the requirements of this rule, the MO HealthNet Division (MHD) may approve and authorize payment for the provision to a Medicaid-eligible recipient of an essential medical service or item that would otherwise exceed the benefit limitations of the medical assistance program. An administrative exception may be made on a case-by-case basis to limitations and restrictions. The director of the MHD will have the final authority to approve payment on a request made to the exception process. These decisions will be made with appropriate medical or pharmaceutical advice and consultation.

(2) Requirements for consideration and provision of a service as an exception to the normal limitations of Medicaid coverage are as follows:

(A) A physician, resident, intern, extern, nurse clinician, nurse practitioner, or registered nurse (RN) acting on the behalf of the physician must certify that medical treatment or items of service which are covered under the Medicaid Program and which, under accepted standards of medical practice, are indicated as appropriate to the treatment of the illness or condition, have been used and found to be medically ineffective in the treatment of the recipient for whom the exception is being requested, or inappropriate for that specific recipient;

(B) All third-party resource benefits must be exhausted before the MO HealthNet program will pay for any treatment or service;

(C) Any drug requested has been approved by the Food and Drug Administration (FDA) and is being prescribed for an FDAapproved indication and route of administration or medical literature must exist justifying the effectiveness of the drug or that specific diagnosis or for that specific route of administration;

(D) Any medical, surgical, or diagnostic service requested which is provided by a physician must be listed in the most recent publication of the CPT Professional Edition code book, which is incorporated by reference and made a part of this

rule as published by The American Medical Association (AMA), 330 North Wabash, Chicago, Illinois 60611, October 25, 2024.

This rule does not incorporate any subsequent amendments or additions;

(E) Any individual for whom an exception request is made must be eligible for MO HealthNet coverage on the date(s) the item or services are provided, or in the case of retroactive eligibility, approval can be granted if requested;

(F) The provider of the service must be an enrolled provider in the MO HealthNet program on the date(s) the item or services are provided;

(G) The item or services for which an exception is requested must be of a type and nature which falls within the broad scope of a medical discipline included in the MO HealthNet program and which does not represent a departure from the accepted standards and precepts of good medical practice;

(H) Requests must be made and approval granted before the requested item or services are provided, or not more than one (1) state working day following the provision of the service.

Retroactive approval of coverage may be granted in cases in which the recipient’s eligibility for MO HealthNet coverage is established;

(I) All requests for exception consideration must be initiated by the attending physician, the resident, intern, extern, nurse clinician, nurse practitioner, or RN acting in the physician’s behalf for an eligible recipient and must be submitted as prescribed in policy of the MHD;

(J) Requests for exception consideration, by whatever means received, must support and demonstrate that one (1) or more of the following conditions are met:

1. The item or service is required to sustain the recipient’s life;

2. The item or service would substantially improve the quality of life for a terminally ill patient;

3. The item or service is necessary as a replacement due to an act occasioned by violence of nature without human interference, such as a tornado or flood; or 4. The item or service is necessary to prevent a higher level of care;

(K) All exception requests must represent cost-effective utilization of MHD funds. When an exception item or service is presented as an alternative, lesser level-of-care than the level otherwise necessary, the exception must be less program costly; and (L) Reimbursement of services and items approved under this exception procedure shall be made in accordance with the MO HealthNet fee schedules or rates for the same or comparable services. For those services for which no MO HealthNet fee schedule or rate is applicable, reimbursement will be determined by the state agency considering costs and charges.

(3) Consideration under this rule shall not be applicable to requests for services under the following circumstances such as, but not limited to— (A) Services that would be provided by individuals whose specialty is not covered by the MO HealthNet program;

(B) Orthodontics;

(C) Inpatient hospital services;

(5/31/26) Denny Hoskins (D) Air transportation;

(E) Alternative services such as personal care, adult day health care, homemaker/chore, hospice, and respite care, regardless of authorization by the Department of Health and Senior Services;

(F) Waiver of MO HealthNet program requirements for documentation, applicable to services requiring a second surgical opinion, voluntary sterilization, hysterectomies, or legal abortions;

(G) Failure to obtain prior authorization as required for a service otherwise covered by MO HealthNet;

(H) Delivery or placement of custom-made items following the recipient’s death or loss of eligibility for the service;

(I) Previous denial by the MHD of a request for exception consideration where the current request fails to present information of significance in overcoming the deficiency upon which the original request was denied;

(J) Requests for additional reimbursement for items or services otherwise covered by the MO HealthNet program;

(K) MO HealthNet waiver services; and (L) Transplants.

Amended: Filed Oct. 2, 2006, effective April 30, 2007. Amended:

Filed Aug. 28, 2018, effective April 30, 2019. Amended: Filed Dec. 16, 2025, effective June 30, 2026. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 207.020, 208.201, and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2025. This rule was previously filed as 13 CSR 40-81.195. Original rule filed May 15, 1987, effective Oct. 11, 1987. Amended: Filed June 4, 1990, effective Dec. 31, 1990.

13 CSR 70-2.200 MO HealthNet Program Benefits for Human Organ and Bone Marrow/Stem Cell Transplants and Related Medical Services {#sec-13-csr-70-2.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-2.200}

PURPOSE: This rule establishes, via regulation, the Department of Social Services’/MO HealthNet Division’s guidelines regarding MO HealthNet coverage and reimbursement for human organ or bone marrow/stem cell transplants and related medical services.

These policies will be administered by the MO HealthNet Division with the assistance and guidance of its medical consultant and/or transplant consultants.

(1) Administration. Through its MO HealthNet program, the Department of Social Services (DSS)/MO HealthNet Division (MHD) will provide limited coverage and reimbursement for the transplantation of human organs or bone marrow/stem cell and the related medical services, including, but not necessarily limited to, treatment and necessary pre-transplant and post-operative care for the specific procedures defined here and as further defined by the DSS/MHD and included in the provider program manuals.

(A) The participant must be MO HealthNet-eligible on each date on which services are rendered.

(B) MO HealthNet shall be the payor of last resort and all other appropriate funding sources must be exhausted prior to obtaining MO HealthNet reimbursement.

(2) Conditions and Limitations.

(A) The procedures of transplantation and the related medical services must be prior authorized by DSS/MHD.

(B) MO HealthNet benefits may be provided for transplantation of the following:

1. Bone marrow/stem cell;

2. Heart;

3. Kidney;

4. Liver;

5. Lung;

6. Small bowel; and 7. Pancreas (in combination with or following a kidney transplant).

(C) Transplants which include multiple organs, at least one (1) of which is covered under subsection (2)(B), may be covered at the recommendation of the medical consultant and/or transplant consultants.

(D) Each request for coverage will be handled on a case-bycase basis. A separate Prior Authorization Request must be submitted for each individual participant and transplant.

(E) In order to be considered for approval, each proposed transplant case must meet all of the requirements of procedures and protocols specific to the service as defined by DSS/ MHD. These procedures and protocols will be developed with input by the MHD’s medical consultant and/or transplant consultants.

(F) Approved organ transplants can only be performed in a facility which submits documentation approved by MHD as complying with the following criteria:

1. The transplant facility must qualify for membership in the national transplantation network and must provide a copy of a current effective certification from the United Network for Organ Sharing (UNOS) granting approval to perform a specific transplant(s). The certification from UNOS will be considered appropriate verification and documentation for MHD transplant facility approval;

2. When the period for initial certification expires, the transplant facility must provide MHD evidence that continued approval from UNOS allowing participation to perform the transplant(s) has been granted;

3. Each type of MO HealthNet-covered organ transplant will be subject to separate UNOS certification for each type of organ transplant;

4. The transplant facility must notify MHD of each new transplant surgeon who becomes a member of the transplant team. The transplant surgeons must be current MO HealthNet enrolled providers;

5. The transplant facility must name the organ procurement organization (OPO) presently utilized by the facility. The transplant facility must furnish a copy of the notification from Centers for Medicare and Medicaid Services (CMS) which designates the facility’s OPO as an acceptable organ procurement source;

6. The transplant facility must provide MHD with a yearly report of the number of patients receiving transplants at the facility and the average charge for the inpatient transplant stay (by type of the transplant(s) performed) as defined by MHD in the provider program manual;

7. Those facilities seeking certification as a MO HealthNetapproved Kidney Transplant Center must furnish a copy of their current Medicare certification indicating active participation in the Medicare Renal Transplant Program; and 8. The facility must submit a copy of its Protocol for Transplantation Cases and Patient Selection Criteria for the type(s) of transplant(s) for which it is requesting transplant facility approval.

(G) Approved bone marrow/stem cell transplants can only be performed in a facility which submits documentation approved by MHD as complying with the following bone marrow/ stem cell transplant facility criteria. An autologous only transplant facility must meet criteria items one through ten (1–10) of the following:

1. A physician(s) with expertise in pediatric and/or adult bone marrow/stem cell transplantation, hematology, and oncology;

2. Identified nursing unit with protective isolation unit for bone marrow/stem cell transplantation;

3. Blood bank with Pheresis capability and the capability to supply required blood products or association with a qualified blood bank;

4. Physicians with expertise in infectious disease, immunology, pathology, and pulmonary medicine;

5. Capability of providing cardiac/respiratory intensive care and renal dialysis;

6. Performance of at least thirteen (13) bone marrow/stem cell transplants a year or demonstrated an ability to care for prolonged marrow failure by treating twenty (20) adult or ten (10) pediatric marrow failure patients per year;

7. Capability for marrow cryopreservation and purging techniques or affiliation with a facility which has these capabilities;

8. Capability to provide psychosocial support to patients and their families;

9. Close affiliation with academically based institutions to insure that all components of comprehensive care for patients undergoing bone marrow/stem cell transplantation are present in the facility. The mere presence or availability of the components one through eight (1–8) is not adequate. The facility must demonstrate that a coordinated bone marrow/stem cell transplantation program is in place and directed by a physician trained in an institution with a well established bone marrow/ stem cell transplantation program;

10. The facility must submit a copy of its Protocol for Transplantation Cases and Patient Selection Criteria for the type of bone marrow/stem cell transplants to be performed at the facility. Once approved as a facility each new type of bone marrow/stem cell transplant or diagnosis added for treatment by the facility must be documented by submitting the new protocol and patient selection criteria;

11. Physicians with expertise in infectious disease, immunology, pathology (of Graft vs. Host Disease), and pulmonary medicine;

12. Tissue typing laboratory with capability to perform typing for HLA-A, B, C, D/DR, and MLC;

13. Cytogenetic laboratory; and 14. Adequate laboratory facility to assay drug levels including Cyclosporine A.

(H) All providers of transplantation and related services must sign a MO HealthNet Provider Participation Agreement in order to receive reimbursement.

(I) In the case of a medical emergency, submittal of the required facility documentation may be waived for a period of ninety (90) days. During that period, the facility must submit the appropriate documentation as described in subsections (2)

(F) or (2)(G) and (2)(J) and (3)(A)—and they shall be financially at risk regarding state approval for any transplant related services rendered prior to the approval of its application.

(J) The transplant facility or surgeon must submit medical documentation that verifies that the transplant candidate has met the facility’s Patient Selection Criteria documented by the facility’s Protocol for Transplantation Cases.

(K) All transportation and housing costs incurred in connection with transplant procedures will be treated as noncovered services.

(L) The transplant procedures and related services outlined previously will be reimbursable when they are performed/ provided by a qualified provider who participates in the MO HealthNet program. In cases involving procedures that are to be performed outside of Missouri, however, the MO HealthNet Division, at its discretion, may require an eligible client’s physician to file a statement indicating why the transplant procedure must be performed at an out-of-state facility.

(M) DSS/MHD will reimburse qualified providers for a presurgery assessment at established MO HealthNet reimbursement rates.

(3) Procedure.

(A) The physician or transplant facility must make a written request to DSS/MHD for coverage of the transplant. This request must include, at a minimum, the following information:

1. Patient’s full name;

2. Date of birth;

3. MO HealthNet ID or Social Security Number;

4. Synopsis of alternative treatments performed and results;

5. Diagnosis and prognosis;

6. Specific transplant type being requested;

7. Name of the selected transplant center. In cases involving out-of-state facilities, a statement from the patient’s physician explaining why the transplant procedure must be performed there. (Note: Those statements may be requested at the discretion of the MO HealthNet Division);

8. Medical records must be submitted which substantiate the patient’s diagnosis, as well as results of the facility’s completed transplant evaluation indicating that the patient meets the facility’s “Patient Selection Protocols;” and 9. Participant permanent residence; pertinent medical

history; availability of other medical or Medicare coverage (including ID number); correspondence from referring physician; consultation reports/letters; transplant evaluation forms; medical records and laboratory reports showing HIV status (within six (6) months of the request date); donor compatibility for bone marrow/stem cell transplants; and full psychiatric/social service evaluations with impression of participant’s ability to be an adequate transplant candidate (within six (6) months of request date).

(B) The request for transplantation will be reviewed by MHD and the transplant facility advised in writing of the decision.

An agreement will be issued on a case-by-case basis for approved transplants.

(4) Reimbursement.

(A) Facility.

1. Reasonable charges will be paid by the MO HealthNet Division up to a maximum cap amount for the type of transplant authorized as listed in the Transplant Provider Manual at http://manuals.momed.com/manuals/. The cap will cover the costs associated with the transplant for the patient’s hospitalization from the date of the transplant procedure until the date of discharge. These charges will include organ procurement, donor costs or both, inpatient surgery costs, and all postsurgical hospital costs as defined in the provider program manual.

A. Reimbursement for multiple organ transplants involving a transplant covered in subsection (2)(B), may not exceed the maximum of highest coverage for highest single transplant.

2. Payment for all other transplant-related medical services provided prior to the date of the transplant surgery or subsequent to the date of discharge will be made at established (5/31/26) Denny Hoskins MO HealthNet Division reimbursable rates, excluding the period and reimbursement set out in and otherwise subject to the limitations as defined in the appropriate provider program manuals.

(B) Physician. Payment for the physician’s services for the actual transplant surgery will be made at established MO HealthNet Division reimburseable rates.

Original rule filed April 2, 1986 effective June 28, 1986. Rescinded and readopted: Filed Jan. 17, 1990, effective April 26, 1990.

Emergency amendment filed July 25, 1991, effective Aug. 5, 1991, expired Dec. 2, 1991. Emergency amendment filed Sept. 27, 1991, effective Oct. 7, 1991, expired Feb. 3, 1992, Amended: Filed Oct. 9, 1991, effective April 9, 1992. Emergency amendment filed Jan. 17, 1992, effective Feb. 4, 1992, expired June 2, 1992. Amended: Filed March 12, 2014, effective Sept. 30, 2014. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012 and 208.201, RSMo 1987, 2007.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013. This rule was previously filed as 13 CSR 40-81.035. Emergency rule filed April 2, 1986, effective April 12, 1986, expired Oct. 10, 1986.

Chapter 3 Conditions of Provider Participation, Reimbursement and Procedure of General Applicability

13 CSR 70-3.030 Administrative Actions for Improperly Paid, False, or Fraudulent {#sec-13-csr-70-3.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.030}

13 CSR 70-3.035 Violations Attested to by the Department of Health and Senior {#sec-13-csr-70-3.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.035}

13 CSR 70-3.040 Duty of Medicaid Participating Hospitals and Other Vendors to Assist {#sec-13-csr-70-3.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.040}

13 CSR 70-3.050 Obtaining Information From Providers of Medical Services {#sec-13-csr-70-3.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.050}

13 CSR 70-3.060 Medicaid Program Payment of Claims for Medicare Part B Services {#sec-13-csr-70-3.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.060}

13 CSR 70-3.110 Second Opinion Requirement Before Nonemergency Elective Surgical {#sec-13-csr-70-3.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.110}

13 CSR 70-3.120 Limitations on Payment of Out-of-State Nonemergency Medical {#sec-13-csr-70-3.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.120}

13 CSR 70-3.130 Computation of Provider Overpayment by Statistical Sampling {#sec-13-csr-70-3.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.130}

13 CSR 70-3.160 Electronic Submission of MO HealthNet Claims and Electronic {#sec-13-csr-70-3.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.160}

13 CSR 70-3.170 Medicaid Managed Care Organization Reimbursement Allowance {#sec-13-csr-70-3.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.170}

13 CSR 70-3.260 Payment Policy for Asthma Education and In-Home Environmental {#sec-13-csr-70-3.260 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.260}

13 CSR 70-3.290 Home and Community-Based Services Waiver Setting {#sec-13-csr-70-3.290 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.290}

13 CSR 70-3.300 Complementary Health and Alternative Therapies for Chronic Pain Reimbursement, and Procedure of General Applicability {#sec-13-csr-70-3.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.300}

13 CSR 70-3.020 Title XIX Provider Enrollment {#sec-13-csr-70-3.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.020}

(Rescinded March 30, 2022)

Amended: Filed March 30, 2007, effective Oct. 30, 2007. Amended:

Filed June 1, 2010, effective Dec. 30, 2010. Rescinded: Filed Aug. 20, 2021, effective March 30, 2022.

History

• AUTHORITY: sections 208.159, 208.164, and 210.924, RSMo 2000 and sections 208.153 and 208.201, RSMo Supp. 2009. This rule was previously filed as 13 CSR 40-81.165. Original rule filed June 14, 1982, effective Sept. 11, 1982. Amended: Filed July 30, 2002, effective Feb. 28, 2003. Amended: Filed April 29, 2005, effective Oct. 30, 2005. Amended: Filed Nov. 1, 2005, effective June 30, 2006.

13 CSR 70-3.030 Administrative Actions for Improperly Paid, False, or Fraudulent Claims for MO HealthNet Services {#sec-13-csr-70-3.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.030}

PURPOSE: This rule establishes the basis on which certain claims for MO HealthNet services or merchandise will be determined to be improperly paid, false, or fraudulent and lists the administrative actions that may be imposed and the method of imposing those actions. publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration.

(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, at its website dss.mo.gov/mhd, July 20, 2022. This rule does not incorporate any subsequent amendments or additions.

(B) When a rule published in the Missouri Code of State Regulations relating to a specific provider type or service incorporates by reference a MO HealthNet provider manual which contains a later date of incorporation than 13 CSR 70- 3.030, the manual incorporated into the more specific rule shall be applied in place of the manual incorporated into 13 CSR 70- 3.030.

(2) The following definitions will be used in administering this

rule:

(A) “Adequate documentation” means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. “Adequate medical records” are records which are of the type and in a form from which symptoms, conditions, diagnosis, treatments, prognosis, and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty.

Not all documentation is considered a medical record. Certain services such as respite, and certain in-home services will not contain all the information that a medical record contains.

All documentation must be made available at the same site at which the service was rendered, unless the services were provided in the participant’s home, via a mobile unit, or other circumstance that would require the records be kept at an office location away from the delivery site. An adequate and complete patient record is a record which is legible, which is made contemporaneously with the delivery of the service, which addresses the patient/client specifics, which include, at a minimum, individualized statements that support the assessment or treatment encounter, and shall include documentation of the following information:

1. First name, last name, and either middle initial or date of birth of the MO HealthNet participant;

2. An accurate, complete, and legible description of each service(s) provided;

3. Name, title, and signature of the MO HealthNet-enrolled provider delivering the service. Inpatient hospital services must have signed and dated physician, physician assistant, nurse practitioner, or psychologist orders within the patient’s medical record for the admission and for services billed to MO HealthNet. For patients registered on hospital records as outpatient, the patient’s medical record must contain signed and dated physician orders for services billed to MO HealthNet.

Services provided by an individual under the direction or supervision are not reimbursed by MO HealthNet. Services provided by a person not enrolled with MO HealthNet are not reimbursed by MO HealthNet;

4. The name of the referring entity, when applicable;

5. The date of service (month/day/year);

6. For those MO HealthNet programs and services that are reimbursed according to the amount of time spent in delivering or rendering a service(s) (except for services American Medical Association Current Procedural Terminology (CPT) procedure codes 99291–99292 and targeted case management services administered through the Department of Mental Health and as specified under 13 CSR 70-91.010 Personal Care Program (4)(A)) the actual begin and end time taken to deliver the service (for example, 4:00–4:30 p.m.) or for Evaluation and Management (E/M) CPT procedures codes 99202-99215, the total time spent on the service must be documented;

7. The setting in which the service was rendered;

8. The plan of treatment, evaluation(s), test(s), findings, results, and prescription(s) as necessary. Where a hospital acts as an independent laboratory or independent radiology service for persons considered by the hospital as “nonhospital” patients, the hospital must have a written request or requisition slip ordering the tests or procedures;

9. The need for the service(s) in relationship to the MO HealthNet participant’s treatment plan;

10. The MO HealthNet participant’s progress toward the goals stated in the treatment plan (progress notes);

11. Long-term care facilities shall be exempt from the seventy-two- (72-) hour documentation requirements rules applying to paragraphs (2)(A)9. and (2)(A)10. However, applicable documentation should be contained and available in the entirety of the medical record;

12. For applicable programs, it is necessary to have adequate invoices, trip tickets/reports, activity log sheets, employee records (excluding health records), and training records of staff; and 13.

A complete patient record must include all aforementioned requirements unless a more specific provider

regulation applies;

(B) “Closed-end provider agreement” means an agreement that is for a specified period of time, not to exceed twenty-four (24) months, and that must be renewed in order for the provider to continue to participate in the MO HealthNet program;

(C) “Contemporaneous” or “Contemporaneously” means at the time the service was performed or within five (5) business days, of the time the service was provided;

(D) “Exclusion” means a penalty where items and services furnished, ordered, or prescribed by a specified individual or entity that will not be reimbursed under Medicare, Medicaid, and all other Federal health care programs until the individual or entity is reinstated by the Office of Inspector General and Missouri Medicaid Audit and Compliance Unit;

(E)

“Federal health care program” means a program as defined in section 1128B(f) of the Social Security Act;

(F) “Fiscal agent” means an organization under contract to the state MO HealthNet agency for providing any services in the administration of the MO HealthNet program;

(G) “MO HealthNet agency” or the “agency” or the “single state agency” means the Department of Social Services, which is the single state agency charged with administering or supervising the administration of the MO HealthNet (Medicaid) program in Missouri;

(H) “Open-end provider agreement” means an agreement that has no specific termination date and continues in force as long as it is agreeable to both parties;

(I) “Participation” means the ability and authority to provide services or merchandise to eligible MO HealthNet participants and to receive payment from the MO HealthNet program for those services or merchandise;

(J) “Person” means any natural person, company, firm, partnership, unincorporated association, corporation, or other legal entity;

(K) “Provider” means any person, partnership, corporation, not-for-profit corporation, professional corporation, or other business entity that enters into a contract or provider agreement with the department or its divisions for the purpose of providing services to eligible persons, and obtaining from the department or its divisions reimbursement pursuant to 208.164, RSMo;

(L) “Record” 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. MO HealthNet claim for payment information, appointment books, financial ledgers, financial journals, or any other kind of patient charge without corresponding adequate medical records do not constitute adequate documentation;

(M) “Supervision” means to direct an employee of the provider in the performance of a covered and allowable service such as under the MO HealthNet dental and nurse midwife programs or a covered and allowable non-psychiatric service under the MO HealthNet physician program. In order to direct the performance of such service, the provider must be in the office where the service is being provided and must be immediately available to give directions in person to the employee actually rendering the service and the adequately documented service must be cosigned by the enrolled billing provider;

(N)

“Suspension from participation” means an exclusion from participation for a specified period of time;

(O) “Suspension of payments” means placement of payments due a provider in an escrow account;

(P) “Termination from participation” means the ending of participation in the MO HealthNet program; and (Q) “Withholding of payments” means a reduction or adjustment of the amounts paid to a provider on pending and subsequently submitted bills for purposes of offsetting overpayments previously made to the provider.

(3) Program Violations.

(A) Administrative actions may be imposed by the MO HealthNet agency against a provider for any one (1) or more of the following reasons:

1. A determination that the provider failed to meet standards under state or federal law for participation (for example, licensure);

2. Failure to comply with the provisions of the signed Missouri Department of Social Services, MO HealthNet Division Title XIX Participation Agreement with the provider relating to health care services. The standard agreement is accessible online and incorporated by reference and made a part of this 65109, at its website www.dss.mo.gov/mhd, November 29, 2022. additions;

3. Rebating or accepting a fee or portion of a fee or charge for a MO HealthNet patient referral, or collecting a portion of the service fee from the participant;

4. Failure to accept MO HealthNet payment as payment in full for covered services or collecting additional payment from a participant or responsible person;

5. Failure to reverse or credit back to MO HealthNet within thirty (30) days any pharmacy claims submitted to the agency that represent products or services not received by the participant; for example, prescriptions that were returned to stock because they were not picked up;

6. For providers of Consumer Directed Services (CDS), failure to submit to MO Medicaid Audit and Compliance (MMAC) a required CDS quarterly Financial and Services report, annual service report, or an annual financial statement audit or financial statement review;

7. Failure to utilize an Electronic Visit Verification (EVV) system that complies with the requirements of 13 CSR 70-3.320 to document delivery of personal care services requiring EVV usage;

8. Failure to submit to MMAC an annual attestation of compliance with the provisions of Section 6032 of the federal Deficit Reduction Act of 2005 by March 1 of each year, or failing to provide a requested copy of an attestation, or failing to provide written notification of having more than one (1) federal tax identification number by September 30 of each year, or failing to provide requested proof of a claimed exemption from the provisions of Section 6032 of the federal Deficit Reduction Act of 2005. The attestation is incorporated by reference and made a part of this rule as published by the Department of Social Services, MMAC Unit, 205 Jefferson St, Jefferson City, MO 65101, November 29, 2022. This rule does not incorporate any subsequent amendments or additions;

9. Failure to advise MMAC, in writing, on enrollment forms specified by the single state agency, of any changes affecting the provider’s enrollment records within ninety (90) days of the change, with the exception of change of ownership or control of any provider which must be reported within thirty (30) days;

10. Refusing to execute a new provider agreement when requested to do so by MMAC in order to preserve the single state agency’s compliance with federal and state requirements; or failure to execute an agreement within thirty (30) days for compliance purposes;

11. Billing and receiving reimbursement from the MO HealthNet program more than once for the same service when the duplicate billings were not caused by the single state agency or its agents;

12. Billing the state MO HealthNet program for services not provided prior to the date of billing (“prebilling”), except in the case of prepaid health plans or pharmacy claims submitted by point-of-service technology, whether or not the prebilling causes loss or harm to the MO HealthNet program;

13. Submitting claims for services not personally rendered by the individually enrolled provider, except for the provisions specified in the MO HealthNet programs where such claims may be submitted only if the individually enrolled provider directly supervised the person who actually performed the service and the person was employed by the enrolled provider at the time the service was rendered. Such policies and procedures are contained in provider manuals which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, November 29, 2022. This rule does not incorporate any subsequent amendments or additions;

14. Failure to provide and maintain quality, necessary, and appropriate services, including adequate staffing for MO HealthNet participants, within accepted medical community standards as adjudged by a body of peers, as set forth in both federal and state statutes or regulations. The medical review may be conducted by qualified peers employed by the single state agency;

15. Breaching of the terms of the MO HealthNet provider agreement or of any current written and published policies and procedures of the MO HealthNet program as it pertains to the specific provider type(s) or failing to comply with the terms of the provider certification on the MO HealthNet claim form. Such policies and procedures are contained in provider manuals which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, November 29, 2022. additions;

16. Failure to meet any of the documentation requirements under this paragraph. All records must be kept a minimum of six (6) years from the date of service unless a more specific provider regulation applies. The minimum six- (6-) year retention of records requirement continues to apply in the event of a change of ownership or discontinuing enrollment in MO HealthNet. Services billed to the MO HealthNet agency that are not adequately documented in the patient’s medical records or for which there is no record that services were performed shall be considered a violation of this section.

Copies of records must be provided upon request or within ten (10) business days from the request to the single state agency or its authorized agents, regardless of the media in which they are kept— A. Failure to maintain documentation which is to be made contemporaneously to the date of service; supplemental documentation is allowable as long as the original documentation is not altered after the documentation has been made contemporaneously and all additional documents are dated and the name of the person who edited the document is included;

B. Failure to maintain records for services provided and all billing done under provider number regardless to whom the reimbursement is paid and regardless of whom in their employment or service produced or submitted the MO HealthNet claim or both;

C. Failure to make available, and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet payments, whether or not the records are commingled with non-Title XIX (Medicaid) records;

D. Failure to make requested records available within ten (10) business days from the request;

E. Failure to keep and make available adequate records which adequately document the services and payments;

F. For providers other than long-term care facilities, failure to retain in legible form for at least six (6) years from the date of service, worksheets, financial records, appointment books, appointment calendars (for those providers who schedule patient/client appointments), adequate documentation of the service, and other documents and records verifying data transmitted to a billing intermediary, whether the intermediary is owned by the provider or not; or G. For long-term care providers, failing to retain in legible form, for at least seven (7) years from the date of service, worksheets, financial records, adequate documentation for the service(s), and other documents and records verifying data transmitted to a billing intermediary, whether the intermediary is owned by the provider or not. The documentation must be maintained so as to protect it from damage or loss by fire, water, computer failure, theft, or any other cause;

17. Removing or coercing from the possession or control of a participant any item of durable medical equipment which has reached MO HealthNet-defined purchase price through MO HealthNet rental payments or otherwise become the property of the participant without paying fair market value to the participant;

18. Failure to timely submit civil rights compliance data or information or failure to timely take corrective action for civil rights compliance deficiencies within thirty (30) days after notification of these deficiencies or failure to cooperate or supply information required or requested by civil rights compliance officers of the single state agency;

19. Billing the MO HealthNet program for services rendered to a participant in a long-term care facility when the resident resided in a portion of the facility which was not MO HealthNetcertified or properly licensed or was placed in a non-licensed or MO HealthNet non-certified bed;

20. Failure to submit proper diagnosis codes, procedure codes, billing codes regardless to whom the reimbursement is paid and regardless of who in their employment or service produced or submitted the MO HealthNet claim;

21. Failure to submit and document, as defined in subsection (2)(A), the length of time (begin and end clock time) actually spent providing a service, except for services as specified under 13 CSR 70-91.010(4)(A) Personal Care Program, regardless to whom the reimbursement is paid and regardless of who in their employment or service produced or submitted the MO HealthNet claim or both;

22. Billing for the same service as another provider when the service is performed or attended by more than one (1) enrolled provider. MO HealthNet will reimburse only one (1) provider for the exact same service;

23. Failure to repay or make arrangements for the repayment of identified overpayments or otherwise improper payments prior to the allowed forty-five (45) days which the provider has to refund the requested amount;

24. Presenting, or causing to be presented, for payment, any false or fraudulent claim for services or merchandise in the course of business related to MO HealthNet by an agent or employee of the provider;

25. Submitting, or causing to be submitted, false information for the purpose of meeting prior authorization requirements or for the purpose of obtaining payments in order to avoid the effect of those changes;

26. Submitting, or causing to be submitted, false information for the purpose of obtaining greater compensation than that to which the provider is entitled under applicable MO HealthNet program policies or rules, including but not limited to the billing or coding of services which results in payments in excess of the fee schedule for the service actually provided or billing or coding of services which results in payments in excess of the provider’s charges to the general public for the same services or billing for higher level of service or increased number of units from those actually ordered or performed or both, or altering or falsifying medical records to obtain or verify a greater payment than authorized by a fee schedule or reimbursement plan;

27. Engaging in conduct or performing an act deemed improper or abusive of the MO HealthNet program or failing to correct deficiencies in provider operations within ten (10) days or a date specified after receiving written notice of these deficiencies from the single state agency or within the time frame provided from any other agency having licensing or certification authority. This will include inappropriate or improper actions relating to the management of participants’ personal funds or other funds;

28. Billing violations as follows:

A. Billing for services through an agent, which were upgraded from those actually ordered and performed;

B. Billing or coding services, either directly or through an agent, in a manner that services are paid for as separate procedures when, in fact, the services were performed concurrently or sequentially and should have been billed or coded as integral components of a total service as prescribed in MO HealthNet policy for payment in a total payment less than the aggregate of the improperly separated services;

C. Billing a higher level of service than is documented in the patient/client record; or D. Unbundling procedure codes;

29. Utilizing or abusing the MO HealthNet program as evidenced by a documented pattern of inducing, furnishing, or otherwise causing a participant to receive services or merchandise not otherwise required or requested by the participant, attending physician, or appropriate utilization review team; or as evidenced by a documented pattern of performing and billing tests, examinations, patient visits, surgeries, drugs, or merchandise that exceed limits or frequencies determined by the department for like practitioners for which there is no medical necessity, or for which the provider has created the need through ineffective services or merchandise previously rendered;

30. Failure to take reasonable measures to review claims for payment for accuracy, duplication, or other errors caused or committed by employees when the failure allows material errors in billing to occur. This includes failure to review remittance advice statements provided which results in payments which do not correspond with the actual services rendered;

31. Submitting a false or fraudulent application for provider status which misrepresents material facts. This shall include concealment or misrepresentation of material facts required on any provider agreements or questionnaires submitted by affiliates when the provider knew, or should have known, the contents of the submitted documents;

32. Violating any laws, regulations, or code of ethics governing the conduct of occupations or professions or regulated industries that pertain to said provider. In addition to all other laws which would commonly be understood to govern or regulate the conduct of occupations, professions, or regulated industries, this provision shall include any violations of the civil or criminal laws of the United States, of Missouri, or any other state or territory, where the violation is reasonably related to the provider’s qualifications, functions, or duties in any licensed or regulated profession or where an element of the violation is fraud, dishonesty, moral turpitude, or an act of violence;

33. Being formally reprimanded or censured by a board of licensure or an association of the provider’s peers for unethical, unlawful, or unprofessional conduct; or any termination, removal, suspension, revocation, denial, probation, consented surrender, or other disqualification of all or part of any license, permit, certificate, or registration related to the provider’s business or profession in Missouri or any other state or territory of the United States;

34. Conducting any action resulting in a reduction or depletion of a long-term care facility MO HealthNet participant’s personal funds or reserve account, unless specifically authorized in writing by the participant, relative, or responsible person;

35. Making any payment to any person in return for referring an individual to the provider for the delivery of any goods or services for which payment may be made in whole or in part under MO HealthNet. Soliciting or receiving any payment from any person in return for referring an individual to another supplier of goods or services regardless of whether the supplier is a MO HealthNet provider for the delivery of any goods or services for which payment may be made in whole or in part under MO HealthNet is also prohibited. “Payment” includes, without limitation, any kickback, bribe, or rebate made, either directly or indirectly, in cash or in-kind;

36. Using fraudulent billing practices arising from billings to third parties for costs of services or merchandise or for gross negligent practice resulting in death or injury or substandard care to persons including but not limited to the provider’s patients;

37. Having an adverse action administered against the provider by another state Medicaid program;

38. An administrative or judicial finding of civil or criminal fraud against the MO HealthNet program or any other state Medicaid program, or any criminal fraud related to the conduct of the provider’s profession or business;

39. Being excluded, suspended, or terminated from participation, or having payments suspended by the Medicare program or any other federal health care program. Voluntarily terminating from the Medicare program or other federal health care program is not a violation.

(4) Any one (1) or more of the following administrative actions may be invoked against providers for any one (1) or more of the program violations specified in section (3) of this rule:

(A) Failure to respond to notice of overpayments or notice of deficiencies in provider operations within the specified forty-five- (45-) day time limit shall be considered cause to withhold future provider payments until the situation in question is resolved;

(B) Termination from participation in the MO HealthNet program for a period of not less than sixty (60) days nor more than ten (10) years;

(C) Suspension of participation in the MO HealthNet program for a specified period of time;

(D) Suspension or withholding of payments to a provider;

(E) Referral to peer review committees including PSROs or utilization review committees;

(F) Recoupment from future provider payments;

(G) Transfer to a closed-end provider agreement not to exceed twelve (12) months or the shortening of an already existing closed-end provider agreement;

(H) Attendance at provider education sessions;

(I) Prior authorization of services;

(J) Review of some or all of the provider’s claims prior to payment;

(K) Referral to the state licensing board for investigation;

(L) Referral to appropriate federal or state legal agency for investigation, prosecution, or both, under applicable federal and state laws;

(M) Retroactive denial of payments; and (N) Denial of payment for any new admission to a skilled nursing facility (SNF), intermediate care facility (ICF), or ICF/ individuals with intellectual disabilities (IID) that no longer meets the applicable conditions of participation (for SNFs) or standards (for ICFs and ICF/IIDs) if the facility’s deficiencies do not pose immediate jeopardy to patients’ health and safety.

Imposition of this administrative action must be in accordance with all applicable federal statutes and regulations.

(5) Imposition of an Administrative Action.

(A) The decision as to the administrative action to be imposed shall be at the discretion of MMAC. The following factors shall be considered in determining the administrative action(s) to be imposed:

1. Seriousness of the offense(s)—The state agency shall consider the seriousness of the offense(s) including but not limited to whether or not an overpayment (that is, financial harm) occurred to the program, whether substandard services were rendered to MO HealthNet participants, or circumstances were such that the provider’s behavior could have caused or contributed to inadequate or dangerous medical care for any patient(s), or a combination of these. Violation of pharmacy laws or rules, practices potentially dangerous to patients, and fraud are to be considered particularly serious;

2. Extent of violations—The state MO HealthNet agency shall consider the extent of the violations as measured by but not limited to the number of patients involved, the number of MO HealthNet claims involved, the number of dollars identified in any overpayment, and the length of time over which the violations occurred. The MO HealthNet agency may calculate an overpayment or impose administrative actions under this rule by reviewing records pertaining to all or part of a provider’s MO HealthNet claims. When records are examined pertaining to part of a provider’s MO HealthNet claims, no random selection process in choosing the claims for review as set forth in 13 CSR 70-3.130 need be utilized by the MO HealthNet agency. But, if the random selection process is not used, the MO HealthNet agency may not construe violations found in the partial review to be an indication that the extent of the violations in any unreviewed claims would exist to the same or greater extent;

3. History of prior violations—The state agency shall consider whether or not the provider has been given notice of prior violations of this rule or other program policies. If the provider has received notice and has failed to correct the deficiencies or has resumed the deficient performance, a history shall be given substantial weight supporting the agency’s decision to invoke administrative actions. If the

history includes a prior imposition of administrative action(s), the agency should not apply a lesser action in the second case, even if the subsequent violations are of a different nature;

4. Prior imposition of administrative actions—The MO HealthNet agency shall consider more severe administrative action in cases where a provider has been subject to actions by the MO HealthNet program, any other governmental medical program, Medicare, or exclusion by any private medical insurance carriers for misconduct in billing or professional practice. Restricted or limited participation in compromise after being notified or a more severe action should be considered as a prior imposition of actions for the purpose of this subsection;

5. Prior provision of provider education—In cases where administrative actions are being considered for billing deficiencies only, the MO HealthNet agency may mitigate its action if it determines that prior provider education was not provided. In cases where actions are being considered for billing deficiencies only and prior provider education has been given, prior provider education followed by a repetition of the same billing deficiencies shall weigh heavily in support of the medical agency’s decision to invoke severe actions; and 6. Actions taken or recommended by peer review groups, licensing boards, or Professional Review Organizations (PRO) or utilization review committees—Actions or recommendations by a provider’s peers shall be considered as serious if they involve a determination that the provider has kept or allowed to be kept, substandard medical records, negligently or carelessly performed treatment or services, or, in the case of licensing boards, placed the provider under restrictions or on probation.

(B) Where a provider has been convicted of defrauding any Medicaid program, has had previous actions invoked due to program abuse, has been terminated from the Medicare program, the MO HealthNet agency shall terminate the provider from participation in the MO HealthNet program.

(C) When an administrative action involving the collection, recoupment, or withholding of MO HealthNet payments from a provider is imposed on a provider, it shall become effective ten (10) days from the date of mailing or delivery of said notice, whichever occurs first. When any other action is imposed on a provider it shall become effective thirty (30) days from the date of mailing or delivery of a decision of the Department of Social Services or its designated division, whichever occurs first. If, in the judgment of the single state agency, the surrounding facts and circumstances clearly show that serious abuse or harm may result from delaying the imposition of an administrative action, any action may be made effective three (3) days after mailing of the notice to the provider or immediately upon receipt of notice by the provider, whichever occurs first.

(D) An administrative action may be applied to all known affiliates of a provider, provided that each decision to include an affiliate is made on a case-by-case basis after giving due regard to all relevant facts and circumstances. The violation, failure, or inadequacy of performance may be imputed to an affiliate when the affiliate knew or should have known of the provider’s actions.

(E) Suspension or termination of any provider shall preclude the provider from participation in the MO HealthNet program, either personally or through claims submitted by any clinic, group, corporation, or other association to the single state agency or its fiscal agents for any services or supplies provided under the MO HealthNet program except for those services or supplies provided prior to the suspension or termination.

(F) No clinic, group, corporation, or other association which is a provider of services shall submit claims for payment to the single state agency or its fiscal agents for any services or supplies provided by, or under the supervision of, a person within the organization who has been suspended or terminated from participation in the MO HealthNet program except for those services or supplies provided prior to the suspension or termination.

(G) When the provisions of the previously mentioned are violated by a provider of services that is a clinic, group, corporation, or other association, the single state agency may suspend or terminate the organization, the individual person, or both, within the organization who knew or should have known of the violation.

(H) When a provider has an administrative action imposed, the single state agency shall notify, as appropriate, the applicable professional society, board of registration or licensure, federal and state agencies of the finding made and the action(s) imposed.

(I) Where a provider’s participation in the MO HealthNet program has been suspended or terminated, the single state agency shall notify the county offices of the suspensions or terminations.

(J) Except where termination has been imposed, a provider who has an administrative action imposed may be required to participate in a provider education program as a condition of continued participation. Provider education programs may include:

1. Telephone and written instructions;

2. Provider manuals and workshops;

3. Instruction in claim form completion;

4. Instruction on the use and format of provider manuals;

5. Instruction on the use of procedure codes;

6. Key provisions of the MO HealthNet program;

7. Instruction on reimbursement rates; and 8. Instruction on how to inquire about coding or billing problems.

(K) Providers that have been suspended from the MO HealthNet program under subsections (4)(B) and (C) may be re-enrolled in the MO HealthNet program upon expiration of the period of suspension from the program after making satisfactory assurances of future compliance. Providers that have been terminated from the MO HealthNet program under subsection (4)(B) may be re-enrolled in the program at the sole discretion of the single state agency and only after providing satisfactory evidence that the past cause for termination has ceased and that future participation is warranted.

(6) Amounts Due the Department of Social Services from a Provider.

(A) If there exists an amount due the Department of Social Services from a provider, the single state agency shall notify the provider or the provider’s representative of the amount of the overpayment. The notice shall be mailed or delivered to the address on the provider’s enrollment record. If the amount due is not sooner paid to the Department of Social Services by or on behalf of the provider, the single state agency may take appropriate action to collect the overpayment forty-five (45) days from the date of mailing or delivery of said notice, whichever occurs first. The single state agency may recover the overpayment by withholding from current MO HealthNet reimbursement. The withholding may be taken from one (1) or more payments until the funds withheld in the aggregate equal the amount due as stated in the notice.

(B) When a provider receives notice of an overpayment and the amount due is in excess of one thousand dollars ($1,000), the provider, within fourteen (14) days of the notice being mailed or delivered to the provider, whichever occurs first, may submit to the single state agency a plan for repayment of forty percent (40%) of the overpayment amount and request that the plan be adopted and adhered to by the single state agency in collecting the overpayment. No repayment plans will be considered for the first sixty percent (60%) of the overpayment amount. If this repayment plan is timely received from a provider, the single state agency shall consider the proposal, together with all the facts and circumstances of the case and reject, accept, or offer to accept a modified version of the provider’s plan for repayment. The single state agency shall notify the provider of its decision within ten (10) days after the proposal is received. If no plan for repayment is agreed upon within thirty (30) days from the date of mailing or delivery of a decision of the notice of the overpayment to the provider, whichever occurs first, the MO HealthNet agency may take appropriate action to collect the balance of the amount due.

(C) If a plan agreed to and implemented under provisions of subsection (6)(B) for repayment of amounts due the Department of Social Services from a provider is breached, discontinued, or otherwise violated by a provider, the single state agency, immediately upon the next payment to the provider, may begin to withhold payments or portions of payments until the entire amount due has been collected.

(D) Repayment or an agreement to repay amounts due the Department of Social Services by a provider shall not prevent the imposition of any administrative action by the single state agency upon the provider.

(E) The single state agency may collect provider overpayments from any other enrolled provider when the other enrolled provider has received payment on behalf of the provider who incurred the overpayment (such as when a provider has directed payment to another enrolled provider). The single state agency may also collect provider overpayments from any enrolled provider with the same federal employer identification number (EIN) as the provider who incurred the overpayment. The state agency shall notify the other enrolled provider(s) forty-five (45) days prior to initiating the overpayment action. The notice shall be mailed to the address on the provider’s(s’) enrollment record. If the amount due is in excess of one thousand dollars ($1,000), the other enrolled provider, within fourteen (14) days of mailing of the notice, may submit to the single state agency a plan for repayment of forty percent (40%) of the overpayment amount and request that the plan be adopted and adhered to by the single state agency in collecting the overpayment. No repayment plan will be considered for the first sixty percent (60%) of the overpayment amount. If this repayment plan is timely received from the other enrolled provider, the single state agency shall consider the proposal, together with all the facts and circumstances of the case and reject, accept, or offer to accept a modified version of the other enrolled provider’s plan for repayment. The single state agency shall notify the other enrolled provider of its decision within ten (10) days after the proposal is received. If no plan for repayment is agreed upon within thirty (30) days after the other enrolled provider receives notice of the overpayment, the Medicaid agency may take appropriate action to collect the balance of the amount due.

This rule was previously filed as 13 CSR 40-81.160. Original rule filed Sept. 22, 1979, effective Feb. 11, 1980. Amended: Filed Nov. 25, 1981, effective March 11, 1982. Emergency amendment filed April 14, 1982, effective April 24, 1982, expired July 10, 1982. Amended: Filed April 14, 1982, effective July 11, 1982. Amended: Filed April 16, 1985, effective Sept. 1, 1985. Emergency amendment filed Dec. 5, 1986, effective Dec. 15, 1986, expired April 13, 1987. Amended: Filed Dec. 16, 1986, effective April 11, 1987. Amended: Filed Jan. 7, 1987, effective April 26, 1987. Emergency amendment filed April 15, 1988, effective April 25, 1988, expired Aug. 22, 1988. Amended: Filed June 2, 1988, effective Aug. 25, 1988. Amended: Filed Aug. 2, 1990, effective Feb. 14, 1991. Emergency amendment filed Dec. 17, 1993, effective Jan. 1, 1994, expired April 30, 1994. Emergency amendment filed April 15, 1994, effective April 30, 1994, expired Aug. 13, 1994. Amended:

Filed Feb. 16, 1994, effective Aug. 28, 1994. Amended: Filed May 16, 2005, effective Nov. 30, 2005. Amended: Filed July 3, 2006, effective Dec. 30, 2006. Amended: Filed Nov. 15, 2006, effective May 30, 2007.

Amended: Filed March 30, 2007, effective Sept. 30, 2007. Amended:

Filed Aug. 31, 2007, effective March 30, 2008. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed Sept. 16, 2013, effective April 30, 2014. Amended: Filed Aug. 15, 2014, effective Feb. 28, 2015. Amended: Filed Oct. 15, 2015, effective April 30, 2016.

Amended: Filed Oct. 3, 2016, effective May 30, 2017. Amended: Filed Sept. 22, 2017, effective May 30, 2018. Amended: Filed July 20, 2022, effective March 30, 2023. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-3.035 Violations Attested to by the Department of Health and Senior Services {#sec-13-csr-70-3.035 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.035}

PURPOSE: This rule adds violations determined by the Department of Health and Senior Services as independent grounds for provider sanctions.

Violations of 13 CSR 70-3.030(3) identified by the Department of Health and Senior Services (DHSS) or its designee during the course of an investigation shall be considered for purposes of sanctions without the need for further investigation by the Missouri Medicaid Audit and Compliance Unit (MMAC). The DHSS shall report any such violations by sworn affidavit to MMAC. Prior violations of 13 CSR 70-3.030(3) or other program violations, including, but not limited to, program violations as determined by and attested to by affidavit by the DHSS, shall be considered in their totality to determine if there is an ongoing pattern of violations. Such pattern of violations shall weigh heavily to support invoking severe sanctions.

History

• AUTHORITY: sections 1.205, 208.153, 208.201, and 660.017, RSMo 2016. Emergency rule filed Oct. 1, 2021, effective Oct. 18, 2021, expired April 15, 2022. Original rule filed Oct. 1, 2021, effective May 30, 2022. Original authority: 1.205, RSMo 1986; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993,

13 CSR 70-3.040 Duty of Medicaid Participating Hospitals and Other Vendors to Assist in Recovering Third-Party Payments {#sec-13-csr-70-3.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.040}

(Rescinded November 30, 2018)

History

• AUTHORITY: section 208.153, RSMo Supp. 1991. This rule was previously filed as 13 CSR 40-81.090. Original rule filed May 20, 1977, effective Sept. 11, 1977. Rescinded: Filed April 18, 2018, effective Nov. 30, 2018.

13 CSR 70-3.050 Obtaining Information From Providers of Medical Services {#sec-13-csr-70-3.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.050}

(Rescinded February 28, 2022)

History

• AUTHORITY: section 207.020, RSMo Supp. 1993. This rule was previously filed as 13 CSR 40-81.060. Original rule filed Sept. 29, 1975, effective Oct. 9, 1975. Rescinded: Filed July 16, 2021, effective Feb. 28, 2022.

13 CSR 70-3.060 Medicaid Program Payment of Claims for Medicare Part B Services {#sec-13-csr-70-3.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.060}

(Rescinded August 11, 1988)

History

• AUTHORITY: sections 208.153, RSMo 1986 and 208.201, RSMo Supp. 1987. Original rule filed March 2, 1988, effective May 12, 1988. Emergency rescission filed April 29, 1988, effective May 9, 1988. Rescinded: Filed May 17, 1988, effective Aug. 11, 1988.

13 CSR 70-3.100 Filing of Claims, MO HealthNet Program {#sec-13-csr-70-3.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.100}

PURPOSE: This rule establishes the general provisions for submission or resubmission of claims and adjustments of claims to MO HealthNet. 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) 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.

(2) Specific claims filing instructions are modified as necessary for efficient and effective administration of the program as required by federal or state law or regulation. For specific claim filing instructions information, reference the appropriate— (A) MO HealthNet provider manual, 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 http://manuals.momed.com/manuals/, January 15, 2020.

This rule does not incorporate any subsequent amendments or additions; and (B) Forms, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed. com/manuals/presentation/forms.jsp, January 15, 2020. This

rule does not incorporate any subsequent amendments or additions.

(3) Time Limit for Original Claim Filing. Claims from participating providers that request MO HealthNet reimbursement must be filed by the provider and received by the state agency within twelve (12) months from the date of service. The counting of the twelve- (12-) month time limit begins with the date of service and ends with the date of receipt.

(A) Claims that have been initially filed with Medicare within the Medicare timely filing requirement and which require separate filing of an electronic claim with MO HealthNet will meet timely filing requirements by being submitted by the provider and received by the state agency within twelve (12) months of the date of service or six (6) months from the date on the Medicare provider’s notice of the allowed claim.

Claims denied by Medicare must be filed by the provider and received by the state agency within twelve (12) months from the date of service. The counting of the twelve- (12-) month time limit begins with the date of service and ends with the date of receipt. Medicare/Medicaid crossover claims must be submitted through an electronic media. Claims that have been initially filed with Medicare and which require separate filing of an electronic claim with MO HealthNet must include the Medicare internal control number or the Medicare claim identification number found on the Medicare provider’s notice.

Paper billings for Medicare/Medicaid crossover claims will not be processed. Paper billings (claims) will not be returned to the provider. Paper billings will not be retained by the MO HealthNet Division or its contractors.

(B) Third-Party Resources.

1. Claims for participants who have a third-party resource that is primary to MO HealthNet must be submitted to the third-party resource for adjudication unless otherwise specified by the MO HealthNet Division. Documentation specified by the MO HealthNet Division which indicates the third-party resource’s adjudication of the claim must be attached to the claim filed for MO HealthNet reimbursement.

If the MO HealthNet Division waives the requirement that the third-party resource’s adjudication must be attached to the claim, documentation indicating the third-party resource’s adjudication of the claim must be kept in the provider’s records and made available to the division at its request. The claim must meet the MO HealthNet timely filing requirement by being filed by the provider and received by the state agency within twelve (12) months from the date of service.

2. The twelve- (12-) month initial filing rule may be extended if a third-party payer, after making a payment to a provider, being satisfied that the payment is correct, later reverses the payment determination, sometime after the twelve (12) months from the date of service has elapsed, and requests the provider return the payment. Because a thirdparty resource was clearly available to cover the full amount of liability, and this was known to the provider, the provider may not have initially filed a claim with the MO HealthNet state agency. Under this set of circumstances, the provider may file a claim with the MO HealthNet agency later than twelve (12) months from the date of services. The provider must submit this type of claim to the Third Party Liability Unit at Post Office Box 6500, Jefferson City, MO 65102-6500 for special handling. The MO HealthNet state agency may accept and pay this specific type of claim without regard to the twelve- (12-) month timely filing rule; however, all claims must be filed for MO HealthNet reimbursement within twenty-four (24) months from the date of service in order to be paid.

(4) Time Limit for Resubmission of a Claim After Twelve (12)

Months From the Date of Service.

(A) Claims which have been originally submitted and received within twelve (12) months from the date of service and denied or returned to the provider may be resubmitted within twenty-four (24) months of the date of service. Those claims must be filed by the provider and received by the state agency within twenty-four (24) months from the date of service. The counting of the twenty-four- (24-) month time limit begins with the date of service and ends with the date of receipt.

(B) Documentation specified by the MO HealthNet Division in MO HealthNet provider manuals which indicates the claim was originally received timely must be attached to the resubmission or entered on the claim form (electronic or paper).

(C) Claims will not be paid when filed by the provider and received by the state agency beyond twenty-four (24) months from the date of service.

(5) Denial. Claims that are not submitted in a timely manner and as described in sections (1) and (2) of this rule will be denied. Except that at any time in accordance with a court order, the agency may make payments to carry out hearing decision, corrective action, or court order to others in the same situation as those directly affected by it. The agency may make payment at any time when a claim was denied due to state agency error or delay, as determined by the state agency.

In order for payment to be made, the state agency must be informed of any claims denied due to state agency error or delay within six (6) months from the date of the remittance advice on which the error occurred; or within six (6) months of the date of completion or determination in the case of a delay; or twelve (12) months from the date of service, whichever is longer.

(6) Time Limit for Filing an Adjustment. Adjustments to a paid claim must be filed within twenty-four (24) months from the date of service.

(7) Definitions.

(A) Claim A—claim is each individual line item of service on a claim form, for which a charge is billed by a provider, for all claim form types except inpatient hospital. An inpatient hospital service claim is all the billed charges contained on one (1) inpatient claim document.

(B) Date of payment/denial—The date of payment or denial of a claim is the date on the remittance advice at the top center of each page under the words remittance advice.

(C) Date of receipt—The date of receipt of a claim is the date the claim is received by the state agency. For a claim which is processed, this date appears as a Julian date in the internal control number (ICN). For a claim which is returned to the provider, this date appears on the Return to Provider form letter.

(D) Date of service—The date of service which is used as the beginning point for determining the timely filing limit applies to the various claim types as follows:

1. Nursing home—The through date or ending date of service for each line item for each participant listed on the claim;

2. Pharmacy—The date dispensed for each line item for each individual participant listed on electronically submitted claims through point-of-service (POS) or the Inter net;

3. Outpatient hospital—The ending date of service for each individual line item on the claim;

4. Professional services (CMS-1500)—The ending date of service for each individual line item on the claim;

5. Dental—The date service was performed for each individual line item on the claim;

6. Inpatient hospital—The through date of service in the area indicating the claimed period of service; and 7. For service which involves the providing of dentures, hearing aids, eyeglasses, or items of durable medical equipment; for example, artificial larynx, braces, hospital beds, wheelchairs, the date of service will be the date of delivery or placement of the device or item.

(E) Internal control number (ICN)—The fiscal agent prints a thirteen- (13-) digit number on each document it processes through the Medicaid Management Information System (MMIS). The year of receipt is indicated by the third and fourth digits and the Julian date appears as the fifth, sixth, and seventh digits. In an example ICN, 490600152006, 06 is the year 2006 and 001 is the Julian date for January 1.

(F) Medicare internal control number—The number assigned to a Medicare claim by the Medicare provider which is used for identification purposes. The Medicare internal control number is also referred to as the Medicare claim identification number.

(G) Julian date—In a Julian system, the days of a year are numbered consecutively from 001 (January 1) to 365 (December 31) or 366 in a leap year. For example, in 1984, a leap year, June 15 is the 167th day of that year, thus, 167 is the Julian date for June 15, 1984.

(H) Twelve- (12-) month time limit—This unit is defined as three hundred sixty-six (366) days.

(I) Twenty-four- (24-) month time limit—This unit is defined as seven hundred thirty-one (731) days.

This rule was previously filed as 13 CSR 40-81.070 and 13 CSR 40-81.071. Original rule filed June 2, 1976, effective Oct. 11, 1976.

Emergency rescission filed July 18, 1979, effective July 31, 1979, expired Nov. 10, 1979. Emergency rule filed July 18, 1979, effective Aug. 1, 1979, expired Nov. 10, 1979. Rescinded and readopted: Filed July 18, 1979, effective Nov. 11, 1979. Rescinded and readopted:

Filed Sept. 12, 1984, effective Jan. 12, 1985. Amended: Filed April 21, 1992, effective Jan. 15, 1993. Amended: Filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed Sept. 23, 1993, effective May 9, 1994.

Amended: Filed Sept. 28, 2001, effective March 30, 2002. Amended:

Filed June 15, 2006, effective Dec. 30, 2006. Amended: Filed Jan. 2, 2008, effective June 30, 2008. Amended: Filed July 31, 2008, effective Jan. 30, 2009. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed Sept. 27, 2018, effective May 30, 2019.

Amended: Filed Jan. 22, 2020, effective Aug. 30, 2020. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-3.105 Timely Payment of MO HealthNet Claims {#sec-13-csr-70-3.105 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.105}

PURPOSE: This rule advises MO HealthNet providers of the time frames in which they can expect payment for the service(s) they provide to MO HealthNet participants. This rule implements

Section 1902(a)(37) of the federal Social Security Act. or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the

rule is printed here. This note refers only to the incorporated by reference material.

(1) As used in this rule, unless the context clearly indicates otherwise, the following terms shall mean:

(A) Claim A—bill submitted by a provider to the MO HealthNet Division for MO HealthNet reimbursement for a procedure, a set of procedures, or a service rendered a MO HealthNet participant for a given diagnosis or a set of related diagnoses;

(B) Clean claim—A claim that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in the state’s claim system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity;

(C) Date of payment—The date of the check or other form of payment;

(D) Date of receipt—The date the MO HealthNet Division receives the claim, as indicated by its date stamp on the claim;

(E) Nonpractitioner claim—Claims for the following services: inpatient hospital, state-operated mental health facility, outpatient hospital, inpatient psychiatric facility for individuals age twenty-one (21) and under, intermediate care facility for the mentally retarded (ICF/MR), home health services (personal care home and community-based services), family planning (rendered by a hospital—inpatient or outpatient), sterilization (rendered by a hospital—inpatient or outpatient), nursing facility; and durable medical equipment; and (F) Practitioner claim—Claims for the following services: physician, dental, clinic, family planning (rendered by a physician, clinic or other practitioner), laboratory and X-ray services, prescribed drugs, early and periodic screening, rural health clinic, sterilization services (rendered by a physician, clinic or other practitioner), and other (chiropractors, podiatrists, psychologists, registered or licensed practical nurses providing private duty nursing services, optometrists, physical therapists, occupational therapists, speech pathologists, audiologists and Christian Science practitioners).

(2) In accordance with Title 42 of the Code of Federal Regulations

part 447 section 45, the MO HealthNet Division, each fiscal year, will process and pay within thirty (30) days of the date of receipt, ninety percent (90%) of all clean claims from practitioners who are in individual or group practice, or who practice in shared health facilities and nonpractitioners.

(3) The MO HealthNet Division, each fiscal year, will process and pay within ninety (90) days of the date of receipt, ninetynine percent (99%) of all clean claims from practitioners who are in individual or group practice, or who practice in shared health facilities and nonpractitioners.

(4) The MO HealthNet Division must pay all other claims within twelve (12) months of the date of receipt. The time limitation does not apply to— (A) Retroactive adjustments;

(B) Claims submitted by providers who are under investigation for fraud or abuse; and (C) Claims submitted to both Medicare and Medicaid.

(5) The MO HealthNet Division may make payments at any time in accordance with a court order, to carry out hearing decisions or agency corrective actions taken to resolve a dispute, or to extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it.

History

• AUTHORITY: section 208.201, RSMo Supp. 2007. Original rule filed Dec. 11, 1991, effective June 25, 1992. Amended: Filed July 31, 2008, effective Jan. 30, 2009.

13 CSR 70-3.110 Second Opinion Requirement Before Nonemergency Elective Surgical Operations {#sec-13-csr-70-3.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.110}

(Rescinded June 30, 2011)

History

• AUTHORITY: section 207.020, RSMo Supp. 1993. This rule was previously filed as 13 CSR 40-81.052. Emergency rule filed Sept. 18, 1981, effective Sept. 28, 1981, expired Jan. 13, 1982. Original rule filed Sept. 18, 1981, effective Jan. 14, 1982. Rescinded: Filed Dec. 1, 2010, effective June 30, 2011.

13 CSR 70-3.120 Limitations on Payment of Out-of-State Nonemergency Medical Services {#sec-13-csr-70-3.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.120}

PURPOSE: This rule establishes a regulatory basis for implementation of prior authorization on all out-of-state nonemergency MO HealthNet-covered services.

(1) All nonemergency, MO HealthNet-covered services, except for those services exempted in section (6) of this rule, which are to be performed or furnished out-of-state for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized in accordance with policies and procedures established by the MO HealthNet Division before the services are provided.

(2) Nonemergency services, for the purpose of the prior authorization requirement, are those services which do not meet the definition of emergency. Emergency services are defined as those services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in a) placing the patient’s health in serious jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part.

(3) Out-of-state is defined as not within the physical boundaries of Missouri. Border-state providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma, and Tennessee) will be considered as being on the same MO HealthNet participation basis as providers of services located within Missouri for purposes of administration of this

rule, except providers as defined in sections 198.006(14) and (23), RSMo.

(4) The out-of-state provider of services must meet the requirements for participation in the MO HealthNet program and have a state-approved participation agreement in effect in order to receive reimbursement for any covered service, emergency or nonemergency.

(5) The patient’s attending physician is responsible for obtaining prior authorization of the services s/he believes to be medically necessary.

(A) Failure to obtain prior authorization for the services shall result in no payment by the MO HealthNet program.

(B) All prior authorization requests must be submitted in accordance with policies and procedures established by the MO HealthNet Division as stated in the respective MO HealthNet Provider Manual 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, and at its website at http://manuals. momed.com/manuals/, January 7, 2022. This rule does not incorporate any subsequent amendments or additions.

(C) Prior authorization by the MO HealthNet agency shall approve the medical necessity of the covered services to be performed only. It shall not guarantee payment as the participant must be eligible on the date the service was provided.

(D) Prior authorization expires one hundred eighty (180) days from the date a specific service was approved by the state, except transplant services. Prior authorization for transplant services will expire three hundred sixty-five (365) days from the date the services were approved by the state.

(E) All requests for prior authorization must be submitted to the Participant Services Unit of the MO HealthNet Division. The physician who is referring the patient for the nonemergency services must call or write the MO HealthNet Division for authorization.

(F) Telephone prior authorizations may be granted.

(6) The following are exempt from the requirement for prior authorization of non-emergency MO HealthNet-covered services for out-of-state providers:

(A) All services provided individuals having both Medicare and MO HealthNet coverage for which Medicare does provide coverage and is the primary payer (crossover claims);

(B) All border state providers as defined in section (3) of this

rule;

(C)

All foster care children living outside Missouri.

Nonemergency services which routinely require prior authorization will continue to require prior authorization by out-of-state providers even though the service was provided to a foster care child. Foster care children are identified on the MO HealthNet ID card with a Type of Assistance (TOA) indicator of “D” or “Z”;

(D) All independent laboratory, Developmental Disabilities waiver Assistive Technology, and emergency ambulance services; and (E) All services provided via telemedicine, which must be performed with the same standard of care as an in-person, face-to-face service.

(7) All other policies and procedures applicable to the MO HealthNet program will be in effect for services provided by out-of-state providers.

This rule was previously filed as 13 CSR 40-81.190. Emergency rule filed Sept. 18, 1981, effective Sept. 28, 1981, expired Jan. 13, 1982.

Original rule filed Sept. 18, 1981, effective Jan. 14, 1982. Amended:

Filed Oct. 21, 1994, effective June 30, 1995. Amended: Filed May 14, 2009, effective Nov. 30, 2009. Amended: Filed Dec. 10, 2019, effective June 30, 2020. Amended: Filed Jan. 7, 2022, effective July 30, 2022. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-3.130 Computation of Provider Overpayment by Statistical Sampling {#sec-13-csr-70-3.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.130}

(Rescinded April 30, 2019)

Amended: Filed Sept. 17, 1986, effective Dec. 11, 1986. Emergency amendment filed Feb. 4, 1987, effective Feb. 14, 1987, expired April 25, 1987. Amended: Filed Feb. 4, 1987, effective June 11, 1987.

Amended: Filed July 30, 2010, effective Feb. 28, 2011. Rescinded:

Filed Aug. 28, 2018, effective April 30, 2019.

History

• AUTHORITY: section 208.165, RSMo 2000 and sections 208.153 and 208.201, RSMo Supp. 2010. This rule was previously filed as 13 CSR 40-81.161. Original rule filed April 14, 1983, effective Oct. 13, 1983.

13 CSR 70-3.140 Direct Deposit of Provider Reimbursement {#sec-13-csr-70-3.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.140}

PURPOSE: This rule requires the direct deposit of MO HealthNet provider payments and describes the procedure by which those payments will be made.

(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 65101, 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 (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.

(3) All direct deposit applications must be signed by the person enrolled in the MO HealthNet program when that provider is an individual. Applications on behalf of groups or businesses (except those described in this rule) must be signed by an owner or managing employee of the entity. Signature stamps or other facsimiles will not be accepted.

(4) MMAC may terminate or suspend the direct deposit option for administrative or legal actions, including, but not limited to, ownership change, duly executed liens or levies, legal judgments, notice of bankruptcy, administrative sanctions for the purpose of ensuring program compliance, death of a provider, and closure or abandonment of an account.

rule filed Oct. 4, 1993, effective June 6, 1994. Amended: Filed June 1, 2010, effective Dec. 30, 2010. Amended: Filed Aug. 27, 2021, effective March 30, 2022. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993,

13 CSR 70-3.150 Authorization To Receive Payment for Medicaid Services {#sec-13-csr-70-3.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.150}

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 1115 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).

(2) Two (2) or more unaffiliated providers may not by agreement or other joint action designate a common business agent or other recipient of their payments under the Missouri Medicaid program.

(3) Authorizations to receive payment that do not meet the foregoing requirements of section (1) of this rule shall be void upon the effective date of this rule.

rule filed July 15, 1998, effective Jan. 30, 1999. *Original authority: 208.158, RSMo 1967 and 208.201, RSMo 1987.

History

• AUTHORITY: sections 208.158 and 208.201, RSMo 1994. Original

13 CSR 70-3.160 Electronic Submission of MO HealthNet Claims and Electronic Remittance Advices {#sec-13-csr-70-3.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.160}

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.

(3) State-required supporting documentation (paper attachments) must be maintained at the place of service for auditing purposes.

(A) The failure of the enrolled MO HealthNet provider to keep (B) The enrolled MO HealthNet provider shall be responsible (C) The records shall be maintained for five (5) years, unless (4) Medical record documentation shall support the medical necessity of the service being provided as well as the frequency of the service. The provider shall establish and maintain a record containing the signature of each participant of service furnished by the MO HealthNet enrolled provider or, when applicable, the signature of a responsible person made on behalf of the participant. Clinical laboratories, radiologists, and pathologists are exempt from the requirement that a MO HealthNet enrolled provider establish and maintain a record containing the signature of each participant of service. A physician’s order shall be documented in the medical record. Clinical laboratories, radiologists, and pathologists shall maintain a record of the ordering physician for a MO HealthNet service for which they request reimbursement.

(A) The failure of the enrolled MO HealthNet provider to keep (B) The enrolled MO HealthNet provider shall be responsible (C) The records shall be maintained for five (5) years, unless (5) The provider shall keep such records, including original source documents, as are necessary to disclose fully the nature and extent of services provided to participants under the MO HealthNet program and to furnish information regarding any payment of claims for providing such services as the MO HealthNet Division, or its designee, may request. The enrolled MO HealthNet provider agrees that the service was medically necessary for the treatment of the condition as indicated by the diagnosis and shall maintain records, including source documents, to verify such.

(A) The failure of the enrolled MO HealthNet provider to keep (B) The enrolled MO HealthNet provider shall be responsible (C) The records shall be maintained for five (5) years, unless (6) The enrolled MO HealthNet provider must identify and bill third party insurance and Medicare coverage prior to billing MO HealthNet.

(7) Sufficient security procedures must be in place to ensure that all transmissions of documents are authorized and protect participant specific data from improper access.

(8) The provider is responsible for assuring that electronic billing software purchased from any vendor or used by a billing agent complies with billing requirements of the MO HealthNet program and shall be responsible for modifications necessary to meet electronic billing standards.

Denny Hoskins (12/31/25)

(9) The enrolled MO HealthNet provider agrees to accept as payment in full the amount paid by MO HealthNet for the electronic media claims submitted for payment.

(10) The submission of an electronic media claim is a claim for MO HealthNet payment.

(A) Any person who, with intent to defraud or deceive, makes, causes to be made, or assists in the preparation of any false statement, misrepresentation, or omission of a material fact in any claim or application for any claim, regardless of amount, knowing the same to be false, is subject to civil or criminal sanctions, or both, under all applicable state and federal statutes.

(11) “Electronic remittance advice” means a remittance that is retrieved via electronic media.

(12) The enrolled MO HealthNet provider agrees to retrieve his/ her remittance advice via electronic media.

(A) To utilize the Internet for electronic remittance advice retrieval, 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) Sufficient security procedures must be in place to ensure that all transmissions of documents are authorized and protect participant specific data from improper access.

Filed June 1, 2010, effective Dec. 30, 2010. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2009. Original rule filed April 29, 2005, effective Nov. 30, 2005. Amended:

13 CSR 70-3.170 Medicaid Managed Care Organization Reimbursement Allowance {#sec-13-csr-70-3.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.170}

(Rescinded November 30, 2021)

2008. Original rule filed June 1, 2005, effective Dec. 30, 2005.

Emergency amendment filed May 5, 2006, effective May 15, 2006, expired Nov. 10, 2006. Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed June 15, 2006, effective Dec. 30, 2006. Emergency amendment filed June 20, 2007, effective July 1, 2007, expired Dec. 27, 2007.

Amended: Filed June 20, 2007, effective Jan. 30, 2008. Emergency amendment filed June 18, 2008, effective July 1, 2008, expired Dec. 28, 2008. Amended: Filed March 17, 2008, effective Sept. 30, 2008.

Emergency amendment filed June 19, 2009, effective July 1, 2009, expired Sept. 30, 2009. Amended: Filed July 1, 2009, effective Jan. 30, 2010. Rescinded: Filed May 28, 2021, effective Nov. 30, 2021.

History

• AUTHORITY: sections 208.201, 208.431, and 208.435, RSMo Supp.

13 CSR 70-3.180 Medical Pre-Certification Process {#sec-13-csr-70-3.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.180}

PURPOSE: This rule establishes the medical pre-certification process of the MO HealthNet Program for certain covered diagnostic and ancillary procedures and services prior to provision of the procedure or service as a condition of reimbursement. The medical pre-certification process serves as a utilization management tool, allowing payment for services that are medically necessary, appropriate, and cost-effective without compromising the quality of care provided to MO HealthNet participants.

(1) Providers are required to obtain pre-certification for certain specified services as outlined in the provider manuals before delivery of services. This rule shall apply to diagnostic and ancillary procedures and services outlined in the provider manuals and provider bulletins when ordered by a healthcare provider, unless provided in an inpatient hospital or emergency room setting. This pre-certification process shall not include primary services performed directly by the provider. In addition to services and procedures that are available through the traditional MO HealthNet program, expanded services are available to children twenty (20) years of age and under through the Healthy Children and Youth (HCY) Program. Some expanded services also require pre-certification. Certain services require pre-certification only when provided in a specific place or when they exceed certain limits. These limitations are explained in detail in the respective 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 http://manuals.momed.com/ manuals/, October 12, 2022. The rule does not incorporate any subsequent amendments or additions. This rule shall only apply to those diagnostic and ancillary procedures or services that are listed in the provider manuals, which are incorporated by reference and made a part of this rule.

(2) All requests for pre-certification must be initiated by an enrolled medical assistance provider and approved by the MO HealthNet Division. A covered service for which pre-certification is required must meet medical criteria established by the MO HealthNet Division’s medical consultants or medical advisory groups in order to be approved.

(3) An approved pre-certification request does not guarantee payment. The provider must be enrolled and verify participant eligibility on the date of service.

(4) Approved services/procedures must be initiated or dispensed within six (6) months of the date the pre-certification approval is issued. Services/procedures initiated or dispensed after the six- (6-) month approval period will be void and payment denied.

(5) The pre-certification for a specific service is time and patient status and/or diagnosis sensitive. A denial at any given time shall not prejudice or impact the decision to grant a future request for the same or similar service.

(6) Pre-certifications for exactly the same service may be granted to allow provision over an extended period of time and may be granted for a term of not more than one (1) year.

(7) If a pre-certification request is denied, the MO HealthNet participant will receive a letter that outlines the reason for the denial and the procedure for appeal. The MO HealthNet participant must contact the MO HealthNet Division’s (12/31/25) Denny Hoskins Participant Services Unit within ninety (90) days of the date of the denial letter to request a hearing. After ninety (90) days, a request to appeal the pre-certification decision is denied.

Original rule filed July 3, 2006, effective Feb. 28, 2007. Amended:

Filed March 2, 2009, effective Aug. 30, 2009. Amended: Filed July 26, 2023, effective Feb. 29, 2024. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-3.190 Telehealth Services {#sec-13-csr-70-3.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.190}

(Rescinded January 30, 2019)

History

• AUTHORITY: section 208.201, RSMo Supp. 2008. Original rule filed Jan. 2, 2008, effective Aug. 30, 2008. Amended: Filed Feb. 17, 2009, effective Aug. 30, 2009. Rescinded: Filed June 8, 2018, effective Jan. 30, 2019.

13 CSR 70-3.200 Ambulance Service Reimbursement Allowance {#sec-13-csr-70-3.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.200}

PURPOSE: This rule establishes the formula for determining the Ambulance Service Reimbursement Allowance each ground emergency ambulance service must pay, except for any ambulance service owned and operated by an entity owned or operated by the board of curators, as defined in Chapter 172, RSMo, or any department of the state, in addition to all other fees and taxes now required or paid, for the privilege of engaging in the business of providing ground emergency ambulance services in Missouri.

(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.

(B) Beginning October 1, 2013, each ground emergency ambulance services provider in this state, except for any ambulance service owned and operated by an entity owned and operated by the state of Missouri, including but not limited to any hospital owned or operated by the board of curators, as defined in Chapter 172, RSMo, or any department of the state, shall, in addition to all other fees and taxes now required or paid, pay an ambulance service reimbursement allowance for the privilege of engaging in the business of providing ambulance services as defined in section 190.100, RSMo. Emergency transport mileage shall be obtained by the division from the providers six (6) months after calendar year end (i.e., calendar year 2021 mileage will be obtained through an affidavit sent out by the state in 2022). Collection of the ambulance service reimbursement allowance beginning October 1, 2022, and thereafter each October 1, shall be based on emergency transport mileage from the prior calendar year.

(i.e., October 1, 2022, shall be based on emergency transport mileage from calendar year 2021).

1. The ambulance service reimbursement allowance owed for currently licensed emergency ambulance providers as defined in section 190.100, RSMo, shall be calculated by multiplying the ambulance service reimbursement allowance tax rate by the emergency transport mileage, as defined above in paragraph (1)(A)5.

A. Exceptions.

(I) For emergency ambulance providers without reported data, emergency transport mileage used to determine the ambulance service reimbursement allowance shall be estimated as follows:

(a) Emergency ambulance providers shall be divided into quartiles based on total emergency ambulance transports;

(b) Emergency transport mileage shall be individually summed and divided by the total emergency ambulance transports in the quartile to yield an average per emergency ambulance transport; and (c) The number of emergency ambulance transports as reported to the Department of Health and Senior Services (Bureau of Emergency Medical Services (BEMS) data) as required by 19 CSR 30-40.375(3) for the emergency ambulance provider without reported data shall be multiplied by the average emergency transport mileage.

2. Each ambulance provider shall submit an affidavit to the department with the following information:

A. Provider name;

B. Contact;

C. Telephone number;

D. Address:

E. Federal tax ID number;

F. MO HealthNet provider number;

G. Emergency transport mileage; and H. Gross receipts attributable to emergency ambulance revenue from Medicare, Medicaid, insurance, and private payments received by the ambulance service.

(C) The Department of Social Services shall provide each emergency ambulance provider with a final determination letter. The letter shall include emergency ambulance provider name, National Provider Identifier (NPI) number, total emergency transport mileage, ambulance service reimbursement allowance tax rate, and annual tax amount.

1. Each emergency ambulance provider required to pay the ambulance service reimbursement allowance shall review the information in the letter and, if necessary, provide the department with correct information. If the information supplied by the department is incorrect, the emergency ambulance provider, within fifteen (15) calendar days of receiving the confirmation schedule, must notify the division and explain the corrections. If the division does not receive corrected information within fifteen (15) calendar days, it will be assumed to be correct, unless the emergency ambulance provider files a protest in accordance with subsection (1)(E) of this regulation.

(D) Payment of the Ambulance Service Reimbursement Allowance.

1. Offset. Each emergency ambulance provider may request that its ambulance service reimbursement allowance Denny Hoskins (12/31/25) be offset against any Missouri Medicaid payment due to that emergency ambulance provider. A statement authorizing the offset must be on file with the division before any offset may be made relative to the ambulance service reimbursement allowance by the emergency ambulance provider. Assessments shall be allocated and deducted over the applicable service period. Any balance due after the offset shall be remitted by the emergency ambulance provider to the department.

The remittance shall be made payable to the director of the Department of Revenue and deposited in the state treasury to the credit of the ambulance service reimbursement allowance fund. If the remittance is not received before the next MO HealthNet payment cycle, the division shall offset the balance due from that check.

2. Check. If no offset has been authorized by the emergency ambulance provider, the division will begin collecting the ambulance service reimbursement allowance on the first day of each month. The ambulance service reimbursement allowance shall be remitted by the emergency ambulance provider to the department. The remittance shall be made payable to the director of the Department of Revenue and deposited in the state treasury to the credit of the ambulance service reimbursement allowance fund.

3. Failure to pay the ambulance service reimbursement allowance. If an emergency ambulance provider fails to pay its ambulance service reimbursement allowance within thirty (30) days of notice, the ambulance service reimbursement allowance shall be delinquent. For any delinquent ambulance service reimbursement allowance, the department may compel the payment of such reimbursement allowance in the circuit court having jurisdiction in the county where the main office of the emergency ambulance provider is located.

In addition, the director of the Department of Social Services or the director’s designee may cancel or refuse to issue, extend, or reinstate an emergency ambulance provider agreement to any emergency ambulance provider that fails to pay such delinquent reimbursement allowance required unless under appeal.

(E) Each emergency ambulance provider, upon receiving written notice of the final determination of its ambulance service reimbursement allowance, may file a protest with the director of the department setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the department. The director of the department shall reconsider the determination and, if the emergency ambulance provider so requested, the director or the director’s designee shall grant the emergency ambulance provider a hearing to be held within forty-five (45) days after the protest is filed, unless extended by agreement between the emergency ambulance provider and the director. The director shall issue a final decision within forty-five (45) days of the completion of the hearing. After a final decision by the director, an emergency ambulance provider’s appeal of the director’s final decision shall be to the Administrative Hearing Commission in accordance with sections 208.156 and 621.055, RSMo.

(2) Ambulance service reimbursement allowance rate beginning October 1, 2022. The ambulance service reimbursement allowance rate beginning October 1, 2022, determined by the division, as set forth in subsection (1)(B) above, is as follows:

(A) Beginning October 1, 2022, the tax rate will be one dollar and fifty-eight cents ($1.58) per mile. MO HealthNet Division will have the discretion to adjust the tax rate on a quarterly

basis. No ambulance service reimbursement allowance shall be collected by the Department of Social Services if the federal Centers for Medicare & Medicaid Services (CMS) determines that such reimbursement allowance is not authorized under Title XIX of the Social Security Act;

(B) Beginning October 1, 2023, the tax rate will be eightyfive cents ($0.85) per mile. MO HealthNet Division will have the discretion to adjust the tax rate on a quarterly basis.

No ambulance service reimbursement allowance shall be collected by the Department of Social Services if the federal Centers for Medicare & Medicaid Services (CMS) determines that such reimbursement allowance is not authorized under Title XIX of the Social Security Act;

(C) Beginning July 1, 2025, the tax rate will be one dollar and sixty-four cents ($1.64) per mile. MO HealthNet Division will have the discretion to adjust the tax rate on a quarterly

basis. No ambulance service reimbursement allowance shall be collected by the department if the federal Centers for Medicare & Medicaid Services (CMS) determines that such reimbursement allowance is not authorized under Title XIX of the Social Security Act; and (D) For each year (October thru September), the total tax amount collected shall not exceed six percent (6%) of emergency ambulance gross receipts in the aggregate as reported in subparagraph (1)(B)2.H.

History

• AUTHORITY: sections 190.836, 208.201, and 660.017, RSMo 2016, and section 190.815, RSMo Supp. 2025. Original rule filed March 19, 2010, effective Nov. 30, 2010. Amended: Filed Oct. 10, 2013, effective April 30, 2014. Emergency amendment filed Feb. 3, 2023, effective Feb. 22, 2023, expired Aug. 20, 2023. Amended: Filed Feb. 2, 2023, effective Aug. 30, 2023. Amended: Filed March 20, 2024, effective Nov. 30, 2024. Emergency amendment filed June 20, 2025, effective July 7, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan. 30, 2026. Original authority: 190.815, RSMo 2009, amended 2022; 190.836, RSMo 2009; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-3.210 Electronic Retention of Records {#sec-13-csr-70-3.210 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.210}

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 (12/31/25) Denny Hoskins 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.

History

• AUTHORITY: section 208.201, RSMo Supp. 2010. Original rule filed July 1, 2011, effective Dec. 30, 2011.

13 CSR 70-3.220 Electronic Health Record Incentive Program {#sec-13-csr-70-3.220 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.220}

PURPOSE: The Health Information Technology and Clinical Health Act (HITECH) offers incentive payments to encourage eligible professionals and hospitals to adopt certified Electronic Health Records (EHRs). This rule establishes the basis on which eligible hospitals and professionals participating in the MO HealthNet Program will be eligible to receive payments when they successfully demonstrate that they have adopted, implemented, or upgraded to certified EHR technology in the first year and meaningfully use certified electronic health record technology in subsequent years.

(1) Definitions. Patient volume shall be calculated as outlined in 42 CFR 495.302–495.306.

(2) Eligible Providers. To qualify for Medicaid incentive payments during the first year, eligible professionals and hospitals must complete registration and attestation requirements, meet volume thresholds for Medicaid patients, and show that they have adopted, implemented, or upgraded to certified electronic health record (EHR) technology. In subsequent years, payments require demonstration of meaningful use of certified EHR technology. To be deemed an “eligible professional or hospital” for the electronic health record incentive program, a professional or hospital must satisfy the following criteria:

(A) The eligible professional or hospital must be currently enrolled as a MO HealthNet provider, either in the fee for service program or a managed care organization which has a contract with the state of Missouri;

(B) The provider must be one (1) of the following:

1. An eligible professional, listed as— A. A physician;

B. A dentist;

C. A certified nurse midwife;

D. A nurse practitioner; or E. A physician assistant practicing in a federally-qualified health center or rural health clinic when a physician assistant is the primary provider, director, or owner of the site;

2. An acute care hospital, defined as a health care facility where the average length of stay is twenty-five (25) days or fewer, which has a Centers for Medicare and Medicaid Services (CMS) certification number with the last four digits in the series 0001–0879 or 1300–1399; or 3. A children’s hospital, defined as a separately certified children’s hospital, either freestanding or a hospital-withinhospital, that predominately treats individuals under twentyone (21) years of age and has a CMS certification number with the last four digits in the series 3300–3399;

(C) For the year for which the provider is applying for an incentive payment— 1. An eligible professional must have at least thirty percent (30%) of the professional’s patient volume covered by Medicaid, except that— A. A pediatrician must have at least twenty percent (20%)

Medicaid patient volume;

B. A professional practicing at a federally-qualified health center or rural health clinic must have at least fifty percent (50%) of patient encounters in a federally-qualified health center or rural health clinic, with a minimum thirty percent (30%) patients who are medically needy, defined as those furnished uncompensated care, or services either at no cost or at a reduced cost based on a sliding scale or ability to pay, or patients covered by the MO HealthNet program or the state’s Children’s Health Insurance Program (CHIP); and C. Professionals have the option to base their volume on either— (I) Their individual Medicaid patient encounters as a percentage of their total individual encounters; or (II) The practice’s total Medicaid encounters as a percentage of the practice’s total patient encounters;

2. An acute care hospital must have ten percent (10%)

Medicaid patient volume; and 3. A children’s hospital is presumed to meet the Medicaid patient volume requirement;

(D) Application and Agreement. Any eligible provider who wants to participate in the Missouri electronic health record incentive program must declare the intent to participate by electronically registering with the Centers for Medicare and Medicaid Services (CMS) using the Medicare and Medicaid electronic health record incentive program registration and attestation website. CMS will notify the Department of Social Services of an eligible provider’s registration for the Medicaid incentive payment program.

1. The department will maintain a website and secure portal with instructions for submitting documentation of patient volume, certified technology, and other information required to apply for the Medicaid EHR incentive at the website, http://mo.arraincentive.com.

2. The applicant shall use the website to— A. Attest to the applicant’s qualifications to receive the incentive payment; and B. Submit an electronic copy of a signed attestation form.

3. The department may request any missing or additional information from the provider. If missing or additional information is required, the department will notify the provider by electronic mail of the specific information needed.

If the provider fails to submit the required information, the department will determine the registration incomplete and application will remain in an incomplete status until the required information is submitted.

4. The department may request additional information from sources other than the provider to validate the provider’s attestation submitted as a result of this rule;

(E) Record Retention. Providers must retain records to support their eligibility for the incentive payment for a minimum of six (6) years. The department will select providers for audit after issuance of an incentive payment. Incentive payment recipients shall cooperate with the department by providing proof of— 1. Eligibility for the incentive program;

2. Medicaid patient volume thresholds;

3. Purchase of certified electronic health record technology; and 4. Meaningful use of electronic health record technology;

(F) Patient Consent Form. Providers must retain records to support the disclosure of patient health information to all treating providers; and (G) Administrative Appeal. Any eligible provider or any provider that claims to be an eligible provider and who has been subject to adverse actions related to the electronic health record incentive program may seek review of the department’s action pursuant to section 621.055, RSMo. Appealable issues include:

1. Provider eligibility determination;

2. Medicaid patient volume thresholds;

3. Incentive payment amounts; or 4. Demonstration of adopting, implementing, upgrading, and meaningful use of technology.

(3) The department will make an incentive payment to a provider as a result of this rule in accordance with the requirements of 42 CFR 495.308–495.312. A provider who has received an incentive payment as a result of this rule must continue to meet the eligibility standards for that payment through the entire payment year. If the department finds that a provider is deficient, the department may take any of the following actions:

(A) Suspend an incentive payment until the provider has removed the deficiency to the satisfaction of the department;

(B) Require full repayment of all or a portion of an incentive payment; or (C) Terminate participation in the MO HealthNet electronic health record incentive program.

History

• AUTHORITY: section 208.201, RSMo Supp. 2010. Original rule filed July 1, 2011, effective Dec. 30, 2011.

13 CSR 70-3.230 Payment Policy for Provider Preventable Conditions for services provided by acute care hospitals or ambulatory surgical centers that result in Provider Preventable Conditions, errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. {#sec-13-csr-70-3.230 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.230}

(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).

(2) Payment to hospitals enrolled as MO HealthNet providers for care related only to the treatment of the consequences of a HCAC will be denied or recovered by the MO HealthNet Division when the HCAC is determined to have occurred during an inpatient hospital stay and would otherwise result in an increase in payment. HCAC conditions are identified in the list of Medicare Hospital Acquired Conditions, which is incorporated by reference and made part of this rule as published by the Centers for Medicare & Medicaid Services (CMS), 7500 Security Boulevard, Baltimore, MD 21244, November 13, 2024. This rule does not incorporate any subsequent (A) Hospitals enrolled as MO HealthNet providers shall include the “Present on Admission” (POA) indicator on the CMS 1450 UB-04 or electronic equivalent when submitting inpatient claims for payment. The POA indicator is to be used according to the Official Coding Guidelines for Coding and Reporting and the Center for Medicare & Medicaid Services (CMS) guidelines.

The POA indicator prompts review of inpatient hospital claims with a HCAC diagnosis code.

(B) All MO HealthNet enrolled hospitals must report HCACs on claims submitted to MO HealthNet for consideration of payment.

(C) The MO HealthNet Division, or its designee, will identify the occurrence of HCACs based on the POA indicator, and calculate the payment recoupments based on the facts of each HCAC, for hospitals reimbursed on a per diem.

(D) The MO HealthNet Division, or its designee, will identify the occurrence for HCACs for hospitals paid on a Diagnosis Related Group (DRG) by identified diagnosis codes. The identified diagnosis code related to the HCAC will be excluded from the claim prior to assigning the All Patient Refined Diagnosis Related Group (APR-DRG) and severity level, which determines the level of payment to the provider.

(3) Payment to hospitals enrolled as MO HealthNet providers for care related only to the treatment of the consequences of an Other Provider-Preventable Condition (OPPC) will be denied or recovered by the MO HealthNet Division when the OPPC is determined to— (A) Be within the control of the hospital;

(B) Have occurred during an inpatient hospital admission, outpatient hospital care, or care in an ambulatory surgical center;

(C) Have resulted in serious harm;

(D) Otherwise result in an increase in payment of the identified OPPC; and (E) Be a 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.

(4) Other Provider-Preventable Conditions (OPPC) are to be billed as follows:

(A) Medical claims using the CMS 1500 claim form must be billed with the surgical procedure code and modifier which indicates the type of OPPC: modifier PA (wrong body part), PB (wrong patient), or PC (wrong surgery), AND/OR at least one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part must be present as one (1) of the first four (4) diagnosis codes on the claim;

(B) Outpatient hospital claims using the CMS 1450 UB-04 claim form or its electronic equivalent must be billed with at least one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part within the first five (5) diagnosis codes listed on the claim;

(C) Inpatient hospital claims, using the CMS 1450 UB-04 claim form or its electronic equivalent must be billed with a type of bill 0110.

1. If there are covered services or procedures provided during the same stay as the OPPC, then the facility must submit two (2) claims; one (1) claim with covered services unrelated to the OPPC event and the other claim for any and all services related to the OPPC event.

2. The Type of Bill 0110 claim must also contain one (1) of the diagnosis codes indicating wrong surgery, wrong patient, or wrong body part within the first five (5) diagnosis codes listed on the claim; and (D) The MO HealthNet Division will identify the occurrence of OPPCs based on the type of bill, diagnoses, procedures, and Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) modifiers submitted on the claim. Payment for the claims will be denied, if appropriate.

(5) A MO HealthNet participant shall not be liable for payment for an item or service related to an OPPC or HCAC or the treatment of consequences of an OPPC or HCAC that would have been otherwise payable by the MO HealthNet Division.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2025. Material in this rule originally filed as

13 CSR 70-15.200. Original rule filed Nov. 30, 2011, effective June 30, 2012. Amended: Filed Aug. 28, 2018, effective April 30, 2019. {#sec-13-csr-70-15.200. omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.200.}

Amended: Filed Nov. 14, 2019, effective May 30, 2020. Amended:

Filed Nov. 13, 2020, effective May 30, 2021. Amended: Filed Nov. 22, 2021, effective June 30, 2022. Amended: Filed Dec. 15, 2022, effective July 30, 2023. Amended: Filed Nov. 6, 2023, effective May 30, 2024. Amended: Filed July 16, 2025, effective Feb. 28, 2026. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-3.240 MO HealthNet Primary Care Health Homes {#sec-13-csr-70-3.240 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.240}

PURPOSE: This rule establishes the MO HealthNet Primary Care Health Home program for MO HealthNet participants with chronic conditions.

(1) Definitions.

(A) EMR—Electronic Medical Records, also referred to as Electronic Health Records (EHR).

(B) Health Home—A primary care practice or site that provides comprehensive primary physical and behavioral health care to MHD patients with chronic physical and/or behavioral health conditions, using a partnership or team approach between the Health Home practice’s/site’s health care staff and patients in order to achieve improved primary care and to avoid preventable hospitalization or emergency department use for conditions treatable by the Health Home.

(C) Meaningful Use Stage One—The American Recovery and Reinvestment Act (ARRA) of 2009 created the Electronic Health Records (EHR) incentive payments program to provide Medicare or Medicaid incentive payments to eligible professionals in primary care practices. Meaningful use means that the eligible professionals or providers document that they are using certified EHR technology in ways that can be measured significantly in quality and in quantity. Stage one of meaningful use means the eligible professionals meet twenty (20) out of twenty-five (25) meaningful use objectives as specified by the Centers for Medicare and Medicaid Services (CMS).

(D) MHD—MO HealthNet Division, Department of Social Services.

(E) NCQA—National Committee for Quality Assurance, an entity chosen by MHD to certify that a primary care practice has obtained a level of Health Home recognition after the practice achieves specified Health Home standards.

(F) Needy Individuals—Patients whose primary care services are either reimbursed by MHD or the Children’s Health Insurance Program (CHIP), or are provided as uncompensated care by the primary care practice, or are furnished at no cost or at reduced cost to patients without insurance.

(G) Patient Panel—The list of patients for whom each provider at the practice site serves as the primary care provider.

(H) CMS—Centers for Medicare and Medicaid Services.

(I) Chronic Pain—Pain that lasts past the time of normal healing and that can lead to other medical conditions such as substance use disorder, becoming overweight/obese, anxiety, and depression. For the purpose of participant eligibility for Primary Care Health Home, chronic pain must be a pre-existing condition for at least twelve (12) consecutive months.

(2) A primary care practice site shall meet the following requirements at the time of the site’s application to be considered for selection as a Health Home site by MHD and for participation in a Health Home learning collaborative:

(A) It must have substantial Medicaid utilization in its patient population, with needy individuals comprising no less than twenty-five percent (25%) of its patient population;

(B) It must demonstrate that it has strong engaged leadership committed to, and capable of, leading the practice site through a continuing Health Home transformation process and sustaining transformed practice processes;

(C) It must have patient panels assigned to each primary care clinician;

(D) It must actively utilize MHD’s comprehensive electronic health record for care coordination and prescription monitoring for MHD participants;

(E) It must utilize an interoperable patient registry to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and produce exception reports for care planning;

(F) It must meet the minimum access requirements of thirdnext-available appointment within thirty (30) days and sameday urgent care;

(G) It must have completed EMR implementation and have been using EMR at stage one of meaningful use for at least six (6) months prior to the beginning of Health Home services; and (H) It must comply with established time frames for Health Home applications, inquiry submission, learning collaborative attendance, and any reporting deadlines.

(3) Health Home Responsibilities After Selection.

(A) Health Home practice sites will have a physician champion to provide physician leadership and encourage practice transformation to the Health Home model. Health Home practice sites shall form a health team comprised of, at a minimum, a primary care physician (i.e., family practice, internal medicine, or pediatrics) or nurse practitioner, a behavioral health consultant, and a nurse clinical care manager. The team will be supported as needed by the care coordinator, Health Home Director, and the practice administrator or office manager. Other team members may include, for example, dietitians, nutritionists, pharmacists, or social workers.

(B) Practice sites selected to be MHD Health Homes shall participate in Health Home webinars, care team forums, and other training opportunities. A Health Home will participate in topical work groups as requested by MHD.

(C) Health Homes shall convene practice team meetings at regular intervals to assist with the practice’s transformation into a Health Home and to support continual Health Home evolution.

(D) A Health Home shall create and maintain a patient registry using EHR software, a stand-alone registry, or a thirdparty data repository and measures reporting system. The patient registry is the system used to obtain information critical to the management of the health of a primary care practice’s patient population, including dates of services, types of services, and laboratory values needed to track chronic conditions. The Health Home’s patient registry will be used for— 1. Patient tracking;

2. Patient risk stratification;

3. Analysis of patient population health status and individual patient needs; and 4. Reporting as specified by MHD.

(E) Primary care practice sites must transform how they operate in order to become Health Homes. Transformation involves mastery of thirteen (13) Health Home core competencies to be taught through the learning collaborative. The thirteen (13) core competencies are— 1. Patient/family/peer/advocate/caregiver-centeredness or a whole-patient orientation to care;

2. Multi-disciplinary team-based approach to care;

3. Personal patient/primary care clinician relationships;

4. Planned visits and follow-up care;

5. Population-based tracking and analysis with patientspecific reminders;

6. Care coordination across settings, including referral and transition management;

7. Integrated clinical care management services focused on high-risk patients including medication management, such as medication histories, medication care plans, and medication reconciliation;

8. Patient and family education;

9. Self-management support by members of the practice team;

10. Involvement of the patient in goal setting, action planning, problem solving, and follow-up;

11. Evidence-based care delivery, including stepped care protocols;

12. Integration of quality improvement strategies and techniques; and 13. Enhanced access.

(F) By the eighteenth month following the receipt of the first MHD Health Home payment, a practice site participating in the Health Home program shall demonstrate to MHD that the practice site has either— 1. Submitted to the National Committee for Quality Assurance (NCQA) an application for Health Home status and has obtained NCQA recognition of Health Home status of at least Level 1 under the most recent NCQA standard; or 2. Applied to a nationally recognized accrediting organization for certification as a Primary Care Medical Home.

(G) A Health Home shall submit to MHD or its designee the following information, as further specified by MHD or its designee, within the specified time frames:

1. Monthly narrative practice reports that describe the Health Home’s efforts and progress toward implementing Health Home practices;

2. Monthly clinical quality indicator reports utilizing clinical data obtained from the Health Home’s patient registry or third-party data repository; and 3. Other reports as specified by MHD.

(H) Practices selected to participate in the Health Home program must provide evidence of Health Home practice transformation on an ongoing basis using measures and standards established by MHD. Evidence of Health Home transformation includes:

1. Development of fundamental Health Home functionality at six (6) months and at twelve (12) months of entering the Health Home program, based on an assessment process to be applied by MHD or its designee;

2. Significant improvement on clinical indicators specified by and reported to MHD or its designee; and 3. Development of quality improvement plans to address gaps and opportunities for improvement identified during and after the Health Home application process.

(I) A Health Home must notify MHD within five (5) working days of the following changes:

1. Changes in the employment or contracting of Health Home team members, or changes in the percentage of fulltime equivalent work time devoted to the Health Home by any Health Home team member; or 2. If the Health Home experiences substantive changes in practice ownership or composition, including:

A. Acquisition by another practice;

B. Acquisition of another practice; or C. Merger with another practice.

(J) Health Homes shall participate in evaluations determined necessary by CMS and/or MHD. Participation in evaluations may require responding to surveys and requests for interviews of Health Home practice staff and patients. Health Homes shall provide all requested information to an evaluator in a timely fashion.

(K) Within three (3) months of selection to be a Health Home, a practice site will develop processes with area hospitals to share information on Health Home participants admitted to inpatient departments or seen in the emergency department.

(L) In order to provide Health Home services to a participant with substance use disorder and who is eligible for Health Home services in accordance with subparagraph (4)(A)2.A., a Primary Care Health Home practice must have at least one (1) performing provider who qualifies and applies for a waiver under the Drug Addiction Treatment Act of 2000 (DATA 2000) to provide medication-assisted treatment.

(M) In order to provide Health Home services to enrolled participants with chronic pain, clinicians in a Primary Care Health Home must participate in monthly interactive video conferences on chronic pain that will be scheduled by accredited academic institutions. The video conferences will include pain management specialists who will provide guidance on the care of participants with a chronic pain diagnosis. Health Homes will directly collaborate with a pain management specialist on the management of these individuals. A pain management specialist is defined as a licensed physician (MD or DO) who is board certified in anesthesiology or pain management.

(4) Health Home Patient Requirements.

(A) To become a MO HealthNet Health Home patient, an individual— 1. Must be an MHD participant or a participant enrolled in an MHD managed care health plan; and 2. Must have at least— A. Two (2) of the following chronic conditions:

(I) Asthma;

(II) Diabetes;

(III) Cardiovascular disease;

(IV) A developmental disability;

(V) Be overweight, as evidenced by having a body mass index (BMI) of at least twenty-five (25) for adults, or being at or above the eighty-fifth (85th) percentile on the standard pediatric growth chart for children;

(VI) Depression;

(VII) Anxiety;

(VIII) Substance use disorder; or (IX) Chronic pain; or B. One (1) chronic health condition and be at risk for a second chronic health condition as defined by MHD. In addition to being a chronic health condition, diabetes shall be a condition that places a patient at risk for a second chronic condition. Smoking or regular tobacco use shall be considered at-risk behavior leading to a second chronic health condition; or C. One (1) of the following stand-alone chronic conditions:

(I) Uncontrolled pediatric asthma as defined by MO HealthNet;

(II) Obesity, as evidenced by having a BMI over thirty (30) for adults, or being above the ninety-fifth (95th) percentile on the standard pediatric growth chart for children; or (III) Chronic pain.

(B) A list of participants eligible for Health Home services and identified by MHD as existing users of services at Health Home practices will be provided monthly to each Health Home based on qualifying chronic health conditions. Health Home organizations will determine enrollees from the lists provided by MHD as well as practice patients identified through the Health Homes’ EMR systems.

(C) After being enrolled in Health Homes, participants will be granted the option at any time to change their Health Homes if desired. Participants will be given the opportunity to opt out of receiving services from their Health Home providers.

(5) Required Health Home Services.

(A) All Health Homes shall provide clinical care management services for enrolled patients, including those who are at high risk for future hospital inpatient admissions or hospital emergency department use.

1. Essential clinical care management services include:

A. Identification of high-risk patients and use of patient information to determine the level of participation in clinical care management services;

B. Assessment of preliminary service needs;

C. Individual treatment plan development for each patient, including patient goals, preferences, and optimal clinical outcomes;

D. Intensive monitoring, follow-up, and clinical management of high-risk patients;

E. Assignment of health team roles and responsibilities by the clinical care manager;

F. Monitoring of individual and population health status and service use to determine adherence to, or variance from, treatment guidelines;

G. Development of treatment guidelines for health teams to follow across risk levels or health conditions; and H. Development and dissemination of reports that indicate progress toward meeting desired outcomes for client satisfaction, health status, service delivery, and costs.

2. Clinical care management activities generally include frequent patient contact, clinical assessment, medication review and reconciliation, communication with treating clinicians, and medication adjustment by protocol.

3. A Health Home shall employ or contract with at least one (1) licensed nurse as the Health Home clinical care manager responsible for providing clinical care management services. The clinical care manager shall function as a member of the Health Home practice team whenever patients of the practice team are receiving clinical care management services.

4. Health Homes shall ensure and document that funding for clinical care management services is used exclusively to provide clinical care management services.

5. Recognized Health Homes may collaborate in the provision of clinical care management services.

(B) Health Homes shall provide health promotion services for their patients. Health promotion services include:

1. Providing health education specific to a patient’s chronic conditions;

2. Emphasizing patient self-direction, planning, and skill development so patients can help manage and monitor their chronic health conditions;

3. Providing support for improving social networks; and 4. Providing health-promoting lifestyle interventions, including, but not limited to:

A. Substance abuse prevention;

B. Smoking prevention and cessation;

C. Nutritional counseling;

D. Obesity prevention and reduction; and E. Physical exercise activities.

(C) All Health Homes shall provide comprehensive care coordination services necessary to implement individual treatment plans, reduce hospital inpatient admissions, and interrupt patterns of frequent hospital emergency department use.

1. Care coordination requires that a member of the Health Home team assist patients in the development, revision, and implementation of their individual treatment plans.

2. Care coordination also includes appropriate linkages, referrals, and follow-ups to needed services and supports.

3. Health Homes that specialize in primary physical health care shall obtain the services of a licensed behavioral health professional to assist with care coordination services.

4. Other essential care coordination activities include:

A. Appointment scheduling;

B. Arranging transportation for medically-necessary services;

C. Monitoring referrals and follow-ups;

D. Providing comprehensive transitional care by collaborating with physicians, nurses, social workers, discharge planners, pharmacists, and other health care professionals to continue implementation of patients’ treatment plans;

E. For patients with developmental disabilities (DD), coordinating with DD case managers for services more directly related to habilitation and other DD-related services;

F. Referring Health Home patients to social and community resources for assistance in areas such as legal services, housing, and disability benefits; and G. Providing individual and family support services by working with patients and their families to increase their abilities to manage the patients’ care and live safely in the community.

(6) Hospitals and participating Health Home sites shall communicate transitional care planning for Health Home participants, including inpatient discharge planning, such that effective patient-centered, quality-driven provider coordination is ensured.

(7) Health Home Payment Components.

(A) General.

1. All Health Home payments to a practice site are contingent on the site meeting the Health Home requirements set forth in this rule. Failure to meet these requirements is grounds for revocation of a site’s Health Home status and termination of payments specified within this rule.

2. MO HealthNet Health Home reimbursement will be in addition to a provider’s existing MHD reimbursement for services and procedures and will not change existing reimbursement for a provider’s non-Health Home services and procedures.

3. No Health Home payments will be made to an MHD Health Home until the calendar month immediately following the Health Home’s first learning collaborative session.

4. Should experience reveal to MHD that elements of the Health Home payment methodology will not function, or are not functioning, as MHD intended, MHD reserves the right to make changes to the payment methodology after consultation with recognized Health Homes and receipt of required federal approvals.

(B) MHD Health Homes shall receive per-member-permonth (PMPM) payments to reimburse Health Home sites for costs incurred for patient clinical care management services, comprehensive care coordination services, health promotion services, and Health Home administrative and reporting costs.

1. A Health Home’s PMPM reimbursement will be determined from the number of patients that choose, or are assigned to, the Health Home site.

2. A current month’s PMPM payments to a Health Home site will be based on— A. The number of Health Home-eligible patients receiving Health Home services at the Health Home in the month considered for payment;

B. The number of Health Home-eligible patients in subparagraph (7)(B)2.A. who are assigned to the Health Home at the beginning of the month considered for payment; and C. The number of Health Home-eligible patients in subparagraphs (7)(B)2.A. and (7)(B)2.B. who are Medicaideligible at the end of the month considered for payment.

3. A Health Home will receive PMPM payments only for MHD or MHD managed care participants who meet the payment requirements in paragraph (7)(B)2. and who have the required qualifying health home conditions specified in

section (4).

4. In order to generate a PMPM payment to a Health Home, a patient assigned to the Health Home must have received at least one (1) non-Health Home service based on paid Medicaid fee for service or managed care claims.

5. In order to receive PMPM payments, a Health Home must demonstrate to MHD that the Health Home has hired, or has contracted with, a clinical care manager to provide services at the Health Home site.

(8) Health Home Corrective Action Plans.

(A) Health Homes shall undergo an assessment process to be applied by MHD or its designee at six (6) months and at twelve (12) months of entering the Primary Care Health Home program. If the assessment shows that a Health Home practice site fails to meet the Health Home requirements as set forth in section (3) of this rule, or fails to provide the required Health Home services as set forth in section (5) of this rule, the Health Home practice site shall participate in a corrective action plan to address any such failures disclosed as a result of the assessment process. The corrective action plan will last for six (6) months and may be extended or renewed at MHD’s discretion. At the end of the corrective action plan period, the Health Home practice site will be reassessed to determine its compliance with the requirements of this rule.

(B) The Health Home practice site will be reassessed at the end of the corrective action plan period, including any extensions and renewals granted by MHD. If the reassessment shows that the Health Home still fails to meet Health Home requirements or provide required Health Home services, MHD shall terminate the Health Home practice site from the Primary Care Health Home program.

rule filed Dec. 15, 2011, effective July 30, 2012. Amended: Filed Sept. 29, 2016, effective June 30, 2017. Amended: Filed Nov. 27, 2019, effective June 30, 2020. *Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993,

13 CSR 70-3.250 Payment Policy for Early Elective Delivery 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. {#sec-13-csr-70-3.250 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.250}

(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 thirtynine (39) weeks gestation without medical necessity.

(2) Early elective deliveries, or deliveries before thirty-nine (39) weeks gestation without a medical indication, shall not be reimbursed by the MO HealthNet Division (MHD).

Those delivery-related services shall be denied or recouped by MHD. Non-payment includes services billed by the delivering physicians/provider and the delivering institution.

(3) Services determined to be caused by Early Elective Delivery— (A) All services provided during the delivery-related stay at the delivering institution for maternal care related to an early elective delivery shall not be reimbursed by MHD. Nonpayment or recoupment includes obstetric and institutional or facility charges; and (B) Non-routine newborn services provided for newborns during the initial delivery-related stay at the delivering institution for conditions resulting from an early elective delivery and that are identified within seventy-two (72) hours of delivery may be subject to review and recoupment. Nonpayment or recoupment includes facility or institutional charges.

(4) Payment for delivery prior to thirty-nine (39) weeks shall only be made if delivery is medically indicated.

(A) Services must be consistent with accepted health care practice standards and guidelines. MHD, through consultants, including expertise in obstetrics and pediatrics/neonatology, shall audit deliveries prior to thirty-nine (39) weeks gestational age that are billed to MHD for medical necessity and review those that would potentially be denied due to questions regarding medical necessity and non-routine services provided for newborns during the initial delivery related stay. Documentation must adequately demonstrate sufficient evidence of medical necessity to justify delivery prior to thirty-nine (39) weeks. Evidence shall include information of substantial nature about the pregnancy-complicating condition which is directly associated with the need for delivery prior to thirty-nine (39) weeks. Delivery will be considered medically necessary if without delivery the mother or child would be adversely affected (significant and immediate impact on the normal function of the body, illness, infection, mortality).

(B) Delivery must be demonstrated to be— 1. Of clear clinical benefit and required for reasons other than convenience of the patient, family, or medical provider; and 2. Appropriate for the pregnancy-complicating condition in question.

(C) The determination of services caused by Early Elective Delivery shall be a final decision of the MO HealthNet Division.

(5) If a newborn or mother or both are transferred to another hospital for higher level care following standard medical practice, the receiving hospital shall not be subject to this early elective delivery policy. The hospital receiving the transfer shall be reimbursed following MHD reimbursement rules.

History

• AUTHORITY: section 208.201, RSMo 2016. Original rule filed March 12, 2014, effective Sept. 30, 2014. Amended: Filed June 18, 2025, effective Jan. 30, 2026.

13 CSR 70-3.260 Payment Policy for Asthma Education and In-Home Environmental Assessments {#sec-13-csr-70-3.260 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.260}

(Moved to 13 CSR 70-25.150)

13 CSR 70-3.280 Home and Community-Based Services Waiver Definitions {#sec-13-csr-70-3.280 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.280}

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.

(2) “Heightened Scrutiny” is a process whereby a provider submits information to Department of Social Services (DSS), or its designee, to overcome the presumption that the setting has the qualities of an institution. If DSS or its designee, based on the information presented by the provider, determines that the setting does have the qualities of a home and community-based setting, the evidence will be sent to the Centers for Medicare and Medicaid Services. The Centers for Medicare and Medicaid Services will review evidence submitted by the state and make a final determination as to whether the evidence is sufficient to overcome the presumption that the setting has the qualities of an institution. These settings include those in a publicly or privately-owned facility that provide inpatient treatment; are on the grounds of, or are immediately adjacent to, a public institution; or that have the effect of isolating individuals receiving Medicaid-funded Home and Community-Based Services (HCBS) from the broader community of individuals not receiving Medicaid-funded HCBS.

(3) “Home and Community-Based Services” are MO HealthNet Division covered services provided to individuals in their own home or community rather than in a hospital, nursing home, or intermediate care facility for individuals with intellectual disabilities.

(4) “Home and Community-Based Services Waiver” is a program approved by the Centers for Medicare and Medicaid Services under the authority of Section 1915(c) of the Social Security Act that provides home and community based services.

(5) “Hospital” is a facility licensed by the Missouri Department of Health and Senior Services, or by the appropriate state agency for facilities located in another state, as an acute care, psychiatric or rehabilitation hospital.

(6) “Institution for Mental Diseases (IMD)” is a hospital, nursing facility, or other institution of seventeen (17) beds or more that is primarily engaged in providing diagnosis, treatment, or care of people with mental diseases.

(7) “Intermediate Care Facilities for individuals with Intellectual disability (ICF/IID)” is a facility as defined at 19 CSR 30-83.010(24).

(8) “Missouri Medicaid Audit and Compliance Unit (MMAC)” is the unit within the Department of Social Services that is responsible for the oversight and auditing of compliance for the Medicaid Title XIX, CHIP Title XXI, and Waiver Program in Missouri, which includes the oversight and auditing of compliance of MO HealthNet providers and Medicaid participants through the lock-in program. MMAC is charged with the responsibility of detecting, investigating, and preventing fraud, waste, and abuse of the Missouri Medicaid Title XIX, CHIP Title XXI, and Waiver Programs.

(9) “MO HealthNet” is the division within the Department of Social Services, pursuant to sections 208.001 and 208.201, RSMo, that administers the Medicaid Title XIX, CHIP Title XXI, and waiver programs, approves claims from MO HealthNet providers for services or merchandise provided to eligible Medicaid participants, and authorizes and disburses payment for those services or merchandise accordingly.

(10) “MO HealthNet Program” is a program operated pursuant to Title XIX of the Social Security Act, Title XXI of the Social Security Act and/or waiver programs authorized by the United States Department of Health and Human Services.

(11) “Licensed Nursing Home” is a skilled nursing facility as defined at 19 CSR 30-83.010(49).

(12) “Person-Centered Service Plan” is a document that is the result of a planning process which identifies the strengths, capacities, preferences, needs, goals, and desired personal outcomes of the individual.

(13) “Provider” is a person or entity who enters into a contract or provider agreement with MMAC for the purpose of providing items or services to Missouri Medicaid participants. Provider includes ordering and referring physicians, dentists, and nonphysician practitioners.

(14) “Provider Owned or Controlled Residential Setting” is a physical place where an individual resides and is owned, coowned, and/or operated by a provider of HCBS. A setting is considered provider owned or controlled if the HCBS provider leases from a third party or owns the property. If the HCBS provider does not lease or own the property but has a direct or indirect financial relationship with the property owner, the setting is considered provider controlled unless the property owner or provider establishes that the nature of the relationship did not affect either the care provided or the financial conditions applicable to tenants.

(15) “Residential Setting” is a physical place to live where an individual has services and supports, ranging from twentyfour- (24-) hour supervision to on-call assistance, to live as independently as possible.

(16) “Revalidation” is a requirement that all existing MO HealthNet Program providers must go through in accordance with 13 CSR 65-2 to continue to be a MO HealthNet Program (17) “Setting” is the place where a home and community-based service or support is provided.

Original rule filed Dec. 21, 2018, effective July 30, 2019. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-3.290 Home and Community-Based Services Waiver Setting Requirements {#sec-13-csr-70-3.290 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.290}

PURPOSE: This rule 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) establishing the requirements that must be met for settings in which home and community-based services are provided under a 1915(c) HCBS Waiver Program. 1915(c) Home and Community-Based Services (HCBS) Waiver Programs are programs that provide home and community based services to individuals who, in the absence of those services, require the level of care provided in a hospital, a nursing facility, or an ICF/IID.

To offer a 1915(c) HCBS Waiver Program the state must submit a waiver application for approval to the Centers for Medicare and Medicare Services, who, on behalf of the Secretary of Health and Human Services, determines if the waiver meets the statutory and regulatory requirements found in 42 CFR 441.301–441.310.

(1) Home and Community-Based Setting Requirements. Home and community-based settings must have all of the following qualities based on the needs of individuals as indicated in their person-centered service plans:

(A) The setting is integrated in and supports full access of individuals receiving Medicaid Home and Community-Based Services (HCBS) to the greater community, including providing opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS;

(B) The setting is selected by the individual from setting options, including non-disability specific settings and an option for a private unit in a residential setting. The setting options are identified and documented in the person-centered service plan and are based on the individual's needs, preferences, and, for residential settings, resources available for room and board;

(C) The setting ensures the individual’s rights of privacy, dignity, and respect, and freedom from coercion and restraint;

(D) The setting optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact;

(E) The setting facilitates individual choice regarding services and supports, and who provides them; and (F) In a provider-owned or controlled residential setting, in addition to the qualities at 13 CSR 70-3.290 (1)(A) through (E), the following additional conditions must be met:

1. The unit or dwelling is a physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/ tenant law of the State of Missouri, county, city, or other designated entity. For settings in which landlord/tenant laws do not apply, a lease, residency agreement, or other form of written agreement must be in place for each HCBS participant, and that document must provide protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord tenant law;

2. Individuals have privacy in their sleeping or living unit including:

A. Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors;

B. Individuals sharing units have a choice of roommates in that setting;

C. Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement;

3. Individuals have the freedom and support to control their own schedules and activities, and have access to food at any time;

4. Individuals are able to have visitors of their choosing at any time;

5. The setting is physically accessible to the individual; and 6. Any modification of the additional conditions, under (1)(F)1. through 4. of this rule, must be supported by a specific assessed need and justified in the person-centered service plan.

If any modifications are made, the following requirements must be documented in the person-centered service plan:

A. A specific and individualized assessed need;

B. Positive interventions and supports used prior to any modifications to the person-centered service plan;

C. Less intrusive methods of meeting the need that have been tried but did not work;

D. A clear description of the condition that is directly proportionate to the specific assessed need;

E. Regular collection and review of data to measure the ongoing effectiveness of the modification;

F. Established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;

G. The informed consent of the individual; and H. An assurance that interventions and supports will cause no harm to the individual.

(2) Settings that are not Home and Community-Based. Home and community-based settings do not include the following:

(A) A nursing facility;

(B) An institution for mental diseases;

(C) An intermediate care facility for individuals with intellectual disabilities;

(D) A hospital; or (E) Any other locations that have qualities of an institutional setting, as determined by the Department of Social Services (DSS) or its designee.

(3) Heightened Scrutiny process. Any setting that is located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment, or in a building on the grounds of, or immediately adjacent to, a public institution, or any other setting that has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS, will be presumed to be a setting that has the qualities of an institution and is not a home and community based setting. The provider may submit information to DSS or its designee as evidence that the setting does have the qualities of a home and communitybased setting. If DSS or its designee, based on the information presented by the provider, determines that the setting does have the qualities of a home and community-based setting, the evidence will be sent to the Centers for Medicare and Medicaid Services to make the final determination as to whether the evidence is sufficient to overcome the presumption that the setting has the qualities of an institution.

(4) Provider Enrollment.

(A) Prior to enrolling with MO HealthNet, HCBS providers will need to certify in writing on forms provided by the Missouri Medicaid Audit and Compliance Unit (MMAC) that they understand and will comply with the requirements of this

rule. Providers will certify by the signature of an authorized agent of the business as part of their MO HealthNet application documentation. Providers that refuse to certify shall be denied enrollment with MO HealthNet.

(B) HCBS providers shall be subject to a pre-enrollment site visit per 13 CSR 65-2.020(9)(B)(2)(B). Enrolling HCBS providers who are non-compliant with sections (1)–(3) of this rule shall be denied enrollment with MO HealthNet.

1. Providers who request in writing an extension to their application process in order to become compliant with sections (1)-(3) of this rule shall be granted thirty (30) calendar days to become compliant, without paying an additional application fee per 13 CSR 65-2.020(5). This thirty- (30-) day time period is in accordance with the provisions of 13 CSR 70-3.020(2)(D) and MMAC shall notify the provider in writing of the thirty- (30-) day extension accordingly. If, at the end of the thirty- (30-) day extension, the provider is still non-compliant, the provider shall be denied enrollment.

(5) Provider Revalidation. All MO HealthNet providers must revalidate in accordance with 13 CSR 65-2.020(4). HCBS providers must be compliant with sections (1)-(3) of this rule upon revalidation or they shall not be entitled to continued MO HealthNet participation. If an enrolled HCBS provider is found to be out of compliance during its revalidation process, the provider shall be granted thirty (30) days to come into compliance or shall be denied continued enrollment in the MO HealthNet program.

(6) Providers enrolled with MO HealthNet on or after March 17, 2014, must be in compliance and maintain continued compliance with all the requirements of this regulation upon publication of the regulation.

(7) Providers enrolled with MO HealthNet prior to March 17, 2014, that do not meet the requirements of this regulation, must come into compliance within ninety (90) days of the publication of this regulation or submit and have approved a remediation plan to come into compliance with the requirements of this regulation. The remediation plan must be submitted and approved by DSS or its designee. All providers must be in compliance with the requirements of this regulation no later than March 17, 2022.

(8) Sanctions. Enrolled providers that are non-compliant with sections (1)-(7) of this rule, during their participation with MO HealthNet, are subject to sanctions per 13 CSR 70-3.030.

(A) DSS or its designee shall inform enrolled providers of noncompliance in writing by e-mail or U.S. Mail.

(B) Enrolled providers shall submit a plan to remediate areas of non-compliance (“transition plan”) to DSS or its designee within forty-five (45) calendar days of the notice of noncompliance.

(C) Remediation must be complete within one hundred twenty (120) days of the notice of non-compliance or the provider shall be subject to sanctions per 13 CSR 70-3.030 (5)(A).

Original rule filed Dec. 21, 2018, effective July 30, 2019. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-3.300 Complementary Health and Alternative Therapies for Chronic Pain Management for the complementary health and alternative therapies for chronic pain management for adult Medicaid participants. The goal of this policy is to improve health outcomes and decrease opioid use by adult participants to manage chronic pain. {#sec-13-csr-70-3.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.300}

(1) Administration.

(A) This rule governs the practice of complementary health and alternative therapy for adult participants as a covered MO HealthNet benefit. The intent of this regulation is to provide complementary health and alternative therapy, coordinated by the prescribing physician, in an effort to provide alternatives to opioid use for the treatment of chronic pain, reduce opioid misuse, improve MO HealthNet participants’ chronic pain management skills, reduce avoidable costs, and improve health outcomes.

(B) Complementary health and alternative therapy for chronic pain management 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 Physician Provider Manual, which is incorporated by reference and made a part of this 65109, at its website http://www.dss.mo.gov/mhd on August 15, 2018. This rule does not incorporate any subsequent (C) The following definitions will be used in administering this rule:

1. “Adult participant” means a person who is at least twenty-one (21) years of age or older and who is enrolled as a MO HealthNet participant;

2. “Complementary health and alternative therapy for chronic pain” combines the use of physical therapy, cognitivebehavioral therapy, chiropractic therapy, and/or acupuncture to promote chronic pain relief for adult participants;

3. “Physical therapy treatment for chronic pain” includes, but is not limited to, participant education and counseling, manual techniques, therapeutic exercises, electrotherapy, and massage;

4. “Cognitive-behavioral therapy for chronic pain” or “CBT” combines treatment of emotional thinking and behavioral health for participants with chronic pain, trains in behavioral techniques, and helps patients modify situational factors and cognitive processes that exacerbate pain;

5. “Chiropractic therapy for the treatment of chronic pain” may include, but is not limited to, spinal manipulation or spinal adjustment, and as further defined by section 331.010.1, RSMo;

6. “Acupuncture” involves the use of needles inserted into the body by piercing of the skin and other modalities as defined by sections 331.030.8 and 324.475(1), RSMo;

7. “Prescribing physician” means a physician licensed under Chapter 334, RSMo, who specializes in family medicine or internal medicine and is authorized to prescribe medication or other therapy within the scope of such person’s practice;

8. “Complementary health and alternative therapy provider” means a complementary health and alternative therapy care provider licensed by the state of Missouri and authorized to provide health care services within the scope of such person’s practice;

9. “First-line non-opioid medication therapy” includes, but is not limited to, analgesics such as non-steroidal antiinflammatory drugs (NSAIDs), acetaminophen, cyclooxygenase 2 (COX-2) inhibitors, SAM-E herbal therapy, topical analgesics, selected antidepressants, selected anticonvulsants, and/or muscle relaxer medication;

10. “Opioid medication therapy” includes any prescription drug, natural or synthetic, that binds to the brain’s opioid receptors having an addiction-forming or addiction-sustaining ability, or being capable of conversion into a drug having such addiction-forming or addiction-sustaining ability;

11. “Chronic pain” means a non-cancer, non-end-of-life pain lasting more than three (3) months, or longer than the duration of normal tissue healing;

12. “Acute pain” means pain, whether resulting from disease, accidental or intentional trauma, or other cause that the practitioner reasonably expects to last only a short period of time. Acute pain does not include chronic pain, pain being treated as part of cancer care, hospice or other end of life care, or pain being treated as part of palliative care; and 13. “High dose opioid therapy” is to be considered as any therapy greater than ninety (>90) MME (morphine milligram equivalents) per day.

(2) Covered Services and Limitations of Complementary Health and Alternative Therapy for Chronic Pain Management.

(A) Participant eligibility.

1. To qualify for complementary health and alternative therapy for chronic pain, a MO HealthNet participant must be an adult participant with— A. Chronic, non-cancer neck and/or back pain; or B. Chronic pain post traumatic injury, such as traumatic injury resulting from a motor vehicle collision; or C. Other chronic pain conditions as medically necessary.

2. A prescribing physician’s referral to a complementary and alternative therapy provider is necessary for the adult participant to be eligible for complementary health and alternative therapy for chronic pain. The prescribing physician must prescribe the complementary health and alternative therapy in the adult participant’s plan of care during a regular in-office visit.

(B) Provider qualifications.

1. To refer or provide complementary health and alternative therapy, the prescribing physician and the complementary health and alternative therapy provider must be currently enrolled as a MO HealthNet provider and currently licensed in Missouri or a bordering state to provide therapy.

2. Both the prescribing physician and the complementary health and alternative therapy provider must meet the provider qualifications outlined in this regulation to deliver and bill for the service.

(C) Medical Services for Complementary Health and Alternative Therapy for Chronic Pain Management.

1. Adult participants may be referred by the prescribing physician for complementary health and alternative therapy to treat and manage chronic back pain, chronic neck pain, chronic pain resulting from a post-traumatic injury, or other chronic pain conditions as medically necessary.

2. The prescribing physician must seek prior authorization from the MO HealthNet Division prior to the adult participant starting complementary health and alternative therapy.

3. A prescribing physician’s referral to a complementary and alternative therapy provider is necessary for the adult participant to be eligible for complementary health and alternative therapy.

4. The prescribing physician will perform an initial assessment and provide the adult participant evidence-based education regarding pain management during the adult participant’s regular in-office visit.

5. The prescribing physician shall evaluate adult participants in the initial assessment for any potentially serious condition and refer the adult participant for further evaluation and/or diagnostic testing as medically necessary.

6. The prescribing physician shall document the injury, all tried and failed treatments, and shall submit any supporting documentation establishing that chronic pain treatment, or whether further chronic pain treatment, is medically necessary.

7. The prescribing physician will work in conjunction with the complementary health and alternative therapy provider(s) to make recommendations regarding medically necessary services based on clinical criteria and the adult participant’s risk.

8. Covered Services and Limitations.

A. Complementary health and alternative therapy services for qualified adult participants requires a determination by the prescribing physician of a combination of physical therapy, chiropractic therapy, acupuncture, and non-opioid medication therapy, as clinically appropriate.

B. Complementary health and alternative therapy services shall be structured according to the prescribing physician’s preference, but with an allowable maximum of thirty (30) total visits or one hundred twenty (120) units per year, and with one (1) unit equaling fifteen (15) minutes in combination of therapy defined by the prescribing physician.

The prescribing physician shall reassess evidence of the adult participant’s improvement and the risks of complementary health and alternative therapy when considering discontinuing or requesting further coverage of complementary health and alternative therapies for chronic pain.

C. An annual maximum of cognitive-behavioral health visits are to be determined based upon best practice and evidence-based guidelines and are listed in the MO HealthNet Physician Provider’s Manual.

9. Non-opioid and opioid therapy for chronic pain shall include initiating the first-line of non-opioid treatment, use of alternative pain therapy, establishing treatment goals, the use of opioids as supported by clinical guidelines, and the implementation of a tapering plan and schedule as clinically appropriate based upon the adult participant’s clinical presentation. The prescribing physician shall document in the patient’s medical record the method of tapering, progress, and challenges that may require intervention for participants currently receiving long-term opioid medications and/or high dose opioids on a clinically appropriate tapering plan.

10. Cognitive behavioral therapy for each adult participant must be re-assessed by a cognitive-behavioral therapy provider every ninety (90) days for continuation of care, including assessment of any impacts on the participant’s ability to work and function, increased self-efficacy, or other clinically significant improvement.

11. The prescribing physician and the complementary health and alternative therapy provider shall reassess and evaluate the risks and benefits to the adult participant of any complementary and alternative therapies and whether the therapies continue to be medically necessary to continuing treatment, requesting further treatment, and/or discontinuing treatment as medically necessary.

A. Provider(s) of complementary health and alternative therapy will make recommendations for a treatment plan, continuation of services, and the final determination of care.

B. The complementary health and alternative therapy must be deemed medically necessary.

(3) Reimbursement Methodology.

(A) Effective for dates of service beginning February 18, 2019, complementary health and alternative therapy for chronic pain management services will be paid at the Medicaid fee schedule and will be published at https://dss.mo.gov/mhd/ providers/fee-for-service-providers.htm under “Fee Schedules & Rate Lists,” which is incorporated by reference and made

part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109 as of November 13, 2018. This rule does not incorporate any subsequent amendments or additions. This fee schedule is calculated based on 62.5% of the Medicare physician fee schedule rates for physical therapy, acupuncture, and chiropractic services using MO Locality 01 as updated August 28, 2018.

(B) Reimbursement shall only be made for services authorized by the MO HealthNet Division or its designee.

section 208.152, RSMo Supp. 2018.* Original rule filed Aug. 15, 2018, effective March 30, 2019. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and

13 CSR 70-3.310 Chiropractic Services {#sec-13-csr-70-3.310 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.310}

PURPOSE: The purpose of this rule is to establish the Department of Social Services’ MO HealthNet Division guidelines regarding coverage and reimbursement for chiropractic services as mandated in House Bill 1516, 99th General Assembly, section 208.152 RSMo.

(1) Administration. The Chiropractic Program shall be administered by the MO HealthNet Division, Department of Social Services. The chiropractic services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at, http://manuals.momed.com/manuals/, May 15, 2019. additions. Chiropractic services covered by the MO HealthNet program shall include only those which are clearly shown to be medically necessary. The MO HealthNet Division considers medically necessary when all of the following criteria are met:

The member has a neuromusculoskeletal disorder; and the medical necessity for treatment is clearly documented; and improvement is documented within the initial two (2) weeks of chiropractic care. If no improvement is documented within the initial two (2) weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified. If no improvement is documented within thirty (30) days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary. The division reserves the right to effect changes in services, limitations, and fees with proper notification to MO HealthNet chiropractic providers.

(2) Provider Participation. To be eligible for participation in the MO HealthNet Chiropractic Program, a provider must be licensed to practice chiropractic by complying with the provisions of Chapter 331, RSMo and shall have signed a participation agreement to provide chiropractic services under the MO HealthNet program.

(3) Participant Eligibility. Any person who is eligible for Title XIX benefits from the Family Support Division and who is found to be in need of chiropractic services in accordance with the procedures described in this rule shall be deemed eligible to receive these services.

(4) Chiropractic Services. Up to twenty (20) visits per year are covered for services limited to examinations, diagnoses, adjustments, manipulations and treatments of malpositioned articulations, and structures of the body provided by licensed chiropractic physicians practicing within their scope of practice.

(5) Records Retention. Providers who provide chiropractic services must follow section 13 CSR 70-3.030.

History

• AUTHORITY: section 208.152, RSMo Supp 2019, and section 660.017, RSMo 2016. Original rule filed May 15, 2019, effective Nov. 30, 2019. Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-3.320 Electronic Visit Verification (EVV) {#sec-13-csr-70-3.320 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.320}

PURPOSE: This rule sets forth requirements for use of electronic verification of services that the MO HealthNet Division may identify and provide to a MO HealthNet participant with a prior authorization or an approved care plan. This rule also defines terms used by MO HealthNet in establishing procedures for the Electronic Visit Verification (EVV) requirements for Medicaid funded in-home services. These definitions apply solely to the information in this chapter. This rule further establishes the minimum necessary criteria required of Medicaid funded Home and Community Based Services provider agencies in relation to implementation of an EVV system. This rule establishes the minimum necessary criteria of the EVV system required to document delivery of Medicaid funded Home and Community Based Services provided in the home of the MO HealthNet participant. Failure to comply with requirements in this section may result in claim denial or termination of contract to deliver services through the MO HealthNet program.

(1) Definitions.

(A) “Agency Model Services” shall mean a service delivery option in which a MO HealthNet-enrolled agency directs service delivery.

(B) “Aggregator Solution” shall mean the electronic system that supports the collection of electronic visit verification vendor data and stores the data for purposes of analysis and monitoring.

(C) “Direct Care Worker” shall mean the individual providing the Medicaid-funded services to the MO HealthNet participant, either through an agency-based or self-directed model, or through a home health agency.

(D) “Electronic Visit Verification (EVV)” shall mean electronic technology used for the purpose of recording the date, location, begin time, end time, type of service, and any related tasks or memos. EVV also verifies the identity of the MO HealthNet participant and direct care worker in relation to Medicaidfunded services authorized by the Department of Health and Senior Services or the Department of Mental Health, or services provided through a home health agency.

(E) “Exception” shall mean any manual adjustment or update to an EVV record, indicated within the EVV system and passed to the aggregator solution.

(F) “Fiscal Agent” shall mean a person or entity that provides financial management services to a self-directed employer.

(G) “Home Health Care Services” shall mean services provided by a MO HealthNet-enrolled, state-licensed, and Medicarecertified home health agency.

(H) “Manual Visit Entry” shall mean any entry that is not made at the time of the visit or any entry that is modified after the original submission to the EVV system.

(I) “Memo” shall mean documentation clarifying services provided during the visit.

(J) “MO HealthNet Participant” shall mean an individual who the Family Support Division has determined eligible for MO HealthNet benefits who is receiving Medicaid-funded services authorized by the Department of Health and Senior Services, the Department of Mental Health, or through a home health agency.

(K) “Provider Agency” shall mean a MO HealthNet-enrolled agency authorized to deliver Medicaid-funded services as defined in this rule or a state-designated fiscal agent.

(L) “Reason Codes” shall mean codes established by the MO HealthNet Division to be utilized by electronic visit verification vendors to explain a manual visit entry/edit or an acknowledgement of exception, passed along to aggregator solution.

(M) “Self-Directed Services” shall mean a service delivery option in which a MO HealthNet participant employs a direct care worker and directs delivery of service themselves.

(N) “Services” shall mean Medicaid-funded services, as identified by procedure code, or other service required by the state to use EVV including— 1. Consumer-directed/self-directed personal care;

2. Home health agency services;

3. Homemaker services/chore services;

4. In-home respite authorized by the Department of Health and Senior Services;

5. Personal care/advanced personal care;

6. Any of the above services reimbursed by a managed care organization; and 7. Any services where federal or state statute or rule requires EVV, but not specifically listed above.

(O) “Task” shall mean, as applicable, description of a service or services including but not limited to tasks authorized on the care plan.

(2) Provider Agency Responsibilities regarding Electronic Visit Verification.

(A) Provider agencies must communicate with MO HealthNet Participants regarding the requirement to utilize EVV to document receipt of services as a condition of participation in services. Provider agencies delivering services shall contract with an EVV vendor who meets all criteria established in this

rule.

(B) Provider agencies and self-directed fiscal agents who deliver or administer services through Medicaid funding shall utilize EVV and shall use the procedure code and associated modifiers for all visits. EVV requirements are applicable to services authorized through the Department of Health and Senior Services and the Department of Mental Health as well as home health agency services.

(C) EVV requirements do not apply to the following services:

1. Adult day care;

2. Authorized nurse visits;

3. Hospice;

4. Private duty nursing;

5. Provider reassessments;

6. Structured family caregiving;

7. Assisting individuals with their necessary daily needs during delivery of other Department of Mental Health Home and Community Based Services;

8. Services provided in a residential/group setting; or 9. Supplies provided by a home health agency.

(D) Except as provided in subsection (2)(C) of this rule, all MO HealthNet participants who receive services must utilize EVV.

MO HealthNet participants who refuse to utilize an electronic system shall no longer be eligible to receive Medicaid funded services as defined in this rule.

(E) Provider agencies must work with MO HealthNet participants to identify the EVV solution that best accommodates the participant’s individual needs. A participant’s refusal to utilize EVV for services authorized by the Department of Health and Senior Services or the Department of Mental Health must be reported to the authorizing agency.

(F) Provider agencies shall identify all direct care workers by entering the caregiver’s respective Family Care Safety Registrant number as assigned per 19 CSR 30-80.010 to 19 CSR 30-80.040.

(G) Manual visit entry shall be utilized only when the EVV system is unavailable or when exigent circumstances, documented by the provider agency, make usage of the system impossible or impractical. Justification documentation must support any instance of human error and such errors must be readily identifiable. Repeated instances of human error are subject to audit. The provider agency shall enter justification documentation into the EVV system, which may include an editor program. Information shall include the date and time of the manual entry, the reason for the entry, and the identification of the person making the entry. Manual call-in and/or call-out entries shall not be created by the direct care worker and/or participant that generated the original visit entry; they should be created by a provider agency supervisor or administrator. The provider agency must pass a manual entry indicator and reason for manual entry to the aggregator solution within documentation time frames established by the Missouri Medicaid Audit and Compliance Unit.

(H) Any adjustment or exception requires the provider agency to enter justification documentation into the EVV system, which may include an editor program, within documentation time frame requirements established by 13 CSR 70-3.030(3)(A)16. Information must include the date and time of the entry and/or update, the reason for the entry and/or update, and the identification of the person making the entry and/or update.

(I) Provider agencies shall report any suspected falsification of EVV data to the Missouri Medicaid Audit and Compliance Unit via the standard reporting process as defined by the Missouri Medicaid Audit and Compliance Unit within two (2) business days of discovery.

(J) All provider agencies must interface EVV data via their EVV vendor with the aggregator solution designated by the Department of Social Services in a format specified by the Department of Social Services and at a frequency of at least once daily for all days that EVV services are provided.

(K) All provider agencies must log in to the aggregator solution upon initial connection and at a minimum of once weekly thereafter, to ensure capture, full functionality, and accuracy of visit data.

(L) All provider agencies must report replacement of their contracted EVV vendor to the Missouri Medicaid Audit and Compliance Unit via the standard reporting process as defined by the Missouri Medicaid Audit and Compliance Unit within thirty (30) days of the effective date.

(3) Electronic Visit Verification Vendor Responsibilities upon Implementation of an Aggregator Solution.

(A) Pursuant to this rule, the Department of Social Services or its designee must approve the EVV system utilized by a provider agency. In order to be approved, the EVV system must have a primary, secure method for collecting visit data through use of one (1) or more of the following:

1. Location technologies, including but not limited to Global Positioning System (GPS);

2. Telephony (if utilized, the telephone number from which the call is placed is used in lieu of GPS coordinates and must be a telephone number from an established landline in the participant’s place of residence. The utilization of any callforwarding technology is not authorized);

3. Fixed devices placed in the home of the MO HealthNet participant which generate a one- (1-) time password or code;

4. Biometric recognition; or 5. Alternative technology that meets the requirements of this rule.

(B) The EVV vendor must successfully complete interface testing with the aggregator solution and be approved by the Department of Social Services or its designee pursuant to this

rule.

(C) Any cost related to development, modification, or testing of EVV systems shall be the responsibility of the EVV vendor.

(D) In the event of modifications of the state’s requirements or policies affecting the electronic collection of visit data, EVV vendors must update systems as necessary and in a time frame determined by the state.

(E) The Department of Social Services may require reapproval of any qualifying EVV system in circumstances including but not limited to a change in data requirements that must be transmitted to the aggregator component or failure to maintain compliance with the department’s requirements. Any cost related to retesting or reapproval shall be the responsibility of the EVV vendor. EVV vendors who fail to maintain continued compliance with EVV requirements are subject to removal from the list of qualifying vendors at the discretion of the state.

(F) EVV vendors must provide the training necessary for provider agency staff to fully utilize the capabilities of the EVV system. Additionally, the EVV vendor must provide support for the system during standard business hours (8 a.m. to 5 p.m.

Central Time Zone) at a minimum.

(G) EVV vendors must send data to the aggregator solution at a minimum of once daily for all dates that visit data is captured by their provider agencies.

(H) EVV vendors must allow for manual entry or adjustment to visit data with required justification including the applicable reason code, the date and time of the entry, and the identification of the person making the entry. These visits must be sent to the aggregator with original and adjusted data.

(I) EVV systems must allow for manual entry into the EVV system in the event of human error, natural disaster, system failure, or when all other forms of entry have been exhausted or are unavailable.

(J) When employing any form of EVV aside from the use of a designated landline telephone or a fixed object in the MO HealthNet participant’s home, the EVV system must use location technologies to record the location of the direct care worker at the start and stop of service delivery.

(K) For situations in which the provider agency’s EVV system does not provide adequate network capacity, the EVV system shall have the ability to enter visit information in an offline mode and upload upon accessing network connectivity.

(L) At a minimum, the EVV system shall meet the following requirements:

1. Record the type of service performed through collection of the designated procedure code and associated modifiers, including, when required, individual tasks as authorized or a memo;

2. Document and verify the MO HealthNet participant’s identity, either by a unique number assigned to the MO HealthNet participant, biometric recognition, or through alternative technology;

3. Document and verify the direct care worker by the collection of the Family Care Safety Registrant number as assigned per 19 CSR 30-80.010 to 19 CSR 30-80.040;

4. Document the date of services delivered;

5. Document the time services begin to the minute;

6. Document the time services end to the minute; and 7. Document the location in which the services began and ended and identify services provided outside the authorized delivery area.

(M) In addition, the EVV system must demonstrate the following requirements are met:

1. Allow for an unlimited number of service codes and tasks to be available for selection as approved by Department of Social Services;

2. Allow for entry of free text memo field for supporting documentation. Field must meet aggregator solution criteria and be available for viewing by end users;

3. Allow for direct care workers to access the same MO HealthNet participant record for verification of service delivery more than once in a twenty-four (24) hour period;

4. Allow for multiple service delivery locations for each MO HealthNet participant, including multiple locations in a single visit;

5. Accommodate more than one (1) MO HealthNet participant and/or direct care worker in the same home or at the same phone number;

6. Document the delivery of multiple types of services during a single visit without impacting the integrity of the visit;

7. Maintain a reliable backup and recovery process to ensure that the EVV system preserves all data in the event of a system malfunction or disaster;

8. Be capable of retrieving current and archived data to produce reports of services and tasks delivered, memos related to service delivery, MO HealthNet participant identity, direct care worker identity, begin and end time of service delivery, begin and end location of service delivery, and dates of service in summary fashion that constitutes adequate documentation of services delivered;

9. Be capable of identifying visits that do not contain all required data elements. These visits must be sent to the aggregator with original and adjusted data; and 10. Retain all data regarding the delivery of services a minimum of six (6) years as required by 13 CSR 70-3.030(3)

(A)16.F. Fiscal and medical records shall coincide with and fully document services billed to the MO HealthNet agency.

Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this

regulation.

(N) Nothing in this rule shall limit the provider agency’s ability to accrue partial units pursuant to 13 CSR 70-91.010.

(O) Reports from the EVV system are subject to review and audit by the Departments of Social Services, Health and Senior Services, Mental Health, or any federal agency, or their designee.

rule filed July 9, 2020, effective Jan. 30, 2021. Amended: Filed May 23, 2022, effective Nov. 30, 2022. Amended: Filed April 23, 2024, effective Nov. 30, 2024. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993,

13 CSR 70-3.330 Telemedicine Services {#sec-13-csr-70-3.330 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-3.330}

PURPOSE: The purpose of this rule is to establish the division’s guidelines regarding coverage and reimbursement for telemedicine services. The goal of this policy is to allow greater access to care for MO HealthNet participants.

(1) Administration.

(A) The telemedicine program shall be administered by the MO HealthNet Division (MHD). This rule is established pursuant to the authority granted to the Missouri Department of Social Services, MO HealthNet Division, to promulgate rules governing the practice of telemedicine in the MO HealthNet Program and to provide services under established, approved MO HealthNet benefits.

(B) Definitions.

1. Asynchronous store-and-forward shall mean the transfer of a participant’s clinically important digital samples, such as still images, videos, audio, text files, and relevant data from an originating site through the use of a camera or similar recording device that stores digital samples that are forwarded via telecommunication to a distant site for consultation by a consulting provider without requiring the simultaneous presence of the participant and the participant’s treating A. Asynchronous store-and-forward technology shall mean cameras or other recording devices that store images which may be forwarded via telecommunication devices at a later time.

B. Asynchronous store-and-forward transfer shall mean the collection of a participant’s relevant health information and the subsequent transmission of that information from an originating site to a provider at a distant site without the participant being present.

2. Distant site shall mean a telemedicine site where the health care provider providing the telemedicine service is physically located.

3. Originating site shall mean a telemedicine site where the MO HealthNet participant receives the telemedicine service.

Originating sites include, but are not necessarily limited to health care provider facilities, participants’ homes, and schools. For the purposes of asynchronous store-and-forward transfer, the originating site shall also mean the location from which the referring provider transfers information to the distant site.

4. Licensed health care provider-patient relationship shall mean that a health care provider licensed under Chapter 334, RSMo, and/or other providers utilizing telemedicine, shall ensure that a properly established provider-patient relationship exists with the participant who receives telemedicine services.

5. Telemedicine shall mean the delivery of health care services by means of information and communication technologies that facilitate the assessment, diagnosis, consultation, treatment, education, care management, and self-management of a participant’s health care while such participant is at the originating site and the provider is at the distant site. Telemedicine shall also include the use of telephonic or asynchronous store-and-forward technology.

Telemedicine services must be performed with the same standard of care as an in-person, face-to-face service.

6. Health care professional shall mean a physician or other health care practitioner licensed, accredited, or certified by the state of Missouri to perform specified health services consistent with state law.

7. Health care provider or provider shall mean a health care professional or a health care facility.

8. Health care service shall mean a service for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease, including but not limited to the provision of drugs or durable medical equipment.

(2) Providers.

(A) Any licensed/enrolled health care professional shall be authorized to provide telemedicine services if such services to MHD participants are within the scope of practice for which the health care provider is licensed and are provided with the same standard of care as services provided in person. This shall not prohibit a health care entity from reimbursing nonclinical staff for services otherwise allowed by law. This includes applied behavior analysis services rendered by a registered behavior technician under the supervision of a licensed behavior analyst or licensed psychologist or any individual provider delivering services within a Department of Mental Health (DMH) licensed, contracted, and/or certified organization.

(B) In order to treat participants in this state through the use of telemedicine, health care providers shall be fully licensed to practice in this state and shall be subject to regulation by their respective professional boards. In addition, psychologists licensed in a Psychology Interjurisdictional Compact (PSYPACT) state may render telemedicine services under the Authority to Practice Interjurisdictional Telepsychology, according to the requirements in the PSYPACT.

(C) A health care provider utilizing telemedicine at either a distant site or an originating site shall be enrolled as a MO HealthNet provider pursuant to 13 CSR 65-2.020 and be fully licensed for practice in the state of Missouri. A health care provider utilizing telemedicine must do so in a manner that is consistent with the provisions of all laws governing the practice of the provider’s profession and shall be held to the same standard of care as a provider employing in-person behavioral health or medical health care.

(D) For purposes of the provision of telemedicine services in the MO HealthNet Program, the provider-patient relationship may be established by the following:

1. An in-person encounter through a medical interview and physical examination;

2. Consultation with another health care professional, or that health care professional’s delegate, who has an established relationship with the patient and an agreement with the health care professional to participate in the patient’s care; or 3. A telemedicine encounter, if the standard of care does not require an in-person encounter, and in accordance with evidence-based standards of practice and telemedicine practice guidelines that address the clinical and technological aspects of telemedicine.

(E) In order to establish a provider-patient relationship through telemedicine— 1. The technology utilized shall be sufficient to establish an informed diagnosis as though the medical interview and physical examination had been performed in person; and 2. Prior to providing treatment, including issuing prescriptions and physician certifications under Article XIV of the Missouri Constitution, a physician who uses telemedicine shall interview the patient, collect or review relevant medical

history, and perform an examination sufficient for diagnosis and treatment of the patient. A questionnaire completed by the patient, whether via the telephone or internet, does not constitute a medical interview and examination for provision of treatment via telemedicine.

(F) A provider agrees to conform to MO HealthNet program policies and instructions as specified in the provider manuals, which are incorporated by reference and made a part of this 65109, at its website http://manuals.momed.com/manuals/, April 14, 2022. This rule does not incorporate any subsequent (3) Covered Services.

(A) A telemedicine service shall be covered only if it is medically necessary.

(B) A telemedicine service must be performed with the same standard of care as an in-person, face-to-face service. If the same standard of care cannot be met, a telemedicine service shall not be provided.

(4) Prior Authorization and Utilization Review.

(A) Utilization Review. All services are subject to utilization review for medical necessity and program compliance.

Reviews can be performed before services are furnished, before payment is made, or after payment is made. The standards and processes for utilization review for telemedicine services shall be the same as those for services not provided through telemedicine.

(B) Prior Authorization. Certain procedures or services can require prior authorization from the MO HealthNet Division or its authorized agents. Services for which prior authorization shall be obtained remain subject to utilization review at any point in the payment process. A service provided through telemedicine is subject to the same prior authorization and utilization review requirements, standards, and processes that exist for the service when not provided through telemedicine.

(C) Eligibility Determination. Prior authorization of services does not guarantee an individual is eligible for a MO HealthNet service. Providers must verify that an individual is eligible for a specific program at the time services are furnished and must determine if the participant has other health insurance.

(D) School Services. Prior to the provision of telemedicine services in a school, the parent or guardian of the child shall provide authorization for the provision of such service. Such authorization shall include the ability for a parent or guardian to authorize services via telemedicine in the school for the remainder of the school year.

(5) Reimbursement.

(A) Reimbursement to the health care provider delivering the telemedicine service at the distant site shall be made at the same amount as the current fee schedule for an in-person service.

(B) The originating site is eligible to receive an originating site/facility fee.

(C) Reimbursement of the originating site fee will be made according to the MO HealthNet Fee Schedule.

(6) Documentation for the Telemedicine Encounter.

(A) Patient records at the distant and originating sites (if a referral is given at the originating site) are to document the telemedicine encounter consistent with the service documentation described in MO HealthNet provider manuals and bulletins.

(B) A health care provider shall keep a complete medical record of a telemedicine service, provided to a participant, including asynchronous store-and-forward images and follow applicable state and federal statutes and regulations for medical record keeping and confidentiality in accordance with 13 CSR 70-3.030.

(C) Records shall be maintained per standards established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and in accordance with 13 CSR 70-3.030.

(7) Confidentiality and Data Integrity.

(A) All telemedicine activities must comply with the requirements of HIPAA.

(B) A provider of a telemedicine service shall implement confidentiality protocols, which shall be available for inspection by the department upon request.

(C) Participant privacy and confidentiality must be maintained at all times while receiving all telemedicine services.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.670, RSMo Supp. 2021. Original rule filed Nov. 22, 2021, effective July 30, 2022. Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; 208.670, RSMo 2007, amended 2016, 2018; and 660.017, RSMo 1993, amended 1995.

Chapter 4 Conditions of Recipient Participation, Rights and Responsibilities

13 CSR 70-4.030 Participant Liability for Medical Services Not Reimbursable to the 13 CSR 70-4.040 {#sec-13-csr-70-4.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.030}

13 CSR 70-4.050 Copayment and Coinsurance for Certain Medicaid-Covered Services {#sec-13-csr-70-4.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.050}

13 CSR 70-4.060 Required Reporting of Injuries Received by MO HealthNet 13 CSR 70-4.070 13 CSR 70-4.100 {#sec-13-csr-70-4.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.060}

13 CSR 70-4.110 Placement of Liens on Property of Certain Institutionalized {#sec-13-csr-70-4.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.110}

13 CSR 70-4.120 Department is the Payer of Last Resort, Department’s Claim for Rights, and Responsibilities {#sec-13-csr-70-4.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.120}

13 CSR 70-4.030 Participant Liability for Medical Services Not Reimbursable to the Provider by the MO HealthNet Agency {#sec-13-csr-70-4.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.030}

PURPOSE: This rule establishes the guidelines for determination of participant liability for medical services not reimbursable to the provider by the MO HealthNet agency.

(1) When an enrolled MO HealthNet provider provides an item or service to a MO HealthNet participant eligible for the item or service on the date provided, there shall be a presumption that the provider accepts the participant’s MO HealthNet benefits and seeks reimbursement from the MO HealthNet agency in accordance with all of the applicable MO HealthNet rules.

This presumption shall be overcome only by written evidence of an agreement between the provider and the participant indicating that MO HealthNet is not the intended payor for the specific item or service but rather that the participant accepts the status and liabilities of a private pay patient. All third-party resource benefits must be exhausted before payment will be made by the division for the item or service rendered to that participant. For purposes of this rule, neither the provider nor the participant shall be required to exhaust all third-party resources in those situations where the provider or participant elect not to pursue contingent liability from a third-party tortfeasor. Both the provider and the participant have an affirmative duty to report the existence of contingent liability to the MO HealthNet Division and the participant has the duty to cooperate with the MO HealthNet Division if the division elects to pursue the contingent liability.

(2) When an item or service is rendered to a MO HealthNet participant who was eligible for the item or service on the date provided and provision of the item or service is billed to the MO HealthNet agency by an enrolled MO HealthNet provider who is not reimbursed by the agency for the item or service claimed, the item or service will not be the liability of the participant if the item or service would have been otherwise payable by the MO HealthNet agency at the MO HealthNet allowable amount had the provider followed all of the policies, procedures and rules applicable to the item or service as of the date provided. If the item or service is not otherwise payable for reasons unrelated to the actions of the provider, the participant is liable to the provider for payment of the item or service.

(3) The creation of a presumptive acceptance by a provider of the MO HealthNet benefits for a MO HealthNet covered service and the requirement for written evidence of an agreement to overcome presumptive acceptance, as established in this rule, shall not be applicable to services provided to a participant who is dually eligible and entitled to both MO HealthNet and Medicare Part B medical insurance benefits.

(4) The provisions of this rule shall apply to items or services provided on or after July 11, 1985.

Amended: Filed March 2, 1988, effective May 12, 1988. Amended:

Filed Oct. 12, 2007, effective April 30, 2008. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993; 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978(2), 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007; and 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007.

History

• AUTHORITY: section 207.020, RSMo 2000 and sections 208.152 and 208.153, RSMo Supp. 2007. This rule was previously filed as 13 CSR 40-81.140. Original rule filed April 16, 1985, effective July 11, 1985.

13 CSR 70-4.040 Eligibility Corrective Action Participant Payments {#sec-13-csr-70-4.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.040}

PURPOSE: This rule establishes the basis on which participants may be reimbursed by the MO HealthNet program for Title XIX services and for services covered under state-only types of assistance programs and after this referred to as MO HealthNet paid by them to providers between the date of the initial agency decision denying their eligibility and the date of the agency or court decision establishing their eligibility for MO HealthNet.

(1) All participants whose eligibility for MO HealthNet benefits is denied and whose eligibility is subsequently established as a result of an agency hearing decision, a court decision based on an agency hearing decision or any other final agency decision rendered on or after January 1, 1986 may be reimbursed by the MO HealthNet agency for MO HealthNet services paid by the participants to providers between the date of the agency decision denying their eligibility and the date of the agency or court decision establishing their eligibility for MO HealthNet benefits.

(A) Payments to a participant will be made only for medical services which were covered services at the time provided in accordance with MO HealthNet program benefits, limitations and requirements applicable to the services or the participant as of the date provided, except that prior authorization requirements will not apply.

(B) Payments may be made for services of either an enrolled MO HealthNet provider or for providers who do not participate in MO HealthNet.

(C) Payments to a participant will be limited to the lesser of the MO HealthNet allowable amount for the covered item or service as of the date provided or the aggregate amount paid by the participant for the covered item or service.

(D) Any medical expenses paid by the participant which are for the purpose of meeting that participant’s spenddown obligation are not payable.

(E) All third-party resource benefits received by the participant for MO HealthNet covered services must be applied against the lesser of the MO HealthNet allowable amount for the covered item or service as of the date provided or the aggregate amount paid by the participant for the covered item or service. No payment shall be made to the participant until all third-party resource benefits have been exhausted as would have been applicable to participants receiving MO HealthNet. For purposes of this rule, neither the provider nor the participant shall be required to exhaust all thirdparty resources in those situations where the provider or the participant elects not to pursue contingent liability from a third-party tortfeasor. Both the provider and the participant have an affirmative duty to report the existence of contingent liability to the MO HealthNet Division and the participant has the duty to cooperate with the MO HealthNet Division if the division elects to pursue the contingent liability.

(F) As evidenced by the MO HealthNet agency’s date of receipt, the participant or person legally responsible will have one (1) year from the date of the final agency or court decision establishing eligibility to submit all written requests for participant payment to the MO HealthNet agency with sufficient documentation to determine the appropriate reimbursement amount under the applicable provisions of subsections (1)(A), (C) and (E) for the MO HealthNet-covered items or services paid by the participant.

rule was previously filed as 13 CSR 40-81.141. Original rule filed April 16, 1985, effective Jan. 1, 1986. Amended: Filed Jan. 22, 1992, effective Sept. 6, 1992. Amended: Filed May 1, 2003, effective Nov. 30, 2003. Amended: Filed Oct. 12, 2007, effective April 30, 2008. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2007. This

13 CSR 70-4.050 Copayment and Coinsurance for Certain Medicaid-Covered Services {#sec-13-csr-70-4.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.050}

(Rescinded March 30, 2022)

Filed Jan. 21, 1983, effective May 12, 1983. Amended: Filed Aug. 14, 1984, effective Nov. 11, 1984. Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed May 16, 2005, effective Nov. 30, 2005. Rescinded: Filed Aug. 20, 2021, effective March 30, 2022.

History

• AUTHORITY: sections 208.152, RSMo Supp. 2004 and as enacted by the 93rd General Assembly, and 208.201, RSMo 2000. This rule was previously filed as 13 CSR 40-81.054. Emergency rule filed Oct. 21, 1981, effective Nov. 1, 1981, expired Feb. 10, 1982. Original rule filed Oct. 21, 1981, effective Feb. 11, 1982. Emergency amendment filed Jan. 21, 1983, effective Feb. 1, 1983, expired May 11, 1983. Amended:

13 CSR 70-4.051 Copayment for Pharmacy Services {#sec-13-csr-70-4.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.051}

(Rescinded November 30, 2022)

section 208.152, RSMo Supp. 2018. This rule was previously filed as 13 CSR 40-81.055. Original rule filed April 14, 1982, effective July 11, 1982. Amended: Filed Oct. 13, 1983, effective Jan. 13, 1984.

Amended: Filed May 15, 2000, effective Nov. 30. 2000. Amended:

Filed Oct. 1, 2018, effective May 30, 2019. Rescinded: Filed May 23, 2022, effective Nov. 30, 2022.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo 2016, and

13 CSR 70-4.060 Required Reporting of Injuries Received by MO HealthNet Participants {#sec-13-csr-70-4.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.060}

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.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. This rule was previously filed as 13 CSR 40-81.092. Original rule filed Aug. 13, 1982, effective Nov. 11, 1982. Amended: Filed May 28, 2021, effective Nov. 30, 2021. Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-4.070 Title XIX Recipient Lock-In Program {#sec-13-csr-70-4.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.070}

(Rescinded January 30, 2019)

Rescinded: Filed June 8, 2018, effective Jan. 30, 2019.

History

• AUTHORITY: section 208.201, RSMo 2000. This rule was previously filed as 13 CSR 40-81.200. Emergency rule filed July 13, 1981, effective Aug. 1, 1981, expired Oct. 10, 1981. Original rule filed July 13, 1981, effective Oct. 11, 1981. Amended: Filed Sept. 4, 1985, effective Dec. 1, 1985. Amended: Filed Nov. 2, 1988, effective Jan. 13, 1989. Amended: Filed Aug. 1, 2003, effective Feb. 29, 2004.

13 CSR 70-4.080 State Children’s Health Insurance Program {#sec-13-csr-70-4.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.080}

PURPOSE: This rule establishes components of the State Children’s Health Insurance Program which will provide health care coverage to uninsured, low income children.

(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.

(2) An uninsured child/children in a family(ies) with gross income of more than one hundred fifty percent (150%) of the federal poverty level shall not have had health insurance prior to application pursuant to section 208.631, RSMo.

(3) Parent(s) and guardian(s) of uninsured children with gross income of more than one hundred fifty percent (150%) but less than three hundred percent (300%) of the federal poverty level must certify, as a part of the application process, that the child does not have access to affordable employer-sponsored health care insurance or other affordable health care coverage available to the parent(s) or guardian(s) through their association with an identifiable group (for example, a trade association, union, professional organization) or through the purchase of individual health insurance coverage. Access to affordable employer-sponsored health care insurance or other affordable health care coverage shall result in the applicant not being eligible for the Health Care for Uninsured Children program for the child/children in families with gross income of more than one hundred fifty percent (150%) but less than three hundred percent (300%) of the federal poverty level.

(A) For families with gross income of more than two hundred twenty-five percent (225%) but less than three hundred percent (300%) of the federal poverty level affordable employer-sponsored health care insurance or other affordable health care coverage is health insurance requiring a monthly dependent premium of five percent (5%) of two hundred twenty-five percent (225%) of the federal poverty level for a family of three (3).

(B) For families with gross income of more than one hundred eighty-five percent (185%) but less than two hundred twentysix percent (226%) of the federal poverty level affordable employer-sponsored health care insurance or other affordable health care coverage is health insurance requiring a monthly dependent premium of four percent (4%) of one hundred eighty-five percent (185%) of the federal poverty level for a family of three (3).

(C) For families with gross income of more than one hundred fifty percent (150%) but less than one hundred eighty-six percent (186%) of the federal poverty level affordable employersponsored health care insurance or other affordable health care coverage is health insurance requiring a monthly dependent premium of three percent (3%) of one hundred fifty percent (150%) of the federal poverty level for a family of three (3).

(4) An uninsured child/children with gross income of more than two hundred twenty-five percent (225%) but less than three hundred percent (300%) of the federal poverty level shall be eligible for service(s) thirty (30) calendar days after the application is received if the required premium has been received. An uninsured child/children with gross income of more than one hundred fifty percent (150%) but less than two hundred twenty-six percent (226%) of the federal poverty level shall be eligible for services once the required premium has been received.

(A) Parent(s) or guardian(s) of uninsured children with gross income of more than one hundred fifty percent (150%) but less than one hundred eighty-six percent (186%) of the federal poverty level are responsible for a monthly premium equal to four percent (4%) of monthly income between one hundred fifty percent (150%) and one hundred eighty-five percent (185%) of the federal poverty level for the family size.

(B) Parent(s) or guardian(s) of uninsured children with gross income of more than one hundred eighty-five percent (185%) but less than two hundred twenty-six percent (226%) of the federal poverty level are responsible for a monthly premium equal to four percent (4%) of monthly income between one hundred fifty percent (150%) and one hundred eighty-five percent (185%) of the federal poverty level for the family size plus eight percent (8%) of monthly income between one hundred eighty-five percent (185%) and two hundred twentyfive percent (225%) of the federal poverty level for the family size.

(C) Parent(s) or guardian(s) of uninsured children with gross income of more than two hundred twenty-five percent (225%) but less than three hundred percent (300%) of the federal poverty level are responsible for a monthly premium equal to four percent (4%) of monthly income between one hundred fifty percent (150%) and one hundred eighty-five percent (185%) of the federal poverty level for the family size plus eight percent (8%) of monthly income between one hundred eightyfive percent (185%) and two hundred twenty-five percent (225%) of the federal poverty level for the family size plus fourteen percent (14%) of monthly income between two hundred twentyfive percent (225%) and three hundred percent (300%) of the federal poverty level for the family size.

(D) The monthly premium shall not exceed five percent (5%) of the family’s gross income.

(E) The premium must be paid prior to service delivery.

(F) The premium notice shall include information on what to do if there is a change in gross income.

(G) No service(s) will be covered prior to the effective date which is thirty (30) calendar days after the date the application is received for uninsured children in families with an income of more than two hundred twenty-five percent (225%) of the federal poverty level.

(5) If the parent(s) or guardian(s) who owes a premium fails to meet the premium payment requirements, a past due notice shall be sent requesting remittance within thirty (30) calendar days from the date of the past due letter.

(6) Premium adjustments shall be calculated yearly in March with an effective date of July 1 of the same calendar year.

Individuals shall be notified of the change in premium amount at least thirty (30) days prior to the effective date.

(7) The thirty- (30-) calendar-day delay in service delivery is not applicable to a child/children already participating in the program when the parent’s or guardian’s income changes. If the household incurs a premium as the result of an annual review, regardless of whether it is a new amount or the same amount, coverage shall be extended for sixty (60) calendar days to allow for premium collection and to ensure continuity in coverage. Coverage shall be discontinued for the child/children if the premium payment is not made within the sixty- (60-) day extension period.

(8) Any child identified as having “special health care needs,” defined as a condition which left untreated would result in the death or serious physical injury of a child, who does not have access to affordable employer-subsidized health care insurance shall not be subject to the thirty- (30-) day waiting period required under section 208.646, RSMo, and once enrolled, shall not be required to be without health care coverage for any period of time in order to be eligible for services under sections 208.631 to 208.657, RSMo, for the parent’s or guardian’s failure to pay a premium, as long as the child meets all other qualifications for eligibility for the remainder of the twelve- (12-) month continuous eligibility period described in section (11) of this rule.

(9) The total aggregate premiums for a family covered by this

rule shall not exceed five percent (5%) of the family’s gross income for a twelve- (12-) month period of coverage beginning with the first month of service eligibility. Waiver of premiums shall be made upon notification and documentation from the family that payments for premiums have been made up to five percent (5%) of their yearly gross income.

(10) For the purposes of this rule, a child/children whose annual maximum benefits of a particular medical service under their private insurance has been exhausted is not considered insured and does not have access to affordable health insurance.

(11) When a household pays its first premium, or pays the first premium due after a completed annual review, coverage for the household’s child(ren) shall extend for a twelve (12) month continuous eligibility period from the month of application or the month of the last completed annual review (whichever is later).

(A) If the household does not pay its first premium due after a completed annual review, then the case will be closed.

(12) A household with children that is not required to pay a premium shall have continuous coverage for the household’s child(ren) for twelve (12) months from the month of application or the month of the last completed annual review (whichever is later).

Filed April 29, 2005, effective Nov. 30, 2005. Amended: Filed Nov. 15, 2005, effective May 30, 2006. Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended:

Filed June 15, 2006, effective Dec. 30, 2006. Amended: Filed Sept. 17, 2007, effective March 30, 2008. Amended: Filed Feb. 1, 2008, effective Aug. 30, 2008. Amended: Filed June 2, 2008, effective Nov. 30, 2008. Amended: Filed Sept. 25, 2014, effective March 30, 2015.

Amended: Filed Sept. 9, 2024, effective April 30, 2025. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; 208.991, RSMo 2013; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: section 208.153, RSMo Supp. 2024, and sections 208.201, 208.991, and 660.017, RSMo 2016. Original rule filed July 15, 1998, effective Feb. 28, 1999. Emergency amendment filed Aug. 4, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended:

13 CSR 70-4.090 State-Funded Missouri Woman’s Health Services Program {#sec-13-csr-70-4.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.090}

PURPOSE: This rule establishes the State-Funded Missouri Woman’s Health Services Program. This program will provide payment for women’s health services for uninsured women who do not qualify for other medical assistance benefits, and would lose their MO HealthNet eligibility sixty (60) days after the birth of their child or sixty (60) days after a miscarriage, and for women ages eighteen (18) to fifty-five (55) who have a net family income of at or below one hundred eighty-five percent (185%) (which is the same as a modified adjusted gross family income of at or below two hundred one percent (201%)) of the Federal Poverty Level (FPL) and have assets totaling no more than two hundred fifty thousand dollars ($250,000), in order to reduce the possibility of a family’s future dependence on welfare as authorized pursuant to section 208.040, RSMo.

(1) Uninsured women who do not qualify for other medical assistance benefits, and would lose their MO HealthNet eligibility sixty (60) days after the birth of their child or sixty (60) days after a miscarriage, and women ages eighteen (18) to fifty-five (55) who have a net family income of at or below one hundred eighty-five percent (185%) (which is equivalent to a modified adjusted gross family income of at or below two hundred one percent (201%)) of the Federal Poverty Level (FPL) and have assets totaling no more than two hundred fifty thousand dollars ($250,000), shall be eligible to receive medical services to the extent and in the manner provided in this regulation. Uninsured women who do not qualify for other medical assistance benefits, and would lose their MO HealthNet eligibility sixty (60) days after the birth of their child or sixty (60) days after a miscarriage regardless of income, and women ages eighteen (18) to fifty-five (55) who have a net income of at or below two hundred one percent (201%)) of the Federal Poverty Level (FPL) and have assets totaling no more than two hundred fifty thousand dollars ($250,000), will continue to be eligible for women’s health services only.

Women’s health services are defined as: pelvic exams and pap tests, sexually transmitted disease testing and treatment (the treatments of medical complications occurring from the sexually transmitted disease are not covered for this program), family planning counseling/education on various methods of birth control, United States Department of Health and Human Services approved methods of contraception including sterilization and x-ray services related to the sterilization, and drugs (excluding antiretrovirals), supplies, or devices related to the women’s health services described in this rule when they are prescribed by a physician or advanced practice nurse, subject to the National Drug Rebate Program requirements.

(2) Uninsured women who do not qualify for other benefits, and would lose their MO HealthNet eligibility sixty (60) days after the birth of their child or sixty (60) days after a miscarriage, and women ages eighteen (18) to fifty-five (55) who have a net income of at or below two hundred one percent (201%)) of the Federal Poverty Level (FPL) and have assets totaling no more than two hundred fifty thousand dollars ($250,000), are not required to pay a co-payment for women’s health services.

(3) The Department of Social Services, MO HealthNet Division shall provide for granting an opportunity for a fair hearing to any applicant or participant whose claim for benefits under the State-Funded Missouri Woman’s Health Services Program is denied by the MO HealthNet Division. The state hearing officers shall have authority to conduct state level hearings of an appeal nature and shall serve as direct representative of the director of the MO HealthNet Division.

(4) Reimbursement. Funding of the family planning and family planning-related services, pregnancy testing, sexually transmitted disease testing and treatment, including pap tests and pelvic exams, and follow-up services of the Missouri Woman’s Health Services Program shall be from general revenue only and none of the funds appropriated may be expended to directly or indirectly subsidize abortion services or procedures or administrative functions, and none of the funds appropriated herein may be paid or granted to an organization that provides abortion services. An otherwise qualified organization shall not be disqualified from receipt of these funds because of its affiliation with an organization that provides abortion services provided that the affiliated organization that provides abortion services is independent of the qualified organization. An independent affiliate that provides abortion services must be separately incorporated from any organization that receives these funds. Such services shall be available to uninsured women who are at least eighteen (18) to fifty-five (55) years of age who have a net income for the household size of at or below two hundred one percent (201%)) of the Federal Poverty Level (FPL) and who is a legal resident of the state.

History

• AUTHORITY: sections 208.040, 208.201, and 660.017, RSMo 2016. Emergency rule filed Sept. 13, 1999, effective Sept. 23, 1999, terminated Oct. 15, 1999. Original rule filed Aug. 16, 1999, effective March 30, 2000. Amended: Filed March 29, 2001, effective Oct. 30, 2001. Emergency amendment filed June 7, 2002, effective July 1, 2002, expired Dec. 27, 2002. Amended: Filed June 11, 2002, effective Nov. 30, 2002. Emergency amendment filed June 7, 2005, effective July 1, 2005, expired Dec. 27, 2005. Amended: Filed June 15, 2005, effective Dec. 30, 2005. Amended: Filed May 14, 2009, effective Nov. 30, 2009. Amended: Filed Sept. 15, 2016, effective April 30, 2017. Original authority: 208.040, RSMo 1939, amended 1941, 1949, 1951, 1953, 1955, 1957, 1973, 1977, 1982, 1983, 1984, 1987, 1994, 1999, 2001, 2009, 2015; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-4.100 Preventing Medicaid Payment of Expenses Used to Meet Spenddown {#sec-13-csr-70-4.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.100}

PURPOSE: This rule establishes the basis on which the Medical Assistance program may reimburse for Title XIX services after spenddown has been met. Spenddown is a process by which aged persons (over sixty-five (65) years), blind persons, or people with disabilities become Medicaid eligible based on their incurred medical expenses when they would not otherwise be eligible.

(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.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.151, RSMo Supp. 2021. Emergency rule filed April 25, 2005, effective May 5, 2005, expired Oct. 31, 2005. Original rule filed April 29, 2005, effective Oct. 30, 2005. Amended: Filed Jan. 7, 2022, effective July 30, 2022. Original authority 208.151, RSMo 1967, amended 1973, 1981, 1982, 1987, 1988, 1989, 1990, 1991, 1993, 1995, 2001, 2005, 2007, 2011, 2013, 2018, 2019, 2020; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-4.110 Placement of Liens on Property of Certain Institutionalized MO HealthNet Participants {#sec-13-csr-70-4.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.110}

PURPOSE: This rule implements the guidelines for placement of liens on the property of certain institutionalized MO HealthNet participants, in accordance with the authority given to states in the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), as amended.

(1) When an applicant for MO HealthNet or a MO HealthNet participant is a patient, or will become a patient, in a nursing facility, intermediate care facility for the developmentally disabled, or other medical institution, the Department of Social Services will determine if the placement of a lien against the property of the applicant or participant is applicable. A lien is imposed on the property of an individual, in accordance with the authority given states in the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), when— (A) The MO HealthNet participant is or has made application to become a patient in a nursing facility, intermediate care facility for the developmentally disabled, or other medical institution, if such individual is required, as a condition of receiving services in such institution, to spend for costs of medical care all but a minimal amount of his/her income required for personal needs;

(B) The institutionalized MO HealthNet participant owns property. Property includes the homestead and all other real property in which the person has a sole legal interest or a legal interest based upon co-ownership of the property;

(C) The department has determined after notice and opportunity for hearing that there is no reasonable expectation that the person can be discharged from the facility within one hundred twenty (120) days and return home. The hearing, if requested, will proceed under the provision of Chapter 536, RSMo, before a hearing officer designated by the director of the Department of Social Services. The fact that there is no reasonable expectation that the person can be discharged from the facility within one hundred twenty (120) days and return home may be substantiated by one (1) of the following:

1. Applicant/participant states in writing that he/she does not intend to return home within one hundred twenty (120) days;

2. Applicant/participant has been in the institution for longer than one hundred twenty (120) days; or 3. A physician states in writing that the applicant/ participant cannot be expected to be discharged within one hundred twenty (120) days of admission; and (D) A lien is imposed on the property unless one (1) of the following persons lawfully resides in the property:

3. The institutionalized person’s spouse;

4. The institutionalized person’s child who is under twentyone (21) years of age or is blind or permanently and totally disabled; or 3. The institutionalized person’s sibling who has an equity interest in the property and who was residing in such individual’s home for a period of at least one (1) year immediately before the date of the individual’s admission to the institution; or 4. The division may require proof of residency pursuant to this subsection. Proof of residency includes, but is not limited to, a utility bill, property tax bill, copy of permanent Missouri driver’s license, copy of Missouri voter’s registration verification, or copy of the most recently filed Federal 1040 income tax form in the name of the institutionalized person’s spouse, child, or sibling.

(2) After determining the applicability of the lien, the MO HealthNet participant is given an Explanation of TEFRA Lien.

A person who objects to the imposition of a lien without good cause is ineligible for medical assistance. Ineligibility is based on the person’s objection without good cause to the imposition of the lien, which impedes the department’s ability to implement its lien requirements.

(3) A lien may be imposed upon the property but the department will not seek adjustment or recovery of the costs of medical assistance correctly paid on behalf of the participant when the participant’s child over the age of twenty-one (21) resides in the home and facts are established, to the satisfaction of the department, by sworn affidavit of the participant’s child or authorized representative with personal knowledge of the facts, conclusively showing that— (A) The participant’s child has lived with and cared for the participant in the participant’s home continuously for the two (2) years immediately prior to the participant entering a nursing facility, intermediate care facility for the developmentally disabled, or other medical institution;

(B) By providing that care the participant’s child has allowed the participant to live at home rather than in a nursing facility, intermediate care facility for the developmentally disabled, or other medical institution;

(C) The participant’s child continues to reside in the home since the participant entered into a nursing facility, intermediate care facility for the developmentally disabled, or other medical institution;

(D) Facts to be included in the affidavit shall include but not be limited to:

1. The number of days and hours each week the child was providing care to the participant;

2. Types of care provided; such as, bathing and grooming, administering medication, providing therapeutic/health related activities;

3. Types of assistance provided; such as, household chores/ cleaning, maintenance, repair, improvements; and 4. Types of errands outside the home provided; such as, shopping for groceries and household items, transportation to medical visits, pharmacy, recreational and social activities, and religious activities;

(E) The department may, at its discretion, require the participant to provide documentation to support the statements in the affidavit;

(F) The affidavit must be provided to the MO HealthNet Division, TEFRA Lien Recoveries at PO Box 6500, Jefferson City, MO 65102-6500 in a timely manner before the lien has been satisfied against the participant’s home;

(G) Upon a determination by the department that the facts established in the affidavit satisfy the department that the exception has been met, then the TEFRA Lien shall be maintained but not enforced so long as the child resides in the property and it is not sold, transferred, or leased, other than the child may take title to the property subject to the lien;

(H) Upon a determination by the department that the facts established in the affidavit do not satisfy the department that the exception has been met, then the lien may be enforced as otherwise provided in section (6); and (I) Participants who object to a TEFRA Lien in a timely manner under this subsection are entitled to a fair hearing, under the provision of Chapter 536, RSMo, before a hearing officer designated by the director of the Department of Social Services. A timely objection must be made in writing to the department within ninety (90) days of the objected adverse decision.

(4) The director of the department or the director’s designee will file for record, with the recorder of deeds of the county in which any real property is situated, a written Certificate of TEFRA Lien. The lien will contain the name of the MO HealthNet participant and a description of the property. The recorder will note the time of receiving such notice and will record and index the certificate of lien in the same manner as deeds of real estate are required to be recorded and indexed.

The county recorder shall be reimbursed per certificate or release filed by the division.

(5) The TEFRA lien shall be for a debt due to the state for medical assistance paid or to be paid on behalf of the MO HealthNet participant. The amount of the lien will be for the full amount due the state at the time the lien is enforced. Fees paid to county recorder of deeds for filing of the lien will be included in the amount of the lien.

(6) The TEFRA lien does not affect ownership interest in a property until it is sold, transferred, or leased, or upon the death of the individual, at which time the lien must be satisfied, subject to the following:

(A) Any costs of sale of the property that are to be paid before the lien must be approved in advance by the department, and if a HUD-1 statement is prepared for that sale transaction, then a copy must be provided to the department prior to the closing for review and approval;

(B) Subject to the provisions of subsection (6)(A), in any case of a pending probate matter in a court of the state of Missouri for the administration of the assets and interests of the participant, including the property subject to the lien, then the following probate costs and expenses may be paid from the sale of the real estate at closing ahead of the lien:

1. Filing fees, publication fees, appraisal fees, personal representative fees, executor fees, attorney’s fees;

2. Costs to maintain and repair the property for sale, such as insurance premiums, professional lawn care services, necessary repairs to prepare for sale, customary real estate sales commissions, or publication of sale notice, and the participant or authorized representative shall produce documentation to support costs and incurred expenses; or 3. Burial costs of the participant; and (C) The lien shall not be released against the real estate, except as required in section (7), until all net equity in the property remaining after closing costs after sale, transfer, or lease has been paid in satisfaction of the lien to the department, after payment of customary and approved costs from the sale proceeds as set forth in subsections (6)(A) and (6)

(B). Closing costs are shared equally by all beneficiaries of the net proceeds of the real estate sale. In no case shall the state directly pay any costs of the sale or probate.

(7) The lien will be dissolved in the event the individual is discharged from the institution and returns home. A Notice of TEFRA Lien Release will be filed within thirty (30) days with the recorder of deeds of the county in which the original Certificate of TEFRA Lien was filed.

Amended: Filed Jan. 10, 2022, effective July 30, 2022. *Original authority: 208.201, RSMo 1987, amended 2007; 208.215, RSMo 1981, amended 1982, 1987, 1990, 1993, 1996, 2005, 2007, 2010, 2014; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201, 208.215, and 660.017, RSMo 2016. Emergency rule filed Aug. 15, 2005, effective Sept. 1, 2005, expires Feb. 27, 2006. Original rule filed May 16, 2005, effective Nov. 30, 2005. Amended: Filed Dec. 15, 2011, effective June 30, 2012.

13 CSR 70-4.120 Department is the Payer of Last Resort, Department’s Claim for Recovery, Participant’s Duty of Cooperation {#sec-13-csr-70-4.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-4.120}

PURPOSE: This rule establishes the procedures for MO HealthNet’s cost recovery of medical expenses from liable third party payments, settlements, awards, judgments, and insurance contracts and a participant’s duty to cooperate.

(1) Definitions. The following definitions shall apply for purposes of this regulation.

(A) “Assignment” is the legal transfer from a participant to the division of the participant’s right to recovery of medical expenses from a liable third party.

(B) “Assist” shall include but not be limited to providing full disclosure of all relevant information regarding a claim against a liable third party or insurer to the division; fully completing any and all forms requested by the division, provision of a Health Insurance Portability and Accountability Act (HIPAA) release to the division when requested; execution of any authorizations necessary to obtain release of any information the division requires in pursuit of the recovery; filing claims with potentially liable insurers when requested by the division; providing documentation of any and all settlement agreements, awards, or judgments related to claims against liable third parties; and timely responding to requests for information from insurers after a claim has been submitted.

(C) “Division” means the MO HealthNet Division of the Department of Social Services.

(D) “Health benefit plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, except that health benefit plan shall not include any coverage pursuant to liability insurance policy, workers’ compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy.

(E) “Health carrier” means an entity subject to the insurance laws and regulations of this state that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services, except that such plan shall not include any coverage pursuant to a liability insurance policy, workers’ compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy.

(F) “Identify” shall mean providing complete names, addresses, telephone numbers, and other relevant contact and location information of all potentially liable third parties, their attorneys, agents, and insurers.

(G) “Liable third party” includes any person, corporation, or institution, any employer as defined under Missouri’s workers’ compensation laws, and any public agency or private agency who is liable, either pursuant to contract or otherwise, to an individual receiving public assistance on account of personal injury, disease, or disability or benefits arising from a health insurance plan to which the individual may be entitled.

(H) “Medical expense” and “medical expenses” are the cost of items and services provided under the Missouri State Medicaid Plan by the division on behalf of a participant which are related to the participant’s claim against a liable third party, expressly excluding payments to vendors.

(I) “Medical treatment” means medical treatment rendered to a participant related to the participant’s claim against a liable or potentially liable third party or insurer.

(J) “Notify” shall mean a written communication to the division of all relevant facts and information known which may be delivered to the division by United States Postal Service, facsimile transmission, or email.

1. In any case where written communication by a participant not represented by an attorney or other legal representative is not possible or is not reasonable due to disability requiring accommodation, the participant may substitute oral communication to the division either in person or by telephonic communication. The division shall provide the participant with written confirmation of the substitute oral communication and detail its contents.

2. Communication to the division from a licensed attorney or legal representative of a participant shall be in writing, or if done orally be followed up by written confirmation of that communication and its detailed contents.

(K) “Participant” is an individual who applies for, is determined eligible for, and receives MO HealthNet benefits provided under sections 208.151 to 208.158 or section 208.204, RSMo.

(L) “Person” is any human being or other entity legally recognized as a person under Missouri law, including but not limited to a corporation, cooperative, partnership, limited liability company, sole proprietorship, mutual insurer, and governmental entity or subdivision.

(M) “Timely” shall mean within a reasonable time; however— 1. In no case shall notification to the division occur later than ten (10) business days from the date of discovery or knowledge of the act or information to be disclosed by the participant to the division; and 2. In no case shall notification to the division occur less than thirty (30) days prior to an anticipated or potential settlement, compromise, judgment, award, or agreement regarding a participant’s claim against a liable third party or potentially liable insurer.

(2) Payer of last resort. The MO HealthNet Division is the payer of last resort of medical assistance benefits to be paid on behalf of a participant, unless otherwise specified by law.

(A) Liable third parties shall meet their legal obligation to (7/31/26) Denny Hoskins pay claims on behalf of a participant before the division pays for a participant’s medical assistance benefits related to the participant’s claim against the liable third party. Any health benefit plan, third-party administrator, administrative service organization, and pharmacy benefits manager shall process and pay all properly submitted medical assistance subrogation claims or MO HealthNet subrogation claims using standard electronic transactions or paper claim forms.

1. For a period of three (3) years from the date services were provided or rendered; however, an entity— A. Shall respond to any inquiry by the state regarding a claim for payment for any health care item or service not later than sixty (60) days after receiving any such inquiry;

B. Shall not be required to reimburse for items or services which are not covered under MO HealthNet;

C. Shall not deny a claim submitted by the state solely on the basis of the date of submission of the claim, the type or format of the claim form, failure to present proper documentation of coverage at the point of sale, or failure to provide prior authorization for the item or service for which the claim is being submitted, except that such shall not apply to the original Medicare fee-for-service program under parts A and B of subchapter XVIII of 42 U.S.C Chapter 7, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of such subchapter, a reasonable cost reimbursement plan under 42 U.S.C. 1395mm, a health care prepayment plan under 42 U.S.C. 1395l, or a prescription drug plan (PDP) offered by a PDP sponsor under part D of subchapter XVIII of 42 U.S.C. Chapter 7 with regards to prior authorizations;

D. Shall not be required to reimburse for items or services for which a claim was previously submitted to the health benefit plan, third-party administrator, administrative service organization, or pharmacy benefits manager by the health care provider or the participant and the claim was properly denied by the health benefit plan, third-party administrator, administrative service organization, or pharmacy benefits manager for procedural reasons, except for timely filing, type or format of the claim form, failure to present proper documentation of coverage at the point of sale, or failure to obtain prior authorization;

E. Shall accept authorization provided by the state that the item or service is covered under the state plan (or waiver of such plan) for such individual, as if such authorization were the prior authorization made by the third-party for such item or service, except that such shall not apply to the original Medicare fee-for-service program under parts A and B of subchapter XVIII of 42 U.S.C Chapter 7, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of such subchapter, a reasonable cost reimbursement plan under 42 U.S.C. 1395mm, a health care prepayment plan under 42 U.S.C. 1395l, or a prescription drug plan offered by a PDP sponsor under part D of subchapter XVIII of 42 U.S.C. Chapter 7;

F. Shall not be required to reimburse for items or services which are not covered under or were not covered under the plan offered by the entity against which a claim for subrogation has been filed; and G. Shall reimburse for items or services to the same extent that the entity would have been liable as if it had been properly billed at the point of sale, and the amount due is limited to what the entity would have paid as if it had been properly billed at the point of sale.

2. If any action by the state to enforce its rights with respect to such claim is commenced within six (6) years of the state’s submission of such claim.

(B) When the division pays medical expenses on behalf of a participant, it shall pursue recovery of the cost of those medical expenses from any liable third party or insurer to the extent recovery is cost effective.

(3) Assignment right to recover medical expenses. Each participant assigns to the division all rights to recovery of medical expenses from liable third parties pursuant to section 208.215.4, RSMo, and by the terms of the voluntary application for assistance submitted to the Family Support Division.

(A) The assignment is limited to recovery of medical expenses only.

(B) The assignment is a claim which automatically attaches to any payments or benefits for medical treatment the participant recovers or expects to recover from a liable third party or insurer.

(C) No attempt to compromise or release the assigned right to recovery of medical expenses shall be effective, enforceable, or valid without the prior written agreement of the division.

(4) MO HealthNet Division has a claim against recovery for medical treatment.

(A) The division shall be entitled to any payments or benefits recovered, or to be recovered, by or on behalf of a participant from a liable third party or insurer to the extent the payment is compensation for medical treatment.

(B) The division shall be entitled to the medical treatment portion of any payments, settlements, awards, judgments, and insurance contracts benefits owed to or paid to or on behalf of the participant from any liable third party or insurer, including insurance contracts owned by the participant, up to the amount of medical expenses paid on behalf of the participant.

(C) No claim of the division shall attach, or be deemed to attach, to any portion of a recovery from a liable third party other than that portion which is compensation of medical (D) The participant, the participant’s attorney, the participant’s appointed representative, a liable third party, insurance carrier, or other interested party may request in writing that the division provide notice of the amount of the division’s current claim.

(E) A notice of claim to a liable third party shall set forth the current amount of the claim. That claim amount shall be valid for thirty (30) days from the date of the notice. The claim amount may increase or decrease over time depending upon the submission and payment of provider claims and credits. It shall be the responsibility of the participant, the participant’s attorney, or the participant’s appointed representative to obtain a valid claim amount from the division when the current claim amount is older than thirty (30) days when seeking to recover medical expenses from a liable third party.

(F) A notice of claim sent to a liable third party shall not include supporting documentation unless the liable third party has provided the division previously with a valid HIPAA release from the participant authorizing that disclosure. The division shall not be obligated to provide supporting documentation in order to have a valid lien without a valid authorization for release of that information from the participant, absent a court order requiring such disclosure or protective order with conditions of disclosure.

(G) Any potentially liable third party who is aware, or reasonably should be aware, of the claim of the department for recovery of medical expenses due to a participant shall keep the department advised of its current contact information including but not limited to mailing address and telephone number.

(5) MO HealthNet Division only has a claim against recovery for medical treatment. Participants, their attorney(s), agents, and other representatives, liable or potentially liable third parties, and insurers shall allocate in settlement agreements that portion of the settlement which is recovery for medical (A) Payment to the division shall be deemed as payment from that portion of the settlement which is recovery for medical (B) The division shall not be bound by, and may object to, any settlement or allocation for medical treatment that does not include the full amount of medical expenses paid by the division.

(C) Where a settlement or judgment does not allocate an amount that is recovery for medical treatment, the division shall allocate as recovery for medical treatment the lesser of the amount of medical expenses paid by the division or onehalf (1/2) of the gross recovery from any and all liable third parties and insurers unless an individualized allocation can be demonstrated.

(D) Participants, their attorney(s), agents, and other representatives may demonstrate an individualized allocation of recovery for medical treatment where the division has objected to a proposed allocation or a settlement or judgment is unallocated by presenting documentation on behalf of the participant to support an individualized allocation. The division may consider documentation of any combination of the following factors as they relate to the incident when determining an individualized allocation:

1. The amount of medical expenses and medical treatment paid by and on behalf of the participant;

2. The amount of future medical treatment expected to be accrued by the participant;

3. The amount of lost wages claimed by the participant;

4. Evidence of paralysis, permanent injury, and/or scarring or disfigurement; and 5. Other factors as they relate to the specific circumstances of the participant’s claim.

(E) The burden of proof shall be on the participant to demonstrate that the division is entitled to recover less than an amount established above.

(F) Parties dissatisfied with the amount allocated as recovery for medical treatment may seek judicial determination of the amount owed to the division under section 208.215.9, RSMo.

(6) The computerized records of the MO HealthNet Division are prima facie evidence of medical expenses paid on behalf of the participant. The computerized records of MO HealthNet Division which are certified by a custodian of those records are prima facie evidence of the money expended on behalf of a participant in any court or administrative proceeding.

(7) Duty of participant, agents, and third parties to cooperate with the division. Participants, their attorney(s), agents, and other representatives, and liable or potentially liable third parties shall fully cooperate with and assist the division, as required by section 208.215.4, RSMo, by providing information identifying liable third parties, providing information to assist the division in pursuit of any resources available from liable third parties and insurers, and in obtaining any resources to which the participant has a claim so the division can recover reimbursement for medical expenses. The duty continues and includes the duty to timely supplement as new information is discovered or known by the participant and the participant’s attorneys, agents, and other representatives.

(A) No participants, attorneys, agents, or other legal representatives shall have the authority to bind the division to any settlement or compromise of any claim of the division without prior written authorization from the division.

(B) Participants, their attorneys, agents, and legal representatives, and liable or potentially liable third parties shall clearly disclose in any settlement or compromise of claims against liable third parties the portion of the recovery which is compensation for medical expenses the division has paid on behalf of the participant.

(C) Cooperation shall include but not be limited to the following:

1. Timely notifying the division of any accident, incident, act, or occurrence which may give rise to a claim against a liable third party for medical expenses;

2. Timely identifying to the division all potentially liable third parties, liable third parties’ legal representatives, and potentially liable insurers;

3. Timely assisting the division in recovering its claim for medical expenses from liable third parties;

4. Timely identifying to the division all legal representatives of the participant with authority to act or inquire on the participant’s behalf, including but not limited to, attorneys, personal representatives, holders of power of attorney, guardians, custodians, and trustees;

5. Timely notifying the division any time the participant files a lawsuit or makes a demand against any liable party, potentially liable insurer, or other entity which may be an available resource for payment of medical expenses; and 6. Timely notifying the division in writing of the dollar amount of any settlement, award, or judgment which is compensation for medical treatment related to the third party’s liability with accompanying explanation for how that amount was determined and documentation of any settlement agreements.

(D) Notification to the division. All notifications to the division under this section shall be delivered as follows:

1. By mail through the United States Postal Service or other postal or package service, to MO HealthNet Division, Third Party Liability Unit, PO Box 6500, 615 Howerton Court, Jefferson City, MO 65102; or 2. By facsimile transmission (573-526-1162) to MO HealthNet Division, Third Party Liability Unit; or 3. By email to MO HealthNet Division, Third Party Liability Unit sent to the email address MHD.costrecovery@dss.mo.gov; or 4. By telephonic communication (573-751-2005) to MO HealthNet Division, Third Party Liability Unit.

(8) Release of right to recover medical expenses. No release, satisfaction, or other form of compromise of the right to recovery of medical expenses from a liable third party shall be valid, effective, or enforceable without the prior express written agreement and acceptance by the division.

(A) Any attempt by any person or entity to cause that right to recovery of medical expenses to be released, satisfied, or otherwise compromised shall be void ab initio and no defense of any claim against any person by the division absent the division’s prior express written agreement and acceptance of that release, satisfaction, or other compromise.

(B) Any release, satisfaction, or other compromise executed or agreed to by the participant without the prior express written agreement of the division shall be prima facie evidence of the participant’s failure to cooperate and intent to defraud the division of its right to recovery of medical expenses.

(7/31/26) Denny Hoskins (9) Form of notification to the division and for request for claim amount. Notification to the department and requests for claim amount shall be made in writing and directed to the MO HealthNet Division in one of the manners specified above in subsection (7)(D) of this rule.

(A) Notifications and requests shall contain, at a minimum, the participant’s name, date of birth, participant number, Social Security number, date of incident or injury, and the names of attorneys, insurers, and other authorized agents of the participant.

(B) Incomplete notifications and requests will be returned to the requestor for completion without processing.

(C) Requests from agents of the participant must be accompanied by a letter of representation on the agent’s official letterhead and must include a valid, currently dated, HIPAA release signed by the participant or a person with verifiable authority to sign for release of the participant’s protected information. Proof of verifiable authority must be sent in with the HIPAA release.

(D) Claim update requests must not be submitted until the original claim request has been fully processed and a response sent.

(E) Failure to comply will result in rejection of premature claim update requests.

(10) Pro rata claim reduction for attorney fees. A participant, his agents, or attorneys may request from the division a pro rata reduction of the claim amount based upon the total attorney fees and reasonable expenses approved by the division and actually incurred by the participant in pursuit of the claims against the liable third party(s).

(A) Any request for a pro rata reduction in the claim shall be made to the division in writing and include all necessary information and supporting documentation regarding the settlement or recovery, including but not limited to— 1. The total amount of settlement or recovery;

2. The total amount of the settlement or recovery which is compensation for medical treatment related to the incident;

3. The total amount of contractual attorney fees incurred;

4. The itemized list with detailed description and total amount of reasonable division-approved expenses;

5. A detailed listing of the claimed expenses with individual items and amounts claimed; and 6. A copy of any written documentation of the settlement or recovery terms.

A. All settlement documentation and information shall be kept strictly confidential by the division and its staff.

(B) No pro rata reduction shall be binding without prior written assurance by the participant or his or her representative that the reported settlement or recovery is final and includes all sources of recovery from the liable third party.

(C) If there are multiple liable third party sources of recovery then the request shall clearly specify a bulk pro rata on all the recoveries or a separate pro rata for each separate recovery and identify any unpaid claims not yet recovered.

(D) The pro rata reduction shall be determined using the following pro rata formula:

1. The participant’s total actual attorney’s fees and approved expenses divided by the total recovery equals a percentage; and 2. The total due the division times that percentage equals the amount that is the division’s pro rata share of attorney’s fees and expenses; and 3. The total due the division less the division’s pro rata share identified above equals the dollar amount of the reduced pro rata claim due the division.

(11) Procedure for participant’s handling receipt of money or benefits from liable third party or insurer. Upon receipt of money or benefits from a liable third party or insurer the participant, his agents, and attorneys shall immediately notify the division and either— (A) Pay the division from the recovery for related medical treatment up to the full amount of the division’s current claim of medical expenses paid by the division on behalf of the participant within sixty (60) days of receipt of the money or benefits; or (B) Place the full amount of the recovery in a trust account for the benefit of the division and immediately institute a proceeding for judicial or administrative determination of the division’s rights to that portion of the recovery which is compensation for related medical treatment the division has paid on behalf of the participant.

(12) Insurance payments where the division asserts a claim.

Any payment by any insurer which is from medical payment coverage is subject to the claim of the division for recovery of medical expenses up to the total amount of the department’s claim.

(13) Informal process to dispute the amount of the division’s claim. If a participant disputes the amount claimed by the division, the participant or the participant’s attorney shall first make a written request to the division within fifteen (15) days of notification of the division’s claim amount to review the claim amount for specific alleged errors for correction before seeking other avenues for resolution of the dispute.

(A) Those items which may be reviewed informally for correction may include but are not limited to:

1. Miscalculation of pro rata reduction;

2. Inclusion of charges for services not related to the participant’s claim against the liable third party giving rise to the claim;

3. Omission of charges for services related to the participant’s claim against the liable third party giving rise to the claim;

4. Incorrect amounts billed or paid for medical assistance;

5. Miscalculation within the billing statement;

6. Claims that the treatments billed were not actually provided to the participant; and 7. Claims that the person identified in the billing statement is not the same person identified in the division’s claim.

(B) Written requests for informal review of a disputed claim shall be delivered to the MO HealthNet Division, Third Party Liability Unit, PO Box 6500, 615 Howerton Court, Jefferson City, MO 65102 or may be sent by facsimile transmission (573) 526- 1162 or email address MHD.costrecovery@dss.mo.gov.

(C) Participants not represented by an attorney or other legal representative may request informal review by oral communication in person or by telephone by calling the Third Party Liability Unit if written communication is not a reasonable form of communication due to disability or other extenuating circumstance.

(D) Upon receipt of a complete and detailed request for informal review due to a participant’s dispute of the claim, the division shall provide a written response to the requesting participant, or his or her representative.

(E) If the informal dispute procedure does not resolve the dispute of the claim to the satisfaction of the participant, the participant may seek resolution of the disputed claim through the procedures set out in section 208.080, RSMo, after receipt of the division’s written response following the division’s review of the dispute.

(F) Failure to pursue resolution through this informal procedure before seeking resolution through other avenues shall be a defense of failure to exhaust administrative remedies for the division.

Amended: Filed Jan. 10, 2022, effective July 30, 2022. Amended:

Filed April 17, 2023, effective Nov. 30, 2023. Amended: Filed Feb. 26, 2026, effective Aug. 30, 2026. *Original authority: 208.201, RSMo 1987, amended 2007; 208.215, RSMo 1981, amended 1982, 1987, 1990, 1993, 1996, 2005, 2007, 2010, 2014; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201, 208.215, and 660.017, RSMo 2016. Original rule filed Sept. 26, 2013, effective March 30, 2014.

Chapter 5 Nonemergency Medical Transportation (NEMT) Services

13 CSR 70-5.010 Nonemergency Medical Transportation (NEMT) Services {#sec-13-csr-70-5.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-5.010}

PURPOSE: This rule establishes the criteria by which the MO HealthNet Division (MHD) reimburses expenses for nonemergency, medically necessary transportation if a participant does not have access to transportation services that are available free of charge.

(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.

(2) MHD shall reimburse the most appropriate and least costly transportation alternative suitable for the participant’s medical condition. If a participant has access to private vehicles or less costly public transportation, those alternatives must be used in lieu of more expensive transportation alternatives.

(A) The alternative transportation services provided include:

1. Bus passes/tickets;

2. Taxi/sedans;

3. Wheelchair van;

4. Multi-passenger vans;

5. Stretcher van;

6. Ambulance;

7. Gas reimbursement; or 8. Volunteer driver program, if approved by the state agency.

(B) Transports are limited to medical treatment within the distance standards set forth in 20 CSR 400-7.095. Exceptions to these standards include:

1. The participant has a previous history of other than routine medical care with the qualified, enrolled medical service provider for a special condition or illness;

2. The participant has been referred by a Primary Care Provider (PCP) to a qualified, enrolled medical service provider for a special condition or illness; and 3. There is not a routine or specialty care appointment available within thirty (30) calendar days to a qualified, enrolled medical service provider within the travel standards.

(3) MHD shall reimburse for the least expensive and most appropriate ancillary services when the medical treatment requires an overnight stay. Ancillary services include meals and lodging.

rule filed May 16, 2005, effective Oct. 30, 2005. Amended: Filed Feb. 1, 2008, effective Aug. 30, 2008. Amended: Filed Aug. 27, 2020, effective March 30, 2021. Amended: Filed May 23, 2022, effective Nov. 30, 2022. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

Chapter 6 Emergency Ambulance Program

13 CSR 70-6.020 Ground Emergency Medical Transportation Uncompensated Cost {#sec-13-csr-70-6.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-6.020}

13 CSR 70-6.010 Emergency Ambulance Program {#sec-13-csr-70-6.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-6.010}

PURPOSE: This rule establishes the regulatory basis for the administration of the emergency ambulance program. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available under the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of provider participation, criteria and methodology for provider reimbursement, participant eligibility, and amount, duration and scope of services covered are included in the ambulance program manual, which is incorporated by reference in this rule and available at the website.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet ambulance program shall be administered by the Department of Social Services, MO HealthNet Division. The ambulance program services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the ambulance program provider manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at www.dss.mo.gov/mhd, May 15, 2019. This rule does not incorporate any subsequent amendments or additions.

(2) Eligible Providers. To be eligible for participation in MO HealthNet, the following requirements shall be met:

(A) Ground Ambulance.

1. The provider must be licensed by the Missouri Department of Health and Senior Services if located in Missouri or licensed by the state regulating authority if located outside the state of Missouri.

2. The provider must be certified to participate in the Title XVIII Medicare program and have a signed and accepted Participation Agreement in effect with the Missouri Department of Social Services, MO HealthNet Division; and (B) Air Ambulance. Air ambulance is defined as any privately or publicly owned conventional air service, rotary wing or fixed-wing specially designed, constructed or modified, maintained or equipped with the intent to be used for the transportation of patients as defined in Federal Aviation Regulations,

Part 135.

1. The air ambulance provider must have a current valid air ambulance license, be licensed by the state regulating authority if located outside of Missouri, have submitted a copy of the current Federal Aviation Regulations, Part 135, (FAA) Air Carrier Certificate issued by the United States Department of Transportation.

2. The air ambulance provider must have a signed and accepted Participation Agreement for the air ambulance program in effect with the Missouri Department of Social Services, MO HealthNet Division.

(3) Participant Eligibility. The ambulance provider must ascertain the patient’s MO HealthNet status before billing for services. The participant’s MO HealthNet/Managed Care eligibility is determined by the Family Support Division. The participant must be eligible for MO HealthNet on the date that a service is provided in order for a provider to receive MO HealthNet reimbursement. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the ambulance program manual. The participant’s eligibility shall be verified in accordance with methodology outlined in the ambulance program manual.

(4) Prior Authorization. Emergency ambulance services do not require prior authorization. All non-emergency, MO HealthNet covered services that are to be performed or furnished out-ofstate for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized before the out-of-state services are provided. A prior authorization is not required for out-of-state emergency services.

(5) Services Covered and Service Limitations. The MO HealthNet ambulance manual shall provide the detailed listing of procedure codes and pricing information covered by the MO HealthNet ambulance program.

(A) Covered ambulance services are— 1. Transportation is made to the nearest appropriate hospital when the criteria for emergency services is met (see (5)

(B) below);

2. On-site treatment provided by an emergency medical technician or by a paramedic that meets the following criteria:

A. The treatment is a result of an emergent or immediate response made by a licensed ambulance service;

B. The emergency medical technician (EMT) or paramedic provides an assessment to determine the MO HealthNet participant’s medical condition;

C. Medically necessary treatment is provided to the participant on-site; and D. The participant is not transported by the responding service provider to an emergency department; and 3. On-site referral for further treatment that meets the following criteria:

A. The referral is a result of an emergent or immediate response made by a licensed ambulance services;

B. The EMT or paramedic provides an assessment to determine the MO HealthNet participant’s medical condition;

C. The referral is provided to the participant; and D. The participant is not transported by the responding service provider to an emergency department.

(B) Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Nearest appropriate hospital is the hospital that is equipped and staffed to provide the needed care for the illness or injury involved. MO HealthNet does not allow transportation to a more distant hospital solely to avail a patient of the services of a specific physician or family or personal preference when considering the nearest appropriate facility.

(C) Exceptions to Emergency Services.

1. MO HealthNet covers medically necessary ambulance services for participants under twenty-one (21) years of age through the Healthy Children and Youth (EPSDT/HCY) program.

The Omnibus Budget Reconciliation Act of 1989 (OBRA 89) expanded medically necessary services for children under the age of twenty-one (21) through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, also known as the Healthy Children and Youth (HCY) program. This allows for non-emergency transportation of children by ambulance for health care when other modes of travel are not medically appropriate and may endanger the child’s health. When other modes of transportation are available that would allow for safe transport of the child, these options must be utilized.

2. Transportation to and from one hospital to another and return for specialized testing and/or treatment is covered.

3. MO HealthNet covers transportation from the point of pickup to two (2) different hospitals made on the same day by the same ambulance provider when it is medically necessary.

4. Ground ambulance transfers of patients from one hospital to another hospital to receive medically necessary inpatient services not available at the first facility shall be covered by MO HealthNet. Hospital transfers shall be covered when the patient has been stabilized at the first hospital, but needs a higher level of care available only at the second hospital.

(D) MO HealthNet covers emergency rotary wing air ambulance only when:

1. Transportation by ground ambulance is contraindicated; or 2. The patient’s medical condition is such that immediate and rapid ambulance transportation is essential and cannot be provided by ground ambulance; or 3. Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities; or 4. The patient’s medical condition is such that the time needed to transport by land, or the instability of transportation by land poses a threat to the patient’s survival or seriously endangers the patient’s health; or 5. The point of pickup is inaccessible by land vehicle; and 6. All other MO HealthNet requirements for coverage are met.

(E) MO HealthNet covers fixed-wing air ambulance when:

1. The weather situation at the time of transport prohibits the use of a rotary wing ambulance; or 2. Transportation by ground ambulance or rotary wing ambulance is contraindicated; or 3. The patient’s medical condition is such that immediate and rapid ambulance transportation is essential and cannot be provided by ground ambulance or rotary wing ambulance; or 4. Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities; or 5. The patient’s medical condition is such that the time needed to transport by land or rotary wing, or the instability of transportation by land or rotary wing ambulance poses a threat to the patient’s survival or seriously endangers the patient’s health; or 6. The point of pickup is inaccessible by land vehicle; and 7. All other MO HealthNet requirements for coverage are met.

(6) Services Not Covered.

(A) Ground Ambulance. The following services are not covered under the ground ambulance program:

1. Ambulance transportation to a physician’s office, a dentist’s office, a nursing home, or a patient’s home except for participants under twenty-one (21) (except ME codes 76-79) through the EPSDT/HCY program;

2. Ambulance services to a hospital for the first stage of labor;

3. Non-emergency ambulance trips are not covered with the exceptions of those services listed above;

4. If a participant is pronounced dead before the ambulance is called, no MO HealthNet payment is made; or 5. Ancillary services and supplies are not covered when the patient is not transported.

(B) Air Ambulance. The following services are not covered under the air ambulance program:

1. Air ambulance trip for the patient’s personal preference;

2. Patient not transported to the nearest hospital with appropriate facilities;

3. Ambulance trips ordered by the Veteran’s Administration Hospital;

4. Transport of medical team (or other medical professionals) to meet a patient;

5. Ground mileage;

6. Transport to a facility that is not an acute care hospital, such as a nursing facility or physician’s office or dentist’s office or independent clinic or independent laboratory or to a patient’s home;

7. Transport if a participant is pronounced dead before the air ambulance is called; or 8. Ancillary services and supplies when the patient is not transported.

(C) When individuals are transported by ambulance to an emergency room and are subsequently treated and released without admission to the hospital, the return trip is not covered under the emergency ambulance program.

(7) General Regulations. General regulations of the MO HealthNet program apply to the ambulance program.

(8) Reimbursement. Payment will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for ambulance services. Reimbursement will not exceed the lesser of the maximum allowed or the provider’s billed charges. Ambulance program services are only payable to the enrolled, eligible, participating provider. The MO HealthNet program cannot reimburse for services performed by non-enrolled providers.

(9) Other Source Payment. The MO HealthNet payment for ambulance services cannot duplicate or replace benefits available to the participant from any other source, public or private. A settlement received from private insurance or litigation as the result of an accident must be used toward payment of the ambulance bill. MO HealthNet shall be the last source of payment on any claim. Any payment received from a private insurance carrier or other acceptable source shall be listed on the claim form. If the settlement received is equal to or exceeds the fee that could be allowed by MO HealthNet, no payment shall be made by MO HealthNet.

(10) Documentation Requirements for Emergency Ambulance Program. All services must be adequately documented in the medical record. Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. Documentation includes the Missouri Ambulance Reporting Form (trip ticket).

In addition to the above documentation requirements, each licensee of an air ambulance must maintain accurate records that contain information concerning the air transportation of each patient. The patient record shall be maintained and shall accurately document the patient care rendered by the medical flight crew and the disposition of the patient at the receiving facility. The documentation of the emergency air ambulance flight record (trip ticket) must contain a description of the patient’s medical condition with sufficient detail to demonstrate the need for emergency air ambulance.

(11) Records Retention. The enrolled MO HealthNet ambulance provider shall keep any records necessary to fully document compliance with this regulation and the services the provider furnishes to participants. These records must be retained for seven (7) years from the date of service. Fiscal and medical records must coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

Amended: Filed July 31, 2008, effective Feb. 28, 2009. Amended:

Filed May 15, 2019, effective Dec. 30, 2019. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2019. Original rule filed Feb. 10, 2006, effective Sept. 30, 2006. Amended: Filed Aug. 1, 2006, effective Feb. 28, 2007. Amended: Filed Aug. 23, 2007, effective March 30, 2008.

13 CSR 70-6.020 Ground Emergency Medical Transportation Uncompensated Cost Reimbursement Program {#sec-13-csr-70-6.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-6.020}

PURPOSE: This rule implements the Ground Emergency Medical Transportation (GEMT) Uncompensated Cost Reimbursement Program established pursuant to section 208.1030, RSMo, which is a voluntary program that makes reconciled cost reimbursement to eligible GEMT providers that furnish qualifying emergency ambulance services to MO HealthNet participants on or after July 1, 2017.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) Scope and Definitions.

(A) Under the Ground Emergency Medical Transportation (GEMT) Uncompensated Cost Reimbursement Program (hereinafter the “program”), the MO HealthNet Division (MHD) makes reconciled cost reimbursement to eligible GEMT providers up to the uncompensated Medicaid costs associated with GEMT services. This reconciled cost reimbursement applies only to GEMT services rendered to MHD participants by eligible GEMT providers on or after July 1, 2017. Total reimbursements from MHD, including the reconciled cost reimbursement, will not exceed one hundred percent (100%) of the eligible GEMT provider’s actual costs of providing GEMT services to MHD participants. The supplemental MHD reimbursement shall be distributed to eligible GEMT providers based on GEMT services provided to MHD participants on a per-transport basis. The reconciled cost reimbursement is not an individual increase to current fee-for-service reimbursement rates.

(B) Definitions.

1. Cost objective means a function or category of service for which costs are incurred.

2. Direct cost means those costs that— A. Meet the direct costs definition in accordance with 2 CFR 200.413.

(I) Can be identified specifically with a particular final cost objective, such as a federal award, or other internally or externally funded activity.

(II) Can be directly assigned to such activities relatively easily with a high degree of accuracy; and B. The direct costs allocated based on a statistical allocation for emergency medical response (EMR) and non-emergency medical response (non-EMR) costs do not meet the definition of direct costs, but are included under direct allocated cost. Estimates are not allowed.

3. Direct allocated costs means costs that cannot be directly assigned to EMR services or non-EMR services relatively easily with a high degree of accuracy. Examples of direct allocated costs include personnel who perform EMR and non-EMR services and overhead departments who perform EMR and non-EMR services.

4. Dry run means a run that does not result in a transport or delivery of on-site Medicaid covered services. Covered services are defined by Medicaid per 13 CSR 70-6.010.

5. Eligible GEMT provider means a provider who is eligible to receive reconciled cost reimbursement under this program because it meets the following requirements continuously during the claiming period:

A. Provides GEMT services to MHD participants;

B. Is enrolled as an MHD provider for the period being claimed; and C. Is owned, operated, or contracted by the state or a political subdivision of the state.

6. Emergency medical response (EMR) means a cost objective that includes all expenditures for GEMT services.

7. Federal financial participation (FFP) means the portion of medical assistance expenditures for emergency medical services that are paid or reimbursed by the Centers for Medicare & Medicaid Services in accordance with the state plan for medical assistance.

8. GEMT services means both the act of transporting an individual from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the patient, as well as the advanced, limited advanced, and basic life support services provided to an individual by eligible GEMT providers before or during the act of transportation.

As of January 1, 2020, GEMT services also include advanced, limited advanced, and basic life support services provided to an individual who is released on the scene without transportation by ambulance to a medical facility. Advanced, limited-advanced, or basic life support services provided to an individual who is released on the scene without transportation by ambulance to a medical facility prior to January 1, 2020, shall not be considered GEMT services. A dry run shall not be considered a transport for purposes of GEMT services. GEMT services exclude all air services.

9. Indirect cost means those costs that are incurred by a supporting organization or related party which are not directly accounted for as costs for EMR services, non-EMR services, or direct allocated costs. Examples of indirect costs include overhead costs (i.e., accounting, human resources, etc.) incurred by a city, county, or other local government agency or special district that benefit the eligible GEMT provider, but the eligible GEMT provider has not been charged for those costs.

The identification of direct allocated costs does not preclude an eligible GEMT provider from also incurring indirect costs, and it is appropriate in certain cases for the uncompensated Medicaid costs to include both direct allocated costs and indirect costs.

10. MHD participant means a patient enrolled in fee-forservice Missouri Medicaid.

11. Non-emergency medical response (non-EMR) means a cost objective that includes expenditures for non-medical emergency services, such as fire suppression not including medical services, and non-emergency ancillary services, such as fire prevention and fire permit issuance that are performed in the absence of an emergency in order to support preparedness, mitigate the need for emergency response, or lessen the severity of an emergency that might occur.

Expenditures assigned to this cost objective are not allowable for determining the cost of emergency transportation.

12. Reconciled cost reimbursement means a payment to eligible GEMT providers up to the uncompensated Medicaid costs associated with GEMT services for MHD participants.

13. Shift means a standard period of time assigned for a complete cycle of work, as set by each eligible GEMT provider.

The number of hours in a shift may vary among providers but will be consistent for each individual provider.

14. Service period means July 1 through June 30 of each Missouri state fiscal year.

15. Transport means GEMT services that are provided by eligible GEMT providers to individuals, regardless of whether the service was billed or paid. Medicaid transports includes GEMT services for Medicaid managed care, Medicaid crossover, and Medicaid fee for service patients. Other payer program transports shall be GEMT services provided to patients with payer sources other than Medicaid. Transportation services that do not involve the act of transporting an individual to the nearest medical facility capable of meeting the emergency medical needs of a patient shall not be included as transports.

16. Uncompensated Medicaid costs means the cost of GEMT services for MHD participants that exceeds the reimbursement received from, but not limited to, Medicaid, patients, and enhanced supplemental payments received from the ambulance service reimbursement allowance under 13 CSR 70-3.200. Cost excludes Medicaid managed care and dual-eligible Medicaid transports.

17. Dual-eligible Medicaid transport means any transport where Medicaid is not the primary payor due to other coverage including Medicare or other private insurance. These costs will not be reimbursed in the GEMT supplemental program.

(2) Participation and Enrollment Requirements.

(A) Participation in the GEMT program is voluntary.

(B) Ambulance providers that are not owned, operated, or contracted by the state or a political subdivision of the state are not eligible to participate in the program.

(C) As a condition of participation under this program, eligible GEMT providers shall transfer an administrative fee to MHD in an amount not to exceed five percent (5%) of the nonfederal share of the uncompensated Medicaid costs associated with GEMT services as identified in the eligible GEMT provider’s asfiled cost report. Such fee shall be transferred separately from the intergovernmental transfer of funds to MHD.

(D) To participate in the GEMT program, an eligible provider shall complete and execute the following forms and return them to MHD or its vendor. An eligible GEMT provider must complete and submit to MHD the following forms, which are incorporated by reference and made a part of this

rule as published by the Department of Social Services, MO HealthNet Division, September 22, 2021, and may be downloaded from https://dss.mo.gov/mhd/providers/gemt.htm, obtained by emailing a written request to Ask.GEMT@dss.mo.gov, or acquired in person at 615 Howerton Court, Jefferson City, MO 65109. This rule does not include any subsequent amendments or additions:

1. GEMT Program Provider Agreement for the MO HealthNet Division Ground Emergency Medical Transportation (GEMT)

Uncompensated Cost Reimbursement Program;

2. Electronic Funds Transfer Authorization Agreement;

3. Intergovernmental Transfer of Public Funds Agreement; and 4. Administration Fee Agreement.

(3) Interim Payments and Cost Settlement Process.

(A) If the eligible GEMT provider’s as-filed cost report reflects that the eligible GEMT provider has uncompensated Medicaid costs associated with GEMT services, the eligible GEMT provider is eligible to receive an interim payment from MHD. The eligible GEMT provider will make an intergovernmental transfer of funds to MHD in an amount equivalent to the nonfederal share of the uncompensated Medicaid costs amount shown on the as-filed cost report. MHD will then make an interim payment to the eligible GEMT provider in the amount of the total uncompensated Medicaid costs.

(B) If the eligible GEMT provider’s as-filed cost report does not reflect any uncompensated Medicaid costs associated with GEMT services, then the provider is not entitled to receive an interim payment from MHD under this supplemental payment program and will not be responsible for any costs associated with implementing the GEMT program.

(C) MHD will audit and reconcile the as-filed cost reports within one (1) year of receipt of the as-filed cost reports, unless MHD determines that additional time is needed, not to exceed three (3) years from receipt of the as-filed cost reports.

To audit and reconcile the as-filed cost reports, MHD will use paid claims data for the service period generated from the Medicaid Managed Information Systems (MMIS) and eligible GEMT provider records. MHD will make adjustments to the as-filed cost report based on the audit and reconciliation and send the provider its preliminary findings after receiving all relevant data from providers. The provider will be given fourteen (14) days to respond to MHD’s preliminary findings, unless an extension is granted by MHD. MHD’s final audit and reconciliation decision will be issued. Cost report will be deemed final once MHD issues a final determination letter and final adjusted cost report. If at the end of the final audit and reconciliation it is determined that the interim payment made to the eligible GEMT provider exceeded the provider’s uncompensated Medicaid costs associated with GEMT services, the provider shall return the excess amount associated with the federal share to MHD and MHD will return the amount to the federal government pursuant to 42 CFR 433.316. If at the end of the final reconciliation it is determined that the interim payment made to the eligible GEMT provider was lower than the provider’s uncompensated Medicaid costs associated with GEMT services, the eligible GEMT provider shall make an additional intergovernmental transfer to MHD in an amount equivalent to the nonfederal share of the underpayment, and MHD will then make an additional payment to the eligible GEMT provider of the full underpayment amount. MHD shall recoup funds paid out under section 208.1030, RSMo, and this regulation upon a disallowance of federal financial participation (FFP) for those funds. The recoupment will follow the process outlined in 13 CSR 70-3.030(6).

(D) Each provider’s uncompensated Medicaid cost associated with GEMT services is the sum of the number of transports for MHD participants provided during the applicable service period shown as paid in MMIS data, excluding Medicaid managed care and dual-eligible Medicaid transports, and contained in eligible GEMT provider records, multiplied by the provider’s per-transport cost rate, less all amounts received and payable from MHD (excluding Medicaid managed care payments) and patients for such transports as shown in the MMIS and eligible GEMT provider records, and all other sources of reimbursement for such transports. Other sources of reimbursement include, but are not limited to, co-payments received from participants, and enhanced supplemental payments received from the ambulance service reimbursement allowance under 13 CSR 70-3.200.

(E) Each provider’s per-transport cost rate is determined on the CMS-approved cost reports by adding the provider’s allowable direct, direct allocated, and indirect costs of providing GEMT services divided by the total number of transports provided for the applicable service period.

(4) Cost Report Requirements.

(A) To receive reconciled cost reimbursement under the GEMT program, each eligible GEMT provider must submit an annual cost report to MHD. Providers shall provide any supporting documentation to substantiate information provided on the cost report as requested by MHD or its contractor. The cost report form and the cost report instructions 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, September 22, 2021, and available at https://dss.mo.gov/mhd/providers/gemt.htm, or by emailing a written request to Ask.GEMT@dss.mo.gov.

This rule does not incorporate any subsequent amendments or additions.

(B) The cost report must be completed in compliance with the requirements set forth in this regulation and the cost report instructions incorporated herein. The eligible GEMT provider shall submit the cost report to MHD by November 30 for the prior state fiscal year ending June 30, unless the provider has submitted a written request to MHD for an extension and such request is granted by MHD. Any written request for an extension must include a detailed explanation of the circumstances supporting the need for additional time. Extensions may be granted by MHD for good cause.

(C) Each provider shall maintain fiscal and statistical records for the services period covered by the cost report. All records must be accurate and sufficiently detailed to substantiate the cost report data. The records must be maintained until the later of— 1. The division certifies that the cost report is finalized and settled; or 2. A period of six (6) years following the submission of the cost report. If an audit is in progress, all records relevant to the audit must be retained until the audit is completed or the final resolution of all audit exceptions, deferrals, and/or disallowances.

(D) All costs reported must be in accordance with the following:

1. Allowable and unallowable costs.

A. Reconciled cost reimbursement is available only for allowable costs incurred for GEMT services rendered to MHD participants based on the provider’s financial data reported on the cost report.

B. Computation of allowable costs and their allocation methodology must be determined in accordance with the Centers for Medicare & Medicaid Services (CMS) Provider Reimbursement Manual (CMS Pub. 15-1), 2 CFR Part 200, and 42 CFR Part 413, except as expressly modified herein.

(I) Part 200 of Title 2, Code of Federal Regulations, is incorporated by reference and made a part of this rule as published by the Office of the Federal Register, 800 North Capitol Street NW, Suite 700, Washington, D.C. 20408, and available at https://dss.mo.gov/proposed-rules, January 1, 2021.

This rule does not incorporate any subsequent amendments or additions.

(II) Part 413 of Title 42, Code of Federal Regulations, is incorporated by reference and made a part of this rule as published by the Office of the Federal Register, 800 North Capitol Street NW, Suite 700, Washington, D.C. 20408, and available at https://dss.mo.gov/proposed-rules, October 1, 2020.

This rule does not incorporate any subsequent amendments or additions.

(III) The Provider Reimbursement Manual—Part 1 (CMS Pub. 15-1) is incorporated by reference and made a part of this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, and available at https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929, September 22, 2021. A copy is available at the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or additions.

C. Costs which are considered unallowable include expenditures, such as bad debts, contributions and donations, entertainment including alcoholic beverages, fundraising costs, lobbying, legal judgments, and fines or penalties, which 2 CFR Part 200 does not permit to be charged to federal programs. If unallowable costs are not easily identifiable from allowable costs, the associated revenues received for providing the unallowable services will be offset against allowable cost. Additionally, for the purposes of Medicaid cost identification for the GEMT program, expenditures attributed to the nonemergency medical response cost objective are not costs incurred for GEMT services.

D. Amounts required to be paid pursuant to the ambulance service reimbursement allowance (AFRA) under 13 CSR 70-3.200, excluding administrative fees and pooling fees, are allowable for GEMT services. Pooling payments received from participation in the ambulance service reimbursement allowance program shall reduce the ambulance service reimbursement allowance amount reported as allowable by the provider.

E. Administrative costs incurred for reimbursing MHD for costs associated with implementing the GEMT program must be excluded from the cost report.

F. Eligible GEMT providers routinely use contract billing service providers to assist with the administrative functions of billing and collecting on patient accounts. Payments to contract billing service providers are an allowable administrative cost.

Fee arrangements based on hourly rates, fixed amounts, percentage of collection, or other methods are all considered allowable for computing uncompensated Medicaid costs; however, all payments to contract billing service providers must not exceed fair market value; and 2. Direct and indirect costs.

A. All direct costs must be reasonable and necessary and must be supported by documentation from which the costs incurred by the provider can be readily discerned and verified with reasonable certainty. Such documentation shall be subject to review by MHD.

B. Eligible GEMT providers that do not provide fire services would not have direct allocated costs and the cost report would reflect only EMR direct costs. Eligible GEMT providers that do not provide fire services but provide training (of non-employees) or nonemergency medical transportation services (e.g., non-emergency transportation between medical facilities or patient homes) shall include the costs of such services in their EMR direct costs, but shall offset those costs by any reimbursement received for such services up to the amount of costs for such services.

C. There is no universal rule for classifying certain costs as either direct cost or direct allocated cost under every accounting system. A cost may be direct cost with respect to some specific service or cost objective, but direct allocated cost with respect to the federal award or other final cost objective.

Therefore, it is essential that each item of cost incurred for the same purpose be treated consistently in like circumstances as a direct cost or a direct allocated cost in order to avoid possible double-charging of federal awards. For example, any cost incurred by an eligible GEMT provider which includes both costs incurred applicable to non-EMR services as well as GEMT services must in their entirety be consistently classified as direct or direct allocated costs.

D. Direct costs for providing GEMT services include only the unallocated payroll costs for the shifts in which personnel dedicate one hundred percent (100%) of their time to providing GEMT services, medical equipment and supplies, and other costs directly related to the delivery of GEMT services, such as first-line supervision, materials and supplies, professional and contracted services, capital outlay, travel, and training.

These costs must be in compliance with federal Medicaid non-institutional reimbursement policy and are directly attributable to the provision of the GEMT services. Directly assigned costs must be supported by auditable records, such as general ledger detail and should be assigned as part of the normal ongoing accounting process.

E. Direct allocated costs for EMR and non-EMR services shall be allocated based on a reasonable method in accordance with the guidelines in 2 CFR Part 200. The allocation statistic should identify and exclude costs associated with any personnel who is not considered a licensed or certified emergency medical technician and/or did not perform Medicaid covered services at an emergency site. If the allocation statistic is not supported by a time study or other adequate documentation to demonstrate dispatched personnel were performing Medicaid covered services at the emergency site, then at a minimum, the cost associated with personnel not on the treating or transporting ambulance should be identified and removed.

This would include the removal of all fire apparatus personnel dispatched to an emergency scene. The cost report shall allow the provider to use any reasonable method allowed in the Centers for Medicare & Medicaid Services (CMS) Provider Reimbursement Manual (CMS Pub. 15-1), 2 CFR Part 200, and 42 CFR Part 413, an example of reasonable methods include, among others— (I) Square footage allocations for capital cost;

(II) Depreciation cost for capital cost; or (III) Time studies for salaries and benefits.

F. When providing allocation information, statistics from the direct allocated costs should not be included in the calculations for allocation between EMR and non-EMR services.

G. Pursuant to 2 CFR Part 200, indirect costs are determined in accordance to one (1) of the following options:

(I) Eligible GEMT providers that receive more than thirty-five million dollars ($35,000,000) in direct federal awards must either have a Cost Allocation Plan (CAP) or a cognizant agency approved indirect rate agreement in place with its federal cognizant agency to identify indirect cost. If the provider does not have a CAP or an indirect rate agreement in place with its federal cognizant agency and it would like to claim indirect cost in association with a non-institutional service, it must obtain one (1) or the other before it can claim any indirect cost;

(II) Eligible GEMT providers that receive less than thirty-five million dollars ($35,000,000) of direct federal awards are required to develop and maintain an indirect rate proposal for purposes of audit. In the absence of an indirect rate proposal, providers may use methods originating from a CAP to identify its indirect cost. If the provider does not have an indirect rate proposal on file or a CAP in place and it would like to claim indirect cost in association with a non-institutional service, it must secure one (1) or the other before it can claim any indirect cost;

(III) Eligible GEMT providers that receive no direct federal funding can use any of the following previously established methodologies to identify indirect cost:

(a) A CAP with its local government;

(b) An indirect rate negotiated with its local government; or (c) Direct identification through use of a cost report; and (IV) If the GEMT provider never established any of the above methodologies, it may do so, or it may elect to use the ten percent (10%) de minimis rate to identify its indirect cost.

Filed Dec. 23, 2025, effective June 30, 2026. *Original authority: 208.201, RSMo 1987, amended 2007; 208.1030, RSMo 2016; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY sections 208.201, 208.1030, and 660.017, RSMo 2016. Original rule filed Sept. 22, 2021, effective April 30, 2022. Amended:

Chapter 8 Program of All-Inclusive Care for the Elderly

13 CSR 70-8.010 Program of All-Inclusive Care for the Elderly {#sec-13-csr-70-8.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-8.010}

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).

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) 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. This rule hereby incorporates by reference and makes a part of this rule 42 CFR 460.102 as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, DC 20408, and which is located on the website of the U.S. Government Publishing Office at https://www.govinfo.gov/app/collection/CFR, October 1, 2023. This rule does not incorporate any subsequent amendments or additions;

(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).

(3) Eligibility Criteria.

(A) To be eligible for PACE services, a participant must— 1. Be at least fifty-five (55) years of age;

2. Reside within a PACE organization’s service area;

3. Meet the state’s level of care requirements;

4. At the time of initial enrollment, reside in a non-institutional setting (e.g., house, apartment) without jeopardizing the participant’s health or safety;

5. Agree to obtain all health-related services only through the PACE organization during the participant’s period of enrollment in PACE;

6. Not be enrolled in one (1) or more of the following (or will discontinue being enrolled in one (1) or more of the following upon enrollment in PACE):

A. A Medicaid managed-care program other than PACE;

B. A hospice program;

C. A Medicaid 1915(c) home and community-based services (HCBS) waiver program;

D. A nursing facility certified by MHD while MHD is covering the person’s nursing facility expenses; or E. A health home;

7. Not reside in a state mental institution or an intermediate care facility for the intellectually disabled; and 8. Not be in a MO HealthNet coverage penalty period for a transfer of property under 42 U.S.C. 1396p(c).

(B) The PACE program is available to eligible Medicaid participants receiving MO HealthNet under a federally funded MO HealthNet eligibility category. The eligible MO HealthNet Medicaid Eligibility (ME) codes can be found in the MO HealthNet Provider Manual and include— 1. E2, 01, 03, 04, 11, 12, 13, 14, 15, 16, 85, and 86;

2. A participant may also have ME 55 or ME 82, but these codes shall be in conjunction with one (1) of the ME codes listed above; and 3. This rule hereby incorporates by reference and makes a part of this rule the PACE Provider Manual as published by the MO HealthNet Division, 615 Howerton Ct., Jefferson City, MO 65109, and which is located on the website of the Missouri Department of Social Services at https://mydss.mo.gov/mhd/ provider-manuals, September 1, 2023. This rule does not incorporate any subsequent amendments or additions.

(4) Eligibility Review.

(A) The PO shall complete a full eligibility review of all potential enrollees. A full eligibility review includes the following steps:

1. Verification of ME code using the eMOMED system;

2. Verification of spenddown eligibility and spenddown amount via eMOMED; and 3. Review of the Department of Health and Senior Services’ (DHSS) Cyber Access system for the presence of a Healthcare Home enrollment or an HCBS care plan. If either is present, the enrollment(s) must end if the participant enrolls in PACE.

(B) The PO shall ensure all eligibility criteria are met at time of enrollment. This shall include— 1. Requesting the termination of Healthcare Home enrollment; and 2. Verifying HCBS care plan is closed.

(5) Enrollment Process.

(A) The PO shall develop and adhere to an enrollment process to be approved by the SAA.

(B) Completion of enrollment documentation and notifications is the responsibility of the PO in accordance with the SAA-approved enrollment process.

(6) Disenrollment Process.

(A) The PO shall develop and adhere to a disenrollment process to be approved by the SAA.

(B) For each participant who is voluntarily or involuntarily disenrolled, the PO shall— 1. Continue to provide for the necessary services to the participant through the last day of enrollment;

(1/29/25) Denny Hoskins 2. Create a discharge plan to help the participant obtain necessary transitional care through appropriate referrals to other Medicaid or Medicare service providers; and 3. Provide the medical records of the participant within five (5) business days after receipt of a legally compliant release of information.

(7) Provider Qualifications.

(A) In order to qualify as a PO, a prospective PO shall— 1. Meet all CMS requirements outlined in the application process through CMS;

2. Enroll as a MO HealthNet provider with the Missouri Medicaid Audit and Compliance Unit (MMAC).

A. Any providers with which the PO contracts for the provision of MO HealthNet-covered services shall also enroll with MMAC; and 3. Shall complete and submit a feasibility study to be approved by the SAA.

(8) Provider Responsibilities.

(A) The PO shall be responsible for completing the SAA LOC assessment tool with the participant and/or authorized representative and submitting the determination to the SAA.

The SAA LOC Assessment tool is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://mydss.mo.gov/ mhd/forms, April 30, 2022. This rule does not incorporate any subsequent amendments or additions.

1. The PO shall complete the LOC assessment accurately based on the resources provided by the SAA. If the PO does not complete the assessment accurately, the SAA may deny the LOC assessment.

2. The PO shall include with the determination that it submits to the SAA any supplemental documentation that the PO used to support its assessment.

3. For purposes of determining eligibility, the LOC determination is only valid for ninety (90) days from the date of assessment.

(B) The PO shall be responsible for enrollment of the participant into PACE services, pursuant to federal and state law.

(C) The PO shall meet all applicable requirements under federal, state, and local law that are relevant to the PACE program and to MO HealthNet providers.

(D) The PO shall adhere to all terms outlined in the PACE program agreement between CMS, the SAA, and the PO.

(E) The PO shall obtain and maintain access to the following systems to be used for eligibility reviews, secure file transmission, enrollments, and disenrollments:

1. eMOMED;

2. CyberAccess (HCBS tab);

3. A File Transfer Protocol (FTP) site as determined by the SAA; and 4. Additional systems as determined by the SAA.

(9) Capitation Payment.

(A) The SAA shall issue to the PO a monthly prospective capitation payment for each PACE-enrolled MO HealthNet participant, and the PO shall assume full financial risk for that participant’s care.

(B) The PO shall deliver a comprehensive service package, including all Medicare and Medicaid-covered services, as well as those additional services specified in the PACE program agreement.

(C) The PO shall consolidate the delivery of care by linking Medicaid and Medicare funding through the pooling of all capitation payments.

(D) In the event that a PACE participant is placed in a skilled nursing facility indefinitely, the Family Support Division (FSD) shall determine if the participant will have a surplus pursuant to 13 CSR 40-2.200. If the participant has a surplus, the PO shall recoup that amount from the participant, and the SAA shall recoup that amount from the capitation payment each month. The steps for Medicaid eligibility recalculation and recoupment are as follows:

1. The PO shall notify the SAA via FTP that a participant is being placed in a skilled nursing facility for a time frame to exceed thirty (30) consecutive days;

A. The PO shall include the participant’s name, departmental client number (DCN), date of birth, the name of the skilled nursing facility, and date the participant was or is being placed in the skilled nursing facility;

B. Should the participant be discharged from the skilled nursing facility, the PO shall notify the SAA of the discharge date; and 2. The PO shall contact the FSD to initiate a determination of the participant’s surplus liability.

(10) Termination of the PACE Program Agreement.

(A) The SAA may, in addition to any actions taken by MMAC pursuant to state law, terminate a PACE program agreement at any time for cause as outlined in the PACE program agreement.

1. Termination for cause includes but is not limited to uncorrected deficiencies in the quality of care furnished to participants, the PACE organization’s failure to comply substantially with conditions for a PACE program, or noncompliance with the terms of the program agreement.

(B) In the event of termination of the PACE program agreement, the PO may seek review of the department’s action pursuant to section 208.156, RSMo.

(11) Annual Behavioral Health Screenings.

(A) The PO shall conduct annual behavioral health screenings.

The PO shall conduct the Short Michigan Alcoholism Screening Test – Geriatric Version (SMAST-G) for every participant.

(B) In addition to the screening test identified in subsection (A) of this section, the PO shall determine which additional annual screening is appropriate for the participant in collaboration with the interdisciplinary team. The PO shall choose one (1) of the following assessments:

1. Rating Anxiety in Dementia (RAID) for participants with dementia; or 2. Geriatric Anxiety Scale – 10 Item Version (GAS-10) for cognitively normal participants.

(12) Provider Reporting.

(A) The PO shall provide to the SAA a list of all providers with whom the PO has a contractual agreement to provide services to the PO’s participants, in an easily readable and accessible format, by close of business on the last business day of each quarter (last business day of March, June, September, and December).

(B) The list of providers shall include the following details:

1. Provider/organization legal name;

2. National Provider Identifier (NPI) number; and 3. The effective date on which the provider enrolled with the PO.

(13) Provider Service Areas.

(A) The PO shall designate its service area in the application process through CMS.

1. A service area is made up of the county, zip code(s), street boundaries, census tract, block, or tribal jurisdictional area, as applicable, in which a participant must live in order to receive services from any given PO. The SAA may require that the service area be made up of one (1) of these types of geographic areas.

2. A PO shall have the exclusive use of its designated service area.

3. The service area shall be established in the program agreement.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2024. Original rule filed Aug. 1, 2022, effective March 30, 2023. Amended: Filed Aug. 2, 2024, effective Feb. 28, 2025. Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-8.020 Oversight of PACE Organizations and Providers {#sec-13-csr-70-8.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-8.020}

PURPOSE: This rule establishes a process of cooperation between the MO HealthNet Division (MHD) and Program of All-Inclusive Care for the Elderly (PACE) organizations and their providers to safeguard against unnecessary and inappropriate utilization of care and services provided to PACE participants.

(1) Scope. This rule implements the oversight and compliance requirements for the Program of All-Inclusive Care for the Elderly (PACE).

(2) Definitions. For purposes of this regulation, the following words and phrases are defined as follows:

(A) “Electronic medical records” (EMR) are defined at 13 CSR 70-3.210(1) Electronic Retention of Records;

(B) “PACE organization” (PO) shall refer to the entity that provides services to participants under a PACE program agreement with CMS and the SAA;

(C) “Participant” shall refer to a person who receives services through the MO HealthNet Division (MHD) and the PACE organization; and (D) “State administering agency” (SAA) shall refer to the Missouri Department of Social Services, MO HealthNet Division (MHD), which for purposes of this rule includes Missouri Medicaid Audit and Compliance (MMAC).

(3) Oversight Process.

(A) The PACE organization shall cooperate with the SAA’s evaluation, oversight, and ongoing monitoring. The PACE organization’s cooperation shall include the following:

1. Permitting the SAA access to inspect any physical locations involved with the PACE organization’s services;

2. Giving the SAA access to the PO’s electronic medical records for five (5) consecutive days each month as determined by the SAA for focused reviews.

A. The PO will have ten (10) business days after notification by email to provide access to the PO’s EMR for its focused review;

3. Providing the SAA with copies of any requested records regarding the PACE organization and services offered to PACE participants through file transfer protocol (FTP) or encrypted email within five (5) business days of the request; and 4. Conducting an annual audit which the SAA may conduct remotely and on-site.

A. A remote audit may include but not be limited to a review of participant files, grievance and appeals logs, call logs, service logs, changes to policies and procedures, and personnel files.

B. An on-site audit may include but not be limited to observations of participants in any settings, and observations and reviews of compliance with policies and procedures.

(B) The PO will be referred to MMAC for any suspected cases of fraud, waste, and abuse.

(4) The PACE organizations and their providers shall comply with the provisions of 13 CSR 70-3.030 and are subject to 13 CSR 65-2.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2024. Original rule filed May 16, 2024, effective Dec. 30, 2024. Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

Chapter 10 Nursing Home Program

13 CSR 70-10.016 Global Per Diem Adjustments to Nursing Facility and HIV Nursing {#sec-13-csr-70-10.016 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.016}

13 CSR 70-10.020 Prospective Reimbursement Plan for Nursing Facility and HIV {#sec-13-csr-70-10.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.020}

13 CSR 70-10.030 Prospective Reimbursement Plan for Nonstate-Operated Facilities {#sec-13-csr-70-10.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.030}

13 CSR 70-10.040 Medicaid Eligibility and Preadmission Screening for Mentally Ill and Intellectually Disabled Individuals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 {#sec-13-csr-70-10.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.040}

13 CSR 70-10.060 Retrospective Reimbursement Plan for State-Operated Facilities for {#sec-13-csr-70-10.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.060}

13 CSR 70-10.070 Limitations on Allowable Nursing Facility Costs to Reserve a Bed for {#sec-13-csr-70-10.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.070}

13 CSR 70-10.100 Limitation on Allowable Capital Cost Overruns for New Institutional {#sec-13-csr-70-10.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.100}

13 CSR 70-10.005 Reasonable Cost-Related Reimbursement Plan for Long-Term Care {#sec-13-csr-70-10.005 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.005}

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.

Editor’s Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office of the Secretary of State or at the headquarters of the agency and is available to any interested person at a cost established by state law. The forms mentioned in this rule follow 13 CSR 70- 10.010.

(1) Objectives.

(A) Uniform Plan. The provisions embodied in this rule define a system of reasonable cost-related reimbursement for longterm 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.

(2) Scope.

(A) Participating Providers. Reasonable cost-related reimbursement for LTC and services is applicable to those facilities with a valid participation agreement in effect on or after July 1, 1976, with the Missouri Department of Social Services. Areas of a facility certified to participate in the Title XIX program by the Department of Social Services or other certifying authority approved by the Department of Social Services and the Department of Health, Education and Welfare (HEW) are covered within this rule. The provisions of this rule shall become effective January 1, 1980; however, year-end cost reports for fiscal years beginning prior to January 1, 1980, shall be prepared in accordance with the prior plan except in those areas where additional covered services have been added by this plan. These additional services shall be handled in a separate line item in the cost report. The provisions contained in this rule shall not have any retroactive effect on the cost reports or determination of any retrospective payment for fiscal years beginning prior to May 11, 1975.

(B) Allowable Costs. Each provider’s total allowable costs (TACs) will be determined by the Department of Social Services from cost reports submitted on a fiscal-year basis. The fiscal year, which will be each provider’s fiscal year, should coincide with the tax year used by the provider in submitting federal income tax reports.

(C) Eligible Recipients. This plan applies only to allowable costs incurred by eligible facilities for eligible recipients certified to medically require long-term, skilled, intermediate care or care for the mentally retarded, or a combination of these.

(3) Changes to Plan. Changes to the plan may be made by the Department of Social Services. Representatives of participating facilities will have an opportunity to make recommendations.

All these changes will be subject to approval by the secretary of HEW and in accordance with sections 536.021 and 536.025, RSMo.

(4) Reporting Requirements.

(A) Annual Cost Report.

1. Each provider shall establish a twelve (12)-month period which is to be designated as the provider’s fiscal year (see subsection (2)(B) of this rule). An annual cost report for the fiscal year shall be submitted by the provider to the department on forms to be furnished for that purpose. The completed forms shall be submitted by each provider within ninety (90) days following the close of its fiscal year.

2. Unless adequate documentation in the following areas has been filed previously with the department, authenticated copies of the following documents must be submitted with the cost report: authenticated copies of all leases related to the activities of the facility, all management contracts, all contracts with consultants, federal and state income tax returns for the fiscal year and documentation of expenditures, by line item, made under all restricted and unrestricted grants.

For restricted grants, a statement verifying the restriction as specified by the donor.

3. Adequate documentation for all line items on the uniform cost reports must be maintained by the facility and must be submitted to the department upon request.

4. Following the ninety (90)-day period, interim payments will be withheld from the facility until the cost report is submitted. Upon receipt of a cost report prepared in accordance with these rules, the interim payments that were withheld will be released.

5. If requested in writing, a reasonable extension of the filing date may be granted for good cause shown.

6. The termination by a provider of participation in the program or a change of ownership requires that the provider submit a cost report for the period ending with the date of termination or change. The cost report is due within forty-five (45) days of the date of termination or change. If requested in writing, a reasonable extension of the filing date may be granted for good cause shown.

(B) Certification of Cost Reports.

1. The accuracy and validity of any cost report, whether annual or interim, must be certified. Certification must be made by one (1) of the following persons (who must be authorized by the governing body of the facility to make the certification and will furnish proof of this authorization): for an incorporated body, an officer of the corporation; for a partnership, a partner; for a sole proprietorship or a sole owner, the owner; or for a public facility, the chief administrative officer of the facility. The cost report must also be notarized by a licensed notary public.

2. Certification statement.

Misrepresentation or falsification of any information contained in this cost report may be punishable by fine, Certification by officer or administrator of provider(s):

I hereby certify that I have read the above statement and that I have examined the accompanying Cost Report and supporting schedules prepared by _________________________ _________________________________________________________ for the cost report period beginning ___, 19 and ending ________, and that to the best of my knowledge and belief, it is and records of the provider(s) in accordance with applicable _________________________________________________________ (C) Interim Reports.

1. From the beginning of its fiscal year, a provider, at its election, may submit cumulative quarterly cost reports.

Insurance premiums, property taxes, professional fees and similar items shall be prorated in this report in order to avoid any distortion of allowable costs.

2. An interim cost report may be submitted for consideration whenever a participating LTC facility changes the level-of-care it has been certified to provide.

3. Whenever additional beds are added, licensed and certified to an existing facility, the facility may file an interim (D) Adequacy of Records.

4. The records and accounting procedures of a provider must be adequate to substantiate purposes of review and audit as may be necessary in accordance with this plan.

5. At all reasonable times, the provider shall make available to the department and its duly authorized agent, including federal agents from HEW, records as are necessary to permit review and audit of the provider’s cost reports. Failure to do so may lead to the penalty stated in paragraph (4)(A)4. of this rule.

6. All records associated with the preparation and documentation of the data associated with the cost report must be retained for seven (7) years from the cost report filing date.

(5) Principles of Reasonable Cost-Related Reimbursement, Allowable Costs.

(A) General Provisions.

1. Nursing facilities participating in the Missouri Medicaid program which provide skilled or intermediate care, or intermediate care facility/mentally retarded (ICF/MR) care, or a combination of these, shall be reimbursed based upon the allowable costs of the individual nursing facility. These costs must be related to ordinary and necessary care for the level-ofcare actually provided.

2. In addition to reimbursement of allowable costs, a proprietary provider shall be paid a reasonable return on owner’s net equity (see section (14)).

3. Allowable costs means those costs of the provider which are allowable for allocation to the Medicaid program based upon the principles established in this rule.

4. The allowability of costs not addressed specifically in this rule will be determined by the director, Department of Social Services, in a manner as to assure uniform application to all providers. This determination may be based upon criteria such as the Medicare Provider Reimbursement Manual (HIM-15).

5. Provider means a nursing home, or other facility as may be designated by the Department of Social Services, duly licensed and certified to participate in the Title XIX program by appropriate state agencies to furnish nursing and other care to individuals who by reason of illness, physical infirmities or advanced age are unable to care for themselves.

6. Payments to providers shall be based upon an individual accounting of the allowable costs of operation of each provider.

The Department of Social Services shall have authority to require uniform accounting and reporting procedures as it deems necessary. As a minimum, standardized definitions, accounting, statistical and reporting procedures as well as expense classifications are to be in accordance with widely accepted understanding and use in health care institutions.

7. A participating nursing home is a provider which has entered into an agreement with the Department of Social Services to accept payments based upon the principles of reimbursement described in this rule and not charge the eligible recipient or any other person for covered items and services except in personal items.

8. A reasonable cost in each related cost area will be determined by the director of the Department of Social Services pursuant to section 208.152, RSMo. At his/her option, the director may follow guidelines set forth in the Medicare and Medicaid Provider Manual (HIM-15, Section 904), “Criteria for Determining Reasonable Compensation General,” as applicable to the operation of the program by Missouri.

(B) Compensation of Owners.

1. Regardless of whether the provider is a corporation, partnership, proprietorship or otherwise, a reasonable allowance of compensation of services of owners shall be an allowable cost, provided the services are actually performed in a necessary function.

2. Compensation shall mean the total benefit received by the owner for the services s/he renders to the facility including: direct payments for managerial, administrative, professional and other services; amount paid by the provider for the personal benefit of the owner; the cost of assets and services which the owner receives from the provider; deferred compensation; and additional amounts determined to be the reasonable value of the services rendered by sole proprietors or partners and not paid by any method enumerated in this

section.

3. Reasonableness of compensation may be determined by reference to or in comparison with compensation paid for comparable services and responsibilities in comparable institutions, or it may be determined by other appropriate means such as the Medicare and Medicaid Provider Reimbursement Manual (HIM-15).

4. Necessary services refers to those services that are pertinent to the operation and sound conduct of the facility; had the provider not rendered these services, then employment of another person(s) to perform the service would be necessary.

(C) Covered Services and Supplies.

1. Skilled nursing facility (SNF) and ICF services and supplies covered by this plan are those found in 42 CFR 442.100—442.516 which include, among other services, the regular room, dietary and nursing services or any other services that are required for standards of participation or certification; also included are minor medical and surgical supplies and the use of equipment and facilities. Services set out in subparagraphs (5)(C)1.G. and H. of this rule shall be covered services effective January 1, 1980.

These items include, but are not limited to, the following:

A. All general nursing services including, but not limited to, administration of oxygen and related medications, handfeeding, incontinency care, tray services and enemas;

B. Items which are furnished routinely and relatively uniformly to all recipients, for example, gowns, water pitchers, basins and bed pans;

C. Items stocked at nursing stations or on the floor in gross supply and distributed or utilized individually in small quantities such as alcohol, applicators, cotton balls, and bandaids, antacids, aspirins (and other non-legend drugs ordinarily kept on hand), suppositories and tongue depressors;

D. Items which are utilized by individual recipients, but which are reusable and expected to be available such as ice equipment and other durable, nondepreciable medical E. Additional items as specified in the appendix to this plan when provided to the patient;

F. Special dietary supplements used for tube feeding or oral feeding such as elemental high nitrogen diet including dietary supplements written as a prescription item by a physician;

G. All laundry services including personal laundry; and H. All general personal care services which are furnished routinely and relatively uniformly to all recipients for their personal cleanliness and appearance shall be covered services, for example, necessary clipping and cleaning of fingernails and toenails, basic hair care, shampoos and shaves to the extent necessary for reasonable personal hygiene. The provider shall not bill the patient or his/her responsible party for this type of personal service.

(I) All consultive services as required by state or federal law or regulation or for proper operation by the provider. Contracts for the purchase of these services must accompany the provider cost report, as specified in paragraph (4)(A)2. of this rule. Failure to do so will result in the penalties specified in paragraph (4)(A)4. of this rule.

(II) All services and supplies not included in allowable costs shall be treated as services and supplies not covered by the Medicaid program.

(III) The provider may collect from recipients, their relatives or from the recipient’s personal needs fund only charges for personal items, noncovered services and supplies and prescription drugs not on the formulary.

(D) Depreciation.

1. An appropriate allowance for depreciation on buildings, and sound conduct of the provider’s business, including items that are used in a normal standby or emergency capacity, is an allowable cost.

2. The depreciation must be identifiable and recorded in the provider’s accounting records, based on the program basis of the asset and prorated over the estimated useful life of the asset using the straight line method of depreciation from the date initially put into service.

3. The program basis of assets shall be lower of the book value of the provider, fair market value at the time of acquisition or the recognized Internal Revenue Service (IRS) tax basis. Donated assets will be allowed basis to the extent of recognition of income resulting from the donation of the asset.

Should a dispute arise between a nursing home facility and the Department of Social Services as to the fair market value at the time of acquisition of a depreciable asset and an appraisal by a third party is required, the appraisal cost will be shared proportionately by the Medicaid program and the nursing home facility in ratio to Medicaid recipients.

4. Allowable methods of depreciation shall be limited to the straight line method. The depreciation method used for an asset under the Medicaid program need not correspond to the method used by a provider for non-Medicaid purposes; however, useful life shall be the same as the provider claims for IRS purposes. Component part depreciation is optional and allowable under this plan.

5. Historical cost is the cost incurred by the provider in acquiring the asset and to prepare it for use except as provided for in this rule. Usually, historical cost includes costs that would be capitalized under generally accepted accounting principles.

For example, in addition to the purchase price, historical cost would include architectural fees, consulting fees and related legal fees. Where a provider has elected for federal income tax purposes to expense certain items, such as interest and taxes during construction, the historical cost basis for Medicaid depreciation purposes may include the amount of these expensed items. However, where a provider did not capitalize these costs and has written off these costs in the year they were incurred, the provider cannot retroactively capitalize any

part of these costs under the program. For Title XIX purposes and this plan, any asset costing less than three hundred dollars ($300) or having a useful life of one (1) year or less may be expensed and not capitalized at the option of the provider.

6. When an asset is acquired by trading in an existing asset, the cost basis of the new asset shall be the sum of the undepreciated cost basis of the traded asset plus the cash paid and subsection (10)(A) shall not apply.

7. For the purpose of determining allowance for depreciation under the Medicaid program, the cost basis of a facility purchased as an ongoing operation after July 1, 1976, shall be the price paid by the purchaser or the appraised value, whichever is lower. If the purchaser cannot demonstrate that the sale was a bona fide sale, the cost basis of the seller shall be determined on the basis of the value reported to IRS for the year immediately preceding the sale.

8. Subject to the principles enumerated in this subsection, the cost basis usable for depreciation of the facility to the purchaser shall be the lower of the purchaser’s book value for the facility, the recognized IRS tax basis or the depreciable cost as determined in paragraph (5)(D)7.

9. Capital expenditures for building construction or for renovation costs which are in excess of one hundred thousand dollars ($100,000) and which cause an increase in a provider’s bed capacity shall not be allowed in the program or depreciation base if these capital expenditures are disallowed by the provisions of federal Social Security Act,

Section 1122(B), Social Security Amendments of 1972, Sections 221(B) and (D) or for failure to comply with any other federal act that promulgates a limitation on reimbursement for capital expenditures under federal or state legislation.

(E) Interest and Finance Costs.

1. Necessary and proper interest on both current and capital indebtedness shall be an allowable cost.

2. Interest is the cost incurred for the use of borrowed for funds borrowed for a relatively short-term. This is usually for purposes as working capital for normal operating expense.

Interest on capital indebtedness is the cost incurred for funds borrowed for capital purposes such as acquisition of facilities and equipment and capital improvements. Generally, loans for capital purposes are long-term loans.

3. Interest may be included in finance charges imposed 4. To be an allowable cost under the Medicaid program, interest (including finance charges, prepaid costs and discount) must be supported by evidence of an agreement that funds were borrowed and that payment of interest and repayment of the funds are required, identifiable in the provider’s accounting records, relating to the reporting period in which the costs are claimed, and necessary and proper for the operation, maintenance or acquisition of the provider’s facilities.

4. Necessary, as used in these rules, means that the interest be incurred on a loan made to satisfy a financial need of the provider and for a purpose reasonably related to recipient care.

Loans which result in excess of funds or investments would not be considered necessary.

6. Proper, as used in these rules, means that the interest be incurred at a rate not in excess of what a prudent borrower would have had to pay in the money market existing at the time the loan was made.

7. Interest on loans to providers by proprietors and general partners shall not be an allowable cost because these loans shall be treated as invested capital and included in the computation of an allowable return on owner’s net equity.

Interest on loans to providers by limited partners or minority stockholders shall be an allowable cost at a rate not in excess of a reasonable rate. If a provider operated by members of a religious order borrows from the order, interest paid to the order shall be an allowable cost.

8. Income from a provider’s qualified retirement fund shall be excluded in consideration of the per-diem rate.

9. A provider shall amortize finance charges, prepaid interest or discount over the period of the loan ratably or by balance where the time period is in excess of twelve (12) months.

10. Usual and customary costs incurred to obtain loans shall be treated as interest expense and shall be allowable costs over the loan period ratably or by means of the constant interest applied method.

11. Usual and customary costs include, but are not limited to, lender’s finance charges or fees, title and recording fees, appraisal fees, legal fees, escrow fees and closing costs.

12. Loan costs shall be allowable costs only to the extent that they meet the criteria established in this rule for the allowance of interest expense in general.

13. Interest expense resultant from capital expenditures excess of one hundred thousand dollars ($100,000) and which cause an increase in a bed capacity by the provider shall not be an allowable cost if those capital expenditures are disallowed by the secretary of Health and Human Services (HHS) for failure to comply with the provisions of federal Social Security Act, Section 1122(B), Social Security Amendments of 1972, Sections 221(B) and (D), or for failure to comply with any other federal or state requirement that promulgates a limitation on reimbursement for capital expenditures.

(F) Rental Costs.

1. Rental costs of land, buildings, furnishings and equipment are allowable costs provided that the rented items are reasonable, necessary and not in essence a purchase of those assets.

2. Necessary rental items are those which are pertinent to the operation and sound conduct of the provider, including items that are used in a normal standby or emergency capacity.

3. Reasonable rental amounts are the lesser of those which are actually paid or those that would be paid to an unrelated party for use of the same property.

4. Determination of reasonableness in individual cases may be established by affidavits of competent, impartial experts who are familiar with the current rentals in the community.

5. The test of reasonableness shall take into account the 6. In the case of rental costs paid to individuals or organizations related to the provider by common ownership or control (or to the lessors or an ongoing facility), the rental amounts shall not exceed the lesser of actual or reasonable costs to constitute allowable costs (see paragraph (5)(F)3.).

6. Related to the provider, common ownership and control have the same meaning as defined in paragraphs (5)(N)2. and 3.

7. Lessor of an ongoing facility means any owner of rented property who had used the property to participate in the Medicaid program on or after January 1, 1976.

8. In the case of rental costs paid to the lessor of an ongoing facility, the rental amounts must not be in excess of reasonable rental costs (see paragraph (5)(F)3.).

(G) Taxes.

1. Taxes levied on or incurred by a provider shall be allowable costs with the exception of the following items:

A. Federal, state or local income and excess profit taxes including any penalties paid them;

B. Taxes, in connection with financing, refinancing or refunding operations such as taxes on the issuance of bonds, property transfer, issuance or transfer of stocks. Generally, these costs are either amortized over the life of the securities or depreciated over the life of the asset. They are not, however, recognized as a tax expense;

C. Taxes from which exemptions are available to the provider;

D. Special assessments on land which represent capital improvements such as sewers, water and pavements. These costs shall be capitalized and depreciated over the period during which the assessment is scheduled to be paid in annual installments;

E. Taxes on property which is not a part of the operation and sound conduct of the provider nor used in a normal standby or emergency capacity;

F. Taxes, such as sales taxes, which are levied against the recipient and collected and remitted by the provider; and G. Self-employment Federal Insurance Contribution Act (FICA) taxes applicable to individual proprietors, partners, members of a joint venture, to the extent these taxes exceed the amount which would have been paid by the provider on the allowable compensation of these persons had the provider organization been an incorporated rather than unincorporated entity.

(H) Issuance of Revenue Bonds and Tax Levies by District and County Facilities. Those nursing home districts and county bonds, in accordance with sections 198.312 and 205.371— 205.375, RSMo will be granted as an allowable cost that interest which is paid per the revenue bonds; depreciation on the plant and equipment of these facilities shall also be an allowable cost. Any tax levies which are collected by nursing home

part by these levies will not be recognized as a revenue offset, (I) Value of Services of Employees.

1. The value of services performed by employees in the facility shall be included in allowable costs to the extent actually compensated, either to the employee directly or to the supplying organization.

2. Services rendered gratis by volunteers, such as those affiliated with the American Red Cross, hospital guilds, auxiliaries, private individuals and similar organizations, shall not be included in allowable costs, as these services traditionally have been rendered on a purely volunteer basis without expectation of any form of reimbursement by the organization through which the service is rendered or by the person rendering the service.

3. Services by priests, ministers, rabbis and similar type professionals shall be an allowable cost provided that the services are not of a religious nature. An example of an allowable cost under this section would be a necessary administrative function performed by a clergyman. The state will not recognize building costs on space set aside primarily for professionals providing any religious function.

Costs for wardrobe and similar items likewise are considered nonallowable.

(J) Fringe Benefits.

1. Life insurance.

A. Types of insurance which are not considered an allowable cost—premiums related to insurance on the lives of officers and key employees are not allowable costs under the following circumstances:

(I) Where, upon the death of an insured officer or key employee, the insurance proceeds are payable directly to the provider. In this case, the provider is a direct beneficiary.

Insurance of this type is referred to as key-man insurance; and (II) Where, insurance on the lives of officers is voluntarily taken out as part of a mortgage loan agreement entered into for building construction and, upon the death of an insured officer, the proceeds are payable directly to the lending institution as a credit against the loan balance. In this case, the provider is an indirect beneficiary. Insurance of this type is referred to as credit-life insurance.

B. Types of insurance which are considered an allowable cost where— (I) Credit life insurance is required as part of a loans granted under certain federal programs; and (II) The relative(s) or estate of the employee is the beneficiary. This type of insurance is considered to be compensation to the employee as a fringe benefit and is an allowable cost to the extent that the amount of coverage is 2. Retirement plans.

A. Contributions to retirement plans for the benefit of employees, including owner employees of the provider, shall be allowable costs provided these plans meet the qualifications established in Section 401 of the Internal Revenue Code of 1954, as amended in the requirements for Title XVIII. These requirements state that—“A trust created or organized in the United States and forming parts of a stock bonus, pension or profit-sharing plan of an employer for the exclusive benefits of his/her employees or their beneficiaries shall constitute a qualified trust under this section if the contributions or the benefits provided under the plan do not discriminate in favor of employees who are—1) officers; 2) shareholders; or 3) highly compensated.” Interest income from funded pension or retirement plans shall be excluded from consideration in determining the allowable costs.

B. Amounts funded to pension and retirement plans, together with associated income, shall be recaptured if not actually paid when due or as anticipated and offset to expenses on the cost report form.

3. Deferred compensation plans.

A. Contributions for the benefit of employees, including owner employees under deferred compensation plans, shall be allowable costs when and to the extent that these costs are actually incurred and met by the provider. Deferred compensation plans must be funded. Provider payments under unfunded deferred compensation plans will be considered as an allowable cost only when paid to the participating employee and only to the extent considered reasonable.

B. Amount paid by tax-exempt organizations to purchase tax-sheltered annuities for employees shall be treated as deferred compensation actually incurred and met by the provider.

C. Amounts funded to deferred compensation plans together with associated income shall be recaptured if not actually paid when due or as anticipated and offset to expenses on the cost report form.

(K) Education and Training Expenses.

1. The cost of on-the-job training which directly benefits the quality of health care of administration of the facility shall be allowable. Off-the-job training involving extended periods exceeding five (5) continuous days is allowable only when specifically authorized in advance by the department.

2. Costs of education and training shall include incidental travel costs but will not include leaves of absence or sabbaticals.

(L) Organizational Costs.

1. Organizational costs may be included in allowable costs on an amortized basis.

2. Organizational costs include, but are not limited to, the following: legal fees incurred in establishing the corporation or other organizations, necessary accounting fees, expenses of temporary directors and organizational meetings of directors and stock holders; and fees paid to states for incorporation.

3. Organizational costs shall be amortized ratably over 4. Where a provider did not capitalize organizational costs and has written off these costs in the year they were incurred, 5. Where a provider is organized within a five (5)-year period prior to his/her entry into the program and properly has capitalized organizational costs using a sixty (60)-month is required. In this instance, the unamortized portion of organizational costs is allowable under the program and shall be amortized over the remaining part of the sixty (60)-month period.

(M) Advertising Costs. Advertising costs which are reasonable, appropriate and helpful in developing, maintaining and furnishing the provider services shall be allowable costs. These costs must be common and accepted occurrences in the field of the activity of the provider.

(N) Costs of Related Organizations.

1. Purchase from related organization(s). Costs applicable to services, facilities and supplies furnished to a provider by organization(s) related to the provider by common ownership or control shall not exceed the lower of the cost to the related organization or the prices of comparable services, facilities or supplies purchased elsewhere. The provider shall be required to identify the related organization(s) and costs to the related organization(s) in the uniform cost report(s). For the

purpose of this section, common ownership and control will be determined by paragraphs (5)(N)2. and 3. of this rule.

2. Related to the provider means the following:

A. With respect to a partnership, each partner;

B. With respect to a limited partnership, the general partner and each limited partner with an interest of five percent (5%) or more in the limited partnership;

C. With respect to a corporation, each person who owns, holds or has the power to vote five percent (5%) or more of any class of securities issued by the corporation and each officer and director; and D. With respect to a natural person, any parent, child, sibling or spouse of that person.

3. For the purposes of this section only, owner of a facility refers to any person who owns an interest of five percent (5%) or more in the following:

A. The land on which any facility is located;

B. The structure(s) in which any facility is located;

C. Any mortgage, contract for deed or other obligation secured in whole or part by the land or structure in or on which any facility is located; or D. Any lease or sublease of the land or structure in or on which a facility is located. Owner does not include a bank, savings bank, trust company, building and loan association, savings and loan association, credit union, industrial loan and thrift company, investment banking firm or insurance company unless the entity directly or through a subsidiary operates a facility.

(O) Utilization Review. Incurred cost for the performance of required utilization review for SNF, ICF, ICF/MR or SNF/ICF combination is an allowable cost. These expenditures must be for the purpose of providing utilization review on behalf of Title XIX recipients. Utilization review costs incurred for Title XVIII and XIX must be apportioned on the basis of recipient days recorded for each program during the reporting period.

(6) Upper Limits.

(A) In no event may the total reimbursement of a provider exceed the lesser of— 1. The current customary charges by the facility to the general public for the same services rendered to the Medicaid recipients except in the case of public facilities rendering services at a nominal charge; these charges will be determined by the standard set forth in the Medicare Provider Reimbursement Manual (HIM-15), Part I, Section 2600;

2. The Title XVIII rates applicable; and 3. One hundred twenty-five percent (125%) of the weighted mean rate paid for each level-of-care group as follows: SNF, ICF, ICF/MR and SNF/ICF combination.

(B) The determination of weighted mean per-diem rates by level-of-care shall be determined and updated quarterly using reimbursement rates in effect the first day of that quarter.

(C) Providers shall be considered as similar facilities when classed by the following levels of care: ICF/MR or SNF, ICF, SNF/ ICF combination.

(D) All costs in excess of the ceiling imposed shall not be carried forward.

(7) Minimum Utilization.

(A) In the event that the occupancy utilization of a provider in a cost-reporting period falls below ninety percent (90%) of its certified bed capacity, appropriate adjustments shall be made to the allowable costs of the provider. Fixed costs will be calculated as if the provider experienced ninety percent (90%) utilization. The fixed costs are laundry, housekeeping, administrative and general costs. Variable costs will be calculated at actual utilization. The variable costs are nursing, dietary and ancillary costs.

(B) In the event a provider’s total reimbursement is reduced below allowable costs due to the limitation in subsection (7)(A), the unreimbursed allowable cost shall be subject to subsection (7)(C) and, if no waiver is granted, the retroactive adjustment shall be the lower of the actual cost or cost established under the provisions of subsection (7)(A).

(C) Subsections (7)(A) and (B) shall be waived for newly constructed facilities, new additions, or both, until an occupancy level of ninety percent (90%) is reached, but that waiver shall not exceed twelve (12) months from the date of licensure. A second waiver may be granted for an additional twelve (12)-month period. Subsections (7)(A) and (B) also will be waived for any facility which is closed completely for six (6) months or more and whose residents are removed, if and when this facility reopens.

(8) Nonreimbursable Costs.

(A) Bad debts, charity and courtesy allowances are deductions from revenue and are not to be included in allowable costs.

(B) Those services that are specifically listed as provided in section 208.152, RSMo are attributable to Medicare and Medicaid and should be billed to those agencies.

(C) Any costs incurred that are related to fund drives are not (D) Costs incurred for research purposes shall not be included as allowable costs.

(E) The cost of services provided under contract or subcontract under the Title XX program is specifically excluded as allowable costs.

(9) Other Revenues.

(A) Other revenues including, but not limited to those listed as follows, will be deducted from the total allowable cost, if included in gross revenue: income from telephone service; sale of employee and guest meals; sale of medical abstracts; sale of scrap and waste food or materials; rental income; cash, trade, quantity time and other discounts, purchase rebates and refunds; recovery on insured loss; parking lot revenues; hospital room reservation charges; vendor machine commission; sales from drugs to other than recipients; sales from medical and surgical supplies to other than recipients; and room reservation charges in excess of two (2) days per quarter.

(B) Interest income received from a funded depreciation account will not be deducted from allowable operating costs provided the interest is applied to the replacement of the asset being depreciated. Interest income other than from funded depreciation in excess of interest expense will not be used to offset other allowable costs.

(C) Cost centers or operations specified by the provider as subsection (10)(D) shall not have their associated cost or revenues included in the covered costs or revenues of the (D) Restricted and Unrestricted Funds.

1. Restricted funds, as used in this rule, mean those funds, cash or otherwise, and including grants, gifts, taxes and income from endowments, which must be used only for a specific purpose designated by the donor. Those restricted funds which are not transferred funds and are designated by the donor for paying operating costs will be offset from the total allowable expenses. If an administrative body has the

2. Unrestricted funds, as used in this rule, mean those funds, cash or otherwise, and including grants, gifts, taxes and income from endowments, that are given to a provider without restriction by the donor as to their use. These funds can be used in any manner desired by the provider. However, those unrestricted funds which are not transferred funds and are used for paying operating costs will be offset from total allowable expenses.

3. Transferred funds, as used in this rule, are those funds appropriated through a legislative or governmental administrative body’s action, state or local, to a state or local governmental provider. The transfer can be state-to-state, state-to-local or local-to-local providers. These funds are not considered a grant or gift for reimbursement purposes, so have no effect on the provider’s allowable cost under this plan.

(10) Gains and Losses on Sales of Fixed Assets.

(A) Gains and losses on the sale or other disposition of buildings, furniture and equipment of a provider shall be taken into account in the determination of allowable costs only to the extent that the following provisions are applicable.

(B) There shall be a recapture of any subsection (10)(A) gain or loss according to the following ratio:

1. The numerator shall be the number of years during the asset life after July 1, 1976, that the provider has been reimbursed for all allowable costs by the Department of Social Services for Title XIX services. For the purposes stated here, the year in which the asset was purchased shall be included but the year in which the asset disposition is made will not be considered;

2. The denominator shall be the number of years the asset was owned and used in the operation of Title XIX facility; and 3. The ratio shall not exceed one hundred percent (100%).

(C) There shall be no recapture of any subsection (10)(A) gain or loss, in accordance with subsection (10)(B), unless subsection (10)(A) gain or loss, exceeds one thousand dollars ($1000).

(D) The provider may designate specific assets or operations with the submission of each cost report that are not to be considered as relating to the nursing facility operation. The gains or losses from the sales of these assets or operations shall not be subject to subsections (10)(A)—(C).

(E) The provisions of subsections (10)(A)—(C) shall not apply to the dispositions of whole nursing facilities or similar changes of ownership.

(11) Apportionment of Costs to Medicaid Recipients.

(A) A provider’s allowable costs shall be apportioned between Medicaid program recipients and other patients so that the share borne by the Medicaid program is based upon actual services received by program recipients.

(B) To accomplish this apportionment, the ratio of recipient’s charges to total patient charges for the service of each ancillary department may be applied to the cost of this department. To this shall be added the cost of routine services for program recipients determined on the basis of a separate average cost per diem for general routine care areas or, at the option of the provider, on the basis of the overall routine care area.

(C) So that its charges may be allowable for use in apportioning costs under the program, each provider should have an established charge structure which is applied uniformly to each patient as services are furnished to the patient and which is reasonably and consistently related to the cost of providing these services.

(D) Average cost per diem for general routine services means the amount computed by dividing the total allowable patient costs for routine services by the total number of patient days of care rendered by the provider in the cost-reporting period.

(E) A patient day of care is that period of service rendered a patient between the census taking hours on two (2) successive days, the day of discharge being counted only when the patient was admitted that same day. A census log shall be maintained in the facility for documentation purposes.

(F) Nursing facilities that provide skilled or intermediate nursing care, or both, to Medicaid recipients may establish distinct part cost centers in their facility provided that adequate accounting and statistical data required to separately determine the nursing care cost of each distinct part is maintained. Each distinct part may share common services and facilities as management services, dietary, housekeeping, building maintenance and laundry.

(G) Reimbursement is to be limited to the lower of the levelof-care required by the recipient or the level-of-care provided in the distinct part to which the recipient is assigned if admitted in accordance with 42 CFR 456.600–456.614.

(H) In no case may a provider’s allowable costs allocated to the Medicaid program include the cost of furnishing services to persons not covered under the Medicaid program.

(12) Accounting Basis.

(A) The cost report submitted must be based on the accrual

basis of accounting.

(B) Governmental institutions that operate on a cash or modified cash basis of accounting may continue to use those methods provided appropriate treatment of capital expenditures is made.

(13) Audits.

(A) Cost reports submitted shall be based upon the provider’s financial and statistical records which must be capable of verification by audit.

(B) If the provider has included the cost of a certified audit of the facility as a covered expense to this plan, a copy of that audit report and accompanying management letter shall be submitted without deletions.

(C) The annual cost report for the fiscal year of the provider shall be subject to audit by the Department of Social Services or their contracted agents. An audit guide will be prepared specifying the audit standards to be employed by the department.

(D) The department will conduct a desk review of all cost reports within four (4) months after submission by the provider and shall provide for on-site audits of facilities wherever cost variances or exceptions are noted by their personnel.

(E) No less than one-third (1/3) of the participating LTC facilities are to be audited each year over a three (3)-year period starting with the close of the cost reporting years beginning on or after January 1, 1977. These audits will be scheduled in a manner as to ensure that, at the close of this three (3)-year period, each participating LTC facility will have been audited.

(F) The department shall retain the annual cost report and any working paper relating to audits of the cost reports for a period of not less than seven (7) full years from the date of (G) In accordance with the provisions of 42 CFR 447.295, a report of each on-site audit shall be submitted to the director of the Department of Social Services.

(H) In accordance with the provisions of 42 CFR 447.293, onsite audits will be performed each year after the initial three (3)year period in at least fifteen percent (15%) of the participating facilities. At least five percent (5%) of the participating facilities shall be selected on a random basis and the remainder on the

basis of exceptional profiles.

(I) Those providers having an annual Title XIX bed-day ratio on total bed days or certified beds of greater than sixty percent (60%), an annual Title XIX payment of two hundred thousand dollars ($200,000) or more, or both, shall be required for at least the first two (2) fiscal years of participation in the plan to have an annual audit of their financial records by an independent certified public accountant. The auditor may issue a qualified audit report stating that confirmations of accounts receivable and accounts payable are not required by the plan. The Department of Social Services will accept a qualified opinion from a certified public accounting firm. A copy of the audit report must be submitted to the department to support the annual cost report of the nursing home facility.

(14) Return on Equity.

(A) A return on a provider’s net equity shall be paid as a part of the interim per-diem rate in addition to allowable costs.

(B) The amount of return on a provider’s net equity shall initially be twelve percent (12%) for the state’s fiscal year period 1976–1977; a new rate of return shall be established by the Department of Social Services each year thereafter prior to October 1 of that year. This rate shall be published yearly and, upon publication, shall be incorporated into this plan.

(C) For the purposes of this paragraph, owner’s net equity is defined according to the Medicare Provider Reimbursement Manual (HIM-15), Section 1202.

(D) The return on owner’s net equity shall be payable only to proprietary providers.

(E) A provider’s return on owner’s net equity shall be apportioned to the Medicaid program on the basis of the provider’s Medicaid program days of care to total recipient days of care during the cost reporting period. For the purpose of this calculation, total recipient days of care shall be the greater of ninety percent (90%) of the provider’s certified bed capacity or actual occupancy rate during the cost year.

(15) Allowance for Known Cost Changes. A provider, at its election, may include with any regularly filed cost report, as an integral part of the report, a statement of known cost changes which reasonably can be anticipated to change the allowable costs of the subsequent cost-reporting period and which fall within guidelines as established by the department. Based upon this information, the provider may obtain an increase in its interim rate to cover the increases, provided adequate documentation is submitted with the report regarding the nature and amount of cost increases and their anticipated effect upon allowable costs in the subsequent reporting period.

(16) Inflationary Adjustments. Inflationary adjustments will be considered in calculating the interim per-diem rate. They will be based upon the past fiscal year and will be adjusted according to an index such as the Composite Consumer Price Index (CPI). Rental, interest, depreciation expenses and property taxes will be excluded from the adjustments.

(17) Interim Rate.

(A) Each participating provider shall be assigned an interim per-diem rate for reimbursement under the Medicaid program which will be based principally upon the cost report of the facility for the preceding reporting period. Interim rates shall be established based upon the date in the cost report, adjusted as described in this rule and subject to further adjustment later by reason of audit changes to the cost report.

(B) A provider’s interim rate for a given period shall take into account its past allowable costs and return on owner’s net equity, all as most recently determined, together with an allowance for known cost increases.

(C) Upon initial entry into the Medicaid program after July 1, 1976, a provider not having had a full year of prior operation may submit budgetary projections of allowable costs to the department for the purpose of establishing an initial Medicaid interim rate. These budgetary projections shall be taken into consideration and included in the initial interim per-diem rate to the extent they do not exceed one hundred twenty-five percent (125%) of the weighted mean rate as determined by

section (6). A new facility must operate at the initial rate for at least six (6) months.

(D) The budgetary projections shall be based upon a minimum occupancy utilization of ninety percent (90%) pursuant to the principles established in section (7).

(E) In the case of a change of ownership of an ongoing facility already participating in the Medicaid program, the rates in effect at the time of the change in ownership shall continue until new interim cost reports are submitted by the new owner in accordance with paragraph (4)(C)1. or 2.

(F) Approved interim rates shall become effective on or before the first day of the third month following the filing of any cost report as described in this rule.

(G) A written notification indicating the SNF, ICF, ICF/MR and SNF/ICF combination per-diem rates respectively will be transmitted to the facility upon approval by the director, Department of Social Services or his/her designee.

(H) In the event either party determines that a significant error or omission has been made in the determination of the per-diem rate, this will be reported within thirty (30) days.

Upon proper analysis of the problem, the Department of Social Services will be authorized to make adjustments consistent with the principles set forth in this rule and shall notify the provider in writing of its decision. In the event the decision is not acceptable, the provider has the right to appeal within sixty (60) days as provided under this plan, section (20).

(18) Retroactive Adjustments. Initial retroactive adjustments for each year payable to the provider and made in accordance with this plan shall be paid as soon as practicable within one hundred eighty (180) days after receipt of the provider’s fiscal year cost report.

(19) Amounts Due the Department of Social Services for a Provider (A) When there is an amount due the Department of Social Services from a provider, the single state agency shall notify the provider or the provider’s representative of the amount of the overpayment. When a provider receives notice of an overpayment and the amount due is in excess of one thousand dollars ($1000), the provider, within twenty (20) days of the notice, shall submit a plan for repayment to the single state agency which shall not exceed six (6) months in duration and request that the plan be adopted and adhered to by the single state agency in collecting the overpayment. If an alternative repayment plan is received timely from a provider, the single state agency shall consider the proposal, together with all the facts and circumstances of the case, and reject, accept or offer to accept a modified version of the provider’s plan for repayment. The single state agency shall notify the provider of its decision within fifteen (15) days after the proposal is received. If no alternative plan for repayment is agreed upon within forty-five (45) days after the provider received notice of the overpayment, the withholding of payments to the provider shall commence as if no alternative plan for repayment had been submitted. Overpayments of one thousand dollars ($1000) or less shall be repaid within forty-five (45) days.

(B) If a plan for repayment of amounts due the Department of Social Services from a provider is breached, discontinued or otherwise violated by a provider, the single state agency, immediately upon the next payment to the provider, shall begin to withhold payments or portions of payments until the entire amount due has been collected.

(C) If a provider fails or refuses to comply with the provisions of this rule, the single state agency, at its discretion, may withhold funds from amounts due the provider in amounts as to guarantee full recovery of an overpayment over a period of time as the single state agency deems warranted under the circumstances.

(D) Repayment or an agreement to repay amounts due the Department of Social Services by a provider shall not prevent the imposition of any sanction by the single state agency upon the provider.

(E) The Department of Social Services shall account to HHS for the amounts on Form HCFA-64 (see 10 CSR 70-10.010) owed by providers no later than the second quarter following the quarter in which the overpayment was determined in accordance with principles of the plan.

(20) Appeals. Unresolved provider disputes involving an amount in excess of five hundred dollars ($500) may be appealed to the Administrative Hearing Commission under the provisions of sections 161.274 and 208.156, RSMo and the corresponding rules established by the commission.

APPENDIX

A & D Ointmen t Air Ma ttresses Air way Oral Ant acid Suspensions Antipr uitic Oil Applica tors, Cotton-Tipped Applica tors, Swab-Eez Aquamatic K P ads (water-heated pad)

Asepto Syr inges Baby P owder Bandages E lastic or Cohesive Bed Frame Equipmen t (for certain immobilized bed patients)

Bedpan, Fractur e Bedside, T issues Bottle , Specimen Cannula—Nasal Casc ara (1 oz.) theter, Indwelling theter Plugs Catheter Tray theters (any size)

Cot ton Balls Customized Cr utches, Canes and Wheelchairs Douche B Drainage B Dressing T ray Drugs , Nonlegend Drugs , Stock (excluding Insulin)

Enema—F leets Enema—Retention Enema S oap Enema S upplies Equipment and S upplies for Diabetic Urine Testing Ey e Pads Female Ur inal Flot ation Mattress or Biowave Mattress Flotation Pads, Turning Frames, or Both Folding F oot Cradle Gastr ic Feeding Unit Gau ze Sponges Gloves , Unsterile and Sterile Gr een Soap Hand- Feeding Heating P ads Ice B Incon tinency Care Incon tinency Pads and Pants Inhalation Ther apy Supplies Aerosol Inhala tors, Self-Contained Aerosol (other t ypes)

Nasal Ca theter Insertion and Tube Steam Vapor izer Intermit tent Positive Pressure Breathing Machines (IPPB)

Irriga tion Bulbs Irriga tion Trays I.

V. Trays Jelly—Lubr icating Kaolin and P ectin Solution Linens , Extra Lotion, S oap and Oil Milk of Magnesia Mineral Oil Nasal Tub Feeding Nursing Services (all) regardless of level, including the Nursing Supplies and Dressings (other than items of personal comfort or cosmetics)

Ointment (nonprescription, skin)

Oxygen Pharmaceuticals, Nonprescription Pumps (aspiration and suction)

Room and Board Suppositories—Nonlegend Tubing—I.V. Trays, Blood Infusion Set, I.V. Tubing

rule filed Dec. 7, 1979, effective Jan. 1, 1980, expired March 12, 1980. Rescinded and readopted: Filed Dec. 7, 1979, effective May 11, 1980. Emergency amendment filed July 23, 1981, effective Aug. 1, 1981, expired Nov. 11, 1981. Amended: Filed July 23, 1981, effective Nov. 12, 1981. Emergency amendment filed Oct. 13, 1981, effective Oct. 23, 1981, expired Jan. 13, 1982. Amended: Filed Oct. 13, 1981, effective Jan. 14, 1982. *Original authority 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993.

History

• authority to re- restrict restricted funds designated by the donor for paying operating costs, these funds will not be offset from total allowable expenses.
• AUTHORITY: section 207.020, RSMo Supp. 1993. This rule was previously filed as 13 CSR 40-81.080. Original rule filed Jan. 16, 1978, effective May 11, 1978. Emergency rescission filed Dec. 7, 1979, effective Dec. 31, 1979, expired March 12, 1980. Emergency

13 CSR 70-10.010 Prospective Reimbursement Plan for Long- Term Care {#sec-13-csr-70-10.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.010}

PURPOSE: This rule establishes a payment plan for long-term care required by the Code of Federal Regulations. The plan describes principles to be followed by Title XIX long-term care providers in making financial reports and presents the necessary procedures for setting rates, making adjustments and auditing the cost reports.

Editor’s Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office of the Secretary of State or at the headquarters of the agency and is available to any interested person at a cost established by state law.

(1) Authority. This rule is established pursuant to the authorization granted to the Department of Social Services, Division of Medical Services to promulgate rules.

(2) Purpose. This rule establishes a methodology for determination of prospective per-diem rates for long-term care (LTC) facilities.

(3) General Principles.

(A) Provisions of this reimbursement plan shall apply only to facilities certified for participation in the Missouri Medical Assistance (Medicaid) program.

(B) The per-diem rates determined by this rule shall apply only to services provided on and after July 1, 1990.

(C) The effective date of this rule shall be July 1, 1990.

(D) The Medicaid program shall provide reimbursement for LTC services based solely on the individual Medicaid-eligible recipient’s covered days of care (within benefit limitations) multiplied by the facility’s Medicaid per-diem rate. No payments may be collected or retained in addition to the Medicaid perdiem rate for covered services. Where third-party payment is involved, Medicaid will be the payor of last resort with the exception of state programs such as Vocational Rehabilitation and the Missouri Crippled Children’s Services.

(E) The Medicaid per-diem rate shall be the lower of— 1. The Medicare (Title XVIII) per-diem rate, if applicable;

2. The per-diem rate as determined in accordance with

section (11); or 3. The LTC ceiling (LTCC). The LTCC in effect on July 1, 1990, shall be a per-diem rate of fifty-four dollars and ninety-five cents ($54.95). The LTCC will be increased by the amounts prescribed in paragraph (12)(A)1. effective for the dates of services and purposes specified in paragraph (12)(A)1.

(F) Medicaid reimbursements shall not be paid for services provided to Medicaid-eligible recipients during any time period in which the facility failed to have a Medicaid participation agreement in effect. A per-diem reimbursement rate may (G) Upon execution of a Medicaid participation agreement, the Medicaid program shall be assigned a provider number by the Division of Medical Services. Facilities previously certified shall retain the same provider number regardless of any change in ownership.

(H) Regardless of changes in ownership for any facility certified for participation in the Medicaid program, the division will issue allowable reimbursements to the facility identified in the current Medicaid participation agreement and will recover from that entity liabilities, sanctions and penalties pertaining to the Medicaid program.

(I) A facility with certified and noncertified beds shall allocate allowable costs related to the provisions of LTC services in an equitable manner. The methods for allocation must be supported by adequate accounting, statistical data, or both, necessary to evaluate the allocation method and its application.

(J) Any facility which is terminated from participation in the Medicare program also shall be terminated from participation in the state’s Medicaid program on the same date as the Medicare determination.

(K) No restrictions nor limitations shall be placed on a recipient’s right to select providers of his/her own choice.

(L) The average Medicaid rate paid shall not exceed the average private pay rate for the same period covered by the facility’s Medicaid cost report. Any amount in excess will be subject to repayment, recoupment, or both.

(4) Definitions.

(A) Allowable cost. Those costs which are allowable for allocation to the Medicaid program based upon the principles established in this rule. The allowability of costs not addressed specifically in this rule shall be determined by the Division of Medical Services. This determination may be based upon criteria such as the Medicare Provider Reimbursement Manual (HIM-15) and section (7) of this rule.

(B) Average private pay rate. The usual and customary charge for non-Medicaid patients determined by dividing total non- Medicaid days of care into revenue net of contractual allowances from the same service that is included in the Medicaid perdiem rate, excluding negotiated payment methodologies with state or federal agencies such as the Veterans Administration and the Missouri Department of Mental Health.

(C) The Building Cost Calculator (formerly known as the Dodge Construction Index). The cost per square foot as published in Calculator and Valuation Guide for a convalescent/nursing home of good quality, masonry wall construction as of midyear 1970 and adjusted by the general purpose Local Building Cost Multiplier as of the following date: 1) the date the original Certificate of Need (CON) or waiver was issued, 2) if a six (6)month extension was granted, the date the first extension was granted, or 3) if the facility was constructed prior to October 1, 1980, the date will be October 1, 1980. The Local Building Cost Multipliers used to adjust costs shall be those established for Columbia, Kansas City and St. Louis. The multiplier to be used in determining a facility’s rate shall be the one established for the city geographically closest to the facility as determined by the straight line distance (not road miles) between the two (2) points, as determined from the latest Missouri official highway map furnished by the Missouri Highways and Transportation Department. Calculator and Valuation Guide is a publication of Calculator, Inc., 12251 Harbor Drive, Woodbridge, VA 22192.

(D) Change of ownership. A change in ownership, control, operation or leasehold interest by any form for any facility certified for participation in the Medicaid program at any time.

(E) Cost report. The Financial and Statistical Report for Nursing Facilities, required attachments as specified in subsection (10)(A) of this rule and all worksheets supplied by the division for this purpose. The cost report shall detail the cost of rendering both covered and noncovered services for the fiscal reporting period in accordance with the procedures prescribed by the division and on forms provided or prescribed, or both, by the division.

(F) Department. The department, unless otherwise specified, (G) Desk review. The Division of Medical Services’ review of a provider’s cost report without on-site audit.

(H) Director. The director, unless otherwise specified, refers to the director, Missouri Department of Social Services.

(I) Division. Unless otherwise designated, division refers to the Division of Medical Services, the division of the Department of Social Services charged with administration of Missouri’s Medical Assistance (Medicaid) program.

(J) Division of Aging. The division of the Department of Social Services responsible for survey, certification and licensure of LTC facilities.

(K) Entity. Any natural person, all corporations, business, partnership or something that exists as a discrete unit.

(L) Facility fiscal year. A facility’s twelve (12)-month fiscal reporting period covering the same twelve (12)-month period (M) Generally accepted accounting principles (GAAP).

Accounting conventions, rules and procedures necessary to describe accepted accounting practice at a particular time promulgated by the authoritative body establishing those principles.

(N) Intermediate care facility (ICF). Prior to October 1, 1990, a facility certified to provide intermediate care under the Title XIX program.

(O) LTC facility. Prior to October 1, 1990, a facility certified to provide skilled nursing services under the Title XIX program (skilled nursing facility (SNF)), or a facility certified to provide intermediate care under the Title XIX program (ICF), or a facility certified to provide skilled nursing and intermediate care under the Title XIX program (SNF/ICF). On and after October 1, 1990, a nursing facility (NF).

(P) New facility. A newly-built LTC facility for which an approved CON or applicable waiver was obtained and which was newly completed and operational on or after July 1, 1990.

(Q) Nursing facility (NF). Effective October 1, 1990, SNFs, SNF/ICFs and ICFs participating in the Medicaid program all will be subject to state and federal laws or regulations for participation as an NF.

(R) Occupancy. A facility’s total actual patient days divided by the total bed days for the same period.

(S) Patient day. The period of service rendered to a patient purposes. Patient day includes the allowable temporary leaveof-absence days per subsection (5)(D). The day of discharge is not a patient day for reimbursement unless it is also the day of admission.

(T) Provider or facility. An LTC facility with a valid Medicaid participation agreement in effect on or after July 1, 1990, with the Department of Social Services for the purpose of providing LTC services to Title XIX-eligible recipients.

(U) Related parties. Parties are related when any one (1) of the following circumstances apply:

1. An entity in which, through its activities, one (1) entity’s transactions are for the benefit of the other and the benefits exceed those which are usual and customary in those dealings;

2. An entity has an ownership or controlling interest in another entity and the entity, or one (1) or more relatives of other entity. For the purposes of this paragraph, ownership investment banking firm or insurance company unless the entity, directly or through a subsidiary, operates a facility; or 3. As used in this rule, the following terms mean:

A. Indirect ownership/interest, an ownership/interest in an entity that has an ownership/interest in another entity. This term includes an ownership/interest in any entity that has an indirect ownership/interest in an entity;

B. Ownership/interest, the possession of equity in the capital, in the stock or in the profits of an entity;

C. Ownership or controlling interest, when an entity— (I) Has an ownership/interest totalling five percent (5%) or more in an entity;

(II) Has an indirect ownership/ interest equal indirect ownership/interest is determined by multiplying the (III) Has a combination of direct and indirect ownership/interest equal to five percent (5%) or more in an entity;

(IV) Owns an interest of five percent (5%) or more in any mortgage, deed of trust, note or other obligation secured (V) Is an officer or director of an entity; or (VI) Is a partner in an entity that is organized as a D. Relative, person related by blood, adoption or (V) Restricted funds. Funds, cash or otherwise, including grants, gifts, taxes and income from endowments which must be used only for a specific purpose designated by the donor.

(W) Skilled nursing facility (SNF). Prior to October 1, 1990, a facility certified to provide skilled nursing services under the Title XIX program.

(X) SNF/ICF combination. Prior to October 1, 1990, a facility certified to provide skilled nursing and intermediate care under the Title XIX program.

(Y) Square footage. The square footage of a facility will be determined from the records of the county assessor of the county where the facility is located. For facilities that are exempt from property tax assessment, the square footage of the facility shall be determined from a certified statement from a licensed architect verifying the square footage of the facility in accordance with the American Institute of Architects Document D101.

(Z) Unrestricted funds. Funds, cash or otherwise, including grants, gifts, taxes and income from endowments which are given to a provider without restriction by the donor as to their use.

(5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per-diem rate but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. Covered supplies, items and services (A) Services, items and supplies required by federal or state law or regulation which must be provided by LTC facilities participating in the Title XIX program;

(B) Semiprivate room and board;

(C) Private room and board when it is necessary to isolate which may be contagious infection, loud irrational speech, and the like;

(D) Temporary leave of absence days for Medicaid recipients, months and not to exceed twelve (12) days for the second six (6) calendar months. Temporary leave of absence days specifically must be provided for in the recipient’s plan of care and physician prescribed. Periods of time during which a recipient is away from the facility because s/he is visiting a friend or relative are considered temporary leaves of absence;

(E) Provision of nursing services;

(F) Provision of personal hygiene and routine care services furnished routinely and relatively uniformly to all residents;

(G) All laundry services, including personal laundry;

(H) All dietary services, including special dietary supplements (I) All consultative services required by federal or state law or regulation;

(J) All therapy services required by federal or state law or

regulation;

(K) All routine care items, including disposables and including, but not limited to, those items specified in Appendix A to this rule;

(L) All nursing care services and supplies, including disposables and including, but not limited to, those items specified in Appendix A to this rule;

(M) Any and all nonlegend antacids, nonlegend laxatives, nonlegend stool softeners and nonlegend vitamins. Providers may not elect which nonlegend drugs in any of the four (4) categories to supply; any and all must be provided to residents as needed and are included in a facility’s per-diem rate; and (N) Hospital leave days as defined in 13 CSR 70-10.070.

(6) Noncovered Supplies, Items and Services. All supplies, items and services which are not either covered in a facility’s perdiem rate, billable to another program in the Missouri Medical Assistance (Medicaid) program or billable to Medicare or other third-party payors. Noncovered supplies, items and services (A) Private room and board unless it is necessary to isolate a recipient due to a medical or social condition, examples of which may be contagious infection and loud irrational speech. Unless a private room is necessary due to a medical or social condition, a private room is a noncovered service and therefore a Medicaid recipient or responsible party may pay the difference between a facility’s semiprivate charge and its charge for a private room. Medicaid recipients may not be placed in private rooms and charged any additional amount above the facility’s Medicaid per diem unless the recipient or responsible party, in writing, specifically requests a private room prior to placement in one and acknowledges that an additional amount not payable by Medicaid will be charged for it;

(B) Supplies, items and services for which payment is made under Missouri Medical Assistance (Medicaid) program directly to a provider(s) other than providers of the LTC services; and (C) Supplies, items and services provided nonroutinely to (7) Allowable cost areas are— (A) Compensation of owners.

1. Compensation of services of owners shall be an allowable cost area, provided the services are actually performed, are necessary and are reasonable.

2. Compensation shall mean the total benefit, within the limitations set forth in this rule, received by the owner for the services s/he renders to the facility, including direct payments for managerial, administrative, professional and other services, amounts paid for the personal benefit of the owner, the cost of assets and services which the owner receives from the provider, and additional amounts determined to be the reasonable value of the services rendered by sole proprietors or partners and not paid by any method previously described in this rule. Compensation must be paid (whether in cash, negotiable instrument or in kind) within seventy-five (75) days published in the Medicare Provider Reimbursement Manual (PRM), Part 1, Section 906.4.

3. Reasonableness of compensation shall be limited as prescribed in subsection (8)(Q).

4. Necessary services refers to those services that are pertinent to the operation and sound conduct of the facility; had the owner not rendered these services, then employment of another entity to perform the service would be necessary;

(B) Covered services and supplies as defined in section (5) of (C) Depreciation.

1. An appropriate allowance for depreciation on buildings, and sound conduct of the provider’s business is an allowable cost item. Finder’s fees are not an allowable cost item.

2. The depreciation must be identifiable and recorded in 3. The basis of assets at the time placed in service shall be the lower of— A. The book value of the provider;

B. Fair market value at the time of acquisition;

C. The recognized Internal Revenue Service (IRS) tax

basis; and D. In the case of change in ownership after July 18, 1984, the cost basis of acquired assets of the owner of record as of July 18, 1984, as of the effective date of the change in ownership or, in the case of a facility which entered the program after July 18, 1984, the owner at the time of the initial entry into the Medicaid program.

4. The basis of donated assets will be allowed to the extent of recognition of income resulting from the donation of the asset. Should a dispute arise between a provider and the division as to the fair market value at the time of acquisition of a depreciable asset and an appraisal by a third party is required, the appraisal cost will be shared proportionately by the Medicaid program and the facility in ratio to Medicaid recipient reimbursable patient days to total patient days.

5. Allowable methods of depreciation shall be limited to the straight-line method. The depreciation method used for an asset under the Medicaid program need not correspond to the method used by a provider for non-Medicaid purposes; however, useful life shall be in accordance with the American Hospital Association’s Guidelines. Component part depreciation is optional and allowable under this rule.

6. Historical cost is the cost incurred by the provider in acquiring the asset and preparing it for use except as provided in this rule. Usually, historical cost includes costs that would be capitalized under GAAP. For example, in addition to the purchase price, historical cost would include architectural fees and related legal fees. When a provider has elected, for federal income tax purposes, to expense certain items, such as interest and taxes during construction, the historical cost basis for Medicaid depreciation purposes may include the amount of these expensed items. However, when a provider did not capitalize these costs and has written off the costs in the year they were incurred, the provider cannot retroactively capitalize any part of these costs under the program. For purposes of this

rule, any asset costing less than one thousand dollars ($1000), or having a useful life of one (1) year or less, may be expensed and not capitalized at the option of the provider.

7. When an asset is acquired by trading in an existing asset, the cost basis of the new asset shall be the sum of 8. For the purpose of determining allowance for depreciation, the cost basis of the asset shall be as described in paragraph (7)(C)3.

8. Capital expenditures for building construction or for provider’s bed capacity shall not be allowed in the depreciation base if the capital expenditures fail to comply with any federal or state law or regulation, such as CON.

9. Amortization of leasehold rights and related interest and finance costs shall not be allowable costs under this rule;

(D) Interest and finance costs.

1. Necessary and proper interest on both current and 2. Interest is the cost incurred for the use of borrowed for funds borrowed for a relatively short term. This is usually for purposes such as working capital for normal operating expenses. Interest on capital indebtedness is the cost incurred for funds borrowed for capital purposes such as acquisition of facilities and capital improvements, and this indebtedness must be amortized over the life of the loan.

2. Interest may be included in finance charges imposed by some lending institutions, or it may be a prepaid cost or 4. Interest (including finance charges, prepaid costs agreement that funds were borrowed and that payment of interest and repayment of the funds are required. The interest costs must be identifiable in the provider’s accounting records, must be related to the reporting period in which the costs are claimed and must be necessary and proper for the operation, maintenance or acquisition of the provider’s facility.

3. Necessary means that the interest be incurred for a loan made to satisfy a financial need of the provider and for a

purpose related to recipient care. Loans which result in excess funds or investments are not considered necessary.

6. Proper means that the interest be incurred at a rate not in excess of what a prudent borrower would have had to pay in the market at the time the loan was made.

7. Interest on loans to for-profit providers by proprietors, partners and any stockholders shall not be an allowable cost item because the loans shall be treated as invested capital and included in the computation of an allowable return on owner’s net equity.

8. If loans for capital indebtedness exceed the asset cost

basis as defined in subsection (7)(C), the interest associated with the portion of the loan(s) which exceeds the asset cost

basis as defined in subsection (7)(C) shall not be allowable.

9. Income from a provider’s qualified retirement fund shall be excluded in consideration of the per-diem rate.

10. A provider shall amortize finance charges, prepaid interest and discounts over the period of the loan ratably or by 11. Usual and customary costs excluding finder’s fees and shall be allowable costs over the period of the loan ratably or by means of the constant rate of interest method.

11. Usual and customary costs shall be limited to the escrow fees and closing costs.

12. Interest expense resultant from capital expenditures which cause an increase in a provider’s bed capacity shall not be an allowable cost item if the capital expenditures fail to comply with any federal or state law or regulation, such as CON;

(E) Rental and leases.

1. Rental and leases of land, buildings, furnishings and equipment are allowable cost areas; provided, that the rented items are necessary and not, in essence, a purchase of those assets. Finder’s fees are not an allowable cost item.

2. Necessary rental and lease items are those which are 3. In the case of related parties, rental and lease amounts cannot exceed the lesser of those which are actually paid or the 4. Determination of reasonable and adequate reimbursement for rental and amounts, except in the case of related parties which is subject to other provisions of this rule, may require affidavits of competent, impartial experts who are familiar with the current rentals and leases.

3. The test of necessary costs shall take into account the 6. Leases subject to CON approval must have that approval 7. If rent or lease costs increase solely as a result of change in ownership after July 18, 1984, the resulting increase which exceeds the allowable capital cost of the owner of record as of July 18, 1984, or, in the case of a facility which entered the program after July 18, 1984, the owner at the time of the initial entry into the Medicaid program, shall be a nonallowable cost;

(F) Real estate and personal property taxes levied on or incurred by a facility.

(G) Issuance of revenue bond and tax levies by district and county facilities. For those nursing home districts and county bonds, that interest which is paid per the revenue bond will be granted as an allowable cost item. Depreciation on the plant and equipment of these facilities also shall be an allowable cost item. Any tax levies which are collected by nursing home (H) Value of services of employees.

1. Except as provided for in this rule, the value of services 2. Services rendered by volunteers such as those affiliated private individuals and similar organizations shall not be an 3. Services by priests, ministers, rabbis and similar type professionals shall be an allowable cost; provided, that the services are not of a religious nature. Building costs on space set aside primarily for professionals providing any religious function shall not be allowable. Costs for wardrobe and similar items likewise are considered nonallowable;

(I) Fringe benefits.

1. Retirement plans.

A. Contributions to qualified retirement plans for the benefit of employees, excluding stockholders, partners and proprietors of the provider shall be an allowable cost. Interest income from funded pension or qualified retirement plans shall be excluded from revenue offsets.

B. Amounts funded to pension and qualified retirement plans, together with associated income, shall be recaptured, if not actually paid when due, as an offset to expenses on the 2. Deferred compensation plans.

A. Contributions for the benefit of employees, excluding stockholders, partners and proprietors, under deferred compensation plans shall be allowable costs when, and to Deferred compensation plans must be funded. Provider payments under unfunded deferred compensation plans will be considered an allowable cost only when paid to the participating employee and only to the extent considered B. Amounts paid by tax-exempt organizations to purchase tax-sheltered annuities for employees shall be treated as deferred compensation actually paid by the provider.

C. Amounts funded to deferred compensation plans 3. Types of insurance which are considered an allowable A. Where credit life insurance is required as part of a loans granted under certain federal programs.

B. Where the relative(s) or estate of the employee, beneficiary. This type of insurance is considered to be a fringe benefit and is an allowable cost area to the extent that the amount of coverage is reasonable;

(J) Education and training expenses.

1. Except for costs associated with nurse aide training, and competency evaluation programs after October 1, 1990, the cost of on-the-job training which directly benefits the quality of health care or administration at the facility shall be allowable.

Off-the-job training involving extended periods exceeding five (5) continuous days is an allowable cost only when specifically authorized in advance in writing by the division.

2. Costs of education and training shall include incidental travel costs but will not include leaves of absence or sabbaticals;

(K) Organizational costs.

1. Organizational costs may be included as an allowable cost, if properly amortized.

2. Organizational cost items include the following: legal fees incurred in establishing the corporation or other organizations, necessary accounting fees, expenses of temporary directors 3. Organizational costs shall be amortized ratably over 4. When a provider did not capitalize organizational costs and has written off those costs in the year they were incurred, 5. Where a provider is organized within a five (5)-year period prior to entry into the program and has properly capitalized organizational costs using a sixty (60)-month organizational costs is an allowable cost area under the program and shall be amortized over the remaining part of the sixty (60)-month period.

3. For change in ownership after July 18, 1984, allowable unamortized portion of organizational cost;

(L) Advertising costs. Advertising costs which are reasonable and appropriate. The costs must be a common and accepted occurrence for providing LTC services.

(M) Cost of supplies and services involving related parties. not exceed the lower of the cost to the supplier or the prices of comparable goods or services obtained elsewhere. In the uniform cost report, a provider shall identify related party suppliers and the type, the quantity and costs to the related party for goods and services obtained from each supplier.

(N) Utilization review. Costs incurred for the performance of required utilization review.

(O) Minimum utilization. In the event the occupancy rate of a facility is below ninety percent (90%), the following cost centers will be adjusted as though the provider experienced ninety percent (90%) occupancy: laundry, housekeeping, plant operation and general and administrative. In no case may costs disallowed under this provision be carried forward to succeeding periods. Cost centers are expenses grouped in accordance with the headings as identified in the cost report.

(P) Return on equity.

1. A return on a provider’s net equity shall be an allowable 2. The amount of return on a provider’s net equity shall not exceed twelve percent (12%) per year.

2. An owner’s net equity is comprised of investment capital and working capital. Investment capital includes the investment in building, property and equipment (cost of land, mortgage payments toward principal and equipment purchase less the accumulative depreciation). Working capital represents the amount of capital which is required to insure proper operation of the facility.

3. The return on owner’s net equity shall be payable only to proprietary providers.

4. A provider’s return on owner’s net equity shall be apportioned to the Medicaid program on the basis of the provider’s Medicaid program reimbursable recipient resident days of care to total resident days of care during the costreporting period. For the purpose of this calculation, total resident days of care shall be the greater of ninety percent (90%) of the provider’s certified bed capacity or actual occupancy during the cost report year;

(Q) Capital.

1. Capital reimbursement will be determined as follows:

A. For facilities entering the program after July 1, 1990, allowable capital is as described in paragraph (7)(Q)2. except the movable equipment rate described in item (7)(Q)2.A.(I)(a)IV. shall be sixty-five cents (65¢) per bed day which equates to two hundred twenty dollars ($220) per bed;

B. For facilities which entered the program after March 18, 1983, and which were not in operation for two (2) years prior to entering the program, allowable capital is as described in paragraph (7)(Q)2.;

C. For facilities which were in operation for two (2) years prior to entering the program and which entered the program between March 18, 1983 and prior to July 1, 1990, allowable capital shall be depreciation; rent or leases, or both; interest and finance costs; organizational costs; and return on equity as described in the provisions of this rule; and D. For facilities which entered the program prior to March 18, 1983, allowable capital shall be depreciation; rent or leases, or both; interest and finance costs; organizational costs; and return on equity as described in the provisions of this rule.

2. In lieu of depreciation; rent or leases, or both; interest and finance costs; organizational costs; and return on equity as described in the provisions of this rule, allowable capital for facilities described in subparagraphs (7)(Q)1.A. and B. shall be the sum of the building and equipment rate, land rate and working capital rate determined in accordance with the following procedures:

A. The building and equipment rate will be computed in the following way:

(I) Determine the lower of— (a) Dodge allowable for building and equipment, which is computed as— I. Reasonable construction or acquisition cost computed by applying the Building Cost Calculator as defined in this rule for the facility geographically closest to St. Louis, Kansas City or Columbia, multiplied by one hundred eight percent (108%) as an allowance for fees authorized as architectural or legal not included in the Building Cost Calculator, multiplied by the square footage of the facility not to exceed three hundred twenty-five (325) square feet per bed;

II. Multiply by a return rate of twelve percent (12%);

III. Divide by ninety-three percent (93%) of the facility’s total available beds multiplied by three hundred sixtyfive (365) days; and IV. Add fifty-three cents (53¢) per bed day to cover the movable equipment, which equates to one hundred eighty dollars ($180) per bed divided by the product of ninety-three percent (93%) multiplied by three hundred sixty-five (365) days;

(b) Actual acquisition cost, which is computed as— I. Actual acquisition cost, which is the original cost to construct or acquire the building, including fixed and movable equipment, and excluding land costs not to exceed the limitations on reimbursement as set forth in 13 CSR 70- 10.100, if applicable;

II. Multiply by a return rate of twelve percent (12%);

III. Divide by ninety-three percent (93%) of the facility’s total available beds multiplied by three hundred sixtyfive (365) days;

B. The land rate.

(I) The maximum allowable land area is defined as five (5) acres for a facility with one hundred (100) or fewer beds and one (1) additional acre for each additional one hundred (100) beds or fraction of beds for a facility with one hundred one (101) or more beds.

(II) Calculation.

(a) For facilities with land areas at or below the maximum allowable land area, multiply the acquisition cost of the land not to exceed the limitations on reimbursement as set forth in 13 CSR 70-10.100, if applicable, by the return rate of twelve percent (12%), divide by ninety-three percent (93%) of the facility’s total available beds multiplied by three hundred sixty-five (365) days.

(b) For facilities with land areas greater than the maximum allowable land area, divide the acquisition cost of the land not to exceed the limitations on reimbursement as set forth in 13 CSR 70-10.100, if applicable, by the total acres, multiply by the maximum allowable land area, multiply by the return rate of twelve percent (12%), divide by ninety-three percent (93%) of the facility’s total available beds, multiplied by three hundred sixty-five (365) days;

C. The working capital rate will be twenty cents (20¢) per day. This amount was determined to be the average daily balance due to a facility for services provided to the state with a return rate of twelve percent (12%), divided by ninety-three percent (93%); and D. If a provider does not provide the actual acquisition cost to determine the building and equipment rate and the land rate, the building and equipment rate will be computed using subpart (7)(Q)2.A.(I)(b), and the land rate will be zero cents (0¢); and (R) Central office, pooled costs, management company costs.

The allowability of the individual cost items contained within central office, pooled costs or management company costs will be determined in accordance with all other provisions of this

rule. The total of central office, pooled costs and management company costs, or a combination of these, are limited to seven percent (7%) of revenues.

(8) Nonallowable Costs. Cost not reasonably related to LTC facility services shall not be included in a provider’s costs.

Contractual allowances, courtesy discounts, charity allowances and similar adjustments or allowances are offsets to revenue and not included in allowable costs. Nonallowable cost areas (A) Amortization on intangible assets, such as goodwill, leasehold rights, covenants, purchased CON, but excluding organizational costs;

(B) Attorney fees related to litigation involving state, local or federal governmental entities and attorneys’ fees which are not related to the provision of LTC services, such as litigation related to disputes between or among owners, operators or administrators;

(C) Bad debts;

(D) Capital cost increases due solely to changes in ownership;

(E) Central office or pooled costs not attributable to the efficient and economical operation of the facility;

(F) Charitable contributions;

(G) Compensation paid to a relative or an owner through a under subsection (7)(A) of this rule;

(H) Costs such as legal fees, accounting and administration costs, travel costs and the costs of feasibility studies which or purchase of any capital asset by acquisition or merger for program;

(I) Directors’ fees included on the cost report in excess of two hundred dollars ($200) per month per individual;

(J) Federal, state or local income and excess profit taxes, including any interest and penalties paid on them;

(K) Late charges and penalties;

(L) Finder’s fees;

(M) Fund-raising expenses;

(N) Interest expense on intangible assets;

(O) Life insurance premiums for officers and owners and (P) Noncovered supplies, services and items as defined in (Q) Owner’s compensation in excess of the applicable range of the most recent survey of administrative salaries paid to individuals other than owners for proprietary and nonproprietary providers as published in the updated Medicare PRM Part 1, Section 905.2 and based upon the total number of working hours.

1. The applicable range will be determined as follows:

A. Number of licensed beds owned or managed; and B. Owners/administrators will be adjusted on the basis of the high range; owners included in home office costs or management company costs will be adjusted on the high range provided the owner works a minimum of forty (40) hours a week in the home office, management company or owned nursing homes. All others will be calculated on the median range.

2. The salary identified in subparagraph (8)(Q)1.B. will be apportioned on the basis of hours worked in the facility(ies), home office or management company as applicable to total hours reported for all business interests. A forty (40)-hour minimum will be applied if total hours for all business interests are less than forty (40) hours;

(R) Prescription drugs;

(S) Religious items or supplies or services of a primarily religious nature performed by priests, rabbis, ministers or other similar types of professionals. Costs associated with portions of the physical plant used primarily for religious functions are also nonallowable;

(T) Research costs;

(U) Resident personal purchases;

(V) Salaries, wages or fees paid to nonworking officers, employees or consultants;

(W) Stockholder relations or stock proxy expenses;

(X) Taxes or assessments for which exemptions are available;

(Y) Value of services (imputed or actual) rendered by nonpaid workers or volunteers; and (Z) All costs associated with nurse aide training and competency evaluation programs after October 1, 1990.

(9) Revenue Offsets.

(A) Other revenues must be identified separately in the cost report if included in gross revenues. These revenues include, but are not limited to, the following:

1. Income from telephone services;

2. Sale of employee and guest meals;

3. Sale of medical abstracts;

4. Sale of scrap and waste food or materials;

5. Rental income;

6. Cash, trade, quantity, time and other discounts;

7. Purchase rebates and refunds;

8. Recovery on insured loss;

9. Parking lot revenues;

10. Vending machine commissions or profits;

11. Sales from drugs to individuals other than Medicaid recipients;

12. Interest income to the extent of interest expense;

13. Noninterest income from investments;

14. Room reservation charges other than covered therapeutic home leave days;

15. Barber and beauty shop revenue;

16. Private room differential;

17. Medicare Part B revenues;

18. Personal services;

19. Activity income; and 20. Revenue recorded for donated services and commodities.

(B) Interest income received from a funded depreciation account will not be deducted from allowable operating costs if that interest is applied to the asset being depreciated.

(C) Restricted funds designated by the donor prior to the (D) Restricted funds designated by the donor for future capital expenditures will not be offset from allowable expenses at any time.

(E) Unrestricted funds not designated by the provider for (F) As applicable, restricted and unrestricted funds will be offset in each cost center, excluding capital costs, in an amount equal to cost center’s proportionate share of allowable expense.

(G) Any tax levies which are collected by nursing home (10) Provider Reporting and Recordkeeping Requirements.

(A) Annual Cost Report.

1. Each provider shall adopt the same twelve (12)-month 2. Each provider is required to complete and submit to the Division of Medical Services an Annual Cost Report, Financial and Statistical Report for Nursing Facilities, including all worksheets, attachments, schedules and requests for additional information from the division. The cost report shall be submitted on forms provided by the division for that

purpose.

3. All cost reports shall be completed in accordance with the requirements of this rule and the cost report instructions.

Financial reporting shall adhere to GAAP except as otherwise specifically indicated in this rule.

4. The cost report submitted must be based on the accrual report on that basis, provided appropriate treatment under GAAP of capital expenditures is made.

5. Cost reports shall be submitted by the first day of the fourth month following the close of the fiscal period.

6. If requested in writing, one (1) thirty (30)-day extension of the filing date may be granted.

7. If a cost report is more than ten (10) days past due, payment will be withheld from the facility until the cost report is submitted. Upon receipt of a cost report prepared in accordance with this rule, the payments that were withheld will be released to the provider. For cost reports which are more than ninety (90) days past due, the department may terminate the provider’s Medicaid participation and retain all payments which have been withheld pursuant to this provision.

8. Authenticated copies of agreements and other significant documents related to the provider’s operation and provision of care to Medicaid recipients must be attached to the cost report at the time of filing unless current and accurate copies have already been filed with the division. Material which must be submitted includes, but is not limited to, the following:

A. Audit, review or compilation statement prepared by an independent accountant, including disclosure statements and management letter or SEC Form 10-K;

B. Contracts or agreements involving the purchase requested by the division, the department or its agents;

C. Contracts or agreements with owners or related D. Contracts with consultants;

E. Documentation of expenditures, by line item, made F. Federal and state income tax returns for the fiscal year, within fifteen (15) days of filing the returns;

G. Leases, rental agreements, or both, related to the activities of the provider;

H. Management contracts;

I. Medicare cost report, if applicable;

J. Statement verifying the restrictions as specified by the donor, prior to donation, for all restricted grants; and K. Working trial balance actually used to prepare identifications.

9. Cost reports must be fully, clearly and accurately completed and all required attachments must be submitted information, documentation or clarification requested by the division or its authorized agent is not provided within fourteen (14) days of the provider’s receipt of the request, payments may be withheld from the facility until the information is submitted.

10. Under no circumstances will the division accept (B) Certification of Cost Reports.

11. The accuracy and validity of the cost report must be certified by the provider. Certification must be made by a person authorized by one (1) of the following: for an incorporated entity, an officer of the corporation; for a partnership, a partner; for a sole proprietorship or sole owner, the owner or licensed operator; or for a public facility, the chief administrative officer of the facility. Proof of authorization shall be furnished upon request.

12. Cost reports must be notarized by a licensed notary 3. The following statement must be signed on each cost Certification Statement: Misrepresentation or falsification of any information contained in this cost report may be punishable by fine, imprisonment, or both, under state or federal law. for the cost report period beginning _________, 19 and ending _________, 19 , and that to the best of my knowledge and belief, it is a true, correct and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. __________________________________ _____________ ________ (C) Adequate Records and Documentation.

13. A provider must keep records in accordance with GAAP and maintain sufficient internal control and documentation to satisfy audit requirements and other requirements of this rule, including reasonable requests by the division or its authorized agent for additional information.

14. Each of a provider’s funded accounts must be maintained separately with all account activity clearly identified.

15. Adequate documentation for all line items on the cost for review by the division or its authorized agent at the same site at which the services were provided. Copies of or its authorized agent upon request.

16. Each facility shall retain all financial information, data (D) Audits.

17. Any cost report submitted may be subject to field audit by the division or its authorized agent.

18. A provider shall have available at the field audit location 3. If a provider maintains any records or documentation at provided, the provider shall transfer the records to the same facility at which the Medicaid services were provided, or the provider must reimburse the division or its authorized agent for reasonable travel costs necessary to perform any part of the field audit in any off-site location, if the location is acceptable to the division.

19. Those providers initially entering the program shall be required to have an annual audit of the financial records used to prepare annual cost reports covering, at a minimum the first two (2) full twelve (12)-month fiscal years of their participation in the Medicaid program. For example: A provider begins business in March, they choose a fiscal year of October 1 to September 30, their first cost report will cover March through September. That cost report may be audited at the option of the provider. The October 1 to September 30 cost report (the first full fiscal year cost report) shall be audited and the next October 1 to September 30 cost report shall be audited.

The audits shall be done by an independent certified public accountant. The auditor may issue a qualified audit report stating that confirmation of accounts receivable and accounts payable are not required by the plan.

(E) Change in Provider Status.

1. Upon termination of participation in the Medicaid program or change of ownership, the provider is required to submit a cost report for the period ending with the date of termination or change, regardless of its tax period. The fully completed cost report with all required attachments and documentation is due within forty-five (45) days after the date of termination or change.

2. The next payment due the provider after the division has received the notification of the termination or change may be held by the division until the cost report is filed. Upon receipt of a cost report prepared in accordance with this rule, the payments that were withheld will be released.

(F) Joint Use of Resources.

1. If a provider has business enterprises in addition to the LTC facility, the revenues, expenses, statistical and financial records of each separate enterprise shall be clearly identifiable.

2. When the facility is owned, controlled or managed by an entity(ies) that owns, controls or manages one (1) or more other facilities, records of central office and other costs incurred outside the facility shall be maintained so as to to, individual facilities. Allocation of central office or pooled costs to individual facilities shall be consistent from year-toyear. If a desk review or field audit established that records are not maintained so as to clearly identify information required by this rule, those commingled costs shall not be recognized as allowable cost in determining the facility’s Medicaid perdiem rate. Allowability of these costs shall be determined in accordance with the provisions of this rule.

(11) Rate Determination. Subject to limitations prescribed elsewhere in these rules, a facility’s per-diem rate shall be determined by the division as described in this section.

(A) A facility with a valid Medicaid participation agreement in effect on June 30, 1990, and with a cost report on file with the division as of December 31, 1989, with a period ending in calendar year 1988 shall be granted a prospective per-diem rate effective for service dates on and after July 1, 1990. This rate will be the greater of the amount determined in the following paragraphs:

1. The allowable cost per patient day as determined by the division from the desk-reviewed or field-audited cost report, or both, with a period ending in calendar year 1988 will be multiplied by one hundred eleven and one-tenth percent (111.1%). One dollar and six cents ($1.06) will be added to this adjusted cost per patient day amount to allow for the April 1, 1990 change in the minimum wage and the total will be subject to and limited by the ceiling amount of fifty-four dollars and ninety-five cents ($54.95). The division will use a cost report which has an ending date in calendar year 1988 which is on file with the division as of December 31, 1989, and no amended information will be accepted after that date. If a facility has more than one (1) cost report with periods ending in calendar year 1988, the report covering a full twelve (12)-month period ending in calendar year 1988 will be used. If none of the reports covers twelve (12) months, the report with the latest period ending in calendar year 1988 will be used; or 2. The per-diem rate in effect for services rendered on June 30, 1990.

(B) A facility with a valid Medicaid participation agreement in effect on June 30, 1990, which does not have a cost report with a period ending in calendar year 1988 shall be granted an interim per-diem rate effective for service dates on and after July 1, 1990, equal to the per-diem rate in effect for services rendered on June 30, 1990. A prospective per-diem rate shall be determined on the basis of the allowable cost per patient day as determined by the division from the desk-reviewed, field-audited, or both, facility fiscal year cost report which covers either the first twelve (12) months of operation under rules applicable at the time the facility entered the Medicaid program or the second twelve (12)-month fiscal year following the initial date of Medicaid certification. The facility must elect the option in writing and it must be received by the Division of Medical Services no later than October 1, 1990. A facility failing to notify the Division of Medical Services of its intent shall have its prospective per-diem rate established on the basis of the second twelve (12)-month facility fiscal year following the initial date of Medicaid certification. This prospective per-diem rate shall be retroactively effective for services beginning on the first day of the facility’s option year but not earlier than July 1, 1990, and shall replace the interim per-diem rate on and after that date. Rate adjustment per paragraph (12)(A)1. which may have been granted for service dates on and after the effective date of the prospective per-diem rate will be applied when effective.

(C) Except as provided in subsection (11)(D), a facility entering the Medicaid program after June 30, 1990, shall receive an interim per-diem rate equal to ninety-five percent (95%) of the LTCC in effect on the initial date of Medicaid certification to be effective for services rendered on and after the initial date of Medicaid certification. A prospective per-diem rate will be determined on the basis of the division’s determination of the allowable cost per patient day as determined by the division from the desk-reviewed, field-audited, or both, facility fiscal year cost report which covers the second twelve (12)-month fiscal year following the facility’s initial date of Medicaid certification for new facilities, and the first twelve (12)-month fiscal year cost report for facilities entering the Medicaid program after June 30, 1990, which are not new facilities. This prospective per-diem rate shall be effective retroactively for services beginning on the first day of the new facility’s second twelve (12)-month fiscal year and the first day of the facility’s first twelve (12)-month fiscal year for facilities entering the Medicaid program after June 30, 1990, which are not new facilities and shall replace the interim per-diem rate on and after that date. Rate adjustment per paragraph (12)(A)1. which may have been granted for service dates on and after the effective date of the prospective per-diem rate will be applied when effective.

(D) A facility with a valid Medicaid participation agreement in effect on or after July 1, 1990, which either voluntarily or program and which reenters the Medicaid program shall have its prospective per-diem rate established as the rate in effect on the day prior to the date of termination from participation in the program plus rate adjustments which may have been granted with effective dates subsequent to the termination date but prior to reentry into the program as described in paragraph (12)(A)1. This prospective per-diem rate shall be effective for service dates on and after the effective date of the reentry following a voluntary or involuntary termination.

(12) Adjustments to the Per-Diem Rate. Subject to the limitations prescribed elsewhere in these rules, a facility’s per-diem rate may be adjusted as described in this section.

(A) Adjustments determined by the division without the advice of the rate advisory committee.

1. Global per-diem rate adjustments. Global per-diem rate adjustments shall be added to the LTCC. All facilities with valid Medicaid participation agreements in effect on the effective date of the adjustments shall be eligible for the global perdiem rate adjustments. A facility with either an interim rate or a prospective per-diem rate may qualify for the global per-diem rate adjustments as follows:

A. Laundry. All facilities with either an interim per-diem rate or a prospective per-diem rate in effect on July 1, 1990, per subsections (11)(A) and (B) shall be granted an increase to their per-diem rate effective July 1, 1990, of fifty cents (50¢) per patient day related to personal laundry;

B. Negotiated trend factor. All facilities with either an interim per-diem rate or a prospective per-diem rate in effect on July 1, 1990, per subsections (11)(A) and (B) shall be granted an increase to their per-diem rate effective July 1, 1990, of forty-seven cents (47¢) per patient day for the negotiated trend factor. This amount is one percent (1%) of the average per-diem rate paid to all facilities on April 30, 1990;

C. Minimum wage adjustment. All facilities with either an interim per-diem rate or a prospective per-diem rate in effect on April 1, 1991, per subsections (11)(A) (C) shall be granted an increase to their per diem of one dollar and six cents ($1.06) effective April 1, 1991, to allow for the April 1, 1991 change in minimum wage. This amount is two and one-tenth percent (2.1%) of the weighted average per-diem rate paid to all facilities on February 28, 1991;

D. FY-92 trend factor and Workers’ Compensation. All facilities with either an interim rate or a prospective per-diem rate in effect on July 1, 1992, shall be granted an increase to their per-diem rate effective July 1, 1992, of three dollars and ninetysix cents ($3.96) per patient day related to the continuation of the FY-92 trend factor and the Workers’ Compensation adjustment. This adjustment is equal to seven and one-half percent (7.5%) of the weighted average per-diem rate of fiftytwo dollars and eighty-two cents ($52.82) for January 1992;

E. FY-93 negotiated trend factor. All facilities with either an interim rate or prospective per-diem rate in effect on July 1, 1992, shall be granted an increase to their per-diem rates effective July 1, 1992, of seventy-four cents (74¢) per patient day for the negotiated trend factor. This adjustment is equal to one and four-tenths percent (1.4%) of the weighted average per-diem rate of fifty-two dollars and eighty-two cents ($52.82) for January 1992; and F. Workers’ Compensation. All facilities with either an interim per-diem rate or a prospective per-diem rate in effect on January 1, 1994, shall be granted an increase to their perdiem rate effective January 1, 1994, of thirty-eight cents (38¢) per patient day related to Workers’ Compensation.

2. Special per-diem rate adjustments. Special per-diem rate adjustments shall not be added to the LTCC. Only those facilities qualifying for special per-diem rate adjustments are eligible for the special per-diem rate adjustments as follows:

A. Nursing home reform.

(I) ICFs. A facility certified for participation as an ICF as of June 30, 1990, or a facility certified after January 1, 1990, as an SNF which did not apply for a change-in-level-of-care adjustment as of June 30, 1990, may be granted the consultant adjustment described in subpart (12)(A)2.A.(I)(a) effective for service dates on and after July 1, 1990. A facility qualifying for the consultant adjustment must apply between July 1, 1990, and December 31, 1990, in order to be considered for or receive the registered nurse (RN) or the licensed practical nurse (LPN) adjustment, or both, described in subparts (12)(A)2.A.(I)(b) and (c), which will be effective beginning on the application date but no earlier than July 1, 1990, subject to applicable waivers.

A facility must demonstrate by September 1, 1992, that they have hired the RNs and LPNs for which they have received an adjustment by submitting a consecutive two (2)-week staffing pattern between the effective date of the adjustment and May 1, 1992; and, to the extent that a facility does not demonstrate by that staffing pattern that it hired the RNs, LPNs, or both, for which it received an adjustment under subparts (12)

(A)2.A.(I)(b) and (c), that facility’s rate will be reduced by the undemonstrated portion of the adjustment, both retroactive to the effective date of the adjustment and prospectively, and the overpayment will be recouped. These are one (1)-time adjustments.

(a) Consultant adjustment. One dollar ($1) will be added to the per-diem rate in effect on July 1, 1990, for qualifying facilities to allow for consultant requirements.

This amount was derived from the 1988 SNF consultant costs converted to a weighted mean cost per patient day and then increased by twenty percent (20%).

(b) RN adjustment. An RN is required for eight (8) consecutive hours, seven (7) days a week. The RN requirement will be compared to a facility’s RN staffing as documented on the 1988 staffing reports (DOA 184) on file as of December 31, 1989, with the Division of Aging. If a facility does not have 1988 staffing reports, the latest report on file as of June 30, 1990, will be used. The difference between the daily RN requirement and the average daily RN staffing per the DOA 184s will be determined and multiplied by a per-hour rate of sixteen dollars and eighty-one cents ($16.81) to arrive at total daily cost. The per-hour rate was derived from 1988 RN rates for ICFs, including fringe benefits at fifteen percent (15%) and then increased by twenty percent (20%). If the total daily cost is positive, it will be divided by average daily licensed occupied beds or ninety percent (90%) of licensed beds, whichever is greater to obtain the RN adjustment to the per-diem rate in effect on July 1, 1990. Occupancy data will be obtained from the fourth quarter 1989 occupancy statistics of the Division of Aging or the most recent data if fourth quarter 1989 occupancy statistics are not available for the facility.

(c) LPN adjustments. For a facility with average daily occupancy of sixty (60) or fewer residents, eight (8) hours of LPN coverage is required for each of two (2) eight (8)-hour shifts seven (7) days a week, except in cases when the RN requirement is waived. If the RN requirement is waived and the facility has average daily occupancy of sixty (60) or fewer residents, eight (8) hours of LPN coverage is required for each of three (3) eight (8)-hour shifts seven (7) days a week. For a facility with occupancy in excess of sixty (60) residents, eight (8) hours of LPN coverage is required for each of three (3) eight (8)-hour shifts seven (7) days a week. The LPN requirement will be compared to the facility’s LPN staffing as documented on the 1988 staffing reports (DOA 184) on file as of December 31, 1989, with the Division of Aging. If a facility does not have 1988 staffing reports, the latest report on file as of June 30, 1990, will be used. The difference between the daily LPN requirement and the average daily LPN staffing per the DOA 184s will be determined and multiplied by a per-hour rate of ten dollars and eighty-three cents ($10.83) to arrive at total daily cost. The per-hour rate was derived from 1988 LPN rates for ICFs, including fringe benefits at fifteen percent (15%) and then increased by twenty percent (20%). If the total daily cost is positive, it will be divided by average daily licensed occupied beds or ninety percent (90%) of licensed beds, whichever is greater to obtain the LPN adjustment to the per-diem rate in effect on July 1, 1990. Occupancy data will be obtained from this fourth quarter 1989 occupancy statistics of the Division of Aging or the most recent data if fourth quarter 1989 occupancy statistics are not available for the facility; and B. High volume provider. A facility must qualify each July 1 for the high volume adjustment. For a facility which has a high volume adjustment on June 30, 1994, and does not qualify July 1, 1994, that facility’s prospective rate will be reduced by the amount of the high volume adjustment included in the facility’s prospective per-diem rate in effect June 30, 1994. The adjustment will be effective for services rendered between July 1, 1994 through June 30, 1995. Effective with the state’s Fiscal Year 1996, the division may reconstruct and redefine the qualifying criteria and payment methodology for the high volume adjustment.

(I) A facility must meet all four (4) of the following qualifications:

(a) A full twelve (12)-month cost report ending in calendar year 1992. For a nonprofit facility that changed ownership or operator, or both, and filed a partial year cost report, the latest period cost report will be considered as a full twelve (12)-month cost report;

(b) One hundred six and two-tenths percent (106.2%) of the allowable cost per patient day as determined by the division from the cost report identified in subpart (12)(A)2.B.(I)

(a) exceeds the LTCC in effect June 30, 1994, as identified in paragraph (3)(E)3.;

(c) Total occupied beds as determined from the cost report identified in subpart (12)(A)2.B.(I)(a) exceeds eighty-five percent (85%) of licensed beds or facilities that had a high volume adjustment on June 30, 1994, and had total occupied beds as determined from the cost report identified in subpart (12)(A)2.B.(I)(a) exceeding eighty-three percent (83%) of licensed beds. If the facility did not include all licensed beds on the cost report, this qualifier will be determined from the Division of Aging quarterly report of licensed occupancy for the 1992 quarter which ends on an ending date closest to the ending date of the cost report; and (d) Medicaid-occupied beds as determined from the cost report identified in subpart (12)(A)2.B.(I)(a) exceeds eighty percent (80%) of the total licensed occupied beds identified in subpart (12)(A)2.B.(I)(c) or provide at minimum sixty-five thousand (65,000) Missouri Medicaid patient days as determined from the cost report identified in subpart (12)

(A)2.B.(I)(a).

(II) The adjustment will be equal to ten percent (10%) of the LTCC which was in effect June 30, 1994. This amount was six dollars and twenty-one cents ($6.21).

(III) If a facility qualifies for the high volume adjustment, their LTCC adjustment will be six dollars and twenty-one cents ($6.21) above the LTCC in effect for services rendered between July 1, 1994 through June 30, 1995;

C. 1967 Life Safety Code (LSC). Currently certified LTC facilities that must comply with a recent interpretation of paragraph 10-133 of the 1967 LSC which requires corridor walls to extend to the roof deck or achieve equivalency under the Fire Safety Evaluation System (FSES) will be reimbursed the reasonable and necessary cost to meet those standards required for compliance through their Medicaid per-diem rate.

The reimbursement shall not be effective until the Division of Aging has confirmed that the corrective action to comply with the 1967 LSC or FSES is operational. Fire sprinkler systems shall be reimbursed over a depreciation life of twenty-five (25) years and other alternative corrective action will be reimbursed over a depreciable life of fifteen (15) years. The nursing home’s rate plus this adjustment will be limited to the Medicaid LTCC per subpart (12)(A)2.B.(I)(a). The division will use a cost report with the latest period ending in calendar year 1992 which is on file with the division as of July 1, 1993. This adjustment will be computed as follows based on the cost documented and submitted to the Division of Medical Services:

(I) Depreciation. The asset value for the actual cost incurred for the approved corrective action to continue in compliance divided by the depreciable useful life;

(II) Interest. The interest cost incurred to finance this project shall be documented by a statement from the lending institution detailing the total interest cost of the loan period.

The total interest cost will be divided by the loan period; and (III) The total of the result of depreciation and interest will be divided by twelve (12) and then multiplied by the number of months covered by the 1991 cost report. This amount will be divided by the greater of actual patient days from the 1991 cost report or ninety percent (90%) of the available bed days from the 1991 cost report;

D. Effective March 1, 1993, any nursing facility licensed under Chapter 198, RSMo and operated by a district or county which receives local tax revenues and certifies these revenues to the Department of Social Services shall receive an adjustment to their per-diem rate. The adjustment shall not exceed ninety percent (90%) of the Medicaid portion of the local tax revenues in aggregate divided by the total projected Medicaid payments for FY-93 for those qualifying facilities. The adjustment will be limited by the class ceiling. Any unused certified local tax revenues will not carry forward into the next state fiscal year’s (I) The Medicaid portion is determined by multiplying the total local tax revenues certified to the Department of Social Services for each facility by each facility’s Medicaid occupancy rate as reported on their 1990 cost report.

(II) The projected Medicaid payments for FY-93 are computed by multiplying the per-diem rate on record with Division of Medical Services for September 1992 times the projected FY-93 Medicaid days for each qualifying facility allocated based on its February 1992 Medicaid census annualized; and E. Effective July 1, 1993, and each July 1 after that, any nursing facility licensed under Chapter 198, RSMo and operated by a district or county which receives local tax revenues and certifies these revenues to the Department of Social Services shall receive an adjustment to its per-diem rate.

The adjustment shall not exceed ninety percent (90%) of the Medicaid portion of the local tax revenue in aggregate divided by the total projected Medicaid payments for those qualifying facilities. The adjustment will be limited by the class ceiling.

Any unused certified local tax revenue will not carry forward into the next state fiscal year’s calculation.

(I) The Medicaid portion is determined by multiplying the total local tax revenues certified to the Department of Social Services for each facility by each facility’s Medicaid occupancy rate as reported on its most recent desk-reviewed (II) The projected Medicaid payments are computed by multiplying the per-diem rate on record with DMS on June 1 each year times the June 1 of each year projected Medicaid days for the following state fiscal year for each qualifying facility allocated based on its reported Medicaid days on the most current cost report on file with DMS.

3. Prospective payment adjustment (PPA). A FY-92 PPA will be provided prior to the end of the state fiscal year for nursing homes with a current provider agreement on file with the DMS as of October 1, 1991, except those facilities that are owned or operated, or both, by the federal government.

A. For nursing homes which qualify, the PPA shall be the lesser of— (I) The nursing home’s facility peer group factor (FPGF) times the projected patient days (PPD) covered by the adjustment year times the prospective payment adjustment factor (PPAF) times the LTCC on October 1, 1991, (FPGF × PPD × PPAF × LTCC). For example: A nursing home having two thousand seven (2007) paid days for the period May 1991 to July 1991 out of a total paid days for this same period of two million one hundred seventy-five thousand two hundred fifty-seven (2,175,257) represents an FPGF of nine-hundredths percent (.09%). So using the FPGF of .09% × 9,750,000 × 32.5% × $56.98=$167,578; or (II) The nursing home’s FPGF times one hundred forty-five percent (145%) of the amount credited to the nursing facility revenue collection center (NFRCC) of the State Title XIX Fund (STF) for the period October 1, 1991 through December 31, 1991.

B. FPGF is determined by using each nursing home’s paid days for the service dates in May 1991 through July 1991 as of August 20, 1991, divided by the sum of the paid days for the same service dates for all nursing homes qualifying as of the determination date of September 12, 1991.

C. LTCC is fifty-six dollars and ninety-eight cents ($56.98) on October 1, 1991.

D. PPAF is equal to thirty-two and five-tenths percent (32.5%) for Fiscal Year 1992 which includes an adjustment for economic trends, Workers’ Compensation and heavy care/ access incentive.

E. PPD is the projection of nine million seven hundred fifty thousand (9,750,000) patient days made on October 1, 1991, for the adjustment year.

4. Other conditions for per-diem rate adjustments. The division may adjust a facility’s per-diem rate both retrospectively and prospectively under the following conditions:

A. Fraud, misrepresentation, errors, audit adjustment.

When information contained in a facility’s cost report is found to be fraudulent, misrepresented or inaccurate, the facility’s reimbursement rate may be reduced, both retroactively and prospectively, if the fraudulent, misrepresented or inaccurate information as originally reported resulted in establishment of a higher reimbursement rate than the facility would have received in the absence of that information. No decision by the Medicaid agency to impose a rate adjustment in the case of fraudulent, misrepresented or inaccurate information in any way shall affect the Medicaid agency’s ability to impose any sanctions authorized by statute or regulation. The fact that fraudulent, misrepresented or inaccurate information reported did not result in establishment of a higher reimbursement rate than the facility would have received in the absence of this information also does not affect the Medicaid agency’s ability to impose any sanctions authorized by statute or regulation;

B. Decisions of the Administrative Hearing Commission C. Court order; and D. Disallowance of federal financial participation.

(B) Adjustments Determined by the Division With the Advice of the Rate Advisory Committee.

1. Advisory committee. The director, Department of Social Services, shall appoint an advisory committee to review and make recommendations pursuant to requests for rate reconsideration which are in accordance with the provisions of paragraph (12)(B)2. The director may accept, reject or modify the advisory committee’s recommendations.

A. Membership. The advisory committee shall be composed of four (4) members representative of the nursing home industry in Missouri, three (3) members from the Department of Social Services and two (2) members who may include, but are not limited to, a consumer representative, an accountant or economist or a representative of the legal profession. Members shall be appointed for terms of twelve (12) months. The director shall select a chairman from the membership who shall serve at the director’s discretion.

B. Procedures.

(I) The committee may hold meetings when five (5) or more members are present and may make recommendations to the department in instances where a simple majority of those present and voting concurs.

(II) The committee shall meet no less than one (1) time each quarter and members shall be reimbursed for expenses.

(III) The Division of Medical Services will summarize each case and make recommendations. The advisory committee may request additional documentation. Failure to submit requested documentation shall be abandonment of the request.

(IV) The committee, at its discretion, may issue its recommendation based on written documentation or may request further justification from the provider sending the request.

(V) The advisory committee shall have ninety (90) days from the receipt of each complete request, or the receipt of any additional documentation, to submit its recommendations in writing to the director. If the committee is unable to make a recommendation within the specified time limit, the director or his/her designee, if the committee establishes good cause, may grant a reasonable extension.

(VI) Final determination on rate adjustment. The director or his/her designee’s final decision on each request shall be issued in writing to the provider within fifteen (15) working days from receipt of the committee’s recommendation.

(VII) If the director or his/her designee’s final determination allows a rate adjustment, it shall become effective on the first day of the month in which the request was made providing that it was made prior to the tenth of the month. If the request is not filed by the tenth of the month, adjustments shall be effective the first day of the following month.

2. Requests for rate adjustments. A participating facility which has a prospective per-diem rate may request adjustment to its prospective per-diem rate only under the conditions described in subparagraph (12)(B)2.A., B. or C. The request must be submitted in writing to the division within one year of the occurrence of the extraordinary circumstance. The request must clearly and specifically identify under which of the conditions the rate adjustment is sought. The total dollar amount of the requested rate adjustment must be supported by complete, accurate and documented records satisfactory to the division. If the division makes a written request for additional information and the facility does not comply within ninety (90) days of the request for additional information, the division shall consider the request withdrawn. Requests for rate adjustments that have been withdrawn by the facility or are considered withdrawn because of failure to supply requested information may be resubmitted once for the requested adjustment. In the case of a rate adjustment request that has been withdrawn and then resubmitted, the effective date shall be the first day of the month in which the resubmitted request was made providing that it was made prior to the tenth day of the month. If the resubmitted request is not filed by the tenth of the month, adjustments shall be effective the first day of the following month. Conditions for rate adjustment are— A. Extraordinary circumstances.

(I) When the provider can show that it incurred higher costs due to circumstances beyond its control; the industry in general; and the costs have a substantial effect.

(II) Extraordinary circumstances include:

(a) Natural disasters; such as fire, earthquakes and flood; 1) that are not covered by insurance; and 2) that occur in a federally-declared disaster area; and (b) Vandalism, civil disorder or both.

(III) The per-diem rate increase will be calculated as (a) To determine what portion of the incurred costs will be paid by the Division of Medical Services, the division will use the quarterly occupancy survey from the Division of Aging for the time period preceding when the extraordinary circumstance occurred;

(b) For one (1)-time costs (costs which will not be incurred in future fiscal years): The costs directly associated with the extraordinary circumstance will be divided by the paid days for the month the rate adjustment becomes effective per part (12)(B)1.B.(VII). This calculation will equal the amount to be added to the per-diem rate for only one (1) month, which will be the month the rate adjustment becomes effective. For this one month only, the LTCC will be waived; and (c) For on-going or capitalized costs (costs that will be incurred in future fiscal years): Ongoing annual costs (that is, depreciation, interest, etc.) will be divided by the greater of: annualized (calculated for a twelve (12)-month period) total patient days from the latest cost report on file or ninety percent (90%) of annualized total bed days. This calculation will equal the amount to be added to the per-diem rate, not to exceed the LTCC in effect on the date of the increase. This rate adjustment will be added to the per-diem rate;

B. Professional service hours. A rate adjustment may be granted if a facility has experienced an increase in total RN and LPN hours. This increase divided by patient days from the latter period must be at least twenty percent (20%) of the average total RN and LPN hours per patient day for the appropriate period. For adjustments requested in state FY-92, this average will be derived from total RN and LPN hours as identified from cost reports for facilities licensed as SNFs with ending dates after July 1, 1990, and prior to January 1, 1991. For each succeeding state fiscal year, this average will be derived from total RN and LPN hours as identified from cost reports with ending dates in the second calendar year prior to the ending date of the state fiscal year. For example, adjustments requested in state FY-93, the data from cost reports with ending dates in calendar year 1991 will be used. This adjustment is available no more frequently than every two (2) years, with the first adjustment available under this plan to be based upon the twelve (12)-month facility fiscal year required cost report with a period ending after the effective date of this rule. This cost report will be compared to the required cost report for the succeeding twelve (12)-month facility fiscal year. For example, a facility with a twelve (12)-month cost report ending September 30, 1990, shall compare total RN and LPN hours corresponding to RN and LPN salaries reported on lines forty-nine (49) and fifty (50) of the cost report plus contracted RN and LPN hours corresponding to the contracted costs identified on the cost report, to similar data from the cost report for the twelve (12)month period ending September 30, 1991. The next available adjustment would be for the twelve (12)-month facility fiscal year required cost report with a period ending September 30, 1993, as compared to the required cost report for the twelve (12)-month period ending September 30, 1991. The adjustment amount will be determined by obtaining the difference in costs per patient day reported for RN and LPN services (salaries, fringe benefits and RN and LPN contract costs) between the two (2) applicable cost reporting periods using the greater of ninety percent (90%) of bed days or actual reported occupancy.

The facility must submit copies of the actual payroll records which support the cost report data as well as billings showing RN and LPN contract hours which support the cost report.

These records must show job title (RN, LPN), actual hours worked, the per-hour rate and the total amount paid for each employee. Any salaried RN or LPN employee will be assumed to be working a forty (40)-hour week for all weeks worked; and C. Additional beds. The division may recommend a rate adjustment for a participating facility which has a prospective per-diem rate in effect, and which increases its bed capacity after July 1, 1990, in accordance with an approved CON or applicable waiver. The recommended rate adjustment will be calculated as the difference between the weighted average allowable capital costs per day as defined in part (12)(B)2.C.(I) and the allowable capital cost per day as determined in subsection (7)(Q).

(I) The weighted average allowable capital cost per day is calculated as the sum of subparts (12)(B)2.C.(I)(a) and (b) divided by the total number of certified beds.

(a) The allowable capital cost per day as determined in subsection (7)(Q) multiplied by the number of existing certified beds.

(b) The allowable capital cost per day for new beds as described in paragraph (7)(Q)2. multiplied by the number of new certified beds, except the movable equipment rate described in subparagraph (7)(Q)2.B. shall be sixty-five cents (65¢) per bed day which equates to two hundred twenty dollars ($220) per bed.

(13) Exceptions.

(A) For those Medicaid-eligible recipient patients who have concurrent Medicare Part A SNF benefits available, Missouri Medical Assistance Program reimbursement for covered days of stay in a qualified facility will be based on this coinsurance as may be imposed under Title XVIII.

(B) The Title XIX reimbursement rate for out-of-state providers shall be set by one (1) of the following methods:

1. For providers which provided services of fewer than one thousand (1000) patient days for Missouri Title XIX recipients, the reimbursement rate shall be the rate paid for comparable services and level-of-care by the state in which the provider is located; and 2. For providers which provided services of one thousand (1000) or more patient days for Missouri Title XIX recipients, the reimbursement rate shall be the lower of— A. The rate paid for comparable services and level-ofcare by the state in which the provider is located; or B. The rate as calculated in section (11).

(14) Sanctions and Overpayments.

(A) In addition to the sanctions and penalties set forth in this

rule, the division also may impose sanctions against a provider in accordance with 13 CSR 70-3.030 Sanctions for False or Fraudulent Claims for Title XIX Services or any other sanction authorized by state or federal law or regulation.

(B) Overpayments due the Medicaid program from a provider (15) Appeals. In accordance with sections 208.156 and 621.055, RSMo, providers may seek a hearing before the Administrative Hearing Commission of final decisions of the director, Department of Social Services or the Division of Medical (16) Payment in Full. Participation in the program shall be services rendered to Medicaid recipients, the amount paid in accordance with these rules and applicable copayments.

(17) Provider Participation. Payments made in accordance with program so that eligible persons can receive the medical care and services included in the state plan at least to the extent these services are available to the general public.

(18) Transition. Cost reports used for rate determination shall be principles provided in this rule.

Covered Supplies & Services Personal Care— Bids (all types)

Disposable Underpads (all types)

Hair Care, Basic (including washing, cuts, sets, brushes, combs, nonlegend shampoo)

Lotion, Soap and Oil Nail Clipping and Cleaning Routine Oral Hygiene (including denture care, cups, cleaner, mouthwashes, toothbrushes and paste)

Shaves, Shaving Cream and Blades Equipment— Bathing Equipment Bed Frame Equipment (including trapeze bars and bedrails)

Bed Pans (all types)

Beds, Manual, Electric Canes (all types)

Crutches (all types)

Foot Cradles (all types)

Heat Cradles Hot Pack Machines Hypothermia Blanket Mattresses (all types)

Patient Lifts (all types)

Respiratory Equipment (compressors, vaporizers, Humidifers, Intermittent Positive Pressure Breathing Machines (IPPB), nebulizers, suction equipment and related supplies and the like)

Specimen Container (cup or bottle)

Urinals (male and female)

Walkers (all types)

Wheelchairs (standard, geriatric and rollabout)

Nursing Care/Patient Care Supplies— Catheter (indwelling and nonlegend supplies)

Decubitus Ulcer Care (pads, dressings, air mattresses, aquamatic K-pads (water-heated pads), alternating pressure pads, flotation pads, or turning frames, or any combination of these, heel protectors, donuts and sheepskins)

Diabetic Blood and Urine Testing Supplies Drainage Sets, Bags, Tubes and the like Dressing Trays (dressings of all types)

Gloves (nonsterile and sterile)

Incontinency Care (including pads, diapers and pants)

Irrigation Trays and Nonlegend Supplies Medicine Droppers Needles (including, but not limited to, hypodermic, scalp, vein)

Nursing Services (regardless of level, administration of oxygen, eating and massages provided by facility personnel)

Nursing Supplies: Lubricating Jelly,, Betadine,Benzoin, Peroxide, A & D Ointment, Tapes, Alcohol, Alcohol Sponges, Applicators, Dressings and Bandages (of all types), Cottonballs, Merthiolate Aerosol and Tongue Depressors Ostomy Supplies (adhesive, appliance, belts, face plates, flanges, barriers, tail closures and bags)

Suture Care (including trays and removal kits)

Syringes, all sizes and types (including Ascepto)

Urinary Drainage Tube and Bottle Therapeutic Agents and Supplies— Enteral Feedings (including by tube, and all related supplies)

I.V. Therapy Supplies (arm boards, needles, tubing and other related supplies)

Oxygen (portable or stationary), Oxygen Delivery Systems, Concentrators and Supplies Other Services and Supplies as Otherwise Determined

rule filed Sept. 18, 1981, effective Oct. 1, 1981, expired Jan. 13, 1982.

Original rule filed Sept. 18, 1981, effective Jan. 14, 1982. Emergency amendment filed Sept. 28, 1981, effective Oct. 7, 1981, expired Jan. 13, 1982. Amended: Filed Oct. 13, 1981, effective Jan. 14, 1982.

Emergency amendment filed June 21, 1982, effective July 1, 1982, expired Oct. 10, 1982. Amended: Filed June 21, 1982, effective Oct. 11, 1982. Emergency amendment filed Oct. 8, 1982, effective Oct. 18, 1982, expired Jan. 12, 1983. Amended: Filed Oct. 8, 1982, effective Jan. 13, 1983. Amended: Filed March 14, 1985, effective July 11, 1985. Emergency amendment filed June 20, 1985, effective July 1, 1985, expired Sept. 30, 1985. Amended: Filed June 20, 1985, effective Oct. 1, 1985. Amended: Filed Aug. 2, 1985, effective Nov. 1, 1985. Amended: Filed Dec. 16, 1985, effective April 25, 1986.

Amended: Filed April 16, 1986, effective July 1, 1986. Amended:

Filed June 17, 1986, effective Sept. 1, 1986. Emergency amendment filed June 30, 1986, effective July 10, 1986, expired Nov. 7, 1986.

Amended: Filed July 3, 1986, effective Oct. 11, 1986. Amended: Filed July 3, 1986, effective Nov. 1, 1986. Amended: Filed Aug. 1, 1986, effective Nov. 13, 1986. Amended: Filed Dec. 16, 1986, effective April 26, 1987. Emergency amendment filed June 19, 1987, effective July 1, 1987, expired Oct. 29, 1987. Emergency amendment filed Aug. 18, 1987, effective Aug. 28, 1987, expired Dec. 25, 1987. Amended:

Filed Aug. 18, 1987, effective Dec. 12, 1987. Amended: Filed Aug. 18, 1987, effective Oct. 25, 1987. Emergency amendment filed July 28, 1988, effective Aug. 6, 1988, expired Dec. 3, 1988. Emergency amendment filed Oct. 4, 1988, effective Oct. 14, 1988, expired Dec. 4, 1988. Amended: Filed Dec. 5, 1988, effective Feb. 24, 1989.

Emergency amendment filed Dec. 16, 1988, effective Jan. 1, 1989, expired May 1, 1989. Amended: Filed Dec. 16, 1988, effective March 11, 1989. Amended: Filed March 3, 1989, effective May 15, 1989.

Amended: Filed Aug. 16, 1989, effective Nov. 11, 1989. Amended:

Filed March 5, 1990, effective June 11, 1990. Emergency rescission and rule filed June 1, 1990, effective July 1, 1990, expired Oct. 28, 1990. Rescinded and readopted: Filed June 1, 1990, effective Sept. 28, 1990. Emergency amendment filed March 4, 1991, effective April 1, 1991, expired July 29, 1991. Amended: Filed March 4, 1991, effective July 8, 1991. Amended: Filed March 18, 1991, effective July 8, 1991. Amended: Filed May 2, 1991, effective Sept. 30, 1991.

Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Amended: Filed June 26, 1991, effective Dec. 9, 1991. Amended: Filed Sept. 4, 1991, effective Jan. 13, 1992.

Emergency amendment filed Oct. 9, 1991, effective Oct. 29, 1991, expired Feb. 25, 1992. Emergency amendment filed Nov. 15, 1991, effective Dec. 3, 1991, expired April 1, 1992. Amended: Filed Nov. 15, 1991, effective April 9, 1992. Emergency amendment filed March 13, 1992, effective April 2, 1992, expired July 30, 1992. Amended:

Filed Feb. 3, 1992, effective June 25, 1992. Amended: Filed March 30, 1992, effective Sept. 6, 1992. Amended: Filed May 5, 1992, effective Jan. 15, 1993. Amended: Filed May 15, 1992, effective Jan. 15, 1993. Emergency amendment filed June 16, 1992, effective July 1, 1992, expired Oct. 28, 1992. Emergency amendment filed June 16, 1992, effective July 1, 1992, expired Oct. 28, 1992. Emergency amendment filed June 26, 1992, effective July 5, 1992, expired Oct. 28, 1992. Emergency amendment filed July 23, 1992, effective Aug. 2, 1992, expired Nov. 29, 1992. Emergency amendment filed July 23, 1992, effective Aug. 2, 1992, expired Nov. 29, 1992. Emergency amendment filed Sept. 25, 1992, effective Oct. 29, 1992, expired Feb. 25, 1993. Emergency amendment filed Sept. 25, 1992, effective Nov. 1, 1992, expired Feb. 27, 1993. Emergency amendment filed Nov. 16, 1992, effective Nov. 30, 1992, expired March 29, 1993.

Emergency amendment filed Nov. 16, 1992, effective Nov. 30, 1992, expired March 29, 1993. Amended: Filed June 16, 1992, effective Feb. 26, 1993. Amended: Filed Sept. 25, 1992, effective May 6, 1993.

Amended: Filed Oct. 15, 1992, effective May 6, 1993. Emergency amendment filed Feb. 18, 1993, effective March 1, 1993, expired June 28, 1993. Amended: Filed Feb. 5, 1993, effective July 8, 1993.

Emergency amendment filed Feb. 16, 1993, effective Feb. 26, 1993, expired June 25, 1993. Emergency amendment filed Feb. 16, 1993, effective Feb. 28, 1993, expired June 27, 1993. Amended: Filed Feb. 18, 1993, effective Sept. 9, 1993. Emergency amendment filed June 15, 1993, effective July 1, 1993, expired Oct. 28, 1993. Emergency amendment filed May 20, 1993, effective June 1, 1993, expired Sept. 28, 1993. Emergency amendment filed June 15, 1993, effective June 30, 1993, expired Oct. 27, 1993. Emergency amendment filed Aug. 17, 1993, effective Sept. 1, 1993, expired Dec. 29, 1993. Amended:

Filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed June 15, 1993, effective Dec. 9, 1993. Emergency amendment filed Aug. 17, 1993, effective Sept. 1, 1993, expired Dec. 29, 1993. Emergency amendment filed Oct. 15, 1993, effective Oct. 29, 1993, expired Feb. 25, 1994. Amended: Filed Aug. 17, 1993, effective March 10, 1994.

Amended: Filed Nov. 2, 1993, effective June 6, 1994. Emergency amendment filed Dec. 17, 1993, effective Jan. 1, 1994, expired April 30, 1994. Emergency amendment filed Dec. 17, 1993, effective Jan. 1, 1994, expired April 28, 1994. Amended: Filed Dec. 2, 1993, effective July 30, 1994. Emergency amendment filed April 19, 1994, effective May 1, 1994, expired Aug. 28, 1994. Amended: Filed Feb. 16, 1994, effective Aug. 28, 1994. Emergency amendment filed June 15, 1994, effective July 1, 1994, expired Oct. 28, 1994.

Emergency amendment filed Sept. 20, 1994, effective Oct. 1, 1994, expired Jan. 28, 1995. Emergency amendment filed Oct. 7, 1994, effective Oct. 29, 1994, expired Feb. 25, 1995. Amended: Filed June 15, 1994, effective Jan. 29, 1995. Emergency amendment filed Sept. 20, 1994, effective Oct. 1, 1994, expired Jan. 28, 1995. Emergency amendment filed Oct. 7, 1994, effective Oct. 29, 1994, expired Feb. 25, 1995. Amended: Filed Sept. 20, 1994, effective May 28, 1995. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; 208.159, RSMo 1979; and 208.201, RSMo 1987.

History

• AUTHORITY: sections 208.153, 208.159 and 208.201, RSMo 1994. This rule was previously filed as 13 CSR 40-81.081. Emergency

13 CSR 70-10.015 Prospective Reimbursement Plan for Nursing Facility Services {#sec-13-csr-70-10.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.015}

PURPOSE: This rule establishes a reimbursement plan for nursing facility services required by the Code of Federal Regulations.

The plan describes principles to be followed by Title XIX nursing facility providers in making financial reports and presents the necessary procedures for setting rates, making adjustments, and auditing the cost reports.

(1) Authority. This regulation is established pursuant to the (2) Purpose. This regulation establishes a methodology for determination of reimbursement rates for nursing facilities.

Subject to limitations prescribed elsewhere in this regulation, a facility’s reimbursement rate shall be determined by the division as described in this regulation. Any reimbursement rate determined by the division shall be a final decision and will be implemented as set forth in the division’s decision letter. The decisions of the division may be subject to review upon properly filing a complaint with the Administrative Hearing Commission (AHC). A nursing facility seeking review by the AHC must obtain a stay from the AHC to stop the division from implementing its final decision if the AHC determines the not limited to, hospice providers, that the rate being received within the scope of the federal Medicaid Program and made (3) General Principles.

(A) Provisions of this reimbursement regulation shall apply only to facilities certified for participation in the MO HealthNet (B) The reimbursement rates determined by this regulation shall apply only to services provided on or after January 1, 1995.

(C) The effective date of this regulation shall be January 1, 1995.

(D) The Medicaid Program shall provide reimbursement for nursing facility services based solely on the individual Medicaid-eligible participant’s covered days of care, within benefit limitations as determined in subsections (5)(D) and (M) multiplied by the facility’s Medicaid reimbursement rate.

No payments may be collected or retained in addition to the otherwise provided for in this regulation. Where third-party payment is involved, Medicaid will be the payer of last resort with the exception of state programs such as vocational rehabilitation and the Missouri Crippled Children’s Services.

(E) The Medicaid reimbursement rate shall be the lower of— 1. The Medicare (Title XVIII) rate, if applicable; or 2. The reimbursement rate as determined in accordance (F) Medicaid reimbursements shall not be paid for services provided to Medicaid-eligible participants during any time period in which the facility failed to have a Medicaid participation agreement in effect. A reimbursement rate may (G) When a nursing facility is found not in compliance with federal requirements for participation in the Medicaid Program, sections 1919(b), (c), and (d) of the Social Security Act (42 U.S.C. 1396r), it may be terminated from the Medicaid Program or it may have imposed upon it an alternative remedy, pursuant to section 1919(h) of the Social Security Act (42 U.S.C. 1396r). In accordance with section 1919(h)(3)(D) of the Social Security Act, the alternative remedy, denial of payment for new admission, is contingent upon agreement to repay payments received if the corrective action is not taken in accordance with the approved plan and timetable. It is also required that the nursing facility establish a directed plan of correction in conjunction with and acceptable to the Department of Health and Senior Services.

(H) Upon execution of a Medicaid participation agreement, the division. Facilities previously certified shall retain the same provider number regardless of any change in ownership.

(I) Regardless of changes in control or ownership for any facility certified for participation in the Medicaid Program, the division shall issue payments to the facility identified in the current Medicaid participation agreement. Regardless of changes in control or ownership for any facility certified for participation in Medicaid, the division shall recover from that entity liabilities, sanctions, and penalties pertaining to the Medicaid Program, regardless of when the services were (J) Changes in ownership, management, control, operation, leasehold interest by whatever form for any facility previously time that results in increased capital costs for the successor owner, management, or leaseholder shall not be recognized for (K) A facility with certified and noncertified beds shall allocate allowable costs related to the provision of nursing facility services on the cost report, in accordance with the cost report instructions. The methods for allocation must be supported by adequate accounting and/or statistical data necessary to evaluate the allocation method and its application.

(L) Any facility which is involuntarily terminated from from participation in the MO HealthNet Program on the same date as the Medicare termination.

(M) No restrictions nor limitations shall, unless precluded by federal or state regulation, be placed on a participant’s right to select providers of his/her own choice.

(N) A nursing facility’s Medicaid reimbursement rate shall not be limited by its average private pay rate.

(O) The reimbursement rates authorized by this regulation may be reevaluated in light of the provider’s cost experience to determine any adjustments needed.

(P) Covered supplies, such as food, laundry supplies, housekeeping supplies, linens, medical supplies, but not limited to, must be accounted for through inventory accounts.

Purchases shall be recorded as inventory and shall be expensed in the fiscal year the items are used. Inventory shall be counted at least annually to coincide with the facility’s fiscal year or the end of the cost report period, if different. Expensing of items shall be recorded by adding purchases to the beginning period inventory and subtracting the end of the period inventory. This inventory control shall begin the first fiscal year ending after the effective date of this plan.

(Q) Medicaid reimbursement will not be paid for a Medicaideligible resident while placed in a non-certified bed in a (R) All illustrations and examples provided throughout this (S) Rebasing.

1. The division based on its discretion shall pick at least one (1) cost report year from cost reports with fiscal years ending in 2001 or later to compare the allowable costs from the selected desk audited and/or field audited cost report year to the reimbursement rate in effect at the time of the comparison.

The rebased rates shall be determined in accordance with

section(s) (20)-(21), as applicable.

2. The asset value will be adjusted annually based on the R. S. Means Construction Index. The asset value as adjusted will be used only for determining reimbursement in section (11) for the year(s) selected above for rebasing and as determined in paragraphs (13)(B)6. and (13)(B)7.

(T) Effective for dates of service beginning April 1, 2010, reimbursement of Medicare/Medicaid crossover claims

Part C inpatient skilled nursing facility benefits shall be as 1. Crossover claims for Medicare Part A inpatient skilled A. The crossover claim must be related to Medicare Part B. The crossover claim must contain approved hundred (100) of each Medicare benefit period; and C. The Other Payer paid amount field on the claim D. The nursing facility’s Medicaid reimbursement rate 2. Crossover claims for Medicare Advantage/Part C (Medicare Advantage) inpatient skilled nursing facility benefits in which a Medicare Advantage plan was the primary payer and the MO HealthNet Division is the payer of last resort for the copay (coinsurance) must meet the following criteria to be A. The crossover claim must be related to Medicare Medicare Beneficiary Plus (QMB Plus); and B. The crossover claim must be submitted as a Medicare online Internet billing system; and C. The crossover claim must contain approved coinsurance days. The amount indicated by the Medicare Advantage plan to be the coinsurance due on the Medicare Advantage plan allowed amount is the crossover amount eligible for MO are established by each Medicare Advantage plan; and D. The Other Payer paid amount field on the claim must plan. The MO HealthNet provider is responsible for accurate E. The nursing facility’s Medicaid reimbursement rate 3. MO HealthNet reimbursement will be the lower of— A. The difference between the nursing facility’s Medicaid B. The coinsurance amount; and 4. Nursing facility providers may not submit a MO (4) Definitions.

(A) Additional beds. Newly constructed beds never certified for Medicaid or never previously licensed by the Department of Health and Senior Services.

(B) Administration. This cost component includes the following lines from the cost report:

1. Version MSIR-1 (7-93): lines 105, 113–120, 122–140, 142–144, 147–150, 152–158 and amortization of organizational costs reported on line 106; and 2. Version MSIR-1 (3-95): lines 111–150.

(C) Age of beds. The age is determined by subtracting the initial licensing year from 1994 for prospective rates effective January 1, 1995 set during the initial 1992 rate base year calculations or the rate setting year for prospective rates effective after January 1, 1995.

(D) Allowable cost. Those costs which are allowable for determined by the MO HealthNet Division and shall be based upon criteria and principles included in this regulation, the Medicare Provider Reimbursement Manual (HIM-15) and GAAP.

Criteria and principles will be applied using this regulation as the first source, the Medicare Provider Reimbursement Manual (HIM-15) as the second source and GAAP as the third source.

(E) Ancillary. This cost component includes the following lines from the cost report:

1. Version MSIR-1 (7-93): lines 62–75, 87–95, 97–103, 145–146;

2. Version MSIR-1 (3-95): lines 71–101.

(F) Asset value. The asset value is the per bed cost of construction used in calculating a facility’s capital cost component per diem utilizing the fair rental value system (FRV) as set forth in subsection (11)(D). The asset value is determined using the RS Means Building Construction Cost publication and the median, total cost of construction per bed for nursing homes from the “S.F., C.F., and % of Total Costs” table, adjusted by the total weighted average index for Missouri cities from the “City Cost Indexes” table. The initial asset value used in setting rates effective January 1, 1995 relating to the initial 1992 base year is the value for 1994 and is thirty-two thousand three hundred thirty dollars ($32,330). The initial asset value is adjusted annually using the estimated Historical Cost Indexes from the RS Means publication for each year and is used to set the prospective rate for new facilities. The asset value in effect at the end of the rate setting period shall be used.

(G) Audit. The examination or inspection of a provider’s cost report, files, and any other supporting documentation by the MO HealthNet Division or its authorized contractor. The MO HealthNet Division or its authorized contractor may perform the following types of audits:

1. Level I Audit - Requires a limited review of provider cost contractor. The limited review may include, but is not limited to, items such as a comparative analysis of a provider’s cost report data to industry data, a review of a provider’s prior year data to determine any outliers that may warrant further review, requesting additional details of the reported information, all of which could lead to potential adjustment(s) after such further review, as well as making any standard adjustments. Level I audits may be provided off-site;

2. Level II Audit - Requires a desk review of provider cost contractor. The desk review may include, but is not limited to, review procedures in a Level I Audit, plus a more detailed analysis of a provider’s cost report data to identify items that would require further review including requesting additional details of the reported information or documentation to support amounts reflected in the cost report. Level II audits may be provided off-site; and 3. Level III Audit – Requires an in depth audit, including, but not limited to, an on-site review of provider cost reports, files, and any other additional information requested and submitted to the MO HealthNet Division or its authorized contractor. The Level III Audit will require an in depth analysis of a provider’s cost report data and an on-site verification of cost report items deemed necessary through a risk assessment or other analyses. Level III audits will require some portions of the provider’s records review be provided on-site.

(H) Average private pay rate. The usual and customary charge for private patient determined by dividing total private patient days of care into private patient revenue net of contractual allowances for the same service that is included in the Medicaid reimbursement rate. This excludes negotiated payment methodologies with state or federal agencies such as the Veteran’s Administration or the Missouri Department of Mental Health. Bad debts, charity care, and other miscellaneous discounts are excluded in the computation of the average private pay rate.

(I) Bad debt. The difference between the amount expected to be received and the amount actually received. This amount may be written off as uncollectible after all collection efforts are exhausted. Collection efforts must be documented and an aged accounts receivable schedule should be kept. Written procedures should be maintained detailing how, when, and by whom a receivable may be written off as a bad debt.

(J) Capital. This cost component will be calculated using a fair rental value system (FRV). The fair rental value is reimbursed in lieu of the costs reported on the following lines of the cost report:

1. Version MSIR-1 (7-93): lines 106–112, except for amortization of organizational costs; and 2. Version MSIR-1 (3-95): lines 102–109.

(K) Capital asset. A facility’s building, building equipment, improvements, and leasehold improvements as defined in HIM-15. Motor vehicles are excluded from this definition.

(L) Capital asset debt. The debt related to the capital assets as determined from the desk audited and/or field audited cost (M) Ceiling. The ceiling is the maximum per diem rate for which a facility may be reimbursed for the patient care, ancillary and administration cost components, and is determined by applying a percentage to the median per diem for the patient care, ancillary, and administration cost components. The percentage is one hundred twenty percent (120%) for patient care, one hundred twenty percent (120%) for ancillary, and one hundred ten percent (110%) for administration.

(N) Certified bed. Any nursing facility or hospital based bed that is certified by the Department of Health and Senior Services to participate in the Medicaid Program.

(O) Change of ownership. A change in ownership, control, operator, or leasehold interest, for any facility certified for (P) Charity care. Offset to gross billed charges to reduce charges for free services provided to specific types of residents, (i.e. charity care provided to meet Hill Burton Fund obligations or care provided by a religious organization for members, etc.).

(Q) Contractual allowance. A contra revenue account to reduce gross charges to the amount expected to be received.

Contractual allowances represent the difference between the private pay rate and a contracted rate which the facility contracted with an outside party for full payment of services rendered (i.e. Medicaid, Medicare, managed care organizations, etc.). No efforts are made to collect the difference.

(R) Cost components. The groupings of allowable costs used ancillary, capital, and administration. In addition, a working capital allowance is provided.

(S) Cost report. The Financial and Statistical Report for Nursing Facilities, required attachments as specified in paragraph (10)

(A)7. of this regulation, and all worksheets supplied by the division for this purpose. The cost report shall detail the cost of rendering both covered and noncovered services for the fiscal reporting period in accordance with this regulation and the cost report instructions and shall be prepared on forms provided by and/or as approved by the division.

1. Cost Report version MSIR-1 (7-93) shall be used for completing cost reports with fiscal years ending prior to January 1, 1995 and shall be denoted as CR (7-93) throughout the remainder of this regulation.

2. Cost Report version MSIR-1 (3-95) shall be used for completing cost reports with fiscal years ending on or after January 1, 1995 and shall be denoted as CR (3-95) throughout the remainder of this regulation.

(T) Data bank. The data from the rate base year cost reports excluding the following facilities: hospital based, state operated, pediatric, HIV, terminated, or interim rate. If a facility has more than one (1) cost report with periods ending in the rate base year, the cost report covering a full twelve- (12-) month period ending in the rate base year will be used.

If none of the cost reports cover a full twelve (12) months, the cost report with the latest period ending in the rate base year will be used.

1. The initial rate base year shall be 1992 and the data bank shall include cost reports with an ending date in calendar year 1992. The 1992 initial base year data shall be used to set rates effective for dates of service beginning January 1, 1995 through June 30, 2004. The 1992 initial base year data is adjusted for the Health Care Finance Administration (HCFA) Market Basket Index for 1993 of 3.9%, 1994 of 3.4%, and nine (9) months of 1995 of 3.3%, for a total adjustment of 10.6%.

2. The rate base year used for rebasing shall be 2001 and the data bank shall include cost reports with an ending date in calendar year 2001. The 2001 rebase year data shall be used to set rates effective for dates of service beginning July 1, 2004 through such time rates are rebased again or calculated on some other cost report as set forth in regulation. The 2001 rebase year data is adjusted for the CMS Market Basket Index for SFY 2002 of 3.2%, SFY 2003 of 3.4%, SFY 2004 of 2.3%, and SFY 2005 of 2.3%, for a total adjustment of 11.2%.

(U) Department. The department, unless otherwise specified, (V) Department of Health and Senior Services. The department of the state of Missouri responsible for the survey, certification, and licensure of nursing facilities as prescribed in Chapter 198, RSMo. Previously, the agency responsible for these duties was the Division of Aging within the Department of Social Services.

(W) Director. The director, unless otherwise specified, refers to the director, Missouri Department of Social Services.

(X) Division. Unless otherwise specified, division refers to (Y) Entity. Any natural person, corporation, business, partnership, or any other fiduciary unit.

(Z) Facility asset value. Total asset value less adjustment for (AA) Facility fiscal year. A facility’s twelve- (12-) month fiscal reporting period covering the same twelve- (12-) month period (BB) Facility size. The number of licensed nursing facility beds as determined from the desk audited and/or field audited cost report which has been verified with Department of Health and Senior Services records.

(CC) Fair rental value system. The methodology used to (DD) Generally accepted accounting principles (GAAP).

(EE) HCFA Market Basket Index. An index showing nursing home market basket indexes. The index is published quarterly by DRI/McGraw Hill. The table used in this regulation is titled “DRI Health Care Cost—National Forecasts, HCFA Nursing Home Without Capital Market Basket.” HCFA became known as the Center for Medicare and Medicaid Services (CMS) and the table name changed accordingly. The publication and publisher have also changed names but the publication still provides essentially the same information. The publication is known as the Health-Care Cost Review and it is published by Global Insight. The same or comparable index and table shall continue to be used, regardless of any changes in the name of the publication, publisher, or table.

(FF) Hospital based. Any nursing facility bed licensed and certified by the Department of Health and Senior Services,

Section for Health Facilities Regulation, which is physically connected to or located in a hospital.

(GG) Interim rate. The interim rate is the sum of one hundred percent (100%) of the patient care cost component ceiling, ninety percent (90%) of the ancillary and administration cost component ceilings, ninety-five percent (95%) of the median per diem for the capital cost component, and the working capital allowance using the interim rate cost component.

The median per diem for capital will be determined from the capital component per diems of providers with prospective rates in effect on January 1, 1995 for the initial rate base year;

July 1, 2004 for the 2001 rebased year; and March 15, 2005 for the revised rebase calculations effective for dates of service beginning April 1, 2005 and for the per diem rate calculation effective for dates of service beginning July 1, 2005 forward.

(HH) Licensed bed. Any skilled nursing facility or intermediate (II) Miscellaneous discounts/other revenue deductions. A contra revenue account to reduce gross charges to the amount expected to be received. These deductions represent other miscellaneous discounts not specifically defined as a bad debt. Written policies must be maintained detailing the circumstances under which the discounts are available and must be uniformly applied.

(JJ) Median. The middle value in a distribution, above and below which lie an equal number of values. The distribution for purposes of this regulation includes the per diems calculated for each facility based on or derived from the data in the data bank. The per diem for each facility is the allowable cost per day which is calculated by dividing the facility’s allowable costs by the patient days. For the administration cost component, each facility’s per diem included in the data bank and used to determine the median shall include the adjustment for minimum utilization set forth in subsection (7)

(O) by dividing the facility’s allowable costs by the greater of the facility’s actual patient days or the calculated minimum utilization days.

(KK) Nursing facility (NF). Effective October 1, 1990, skilled 198, RSMo, participating in the Medicaid Program will all be (LL) Occupancy rate. A facility’s total actual patient days from the desk audited and/or field audited cost report. For a distinct part facility that only has part of its total licensed beds certified for participation in the MO HealthNet program and that completes a worksheet one, version MSIR (7-93) or (3-95) of the cost report, determines the occupancy rate from the total actual patient days from the certified portion of the facility divided by the total bed days from the certified portion for the same period, as determined from the desk audited and/or field audited cost report.

(MM) Patient care. This cost component includes the following lines from the cost report:

1. Version MSIR-1 (7-93): lines 45–60, 77–85; and 2. Version MSIR-1 (3-95): lines 46–70.

(NN) Patient day. The period of service rendered to a patient purposes. “Patient day” includes the allowable temporary leave-of-absence days per subsection (5)(D) and hospital leave days per subsection (5)(M). The day of discharge is not a patient day for reimbursement unless it is also the day of admission.

(OO) Per diem. The daily rate calculated using this regulation’s cost components and used in the determination of a facility’s prospective and/or interim rate.

(PP) Provider or facility. A nursing facility with a valid Social Services for the purpose of providing nursing facility services to Title XIX-eligible participants.

(QQ) Prospective rate. The rate determined from the rate (RR) Rate setting period. The period in which a facility’s prospective rate is determined. The cost report that contains the data covering this period will be used to determine the facility’s prospective rate and is known as the rate setting cost report. The rate setting period for a facility is determined from applicable regulations on or after July 1, 1990.

(SS) Reimbursement rate. A prospective or interim rate.

(TT) Related parties. Parties are related when any one (1) of 1. An entity where, through its activities, one (1) entity’s exceed those which are usual and customary in such dealings;

2. An entity has an ownership or controlling interest in another entity; and the entity, or one (1) or more relatives of other entity. For the purposes of this paragraph, ownership, entity directly, or through a subsidiary, operates a facility; and 3. As used in this regulation, the following terms mean:

A. Indirect ownership/interest means an ownership B. Ownership interest means the possession of equity in the capital, in the stock, or in the profits of an entity.

Ownership or controlling interest is when an entity— (I) Has an ownership interest totalling five percent (5%)

(II) Has an indirect ownership interest equal (III) Has a combination of direct and indirect ownership (IV) Owns an interest of five percent (5%) or more in (V) Is an officer or director of an entity; or (VI) Is a partner in an entity that is organized as a C. Relative means person related by blood, adoption, or (UU) Replacement beds. Newly constructed beds never certified for Medicaid or previously licensed by the Department of Health and Senior Services and put in service in place of existing Medicaid beds. The number of replacement beds being certified for Medicaid shall not exceed the number of beds being replaced.

(VV) Renovations/major improvements. Capital cost incurred for improving a facility excluding replacement beds and additional beds.

(WW) Restricted funds. Funds, cash, cash equivalent, or (XX) Total facility size. Facility size plus increases minus decreases of licensed nursing facility beds plus calculated bed equivalents for renovations/major improvements.

(YY) Unrestricted funds. Funds, cash, cash equivalents, income from endowments, that are given to a provider without (5) Covered Supplies, Items, and Services. All supplies, items, that would otherwise be covered in a reimbursement rate but which are also billable to the Title XVIII Medicare Program the Title XVIII Medicare Program. Covered supplies, items, and services include, but are not limited to, the following:

(A) Services, items, and covered supplies required by federal or state law or regulation that must be provided by nursing facilities participating in the Title XIX program;

(B) Semiprivate room and board;

(C) Private room and board when it is necessary to isolate a participant due to a medical or social condition examples of which may be contagious infection, loud irrational speech;

(D) Temporary leave of absence days for Medicaid participants, not to exceed twelve (12) days for the first six (6) calendar months and not to exceed twelve (12) days for the second six (6) calendar months. Temporary leave of absence days must be specifically provided for in the participant’s plan of care and prescribed by a physician. Periods of time during which a participant is away from the facility visiting a friend or relative are considered temporary leaves of absence;

(E) Provision of personal hygiene and routine care services (F) All laundry services, including personal laundry;

(G) All dietary services, including special dietary supplements (H) All consultative services required by federal or state law (I) All therapy services required by federal or state law or (J) All routine care items including, but not limited to, those (K) All nursing services and supplies including, but not limited to, those items specified in Appendix A to this regulation;

(L) All nonlegend antacids, nonlegend laxatives, nonlegend stool softeners, and nonlegend vitamins. Providers may not elect which nonlegend drugs in any of the four (4) categories to supply; any and all must be provided to residents as needed and are included in a facility’s reimbursement rate; and (M) Hospital leave days as defined in 13 CSR 70-10.070.

(6) Noncovered Supplies, Items, and Services. All supplies, items, and services which are either not covered in a facility’s reimbursement rate or are billable to another program in Medicaid, Medicare, or other third-party payer. Noncovered supplies, items, and services include, but are not limited to, the (A) Private room and board unless it is necessary to isolate a participant due to a medical or social condition, examples of which may be contagious infection, loud irrational speech, etc. Unless a private room is necessary due to such a medical or social condition, a private room is a non-covered service and a Medicaid participant or responsible party may therefore pay the difference between a facility’s semiprivate charge and its charge for a private room. Medicaid participants may not be placed in private rooms and charged any additional amount above the facility’s Medicaid reimbursement rate unless the participant or responsible party specifically requests in writing a private room prior to placement in a private room and acknowledges that an additional amount not payable by Medicaid will be charged for a private room;

(B) Supplies, items, and services for which payment is made under other Medicaid programs directly to a provider(s) other than providers of the nursing facility services; and (C) Supplies, items, and services provided nonroutinely to (7) Allowable Cost Areas.

(A) Compensation of Owners.

1. Compensation of services of owners shall be an allowable prescribed in subsection (8)(P).

2. Compensation shall mean the total benefit, within the payments for managerial, administrative, professional and from the provider, and additional amounts determined to be the reasonable value of the services rendered by sole proprietors or partners and not paid by any method previously described in this regulation. Compensation must be paid (whether in cash, negotiable instrument, or in kind) within seventy-five (75) days published in the Medicare Provider Reimbursement Manual, Part 1, Section 906.4.

(B) Covered services and supplies as defined in section (5) of this regulation.

(C) Capital Assets.

1. Capital assets shall include historical costs that would include, but not be limited to, architectural fees, related legal fees, interest, and taxes during construction.

2. For purposes of this regulation, any asset or improvement costing greater than one thousand dollars ($1,000) and having a useful life greater than one (1) year in accordance with 3. In addition to the American Hospital Association capitalized asset and shall have a three- (3-) year useful life.

(D) Vehicle Costs. Costs related to allowable vehicles shall be accounted for as set forth below. Allowable vehicles are vehicles that are a necessary part of the operation of a nursing facility and are limited as follows: One (1) vehicle per sixty (60) licensed beds is allowable. For example, one (1) vehicle is allowed for a facility with zero to sixty (0–60) licensed beds, two (2) vehicles are allowed for a facility with sixty-one to one hundred twenty (61–120) licensed beds, and so forth. Vehicles subject to the limit include cars, trucks, vans, sport utility vehicles (SUVs), and shuttle buses. Golf carts, utility terrain vehicles (UTVs), all terrain vehicles (ATVs), and other vehicles not aforementioned in this subsection shall not be included in the total vehicle count for the limit. Costs related to vehicles that are disallowed shall also be disallowed and adjustments made accordingly.

1. Depreciation.

A. An appropriate allowance for depreciation on allowable vehicles is reported on line 139 of the cost report, version MSIR-1 (7-93) and on line 133 of CR (3-95).

B. The depreciation must be identifiable and recorded in the provider’s accounting records, based on the basis of the vehicle and prorated over the estimated useful life of the vehicle in accordance with American Hospital Association depreciable guidelines using the straight line method of depreciation from the date initially put into service.

C. The basis of vehicle cost at the time placed in service (I) The book value of the provider;

(II) Fair market value at the time of acquisition; or (III) The recognized Internal Revenue Service (IRS) tax D. The basis of a donated vehicle will be allowed to the The appraisal cost will be the sole responsibility of the nursing E. Historical cost will include the cost incurred to prepare the vehicle for use by the nursing facility.

F. When a vehicle is acquired by trading in an existing 2. Interest. Interest cost on vehicle debt related to allowable vehicles shall be reported on line 139 of CR (7-93) and line 134 of CR (3-95).

3. Insurance. Insurance cost related to allowable vehicles shall be reported on line 140 of CR (7-93) and line 135 of CR (3- 95).

4. Rental and leases. Lease cost related to allowable vehicles shall be reported on line 139 of CR (7-93) and on line 135 of CR (3-95).

5. Personal property taxes. Personal property taxes related to allowable vehicles shall be reported on line 112 of CR (7-93) and on line 109 of CR (3–95).

6. Other miscellaneous maintenance and repairs. Other miscellaneous maintenance and repairs related to allowable vehicles shall be reported on line 139 of CR (7-93) and on line 135 of CR (3-95).

(E) Insurance.

1. Property insurance. Insurance cost on property of the nursing facility used to provide nursing facility services.

Property insurance should be reported on line 109 of the cost report version MSIR-1 (7-93) and line 107 of CR (3-95).

2. Other insurance. Liability, umbrella, and other general insurance for the nursing facility should be reported on line 140 of the cost report version MSIR-1 (7–93) and line 136 of CR (3–95).

3. Workers’ compensation insurance. Insurance cost for workers’ compensation should be reported on the applicable workers’ compensation lines on the cost report corresponding to the employee salary groupings.

(F) Interest and Borrowing Costs on Capital Asset Debt.

Allowable interest and borrowing costs, as set forth below, are reimbursed as part of the capital cost component per diem detailed in subsection (11)(D).

1. Interest will be reimbursed for necessary loans for outstanding capital asset debt from the rate setting cost report at the prime rate plus two (2) percentage points, as set forth in paragraph (11)(D)3.

2. Loans (including finance charges, prepaid costs, agreement that funds were borrowed and repayment of the funds are required. The loan costs must be identifiable in the provider’s accounting records, must be related to the reporting period in which the costs are claimed, and must be necessary for the acquisition and/or renovation of the provider’s facility.

3. Necessary means that the loan be incurred to satisfy a financial need of the provider and for a purpose related to participant care. Loans which result in excess funds or investments are not considered necessary.

4. A provider shall capitalize borrowing costs and amortize them over the life of the loan on a straight-line basis. Borrowing costs include loan costs (that is, lender’s title and recording fees, appraisal fees, legal fees, escrow fees, and other closing costs), finance charges, prepaid interest, and discounts. Finder’s fees are not allowed.

5. If loans for capital asset debt exceed the facility asset value, the interest and borrowing costs associated with the portion of the loan or loans which exceeds the facility asset value shall not be allowable.

6. An illustration of how allowable interest and allowable borrowing costs is calculated is detailed in paragraphs (11)(D)3. and 4.

(G) Rental and Leases.

1. Capitalized leases, as defined by GAAP, are to be reported on the books of the facility as if the facility owns the property (i.e., the building, equipment, and related expenses are recorded on the books of the facility) in accordance with subsections (7)

(C), (E), (F) and (H). A facility operating its building under a capital lease shall have its capital cost component calculated using the fair rental value system.

2. Operating leases, as defined by GAAP, shall be reported on line 103 of CR (3-95). A facility operating its building under an operating lease shall have its capital cost component calculated using the fair rental value system. A facility may record the property insurance, real estate taxes and personal property taxes directly on the applicable capital lines of the cost report (i.e., lines 107, 108, and 109 of CR (3-95), respectively), and include the costs of such in calculating the pass-through expenses portion of the capital rate if it meets the following criteria:

A. If the cost of the property insurance, real estate taxes, and personal property taxes are a distinct component of a facility’s operating lease for the building and the lease payment is directly affected or changed by the amount of these items; and B. The cost of the property insurance, real estate taxes, and personal property taxes included in the lease must be documented and supported by the property insurance premium notice and tax assessment notices relating to the (H) Real Estate and Personal Property Taxes. Taxes levied on or incurred by a facility used to provide nursing facility (I) Value of Services of Employees.

1. Except as provided for in this regulation, the value of services performed by employees in the facility shall be included as an allowable cost area to the extent actually compensated, either to the employee or to the supplying organization.

2. Services rendered by volunteers such as those affiliated 3. Services by priests, ministers, rabbis, and similar type (J) Employee Benefits.

3. Retirement plans.

A. Contributions to IRS qualified retirement plans shall B. Amounts funded to pension and qualified retirement plans, together with associated income, shall be recaptured, if not actually paid when due, as an offset to expenses on the cost 2. Deferred compensation plans.

A. Contributions shall be allowable costs when, and to B. Amounts paid by organizations to purchase tax- C. Amounts funded to deferred compensation plans 3. Types of insurance which are considered an allowable cost:

A. Credit life insurance (term insurance), if required as

part of a mortgage loan agreement. An example, would be insurance on loans granted under certain federal programs;

B. Where the relative(s) or estate of the employee, the employees salary groupings; and C. Health, disability, dental, etc., insurances for (K) Education and Training Expenses.

1. The cost of on-the-job training which directly benefits shall be allowable, except for costs associated with nurse aide training and competency evaluation program.

2. Costs of education and training shall include travel costs, but will not include leaves of absence or sabbaticals.

(L) Organizational Costs.

1. Organizational cost items include the following: legal fees incurred in establishing the corporation or other organizations; necessary accounting fees; expenses of temporary directors and organizational meetings of directors and stockholders; and 2. Organizational costs shall be amortized ratably over 3. Where a provider is organized within a five- (5-) year period prior to its entry into the program and has properly organizational costs is an allowable cost under the program and shall be amortized over the remaining part of the sixty- (60-) month period.

2. For change in ownership after July 18, 1984, allowable (M) Advertising Costs. Advertising costs which are reasonable and accepted occurrence for providing nursing facility services.

(N) Cost of Supplies and Services Involving Related Parties.

(O) Minimum Utilization. In the event the occupancy rate of a facility is below eighty-five percent (85%), the administration and capital cost components will be adjusted as though the provider experienced eighty-five percent (85%) occupancy.

The adjustment for minimum utilization is reflected in the calculation of the per diem for the administration and capital cost components. If the provider’s occupancy is less than eighty-five percent (85%), the total allowable costs are divided by the minimum utilization days rather than the facility’s actual patient days. Minimum utilization days are calculated by multiplying the facility’s bed days by the minimum utilization percent. Bed days are calculated by multiplying the number of beds licensed during the cost report period times the days in the cost report period. If the facility is removing the noncertified area revenues and expenses by completing a worksheet 1, bed days are calculated by multiplying the number of beds certified during the cost report period times the days in the cost report period. In no case may costs disallowed under this provision be carried forward to succeeding periods.

(P) Central Office/Home Office or Management Company Costs. The allowability of the individual cost items contained within central office/home office or management company costs will be determined in accordance with all other provisions of this regulation. The total of central office/home office and/or management company costs, as reported on lines 129 and 130 of the cost report, version MSIR (7-93) and lines 121 and 122 of CR (3-95), are limited to seven percent (7%) of gross revenues less contractual allowances.

(Q) Start-Up Costs. Expenses incurred prior to opening, as straight-line method over sixty (60) months. The amortization and would be reported on line 49, RN of CR (7-93) and line 51 of CR (3-95).

(R) Reusable Items. Costs incurred for items, such as linen and bedding, but not limited to, shall be classified as inventory when purchased and expensed as the item is used.

(S) Nursing Facility Reimbursement Allowance (NFRA).

Effective October 1, 1996, the fee assessed to nursing facilities in the state of Missouri for the privilege of doing business in the state will be an allowable cost.

(8) Non-allowable Costs. Costs not reasonably related to nursing facility services shall not be included in a provider’s costs. Nonallowable costs include, but are not limited to, the following:

(A) Amortization on intangible assets, such as goodwill, leasehold rights, covenants, and purchased certificates of need;

(B) Bad debts, contractual allowances, courtesy discounts, (C) Capital cost increases due solely to changes in ownership;

(D) Charitable contributions;

(E) Compensation paid to a relative or an owner through a (F) Costs such as legal fees, accounting and administrative are attributable to the negotiation or settlement of the sale or purchase of any capital asset by acquisition or merger for which any payment has been previously made under the program;

(G) Directors’ fees included on the cost report in excess of two (H) Federal, state, or local income and excess profit taxes, (I) Late charges and penalties;

(J) Finder’s fees;

(K) Fund-raising expenses;

(L) Interest expense on loans for intangible assets;

(M) Legal fees related to litigation involving the department and attorney’s fees which are not related to the provision of (N) Life insurance premiums for officers and owners and (O) Noncovered supplies, services, and items as defined in (P) Owner’s compensation in excess of the applicable range of the most recent survey of administrative salaries paid to individuals other than owners for proprietary and nonproprietary providers as published in the updated Medicare Provider Reimbursement Manual Part 1, Section 905.2 and based upon the total number of working hours.

1. The applicable range will be determined as follows:

A. Number of licensed beds owned or managed; and B. Owners acting as administrators will be adjusted on the basis of the high range. Owners included in home office costs or management company costs will be adjusted on the high range. All others will be calculated on the median range.

2. The salary identified above will be apportioned on (Q) Prescription drugs;

(R) Religious items or supplies or services of a primarily (S) Research costs;

(T) Resident personal purchases provided nonroutinely to (U) Salaries, wages, or fees paid to nonworking officers, employees, or consultants;

(V) Cost of stockholder meetings or stock proxy expenses;

(W) Taxes or assessments for which exemptions are available;

(X) Value of services (imputed or actual) rendered by nonpaid (Y) All costs associated with nurse aide training and competency evaluation program; and (Z) Losses from disposal of assets.

(9) Revenue Offsets.

(A) Other revenues must be identified separately in the revenues include, but are not limited to, the following:

1. Income from telephone services;

2. Sale of employee and guest meals;

3. Sale of medical abstracts;

4. Sale of scrap and waste food or materials;

5. Cash, trade, quantity, time, and other discounts;

6. Purchase rebates and refunds;

7. Recovery on insured loss;

8. Parking lot revenues;

9. Vending machine commissions or profits;

10. Sales from supplies to individuals other than nursing facility participants;

11. Room reservation charges other than covered therapeutic home leave days and hospital leave days;

12. Barber and beauty shop revenue;

13. Private room differential;

14. Medicare Part B revenues.

A. Revenues received from Part B charges through Medicare intermediaries will be offset.

B. Seventy-five percent (75%) of the revenues received from Part B charges through Medicare carriers will be offset;

15. Personal services;

16. Activity income; and 17. Revenue recorded for donated services and commodities.

(B) Restricted funds designated by the donor prior to the (C) Restricted funds designated by the donor for capital (D) Unrestricted funds not designated by the provider for (E) As applicable, restricted, and unrestricted funds will be (F) Any tax levies which are collected by nursing home districts or county homes that are supported in whole or in part by these levies, will not be offset.

(G) Gains on disposal of assets will not be offset from allowable expenses.

(10) Provider Reporting and Record Keeping Requirements.

(A) Annual Cost Report. The cost report (version MSIR-1 (3- 95)) and cost report instructions (revised 3-95) 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, March 1, 2021. This

rule does not incorporate any subsequent amendments or 1. Each provider shall adopt the same twelve- (12-) month 2. Each provider is required to complete and submit to the division or its authorized contractor an annual cost report, including all worksheets, attachments, schedules, and requests for additional information from the division or its authorized contractor. The cost report shall be submitted on forms provided by the division or its authorized contractor for that purpose. Any substitute or computer generated cost report must have prior approval by the division or its authorized contractor.

3. All cost reports shall be completed in accordance 4. The cost report submitted must be based on the accrual 5. Cost reports shall be submitted by the first day of the sixth month following the close of the fiscal period. A provider may request, in writing, a reasonable extension of the cost report filing date for circumstances that are beyond the control of the provider and that are not a product or result of the negligence or malfeasance of the nursing facility. Such circumstances may include public health emergencies; unavoidable acts of nature such as flooding, tornado, earthquake, lightning, hurricane, natural wildfire, or other natural disaster; or, vandalism and/ or civil disorder. The division may, at its discretion, grant the extension.

4. If a cost report is more than ten (10) days past due, withheld will be released to the provider. For cost reports which are more than ninety (90) days past due, the department agreement and if terminated retain all payments which have 7. Copies of signed agreements and other significant documents related to the provider’s operation and provision of care to MO HealthNet participants must be attached (unless otherwise noted) to the cost report at the time of filing unless current and accurate copies have already been filed with the division or its authorized contractor. Material which must be submitted or available upon request includes, but is not limited to, the following:

A. Audit prepared by an independent accountant, including disclosure statements and management letter or SEC Form 10-K;

B. Contracts or agreements involving the purchase requested by the division, the department, or its authorized C. Contracts or agreements with owners or related D. Contracts with consultants;

E. Documentation of expenditures, by line item, made F. Federal and state income tax returns for the fiscal year, if requested by the division, the department, or its authorized G. Leases and/or rental agreements related to the activities of the provider if requested by the division, the department, or its authorized contractor;

H. Management contracts;

I. Medicare cost report, if applicable;

J. Review and compilation statement;

K. Statement verifying the restrictions as specified by L. Working trial balance actually used to prepare the M. Schedule of capital assets with corresponding debt.

8. Cost reports must be fully, clearly, and accurately information, documentation, or clarification requested by the division or its authorized contractor is not provided within 9. Under no circumstances will the division accept amended cost reports for rate determination or rate adjustment after the date of the division’s notification of the final determination of the rate.

9. Exceptions. A cost report is not required for the A. Hospital based providers which provide less than one thousand (1,000) patient days of nursing facility services for Missouri Title XIX participants, relative to their fiscal year.

B. Change in provider status. The cost report filing requirement for the cost report relating to the terminating provider from a change of control, ownership, or termination of participation in the MO HealthNet program is not required, unless the terminating cost report is a full twelve- (12-) month cost report. If a rebase is done for a year in which there is no cost report, the cost report for the year prior to the change of control, ownership, or termination shall be used in the rebase calculation. A trend from the prior year cost report to the rebase year may be applied, if applicable.

11. Notification of change in provider status and withholding of funds for a change in provider status. A provider shall provide written notification to the assistant deputy director of the Institutional Reimbursement Unit of the division prior to a change of control, ownership, or termination of participation in the MO HealthNet program. The division may withhold funds due to a change in provider status as A. If the division receives notification prior to the in the MO HealthNet program, the division will withhold a minimum of thirty thousand dollars ($30,000) of the remaining payments from the old/terminating provider. After six (6) months, any payments withheld will be released to the old/ terminating provider, less any amounts owed to the division such as unpaid NFRA, overpayments, etc.; or B. If the division does not receive notification prior to a change of control or ownership, the division will withhold thirty thousand dollars ($30,000) of the next available MO HealthNet payment from the provider identified in the current MO HealthNet participation agreement. If the MO HealthNet payment is less than thirty thousand dollars ($30,000), the entire payment will be withheld. After six (6) months, any payments withheld will be released to the provider identified in the current MO HealthNet participation agreement, less any amounts owed to the division such as unpaid NFRA, overpayments, etc.

(B) Certification of Cost Reports.

1. The accuracy and validity of the cost report must be 2. Cost reports must be notarized by a commissioned notary public.

2. The following statement must be signed on each cost report to certify its accuracy and validity: Certification Statement: Misrepresentation or falsification of any information contained in this cost report may be punishable by fine and/or imprisonment under state or federal law. schedules prepared by (provider name and number) for the cost report period beginning (date/year) and ending (date/ year), and that to the best of my knowledge and belief, it is a and records of the provider in accordance with applicable (Signature) _______________________________ __________________________ (Title) (Date)

(C) Adequate Records and Documentation.

1. A provider must keep records in accordance with GAAP authorized contractor for additional information.

2. Each of a provider’s funded accounts must be separately 3. Adequate documentation for all line items on the cost for review by the division or its authorized contractor at the same site at which the services were provided or at the central or its authorized contractor upon request.

3. Each facility shall retain all financial information, data, (D) Audits.

4. Any cost report submitted may be subject to a Level III Audit (also known as a field audit) by the division or its authorized contractor.

5. A provider shall have available at the field audit location 3. If a provider maintains any records or documentation at contractor for reasonable travel costs necessary to perform any 4. Those providers initially entering the program shall be required to have an annual independent audit of the financial records, used to prepare annual cost reports covering, at a minimum, the first two (2) full twelve- (12-) month fiscal years of their participation in the Medicaid Program, in accordance with GAAP and generally accepted auditing standards. The audit shall include, but may not be limited to, the Balance Sheet, Income Statement, Statement of Retained Earnings, and Statement of Cash Flow. For example, a provider begins participation in the Medicaid program in March and chooses a fiscal year of October 1 to September 30. The first cost report will cover March through September. That cost report may be audited at the option of the provider. The October 1 to September 30 cost report, the first full twelve- (12-) month September 30 cost report, the second full twelve- (12-) month independent certified public accountant. The independent audits of the first two (2) full twelve- (12-) month fiscal years may be performed at the same time. The provider may submit two (2) independent audit reports (i.e., one for each year) or they may submit one (1) combined independent audit report covering both years. The independent audit report(s) for combined audits are due with the filing of the second full twelve- (12-) month cost report. If the independent audits are combined, the provider must notify the division of such by the due date of the first full twelve- (12-) month cost report.

(E) Joint Use of Resources.

1. If a provider has business enterprises in addition to the nursing facility, the revenues, expenses, statistical, and 2. When the facility is owned, controlled or managed by an entity(ies) that own, control, or manage one (1) or more other facilities, records of central office and other costs incurred outside the facility shall be maintained so as to separately identify revenues and expenses of, and allocations to, individual facilities. Direct allocation of cost, such as RN consultant, which can be directly identifiable in the central office/home office cost and directly allocated to a facility by actual amounts or actual time spent. These direct costs shall be reported on the appropriate lines of the cost report. Allocation of central office/ home office or management company costs to individual facilities should be consistent from year-to-year. If a desk audit or field audit establishes that records are not maintained so as to clearly identify information required by this regulation, those commingled costs shall not be recognized as allowable costs in determining the facility’s Medicaid reimbursement rate.

Allowability of these costs shall be determined in accordance with the provisions of this regulation.

(11) Cost Components and Per Diem Calculation. The division will use the rate setting cost report to determine the nursing facility’s per diem rate for each cost component, as set forth in this section, and its prospective rate, as continued and set forth in the remaining sections of the regulation.

(A) Patient Care. Each nursing facility’s patient care per diem shall be the lower of the— 1. Allowable cost per patient day for patient care as including applicable trends; or 2. Per diem ceiling of one hundred twenty percent (120%) of the patient care median determined by the division from the (B) Ancillary. Each nursing facility’s ancillary per diem will be the lower of the— 1. Allowable cost per patient day for ancillary as determined by the division from the rate setting cost report, including applicable trends; or 2. Per diem ceiling of one hundred twenty percent (120%) of the ancillary median determined by the division from the (C) Administration. Each nursing facility’s administration per diem shall be the lower of the— 1. Allowable cost per patient day for administration as including applicable trends, and adjusted for minimum utilization, if applicable, as described in subsection (7)(O); or 2. Per diem ceiling of one hundred ten percent (110%) of the administration median determined by the division from the data bank. The administration median shall be based on the administration per diems that have been adjusted for minimum utilization, if applicable, as described in subsection (7)(O).

(D) Capital. Each nursing facility’s capital per diem shall be determined using the fair rental value system (FRV), which consists of five (5) elements—rental value, return, computed interest, borrowing costs, and pass-through expenses. The calculation for each element, as well as the overall capital per diem, is detailed below in paragraphs (11)(D)1.–6.

1. Rental value.

A. Determine the total asset value.

(I) Determine facility size from the rate setting cost (II) Determine the number of increased licensed beds after the end of the facility’s 1992 desk audited and/or field audited cost report but prior to July 1, 1994 (this is only applicable for the 1992 initial rate base year for rates effective January 1, 1995).

(III) Determine the bed equivalency for renovations/ major improvements from the date facility was originally licensed through June 30, 1994 for the 1992 initial rate base year for rates effective January 1, 1995 or through the end of the rate setting period for prospective rates effective after January 1, 1995, by taking the cost of the renovations/major improvements divided by the asset value per bed for the year of the renovation/major improvement rounded to the nearest whole bed. The cost of the renovation/major improvement must be at least the asset value per bed for the year of the renovation/ major improvement for each bed equivalency. For example, a renovations/major improvements done in 1994 with a cost of two hundred twenty thousand dollars ($220,000) is equal to six (6) beds. ($220,000/$32,330 equals 6.80 beds rounded down to 6 beds).

(IV) Determine the number of decreased licensed beds after the end of the facility’s 1992 cost report but prior to July 1, 1994 (this is only applicable for the 1992 initial rate base year for rates effective January 1, 1995).

(V) The Total Facility Size is the sum of (I), (II), and (III) less (IV).

(VI) The Total Asset Value is the total facility size times the asset value.

B. Determine the reduction for age. The age of the beds is determined by subtracting the year the beds were originally licensed from the year relative to the end of the rate setting period. The reduction for age is determined by multiplying the age of the beds by one percent (1%) up to a maximum of forty percent (40%). For multiple licensing dates, the result of the weighted average age calculation will be limited to forty percent (40%).

(I) The age of the beds for multiple licensing dates is calculated on a weighted average method rounded to the nearest whole year. For example, using 1994 as the rate base year for a facility with original licensure in 1977 of sixty (60) beds and an additional licensure of sixty (60) beds in 1982 and ten (10) beds in 1990, the reduction is calculated as follows: 1990 4 10 40 Total 130 1780 Weighted Average Age—1780/130 beds = 13.69 years rounded to 14 years. This results in a reduction for age of the beds of 14%.

(II) The age of the beds for replacement beds is calculated on a weighted average method rounded to the nearest whole year with the oldest beds always being replaced first. For example, a facility with one hundred twenty (120) beds licensed in 1978 with replacement of sixty (60) beds in 1988, the reduction is calculated as follows: 1978 16 60 960 1988 6 60 360 Total 120 1320 Weighted Average Age—1320/120 = 11.00 years. This results in a reduction for age of the beds of 11%.

(III) The age of the beds for reductions in licensed beds is calculated on a weighted average method rounded to the nearest whole year with the oldest beds always being delicensed first. For example, a facility with original licensure in 1977 of sixty (60) beds, additional licensure of sixty (60) beds in 1982 and ten (10) beds in 1990 and a reduction of ten (10) beds in 1985, the reduction percentage is calculated as follows: 1990 4 10 40 1985* 17 (10) (170)

Total 120 1610 * reduction of 1977 beds Weighted Average Age—1610/120 beds = 13.41 years rounded to thirteen (13) years. This results in a reduction for age of the beds of 13%.

(IV) The age of the bed equivalents for renovations/ major improvements is calculated on a weighted average method rounded to the nearest whole year. For example, a one hundred twenty (120) bed facility licensed in 1978 undertakes two (2) renovations: $200,000 in 1983 and $100,000 in 1993. The asset value per bed is $25,250 for 1983 and $32,039 for 1993. The bed equivalency is seven (7) beds for 1983 and three (3) beds for 1993, the reduction percentage is calculated as follows:

Licensure/ Construction Age × 1978 16 120 1920 1983 11 7 77 1993 1 3 3 Total 130 2000 Weighted Average Method—2000/130 = 15.38 years rounded to 15 years. This results in a reduction for age of beds of 15%.

C. Determine the facility asset value. The facility asset value is the total asset value set forth in subparagraph (11)(D)1.A. less the reduction for age set forth in subparagraph (11)(D)1.B.

D. Determine the rental value. Multiply the facility asset value by two and one-half percent (2.5%) to determine the rental value. The two and one-half percent (2.5%) is based on a forty- (40-) year life.

E. The following is an illustration of how subparagraphs (11)(D)1.A., B., C. and D. determine the rental value:

(I) Assumptions: 1992 Rate Setting Cost Report Licensed beds 170 Bed equivalents 4 Total facility size 174 beds Weighted average age of the beds 23 years Asset value $32,330 (II) The total asset value is the product of the total facility size times the asset value;

Total facility size 174 Asset value × $32,330 Total asset value $5,625,420 (III) Facility asset value is total asset value less the reduction for age of the beds; and Total asset value $5,625,420 × Age of beds × 23% -Reduction for age (23%) $1,293,847 (IV) Rental value is the facility asset value multiplied by 2.5%. × 2.5% Rental value $108,289 2. Return.

A. Reduce the facility asset value by the necessary outstanding capital asset debt from the rate setting cost report, but not less than zero (0), times the rate of return. The rate of return is the yield for the thirty- (30-) year Treasury Bond as reported by the Federal Reserve Board plus two percent (2%), (I) For the initial 1992 rate base year for rates effective for dates of service from January 1, 1995 through June 30, 2004, the rate of return shall be set using the yield for the thirty- (30-) year Treasury Bond reported by the Federal Reserve Board and published in the Wall Street Journal for the week ending September 2, 1994, plus two percent (2%). The yield for the week ending September 2, 1994 is 7.48% plus 2% equals a total rate of return of 9.48%.

(II) For rates effective for dates of services beginning July 1, 2004, the rate of return is detailed in sections (20) and (21).

B. The debt associated with increases in licensed beds or renovations/major improvements after the end of the facility’s 1992 desk audited and/or field audited cost report and prior to July 1, 1994, will be added to the capital asset debt from the 1992 desk audited and/or field audited cost report (this is only applicable for the 1992 initial rate base year for rates effective January 1, 1995). The facility shall provide adequate documentation to support the additional debt as required in paragraph (7)(F)2. If adequate documentation is not provided to support the additional asset debt, it will be assumed to equal the facility asset value.

C. The following is an illustration of how subparagraph (11)(D)2.A. is calculated:

Capital asset debt $2,371,094 $1,960,479 Rate of return × 9.48% Return $ 185,853 3. Computed interest.

A. Computed interest will be calculated by multiplying the lessor of the necessary outstanding capital asset debt from the rate setting cost report or the facility asset value as determined in subparagraph (11)(D)1.C. by the interest rate. The interest rate is the prime rate plus two percent (2%), as follows:

(I) For the initial 1992 rate base year for rates effective for dates of service from January 1, 1995 through June 30, 2004, the interest rate shall be set using the Chase Manhattan prime rate in effect on the first business day of September as published in the Wall Street Journal, plus two percent (2%). The prime rate effective September 1, 1994 is 7.75% plus 2% equals a total interest rate of 9.75%. For replacement beds, additional beds, and new facilities placed in service after August 31, 1995, the prime rate will be updated annually on the first business day of each September based on the Chase Manhattan prime rate plus two (2) percentage points;

(II) For rates effective for dates of services beginning July 1, 2004, the interest rate is detailed in sections (20) and (21).

B. The following is an illustration of how computed interest is calculated:

Example A: Example B:

Facility Asset Facility Asset Value < Debt Value > Debt Assumptions:

Facility asset value $2,000,000 $4,331,573 asset debt $2,500,000 $2,371,094 Term of debt 25 years 25 years Prime rate— September 2, 1994 7.75% 7.75% Computed interest calculation:

Facility asset value (Ex. A) $2,000,000 asset debt (Ex. B) $2,371,094 Interest rate (prime rate + 2%) × 9.75% × 9.75% Computed interest $ 195,000 $ 231,182 4. Borrowing costs.

A. A provider shall capitalize allowable borrowing costs and amortize them over the life of the loan on a straight-line B. If loans for capital asset debt exceed the facility asset value, the borrowing costs associated with the portion of the loan or loans which exceeds the facility asset value shall not be allowable.

C. The following is an illustration of how allowable borrowing costs are calculated, using the data from the interest calculation example detailed above in (11)(D)3.B.:

Assumptions:

Loan costs = $120,000 Discount costs = $125,000 Total borrowing costs = $245,000 Example A Example B Facility asset value $2,000,000 $4,331,573 asset debt / 2,500,000 / 2,371,094 Percent of borrowing costs allowed 80% 100% Borrowing costs ×$245,000 ×$245,000 Allowable portion to be amortized $196,000 $245,000 Term of debt / 25 years / 25 years Allowable borrowing costs $7,840 $9,800 5. Pass-through expenses.

A. Add the following pass-through expenses, including applicable trends:

(I) Property insurance – line 109 of CR (7-93) and line 107 of CR (3-95);

(II) Real estate taxes – line 111 of CR (7-93) and line 108 of CR (3-95);

(III) Personal property taxes – line 112 of CR (7-93) and line 109 of CR (3-95);

6. Capital component per diem calculation. A per diem is calculated for each element detailed above in paragraph (11)

(D)1.–5. which are then added together to determine the total capital cost component per diem.

A. Rental value, return and computed interest per diems. A per diem is calculated by dividing the rental value, the return and the computed interest by the computed patient days, rounded to the nearest cent. Computed patient days are equal to the total facility size (i.e., number of licensed beds plus equivalencies) determined in part (11)(D)1.A.(V) times three hundred sixty-five (365) adjusted by the greater of the minimum utilization as determined in subsection (7)(O) or the facility’s occupancy from the rate setting cost report. The following is an illustration of how this subparagraph (11)(D)6.A. is calculated:

Allowable Computed Per Cost Patient Days* Diem Rental value $108,289 56,079 $1.93 Return $185,853 56,079 $3.31 Computed interest (from Ex. B) $231,182 56,079 $4.12 * Computed patient days:

Total facility size 174 × 365 days × 365 Subtotal 63,510 Greater of minimum utilization or facility occupancy × 88.30% ** Computed patient days 56,079 ** Assumption: facility occupancy from the rate setting cost report = 88.30% B. Borrowing costs/pass-through expenses per diems.

A per diem is calculated by dividing the borrowing costs and the pass-through expenses by the greater of the minimum utilization days as determined in subsection (7)(O) or the facility’s patient days from the rate setting cost report, rounded to the nearest cent. The following is an illustration of how subparagraph (11)(D)6.B. is calculated:

Allowable Patient Per Cost Days* Diem Borrowing costs (from Ex.B) $9,800 54,940 $0.18 Pass-through expenses $48,142 54,940 $0.88 *Patient days—the greater of:

a. minimum utilization days = 170 × 366 × 85% = 52,887 (Note: 1992 is a leap year; therefore, 366 days are used); or b. facility patient days = 54,940 (Assumption—this is the number of actual patient days reported on rate setting cost report)

C. The capital cost component per diem is the sum of the per diems determined in subparagraphs (11)(D)6.A. and (11)

(D)6.B.

Rental value $ 1.93 Return $ 3. 31 Computed interest $ 4.12 Borrowing costs $ 0.18 Pass-through expenses $ 0.88 Total capital cost component per diem $10.42 (E) Working Capital Allowance. Each nursing facility’s working capital per diem shall be equal to one and one-tenth (1.1) months of the sum of each facility’s per diem for patient care, ancillary, and administration times the interest rate set forth in (11)(D)3., rounded to the nearest cent. The following is an illustration of how this subsection (11)(E) is calculated:

Patient care $38.00 Ancillary $ 6.00 Administration $11.00 Total per diem $55.00 Divided by 12 months 12 $ 4.58 Times 1.1 months 1.1 $ 5.04 Times Interest Rate (Prime + 2%) 9.75% Working capital allowance per day $ 0.49 (F) The following is an illustration of how subsections (11)(A)– (E) determine the total per diem rate for the cost components:

Allowable Cost Ceiling Per Diem Patient Care $38.00 $40.00 $38.00 Ancillary $ 8.00 $ 6.00 $ 6.00 Administration $12.00 $11.00 $11.00 Capital (FRV) $10.42 Working capital allowance $ 0.49 Total per diem $65.91 (12) Reimbursement Rate Determination. A facility’s reimbursement rate shall be determined by the division as described in this regulation. Any facility with an interim rate on December 31, 1994, shall be granted an interim rate effective for services on and after January 1, 1995, as prescribed in subsection (4)(HH), if applicable. A prospective rate determined from this regulation shall be retroactively effective for services beginning on the first day of the facility’s second twelve- (12-) month fiscal year but not earlier than January 1, 1995, and shall replace the interim on and after January 1, 1995.

(A) A facility with a valid Medicaid participation agreement in effect on December 31, 1994, and with a 1992 cost report on file with the division as of December 31, 1993, with a rate setting period ending in calendar year 1992 or prior shall be granted a prospective rate effective for service dates on and after January 1, 1995. For services before January 1, 1995, a prospective rate shall be determined on the basis of the allowable cost per patient day as determined by the division from the desk audited and/or field audited facility fiscal year cost report under regulations applicable on July 1, 1990. The prospective rate shall be the greater of the following:

1. The per diem rate as determined in section (11); or 2. The prospective rate in effect for services rendered on (B) A facility with a valid Medicaid participation agreement rate setting period ending in calendar year 1993 shall have their prospective rate for services after December 31, 1994, based on the 1993 rate setting cost report. For services before January 1, 1995, a prospective rate shall be determined on the basis of the allowable cost per patient day as determined by the division from the desk audited and/or field audited facility fiscal year cost report under regulations applicable on July 1, 1990. For services on or after January 1, 1995, a prospective rate will be the greater of the following:

2. The per diem rate as calculated in accordance with

section (11), except the 1993 desk audited and/or field audited cost report will be used. The HCFA Market Basket Index for 1993, 1994, and nine (9) months of 1995 of 10.6% will be replaced with the 1994 and 1995 HCFA Market Basket Index of 3.4% and 3.3% respectively for a total of 6.7%; or 2. The prospective rate in effect for services rendered on (C) A facility with a valid Medicaid participation agreement in effect on December 31, 1994, which has a cost report with a rate setting period ending in calendar year 1994 shall have their prospective rate for services after December 31, 1994, based on the 1994 rate setting cost report. For services before January 1, 1995, a prospective rate shall be determined on the

basis of the allowable cost per patient day as determined by the division from the desk audited and/or field audited facility fiscal year cost report under regulations applicable on July 1, 1990. For services on or after January 1, 1995, a prospective rate will be the greater of the following:

1. The per diem rate as calculated in accordance with

section (11), except the 1994 desk audited and/or field audited cost report will be used. The HCFA Market Basket Index for 1993, 1994, and nine (9) months of 1995 of 10.6% will be replaced with the 1995 HCFA Market Basket Index of 3.3%; or 2. The prospective rate in effect for services rendered on (D) A facility with a valid Medicaid participation agreement rate setting period ending after December 31, 1994, but before December 1, 1995, shall have their prospective rate for services after December 31, 1994, based on the rate setting cost report ending after December 31, 1994 but before December 1, 1995.

For services before January 1, 1995, a prospective rate shall be determined on the basis of the allowable cost per patient day as determined by the division from the desk audited and/or field audited facility fiscal year cost report under regulations applicable on July 1, 1990. For services on or after January 1, 1995, a prospective rate will be the greater of the following:

1. The per diem rate as calculated in accordance with

section (11), except the fiscal year ending after December 31, 1994 but prior to December 1, 1995, desk audited and/or field audited cost report will be used. The HCFA Market Basket Index for 1993, 1994, and nine (9) months of 1995 will not be applied;

2. The prospective rate in effect for services rendered on December 31, 1994.

(E) A facility with a valid Medicaid participation agreement rate setting period ending after November 30, 1995, shall have their prospective rate based on a rate setting cost report ending after November 30, 1995. A prospective rate will be effective for services on or after the first day of the rate setting period as determined in section (11), except the desk audited and/or field audited cost report ending after November 30, 1995, will be used. The 1993, 1994, and nine (9) months of 1995 HCFA Market Basket Index will not be applied.

(F) A facility entering the MO HealthNet program after December 31, 1994, shall receive an interim rate as defined in subsection (4)(HH) to be effective on the initial date of MO HealthNet certification. A prospective rate shall be determined in accordance with this regulation from the desk audited and/ or field audited facility fiscal year cost report which covers the second full twelve- (12-) month fiscal year following the facility’s initial date of MO HealthNet certification. The HCFA Market Basket Index for 1993, 1994, and nine (9) months of 1995 will not be applied. This prospective rate shall be retroactively effective and shall replace the interim rate for services beginning on the first day of the facility’s second full twelve- (12-) month fiscal year.

(G) A facility with a valid Medicaid participation agreement in effect after December 31, 1994, which either voluntarily or Program and which reenters the Medicaid Program, shall have its prospective rate established as the rate in effect on the day prior to the date of termination from participation in the program plus rate adjustments which may have been granted with effective dates subsequent to the termination date but prior to reentry into the program as described in subsection (13)

(A). This prospective rate shall be effective for service dates on and after the effective date of the reentry following a voluntary or involuntary termination.

(13) Adjustments to the Reimbursement Rates. Subject to the

section, 13 CSR 70-10.016, and 13 CSR 70-10.017.

(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 as set forth in 13 CSR 70- 10.016. Global per diem rate adjustments shall be added to the specified cost component ceiling.

(B) Special Per Diem Rate Adjustments. Special per diem rate adjustments may be added to a qualifying facility’s rate 1. Patient care incentive. Each facility with a prospective rate on or after January 1, 1995, shall receive a per diem adjustment equal to ten percent (10%) of the facility’s allowable patient care per diem subject to a maximum of one hundred thirty percent (130%) of the patient care median when added to the patient care per diem as determined in subsection (11)

(A). This adjustment will not be subject to the cost component ceiling of one hundred twenty percent (120%) for the patient care median.

2. Ancillary incentive. Each facility with a prospective rate on or after January 1, 1995, and which meets one (1) of the A. If the facility’s allowable ancillary per diem as determined in subsection (11)(B) is below ninety percent (90%) of the ancillary median, the adjustment is equal to one-half (1/2) of the difference between one hundred twenty percent (120%) and ninety percent (90%) of the ancillary median. The following is an illustration of how the ancillary per diem adjustment is calculated: 120% of median $6.62 90% of median $4.97 Difference $1.65 1/2 the difference 2 Per diem adjustment $ .83 B. If the facility’s allowable ancillary per diem as determined in subsection (11)(B) is between ninety percent (90%) and one hundred twenty percent (120%) of the median, the adjustment is equal to one-half (1/2) of the difference between one hundred twenty percent (120%) of the median and the facility’s allowable ancillary per diem. The following is an illustration of how the ancillary per diem adjustment is calculated: 90% of median $4.97 120% of median $6.62 Ancillary per diem $5.21 Difference $1.41 1/2 the difference 2 Per diem adjustment $ .71 3. Multiple component incentive. Each facility with a prospective rate on or after January 1, 1995, and which meets the following criteria shall receive a per diem adjustment:

A. If the sum of the facility’s patient care per diem and ancillary per diem, as determined in subsections (11)(A) and (B), is greater than or equal to sixty percent (60%) but less than or equal to eighty percent (80%), rounded to four (4) decimal places (.5985 or .8015 would not receive the adjustment), of the facility’s total per diem, the adjustment is as follows:

Percent of Total Per Diem Rate Incentive < 60% $0.00 > or = 60% but < 65% $1.15 > or = 65% but < 70% $1.30 > or = 70% but < 75% $1.45 > or = 75% but < or 80% = $1.60 B. A facility shall receive an additional incentive if it receives the adjustment in subparagraph (13)(B)3.A. and the following calculation is greater than seventy-five percent (75%), rounded to four (4) decimal places (.7485 would not receive the adjustment): Medicaid days divided by the licensed nursing facility patient days from the facility’s desk audited and/or field audited 1992 cost report. The adjustment is as follows:

Calculated Percentage Incentive < 75% $0.00 > or = 75% but < 80% $0.15 > or = 80% but < 85% $0.30 > or = 85% but < 90% $0.45 > or = 90% but < 95% $0.60 > or = 95% $0.75 4. 1967 Life Safety Code (LSC). Currently certified nursing facilities that must comply with a recent interpretation of paragraph 10-133 of the 1967 LSC which requires corridor walls to extend to the roof deck or achieve equivalency under the Fire Safety Evaluation System (FSES) will be reimbursed the reasonable and necessary cost to meet those standards required for compliance through their reimbursement rate.

The reimbursement shall not be effective until the Department of Health and Senior Services has confirmed that the corrective action to comply with the 1967 LSC or FSES is operational and has reviewed the cost for compliance. Fire sprinkler systems shall be reimbursed over a depreciation life of twenty-five (25) years, and other alternative corrective action will be reimbursed over a depreciable life of fifteen (15) years. The division will use a desk audited and/or field audited cost report with the latest period ending in calendar year 1992 which is on file with the division as of December 31, 1993. This adjustment will be computed based on the documented cost submitted to the division as follows:

A. Depreciation. The cost incurred for the approved corrective action to continue in compliance divided by the depreciable useful life;

B. Interest. The interest cost incurred to finance this project shall be documented by a statement from the lending institution detailing the total interest cost of the loan period.

The total interest cost will be divided by the loan period on a straight-line basis; and C. The total of subparagraphs (13)(B)4.A. and B. will be divided by twelve (12) and then multiplied by the number of months covered by the 1992 cost report. This amount will be divided by the greater of actual patient days from the 1992 cost report or eighty-five percent (85%) of the licensed bed days from the 1992 cost report.

5. Any facility that had a 1967 LSC adjustment included in their December 31, 1994 reimbursement rate shall have that adjustment added to their January 1, 1995 reimbursement rate.

6. Replacement beds. A facility with a prospective rate in effect on or after January 1, 1995, may request a rate adjustment for replacement beds that resulted in the same number of beds being delicensed with the Department of Health and Senior Services. The facility shall provide documentation from the Department of Health and Senior Services that verifies the number of beds used for replacement have been delicensed from that facility. The rate adjustment will be calculated as the difference between the capital component per diem (fair rental value (FRV)) prior to the replacement beds being placed in service and the capital component per diem (FRV) including the replacement beds placed in service as calculated in subsection (11)(D) including the replacement beds placed in service. The capital component is calculated for the replacement beds using the asset value per licensed bed date the replacement beds are placed in service.

7. Additional beds. A facility with a prospective rate in effect on or after January 1, 1995, may request a rate adjustment for additional beds. The facility must obtain an approved certificate of need or applicable waiver for the additional beds. The rate adjustment will be calculated as the difference between the capital component per diem (FRV) prior to the additional beds being placed in service and the capital component per diem (FRV) including the additional beds as calculated in subsection (11)(D) including the additional beds placed in service. The capital component is calculated for the additional beds using the asset value per licensed bed date the additional beds are placed in service.

8. Extraordinary circumstances. A participating facility which has a prospective rate may request an adjustment to its prospective rate due to extraordinary circumstances.

This request must be submitted in writing to the division within one (1) year of the occurrence of the extraordinary circumstance. The request must clearly and specifically identify the conditions for which the rate adjustment is sought. The dollar amount of the requested rate adjustment must be Requests for rate adjustments that have been withdrawn by the facility or are considered withdrawn because of failure to supply requested information may be resubmitted once for the requested rate adjustment. In the case of a rate adjustment request that has been withdrawn and then resubmitted, the effective date shall be the first day of the month in which the resubmitted request was made providing that it was made prior to the tenth day of the month. If the resubmitted request is not filed by the tenth of the month, rate adjustments shall be A. When the provider can show that it incurred higher costs due to circumstances beyond its control, the industry in general, and the costs have a substantial cost effect;

B. Extraordinary circumstances, beyond the reasonable control of the nursing facility and is not a product or result of the negligence or malfeasance of the nursing facility, include:

(I) Unavoidable acts of nature are hurricane, flooding, earthquake, tornado, lightening, natural wildfire, or other natural disaster for which no one can be held responsible that are not covered by insurance and that occur in a federally declared disaster area; or (II) Vandalism and/or civil disorder that are not covered by insurance; and C. The rate increase shall be calculated as follows:

(I) The one- (1-) time costs (costs that will not be incurred in future fiscal years)— (a) To determine what portion of the incurred costs will be paid, the division will use the patient occupancy days from latest available quarterly occupancy survey from the Department of Health and Senior Services for the time period preceding when the extraordinary circumstances occurred;

(b) The costs directly associated with the extraordinary circumstances will be multiplied by the above percent. This amount will be divided by the paid days for the month the rate adjustment becomes effective per paragraph (13)(B)8. This calculation will equal the amount to be added to the prospective rate for only one (1) month, which will be the month the rate adjustment becomes effective. For this one (1) month only, the ceiling will be waived;

(II) For ongoing costs (costs that will be incurred in future fiscal years): Ongoing annual costs will be divided by the greater of: annualized (calculated for a twelve- (12-) month period) total patient days from the latest cost report on file or eighty-five percent (85%) of annualized total bed days. This calculation will equal the amount to be added to the respective cost center, not to exceed the cost component ceiling. The rate adjustment, subject to ceiling limits, will be added to the prospective rate; and (III) For capitalized costs, a capital component per diem (FRV) will be calculated as determined in subsection (11)

(D). The rate adjustment will be calculated as the difference between the capital component per diem (FRV) prior to the extraordinary circumstances and the capital component per diem (FRV) including the extraordinary circumstances.

9. Quality Assurance Incentive.

A. Each nursing facility with an interim or prospective rate on or after July 1, 2000, shall receive a per diem adjustment of three dollars and twenty cents ($3.20). The Quality Assurance Incentive adjustment will be added to the facility’s current rate.

B. The Quality Assurance Incentive per diem increase shall be used to increase the expenditures to a nursing facility’s direct patient care costs. Direct patient care costs include all expenses in the patient care cost component (i.e., lines 46 through 69 of Schedule B in the Title XIX Cost Report). Any increases in wages and benefits already codified in a collective bargaining agreement in effect as of July 1, 2000, will not be counted towards the expenditure requirements of the Quality Assurance Incentive as stated above. Nursing facilities with collective bargaining agreements shall provide such agreements to the division.

10. High volume adjustment. Effective for dates of service July 1, 2000, a high volume adjustment shall be granted to qualifying providers. A provider must qualify each July 1, the beginning of each state fiscal year (SFY), for the high volume adjustment and the adjustment will be effective for services rendered during the SFY, July 1 through June 30. For a provider who has a high volume adjustment on June 30, but does not qualify for the high volume adjustment on July 1 of the subsequent SFY, that provider’s prospective rate will be reduced by the amount of the high volume adjustment included in the facility’s prospective rate in effect June 30.

A. Each facility with a prospective rate on or after July 1, 2000, and which meets all of the following criteria shall receive a per diem adjustment:

(I) Have on file at the division a full twelve- (12-) month cost report ending in the third calender year prior to the state fiscal year in which the adjustment is being determined (i.e., for SFY 2001, the third prior year would be 1998, for SFY 2002, the third prior year would be 1999, etc.);

(II) The Medicaid patient days as determined from the cost report identified in part (13)(B)10.A.(I) exceeds eighty-five percent (85%) of the total patient days for all nursing facility licensed beds;

(III) The allowable cost per patient day as determined by the division from the applicable cost report for the patient care, ancillary, and administration cost components, as set forth in paragraphs (11)(A)1., (11)(B)1., and (11)(C)1., exceeds the per diem ceiling for each cost component in effect at the end of the cost report period; and (IV) State owned or operated facilities shall not be eligible for this adjustment.

B. The adjustment will be equal to ten percent (10%) of the sum of the per diem ceilings for the patient care, ancillary, and administration cost components in effect on July 1 of each year. Effective July 1, 2002, the adjustment shall not accumulate from year-to-year.

C. The division may reconstruct and redefine the qualifying criteria and payment methodology for the high volume adjustment.

D. Second tier high volume adjustment. Effective for dates of service July 1, 2002, a second tier high volume adjustment shall be granted to qualifying providers.

(I) If a nursing facility qualifies for the first tier high volume adjustment, as set forth above in subparagraph (13)

(B)10.A., it may qualify for the second tier adjustment if it meets the following criteria:

(a) The Medicaid patient days as determined from the cost report identified in part (13)(B)10.A.(I) exceeds ninetythree percent (93%) of the total patient days for all nursing facility licensed beds;

(b) The allowable cost per patient day as determined by the division from the applicable cost report for the patient care cost component, as set forth in paragraph (11)(A)1., exceeds one hundred twenty percent (120%) of the per diem ceiling for the patient care cost component in effect at the end of the cost report period; and (c) The allowable cost per patient day as determined by the division from the applicable cost report for the administration cost component, as set forth in paragraph (11)

(C)1., is less than one hundred fifty percent (150%) of the per diem ceiling for the administration cost component in effect at the end of the cost report period.

(II) The second tier high volume adjustment will be calculated as a percentage, to be determined by the Department of Social Services, of the sum of the per diem ceilings for the patient care, ancillary, and administration cost components in effect on July 1 of each year.

(a) The adjustment for State Fiscal Year 2003 shall be eighteen dollars and fifty-six cents ($18.56) per Medicaid day.

(b) The adjustment for SFY 2004 shall be nineteen dollars and seventy-one cents ($19.71) per Medicaid day.

(III) The adjustment shall be distributed based on a quarterly amount, in addition to per diem payments, based on Medicaid days determined from the paid day report from Missouri’s fiscal agent for pay cycles during the immediately preceding state fiscal year.

(IV) The state share of the second tier high volume adjustment shall come from certified public funds. If the aggregate certified public funds are less than the state match required, the total aggregate second tier high volume adjustment will be adjusted downward accordingly.

(V) A nursing facility must qualify for the adjustment each year to receive the additional quarterly payments.

E. High volume adjustment for nursing facilities without a full twelve- (12-) month cost report. Effective for dates of service on or after January 17, 2003, the full twelve- (12-) month cost report requirement set forth in (13)(B)10.A.(I) shall include nursing facilities that have on file at the division two (2) partial year cost reports that when combined cover a full twelve- (12-) month period.

F. Medicaid hospice days to be included in determination of Medicaid occupancy. Effective for dates of service on or after January 17, 2003, the Medicaid patient days used to determine the Medicaid occupancy requirement set forth in part (13)

(B)10.A.(II) shall be calculated by adding the days paid for by the Medicaid nursing facility program plus the days paid for by the Medicaid hospice program from the cost report identified in part (13)(B)10.A.(I).

G. State Fiscal Year (SFY) 2004 Ninety Percent (90%)

Medicaid High Volume Grant.

(I) Effective for SFY 2004, additional one (1) time funding shall be provided to nursing facilities that qualify for the first tier high volume adjustment, as set forth above in subparagraph (13)(B)10.A., and whose Medicaid patient days as determined from the cost report identified in part (13)(B)10.A.(I) exceeds ninety percent (90%) of the total patient days for all nursing facility licensed beds.

(II) The SFY 2004 High Volume Grant will be calculated as a per diem adjustment based upon the funding appropriated by the general assembly and the Medicaid days incurred by the qualifying providers during SFY 2003. The adjustment for State Fiscal Year 2004 shall be two dollars and thirty-six cents ($2.36) per Medicaid day.

(III) The adjustment shall be distributed based on a quarterly amount, in addition to per diem payments, based on Medicaid days determined from the paid days report from Missouri’s fiscal agent for pay cycles during State Fiscal Year 2003.

H. High volume adjustment for nursing facilities placed in receivership.

(I) For facilities placed in receivership under Missouri law after December 31, 2001, the division shall make a determination as to whether the operator of the facility when the receivership ended (i.e., successor operator) is a related party to the facility placed in receivership. If the successor operator is determined to be an unrelated party and the facility was receiving the high volume adjustment prior to the receivership, the facility shall continue to receive the high volume adjustment during the receivership and until the adjustment is based on the first full year cost report prepared by the successor operator.

(II) Any adjustments contingent upon the facility qualifying for the high volume adjustment shall not be granted if the facility did not qualify for the high volume adjustment except as provided in part (13)(B)10.G.(I) above.

(III) This provision only applies until the first full year cost report is available, after which the facility must qualify for the high volume adjustment each year as specified in subparagraphs (13)(B)10.A., B., and C. in order to receive it.

11. Minimum Rate Adjustment. A minimum rate adjustment shall be granted to qualifying providers, as follows:

A. Effective for dates of service beginning July 1, 2001, the minimum Medicaid reimbursement rate for nursing facility services shall be eighty-five dollars ($85).

12. Invasive Ventilator Care Adjustment. Effective for dates of service beginning January 1, 2013, a per diem adjustment shall be granted for ventilator services provided by qualifying providers to qualifying MO HealthNet participants as set forth in 13 CSR 70-10.017.

(C) Conditions for prospective rate adjustments. The division 1. Fraud, misrepresentation, errors. When information also does not affect the division’s ability to impose any sanctions authorized by statute or regulation;

2. Decisions of the Administrative Hearing Commission, 3. Court order; and 4. Disallowance of federal financial participation.

(14) Exceptions.

(A) Requirements for Placement of MO HealthNet Participants in Out-of-State Nursing Facilities and Reimbursement for Outof-State Nursing Facilities.

1. In order to provide nursing facility services to MO HealthNet participants when there is no Missouri nursing facility with a suitable bed available that meets the medical needs of the participant, the division may authorize placement of a MO HealthNet participant in an out-of-state facility.

2. The division will only authorize placement of a MO HealthNet participant into an out-of-state facility if— A. No Missouri nursing facility bed is available that meets the medical needs of the participant;

B. In-state alternatives for providing services have been exhausted; and C. Prior approval for placement into an out-of-state nursing facility is requested from and approved by the division.

3. Once a Missouri nursing facility bed meeting the medical needs of the participant is available, the participant must return to Missouri. If the participant does not return to Missouri, the division shall withhold payments for nursing facility services, unless the participant’s health would be endangered if required to travel to Missouri. Participant’s physician would need to certify that the participant’s health would be endangered from the travel to Missouri.

4. No fiscal year-end Missouri Medicaid cost report will be required from the out-of-state nursing facility nor will there be any requirement for Missouri-conducted periodic audits.

5. The Title XIX reimbursement rate for out-of-state providers shall be set as follows:

A. For out-of-state providers which provided services for Missouri Title XIX participants, the reimbursement rate shall be the lower of— (I) The weighted average MO HealthNet rate for comparable services at the beginning of the state fiscal year in which the provider enters the MO HealthNet program; or (II) The rate paid to the out-of-state nursing facility for comparable services by the state in which the provider is located. The out-of-state provider must notify the division of any reimbursement changes made by its state Medicaid agency. The provider must also include a copy of the rate letter issued by their state Medicaid agency detailing the rate and effective date. The effective date of the rate change is as (a) Rate increases—If the provider notifies the division within thirty (30) days of receipt of notification from their state of the per diem rate increase, the effective date of the rate increase for purposes of reimbursement from Missouri shall be the same date as indicated in the issuing state’s rate letter. If the division does not receive written notification from the provider within thirty (30) days of the date the provider received notification from their state of the rate increase, the effective date of the rate increase for purposes of reimbursement from Missouri shall be the first day of the month following the date the division receives notification; or (b) Rate decreases—The effective date of the rate decrease for purposes of reimbursement from Missouri shall be the same date as indicated in the issuing state’s rate letter.

(B) The Title XIX reimbursement rate for hospital based providers that provide services of less than one thousand (1,000) patient days for Missouri Title XIX participants, relative to their fiscal year, and that are exempt from filing a cost report as prescribed in section (10) shall be determined as follows:

1. For hospital based nursing facilities that have less than one thousand (1,000) Medicaid patient days, the rate base cost report will not be required. The prospective rate will be the sum of the ceilings for the patient care, ancillary, and administration cost components, plus the working capital allowance and the median per diem for capital. In addition, the patient care incentive of ten percent (10%) of the patient care median will be granted; and 2. For hospital based nursing facilities with a provider agreement in effect on December 31, 1994, a prospective rate shall be set by one (1) of the following:

A. The hospital based nursing facility requests, in writing, that their prospective rate be determined from their rate setting cost report as set forth in this regulation; or B. The sum of the ceilings for patient care, ancillary, administration and working capital allowance, and the median per diem for capital from the permanent capital per diem in effect January 1, 1995 for the initial rate base year; July 1, 2004 for the 2001 rebased year; and March 15, 2005 for the revised rebase calculations effective for dates of service beginning April 1, 2005 and for the per diem rate calculation effective for dates of service beginning July 1, 2005 forward. In addition, the patient care incentive of ten percent (10%) of the patient care median will be granted.

(15) Sanctions and Overpayments.

(A) In addition to the sanctions and penalties set forth in this

regulation, the division may also impose sanctions against a provider in accordance with 13 CSR 70-3.030 Sanctions for False or Fraudulent Claims for Title XIX Services, or any other sanction authorized by state or federal law or regulations.

(B) Overpayments due the Medicaid program from a provider (16) Appeals. In accordance with sections 208.156, RSMo and 622.055, RSMo providers may seek hearing before the Administrative Hearing Commission of final decisions of the director or the division.

(17) Payment in Full. Participation in the program shall be services rendered to Medicaid participants, the amount paid (18) Provider Participation. Payments made in accordance (19) Transition. Cost reports used for rate determination shall be adjusted by the division in accordance with the applicable cost principles provided in this regulation.

(20) Rebasing of Nursing Facility Rates.

(A) Effective July 1, 2004, nursing facility rates shall be rebased on an annual basis. The rebased rates shall be phased in as set forth below in subsection (20)(B). Each nursing facility shall have its prospective rate recalculated using the same (1)–(19) of this regulation, unless otherwise noted in this section (20). The following items have been updated to reflect the rebase:

1. Nursing facility rates shall be rebased on an annual

basis using the cost report year that is three (3) years prior to the effective date of the rate change. For example, for SFY 2005, the effective date of the rate change is for dates of service beginning July 1, 2004 and the cost report year used to recalculate rates shall be 2001; for SFY 2006, the effective date of the rate change is for dates of service beginning July 1, 2005 and the cost report year used to recalculate rates shall be 2002; etc.

A. A new databank shall be developed from the cost reports for each rebase year in accordance with paragraph (20)

(A)1. and subsection (4)(S).

B. The costs in the databank shall be trended using the indices from the most recent publication of the Health-Care Cost Review available to the division using the “CMS Nursing Home without Capital Market Basket” table. The costs shall be trended using the second quarter indices for each year. The costs shall be trended for the years following the cost report year, up to and including the state fiscal year corresponding to the effective date of the rates. For SFY 2005, the trends are from the First Quarter 2004 publication of the Health-Care Cost Review and include the following:

(I) 2002:2 = 3.2%

(II) 2003:2 = 3.4%

(III) 2004:2 = 2.3%

(IV) 2005:2 = 2.3%

(V) The total trend applied to the 2001 cost report data C. The medians and ceilings shall be recalculated each year, based upon the trended costs included in the new databank that is developed each year.

D. The costs, beds, days, renovations/major improvements, databank shall be used to recalculate each facility’s rate. The costs reflected in each facility’s cost report shall be trended as detailed above in (20)(A)1.B.;

2. The asset value used to determine the capital cost each year based upon the RS Means Building Construction Cost Data for the year coinciding with the effective date of the rates.

The asset value is determined by using the median, total cost of construction per bed for nursing homes from the “S.F., C.F., and % of Total Costs” table and adjusting it by the total weighted average index for Missouri cities from the “City Cost Indexes” table. For SFY 2005, the asset value shall be forty-one thousand seven hundred twenty-eight dollars ($41,728);

3. The age of the beds shall be calculated from the year coinciding with the effective date of the rates;

4. The interest rate used in determining the capital cost component and working capital allowance, as set forth in subsections (7)(F), (11)(D), and (11)(E), shall be updated to reflect the prime rate as reported by the Federal Reserve and published in the Wall Street Journal on the first business day of June for the year coinciding with the effective date of the rates plus two percent (2%). For SFY 2005, the interest rate shall be the prime rate of four percent (4%), as published June 1, 2004, plus two percent (2%) for a total of six percent (6%);

5. The rate of return used in determining the capital cost to reflect the interest (i.e., coupon) rate for the most recent issue of thirty- (30-) year Treasury Bonds in effect on the first business day of June for the year coinciding with the effective date of the rates plus two percent (2%). For SFY 2005, the rate of return shall be the thirty- (30-) year Treasury Bond rate of 5.375%, effective June 1, 2004, plus two percent (2%) for a total of 7.375%;

6. The administration cost component per diem calculation shall not be adjusted for minimum utilization;

7. The capital cost component per diem calculation shall be adjusted for minimum utilization using the Department of Health and Senior Services’ (DHSS) Intermediate Care Facility/ Skilled Nursing Facility Certificate of Need Quarterly Survey (CON Quarterly Survey) for the most recent quarter available to the division relative to the effective date of the rates.

The occupancy data from the CON Quarterly Survey shall be adjusted by the division using total licensed beds rather than available beds as is used by DHSS. For SFY 2005, the minimum utilization percent for the capital component is the adjusted industry average from the October–December 2003 CON Quarterly Survey and shall be seventy-three percent (73%);

8. The high volume adjustment for SFY 2005 shall continue to be based on the 2001 cost report rather than the cost report ending in the third calendar year prior to the state fiscal year as set forth in (13)(B)10.A.(I). The remaining criteria and calculations set forth in (13)(B)10. shall continue to be applicable. Therefore, facilities receiving the high volume adjustment for SFY 2004 shall continue to receive the same high volume adjustment for the first year of the rebase (i.e., July 1, 2004–June 30, 2005); and 9. Since rates are being recalculated each year, rate adjustment requests for replacement beds, additional beds, and/or extraordinary circumstances as set forth in paragraphs (13)(B)6., (13)(B)7., and (13)(B)8. are no longer allowed.

(B) The rebased rates shall be phased in, as set forth below:

1. A preliminary rebased rate shall be calculated using the same principles and methodology as detailed throughout sections (1)–(19) of this regulation and the updated items detailed above in paragraphs (20)(A)1.–9.

2. The total increase resulting from the rebase each year shall be calculated as follows:

A. Each facility’s current rate as of June 30 of each year shall be compared to the preliminary rebased rate effective July 1 of the following SFY. For example, for SFY 2005, the facility’s rate as of June 30, 2004 shall be compared to the preliminary rebased rate effective July 1, 2004; for SFY 2006, the facility’s rate as of June 30, 2005 shall be compared to the preliminary rebased rate effective July 1, 2005; etc.

(I) The high volume adjustment, if applicable, and the NFRA shall not be included in the current rate or the preliminary rebased rate for comparison purposes in determining the total increase.

(II) The high volume adjustment, if applicable, and the subparagraph (20)(B)2.B.

B. If the preliminary rebased rate is greater than the current rate, the difference between the two (2) shall represent the total increase that will be phased in by granting one-third (1/3) of the total increase each year. For SFY 2005, one-third (1/3) of the total increase shall be added to the facility’s current rate as of June 30, 2004, less the reduction in the nursing July 1, 2004 as set forth in 13 CSR 70-10.016. The high volume adjustment, if applicable, and the current NFRA shall be added to that total and shall be the facility’s prospective rate for SFY 2005.

C. If the preliminary rebased rate is less than the current rate, the facility shall continue to receive its current rate with any applicable adjustments for high volume and NFRA for the S F Y.

(C) Interim rates and rates for hospital-based facilities that do not submit cost reports due to having less than one thousand (1,000) patient days for Medicaid residents shall also be recalculated and increases given each July 1 as set forth above.

(D) Effective for dates of service beginning April 1, 2005, the rebased rates for SFY 2005 shall be calculated as follows:

1. The audited 2001 cost report data shall continue to be used to develop the databank and to determine each nursing facility’s rebased rate. The audited 2001 cost report data; the licensed beds data; and the bed equivalencies data used to determine each nursing facility’s final rate paid for dates of services effective July 1, 2004 shall be deemed final. This finalized data will be used as the base to calculate the rates effective April 1, 2005. The following items have been revised for the April 1, 2005 rate calculation:

A. A new databank shall be developed using the audited 2001 cost report data set forth above in paragraph (20)(D)1. for nursing facilities enrolled in the Medicaid program as of March 15, 2005 in accordance with subsection (4)(S); and B. The administration and capital cost components shall be adjusted for minimum utilization at eighty-five percent (85%) occupancy, rather than as set forth in paragraph (20)

(A)6.–7.

(E) Prospective Rate Determination for Newly Medicaid Certified Nursing Facilities. As set forth in subsection (12)(F), a nursing facility never previously certified for participation in the Medicaid program shall receive an interim rate upon entering the Medicaid program and have its prospective rate set on its second full twelve- (12-) month cost report following the facility’s initial date of certification. The prospective rate shall be calculated in accordance with the provisions of the regulation in effect from the beginning of the facility’s rate setting period through the date the prospective rate is determined, as detailed below. If industry-wide rate changes were implemented during this period the provision of the

regulation relating to the effective date of the rate change shall be the governing regulation for those dates of service.

For example, for a rate setting period of January 1, 2004 through December 31, 2004, the facility’s initial prospective rate effective January 1, 2004 shall be set in accordance with the regulations in effect at that time and rate changes that occurred after January 1, 2004 shall be calculated in accordance with the regulation applicable to each rate change throughout the period, as follows: the facility’s initial prospective rate effective January 1, 2004 shall be set in accordance with the regulations in effect at that time (sections (1)–(19)); nursing facility rates were rebased effective July 1, 2004 per section (20); the rebase provisions were modified effective April 1, 2005 under subsection (20)(D); the per diem rate calculation effective for dates of service beginning July 1, 2005 ar e detailed in section (21); a quality improvement adjustment of three dollars and seventeen cents ($3.17) per day was granted effective July 1, 2006 in 13 CSR 70-10.016; etc.

1. A nursing facility that did not have a prospective rate established when rates were rebased on July 1, 2004, shall have its prospective rate for dates of service beginning on or after July 1, 2004 through June 30, 2005 established on the rate setting cost report in accordance with section (20), consistent with the rest of the nursing facility industry.

2. As set forth in paragraphs (20)(B)1. and 2., a preliminary rate shall be calculated and compared to the facility’s rate as of June 30, 2004, less the reduction in the nursing facility operations adjustment of fifty-four cents (54¢) effective July 1, 2004 as set forth in 13 CSR 70-10.016, to determine the total increase. The NFRA shall not be included in the preliminary rate or the June 30, 2004 rate for comparison purposes in A. If the facility will have a prospective rate established on June 30, 2004 once the prospective rate setting process is complete, the prospective rate shall be the rate for comparison purposes in determining the total increase.

B. If the facility will not have a prospective rate established on June 30, 2004 once the prospective rate setting process is complete, the division will calculate a June 30, 2004 computed rate which will be used as the rate for comparison purposes in determining the total increase as follows:

(I) The rate setting cost report as determined in subsection (12)(F) shall be used.

(II) The allowable costs from the rate setting cost report will be negatively trended back to June 30, 2004 using the indices from the most recent publication of the Health- Care Cost Review available to the division using the “CMS Nursing Home without Capital Market Basket” table. The allowable costs shall be negatively trended using the second quarter indices for each year, beginning with the index for the year relative to the end of the rate setting period back to and including the index for 2005. For example, a rate setting cost report for the period July 1, 2006 through June 30, 2007, shall have a 2007 rate setting year. The allowable costs shall be negatively trended by the 2007 second quarter index, the 2006 second quarter index, and the 2005 second quarter index. The resulting allowable costs shall be used to determine the June 30, 2004 computed rate.

(III) The computed rate shall be calculated in accordance with sections (1)–(19) of this regulation, prior to the rebase, using the regulations applicable to calculating a June 30, 2004 rate including the cost component ceilings, interest, rate of return, etc. in effect on June 30, 2004.

3. If the preliminary rate is greater than the June 30, 2004 rate, the facility shall receive one-third (1/3) of the total increase of the preliminary rate over the June 30, 2004 rate, less the reduction in the nursing facility operations adjustment of fifty-four cents (54¢) effective July 1, 2004 as set forth in 13 CSR 70-10.016. The one-third (1/3) increase shall be added to the June 30, 2004 rate, less the reduction in the nursing facility 2004 as set forth in 13 CSR 70-10.016. The NFRA in effect shall be added to that total to determine the prospective rate.

4. If the preliminary rate is less than the June 30, 2004 rate, the facility’s June 30, 2004 rate plus the NFRA in effect shall become the prospective rate.

(21) Per Diem Rate Calculation Effective for Dates of Service Beginning July 1, 2005. Effective for dates of service beginning July 1, 2005, the rebase provisions set forth in section (20) shall not apply. Effective for dates of service beginning July 1, 2005, the per diem rates shall be calculated using the same (1)–(19) of this regulation, except that the data indicated in this

section (21) shall be used.

(A) The audited 2001 cost report data shall be used to develop the databank and to determine each nursing facility’s per diem rate. The audited 2001 cost report data; the licensed beds data; and the bed equivalencies data used to determine each nursing facility’s final rate paid for dates of services effective July 1, 2004 shall be deemed final. This finalized data will be used as the base to calculate the rates effective July 1, 2005.

1. A new databank shall be developed using the audited 2001 cost report data set forth above in subsection (21)(A) for nursing facilities enrolled in the Medicaid program as of March 15, 2005 in accordance with subsection (4)(S).

2. The costs in the databank shall be trended using the second quarter indices from the First Quarter 2004 publication of the Health-Care Cost Review using the “CMS Nursing Home without Capital Market Basket” table. The costs shall be trended for the years following the cost report year, up to and including SFY 2005. The trends applied to the 2001 cost report data include the following:

A. 2002:2 = 3.2%

B. 2003:2 = 3.4%

C. 2004:2 = 2.3%

D. 2005:2 = 2.3%

E. The total trend applied to the 2001 cost report data 3. The medians and ceilings shall be recalculated, based upon the trended costs included in the new databank.

4. The costs, beds, days, renovations/major improvements, databank shall be used to calculate each nursing facility’s rate.

The costs reflected in each facility’s cost report shall be trended as detailed above in paragraph (21)(A)2.

(B) The asset value used to determine the capital cost component, as set forth in subsection (11)(D), shall be based upon the 2004 publication of the RS Means Building Construction Cost Data. The asset value is determined by using the median, total cost of construction per bed for nursing homes from the “S.F., C.F., and % of Total Costs” table and adjusting it by the total weighted average index for Missouri cities from the “City Cost Indexes” table. The asset value shall be forty-one thousand seven hundred twenty-seven dollars and fifty cents ($41,727.50).

(C) The age of the beds shall be calculated from 2004.

(D) The interest rate used in determining the capital cost component and working capital allowance, as set forth in subsections (7)(F), (11)(D), and (11)(E), shall be the prime rate as reported by the Federal Reserve and published in the Wall Street Journal on the first business day of June 2004 plus two percent (2%). The interest rate shall be the prime rate of four percent (4%), as published June 1, 2004, plus two percent (2%) for a total of six percent (6%).

(E) The rate of return used in determining the capital cost component, as set forth in subsection (11)(D), shall be the interest (i.e., coupon) rate for the most recent issue of thirty- (30-) year Treasury Bonds in effect on the first business day of June 2004 plus two percent (2%). The rate of return shall be the thirty- (30-) year Treasury Bond rate of 5.375%, effective June 1, 2004, plus two percent (2%) for a total of 7.375%.

(F) The administration and capital cost components shall be adjusted for minimum utilization at eighty-five percent (85%) occupancy.

(G) The high volume adjustment shall continue to be that determined for SFY 2004. The 2001 cost report shall continue to be used rather than the cost report ending in the third calendar year prior to the state fiscal year as set forth in part (13)(B)10.A.(I), and the remaining criteria and calculations set forth in paragraph (13)(B)10. shall continue to be that used in the SFY 2004 calculation. Therefore, facilities receiving the high volume adjustment for SFY 2004 shall continue to receive that same high volume adjustment which will be included in its rate effective for dates of service beginning July 1, 2005.

(H) Rate adjustment requests for replacement beds, additional beds, and/or extraordinary circumstances as set forth in paragraphs (13)(B)6., (13)(B)7., and (13)(B)8. are no longer allowed.

1. Beginning State Fiscal Year 2016, an adjustment to the capital rate may be allowed for extraordinary circumstances as set forth in paragraph (13)(B)8. except the requirement that the occurrence is not covered by insurance does not have to be met. If a nursing facility is destroyed by an unavoidable act of nature beyond the control of the facility or vandalism and/or civil disorder the rebuilt nursing facility may apply for an adjustment to the capital component of the per diem rate, as calculated in part (13)(B)8.C.(III). The rate adjustment will be effective the date the rebuilt nursing facility is placed in service.

(I) Facility size and occupancy rate adjustment. If a facility qualifies for the facility size and occupancy rate adjustment, its facility size and occupancy rate shall be adjusted and used in the calculation of its per diem rate.

1. Qualifying criteria. A nursing facility may qualify for a facility size and occupancy adjustment if it meets all of the following criteria:

A. The facility has been operating only fifty percent (50%) of its licensed bed capacity; and B. Every resident has been residing in a private room;

C. The facility has been operating as such (as detailed in subparagraphs A. and B. above) from the beginning of their 2001 cost report period through the date the rate is effective as reported on the quarterly survey form, “Missouri Department of Health and Senior Services, Division of Senior Services and

Regulation, ICF/SNF Certificate of Need Quarterly Survey” (form MO 886-9001(6-95)) (quarterly survey); and D. The facility’s intent for operating as such is to qualify for a Certificate of Need (CON) in accordance with section 197.318.9, RSMo 2000.

2. Calculation of adjusted facility size, adjusted occupancy rate, and adjusted per diem rate.

A. Adjusted facility size. The facility size as defined in subsection (4)(BB) and used in the determination of a facility’s capital cost component under the fair rental value system set forth in subsection (11)(D) shall be adjusted to reflect fifty percent (50%) of the licensed bed capacity.

B. Adjusted occupancy rate. The occupancy rate as defined in subsection (4)(MM) shall be adjusted to reflect fifty percent (50%) of the licensed bed capacity by adjusting the bed days used to determine the occupancy rate. The bed days shall be calculated using fifty percent (50%) of the licensed bed capacity and the adjusted occupancy rate shall be calculated by dividing the facility’s total actual patient days by the adjusted bed days.

C. The adjusted facility size and the adjusted occupancy rate shall be used to determine the facility’s per diem rate in accordance with the remaining provisions of this regulation.

3. The facility must notify the division in writing that it qualifies for this adjustment and provide the proper documentation, including the following:

A. A copy of the quarterly surveys from the beginning of the 2001 cost report period through the date the rate is effective; and B. A copy of an approved CON obtained under section 197.318.9, RSMo 2000, or a written statement indicating the facility’s intention of obtaining a CON under section 197.318.9, RSMo 2000, including a specific time line detailing when they plan to apply for the CON and when they plan to begin construction relative to the CON;

C. The division shall accept such written notification from facilities that qualify for this adjustment as of July 1, 2005 for up to thirty (30) days after the effective date of this amendment.

4. This adjustment shall only apply to nursing facilities with a prospective rate on July 1, 2005 and shall only be granted for the July 1, 2005 rate calculation.

5. Loss of facility size and occupancy rate adjustment and recalculation of per diem rate. If a facility’s per diem rate has been set using an adjusted facility size and an adjusted occupancy rate and at least one (1) of the conditions set forth below in subparagraphs (21)(I)5.A.(I)–(IV) is met, the facility will no longer receive the adjustment to the facility size and occupancy rate in determining its per diem rate and its per diem rate shall be recalculated.

A. The conditions for losing the facility size and occupancy rate adjustment include the following:

(I) The facility ceases to operate at fifty percent (50%) of its licensed bed capacity; or (II) The facility ceases to operate with every resident residing in a private room; or (III) The facility does not apply for a CON under section 197.318.9, RSMo 2000 within five (5) years of receiving the adjustment; or (IV) The facility does not begin the construction relative to the CON obtained under section 197.318.9, RSMo 2000 within five (5) years of receiving the adjustment.

B. If the facility size and occupancy rate adjustment is lost, the facility’s per diem rate shall be recalculated using the unadjusted facility size as set forth in subsection (4)(BB) and the unadjusted bed days and unadjusted occupancy rate as set forth in subsection (4)(MM).

C. The facility must notify the division within thirty (30) days if it no longer qualifies for the facility size and occupancy rate adjustment as a result of meeting one (1) of the conditions listed above in subparagraph (21)(I)5.A.

(I) If the facility notifies the division of such within thirty (30) days, the effective date of the rate recalculation shall be the date that one (1) of the conditions set forth above in subparagraph (21)(I)5.A. is met. If more than one (1) of the conditions apply, the effective date shall be the earliest date.

The facility shall repay the division any overpayment resulting from the loss of the facility size and occupancy rate adjustment.

(II) If the facility does not notify the division within thirty (30) days, the effective date of the rate recalculation shall be the date the facility size and occupancy rate adjustment was originally granted. The facility shall repay the division any overpayment resulting from the loss of the facility size and occupancy rate adjustment.

(J) The rates effective for dates of service beginning July 1, 2005 shall be determined, as set forth below:

1. A preliminary rate for July 1, 2005 shall be calculated using the same principles and methodology as detailed throughout sections (1)–(19) of this regulation and the updated items detailed above in subsections (21)(A)–(I).

2. The total increase resulting from the July 1, 2005 preliminary rate calculation shall be calculated as follows:

A. Each facility’s rate as of June 30, 2004, less the reduction in the nursing facility operations adjustment of fifty-four cents (54¢) effective July 1, 2004 as set forth in 13 CSR 70-10.016, shall be compared to the July 1, 2005 preliminary rate (I) The high volume adjustment, if applicable, and the NFRA shall not be included in the June 30, 2004 rate or the July 1, 2005 preliminary rate for comparison purposes in (II) The high volume adjustment, if applicable, and the subparagraphs (21)(J)2.B. and (21)(J)2.C.;

B. If the July 1, 2005 preliminary rate is greater than the June 30, 2004 rate including the reduction in the nursing July 1, 2004 as set forth in 13 CSR 70-10.016, the difference between the two (2) shall represent the total increase. Effective for dates of service beginning July 1, 2005, one-third (1/3) of the total increase shall be added to the facility’s rate as of June 30, 2004 including the reduction in the nursing facility operations adjustment of fifty-four cents (54¢) effective July 1, 2004 as set forth in 13 CSR 70-10.016. The high volume adjustment, if applicable, and the current NFRA shall be added to that total and shall be the facility’s prospective rate for dates of service beginning July 1, 2005;

C. If the July 1, 2005 preliminary rate is less than the June 30, 2004 rate including the reduction in the nursing facility 2004 as set forth in 13 CSR 70-10.016, the facility’s prospective rate shall be the facility’s rate as of June 30, 2004 including the reduction in the nursing facility operations adjustment of fifty-four cents (54¢) effective July 1, 2004 as set forth in 13 CSR 70-10.016 plus the high volume adjustment, if applicable, and the current NFRA.

(K) Interim rates and rates for hospital-based facilities that do not submit cost reports due to having less than one thousand (1,000) patient days for Medicaid residents shall also be recalculated and increases given as set forth above.

(L) Prospective Rate Determination for Nursing Facilities Newly Medicaid Certified after June 30, 2004. As set forth in subsection (12)(F), a nursing facility never previously certified for participation in the Medicaid program shall receive an interim rate upon entering the Medicaid program and have its prospective rate set on its second full twelve- (12-) month cost report following the facility’s initial date of certification. The prospective rate shall be calculated in accordance with the provisions of the regulation in effect from the beginning of the facility’s rate setting period through the date the prospective rate is determined, as detailed below. If industry-wide rate changes were implemented during this period the provision of the regulation relating to the effective date of the rate change shall be the governing regulation for those dates of service.

For example, for a rate setting period of January 1, 2006 through December 30, 2006, the facility’s initial prospective rate effective January 1, 2006 shall be set in accordance with the regulations in effect at that time and rate changes that occurred after January 1, 2006 shall be calculated in accordance with the regulation applicable to each rate change throughout the period, as follows: the facility’s initial prospective rate effective January 1, 2006 shall be set in accordance with the regulations in effect at that time, section (21) (i.e., the per diem rate calculation effective for dates of service beginning July 1, 2005 are detailed in section (21)); a quality improvement adjustment of three dollars and seventeen cents ($3.17) per day was granted effective July 1, 2006 in paragraph (13)(A)10.; etc.

1. A nursing facility never previously certified for participation in the Medicaid program that originally enters the Medicaid program after June 30, 2004 shall have its prospective rate for dates of service beginning on or after July 1, 2005 calculated in accordance with the provisions of section (21), consistent with the rest of the nursing facility industry.

The following items shall be updated annually and shall be used in determining the prospective rate, as follows:

A. Asset value. The asset value used to determine the capital cost component, as set forth in subsection (11)

(D), shall be adjusted annually based upon the R. S. Means Building Construction Cost Data published each year using the “Historical Cost Indexes” table. The asset value for the year relative to the end of the rate setting period shall be used;

B. Age of beds. The age of the beds shall be calculated by subtracting the year the beds were originally licensed from the year relative to the end of the rate setting period;

C. Interest rate. The interest rate used in determining the capital cost component and working capital allowance, as set forth in subsections (7)(F), (11)(D), and (11)(E), shall be updated annually using the prime rate reported by the Federal Reserve and published in the Wall Street Journal on the first business day of June of each year plus two percent (2%). The interest rate in effect at the end of the rate setting period shall be used.

2. A preliminary rate at the beginning of the rate setting period shall be calculated using the same principles and methodology as detailed throughout sections (1)–(19) of this

regulation and the updated items detailed in section (21).

3. The preliminary rate at the beginning of the rate setting period shall be compared to a June 30, 2004 computed rate as detailed below to determine the total increase. The NFRA shall not be included in the preliminary rate or the June 30, 2004 computed rate for comparison purposes in determining the total increase.

A. The June 30, 2004 computed rate for comparison purposes shall be calculated as follows:

(I) The rate setting cost report as determined in subsection (12)(F) shall be used;

(II) The allowable costs from the rate setting cost report will be negatively trended back to June 30, 2004 using the indices from the most recent publication of the Health- Care Cost Review available to the division using the “CMS Nursing Home without Capital Market Basket” table. The allowable costs shall be negatively trended using the second quarter indices for each year, beginning with the index for the year relative to the end of the rate setting period back to and including the index for 2005. For example, a rate setting cost report for the period July 1, 2006 through June 30, 2007, shall have a 2007 rate setting year. The allowable costs shall be negatively trended by the 2007 second quarter index, the 2006 second quarter index, and the 2005 second quarter index. The resulting allowable costs shall be used to determine the June 30, 2004 computed rate;

(III) The computed rate shall be calculated in accordance with sections (1)-(19) of this regulation, prior to the rebase, using the regulations applicable to calculating a June 30, 2004 rate including the cost component ceilings, interest, rate of return, etc. in effect on June 30, 2004.

B. If the preliminary rate at the beginning of the rate setting period is greater than the June 30, 2004 computed rate, the facility shall receive one-third of the total increase of the preliminary rate over the June 30, 2004 computed rate.

The one-third increase shall be added to the facility’s June 30, 2004 computed rate. The NFRA in effect shall be added to the total and shall be the facility’s prospective rate effective at the beginning of the rate setting period.

C. If the preliminary rate at the beginning of the rate setting period is less than the June 30, 2004 computed rate, the facility’s June 30, 2004 computed rate plus the NFRA in effect shall become the prospective rate effective the beginning of the rate setting period.

(M) Prospective Rate Determination for Previously Medicaid Certified Nursing Facilities Reentering the Medicaid Program.

As set forth in subsection (12)(G), a nursing facility that was previously certified for participation in the Medicaid Program and either voluntarily or involuntarily terminated from the Medicaid Program which then reenters the Medicaid Program shall have its prospective rate established as the rate in effect on the day prior to the date of termination from participation in the program plus rate adjustments which may have been granted subsequent to the termination date but prior to reentry into the program. The prospective rate for nursing facilities that reentered the Medicaid Program after nursing facility rates were rebased July 1, 2004 shall be calculated as 1. If there is a 2001 cost report for the nursing facility, regardless of the owner/operator who completed the 2001 cost report, the prospective rate shall be based on the 2001 cost report in accordance with section (21); or 2. If there is not a 2001 cost report for the nursing facility, the prospective rate in effect when the facility terminated from the program shall be adjusted to reflect the rate changes granted through June 30, 2004 and shall be the June 30, 2004 rate to be compared to the preliminary rebased interim rate to determine the total increase, the one-third increase and the rebased prospective rate, in accordance with section (21), consistent with the rest of the nursing facility industry.

(N) Nursing facilities who qualify to have their prospective rate set in accordance with the provisions of subsection (20)(E) shall continue to receive the rate determined from subsection (20)(E) for dates of service beginning July 1, 2005.

(22) Prospective Rate Determination Beginning November 1, 2020. Prospective rates determined on or after November 1, 2020 shall be calculated as follows:

(A) Prospective Rate Determination for Nursing Facilities Newly Medicaid Certified after June 30, 2004. As set forth in subsection (12)(F), a nursing facility never previously certified for participation in the Medicaid program shall receive an interim rate upon entering the Medicaid program. The nursing facility shall have its prospective rate set on its second full twelve- (12-) month cost report following the facility’s initial date of certification, referred to as the rate setting cost report.

The period to which the rate setting cost report relates is referred to as the rate setting period;

(B) The prospective rate shall be calculated in accordance with the provisions of the regulation in effect from the beginning of the facility’s rate setting period through the date the prospective rate is determined, as detailed below. If industry-wide rate changes were implemented during this period the provision of the regulation relating to the effective date of the rate change shall be the governing regulation for those dates of service; and (C) The prospective rate shall be calculated using the same (1)–(19) of this regulation and the updated items detailed in subsections (21)(A)-(L), except for the following:

1. Paragraphs (21)(L)2. and (21)(L)3. shall not be applied in determining the prospective rate; and 2. The total rate determined from the rate setting cost report shall be adjusted by any global per diem adjustments granted after the beginning of the facility’s rate setting period through the effective date of the prospective rate; and 3. The effective date for a facility’s prospective rate is as A. The effective date for facilities with a rate setting cost report period that begins prior to November 1, 2020 shall be November 1, 2020; and B. The effective date for facilities with a rate setting cost report period that begins after November 1, 2020 shall be the beginning of the rate setting cost report period; and 4. The total rate that has been trended shall be limited to a cap, referred to as the total rate cap. The total trended rate shall be limited to the total rate cap that is in effect on the effective date of the prospective rate, as follows:

A. The total rate cap in effect on November 1, 2020 is one hundred ninety dollars ($190); and B. The total rate cap set forth above, one hundred ninety dollars ($190), shall be adjusted by any global per diem adjustments granted after November 1, 2020; and 5. Once the prospective rate is finalized, a retroactive payment shall be made back to the effective date, if applicable;

6. The prospective rate determined in (22)(C)1.-5. shall be adjusted by any global per diem adjustments set forth in 13 CSR 70-10.016 that are granted after the effective date of the prospective rate.

COVERED SUPPLIES AND SERVICES PERSONAL CARE

Oral hygiene including denture care, cups, cleaner, mouthwashes, toothbrushes, and paste Nail clipping and cleaning routine K pads (water heated pads), alternating pressure pads, flotation pads, and/or turning frames, heel protectors, donuts and sheepskins Needles including, but not limited to, hypodermic, scalp, vein eating and massages provided by facility personnel A and D Ointment, tapes, alcohol, alcohol sponges, applicators, Oxygen (portable or stationary), oxygen delivery systems, concentrators, and supplies

Emergency amendment filed Aug. 12, 1997, effective Sept. 1, 1997, expired Feb. 27, 1998. Amended: Filed Aug. 12, 1997, effective Feb. 28, 1998. Emergency amendment filed Sept. 19, 1997, effective Oct. 1, 1997, expired March 29, 1998. Amended: Filed Sept. 25, 1997, effective March 30, 1998. Amended: Filed March 2, 1998, effective Oct. 30, 1998. Amended: Filed July 15, 1998, effective Feb. 28, 1999.

Emergency amendment filed Sept. 21, 1998, effective Oct. 1, 1998, expired March 29, 1999. Amended: Filed Sept. 21, 1998, effective May 30, 1999. Emergency amendment filed Sept. 20, 1999, effective Oct. 1, 1999, expired March 29, 2000. Amended: Filed Aug. 30, 1999, effective March 30, 2000. Emergency amendment filed July 18, 2000, effective July 28, 2000, expired Jan. 24, 2001. Amended: Filed June 29, 2000, effective Feb. 28, 2001. Amended: Filed Oct. 6, 2000, effective April 30, 2001. Amended: Filed Aug. 2, 2001, effective Feb. 28, 2002. Amended: Filed July 30, 2002, effective Jan. 30, 2003.

Emergency amendment filed Jan. 3, 2003, effective Jan. 17, 2003, expired July 15, 2003. Amended: Filed Jan. 3, 2003, effective June 30, 2003. Emergency amendment filed Sept. 22, 2003, effective Oct. 1, 2003, terminated Oct. 29, 2003. Amended: Filed Sept. 22, 2003, effective May 30, 2004. Amended: Filed March 12, 2004, effective Sept. 30, 2004. Emergency amendment filed June 18, 2004, effective July 1, 2004, expired Dec. 15, 2004. Amended: Filed Aug. 16, 2004, effective Feb. 28, 2005. Emergency amendment filed March 21, 2005, effective April 1, 2005, expired Sept. 27, 2005. Emergency amendment filed June 20, 2005, effective July 1, 2005, expired Dec. 27, 2005. Amended: Filed March 29, 2005, effective Sept. 30, 2005.

Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed May 15, 2006, effective Nov. 30, 2006. Emergency amendment filed Sept. 17, 2007, effective Oct. 1, 2007, expired March 28, 2008. Amended: Filed March 30, 2007, effective Nov. 30, 2007. Amended: Filed July 1, 2008, effective Jan. 30, 2009. Emergency amendment filed March 11, 2010, effective April 1, 2010, expired Sept. 27, 2010. Amended: Filed March 11, 2010, effective Sept. 30, 2010. Amended: Filed July 1, 2013, effective Jan. 30, 2014. Amended: Filed Oct. 15, 2015, effective April 30, 2016. ** Amended: Filed Feb. 26, 2021, effective Aug. 30, 2021. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, **Pursuant to Executive Order 21-09, 13 CSR 70-10.015, paragraphs (10)(A)5. and 6. was suspended from April 9, 2020 through December 31, 2021.

History

• AUTHORITY: sections 208.153, 208.159, 208.201, and 660.017, RSMo 2016. Emergency rule filed Dec. 21, 1994, effective Jan. 1, 1995, expired April 30, 1995. Emergency rule filed April 21, 1995, effective May 1, 1995, expired Aug. 28, 1995. Original rule filed Dec. 15, 1994, effective July 30, 1995. Emergency amendment filed Sept. 1, 1995, effective Oct. 1, 1995, expired March 28, 1996. Amended: Filed Sept. 1, 1995, effective March 30, 1996. Amended: Filed Dec. 22, 1995, effective Aug. 30, 1996. Amended: Filed Feb. 1, 1996, effective Sept. 30, 1996. Emergency amendment filed Sept. 20, 1996, effective Oct. 1, 1996, expired March 29, 1997. Emergency amendment filed Oct. 22, 1996, effective Nov. 1, 1996, expired April 29, 1997.

13 CSR 70-10.016 Global Per Diem Adjustments to Nursing Facility and HIV Nursing Facility Reimbursement Rates {#sec-13-csr-70-10.016 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.016}

PURPOSE: This rule sets forth the global per diem adjustments to be applied to nursing facility reimbursement rates, established in 13 CSR 70-10.015, and HIV nursing facility reimbursement rates, established in 13 CSR 70-10.080. The global per diem adjustments were previously included in 13 CSR 70-10.015 and 13 CSR 70-10.080.

(1) Authority. This regulation is established pursuant to the (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

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 2. FY-97 negotiated trend factor— A. Facilities with either an interim rate or prospective rate in effect on October 1, 1996, shall be granted an increase to their per diem effective October 1, 1996, of three and seventenths percent (3.7%) 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 3. Nursing Facility Reimbursement Allowance (NFRA).

Effective October 1, 1996, all facilities with either an interim rate or a prospective rate shall have its per diem adjusted to include the current NFRA as an allowable cost in its reimbursement rate calculation.

4. Minimum wage adjustment. All facilities with either an interim rate or a prospective rate in effect on November 1, 1996, shall be granted an increase to their per diem effective November 1, 1996, of two dollars and forty-five cents ($2.45) to allow for the change in minimum wage.

Utilizing Fiscal Year 1995 cost report data, the total industry hours reported for each payroll category was multiplied by the fifty-cent (50¢) increase, divided by the patient days for the facilities reporting hours for that payroll category, and factored up by eight and sixty-seven hundredths percent (8.67%) to account for the related increase to payroll taxes. This calculation excludes the director of nursing, the administrator, and assistant administrator.

5. Minimum wage adjustment. All facilities with either an interim rate or a prospective rate in effect on September 1, 1997, shall be granted an increase to their per diem effective September 1, 1997, of one dollar and ninety-eight cents ($1.98) to allow for the change in minimum wage. Utilizing Fiscal Year 1995 cost report data, the total industry hours reported for each payroll category was multiplied by the forty-cent (40¢) increase, divided by the patient days for the facilities reporting hours for that payroll category, and factored up by eight and sixty-seven hundredths percent (8.67%) to account for the related increase to payroll taxes. This calculation excludes the director of nursing, the administrator, and assistant administrator.

6. FY-98 negotiated trend factor— A. Facilities with either an interim rate or prospective rate in effect on October 1, 1997, shall be granted an increase to their per diem effective October 1, 1997, of three and four-tenths percent (3.4%) 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 for nursing facilities and 13 CSR 70-10.080 for HIV nursing facilities; or B. Facilities that were granted a prospective rate based 7. FY-99 negotiated trend factor— A. Facilities with either an interim rate or prospective rate in effect on October 1, 1998, shall be granted an increase to their per diem effective October 1, 1998, of two and one-tenth percent (2.1%) of the cost determined in paragraphs (11)(A)1., (11)(B)1., (11)(C)1., the property insurance and property taxes detailed in subsection (11)(D) of 13 CSR 70-10.015 for nursing facilities and 13 CSR 70-10.080 for HIV nursing facilities, and the minimum wage adjustments detailed in paragraphs (3)(A)4. and (3)(A)5. of this regulation; or B. Facilities that were granted a prospective rate based on October 1, 1998, shall have their increase determined by 8. FY-2000 negotiated trend factor— A. Facilities with either an interim rate or prospective rate in effect on July 1, 1999, shall be granted an increase to their per diem effective July 1, 1999, of one and ninetyfour hundredths percent (1.94%) of the cost determined in subsections (11)(A), (11)(B), (11)(C), the property insurance and property taxes detailed in subsection (11)(D) of 13 CSR 70-10.015 for nursing facilities and 13 CSR 70-10.080 for HIV nursing facilities, and the minimum wage adjustments detailed in paragraphs (3)(A)4. and (3)(A)5. of this regulation; 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 July 1, 1999, shall have their increase determined by subsection (3)

(S) of 13 CSR 70-10.015.

9. FY-2004 nursing facility operations adjustment— A. Facilities with either an interim rate or prospective rate in effect on July 1, 2003, shall be granted an increase to their per diem effective for dates of service beginning July 1, 2003, through June 30, 2004, of four dollars and thirty-two cents ($4.32) for the cost of nursing facility operations. Effective for dates of service beginning July 1, 2004, the per diem adjustment shall be reduced to three dollars and seventy-eight cents ($3.78); and B. The operations adjustment shall be added to the facility’s current rate as of June 30, 2003, and is effective for payment dates after August 1, 2003.

10. FY-2007 quality improvement adjustment— A. Facilities with either an interim rate or prospective rate in effect on July 1, 2006, shall be granted an increase to their per diem effective for dates of service beginning July 1, 2006, of three dollars and seventeen cents ($3.17) to improve the quality of life for nursing facility residents; and B. The quality improvement adjustment shall be added to the facility’s current rate as of June 30, 2006, and is effective for dates of service beginning July 1, 2006, and after.

11. FY-2007 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on February 1, 2007, shall be granted an increase to their per diem rate effective for dates of service beginning February 1, 2007, of three dollars and zero cents ($3.00) to allow for a trend adjustment to ensure quality nursing facility services; and B. The trend adjustment shall be added to the facility’s reimbursement rate as of January 31, 2007, and is effective for dates of service beginning February 1, 2007, for payment dates after March 1, 2007.

12. FY-2008 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2007, shall be granted an increase to 1, 2007, of six dollars and zero cents ($6.00) to allow for a trend B. The trend adjustment shall be added to the facility’s current rate as of June 30, 2007, and is effective for dates of service beginning July 1, 2007.

13. FY-2009 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2008, shall be granted an increase to 1, 2008, of six dollars and zero cents ($6.00) to allow for a trend B. The trend adjustment shall be added to the facility’s current rate as of June 30, 2008, and is effective for dates of service beginning July 1, 2008.

14. FY-2010 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2009, shall be granted an increase to 1, 2009, of five dollars and fifty cents ($5.50) to allow for a trend B. The trend adjustment shall be added to the facility’s current rate as of June 30, 2009, and is effective for dates of service beginning July 1, 2009.

15. FY-2012 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on October 1, 2011, shall be granted an increase to their per diem rate effective for dates of service beginning October 1, 2011, of six dollars and zero cents ($6.00) to allow for B. The trend adjustment shall be added to the facility’s current rate as of September 30, 2011, and is effective for dates of service beginning October 1, 2011; and C. This increase is contingent upon the federal assessment rate limit increasing to six percent (6%) and is subject to approval by the Centers for Medicare and Medicaid 16. FY-2013 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2012, shall be granted an increase to 1, 2012, of six dollars and zero cents ($6.00) to allow for a trend adjustment to ensure quality nursing facility services;

B. The trend adjustment shall be added to the facility’s current rate as of June 30, 2012, and is effective for dates of service beginning July 1, 2012; and C. This increase is contingent upon approval by the 17. FY-2014 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2013, shall be granted an increase to their per diem rate effective for dates of services beginning July 1, 2013, of three percent (3.0%) of their current rate, less certain fixed cost items. The fixed cost items are the per diem amounts included in the facility’s current rate from the following: subsection (2)(O) of 13 CSR 70-10.110, paragraphs (11)

(D)1., (11)(D)2., (11)(D)3., (11)(D)4., (13)(B)3., and (13)(B)10. of 13 CSR 70-10.015;

B. The trend adjustment shall be added to the facility’s current rate as of June 30, 2013, and is effective for dates of service beginning July 1, 2013; and C. This increase is contingent upon approval by the 18. FY-2015 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2014, shall be granted an increase to 1, 2014, of one dollar and twenty-five cents ($1.25) to allow for B. The trend adjustment shall be added to the facility’s current rate as of June 30, 2014, and is effective for dates of service beginning July 1, 2014; and C. This increase is contingent upon approval by the 19. January 1, 2016 – June 30, 2016 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on January 1, 2016, shall be granted an increase to their per diem rate effective for dates of services beginning January 1, 2016, of two dollars and nine cents ($2.09) to allow for a trend adjustment to ensure quality nursing facility services;

B. The trend adjustment will not be added to the facility’s rate after June 30, 2016; and C. This increase is contingent upon approval by the Centers for Medicare and Medicaid Services and sufficient funding available through the Tax Amnesty Fund.

20. Continuation of FY-2016 trend adjustment and FY-2017 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2016, shall continue to be granted an increase to their per diem rate effective for dates of service beginning July 1, 2016, of two dollars and nine cents ($2.09);

B. Facilities with either an interim rate or a prospective rate in effect on July 1, 2016, shall be granted an increase to 1, 2016, of two dollars and eighty-three cents ($2.83) to allow for C. The trend adjustment of two dollars and eighty-three cents ($2.83) shall be added to the facility’s rate as of June 30, 2016, which includes the two dollars and nine cents ($2.09) 2016; and D. These increases are contingent upon approval by the 21. FY-2018 per diem adjustment— A. Facilities with either an interim rate or a prospective rate in effect on August 1, 2017, shall be subject to a decrease in their per diem rate effective for dates of services August 1, 2017 through June 30, 2018, of five dollars and thirty-seven cents ($5.37);

B. The per diem adjustment of five dollars and thirtyseven cents ($5.37) shall be deducted from the facility’s current rate as of July 31, 2017, and is effective for dates of service beginning August 1, 2017;

C. Effective for dates of service beginning July 1, 2018, the per diem decrease shall be reduced to four dollars and eighty-three cents ($4.83). A per diem adjustment of fifty-four cents ($0.54) shall be added to the facilities current rate as of June 30, 2018, which includes the five dollars and thirty-seven cents ($5.37) decrease, and is effective for dates of service beginning July 1, 2018; and D. This decrease is contingent upon approval by the 22. FY-2019 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2018, shall be granted an increase to their per diem rate effective for dates of services beginning July 1, 2018, of seven dollars and seventy-six cents ($7.76) to allow for a trend adjustment to ensure quality nursing facility services;

B. The rate to which the FY-2019 trend adjustment of seven dollars and seventy-six cents ($7.76) shall be added is the facility’s rate as of June 30, 2018, plus the fifty-four cents ($0.54) per diem adjustment effective July 1, 2018, set forth in subparagraph (3)(A)21.C. and is effective for dates of service beginning July 1, 2018. This trend adjustment shall result in a rate no greater than eight dollars and thirty cents ($8.30) higher than the rate in effect on January 1, 2018; and C. This increase is contingent upon approval by the 23. FY-2019 additional trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on February 1, 2019, shall be granted an increase to their per diem rate effective for dates of service February 1, 2019 through June 30, 2019, of one dollar and twenty-nine cents ($1.29) to allow for a trend adjustment to ensure quality nursing facility services;

B. The per diem adjustment of one dollar and twentynine cents ($1.29) shall be added to the facility’s rate as of January 31, 2019, and is effective for dates of service beginning February 1, 2019 through June 30, 2019;

C. Effective for dates of service beginning July 1, 2019, the per diem increase shall be reduced to fifty-four cents ($0.54). A per diem adjustment of seventy-five cents ($0.75) shall be deducted from the facility’s rate as of June 30, 2019, which includes the one dollar and twenty-nine cents ($1.29) 2019.

D. These per diem adjustments are contingent upon approval by the Centers for Medicare and Medicaid Services.

24. FY-2020 trend adjustment— A. Facilities with either an interim rate or a prospective rate in effect on August 1, 2019, shall be granted an increase to their per diem rate effective for dates of service August 1, 2019 through June 30, 2020, of one dollar and sixty-one cents ($1.61) to allow for a trend adjustment to ensure quality nursing facility services;

B. The rate to which the FY-2020 trend adjustment of one dollar and sixty-one cents ($1.61) shall be added is the facility’s rate as of July 31, 2019 set forth in subparagraph (13)(A)23.C. The FY-2020 trend adjustment shall be effective for dates of service beginning August 1, 2019 through June 30, 2020.

C. Effective for dates of service beginning July 1, 2020, the per diem increase shall be reduced to one dollar and forty-nine cents ($1.49). A per diem adjustment of twelve cents ($0.12) shall be deducted from the facility’s rate as of June 30, 2020, which includes the one dollar and sixty-one cents ($1.61) 2020.

D. These per diem adjustments are contingent upon approval by the Centers for Medicare and Medicaid Services 25. FY-2022 COVID-19 National Emergency adjustment— A. Facilities with either an interim rate or a prospective rate in effect on July 1, 2021, shall be granted an increase to their per diem rate effective for dates of service July 1, 2021, through June 30, 2022, of ten dollars and eighteen cents ($10.18) to allow for an adjustment for increases in costs associated with staffing, supplies, social distancing standards, and other factors due to the COVID-19 national emergency;

B. The rate to which the FY-2022 adjustment of ten dollars and eighteen cents ($10.18) shall be added is the facility’s rate as of June 30, 2021, set forth in subparagraph (13)

(A)24.C. The FY-2022 adjustment shall be effective for dates of service beginning July 1, 2021, through June 30, 2022.

C. The FY-2022 adjustment will not be included in the per diem rate for dates of service after June 30, 2022. A per diem adjustment of ten dollars and eighteen cents ($10.18) shall be deducted from the facility’s rate as of June 30, 2022, which includes the ten dollars and eighteen cents ($10.18) increase, and is effective for dates of service beginning July 1, 2022.

RSMo 2016.* Original rule filed July 1, 2008, effective Jan. 30, 2009. Emergency rule filed Oct. 3, 2008, effective Oct. 13, 2008, expired April 10, 2009. Emergency amendment filed Nov. 9, 2009, effective Nov. 19, 2009, expired Jan. 30, 2010. Amended:

Filed July 1, 2009, effective Jan. 30, 2010. Emergency amendment filed Sept. 20, 2011, effective Oct. 1, 2011, expired March 28, 2012.

Amended: Filed July 1, 2011, effective Dec. 30, 2011. Amended:

Filed June 20, 2012, effective Jan. 30, 2013. Amended: Filed Oct. 30, 2013, effective May 30, 2014. Amended: Filed July 15, 2014, effective Jan. 30, 2015. Amended: Filed Nov. 16, 2015, effective May 30, 2016. Amended: Filed May 16, 2016, effective Nov. 30, 2016.

Emergency amendment filed July 21, 2017, effective Aug. 1, 2017, expired Feb. 22, 2018. Amended: Filed July 21, 2017, effective Jan. 30, 2018. Amended: Filed Sept. 28, 2018, effective April 30, 2019.

Emergency amendment filed Dec. 21, 2018, terminated May 31, 2019. Emergency amendment filed May 9, 2019, effective June 1, 2019, expired Dec. 30, 2019. Amended: Filed May 9, 2019, effective Dec. 30, 2019. Emergency amendment filed Jan. 16, 2020, effective Jan. 31, 2020, expired July 28, 2020. Amended: Filed Jan. 16, 2020, effective Aug. 30, 2020. Emergency amendment filed Sept. 13, 2021, effective Sept. 27, 2021, expired March 25, 2022. Amended: Filed Sept. 13, 2021, effective March 30, 2022. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-10.017 Nursing Facility Invasive Ventilator Program {#sec-13-csr-70-10.017 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.017}

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.

(2) Reimbursement for Invasive Ventilator Care. Providers approved for participation in the Invasive Ventilator Program will receive payment in the form of a per diem add-on to their reimbursement rate established in accordance with 13 CSR 70- 10.015. The per diem add-on amount will be one hundred fifty dollars ($150.00) will be paid for MO HealthNet participants who are dependent on a ventilator full time as a means of life support.

(3) Provider Requirements for Participation in the Invasive Ventilator Program.

(A) Nursing facilities seeking to participate in the Invasive Ventilator Program must submit the following information to Missouri Medicaid Audit and Compliance (MMAC), Provider Enrollment Unit:

1. A completed Invasive Ventilator Program Provider application; and 2. Any other information or documentation requested by MMAC to assist in determining enrollment status.

(B) MMAC may enter into agreements with facilities for the participation in the MO HealthNet Invasive Ventilator Program through the provider enrollment process only if the provider agrees to the following terms:

1. The provider must maintain and provide documentation demonstrating— A. Medicaid (Title XIX) Certification;

B. The provider has the capacity and capability to provide invasive ventilator medical care as documented by DHSS, MO HealthNet Division (MHD), and MMAC records;

C. Adherence to regulatory requirements established by DHSS, MHD, and MMAC;

D. The medical condition of the participant to verify they meet the criteria for participation in this program; and E. The provider has the following written agreements:

(I) A written agreement with an enrolled MO HealthNet Durable Medical Equipment (DME) provider which must include a service contract for invasive ventilator equipment.

DME providers will bill MO HealthNet for the necessary ventilator;

(II) A written agreement with a local emergency transportation provider;

(III) A written agreement with a local hospital capable of providing the necessary care for invasive ventilatordependent participants, when appropriate;

(IV) Presence of written emergency procedures including but not limited to the following:

(a) Procedures to care for and transport invasive ventilator-dependent participants in the event of an emergency evacuation;

(b) Procedures to care for invasive ventilatordependent participants in the event of power failure; and (c) Procedures to care for invasive ventilatordependent participants in the event of equipment failure;

2. Individuals qualifying for participation in the Invasive Ventilator Program must be placed in contiguous rooms; and 3. In addition to the covered items and services included in the reimbursement rate set forth in 13 CSR 70-10.015— A. The nursing facility must purchase one (1) Ambu bag per invasive ventilator dependent participant and place it in a designated location readily accessible at the bedside to ensure access in the event of an emergency;

B. The provider must ensure the necessary equipment to accommodate the needs of the invasive ventilator-dependent participants is provided by the DME provider. The equipment and supplies covered under the MO HealthNet DME program will be payable directly to the DME provider;

C. Proper invasive ventilator and tracheostomy supplies and equipment are provided to the participant;

D. Each invasive ventilator is equipped with an alarm on both the pressure valve and the volume valve; and E. Each invasive ventilator is equipped with internal batteries to provide a short term back-up system in case of a total loss of power, and the battery must be checked as recommended by the manufacturer.

(C) Termination of Participation in Invasive Ventilator 1. Providers desiring to discontinue providing invasive ventilator services shall notify MMAC Provider Enrollment Unit in writing, at least sixty (60) days prior to the date of termination. Payment for invasive ventilator participants already residing in facilities who wish to discontinue providing invasive ventilator services will remain at the previous invasive ventilator rate as long as the participant meets the invasive ventilator criteria and as long as all related criteria are met by the provider or the participant is discharged.

(4) Participant Eligibility for Participation in Invasive Ventilator (A) Pre-certification must be obtained through MO HealthNet in order to receive payment under the Invasive Ventilator Program. The pre-certification must be initiated by an authorized medical assistance provider who has evaluated the medical needs of the individual. Authorized providers include physicians, advanced practice nurses, respiratory therapists, hospitals, and nursing facilities.

1. The pre-certification application will be available by contacting the Clinical Services Unit/Invasive Ventilator 2. The pre-certification period will be approved for the duration of the physician’s prescription for invasive ventilation.

If the invasive ventilator is used for weaning purposes, a precertification must be completed every ninety (90) days to ensure individuals still meet the requirements for participation in this program. An approved pre-certification request does not guarantee payment. The provider must verify participant eligibility on the date of service using the Interactive Voice Response (IVR) System at (573) 635-8908 or by logging onto the MO HealthNet Internet Web portal at www.emomed.com.

(B) Accessibility to Records. The provider must make accessible to MHD, MMAC, and/or DHSS all provider, participant, and other records necessary to determine that the needs of the participant are being met and to determine the appropriateness of invasive ventilator services.

(C) In the event that it is determined through the precertification process that the participant is no longer in need of or receiving invasive ventilator services, MHD shall discontinue the add-on per diem authorized by this regulation for the participant and reduce the rate of payment to the provider to the provider’s standard MO HealthNet per diem rate established under 13 CSR 70-10.015.

(5) Cost Reporting Requirements.

(A) Providers will be required to separately identify the invasive ventilator-dependent patient days regardless of payer source that relate to dates of service within the cost reporting time period by completing a supplemental schedule as provided by MHD.

(B) Due to the complex record-keeping requirements needed to identify the specific cost of this program, MHD will remove the cost as a revenue offset determined as follows. The days from each category identified above will be multiplied by the related Invasive Ventilator add-on amount and offset against the expenses. This will ensure the additional cost of caring for these participants will be removed from the allowable cost in determining the prospective reimbursement rate. The offset will be allocated among the cost components as follows:

Patient Care—sixty percent (60%), Ancillary—thirty percent (30%), and Administrative—five percent (5%). The remaining five percent (5%) will not be offset because the capital costs are easily identified and will be removed as non-allowable.

History

• AUTHORITY: section 208.159, RSMo 2000, and sections 208.153 and 208.201, RSMo Supp. 2012. Original rule filed April 1, 2013, effective Oct. 30, 2013. Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.159, RSMo 1979; and 208.201, RSMo 1987, amended 2007.

13 CSR 70-10.020 Prospective Reimbursement Plan for Nursing Facility and HIV Nursing Facility Services {#sec-13-csr-70-10.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.020}

PURPOSE: This rule establishes a reimbursement plan for nursing facility and HIV nursing facility services required by the Code of Federal Regulations. The plan describes principles to be followed by Title XIX nursing facility and HIV nursing facility providers in preparing and submitting cost reports and sets forth the principles and methodology for determining the reimbursement for nursing facility and HIV nursing facility providers. This rule provides for a rebasing of nursing facility and HIV nursing facility per diem rates using a more current cost report year and incorporates acuity and value based purchasing adjustments in determining the per diem rate.

(1) Authority. This regulation is established pursuant to the (2) Purpose. This regulation establishes a methodology for determination of reimbursement rates for nursing facilities and human immunodeficiency virus (HIV) nursing facilities participating in the MO HealthNet Program, which is Missouri’s Medicaid program. Hereinafter, the term nursing facility/ ies shall refer to both nursing facilities and HIV nursing facilities unless specifically stated otherwise. Subject to reimbursement rate shall be determined by the division as described in this regulation. Any reimbursement rate determined by the division shall be a final decision and will be implemented as set forth in the division’s decision letter.

The decisions of the division may be subject to review upon properly filing a complaint with the Administrative Hearing Commission (AHC). A nursing facility seeking review by the AHC must obtain a stay from the AHC to stop the division from implementing its final decision if the AHC determines the not limited to hospice providers, that the rate being received within the scope of the federal Medicaid Program and made (3) General Principles.

(A) Provisions of this reimbursement regulation shall apply only to facilities certified for participation in the MO HealthNet (B) The reimbursement rates determined by this regulation shall apply only to services provided on or after July 1, 2022.

(C) The effective date of this regulation shall be July 1, 2022.

(D) The Medicaid Program shall provide reimbursement for nursing facility services based solely on the individual Medicaid-eligible participant’s covered days of care, within benefit limitations as determined in subsections (5)(D), multiplied by the facility’s Medicaid reimbursement rate. No payments may be collected or retained in addition to the otherwise provided for in this regulation. Where third-party payment is involved, Medicaid will be the payer of last resort with the exception of state programs such as vocational rehabilitation and the Missouri Crippled Children’s Services.

(E) The Medicaid reimbursement rate shall be the lower of— 1. The Medicare (Title XVIII) rate, if applicable; or 2. The reimbursement rate as determined in accordance (F) Medicaid reimbursements shall not be paid for services provided to Medicaid-eligible participants during any time period in which the facility failed to have a Medicaid participation agreement in effect. A reimbursement rate may (G) When a nursing facility is found not in compliance with federal requirements for participation in the Medicaid Program, sections 1919(b), (c), and (d) of the Social Security Act (42 U.S.C. 1396r), it may be terminated from the Medicaid Program or it may have imposed upon it an alternative remedy, pursuant to section 1919(h) of the Social Security Act (42 U.S.C. 1396r). In accordance with section 1919(h)(3)(D) of the Social Security Act, the alternative remedy, denial of payment for new admission, is contingent upon agreement to repay payments received if the corrective action is not taken in accordance with the approved plan and timetable. It is also required that the nursing facility establish a directed plan of correction in conjunction with and acceptable to the Department of Health and Senior Services.

(H) Upon execution of a Medicaid participation agreement, the Missouri Medicaid Audit and Compliance division of the Department of Social Services.

(I) The division shall recover liabilities, sanctions, and penalties pertaining to the Medicaid Program associated with the provider number, regardless of when the services were (J) Changes in ownership, management, control, operation, leasehold interest by any form for any facility previously time that results in increased costs for the successor owner, management, or leaseholder shall not be recognized for (K) A facility with certified and noncertified beds shall allocate allowable costs related to the provision of nursing facility services on the cost report, in accordance with the cost report instructions. The methods for allocation must be supported by adequate accounting and/or statistical data necessary to evaluate the allocation method and its application.

(L) Any facility which is involuntarily terminated from from participation in the MO HealthNet Program on the same date as the Medicare termination.

(M) No restrictions nor limitations shall, unless precluded by federal or state law, be placed on a participant’s right to select providers of his/her own choice.

(N) A nursing facility’s Medicaid reimbursement rate shall not be limited by its average private pay rate.

(O) The reimbursement rates authorized by this regulation may be reevaluated in light of the provider’s cost experience to determine any adjustments needed.

(P) Covered supplies, such as food, laundry supplies, housekeeping supplies, linens, medical supplies, but not limited to, must be accounted for through inventory accounts.

Purchases shall be recorded as inventory and shall be expensed in the fiscal year the items are used. Inventory shall be counted at least annually to coincide with the end of the cost report period. Expensing of items shall be recorded by adding purchases to the beginning period inventory and subtracting the end of the period inventory. This inventory control shall begin the first fiscal year ending after the effective date of this plan.

(Q) Medicaid reimbursement will not be paid for a Medicaideligible resident while placed in a non-certified bed in a (R) All illustrations and examples provided throughout this (S) Reimbursement of Medicare/Medicaid crossover claims

Part C inpatient skilled nursing facility benefits shall be as 1. Crossover claims for Medicare Part A inpatient skilled A. The crossover claim must be related to Medicare Part B. The crossover claim must contain approved hundred (100) of each Medicare benefit period;

C. The Other Payer paid amount field on the claim D. The nursing facility’s Medicaid reimbursement rate 2. Crossover claims for Medicare Advantage/Part C (Medicare Advantage) inpatient skilled nursing facility benefits in which a Medicare Advantage plan was the primary payer and the MO HealthNet Division is the payer of last resort for the copay (coinsurance) must meet the following criteria to be A. The crossover claim must be related to Medicare Medicare Beneficiary Plus (QMB Plus);

B. The crossover claim must be submitted as a Medicare online Internet billing system;

C. The crossover claim must contain approved coinsurance days. The amount indicated by the Medicare Advantage plan to be the coinsurance due on the Medicare Advantage plan allowed amount is the crossover amount eligible for MO are established by each Medicare Advantage plan;

D. The Other Payer paid amount field on the claim must plan. The MO HealthNet provider is responsible for accurate E. The nursing facility’s Medicaid reimbursement rate 3. MO HealthNet reimbursement will be the lower of— A. The difference between the nursing facility’s Medicaid B. The coinsurance amount; and 4. Nursing facility providers may not submit a MO (4) Definitions.

(A) Administration. This cost component includes costs reported in the cost report on lines 111-150.

(B) Age of beds. The age is determined by subtracting the initial licensing year from the rate base year used to determine the prospective rate.

(C) Allowable cost. Those costs which are allowable for determined by the MO HealthNet Division and shall be based upon criteria and principles included in this regulation, the Medicare Provider Reimbursement Manual (CMS Publications 15-1 and 15-2), and Generally Accepted Accounting Principles (GAAP).

Criteria and principles will be applied using this regulation as the first source, the Medicare Provider Reimbursement Manual as the second source, and GAAP as the third source.

(D) Ancillary. This cost component includes costs reported in the cost report on lines 71-101.

(E) Asset value. The asset value is the per bed cost of construction used in calculating a facility’s capital cost component per diem utilizing the fair rental value (FRV) system as set forth in subsection (11)(D).

1. The 2019 asset value used in setting rates effective July 1, 2022, is sixty-four thousand seven hundred one dollars ($64,701) and is calculated as follows:

A. The median cost per square foot for nursing facilities of one hundred fifty-six dollars ($156) is multiplied by the average square feet per bed of four hundred thirty-five (435).

This product is adjusted for Missouri cities. The sources of the data are as follows:

(I) Median cost per square foot – 2019 Building Construction Costs with RSMeans Data publication, 50 17 | Project Costs table, Unit Costs Median of Total Project Costs for Nursing Home and Assisted Living;

(II) Average square feet per bed – 2019 cost report data bank; and (III) Adjustment for Missouri cities – 2019 Building Construction Costs with RSMeans Data publication, City Cost Indexes table, Weighted Average index for Missouri cities.

2. The 2019 asset value is adjusted annually on July 1 using the Historical Cost Indexes table from the Building Construction Costs with RSMeans Data publication for each year.

3. The adjusted asset values will be used to update the capital rate annually as set forth in paragraph (11)(H)4. and to set the prospective rate for new facilities. The asset value for the year relative to the rate base year (i.e., the end of the rate setting period) shall be used to determine the prospective rate for new facilities.

(F) Audit. The examination or inspection of a provider’s cost report, files, and any other supporting documentation by the MO HealthNet Division or its authorized contractor. The MO HealthNet Division or its authorized contractor may perform the following types of audits:

1. Level I Audit - Requires a limited review of provider cost contractor. The limited review may include but is not limited to items such as a comparative analysis of a provider’s cost report data to industry data, a review of a provider’s prior year data to determine any outliers that may warrant further review, requesting additional details of the reported information, all of which could lead to potential adjustment(s) after such further review, as well as making any standard adjustments. Level I audits may be provided off-site;

2. Level II Audit - Requires a desk review of provider cost contractor. The desk review may include but is not limited to review procedures in a Level I Audit, plus a more detailed analysis of a provider’s cost report data to identify items that would require further review including requesting additional details of the reported information or documentation to support amounts reflected in the cost report, all of which could lead to potential adjustment(s) after such further review, as well as making any standard adjustments. Level II audits may be provided off-site; and 3. Level III Audit – Requires an in depth audit, including but not limited to an on-site review of provider cost reports, files, and any other additional information requested and submitted to the MO HealthNet Division or its authorized contractor. The Level III Audit will require an in-depth analysis of a provider’s cost report data and an on-site verification of cost report items deemed necessary through a risk assessment or other analyses, all of which could lead to potential adjustment(s) after such further review, as well as making any standard adjustments. Level III audits will require some portions of the provider’s records review be provided on-site.

(G) Average private pay rate. The usual and customary charge for private pay patients determined by dividing total private patient days of care into private pay revenue, net of contractual allowances, for the same service that is included in the Medicaid reimbursement rate. Private pay revenue excludes negotiated payment methodologies with state or federal agencies such as the Veteran’s Administration or the Missouri Department of Mental Health. Bad debts, charity care, and other miscellaneous discounts are not subtracted from private pay revenue in the computation of the average private pay rate.

(H) Bad debt. The difference between the amount expected to be received (i.e., revenues less contractual allowance) and the amount actually received. This amount may be written off as uncollectible after all collection efforts are exhausted.

Collection efforts must be documented and an aged accounts receivable schedule should be kept. Written procedures should be maintained detailing how, when, and by whom a receivable may be written off as a bad debt.

(I) Bed days. The total number of days that are available to care for patients based on a facility’s total licensed beds, regardless of whether the bed is occupied or not. Bed days are calculated by multiplying the number of beds licensed during the cost report period times the days in the cost report period.

If the facility is removing the noncertified area revenues and expenses by completing a worksheet 1 of the cost report, bed days are calculated by multiplying the number of beds certified during the cost report period times the days in the cost report period.

(J) Capital. This cost component will be calculated using a fair rental value system (FRV). The fair rental value is reimbursed in lieu of the costs reported in the cost report on lines 102-110.

(K) Capital asset. A facility’s building, building equipment, improvements, and leasehold improvements as defined in the Medicare Provider Reimbursement Manual. Motor vehicles are excluded from this definition.

(L) Capital asset debt. The debt related to the capital assets as determined from the cost report.

(M) Capital expenditures. Capital costs incurred for improving a facility.

(N) Case Mix Index (CMI). Weight or numeric score assigned to a resident classification system (e.g., Resource Utilization Group (RUG), Patient-Driven Payment Model (PDPM), etc.) grouping to reflect the relative resources predicted to care for a resident. The average acuity level of patients in a facility can be determined and expressed by calculating an average of the individual CMI values for each resident. Resident classifications are determined from information derived from the Minimum Data Set (MDS) evaluations for a given period.

1. Resident classification systems used to determine CMI.

A. RUG IV. Effective for dates of service from July 1, 2022, through June 30, 2024, the Resource Utilization Group (RUG) IV, 48 groups, Logic Version 1.03, CMI Set F01 (48-Grp)

(i.e., RUG IV 48 group model classification system) is used to determine the CMIs used in this regulation and is incorporated by reference and made a part of this rule as published by the Centers for Medicare & Medicaid Services (CMS) at its website, https://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/NursingHomeQualityInits/ NHQIMDS30TechnicalInformation, June 29, 2022. Applicable files are RUG-IV DLL Package V1.04.1 Final (.zip) and RUG III Files & RUG IV Files (.zip). This rule does not incorporate any subsequent amendments or additions.

B. Patient Driven Payment Model (PDPM). Effective for dates of service beginning July 1, 2024, the PDPM nursing component case mix groups (CMG) and case mix index table effective October 1, 2023, as listed in the final Skilled Nursing Facility Prospective Payment System (SNF PPS) payment rule for FY 2024, as published by the Office of the Federal Register at 7 G Street NW, Suite A-734, Washington, DC 20401, August 7, 2023, is used to determine the CMIs used in this regulation and is incorporated by reference and made a part of this rule.

This rule does not incorporate any subsequent amendments or 2. Individual CMIs are calculated as follows:

A. Providers should follow CMS guidelines for completing and submitting MDS assessments. No extra MDS assessments are required as a result of this rule;

B. An index maximizing methodology is used to calculate the individual CMI for RUG classifications. The index maximizing classification system will select the RUG with the highest CMI for individuals that qualify for multiple RUGs; and C. A hierarchical methodology is used to determine the individual CMI for the PDPM nursing component classifications.

(I) The hierarchical classification system will work through the PDPM nursing classifications in order and select the first group for which the patient qualifies.

(II) The nursing classification hierarchical order includes— (a) Extensive services;

(b) Special care high;

(c) Special care low;

(d) Clinically complex;

(e) Behavioral symptoms and cognitive perfor manc e; and (f) Reduced physical function.

(III) The first of the twenty-five (25) individual PDPM nursing groups for which the patient qualifies is the assigned PDPM nursing classification.

3. Facility CMIs are calculated as follows:

A. Facility CMI calculations will be based on quarterly point-in-time data snapshots. These snapshot dates are January 1, April 1, July 1, and October 1;

B. The midnight census will determine the residents that are included in the facility’s CMI;

C. The Assessment Reference Date (ARD) will be used to determine the assessment included in each quarterly CMI calculation;

D. A look-back period of one hundred eighty (180) days will be used to determine the residents included in calculating the facility CMI. The look-back period cutoff date is the day prior to the snapshot date (i.e., for the January 1 CMI calculation, the ARD would need to be December 31 or earlier);

E. The most current MDS assessment for an individual in the look-back period of one hundred eighty (180) days will be used;

F. Only assessments that are included in the MDS data sent to the state through the CMS system will be available for case mix calculations;

G. An average acuity level will be determined for each facility for each snapshot date by using a simple average of the CMI values for all residents included in the data for the snapshot date.

(I) Medicaid CMI. The average acuity level for Medicaid patients in a facility.

(a) Medicaid pending residents will be included in the facility’s Medicaid CMI calculation.

(b) Medicaid hospice residents will be included in the facility’s Medicaid CMI calculation.

(c) Medicaid managed care residents will be included in the facility’s Medicaid CMI calculation.

(II) Total CMI. The average acuity level for all patients in a facility; and H. When facility-specific CMI data is not available, the statewide average CMI will be used.

4. Resident listings.

A. Nursing facilities will be provided a draft resident listing to review for accuracy and will be given a minimum of two (2) weeks to correct resident listings that are not accurate.

(I) The draft resident listing will include resident specific information including but not limited to— (a) The resident’s name and identification number;

(b) The payment source;

(c) The ARD;

(d) The PDPM nursing code and corresponding CMI;

(e) Whether the resident has a mental illness di agnosis tha t qualifies for the mental illness diagnosis add-on which is used to determine the facility’s Medicaid CMI; and (f) Whether the facility qualifies for the mental illness diagnosis add-on.

(II) Nursing facilities will be notified when the draft resident listings are available to review and will include the due date for when all corrections must be done.

B. Facilities may submit corrections to the draft resident listings as follows:

(I) Payer source. Corrections to the payer source for a resident should be submitted to the division or its authorized contractor; and (II) Other corrections. Any corrections to the data other than corrections to the payer source must be submitted through the CMS Internet Quality Improvement and Evaluations System (iQIES). Chapter 5 of the Long-term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual discusses submission and correction of MDS assessments. The RAI manual is incorporated by reference in this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Blvd., Baltimore, MD 21244, October 1, 2024. This rule does not C. A final resident listing will be prepared based on the draft resident listing plus any corrections submitted by the facility by the due date.

D. No corrections will be accepted after the due date unless the division or its authorized contractor has given prior approval.

E. The final resident listing will be used to determine the CMI and mental illness diagnosis add-on included in a facility’s per diem rate and will be provided when the final per diem rate is determined.

F. If any of a facility’s corrections that were submitted on a timely basis were not captured in the final resident listing, the facility may submit a request to the division or its authorized contractor to review. The request must include documentation supporting their claim.

(O) Ceiling. The ceiling is the maximum per diem rate for which a facility may be reimbursed for the patient care, ancillary, and administration cost components, and is determined by applying a percentage to the median per diem for the patient care, ancillary, and administration cost components. The percentage is one hundred twenty percent (120%) for patient care, one hundred twenty percent (120%) for ancillary, and one hundred ten percent (110%) for administration.

(P) Certified bed. Any licensed nursing facility or hospital based bed that is approved by the Department of Social Services to participate in the Medicaid Program.

(Q) Change of ownership. A change in ownership, control, operator, or leasehold interest, for any facility certified for (R) Charity care. Offset to gross billed charges to reduce charges for free services provided to specific types of residents, (i.e., charity care provided by a religious organization for members, etc.).

(S) CMS Market Basket Index. An index that measures the price movements of goods, services, and labor purchased by nursing homes. The index is published quarterly in the IHS Markit/Healthcare Cost Review. The “Total - %MOVAVG” index from “Table 6.7 CMS Nursing Home without Capital Market Basket” shall be used for the trending calculations in this

regulation. The same or comparable index and table shall continue to be used, regardless of any changes in the name or title of the publication, publisher, or table.

(T) Contractual allowance. A contra revenue account to reduce gross charges to the amount expected to be received.

Contractual allowances represent the difference between the private pay rate and a contracted rate which the facility contracted with an outside party for full payment of services rendered (i.e., Medicaid, Medicare, managed care organizations, etc.). No efforts are made to collect the difference.

(U) Cost components. The groupings of allowable costs used ancillary, capital, and administration.

(V) Cost report. The Financial and Statistical Report for Nursing Facilities, cost report instructions, all worksheets supplied by the division for this purpose, and required attachments as specified in paragraph (10)(A)7. of this regulation. The cost report shall detail the cost of rendering both covered and noncovered services for the fiscal reporting period in accordance with this regulation and the cost report instructions and shall be prepared on forms provided by and/or as approved by the division.

1. Cost Report version MSIR-1 (3-95) and cost report instructions (revised 3-95) shall be used for completing cost reports with fiscal years ending on or after January 1, 1995, and shall be denoted as CR (3-95).

2. Cost report version MSIR-1 (3-95) and cost report instructions (revised 3-95) 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, June 30, 2022. This rule does not (W) Data bank. The data from the rate base year cost reports used to determine the medians, ceilings, and per diem rates for nursing facilities.

3. A separate data bank shall be created for nursing facilities and HIV nursing facilities, as follows:

A. The data bank for nursing facilities shall include all nursing facilities except hospital based facilities and HIV facilities; and B. The data bank for HIV nursing facilities shall only include HIV nursing facilities.

2. If a facility has more than one (1) cost report with periods ending in the rate base year, the cost report covering a full twelve- (12-) month period ending in the rate base year will be used. If none of the cost reports cover a full twelve (12) months, the cost report with the latest period ending in the rate base year will be used. Beginning with the SFY 2025 rebase, cost reports must cover more than three (3) full months to be used for rebasing. Cost reports covering three (3) months or less will not be used. If a facility does not have a cost report for the rebase year, the cost report for the year prior to the rebase year shall be used.

3. Nursing facilities that terminated from the MO HealthNet program during the rate base year shall not be included in the 4. Nursing facilities operating under an interim rate that have at least a second full year cost report after entering the Medicaid program that coincides with the rate base year may be included in the data bank. Interim rate facilities without such a cost report for the rate base year shall not be included in the data bank. Beginning with the SFY 2025 rebase, nursing facilities operating under an interim rate will not be included in the data bank.

4. The initial rate base year used for rebasing shall be 2019 and the data bank shall include cost reports with an ending date in calendar year 2019. The 2019 rebase year data shall be used to set rates effective for dates of service beginning July 1, 2022, through such time rates are rebased again or calculated on some other cost report as set forth in regulation. The 2019 year data shall be adjusted for the following and shall be used to determine the medians, ceilings, and per diem rates for the nursing facilities:

A. The following allowable salaries shall be adjusted by two percent (2%):

(I) Aides and orderlies (Line 53 of CR (3-95));

(II) Dietary salaries (Line 60 of CR (3-95));

(III) Laundry salaries (Line 85 of CR (3-95));

(IV) Housekeeping salaries (Line 91 of CR (3-95)); and (V) Beauty and barber salaries (Line 94 of CR (3-95));

B. The total allowable costs, including the salary adjustments detailed above in subparagraph (4)(W)5.A., shall be trended through June 30, 2022, by the difference in the CMS Market Basket Index (i.e., the “Total – %MOVAVG” index for 2022:2 from the fourth-quarter 2021 publication) and the midpoint of the facility’s rate setting cost report year; and C. The total patient care costs, including the salary adjustments and trends, shall be adjusted to match the state wide a verage total CMI by multiplying the total patient care costs by the quotient of the state-wide average total CMI divided by the facility cost report total CMI.

(I) A cost report total CMI is determined for each facility based on a simple average of the four (4) quarterly total CMIs covering the facility’s cost report period.

(II) The state-wide total CMI is a simple average of the cost report CMIs for all nursing facilities included in the databank.

6. SFY 2025 rebase. Effective for dates of service beginning July 1, 2024, nursing facility rates shall be rebased using a data bank with cost report ending dates in calendar year 2022, except in instances where 2022 data is not available as explained in paragraph (4)(W)2. of this rule. The 2022 rebase year data shall be used to set rates effective for dates of service beginning July 1, 2024, through such time rates are rebased again or calculated on some other cost report as set forth in

regulation. The 2022 base year data shall be adjusted for the following and shall be used to determine the medians, ceilings, and per diem rates for the nursing facilities:

A. The following allowable salaries shall be adjusted by two percent (2%):

(I) Aides and orderlies (Line 53 of CR (3-95));

(II) Dietary salaries (Line 60 of CR (3-95));

(III) Laundry salaries (Line 85 of CR (3-95));

(IV) Housekeeping salaries (Line 91 of CR (3-95)); and (V) Beauty and barber salaries (Line 94 of CR (3-95));

B. The total allowable costs, including the salary adjustments detailed above in subparagraph (4)(W)6.A. of this

rule, shall be trended through June 30, 2024, by the difference in the CMS Market Basket Index (i.e., the “Total—%MOVAVG” index for 2024:2 from the first-quarter 2024 publication) and the midpoint of the facility’s rate setting cost report year; and C. The total patient care costs, including the salary adjustments and trends, shall be adjusted to match the state wide a verage total CMI by multiplying the total patient care costs by the quotient of the state-wide average total CMI divided by the facility cost report total CMI.

(I) A cost report total CMI is determined for each facility based on a resident-weighted average of the four (4) quarterly total CMIs covering the facility’s cost report period.

(II) The state-wide total CMI is a simple average of the cost report CMIs for all nursing facilities included in the databank.

(X) Department. The department, unless otherwise specified, (Y) Department of Health and Senior Services. The department of the state of Missouri responsible for the survey, certification, and licensure of nursing facilities as prescribed in

Chapter 198, RSMo.

(Z) Director. The director, unless otherwise specified, refers to (AA) Division. Unless otherwise specified, division refers to (BB) Entity. Any natural person, corporation, business, partnership, or any other fiduciary unit.

(CC) Facility asset value. Total asset value less adjustment for (DD) Facility fiscal year. A facility’s twelve- (12-) month fiscal reporting period. If the facility is also participating in the Title XVIII Medicare (Medicare) program, the Medicaid cost report period shall be the same as the Medicare cost report period.

If the provider does not participate in Medicare, the Medicaid cost report should have the same twelve- (12-) month fiscal year consistent with the facility’s accounting and reporting period.

(EE) Facility size. The number of licensed nursing facility beds as determined from the cost report.

(FF) Fair rental value (FRV) system. The methodology used to (GG) Generally accepted accounting principles (GAAP).

(HH) Hospital based. Any nursing facility bed licensed and certified which is physically connected to or located in a hospital.

(II) Interim rate. The interim rate is the sum of one hundred percent (100%) of the patient care cost component ceiling, ninety percent (90%) of the ancillary and administration cost component ceilings, and ninety-five percent (95%) of the median per diem for the capital cost component.

1. The median per diem for capital will be determined from the capital component per diems of providers with prospective rates in effect on July 1, 2022, for the initial 2019 rate base year.

2. Beginning with the SFY 2025 rebase, the median per diem for capital will be determined from the capital component per diems of providers included in the data bank.

(JJ) Licensed bed. Any skilled nursing facility or intermediate (KK) Minimum Data Set (MDS). A standardized, primary, and comprehensive tool used to assess a patient’s functional, medical, psychosocial, and cognitive status for residents of nursing facilities to participate in Medicare and Medicaid.

1. Providers should follow CMS guidelines for completing and submitting MDS assessments. No extra MDS assessments are required as a result of this rule.

2. Assessments should comply with CMS guidance as provided through the Resident Assessment Instrument (RAI)

Manual in effect at the time of the assessment.

3. CMS is the only source for MDS data. All MDS initial submissions, corrections, etc., must be submitted through the CMS iQIES according to CMS procedures.

4. MDS reviews. Beginning July 1, 2024, the division or its authorized contractor shall conduct reviews of a facility’s MDS data to verify that residents have been properly classified and that the facility is following CMS procedures and documentation requirements.

A. The general timeline is for MDS reviews to be performed on selected assessments contained in the most recently finalized resident listing at the start of the MDS review quarter, with the quarterly review periods and assessments continually being updated quarterly. For example, MDS reviews completed by the division or its authorized contractor during the January – March 2026 quarter will primarily review MDS assessments contained in the October 2025 final resident listing. MDS reviews completed by the division or its authorized contractor during the April – June 2026 quarter will primarily review MDS assessments contained in the January 2026 final resident listing.

B. The division or its authorized contractor will contact a facility that is the subject of an MDS review at least five (5) business days prior to the review.

C. An entrance conference will be held at the beginning of each day of the MDS review. The facility will be provided a list of MDS assessments to be reviewed that day for which the facility must provide documentation to support the assessment.

(I) A facility liaison will be required to locate, navi ga te, or otherwise assist with medical record documentation requested by the Registered Nurse (RN) Reviewer(s).

(II) Only the original legal medical record supported documentation will be accepted.

(III) Creating or altering original legal medical record supporting documentation before, during, or after the case mix review is not permissible. Suspected intentional alteration of or creation of supporting documentation after MDS assessments have been completed and transmitted or during the case mix review shall be reported to the Missouri Department of Social Services and referred to the Medicaid Fraud Control Unit of the Attorney General’s Office of Missouri for investigation of possible fraud. Such an investigation could result in a felony or misdemeanor criminal conviction. In addition, the state may exercise the right to complete an additional review.

D. An exit conference will be held at the end of each day of the MDS review to discuss the preliminary results of the review completed that day.

(I) No new, additional information will be accepted for MDS assessments completed that day after the exit conference begins.

E. Informal reconsideration request. If a facility disagrees with the MDS review findings, a written request for an informal reconsideration must be submitted to the division or its authorized contractor within fifteen (15) business days following the close of the MDS review (i.e., after the last exit conference). Otherwise, the results of the MDS review findings are considered final.

(I) If an informal reconsideration request is submitted, it must contain specific details surrounding which MDS review findings the facility disagrees with and the reasons or justifications behind those disagreements.

(II) Only documentation submitted during the initial review may be considered in the reconsideration request and no new documentation may be presented.

(III) Reconsiderations of MDS review findings not filed in accordance with the above timeline, and only filed at the issuance of the recalculated per diem rate or posting of the revised final resident listing, will not be considered.

(IV) The division or its authorized contractor will review the facility’s informal reconsideration request within fifteen (15) business days of receipt of the request and will send written notification of the final results of the reconsideration to the facility.

F. After the close of the MDS review, the division or its authorized contractor shall submit its findings in an MDS Review Summary letter to the facility within twenty (20) business days following the final exit conference date. If the facility submitted an informal reconsideration request, the MDS Review Summary letter may be delayed.

G. Validation Improvement Plan (VIP). If the results of the MDS review indicate a substantial percentage of unsupported assessments, the facility may be required to complete a Validation Improvement Plan (VIP). If required, the details and guidelines for a VIP will be outlined in the MDS Review Summary letter. Should a facility not follow the VIP requirements, additional action may be taken by the division, such as an expedited subsequent MDS review.

H. MDS submissions that are not correct will be adjusted and will be used to recalculate the PDPM and associated CMI. A revised final resident listing with the corrected PDPM assessment classification and recalculated CMI for the period under MDS review will be prepared and issued to the facility upon completion of the MDS review process, or upon completion of the informal reconsideration process, if applicable.

I. Rate adjustments.

(I) A facility’s per diem rate will be adjusted based on the revisions to the PDPM and associated CMI after the initial training and education period, as set forth below in section (12) of this rule.

(II) MDS reviews completed on assessment data contained in the January and April final resident listings may impact July 1 per diem rates.

(III) MDS reviews completed on assessment data contained in the July and October final resident listings may impact January 1 per diem rates.

(LL) Minimum utilization days. Calculated number of patient days, based on the minimum utilization percentage, which will be used in the determination of the facility’s administration and capital cost component per diems if the facility’s occupancy is below the minimum utilization percent set forth in subsection (7)(N). Minimum utilization days are calculated by multiplying the facility’s bed days by the minimum utilization percent set forth in subsection (7)(N).

(MM) Miscellaneous discounts/other revenue deductions.

A contra revenue account to reduce gross charges to the amount expected to be received. These deductions represent other miscellaneous discounts not specifically defined as a bad debt. Written policies must be maintained detailing the circumstances under which the discounts are available and must be uniformly applied.

(NN) Median. The middle value in a distribution, above and below which lie an equal number of values. The distribution for purposes of this regulation includes the per diems calculated for each facility based on or derived from the data in the data bank. The per diem for each facility is the allowable cost per day which is calculated by dividing the facility’s allowable costs by the patient days. For the administration cost component, each facility’s per diem included in the data bank and used to determine the median shall include the adjustment for minimum utilization set forth in subsection (7)

(N) by dividing the facility’s allowable costs by the greater of the facility’s actual patient days or the calculated minimum utilization days.

(OO) Medicare Provider Reimbursement Manual (CMS Publications 15-1 and 15-2). Guidelines and policies to implement Medicare (Title VIII) regulations which set forth principles for determining the reasonable cost of provider services.

1. The Medicare Provider Reimbursement Manual (CMS Publications 15-1 and 15-2) is incorporated by reference and made a part of this rule as published by the Centers for Medicare & Medicaid Services (CMS) at its website https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper- Based-Manuals-Items/CMS021929 and https://www.cms.gov/ Regulations-and-Guidance/Guidance/Manuals/Paper-Based- Manuals-Items/CMS021935, June 29, 2022. This rule does not 2. The federal regulations 42 CFR 413 forming the basis of the Medicare Provider Reimbursement Manual (CMS Publications 15-1 and 15-2) is incorporated by reference and made a part of this rule as published by CMS at its website https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/

part-413?toc=1, June 29, 2022. This rule does not incorporate any subsequent amendments or additions.

3. The Medicare Provider Reimbursement Manual (CMS Publications 15-1 and 15-2) shall be referred to as the Medicare PRM throughout this regulation.

(PP) Nursing facility (NF). Effective October 1, 1990, skilled 198, RSMo, participating in the Medicaid program will all be 1. HIV nursing facility. A nursing facility that operates exclusively for persons with the human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS) and that was granted an exemption from Certificate of Need under section 197.316, RSMo.

2. New MO HealthNet nursing facility. A qualified facility not previously certified for participation in the Medicaid program within the last twenty-four (24) months. A new MO HealthNet nursing facility shall be given an interim reimbursement rate until a prospective rate is established on its rate setting cost report. A facility previously Medicaid certified within the last twenty-four (24) months (i.e., a facility that terminated participation in the MO HealthNet program and subsequently re-enrolled in the MO HealthNet program) is not considered to be a new MO HealthNet nursing facility regardless of any changes, including but not limited to a change of ownership, change of operator, tax identification change, merger, bankruptcy, name change, address change, payment address change, Medicare number change, National Provider Identifier (NPI) change, or facilities/offices that have been closed and reopened at the same or different locations. This includes replacement facilities, which are newly constructed facilities with beds never certified for Medicaid or previously licensed by the Department of Health and Senior Services and put in service in place of existing Medicaid beds.

(QQ) Occupancy rate. The occupancy rate is the percentage of a facility’s capacity that is occupied by patients. This may also be referred to as occupancy, utilization, or utilization rate.

1. Total occupancy rate. A facility’s total actual patient days from the cost report. For a distinct part facility that only has

part of its total licensed beds certified for participation in the MO HealthNet program and that completes a worksheet one of the cost report, the occupancy rate is determined by dividing the total actual patient days from the certified portion of the facility by the total bed days from the certified portion for the same period from the cost report.

2. Medicaid occupancy rate. A facility’s Medicaid patient days divided by the total patient days for the same period as determined from the cost report.

(RR) Patient care. This cost component includes costs reported in the cost report on lines 46-70.

(SS) Patient day. The period of service rendered to a patient purposes. “Patient day” includes the allowable temporary leaveof-absence days per subsection (5)(D). The day of discharge is not a patient day for reimbursement unless it is also the day of admission.

(TT) Per diem. The daily rate calculated using this regulation’s cost components and used in the determination of a MO HealthNet facility’s prospective and/or interim rate.

(UU) Provider or facility. A nursing facility or HIV nursing facility with a valid Medicaid participation agreement with the Department of Social Services for the purpose of providing nursing facility or HIV nursing facility services to Title XIXeligible participants.

(VV) Prospective rate. The MO HealthNet reimbursement rate determined from the rate setting cost report.

(WW) Rate setting period or rate base year. The period in which a facility’s MO HealthNet’s prospective rate is determined. The cost report that contains the data covering this period will be used to determine the facility’s prospective rate and is known as the rate setting cost report or rate base year cost report.

(XX) Reimbursement rate. A prospective or interim rate.

(YY) Related parties. Parties are related when any one (1) of 1. An entity where, through its activities, one (1) entity’s exceed those which are usual and customary in such dealings;

2. An entity has an ownership or controlling interest in another entity; and the entity, or one (1) or more relatives of other entity. For the purposes of this paragraph, ownership, entity directly, or through a subsidiary, operates a facility; and 3. As used in this regulation, the following terms mean:

A. Indirect ownership/interest means an ownership B. Ownership interest means the possession of equity in the capital, in the stock, or in the profits of an entity.

Ownership or controlling interest is when an entity— (I) Has an ownership interest totaling five percent (5%)

(II) Has an indirect ownership interest equal (III) Has a combination of direct and indirect ownership (IV) Owns an interest of five percent (5%) or more in (V) Is an officer or director of an entity; or (VI) Is a partner in an entity that is organized as a C. Relative means person related by blood, adoption, or (ZZ) Restricted funds. Funds, cash, cash equivalent, or (AAA) Total facility size. Facility size plus increases minus decreases of licensed nursing facility beds plus calculated bed equivalents for renovations/major improvements.

(BBB) Unrestricted funds. Funds, cash, cash equivalents, income from endowments that are given to a provider without (5) Covered Supplies, Items, and Services. All supplies, items, that would otherwise be covered in a reimbursement rate but which are also billable to the Title XVIII Medicare Program the Title XVIII Medicare Program. Covered supplies, items, and services include but are not limited to the following:

(A) Supplies, items, and services required by federal or state law or regulation that must be provided by nursing facilities participating in the Title XIX program;

(B) Room and board. A private room must be provided, at no additional charge, if it is necessary to isolate a participant due to a medical or social condition, examples of which may be contagious infection or loud irrational speech;

(C) Temporary leave of absence days for Medicaid participants, months and not to exceed twelve (12) days for the second six (6) calendar months. Temporary leave of absence days must be specifically provided for in the participant’s plan of care and prescribed by a physician. Periods of time during which a participant is away from the facility visiting a friend or relative are therapeutic home leave days and considered temporary leaves of absence. Hospital leave days, as defined in 13 CSR 70- 10.070, are also considered temporary leaves of absence and each hospital leave day is counted as two (2) temporary leave of absence days in determining the twelve (12) allowable leave days for each six- (6-) month period described above;

(D) Provision of personal hygiene and routine care services (E) All laundry services, including personal laundry;

(F) All dietary services, including special dietary supplements (G) All consultative services required by federal or state law (H) All therapy services required by federal or state law or (I) All routine care items including but not limited to those (J) All nursing services and supplies including but not limited to those items specified in Appendix A to this regulation; and (K) All non-legend antacids, non-legend laxatives, nonlegend stool softeners, and non-legend vitamins. Providers may not elect which non-legend drugs in any of the four (4) categories to supply; any and all must be provided to residents as needed and are included in a facility’s reimbursement rate.

(6) Non-covered Supplies, Items, and Services. Non-covered supplies, items, and services include but are not limited to the (A) Supplies, items, and services which are not covered in a facility’s reimbursement rate;

(B) Supplies, items, and services billable to another program in Medicaid for which payment is made directly to a provider(s) other than providers of the nursing facility services;

(C) Supplies, items, and services that are billable to Medicare or other third-party payer; and (D) Supplies, items, and services provided non-routinely to (7) Allowable Cost Areas.

(A) Compensation of Owners.

1. Compensation of services of owners shall be an allowable prescribed in subsection (8)(P).

2. Compensation shall mean the total benefit, within the payments for managerial, administrative, professional and from the provider, and additional amounts determined to be the reasonable value of the services rendered by sole proprietors or partners and not paid by any method previously described in this regulation. Compensation must be paid (whether in cash, negotiable instrument, or in kind) within seventy-five (75) days after the close of the cost report period in accordance with the guidelines published in the Medicare PRM, Part 1, Section 906.4.

(B) Covered supplies, items, and services as defined in section (5) of this regulation.

(C) Capital Assets.

1. Capital assets shall include historical costs that would include but not be limited to architectural fees, related legal fees, interest, and taxes during construction.

2. For purposes of this regulation, any asset or improvement costing greater than one thousand dollars ($1,000) and having a useful life greater than one (1) year in accordance with 3. In addition to the American Hospital Association capitalized asset and shall have a three- (3-) year useful life.

(D) Vehicle Costs. Costs related to allowable vehicles shall be accounted for as set forth below. Allowable vehicles are vehicles that are a necessary part of the operation of a nursing facility and are limited as follows: One (1) vehicle per sixty (60) licensed beds is allowable. For example, one (1) vehicle is allowed for a facility with zero to sixty (0–60) licensed beds, two (2) vehicles are allowed for a facility with sixty-one to one hundred twenty (61–120) licensed beds, and so forth. Vehicles subject to the limit include cars, trucks, vans, sport utility vehicles (SUVs), and shuttle buses. Golf carts, utility terrain vehicles (UTVs), all terrain vehicles (ATVs), and other vehicles not aforementioned in this subsection shall not be included in the total vehicle count for the limit. If the number of vehicles exceeds the limit, the oldest vehicle(s) based on the date the facility acquired the vehicle(s), and the associated costs, are allowable. Costs related to vehicles that are disallowed shall also be disallowed and adjustments made accordingly.

1. Depreciation.

A. An appropriate allowance for depreciation on allowable vehicles is reported on line 133 of CR (3-95).

B. The depreciation must be identifiable and recorded in the provider’s accounting records, based on the basis of the vehicle and prorated over the estimated useful life of the vehicle in accordance with American Hospital Association depreciable guidelines using the straight line method of depreciation from the date initially put into service.

C. The basis of vehicle cost at the time placed in service (I) The book value of the provider;

(II) Fair market value at the time of acquisition; or (III) The recognized Internal Revenue Service (IRS) tax D. The basis of a donated vehicle will be allowed to the The appraisal cost will be the sole responsibility of the nursing E. Historical cost will include the cost incurred to prepare the vehicle for use by the nursing facility.

F. When a vehicle is acquired by trading in an existing 2. Interest. Interest cost on vehicle debt related to allowable vehicles shall be reported on line 134 of CR (3-95).

3. Insurance. Insurance cost related to allowable vehicles shall be reported on line 135 of CR (3-95).

4. Rental and leases. Lease cost related to allowable vehicles shall be reported on line 135 of CR (3-95).

5. Personal property taxes. Personal property taxes related to allowable vehicles shall be reported on line 109 of CR (3-95).

6. Other miscellaneous maintenance and repairs. Other miscellaneous maintenance and repairs related to allowable vehicles shall be reported on line 135 of CR (3-95).

(E) Insurance.

1. Property insurance. Insurance cost on property of the nursing facility used to provide nursing facility services.

Property insurance should be reported on line 107 of CR (3-95).

2. Other insurance. Liability, umbrella, and other general insurance for the nursing facility should be reported on line 136 of CR (3-95).

3. Workers’ compensation insurance. Insurance cost for workers’ compensation should be reported on the applicable workers’ compensation lines on the cost report corresponding to the employee salary groupings.

(F) Rental and Leases.

1. Capitalized leases, as defined by GAAP, are to be reported on the books of the facility as if the facility owns the property (i.e., the building, equipment, and related expenses are recorded on the books of the facility) in accordance with subsections (7)(C), (E), and (G). Lease expenses shall be reported on line 103 of the CR (3-95). A facility operating its building under a capital lease shall have its capital cost component calculated using the fair rental value system. A facility may record the property insurance, real estate taxes, and personal property taxes directly on the applicable capital lines of the cost report (i.e., lines 107, 108, and 109 of CR (3-95), respectively), and include the costs of such in calculating the pass-through expenses portion of the capital rate if it meets the following criteria:

A. If the cost of the property insurance, real estate taxes, and personal property taxes are a distinct component of a facility’s operating lease for the building and the lease payment is directly affected or changed by the amount of these items; and B. The cost of the property insurance, real estate taxes, and personal property taxes included in the lease must be documented and supported by the property insurance premium notice and tax assessment notices relating to the (G) Real Estate and Personal Property Taxes. Taxes levied on or incurred by a facility used to provide nursing facility (H) Value of Services of Employees.

1. Except as provided for in this regulation, the value of services performed by employees in the facility shall be included as an allowable cost area to the extent actually compensated, either to the employee or to the supplying organization.

2. Services rendered by volunteers such as those affiliated 3. Services by priests, ministers, rabbis, and similar type (I) Employee Benefits.

3. Retirement plans.

A. Contributions to IRS qualified retirement plans shall B. Amounts funded to pension and qualified retirement plans, together with associated income, shall be recaptured, if not actually paid when due, as an offset to expenses on the 2. Deferred compensation plans.

A. Contributions shall be allowable costs when, and to B. Amounts paid by organizations to purchase tax- C. Amounts funded to deferred compensation plans 3. Types of insurance which are considered an allowable cost— A. Credit life insurance (term insurance), if required as

part of a mortgage loan agreement. An example would be insurance on loans granted under certain federal programs;

B. Where the relative(s) or estate of the employee, excluding stockholders, partners, and proprietors, is the the employees’ salary groupings; and C. Health, disability, dental, etc., insurances for (J) Education and Training Expenses.

1. The cost of on-the-job training which directly benefits shall be allowable, except for costs associated with nurse aide training and competency evaluation program which the facility may be reimbursed for under 13 CSR 70-10.120 Reimbursement for Nurse Assistant Training.

2. Costs of education and training shall include travel costs, but will not include leaves of absence or sabbaticals.

(K) Organizational Costs.

1. Organizational cost items include legal fees incurred in establishing the corporation or other organizations, necessary accounting fees, expenses of temporary directors 2. Organizational costs shall be amortized ratably over 3. Where a provider is organized within a five- (5-) year period prior to its entry into the program and has properly organizational costs is an allowable cost under the program and shall be amortized over the remaining part of the sixty- (60-) month period.

2. For change in ownership allowable amortization will be limited to the prior owner’s allowable unamortized portion of organizational cost.

(L) Advertising Costs. Advertising costs which are reasonable and accepted occurrence for providing nursing facility services.

(M) Cost of Supplies and Services Involving Related Parties.

(N) Minimum Utilization. In the event the occupancy rate of a facility is below eighty percent (80%), the administration and capital cost components will be adjusted as though the provider experienced eighty percent (80%) occupancy.

The adjustment for minimum utilization is reflected in the calculation of the per diem for the administration and capital cost components. If the provider’s occupancy is less than eighty percent (80%), the total allowable costs are divided by the minimum utilization days rather than the facility’s actual patient days. In no case may costs disallowed under this provision be carried forward to succeeding periods.

(O) Home Office or Management Company Costs. The allowability of the individual cost items contained within home office (also known as central office) or management company costs will be determined in accordance with all other provisions of this regulation. The total of home office and/or management company costs, as reported on lines 121 and 122 of CR (3-95), are limited to seven percent (7%) of gross revenues less contractual allowances.

(P) Start-Up Costs. Expenses incurred prior to opening, as straight-line method over sixty (60) months. The amortization and would be reported on line 51 of CR (3-95).

(Q) Reusable Items. Costs incurred for items such as linen and bedding shall be classified as inventory when purchased and expensed as the item is used.

(R) Nursing Facility Reimbursement Allowance (NFRA). The fee assessed to nursing facilities in the state of Missouri for the privilege of doing business in the state will be an allowable (8) Non-allowable Costs. Costs not reasonably related to nursing facility services shall not be included in a provider’s costs. Nonallowable costs include but are not limited to the following:

(A) Amortization on intangible assets, such as goodwill, leasehold rights, covenants, and purchased certificates of need;

(B) Bad debts, contractual allowances, courtesy discounts, (C) Capital cost increases due solely to changes in ownership;

(D) Charitable contributions;

(E) Compensation paid to a relative or an owner through a (F) Costs such as legal fees, accounting and administrative or purchase of any capital asset by acquisition or merger for program;

(G) Directors’ fees included on the cost report in excess of two (H) Federal, state, or local income and excess profit taxes, (I) Late charges and penalties;

(J) Finder’s fees;

(K) Fund-raising expenses;

(L) Interest expense on loans for intangible assets;

(M) Legal fees related to litigation involving the department and attorney’s fees which are not related to the provision of (N) Life insurance premiums for officers, owners, and (O) Non-covered supplies, items, and services as defined in (P) Owner’s compensation in excess of the applicable range of administrative salaries paid to individuals other than owners for proprietary and non-proprietary providers and based upon the total number of working hours.

1. Following is the division’s 2019 Owner Compensation Guidelines. The division’s 2019 Owner Compensation Guidelines shown below shall be updated annually using the CMS Market Basket Index for Wages (i.e., IHS Markit/Healthcare Cost Review publication, “Table 6.7 CMS Nursing Home without Capital Market Basket,” and the “Wages -%MOVAVG” index).

Owner Compensation Guidelines Year Bed Size Low High Median 2019 0 - 74 $55,917 $100,415 $71,552 75 - 99 $42,080 $102,208 $72,151 100 - 149 $60,132 $121,451 $78,162 150 - 200 $62,536 $122,652 $96,202 200+ $72,151 $180,379 $99,203 2. The applicable range will be determined as follows:

A. Number of licensed beds owned or managed; and B. Owners acting as administrators will be adjusted on the basis of the high range. Owners included in home office costs or management company costs will be adjusted on the high range. All others will be calculated on the median range.

3. The salary identified above will be apportioned on (Q) Prescription drugs;

(R) Religious supplies, items, or services of a primarily (S) Research costs;

(T) Resident personal purchases provided non-routinely to (U) Salaries, wages, or fees paid to nonworking officers, employees, or consultants;

(V) Cost of stockholder meetings or stock proxy expenses;

(W) Taxes or assessments for which exemptions are available;

(X) Value of services (imputed or actual) rendered by nonpaid (Y) All costs associated with nurse aide training and competency evaluation program which the facility may be reimbursed for under 13 CSR 70-10.120 Reimbursement for Nurse Assistant Training; and (Z) Losses from disposal of assets.

(9) Revenue Offsets.

(A) Other revenues must be identified separately in the revenues include but are not limited to the following:

1. Income from telephone services;

2. Sale of employee and guest meals;

3. Sale of medical abstracts;

4. Sale of scrap and waste food or materials;

5. Cash, trade, quantity, time, and other discounts;

6. Purchase rebates and refunds;

7. Recovery on insured loss;

8. Parking lot revenues;

9. Vending machine commissions or profits;

10. Sales from supplies to individuals other than nursing facility participants;

11. Room reservation charges other than covered therapeutic home leave days and hospital leave days;

12. Barber and beauty shop revenue;

13. Private room differential;

14. Medicare Part B revenues.

A. Revenues received from Part B charges through Medicare will be offset.

B. For purposes of determining reimbursement, the total therapy revenues reported on Schedule A, lines 12, 13, and 16 that are offset shall not exceed the total therapy expenses reported on Schedule B, lines 72-75 and lines 78-79.

15. Personal services;

16. Activity income; and 17. Revenue recorded for donated services and commodities.

(B) Restricted funds designated by the donor prior to the (C) Restricted funds designated by the donor for capital (D) Unrestricted funds not designated by the provider for (E) As applicable, restricted, and unrestricted funds will be (F) Any tax levies which are collected by nursing home

part by these levies, will not be offset.

(G) Gains on disposal of assets will not be offset from allowable expenses.

(10) Provider Reporting and Recordkeeping Requirements.

(A) Annual Cost Report.

1. Each provider shall adopt the same twelve- (12-) month fiscal period for completing its Medicaid cost report as is used for its Medicare cost report, if the facility also participates in the Medicare program. If the provider does not participate in Medicare, the Medicaid cost report should have the same twelve- (12-) month fiscal year consistent with the facility’s accounting and reporting period.

2. Each provider is required to complete and submit to the division or its authorized contractor an annual cost report, including all worksheets, attachments, schedules, and requests for additional information from the division or its authorized contractor. The cost report shall be submitted on forms provided by the division or its authorized contractor for that purpose.

Any substitute or computer-generated cost report must have prior approval by the division or its authorized contractor.

3. All cost reports shall be completed in accordance 4. The cost report submitted must be based on the accrual 5. Cost reports shall be submitted by the first day of the sixth month following the close of the fiscal period. A provider may request, in writing, a reasonable extension of the cost report filing date if there has been an extension granted for its Medicare cost report, if applicable, or for circumstances that are beyond the control of the provider and that are not a product or result of the negligence or malfeasance of the nursing facility. Such circumstances may include public health emergencies; unavoidable acts of nature such as flooding, tornado, earthquake, lightning, hurricane, natural wildfire, or other natural disaster; or, vandalism and/or civil disorder. The division may, at its discretion, grant the extension.

4. If a cost report is more than ten (10) days past due, withheld will be released to the provider. For cost reports which are more than ninety (90) days past due, the department agreement and if terminated retain all payments which have 7. Copies of signed agreements and other significant documents related to the provider’s operation and provision of care to MO HealthNet participants must be attached (unless otherwise noted) to the cost report at the time of filing unless current and accurate copies have already been filed with the division or its authorized contractor. Material which must be submitted or available upon request includes but is not limited to the following:

A. Audit prepared by an independent accountant, including disclosure statements and management letter or SEC Form 10-K;

B. Contracts or agreements involving the purchase requested by the division, the department, or its authorized C. Contracts or agreements with owners or related D. Contracts with consultants;

E. Documentation of expenditures, by line item, made F. Federal and state income tax returns for the fiscal year, if requested by the division, the department, or its authorized G. Leases and/or rental agreements related to the activities of the provider, if requested by the division, the department, or its authorized contractor;

H. Management contracts;

I. Medicare cost report, if applicable;

J. Review and compilation statement;

K. Statement verifying the restrictions as specified by L. Working trial balance actually used to prepare the M. Schedule of capital assets with corresponding debt.

8. Cost reports must be fully, clearly, and accurately information, documentation, or clarification requested by the division or its authorized contractor is not provided within 9. Under no circumstances will the division accept 10. Exceptions. A cost report may not be required for the A. Hospital-based providers which provide less than one thousand (1,000) patient days of nursing facility services for Missouri Title XIX participants, relative to their fiscal year;

B. Change in provider status. The cost report filing requirement for the cost report relating to the terminating provider from a change of control, ownership, or termination of participation in the MO HealthNet program is not required, unless the terminating cost report is a full twelve- (12-) month cost report. The division may waive the cost report filing requirement for the twelve- (12-) month terminating cost report or the last twelve- (12-) month fiscal year end cost report resulting from a change of control, ownership, or termination of participation in the MO HealthNet program if the old/terminating provider can show financial hardship in providing the cost report. The old/terminating provider must submit a request to the division, indicating and providing documentation for the financial hardship caused by filing the (I) If a cost report for a year that is used to calculate per diem rates is not submitted, the cost report for the year prior to the rate setting year shall be used to determine the per diem rate, consistent with subsection (4)(W) of this rule.

(II) The new provider may obtain the data needed to prepare a cost report that covers the period that the old/ terminating provider operated the facility and may submit a cost report as follows:

(a) The new provider may prepare and submit a cost report that covers the old/terminating provider’s cost report period;

(b) The new provider may combine the data from the old/terminating provider with the data from the new provider and submit a twelve- (12-) month cost report that covers the new provider’s cost report period, if it occurs in the same year as the old owner;

(c) The new provider must notify the division of its intention to complete a cost report covering the old provider’s cost report period including the cost report period that will be submitted;

(d) The cost report is due by the first day of the sixth month following the close of the cost report period, consistent with paragraph (10)(A)5. of this rule, regardless of whether the cost report covers only the old/terminating provider’s cost report period or it covers the new provider’s cost report period;

(e) It is the new provider’s responsibility to deter mine if the old/termina ting provider will submit a cost report and to obtain any information it needs; and C. New MO HealthNet facility or recertified MO Health- Net facility. The first cost report for a new facility enrolled in the MO HealthNet program or a facility that had terminated from participation in the MO HealthNet program and was recertified in the MO HealthNet program may not be required if it is a short period cost report. A short period cost report cov ers thr ee (3) months or less of nursing facility services for MO HealthNet participants, relative to the facility’s fiscal year.

(I) If the provider participates in the Medicare program, the provider must complete the MO HealthNet cost report covering the same period as the Medicare cost report unless a short period cost report would still be required by Medicare but is not required by MO HealthNet because it covers three (3) months or less. For example— (a) Example A: A facility enters the Medicaid/ Medicare program on December 20 and has a December 31 fiscal year end. If Medicare requires that the December 20 – December 31 period be combined with the subsequent year cost report, then the MO HealthNet cost report should cover the same period; and (b) Example B: A facility enters the Medicaid/ Medicare program on October 20 and has a December 31 fiscal year end. If Medicare requires that a cost report be submitted for October 20 through December 31, the facility may request that the division waive that cost report for MO HealthNet since it is within the three- (3-) month short period. The division must approve the request to waive the cost report.

(II) If the facility does not participate in Medicare, the facility must contact the division regarding the treatment of the short period cost report and the division must approve such treatment. The provider may— (a) Submit the short period cost report; or (b) Combine the short period with the cost report for the subsequent year; or (c) Choose not to submit information relating to the short period either on a stand-alone cost report basis or combined with the subsequent year cost report.

11. Notification of change in provider status and withholding of funds for a change in provider status. A provider shall notify the Institutional Reimbursement Unit of the division via email at IRU.NursingFacility@dss.mo.gov prior to a change of control, ownership, or termination of participation in the MO HealthNet program. The division may withhold funds due to a change in provider status as follows:

A. If the division receives notification prior to the in the MO HealthNet program, the division may withhold funds from the old/terminating provider’s remaining payments for any amounts owed to the division including but not limited to unpaid NFRA, overpayments, and system claim adjustment credits. If the division can determine the amount the provider owes, the division may withhold that amount from the old/ terminating provider’s remaining payments. If the division cannot determine the amount a provider owes, it may withhold a minimum of thirty thousand dollars ($30,000) of the remaining payments from the old/terminating provider.

After six (6) months, any payments withheld will be released to the old/terminating provider, less any amounts owed to the division, including but not limited to unpaid NFRA, overpayments, and system claim adjustment credits; or B. If the division does not receive notification prior to a change of control or ownership, the division may withhold funds from the provider identified in the current MO HealthNet participation agreement for any amounts owed to the division from the old/terminating provider, including but not limited to unpaid NFRA, overpayments, and system claim adjustment credits. If the division can determine the amount the old/ terminating provider owes, the division may withhold that amount from the current provider’s payments. If the division cannot determine the amount the old/terminating provider owes, it may withhold a minimum of thirty thousand dollars ($30,000) of the next available MO HealthNet payment from the provider identified in the current MO HealthNet participation agreement. If the MO HealthNet payment is less than thirty thousand dollars ($30,000), the entire payment will be withheld. After six (6) months, any payments withheld will be released to the provider identified in the current MO HealthNet participation agreement, less any amounts owed to the division, including but not limited to unpaid NFRA, overpayments, and system claim adjustment credits.

(B) Certification of Cost Reports.

1. The accuracy and validity of the cost report must be 2. The following statement must be signed on each cost CERTIFICATION STATEMENT:

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION

CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY FINE

AND/OR IMPRISONMENT UNDER STATE AND FEDERAL LAW.

CERTIFICATION OF OFFICER OR ADMINISTRATOR OF PROVIDER

I HEREBY CERTIFY that I have read the above statement and that schedules prepared by (provider name) for the cost report period beginning (date/year) and ending (date/year), and that to the best of my knowledge and belief, it is a true, correct, and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted.

AUTHORIZED SIGNATURE

TITLE

DATE

(C) Adequate Records and Documentation.

1. A provider must keep records in accordance with GAAP authorized contractor for additional information.

2. Each of a provider’s funded accounts must be separately 3. Adequate documentation for all line items on the cost for review by the division or its authorized contractor at the same site at which the services were provided or at the central or its authorized contractor upon request.

3. Each facility shall retain all financial information, data, (D) Audits.

4. Any cost report submitted may be subject to a Level III Audit (also known as a field audit) by the division or its authorized contractor.

5. A provider shall have available at the field audit location 3. If a provider maintains any records or documentation at contractor for reasonable travel costs necessary to perform any 4. Those providers initially entering the MO HealthNet pro gram shall be required to have an annual independent audit of the financial records, used to prepare annual cost reports cover ing, at a minimum, the first two (2) full twelve- (12-) month fiscal years of their participation in the MO HealthNet Program, in accordance with GAAP and generally accepted auditing standards. The audit shall include but may not be limited to the Balance Sheet, Income Statement, Statement of Retained Earnings, and Statement of Cash Flow. For example, a provid er begins participation in the Medicaid program in March and chooses a fiscal year of October 1 to September 30. The first cost report will cover March through September. That cost report may be audited at the option of the provider. The October 1 to September 30 cost report, the first full twelve- (12-) month September 30 cost report, the second full twelve- (12-) month independent certified public accountant. The independent au dit s of the first two (2) full twelve- (12-) month fiscal years may be performed at the same time. The provider may submit two (2) independent audit reports (i.e., one for each year) or they may submit one (1) combined independent audit report covering both years. The independent audit report(s) for combined audits are due with the filing of the second full twelve- (12-) month cost report. If the independent audits are combined, the provider must notify the division of such by the due date of the first full twelve- (12-) month cost report. If a provider terminates prior to the date that the independent audit is due, the inde penden t audit is not required.

(E) Joint Use of Resources.

1. If a provider has business enterprises in addition to the nursing facility, the revenues, expenses, statistical, and 2. When the facility is owned, controlled or managed by an entity(ies) that own, control, or manage one (1) or more other facilities, records of central office and other costs incurred outside the facility shall be maintained so as to to, individual facilities. Direct allocation of cost, such as RN consultant, which can be directly identifiable in the central office/home office cost and directly allocated to a facility by actual amounts or actual time spent. These direct costs shall be reported on the appropriate lines of the cost report. Allocation of central office/home office or management company costs to individual facilities should be consistent from year to year.

If a desk audit or field audit establishes that records are not maintained so as to clearly identify information required by this regulation, those commingled costs shall not be recognized as allowable costs in determining the facility’s Medicaid reimbursement rate. Allowability of these costs shall be determined in accordance with the provisions of this (11) Prospective Rate Determination. The division will use the rate setting cost report described in subsection (11)(I) to determine the nursing facility’s prospective rate, as detailed in subsections (11)(A)-(I) below.

(A) Patient Care. Each nursing facility’s patient care per diem shall be calculated as follows— 1. The base patient care per diem shall be the lower of the— A. Allowable cost per patient day for patient care as including applicable adjustments and trends; or B. Per diem ceiling of one hundred twenty percent (120%) of the patient care median determined by the division from the data bank;

2. The base patient care per diem determined in paragraph (11)(A)1. shall be adjusted by the facility’s average Medicaid CMI from the two (2) preceding quarterly calculations relative to the effective date of the rate (i.e., for 2019 rebase rates effective July 1, 2022, the January 1, 2022, and April 1, 2022, CMI calculations shall be used) and shall be the facility’s patient care per diem to be included in the facility’s total prospective per diem rate; and 3. Following is an illustration of the calculation of the patient care per diem:

Lower of Ceiling/ Per Total Patient Care Costs $3,285,275 Aides & Orderlies $918,303 Dietary Salaries $248,776 Total $1,167,079 Salary Adjustment 2% $23,342 Adjusted Patient Care $3,308,617 Trended Cost $3,563,050 Statewide Average Total CMI .8744 Cost Report Total CMI .9664 Total CMI Adjusted Costs ($3,563,050* .8744/.9664) $3,223,852 Base Patient Care Per Diem $105.79 $127.12 $105.79 Medicaid CMI .8206 Medicaid CMI Adjusted Patient Care Per Diem ($105.79* .8206/.8744) $99.28 (B) Ancillary. Each nursing facility’s ancillary per diem will be the lower of the— 1. Allowable cost per patient day for ancillary as determined by the division from the rate setting cost report, including applicable adjustments and trends; or 2. Per diem ceiling of one hundred twenty percent (120%) of the ancillary median determined by the division from the data bank;

3. Following is an illustration of the calculation of the ancillary per diem:

Lower of Ceiling / Per Total Ancillary Costs $454,281 Laundry Salaries $58,002 Housekeeping Salaries $137,329 Beauty & Barber Salaries $0 Total $195,331 Salary Adjustment 2% $3,907 Adjusted Ancillary $458,188 Trend 7.69% Trended Cost $493,423 Ancillary Per Diem $16.19 $21.48 $16.19 (C) Administration. Each nursing facility’s administration per diem shall be the lower of the— 1. Allowable cost per patient day for administration as including applicable trends, and adjusted fo r minimum utilization, if applicable, as described in subsection (7)(N); or 2. Per diem ceiling of one hundred ten percent (110%) of the administration median determined by the division from the data bank. The administration median shall be based on the administration per diems that have been adjusted for minimum utilization, if applicable, as described in subsection (7)(N);

3. Following is an illustration of the calculation of the administration per diem:

Lower of Ceiling / Per Administration Costs $1,772,163 Trended Cost $1,908,442 Minimum Utilization Days 44,384 Greater of Total Patient Days or Min. Utilization Days 44,384 Administration Per $43.00 $35.73 $35.73 (D) Capital. Each nursing facility’s capital per diem shall be determined using the fair rental value system (FRV), which consists of two (2) elements — rental value and pass-through expenses. The calculation for each element, as well as the overall capital per diem, is detailed below in paragraphs (11)

(D)1.–3.

1. Rental value.

A. Determine the total asset value.

(I) Determine facility size from the rate setting cost report. The changes in the number of licensed beds (i.e., increases and decreases) from the date the facility was originally licensed through the end of the rate setting cost report period should be determined and should result in the same number of licensed beds at the end of the facility’s rate (a) Facility size and occupancy rate adjustment.

Beginning with the SFY 2025 rebase, a facility may request a facility size and occupancy rate adjustment, which provides for the number of licensed beds as of the April 1 that precedes the July 1 rate calculation to be used to determine the facility size and occupancy rate rather than the number of licensed beds at the end of the applicable cost report period.

I. Qualifying criteria. A nursing facility may qualify for a facility size and occupancy adjustment if it meets all of the following criteria:

a. The facility operated at less than its licensed bed capacity during the cost report period used to determine the facility’s capital rate so that it could provide single occupancy accommodations;

b. The facility operated as such at least from the beginning of the facility’s cost report period used to determine the facility’s capital rate through the April 1 that precedes the July 1 rate calculation; and c. The facility reduced the number of licensed beds to be equal to the number of single occupancy rooms that the facility will operate with going forward. The reduction in licensed beds must be effective on or before the April 1 that precedes the July 1 rate calculation.

II. Calculation of adjusted facility size, adjusted occupancy rate, and adjusted per diem rate.

a. Adjusted facility size. The facility size as defined in subsection (4)(EE) of this rule and used in the determination of a facility’s capital cost component under the fair rental value system set forth in subsection (11)(D) of this

rule shall be adjusted to reflect the licensed bed capacity as of the April 1 that precedes the July 1 rate calculation.

b. Adjusted occupancy rate. The occupancy rate as defined in subsection (4)(QQ) of this rule shall be adjusted to reflect the licensed beds as of the April 1 that precedes the July 1 rate calculation rather than the licensed beds reflected on the applicable cost report. The bed days will be calculated using the licensed beds as of the April 1 that precedes the July 1 rate calculation and the adjusted occupancy rate will be calculated by dividing the facility’s total actual patient days by the adjusted bed days.

c. The adjusted facility size and the adjusted occupancy rate shall be used to determine the facility’s per diem rate in accordance with the remaining provisions of this III. The facility must request in writing the facility size and occupancy rate adjustment and provide the proper documentation to show that it qualifies for the adjustment, including the following:

a. A copy of the quarterly surveys from the beginning of the applicable cost report period through the April 1 that precedes the July 1 rate calculation showing that the facility’s number of available beds was less than its full licensed bed capacity;

b. A copy of the approved change in the number of licensed beds that includes a notation that the rooms are single occupancy;

c. A statement from the facility that it will continue to operate single occupancy rooms; and d. For the July 1, 2024, rate calculation, the division shall accept such written requests from facilities that qualify for this adjustment as of July 1, 2024, for up to thirty (30) days after the effective date of this rule. The rate adjustment shall be retroactive back to July 1, 2024. For subsequent rate calculations, a facility must submit the request, including all documentation showing that they qualify for the adjustment, to the division by the May 1 that precedes the July 1 rate calculation, and the rate adjustment shall be effective on July 1.

IV. This adjustment shall only apply to nursing facilities with a prospective rate and shall remain in effect for all subsequent rates determined from the 2022 cost report used to rebase rates.

V. Loss of facility size adjustment and recalculation of per diem rate. If a facility’s per diem rate has been calculated using an adjusted facility size and an adjusted occupancy rate and the facility ceases to operate with only single occupancy accommodations, the facility will no longer receive the adjustment to the facility size and occupancy rate in determining its per diem rate.

a. If the facility size and occupancy rate adjustment is lost, the facility’s per diem rate will be recalculated using the facility size as set forth in subsection (4)(EE) and the bed days and occupancy rate as set forth in subsection (4)(QQ) of b. The facility must notify the division within thirty (30) days if it no longer qualifies for the facility size and occupancy rate adjustment.

c. If the facility notifies the division of such within thirty (30) days, the effective date of the rate recalculation will be the date that the facility stopped operating with only single occupancy accommodations.

d. If the facility does not notify the division within thirty (30) days, the effective date of the rate recalculation will be the date the facility size and occupancy rate adjustment was originally granted. The facility shall repay the division any overpayment resulting from the loss of the facility size and occupancy rate adjustment.

(II) Determine the bed equivalency for capital expenditures from the date the facility was originally licensed through the end of the rate setting cost report period by taking the cost of the capital expenditures for each year divided by the asset value per bed for the year of the capital expenditures rounded down to the nearest whole bed. The cost of the capital expenditures must be at least the asset value per bed for the year of the capital expenditures for each bed equivalency. For example, a capital expenditures done in 2009 with a cost of two hundred seventy thousand dollars ($270,000) is equal to five (5) beds. ($270,000/$47,948 equals 5.65 beds rounded down to 5 beds).

(III) The Total Facility Size is the sum of (I) and (II).

(IV) The Total Asset Value is the total facility size times the asset value.

B. Determine the reduction for age. The age of the beds is determined by subtracting the year the beds were originally licensed from the year relative to the rate base year. The age of bed equivalencies for capital expenditures is calculated by subtracting the year the capital expenditures were made from the year relative to the rate base year. The age of the beds for multiple licensing dates (i.e., for increases and decreases in licensed beds) and multiple bed equivalencies is calculated on a weighted average method rounded to the nearest whole year.

For licensed bed decreases and replacement beds, the oldest beds are delicensed first. The reduction for age is determined by multiplying the age of the beds by one percent (1%) up to a maximum of forty percent (40%).

C. Determine the facility asset value. The facility asset value is the total asset value set forth in subparagraph (11)

(D)1.A. less the reduction for age set forth in subparagraph (11)

(D)1.B.

D. Determine the rental value. Multiply the facility asset value by six and three hundred seventy-fifths percent (6.375%) to determine the rental value. The six and three hundred seventy-fifths percent (6.375%) is comprised of two and one-half percent (2.5%), which is based on a forty- (40-) year life, plus three and eight hundred seventy-fifths percent (3.875%) for a return. The three and eight hundred seventy-fifths percent (3.875%) is based on the Treasury Bill thirty- (30-) year coupon rate in effect as of January 1, 2022, of one and eight hundred seventy-fifths percent (1.875%) plus two percent (2%).

E. The following is an illustration of how subparagraphs (11)(D)1.A., B., C., and D. determine the rental value.

(I) The following is the determination of the total facility size and the age of the beds:

Historical Base Data * Total Facility Size Age Age x Beds Licensed Beds 75 Bed Equivalents 0 Totals 75 30 2,250 * This is the cumulative, historical data previously used to determine existing nursing facilities’ prospective rates under 13 CSR 70-10.015.

Licensure History * Licensure Year No. of Bed Incr/(Decr)

From 2019 Age x Beds Bed Increases / Decreases: 2003 15 16 240 2004 5 15 75 2006 10 13 130 2008 (5) 30 (150)

Totals (Bed Incr/(Decr thru 2019) 25 295 Total Licensed Beds (Base Data + Bed Incr/(Decr)) 100 * This is the licensure history from 2002-2019 which reflects the licensure changes subsequent to the Historical Base Data shown above.

Capital Expenditure History * Year Allowable Capital Expenditures for Bed Equiv Asset Value – Year of Capital Expenditures Bed Equivalents From x Beds 2002 $1,677,164 $35,325 47 17 799 2009 $170,824 $47,948 3 10 30 2014 $310,351 $52,042 5 5 25 2018 $84,308 $53,769 1 1 1 2019 $145,692 $64,701 2 0 0 Totals (Bed Equiv. through 2019) 58 855 Total Bed Equiv. (Base Data + Bed Equiv thru 2019) 58 * This is the capital expenditure and bed equivalency history from 2002-2019 which reflects the changes subsequent to the Historical Base Data shown above.

Total Facility Size and Weighted Average Age Total Facility Size (Licensed Beds + Bed Equiv.) 158 3,400 Weighted Average Age (3,495 / 158) 22 (II) The total asset value is the product of the total facility size times the asset value.

Total facility size 158 x Asset value - 2019 $64,701 Total asset value $10,222,758 (III) Facility asset value is total asset value less the reduction for age of the beds.

Total asset value $10,222,758 x Age of beds x 1% 22% - Reduction for age (max 40%) ($2,249,007)

Facility asset value $7,973,751 (IV) Rental value is the facility asset value multiplied by 6.375%.

Facility asset value $7,973,751 x Rental value percent x 6.375% Rental value $508,327 2. Pass-through expenses.

A. Add the following pass-through expenses, including applicable trends:

(I) Property insurance – line 107 of CR (3-95);

(II) Real estate taxes – line 108 of CR (3-95); and (III) Personal property taxes – line 109 of CR (3-95).

3. Capital component per diem calculation. A per diem is calculated for each element detailed above in paragraphs (11)

(D) 1.–2., which are then added together to determine the total capital cost component per diem.

A. Rental value per diem. A per diem is calculated by dividing the rental value by the computed patient days, rounded to the nearest cent. Computed patient days are equal to the total facility size (i.e., number of licensed beds plus equivalencies) determined in part (11)(D)1.A.(III) multiplied by three hundred sixty-five (365) adjusted by the greater of the minimum utilization as determined in subsection (7)(N) or the facility’s occupancy from the rate setting cost report. The following is an illustration of how the rental value per diem is calculated:

Cost Computed Patient Days ** Per Diem Rental Value $508,327 46,136 $ 11.02 * Computed Patient Days Total facility size 158 x 365 days x 365 Subtotal 57,670 Greater of Minimum Utilization 80.00% Facility Occupancy ** 56.63% x 80.00% Computed Patient Days 46,136 ** Assumption: facility occupancy from the rate setting cost report = 56.63% B. Pass-through expenses per diem. A per diem is calculated by dividing the pass-through expenses by the greater of the minimum utilization days as determined in subsection (7)(N) or the facility’s patient days from the rate setting cost report, rounded to the nearest cent. The following is an illustration of how the pass-through per diem is calculated:

Cost Patient Days * Per Pass-Through Expenses:

Property Insurance $23,969 Real Estate Taxes $61,962 Personal Property Taxes $3,408 Total Pass-Through Expenses $89,339 Total Trended Pass-Through Expenses $96,209 43,050 $2.23 * Patient days - Greater of a. Facility patient days 30,475 b. Minimum utilization days Beddays 53,812 x Minimum Utilization Percent x 80% Minimum utilization days 43,050 C. The capital cost component per diem is the sum of the per diems determined in subparagraphs (11)(D)3.A. and B.

Rental value $11.02 Pass-through expenses $ 2.23 Total capital cost component per diem $13.25 (E) The following is an illustration of how subsections (11)

(A)–(D) determine the total per diem for the cost components:

Cost Component Per Diem Patient Care $99.28 Ancillary $16.19 Administration $35.73 Capital (FRV) $13.25 Total Cost Component Per Diem $164.45 (F) Special Per Diem Adjustments. Special per diem rate adjustments may be added to a qualifying facility’s rate 1. Patient care incentive. Each facility with a prospective rate on or after July 1, 2022, shall receive a per diem adjustment equal to four and seventy-fifths percent (4.75%) of the facility’s patient care per diem determined in paragraph (11)(A)1. subject to a maximum of one hundred thirty percent (130%) of the patient care median when added to the patient care per diem as determined in paragraph (11)(A)1. This adjustment will not be subject to the cost component ceiling of one hundred twenty percent (120%) for the patient care median.

2. Multiple component incentive. Each facility with a prospective rate on or after July 1, 2022, and which meets the A. If the sum of the facility’s patient care per diem and ancillary per diem, as determined in subsections (11)(A) and (11)

(B), is greater than or equal to seventy percent (70%), rounded to four (4) decimal places (.6985 would not receive the adjustment) of the facility’s total per diem, the adjustment is as Patient Care & Ancillary Percent of Total Rate Incentive < 70% $0.00 > or = 70% but < 75% $0.10 > or = 75% but < or = 80% $0.15 > 80% $0.20 B. A facility shall receive an additional incentive if it receives the adjustment in subparagraph (11)(F)2.A. and if the facility’s Medicaid utilization percent is greater than eighty-five percent (85%), rounded to four (4) decimal places (.8485 would not receive the adjustment). The adjustment is as follows:

Medicaid Utilization Percent Incentive < 85% $0.00 > or = 85% but < 90% $0.10 > or = 90% but < 95% $0.15 > or = 95% $0.20 3. Value Based Purchasing (VBP) Incentive. Each facility with a prospective rate on or after July 1, 2022, and which meets the following criteria shall receive a per diem adjustment:

A. The facility shall receive a per diem adjustment for each Quality Measure (QM) Performance threshold that it meets.

The threshold for each QM is based on national cut-points used by CMS in its Five-Star Rating System. Each threshold is the maximum QM value a facility can have in order to receive the per diem adjustment. These thresholds are listed in Table A3 of the Five-Star Quality Rating System: Technical Users’ Guide dated January 2017. The thresholds listed in Table A3 have been rounded to the nearest tenth for purposes of determining the VBP Incentive. Table A3 of the Five-Star Quality Rating System:

Technical Users’ Guide dated January 2017 is incorporated by reference and made a part of this rule as published by CMS and available at https://dss.mo.gov/mhd/providers/nursing-homereimbursement-resources.htm. This rule does not incorporate any subsequent amendments or additions.

(I) SFY 2023 QM Performance Measure Table. The facility’s most current twelve- (12-) month rolling average QM value as of January 21, 2022, is used to determine the per diem adjustment(s) the facility qualified to receive for the rates effective July 1, 2022. The QM Performance Measure threshold, rounded to the nearest tenth, and per diem adjustments are as follows:

Decline in Late-Loss ADLs < or = 10.0% $1.00 Decline in Mobility on Unit < or = 8.0% $1.00 < or = 2.7% $1.00 Anti-Psychotic Medications < or = 6.8% $1.00 Falls w/ Major Injury < or = 1.3% $1.00 In-Dwelling Catheter < or = 1.1% $1.00 Urinary Tract Infection < or = 1.9% $1.00 (II) SFY 2024 QM Performance Measure Table. Effective for dates of service beginning July 1, 2023, the QM Performance Measure per diem adjustments are as follows:

Decline in Late-Loss ADLs < or = 10.0% $1.87 Decline in Mobility on Unit < or = 8.0% $1.87 < or = 2.7% $1.87 Anti-Psychotic Medications < or = 6.8% $1.87 Falls w/ Major Injury < or = 1.3% $1.87 In-Dwelling Catheter < or = 1.1% $1.87 Urinary Tract Infection < or = 1.9% $1.87 (III) SFY 2025 QM Performance Measure Table. Effective for dates of service beginning July 1, 2024, the QM Performance Measure per diem adjustments are as follows:

Decline in Late-Loss ADLs < or = 10.0% $3.04 Decline in Mobility on Unit < or = 8.0% $3.04 < or = 2.7% $3.04 Anti-Psychotic Medications < or = 6.8% $3.04 Falls w/ Major Injury < or = 1.3% $3.04 In-Dwelling Catheter < or = 1.1% $3.04 Urinary Tract Infection < or = 1.9% $3.04 (IV) SFY 2026 QM Performance Measure Table. Effective for dates of service beginning July 1, 2025, the QM Performance Measures and related per diem adjustments are as follows:

Decline in Late-Loss ADLs residents whose need for help with daily activities has increased) < or = 10.0% $3.42 Decline in Mobility on Unit residents whose ability to walk independently worsened) < or = 8.0% $3.42 High-Risk Residents w/ Pressure Ulcers (percentage of high risk long-stay residents with pressure ulcers) < or = 2.7% $3.42 Anti-Psychotic Medications residents who received an antipsychotic medication) < or = 6.8% $3.42 Falls w/ Major Injury residents experiencing one (1) or more falls with major injury) < or = 1.3% $3.42 In-Dwelling Catheter residents with a catheter inserted and left in their bladder) < or = 1.1% $3.42 Urinary Tract Infection residents with a urinary tract infection) < or = 1.9% $3.42 B. A VBP percentage will also be applied to the per diem adjustment for each facility that qualifies for a VBP Incentive.

The VBP percentage will be determined by the total QM score calculated from the Five-Star Rating System scores for each of the eight (8) long-stay QMs, as follows:

(I) The eight (8) long-stay QMs included in the total QM score to determine the VBP percentage include the following:

(a) Decline in Late-Loss ADLs;

(b) Decline in Mobility on Unit;

(c) High-Risk Residents w/ Pressure Ulcers;

(d) Anti-Psychotic Medications;

(e) Falls w/ Major Injury;

(f) In-Dwelling Catheter;

(g) Urinary Tract Infection; and (h) Physical Restraints;

(II) The facility’s most current twelve- (12-) month rolling average QM value as of January 21, 2022, is used to determine the facility’s QM Score and VBP percentage for the rates effective July 1, 2022;

(III) For each QM value, the corresponding number of QM points will be determined from Table A3 of the Five-Star Quality Rating System: Technical Users’ Guide dated January 2017;

(IV) The QM points for all of the QMs will be summed to determine the facility’s total QM Score; and (V) The VBP percentage for each scoring range is listed in the following table.

QM Scoring Tier Minimum Score VBP Percentage 1 600 100% 2 520 75% 3 440 50% 4 360 25% 5 0 0% 4. Mental illness (MI) diagnosis add-on. Each facility with a prospective rate on or after July 1, 2022, and which meets the A. If at least forty percent (40%) of a facility’s Medicaid participants have the following mental illness diagnosis, the facility shall receive a per diem adjustment of five dollars ($5.00):

(I) Schizophrenia; and (II) Bi-polar.

(G) Prospective Rate Calculation.

1. A preliminary per diem shall be calculated and is the sum of— A. The cost component per diems as set forth in subsec tions (11)(A)-(11)(E); and B. The patient care incentive and multiple component incentive set forth in paragraphs (11)(F)1. and (11)(F)2., respectively.

2. A base rate shall be determined and is the greater of— A. The preliminary per diem; and B. The facility’s prospective rate as of June 30, 2022, excluding NFRA.

C. The base rate for new nursing facilities operating under an interim rate, whose initial prospective rate is effective on or after July 1, 2022, is the greater of— (I) The preliminary per diem; and (II) The facility’s interim rate on the day before the effective date of the initial prospective rate, excluding NFRA.

3. The facility’s rebased rate shall be the sum of— A. The facility’s base rate; and B. The NFRA in effect for the applicable date of service.

4. The facility’s prospective rate shall be the sum of— A. The facility’s rebased rate;

B. The VBP Add-On set forth in paragraph (11)(F)3., if applicable; and C. The Mental Illness Diagnosis Add-On set forth in paragraph (11)(F)4., if applicable.

5. The following is an illustration of how subsections (11)

(A)–(G) determine a facility’s prospective rate:

Cost Component Per Diem Patient Care $99.28 Ancillary $16.19 Administration $35.73 Capital (FRV) $13.25 Total Cost Component Per Diem $164.45 Patient Care Incentive $5.03 Multiple Component Incentive $0.10 Total Patient Care & Multiple Component Incentives $5.13 Preliminary Per Diem $169.58 Current Prospective Rate (excluding NFRA) – June 30, 2022 $163.98 Base Rate - Greater of Preliminary Per Diem or June 30, 2022 Prospective Rate $169.58 NFRA – July 1, 2022 $12.93 Total Rebased Rate $182.51 VBP Incentive $2.00 VBP Payment Percent 75% VBP Add-On Per Diem Rate $1.50 Mental Illness Diagnosis Add-On $0.00 Total Prospective Rate – July 1, 2022 $184.01 (H) Semi-Annual and Annual Rate Updates. Each facility with a prospective rate on or after July 1, 2022, shall have its rate updated for the following items as described below:

1. Semi-annual acuity adjustment for patient care per diem rate. Each facility’s patient care per diem rate will be adjusted semi-annually using a current Medicaid CMI. The patient care per diem rate will be adjusted effective for dates of service beginning January 1 and July 1 of each year. The Medicaid CMI will be updated based on the facility’s average Medicaid CMI from the two (2) preceding quarterly calculations. The allowable patient care cost per day determined in paragraph (11)(A)1. shall be adjusted by the applicable Medicaid CMI and shall be the facility’s patient care per diem to be included in the facility’s total prospective per diem rate, effective each January 1 and July 1. The applicable Medicaid CMI are as follows:

A. Effective for dates of service beginning January 1 of each year, each facility’s Medicaid CMI will be updated using the average of the preceding July 1 and October 1 quarterly Medicaid CMI calculations; and B. Effective for dates of service beginning July 1 of each year, each facility’s Medicaid CMI will be updated using the average of the preceding January 1 and April 1 quarterly Medicaid CMI calculations;

2. Semi-annual adjustment for VBP Incentive. Each facility’s QM Performance data shall be re-evaluated semi-annually and the per diem add-on rate shall be adjusted accordingly. The VBP will be recalculated effective for dates of service beginning January 1 and July 1 of each year. The QM Performance data will be updated based on the most current data available as of November 15 for the January 1 rate adjustment and as of May 15 for the July 1 rate adjustment. For facilities that do not have updated data as of the review date, prior period data will be carried forward. This provision will be applied to data frozen by CMS. A facility must meet the criteria set forth in paragraph (11)(F)3. each period and will lose any per diem adjustments for which it does not continue to qualify;

3. Semi-annual adjustment for mental illness diagnosis add-on. Each facility’s Mental Illness Diagnosis data shall be re-evaluated semi-annually and the per diem add-on rate shall be adjusted accordingly. The Mental Illness Diagnosis will be recalculated effective for dates of service beginning January 1 and July 1 of each year. The Mental Illness Diagnosis data will be updated based on the final resident listing for October for the January 1 rate adjustment and the final resident listing for April for the July 1 rate adjustment. For facilities that do not have updated data as of the review date, prior period data will be carried forward. A facility must meet the criteria set forth in paragraph (11)(F)4. each period and will lose any per diem adjustments for which it does not continue to qualify;

4. Annual capital rate update. Each facility’s capital rate will be recalculated annually by updating the rental value portion of the capital rate. The capital rate will be recalculated at the beginning of each state fiscal year (SFY), effective for dates of service beginning July 1, as follows:

A. The total facility size will be updated each year for any increases or decreases in licensed beds and capital expenditures that qualify as bed equivalencies, as follows:

(I) For SFY 2024, effective for dates of service beginning July 1, 2023, the total facility size will be updated using information from the 2020 and 2021 cost reports; and (II) For SFY 2025 forward, the total facility size will be updated using the information from the third prior year cost report relative to the SFY (i.e., for SFY 2025, the facility size will be updated using 2022 cost report data);

B. The weighted average age of the facility shall be updated each year. The age shall be calculated from the year coinciding with the latest cost report used to update the facility size above in subparagraph (11)(A)1.A. (i.e., the age for SFY 2024 shall be calculated from 2021, the age for SFY 2025 shall be calculated from 2022, etc.); and C. The asset value shall be updated each SFY. The asset value shall be updated for the year coinciding with the latest cost report used to update the facility size above in subparagraph (11)(A)1.A. (i.e., for SFY 2024 the 2021 asset value shall be used, for SFY 2025 the 2022 asset value shall be used, etc.); and 5. A facility’s prospective rate shall be increased or decreased based upon the semi-annual and annual rate adjustments, but the rate shall not be decreased below the facility’s June 30, 2022, prospective rate.

(I) Rate Setting Cost Report.

1. A facility with a valid Medicaid participation agreement and a prospective rate in effect on June 30, 2022, shall have its prospective rate rebased on its 2019 cost report. If a facility does not have a 2019 cost report, the next available cost report year shall be used as the rate setting cost report.

2. A nursing facility never previously certified for participation in the MO HealthNet program that originally enters the MO HealthNet program after June 30, 2022, shall receive an interim rate, as defined in subsection (4)(JJ), effective on the initial date of MO HealthNet certification. A prospective rate shall be determined in accordance with this regulation from the audited facility fiscal year cost report which covers the second full twelve- (12-) month fiscal year following the facility’s initial date of MO HealthNet certification. This prospective rate shall be retroactively effective to the first day of the facility’s second full twelve- (12-) month fiscal year and shall replace the interim rate for dates of service beginning on the first day of the facility’s second full twelve- (12-) month fiscal year. The following items shall be updated annually and shall be used in determining the prospective rate:

A. Ceilings. The ceiling used to determine the prospective rate shall be the ceiling in effect at the beginning of the rate setting period;

B. Asset Value. The asset value shall be updated annually as set forth in subsection (4)(E). The asset value for the year coinciding with the rate setting cost report year (i.e., the end of the cost report period) shall be used; and C. Age of Beds and Bed Equivalencies. The age of beds shall be calculated by subtracting the year the beds were originally licensed from the year coinciding with the rate setting cost report year (i.e., the end of the cost report period).

The age of bed equivalencies shall be calculated by subtracting the year the capital expenditures were made from the year coinciding with the rate setting cost report (i.e., the end of the rate setting cost report period).

3. A facility with a valid Medicaid participation agreement in effect after June 30, 2022, which either voluntarily or Program and which reenters the Medicaid Program within two (2) years, shall have its prospective rate established as the rate in effect on the day prior to the date of termination from participation in the program plus rate adjustments which may have been granted with effective dates subsequent to the termination date but prior to reentry into the program as described in subsection (12)(A). This prospective rate shall be effective for service dates on and after the effective date of the reentry following a voluntary or involuntary termination.

(12) Adjustments to the Reimbursement. Subject to the limitations prescribed elsewhere in this regulation, a facility’s reimbursement rate may be adjusted as described in this section and 13 CSR 70-10.017.

(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 as set forth below:

1. SFY 2024 Per Diem Rate Adjustment.

A. Effective for dates of service beginning July 1, 2023, facilities with either an interim rate or a prospective rate in effect on July 1, 2023, shall be granted an increase to their per diem rate of ten dollars and zero cents ($10.00);

B. Effective for dates of service beginning July 1, 2023, and ending December 31, 2023, the rate to which the SFY 2024 per diem adjustment of ten dollars and zero cents ($10.00) shall be added is the facility’s July 1, 2023, rate after all rate setting procedures have been applied, including adjustments for the Semi-Annual and Annual Rate Updates set forth in subsection (11)(H) that are effective July 1, 2023, and after selecting the greater of the Preliminary Per Diem or the June 30, 2022, prospective rate (excluding NFRA), and adding the NFRA per diem, VBP incentive, and MI add-on effective July 1, 2023. The increased VBP per diem adjustments effective July 1, 2023, detailed above in part (11)(F)3.A.(II) and shown in the accompanying QM Performance Measure table shall be used in this calculation. The SFY 2024 per diem adjustment of ten dollars and zero cents ($10.00) is not added to the facility’s June 30, 2022, prospective rate and is not allocated and added to the cost component ceilings in performing this calculation.

C. Subsequent Semi-Annual and Annual Rate Updates.

Effective for dates of service beginning with the effective date of the rate change (i.e., January 1 or July 1) and ending on the day prior to the effective date of the next rate change (i.e., December 31 or June 30), the SFY 2024 per diem adjustment of ten dollars and zero cents ($10.00) will be added to the facility’s rate after all rate setting procedures have been applied, including the Semi-Annual and Annual Rate Updates set forth in subsection (11)(H) that are effective on the date of the rate change, and after selecting the greater of the Preliminary Per Diem or the June 30, 2022, prospective rate (excluding NFRA), and adding the NFRA per diem, VBP Incentive, and MI add-on effective on the date of the rate change. The increased VBP per diem adjustments effective July 1, 2023, detailed above in part (11)(F)3.A.(II) and shown in the accompanying QM Performance Measure table shall be used in this calculation. The SFY 2024 per diem adjustment of ten dollars and zero cents ($10.00) is not added to the facility’s June 30, 2022, prospective rate and is not allocated and added to the cost component ceilings in performing this calculation. The SFY 2024 per diem adjustment of ten dollars and zero cents ($10.00) shall only be included in the rate once for each effective date; it is not a cumulative adjustment from one effective date to the next.

D. New Nursing Facilities. For new nursing facilities never previously certified for participation in the MO HealthNet program that need to have their prospective rate determined as set forth in subsection (11)(I), the SFY 2024 per diem adjustment of ten dollars and zero cents ($10.00) will be added to the facility’s rate beginning July 1, 2023, in the same manner as detailed above in subparagraphs (12)(A)1.B and (12)(A)1.C.

(B) Extraordinary Circumstances. A participating facility which has a prospective rate may request an adjustment to its reimbursement due to extraordinary circumstances. This request must be submitted in writing to the division within one (1) year of the occurrence of the extraordinary circumstance.

The request must clearly and specifically identify the conditions for which the reimbursement adjustment is sought. The dollar amount of the requested reimbursement adjustment must be Requests for reimbursement adjustments that have been withdrawn by the facility or are considered withdrawn because of failure to supply requested information may be resubmitted once for the requested reimbursement adjustment. In the case of a reimbursement adjustment request that has been withdrawn and then resubmitted, the effective date shall be the first day of the month in which the resubmitted request was made providing that it was made prior to the tenth day of the month. If the resubmitted request is not filed by the tenth of the month, reimbursement adjustments shall be 1. When the provider can show that it incurred higher costs due to circumstances beyond its control, the circumstances were not experienced by the nursing home industry in general, and the costs have a substantial cost effect;

2. Extraordinary circumstances, which are beyond the reasonable control of the nursing facility and are not a product or result of the negligence or malfeasance of the nursing facility, include but are not limited to— A. Unavoidable acts of nature that occur in a federally declared disaster area. Unavoidable acts of nature may include hurricane, flooding, earthquake, tornado, lightening, natural wildfire, or other natural disaster for which no one can be held responsible; or B. Vandalism and/or civil disorder; and 3. Adjustment to a facility’s reimbursement for extraordinary circumstances shall only be for costs that are not covered by insurance. The reimbursement adjustment(s) shall be calculated as follows:

A. For one- (1-) time costs that will not be incurred in future fiscal years — (I) Costs directly associated with the extraordinary circumstances that have not been covered by insurance will be multiplied by the Medicaid occupancy percent from the latest cost report available for the time period preceding when the extraordinary circumstances occurred; and (II) This amount will be paid to the facility as a one- (1-) time, lump sum payment;

B. For ongoing costs that will be incurred in future fiscal years— (I) Ongoing annual costs will be divided by the greater of— (a) Annualized (calculated for a twelve- (12-) month period) total patient days from the latest cost report on file; or (b) Minimum utilization days; and (II) This calculation will be a per diem rate adjustment that will be added to the respective cost center, not to exceed the cost component ceiling. The rate adjustment, subject to ceiling limits, will be added to the prospective rate; and C. For capitalized costs, the capital cost component per diem rate is updated at the beginning of each SFY so any capital expenditures resulting from the extraordinary circumstances will be captured during that annual rate update.

(C) Invasive Ventilator Care Adjustment. A per diem adjustment shall be granted for ventilator services provided by qualifying providers to qualifying MO HealthNet participants as set forth in 13 CSR 70-10.017.

(D) Conditions for prospective rate adjustments. The division 1. Fraud, misrepresentation, errors. When information also does not affect the division’s ability to impose any sanctions authorized by statute or regulation;

2. Decisions of the Administrative Hearing Commission, 3. Court order;

3. Disallowance of federal financial participation; and 5. MDS reviews.

A. If a facility’s MDS submissions were corrected as a result of an MDS review and resulted in a revised CMI, a facility’s per diem rate shall be adjusted as follows:

(I) For reviews completed between July 1, 2024, and December 31, 2025, per diem rates will only be adjusted for increases in the CMI;

(II) For reviews completed between January 1, 2026, and December 31, 2026, per diem rates will be adjusted for any changes to the CMI. The per diem rate may be increased or decreased based on the adjusted CMI; and (III) For reviews completed after January 1, 2027, per diem rates will only be adjusted for decreases in the CMI.

B. Per diem rate adjustments and payment adjustments.

(I) The per diem rate will be recalculated using the Medicaid CMI that has been revised based on the corrected MDS submissions.

(II) The revised per diem rate will replace the per diem rate with the incorrect CMI for the period that the incorrect rate was in effect. The revised per diem rate will be retroactive to the initial effective date of the rate being revised and will remain in place until the effective date of the following rate.

(III) The payments corresponding to the per diem rate with the incorrect CMI will be adjusted to reflect the revised per diem rate including the corrected CMI.

(a) Additional payments will be made to nursing facilities with increases in the per diem rate resulting from the corrected CMI.

(b) Payments will be recouped from nursing facilities with decreases in the per diem rate resulting from the corrected CMI.

(13) Exceptions.

(A) Requirements for Placement of MO HealthNet Participants in Out-of-State Nursing Facilities and Reimbursement for Outof-State Nursing Facilities.

1. In order to provide nursing facility services to MO HealthNet participants when there is no Missouri nursing facility with a suitable bed available that meets the medical needs of the participant, the division may authorize placement of a MO HealthNet participant in an out-of-state facility.

2. The division will only authorize placement of a MO HealthNet participant into an out-of-state facility if— A. No Missouri nursing facility bed is available that meets the medical needs of the participant;

B. In-state alternatives for providing services have been exhausted; and C. Prior approval for placement into an out-of-state nursing facility is requested from and approved by the division.

3. Once a Missouri nursing facility bed meeting the medical needs of the participant is available, the participant must return to Missouri. If the participant does not return to Missouri, the division shall withhold payments for nursing facility services, unless the participant’s health would be endangered if required to travel to Missouri. Participant’s physician would need to certify that the participant’s health would be endangered from the travel to Missouri.

4. No fiscal year-end Missouri Medicaid cost report will be required from the out-of-state nursing facility nor will there be any requirement for Missouri-conducted periodic audits.

5. The Title XIX reimbursement rate for out-of-state providers shall be set as follows:

A. For out-of-state providers which provided services for Missouri Title XIX participants, the reimbursement rate shall be the lower of— (I) The weighted average MO HealthNet rate for comparable services at the beginning of the state fiscal year in which the provider enters the MO HealthNet program; or (II) The rate paid to the out-of-state nursing facility for comparable services by the state in which the provider is located. The out-of-state provider must notify the division of any reimbursement changes made by its state Medicaid agency. The provider must also include a copy of the rate letter issued by their state Medicaid agency detailing the rate and effective date. The effective date of the rate change is as (a) Rate increases—If the provider notifies the division within thirty (30) days of receipt of notification from their state of the per diem rate increase, the effective date of the rate increase for purposes of reimbursement from Missouri shall be the same date as indicated in the issuing state’s rate letter. If the division does not receive written notification from the provider within thirty (30) days of the date the provider received notification from their state of the rate increase, the effective date of the rate increase for purposes of reimbursement from Missouri shall be the first day of the month following the date the division receives notification; or (b) Rate decreases—The effective date of the rate decrease for purposes of reimbursement from Missouri shall be the same date as indicated in the issuing state’s rate letter.

(B) Hospital Based Nursing Facilities.

1. The Title XIX reimbursement rate for hospital based providers that provide services of less than one thousand (1,000) patient days for Missouri Title XIX participants, relative to their fiscal year, and that are exempt from filing a cost report as prescribed in section (10) shall be determined as follows:

A. For hospital based nursing facilities that have less than one thousand (1,000) Medicaid patient days, the rate base cost report will not be required; and B. The prospective rate will be the sum of the ceilings for the patient care, ancillary, and administration cost components plus the median per diem for capital. In addition, the patient care incentive of four and seventy-five hundredths percent (4.75%) of the patient care median will be granted.

2. For hospital based nursing facilities that provide one thousand (1,000) or more patient days for Missouri Title XIX participants, relative to their fiscal year, a prospective rate shall be set by one (1) of the following:

A. The hospital based nursing facility requests, in writing, that their prospective rate be determined from their rate setting cost report as set forth in this regulation; or B. The sum of the ceilings for the patient care, ancillary, and administration cost components plus the median per diem for capital. In addition, the patient care incentive of four and seventy-five hundredths percent (4.75%) of the patient care median will be granted.

(14) Sanctions and Overpayments.

(A) In addition to the sanctions and penalties set forth in this regulation, the division may also impose sanctions against a provider in accordance with 13 CSR 70-3.030 Sanctions for False or Fraudulent Claims for Title XIX Services, or any other sanction authorized by state or federal law or regulations.

(B) Overpayments due the Medicaid program from a provider (15) Appeals. In accordance with sections 208.156, RSMo, and 622.055, RSMo, providers may seek hearing before the Administrative Hearing Commission of final decisions of the director or the division.

(16) Payment in Full. Participation in the program shall be services rendered to Medicaid participants, the amount paid (17) Provider Participation. Payments made in accordance (18) Transition. Cost reports used for rate determination shall be principles provided in this regulation.

COVERED SUPPLIES AND SERVICES

PERSONAL CARE

Oral hygiene including denture care, cups, cleaner, mouthwashes, toothbrushes, and paste Nail clipping and cleaning routine K pads (water heated pads), alternating pressure pads, flotation pads, and/or turning frames, heel protectors, donuts and sheepskins Needles including but not limited to hypodermic, scalp, vein restorative nursing care, nursing supplies, assistance with eating and massages provided by facility personnel A and D Ointment, tapes, alcohol, alcohol sponges, applicators, Oxygen (portable or stationary), oxygen delivery systems, concentrators, and supplies

rule filed May 16, 2023, effective Dec. 30, 2023. Emergency amendment filed Feb. 21, 2024, effective March 6, 2024, expired Sept. 1, 2024. Amended: Filed Feb. 21, 2024, effective Aug. 30, 2024.

Emergency amendment filed Jan. 21, 2025, effective Feb. 4, 2025, expired Aug. 2, 2025. Amended: Filed Jan. 21, 2025, effective Aug. 30, 2025. Amended: Filed Nov. 24, 2025, effective May 30, 2026. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.159, RSMo 1979; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.159, 208.201, and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2025. Emergency rule filed May 16, 2023, effective May 31, 2023, expired Nov. 26, 2023. Original

13 CSR 70-10.030 Prospective Reimbursement Plan for Nonstate-Operated Facilities for ICF/IID Services {#sec-13-csr-70-10.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.030}

PURPOSE: This rule establishes a payment plan for nonstateoperated intermediate care facility for individuals with intellectual disabilities services. The plan describes principles to be followed by Title XIX intermediate care facility for individuals with intellectual disabilities providers in making financial reports and presents the necessary procedures for setting rates, making adjustments, and auditing the cost reports.

(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, 1. The Medicare per diem rate, if applicable; or 2. The reimbursement rate as determined in accordance (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.

(3) Definitions.

(A) “Allowable Cost Areas” means those cost areas that are allowable for allocation to the MO HealthNet program based upon the principles established in this rule. The allowability of cost areas, not specifically addressed in this rule, will be based upon criteria of the Medicare Provider Reimbursement Manual (HIM-15) and section (6) of this rule.

(B) “Average Private Pay Charge” means the usual and customary charge for non-MO HealthNet patients determined by dividing total non-MO HealthNet days of care into total revenue collected for the same service that is included in the MO HealthNet per diem rate, excluding negotiated payment methodologies with the Veterans Administration and the Missouri Department of Mental Health.

(C) “Cost Report” means a report detailing the cost of rendering covered services for the fiscal reporting period.

Providers must file the cost report on forms provided by and in accordance with the procedures of the Department of Social (D) “Department” means the Missouri Department of Social Services, unless otherwise specified.

(E) “Director” means the director of the Missouri Department of Social Services, unless otherwise specified.

(F) “Effective Date” means November 1, 1986.

(G) “ICF/IID” means nonstate-operated facilities certified to provide intermediate care for individuals with intellectual disabilities under the Title XIX program.

(H) “Medicare Rate” means the allowable cost of care permitted by Medicare standards and principles of reimbursement.

(I) “New Construction” means newly built facilities or parts, for which an approved Certificate of Need (CON) or applicable waivers were obtained and which were newly completed and operational on or after November 1, 1986.

(J) “New Owners” means the original owners of new construction.

(K) “Providers” means, under the Prospective Reimbursement Plan, a nonstate-operated ICF/IID facility with a valid participation agreement, in effect on or after October 31, 1986, with the Missouri Department of Social Services for the purpose of providing long-term care (LTC) services to Title XIX-eligible participants. Facilities certified to provide intermediate care services to individuals with intellectual disabilities under the Title XIX program may be offered a MO HealthNet participation agreement on or after January 1, 1990, only if 1) the facility has no more than fifteen (15) beds for individuals with intellectual disabilities, and 2) there is no other licensed residential living facility for individuals with intellectual disabilities within a radius of one-half (1/2) mile of the facility seeking participation in the MO HealthNet program.

(L) “Reasonable and Adequate Reimbursement” means reimbursement levels which meet the needs of an efficiently and economically operated facility and which in no case exceed normal market costs.

(M) “Related Parties” means— 1. An individual or group, regardless of the business structure of either, where, through their activities, one (1) individual’s or group’s transactions are for the benefit of the other and the benefits exceed those which are usual and customary in the dealings;

2. One (1) or more persons have an ownership or controlling interest in a party, and the person(s) or one (1) or more relatives of the person(s) has an ownership or controlling interest in the other party. For the purposes of this paragraph, ownership entity, directly or through a subsidiary, operates a facility; or 3. As used in section (3), the following terms mean:

A. “Indirect Ownership” or “Indirect Interest” means an ownership interest in an entity that has an ownership interest in another entity. This term includes an ownership interest in any entity that has an indirect ownership interest in an entity;

B. “Ownership Interest” means the possession of equity in the capital, in the stock, or in the profits of an entity;

C. “Ownership Interest” or “Controlling Interest” means a person or corporation(s)— (I) Has an ownership interest totaling five percent (5%)

(II) Has an indirect ownership interest equal (III) Has a combination of direct and indirect ownership (IV) Owns an interest of five percent (5%) or more in by an entity, if that interest equals at least five percent (5%) of of ownership resulting from the obligations is determined by (V) Is an officer or director of an entity; or (VI) Is a partner in an entity that is organized as a partnership;

D. “Relative” means persons related by blood or marriage to the fourth degree of consanguinity; and E. “Entity” means any person, corporation, partnership, or association.

(N) “Rural” means those counties that are not defined as urban.

(O) “Urban” means counties that are standard metropolitan statistical areas including Andrew, Boone, Buchanan, Cass, Christian, Clay, Franklin, Greene, Jackson, Jasper, Jefferson, Newton, Platte, Ray, St. Charles, St. Louis, and St. Louis City.

(4) ICF/IID Rate Computation. Except in accordance with other provisions of this rule, the provisions of this section shall apply to all providers of ICF/IID services certified to participate in Missouri’s MO HealthNet program. Rate determination shall be based on reasonable and adequate reimbursement levels for allowable cost items described in this rule which are related to ordinary and necessary care for the level-of-care provided for an efficiently and economically operated facility. All providers shall submit documentation of expenses for allowable cost areas. The department shall have authority to require those uniform accounting and reporting procedures and forms as it deems necessary. A reasonable and adequate reimbursement in each allowable cost area will be determined.

(A) Prospective Reimbursement Rate Determination through December 31, 2018.

1. The Title XIX prospective per diem reimbursement rate for the remainder of state Fiscal Year 1987 shall be the facility’s per diem reimbursement payment rate in effect on October 31, 1986, as adjusted by updating the facility’s allowable base year to its 1985 fiscal year. Each facility’s per diem costs as reported on its Fiscal Year 1985 Title XIX cost report will be determined in accordance with the principles set forth in this rule. If a facility has not filed a 1985 fiscal year cost report, the MO HealthNet Division will use the most current cost report on file with the department to set a facility’s per diem rate. Facilities with less than a full twelve- (12-) month 1985 fiscal year will not have their base year rates updated.

2. For state FY-88 and dates of service beginning July 1, 1987, the negotiated trend factor shall be equal to two percent (2%) to be applied in the following manner: Two percent (2%) operated ICF/IID facilities on June 1, 1987, shall be added to each facility’s rate.

3. For state FY-89 and dates of service beginning January 1, 1989, the negotiated trend factor shall be equal to one percent (1%) to be applied in the following manner: One percent (1%) operated ICF/IID facilities on June 1, 1988, shall be added to each facility’s rate.

4. For state FY-91 and dates of service beginning July 1, 1990, the negotiated trend factor shall be equal to one percent (1%) to be applied in the following manner: One percent (1%) operated ICF/IID facilities on June 1, 1990, shall be added to each facility’s rate.

5. Prospective payment adjustment (PPA). A FY92 PPA will be provided prior to the end of the state fiscal year for nonstateoperated ICF/IID facilities with a current provider agreement on file with the MO HealthNet Division as of October 1, 1991.

A. For providers that qualify, the PPA shall be the lesser of— (I) The provider’s facility peer group factor (FPGF) times the projected patient days (PPD) covered by the adjustment year times the prospective payment adjustment factor (PPAF) times the nonstate-operated intermediate care facility for individuals with intellectual disabilities ceiling (ICFIIDC) on October 1, 1991 (FPGF × PPD × PPAF × ICFIIDC). For example: A provider having nine hundred twenty (920) paid days for the period May 1991 to July 1991 out of a total paid days for this same period of twentyeight thousand five hundred sixty-one (28,561) represents an FPGF of three and twenty-two hundredths percent (3.22%). So using the FPGF of 3.22% × 114,244 × 24.5% × $156.01 = $140,607; or (II) The provider FPGF times one hundred forty-five percent (145%) of the amount credited to the intermediate care revenue collection center (ICRCC) of the State Title XIX Fund (STF) for the period October 1, 1991 through December 31, 1991.

B. FPGF—is determined by using each ICF/IID facility’s paid days for the service dates in May 1991 through July 1991 as of September 20, 1991, divided by the sum of the paid days for the same service dates for all providers qualifying as of the determination date of October 16, 1991.

C. ICFIIDC—is one hundred fifty-six dollars and one cent ($156.01) on October 1, 1991.

D. PPAF—is equal to twenty-four and one half percent (24.5%) for fiscal year 1992 which includes an adjustment for economic trends.

E. PPD—is the projection of one hundred fourteen thousand two hundred forty-four (114,244) patient days made on October 1, 1991, for the adjustment year.

6. FY-92 trend factor and Workers’ Compensation. All facilities with either an interim rate or a prospective per diem rate in effect on September 1, 1992, shall be granted an increase to their per diem rate effective September 1, 1992, of eight dollars and eighty-six cents ($8.86) per patient day related to the continuation of the FY-92 trend factor and the Workers’ Compensation adjustment. This adjustment is equal to seven and one-half percent (7.5%) of the March 1992 weighted average per diem rate of one hundred eighteen dollars and fourteen cents ($118.14) for all nonstate-operated ICF/IID facilities.

7. FY-93 negotiated trend factor. All facilities with either an interim rate or prospective per diem rate in effect on September 1, 1992, shall be granted an increase to their per diem rate effective September 1, 1992, of one dollar and sixtysix cents ($1.66) per patient day for the negotiated trend factor.

This adjustment is equal to one and four-tenths percent (1.4%) of the March 1992 weighted average per diem rate of one hundred eighteen dollars and fourteen cents ($118.14) for all nonstate-operated ICF/IID facilities.

8. FY-96 negotiated trend factor. All nonstate-operated ICF/IID facilities shall be granted an increase to their per diem rates effective for dates of service beginning January 1, 1996, of six dollars and seven cents ($6.07) per patient day for the negotiated trend factor. This adjustment is equal to four and six-tenths percent (4.6%) of the weighted average per diem rates paid to nonstate-operated ICF/IID facilities on June 1, 1995, of one hundred and thirty-one dollars and ninety-three cents ($131.93).

9. State FY-99 trend factor. All nonstate-operated ICF/IID effective for dates of service beginning July 1, 1998, of four dollars and forty-seven cents ($4.47) per patient day for the ICF/IID facilities on June 30, 1998, of one hundred forty-eight dollars and ninety-nine cents ($148.99).

10. State FY-2000 trend factor. All nonstate-operated ICF/ IID facilities shall be granted an increase to their per diem rates effective for dates of service beginning July 1, 1999, of four dollars and sixty-three cents ($4.63) per patient day for the ICF/IID facilities on April 30, 1999, of one hundred fifty-four dollars and forty-three cents ($154.43). This increase shall only be used for increases for the salaries and fringe benefits for direct care staff and their immediate supervisors.

11. State FY-2001 trend factor. All nonstate-operated ICF/ IID facilities shall be granted an increase to their per diem rates effective for dates of service beginning July 1, 2000, of four dollars and eighty-one cents ($4.81) per patient day for the ICF/IID facilities on April 30, 2000, of one hundred sixty dollars and twenty-three cents ($160.23). This increase shall only be used for increases for salaries and fringe benefits for direct care staff and their immediate supervisors.

12. State FY-2007 trend factor. All nonstate-operated ICF/ IID facilities shall be granted an increase of seven percent (7%) to their per diem rates effective for dates of service billed for state fiscal year 2007 and thereafter. This adjustment is equal to seven percent (7%) of the per diem rate paid to nonstateoperated ICF/IID facilities on June 30, 2006.

13. State FY-2008 trend factor. Effective for dates of service beginning July 1, 2007, all nonstate-operated ICF/IID facilities shall be granted an increase to their per diem rates of two percent (2%) for the trend factor. This adjustment is equal to two percent (2%) of the per diem rate paid to nonstate-operated ICF/IID facilities on June 30, 2007.

14. State FY-2009 trend factor. Effective for dates of service beginning July 1, 2008, all nonstate-operated ICF/IID facilities shall be granted an increase to their per diem rates of three percent (3%) for the trend factor. This adjustment is equal to three percent (3%) of the per diem rate paid to nonstateoperated ICF/IID facilities on June 30, 2008.

15. State FY-2009 catch up increase. Effective for dates of service beginning July 1, 2008, all nonstate-operated ICF/IID of thirteen and ninety-five hundredths percent (13.95%). This adjustment is equal to thirteen and ninety-five hundredths percent (13.95%) of the per diem rate paid to nonstate-operated ICF/IID facilities on June 30, 2008. This increase is intended to provide compensation to providers for the years where no trend factor was given. The catch up increase was based on the CMS PPS Skilled Nursing Facility Input Price Index (four- (4-) quarter moving average).

16. State FY-2012 trend factor. Effective for dates of service beginning October 1, 2011, all nonstate-operated ICF/IID of one and four tenths percent (1.4%) for the trend factor. This adjustment is equal to one and four tenths percent (1.4%) of the per diem rate paid to nonstate-operated ICF/IID facilities on September 30, 2011.

17. State FY-2014 trend factor. Effective for dates of service beginning January 1, 2014, all nonstate-operated ICF/IID facilities shall be granted an increase to their per diem rates of three percent (3%) for the trend factor. This adjustment is equal to three percent (3%) of the per diem rate paid to nonstateoperated ICF/IID facilities on December 31, 2013.

18. State FY-2016 trend factor. Effective for dates of service beginning February 1, 2016, all nonstate-operated ICF/IID facilities shall be granted an increase to their per diem rates of one percent (1%) for the trend factor. This adjustment is equal to one percent (1%) of the per diem rate paid to nonstate-operated ICF/IID facilities on January 31, 2016.

19. State FY-2017 trend factor. Effective for dates of service beginning September 1, 2016, all nonstate-operated ICF/IID of two percent (2%) for the trend factor. This adjustment is equal to two percent (2%) of the per diem rate paid to nonstateoperated ICF/IID facilities on August 31, 2016.

20. State FY-2018 per diem adjustment. Effective for dates of service beginning September 1, 2017, all nonstate-operated ICF/IID facilities shall be subject to a decrease to their per diem rates of two and eighty-two hundredths percent (2.82%). This adjustment is equal to two and eighty-two hundredths percent (2.82%) of the per diem rate paid to nonstate-operated ICF/IID facilities on August 31, 2017.

(B) Per Diem Rate Calculation Effective for Dates of Service Beginning January 1, 2019. Effective for dates of service beginning January 1, 2019, the MO HealthNet Division shall rebase nonstate-operated ICF/IID facilities’ per diem rates using the facilities’ 2017 fiscal year-end cost reports. The rebased rates are contingent upon approval of the state plan amendment by the Centers for Medicare and Medicaid Services.

1. Prospective Rate Calculation.

A. Each nonstate-operated ICF/IID shall have its prospective rate recalculated based on its 2017 fiscal year end cost report using the same principles and methodology as detailed throughout sections (1)-(13) of this regulation.

(I) The costs from the 2017 fiscal year end cost reports shall be trended using the indices from the most recent publication of the Healthcare Cost Review available to the division using the “CMS Nursing Home without Capital Market Basket” table. The costs shall be trended using the four- (4-) quarter moving average. The costs shall be trended for the years following the cost report year, up to and including the state fiscal year corresponding to the effective date of the rates.

For SFY 2019, the trends are as follows:

(a) 2018=3.025% (b) 2019=2.65% (II) If a facility’s total calculated per diem set forth in this section is less than the facility’s current rate, the facility shall continue to receive its current rate.

(III) The division will use the FY 2017 cost report to determine the ICF/IID prospective rate, set forth as follows:

(a) Total Routine Service Cost. Total routine service cost includes patient care, ancillary, dietary, laundry, housekeeping, plant operations, and administration. Each ICF/ IID’s Title XIX Routine Service Cost per diem shall be calculated I. The total routine service costs as reported on the cost report shall be adjusted for minimum utilization, if applicable, trended to the current state fiscal year, and divided by the total patient days to determine the per diem.

The minimum utilization adjustment will be determined by applying the unused capacity percent to the sum of the laundry, housekeeping, plant operations, and administration expenses. The following is an illustration of how this item (4)

(B)1.A.(III)(a)I. is calculated:

Licensed/Certified Bed Days (9 beds x 365 days) 3,285 Percent Occupied (2,900/3,285) 88% Bed Days @ Minimum Occupancy of 90% (3,285 x 90%) 2,957 Unused Capacity (90% of Bed Days Less Total Patient Days) 57 Unused Capacity Percent for Minimum Utilization Adjustment (Unused Capacity/90% of Bed Days) 1.93% Minimum Utilization Days for Return on Owner’s Equity (Greater of 90% of Bed Days or Total Patient Days) 2,957 Minimum Utilization Adjustment Laundry $ 5,000 Housekeeping $ 8,000 Plant Operations $ 46,000 Administration $165,000 Total Expense $224,000 Unused Capacity Percent 1.93% Minimum Utilization Adjustment (Unused Capacity Percent x Total Expense) $ 4,323 Patient Care $400,000 Ancillary $ 10,000 Dietary $ 25,000 Laundry $ 5,000 Housekeeping $ 8,000 Plant Operations $ 46,000 Administration $165,000 Total Routine Service Cost $659,000 Less: Minimum Utilization Adjustment ($ 4,323)

Routine Service Cost, Adjusted for Minimum Utilization $654,677 SFY 2018 Trend 3.025% SFY 2019 Trend 2.65% Trended Routine Service Cost $692,355 Routine Service Cost Per Diem $ 238.74 (b) Intermediate Care Facility for Individuals with Intellectual Disabilities Federal Reimbursement Allowance (ICF/IID FRA). The SFY 2019 ICF/IID FRA provider assessment as determined in accordance with 9 CSR 10-31.030 is divided by total patient days to determine the ICF/IID FRA per diem.

I. The following is an illustration of how the ICF/ IID FRA assessment is calculated:

SFY 2019 ICF/IID FRA Assessment $40,000 ICF/IID FRA Per Diem $ 13.79 (c) Return on Equity. An owner’s net equity consists of investment capital and working capital as indicated in subsection (6)(S). Each ICF/IID’s Return on Equity per diem is calculated as follows:

I. Investment Capital. Investment capital includes the investment in building, property, and equipment (cost of land, mortgage payments toward principal, and equipment purchase less the accumulated depreciation).

II. Working Capital. Working capital represents the amount of capital which is required to ensure proper operation of the facility and shall be calculated as 1.1 months of the total expenses less depreciation.

III. The total net equity shall be multiplied by the rate of return as set forth in subsection (6)(S) to determine the return on equity. The return on equity is subject to the minimum occupancy percent of ninety percent (90%) in determining the per diem.

IV. The following is an illustration of how this

subpart (4)(B)1.A.(III)(c) is calculated:

Investment Capital Equipment Building Total Cost $130,000 $300,000 $430,000 Less: Prior Years Depreciation ($120,000) ($225,000) ($345,000)

Less: Current Year Depreciation ($2,400) ($8,500) ($10,900)

Total Investment Capital $7,600 $66,500 $74,100 Working Capital Total Expenses $659,000 Less: Current Year Depreciation Expense ($10,900) $648,100 Divided by 12 Months 12 $ 54,008 Times 1.1 Months 1.1 Total Working Capital $ 59,409 Net Equity (Investment Capital + Working Capital) $133,509 Rate of Return 5.125% Return on Equity $ 6,842 Minimum Utilization Days 2,957 Return on Equity Per Diem $ 2.31 (c) Rebased Per Diem Rate. The total calculated per diem is the sum of the Routine Service Cost per diem, the ICF/IID FRA per diem and the Return on Equity per diem. To determine the rebased per diem rate, the total calculated per diem is compared to the current per diem rate and the facility will be held harmless if the total calculated per diem is less than the current per diem rate (i.e., if the total calculated per diem is less than the current per diem rate, the facility would receive the current per diem).

Routine Service Cost per diem $238.74 ICF/IID FRA per diem $ 13.79 Return on Equity per diem $ 2. 31 Total Calculated Per Diem $254.84 Current Per Diem Rate $200.00 Rebased Per Diem Rate $254.84 (If the total calculated per diem is less than the current per diem rate, the facility would receive the current per diem rate)

B. Effective for dates of service beginning October 1, 2022, each nonstate-operated ICF/IID shall have its prospective rate recalculated based on its 2020/2021 fiscal yearend cost report using the same principles and methodology as detailed throughout sections (1)-(13) of this regulation and as set forth in subparagraph (4)(B)1.A.

(I) The nonstate-operated ICF/IID shall have its prospective rate recalculated based on their 2021 fiscal year-end cost report unless they do not have a full twelve- (12-) month 2021 fiscal year end cost report in which case the 2020 fiscal year-end cost report shall be used to calculate the prospective rate.

(II) The costs from the 2020 and 2021 fiscal year-end cost reports shall be trended using the indices from the most recent publication of the Healthcare Cost Review available to the division using the “CMS Nursing Home without Capital Market Basket” table. The costs shall be trended using the four- (4-) quarter moving average. The costs shall be trended for the years following the cost report year, up to and including the state fiscal year corresponding to the effective date of the rates.

For SFY 2023, the trends are as follows:

(a) 2021=2.825% (b) 2022=2.500% (c) 2023=3.3800% (III) The current year depreciation will not be deducted from the working capital to determine Return on Equity.

2. Interim Rate Calculation.

A. In the case of a newly certified facility where a valid Title XIX participation agreement has been executed, a request for an interim rate must be submitted in writing to the MO HealthNet Division.

(I) The interim rate shall be determined based on the projected estimated operating costs. The facility’s request must specifically and clearly identify the interim rate and be supported by complete and accurate documentation satisfactory to the single state agency. Documentation submitted must include a budget of the projected estimated operating costs. Other documentation may also be required to be submitted upon the request of the division.

(II) The establishment of the prospective rate for all new construction facility providers shall be based on the second full facility fiscal year cost report (i.e., rate setting cost report) prepared in accordance with the principles of this

rule. This cost report shall be based on actual operating costs and shall be prepared and submitted in accordance with the reporting requirements in section (7) of this rule.

(III) Prior to establishment of a prospective rate for newly certified facility providers, the cost reports may be subject to an on-site audit by the Department of Social Services or authorized representative to determine the facility’s actual allowable costs. Allowability of costs will be determined as described in subsection (3)(A) of this rule.

(IV) The cost report, audited or unaudited, will be reviewed by the MO HealthNet Division, and a prospective reimbursement rate shall be determined on the allowable per diem cost as set forth in section (4) of this rule. The prospective reimbursement rate shall be effective on the first day of the facility’s rate setting cost report and payment adjustments shall be made for claims paid at the interim rate.

3. Adjustments to rates. The prospectively determined reimbursement rate may be adjusted only under the following conditions:

A. When information contained in a facility’s cost report is found to be fraudulent, misrepresented, or inaccurate, the facility’s reimbursement rate may be reduced, both retroactively and prospectively, if the fraudulent, misrepresented, or inaccurate information as originally reported resulted in establishment of a higher reimbursement rate than the facility would have received in the absence of this information.

No decision by the MO HealthNet agency to impose a rate adjustment in the case of fraudulent, misrepresented, or inaccurate information in any way shall affect the MO HealthNet agency’s ability to impose any sanctions authorized by statute or rule. The fact that fraudulent, misrepresented, or inaccurate information reported did not result in establishment of a higher reimbursement rate than the facility would have received in the absence of the information also does not affect the MO HealthNet agency’s ability to impose any sanctions authorized by statute or rules;

B. Extraordinary circumstances. A participating facility that has a prospective rate may request an adjustment to its prospective rate due to extraordinary circumstances. This request should be submitted in writing to the division within one (1) year of the occurrence of the extraordinary circumstance.

The request should clearly and specifically identify the conditions for which the rate adjustment is sought. The dollar amount of the requested rate adjustment should be supported by complete and accurate documentation satisfactory to the division. If the division makes a written request for additional information and the facility does not comply within ninety (90) days of the request for additional information, the division shall consider the request withdrawn. Requests for rate adjustments that have been withdrawn by the facility or are considered withdrawn because of failure to supply requested information may be resubmitted once for the requested rate adjustment. In the case of a rate adjustment request that has been withdrawn and then resubmitted, the effective date shall be the first day of the month in which the resubmitted request was made providing that it was made prior to the tenth day of the month. If the resubmitted request is not filed by the tenth of the month, rate adjustments shall be effective the first day of the following month. Conditions for an extraordinary circumstance are as follows:

(I) When the provider can show that it incurred higher costs due to circumstances beyond its control, and the circumstances are not experienced by the nursing home or ICF/IID industry in general, and the circumstances have a substantial cost effect; and (II) Extraordinary circumstances, which are beyond the reasonable control of the ICF/IID and are not a product or result of the negligence or malfeasance of the ICF/IID, include— (a) Unavoidable acts of nature are natural wildfire, earthquakes, hurricane, tornado, lightning, flooding, or other natural disasters for which no one can be held responsible, that are not covered by insurance and that occur in a federally declared disaster area; or (b) Vandalism, civil disorder, or both that are not covered by insurance; or (c) Replacement of capital depreciable items not built into existing rates that are the result of circumstances not related to normal wear and tear or upgrading of existing system;

C. When an adjustment is based on an Administrative Hearing Commission or court decision;

D. New, expanded, or terminated services may be subject to rate review;

E. Disallowance of federal financial participation; and F. The following will not be subject to review:

(I) The negotiated trend factor;

(II) The use of prospective reimbursement rate; and (III) The cost base for the per diem rates except as specified in this rule.

(5) Covered Services and Supplies.

(A) ICF/IID services and supplies covered by the per diem reimbursement rate under this plan, and which the ICF/IID must provide, as required by federal or state law or rule and include, among other services, the regular room, dietary and nursing services, or any other services that are required for standards of participation or certification. Also included are minor medical and surgical supplies and the use of equipment and facilities. These items include but are not limited to the 1. All general nursing services including but not limited to administration of oxygen and related medications, handfeeding, incontinency care, tray service, and enemas;

2. Items that are furnished routinely and relatively uniformly to all participants, for example, gowns, water pitchers, soap, basins, and bed pans;

3. Items such as alcohol, applicators, cotton balls, bandaids, and tongue depressors;

4. All nonlegend antacids, nonlegend laxatives, nonlegend stool softeners, and nonlegend vitamins. Any nonlegend drug in one (1) of these four (4) categories must be provided to residents as needed and no additional charge may be made to any party for any of these drugs. Facilities may not elect which nonlegend drugs in any of the four (4) categories to supply; facilities must provide all as needed within the existing per diem rate;

5. Items which are utilized by individual participants but which are reusable and expected to be available, such as ice equipment, and other durable, nondepreciable medical 6. Additional items as specified in the appendix to this plan when required by the patient;

6. Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diet, including dietary supplements written as a prescription item by a physician;

7. All laundry services except personal laundry, which is a noncovered service;

8. All general personal care services that th e facility furnishes routinely and relatively uniformly to all participants for their personal cleanliness and appearance shall be covered services, for example, necessary clipping and cleaning of fingernails and toenails, basic hair care, shampoos, and shaves to the extent necessary for reasonable personal hygiene. The provider shall not bill the patient or his/her responsible party for this type of personal service;

9. All consultative services as required by state or federal law or regulation or for proper operation by the provider.

Contracts for the purchase of these services must accompany the provider cost report. Failure to do so will result in the penalties specified in section (8) of this rule;

11. Semiprivate room and board and private room and board when necessary to isolate a participant due to a medical or social condition, such as contagious infection, irrational loud speech, and the like. Unless a private room is necessary due to a medical or social condition, a private room is a noncovered service, and a MO HealthNet participant or responsible party may therefore pay the difference between a facility’s semiprivate charge and its charge for a private room. MO HealthNet participants may not be placed in private rooms and charged any additional amount above the facility’s MO HealthNet per diem unless the participant or responsible party in writing specifically requests a private room prior to placement in a private room and acknowledges that an additional amount not payable by MO HealthNet will be charged for a private room;

12. Twelve (12) days per any period of six (6) consecutive months during which a participant is on a temporary leave of absence from the facility. The provider shall specifically provide for temporary leave of absence days in the participant’s plan of care. Periods of time during which a participant is away from the facility because s/he is visiting a friend or relative are considered temporary leaves of absence; and 13. Days when participants are away from the facility overnight on facility-sponsored group trips under the continuing supervision and care of facility personnel.

(6) Allowable Cost Areas.

(A) Compensation of Owners.

1. Allowance of compensation of services of owners shall be an allowable cost area, provided the owner actually performs the services and the services are necessary.

2. “Compensation” means the total benefit to the owner, within the limitations set forth in this rule, of the services s/he renders to the facility. Compensation includes direct payments to the owner for managerial, administrative, professional, and other services; amounts paid by the provider for the personal benefit of the owner; the cost of assets and services that the owner receives from the provider; and additional amounts determined to be the reasonable value of the services rendered by sole proprietors or partners and not paid by any method previously described.

3. MO HealthNet auditors may determine the reasonableness of compensation by reference to or in comparison with compensation paid for comparable institutions or it may be determined by other appropriate means such as the Medicare and Medicaid Provider Reimbursement Manual (HIM-15) or by other means.

4. Necessary services refers to those services that are pertinent to the operation and sound conduct of the facility, had the provider not rendered these services, then employment of another person(s) to perform the service would be necessary.

(B) Covered services and supplies as defined in section (5) of (C) Depreciation.

1. An appropriate allowance for depreciation on buildings, furnishings, and equipment that are part of the operation and sound conduct of the provider’s business is an allowable cost item. Finder’s fees are not an allowable cost item.

2. The depreciation must be identifiable and recorded in 3. The basis of assets at the time placed in service shall be the lower of— A. The book value of the provider;

B. Fair market value at the time of acquisition;

C. The recognized Internal Revenue Service (IRS) tax

basis; and D. In the case of the change in ownership, the cost basis of acquired assets of the owner of record on or after July 18, 1984, as of the effective date of the change of ownership; or in the case of a facility which entered the program after July 18, 1984, the owner at the time of the initial entry into the MO HealthNet program.

4. The MO HealthNet Division will allow the basis of donated assets to the extent of the recognized income resulting from the donation of the asset. Should a dispute arise between a provider and the Department of Social Services as to the fair market value at the time of acquisition of a depreciable asset and an appraisal by a third party is required, the appraisal cost will be shared proportionately by the MO HealthNet program and the facility in ratio to MO HealthNet participant reimbursable patient days to total patient days.

5. Allowable methods of depreciation shall be limited to the straight-line method. The depreciation method used for an asset under the MO HealthNet program need not correspond to the method used by a provider for non-MO HealthNet purposes; however, useful life shall be in accordance with the American Hospital Association’s Guidelines. Component part depreciation is optional and allowable under this plan.

6. “Historical cost” means the cost incurred by the provider in acquiring the asset and preparing it for use, except as provided in this rule. Usually, historical cost includes costs that would be capitalized under generally accepted accounting principles. For example, in addition to the purchase price, historical cost would include architectural fees and related legal fees. Where a provider has elected, for federal income tax purposes, to expense certain items such as interest and taxes during construction, the historical cost basis for MO HealthNet depreciation purposes may include the amount of these expensed items. However, where a provider did not capitalize these costs and has written off the costs in the year they were incurred, the provider cannot retroactively capitalize any part of these costs under the program. For Title XIX purposes and this rule, any asset costing less than five hundred dollars ($500) or having a useful life of one (1) year or less, may be expensed and not capitalized at the option of the provider, or in the case of a facility which entered the program after July 18, 1984, the owner at the time of the initial entry into the MO HealthNet 7. When an asset is acquired by trading in an existing asset, the cost basis of the new asset shall be the sum of the 8. For the purpose of determining allowance for depreciation, the cost basis of the asset shall be as prescribed in paragraph (6)(C)3.

7. Capital expenditures for building construction or for provider’s bed capacity shall not be allowed in the program or depreciation base if these capital expenditures fail to comply with any other federal or state law or regulation, such as Certificate of Need (CON).

8. Amortization of leasehold rights and related interest and finance costs shall not be allowable costs under this plan.

(D) Interest and Finance Costs.

1. Necessary and proper interest on both current and 2. Interest is the cost incurred for the use of borrowed for funds borrowed for a relatively short term. This is usually for those purposes as working capital for normal operating expenses. Interest on capital indebtedness is the cost incurred for funds borrowed for capital purposes, such as the acquisition of facilities and capital improvements, and this indebtedness must be amortized over the life of the loan.

2. Interest may be included in finance charges imposed 4. To be an allowable cost item, interest (including finance charges, prepaid costs, and discounts) must be supported by evidence of an agreement that funds were borrowed and that payment of interest and repayment of the funds are required, identifiable in the provider’s accounting records, relating to the reporting period in which the costs are claims, and necessary and proper for the operation, maintenance, or acquisition of the provider’s facilities.

3. Necessary means that the interest be incurred for a loan made to satisfy a financial need of the provider and for a

purpose related to participant care. Loans that result in excess funds or investments are not considered necessary.

6. Proper means that the interest be incurred at a rate not in excess of what a prudent borrower would have had to pay in the money market existing at the time the loan was made, and provided further the department shall not reimburse for interest and finance charges any amount in excess of the prime rate current at the time the loan was obtained.

7. Interest on loans to providers by proprietors, partners, and any stockholders shall not be an allowable cost item because the loans shall be treated as invested capital and included in the computation of an allowable return on owner’s net equity. If a facility operated by a religious order borrows from the order, interest paid to the order shall be an allowable 8. If loans for capital indebtedness exceed the asset cost

basis as defined in subsection (6)(C) of this rule, the interest associated with the portion of the loan(s) which exceed the asset cost basis as defined in subsection (6)(C) of this rule shall not be allowable.

9. Income from a provider’s qualified retirement fund shall be excluded in consideration of the per diem rate.

10. A provider shall amortize finance charges, prepaid interest, and discount over the period of the loan ratably or by 11. Usual and customary costs, excluding finder’s fees, and shall be allowable costs over the loan period ratably or by means of the constant interest applied method.

11. Usual and customary costs shall be limited to the escrow fees, and closing costs.

12. Interest expense resultant from capital expenditures which cause an increase in a bed capacity by the provider shall not be an allowable cost item if the capital expenditure fails to comply with other federal or state law or rules such as CON.

(E) Rental and Leases.

1. Rental and leases of land, buildings, furnishings, and equipment are allowable cost areas if the rented items are necessary and not in essence a purchase of those assets.

Finder’s fees are not an allowable cost item.

2. Necessary rental and lease items are those that are 3. In the case of related parties, rental and lease amounts cannot exceed the lesser of those that are actually paid or the 4. Determination of reasonable and adequate reimbursement for rental and amounts, except in the case of related parties that is subject to other provisions of this rule, may require affidavits of competent, impartial experts who are familiar with the current rentals and leases.

3. The test of necessary costs shall take into account the 6. Leases subject to CON approval must have that approval 7. If rent or lease costs increase solely as a result of change in ownership, the resulting increase which exceeds the allowable capital cost of the owner of record as of July 18, 1984, or in the case of a facility which entered the program after July 18, 1984, the owner at the time of the initial entry into the MO HealthNet program, shall be a nonallowable cost.

(F) Taxes. Taxes levied on or incurred by providers shall be allowable cost areas with the exceptions of the following items:

1. Federal, state, or local income and excess profit taxes including any interest and penalties paid;

2. Taxes in connection with financing, refinancing, or refunding operations, such as taxes on the issuance of bond, property transfer, issuance of transfer of stocks;

3. Taxes for which exemptions are available to the provider;

4. Special assessments on land that represent capital improvements. These costs shall be capitalized and depreciated over the period during which the assessment is scheduled to be paid;

5. Taxes on property which are not a part of the operation of the provider;

6. Taxes which are levied against a resident and collected and remitted by the provider; and 7. Self-employment Federal Insurance Contributions Act (FICA) taxes applicable to individual proprietors, partners, or members of a joint venture to the extent the taxes exceed the amount which would have been paid by the provider on the allowable compensation of the persons had the provider organization been an incorporated rather than unincorporated entity.

(G) Issuance of Revenue Bond and Tax Levies by District and County Facilities. Those nursing home districts and county bonds, that interest which is paid per the revenue bond will be an allowable cost item. Depreciation on the plant and equipment of these facilities also shall be an allowable cost item. Any tax levies which are collected by nursing home (H) Value of Services of Employees.

1. Except as provided for in this rule, the value of services 2. Services rendered by volunteers, such as those affiliated with the American Red Cross, hospital guilds, auxiliaries, private individuals, and similar organizations, shall not be included as an allowable cost area, as the services have traditionally been rendered on a purely volunteer basis without expectation of any form of reimbursement by the organization through which the service is rendered or by the person rendering the service.

2. Services by priests, ministers, rabbis, and similar type professionals shall be an allowable cost area; provided, that the services are not of a religious nature. An example of an allowable cost area under this section would be a necessary administrative function performed by a clergyman. The state will not recognize building costs on space set aside primarily for professionals providing any religious function. The MO HealthNet Division considers costs for wardrobe and similar items likewise nonallowable.

(I) Fringe Benefits.

1. Life insurance.

A. Types of insurance that the MO HealthNet Division does not consider an allowable cost area; premiums related to insurance on the lives of officers and key employees are not allowable cost areas under the following circumstances:

(I) Where, upon the death of an insured officer or key employee, the insurance proceeds are payable directly to the provider. In this case, the provider is a direct beneficiary.

Insurance of this type is referred to as key-man insurance; and (II) Where insurance on the lives of officers is voluntarily taken out as part of a mortgage loan agreement entered into for building construction and, upon the death of an insured officer, the proceeds are payable directly to the lending institution as a credit against the loan balance. In this case, the provider is an indirect beneficiary.

B. Types of insurance which are considered an allowable cost area— (I) Where credit life insurance is required as part of a loans granted under certain federal programs; and (II) Where the relative(s) or estate of the employee, excluding stockholders, partners, and proprietors, is the beneficiary. The MO HealthNet Division considers this type of insurance a fringe benefit and is an allowable cost area to the extent that the amount of coverage is reasonable.

2. Retirement plans.

A. Contributions to qualified retirement plans for the benefit of employees excluding stockholders, partners, and proprietors of the provider shall be allowable cost areas.

Facilities shall exclude interest income from funded pensions or retirement plans from consideration in determining the allowable cost area.

B. Amounts funded to pension and retirement plans, together with associated income, shall be recaptured if not report form.

3. Deferred compensation plans.

A. Contributions for the benefit of employees, excluding stockholders, partners, and proprietors, under deferred compensation plans shall be all allowable cost areas when, and to the extent that, the costs are actually paid by the provider.

Deferred compensation plans must be funded. Provider payments under unfunded deferred compensation plans will be considered as an allowable cost area only when paid to the participating employee and only to the extent considered B. Amounts paid by tax-exempt organizations to purchase tax-sheltered annuities for employees shall be treated as deferred compensation actually paid by the provider.

C. Amounts funded to deferred compensation plans, together with associated income if not actually paid when due, as an offset to expenses on the cost report form.

(J) Education and Training Expenses.

1. The cost of on-the-job training that directly benefits shall be allowable. Off-the-job training involving extended periods exceeding five (5) continuous days is an allowable cost item only when specifically authorized in advance by the department.

2. Cost of education and training shall include incidental travel costs, but will not include leaves of absence or sabbaticals.

(K) Organizational Cost Items.

1. Organizational cost items may be included as an allowable cost area on an amortized basis.

2. Organizational cost items include the following: legal fees incurred in establishing the corporation or other organizations, necessary accounting fees, expenses of temporary directors, fees paid to states of incorporation.

3. The provider shall amortize organizational costs ratably over a period of sixty (60) months beginning with the date of 4. Where a provider did not capitalize organizational costs and has written off those costs in the year they were incurred, 5. Where a provider is organized within a five- (5-) year period prior to entering the program and has properly organizational costs is an allowable cost area under the program and shall be amortized over the remaining part of the sixty- (60-) month period.

4. For change in ownership after July 18, 1984, allowable (L) Advertising Costs. Advertising costs that are reasonable, appropriate, and helpful in developing, maintaining, and furnishing services shall be an allowable cost area. The costs must be common and accepted occurrence in the field of the activity of the provider.

(M) Cost of Suppliers Involving Related Parties. Costs applicable to facilities, goods, and services furnished to a provider by a supplier related to the provider shall not exceed the lower of the cost to the supplier or the prices of comparable facilities, goods, or services obtained elsewhere. A provider shall identify suppliers related to it in the uniform cost report and the type-quantity and costs of facilities, goods, and services obtained from each supplier.

(N) Utilization Review. Incurred cost for the performance of required utilization review for ICF/IID is an allowable cost area.

The expenditures must be for providing utilization review on behalf of a Title XIX participant. The provider shall apportion utilization review costs incurred for Title XVIII and Title XIX based on reimbursable participant days recorded for each program during the reporting period.

(O) Minimum Utilization. In the event the occupancy of a provider is below ninety percent (90%), the provider will calculate the following cost centers as if the provider experienced ninety percent (90%) occupancy: laundry, housekeeping, general, administrative, and plant operation costs. In no case may the provider carry forward costs disallowed under this provision to succeeding periods.

(P) Nonreimbursable Costs.

1. Bad debts, charity, and courtesy allowances are deductions from revenue and are not to be included as allowable costs.

2. Those services that are specifically provided by Medicare and MO HealthNet must be billed to those agencies.

3. Any costs incurred that are related to fund drives are not 4. Costs incurred for research purposes shall not be included as allowable costs.

4. The cost of services provided under the Title XX program, by contract or subcontract, is specifically excluded as an allowable item.

5. Attorney fees related to litigation involving state, local, or federal governmental entities and attorneys’ fees which are not related to the provision of LTC services, such as litigation related to disputes between or among owners, operators, or administrators.

6. Costs, such as legal fees, accounting and administration or purchase of any capital asset by acquisition of merger for (Q) Other Revenues. Other revenues, including those listed that follow and excluding amounts collected under paragraph (5)(A)8. will be deducted from the total allowable cost and must be shown separately in the cost report by use of a separate schedule if included in the gross revenue: income from telephone services; sale of employee and guest meals; sale of medical abstracts; sale of scrap and waste food or materials; rental income; cash, trade, quantity time, and other discounts; purchase rebates and refunds; recovery on insured loss; parking lot revenues; vending machine commissions or profit; sales from drugs to other than participants; income from investments of whatever type; and room reservation charges for temporary leave of absence days which are not covered services under section (5) of this rule. Failure by the provider to, in a readily ascertainable manner, separately account for any of the revenues specifically set out previously in this rule, shall result in the provider’s termination from the program.

7. Interest income received from a funded depreciation account will not be deducted from allowable operating costs if interest is applied to the replacement of the asset being depreciated.

8. Cost centers or operations specified by the provider in subsection (6)(R) of this rule shall not have their associated cost or revenues included in the covered costs or revenues of the facility.

9. Restricted and unrestricted funds.

A. “Restricted funds,” as used in this rule, mean those funds, cash or otherwise, including grants, gifts, taxes, and income from endowments, which the provider shall only use for a specific purpose designated by the donor. Those restricted funds that are not transferred funds and are designated by the donor for paying operating costs will be offset from the total allowable expenses. If an administrative body has the authority to re-restrict restricted funds designated by the donor for paying operating costs, the provider will not offset the funds from the total allowable expenses.

B. “Unrestricted funds,” as used in this rule, mean those funds, cash or otherwise, including grants, gifts, taxes, and income from endowments, that a donor gives to a provider without restriction as to their use. The provider can use these funds in any manner. However, those unrestricted funds that are not transferred funds and that the provider uses to pay operating costs will be offset from total allowable expenses.

C. Transferred funds, as used in this rule, are those funds appropriated through a legislative or governmental administrative body’s action, state or local, to a state or local government provider. The transfer can be state-to-state, stateto-local, or local-to-local provider. The MO HealthNet Division does not consider these funds a grant or gift for reimbursement purposes, so have no effect on the provider’s allowable cost under this plan.

(R) Apportionment of Costs to MO HealthNet Participant Residents.

1. Providers shall apportion their allowable cost areas between MO HealthNet program participant residents and other residents so that the share of allowable cost areas borne by the MO HealthNet program is based upon actual services received by MO HealthNet program participants.

2. To accomplish this apportionment, providers shall apply the ratio of patient days for MO HealthNet participants to the total patient days.

3. Average cost per diem for general routine services means the amount computed by dividing the total allowable patient costs for routine services by the total number of patient days of care rendered by the provider in the cost-reporting period.

4. A patient day of care is that period of service rendered a patient between the census-taking hours on two (2) consecutive days, including the twelve (12) temporary leave of absence days per any period of six (6) consecutive months as specifically covered under section (5) of this rule, the day of discharge being counted only when the patient was admitted the same day. The provider shall maintain a census log in the facility for documentation purposes. Census shall be taken daily at midnight. A day of care includes those overnight periods when a participant is away from the facility on a facility-sponsored group trip and remains under the supervision and care of facility personnel.

5. ICF/IID facilities that provide intermediate care services to MO HealthNet participants may establish distinct part cost centers in their facility provided that adequate accounting and statistical data required to separately determine the nursing care cost of each distinct part is maintained. Each distinct part may share the common services and facilities, such as management services, dietary, housekeeping, building maintenance, and laundry.

6. In no case may a provider’s allowable costs allocated to the MO HealthNet program include the cost of furnishing services to persons not covered under the MO HealthNet (S) Return on Equity.

7. A return on a provider’s net equity shall be an allowable 2. The amount of return on a provider’s net equity shall be calculated using the nursing home allowable percentage as defined in 13 CSR 70-10.015 Prospective Reimbursement Plan for Nursing Facility Services.

8. An owner’s net equity is comprised of investment capital and working capital. Investment capital includes the investment in building, property, and equipment (cost of land, mortgage payments toward principle, and equipment purchase less the accumulative depreciation). Working capital represents the amount of capital that is required to ensure proper operation of the facility.

9. The return on owner’s net equity shall be payable only to proprietary providers.

10. The provider shall apportion its return on the owner’s net equity to the MO HealthNet program based on the provider’s MO HealthNet program reimbursable participant resident days of care to total resident days of care during the cost-reporting period. For the purpose of this calculation, total resident days of care shall be the greater of ninety percent (90%) of the provider’s certified bed capacity or actual occupancy during the cost year.

(T) Intermediate Care Facility for Individuals with Intellectual Disabilities Federal Reimbursement Allowance (ICF/IID FRA).

The fee assessed to ICF/IIDs in the state of Missouri for the privilege of doing business in the state will be an allowable (7) Reporting Requirements.

(A) Annual Cost Report.

1. Each provider shall establish a twelve- (12-) month fiscal period which is to be designated as the provider’s fiscal year. The provider shall submit an annual cost report for the fiscal year to the department on forms to be furnished by the department for that purpose. Each provider shall submit the completed cost report by the first day of the sixth month following the close of the fiscal period.

2. Unless the provider has previously filed adequate and current documentation in the following areas with the department, authenticated copies of the following documents must be submitted by the provider with the cost reports: authenticated copies of all leases related to the activities of the facility; all management contracts, all contracts with consultants; federal and state income tax returns for the fiscal year; and documentation of expenditures, by line item, made under all restricted and unrestricted grants. For restricted grants, a statement verifying the restriction as specified by the donor.

3. The facility shall maintain adequate documentation for all line items on the uniform cost reports and must submit the document to the department upon request.

4. If a cost report is more than ten (10) days past due, report is submitted. Upon receipt of a cost report prepared in accordance with this regulation, the department will release the withheld payments to the provider. For cost reports which are more than ninety (90) days past due, the department agreement and if terminated, retain all payments which have 5. If a provider notifies, in writing, the director of the Institutional Reimbursement Unit of the division prior to the in the MO HealthNet program, the division may withhold all remaining payments from the selling provider until the provider files the cost report. The fully completed cost report with all required attachments and documentation is due the first day of the sixth month after the date of change of control, ownership, or termination. Upon receipt of a cost report prepared in accordance with this regulation, the department will release any withheld payment to the selling provider.

(B) Certification of Cost Reports.

1. The facility must certify the accuracy and validity of any cost report. Certification must be made by one (1) of the following persons (who must be authorized by the governing body of the facility to make the certification and will furnish proof of the authorization): an incorporated entity, an officer of the corporation; for a partnership, a partner; for a sole proprietorship or sole owner, the owner; or for a public facility, the chief administrative officer of the facility. The cost report must also be notarized by a licensed notary public.

2. Certification statement.

Misrepresentation or falsifications of any information contained in this report may be punishable by fine, Certification by officer or administrator of provider: ____________________________________ (Provider’s name(s) and number(s)) for the cost report period beginning, _________________, 20 and ending ____________, 20, and that to the best of my knowledge and belief, it is a true, correct, and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. ________________________________ _____________ __________ (C) Adequacy of Records.

1. The provider must make available to the department or its duly authorized agent, including federal agents from Health and Human Services (HHS), at all reasonable times, the records as are necessary to permit review and audit of provider’s cost reports. Failure to do so may lead to sanctions available in

section (8) of this rule.

2. The provider shall retain all records associated with the preparation and documentation of the data associated with the cost report for seven (7) years from the cost report filing date.

(D) Accounting Basis.

1. The provider shall base the submitted cost report on the accrual basis of accounting.

2. Governmental institutions that operate on a cash or modified cash basis of accounting may continue to use those methods, provided the governmental institution treats capital expenditures appropriately.

(E) Audits.

1. The provider shall base cost reports upon the provider’s financial and statistical records that must be capable of verification by audit.

2. If the provider has included the cost of a certified audit of the facility as an allowable cost item to the plan, a copy of that audit report and accompanying letter shall be submitted without deletions.

3. The annual cost report for the fiscal year of the provider may be subject to audit by the Department of Social Services or its contracted agents. Twelve- (12-) month cost reports for new construction facilities required to be submitted under

section (4) of this rule may be audited by the department or its contracted agents prior to establishment of a permanent rate.

4. The department or authorized agent will conduct a desk review of all cost reports after submission by the provider and shall provide for on-site audits of facilities wherever their personnel notes a cost variance or exception.

5. The department shall retain the annual cost report and any working papers relating to the audits of those cost reports for a period of not less than seven (7) full years from the date of 6. Those providers having an annual Title XIX bed-day ratio on total bed days or certified beds of greater than sixty percent (60%) or an annual Title XIX payment of two hundred thousand dollars ($200,000) or more, or both, shall be required, for at least the first two (2) fiscal years of participation in the plan, to have an annual audit of their financial records by an independent certified public accountant. The auditor may issue a qualified audit report stating that confirmations of accounts receivable and accounts payable are not required by the plan. For the purposes of the paragraph, the Department of Social Services will accept unqualified opinions only if they are from a certified public accounting firm. A copy of the audit report must be submitted to the department to support the annual cost report of the facility.

(8) Sanctions and Overpayments.

(A) The department may impose sanctions against a provider in accordance with 13 CSR 70-3.030 and other federal or state statutes and regulations.

(B) In the case of overpayments to providers based on but not limited to field or audit findings or determinations based on a comprehensive operational review of the facility, the provider shall repay the overpayment in accordance with the provisions as set forth in 13 CSR 70-3.030.

(9) Exceptions.

(A) For those MO HealthNet-eligible participant patients who have concurrent Medicare Part A skilled nursing facilities benefits available, MO HealthNet reimbursement for covered days of stay in a qualified facility will be based on the coinsurance as may be imposed under the Medicare Program.

(B) The Title XIX reimbursement rate for out-of-state providers shall be set by one (1) of the following methods:

1. For providers which provided prior authorized services of fewer than one thousand (1,000) patient days for Missouri Title XIX participants, the reimbursement rate shall be the rate paid for comparable services and level-of-care by the state in which the provider is located; and 2. For providers that provide prior authorized services of one thousand (1,000) or more patient days for Missouri Title XIX participants, the reimbursement rate shall be the lower of— A. The rate paid for comparable services and level-ofcare by the state in which the provider is located; or B. The rate calculated in section (4) of this rule.

(10) Payment Assurance.

(A) The state will pay each provider, which furnished the services in accordance with the requirements of the state plan, the amount determined for services furnished by the provider according to the standards and methods set forth in these rules.

(B) Where third-party payment is involved, MO HealthNet will be the payor of last resort with the exception of state programs such as Vocational Rehabilitation and the Missouri Crippled Children’s Service. Procedures for remitting thirdparty payments are provided in the MO HealthNet program provider manuals.

(11) Provider Participation. Payments made in accordance with program so that eligible persons can receive medical care and services included in the state plan at least to the extent these services are available to the general public.

(12) Payment in Full. Participation in the program shall be limited to providers who accept as payment in full for covered services rendered to MO HealthNet participants, the amount paid in accordance with these rules and applicable copayments.

(13) Plan Evaluation. The provider will maintain documentation to effectively monitor and evaluate experience during administration of this rule.

A & D Ointment Aerosol Inhalators, Self-Contained Aerosol, Other Types Air Mattresses Airway Oral Applicators, Cotton-Tipped Applicators, Swab-Eez Aquamatic K Pads (water-heated pad)

Asepto Syringes Bandages (elastic or cohesive)

Bed Frame Equipment (for certain immobilized bed patients)

Bedpan, Fracture Bottle, Specimen Cannula Nasal Catheter Indwelling Catheter Plugs Catheter Trays Catheter (any size)

Cotton Balls Customized Crutches, Canes, and Wheelchairs Drainage Bags Dressing Tray Enema Soap Equipment and Supplies for Diabetic Urine Testing Eye Pads Female Urinal Flotation Mattress or Biowave Mattress Flotation Pads, Turning Frames, or both Folding Foot Cradle Gastric Feeding Unit Gauze Sponges Gloves, Unsterile and Sterile Green Soap Hand-Feeding Incontinency Care Incontinency Pads and Pants Inhalation Therapy Supplies Intermittent Positive Pressure Breathing Machine (IPPB)

Irrigation Bulbs Irrigation Trays I.V. Trays Jelly, Lubricating Lines, Extra Lotion, Soap, and Oil Nasal Catheter, Insertion and Tube Nasal Tube Feeding Nursing Services (all) regardless of level including the Nursing Supplies and Dressing (other than items of personal comfort or cosmetic)

Oxygen Mask Pump (aspiration and suction)

Room and Board (semiprivate or private if necessitated by a medical or social condition)

Steam Vaporizer Suture Removal Kit Syringes (all sizes)

Tape (for laboratory test)

Tubing I.V. Trays, Blood Infusion Set, I.V. Tubing RSMo 2016.* This rule was previously filed as 13 CSR 40-81.083.

Original rule filed Aug. 13, 1982, effective Nov. 11, 1982. Rescinded:

Filed July 12, 1984, effective Oct. 11, 1984. Readopted: Filed July 3, 1986, effective Nov. 1, 1986. Amended: Filed Dec. 16, 1986, effective April 26, 1987. Emergency amendment filed June 19, 1987, effective July 1, 1987, expired Oct. 29, 1987. Amended: Filed Aug. 18, 1987, effective Oct. 25, 1987. Emergency amendment filed Feb. 5, 1988, effective Feb. 15, 1988, expired June 13, 1988. Amended: Filed Feb. 5, 1988, effective June 11, 1988. Emergency amendment filed Dec. 16, 1988, effective Jan. 1, 1989, expired May 1, 1989. Amended:

Filed Dec. 5, 1988, effective Feb. 24, 1989. Amended: Filed Dec. 16, 1988, effective March 11, 1989. Amended: Filed Aug. 16, 1989, effective Nov. 11, 1989. Amended: Filed Dec. 1, 1989, effective Feb. 25, 1990. Rescinded and readopted: Filed March 5, 1990, effective June 11, 1990. Amended: Filed May 30, 1990, effective Sept. 28, 1990. Emergency amendment filed Nov. 15, 1991, effective Dec. 3, 1991, expired April 1, 1992. Emergency amendment filed March 13, 1992, effective April 2, 1992, expired July 30, 1992. Amended:

Filed Nov. 15, 1991, effective April 9, 1992. Emergency amendment filed July 17, 1992, effective Sept. 1, 1992, expired Dec. 29, 1992.

Emergency amendment filed Dec. 8, 1992, effective Dec. 31, 1992, expired April 28, 1993. Amended: Filed July 17, 1992, effective April 8, 1993. Amended: Filed Dec. 14, 1992, effective June 7, 1993.

Amended: Filed Nov. 21, 1994, effective June 30, 1995. Emergency amendment filed Dec. 15, 1995, effective Jan. 1, 1996, expired June 28, 1996. Amended: Filed Oct. 10, 1995, effective May 30, 1996.

Amended: Filed Oct. 16, 1995, effective May 30, 1996. Emergency amendment filed Feb. 23, 1999, effective March 5, 1999, expired Aug. 31, 1999. Amended: Filed May 27, 1999, effective Nov. 30, 1999.

Emergency amendment filed Sept. 20, 1999, effective Oct. 1, 1999, expired March 29, 2000. Amended: Filed Feb. 14, 2001, effective Aug. 30, 2001. Emergency amendment filed Jan. 24, 2007, effective Feb. 3, 2007, expired Aug. 1, 2007. Amended: Filed Jan. 16, 2007, effective July 30, 2007. Emergency amendment filed June 20, 2007, effective July 1, 2007, expired Dec. 27, 2007. Amended: Filed June 20, 2007, effective Jan. 30, 2008. Emergency amendment filed June 18, 2008, effective July 1, 2008, expired Dec. 28, 2008. Amended:

Filed July 1, 2008, effective Jan. 30, 2009. Emergency amendment filed Sept. 20, 2011, effective Oct. 1, 2011, expired March 29, 2012.

Amended: Filed Sept. 20, 2011, effective March 30, 2012. Amended:

Filed Dec. 13, 2013, effective June 30, 2014. Emergency amendment filed Aug. 15, 2016, effective Sept. 1, 2016, expired Feb. 27, 2017.

Amended: Filed Aug. 15, 2016, effective March 30, 2017. Emergency amendment filed Aug. 22, 2017, effective Sept. 1, 2017, expired Feb. 27, 2018. Amended: Filed Aug. 22, 2017, effective Feb. 28, 2018.

Emergency amendment filed Oct. 25, 2019, effective Nov. 8, 2019, expired May 5, 2020. Amended: Filed Oct. 25, 2019, effective May 30, 2020. Emergency amendment filed March 16, 2023, effective March 30, 2023, expired Sept. 25, 2023. Amended: Filed March 16, 2023, effective Oct. 30, 2023. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-10.040 Medicaid Eligibility and Preadmission Screening for Mentally Ill and Intellectually Disabled Individuals {#sec-13-csr-70-10.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.040}

PURPOSE: This rule outlines the preadmission screening requirements related to eligibility for Title XIX.

(1) Any individual who is admitted to a Medicaid certified nursing facility (NF) bed on or after January 1, 1989, and has not been screened for mental illness (MI), intellectual disability (ID), or related condition (RC) prior to admission or who does not have a valid special admission category will not be eligible for Title XIX payments to be made on his/her behalf for NF (A) The facility must complete a preadmission screening for individuals with a mental illness and individuals with ID as described in 42 Code of Federal Regulations (CFR) 483.20(k).

(B) For purposes of this rule an individual is considered to have mental illness if the individual has a serious mental illness as defined in 42 CFR 483.102(b)(1).

(C) For purposes of this rule an individual is considered to have an ID if the individual is intellectually disabled as defined in 42 CFR 483.102(b)(3) or is a person with a related condition as described in 42 CFR 435.1010.

(2) The requirement for preadmission screening applies whether the individual is a Medicare beneficiary, Medicaid recipient or private pay.

(3) Preadmission screening and resident reviews (PASRR) will include an assessment of the individual’s— (A) Physical condition;

(B) Mental condition;

(C) Need for nursing facility services to comply with 42 CFR 483.112(a); and (D) Need for specialized services for MI, ID, or RC.

1. If a Medicaid nursing facility resident is determined to need specialized services, the state will provide or arrange for such services while the Medicaid participant is in a nursing (4) For purposes of this rule, the term “specialized services” is defined for individuals with— (A) MI as the continuous and aggressive implementation of an individualized plan of care developed and supervised by an interdisciplinary team, which includes a physician, qualified mental health professional and, as appropriate, other professional that prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of MI that necessitates supervision by trained mental health personnel and is directed toward diagnosing and reducing the resident’s behavioral symptoms that necessitated institutionalization, improving his or her level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time;

(B) ID or other RC(s) as a continuous program for each client that results in treatment that meets the requirements of 42 CFR 483.440(a)(1) and includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and services that are directed towards the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of current optimal function status. Specialized services do not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous treatment (5) Medical information needed to do the assessments will be furnished by the attending physician. Other information needed to make the assessments, such as social history and behavior, may be furnished by the individual, guardian, family members, social workers, or other persons.

(6) The preadmission screening and resident review process has two (2) parts: Level I and Level II.

(A) The purpose of a Level I screening is to identify a nursing facility applicant or resident suspected of having a MI, ID, or RC.

(B) The purpose of a Level II evaluation is to perform a comprehensive evaluation in person or by telehealth to validate the applicant has a MI, ID, or RC and evaluate the individual’s treatment needs to determine if NF services are needed and if specialized services are required. If a determination is made that placement in an NF is inappropriate, no Title XIX vendor payments will be made or continue to be made in the case of a resident already in the NF unless the resident meets the requirements of 42 CFR 483.118(c)(1) and elects to stay in the NF.

1. For those individuals already residing or admitted to a NF who experience a change of condition or for those individuals who fall under a special admission category specified in subsection (7)(D), a resident review of the individual’s records in accordance with 42 CFR 483.134 and 483.136 may be required to determine if specialized services are appropriate or if modifications are needed.

(7) Any individual identified as having a suspected MI, ID, or RC by the Level I screening will be referred to Department of Mental Health (DMH) for a Level II evaluation. A Level II evaluation is required prior to admittance into a certified bed located in an NF, unless a valid special admission category, as specified in subsection (7)(D), applies.

(A) DMH or its designee will perform all Level II evaluations.

If a review indicates a level of services that can only be furnished in an intermediate care facility for individuals with intellectual disabilities (ICF/IID), within the Home and Community Based Waiver for the Developmentally Disabled or an acute care mental hospital, that individual is inappropriate for admission or continued stay in an NF. This will be true even if the individual meets the level of care under 19 CSR 30- 81.030 needed for authorization of Medicaid nursing facility (B) Any individual determined through the Level II evaluation to require specialized services and to not require NF services shall be discharged if the Level II evaluation determines that the individual’s nursing care needs can be met in other settings regardless of the level of care under 19 CSR 30-81.030 unless the resident meets the requirements of 42 CFR 483.118(c)

(1) and elects to stay in the NF.

1. If an individual described in subsection (7)(A) has medical needs which can only be met in an NF, as confirmed by and recommended by a Level II evaluation and communicated to the NF by the Department of Health and Senior Services (DHSS), that individual may be admitted or continue to remain in an NF. If the medical condition improves and nursing needs could be met in other settings, the individual shall be discharged unless the resident meets the requirements of 42 CFR 483.118(c)(1) and elects to stay in the NF.

2. A written evaluation report must be prepared at the conclusion of each Level II evaluation. The evaluation report must identify the specific nursing facility services, intellectual disability services, or mental health services required to meet the evaluated individual’s needs.

3. Notice of a decision resulting from a Level II evaluation shall be sent to the referring entity who submitted the Level I screening forms and the proposed placement facility, if different, as well as the evaluated individual and his or her legal representative, the individual’s attending physician, and the discharging hospital unless the hospital discharge is exempt from the preadmission screening per 42 CFR 483.106(b)

(2).

(C) Any individual admitted to or currently residing in an NF and identified as having a suspected MI, ID, or RC by the Level I screening shall be subject to a Level II evaluation.

(D) Special admission categories are subject to advanced group determinations as defined in 42 CFR 483.130(b)(1) and are based on the criteria specified in 42 CFR 483.130(c).

1. The following special admission categories may be admitted directly to an NF after the Level I screening is completed and receive the Level II evaluation or resident review following admission as appropriate based on the individual’s medical condition or admission justification:

A. Terminal illness. As defined by the Social Security Act, an individual is terminally ill if there is a medical prognosis that the individual’s life expectancy is six (6) months or less;

B. Severely ill. The person is comatose, ventilator dependent, functions at brain stem level, or has a diagnosis of chronic obstructive pulmonary disease, severe Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis, or congestive heart failure that results in a level of physical impairment so severe the individual could not be expected to benefit from specialized services;

C. Emergency provisional admission. This category is for a situation in which an individual needs placement to protect the individual from serious physical harm to self or others.

The NF must contact DHSS Adult Abuse and Neglect Hotline to make a formal request prior to admission. This special admission category requires prior authorization by DHSS as an emergency. No more than seven (7) days will be allowed for an emergency admission. The Department of Social Services, Family Support Division (FSD), will manage those dates based on information from DHSS. If the individual needs to stay in the NF longer than seven (7) days, the NF must immediately notify DHSS to determine continued stay. A comprehensive Level II evaluation or resident review must be performed after the initial seven- (7-) day period if continued stay is necessary;

D. Respite care. An individual may be admitted and remain in an NF for thirty (30) consecutive days or less with a forty-two- (42-) day maximum in twelve (12) months in order to provide respite for the individual’s caregiver. A comprehensive Level II evaluation is not required for the first thirty (30) consecutive days. FSD will control the NF authorized payment dates by means of a form they send to DHSS. No payment will be made to the NF beyond the thirty (30) days. If a situation arises in which the stay is longer than thirty (30) days, the NF must contact DHSS. If a continued stay is authorized, a comprehensive Level II evaluation or resident review must be performed within forty (40) calendar days of the individual’s admission to the NF if continued stay is necessary; and E. Direct transfer from a hospital. If a physician attests that the individual is likely to need thirty (30) days or less of NF care for the condition for which the individual was hospitalized, the individual may be admitted to an NF and no Level II evaluation or resident review is required during that thirty (30) days or less period. NF payment will be made for no more than thirty (30) days. If after admission to the NF it becomes apparent that the individual will need NF care longer than thirty (30) days, the NF must immediately notify DHSS. If a continued stay is approved, a comprehensive Level II evaluation must be performed within forty (40) calendar days of the individual’s admission to the NF.

(8) The Department of Social Services, DHSS, and DMH will have joint responsibility for the preadmission screening process.

(9) This rule incorporates by reference the following materials, as published by U.S. Government Publishing Office, U.S.

Superintendent of Documents, Washington, DC 20402, October 1, 2023. This rule does not incorporate any subsequent amendments or additions:

(A) 42 CFR section 483.20(k);

(B) 42 CFR section 483.102(b)(1);

(C) 42 CFR section 483.102(b)(3);

(D) 42 CFR section 435.1010;

(E) 42 CFR section 483.112(a);

(F) 42 CFR section 483.440(a)(1);

(G) 42 CFR section 483.118(c)(1);

(H) 42 CFR section 483.134;

(I) 42 CFR section 483.136;

(J) 42 CFR section 483.106(b)(2);

(K) 42 CFR section 483.130(b)(1); and (L) 42 CFR section 483.130(c).

Amended: Filed Nov. 14, 2025, effective May 30, 2026. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024, and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: section 208.201, RSMo 2016, and section 208.153, RSMo Supp. 2025. Emergency rule filed Dec. 30, 1988, effective Jan. 10, 1989, expired April 29, 1989. Original rule filed Feb. 15, 1989, effective April 27, 1989. Amended: Filed June 6, 1989, effective Aug. 24, 1989. Amended: Filed July 23, 1991, effective Dec. 9, 1991. Amended: Filed May 27, 1999, effective Jan. 30, 2000.

13 CSR 70-10.050 Pediatric Nursing Care Plan {#sec-13-csr-70-10.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.050}

(Rescinded August 30, 2018)

Original rule filed Sept. 26, 1989, effective Feb. 11, 1990. Emergency amendment filed Oct. 5, 1992, effective Nov. 1, 1992, expired Feb. 28, 1993. Emergency amendment filed Feb. 16, 1993, effective Feb. 28, 1993, expired June 27, 1993. Amended: Filed Oct. 5, 1992, effective May 6, 1993. Amended: Filed Oct. 16, 1995, effective May 30, 1996. Emergency amendment filed Oct. 15, 1996, effective Oct. 25, 1996, expired April 22, 1997. Emergency amendment filed Oct. 22, 1996, effective Nov. 1, 1996, expired April 29, 1997. Emergency amendment filed Aug. 12, 1997, effective Sept. 1, 1997, expired Feb. 27, 1998. Amended: Filed Aug. 12, 1997, effective Feb. 28, 1998.

Amended: Filed May 27, 1999, effective Nov. 30, 1999. Emergency amendment filed, Sept. 20, 1999, effective Oct. 1, 1999, expired March 29, 2000. Emergency amendment filed July 18, 2000, effective July 28, 2000, expired Jan. 24, 2001. Amended: Filed June 30, 2000, effective Feb. 28, 2001. Amended: Filed Nov. 15, 2001, effective May 30, 2002. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: sections 208.153, 208.159 and 208.201, RSMo 2000.

13 CSR 70-10.060 Retrospective Reimbursement Plan for State-Operated Facilities for ICF/MR Services {#sec-13-csr-70-10.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.060}

PURPOSE: This rule establishes a payment plan for state-operated providers of services required by the Code of Federal Regulations.

The plan describes principles to be followed by Title XIX intermediate care facility/mentally retarded providers in making financial reports and presents the necessary procedures for setting rates, making adjustments and auditing the cost reports. or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here.

This note refers only to the incorporated by reference material. The forms mentioned in this rule follow 13 CSR 70-10.010.

(1) Objectives. The retrospective rate plan described in this

rule shall apply to state-operated intermediate care facility/ mentally retarded (ICF/MR) facilities for dates of service on and after March 1, 1990, and the objective of this plan is to provide reimbursement of allowable cost.

(2) General Principles. The Missouri Medical Assistance program shall reimburse qualified providers of ICF/MR 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 as described in sections (4) and (5).

(3) Definitions.

(A) Allowable cost areas. Those cost areas which are allowable for allocation to the MO HealthNet program based upon the principles established in this plan. The allowability of cost areas not specifically addressed in this plan will be based upon criteria of the Medicare Provider Reimbursement Manual (HIM- 15) and section (7) of this rule.

(B) Cost report. The cost report shall detail the cost of rendering covered services for the fiscal reporting period.

Providers must file the cost report on forms provided by and in accordance with the procedures of the department.

(C) Department. The department, unless otherwise specified, (D) Director. The director, unless otherwise specified, refers to (E) Division. The division, unless otherwise specified, refers to the MO HealthNet Division.

(F) Effective date. The plan effective date shall be for services furnished on and after March 1, 1990.

(G) ICF/MR. State-operated facilities certified to provide intermediate care for the mentally retarded under the Title XIX (H) Medicare rate. This is the allowable cost of care permitted by Medicare standards and principles of reimbursement (42 CFR part 405).

(I) New construction. Newly built facilities or parts for which an approved Certificate of Need (CON) or applicable waivers were obtained and which were newly completed and operational on or after March 1, 1990.

(J) Patient days. Patient day of care is that period of service rendered a patient between the census-taking hours on two (2) consecutive days, including the twelve (12) temporary leave of absence days per any period of six (6) consecutive months as specifically covered under section (6) of this rule, the day of discharge being counted only when the patient was admitted the same day. A census log shall be maintained in the facility for documentation purposes. Census shall be taken daily at midnight. A day of care includes those overnight periods when a participant is away from the facility on a facility-sponsored group trip and remains under the supervision and care of facility personnel.

(K) Providers. A provider under the Retrospective Reimbursement Plan is a state-operated ICF/MR facility with a valid participation agreement in effect on or after February 28, 1990, with the Missouri Department of Social Services for the purpose of providing long-term care (LTC) services to Title XIX-eligible participants.

(L) Reasonable and adequate reimbursement. Reimbursement levels which meet the needs of an efficiently and economically operated facility.

(4) Interim Rate.

(A) For service dates beginning March 1, 1990 through and including June 30, 1991, each provider shall be assigned an interim per diem rate for reimbursement under the Missouri Medicaid program. The interim per diem rate will be based on the provider’s fiscal year FY-89 desk-reviewed allowable costs inflated forward on the basis of the historical rate of change.

This rate of change shall be thirty-five percent (35%) of the following amount: the percentage increase between the FY- 87 weighted mean allowable cost per patient day for all stateoperated facilities (WMACPPDSOF) and the FY-89 WMACPPDSOF annualized by dividing by two (2).

FY-87 WMACPPDSOF $128.06

FY-89 WMACPPDSOF $161.47

Percent of Change ($161.47 - $128.06) ÷ $128.06 = 26.09% Annualized Percent of Change (26.09% ÷ 2) = 13.04% 35% of Annualized Percent of Change (13.04% × 35%) = 4.57% Facility FY-89 Allowable Cost $24,220,500 Facility FY-89 Patient Days 150,000 Inflated Cost ($24,220,500 × 104.57%) = $25,327,376 Interim Rate ($25,327,376 ÷ 150,000) = $168.85 (B) For service dates beginning July 1, 1991 and annually after that, each provider shall be assigned an interim per-diem rate based on the provider’s second prior year desk-reviewed allowable costs inflated forward on the basis of the historical rate of change. This rate of change shall be fifty percent (50%) of the following amount: the percentage increase between the fourth prior year WMACPPDSOF and the second prior year WMACPPDSOF annualized by dividing by two (2). For example with the July 1, 1991 interim rate, the fourth prior year is the facility fiscal year ending June 30, 1988, and the second prior year is the facility fiscal year ending June 30, 1990.

FY-88 WMACPPDSOF $160

FY-90 WMACPPDSOF $180

Percent of Change ($180 - $160) ÷ $160 =12.50% Annualized Percent of Change ($12.50 ÷ 2) = 6.25% 50% of Annualized Percent of Change (6.25% × 50%) = 3.13% Facility FY-90 Allowable Cost $27,000,000 Facility FY-90 Patient Days 150,000 Inflated Cost ($27,000,000 × 103.13%) = $27,845,100 Interim Rate ($27,845,100 ÷ 150,000) = $185.63 (C) In the case of newly constructed state-operated ICF/ MR facilities or existing facilities not previously certified to participate in the Title XIX Program entering the MO HealthNet Program after February 28, 1990, the facilities shall have an interim rate based on one hundred twenty-five percent (125%) of the weighted mean rate of all providers for the month prior to entering the MO HealthNet program until the time a second prior year cost report is available, at which time the provisions of subsection (4)(B) will apply.

Weighted Mean Rate of All Providers (7/01/91) $160 Interim Rate Effective (8/01/91)

($160 × 125%) = $200 (D) When information contained in a facility’s cost report is found to be fraudulent, misrepresented or inaccurate, the facility’s interim rate at the discretion of the division may be both retroactively and prospectively adjusted if the fraudulent, misrepresented or inaccurate information as originally reported resulted in establishment of a different interim rate than the facility would have received in the absence of that information.

(5) Retroactive Adjustments.

(A) The division shall desk review the MO HealthNet cost reports for each facility and shall determine the facility’s allowable cost per patient day. This shall be the final per diem rate for the service dates covered by the cost report. A payment adjustment will be made equal to the difference between the final per diem rate and the interim per diem rate multiplied by the MO HealthNet days corresponding to the service dates covered by the interim per diem rate. For the period March 1, 1990 through June 30, 1990, the full facility Fiscal Year 1990 Medicaid cost report will be used to establish the final per diem rate for payment adjustment purposes.

(B) When information contained in a facility’s cost report is found to be fraudulent, misrepresented or inaccurate, the facility’s final rate at the discretion of the division may be both retroactively and prospectively adjusted if the fraudulent, misrepresented or inaccurate information as originally reported resulted in establishment of a different final rate than the facility would have received in the absence of that information.

(6) Covered Services and Supplies. ICF/MR services and supplies covered by the per diem reimbursement rate under this rule, and which must be provided, are found in 42 CFR 442.100– 442.516 and include, among other services, the regular room, dietary and nursing services or any other services that are required for standards of participation or certification, also included are minor medical and surgical supplies and the use of equipment and facilities. These items include, but are not limited to, the following:

(A) All general nursing services including, but not limited to, administration of oxygen and related medications, handfeeding, incontinency care, tray service and enemas;

(B) Items which are furnished routinely and relatively uniformly to all participants, for example, gowns, water pitchers, soap, basins and bed pans;

(C) Items such as alcohol, applicators, cotton balls, bandaids and tongue depressors;

(D) All nonlegend antacids, nonlegend laxatives, nonlegend stool softeners and nonlegend vitamins. All nonlegend drugs in one (1) of these four (4) categories must be provided to residents as needed and no additional charge may be made to any party for any of these drugs. Facilities may not elect which nonlegend drugs in any of the four (4) categories to supply; all must be provided as needed within the existing per-diem rate;

(E) Items which are utilized by individual participants but which are reusable and expected to be available such as ice equipment and other durable, nondepreciable medical (F) Additional items as specified in the appendix to this plan when required by the patient;

(G) Special dietary supplements used for tube feeding or oral feeding such as elemental high nitrogen diet, including dietary supplements written as a prescription item by a physician;

(H) All laundry services including personal laundry;

(I) All general personal care services which are furnished routinely and relatively uniformly to all participants for their personal cleanliness and appearance shall be covered services; for example, necessary clipping and cleaning of fingernails and toenails, basic hair care, shampoos and shaves to the extent necessary for reasonable personal hygiene. The provider shall not bill the patient or his/her responsible party for this type of personal service;

(J) All consultative services as required by state or federal law or rule or for proper operation by the provider. Contracts for the purchase of these services must accompany the provider cost report. Failure to do so will result in the penalties specified in

section (9) of this rule;

(K) Semiprivate room and board and private room and board when necessary to isolate a participant due to a medical or social condition, such as contagious infection, irrational loud speech and the like. Unless a private room is necessary due to a medical or social condition, a private room is a noncovered service and a MO HealthNet participant or responsible party may pay the difference between a facility’s semiprivate charge and its charge for a private room. MO HealthNet participants may not be placed in private rooms and charged any additional amount above the facility’s MO HealthNet per diem unless the participant or responsible party specifically requests in writing a private room prior to placement in a private room and acknowledges that an additional amount not payable by MO HealthNet will be charged for a private room;

(L) Twelve (12) days per any period of six (6) consecutive months during which a participant is on a temporary leave of absence from the facility. These temporary leave of absence days specifically must be provided for in the participant’s plan of care. Periods of time during which a participant is away from the facility because s/he is visiting a friend or relative are considered temporary leaves of absence; and (M) Days when participants are away from the facility overnight on facility-sponsored group trips under the continuing supervision and care of facility personnel.

(7) Allowable Cost Areas.

(A) Covered Services and Supplies as Defined in Section (6) of This Plan.

(B) Depreciation.

1. An appropriate allowance for depreciation on buildings, and sound conduct of the provider’s business is an allowable cost item. Finder’s fees are not an allowable cost item.

2. The depreciation must be identifiable and recorded in 3. The basis of assets shall be the lower of the book value of the provider, fair market value at the time of acquisition or the recognized Internal Revenue Service (IRS) tax basis. Donated assets will be allowed basis to the extent of recognition of income resulting from the donation of the asset. Should a dispute arise between a provider and the Department of Social Services as to the fair market value at the time of acquisition of a depreciable asset and an appraisal by a third party is required, the appraisal cost will be shared proportionately by the MO HealthNet program and the facility in ratio to MO HealthNet participant reimbursable patient days to total patient days.

3. Allowable methods of depreciation shall be limited to the straight-line method. The depreciation method used for an asset under the MO HealthNet program need not correspond to the method used by a provider for non-MO HealthNet purposes; however, useful life shall be in accordance with the American Hospital Association’s Guidelines. Component part depreciation is optional and allowable under this rule.

4. Historical cost is the cost incurred by the provider in acquiring the asset and preparing it for use except as provided in this rule. Usually, historical cost includes costs that would be capitalized under generally accepted accounting principles.

For example, in addition to the purchase price, historical cost would include architectural fees and related legal fees. Where a provider has elected to expense certain items such as interest and taxes during construction, the historical cost basis for MO HealthNet depreciation purposes may include the amount of these expensed items. However, where a provider did not capitalize these costs and has written off the costs in the year they were incurred, the provider cannot retroactively capitalize any part of these costs under the program. For Title XIX purposes and this rule, any asset costing less than five hundred dollars ($500) or having a useful life of one (1) year or less may be expensed and not capitalized at the option of the provider.

6. When an asset is acquired by trading in an existing asset, the cost basis of the new asset shall be the sum of 7. Capital expenditures for building construction or for provider’s bed capacity shall not be allowed in the program or depreciation base if the capital expenditures have not received approved CON or waiver.

7. Amortization of leasehold rights and related interest and finance costs shall not be allowable costs under this plan.

(C) Interest and Finance Costs.

1. Necessary and proper interest on both current and 2. Interest is the cost incurred for the use of borrowed funds. Interest on current indebtedness is the cost incurred for funds borrowed for a relatively short-term. This is usually for purposes as working capital for normal operating expenses.

Interest on capital indebtedness is the cost incurred for funds borrowed for capital purposes such as acquisition of facilities and capital improvements and this indebtedness must be amortized over the life of the loan.

3. Interest may be included in finance charges imposed 4. To be an allowable cost item, interest (including finance charges, prepaid costs and discounts) must be supported by evidence of an agreement that funds were borrowed and that payment of interest and repayment of the funds are required, identifiable in the provider’s accounting records, relating to the reporting period in which the costs are claims and necessary and proper for the operation, maintenance or acquisition of the provider’s facilities.

4. Necessary means that the interest be incurred for a loan made to satisfy a financial need of the provider and for a purpose related to participant care. Loans which result in excess funds or investments are not considered necessary.

5. Proper means that the interest be incurred at a rate not in excess of what a prudent borrower would have had to pay in the money market existing at the time the loan was made and provided further the department shall not reimburse for interest and finance charges any amount in excess of the prime rate current at the time the loan was obtained.

6. Income from a provider’s qualified retirement fund shall be excluded in consideration of the per diem rate.

7. A provider shall amortize finance charges, prepaid interest and discount over the period of the loan ratably or by 9. Usual and customary costs excluding finder’s fees and shall be allowable costs over the loan period ratably or by means of the constant interest applied method.

8. Usual and customary costs shall be limited to the escrow fees and closing costs.

9. Interest expense resulting from capital expenditures which cause an increase in a bed capacity by the provider shall not be an allowable cost item if the expenditure fails to comply with other federal or state requirements that promulgate a limitation on reimbursement for capital expenditures, such as CON.

(D) Rental and Leases.

1. Rental and leases of land, buildings, furnishings and equipment are allowable cost areas; provided, that the rented items are necessary and not in essence a purchase of those assets. Finder’s fees are not an allowable cost item.

2. Necessary rental and lease items are those which are 3. In the case of related parties, rental and lease amounts cannot exceed the lesser of those which are actually paid or the 4. Determination of reasonable and adequate reimbursement for rental and lease amounts, except in the case of related parties which is subject to other provisions of this plan, may require affidavits of competent, impartial experts who are familiar with the current rentals and leases.

3. The test of necessary costs shall take into account the 6. Leases subject to CON approval must have that approval (E) Taxes. Taxes levied on or incurred by providers shall be allowable cost areas with the exceptions of the following items:

4. Federal, state or local income and excess profit taxes including any interest and penalties paid;

5. Taxes in connection with financing, refinancing or refunding operations such as taxes on the issuance of bond, property transfer, issuance or transfer of stocks;

6. Taxes for which exemptions are available to the provider;

7. Special assessments on land which represent capital improvements. These costs shall be capitalized and depreciated over the period during which the assessment is scheduled to be paid;

8. Taxes on property which is not a part of the operation of the provider; and 6. Taxes which are levied against a resident and collected and remitted by the provider.

(F) Value of Services of Employees.

1. Except as provided for in this rule, the value of services 2. Services rendered by volunteers, such as those affiliated with the American Red Cross, hospital guilds, auxiliaries, private individuals and similar organizations, shall not be included as an allowable cost area, as the services traditionally have been rendered on a purely volunteer basis without expectation of any form of reimbursement by the organization through which the service is rendered or by the person rendering the service.

2. Services by priests, ministers, rabbis and similar type professionals shall be an allowable cost area, provided that the services are not of a religious nature. An example of an allowable cost area under this section would be a necessary administrative function performed by a clergyman. The state will not recognize building costs on space set aside primarily for professionals providing any religious function.

Costs for wardrobe and similar items likewise are considered nonallowable.

(G) Fringe Benefits.

1. Life insurance.

2. Retirement plans. Contributions to qualified retirement plans, as determined by the United States IRS, for the benefit of employees of the provider shall be allowable cost area.

(H) Education and Training Expenses.

1. The cost of training which directly benefits the quality of health care or administration at the facility shall be allowable.

2. Cost of education and training shall include travel costs incidental to training but will not include leaves of absence or sabbaticals.

(I) Advertising Costs. Advertising costs which are reasonable, appropriate and helpful in developing, maintaining and furnishing services shall be an allowable cost area. The costs must be common and accepted occurrence in the field of the activity of the provider.

(J) Central Office and State Central Service Costs. Costs which are appropriately distributed to the provider as direct costs, properly allocated to the provider, or allocated in accordance with approved cost allocation plans when plans are required, shall be allowable.

(K) Utilization Review. Incurred cost for the performance of required utilization review for ICF/MR is an allowable cost area. The expenditures must be for the purpose of providing utilization review on behalf of Title XIX participants. Utilization review costs incurred for Title XVIII and XIX must be apportioned on the basis of reimbursable participant days recorded for each program during the reporting period.

(L) Minimum Utilization. In the event the occupancy utilization of a provider is below ninety percent (90%) of its certified bed capacity, appropriate adjustments shall be made to the allowable cost areas of the provider. Fixed costs will be calculated as if the provider experienced ninety percent (90%) utilization. The fixed costs are laundry, housekeeping, general and administrative and plant operation costs. Variable costs will be calculated at actual utilization. The variable costs are nursing, dietary and ancillary costs. In no case may costs disallowed under this provision be carried forward to succeeding periods.

(M) Nonreimbursable Costs.

1. Bad debts, charity and courtesy allowances are deductions from revenue and are not to be included as allowable costs.

2. Those services that are specifically provided by Medicare and MO HealthNet must be billed to those agencies.

3. Any costs incurred that are related to fund drives are not 4. Costs incurred for research purposes shall not be included as allowable costs.

4. The cost of services provided under the Title XX program, by contract or subcontract, is specifically excluded as an allowable item.

(N) Other Revenues. Other revenues, including those listed that follow, will be deducted from the total allowable cost, and must be shown separately in the cost report by use of a separate schedule if included in the gross revenue: income from telephone services; sale of employee and guest meals; sale of medical abstracts; sale of scrap and waste food or materials; rental income; cash, trade, quantity time and other discounts; purchase rebates and refunds; parking lot revenues; vending machine commission or profit; sales from drugs to other than participants; Medicare Part B revenues; and room reservation charges for temporary leave of absence days which are not covered services under section (6) of this rule. Failure to separately account for any of the revenues specifically set out previously in this rule in a readily ascertainable manner shall result in termination from the program.

(O) Apportionment of Costs to MO HealthNet Participant Residents. Provider’s allowable cost areas shall be apportioned between the certified ICF/MR portion and the noncertified portion so that the share borne by the MO HealthNet program is based upon actual services received by program participants.

(8) Reporting Requirements.

(A) Annual Cost Report.

1. Each provider shall establish a twelve (12)-month period which is to be designated as the provider’s fiscal year. An annual cost report for the fiscal year shall be submitted by the provider to the department on forms to be furnished for that purpose.

The completed forms shall be submitted by each provider within ninety (90) days following the close of its fiscal year.

2. Unless adequate and current documentation in the following areas have previously been filed with the department, authenticated copies of the following documents must be submitted with the cost reports: authenticated copies of all leases related to the activities of the facility, all management contracts and all contracts with consultants.

3. Adequate documentation for all line items on the uniform cost reports must be maintained by the facility and must be submitted to the department upon request.

4. Following the ninety (90)-day period, payments will be withheld from the facility until the cost report is submitted.

Upon receipt of a cost report prepared in accordance with these rules, the payments that were withheld will be released.

5. If requested in writing, a thirty (30)-day extension of the filing date may be granted for good cause shown.

6. The termination of or by a provider of participation in the program requires that the provider submit a cost report for the period ending with the date of termination. The cost report is due within forty-five (45) days of the date of termination. Cost reports under this paragraph shall conform to the principles of

section (7). The final payment due providers shall be withheld until their cost report is filed.

7. Cost reports shall be based upon the provider’s financial and statistical records which must be capable of verification by audit.

8. The annual cost report for the fiscal year of the provider may be subject to audit by the Department of Social Services or its contracted agents.

9. The department shall retain the annual cost report and any working papers relating to the audits of the cost reports for a period of not less than seven (7) full years from the date of (B) Certification of Cost Reports.

10. The accuracy and validity of any cost report must be certified. Certification must be made by one (1) of the following persons (who must be authorized by the governing body of the facility to make the certification and will furnish proof of authorization): an incorporated entity, an officer of the corporation; for a partnership, a partner; for a sole proprietorship or sole owner, the owner; or for a public facility, the chief administrative officer of the facility. The cost report also must be notarized by a licensed notary public.

11. Certification statement.

Misrepresentation or falsification of any information contained in this report may be punishable by fine, Certification by officer or administrator of provider:

I have examined the accompanying Cost Report and supporting ____________________________________ for the cost report period beginning ________________, 19 and ending ________________, 19 and that to the best of my knowledge and belief, it is a true, correct and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. __________________________ ____________________ _________ (C) Adequacy of Records.

1. The provider must make available to the department or its duly authorized agent, including federal agents from the Department of Health and Human Services (HHS), at all reasonable times, records as are necessary to permit review and audit of provider’s cost reports. Failure to do so may lead to sanctions stated in paragraph (8)(A)4. of this rule or other sanctions available in section (9).

2. All records associated with the preparation and documentation of the data associated with the cost report must be retained for seven (7) years from the cost report filing date.

(D) Accounting Basis.

1. The cost report submitted must be based on the accrual

basis of accounting.

2. Governmental institutions that operate on a cash or modified cash basis of accounting may continue to use those methods, provided appropriate treatment of capital expenditures is made.

(9) Sanctions and Overpayments.

(A) Sanctions may be imposed against a provider in accordance with 13 CSR 70-3.030 and other federal or state statutes and regulations.

(B) In the case of overpayments, the provider shall repay the overpayment in accordance with the provisions as set forth in 13 CSR 70-3.030.

(10) Payment Assurance.

(A) The state will pay each provider, which furnished the services in accordance with the requirements of the state plan, the amount determined for services furnished by the provider according to the standards and methods set forth in these rules.

(B) Where third-party payment is involved, MO HealthNet will be the payor of last resort with the exception of state programs such as Vocational Rehabilitation and the Missouri Crippled Children’s Service. Procedures for remitting thirdparty payments are provided in the Missouri Medical Assistance (MO HealthNet) Program provider manuals.

(11) Provider Participation. Payments made in accordance with program so that eligible persons can receive medical care and services included in the state plan at least to the extent these services are available to the general public.

(12) Payment in Full. Participation in the program shall be limited to providers who accept as payment in full for covered services rendered to MO HealthNet participants, the amount paid in accordance with these rules and applicable copayments.

(13) Plan Evaluation. Documentation will be maintained to effectively monitor and evaluate experience during administration of this plan.

(14) Transition. Cost reports used for the determination of the rates and the historical rate of change shall be adjusted by the division in accordance with the cost principles provided in this plan.

A & D Ointment Aerosol Inhalators, Self-Contained Aerosol, Other Types Air Mattresses Airway—Oral Applicators, Cotton-Tipped Applicators, Swab-Eez Aquamatic K Pads (water-heated pad)

Asepto Syringes Bandages (elastic or cohesive)

Bed Frame Equipment (for certain immobilized bed patients)

Bedpan, Fracture Bottle, Specimen Cannula—Nasal Catheter Indwelling Catheter Plugs Catheter Trays Catheter (any size)

Cotton Balls Customized Crutches, Canes and Wheelchairs Drainage Bags Dressing Tray Enema Soap Equipment and Supplies for Diabetic Urine Testing Eye Pads Female Urinal Flotation Mattress or Biowave Mattress Flotation Pads, Turning Frames, or both Folding Foot Cradle Gastric Feeding Unit Gauze Sponges Gloves, Unsterile and Sterile Green Soap Hand-Feeding Incontinency Care Incontinency Pads and Pants Inhalation Therapy Supplies Intermittent Positive Pressure Breathing Machine (IPPB)

Irrigation Bulbs Irrigation Trays I.V. Trays Jelly—Lubricating Lines, Extra Lotion, Soap and Oil Nasal Catheter, Insertion and Tube Nasal Tube Feeding Nursing Services (all) regardless of level, including the Nursing Supplies and Dressing (other than items of personal comfort or cosmetic)

Oxygen Mask Pump (aspiration and suction)

Room and Board (semiprivate or private if necessitated by a medical or social condition)

Steam Vaporizer Suture Removal Kit Syringes (all sizes)

Tubing I.V. Trays, Blood Infusion Set, I.V. Tubing

History

• AUTHORITY: sections 208.159, RSMo 2000 and 208.153 and 208.201, RSMo Supp. 2007. Original rule filed March 5, 1990, effective June 11, 1990. Amended: Filed Dec. 14, 1992, effective June 7, 1993. Amended: Filed Aug. 15, 2007, effective March 30, 2008. Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.159, RSMo 1979; and 208.201, RSMo 1987, amended 2007.

13 CSR 70-10.070 Limitations on Allowable Nursing Facility Costs to Reserve a Bed for Absences Due to Hospital Admission {#sec-13-csr-70-10.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.070}

PURPOSE: This rule outlines the coverage of nursing facility costs to reserve a bed in a nursing facility during an absence from the facility due to a hospital admission of three (3) days or less and the limitations related to that coverage.

(1) Payment to a nursing facility (NF) for hospital leave days is authorized for days in which a Medicaid participant is absent from the NF due to admission to a hospital for services which cannot be performed on an outpatient basis, subject to the (A) The nursing facility in which the Medicaid resident resides is licensed under Chapter 198, RSMo;

(B) The NF is in compliance with all federal and state certification standards;

(C) The occupancy rate of the NF is at or above ninety-seven percent (97.00%), rounded to four (4) decimal places (i.e., 0.9700 or 97.00%), of Medicaid certified beds for the quarter prior to the quarter during which hospital leave is taken. The occupancy rate is based on the data from the Certificate of Need (CON)

Quarterly Survey from the Department of Health and Senior Services. The quarters referenced herein are calendar year quarters (i.e., January – March, April – June, July – September, and October – December);

(D) The Medicaid participant is admitted to a hospital for a medical condition, which cannot be treated on an outpatient

basis, with a total stay of three (3) days or less; and (E) The hospital provides a discharge plan for the participant which includes returning to the facility requesting the hospital leave days.

(2) The payment for hospital leave days shall only be provided for qualified hospital stays of three (3) days or less. A qualified hospital stay is one in which the medical condition cannot be treated on an outpatient basis.

(3) The hospital leave days billed by the nursing facility shall be held in suspense until the nursing home bill, hospital bill, and quarterly census have been received by the MO HealthNet Division so appropriate payment can be determined.

(4) Payment for authorized hospital leave days shall be at the per-diem rate for the respective provider.

(5) For each day that Medicaid reimburses a nursing facility, pursuant to this subsection, the Medicaid participant shall be ineligible for reimbursement to nursing facilities for two otherwise available temporary leave of absence days as described in 13 CSR 70-10.015(5)(D). The total hospital leave days and temporary leave of absence days shall not exceed the limits for the periods defined in 13 CSR 70-10.015(5)(D).

RSMo 2016.* Emergency rule filed Dec. 17, 1993, effective Dec. 27, 1993, expired April 25, 1994. Emergency rule filed April 15, 1994, effective May 1, 1994, expired Aug. 28, 1994. Original rule filed Nov. 2, 1993, effective June 6, 1994. Amended: Filed Aug. 28, 2018, effective April 30, 2019. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; 208.159, RSMo 1979; 208.201, RSMo 1987; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-10.080 Prospective Reimbursement Plan for HIV Nursing Facility Services {#sec-13-csr-70-10.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.080}

PURPOSE: This rule establishes a payment plan for HIV nursing facility services. The plan describes principles to be followed by Title XIX HIV nursing facility providers in making financial reports and presents the necessary procedures for setting rates, making adjustments, and auditing the cost reports.

(1) Authority. This regulation is established pursuant to the (2) Purpose. This regulation establishes a methodology for determination of reimbursement rates for human immunodeficiency virus (HIV) nursing facilities, operated exclusively for persons with HIV that causes acquired immunodeficiency syndrome (AIDS). Subject to limitations prescribed elsewhere in this regulation, a facility’s reimbursement rate shall be determined by the division as described in this regulation. Any reimbursement rate determined by the division shall be a final decision and will be implemented as set forth in the division’s decision letter.

The decisions of the division may be subject to review upon properly filing a complaint with the Administrative Hearing Commission (AHC). A nursing facility seeking review by the AHC must obtain a stay from the AHC to stop the division from implementing its final decision if the AHC determines the not limited to hospice providers, that the rate being received within the scope of the Federal Medicaid Program and made (3) General Principles.

(A) Provisions of this reimbursement regulation shall apply only to HIV nursing facilities certified for participation in the Missouri Medical Assistance (Medicaid) Program.

(B) The reimbursement rates determined by this regulation shall apply only to services for HIV residents provided on or after December 1, 1995.

(C) The effective date of this regulation shall be December 1, 1995.

(D) The Medicaid Program shall provide reimbursement for HIV nursing facility services based solely on the individual Medicaid-eligible recipient’s covered days of care, within benefit limitations as determined in subsections (5)(D) and (5)

(M) multiplied by the facility’s Medicaid reimbursement rate.

No payments may be collected or retained in addition to the otherwise provided for in this plan. Where third-party payment is involved, Medicaid will be the payor of last resort with the exception of state programs such as Vocational Rehabilitation and the Missouri Crippled Children’s Services.

(E) The Medicaid reimbursement rate shall be the lower of:

1. The Medicare (Title XVIII) rate, if applicable; or 2. The reimbursement rate as determined in accordance with sections (11), (12), and (13) of this rule.

(F) Medicaid reimbursements shall not be paid for services provided to Medicaid-eligible recipients during any time period in which the facility failed to have a Medicaid participation agreement in effect. A reimbursement rate may not be established for a facility if a Medicaid participation agreement is not in effect.

(G) When an HIV nursing facility is found not in compliance with federal requirements for participation in the Medicaid Program, sections 1919(b), (c), and (d) of the Social Security Act (42 U.S.C. 1396r), it may be terminated from the Medicaid Program or it may have imposed upon it an alternative remedy, pursuant to section 1919(h) of the Social Security Act (42 U.S.C. 1396r). In accordance with section 1919(h)(3)(D) of the Social Security Act, the alternative remedy, denial of payment for new admission, is contingent upon agreement to repay payments received if the corrective action is not taken in accordance with the approved plan and timetable. It is also required that the HIV nursing facility establish a directed plan of correction in conjunction with and acceptable to the Division of Aging.

(H) Upon execution of a Medicaid participation agreement, the division. Facilities previously certified shall retain the same provider number and interim or prospective rate regardless of any change in ownership.

(I) Regardless of changes in control or ownership for any facility certified for participation in the Medicaid Program, the division shall issue payments to the facility identified in the current Medicaid participation agreement. Regardless of changes in control or ownership for any facility certified for participation in Medicaid, the division shall recover from the entity identified in the current Medicaid participation agreement, liabilities, sanctions, and penalties pertaining to the Medicaid Program, regardless of when the services were (J) Changes in ownership, management, control, operation, leasehold interest by whatever form for any facility previously time that results in increased capital costs for the successor owner, management, or leaseholder shall not be recognized for (K) A facility with certified and noncertified beds shall allocate allowable costs related to the provision of HIV nursing facility services on the cost report, in accordance with the cost report instructions. The methods for allocation must be supported by adequate accounting and/or statistical data necessary to evaluate the allocation method and its application.

(L) Any facility which is involuntarily terminated from from participation in the Medicaid Program on the same date as the Medicare termination.

(M) No restrictions nor limitations shall, unless precluded by federal or state regulation, be placed on a recipient’s right to select providers of his/her own choice.

(N) Rebasing. Effective July 1, 2004, HIV nursing facility rates shall be rebased on an annual basis, as set forth in section (20).

(O) The reimbursement rates authorized by this regulation may be reevaluated at least on an annual basis in light of the provider’s cost experience to determine any adjustments needed to assure coverage of cost increases that must be incurred by efficiently and economically operated providers.

(P) Covered supplies, such as, but not limited to, food, laundry supplies, housekeeping supplies, linens, medical supplies, must be accounted for through inventory accounts. Purchases shall be recorded as inventory and shall be expensed in the fiscal year the items are used. Inventory shall be counted at least annually to coincide with the facility’s fiscal year or the end of the cost report period, if different. Expensing of items shall be recorded by adding purchases to the beginning period inventory and subtracting the end of the period inventory. This inventory control shall begin the first fiscal year ending after the effective date of this plan.

(Q) Medicaid reimbursement will not be paid for a Medicaideligible resident while placed in a noncertified bed in an HIV (R) All illustrations and examples provided throughout this (S) Each state fiscal year the department shall submit to the Office of Administration for consideration a budget item based on the HCFA Market Basket Index for Nursing Homes representing a statistical measure of the change in costs of goods and services purchased by HIV nursing facilities during the course of one (1) year. The submission of the budget item by the department has no correlation to determining the costs that are incurred by an efficiently and economically operated facility. Any trend factor granted shall be applied to the patient care, ancillary, and administration cost components.

(T) Effective for dates of service beginning April 1, 2010, reimbursement of Medicare/Medicaid crossover claims

Part C inpatient skilled nursing facility benefits in an HIV nursing facility shall be as follows:

1. Crossover claims for Medicare Part A inpatient skilled A. The crossover claim must be related to Medicare Part B. The crossover claim must contain approved hundred (100) of each Medicare benefit period; and C. The Other Payer paid amount field on the claim D. The nursing facility’s Medicaid reimbursement rate 2. Crossover claims for Medicare Advantage/Part C (Medicare Advantage) inpatient skilled nursing facility benefits in which a Medicare Advantage plan was the primary payer and the MO HealthNet Division is the payer of last resort for the copay (coinsurance) must meet the following criteria to be A. The crossover claim must be related to Medicare Medicare Beneficiary Plus (QMB Plus); and B. The crossover claim must be submitted as a Medicare online Internet billing system; and C. The crossover claim must contain approved coinsurance days. The amount indicated by the Medicare Advantage plan to be the coinsurance due on the Medicare Advantage plan allowed amount is the crossover amount eligible for MO are established by each Medicare Advantage plan; and D. The Other Payer paid amount field on the claim must plan. The MO HealthNet provider is responsible for accurate E. The nursing facility’s Medicaid reimbursement rate 3. MO HealthNet reimbursement will be the lower of— A. The difference between the nursing facility’s Medicaid B. The coinsurance amount; and 4. HIV nursing facility providers may not submit a MO (4) Definitions.

(A) Additional beds. Newly constructed beds never certified for Medicaid or never previously licensed by the Division of Aging.

(B) Administration. This cost component includes the following lines from the cost report version MSIR-1 (3-95): lines 111–131, 133–149, 151–158.

(C) Age of beds. The age is determined by subtracting the initial licensing year from 1995 or the current year, if later.

(D) Allowable cost. Those costs which are allowable for determined by the Division of Medical Services and shall be based upon criteria and principles included in this regulation, the Medicare Provider Reimbursement Manual (HIM-15) and Generally Accepted Accounting Principles (GAAP). Criteria and principles will be applied using this regulation as the first source, the Medicare Provider Reimbursement Manual (HIM-15) as the second source and GAAP as the third source.

(E) Ancillary. This cost component includes the following lines from the cost report version MSIR-1 (3-95): lines 71–89, 91–100.

(F) Asset value. The asset value is thirty-two thousand seven hundred twenty-three dollars ($32,723) and is used in calculating the fair rental value system.

(G) Average private pay rate. The usual and customary charge for private patient determined by dividing total private patient days of care into private patient revenue net of contractual allowances and bad debt expense for the same service that is included in the Medicaid reimbursement rate. This excludes negotiated payment methodologies with state or federal agencies such as the veteran’s administration or the Missouri Department of Mental Health.

(H) Capital. This cost component will be calculated using a fair rental value system. The fair rental value is reimbursed in lieu of the costs reported on lines 102–109 of the cost report version MSIR-1 (3-95) except for amortization of organizational costs.

(I) Capital asset. A facility’s building, building equipment, improvements, and leasehold improvements as defined in HIM-15. Motor vehicles are excluded from this definition.

(J) Capital asset debt. The debt related to the capital assets as determined from the desk audited and/or field audited cost (K) Ceiling. The ceiling is determined by applying a percentage to the median per diem for the patient care, ancillary and administration cost components. The percentage is one hundred twenty percent (120%) for patient care, one hundred twenty percent (120%) for ancillary and one hundred ten percent (110%) for administration.

(L) Certified bed. Any HIV nursing facility bed that is certified by the Division of Aging to participate in the Medicaid Program.

(M) Change of ownership. A change in ownership, control, operator or leasehold interest, for any facility certified for (N) Cost components. The groupings of allowable costs used ancillary, capital, and administration. In addition, a working capital allowance is provided.

(O) Cost report. The Financial and Statistical Report for Nursing Facilities, required attachments as specified in paragraph (10)

(A)8. of this regulation and all worksheets supplied by the division for this purpose. The cost report shall detail the cost of rendering both covered and noncovered services for the fiscal reporting period in accordance with this regulation, cost report instruction and on forms or diskettes provided by or as approved by the division or both.

(P) Data bank. The data from the desk audited and/or field audited rate setting cost report for HIV nursing facilities.

(Q) Department. The department, unless otherwise specified, (R) Desk audit. The Division of Medical Services’ or its authorized agent’s audit of a provider’s cost report without a field audit.

(S) Director. The director, unless otherwise specified, refers to (T) Division of Aging. The division of the Department of Social Services responsible for survey, certification, and licensure as prescribed in Chapter 198, RSMo.

(U) Division. Unless otherwise specified, division refers to (V) Entity. Any natural person, corporation, business, partnership or any other fiduciary unit.

(W) Facility asset value. Total asset value less adjustment for (X) Facility fiscal year. A facility’s twelve (12)-month fiscal reporting period covering the same twelve (12)-month period (Y) Facility size. The number of licensed HIV nursing facility beds as determined from the desk audited and/or field audited (Z) Fair rental value system (FRVS). The methodology used to (AA) Field audit. An on-site audit of the HIV nursing facility’s records performed by the department or its authorized agent.

(BB) Generally Accepted Accounting Principles (GAAP).

(CC) HCFA Market Basket Index. An index showing nursing home market basket indexes. The index is published quarterly by DRI/McGraw Hill. The table used in this regulation is titled “DRI Health Care Cost—National Forecasts, HFCA Nursing Home Without Capital Market Basket.”

(DD) HIV nursing facility. Any facility licensed under Chapter 198, RSMo granted an exemption from Certificate of Need under

section 197.316, RSMo and certified by the Division of Aging.

(EE) HIV nursing facility resident. A person that resides in a HIV nursing facility that has the HIV that causes AIDS.

(FF) Interim rate. The interim rate shall be based upon the budgeted cost report (version MSIR-1 (3-95)) that has been submitted to the division. The interim rate shall be the sum of one hundred percent (100%) of the budgeted patient care costs, ninety percent (90%) of the budgeted ancillary costs and administration costs, ninety-five percent (95%) of the capital cost, and the working capital allowance using the interim rate cost components.

(GG) Licensed bed. Any skilled nursing facility or intermediate Division of Aging.

(HH) Median. The middle value in a distribution, above and below which lie an equal number of values. This distribution is based on the databank.

(II) Nursing facility (NF). Effective October 1, 1990, skilled nursing facilities, filled nursing facilities/intermediate care 198, RSMo, participating in the Medicaid Program will all be (JJ) Occupancy rate. A facility’s total actual patient days divided by the total bed days for the same period as determined from the desk audited and/or field audited cost report. For a distinct part facility that completes a worksheet one (1) of cost report, version MSIR-1 (3-95), determine the occupancy rate from the total actual patient days from the certified portion of the facility divided by the total bed days from the certified portion for the same period, as determined from the desk audited and/or field audited cost report.

(KK) Patient care. This cost component includes the following lines from the cost report version MSIR-1 (3-95): lines 46–69.

(LL) Patient day. The period of service rendered to a patient purposes. “Patient day” includes the allowable temporary leave-of-absence days per subsection (5)(D) and hospital leave days per subsection (5)(M). The day of discharge is not a patient day for reimbursement unless it is also the day of admission.

(MM) Per diem. The daily rate calculated using this regulation’s cost components and used in the determination of a facility’s prospective and/or interim rate.

(NN) Provider or facility. An HIV nursing facility with a valid Social Services for the purpose of providing HIV nursing facility services to Title XIX-eligible recipients.

(OO) Prospective rate. The rate determined from the rate (PP) Rate setting cost report. The desk audited and/or field audited cost report relating to a facility’s rate setting period.

(QQ) Rate setting period. The period for which a facility’s prospective rate is determined. The rate setting period shall apply to the annual rebasing of rates as set forth in (3)(N) as well as to facilities who have an interim rate and whose initial prospective rate is being set. For interim rate facilities, the rate setting period is the second full twelve (12)-month cost report following the facility’s initial date of Medicaid certification.

(RR) Reimbursement rate. A prospective or interim rate.

(SS) Related parties. Parties are related when any one (1) of 1. An entity where, through its activities, one (1) entity’s exceed those which are usual and customary in such dealings.

2. An entity has an ownership or controlling interest in another entity; and the entity, or one (1) or more relatives of the entity, has an ownership or controlling interest in the other entity. For the purposes of this paragraph, ownership investment banking firm or insurance company unless the entity directly, or through a subsidiary, operates a facility.

3. As used in this regulation, the following terms mean:

A. Indirect ownership/interest means an ownership B. Ownership interest means the possession of equity in the capital, in the stock, or in the profits of an entity. Ownership or controlling interest is when an entity:

(I) Has an ownership interest totaling five percent (5%)

(II) Has an indirect ownership interest equal to five percent (5%) or more in an entity. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in each entity;

(III) Has a combination of direct and indirect ownership (IV) Owns an interest of five percent (5%) or more in (V) Is an officer or director of an entity; or (VI) Is a partner in an entity that is organized as a partnership.

C. Relative means person related by blood, adoption, or (TT) Replacement beds. Newly constructed beds never certified for Medicaid or previously licensed by the Division of Aging or the Department of Health and put in service in place of existing Medicaid beds. The number of replacement beds being certified for Medicaid shall not exceed the number of beds being replaced.

(UU) Renovations/major improvements. Capital cost incurred for improving a facility excluding replacement beds and additional beds.

(VV) Restricted funds. Funds, cash, cash equivalents, or (WW) Total facility size. Facility size plus increases minus decreases of licensed HIV nursing facility beds plus calculated bed equivalents for renovations/major improvements.

(XX) Unrestricted funds. Funds, cash, cash equivalents, income from endowments, that are given to a provider without (YY) Incorporation by Reference. This rule adopts and incorporates by reference the provisions of the— 1. Financial and Statistical Report for Nursing Facilities (version MSIR-1 (3-95)) and the cost report instructions (revised 3/95) published by the Missouri Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, August 1, 2008. This rule does not incorporate any subsequent amendments or additions;

2. MO HealthNet Nursing Home Manual, which is published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website www.dss.mo.gov/mhd, August 1, 2008. This rule does not incorporate any subsequent amendments or additions.

(5) Covered Supplies, Items, and Services. All supplies, items, which would otherwise be covered in a reimbursement rate but which are also billable to the Title XVIII Medicare Program the Title XVIII Medicare Program. Covered supplies, items, and services include, but are not limited to, the following:

(A) Services, items, and covered supplies required by federal or state law or regulation which must be provided by nursing facilities participating in the Title XIX Program;

(B) Semi-private room and board;

(C) Private room and board when it is necessary to isolate which may be contagious infection, loud irrational speech, etc.;

(D) Temporary leave of absence days for Medicaid recipients, months and not to exceed twelve (12) days for the second six (6) calendar months. Temporary leave of absence days must be specifically provided for in the recipient’s plan of care and prescribed by a physician. Periods of time during which a recipient is away from the facility visiting a friend or relative are considered temporary leaves of absence;

(E) Provision of personal hygiene and routine care services (F) All laundry services, including personal laundry;

(G) All dietary services, including special dietary supplements (H) All consultative services required by federal or state law (I) All therapy services required by federal or state law or (J) All routine care items including, but not limited to, those (K) All nursing services and supplies including, but not limited to, those items specified in Appendix A to this regulation;

(L) All nonlegend antacids, nonlegend laxatives, nonlegend stool softeners and nonlegend vitamins. Providers may not elect which nonlegend drugs in any of the four (4) categories to supply; any and all must be provided to residents as needed and are included in a facility’s reimbursement rate; and (M) Hospital leave days as defined in 13 CSR 70-10.070.

(6) Noncovered Supplies, Items, and Services. All supplies, items, and services which are either not covered in a facility’s reimbursement rate or are billable to another program in Medicaid, Medicare, or other third party payor. Noncovered supplies, items, and services include, but are not limited to, the following:

(A) Private room and board unless it is necessary to isolate which may be contagious infection, loud irrational speech, etc. Unless a private room is necessary due to such a medical or social condition, a private room is a noncovered service and a Medicaid recipient or responsible party may therefore pay the difference between a facility’s semi-private charge and its charge for a private room. Medicaid recipients may not be placed in private rooms and charged any additional amount above the facility’s Medicaid reimbursement rate unless the recipient or responsible party specifically requests in writing a private room prior to placement in a private room and acknowledges that an additional amount not payable by Medicaid will be charged for a private room;

(B) Supplies, items, and services for which payment is made under other Medicaid Programs directly to a provider or providers other than providers of the HIV nursing facility services; and (C) Supplies, items, and services provided nonroutinely to (7) Allowable Cost Areas.

(A) Compensation of Owners.

1. Compensation of services of owners shall be an allowable prescribed in subsection (8)(Q).

2. Compensation shall mean the total benefit, within the payments for managerial, administrative, professional, and from the provider, and additional amounts determined to be the reasonable value of the services rendered by sole proprietors or partners and not paid by any method previously described in this regulation. Compensation must be paid (whether in cash, negotiable instrument, or in kind) within seventy-five (75) days published in the Medicare Provider Reimbursement Manual, Part 1, section 906.4.

(B) Covered services and supplies as defined in section (5) of this regulation.

(C) Capital Assets.

1. Capital Assets shall include historical costs that would include, but are not limited to, architectural fees, related legal fees, interest and taxes during construction.

2. For purposes of this regulation, any asset or improvement having a useful life greater than one (1) year in accordance with 3. In addition to the American Hospital Association capitalized asset and shall have a three (3)-year useful life.

(D) Depreciation—Vehicle.

1. An appropriate allowance for depreciation on vehicles which are a necessary part of the operation of a HIV nursing facility is an allowable cost. One (1) vehicle per sixty (60) licensed beds is allowable. For example, one vehicle is allowed for a facility with zero to sixty (0–60) licensed beds, two (2) vehicles are allowed for a facility with sixty-one to one hundred twenty (61–120) licensed beds, etc. Depreciation is treated as an administration cost and is reported on line 133 of the cost report, version MSIR-1 (3-95).

2. The depreciation must be identifiable and recorded in vehicle and prorated over the estimated useful life of the vehicle in accordance with American Hospital Association depreciable guidelines using the straight line method of depreciation from the date initially put into service.

3. The basis of vehicle cost at the time placed in service shall be the lower of:

A. The book value of the provider;

B. Fair market value at the time of acquisition; or C. The recognized Internal Revenue Service (IRS) tax 4. The basis of a donated vehicle will be allowed to the The appraisal cost will be the sole responsibility of the HIV 5. Historical cost will include the cost incurred to prepare the vehicle for use by the HIV nursing facility.

6. When a vehicle is acquired by trading in an existing (E) Insurance.

7. Property insurance. Insurance cost on property of the HIV nursing facility used to provide HIV nursing facility services.

Property insurance should be reported on line 107 of the cost report version MSIR-1 (3-95).

2. Other insurance. Liability, umbrella, vehicle, and other general insurance for the HIV nursing facility should be reported on line 136 of the cost report version MSIR-1 (3-95).

3. Workers’ Compensation insurance should be reported on the applicable payroll lines on the cost report for the employee salary groupings.

(F) Interest and Finance Costs.

1. Interest will be reimbursed for necessary loans for capital asset debt at the Chase Manhattan prime rate on July 3, 1995, plus two percentage (2%) points. For replacement beds, additional beds, and new facilities placed in service after June 30, 1996, the prime rate will be updated annually on the first business day of each July based on the Chase Manhattan prime rate plus two percentage (2%) points.

2. Loans (including finance charges, prepaid costs, agreement that funds were borrowed and repayment of the funds are required. The loan costs must be identifiable in the provider’s accounting records, must be related to the reporting period in which the costs are claimed, and must be necessary for the operation, maintenance, or acquisition of the provider’s 3. Necessary means that the loan be incurred to satisfy a financial need of the provider and for a purpose related to recipient care. Loans which result in excess funds or investments are not considered necessary.

3. A provider shall capitalize loan costs (for example escrow fees, and other closing costs), finance charges, prepaid interest, and discounts. The loan costs shall be amortized over the life of the loan on a straight line basis.

4. If loans for capital asset debt exceed the facility asset value, the interest associated with the portion of the loan or loans which exceeds the facility asset value shall not be allowable.

5. The following is an illustration of how allowable interest is calculated:

Outstanding Capital Asset Debt $2,500,000 Term of Debt 25 years Interest Rate (Chase Manhattan prime + 2%) 10 percent Facility Asset Value $2,000,000 Discount $125,000 Loan Costs $120,000 Allowable interest calculation—use the lesser of the facility asset value or the outstanding capital asset debt.

Other Allowable Borrowing Costs:

Discount— $2,000,000/$2,500,000 × $125,000 = $100,000 Loan Cost— $2,000,000/$2,500,000 × $120,000 = $ 96,000 Allowable Interest— $2,000,000 × 10% = $200,000 Discount— $100,000/25 years = $ 4,000 Loan Cost— $96,000/25 years = $ 3,840 Allowable Interest and Other Borrowing Costs $207,840 7. Interest cost on vehicle debt for allowable vehicles per paragraph (7)(D)1. is treated as an administration cost and reported on line 134 of the cost report version MSIR-1 (3-95).

(G) Rental and Leases.

1. Capitalized leases, as defined by GAAP, will be reimbursed in accordance with subsections (7)(C) and (7)(E).

2. Lease cost related to allowable vehicles per paragraph (7)

(D)1. shall be treated as an administrative cost and be reported on line 135 of the cost report version MSIR-1 (3-95).

3. Operating leases, as defined by GAAP, will be part of the fair rental value system.

(H) Real Estate and Personal Property Taxes. Taxes levied on or incurred by a facility used to provide HIV nursing facility (I) Value of Services of Employees.

1. Except as provided for in this regulation, the value of services performed by employees in the facility shall be included as an allowable cost area to the extent actually compensated, either to the employee or to the supplying organization.

2. Services rendered by volunteers such as those affiliated 3. Services by priests, ministers, rabbis, and similar type (J) Employee Benefits.

3. Retirement plans.

A. Contributions to IRS qualified retirement plans shall B. Amounts funded to pension and qualified retirement plans, together with associated income, shall be recaptured, if not actually paid when due, as an offset to expenses on the cost 2. Deferred compensation plans.

A. Contributions shall be allowable costs when, and to B. Amounts paid by organizations to purchase tax- C. Amounts funded to deferred compensation plans 3. Types of insurance which are considered an allowable cost:

A. Credit life insurance (term insurance), if required as

part of a mortgage loan agreement. An example, would be insurance on loans granted under certain federal programs.

B. Where the relative(s) or estate of the employee, the employees salary groupings.

C. Health, disability, dental, etc., insurances for (K) Education and Training Expenses.

1. The cost of on-the-job training which directly benefits the quality of health care or administration at the facility shall be allowable, except for costs associated with Nurse Aide Training and Competency Evaluation Program.

2. Costs of education and training shall include travel costs but will not include leaves of absence or sabbaticals.

(L) Organizational Costs.

1. Organizational cost items include the following: legal fees incurred in establishing the corporation or other organizations; necessary accounting fees; expenses of temporary directors and organizational meetings of directors and stockholders; and 2. Organizational costs shall be amortized ratably over 3. Where a provider is organized within a five (5)-year period prior to its entry into the program and has properly capitalized organizational costs using a sixty (60)-month amortization period, no change in the rate of amortization is required. In this instance the unamortized portion of organizational costs is an allowable cost under the program and shall be amortized over the remaining part of the sixty (60)-month period.

2. For change in ownership after July 18, 1984, allowable (M) Advertising Costs. Advertising costs which are reasonable and accepted occurrence for providing HIV nursing facility (N) Cost of Supplies and Services Involving Related Parties.

(O) Minimum Utilization. In the event the occupancy rate of a facility is below eighty-five percent (85%), the administration and capital cost components will be adjusted as though the provider experienced eighty-five percent (85%) occupancy. In no case may costs disallowed under this provision be carried forward to succeeding periods.

(P) Central Office/Home Office or Management Company Costs. The allowability of the individual cost items contained within central office/home office or management company costs will be determined in accordance with all other provisions of this regulation. The total of central office/home office and/ or management company costs, as reported on lines 121 and 122 of the cost report, version MSIR-1 (3-95), are limited to seven percent (7%) of gross revenues less contractual allowances.

(Q) Start-Up Costs. Expenses incurred prior to opening, as straight line method over sixty (60) months. The amortization and would be reported on line 51 of the cost report, version MSIR-1 (3-95), RN.

(R) Reusable Items. Costs incurred for items, such as linen and bedding, but not limited to, shall be classified as inventory when purchased and expensed as the item is used.

(S) Nursing Facility Reimbursement Allowance (NFRA).

Effective October 1, 1996, the fee assessed to nursing facilities in the state of Missouri for the privilege of doing business in the state will be an allowable cost.

(8) Nonallowable Costs. Costs not reasonably related to HIV nursing facility services shall not be included in a provider’s costs. Nonallowable costs include, but are not limited to, the (A) Amortization on intangible assets, such as goodwill, leasehold rights, covenants, and purchased certificates of need;

(B) Bad debts, contractual allowances, courtesy discounts, (C) Capital cost increases due solely to changes in ownership;

(D) Charitable contributions;

(E) Compensation paid to a relative or an owner through a (F) Costs such as legal fees, accounting and administrative are attributable to the negotiation or settlement of the sale or purchase of any capital asset by acquisition or merger for which any payment has been previously made under the program;

(G) Directors’ fees included on the cost report in excess of two (H) Federal, state, or local income and excess profit taxes, (I) Late charges and penalties;

(J) Finder’s fees;

(K) Fund-raising expenses;

(L) Interest expense on loans for intangible assets;

(M) Legal fees related to litigation involving the department and attorneys fees which are not related to the provision of HIV (N) Life insurance premiums for officers and owners and (O) Noncovered supplies, services, and items as defined in (P) Owner’s compensation in excess of the applicable range of the most recent survey of administrative salaries paid to individuals other than owners for proprietary and nonproprietary providers as published in the updated Medicare Provider Reimbursement Manual Part 1, section 905.2 and based upon the total number of working hours.

1. The applicable range will be determined as follows:

A. Number of licensed beds owned or managed; and B. Owner/administrators will be adjusted on the basis of the high range. Owners included in home office costs or management company costs will be adjusted on the high range. All others will be calculated on the median range.

2. The salary identified above will be apportioned on (Q) Prescription drugs;

(R) Religious items or supplies or services of a primarily (S) Research costs;

(T) Resident personal purchases provided nonroutinely to (U) Salaries, wages, or fees paid to nonworking officers, employees or consultants;

(V) Cost of stockholder meetings or stock proxy expenses;

(W) Taxes or assessments for which exemptions are available;

(X) Value of services (imputed or actual) rendered by nonpaid (Y) All costs associated with Nurse Aide Training and Competency Evaluation Program; and (Z) Losses from disposal of assets.

(9) Revenue Offsets.

(A) Other revenues must be identified separately in the revenues include, but are not limited to, the following:

1. Income from telephone services;

2. Sale of employee and guest meals;

3. Sale of medical abstracts;

4. Sale of scrap and waste food or materials;

5. Cash, trade, quantity, time, and other discounts;

6. Purchase rebates and refunds;

7. Recovery on insured loss;

8. Parking lot revenues;

9. Vending machine commissions or profits;

10. Sales from supplies to individuals other than HIV nursing facility recipients;

11. Room reservation charges other than covered therapeutic home leave days and hospital leave days;

12. Barber and beauty shop revenue;

13. Private room differential;

14. Medicare Part B revenues.

A. Revenues received from Part B charges through Medicare intermediaries will be offset.

B. Seventy-five percent (75%) of the revenues received from Part B charges through Medicare carriers will be offset;

15. Personal services;

16. Activity income; and 17. Revenue recorded for donated services and commodities.

(B) Restricted funds designated by the donor prior to the (C) Restricted funds designated by the donor for capital (D) Unrestricted funds not designated by the provider for (E) As applicable, restricted and unrestricted funds will be (F) Any tax levies which are collected by nursing home districts or county homes that are supported in whole or in part by these levies, will not be offset.

(G) Gains on disposal of assets will not be offset from allowable expenses.

(10) Provider Reporting and Record Keeping Requirements.

(A) Annual Cost Report. The cost report (version MSIR-1 (3- 95)) and cost report instructions (revised 3/95) 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, August 1, 2008. This

rule does not incorporate any subsequent amendments or 1. Each provider shall adopt the same twelve (12)-month 2. Each provider is required to complete and submit to the division an annual cost report, including all worksheets, attachments, schedules, and requests for additional information from the division. The cost report shall be submitted on forms provided by the division for that purpose. Any substitute or computer generated cost report must have prior approval by the division.

3. All cost reports shall be completed in accordance 4. The cost report submitted must be based on the accrual 5. Cost reports shall be submitted by the first day of the fourth month following the close of the fiscal period, unless an extension has been granted.

4. If requested in writing and postmarked prior to the first day of the fourth month following the close of the fiscal period, one (1) thirty (30)-day extension of the filing date may be granted.

5. If a cost report is more than ten (10) days past due, payment shall be withheld from the facility until the cost withheld will be released to the provider. For cost reports which are more than ninety (90) days past due, the department may terminate the provider’s Medicaid participation agreement and, if terminated, retain all payments which have been withheld pursuant to this provision.

6. Copies of signed agreements and other significant documents related to the provider’s operation and provision of care to Medicaid recipients must be attached (unless otherwise noted) to the cost report at the time of filing unless current and accurate copies have already been filed with the division.

Material which must be submitted or available upon request includes, but is not limited to, the following:

A. Audit prepared by an independent accountant, including disclosure statements and management letter or SEC Form 10-K;

B. Contracts or agreements involving the purchase requested by the division, the department, or its agents;

C. Contracts or agreements with owners or related D. Contracts with consultants;

E. Documentation of expenditures, by line item, made F. Federal and state income tax returns for the fiscal year, if requested by the division, the department, or its agents;

G. Leases and/or rental agreements related to the activities of the provider if requested by the division, the department, or its agents;

H. Management contracts;

I. Medicare cost report, if applicable;

J. Review and compilation statement;

K. Statement verifying the restrictions as specified by L. Working trial balance actually used to prepare the M. Schedule of capital assets with corresponding debt.

9. Cost reports must be fully, clearly, and accurately information, documentation, or clarification requested by the division or its authorized agent is not provided within 10. Under no circumstances will the division accept (B) Certification of Cost Reports.

10. The accuracy and validity of the cost report must be 2. Cost reports must be notarized by a commissioned notary public.

11. The following statement must be signed on each cost Certification Statement: Misrepresentation or falsification of any information contained in this cost report may be punishable by fine and/or imprisonment under state or federal law. schedules prepared by (provider name and number) for the cost report period beginning (date/year) and ending (date/ year), and that to the best of my knowledge and belief, it is a and records of the provider in accordance with applicable ___________________________ _________________ ___________ (C) Adequate Records and Documentation.

12. A provider must keep records in accordance with GAAP authorized agent for additional information.

13. Each of a provider’s funded accounts must be separately 3. Adequate documentation for all line items on the cost for review by the division or its authorized agent at the same site at which the services were provided or at the central or its authorized agent upon request.

14. Each facility shall retain all financial information, data, and records relating to the operation and reimbursement of the facility for a period of not less than seven (7) years.

(D) Audits.

1. Any cost report submitted may be subject to field audit by the division or its authorized agent.

2. A provider shall have available at the field audit location 3. If a provider maintains any records or documentation at agent for reasonable travel costs necessary to perform any 4. Those providers initially entering the program shall be required to have an annual independent audit of the financial records, used to prepare annual cost reports covering at a minimum the first two (2) full twelve (12)-month fiscal years of their participation in the Medicaid Program, in accordance with GAAP and generally accepted auditing standards. The audit shall include, but may not be limited to, the Balance Sheet, Income Statement, Statement of Retained Earnings, and Statement of Cash Flow. For example, a provider begins participation in the Medicaid Program in March and chooses a fiscal year of October 1 to September 30. The first cost report will cover March through September. That cost report may be audited at the option of the provider. The October 1 to September 30 cost report, the first full twelve (12)-month September 30 cost report, the second full twelve (12)-month independent certified public accountant.

(E) Change in Provider Status.

1. If a provider notifies, in writing, the director of the Institutional Reimbursement Unit of the division prior to the change of control, ownership, or termination of participation in the Medicaid Program, the division will withhold all remaining payments from the selling provider until the cost report is filed.

The fully completed cost report with all required attachments and documentation is due the first day of the fourth month after the date of change of control, ownership, or termination.

Upon receipt of a cost report prepared in accordance with this

regulation, any payment that was withheld will be released to the selling provider.

2. If the director of the Institutional Reimbursement Unit does not receive, in writing, notification of a change of control or ownership and a cost report ending with the date of the change of control or ownership, upon learning of a change of control or ownership, thirty thousand dollars ($30,000) of the next available full month Medicaid payment, after learning of the change of control or ownership, will be withheld from the provider identified in the current Medicaid participation agreement until a cost report is filed.

If the Medicaid payment is less than thirty thousand dollars ($30,000), the entire payment will be withheld. Once the cost report, prepared in accordance with this regulation, is received the payment will be released to the provider identified in the current Medicaid participation agreement.

(F) Joint Use of Resources.

1. If a provider has business enterprises in addition to the HIV nursing facility, the revenues, expenses, statistical, and 2. When the facility is owned, controlled, or managed by an entity or entities that own, control, or manage one (1) or more other facilities, records of central office and other costs incurred outside the facility shall be maintained so as to to, individual facilities. Direct allocation of cost, such as RN consultant, which can be directly identifiable in the central office/home office cost and directly allocated to a facility by actual amounts or actual time spent. These direct costs shall be reported on the appropriate lines of the cost report.

Allocation of central office/home office or management company costs to individual facilities should be consistent from year-to-year. If a desk audit or field audit establishes that records are not maintained so as to clearly identify information required by this regulation, those commingled costs shall not be recognized as allowable costs in determining the facility’s Medicaid reimbursement rate. Allowability of these costs shall be determined in accordance with the provisions of this (11) Cost Components and Per-Diem Calculation. The division will use the HIV nursing facility rate setting cost report.

(A) Patient Care. Each HIV nursing facility’s patient care per diem shall be the lower of— 1. Allowable cost per patient day for patient care as determined by the division from the rate setting cost report; or 2. The per diem ceiling of one hundred twenty percent (120%) of the patient care median determined by the division from the data bank.

(B) Ancillary. Each HIV nursing facility’s ancillary per diem will be the lower of— 1. Allowable cost per patient day for ancillary as determined by the division from the rate setting cost report; or 2. The per diem ceiling of one hundred twenty percent (120%) of the ancillary median determined by the division from the data bank.

(C) Administration. Each HIV nursing facility’s administration per diem shall be the lower of— 1. Allowable cost per patient day for administration as determined by the division from the rate setting cost report and adjusted for minimum utilization, if applicable, as described in subsection (7)(O); or 2. The per diem ceiling of one hundred ten percent (110%) of the administration median determined by the division from the data bank.

(D) Capital. Each HIV nursing facility’s capital per diem shall be determined using the fair rental value system as follows:

1. Rental value.

A. Determine the total asset value.

(I) Determine facility size from the rate setting cost (II) Determine the number of increased licensed beds after the rate setting cost report.

(III) Determine the bed equivalency for renovations/ major improvements after November 30, 1995, by taking the cost of the renovations/major improvements divided by the asset value per bed for the year of the renovation/major improvement rounded to the nearest whole bed. The cost must be at least the asset value per bed for the year of the renovation/major improvement. For example, a renovations/ major improvements cost of two hundred thousand dollars ($200,000) is equal to six (6) beds. ($200,000/$32,723 equals 6.11 beds rounded to 6 beds).

(IV) Determine the number of decreased licensed beds after the rate setting cost report.

(V) Sum of (I), (II), (III) less (IV) times the asset value is the Total Asset Value.

B. Determine the reduction for age by multiplying the age of the beds by one percent (1%) up to forty percent (40%). For multiple licensing dates, the result of the weighted average age calculation will be limited to forty percent (40%).

(I) The age of the beds for multiple licensing dates is calculated on a weighted average method rounded to the nearest whole year. For example, a facility with original licensure in 1977 of sixty (60) beds and an additional licensure of sixty (60) beds in 1982 and ten (10) beds in 1993, the reduction is calculated as follows: 1993 1 10 10 Total 130 1750 Weighted Average Age—1750/130 beds = 13.5 years rounded to 14 years. This results in a reduction for age of the beds of fourteen percent (14%).

(II) The age of the beds for replacement beds is calculated on a weighted average method rounded to the nearest whole year with the oldest beds always being replaced first. For example, a facility with one hundred twenty (120) beds licensed in 1978 with replacement of sixty (60) beds in 1988, the reduction is calculated as follows 1978 16 60 960 1988 6 60 360 Total 120 1320 Weighted Average Age—1320/120 = 11 years. This results in a reduction for age of the beds of eleven percent (11%).

(III) The age of the beds for reductions in licensed beds is calculated on a weighted average method rounded to the nearest whole year with the oldest beds always being delicensed first. For example, a facility with original licensure in 1977 of sixty (60) beds, additional licensure of sixty (60) beds in 1982 and ten (10) beds in 1993 and a reduction of ten (10) beds in 1985, the reduction percentage is calculated as follows: 1993 1 10 10 1985* 17 (10) (170)

Total 120 1580 *reduction of 1977 beds Weighted Average Age—1580/120 beds = 13.2 years rounded to 13 years. This results in a reduction for age of the beds of thirteen percent (13%).

(IV) The age of the beds equivalents for renovations/ major improvements is calculated on a weighted average method rounded to the nearest whole year. For example, a one hundred twenty (120)-bed facility licensed in 1978 undertakes two (2) renovations: two hundred thousand dollars ($200,000) in 1983 and one hundred thousand dollars ($100,000) in 1993.

The asset value per bed is thirty-two thousand seven hundred twenty-three dollars ($32,723). The bed equivalency is six (6) beds for 1983 and three (3) beds for 1993, the reduction percentage is calculated as follows:

Licensure/ Construction Year Age Beds Age × Beds 1978 16 120 1920 1983 11 6 66 1993 1 3 3 Total 129 1989 Weighted Average Method—1989/129 = 15.42 years rounded to 15 years. This results in a reduction for age of beds of fifteen percent (15%).

C. The facility asset value is subparagraph (11)(D)1.A. less subparagraph (11)(D)1.B.

D. Multiply the facility asset value by two and one-half percent (2.5%) to determine the rental value. The two and onehalf percent (2.5%) is based on a forty (40)-year life.

E. The following is an illustration of how subparagraphs (11)(D)1.A., (11)(D)1.B., and (11)(D)1.C., (11)(D)1.D. determines the rental value:

(I) Total Facility Size 174 beds Weighted Average Age of the Beds 23 years Capital Asset Debt $2,371,094 Asset Value $ 32,723 (II) The Total Asset Value is the product of the Total Facility Size times the Asset Value;

Total Facility Size 174 Asset Value × $32,723 Total Asset Value $5,693,802 (III) Facility Asset Value is Total Asset Value less the Reduction for Age of the Beds; and Reduction for Age (23%) $1,309,574 Facility Asset Value $4,384,228 (IV) Rental Value is the Facility Asset Value multiplied by 2.5%.

Rental Value × 2.5% $ 109,606 2. Rate of return.

A. Reduce the Facility Asset Value by the Capital Asset Debt, but not less than zero (0), times the percentage of return.

The percentage of return is the yield for the thirty (30)-year Treasury Bond as reported by the Federal Reserve Board and published in the Wall Street Journal for the week ending June 30, 1995, plus two (2) percentage points. The rate is 6.58% for the week ending June 30, 1995, plus 2% for a total of 8.58%.

B. The debt associated with increases in licensed beds or renovations/major improvements after the end of the facility’s rate setting cost report and will be added to the capital asset debt from the rate setting cost report. The facility shall provide adequate documentation to support the additional debt as required in paragraph (7)(E)2. If adequate documentation is not provided to support the additional asset debt, it will be assumed to equal the facility asset value.

C. The following is an illustration of how subparagraph (11)(D)2.A. is calculated:

Facility Asset Value $4,331,573 Capital Asset Debt $2,371,094 $1,960,479 Percentage of Return × 9.48% Rate of Return $ 185,853 3. Computed interest and pass through expenses.

A. Add property insurance (line 107) and property taxes (lines 108 and 109). Also add interest subject to limits identified in subsection (7)(F). These lines are found in the cost report, version MSIR-1 (3-95).

B. The following is an illustration of how subparagraph (11)(D)3.A. is calculated:

Computed Interest $207,840 Insurance $ 7, 594 Property Taxes $ 40,548 Pass Through Expenses $ 48,142 4. Capital Component Per Diem Calculation.

A. A per diem is calculated by dividing the sum of rental value, rate of return, and computed interest by the number of beds determined in subparagraph (11)(D)1.A. times three hundred sixty-five (365) adjusted by the greater of the minimum utilization as determined in subsection (7)(O) or the facility’s occupancy from the rate setting cost report. The following is an illustration of how subparagraph (11)(D)4.A. is calculated:

Rental Value $108,289 Rate of Return $185,853 Computed Interest $207,840 Total $501,982 Divided by Annualized Patient Days 56,077 Capital Per Diem $ 8.95 B. A per diem is calculated by dividing the pass through expenses by the greater of the minimum utilization as determined in subsection (7)(O) or the facility’s patient days from the rate setting cost report. The following is an illustration of how subparagraph (11)(D)4.B. is calculated:

Pass Through Expenses $48,142 Patient Days 55,146 Pass Through Per Diem $ .87 C. The capital component per diem is the sum of subparagraph (11)(D)4.A. and (11)(D)4.B.

Capital Per Diem $ 8.95 Pass-Through Per Diem $ .87 Total Capital Component Per Diem $ 9.82 (E) Working Capital Allowance. Each HIV nursing facility’s working capital per diem shall be equal to one and one-tenth (1.1) months of each facility’s per diem for patient care, ancillary, and administration times the Chase Manhattan prime rate on July 3, 1995, plus two (2) percentage points. The following is an illustration of how subsection (11)(E) is calculated:

Patient Care $30.00 Ancillary $ 7.00 Administration $20.00 Total Per Diem $57.00 divided by 12 months 12 $ 4.75 Times 1.1 months 1.1 $ 5.23 Times Prime + 2% (Chase Manhattan plus 2%) 11% Working Capital Allowance per day $ .58 (F) The following is an illustration of how subsections (11)(A), (11)(B), (11)(C), (11)(D), and (11)(E) determine the per diem rate:

Allowable Cost Ceiling Per Diem Patient Care $38.00 $40.00 $38.00 Ancillary $ 8.00 $ 6.00 $ 6.00 Administration $12.00 $11.00 $11.00 Capital (FRV) $ 9.82 Working Capital Allowance $ .58 Total Per Diem $65.40 (12) Reimbursement Rate Determination. An HIV nursing facility’s reimbursement rate shall be determined by the division as described in sections (11), (12), (13), and (14), subject to limitations prescribed elsewhere in this regulation.

(A) A facility entering the Medicaid Program after November 30, 1995, shall receive an interim rate as defined in subsection (4)(FF) to be effective on the initial date of Medicaid certification. A prospective rate shall be determined in accordance with

section (11) from the desk audited and/or field audited facility fiscal year cost report which covers the second full twelve (12)-month fiscal year following the facility’s initial date of Medicaid certification. This prospective rate shall be retroactively effective and shall replace the interim rate for services beginning on the first day of the facility’s second full twelve (12)-month fiscal year.

(B) A facility with a valid Medicaid participation agreement in effect after November 30, 1995, which either voluntarily or involuntarily terminates its participation in the Medicaid Program and which re-enters the Medicaid Program, shall have its prospective rate established as the rate in effect on the day prior to the date of termination from participation in the program plus rate adjustments which may have been granted with effective dates subsequent to the termination date but prior to re-entry into the program as described in subsection (13)(A). This prospective rate shall be effective for service dates on and after the effective date of the re-entry following a voluntary or involuntary termination.

(13) Adjustments to the Reimbursement Rates. Subject to the

section and 13 CSR 70-10.016.

(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 as set forth in 13 CSR 70- 10.016. Global per diem rate adjustments shall be added to the specified cost component ceiling.

(B) Special Per Diem Rate Adjustments. Special per diem rate adjustments may be added to a qualifying facility’s rate 1. Replacement beds. A facility with a prospective rate in effect on or after November 30, 1995, may request a rate adjustment for replacement beds that resulted in the same number of beds being delicensed with the Division of Aging.

The facility shall provide documentation from the Division of Aging that verifies the number of beds used for replacement have been delicensed from that facility. The rate adjustment will be calculated as the difference between the capital component per diem (fair rental value, FRV) prior to the replacement beds being placed in service and the capital component per diem FRV including the replacement beds placed in service as calculated in subsection (11)(D) including the replacement beds placed in service. The capital component is calculated for the replacement beds using the asset value per licensed bed as determined using the R. S. Means Construction Index for nursing facility beds adjusted for the Missouri indexes for the date the replacement beds are placed in service.

2. Additional beds. A facility with a prospective rate in effect on or after November 30, 1995, may request a rate adjustment for additional beds. The facility must obtain an approved certificate of need or applicable waiver for the additional beds. The rate adjustment will be calculated as the difference between the capital component per diem FRV prior to the additional beds being placed in service and the capital component per diem FRV including the additional beds as calculated in subsection (11)(D) including the additional beds placed in service. The capital component is calculated for the additional beds using the asset value per licensed bed date the additional beds are placed in service.

3. Extraordinary circumstances. A participating facility which has a prospective rate may request an adjustment to its prospective rate due to extraordinary circumstances.

This request must be submitted in writing to the division within one (1) year of the occurrence of the extraordinary circumstance. The request must clearly and specifically identify the conditions for which the rate adjustment is sought. The dollar amount of the requested rate adjustment must be Requests for rate adjustments that have been withdrawn by the facility or are considered withdrawn because of failure to supply requested information may be resubmitted once for the requested rate adjustment. In the case of a rate adjustment request that has been withdrawn and then resubmitted, the effective date shall be the first day of the month in which the resubmitted request was made providing that it was made prior to the tenth day of the month. If the resubmitted request is not filed by the tenth of the month, rate adjustments shall be A. When the provider can show that it incurred higher costs due to circumstances beyond its control, the industry in general and the costs have a substantial cost effect;

B. Extraordinary circumstances include:

(I) Natural disasters such as fires, earthquakes, and floods that are not covered by insurance and that occur in a federally declared disaster area; and (II) Vandalism and/or civil disorder that are not covered by insurance; and C. The rate increase shall be calculated as follows:

(I) The one (1) time costs (costs that will not be incurred in future fiscal years):

(a) To determine what portion of the incurred costs will be paid, the division will use the patient occupancy days from latest available quarterly occupancy survey from the Division of Aging for the time period preceding when the extraordinary circumstances occurred; and (b) The costs directly associated with the extraordinary circumstances will be multiplied by the above percent. This amount will be divided by the paid days for the month the rate adjustment becomes effective per paragraph (13)(B)8. This calculation will equal the amount to be added to the prospective rate for only one (1) month, which will be the month the rate adjustment becomes effective. For this one (1) month only, the ceiling will be waived.

(II) For ongoing costs (costs that will be incurred in future fiscal years): Ongoing annual costs will be divided by the greater of: annualized (calculated for a twelve (12)-month period) total patient days from the latest cost report on file or eighty-five percent (85%) of annualized total bed days. This calculation will equal the amount to be added to the respective cost center, not to exceed the cost component ceiling. The rate adjustment, subject to ceiling limits will be added to the prospective rate.

(III) For capitalized costs, a capital component per diem FRV will be calculated as determined in subsection (11)

(D). The rate adjustment will be calculated as the difference between the capital component per diem FRV prior to the extraordinary circumstances and the capital component per diem FRV including the extraordinary circumstances.

4. Quality Assurance Incentive.

A. Each HIV nursing facility with an interim or prospective rate on or after July 1, 2000, shall receive a per diem adjustment of $3.20. The Quality Assurance Incentive adjustment will be added to the facility’s current rate.

B. The Quality Assurance Incentive per diem increase shall be used to increase the expenditures to a nursing facility’s direct patient care costs. Direct patient care costs include all expenses in the patient care cost component (i.e., lines 46 through 69 of Schedule B in the Title XIX Cost Report). Any increases in wages and benefits already codified in a collective bargaining agreement in effect as of July 1, 2000, will not be counted towards the expenditure requirements of the Quality Assurance Incentive as stated above. Nursing facilities with collective bargaining agreements shall provide such agreements to the division.

(C) Conditions for Prospective Rate Adjustments. The division 1. Fraud, misrepresentation, errors. When information also does not affect the division’s ability to impose any sanctions authorized by statute or regulation;

2. Decisions of the Administrative Hearing Commission, 3. Court Order; and 4. Disallowance of federal financial participation.

(14) Exceptions.

(A) For those Medicaid-eligible recipients who have concurrent Medicare Part A skilled nursing facility benefits available, Medicaid reimbursement for covered days of stay in a qualified facility will be based on this coinsurance as may be imposed under Title XVIII.

(15) Sanctions and Overpayments.

(A) In addition to the sanctions and penalties set forth in this

regulation, the division may also impose sanctions against a provider in accordance with state regulation 13 CSR 70-3.030, Sanctions for False or Fraudulent Claims for Title XIX Services, or any other sanction authorized by state or federal law or regulations.

(B) Overpayments due the Medicaid Program from a provider shall be recovered by the division in accordance with state

regulation 13 CSR 70-3.030, Sanctions for False or Fraudulent Claims for Title XIX Services.

(16) Appeals. In accordance with sections 208.156 and 622.055, RSMo, providers may seek hearing before the Administrative Hearing Commission of final decisions of the director or the division.

(17) Payment in Full. Participation in the program shall be services rendered to Medicaid recipients, the amount paid (18) Provider Participation. Payments made in accordance (19) Transition. Cost reports used for rate determination shall be principles provided in this regulation.

(20) Rebasing of HIV Nursing Facility Rates.

(A) Effective July 1, 2004, HIV nursing facility rates shall be rebased on an annual basis. The rebased rates shall be phased in as set forth below in subsection (20)(B). Each HIV nursing facility shall have its prospective rate recalculated using the same principles and methodology as detailed throughout sections (1)–(19) of this regulation, unless otherwise noted in this section (20). The following items have been updated to reflect the rebase:

1. HIV nursing facility rates shall be rebased on an annual

basis using the cost report year that is three (3) years prior to the effective date of the rate change. For example, for SFY 2005, the effective date of the rate change is for dates of service beginning July 1, 2004 and the cost report year used to recalculate rates shall be 2001; for SFY 2006, the effective date of the rate change is for dates of service beginning July 1, 2005 and the cost report year used to recalculate rates shall be 2002; etc.

A. A new databank shall be developed from the cost reports for each rebase year in accordance with paragraph (20)

(A)1. and subsection (4)(P).

B. The costs in the databank shall be trended using the indices from the most recent publication of the Health-Care Cost Review available to the division using the “CMS Nursing Home without Capital Market Basket” table. The costs shall be trended using the second quarter indices for each year. The costs shall be trended for the years following the cost report year, up to and including the state fiscal year corresponding to the effective date of the rates. For SFY 2005, the trends are from the First Quarter 2004 publication of the Health-Care Cost Review and include the following:

(I) 2002:2 = 3.2%

(II) 2003:2 = 3.4%

(III) 2004:2 = 2.3%

(IV) 2005:2 = 2.3%

(V) The total trend applied to the 2001 cost report data C. The medians and ceilings shall be recalculated each year, based upon the trended costs included in the new databank that is developed each year.

D. The costs, beds, days, renovations/major improvements, databank shall be used to recalculate each facility’s rate. The costs reflected in each facility’s cost report shall be trended as detailed above in (20)(A)1.B.

2. The asset value used to determine the capital cost each year based upon the RS Means Building Construction Cost Data for the year coinciding with the effective date of the rates.

The asset value is determined by using the median, total cost of construction per bed for nursing homes from the “S.F., C.F., and % of Total Costs” table and adjusting it by the total weighted average index for Missouri cities from the “City Cost Indexes” table. For SFY 2005, the asset value shall be forty-one thousand seven hundred twenty-eight dollars ($41,728).

3. The age of the beds shall be calculated from the year coinciding with the effective date of the rates.

4. The interest rate used in determining the capital cost component and working capital allowance, as set forth in subsections (7)(F), (11)(D), and (11)(E), shall be updated to reflect the prime rate as reported by the Federal Reserve and published in the Wall Street Journal on the first business day of June for the year coinciding with the effective date of the rates plus two percent (2%). For SFY 2005, the interest rate shall be the prime rate of four percent (4%), as published June 1, 2004, plus two percent (2%) for a total of six percent (6%).

5. The rate of return used in determining the capital cost to reflect the interest (i.e., coupon) rate for the most recent issue of thirty (30)-year Treasury Bonds in effect on the first business day of June for the year coinciding with the effective date of the rates plus two percent (2%). For SFY 2005, the rate of return shall be the thirty (30)-year Treasury Bond rate of 5.375%, effective June 1, 2004, plus two percent (2%) for a total of 7.375%.

6. The administration cost component per diem calculation shall not be adjusted for minimum utilization.

7. The capital cost component per diem calculation shall be adjusted for minimum utilization using the Department of Health and Senior Services’ (DHSS) Intermediate Care Facility/ Skilled Nursing Facility Certificate of Need Quarterly Survey (CON Quarterly Survey) for the most recent quarter available to the division relative to the effective date of the rates.

The occupancy data from the CON Quarterly Survey shall be adjusted by the division using total licensed beds rather than available beds as is used by DHSS. For SFY 2005, the minimum utilization percent for the capital component is the adjusted industry average from the October–December 2003 CON Quarterly Survey and shall be seventy-three percent (73%).

8. Since rates are being recalculated each year, rate adjustment requests for replacement beds, additional beds, and/or extraordinary circumstances as set forth in paragraphs (13)(B)1., (13)(B)2., and (13)(B)3. are no longer allowed.

(B) The rebased rates shall be phased in, as set forth below:

1. A preliminary rebased rate shall be calculated using the same principles and methodology as detailed throughout sections (1)–(19) of this regulation and the updated items detailed above in paragraphs (20)(A)1.–8.

2. The total increase resulting from the rebase each year shall be calculated as follows:

A. Each facility’s current rate as of June 30 of each year shall be compared to the preliminary rebased rate effective July 1 of the following SFY. For example, for SFY 2005, the facility’s rate as of June 30, 2004 shall be compared to the preliminary rebased rate effective July 1, 2004; for SFY 2006, the facility’s rate as of June 30, 2005 shall be compared to the preliminary rebased rate effective July 1, 2005; etc.

(I) The NFRA shall not be included in the current rate or the preliminary rebased rate for comparison purposes in (II) The current NFRA shall be added to the rate determined below in subparagraph (20)(B)2.B.

B. If the preliminary rebased rate is greater than the current rate, the difference between the two (2) shall represent the total increase that will be phased in by granting one-third (1/3) of the total increase each year. For SFY 2005, one-third (1/3) of the total increase shall be added to the facility’s current rate as of June 30, 2004, less the reduction in the nursing facility 2004 as set forth in (13)(A)5. The current NFRA shall be added to that total and shall be the facility’s prospective rate for SFY 2005.

C. If the preliminary rebased rate is less than the current rate, the facility shall continue to receive its current rate including the current NFRA for the SFY.

(C) Effective for dates of service beginning April 1, 2005, the rebased rates for SFY 2005 shall be calculated as follows:

1. The audited 2001 cost report data shall continue to be used to develop the databank and to determine each nursing facility’s rebased rate. The audited 2001 cost report data; the licensed beds data; and the bed equivalencies data used to determine each nursing facility’s final rate paid for dates of services effective July 1, 2004 shall be deemed final. This finalized data will be used as the base to calculate the rates effective April 1, 2005. The following items have been revised for the April 1, 2005 rate calculation:

A. A new databank shall be developed using the audited 2001 cost report data set forth above in paragraph (20)(C)1. for nursing facilities enrolled in the Medicaid program as of March 15, 2005 in accordance with subsection (4)(S).

B. The administration and capital cost components shall be adjusted for minimum utilization at eighty-five percent (85%) occupancy, rather than as set forth in paragraphs (20)

(A)6.–7.

(21) Per Diem Rate Calculation Effective for Dates of Service Beginning July 1, 2005. Effective for dates of service beginning July 1, 2005, the rebase provisions set forth in section (20) shall not apply. Effective for dates of service beginning July 1, 2005, the per diem rates shall be calculated using the same (1)–(19) of this regulation, except that the data indicated in this

section (21) shall be used.

(A) The audited 2001 cost report data shall be used to develop the databank and to determine each nursing facility’s per diem rate. The audited 2001 cost report data; the licensed beds data; and the bed equivalencies data used to determine each nursing facility’s final rate paid for dates of services effective July 1, 2004 shall be deemed final. This finalized data will be used as the base to calculate the rates effective July 1, 2005.

1. A new databank shall be developed using the audited 2001 cost report data set forth above in subsection (21)(A) for nursing facilities enrolled in the Medicaid program as of March 15, 2005 in accordance with subsection (4)(S).

2. The costs in the databank shall be trended using the second quarter indices from the First Quarter 2004 publication of the Health-Care Cost Review using the “CMS Nursing Home without Capital Market Basket” table. The costs shall be trended for the years following the cost report year, up to and including SFY 2005. The trends applied to the 2001 cost report data include the following:

A. 2002:2 = 3.2%

B. 2003:2 = 3.4%

C. 2004:2 = 2.3%

D. 2005:2 = 2.3%

E. The total trend applied to the 2001 cost report data 3. The medians and ceilings shall be recalculated, based upon the trended costs included in the new databank.

4. The costs, beds, days, renovations/major improvements, databank shall be used to calculate each nursing facility’s rate.

The costs reflected in each facility’s cost report shall be trended as detailed above in paragraph (21)(A)2.

(B) The asset value used to determine the capital cost component, as set forth in subsection (11)(D), shall be based upon the 2004 publication of the RS Means Building Construction Cost Data. The asset value is determined by using the median, total cost of construction per bed for nursing homes from the “S.F., C.F., and % of Total Costs” table and adjusting it by the total weighted average index for Missouri cities from the “City Cost Indexes” table. The asset value shall be forty-one thousand seven hundred twenty-seven dollars and fifty cents ($41,727.50).

(C) The age of the beds shall be calculated from 2004.

(D) The interest rate used in determining the capital cost component and working capital allowance, as set forth in subsections (7)(F), (11)(D), and (11)(E), shall be the prime rate as reported by the Federal Reserve and published in the Wall Street Journal on the first business day of June 2004 plus two percent (2%). The interest rate shall be the prime rate of four percent (4%), as published June 1, 2004, plus two percent (2%) for a total of six percent (6%).

(E) The rate of return used in determining the capital cost component, as set forth in subsection (11)(D), shall be the interest (i.e., coupon) rate for the most recent issue of thirty (30)-year Treasury Bonds in effect on the first business day of June 2004 plus two percent (2%). The rate of return shall be the thirty (30)-year Treasury Bond rate of 5.375%, effective June 1, 2004, plus two percent (2%) for a total of 7.375%.

(F) The administration and capital cost components shall be adjusted for minimum utilization at eighty-five percent (85%) occupancy.

(G) Rate adjustment requests for replacement beds, additional beds, and/or extraordinary circumstances as set forth in paragraphs (13)(B)1., (13)(B)2., and (13)(B)3. are no longer allowed.

(H) The rates effective for dates of service beginning July 1, 2005 shall be determined as set forth below:

1. A preliminary rate for July 1, 2005 shall be calculated using the same principles and methodology as detailed throughout sections (1)–(19) of this regulation and the updated items detailed above in subsections (21)(A)–(G).

2. The total increase resulting from the July 1, 2005 preliminary rate calculation shall be calculated as follows:

A. Each facility’s rate as of June 30, 2004, less the reduction in the nursing facility operations adjustment of fiftyfour cents (54¢) effective July 1, 2004 as set forth in paragraph (13)(A)5., shall be compared to the July 1, 2005 preliminary rate (I) The high volume adjustment, if applicable, and the NFRA shall not be included in the June 30, 2004 rate or the July 1, 2005 preliminary rate for comparison purposes in (II) The high volume adjustment, if applicable, and the subparagraphs (21)(H)2.B. and (21)(H)2.C.

B. If the July 1, 2005 preliminary rate is greater than the June 30, 2004 rate including the reduction in the nursing July 1, 2004 as set forth in paragraph (13)(A)5., the difference between the two (2) shall represent the total increase. Effective for dates of service beginning July 1, 2005, one-third (1/3) of the total increase shall be added to the facility’s rate as of June 30, 2004 including the reduction in the nursing facility operations adjustment of fifty-four cents (54¢) effective July 1, 2004 as set forth in paragraph (13)(A)5. The high volume adjustment, if applicable, and the current NFRA shall be added to that total and shall be the facility’s prospective rate for dates of service beginning July 1, 2005.

C. If the July 1, 2005 preliminary rate is less than the June 30, 2004 rate including the reduction in the nursing facility 2004 as set forth in paragraph (13)(A)5., the facility’s prospective rate shall be the facility’s rate as of June 30, 2004 including the reduction in the nursing facility operations adjustment of fiftyfour cents (54¢) effective July 1, 2004 as set forth in paragraph (13)(A)5. plus the high volume adjustment, if applicable, and the current NFRA.

COVERED SUPPLIES AND SERVICES PERSONAL CARE

Oral hygiene including denture care, cups, cleaner, mouthwashes, toothbrushes, and toothpaste Nail clipping and cleaning-routine K pads (water heated pads), alternating pressure pads, flotation pads, and/or turning frames, heel protectors, donuts and sheepskins Needles including, but not limited to, hypodermic, scalp, vein eating and massages provided by facility personnel A and D ointment, tapes, alcohol, alcohol sponges, applicators, Oxygen (portable or stationary), oxygen delivery systems, concentrators, and supplies

Amended: Filed Sept. 21, 1998, effective May 30, 1999. Emergency amendment filed Sept. 20, 1999, effective Oct. 1, 1999, expired March 29, 2000. Amended: Filed Aug. 30, 1999, effective March 30, 2000. Emergency amendment filed July 18, 2000, effective July 28, 2000, expired Jan. 24, 2001. Amended: Filed June 30, 2000, effective Feb. 28, 2001. Emergency amendment filed Sept. 22, 2003, effective Oct. 1, 2003, terminated Oct. 29, 2003. Amended: Filed Sept. 22, 2003, effective May 30, 2004. Emergency amendment filed June 18, 2004, effective July 1, 2004, expired Dec. 15, 2004. Amended: Filed Aug. 16, 2004, effective Feb. 28, 2005. Emergency amendment filed March 21, 2005, effective April 1, 2005, expired Sept. 27, 2005. Emergency amendment filed June 20, 2005, expired Dec. 27, 2005. Amended: Filed March 29, 2005, effective Sept. 30, 2005.

Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed May 15, 2006, effective Nov. 30, 2006. Emergency amendment filed Sept. 17, 2007, effective Oct. 1, 2007, expired March 28, 2008. Amended: Filed March 30, 2007, effective Nov. 30, 2007. Amended: Filed July 1, 2008, effective Jan. 30, 2009. Amended: Filed March 11, 2010, effective Sept. 30, 2010. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2009. Original rule filed Aug. 1, 1995, effective March 30, 1996. Emergency amendment filed Oct. 15, 1996, effective Oct. 25, 1996, expired April 22, 1997. Emergency amendment filed Aug. 12, 1997, effective Sept. 1, 1997, expired Feb. 27, 1998. Amended: Filed Aug. 12, 1997, effective Feb. 28, 1998. Emergency amendment filed Sept. 19, 1997, effective Oct. 1, 1997, expired March 29, 1998. Amended: Filed Sept. 25, 1997, effective March 30, 1998. Emergency amendment filed Sept. 21, 1998, effective Oct. 1, 1998, expired March 29, 1999.

13 CSR 70-10.100 Limitation on Allowable Capital Cost Overruns for New Institutional Health Services in Title XIX Reimbursement Rate Setting {#sec-13-csr-70-10.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.100}

PURPOSE: This rule establishes a limitation on the allowance of capital cost overruns in the construction of new institutional health services for Title XIX reimbursement rate setting purposes.

(1) For implementation purposes of this rule, the following definitions shall apply:

(A) Cost overrun is that part of project costs for new institutional health services in excess of ten percent (10%) of the initial project estimate;

(B) Initial project estimate— 1. Is the dollar amount for which the Missouri Health Facilities Review Committee issued a Certificate of Need (CON);

2. For those facilities deemed to have received a CON, is the dollar amount specified on the binding construction or purchase contract which was executed prior to October 1, 1980;

(C) New institutional health services are those as specified in

section 197.305(9), RSMo; and (D) Project costs are those costs subject to review under CON and include the general construction costs, site work, land acquisition costs, architectural and engineering fees, contingency costs, interest during construction, financing costs and equipment acquisition costs.

(2) Project costs for new institutional health services in excess of ten percent (10%) of the initial project estimates shall not be considered in establishing a Title XIX per-diem rate for the first thirty-six (36) months that a facility receives payment for services provided under section 208.152, RSMo for any facility that applies for approval or consent for a cost overrun on or after November 11, 1982. This limitation is effective whether or not approval is granted under section 197.315.7, RSMo. If approval or consent is given, a facility’s cost overrun will be considered in establishing a Title XIX per-diem rate after the thirty-six (36)-month period in accordance with the provisions of the Title XIX reimbursement plan applicable to the provider type and subject to the limitations.

(3) If a facility applies for approval or consent for a cost overrun prior to November 11, 1982, and subsequently receives the requisite approval or consent, the dollar amount of the cost overrun will be considered in establishing a Title XIX perdiem rate in accordance with the provisions of the Title XIX reimbursement plan applicable to the provider type and subject to the limitations of the plan, notwithstanding the provisions of section 197.357, RSMo.

History

• AUTHORITY: sections 207.020, RSMo Supp. 1993, 208.159, RSMo 1986 and 208.153, RSMo Supp. 1991. This rule was previously filed as 13 CSR 40-81.082. Emergency rule filed Aug. 5, 1982, effective Aug. 15, 1982, expired Nov. 10, 1982. Original rule filed Aug. 5, 1982, effective Nov. 11, 1982. Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991; and 208.159, RSMo 1979.

13 CSR 70-10.110 Nursing Facility Reimbursement Allowance {#sec-13-csr-70-10.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.110}

PURPOSE: This regulation is necessary to outline the provisions allowed in House Bill 1362.

(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 B. Has in effect a transfer agreement with one (1) or more hospitals as required by federal law; and C. Meets the requirements for a nursing facility described in section 1919(b)–(d) of the Social Security Act; or D. Is licensed in accordance with Chapter 198, RSMo, as a skilled nursing facility.

2. Fiscal period. A facility’s twelve- (12-) month fiscal reporting period. If the facility is also participating in the Title XVIII Medicare (Medicare) program, the Medicaid cost report period shall be the same as the Medicare cost report period.

If the provider does not participate in Medicare, the Medicaid cost report should have the same twelve- (12-) month fiscal year consistent with the facility’s accounting and reporting period.

3. Department. Department of Social Services.

4. Director. Director of the Department of Social Services.

5. Division. MO HealthNet Division, Department of Social 6. Department of Health and Senior Services (DHSS). The Missouri state agency responsible for licensing and inspecting all long-term care facilities operating in Missouri and certifying annually those facilities participating in the Medicare or Medicaid program.

6. Engaging in the business of providing nursing facility services. Accepting payment for nursing facility services 8. Quarterly survey. The survey filled out each quarter by a nursing facility providing data on its licensed and certified beds and the related resident occupancy days (ROD) that is submitted to the DHSS. The survey, “Missouri Department of Health and Senior Services, Certificate of Need Quarterly Survey,” incorporated by reference in this rule, is published by the Department of Health and Senior Services, Division of Senior Services and Regulation, PO Box 570, Jefferson City, MO 65102 and is available at https://consurvey.dhss.mo.gov/ CONFacility/Login.aspx, June 23, 2025. This rule does not 9. Applicable quarterly survey. The quarterly survey used by the division from which the patient occupancy days are taken to determine the NFRA assessment for a given period as set forth in section (2).

7. Patient occupancy days. The number of days that residents occupied the licensed beds in a nursing facility as shown on the quarterly survey, line D. “Number of occupied RODs (days patients in beds or beds held).”

8. Annualized level of patient occupancy days. The annual level of patient occupancy days used to determine the annual NFRA assessment.

A. For existing nursing facilities whose NFRA assessment is set in accordance with paragraph (1)(B)1. of this regulation, the annualized level of patient occupancy days is calculated by taking the number of patient occupancy days shown on line D. of the quarterly survey multiplied by four (4).

B. For nursing facilities whose NFRA assessment is not set by the general rule set forth in paragraph (1)(B)1. (i.e., it is an exception set under subparagraph (1)(B)1.A., is a new facility set under paragraph (1)(B)2., qualifies for a NFRA adjustment in accordance with section (3), etc.), the annualized level of patient occupancy days may be calculated differently and is set forth in those sections.

12. Licensed beds. Any skilled nursing facility or intermediate care facility bed meeting the licensing requirement of the 13. Licensed bed days. The total number of patient days available for use during a given period for all licensed beds. For purposes of this regulation, licensed bed days are calculated for an annual period and is the number of licensed beds times three hundred sixty-five (365) days.

13. Change of ownership. A change in the ownership, control, operator, or leasehold interest.

(B) Each nursing facility, except any nursing facility operated by the Department of Mental Health, engaging in the business of providing nursing facility services in Missouri shall pay a Nursing Facility Reimbursement Allowance (NFRA).

1. The NFRA owed for existing nursing facilities shall be calculated by multiplying the NFRA rate by the annualized level of patient occupancy days from the applicable quarterly survey. The NFRA shall be divided by and collected over the number of months for which each NFRA rate is effective. The NFRA rates, effective dates, and applicable quarterly surveys are set forth in section (2).

A. Exceptions.

(I) If an existing nursing facility is not open for the entire quarter relative to the applicable quarterly survey, as set forth in section (2), and the applicable quarterly survey does not represent a full quarter’s worth of days due to a termination, temporary closure, change of ownership, etc., the annualized level of patient occupancy days used to determine the NFRA shall be the greater of— (a) The annualized level of patient occupancy days from the quarterly survey immediately prior to the applicable quarterly survey, if it represents a full quarter’s worth of days;

(b) Fifty percent (50%) of licensed bed days (i.e., number of licensed beds times three hundred sixty-five (365) days times fifty percent (50%)).

(II) If an existing nursing facility did not submit the applicable quarterly survey, the annualized level of patient occupancy days used to determine the NFRA shall be the greater of— (a) The facility’s current NFRA assessment (i.e., the NFRA assessment that is in effect prior to the new SFY update for which the facility did not submit a survey); or (b) Eighty percent (80%) of licensed bed days.

(III) If a nursing facility has intermediate care facility (ICF) licensed beds and skilled nursing facility (SNF) licensed beds and none of the beds are Medicaid certified, only the SNF beds are subject to NFRA. The annualized level of patient occupancy days used to determine the NFRA shall be determined by multiplying the occupancy percentage from the applicable quarterly survey by the licensed bed days for the SNF licensed beds (i.e., number of SNF licensed beds times three hundred sixty-five (365) days).

(IV) If two (2) existing nursing facilities merge, with one (1) nursing facility terminating and transferring its beds to the remaining facility, the NFRA for the two (2) previously independent nursing facilities shall be added together and assessed to the remaining facility.

2. The initial NFRA owed by a newly licensed nursing facility that just opened as a result of receiving a Certificate of Need (CON) for a new nursing facility shall be calculated by multiplying the NFRA rate by the annualized level of patient occupancy days based on fifty percent (50%) of licensed bed days. The NFRA shall be prorated for the number of months remaining in the NFRA period. If a nursing facility’s licensure date is after the first day of a month, the NFRA will be collected beginning with the first day of the month following the actual licensure date.

3. If a nursing facility ceases to provide nursing facility services, the nursing facility is not required to pay the NFRA during the months in which it does not have residents, even though it may retain a license due to temporary closure for renovations, replacement, etc. If a nursing facility provided nursing facility services for any portion of a month, it shall pay the NFRA for the entire month (i.e., the NFRA shall not be prorated for the month in which it ceases to provide nursing facility services). If the facility reopens, it shall resume paying the NFRA. It shall owe the same NFRA as it did prior to closing, if the NFRA has not changed per section (2) below. If the NFRA has changed, the facility shall be assessed in accordance with paragraph (1)(B)1. above.

(C) Payment of the NFRA.

1. Offset. Each nursing facility may request that their Nursing Facility Reimbursement Allowance be offset against any Missouri Medicaid payment due to that nursing facility.

A statement authorizing the offset must be on file with the division before any offset may be made relative to the nursing facility reimbursement allowance by the nursing facility. Assessments shall be allocated and deducted over the applicable service period. Any balance due after the offset shall be remitted by the nursing facility to the department.

The remittance shall be made payable to the Director of the Department of Revenue and deposited in the state treasury to the credit of the Nursing Facility Reimbursement Allowance Fund. If the remittance is not received before the next Medicaid payment cycle, the division shall offset the balance due from that check.

2. Check. If no offset has been authorized by the nursing facility, the division will begin collecting the nursing facility reimbursement allowance on the first day of each month. The NFRA shall be remitted by the nursing facility to the department.

The remittance shall be made payable to the director of the Department of Revenue and deposited in the state treasury to the credit of the Nursing Facility Reimbursement Allowance Fund.

3. Failure to pay the NFRA. If a nursing facility fails to pay its NFRA within thirty (30) days of notice, the NFRA shall be delinquent. For any delinquent NFRA, the department may proceed to enforce the state’s lien of the property of the nursing facility, may cancel or refuse to issue, extend, or reinstate the Medicaid provider agreement or may seek denial, suspension, or revocation of license granted under Chapter 198, RSMo. The new owner, as a result of a change in ownership, shall have his/her NFRA paid by the same method the previous owner elected.

(D) Each nursing facility, upon receiving written notice of the final determination of its Nursing Facility Reimbursement Allowance, may file a protest with the director of the department setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the department. The director of the department shall reconsider the determination and, if the nursing facility so requested, the director or the director’s designee shall grant the nursing facility a hearing to be held within forty-five (45) days after the protest is filed, unless extended by agreement between the nursing facility and the director. The director shall issue a final decision within forty-five (45) days of the completion of the hearing. After a final decision by the director, a nursing facility’s appeal of the director’s final decision shall be to the Administrative Hearing Commission in accordance with sections 208.156 and 621.055, RSMo.

(2) NFRA Rates. The amount of the fees imposed under this rule shall not exceed the percentage of net patient service revenues permitted by federal regulation pursuant to 42 CFR 433.68 as determined by the department on a per occupied bed per day

basis. Federal regulation 42 CFR 433.68 specifies that permissible health care related taxes shall produce revenues that are less than or equal to six percent (6%) of the revenues received by the health care provider. Federal regulation 42 CFR 433.68 is incorporated by reference as published by Office of the Federal Register, National Archives and Records Administration, 732 N. Capitol Street NW, Washington, DC 20401, October 1, 2024.

This rule does not incorporate any subsequent amendments or additions. The NFRA rates determined by the division are (A) The NFRA will be two dollars and seventy-six cents ($2.76) per patient occupancy day for the period January 1, 1995, through September 30, 1995, and collected over nine (9) months (February 1995 through October 1995). The applicable June 1994 quarterly survey;

(B) The NFRA will be three dollars and fifty-five cents ($3.55) per patient occupancy day for the period October 1, 1995, through September 30, 1996, and collected over twelve (12) months (November 1995 through October 1996). The applicable June 1995 quarterly survey;

(C) The NFRA will be five dollars and thirty cents ($5.30) per patient occupancy day for the period October 1, 1996, through September 30, 1997, and collected over twelve (12) months (November 1996 through October 1997). The applicable June 1996 quarterly survey;

(D) The NFRA will be five dollars and eighty-eight cents ($5.88) per patient occupancy day for the period October 1, 1997, through September 30, 1998, and collected over twelve (12) months (November 1997 through October 1998). The of Aging’s June 1997 quarterly survey;

(E) The NFRA will be five dollars and eighty-eight cents ($5.88) per patient occupancy day for the period October 1, 1998, through September 30, 1999, and collected over twelve (12) months (November 1998 through October 1999). The of Aging’s June 1998 quarterly survey;

(F) The NFRA will be seven dollars and four cents ($7.04) per patient occupancy day, effective October 1, 1999. The of Aging’s June 1999 quarterly survey;

(G) The NFRA will be seven dollars and fifty cents ($7.50) per patient occupancy day, effective July 1, 2000. The applicable December 1999 quarterly survey;

(H) The NFRA will be seven dollars and thirty cents ($7.30) per patient occupancy day, effective July 1, 2001. The applicable December 2000 quarterly survey;

(I) The NFRA will be eight dollars and forty-two cents ($8.42) per patient occupancy day, effective July 1, 2003. The applicable quarterly survey for this period shall be the Department of Health and Senior Services’ December 2002 quarterly survey;

(J) Effective January 1, 2005, the applicable quarterly survey shall be the June 2004 quarterly survey. The NFRA will continue to be eight dollars and forty-two cents ($8.42) per patient occupancy day;

(K) Effective July 1, 2005, the applicable quarterly survey shall be updated at the beginning of each state fiscal year using the previous December’s quarterly survey;

(L) Effective July 1, 2009, the NFRA will be nine dollars and seven cents ($9.07) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K);

(M) Effective January 1, 2010, the NFRA will be nine dollars and twenty-seven cents ($9.27) per patient occupancy day. The (2)(K);

(N) Effective October 1, 2011, the NFRA will be eleven dollars and seventy cents ($11.70) per patient occupancy day. The (2)(K);

(O) Effective July 1, 2012, the NFRA will be twelve dollars and eleven cents ($12.11) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K);

(P) Effective July 1, 2015, the NFRA will be thirteen dollars and forty cents ($13.40) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K); and (Q) Effective July 1, 2018, the NFRA will be twelve dollars and ninety-three cents ($12.93) per patient occupancy day. The (2)(K).

(3) NFRA Adjustment Request. A facility being assessed the NFRA may request that its current NFRA assessment be adjusted, as set forth below.

(A) Qualifying Criteria. In order for a facility to receive an adjustment to its current NFRA assessment, it must meet all of the following criteria:

1. The facility must decrease its licensed bed capacity by at least fifteen percent (15%).

2. The facility must draft a written statement documenting that the decrease in licensed bed capacity is intended to be permanent.

A. If the facility increases its licensed capacity back to the original capacity within one (1) year of the decrease, the NFRA adjustment shall be voided and the facility shall resume paying the original NFRA beginning with the first of the month in which the facility made the request to DHSS to increase licensed capacity.

3. The annualized level of patient occupancy days currently being assessed is not possible to attain because it is greater than one hundred percent (100%) of its new licensed capacity.

For example, assume a facility had one hundred thirty (130) licensed beds and was being assessed on an average of one hundred (100) beds:

A. If a facility decreased its license by twenty (20) beds, being left with a total of one hundred ten (110) licensed beds, the facility could still obtain the occupancy at which it was assessed (i.e., one hundred (100) beds being assessed is less than the one hundred ten (110) licensed bed capacity). Therefore, it would not meet the criteria for a NFRA adjustment.

B. If a facility decreased its license by forty (40) beds, being left with a total of ninety (90) licensed beds, the facility could not obtain the occupancy at which it was assessed (i.e., one hundred (100) beds being assessed is greater than the ninety (90) licensed bed capacity). Therefore, it would meet the criteria for a NFRA adjustment.

4. The facility must submit a written request to the division that includes an explanation as to why it believes it qualifies for an adjustment to its NFRA and documentation supporting its request. The following documentation is required:

A. A copy of the facility’s request submitted to the DHSS and/or the CON program that its licensed bed capacity be decreased.

B. A copy of the license issued as a result of the request for the decrease and all licenses issued from that point forward to the current license.

C. If the facility’s request submitted to the DHSS and/or the CON program to decrease its licensed bed capacity did not include a statement that the facility intended for the decrease to be permanent, such a statement must be submitted with the NFRA Adjustment Request.

D. The division may obtain this documentation and any other documentation it deems relevant to satisfy itself that the facility’s licensed bed capacity has been decreased and the facility intends for the decrease to be permanent from the facility, the DHSS, the CON program, or any other source it deems appropriate.

E. If the division makes a written request for additional information and the facility does not comply within ninety (90) days of the request, the division shall consider the NFRA Adjustment Request withdrawn.

(B) Calculation of Adjustment. A nursing facility meeting the criteria for a NFRA Adjustment shall have its NFRA recalculated and it shall replace the current NFRA. The revised, adjusted NFRA shall be calculated as follows:

1. The facility’s new, decreased licensed bed capacity shall be multiplied by three hundred sixty-five (365) days to determine the annualized level of patient occupancy days;

2. The new annualized level of patient occupancy days shall be multiplied by the current NFRA rate set forth in section (2) to determine the revised annual assessment; and 3. The revised annual assessment shall be divided by twelve (12) months to determine the revised monthly assessment that the facility will owe beginning with the effective date of the adjustment.

(C) Effective Date of NFRA Adjustment. The effective date of the NFRA Adjustment shall be the first day of the month following the date the request is received; it will not be retroactive back to the effective date of the original NFRA.

Original rule filed Dec. 15, 1994, effective July 30, 1995. Emergency amendment filed Sept. 5, 1995, effective Oct. 1, 1995, expired March 28, 1996. Amended: Filed May 30, 1995, effective Dec. 30, 1995. Amended: Filed Sept. 5, 1995, effective March 30, 1996.

Emergency amendment filed Sept. 20, 1996, effective Oct. 1, 1996, expired March 29, 1997. Emergency amendment filed Sept. 19, 1997, effective Oct. 1, 1997, expired March 29, 1998. Amended: Filed Sept. 25, 1997, effective March 30, 1998. Emergency amendment filed Sept. 21, 1998, effective Oct. 1, 1998, expired March 29, 1999.

Amended: Filed Sept. 21, 1998, effective May 30, 1999. Emergency amendment filed Sept. 20, 1999, effective Oct. 1, 1999 expired March 29, 2000. Amended: Filed Aug. 30, 1999, effective March 30, 2000. Amended: Filed Feb. 29, 2000, effective Oct. 30, 2000.

Emergency amendment filed Aug. 29, 2001, effective Sept. 8, 2001, expired March 6, 2002. Amended: Filed Aug. 29, 2001, effective March 30, 2002. Emergency amendment filed Sept. 22, 2003, effective Oct. 1, 2003, terminated Oct. 29, 2003. Amended: Filed Sept. 22, 2003, effective May 30, 2004. Emergency amendment filed Dec. 17, 2004, effective Jan. 1, 2005, expired June 29, 2005.

Amended: Filed Dec. 17, 2004, effective July 30, 2005. Emergency amendment filed Nov. 9, 2009, effective Nov. 19, 2009, expired Dec. 31, 2009. Amended: Filed July 1, 2009, effective Jan. 30, 2010.

Emergency amendment filed Dec. 1, 2009, effective Jan. 1, 2010, expired June 29, 2010. Amended: Filed Dec. 1, 2009, effective June 30, 2010. Emergency amendment filed Sept. 20, 2011, effective Oct. 1, 2011, expired March 28, 2012. Amended: Filed July 1, 2011, effective Dec. 30, 2011. Emergency amendment filed June 20, 2012, effective July 1, 2012, expired Dec. 28, 2012. Amended: Filed July 2, 2012, effective Jan. 30, 2013. Emergency amendment filed June 19, 2015, effective July 1, 2015, expired Dec. 28, 2015. Amended: Filed July 1, 2015, effective Jan. 30, 2016. Emergency amendment filed May 9, 2019, effective June 1, 2019, expired Dec. 30, 2019. Amended:

Filed May 9, 2019, effective Dec. 30, 2019. Emergency amendment filed June 23, 2025, effective July 8, 2025, expired Feb. 26, 2026.

Amended: Filed Aug. 12, 2025, effective March 30, 2026. *Original authority: 198.401, RSMo 1994; 198.403, RSMo 1994; 198.406, RSMo 1994; 198.409, RSMo 1994; 198.412, RSMo 1994; 198.416, RSMo 1994; 198.418, RSMo 1994; 198.421, RSMo 1994, amended 2014; 198.424, RSMo 1994; 198.427, RSMo 1994; 198.431, RSMo 1994; 198.433, RSMo 1994; 198.436, RSMo 1994, amended 1995; 198.439, RSMo 1994, amended 1996, 1999, 2002, 2005, 2006, 2007, 2011, 2015, 2016, 2018, 2019, 2020, 2021, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.159, RSMo 1979; and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: sections 198.401, 198.403, 198.406, 198.409, 198.412, 198.416, 198.418, 198.421, 198.424, 198.427, 198.431, 198.433, 198.436, 208.159, and 208.201, RSMo 2016, and sections 198.439 and 208.153, RSMo Supp. 2025. Emergency rule filed Dec. 21, 1994, effective Jan. 1, 1995, expired April 30, 1995. Emergency rule filed April 21, 1995, effective May 1, 1995, expired Aug. 28, 1995.

13 CSR 70-10.120 Reimbursement for Nurse Assistant Training {#sec-13-csr-70-10.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.120}

PURPOSE: This rule establishes a methodology for payment of nurse assistant training as required by the Omnibus Budget Reconciliation Act 87.

(1) Definitions.

(A) “Nurse assistant training agency” is an agency which is approved by the Department of Health and Senior Services under 19 CSR 30-84.010(7).

(B) “Basic course” is the seventy-five (75) hours of classroom training, the one hundred (100) hours of on-the-job supervised training, and the final examination of the approved nurse assistant training course.

(C) “Challenge the final examination” means taking the final examination of the basic course without taking the entire basic course.

(D) “Cost report” is the Financial and Statistical Report for Nursing Facilities, required attachments, and all worksheets supplied by the division for this purpose per 13 CSR 70-10.015, effective January 1, 1995, through June 30, 2022, and 13 CSR 70- 10.020, effective beginning July 1, 2022. The cost report details the cost of rendering both covered and noncovered services for the fiscal reporting period in accordance with the procedures prescribed by the division, and on forms provided by and/or approved by the division.

(E) “Department of Health and Senior Services” is the department responsible for the survey, certification, and licensure as prescribed in Chapter 198, RSMo.

(F) “Desk audit” is the MO HealthNet Division or its authorized agent’s audit of a provider’s cost report without a field audit.

(G) “Division,” unless otherwise specified, refers to the Department of Social Services, MO HealthNet Division that is charged with administration of MO HealthNet (Medicaid)

(H) “Facility fiscal year” is a facility’s twelve- (12-) month fiscal reporting period.

(I) “Field audit” is an on-site audit of the nursing facility’s records performed by the department or its authorized agent.

(J) “Nursing facility (NF)” is, effective October 1, 1990, skilled 198, RSMo participating in the Medicaid Program will all be (K) “Occupancy rate” is a facility’s total actual patient days from the desk audited and/or field audited cost report.

(L) “Patient day” is the period of service rendered to a patient purposes. Patient day includes the allowable temporary leaveof-absence days per 13 CSR 70-10.015(5)(D), effective January 1, 1995, through June 30, 2022, and 13 CSR 70-10.020(5)(C), effective beginning July 1, 2022, and hospital leave days per

13 CSR 70-10.070. The day of discharge is not a patient day for reimbursement purposes unless it is also the day of admission. {#sec-13-csr-70-10.070. omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.070.}

(M) “Provider or facility” is a nursing facility with a valid Social Services for the purpose of providing nursing facility services to Title XIX-eligible participants.

(2) General Principles.

(A) Provisions of this reimbursement plan shall apply only to nursing facilities with valid provider agreements certified by the Department of Social Services, Missouri Medicaid Audit and Compliance (MMAC) for participation in the MO HealthNet (B) The reimbursement determined by this regulation shall apply only to costs incurred for nurse assistant training and competency evaluations for nurse assistants beginning the training after February 26, 1993.

(C) Program Approval—The Department of Health and Senior Services will approve or disapprove nurse assistant training programs in the state of Missouri. If the Department of Health and Senior Services withdraws approval of a formerly approved nurse assistant training program, the facility may continue to teach (and bill MO HealthNet for) those nurse assistants who had already begun the training program. However, that facility may not begin training (or bill the division) for any additional nurse assistants until it again receives approval from the Department of Health and Senior Services. Nursing facilities receiving a “level A” violation or extended or partially extended survey will be ineligible for reimbursement for a period of two (2) years after the date of exit interview by the Department of Health and Senior Services.

(D) Training Agencies—Any nurse assistant training agency must be approved by the Department of Health and Senior Services per 19 CSR 30-84.010(7). This training agency must provide seventy-five (75) classroom hours of instruction and one hundred (100) hours on-the-job training. The seventy-five (75) classroom hours of instruction may include lecture, discussion, video/film usage, demonstration, and return demonstration by an approved registered nurse (RN) instructor who remains with and is always available to students to answer questions and to conduct the class. The one hundred (100) hours onthe-job training shall be done by an approved RN or licensed practical nurse (LPN) who meets 19 CSR 30-84.010 clinical supervisor qualifications and who directly observes their skills when checking their competencies. The one hundred (100) hours on-the-job training shall be devoted to the student; and the clinical supervisor or instructor must not have other job duties at the same time, such as but not limited to, charge nurse duties, medication pass duties and/or treatment duties.

The facility will not be reimbursed in the per-diem rate for the salary/fringes of the RN and/or LPN for time spent teaching the nurse assistant training program.

(E) Medicaid Cost Reports—Costs for nurse assistant training and competency evaluations are to be reported in the nonallowable column on the Medicaid cost report and are not to be covered in the per-diem rate. These costs include: any charge for training by an outside training agency, the cost of the competency evaluation, teacher salaries and fringes, necessary textbooks, and other required course materials.

However, costs for salaries of nurse assistants in training or replacement nurse assistants for those in training or testing are to be reported in the allowable column on the Medicaid cost report and are to be covered in the per-diem rate.

(F) Billing—Nursing facilities with valid provider agreements may bill the MO HealthNet Division for costs incurred for nurse assistant training and competency evaluations for nurse assistants beginning the training after February 26, 1993.

Facilities may only bill for nurse assistants trained by an approved training agency and tested by an approved state examiner. This state examiner must be approved per 19 CSR 30-84.010(9) and must have a signed agreement with the Department of Health and Senior Services. Facilities may bill once a month on an approved nurse assistant training billing form.

(G) Medicaid Utilization—Reimbursement will be allocated based on the ratio of Medicaid days to total patient days as reported on the latest Medicaid cost report filed by the facility with a year ending in the most recent year that all nursing facility Medicaid cost reports have been desk audited. If the facility did not have a Medicaid cost report ending in the most recent year that all nursing facility Medicaid cost reports have been desk audited, then the average ratio of Medicaid days to total patient days for all cost reports with ending dates in the most recent year that all nursing facility Medicaid cost reports have been desk audited will be used in calculating reimbursement.

(H) Prohibition of Charges—No nurse assistant who is employed by, or who has an offer of employment from, a nursing facility on the date on which the assistant begins a training and testing program may be charged for any portion of the program.

(3) Reimbursement for Nurse Assistants Employed at the Time of Training. If a nurse assistant is employed at a nursing facility and then passes an approved nurse assistant training and competency evaluation program, the division will reimburse a facility if all the following criteria are met:

(A) The nurse assistant is on the Missouri Department of Health and Senior Services nurse assistant register;

(B) The individual is employed by the billing nursing facility at the time of passing the competency evaluation (final exam);

(C) The following reimbursement amounts will be prorated based on Medicaid utilization:

1. One thousand five hundred dollars ($1,500) for a nurse assistant completing the entire basic course (all lesson plans, seventy-five (75) hours classroom training, and one hundred (100) hours on-the-job training) and passing the final exam, as Classroom Training $600 On-the-Job Training $575 Textbook and Supplies $200 Written Test $30 Skills Test $95 Total Allowable to be Prorated on Medicaid Utilization $1,500 2. A percentage of the one thousand five hundred dollars ($1,500) for nurse assistants who only complete a portion of the lesson plans and pass the final exam will be paid.

The percentage will be based on how many lesson plans were completed. For example: If no on-the-job training was provided, and if only lesson plans 1, 2, 4, 5, 6, 8, 9, 10, 11, 12, 41, 42, and 43 were completed, the percentage of the $1,500 allowable would be— Classroom Training ($600 x 18.75 hours/75 hours) $150 On-the-Job Training $0 Textbook and Supplies $200 Written Test $30 Skills Test $95 Total Allowable to be Prorated on Medicaid Utilization $475 3. One hundred twenty-five dollars ($125) for nurse assistants who do not complete any lesson plans through a challenge and pass the final exam;

(D) The facility which employs the nurse assistant must submit the bill for reimbursement to the division on the approved billing form; and (E) The facility must bill for nurse assistant training and/or competency exam within one (1) year after the nurse assistant passed the final exam. Nurse assistant training that was completed prior to one (1) year before the effective date of this

regulation and began after February 26, 1993, will be allowed.

(4) Reimbursement for Nurse Assistants Not Yet Employed at the Time of Training. If a nurse assistant is not employed at a nursing facility and that individual pays for the nurse assistant training and competency evaluation program, the division will reimburse a facility if all the following criteria are met:

(A) The nurse assistant is on the Missouri Department of Health and Senior Services nurse assistant register;

(B) The individual is employed by the billing nursing facility not later than twelve (12) months after passing the final exam;

(C) The individual incurred costs for the training and testing, and the billing nursing facility submits to the division documentary evidence of those costs. The division will not reimburse costs if the nurse assistant received funding for the training through a grant or other funding source that is not required to be repaid by the nurse assistant;

(D) The billing nursing facility must submit documentation that it has paid the nurse assistant for the cost it is submitting to the division;

(E) The facility which employs the nurse assistant must submit the bill for reimbursement to the division on the approved billing form;

(F) The division will prorate costs based on Medicaid utilization as follows:

1. One thousand five hundred dollars ($1,500) for a nurse assistant completing the entire basic course (all lesson plans, seventy-five (75) hours classroom training, and one hundred (100) hours on-the-job training) and passing the final exam;

2. A percentage of the one thousand five hundred dollars ($1,500) for nurse assistants who only complete a portion of the lesson plans and pass the final exam. The percentage will be based on how many lesson plans were completed. See paragraph (3)(C)2. of this regulation; and 3. One hundred twenty-five dollars ($125) for nurse assis t ants who do not complete any lesson plans through a chal lenge pr ocess and pass the final exam; and (G) The MO HealthNet Division will subtract one-twelfth (1/12) of allowable reimbursement for each month that the nurse assistant is not employed after passing the final exam.

RSMo 2016, and section 208.152, RSMo Supp. 2023.* Original rule filed May 30, 1995, effective Dec. 30, 1995. Amended: Filed Feb. 15, 1996, effective Sept. 30, 1996. Amended: Filed Aug. 8, 2018, effective March 30, 2019. Emergency amendment filed Feb. 26, 2024, effective March 11, 2024, expired Sept. 6, 2024. Amended:

Filed Feb. 26, 2024, effective Aug. 30, 2024. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.159, RSMo 1979; 208.201, RSMo 1987, amended 2007; 660.017, RSMo

13 CSR 70-10.150 Enhancement Pools {#sec-13-csr-70-10.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.150}

(Rescinded June 30, 2018)

Emergency rule filed Nov. 3, 2000, effective Nov. 13, 2000, expired May 11, 2001. Original rule filed Nov. 13, 2000, effective May 30, 2001. Emergency amendment filed July 9, 2001, effective July 19, 2001, expired Feb. 28, 2002. Amended: Filed July 9, 2001, effective Dec. 30, 2001. Emergency amendment filed Oct. 29, 2002, effective Nov. 8, 2002, expired May 6, 2003. Amended: Filed Oct. 29, 2002, effective April 30, 2002. Rescinded: Filed Nov. 3, 2017, effective June 30, 2018.

Rule Action Notice: 13 CSR 70-10.150(1)(B) Rule Suspension. The Missouri Constitution authorizes the governor to control the rate at which appropriations are expended or reduce expenditures below the appropriated amount when actual revenues are less than estimated. The State Fiscal Year (SFY) 2002 revenue projection is expected to be $750 million less than the original consensus revenue forecast, which was established in December, 2000. This original forecast was the basis upon which the SFY 2002 budget was established by the General Assembly and the governor. The current revenue projection is $230 million less than the revised consensus revenue forecast, which was established in December, 2001. Attempts to access the Rainy Day Fund were not supported by a super majority in the House, even though accessing the fund was proposed by the governor and supported by the Senate.

Subsequently, the Department of Social Services was notified by the governor that monies appropriated in SFY 2002 for nursing facility efficiency grants in the approximate amount of $20 million would not be available for expenditure. These monies were contained in House Bill 11, Section 11.445. At this time, the Department of Social Services must suspend the rule authorizing the payment of these monies, effective immediately.

Action Taken: Rule 13 CSR 70-10.150(1)(B) is suspended. Authority:

Missouri Constitution Article IV, Section 27, and sections 536.022 and 208.201, RSMo 2000. Rule suspension filed May 22, 2002.

Attention: Pursuant to the Temporary Restraining Order of Circuit Judge Thomas J. Brown, of the 19th Judicial Circuit, Division I, entered on the 21st day of June 2002, this “Notice of Rule Suspension” is hereby temporarily enjoined from taking effect, until further action by said Court. Cole County Circuit Court, Case No. 02CV324451. (see July 1, 2002, Missouri Register (27 MoReg 1126–1128).

History

• AUTHORITY: sections 208.153, 208.159 and 208.201, RSMo 2000.

13 CSR 70-10.160 Public Nursing Facility Upper Payment Limit Payments {#sec-13-csr-70-10.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-10.160}

PURPOSE: This rule implements a supplemental payment program for qualifying public nursing facilities.

(1) Effective for dates of service beginning July 1, 2013, Nursing Facility Upper Payment Limit (UPL) payments shall be made as set forth below in subsections (1)(A)-(1)(C). Maximum aggregate payments to all qualifying nursing facilities shall not exceed the UPL defined in 42 CFR 447.272 in each state fiscal year.

(A) An annual UPL payment shall be made after 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.

1. A public nursing facility is defined as being owned or operated by a public entity.

(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.

rule filed Feb. 15, 2012, effective Aug. 30, 2012. Amended: Filed July 1, 2013, effective Jan. 30, 2014. Amended: Filed Aug. 15, 2014, effective Feb. 28, 2015. Amended: Filed Aug. 28, 2018, effective April 30, 2019. *Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

Chapter 15 Hospital Program

13 CSR 70-15.020 Procedures for Admission Certification, Continued Stay Review, and {#sec-13-csr-70-15.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.020}

13 CSR 70-15.070 Inpatient Psychiatric Services for Individuals Under Age {#sec-13-csr-70-15.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.070}

13 CSR 70-15.080 Payment Method for General Relief Recipient Hospital Outpatient {#sec-13-csr-70-15.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.080}

13 CSR 70-15.090 Procedures for Evaluation of Appropriate Inpatient Hospital Admissions {#sec-13-csr-70-15.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.090}

13 CSR 70-15.170 Enhanced Disproportionate Share Payment to Trauma Hospitals for the Cost of Care to the Uninsured Provided by Physicians Not {#sec-13-csr-70-15.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.170}

13 CSR 70-15.180 Grant to Trauma Hospitals for the Care Provided by Physicians Not {#sec-13-csr-70-15.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.180}

13 CSR 70-15.190 Out-of-State Hospital Services Reimbursement Plan . . . . . . . . . . . . . . . . . . 31 {#sec-13-csr-70-15.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.190}

13 CSR 70-15.200 Payment Policy for a Preventable Serious Adverse Event or Hospital or Ambulatory Surgical Center-Acquired Condition {#sec-13-csr-70-15.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.200}

13 CSR 70-15.010 Inpatient Hospital Services Reimbursement Methodology {#sec-13-csr-70-15.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.010}

PURPOSE: This rule establishes the legal basis for the administration of the state agency’s plan for reimbursement of covered inpatient hospital services in accordance with the principles and provisions described in this rule, and also establishes the legal basis for the state agency’s methodology employed for reimbursement of covered outpatient hospital services.

(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 reimbursement methodologies are established in accordance with sections (4), (5), and (6).

2. Outpatient reimbursement is established in accordance with 13 CSR 70-15.160.

3. Supplemental payments, graduate medical education (GME) payments, and psych adjustment payments are established in accordance with 13 CSR 70-15.015.

4. Disproportionate share hospital (DSH) payment is established in accordance with 13 CSR 70-15.220.

5. Upper payment limit (UPL) payment is established in accordance with 13 CSR 70-15.230.

(C) The Title XIX reimbursement for hospitals located outside Missouri will be established in accordance with 13 CSR 70- 15.190.

(2) Definitions.

(A) Allowable costs. Allowable costs are those related to covered MO HealthNet services defined as allowable in 42 CFR chapter IV, part 413, except as specifically excluded or restricted in 13 CSR 70-15.010 or the MO HealthNet hospital provider manual and detailed on the audited Medicaid cost report. Penalties or incentive payments as a result of Medicare target rate calculations shall not be considered allowable costs.

Implicit in any definition of allowable cost is that this cost is allowable only to the extent that it relates to patient care; is reasonable, ordinary, and necessary; and is not in excess of what a prudent and cost-conscious buyer pays for the given service or item.

(B) Bad debt. Bad debts include the costs of caring for patients who have insurance but are not covered for the particular services, procedures, or treatment rendered. Bad debts do not include the cost of caring for patients whose insurance covers the given procedures but limits coverage. In addition, bad debts do not include the cost of caring for patients whose insurance covers the procedure although the total payments to the hospital are less than the actual cost of providing care.

(C) Base year cost report. Audited Medicaid cost report from the third prior calendar year. If a facility has more than one (1) cost report with periods ending in the third prior calendar year, the cost report covering a full twelve- (12-) month period will be used. If none of the cost reports covers a full twelve (12) months, the cost report with the latest period will be used. If a hospital’s base year cost report is less than or greater than a twelve- (12-) month period, the data shall be adjusted, based on the number of days reflected in the base year cost report to a twelve- (12-) month period. Any changes to the base year cost report after the division issues a final decision on assessment or payments will not be included in the calculations.

(D) Charity care. Results from a provider’s policy to provide health care services free of charge or a reduction in charges because of the indigence or medical indigence of the patient.

(E) Contractual allowances. Difference be tween established rates for covered services and the amount paid by third-party payers under contractual agreements.

(F) Cost report. A cost report details, for purposes of both Medicare and MO HealthNet reimbursement, the cost of rendering covered services for the fiscal reporting period. The Medicare/Medicaid Uniform Cost Report contains the forms utilized in filing the cost report. The Medicare/Medicaid Cost Report version 2552-10 (CMS 2552-10) shall be used for fiscal years beginning on and after May 1, 2010.

(G) Division. Unless otherwise designated, division refers to the MO HealthNet Division (MHD), a division of the Department (H) Diagnosis Related Group (DRG) relative weight. A numerical value that reflects the relative resource intensity or costliness of treating patients within a specific DRG compared to the average inpatient case.

(I) Medicaid inpatient days. Medicaid inpatient days are paid Medicaid days for inpatient hospital services as reported by the Medicaid Management Information System (MMIS).

(J) Nonreimbursable items. For purposes of reimbursement of reasonable cost, the following are not subject to reimbursement:

1. Allowances for return on equity capital;

2. Amounts representing growth allowances in excess of the intensity allowance, profits, efficiency bonuses, or a combination of these;

3. Cost in excess of the principal of reimbursement specified in 42 CFR chapter IV, part 413; and 4. Costs or services specifically excluded or restricted in this rule or the MO HealthNet hospital provider manual.

(K) Reasonable cost. The reasonable cost of inpatient hospital services is an individual hospital’s Medicaid cost per day as determined in accordance with section (4) of this regulation using the base year cost report.

(L) Specialty pediatric hospital. An inpatient pediatric acute care facility which— 1. Is licensed as a hospital by the Missouri Department of Health and Senior Services under Chapter 197 of the Missouri Revised Statutes;

2. Has been granted substantive waivers by the Missouri Department of Health and Senior Services from compliance with material hospital licensure requirements governing a) the establishment and operation of an emergency department, and b) the provision of pathology, radiology, laboratory, and central services; and 3. Is not licensed to operate more than sixty (60) inpatient beds.

(M) Trend factor. The trend factor is a measure of the change in costs of goods and services purchased by a hospital during the course of one (1) year.

(N) Federal reimbursement allowance (FRA). The fee assessed to hospitals for the privilege of engaging in the business of providing inpatient health care in Missouri. The FRA shall be an allowable cost to the hospital. The FRA is identified in 13 CSR 70-15.110. Effective January 1, 1999, the assessment shall be an allowable cost.

(O) Incorporation by reference. This rule incorporates by reference the following:

1. The Hospital Manual as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, July 1, 2025. This rule does not 2. Chapter 40 of The Provider Reimbursement Manual —

Part 2, that includes the CMS 2552-10 cost report form and instructions, as published by the Centers for Medicare & Medicaid Services (CMS), 7500 Security Boulevard, Baltimore, MD 21244, February 21, 2024. This rule does not incorporate any subsequent amendments or additions;

3. 42 CFR Chapter IV, Part 413, as published by the Office incorporate any subsequent amendments or additions. Only the cost principles from 42 CFR 413 are incorporated by reference;

4. The Missouri Inpatient (IP) APR-DRG Calculator as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, July 1, 2025. This rule does not incorporate any subsequent 5. The Medicare Inpatient Prospective Payment System (IPPS) FY 2025 Table 2 Case-Mix Index and Wage Index Table by CMS Certification Number (CCN) as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, October 2, 2024. This rule does not incorporate any subsequent amendments or additions; and 6. The Medicare IPPS FY 2025 Table 3 Wage Index Table by CBSA as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, October 2, 2024. This rule does not incorporate any subsequent amendments or additions.

(3) Reporting Requirements.

(A) Cost reports.

1. Each hospital participating in the MO HealthNet program shall submit a cost report in the manner prescribed by the division. The cost report shall be submitted within five (5) calendar months after the close of the reporting period. The period of a cost report is defined in 42 CFR 413.24(f).

A. All cost reports shall be submitted and certified by an officer or administrator of the hospital.

B. If a cost report is more than ten (10) days past due, the division may withhold fifty thousand dollars ($50,000) in MO HealthNet payments from the hospital until the hospital submits the cost report. If the MO HealthNet payment is less than fifty thousand dollars ($50,000), the entire payment will be withheld. Upon the division’s or its authorized contractor’s receipt of the cost report prepared in accordance with this

regulation, the payment that was withheld will be released to the hospital.

C. A single extension, not to exceed thirty (30) days, may be granted upon the request of the hospital and the approval of the division when the hospital’s operation is significantly affected due to extraordinary circumstances over which the hospital had no control, such as fire or flood. The request must be in writing and postmarked prior to the first day of the sixth month following the hospital’s fiscal year end.

2. The change of control or ownership of a hospital of participation in the program requires that the hospital submit a cost report for the period ending with the date of change of control or ownership within five (5) calendar months after the close of the reporting period.

A. Upon learning of a change of control or ownership, the division may withhold fifty thousand dollars ($50,000) of the next available MO HealthNet payment from the hospital identified in the current MO HealthNet participation agreement until the cost report is filed. If the MO HealthNet payment is less than fifty thousand dollars ($50,000), the entire payment will be withheld. Once the cost report prepared in accordance with this regulation is received, the payment will be released to the hospital identified in the current MO HealthNet participation agreement.

B. The division may, at its discretion, delay the withholding of funds specified in subparagraph (3)(A)2.A. until the cost report is due based on assurances satisfactory to the division that the cost report will be timely filed. A request jointly submitted by the buying and selling entities may provide adequate assurances. The buying entity must accept responsibility for ensuring timely filing of the cost report and authorize the division to immediately withhold fifty thousand dollars ($50,000) if the cost report is not timely filed.

3. The termination of or by a hospital of participation in the MO HealthNet program requires that the hospital submit a cost report for the period ending with the date of termination within five (5) calendar months from the date of the CMS tieout notice. No extension in the submitting of cost reports shall be allowed when a termination of participation has occurred.

A. Upon learning of the termination, the division may withhold fifty thousand dollars ($50,000) of the next available MO HealthNet payment from the hospital until the cost report is filed. If the MO HealthNet payment is less than fifty thousand dollars ($50,000), the entire payment will be withheld. Upon the division’s or its authorized contractor’s receipt of the cost report prepared in accordance with this regulation, the payment that was withheld will be released to the hospital.

4. Amended cost reports or other supplemental. The division or its authorized contractor will notify the hospital by letter when the audit of its cost report is completed. Since this data will be used in the calculation of per diem rates, and other Medicaid payments, the hospital shall review the audited cost report data and submit amended or corrected data to the division or its authorized contractor within fifteen (15) days.

Data received after the fifteen- (15-) day deadline will not be considered by the division for per diem rates, or other Medicaid payments unless the hospital requests in writing and receives an extension to file additional information prior to the end of the fifteen- (15-) day deadline.

(B) Records.

1. All hospitals are required to maintain financial and statistical records in accordance with 42 CFR 413.20. For purposes of this plan, statistical and financial records shall include beneficiaries’ medical records and patient claim logs separated for inpatient and outpatient services billed to and paid for by MO HealthNet (excluding cross-over claims) respectively. All records must be available upon request to representatives, employees, or contractors of the MO HealthNet program, Missouri Department of Social Services, General Accounting Office (GAO), or the United States Department of Health and Human Services (HHS). The content and organization of the inpatient and outpatient logs shall include the following:

A. A separate log for each fiscal year must be maintained by either date of service or date of payment for claims and all adjustments of those claims for services provided in the fiscal period. Lengths of stay covering two (2) fiscal periods should be recorded by date of admission. The information from the log should be used to complete the Medicaid worksheet in the hospital’s cost report;

B. A year-to-date total must appear at the bottom of each log page or after each applicable group total, or a summation page of all subtotals for the fiscal year activity must be included with the log; and C. Not to be included in the logs are denied claims or line item charges. This would include payments for hospital-based physicians and certified registered nurse anesthetists billed by the hospital on a professional services claim or payments for services provided by the hospital through enrollment as a MO HealthNet provider-type other than hospital.

2. Records of related organizations, as defined by 42 CFR 413.17, must be available upon demand to those individuals or organizations as listed in paragraph (3)(B)1. of this rule.

(C) Cost report audits.

1. The examination or inspection of a hospital’s cost report, files, and any other supporting documentation by the division or its authorized contractor. The division or its authorized contractor may perform the following types of audits:

A. Level I audit—Requires a more narrow scope of review of hospital cost reports, files, and any other additional information requested and submitted to the division or its authorized contractor. The limited review may include items such as comparative analysis of a hospital’s cost report data to industry data, a review of a hospital’s prior year data to determine any outliers that may warrant further review, requesting additional details of the reported information, all of which could lead to potential adjustment(s) after such further review, as well as making standard adjustments, etc. Level I audits may be provided off-site;

B. Level II audit—Requires a desk review of hospital cost reports, files, and any other additional information requested and submitted to the division or its authorized contractor. The desk review may include review procedures in a level I audit plus a more detailed analysis of a hospital’s cost report data to identify items that would require further review including requesting additional details of the reported information, documentation to support amounts reflected in the cost report, etc. Level II audits may be provided off-site; or C. Level III audits—Requires an in-depth audit, including an on-site review, of hospital cost reports, files, and any other additional information requested and submitted to the division or its authorized contractor. The level III audit will require an in-depth analysis of a hospital’s cost report data and an on-site verification of cost report items deemed necessary through a risk assessment or other analyses, etc. Level III audits will require some portion of the hospital’s records review be provided on-site.

(4) Inpatient Per Diem Reimbursement Methodology. Effective for admit dates beginning July 1, 2025, the Missouri hospitals listed in subsection (4)(A) will continue to be reimbursed under the inpatient per diem reimbursement methodology and shall receive a Missouri Medicaid per diem rate as calculated in subsection (4)(B).

(A) The following hospitals will continue to be reimbursed under the inpatient per diem reimbursement methodology:

1. In-state specialty pediatric hospitals;

2. In-state pediatric hospitals that are licensed for fewer than fifteen (15) beds and specialized in pediatric orthopedic care;

3. In-state free-standing psychiatric hospitals;

4. In-state free-standing rehabilitation hospitals;

5. In-state free-standing long-term acute care (LTAC) hospitals; and 6. In-state hospitals enrolled in Medicaid on or after January 1, 2025, that have eighty percent (80%) or greater patient mix in mental health and substance abuse.

(B) The per diem shall be determined from the base year cost report in accordance with the following formula:

PER DIEM = ((TAC / MPD) * TI) + MIP FRA

1. MIP FRA—Medicaid inpatient share of Federal Reimbursement Allowance (FRA). The Medicaid inpatient share of the FRA assessment will be calculated by dividing the hospital’s Medicaid fee-for-service (FFS) and managed care (MC) inpatient days from the base year cost report by total hospital inpatient days from the base year cost report to arrive at the Medicaid utilization percentage. This percentage is then multiplied by the inpatient FRA assessment for the current SFY to arrive at the increased allowable Medicaid cost. This cost is then divided by the estimated Medicaid FFS and MC days for the current SFY to arrive at the increased Medicaid cost per day.

The estimated Medicaid FFS and MC days are paid days from the second prior calendar year;

2. MPD—Medicaid FFS inpatient days from the base year cost report;

3. TI—Trend indices. The trend indices are applied to the TAC per day of the per diem rate. The trend index for the base year is used to adjust the TAC per day to a common fiscal year end of June 30. The adjusted TAC per day shall be trended through the current SFY;

4. TAC—Medicaid allowable inpatient routine and special care unit costs, and ancillary costs, from the base year cost report, will be added to determine the hospital’s Medicaid total allowable cost (TAC);

5. The per diem for private free-standing psychiatric hospitals shall be the greater of one thousand one hundred ninety-four dollars and twenty-two cents ($1,194.22) or the per diem as calculated in subsection (4)(B);

6. The per diem shall not exceed the average Medicaid inpatient charge per diem as determined from the base year cost report and adjusted, by the TI, except for federally deemed critical access hospitals whose Medicaid FFS charges equal sixty percent (60%) or less of its Medicaid FFS costs;

7. The per diem shall be adjusted for rate increases granted in accordance with subsections (4)(D) and (4)(E); and 8. If the hospital does not have a base year cost report, the inpatient per diem will be the weighted average statewide per diem rate as determined in section (5).

(C) Trend indices (TI). For trend indices for SFY 2018 and forward, refer to the Hospital Market Basket index as published in Healthcare Cost Review by Institute of Health Systems, or equivalent publication, regardless of any changes in the name of the publication or publisher, for each SFY.

(D) Adjustments to rates. A hospital’s inpatient per diem rate may be adjusted only under the following circumstances:

1. When information contained in the cost report is found to be intentionally misrepresented, such adjustment shall be made retroactive to the date of the original rate. Such adjustment shall not preclude the division from imposing any sanctions authorized by any statute or regulation; and 2. When a rate reconsideration is granted in accordance with subsection (4)(E).

(E) Rate reconsideration.

1. Rate reconsideration may be requested under this subsection for changes in allowable costs which occur subsequent to the base year cost report described in subsection (4)(B). The effective date for any increase granted under this subsection shall be no earlier than the first day of the month following the division’s final determination of the rate reconsideration.

2. The following may be subject to review under procedures established by the division:

A. New or expanded inpatient services. A hospital, at times, may offer to the public new or expanded inpatient services which may require certificate of need (CON) approval.

(I) A state hospital, i.e., one owned or operated by the Board of Curators as provided for in Chapter 172, RSMo, or one owned or operated by the Department of Mental Health, may offer new or expanded inpatient services to the public provided it receives legislative appropriations for the project.

A state hospital may submit a request for inpatient rate reconsideration if the project meets or exceeds a cost threshold of one (1) million dollars for capital expenditures or one (1) million dollars for major medical equipment expenditures as described in 19 CSR 60-50.300.

(II) Non-state hospitals may also offer new or expanded inpatient services to the public, and incur costs associated with the additions or expansions which may qualify for inpatient rate reconsideration requests. Such projects may require a CON. Rate reconsideration requests for projects requiring CON review must include a copy of the CON program approval. Nonstate hospitals may request inpatient rate reconsiderations for projects not requiring review by the CON program, provided each project meets or exceeds a cost threshold of one (1) million dollars for capital expenditures as described in 19 CSR 60-50.300.

(III) A hospital (state or non-state) will have six (6) months after the new or expanded service project is completed and the service is offered to the public to submit a request for inpatient rate reconsideration, along with a budget of the project’s costs. The rate reconsideration request and budget will be subject to review. Upon completion of the review, the hospital’s inpatient reimbursement rate may be adjusted, if indicated. Failure to submit a request for rate reconsideration and project budget within the six- (6-) month period shall disqualify the hospital from receiving a rate increase prior to recognizing the increase through the trended cost calculation.

(IV) Rate reconsiderations due to new or expanded services will be determined as total allowable project cost (i.e., the sum of annual depreciation, annualized interest expense, and annual additional operating costs) multiplied by the ratio of total inpatient costs (less SNF and swing bed cost) to total hospital cost as submitted on the most recent cost report filed with the division or its authorized contractor as of the review date divided by total acute care patient days including all special care units and nursery, but excluding swing bed days.

The most recent cost report filed must be audited prior to the finalization of the rate reconsideration.

(V) Total acute care patient days (excluding nursery and swing bed days) must be at least sixty percent (60%) of total possible bed days. Total possible bed days will be determined using the number of licensed beds times three hundred sixtyfive (365) days. If the total acute care patient days (excluding nursery and swing bed days) are less than sixty percent (60%) of total possible bed days, the sixty percent (60%) number plus nursery days will be used to determine the rate increase. If the total acute care patient days (excluding nursery and swing bed days) are at least sixty percent (60%) of total possible bed days, the total acute care patient days plus nursery days will be used to determine the rate increase. This computation will apply to capital costs only.

(VI) Major medical equipment costs included in rate reconsideration requests shall not include costs to replace current major medical equipment if the replacement does not result in new or expanded inpatient services. The replacement of inoperative or obsolete major medical equipment, by itself, does not qualify for rate reconsideration, even if the new equipment costs at least one (1) million dollars; and B. When the hospital experiences extraordinary circumstances which may include but are not limited to an act of God, war, or civil disturbance.

3. The following will not be subject to review under these procedures:

A. The use of Medicare standards and reimbursement principles;

B. The method for determining the trend factor;

C. The use of all-inclusive prospective reimbursement rates; and D. Increased costs for the successor owner, management, or leaseholder that result from changes in ownership, management, control, operation, or leasehold interests by whatever form for any hospital previously certified at any time for participation in the Medicaid program.

4. The request for a rate reconsideration must be submitted in writing to the division and must specifically and clearly identify the project and the total dollar amount involved. The total dollar amount must be supported by generally accepted accounting principles. The hospital shall demonstrate the rate reconsideration is necessary, proper, and consistent with efficient and economical delivery of covered patient care services. The hospital will be notified of the division’s decision in writing within sixty (60) days of receipt of the hospital’s written request or within sixty (60) days of receipt of any additional documentation or clarification which may be required, whichever is later. Failure to submit requested information within the sixty- (60-) day period shall be grounds for denial of the request.

(5) Inpatient Per Diem Reimbursement Rate Computation for New Hospitals. Effective for admit dates beginning July 1, 2025, for new Missouri hospitals that continue to be reimbursed under the per diem reimbursement methodology, each new Missouri hospital’s rate setting cost report shall be the first full fiscal year cost report, which includes inpatient Medicaid costs, otherwise the hospital shall continue to receive the weighted average statewide per diem rate as determined below.

(A) Free-standing psychiatric hospitals. In the absence of adequate cost data, a new hospital’s Medicaid rate shall be one hundred percent (100%) of the maximum per diem rate for a free-standing psychiatric hospital, excluding the state psychiatric hospitals, until a prospective rate is determined on the hospital’s rate setting cost report, in accordance with

section (4).

(B) Long-term acute care hospitals. In the absence of adequate cost data, a new hospital’s Medicaid rate shall be one hundred percent (100%) of the weighted average statewide per diem rate for long-term acute care hospitals until a prospective rate is determined on the hospital’s rate setting cost report, in accordance with section (4).

(C) Rehabilitation hospitals. In the absence of adequate cost data, a new hospital’s Medicaid rate shall be one hundred percent (100%) of the weighted average statewide per diem rate for rehabilitation hospitals until a prospective rate is determined on the hospital’s rate setting cost report, in accordance with

section (4).

(6) Inpatient Diagnosis Related Group (DRG) Reimbursement Methodology. Effective for discharge dates beginning July 1, 2025, Missouri hospitals shall be reimbursed under the DRG reimbursement methodology using components from the base year cost report and claims data period. Those components are from the following data sources:

(A) Historical claims data: FFS claims and MC encounter data from MMIS for SFY 2024.

1. Future updates will utilize FFS claims and MC encounter data from MMIS for the second full prior calendar year (i.e., for SFY 2027, calendar year 2024 paid claims will be utilized);

(B) Cost report data: The fourth prior year cost reports.

1. Future updates will utilize the third prior year audited cost reports available as of January 31 prior to the beginning of the SFY;

(C) Labor portion and wage index: Federal fiscal year (FFY) 2025 inpatient prospective payment system (IPPS) wage data.

1. Future updates will be obtained from the final rule or any subsequent correction notice that is available as of January 31 prior to the beginning of the SFY;

(D) Hospitals reimbursed under DRG— 1. All hospitals except for those listed in subsection (4)(A);

(E) DRG grouper type.

1. The DRG grouper utilized to classify cases into DRG categories will be the Solventum All-Patient Refined (APR) DRG.

2. The version utilized is 42, released on October 1, 2024;

(F) Statewide base rates development.

1. Statewide base rates.

A. The base year claims data (FFS claims and MC encounters) is repriced under the current reimbursement methodology. This base year repricing establishes the intended budget for the DRG system. The in-state hospital data and out-of-state hospital data is separated and, utilizing the DRG formula, a base rate is iterated for each set of claims data;

(G) Hospital base rate components.

1. Statewide base rate.

A. Two (2) base rates are established for reimbursement in the DRG system. One (1) for in-state hospitals and one (1) for out-of-state hospitals.

2. Wage index.

A. For Medicare IPPS hospitals, the wage index is based on the Medicare IPPS post-reclass effective as of the October prior to the beginning of the SFY.

B. For non-Medicare IPPS hospitals, the wage index is based on the Medicare IPPS for the hospital’s Medicare Corebased Statistical Area (CBSA) effective as of the October prior to the beginning of the SFY.

C. In-state federally deemed critical access hospitals (CAH) will have their wage index set to 1.000, regardless of their assigned CBSA.

3. Hospital DRG rate add-ons.

A. Free-standing in-state children’s hospitals will receive a two thousand five hundred dollar ($2,500) rate add-on to their base rate.

B. In-state federally deemed CAHs will receive a one thousand five hundred dollar ($1,500) rate add-on to their base rate.

C. Indirect Medical Education (IME) Factor.

(I) In-state hospitals with approved medical education programs identified in the Medicare cost report will have an IME add-on to their base rate. The IME formula is calculated from the base year cost report as follows:

(a) Full-time employee (FTE) counts: Worksheet S-3, Lines 14, 16, and 17, Column 9.

I. Updated FTEs can be submitted to the division if a hospital meets the criteria in 13 CSR 70-15.015(9)(D);

(b) Sum of hospital beds: Worksheet S-3, Lines 14, 16, and 17, Column 2; and (c) Formula: Round (1.35 * ((1 + (FTE counts / hospital beds)) .405 – 1),4) * 50%.

4. Hospital specific base rates.

A. Each hospital will have a specific base rate calculated based on the following formula:

(I) Adjust the statewide base rate by the wage index.

(a) Wage adjusted rate = (statewide base rate * labor portion * wage index) + (statewide base rate * (1 – labor portion));

(II) Add IME (if applicable) to the wage adjusted rate.

(a) IME and wage adjusted rate = wage adjusted rate * IME factor; and (III) Add children’s or CAH add-on (if applicable).

(a) Hospital specific rate = IME and wage adjusted rate + children’s or CAH add-on;

(H) Hospital cost-to-charge ratios (CCR).

1. Utilizing the base year cost reports, hospital specific CCRs are established.

A. Costs: Worksheet D-1, Line 49, Title XIX (if there is not Title XIX, then Title XVIII is utilized).

B. Charges: Worksheet D-3, Lines 30–35, and 202, Column 2, Title XIX (if there is no Title XIX, then Title XVIII is utilized);

(I) Transfer payments.

1. Transfers shall be identified as claims with a discharge status of 02, 05, and 66 and not having an assigned DRG of 580 or 581.

2. The reimbursement to hospitals for inpatient services provided to claims identified as transfers shall be the lesser of A. or B. below:

A. The DRG amount.

(I) Formula: Hospital Specific Base Rate * DRG relative weight; and B. The amount in subparagraph (6)(I)2.A. divided by the assigned DRGs average length of stay (ALOS) multiplied by the claims length of stay (LOS) plus one (1).

(I) Formula: (DRG payment / DRG ALOS) * (LOS + 1);

(J) Outlier payments.

1. Cost outlier payments are an additional payment made at the time a claim is processed for exceptionally costly services.

A. A cost outlier threshold shall be established for each DRG at the time the DRG relative weights are calculated, using the same information used to establish the relative weights.

The cost threshold is the greater of thirty thousand dollars ($30,000) or mean cost for the DRG plus 1.96 standard deviation.

B. Charges for non-covered services and services not reimbursed under the inpatient DRG methodology shall be deducted from the total billed charges. The remaining billed charges are converted to cost using the hospital specific CCR.

C. If the net cost for the claim exceeds the cost outlier threshold, a cost outlier payment is made at eighty percent (80%) of the costs above the threshold.

D. DRGs excluded from cost outliers.

(I) Mental Health and Substance Abuse DRGs.

(a) DRGs 750-1 through 776-4.

2. Day outlier payments are an additional payment made at the time a claim is processed for exceptionally long lengths of stay in the Mental Health and Substance Abuse DRGs (DRGs 750-1 through 776-4).

A. A day outlier threshold shall be established for each DRG at the time the DRG relative weights are calculated, using the same information used to establish the relative weights.

The day threshold is the ALOS of the DRG.

B. A day outlier per diem payment may be made for covered days in excess of the day outlier threshold at the rate of five hundred dollars ($500) per day;

(K) Policy adjustors. Claims for inpatient stays that meet certain criteria will qualify for further adjustments to the payments.

1. Pediatric.

A. Adjustment factor: 1.70.

B. Qualifying criteria: The DRG’s assigned service category is Pediatric.

2. General Medicine.

A. Adjustment factor: 1.31.

B. Qualifying criteria: The DRG’s assigned service category is General Medicine.

3. Mental Health and Substance Abuse.

A. Adjustment factor: 1.92.

B. Qualifying criteria: The DRG’s assigned service category is Mental Health and Substance Abuse.

4. Obstetrics.

A. Adjustment factor: 1.27.

B. Qualifying criteria: The DRG’s assigned service category is Obstetrics;

(L) Example DRG claim calculation.

(M) New hospitals shall be assigned the following DRG payment components:

1. Statewide base rate based upon their in-state or out-ofstate status;

2. Wage index based upon the CBSA in which the hospital resides;

3. Hospital specific CCR based upon their most recently filed cost report.

A. In the absence of a cost report, the following CCR will be utilized:

(I) In-state: The average CCR of all in-state hospitals reimbursed by DRG until a cost report has been filed with the division; and (II) Out-of-state: The average urban CCR in the state the hospital resides, as found in the Medicare prospective payment system (PPS) annual release documents;

4. Base rate add-ons.

A. For new in-state hospitals only, base rate add-ons will be considered based upon the designation of the hospital.

(I) New free-standing in-state children’s hospitals will be eligible for the children’s base rate add-on.

(II) New in-state federally deemed CAHs will be eligible for the CAH base rate add-on.

(7) Hospital Mergers. Hospitals that merge their operations under one (1) Medicare and Medicaid provider number shall have their Medicaid reimbursement combined under the surviving hospital’s (the hospital’s whose Medicare and Medicaid provider number remained active) Medicaid provider number.

(A) The per diem rate for merged hospitals shall be calculated— 1. For the remainder of the SFY in which the merger occurred, the merged rate is calculated by multiplying each hospital’s estimated Medicaid paid days by its per diem rate, summing the estimated per diem payments and estimated Medicaid paid days, and then dividing the total estimated per diem payments by the total estimated paid days to determine the weighted per diem rate. The effective date of the weighted per diem rate will be the date of the merger; or 2. For subsequent SFYs, the per diem rate will be based on the combined data from the base year cost report for each facility.

(8) Payment Assurance. The state will pay each hospital, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the hospital according to the standards and methods set forth in the rules implementing the hospital reimbursement (9) Inappropriate Placements.

(A) The hospital inpatient reimbursement as determined under this plan shall not apply to any participant who is receiving inpatient hospital care when the participant is only in need of nursing home care.

1. If a hospital has an established intermediate care facility/ skilled nursing facility (ICF/SNF) or SNF-only MO HealthNet rate for providing nursing home services in a distinct part setting, reimbursement for nursing home services provided in the inpatient hospital setting shall be made at the hospital’s ICF/ SNF or SNF-only rate.

2. No MO HealthNet payments will be made on behalf of any participant who is receiving inpatient hospital care and is not in need of either inpatient or nursing home care.

Emergency amendment filed June 21, 1982, effective July 1, 1982, expired Oct. 10, 1982. Amended: Filed June 21, 1982, effective Oct. 11, 1982. Emergency amendment filed July 21, 1982, effective July 30, 1982, expired Nov. 27, 1982. Emergency amendment filed June 21, 1983, effective July 1, 1983, expired Oct. 12, 1983. Amended: Filed June 21, 1983, effective Oct. 13, 1983. Amended: Filed Sept. 13, 1983, effective Dec. 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired April 11, 1984. Emergency amendment filed March 14, 1984, effective March 28, 1984, expired June 10, 1984. Amended: Filed March 14, 1984, effective June 11, 1984.

Emergency amendment filed June 21, 1984, effective July 1, 1984, expired Oct. 10, 1984. Amended: Filed July 12, 1984, effective Oct. 11, 1984. Amended: Filed Sept. 12, 1984, effective Jan. 12, 1985.

Amended: Filed Jan. 15, 1985, effective May 27, 1985. Amended:

Filed May 16, 1985, effective Sept. 1, 1985. Emergency amendment filed June 20, 1985, effective July 1, 1985, expired Oct. 28, 1985.

Amended: Filed June 20, 1985, effective Oct. 1, 1985. Amended:

Filed Sept. 4, 1985, effective Dec. 1, 1985. Emergency amendment filed Oct. 17, 1985, effective Oct. 27, 1985, expired Jan. 11, 1986.

Amended: Filed Oct. 17, 1985, effective Feb. 13, 1986. Amended:

Filed Dec. 16, 1985, effective April 1, 1986. Amended: Filed Feb. 14, 1986, effective May 11, 1986. Amended: Filed March 17, 1986, effective June 28, 1986. Amended: Filed April 2, 1986, effective July 1, 1986. Amended: Filed Aug. 1, 1986, effective Oct. 11, 1986.

Emergency amendment filed Sept. 19, 1986, effective Oct. 1, 1986, expired Jan. 15, 1987. Emergency amendment filed Sept. 24, 1986, effective Oct. 4, 1986, expired Jan. 29, 1987. Emergency amendment filed Oct. 22, 1986, effective Nov. 1, 1986, expired Feb. 1, 1987.

Amended: Filed Nov. 4, 1986, effective Jan. 30, 1987. Amended:

Filed Nov. 12, 1986, effective Feb. 2, 1987. Amended: Filed Nov. 14, 1986, effective Jan. 30, 1987. Emergency amendment filed June 19, 1987, effective July 1, 1987, expired Oct. 29, 1987. Amended: Filed Aug. 18, 1987, effective Oct. 25, 1987. Amended: Filed Jan. 5, 1988, effective March 25, 1988. Amended: Filed March 2, 1988, effective May 12, 1988. Emergency amendment filed April 15, 1988, effective April 25, 1988, expired Aug. 22, 1988. Emergency amendment filed May 17, 1988, effective May 27, 1988, expired Sept. 23, 1988.

Amended: Filed May 17, 1988, effective Aug. 11, 1988. Amended:

Filed June 2, 1988, effective Aug. 25, 1988. Emergency amendment filed June 21, 1988, effective July 1, 1988, expired Oct. 28, 1988.

Amended: Filed June 28, 1988, effective Sept. 29, 1988. Emergency amendment filed July 15, 1988, effective July 25, 1988, expired Nov. 21, 1988. Amended: Filed July 15, 1988, effective Oct. 29, 1988.

Emergency amendment filed Aug. 5, 1988, effective Aug. 15, 1988, expired Dec. 13, 1988. Amended: Filed Oct. 18, 1988, effective Jan. 13, 1989. Emergency amendment filed Dec. 16, 1988, effective Jan. 1, 1989, expired May 1, 1989. Amended: Filed Aug. 16, 1989, effective Nov. 11, 1989. Amended: Filed Sept. 26, 1989, effective Dec. 28, 1989.

Emergency amendment filed Dec. 1, 1989, effective Jan. 1, 1990, expired April 29, 1990. Amended: Filed Dec. 1, 1989, effective Feb. 25, 1990. Amended: Filed Dec. 1, 1989, effective May 11, 1990.

Amended: Filed Jan. 10, 1989, effective April 12, 1990. Amended:

Filed Feb. 5, 1990, effective May 11, 1990. Amended: Filed Feb. 16, 1990, effective April 26, 1990. Emergency amendment filed May 30, 1990, effective July 1, 1990, expired Oct. 28, 1990. Amended: Filed May 30, 1990, effective Sept. 28, 1990. Emergency amendment filed May 30, 1990, effective July 1, 1990, expired Oct. 28, 1990. Amended:

Filed May 30, 1990, effective Sept. 28, 1990. Amended: Filed Oct. 2, 1990, effective Feb. 14, 1991. Emergency amendment filed Oct. 15, 1990, effective Nov. 1, 1990, expired Feb. 28, 1991. Amended: Filed Oct. 15, 1990, effective Feb. 14, 1991. Amended: Filed Oct. 15, 1990, effective Feb. 14, 1991. Emergency amendment filed Dec. 21, 1990, effective Jan. 1, 1991, expired March 31, 1991. Emergency amendment filed Jan. 3, 1991, effective Jan. 15, 1991, expired May 13, 1991. Amended: Filed Feb. 14, 1991, effective July 8, 1991.

Emergency amendment filed March 4, 1991, effective March 14, 1991, expired May 13, 1991. Emergency amendment filed March 7, 1991, effective March 17, 1991, expired July 14, 1991. Amended: Filed March 7, 1991, effective Aug. 30, 1991. Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Amended: Filed June 18, 1991, effective Oct. 31, 1991.

Emergency amendment filed July 5, 1991, effective July 15, 1991, expired Aug. 15, 1991. Amended: Filed July 2, 1991, effective Dec. 9, 1991. Amended: Filed July 2, 1991, effective Dec. 9, 1991. Emergency amendment filed Aug. 8, 1991, effective Aug. 18, 1991, expired Dec. 15, 1991. Amended: Filed Aug. 5, 1991, effective Jan. 13, 1992.

Emergency amendment filed Oct. 11, 1991, effective Oct. 21, 1991, expired Feb. 17, 1992. Emergency amendment filed Oct. 18, 1991, effective Oct. 28, 1991, expired Feb. 24, 1992. Emergency amendment filed Oct. 18, 1991, effective Oct. 28, 1991, expired Feb. 24, 1992.

Amended: Filed Oct. 18, 1991, effective April 9, 1992. Emergency amendment filed Nov. 15, 1991, effective Dec. 3, 1991, expired April 1, 1992. Emergency amendment filed March 13, 1992, effective April 2, 1992, expired July 30, 1992. Amended: Filed Nov. 15, 1991, effective April 9, 1992. Emergency amendment filed Feb. 3, 1992, effective Feb. 18, 1992, expired June 16, 1992. Emergency amendment filed Feb. 7, 1992, effective Feb. 19, 1992, expired June 17, 1992. Emergency amendment filed March 13, 1992, effective April 2, 1992, expired July 30, 1992. Emergency amendment filed April 2, 1992, effective April 18, 1992, expired Aug. 15, 1992.

Emergency amendment filed Aug. 6, 1992, effective Aug. 16, 1992, expired Dec. 13, 1992. Amended: Filed April 2, 1992, effective Feb. 26, 1993. Emergency amendment filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency amendment filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency amendment filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency amendment filed Nov. 3, 1992, effective Nov. 20, 1992, expired March 19, 1993. Emergency amendment filed Nov. 3, 1992, effective Nov. 20, 1992, expired March 19, 1993.

Emergency amendment filed Nov. 16, 1992, effective Dec. 2, 1992, expired March 31, 1993. Emergency amendment filed Jan. 15, 1993, effective Jan. 25, 1993, expired May 24, 1993. Emergency amendment filed Jan. 15, 1993, effective Jan. 25, 1993, expired May 24, 1993. Emergency amendment filed Jan. 15, 1993, effective Jan. 25, 1993, expired May 24, 1993. Emergency amendment filed March 2, 1993, effective March 22, 1993, expired July 19, 1993.

Amended: Filed Sept. 21, 1992, effective June 7, 1993. Amended:

Filed Sept. 21, 1992, effective June 7, 1993. Amended: Filed Nov. 3, 1992, effective June 7, 1993. Amended: Filed Nov. 3, 1992, effective June 7, 1993. Amended: Filed Nov. 16, 1992, effective June 7, 1993.

Emergency amendment filed May 14, 1993, effective May 25, 1993, expired Sept. 21, 1993. Emergency amendment filed May 14, 1993, effective May 25, 1993, expired Sept. 21, 1993. Emergency amendment filed May 14, 1993, effective May 25, 1993, expired Sept. 21, 1993. Emergency amendment filed June 17, 1993, effective June 27, 1993, expired Oct. 24, 1993. Emergency amendment filed June 18, 1993, effective July 1, 1993, expired Oct. 28, 1993. Amended:

Filed March 16, 1993, effective Oct. 10, 1993. Amended: Filed April 6, 1993, effective Oct. 10, 1993. Emergency amendment filed Sept. 2, 1993, effective Sept. 18, 1993, expired Jan. 15, 1994. Emergency amendment filed Sept. 2, 1993, effective Sept. 18, 1993, expired Jan. 15, 1994. Amended: Filed Sept. 2, 1993, effective Jan. 31, 1994.

Emergency amendment filed Oct. 15, 1993, effective Oct. 25, 1993, expired Feb. 21, 1994. Amended: Filed Oct. 15, 1993, effective June 6, 1994. Amended: Filed Oct. 15, 1993, effective June 6, 1994.

Emergency amendment filed Dec. 2, 1993, effective Dec. 18, 1993, expired April 16, 1994. Amended: Filed Dec. 2, 1993, effective July 30, 1994. Emergency amendment filed Dec. 13, 1993, effective Jan. 5, 1994, expired May 4, 1994. Amended: Filed Dec. 13, 1993, effective July 30, 1994. Emergency amendment filed Dec. 20, 1993, effective Jan. 1, 1994, expired April 30, 1994. Amended: Filed Dec. 20, 1993, effective July 30, 1994. Emergency amendment filed Jan. 14, 1994, effective Feb. 2, 1994, expired June 1, 1994. Amended: Filed Jan. 14, 1994, effective July 30, 1994. Emergency amendment filed Jan. 14, 1994, effective Feb. 2, 1994, expired June 1, 1994. Emergency amendment filed Jan. 26, 1994, effective Feb. 5, 1994, expired June 4, 1994. Amended: Filed Jan. 14, 1994, effective July 30, 1994.

Emergency amendment filed Feb. 16, 1994, effective Feb. 26, 1994, expired June 25, 1994. Emergency amendment filed March 14, 1994, effective April 2, 1994, expired July 30, 1994. Emergency amendment filed April 4, 1994, effective April 16, 1994, expired July 29, 1994. Emergency amendment filed April 6, 1994, effective April 17, 1994, expired Aug. 14, 1994. Emergency amendment filed April 25, 1994, effective May 5, 1994, expired Sept. 1, 1994. Emergency amendment filed May 20, 1994, effective June 2, 1994, expired Sept. 29, 1994. Emergency amendment filed May 20, 1994, effective June 2, 1994, expired Sept. 29, 1994. Emergency amendment filed May 20, 1994, effective June 5, 1994, expired Oct. 2, 1994. Emergency amendment filed June 2, 1994, effective June 12, 1994, expired Oct. 9, 1994. Emergency amendment filed June 2, 1994, effective June 12, 1994, expired Oct. 9, 1994. Amended: Filed Feb. 28, 1994, effective Sept. 30, 1994. Emergency amendment filed June 15, 1994, effective June 25, 1994, expired Oct. 22, 1994. Emergency amendment filed June 16, 1994, effective June 26, 1994, expired Oct. 23, 1994. Emergency amendment filed June 20, 1994, effective July 1, 1994, expired Oct. 28, 1994. Emergency amendment filed June 23, 1994, effective July 12, 1994, expired Nov. 8, 1994. Amended:

Filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed June 15, 1994, effective Jan. 29, 1995. Emergency amendment filed Aug. 30, 1994, effective Sept. 9, 1994, expired Jan. 6, 1995. Emergency amendment filed Sept. 23, 1994, effective Oct. 3, 1994, expired Jan. 30, 1995. Emergency amendment filed Oct. 7, 1994, effective Oct. 23, 1994, expired Feb. 19, 1995. Emergency amendment filed Oct. 12, 1994, effective Oct. 22, 1994, expired Feb. 18, 1995. Emergency amendment filed Dec. 15, 1994, effective Jan. 1, 1995, expired April 30, 1995. Emergency amendment filed Jan. 20, 1995, effective Jan. 31, 1995, expired May 30, 1995. Emergency amendment filed Feb. 9, 1995, effective Feb. 20, 1995, expired June 19, 1995. Emergency amendment filed June 20, 1995, effective June 30, 1995, expired Oct. 27, 1995. Emergency amendment filed June 20, 1995, effective July 1, 1995, expired Oct. 28, 1995. Amended: Filed Dec. 15, 1994, effective July 30, 1995. Amended: Filed Feb. 9, 1995, effective Aug. 30, 1995. Emergency amendment filed July 31, 1995, effective Aug. 10, 1995, expired Dec. 7, 1995. Amended: Filed May 15, 1995, effective Dec. 30, 1995. Amended: Filed May 19, 1995, effective Dec. 30, 1995. Emergency amendment filed Nov. 27, 1995, effective Dec. 8, 1995, expired June 4, 1996. Emergency amendment filed Dec. 1, 1995, effective Dec. 11, 1995, expired June 7, 1996. Emergency amendment filed Feb. 5, 1996, effective Feb. 15, 1996, expired Aug. 12, 1996. Amended: Filed Nov. 15, 1995, effective May 30, 1996.

Amended: Filed Nov. 27, 1995, effective July 30, 1996. Amended:

Filed Feb. 15, 1996, effective Aug. 30, 1996. Emergency amendment filed June 21, 1996, effective July 1, 1996, expired Dec. 27, 1996.

Amended: Filed June 17, 1996, effective Jan. 30, 1997. Amended:

Filed June 17, 1996, effective Jan. 30, 1997. Emergency amendment filed Sept. 13, 1996, effective Oct. 1, 1996, expired March 29, 1997.

Amended: Filed Sept. 13, 1996, effective April 30, 1997. Amended:

Filed June 3, 1997, effective Dec. 30, 1997. Emergency amendment filed June 3, 1997, effective June 13, 1997, expired Dec. 9, 1997.

Amended: Filed June 3, 1997, effective Dec. 30, 1997. Emergency amendment filed June 3, 1997, effective July 1, 1997, expired Dec. 27, 1997. Amended: Filed June 3, 1997, effective Dec. 30, 1997.

Emergency amendment filed June 3, 1997, effective June 13, 1997, expired Dec. 9, 1997. Amended: Filed June 3, 1997, effective Dec. 30, 1997. Emergency amendment filed March 2, 1998, effective April 1, 1998, expired Sept. 27, 1998. Amended: Filed March 2, 1998, effective Sept. 30, 1998. Emergency amendment filed Aug. 31, 1998, effective Sept. 10, 1998, expired March 8, 1999. Amended: Filed Jan. 14, 1999, effective July 30, 1999. Amended: Filed May 14, 1999, effective Nov. 30, 1999. Amended: Filed May 14, 1999, effective Nov. 30, 1999. Emergency amendment filed June 18, 1999, effective June 28, 1999, expired Dec. 24, 1999. Amended: Filed July 1, 1999, effective Jan. 30, 2000. Emergency amendment filed Nov. 22, 1999, effective Dec. 2, 1999, terminated May 4, 2000. Amended: Filed Aug. 16, 1999, effective April 30, 2000. Amended: Filed Dec. 15, 1999, effective June 30, 2000. Emergency amendment filed May 1, 2000, effective May 11, 2000, terminated Sept. 4, 2000. Emergency amendment filed Aug. 25, 2000, effective Sept. 4, 2000, expired March 2, 2001. Amended: Filed May 1, 2000, effective Dec. 30, 2000.

Emergency amendment filed April 9, 2001, effective April 19, 2001, expired Oct. 15, 2001. Amended: Filed April 9, 2001, effective Sept. 30, 2001. Amended: Filed Aug. 24, 2001, effective March 30, 2002.

Emergency amendment filed May 28, 2002, effective June 6, 2002, expired Dec. 2, 2002. Amended: Filed April 29, 2002, effective Nov. 30, 2002. Amended: Feb. 18, 2003, effective Aug. 30, 2003. Amended:

Filed Jan. 29, 2004, effective Aug. 30, 2004. Amended: Filed June 15, 2005, effective Dec. 30, 2005. Amended: Filed Feb. 1, 2006, effective July 30, 2006. Amended: Filed July 3, 2006, effective Dec. 30, 2006.

Amended: Filed Feb. 27, 2007, effective Aug. 30, 2007. Emergency amendment filed June 18, 2008, effective July 1, 2008, expired Dec. 28, 2008. Amended: Filed July 1, 2008, effective Jan. 30, 2009.

Emergency amendment filed Dec. 18, 2009, effective Jan. 1, 2010, expired June 29, 2010. Amended: Filed Aug. 3, 2009, effective March 30, 2010. Emergency amendment filed June 17, 2010, effective July 1, 2010, expired Dec. 27, 2010. Amended: Filed June 17, 2010, effective Jan. 30, 2011. Emergency amendment filed May 20, 2011, effective June 1, 2011, expired Nov. 28, 2011. Amended: Filed May 20, 2011, effective Jan. 30, 2012. Emergency amendment filed June 20, 2012, effective July 1, 2012, expired Dec. 28, 2012. Amended: Filed June 20, 2012, effective Jan. 30, 2013. Emergency amendment filed June 20, 2013, effective July 1, 2013, expired Dec. 28, 2013. Amended:

Filed July 1, 2013, effective Jan. 30, 2014. Emergency amendment filed June 20, 2014, effective July 1, 2014, expired Dec. 27, 2014.

Amended: Filed July 1, 2014, effective Jan. 30, 2015. Emergency amendment filed June 19, 2015, effective July 1, 2015, expired Dec. 28, 2015. Amended: Filed July 1, 2015, effective Jan. 30, 2016.

Emergency amendment filed June 20, 2016, effective July 1, 2016, expired Dec. 27, 2016. Amended: Filed June 23, 2016, effective Jan. 30, 2017. Emergency amendment filed June 20, 2017, effective July 1, 2017, expired Feb. 22, 2018. Amended: Filed June 20, 2017, effective Jan. 30, 2018. Emergency amendment filed June 21, 2018, effective July 1, 2018, expired Feb. 28, 2019. Amended: Filed June 21, 2018, effective Jan. 30, 2019. Amended: Filed April 30, 2020, effective Nov. 30, 2020. Emergency amendment filed June 14, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 14, 2022, effective Jan. 30, 2023. Amended: Filed Oct. 23, 2023, effective May 30, 2024. Emergency amendment filed July 26, 2024, effective Aug. 9, 2024, expired Feb. 27, 2025. Amended: Filed Oct. 23, 2024, effective May 30, 2025. Emergency amendment filed June 23, 2025, effective July 8, 2025, expired Feb. 26, 2026. Amended: Filed Feb. 19, 2026, effective Aug. 30, 2026. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2025. This rule was previously filed as 13 CSR 40-81.050. Original rule filed Feb. 13, 1969, effective Feb. 23, 1969. Emergency rescission and rule filed Sept. 21, 1981, effective Oct. 1, 1981, expired Jan. 13, 1982. Rescinded and readopted: Filed Sept. 21, 1981, effective Jan. 14, 1982.

13 CSR 70-15.011 Reimbursement for Essential Disproportionate Share Hospitals Emergency rule filed April 21, 1995, effective May 1, 1995, expired June 30, 1995. {#sec-13-csr-70-15.011 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.011}

13 CSR 70-15.015 Supplemental Payments {#sec-13-csr-70-15.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.015}

PURPOSE: This rule provides for the calculation of the Direct Medicaid payments made on or after July 1, 2019.

(1) Definitions.

(A) Base year cost report. Audited Medicaid cost report from the third prior calendar year. If a facility has more than one (1) cost report with periods ending in the third prior calendar year, the cost report covering a full twelve- (12-) month period will be used. If none of the cost reports covers a full twelve (12) months, the cost report with the latest period will be used. If a hospital’s base year cost report is less than or greater than a twelve- (12-) month period, the data shall be adjusted, based on the number of days reflected in the base year cost report to a twelve- (12-) month period. Any changes to the base year cost report after the division issues a final decision on assessment or payments will not be included in the calculations.

(B) Case mix index (CMI). The hospital CMI is determined based on the hospital’s MO HealthNet inpatient claims and Solventum All-Patient Refined Diagnosis Related Groups (APR- DRG) software, a grouping algorithm to categorize inpatient discharges with similar treatment characteristics requiring similar hospital resources.

1. For SFY 2026 and forward, the basis of the case mix index will be determined by the division based on the inpatient dataset utilized in the annual update of the Missouri APR-DRG reimbursement methodology.

(C) Cost report. A cost report details, for purposes of both Medicare and MO HealthNet reimbursement, the cost of rendering covered services for the fiscal reporting period. The Medicare/Medicaid Uniform Cost Report contains the forms utilized in filing the cost report. The Medicare/Medicaid Cost Report version 2552-10 (CMS 2552-10) shall be used for fiscal years beginning on and after May 1, 2010.

(D) Division. Unless otherwise designated, division refers to the MO HealthNet Division (MHD), a division of the Department (E) Medicaid fee-for-service (FFS) inpatient days. Medicaid FFS inpatient days are paid Medicaid FFS days for inpatient hospital services as reported by the Medicaid Management Information System (MMIS) from the second prior calendar year.

(F) Medicaid managed care (MC) inpatient days. Medicaid MC inpatient days are paid Medicaid MC days for inpatient hospital services as reported by the Managed Care Health Plans on the Hospital Services Reporting Form from the second prior calendar year.

(G) Federal reimbursement allowance (FRA). The fee assessed to hospitals for the privilege of engaging in the business of providing inpatient health care in Missouri. The FRA shall be an allowable cost to the hospital. The FRA is identified in 13 CSR 70-15.110. Effective January 1, 1999, the assessment shall be an allowable cost.

(H) State-deemed critical access hospital (CAH). A public hospital located in a county in the Missouri Bootheel with no more than one hundred five (105) acute care inpatient beds.

(2) Inpatient Direct Medicaid Payments.

(A) Inpatient direct Medicaid payments will be made to hospitals that are reimbursed under an APR-DRG reimbursement methodology for the following allowable MO HealthNet cost:

1. The increased MO HealthNet cost resulting from the FRA assessment becoming an allowable cost on January 1, 1999.

(B) The division will calculate the inpatient direct Medicaid payment as follows:

1. The Medicaid share of the inpatient FRA assessment will be calculated by dividing the hospital’s inpatient Medicaid days, FFS and MC, by the total inpatient hospital days from the base year cost report to arrive at the Medicaid utilization percentage. This percentage is then multiplied by the inpatient FRA assessment for the current state fiscal year (SFY) to arrive at the increase allowable Medicaid cost for the inpatient FRA assessment. This amount will then be divided by the total of Medicaid FFS inpatient days and Medicaid MC inpatient days to arrive at a per day amount; and 2. The per day amount calculated in (2)(B)1. will be multiplied by the Medicaid FFS inpatient days to arrive at the FFS inpatient direct Medicaid payment.

(C) The division will calculate the inpatient direct Medicaid payment for new hospitals as follows:

1. In the absence of adequate cost report data, a new hospital’s Medicaid share of the inpatient FRA assessment shall be one hundred percent (100%) of the weighted average statewide Medicaid per day amount, as calculated in paragraph (2)(B)1., for the hospital type (i.e., acute care hospital, psychiatric hospital, long-term care hospital, rehabilitation hospital); and 2. In the absence of Medicaid FFS inpatient days, a new hospital’s paid days shall be one hundred percent (100%) of the average statewide Medicaid FFS inpatient days for the hospital type (i.e., acute care hospital, psychiatric hospital, long term care hospital, rehabilitation hospital). These days are then multiplied by the per day amount calculated in (2)(C)1. to arrive at the FFS inpatient direct Medicaid payment.

(D) Effective for payments made on or after July 1, 2025, only the FFS component of the Medicaid share of the inpatient assessment will be included in the inpatient direct Medicaid (3) Outpatient Direct Medicaid Payments.

(A) Outpatient direct Medicaid payments will be made to hospitals for the following allowable MO HealthNet cost:

1. The increased MO HealthNet cost resulting from the FRA assessment becoming an allowable cost on January 1, 1999.

(B) The division will calculate the outpatient direct Medicaid payment as follows:

1. The Medicaid share of the outpatient FRA assessment will be calculated by dividing the hospital’s outpatient Medicaid charges, FFS and MC, by the total outpatient hospital charges from the base year cost report to arrive at the Medicaid utilization percentage. This percentage is then multiplied by the outpatient FRA assessment for the current SFY to arrive at the increased allowable Medicaid cost for the outpatient FRA assessment; and 2. The FFS outpatient ratio will be calculated by dividing the hospital’s outpatient FFS Medicaid charges by the hospital’s outpatient Medicaid charges, FFS and MC. This ratio is then multiplied by the increased allowable Medicaid cost for the outpatient FRA assessment to arrive at the FFS outpatient direct Medicaid payment.

(C) The division will calculate the outpatient direct Medicaid payment for new hospitals as follows:

1. In the absence of a base year cost report, a new hospital’s Medicaid share of the outpatient FRA assessment shall be one hundred percent (100%) of the weighted average statewide Medicaid utilization percentage, as calculated in paragraph (3)

(B)1., for the hospital type (i.e., acute care hospital, psychiatric hospital, long term care hospital, rehabilitation hospital).

This percentage is then multiplied by the outpatient FRA assessment for the current SFY to arrive at the increased allowable Medicaid cost for the outpatient FRA assessment;

2. In the absence of a base year cost report, a new hospital’s FFS outpatient ratio shall be one hundred percent (100%) of the weighted average statewide FFS outpatient ratio, as calculated in paragraph (3)(B)2., for the hospital type (i.e., acute care hospital, psychiatric hospital, long term care hospital, rehabilitation hospital). This ratio is then multiplied by the increased allowable Medicaid cost for the outpatient FRA assessment to arrive at the FFS direct Medicaid payment.

(D) Effective for payments made on or after July 1, 2022, only the FFS component of the Medicaid share of the outpatient FRA assessment will be included in the outpatient direct Medicaid (4) Acuity Adjustment Payment (AAP).

(A) Beginning with SFY 2026, hospitals that are paid on a per diem and meet the requirements set forth below shall receive an AAP. A hospital that is designated as a long-term acute care hospital, free-standing psychiatric hospital, or a free-standing rehabilitation hospital does not qualify to receive an AAP. For purposes of this section, Medicaid payments received shall include the following payments:

1. The Medicaid per diem payments, AAP, PC payment, and stop-loss payment (SLP).

(B) A hospital shall receive an AAP if the hospital’s MO HealthNet case mix index is greater than a threshold set annually by the division. The preliminary AAP is calculated by multiplying the hospital’s MO HealthNet case mix index times the estimated Medicaid FFS claims payments for the coming SFY. The estimated Medicaid FFS claims payments are calculated by multiplying the Medicaid FFS inpatient days times the per diem for the coming SFY. If the hospital’s estimated Medicaid FFS claims payments for the coming SFY plus the preliminary AAP exceeds the hospital’s prior SFY Medicaid FFS payments received increased by a stop-gain percentage, the preliminary AAP will be reduced so the estimated Medicaid FFS claims payments for the coming SFY plus the final AAP is equal to the stop-gain percent of the hospital’s prior SFY Medicaid FFS payments received. If no reduction is necessary, the preliminary AAP shall be considered final.

(C) The annual final AAP will be calculated for each hospital at the beginning of each SFY. The annual amount will be paid out over the number of financial cycles during the SFY.

(5) Poison Control (PC) Payment.

(A) The PC payment shall be determined for hospitals which operated a poison control center during the base year and which continues to operate a poison control center. The PC payment shall reimburse the hospital for the Medicaid share of the total poison control cost and shall be determined as 1. The total poison control cost from the base year cost report will be divided by the total hospital days from the base year cost report to determine a cost per day. This cost per day will then be multiplied by the estimated Medicaid FFS inpatient days and Medicaid MC inpatient days; and 2. The annual final PC payment will be calculated for each amount will be paid out over the number of financial cycles during the SFY.

(6) Stop-Loss Payment (SLP) for Hospitals That Are Reimbursed Under the Per Diem Reimbursement Methodology.

(A) Beginning with SFY 2026 hospitals that are paid on a per diem and meet the requirements set forth below shall receive an SLP. For purposes of this section, Medicaid payments received shall include the following payments:

1. The Medicaid per diem payments, AAP, PC payment, and SLP.

(B) Total estimated Medicaid FFS payments for the coming SFY for each hospital shall include estimated Medicaid FFS claims payments, and any final AAP and PC payment. The total estimated Medicaid FFS payments for each hospital shall be subtracted from the hospital’s prior SFY Medicaid FFS payments received then summed to calculate a total increase or decrease in payments for the entire private ownership group. A positive result represents a decrease in payments and a negative amount represents an increase in payments. If the result is a decrease in total payments to the private ownership group, this amount shall represent the total stop-loss amount.

1. SLP will be made if a total stop-loss amount was calculated in subsection (6)(B). Each hospital that shows a decrease in Medicaid payments shall receive a SLP in the amount of the decrease in payments unless the sum of each hospital’s SLP is greater than the total stop-loss amount. If the sum is greater than the total stop-loss amount, each hospital’s SLP shall be calculated by multiplying the total stop-loss amount times the ratio of the hospital’s decrease in Medicaid payments to the total decrease in payments for the entire private ownership group.

2. Free-standing psychiatric hospitals. Total estimated Medicaid FFS payments for the coming SFY for each hospital shall include estimated Medicaid FFS claims payments, and any final AAP and PC payment. The total estimated Medicaid FFS payments for each hospital shall be subtracted from the hospital’s prior SFY Medicaid FFS payments received then summed to calculate a total increase or decrease in payments for the entire privately owned free-standing psychiatric hospital ownership group. A positive result represents a decrease in payments and a negative amount represents an increase in payments.

A. If a hospital has a decrease in payments as calculated in paragraph (6)(B)2., the hospital will receive a payment equal to the amount of payment decrease. If the hospital has an increase in payments as calculated in paragraph (6)(B)2., the hospital will not receive any additional payments.

(C) The annual SLP will be calculated for each hospital at the beginning of each SFY. The annual amount will be paid out over the number of financial cycles during the SFY.

(7) Stop-Loss Payment (SLP) for Hospitals That Are Reimbursed Under the APR-DRG Reimbursement Methodology.

(A) Beginning with SFY 2026 hospitals that are paid under the APR-DRG and meet the requirements set forth below shall receive a SLP.

1. Total estimated Medicaid claims-based payments from the DRG base year are calculated. The DRG claims based system is calculated based on 13 CSR 70-15.010(6). The FFS supplemental payments for the most recent SFY are added to each hospital’s estimated reimbursement.

2. The estimated DRG payments are then subtracted from the per diem repriced claims plus the FFS supplemental payments to get an estimated difference in reimbursement.

3. If the estimated DRG payment is greater than the per diem repriced claims plus the FFS supplemental payments, then no SLP will be calculated.

4. If the estimated DRG payment is less than the per diem repriced claims plus the FFS supplemental payments, then a SLP will be calculated to hold a hospital to a maximum of a one and seven thousand five hundred forty-five ten thousandths percent (1.7545%) estimated loss.

5. SLP special considerations.

A. If the following hospital types are eligible for a SLP, then their stop loss is held to zero percent (0%):

(I) Federally deemed CAHs;

(II) Safety net hospitals as defined in subparagraph (13)

(A)1.A.; and (III) State-deemed CAHs.

6. The annual SLP will be calculated for each hospital at the beginning of each SFY. The annual amount will be processed over the number of financial cycles during the SFY.

7. The SLP calculations are based on a prospective estimate using historical claims data and will not be trued up with actual claims data at the end of the SFY.

(8) Psych Adjustment (PA) Payment.

(A) Beginning with SFY 2026, hospitals that have FFS psychiatric hospital days as identified in the MMIS shall receive a PA payment.

1. The PA payment is a set dollar amount appropriated by the General Assembly pursuant to section 11.780 of CCS SS SCS HCS HB 11 (2025), and distributed to eligible hospitals proportionately as follows:

A. The FFS psychiatric hospital days for each hospital will be divided by the total FFS psychiatric hospital days for all hospitals to determine a percentage for each hospital. This percentage will then be multiplied by the set dollar amount in paragraph (8)(A)1. to determine the PA payment. The FFS psychiatric hospital days are paid days from the second prior calendar year.

2. The annual final PA payment will be calculated for each amount will be paid out over the number of financial cycles during the SFY.

(9) Medicaid Direct Graduate Medical Education (GME)

Payments. Beginning with SFY 2023, a GME payment calculated as the sum of the intern and resident based GME payment and the GME stop-loss payment shall be made to any acute care hospital that provides graduate medical education.

(A) Intern and resident (I&R) based GME payment. The I&R based GME payment will be based on the per I&R Medicaid allocated GME costs not to exceed a maximum amount per I&R.

The division will determine the number of full-time equivalent (FTE) I&Rs. Total GME costs will be determined using Worksheet A of the base year cost report adjusted by the trend index.

Total GME costs is multiplied by the ratio of Medicaid FFS and MC days to total days to determine the Medicaid allocated GME costs which is then divided by the number of FTE I&Rs to calculate the Medicaid allocated cost per I&R. The I&R based GME payment is calculated as the number of FTE I&Rs multiplied by the minimum established by the division or the Medicaid allocated cost per I&R.

(B) GME stop-loss payment. The total I&R based GME payment for each hospital shall be subtracted from the hospital’s prior SFY GME payments received then summed to calculate a total increase or decrease in payments for the entire group of hospitals that provide graduate medical education. A positive result represents a decrease in payments and a negative amount represents an increase in payments. If the result is a decrease in total payments to the hospitals, this amount shall represent the total GME stop-loss amount. GME stop-loss payments will be made if a total GME stop-loss payment amount was calculated in the subsection above. Each hospital that shows a decrease in GME Medicaid payments shall receive a GME stop-loss payment in the amount of the decrease in payments unless the sum of each hospital’s GME stop-loss payment is greater than the total GME stop-loss amount. If the sum is greater than the total GME stop-loss amount, each hospital’s GME stop-loss payment shall be calculated by multiplying the total GME stop-loss amount times the ratio of the hospital’s decrease in GME Medicaid payments to the total decrease in GME Medicaid payments.

(C) Hospitals who implement a GME program prior to July 1 of the SFY and do not have a base year cost report to determine GME costs shall receive an I&R based GME payment based on the statewide average per resident amount (PRA) determined as follows:

1. The number of FTE I&Rs shall be reported to the division by June 1 prior to the beginning of the SFY in order to have a GME payment calculated; and 2. The I&R based GME payment shall be calculated as the number of FTE I&Rs multiplied by the Medicaid capped statewide average PRA. The Medicaid capped statewide average PRA is calculated as follows:

A. By applying a straight average to the list of hospital PRA’s with the following criteria:

(I) A hospital’s PRA used in the straight average shall be the minimum as established by the division or the hospital’s actual PRA.

(D) Hospitals who expand a currently federally approved GME program as of July 1 of the SFY shall have the ability to submit updated I&R numbers to the division.

1. The number of expanded FTE I&Rs shall be reported to the division by June 1 prior to the beginning of the SFY in order to have a GME payment calculated; and 2. The I&R based GME payment shall be calculated as the expanded number of FTE I&Rs multiplied by the minimum of the hospital-specific PRA or Medicaid capped statewide average PRA as described in subsection (9)(A).

(E) The hospital’s I&R based GME payment plus GME stop-loss payment, if applicable, will be calculated for each hospital at the beginning of each SFY. The annual amount will be paid on a quarterly basis during the SFY.

(10) Medicaid Indirect Medical Education (IME) Payment.

Beginning with SFY 2026, an IME payment will be paid to public acute care safety-net hospitals who serve as the primary teaching hospitals for the state’s two (2) public medical schools, University of Missouri – Columbia School of Medicine and University of Missouri – Kansas City School of Medicine.

The payment will be for the difference between IME payments paid under the DRG methodology and one hundred percent (100%) of allowable funds. The payment will be calculated as (A) IME add-on amount = wage adjusted rate x IME factor;

1. Wage adjusted rate is defined in 13 CSR 70-15.010(6)

(G)4.A.(I)(a); and 2. IME factor is defined in 13 CSR 70-15.010(6)(G)3.C.

(B) Case-mix index as defined in subsection (1)(B).

(C) Claim count: FFS and MC paid claims from the second prior SFY.

1. Example: SFY 2026 IME payment will utilize SFY 2024 claim counts.

2. Future updates will utilize FFS and MC paid claims from the second full prior calendar year (i.e., for SFY 2027 beginning July 1, 2026, calendar year 2024 paid claims will be utilized).

(D) Formula: IME add-on amount x case-mix index x claim count.

(E) The hospital’s IME payment will be calculated for each amount will be processed on a quarterly basis during the SFY.

(11) Children’s Outlier (CO) Payment. Effective for discharges on or after July 1, 2025, children’s outlier payments will no longer be made.

(A) The outlier year is based on a discharge date between July 1 and June 30.

(B) Beginning July 1, 2022, for fee-for-service claims only, outlier payments for medically necessary inpatient services involving exceptionally high cost or exceptionally long lengths of stay for MO HealthNet-eligible children under the age of six (6) will be made to hospitals meeting the federal disproportionate share hospital (DSH) requirements in paragraph (10)(B)1. and for MO HealthNet-eligible infants under the age of one (1) will be made to any other Missouri Medicaid hospital.

1. The following criteria must be met to be eligible for outlier payments for children one (1) year of age to children under six (6) years of age:

A. If the facility offered nonemergency obstetric services as of December 21, 1987, there must be at least two (2) obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to these services under the Missouri Medicaid plan. In the case of a hospital located in a rural area (area outside of a metropolitan statistical area, as defined by the federal Executive Office of Management and Budget), the term obstetrician includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures. This section does not apply to hospitals either with inpatients predominantly under eighteen (18) years of age or which did not offer nonemergency obstetric services as of December 21, 1987; and B. As determined from the base year audited Medicaid cost report, the hospital must have either— (I) A Medicaid inpatient utilization rate (MIUR) at least one (1) standard deviation above the state’s mean MIUR for all Missouri hospitals. The MIUR will be expressed as the ratio of total Medicaid days (TMD) (including such patients who receive benefits through a managed care entity) provided under a state plan divided by the provider’s total number of inpatient days (TNID). The state’s mean MIUR will be expressed as the ratio of the sum of the total number of the Medicaid days for all Missouri hospitals divided by the sum of the total patient days for the same Missouri hospitals. Data for hospitals no longer participating in the program will be excluded;

MIUR = TMD / TNID or (II) A low-income utilization rate (LIUR) in excess of twenty-five percent (25%). The LIUR shall be the sum (expressed as a percentage) of the fractions, calculated as follows:

(a) Total MO HealthNet patient revenues (TMPR) paid to the hospital for patient services under a state plan plus the amount of the cash subsidies (CS) directly received from state and local governments, divided by the total net revenues (TNR) (charges minus contractual allowances, discounts, and the like) for patient services plus the CS; and (b) The total amount of the hospital’s charges for patient services attributable to charity care (CC) less CS directly received from state and local governments in the same period, divided by the total amount of the hospital’s charges (THC) for patient services. The total patient charges attributed to CC shall not include any contractual allowances and discounts other than for indigent patients not eligible for MO HealthNet under a state plan.

LIUR = ((TMPR + CS) / (TNR + CS)) + ((CC - CS) / THC)

2. The following criteria must be met for the services to be eligible for outlier review:

A. The patient must be a MO HealthNet-eligible infant under the age of one (1) year or, for hospitals that meet the federal DSH requirements, a MO HealthNet-eligible child under the age of six (6) years, as of the date of discharge; and B. One (1) of the following conditions must be satisfied:

(I) The total reimbursable charges for dates of service must be at least one hundred fifty percent (150%) of the sum of claim payments for each claim; or (II) The dates of service must exceed sixty (60) days and less than seventy-five percent (75%) of the total service days were reimbursed by MO HealthNet.

3. Claims eligible for outlier review must— A. Have been submitted in their entirety for claims processing;

B. The claim must have been paid; and C. An annual outlier file, for paid claims only, must be submitted to the division no later than December 31 of the second calendar year following the end of the outlier year (i.e., claims for outlier year 2022 are due no later than December 31, 2024).

4. After the review, reimbursable costs for each claim will be determined using the following data from the audited Medicaid hospital cost report for the year ending in the same calendar year as the outlier year (i.e., Medicaid hospital cost reports ending in 2022 will be used for the 2022 outlier year):

A. Average routine (room and board) costs for the general and special care units for all days of the stay eligible per the outlier review; and B. Ancillary cost-to-charge ratios applied to claim ancillary charges determined eligible for reimbursement per the outlier review.

5. The outlier payments will be determined for each hospital as follows:

A. Sum all reimbursable costs for all eligible outlier claims to equal total reimbursable costs;

B. Subtract total claim payments, which includes MO HealthNet claims payments, third-party payments, and copays, from total reimbursable costs to equal excess cost; and C. Multiply excess costs by fifty percent (50%).

(12) Safety Net Hospitals.

(A) Inpatient hospital providers may qualify as a safetynet hospital based on the following criteria. Hospitals shall qualify for a period of only one (1) SFY and must requalify at the beginning of each SFY to continue their safety-net hospital designation:

1. As determined from the most recent DSH survey for the MIUR and LIUR and from the base year cost report for the licensed beds and the occupancy rate— A. A public non-state governmental acute care hospital with a LIUR of at least twenty percent (20%), a MIUR greater than one (1) standard deviation from the mean, is licensed for fifty (50) inpatient beds or more, and has an occupancy rate of at least forty percent (40%). The hospital must meet one (1) of the federally mandated DSH qualifications;

2. The hospital is owned or operated by the Board of Curators as defined in Chapter 172, RSMo; or 3. The hospital is a public hospital operated by the treatment of mental disorders.

(13) Hospital Mergers. Hospitals that merge their operations under one (1) Medicare and Medicaid provider number shall have their Medicaid reimbursement combined under the surviving hospital’s (the hospital’s whose Medicare and Medicaid provider number remained active) Medicaid provider number.

(A) The other Medicaid payments, if applicable, shall be— 1. Combined under the surviving hospital’s Medicaid provider number for the remainder of the SFY in which the merger occurred; and 2. Calculated for subsequent SFYs based on the combined data from the base year cost report for each facility.

(14) Payment Assurance. The state will pay each hospital, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the hospital according to the standards and methods set forth in the rules implementing the hospital reimbursement (15) Directed Payments. Effective July 1, 2022, the Missouri Medicaid managed care organizations shall make inpatient and outpatient directed payments to in-state in-network hospitals pursuant to 42 CFR 438.6(c) as approved by the Centers for Medicare & Medicaid Services.

Amended: Filed Aug. 26, 2021, effective March 30, 2022. Emergency amendment filed June 14, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 14, 2022, effective Jan. 30, 2023.

Emergency amendment filed June 20, 2025, effective July 7, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993,

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2025. This rule was previously filed as part of 13 CSR 70-15.010. Emergency rule filed April 30, 2020, effective May 15, 2020, expired Feb. 24, 2021. Original rule filed April 30, 2020, effective Nov. 30, 2020. Emergency amendment filed Aug. 26, 2021, effective Sept. 10, 2021, expired March 8, 2022.

13 CSR 70-15.020 Procedures for Admission Certification, Continued Stay Review, and Validation Review of Hospital Admissions {#sec-13-csr-70-15.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.020}

PURPOSE: The MO HealthNet Division establishes admission certification and validation procedures on which hospitals furnishing inpatient care to MO HealthNet participants will be reviewed to determine that admissions are medically necessary and appropriate for inpatient care. publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this

rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet Division, Department of Social Services, shall administer the Hospital Program. Hospital Program services covered and not covered and the limitations under which services are covered shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Hospital Provider Manual. The MO HealthNet Hospital Provider Manual is incorporated by reference and made part of this rule as published by the Department of Social Services, MO 65109, October 6, 2025. This rule does not incorporate any (A) The following definitions will be used in administering this rule:

1. Admission. Admission means the act of registration and entry into a general medical and surgical, psychiatric, or rehabilitation hospital on the order of a qualified medical practitioner or medical professional having privileges of admission for the purpose of providing inpatient hospital services under the supervision of a physician member of the hospital’s medical staff;

2. Admission certification. Admission certification means the determination by the medical review agent, as transmitted to the hospital/physician and the fiscal agent, that the admission of a participant for inpatient hospital services is approved as medically necessary, reasonable, and appropriate as to placement at an acute level of care;

3. Admitting diagnosis. Admitting diagnosis means the physician’s tentative or provisional diagnosis of the participant’s condition as a basis for examination and treatment when the admission certification is requested;

4. Admitting medical professional. Admitting medical professional means a physician or other person authorized by state licensure law to order hospital services and who has admission privileges to order the participant’s inpatient admission to the hospital;

5. Certification number. Certification number means the number issued by the medical review agent that establishes that, based upon information furnished by the provider, a participant’s admission for inpatient hospital services is approved as medically necessary;

6. Department. Department means the Missouri Department of Social Services;

7. Emergency admission. Emergency admission means an admission in which the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) that absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part;

8. Fee for service. Fee for service refers to participants and/ or services not included in the MO HealthNet Managed Care program or other prepaid health plans;

9. Inpatient hospital service. Inpatient hospital service means a service provided by or under the supervision of a medical professional after a participant’s admission to a hospital and furnished in the hospital for the care and treatment of the participant;

10. Managed Care. Managed Care is a program under which some MO HealthNet participants are enrolled with a health plan who contracts with the department to provide a package of MO HealthNet benefits for a monthly fee per enrollee;

11. Medical record. Medical record means all or any portion of the medical record as requested by the medical review agent;

12. Medical review agent. Medical review agent means the state’s representative who is authorized to make decisions about admission certifications and validation reviews;

13. Medically necessary. Medically necessary means an inpatient hospital service that is consistent with the participant’s diagnosis or condition and is in accordance with the criteria as specified by the department;

14. Nurse reviewer. Nurse reviewer means a person who is employed by or under contract with the medical review agent and who is licensed to practice professional nursing in Missouri;

15. Pertinent information. Pertinent information means any information that the physician, hospital, or participant feels may justify or qualify the hospitalization;

16. Physician reviewer. Physician reviewer means a physician who is a peer of the admitting/attending physician or who specializes in the type of care under review. Exceptions will be made only if the efficiency or effectiveness of the review would be compromised, but in every situation the review will be performed by a physician;

17. Readmission. Readmission means an admission that occurs within fifteen (15) days of a discharge of the same participant from the same or a different hospital. The fifteen- (15-) day period does not include the day of discharge or the day of readmission;

18. Participant. Participant means a person who has applied and been determined eligible for MO HealthNet benefits;

19. Reconsideration. Reconsideration means a review of a denial or withdrawal of admission certification;

20. Required information. Required information means the information to be provided by the medical professional or hospital to obtain a preadmission or post-admission certification, which includes participant, medical professional, and hospital identifying information, admission date, admission diagnosis, procedures, surgery date, indications for inpatient setting, and plan of care;

21. Transfer. Transfer means the movement of a participant after admission from one (1) hospital directly to another or within the same facility;

22. Urgent admission. Urgent admission means a case which requires prompt admission to the hospital to prevent deterioration of a medical condition from an urgent to an emergency situation;

23. Utilization review assistant. Utilization review assistant means a person who is employed by or is under contract with the medical review agent who is the preliminary reviewer to assess the need for nurse review when the level of care criteria are not immediately met based on the standardized tool for determining level of care;

24. Validation review. Validation review means a review conducted after admission certification has been approved.

The review is focused on validating the admitting information and confirming the determination of medical necessity of the admission; and 25. Written request. A notice to the address of the provider as listed in the MO HealthNet Division’s system, in writing, transmitted via the U.S. mail or other private or common carrier, facsimile, email, or any other method/mode of transmittal that is deemed by MO HealthNet to be an efficient, cost-effective, verifiable, and a reliable method or mode of communication with the provider, applying provider, or provider’s representative.

(2) As required by Title 42, Code of Federal Regulations (CFR) part 456, admissions of MO HealthNet participants to MO HealthNet participating hospitals in Missouri and bordering states are subject to admission certification procedures and validation review with the following exceptions:

(A) Admissions of participants enrolled in a MO HealthNet Managed Care health plan;

(B) Admissions of participants eligible for both Part A Medicare and MO HealthNet;

(C) Admissions for deliveries;

(D) Admissions for newborns; and (E) Admissions for certain pregnancy-related diagnoses. The diagnoses codes for deliveries, newborns, and pregnancyrelated conditions are as published in the ICD (Internal Classification of Diseases, Clinical Modification) code book.

Admissions with diagnoses codes for missed abortion, pregnancy with abortive outcome, and postpartum condition or complication will continue to require admission certification and validation review.

(3) The admission certification procedure and validation review will be performed by a medical review agent. The confidentiality of all information shall be adhered to in accordance with section 208.155, RSMo and Title 42, CFR part 431, subpart F. The medical review agent’s decisions related to certification or non-certification of MO HealthNet admissions are advisory in nature. The department is the final payment

(4) The types of certification and review include:

(A) Prospective (Preadmission) certification of nonemergency (elective) admissions of MO HealthNet participants with established eligibility on date of admission;

(B) Admission (Initial) certification of emergency and urgent admissions of MO HealthNet participants with established eligibility on date of admission and obtained prior to discharge;

(C) Continued Stay Review (CSR) to add days to an existing certification. This review is done prior to discharge or within fourteen (14) days after discharge;

(D) Retrospective certification (post discharge) is only appropriate if participant’s or provider’s eligibility is not established prior to the patient’s discharge date. Other retrospective certification requests are reviewed on a case-bycase basis. Retrospective reviews are not allowed for requests that were initiated while inpatient but failed to include sufficient clinical information to obtain certification;

(E) Retrospective validation review of statistically valid sample cases to assure information provided during admission certification is substantiated by documentation in the medical record; and (F) A review of quality will be performed for those cases selected as part of the focused and random validation and Certification of Need Samples. Potential quality issues that represent a minor or less than serious risk to a patient will not be pursued. However, potentially serious quality issues will proceed through three (3) levels of specialty physician review if the issue is upheld by the physician reviewers at the first and second level physician review.

(5) Time requirements for the certification procedures are as (A) Medical professional or hospital notification to the medical review agent of a planned elective admission must occur no later than two (2) full working days prior to the date of the planned admission;

(B) Medical professional or hospital notification to the medical review agent of the occurrence of an emergency or urgent admission is required by the end of the first full working day after the date of the actual admission or prior to discharge, whichever comes first;

(C) Medical professional or hospital notification to the medical review agent of the need for a continued stay review must occur prior to discharge or within fourteen (14) working days after discharge;

(D) The medical review agent will determine the medical necessity of admissions specified in subsections (4)(A) and (B) at the time the request is made or by the end of the next working day after receipt of all required information from the medical professional or hospital;

(E) The hospital shall submit, at its own expense, the participant’s medical record to the medical review agent for retrospective certification cases specified in subsection (4)(D);

(F) After receipt of all the required medical record information, the medical review agent will determine medical necessity of admissions specified in subsection (4)(D) within thirty (30) calendar days. Cases submitted for physician review must be completed within this same thirty- (30-) day period.

(6) A standardized assessment tool for determining level of care is to be used in the admission certification and validation review. With regards to ambulatory procedure screenings, if the procedure meets criteria to be done in the outpatient setting versus inpatient, the case will be reviewed by a physician for final determination, which may result in denial of the certification request. Urgent/emergency criteria are used as guidelines for determination of type of admission and are defined in subsection (1)(A).

(7) The admission certification procedure is as follows:

(A) Certification requests can be made in the following manner:

1. For prospective, initial admission, and continued stay reviews, the medical professional or hospital submits the request through CyberAccess Web tool or contacts the medical review agent to provide the required information to obtain certification; or 2. For retrospective certification the hospital submits, at its own expense, the participant’s medical record to the medical review agent to obtain certification which is to include the emergency room record; history and physical; any operative, pathology, or consultation reports; the first three (3) days of physician or other medical professional orders including the inpatient admitting orders, progress notes, nurses’ notes, graphic vital signs, medication sheets, and diagnostic testing results;

(B) Initial screening of information for reviews in paragraph (7)(A)1. is conducted through the online CyberAccess Web tool, by utilization review assistants or by nurse reviewers using the criteria in section (6) as appropriate to the case under review;

(C) Initial screening of information for reviews in paragraph (7)(A)2. is conducted by a utilization review assistant or nurse reviewer using the criteria in section (6) as appropriate to the case under review;

(D) If the medical information submitted regarding the patient’s condition and planned services meets the applicable criteria in section (6), the approval decision and a unique certification number are communicated to the medical professional and hospital via the CyberAccess Web tool;

(E) If the applicable criteria in section (6) are not met, the nurse reviewer refers the case to a physician reviewer for a medical necessity determination. The physician reviewer is not bound by any criteria and makes the determination based on medical facts in the case using his/her medical judgment;

(F) If the physician reviewer approves the admission, the approval determination and unique certification number are communicated to the medical professional and hospital via the CyberAccess Web tool;

(G) The attending medical professional will be contacted prior to a denial determination and allowed the opportunity to provide additional information. This additional information will be considered by the physician reviewer prior to a determination to approve or deny admissions. Determination decisions will be communicated as follows:

1. If the admission is approved, the approval determination and unique certification number are communicated to the medical professional and hospital via the CyberAccess Web tool; and 2. Denial determinations are communicated via mail to the medical professional, hospital, and participant. The status can also be found on the CyberAccess Web tool;

(H) The medical professional, hospital, or participant who is dissatisfied with an initial denial determination is entitled to a reconsideration review by the medical review agent as outlined in section (8); and (I) If inpatient admission is approved and surgery is planned, day of surgery admission will be required unless the physician reviewer approves a preoperative day for evaluating concurrent medical conditions or other risk factors.

(8) Reconsideration Review Requests. The medical review agent’s denial decisions relate to medical necessity and appropriateness of the inpatient setting in which services were furnished or are proposed to be furnished. The procedure to request reconsideration of an initial denial determination is as (A) Time Requirements— 1. To request a reconsideration review for a patient for a prospective admission or for a patient still in the hospital, the provider should telephone a request to the medical review agent. In either of these situations, the request for reconsideration must be received within three (3) working days of receipt of the written denial notice. In order to expedite the process, the provider must indicate that this is a request for a reconsideration review. The medical review agent will complete the reconsideration review and issue a determination within three (3) working days of receipt of the request and all pertinent information; and 2. If the patient has been discharged from the hospital, the provider must submit a request for reconsideration in writing or by facsimile (fax). This reconsideration cannot be requested by telephone. The request must be made within sixty (60) calendar days of receipt of the written denial notice. The medical review agent will complete the reconsideration review within thirty (30) calendar days after receipt of the request for reconsideration review, medical records, and all pertinent information. A written notice will be issued to the participant, medical professional, and hospital within three (3) working days after the reconsideration review is completed. This information may also be accessed through the CyberAccess Web tool;

(B) The reconsideration review shall consist of a review of all medical records and additional documentation submitted by any one of the parties receiving the initial denial notice;

(C) The reconsideration will be conducted by a physician reviewer who has had no previous involvement in the case;

(D) Reconsideration determination by the medical review agent is the final level of the review for the provider. The division will accept the medical review agent’s decision; and (E) If the participant disagrees with a reconsideration denial by the medical review agent, s/he has the right to a fair hearing under sections 208.080, RSMo, and 208.156, RSMo.

(9) Validation Sample of Approved Admissions.

(A) A quarterly validation sample of approved admissions will be selected to ensure that the information provided during the certification process is substantiated by documentation and clinical findings in the medical record.

(B) The sample size will be a statistically valid number of certified admissions.

(C) For admissions subject to a validation review, the medical review agent will request medical records. Providers have thirty (30) calendar days from the date of written request to submit documentation. At rates determined by state statute 191.227, RSMo, provider costs associated with submission of requested documentation will be reimbursed regardless of the medium used for submission. Records not received within the thirty (30) days will result in the admission being denied and claim payment recouped.

(D) Admission certification is not a guarantee of MO HealthNet payment. If the information provided during the certification process cannot be validated in the medical record by a nurse reviewer using the criteria in section (6), or was false, misleading or incomplete, the case will be referred to a physician reviewer for a medical necessity determination. The physician reviewer is not bound by any criteria and makes the determination based on medical facts in the case using his/her medical judgment.

(E) The medical professional or hospital will be allowed an opportunity to respond to a proposed denial prior to issuance of a final denial notice.

(F) If the physician reviewer determines the admission was not medically necessary, a denial notice will be issued to all parties. Reconsideration review procedures in section (8) apply to this review.

(G) A validation review determination of denial will result in recovery of MO HealthNet payments in accordance with 13 CSR 70-3.030. Overpayment determinations may be appealed to the Administrative Hearing Commission within thirty (30) days of the date of the notice letter if the sum in dispute exceeds five hundred dollars ($500).

(H) Review of the quality of care will also be performed on the validation review sample. Potentially serious quality of care issues identified by the nurse reviewer will be referred to a physician of the medical review agent.

(10) As specific in relation to administration of the provisions of this rule and not otherwise inconsistent with participant liability as determined under provisions of 13 CSR 70-4.030, participant liability issues for admission certification and validation review are as follows:

(A) The participant is liable for inpatient hospital services in the following circumstances:

1. When the prospective request for certification is denied and the participant is notified of the denial but the participant chooses to be admitted, s/he is liable for all days;

2. When an admission request for certification is denied, the participant is liable for those days of inpatient hospital service provided after the date of the denial notification to him/ her;

3. When the participant’s eligibility was not established on or by the date of admission and the request for certification is denied, the participant is liable for all days; and 4. When the participant has signed a written agreement with the provider indicating that MO HealthNet is not the intended payer for the specific item or service, s/he is liable for all days. The agreement must be signed prior to receiving the services. In this situation, the participant accepts the status and liabilities of a private pay patient in accordance with 13 CSR 70-4.030; and (B) The participant is not liable for inpatient hospital services in the following circumstances:

4. When the provider fails to comply with prospective certification requirements, the participant is not liable for any days;

5. When an admission request for certification of an admission is denied, the participant is not liable for those days of inpatient hospital service provided prior to and including the date of the notification to him/her of the denial; and 3. When the medical review agent performs a validation review as provided in section (9) of this rule and determines an admission was not medically necessary for inpatient services, the participant is not liable for any days.

(11) Continued stay reviews, when necessary, will be performed for all fee-for-service MO HealthNet participants subject to admission certification to determine that services are medically necessary and appropriate for inpatient care. The continued stay review procedure is as follows:

(A) When extended hospitalization is indicated beyond the initial length of stay assigned by the medical review agent for prospective or admission certification, the hospital and attending medical professional are required to provide additional medical information to warrant the continued hospital stay as well as request the number of additional days needed prior to discharge or within fourteen (14) working days after discharge.

If the request for continued stay review is received fifteen (15) or more working days post discharge, it is considered a retrospective review and the requirements mentioned in subsection (5)(E) will apply;

(B) For continued stay reviews, either initiated via the CyberAccess Web tool or the telephone, the findings from the standardized tool for determining level of care will be applied to any additional diagnosis or surgical procedures indicated.

The medical professional and/or hospital may also upload any additional supporting documentation into the CyberAccess Web tool;

(C) A physician will review cases when continued stay is requested beyond the findings from the standardized tool for determining level of care. The physician reviewer shall approve or deny the continued stay days;

(D) The requesting medical professional and hospital are notified in cases of denial only. All others are found on the CyberAccess Web tool; and (E) Information contained in sections (8)–(10) of this rule also apply to continued stay reviews.

(12) Continued stay reviews will be performed for diagnoses relating to alcohol and drug abuse to determine that services are medically necessary and appropriate for inpatient care. The continued stay review procedure for alcohol and drug abuse detoxification services is as follows:

(A) At the time of admission certification, as described in section (7) of this rule, the hospital or attending medical professional shall specify the anticipated medically necessary length-of-stay;

(B) If the applicable criteria in section (6) of this rule is met, the utilization review assistant or nurse reviewer shall assign a number of days not to exceed three (3) days;

(C) If an extension of services is required, the hospital or attending medical professional shall contact the medical review agent either by the CyberAccess Web tool or by telephone to request additional days for inpatient hospital care. If the applicable criteria in section (6) of this rule is met, the utilization review assistant or nurse reviewer shall assign a total length-ofstay days not to exceed five (5) days;

(D) If either the applicable criteria in section (6) of this rule is not met or the total length-of-stay exceeds five (5) days, the case shall be referred to a physician reviewer. The physician reviewer is not bound by the criteria in section (6) of this rule and makes the determination based on medical facts in the case using his/ her medical judgment. The physician reviewer shall approve or deny the admission or continued stay days; and (E) The medical professional and hospital are notified of the review decision as stated in section (7) of this rule.

(13) The MO HealthNet program, in accordance with 191.710, RSMo, will request that hospital providers report all rehospitalizations of infants born premature at earlier than thirty-seven (37) weeks gestational age within their first six (6) months of life.

(14) Large case management will be performed for fee-forservice participants with potentially catastrophic conditions whenever specific trigger diagnoses or other qualifying events are met.

(A) Large case management procedures for fee-for-service participants are as follows:

1. Preadmission review nurses identify patients who may qualify and benefit from case management, and refer these cases to a case manager of the medical review agent. Cases include, but are not limited to, the following:

A. Patients with high costs or anticipated high costs; or B. Patients with repeated admissions or unusually long lengths-of-stay; or C. Patients who encounter significant variances from the intervention or from expected outcomes associated with a clinical path; or D. Patients who meet one (1) or more of the indicators on the Trigger Diagnosis/Qualifying Events list;

2. The medical review agent will complete an initial screening which will include a review of the medical information and interviews with the health care providers and patient, if needed or feasible;

3. An in-depth assessment will be conducted, which will include evaluation of the patient’s health status, health care treatment and service needs, support system, home environment, and physical and psychosocial functioning. The assessment will be used to recommend one (1) of the following:

A. Reassessment later; or B. No potential for case management; or C. Active monitoring in anticipation of a future plan for alternative treatment; or D. An alternative treatment plan is indicated;

4. If an alternative treatment plan is indicated, the medical review agent will collaborate with the patient’s attending medical professional to develop an alternative treatment plan. The attending medical professional is responsible for implementation of the alternative treatment plan; and 5. The medical review agent will monitor and assess the effectiveness of the case management and will report to the state.

rule filed Oct. 20, 1989, effective Nov. 1, 1989, expired Feb. 28, 1990.

Original rule filed Nov. 2, 1989, effective Feb. 25, 1990. Amended:

Filed June 18, 1991, effective Jan. 13, 1992. Amended: Filed July 2, 1992, effective Feb. 26, 1993. Amended: Filed July 1, 1996, effective Feb. 28, 1997. Amended: Filed Feb. 1, 2008, effective Aug. 30, 2008.

Amended: Filed Oct. 15, 2015, effective April 30, 2016. Amended:

Filed Jan. 7, 2022, effective July 30, 2022. Amended: Filed March 4, 2026, effective Sept. 30, 2026.

History

• authority. The medical review agent’s review decisions will be used as the basis for MO HealthNet reimbursement.
• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Emergency

13 CSR 70-15.030 Payment and Payment Limitations for Inpatient Hospital Care {#sec-13-csr-70-15.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.030}

PURPOSE: This rule establishes payment and payment limitations for all inpatient hospital admissions. Information is provided for hospital inpatient admissions that are exempt from certification.

(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, March 11, 2026.

All other admissions require certification per 13 CSR 70-15.020.

(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 Hospital Manual, which is incorporated by reference in this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, January 28, 2026. This rule does not incorporate any subsequent amendments or additions.

(2) The counting of days which may be reimbursed per inpatient stay shall be from the beginning date of admission for a continuous period of hospitalization, unless conditions described in subsection (2)(A) or (B) apply.

(A) If the participant’s beginning date of eligibility is later than the date of admission, the counting of days which may be allowable will be from the beginning eligibility date.

(B) If the participant has exhausted Title XVIII inpatient benefits, the counting of days which may be allowable will be from the date following the date on which the Title XVIII benefits are exhausted.

(3) Reimbursement shall be made in accordance with 13 CSR 70-15.010 for only allowable days during which the participant is eligible.

section 208.201, RSMo 2016.* This rule was previously filed as 13 CSR 40-81.051. Emergency rule filed April 7, 1981, effective April 20, 1981, expired July 10, 1981. Original rule filed April 7, 1981, effective July 11, 1981. Emergency amendment filed July 15, 1981, effective Aug. 1, 1981, expired Oct. 10, 1981. Emergency amendment filed Aug. 21, 1981, effective Sept. 1, 1981, expired Dec. 10, 1981.

Amended: Filed July 15, 1981, effective Oct. 11, 1981. Emergency amendment filed Nov. 20, 1981, effective Dec. 1, 1981, expired March 10, 1982. Amended: Filed Aug. 21, 1981, effective Dec. 11, 1981. Amended: Filed Nov. 20, 1981, effective March 11, 1982.

Amended: Filed April 14, 1982, effective July 11, 1982. Emergency amendment filed Nov. 24, 1982, effective Dec. 4, 1982, expired March 10, 1983. Amended: Filed Nov. 24, 1982, effective March 11, 1983. Emergency amendment filed April 8, 1983, effective April 18, 1983, expired July 10, 1983. Amended: Filed April 8, 1983, effective July 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired April 11, 1984. Emergency amendment filed March 14, 1984, effective March 28, 1984, expired June 10, 1984.

Amended: Filed March 14, 1984, effective June 11, 1984. Amended:

Filed Oct. 15, 1984, effective Feb. 11, 1985. Amended: Filed Jan. 15, 1985, effective April 11, 1985. Amended: Filed April 2, 1986, effective Sept. 1, 1986. Amended: Filed June 17, 1986, effective Sept. 1, 1986.

Emergency amendment filed Sept. 17, 1986, effective Sept. 27, 1986, expired Jan. 25, 1987. Amended: Filed Aug. 1, 1986, effective Oct. 11, 1986. Amended: Filed Nov. 14, 1986, effective Jan. 30, 1987.

Amended: Filed May 4, 1987, effective July 23, 1987. Amended:

Filed Jan. 5, 1988, effective March 25, 1988. Amended: Filed April 4, 1988, effective July 1, 1988. Emergency amendment filed Dec. 1, 1989, effective Jan. 1, 1990, expired April 29, 1990. Amended: Filed Dec. 1, 1989, effective Feb. 25, 1990. Amended: Filed Dec. 4, 1989, effective Feb. 25, 1990. Emergency amendment filed June 18, 1991, effective July 15, 1991, expired Oct. 28, 1991. Amended: Filed March 18, 1991, effective Aug. 30, 1991. Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Emergency amendment filed Oct. 15, 1991, effective Oct. 29, 1991, expired Feb. 6, 1992. Emergency amendment filed Oct. 15, 1991, effective Oct. 29, 1991, expired Feb. 6, 1992. Amended: Filed June 18, 1991, effective Oct. 31, 1991. Amended: Filed June 18, 1991, effective Oct. 31, 1991.

Amended: Filed June 15, 2005, effective Dec. 30, 2005. Amended:

Filed July 16, 2007, effective Feb. 29, 2008. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed May 5, 2016, effective Nov. 30, 2016. Amended: Filed Jan. 10, 2022, effective July 30, 2022. Amended: Filed March 2, 2026, effective Sept. 30, 2026. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: sections 208.152 and 208.153, RSMo Supp. 2025, and

13 CSR 70-15.040 Hospital Outpatient Settlements {#sec-13-csr-70-15.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.040}

PURPOSE: This regulation defines the specific procedures used to calculate the final outpatient settlements for hospital providers.

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) General. This regulation defines the specific procedures used to calculate outpatient settlements for Missouri in-state 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.

(2) Definitions.

(A) Medicaid payments. Medicaid payments included in the settlement include actual Medicaid claims payments, partial insurance payments on claims, and patient liability amounts for coinsurance and deductibles. If the insurance payments exceed the Medicaid liability, the claim will not be considered a Medicaid claim.

(B) Outpatient services/cost. Reimbursable outpatient services or costs are services or costs that are provided prior to the patient being admitted to the hospital. Only outpatient services or cost which are reimbursed on a percentage of charge as defined in 13 CSR 70-15.160 will be included in the final settlement, unless they are excluded elsewhere in this

regulation.

(C) Ancillary charges. Ancillary charges are the charges billed by the hospital for services that are not routinely provided in the routine care center and are not provided to all patients.

(D) New hospitals. A hospital which does not have a fourth prior year cost report necessary for establishment of a prospective rate will have final settlement calculated for their initial three (3) cost report periods.

(E) Nominal charge provider. A nominal charge provider must meet one (1) of the following criteria:

1. An acute care hospital with an unsponsored care ratio of at least sixty-five percent (65%) and is licensed for fifty (50) inpatient beds or more and has an occupancy rate of more than forty percent (40%). The unsponsored care ratio is determined as the sum of bad debts and charity care divided by total net revenue. The hospital must meet one (1) of the federally mandated disproportionate share qualifications; or 2. A public non-state governmental acute care hospital with a low income utilization rate (LIUR) of at least fifty percent (50%) and a Medicaid inpatient utilization rate (MIUR) greater than one (1) standard deviation from the mean, and is licensed for fifty (50) inpatient beds or more and has an occupancy rate of at least forty percent (40%); or 3. The hospital is a public hospital operated by the treatment of mental disorders.

(F) Division. Unless otherwise designated, division refers to the MO HealthNet Division (MHD) a division of the Department (G) Incorporation by reference. This rule incorporates by reference the following:

1. The Hospital Provider Manual 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://manuals. momed.com/manuals, September 10, 2021. This rule does not incorporate any subsequent amendments or additions; and 2. 42 CFR part 413, which is incorporated by reference and made a part of this rule as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, DC 20408, and available at https://www.ecfr.gov/current/title-42/

chapter-IVsubchapter-B/part-413?toc=1, November 1, 2021. This (3) Hospital Outpatient Settlements will be calculated as (A) The hospital’s Medicaid outpatient cost will be determined by multiplying the overall outpatient cost-to-charge ratio, determined in accordance with paragraph (3)(A)1. of this rule, by the Medicaid charges from subsection (1)(B) of this rule.

To this product will be added the Medicaid outpatient share of Direct Graduate Medical Education (GME) to arrive at the total outpatient Medicaid cost. The GME will be determined during the Medicaid cost report audit. The Medicaid payments from subsection (1)(B) will be substracted from the total outpatient Medicaid cost to determine the final overpayment or underpayment.

1. The overall outpatient cost-to-charge ratio will be determined by multiplying the outpatient charges for each ancillary cost center, excluding Provider Based Rural Health Clinic (PBRHC) or Provider Based Federally Qualified Health Centers (PBFQHC), on worksheet C part I column 7 by the appropriate cost-to-charge ratio from worksheet C part I column 9 to determine the outpatient cost for each cost center.

Total the outpatient costs from each cost center and total the outpatient charges from each cost center. Divide the total outpatient costs by the total outpatient charges to arrive at the overall outpatient cost-to-charge ratio.

(4) Under no circumstances will the division accept amended cost reports for final settlement determination or adjustment after the date of the division’s notification of the final settlement amount.

Amended: Filed Aug. 24, 2001, effective March 30, 2002. Emergency amendment filed June 20, 2002, effective July 1, 2002, expired Feb. 27, 2003. Amended: Filed June 14, 2002, effective Jan. 30, 2003.

Amended: Filed Sept. 22, 2021, effective April 30, 2022. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; 208.471, RSMo 1992, amended 2001, 2014, 2018; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and sections 208.152 and 208.471, RSMo Supp. 2021. Original rule filed June 2, 1994, effective Dec. 30, 1994. Amended: Filed June 3, 1997, effective Dec. 30, 1997. Amended: Filed May 14, 1999, effective Nov. 30, 1999. Amended: Filed June 15, 1999, effective Dec. 30, 1999.

13 CSR 70-15.070 Inpatient Psychiatric Services for Individuals Under Age Twenty-One {#sec-13-csr-70-15.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.070}

PURPOSE: This rule provides the legal basis where inpatient psychiatric services provided eligible individuals under the age of twenty-one might be afforded coverage for purposes of vendor payment under the Title XIX Medicaid program.

(1) Pursuant to provisions of section 208.161, RSMo, MO Health- Net coverage will be afforded to eligible individuals under age twenty-one (21) for inpatient psychiatric services provided under the following conditions:

(A) Under the direction of a physician; and (B) In a psychiatric hospital facility or an inpatient psychiatric program in a hospital, either of which is accredited by a national organization whose psychiatric hospital accrediting program has been approved by Centers for Medicare & Medicaid Services (CMS) or is licensed by the hospital licensing authority of Missouri; or (C) In a psychiatric residential treatment facility (PRTF) that is operated as a public institution by the Missouri Department of Mental Health (DMH) and is exempt from the hospital licensing law, that is accredited by the Joint Commission, the Council on Accreditation, The Commission on Accreditation of Rehabilitation Facilities, Det Norske Veritas (DNV) or equivalent organization, and is certified as complying with the requirements at 42 CFR 441 subpart D and the condition of participation at 42 CFR 483 subpart G by the designated state agency for which such authority has been authorized; or (D) In a privately operated PRTF that is accredited by the Joint Commission, the Council on Accreditation, the Commission on Accreditation of Rehabilitation Facilities, Det Norske Veritas (DNV), or equivalent organization, and is certified as complying with the requirements at 42 CFR 441 subpart D and the condition of participation at 42 CFR 483 subpart G by the designated state agency for which such authority has been authorized; and (E) For claimants under the age of twenty-one (21) or, if receiving the services immediately before attaining the age of twenty-one (21), not to extend beyond the earlier of the date— 1. Services are no longer required; or 2. Individual reaches the age of twenty-two (22).

(2) Reimbursement for inpatient psychiatric services, as provided for in this rule, shall be made as follows:

(A) For psychiatric hospitals and inpatient psychiatric programs within general hospitals, reimbursement will be calculated in accordance with the provisions for inpatient hospital care reimbursement at 13 CSR 70-15.010;

(B) For state-operated PRTF services for individuals under the age of twenty-one (21), reimbursement will be calculated as 1. The MO HealthNet Division shall reimburse stateoperated PRTFs for services based on the individual participant’s days of care multiplied by the facility’s Title XIX per diem rate less any payments made by participants;

2. The per diem for a state-operated PRTF is calculated as A. Determine the total costs from the second prior year hospital cost report (i.e., FY 2021 per diem rate is based off the hospital’s 2019 cost report) for PRTF services;

B. Trend the total cost of the state operated PRTF by the Hospital Market Basket index as published in Healthcare Cost Review by Institute of Health Systems (IHS), or equivalent publication, regardless of any changes in the name of the publication or publisher;

C. Determine the total PRTF patient days from the DMH Customer Information Management, Outcomes and Reporting (CIMOR) system for the second prior year to correspond with the hospital cost report; and D. Divide the trended cost as determined in subparagraphs (2)(B)2.A. and (2)(B)2.B. of this rule by the total patient days as determined in subparagraph (2)(B)2.C. of this rule to arrive at the state-operated PRTF per diem; and 3. The per diem is updated each state fiscal year using the second prior year cost report;

(C) For private PRTF services for individuals under the age of twenty-one (21), reimbursement will be calculated as follows:

1. Effective for dates of service on or after September 29, 2021, the division will reimburse private PRTFs on a prospective per diem rate. The prospective Missouri private PRTF per diem rate was created using a wage rate model which utilized data derived from cost surveys prepared and submitted by potential PRTF providers. These cost surveys were collected February 2021 or prior. The model specifically examines potential facility, occupancy, staff to patient ratios, necessary nursing hours per patient day, direct care and behavioral health professional wage and overhead expense, and risk factors. For a detailed breakdown of these calculations, see https://dss.mo.gov/mhd/ cs/psych/pdf/mo-prtf-wage-rate-build-model.pdf. The Missouri Prospective PRTF Rate Methodology document is incorporated by reference and made a part of this rule as published by the Howerton Court, Jefferson City, MO 65109, on its website at https://dss.mo.gov/mhd/cs/psych/pdf/mo-prtf-wage-rate-buildmodel.pdf, October 1, 2021. This rule does not incorporate any subsequent amendments or additions. The per diem rate is included in the MO HealthNet Division (MHD) fee schedule, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO Health- Net Division, 615 Howerton Court, Jefferson City, MO 65109, August 13, 2021. This rule does not incorporate any subsequent amendments or additions; and (D) For state-operated and private PRTFs, medical leave days and therapeutic leave days will be paid to the PRTF at fifty percent (50%) of the per diem rate. Medical leave days include inpatient hospital medical/surgical stays and inpatient hospital psychiatric stays. Five (5) days of leave are allowed for medical/ surgical stays per treatment episode, and five (5) days of leave are allowed for inpatient psychiatric stays per treatment episode. Therapeutic leave is for purposes of transition from the PRTF to the designated placement and must be included in the participant’s plan of care. Ten (10) days of leave are allowed for therapeutic leave per treatment episode.

(3) A written and signed certification of need for services must be completed for every admission reimbursed by Medicaid that attests to— (A) Ambulatory care resources available in the community do not meet the treatment needs of the youth;

(B) Inpatient treatment under the direction of a physician is needed; and (C) The services can reasonably be expected to improve the patient’s condition, or prevent further regression, so that the services will no longer be needed.

(4) The certifications of need for care shall be made by different teams depending on the status of the individual patients as (A) For an individual who is receiving Medicaid at the time of admission, the certification of need shall be made by an independent team of health professionals that— 1. Includes a physician;

2. Has competence in diagnosis and treatment of mental illness, preferably in child psychiatry; and 3. Has knowledge of the individual’s situation;

(B) For an individual who applies for Medicaid while in the facility, the certification of need shall be made by the treatment facility interdisciplinary team responsible for the individual’s plan of care as specified in section (5). The certification of need is to be made before submitting a Medicaid claim for payment and must cover any period for which Medicaid claims are made; or (C) For an individual who undergoes an emergency admission, the certification of need shall be made by the treatment facility interdisciplinary team responsible for the individual’s plan of care as specified in section (5) within fourteen (14) days after admission.

(5) The treatment facility’s interdisciplinary team shall be a team of physicians and other personnel who are employed by, or provide services to patients in, the facility.

(A) The team shall include, as a minimum, either— 1. A board-eligible or board-certified psychiatrist who is a licensed physician;

2. A clinical psychologist who has a doctoral degree and is licensed and a physician licensed to practice medicine or osteopathy; or 3. A physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of behavioral health disorders, and a psychologist who has a master’s degree or doctorate in clinical psychology and is licensed.

(B) The team also shall include one (1) of the following:

1. A psychiatric social worker who is licensed;

2. A licensed registered nurse with specialized training or one (1) year’s experience in treating individuals with behavioral health disorders;

3. An occupational therapist who is licensed and who has specialized training or one (1) year of experience in treating individuals with behavioral health disorders; or 4. A psychologist who has a master’s degree or doctorate in clinical psychology and is licensed.

(C) The team must be capable of performing the following responsibilities:

1. Assessing the individual’s immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities;

2. Assessing the potential resources of the individual’s family;

3. Setting treatment objectives; and 4. Prescribing therapeutic modalities to achieve the plan of care objectives.

(6) Inpatient psychiatric services shall include active treatment which means implementation of a professionally developed and supervised individual plan of care, as described in section (7), that meets the following requirements:

(A) Developed and implemented no later than fourteen (14) days after admission; and (B) Designed to achieve the participant’s discharge from inpatient status at the earliest possible time.

(7) An individual plan of care is a written plan developed for each participant to improve his/her condition to the extent that inpatient care is no longer necessary. The plan of care shall— (A) Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral, and developmental aspects of the participant’s situation and reflects the need for inpatient psychiatric care;

(B) Be developed by a team of professionals specified under

section (5) in consultation with the participant, and his/her parents, legal guardians, or others in whose care s/he will be released after discharge;

(C) State treatment objectives;

(D) Prescribe an integrated program of therapies, activities, and experiences designed to meet objectives;

(E) Include, at an appropriate time, post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the participant’s family, school, and community upon discharge; and (F) Be reviewed every thirty (30) days by the treatment facility interdisciplinary team specified in section (5) to provide the following requirements:

1. Determine that services being provided are or were required on an inpatient basis; and 2. Recommend changes in the plan as indicated by the participant’s overall adjustment as an inpatient.

(8) Before admission or before authorization for payment, the team described in section (4) of this rule must make medical, psychiatric, and social evaluations of each applicant’s or participant’s need for care in the hospital or PRTF. Each medical evaluation must include the following elements:

(A) Diagnoses;

(B) Summary of present medical findings;

(C) Medical history;

(D) Mental and physical functional capacity;

(E) Prognoses; and (F) A recommendation by a licensed physician concerning admission to or continued care in the hospital or PRTF for individuals who apply for Medicaid after admission.

(9) Audits to monitor facility or program compliance shall be performed by a medical review agent as authorized by the MO HealthNet Division. Inpatient admissions of July 1, 1991, and after will be subject to audits, which may include up to one hundred percent (100%) of Medicaid admissions.

Documentation of certification of need, medical/psychiatric/ social evaluations, plan of care, and active treatment shall be a part of the individual’s medical record. All required documentation must be a part of the medical record at the time of audit to be considered during the audit. Failure of the medical record to contain the required documents at the time of audit shall result in recoupment. The medical review agent’s audit process is as follows:

(A) The facility has thirty (30) calendar days from the date of the request to furnish medical records for desk audits. At rates determined by the medical review agent, provider costs associated with submission of records will be reimbursed.

Records not received within thirty (30) days will result in the services being denied and the Medicaid payment recouped;

(B) Review of the certification of need, medical/psychiatric/ social evaluations, and plan of care documentation is performed to determine compliance with this rule;

(C) A sample of claims is reviewed for quality of care;

(D) An initial review of the medical record information for active treatment is performed by either a nurse who is licensed or social worker reviewer who is licensed using a nationally recognized, evidence-based clinical tool;

(E) If the medical record documentation regarding the patient’s condition and planned services meet the criteria in subsection (9)(D) of this rule, the services are approved by either the nurse or social worker reviewer;

(F) If the criteria in subsection (9)(D) of this rule is not met, the nurse or social worker reviewer refers the case to a physician reviewer who is a licensed physician for a determination of documentation and medical necessity. The physician reviewer is not bound by criteria used by the nurse or social worker reviewer. The physician reviewer uses his/her medical judgment to make a determination based on the documented medical facts in the record;

(G) If the physician reviewer denies the admission or days of stay, the attending physician and facility shall be notified.

The facility may request of the medical review agent a reconsideration review. The facility is notified of the medical review agent’s reconsideration determination;

(H) Reconsideration determination is the final level of review by the medical review agent. The division will accept the medical review agent’s decision;

(I) Facilities are notified by the MO HealthNet Division if an adjustment of Medicaid payments is required as a result of audit findings;

(J) The following Medicaid policies apply for calculation of Medicaid payments:

1. Medicaid shall reimburse nursing facility care provided in the inpatient hospital or PRTF setting in accordance with 13 CSR 70-15.010;

2. No Medicaid payment shall be made on behalf of any participant who is receiving inpatient hospital care and is not in need of either inpatient or nursing facility care. No payment will be made for outpatient services rendered on an inpatient

basis; or 3. Medicaid shall not pay for admissions or continued days for social situations, placement problems, court commitments, or abuse/neglect without medical risk; and (K) Overpayment determinations may be appealed in accordance with section 208.156, RSMo.

Amended: Filed June 18, 1991, effective Dec. 9, 1991. Emergency amendment filed Aug. 13, 2021, effective Sept. 29, 2021, expired March 27, 2022. Amended: Filed Aug. 13, 2021, effective March 30, 2022. Amended: Filed May 17, 2023, effective Dec. 30, 2023.

Emergency amendment filed Dec. 16, 2025, effective Dec. 31, 2025, expired June 28, 2026. Amended: Filed Dec. 16, 2025, effective July

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. This rule was previously filed as 13 CSR 40-81.053. Emergency rule filed Sept. 24, 1981, effective Oct. 4, 1981, expired Jan. 13, 1982. Original rule filed Sept. 24, 1981, effective Jan. 14, 1982. Emergency amendment filed Sept. 13, 1991, effective Oct. 2, 1991, expired Jan. 29, 1992.

13 CSR 70-15.080 Payment Method for General Relief Recipient Hospital Outpatient Services {#sec-13-csr-70-15.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.080}

(Rescinded December 30, 2005)

History

• AUTHORITY: section 207.020, RSMo 1986. This rule was previously filed as 13 CSR 40-81.180. Emergency rule filed July 15, 1981, effective Aug. 1, 1981, expired Oct. 10, 1981. Original rule filed July 15, 1981, effective Oct. 11, 1981. Rescinded: Filed June 15, 2005, effective Dec. 30, 2005.

13 CSR 70-15.090 Procedures for Evaluation of Appropriate Inpatient Hospital Admissions and Continued Days of Stay {#sec-13-csr-70-15.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.090}

(Rescinded May 30, 2020)

Rescinded: Filed Nov. 2, 1989, effective Jan. 26, 1990. Emergency

rule filed June 4, 1990, effective June 28, 1990, expired Oct. 25, 1990.

Readopted: Filed June 4, 1990, effective Nov. 30, 1990. Amended:

Filed Nov. 3, 2017, effective June 30, 2018. Rescinded: Filed Oct. 25, 2019, effective May 30, 2020.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo 2016. This rule was previously filed as 13 CSR 40-81.162. Original rule filed May 3, 1985, effective Sept. 1, 1985. Amended: Filed Nov. 15, 1988, effective Feb. 11, 1989. Amended: Filed April 4, 1989, effective June 29, 1989.

13 CSR 70-15.100 Unreimbursed Care Payment Methodology Emergency rule filed May 4, 1992, effective May 15, 1992, expired Sept. 11, 1992. {#sec-13-csr-70-15.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.100}

13 CSR 70-15.110 Federal Reimbursement Allowance (FRA) {#sec-13-csr-70-15.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.110}

PURPOSE: This rule establishes the formula for determining the Federal Reimbursement Allowance each hospital, except public hospitals which are operated primarily for the care and treatment of mental disorders and any hospital operated by the Department of Health, is required to pay for the privilege of engaging in the business of providing inpatient health care in Missouri.

(1) Federal Reimbursement Allowance (FRA). FRA shall be assessed as described in this section.

(A) Definitions.

1. Bad debts—Amounts considered to be uncollectible from accounts and notes receivable that were created or acquired in providing services. Allowable bad debts include the costs of caring for patients who have insurance, but their insurance does not cover the particular service procedures or treatment rendered.

2. Base year cost report—Audited Medicaid cost report from the third prior calendar year. If a hospital has more than one (1) cost report with periods ending in the third prior calendar year, the cost report covering a full twelve- (12-) month period will be used. If none of the cost reports covers a full twelve (12) months, the cost report with the latest period will be used. If a hospital’s base year cost report is less than or greater than a twelve- (12-) month period, the data shall be adjusted, based on the number of days reflected in the base year cost report, to a twelve- (12-) month period. Any changes to the base year cost report after the division issues a final decision on assessment will not be included in the calculations.

3. Charity care—Those charges written off by a hospital based on the hospital’s policy to provide health care services free of charge or at a reduced charge because of the indigence or medical indigence of the patient.

4. Contractual allowances—Difference between established rates for covered services and the amount paid by thirdparty payers under contractual agreements. The Federal Reimbursement Allowance (FRA) is a cost to the hospital, regardless of how the FRA is remitted to the MO HealthNet Division, and shall not be included in contractual allowances for determining revenues. Any redistributions of MO HealthNet payments by private entities acting at the request of participating health care providers shall not be included in contractual allowances or determining revenues or cost of patient care.

5. Department—Department of Social Services.

6. Director—Director of the Department of Social Services.

7. Division—MO HealthNet Division, Department of Social Services.

8. Engaging in the business of providing inpatient health care—Accepting payment for inpatient services rendered.

9. Federal Reimbursement Allowance (FRA)—The fee assessed to hospitals for the privilege of engaging in the business of providing inpatient health care in Missouri. The FRA is an allowable cost to the hospital.

10. Fiscal period—Twelve- (12-) month reporting period determined by each hospital.

11. Gross hospital service charges—Total charges made by the hospital for inpatient and outpatient hospital services that are covered under 13 CSR 70-15.010.

12. Hospital—A place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment, or care for not fewer than twenty-four (24) hours in any week of three (3) or more nonrelated individuals suffering from illness, disease, injury, deformity, or other abnormal physical conditions; or a place devoted primarily to provide, for not fewer than twenty-four (24) hours in any week, medical or nursing care for three (3) or more nonrelated individuals. The term hospital does not include convalescent, nursing, shelter, or boarding homes as defined in Chapter 198, RSMo.

13. Hospital revenues subject to FRA assessment effective July 1, 2008—Each hospital’s inpatient adjusted net revenues and outpatient adjusted net revenues subject to the FRA assessment will be determined as follows:

A. Obtain “Gross Total Charges” from Worksheet G-2, Line 25, Column 3 from CMS 2552-96, or Worksheet G-2, Line 28, Column 3 from CMS 2552-10, of the third prior year cost report (i.e., FRA fiscal year cost report) for the hospital.

Charges shall exclude revenues for physician services. Charges related to activities subject to the Missouri taxes assessed for outpatient retail pharmacies and nursing facility services shall also be excluded. “Gross Total Charges” will be reduced by the following:

(I) “Nursing Facility Charges” from Worksheet C, Part I, Line 35, Column 6 from CMS 2552-96, or Worksheet C, Part I, Line 45, Column 6 from CMS 2552-10;

(II) “Swing Bed Nursing Facility Charges” from Worksheet G-2, Line 5, Column 1 from CMS 2552-96, or Worksheet G-2, Line 6, Column 1 from CMS 2552-10;

(III) “Nursing Facility Ancillary Charges” as determined from the Department of Social Services, MO HealthNet Division, nursing home cost report. (Note: To the extent that the gross hospital charges, as specified in subparagraph (1)(A)13.A. above, include long-term care charges, the charges to be excluded through this step shall include all long-term care ancillary charges including skilled nursing facility, nursing facility, and other long-term care providers based at the hospital that are subject to the state’s provider tax on nursing facility services.);

(IV) “Distinct Part Ambulatory Surgical Center Charges” from Worksheet G-2, Line 22, Column 2 from CMS 2552-96, or Worksheet G-2, Line 25, Column 2 from CMS 2552-10;

(V) “Ambulance Charges” from Worksheet C, Part I, Line 65, Column 7 from CMS 2552-96, or Worksheet C, Part I, Line 95, Column 7 from CMS 2552-10;

(VI) “Home Health Charges” from Worksheet G-2, Line 19, Column 2 from CMS 2552-96, or Worksheet G-2, Line 22, Column 2 from CMS 2552-10;

(VII) “Total Rural Health Clinic Charges” from Worksheet C, Part I, Column 7, Lines 63.50–63.59 from CMS 2552-96, or Worksheet C, Part I, Column 7, Line 88 and subsets from CMS 2552-10; and (VIII) “Other Non-Hospital Component Charges” from Worksheet G-2, Lines 6, 8, 21, 21.02, 23, and 24 from CMS 2552- 96, or Worksheet G-2, Lines 5, 7, 9, 21, 24, 26, and 27 from CMS 2552-10;

B. Obtain “Net Revenue” from Worksheet G-3, Line 3, Column 1. The state will ensure this amount is net of bad debts and other uncollectible charges by survey methodology;

C. “Adjusted Gross Total Charges” (the result of the computations in subparagraph (1)(A)13.A.) will then be further adjusted by a hospital-specific collection-to-charge ratio determined as follows:

(I) Divide “Net Revenue” by “Gross Total Charges”; and (II) “Adjusted Gross Total Charges” will be multiplied by the result of part (1)(A)13.C.(I) to yield “Adjusted Net Revenue”;

D. Obtain “Gross Inpatient Charges” from Worksheet G-2, Line 25, Column 1 from CMS 2552-96, or Worksheet G-2, Line 28, Column 1 from CMS 2552-10, of the most recent cost report that is available for a hospital;

E. Obtain “Gross Outpatient Charges” from Worksheet G-2, Line 25, Column 2 from CMS 2552-96, or Worksheet G-2, Line 28, Column 2 from CMS 2552-10, of the most recent cost report that is available for a hospital;

F. Total “Adjusted Net Revenue” will be allocated between “Net Inpatient Revenue” and “Net Outpatient Revenue” as (I) “Gross Inpatient Charges” will be divided by “Gross Total Charges”;

(II) “Adjusted Net Revenue” will then be multiplied by the result to yield “Net Inpatient Revenue”; and (III) The remainder will be allocated to “Net Outpatient Revenue”; and G. The trend indices, if greater than zero percent (0%), will be determined based on the Health Care Costs index as published in Healthcare Cost Review by Institute of Health Systems (IHS), or equivalent publication, regardless of any changes in the name of the publication or publisher, for each state fiscal year (SFY). The trend indices listed below will be applied to the apportioned inpatient adjusted net revenue and outpatient adjusted net revenue in order to inflate or trend forward the adjusted net revenues from the FRA fiscal year cost report to the current state fiscal year to determine the inpatient and outpatient adjusted net revenues subject to the FRA assessment.

(I) SFY 2023 =

(a) Inpatient Adjusted Net Revenues—3.8% (b) Outpatient Adjusted Net Revenues—0% (II) SFY 2024 = (a) Inpatient Adjusted Net Revenues—0% (b) Outpatient Adjusted Net Revenues—0% (III) SFY 2025 = (a) Inpatient Adjusted Net Revenues—0% (b) Outpatient Adjusted Net Revenues—0% (IV) SFY 2026 = (a) Inpatient Adjusted Net Revenues – 4.5% (b) Outpatient Adjusted Net Revenues – 0% (B) Each hospital engaging in the business of providing health care in Missouri shall pay an FRA. The FRA shall be calculated by the Department of Social Services.

1. The FRA shall be as described beginning with section (2) and going forward.

2. If a hospital does not have a third prior year cost report on which to determine the hospital revenues subject to FRA assessment as set forth in paragraph (1)(A)13., inpatient and outpatient adjusted net revenues shall be based upon the projections included with its Certificate of Need (CON) application on the “Service-Specific Revenues and Expenses” form (CON projections) required in a full CON review as described in 19 CSR 60-50.470. If the hospital did not go through a full CON review, it must submit a completed “Service-Specific Revenues and Expenses” form that has been verified by an independent auditor.

A. The hospital must provide the division with the breakdown of the inpatient and outpatient revenues that tie to the CON projections.

B. The CON projections and the breakdown of the inpatient and outpatient revenues are subject to review and validation by the division.

C. Once the facility has a third prior year cost report, the assessment shall be based on the actual inpatient and outpatient adjusted net revenues from such cost report.

3. The FRA assessment for hospitals that merge operation under one (1) Medicare and MO HealthNet provider number shall be determined as follows:

A. The previously determined FRA assessment for each hospital shall be combined under the active MO HealthNet provider number for the remainder of the state fiscal year after the division receives official notification of the merger; and B. The FRA assessment for subsequent fiscal years shall be based on the combined data for both facilities.

4. A hospital which either voluntarily or involuntarily terminates its license and which becomes relicensed will be assessed the same inpatient and outpatient assessment as the previous hospital owner/operator if the hospital becomes relicensed during the same state fiscal year. If the hospital does not become relicensed during the same state fiscal year, the inpatient and outpatient assessment will be determined based on the applicable base year data (i.e., third prior year). If the hospital does not have the applicable base year data, the inpatient and outpatient assessment will be based on the most recent cost report data available and will include annual trend factor adjustments from the year subsequent to the cost report period through the state fiscal year for which the assessments are being determined.

(C) The division shall prepare a confirmation schedule of the information from each hospital’s third prior year cost report and provide each hospital with this schedule. Each hospital required to pay the FRA shall review the confirmation schedule and confirm the information is correct or provide correct information within fifteen (15) days of receiving the confirmation schedule. If the hospital fails to submit the corrected data within the fifteen- (15-) day time period, the hospital shall be barred from submitting corrected data later to have its FRA assessment or the additional payments from 13 CSR 70-15.010, 13 CSR 70-15.015, 13 CSR 70-15.220, and 13 CSR 70- 15.230 adjusted.

1. The FRA will be offset against any Missouri Medicaid payment due the hospital. The FRA assessments shall be allocated and deducted over the applicable period.

2. A letter will be sent to the hospital indicating the FRA balance due after offset, if any, at the end of each state fiscal quarter. The FRA balance due shall be remitted by the hospital to the MO HealthNet Division as stated in the letter.

(2) The FRA assessment shall not exceed six percent (6%) of the revenues.

(A) Beginning July 1, 2022, the FRA assessment shall be determined at a rate of five and four-tenths percent (5.40%) of (B) Beginning July 1, 2023, the FRA assessment shall be determined at a rate of four and eight-tenths percent (4.80%) of (C) Beginning July 1, 2024, the FRA assessment shall be determined at a rate of four and two-tenths percent (4.20%) of (D) Beginning July 1, 2025, the FRA assessment shall be determined at a rate of five percent (5.0%) of each hospital’s revenues as set forth in paragraph (1)(A)13. The FRA assessment rate will be applied individually to the hospital’s inpatient adjusted net revenues and outpatient adjusted net revenues. The hospital’s total FRA assessment is the sum of the assessment determined from its inpatient adjusted net revenue plus the assessment determined for its outpatient adjusted net revenue.

Amended: Filed Oct. 15, 1993, effective June 6, 1994. Emergency amendment filed Sept. 23, 1994, effective Oct. 3, 1994, expired Feb. 1, 1995. Emergency amendment filed Jan. 20, 1995, effective Jan. 31, 1995, expired May 30, 1995. Emergency amendment filed Feb. 9, 1995, effective Feb. 20, 1995, expired June 19, 1995. Amended:

Filed Feb. 9, 1995, effective Aug. 30, 1995. Emergency amendment filed June 20, 1995, effective July 1, 1995, expired Oct. 28, 1995.

Emergency amendment filed July 31, 1995, effective Aug. 10, 1995, expired Dec. 7, 1995. Amended: Filed May 19, 1995, effective Dec. 30, 1995. Emergency amendment filed Nov. 27, 1995, effective Dec. 8, 1995, expired June 4, 1996. Amended: Filed Nov. 27, 1995, effective June 30, 1996. Emergency amendment filed June 21, 1996, effective July 1, 1996, expired Dec. 27, 1996. Amended: Filed April 15, 1996, effective Nov. 30, 1996. Emergency amendment filed June 21, 1996, effective July 1, 1996, expired Dec. 31, 1996. Emergency amendment filed Sept. 13, 1996, effective Oct. 1, 1996, expired March 29, 1997.

Amended: Filed Sept. 13, 1996, effective April 30, 1997. Emergency amendment filed June 3, 1997, effective July 1, 1997, expired Dec. 27, 1997. Amended: Filed June 3, 1997, effective Dec. 30, 1997.

Emergency amendment filed March 2, 1998, effective April 1, 1998, expired Sept. 28, 1998. Amended: Filed March 2, 1998, effective Sept. 30, 1998. Emergency amendment filed Aug. 31, 1998, effective Sept. 10, 1998, expired March 8, 1999. Amended: Filed Jan. 14, 1999, effective July 30, 1999. Emergency amendment filed March 29, 1999, effective April 8, 1999, expired Oct. 4, 1999. Amended: Filed Aug. 16, 1999, effective March 30, 2000. Amended: Filed March 3, 2000, effective Oct. 30, 2000. Emergency amendment filed June 8, 2001, effective June 18, 2001, expired Dec. 8, 2001. Amended: Filed June 8, 2001, effective Nov. 30, 2001. Amended: Filed Sept. 11, 2001, effective March 30, 2002. Emergency amendment filed May 28, 2002, effective June 6, 2002, expired Dec. 2, 2002. Amended: Filed April 29, 2002, effective Nov. 30, 2002. Emergency amendment filed April 29, 2003, effective May 9, 2003, terminated Sept. 18, 2003.

Amended: Filed April 29, 2003, effective Nov. 30, 2003. Emergency amendment filed Sept. 8, 2003, effective Sept. 18, 2003, expired March 15, 2004. Amended: Filed Sept. 8, 2003, effective March 30, 2004. Emergency amendment filed June 7, 2004, effective June 17, 2004, expired Dec. 13, 2004. Amended: Filed June 7, 2004, effective Dec. 30, 2004. Emergency amendment filed Sept. 10, 2004, effective Sept. 20, 2004, expired March 18, 2005. Amended: Filed Sept. 27, 2004, effective March 30, 2005. Emergency amendment filed June 7, 2005, effective June 17, 2005, expired Dec. 13, 2005. Amended:

Filed June 15, 2005, effective Dec. 30, 2005. Emergency amendment filed May 10, 2006, effective May 20, 2006, expired Nov. 15, 2006.

Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended: filed May 10, 2006, effective Nov. 30, 2006. Emergency amendment filed June 20, 2007, effective July 1, 2007, expired Dec. 27, 2007. Amended: Filed June 20, 2007, effective Jan. 30, 2008. Emergency amendment filed June 18, 2008, effective July 1, 2008, expired Dec. 28, 2008. Amended: Filed July 1, 2008, effective Jan. 30, 2009. Emergency amendment filed June 19, 2009, effective July 1, 2009, expired Dec. 28, 2009. Amended: filed July 1, 2009, effective Jan. 30, 2010. Emergency amendment filed Dec. 1, 2009, effective Jan. 1, 2010, expired June 29, 2010. Amended:

Filed Dec. 1, 2009, effective June 30, 2010. Emergency amendment filed June 17, 2010, effective July 1, 2010, expired Dec. 27, 2010.

Amended: Filed June 17, 2010, effective Jan. 30, 2011. Emergency amendment filed Sept. 20, 2011, effective Oct. 1, 2011, expired March 28, 2012. Amended: Filed July 1, 2011, effective Jan. 30, 2012.

Emergency amendment filed June 20, 2012, effective July 1, 2012, expired Dec. 28, 2012. Amended: Filed July 2, 2012, effective Jan. 30, 2013. Emergency amendment filed June 20, 2013, effective July 1, 2013, expired Dec. 28, 2013. Amended: Filed July 1, 2013, effective Jan. 30, 2014. Emergency amendment filed June 20, 2014, effective July 1, 2014, expired Dec. 27, 2014. Amended: Filed July 1, 2014, effective Jan. 30, 2015. Emergency amendment filed June 19, 2015, effective July 1, 2015, expired Dec. 28, 2015. Amended: Filed July 1, 2015, effective Jan. 30, 2016. Emergency amendment filed June 20, 2016, effective July 1, 2016, expired Dec. 27, 2016. Amended:

Filed June 23, 2016, effective Jan. 30, 2017. Emergency amendment filed June 20, 2017, effective July 1, 2017, expired Feb. 22, 2018.

Amended: Filed June 20, 2017, effective Jan. 30, 2018. Emergency amendment filed June 21, 2018, effective July 1, 2018, expired Feb. 28, 2019. Amended: Filed June 21, 2018, effective Jan. 30, 2019.

Amended: Filed April 30, 2020, effective Nov. 30, 2020. Emergency amendment filed Aug. 26, 2021, effective Sept. 10, 2021, expired March 8, 2022. Amended: Filed Aug. 26, 2021, effective April 30, 2022. Emergency amendment filed June 15, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 15, 2022, effective Jan. 30, 2023. Emergency amendment filed June 15, 2023, effective June 30, 2023, expired Dec. 26, 2023. Amended: Filed June 28, 2023, effective Feb. 29, 2024. Emergency amendment filed July 26, 2024, effective Aug. 9, 2024, expired Feb. 27, 2025. Amended: Filed July 26, 2024, effective Feb. 28, 2025. Emergency amendment filed June 20, 2025, effective July 7, 2025, expired Feb. 26, 2026. Amended:

Filed June 23, 2025, effective Jan. 30, 2026. *Original authority: 208.201, RSMo 1987, amended 2007; 208.453, RSMo 1992, amended 1994, 2010; 208.455, RSMo 1992, amended 1993, 1994, 1995; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201, 208.453, 208.455, and 660.017, RSMo 2016. Emergency rule filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency rule filed Jan. 15, 1993, effective Jan. 25, 1993, expired May 24, 1993. Original rule filed Sept. 21, 1992, effective June 7, 1993. Emergency amendment filed Sept. 2, 1993, effective Sept. 18, 1993, expired Jan. 15, 1994.

13 CSR 70-15.150 Enhancement Pools {#sec-13-csr-70-15.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.150}

(Rescinded September 30, 2018)

rule filed April 9, 2001, effective April 19, 2001, expired Oct. 15, 2001.

Original rule filed April 9, 2001, effective Sept. 30, 2001. Rescinded:

Filed March 2, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo 2000. Emergency

13 CSR 70-15.160 Outpatient Hospital Services Reimbursement Methodology {#sec-13-csr-70-15.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.160}

PURPOSE: This rule establishes the payment methodology for outpatient hospital services.

(1) Outpatient Simplified Fee Schedule (OSFS) Payment Methodology.

(A) Definitions. The following definitions will be used in administering section (1) of this rule:

1. Ambulatory Payment Classification (APC). Medicare’s ambulatory payment classification assignment groups of Current Procedural Terminology (CPT) or Healthcare Common Procedures Coding System (HCPCS) codes. APCs classify and group clinically similar outpatient hospital services that can be expected to consume similar amounts of hospital resources.

All services within an APC group have the same relative weight used to calculate the payment rates;

2. APC conversion factor. The unadjusted national conversion factor calculated by Medicare effective January 1 of each year, as published with the Medicare Outpatient Prospective Payment System (OPPS) Final Rule, and used to convert the APC relative weights into a dollar payment. The Medicare OPPS Final Rule is incorporated by reference and made a part of this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, December 20, 2024. This rule does not incorporate any subsequent 3. APC relative weight. The national relative weights calculated by Medicare for the Outpatient Prospective Payment System;

3. Current Procedural Terminology (CPT). A medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations;

4. Dental procedure codes. The procedure codes found in the Code on Dental Procedures and Nomenclature (CDT), a national uniform coding method for dental procedures maintained by the American Dental Association;

5. Federally Deemed Critical Access Hospital. Hospitals that meet the federal definition found in 42 Code of Federal Regulations (CFR) 485.606(b), which is incorporated by reference in this rule as published by U.S. Government Publishing Office, U.S. Superintendent of Documents, Washington, DC 20402, October 1, 2023. This rule does not incorporate any subsequent 7. HCPCS. The national uniform coding method maintained by the Centers for Medicare & Medicaid Services (CMS) that incorporates the American Medical Association (AMA)

Physicians CPT and the three (3) HCPCS unique coding levels I, II, and III;

8. Medicare Inpatient Prospective Payment System (IPPS) wage index. The wage area index values are calculated annually by Medicare, published as part of the Medicare IPPS Final Rule;

9. Missouri conversion factor. The single, statewide conversion factor used by the MO HealthNet Division (MHD) to determine the APC-based fees, uses a formula based on Medicare OPPS. The formula consists of sixty percent (60%) of the APC conversion factor, as defined in paragraph (1)(A)2. multiplied by the St. Louis, MO, Medicare IPPS wage index value, plus the remaining forty percent (40%) of the APC conversion factor, with no wage index adjustment;

10. Nominal charge provider. A nominal charge provider is determined from the third prior year audited Medicaid cost report. The hospital must meet the following criteria:

A. A public non-state governmental acute care hospital with a low-income utilization rate (LIUR) of at least twenty percent (20%) and a Medicaid inpatient utilization rate (MIUR) greater than one (1) standard deviation from the mean, and is licensed for fifty (50) inpatient beds or more and has an occupancy rate of at least forty percent (40%). The hospital must meet one (1) of the federally mandated Disproportionate Share qualifications; or B. The hospital is a public hospital operated by the treatment of mental disorders; and C. A hospital physically located in the state of Missouri;

11. Outpatient Prospective Payment System (OPPS).

Medicare’s hospital outpatient prospective payment system mandated by the Balanced Budget Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA); and 12. Payment level adjustment. The percentage applied to the Medicare fee to derive the OSFS fee.

(B) Effective for dates of service beginning July 20, 2021, outpatient hospital services shall be reimbursed on a predetermined fee-for-service basis using an OSFS based on the APC groups and fees under the Medicare Hospital OPPS. When service coverage and payment policy differences exist between Medicare OPPS and Medicaid, MHD policies and fee schedules are used. The fee schedule will be updated as follows:

1. MHD will review and adjust the OSFS annually on July 1 based on the payment method described in subsection (1)(D);

2. The OSFS is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO 65109, August 5, 2025. This rule does not incorporate any (C) Payment will be the lower of the provider’s charge or the payment as calculated in subsection (1)(D).

(D) Fee schedule methodology. Fees for outpatient hospital services covered by the MO HealthNet program are determined by the HCPCS procedure code at the line level and the following hierarchy:

1. The APC relative weight or payment rate assigned to the procedure in the Medicare OPPS Addendum B is used to calculate the fee for the service, with the exception of the hospital observation per hour fee which is calculated based on the method described in subparagraph (1)(D)1.B. Fees derived from APC weights and payment rates are established using the Medicare OPPS Addendum B effective as of January 1 of each year as published by the CMS for Medicare OPPS. The Medicare OPPS Addendum B is incorporated by reference and made a

part of this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, January 9, 2025. This rule does not incorporate any A. The fee is calculated using the APC relative weight times the Missouri conversion factor. The resulting amount is then multiplied by the payment level adjustment of ninety percent (90%) to derive the OSFS fee.

B. The hourly fee for observation is calculated based on the relative weight for the Medicare APC (using the Medicare OPPS Addendum A effective as of January 1 of each year as published by the CMS for Medicare OPPS), which corresponds with comprehensive observation services multiplied by the Missouri conversion factor divided by forty (40), the maximum payable hours by Medicare. The resulting amount is then multiplied by the payment level adjustment of ninety percent (90%) to derive the OSFS fee. The Medicare OPPS Addendum A is incorporated by reference and made a part of this rule as 7500 Security Boulevard, Baltimore, MD 21244, January 9, 2025.

C. For those APCs with no assigned relative weight, ninety percent (90%) of the Medicare APC payment rate is used as the fee;

2. If there is no APC relative weight or APC payment rate established for a particular service in the Medicare OPPS Addendum B, then the MHD approved fee will be ninety percent (90%) of the rate listed on other Medicare fee schedules, effective as of January 1 of each year: Clinical Laboratory Fee Schedule; Physician Fee Schedule; and Durable Medical Equipment Prosthetics/Orthotics and Supplies Fee Schedule, applicable to the outpatient hospital service.

A. The Medicare Clinical Laboratory Fee Schedule is incorporated by reference and made a part of this rule as 7500 Security Boulevard, Baltimore, MD 21244, January 9, 2025.

B. The Medicare Physician Fee Schedule is incorporated by reference and made a part of this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, January 10, 2025. This rule does not incorporate any subsequent amendments or additions.

C. The Medicare Durable Medical Equipment Prosthetics/ Orthotics and Supplies Fee Schedule is incorporated by reference and made a part of this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, December 17, 2024. This rule does not 3. Fees for dental procedure codes in the outpatient hospital setting are calculated based on thirty-eight and onehalf percent (38.5%) of the fiftieth percentile fee for Missouri reflected in the 2025 National Dental Advisory Service (NDAS).

The 2025 NDAS is incorporated by reference and made a part of this rule as published by Wasserman Medical & Dental, PO Box 510949, Milwaukee, WI 53203, January 2, 2025. This rule does not incorporate any subsequent amendments or additions;

4. If there is no APC relative weight, APC payment rate, other Medicare fee schedule rate, or NDAS rate established for a covered outpatient hospital service, then a MO HealthNet fee will be determined using the MHD Dental, Medical, Other Medical or Independent Lab—Technical Component fee schedules.

A. The MHD Dental Fee Schedule is incorporated by reference and made a part of this rule as published by the B. The MHD Medical Fee Schedule is incorporated by reference and made a part of this rule as published by the C. The MHD Other Medical Fee Schedule is incorporated by reference and made a part of this rule as published by the D. The MHD Independent Lab—Technical Component Fee Schedule is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO 65109, May 5, 2025. This rule does not incorporate any subsequent amendments or additions;

5. In-state federally deemed critical access hospitals will receive an additional forty percent (40%) of the rate as determined in paragraph (1)(B)2. for each billed procedure code; and 6. Nominal charge providers will receive an additional forty percent (40%) of the rate as determined in paragraph (1)

(B)2. for each billed procedure code.

(E) Packaged services. MHD adopts Medicare guidelines for procedure codes identified as “Items and Services Packaged into APC Rates” under Medicare OPPS Addendum D1. These procedures are designated as always packaged. Claim lines with packaged procedure codes will be considered paid but with a payment of zero (0). The Medicare OPPS Addendum D1 is incorporated by reference and made a part of this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, November 24, 2024.

This rule does not incorporate any subsequent amendments or additions.

(F) Inpatient only services. MHD adopts Medicare guidelines for procedure codes identified as “Inpatient Procedures” under Medicare OPPS Addendum D1. These procedures are designated as inpatient only (referred to as the inpatient only (IPO) list).

Claim lines with inpatient only procedures will not be paid under the OSFS.

(G) Multiple procedure discounting. Effective for dates of service beginning July 1, 2024, MHD applies multiple procedure discounting for those procedure codes identified as “Procedure or Service, Multiple Procedure Reduction Applies” under Medicare OPPS Addendum D1. These procedures are paid separately but are discounted when two (2) or more services are billed on the same date of service. Procedure codes considered for the multiple procedure reduction under the OSFS exclude dental procedures. The multiple procedure claim line with the highest allowed amount is priced at one hundred percent (100%) of the maximum allowed amount. The second and subsequent covered procedures are priced at fifty percent (50%) of the maximum allowed amount. The Medicare OPPS Addendum D1 is incorporated by reference and made a

part of this rule as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, November 24, 2024. This rule does not incorporate any (H) Modifier 50 bilateral procedure pricing. Effective for dates of service beginning July 1, 2024, MHD applies bilateral procedure pricing for those procedure codes identified on the Medicare National Physician Fee Schedule Relative Value File with an indicator of one (1) under the BILAT SURG column.

These procedures may be subject to a payment adjustment when billed with modifier 50 and performed bilaterally on both sides of the body at the same operative session. Claim lines appropriately billed with these bilateral procedures and modifier 50 are priced at one hundred fifty percent (150%) of the maximum allowed amount for a single code. The Medicare National Physician Fee Schedule Relative Value File is incorporated by reference and made a part of this rule as 7500 Security Boulevard, Baltimore, MD 21244, January 10, 2025.

(I) Drugs. Effective for dates of service beginning April 1, 2019, outpatient drugs are reimbursed in accordance with the methodology described in 13 CSR 70-20.070.

(J) Payment for outpatient hospital services under this rule will be final, with no cost settlement.

(2) Outpatient Rate Adjustment.

(A) Rate Adjustment.

1. A rate adjustment may be requested by in-state federally deemed critical access hospitals under this subsection for changes in outpatient allowable costs related to building a new replacement hospital. The effective date for any increase granted under this subsection shall be no earlier than the first day of the month following the division’s final determination of the rate adjustment.

A. In-state federally deemed critical access hospitals that build a new replacement hospital and incur costs associated with the new hospital may request an outpatient rate adjustment. A rate adjustment request for projects requiring certificate of need (CON) review must include a copy of the CON program approval.

B. An in-state federally deemed critical access hospital will have six (6) months after the new hospital is completed and open to the public to submit a request for outpatient rate adjustment, along with a budget of the project’s costs. The rate adjustment request, the project’s budget, and any other documentation related to the replacement building’s costs shall be provided to MHD. Upon completion of MHD’s review, the hospital’s outpatient reimbursement rate may be adjusted, if indicated. Failure to submit a request for rate adjustment and project budget within the six- (6-) month period shall disqualify the hospital from receiving a rate increase.

C. Rate adjustments due to building a new hospital will be determined as the increase in capital and operating costs multiplied by the ratio of total Medicaid outpatient costs to total hospital costs as submitted on the most recent audited cost report as of the review date divided by the FFS Medicaid outpatient payments from the audited cost report. This percentage increase will be multiplied by the current critical access hospital outpatient increase and the result added to the current outpatient increase to determine the new increase to the fee schedule amounts. The increase will be limited to twenty-five percent (25%) of the critical access hospital outpatient increase and will be limited to thirty (30) years.

2. The request for a rate adjustment must be submitted in writing to the division and must specifically and clearly identify the project and the total dollar amount involved. The total dollar amount must be supported by generally accepted accounting principles. The hospital will be notified of the division’s decision in writing within sixty (60) days of receipt of the hospital’s written request or within sixty (60) days of receipt of any additional documentation or clarification which may be required, whichever is later. Failure to submit requested information within the sixty- (60-) day period, shall be grounds for denial of the request.

Original rule filed June 14, 2002, effective Jan. 30, 2003. Amended:

Filed May 3, 2004, effective Oct. 30, 2004. Amended: Filed June 15, 2005, effective Dec. 30, 2005. Emergency amendment filed Sept. 21, 2010, effective Oct. 1, 2010, expired March 29, 2011. Amended: Filed Sept. 30, 2010, effective March 30, 2011. Emergency amendment filed Sept. 20, 2011, effective Oct. 1, 2011, expired March 28, 2012.

Amended: Filed July 1, 2011, effective Feb. 29, 2012. Emergency amendment filed June 20, 2012, effective July 1, 2012, expired Dec. 28, 2012. Amended: Filed June 20, 2012, effective Jan. 30, 2013.

Amended: Filed July 1, 2013, effective Jan. 30, 2014. Amended: Filed May 1, 2018, effective Jan. 1, 2019. Amended: Filed Jan. 8, 2019, effective July 30, 2019. Amended: Filed April 21, 2021, effective Nov. 30, 2021. Emergency amendment filed June 13, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 13, 2022, effective Jan. 30, 2023. Emergency amendment filed June 15, 2023, effective June 30, 2023, expired Dec. 26, 2023. Amended: Filed July 13, 2023, effective Jan. 30, 2024. Emergency amendment filed Oct. 16, 2024, effective Oct. 30, 2024, expired April 27, 2025. Amended:

Filed Oct. 16, 2024, effective May 30, 2025. Emergency amendment filed June 20, 2025, effective July 7, 2025, expired Feb. 26, 2026.

Amended: Filed June 23, 2025, effective Jan. 30, 2026. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993,

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2025. Emergency rule filed June 20, 2002, effective July 1, 2002, expired Feb. 27, 2003.

13 CSR 70-15.170 Enhanced Disproportionate Share Payment to Trauma Hospitals for the Cost of Care to the Uninsured Provided by Physicians Not Employed by the Hospital Emergency rule filed June 20, 2002, effective July 1, 2002, expired Feb. 27, 2003. {#sec-13-csr-70-15.170 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.170}

13 CSR 70-15.180 Grant to Trauma Hospitals for the Care Provided by Physicians Not Employed by the Hospital Emergency rule filed June 6, 2007, effective June 16, 2007, expired Dec. 12, 2007. {#sec-13-csr-70-15.180 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.180}

13 CSR 70-15.190 Out-of-State Hospital Services Reimbursement Plan {#sec-13-csr-70-15.190 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.190}

PURPOSE: This rule establishes the method of reimbursing outof-state hospitals for inpatient or outpatient care provided to any recipients of Missouri Medicaid, whether they are under age twenty-one (21) or age twenty-one (21) and over.

(1) Covered inpatient hospital services include those items and services allowed by the Medicaid State Plan including medically necessary care in a semi-private room. If prior authorized, Missouri Medicaid may reimburse for a private room if it is certified medically necessary by a physician to avoid jeopardizing the health of the patient or to protect the health and safety of other patients. No payment will be made for any portion of the room charge when the participant requests and is provided a private room when the private room is not medically necessary.

(2) Payment for authorized inpatient hospital services shall be made according to subsections (2)(A) or (2)(B) for services provided outside Missouri if the services are covered by the Missouri Medicaid Program. To be reimbursed for furnishing services to Missouri Medicaid participants, out-of-state hospitals must complete a Missouri Medicaid Program Provider Participation Application and have the application approved by the Missouri Department of Social Services, Missouri Medicaid Audit and Compliance (MMAC).

(A) The payment for authorized inpatient hospital services provided by an out-of-state free-standing psychiatric hospital shall be the lowest of— 1. The hospital’s per diem rate, which will be the weighted statewide average per diem rate for Missouri free-standing psychiatric hospitals as calculated by the MO HealthNet Division for the State Fiscal Year (SFY) in which the service was provided; or 2. The amount of total charges billed by the hospital. The hospital’s billed charges must be their usual and customary charges for services; or 3. The Medicare deductible or coinsurance, if applicable, up to the amount allowed by the Missouri Medicaid program.

(B) The payment for authorized inpatient hospital services provided by an out-of-state hospital, except for free-standing psychiatric hospitals, shall be calculated using an All Patient Refined Diagnosis Related Groups (APR DRG) reimbursement methodology as described in 13 CSR 70-15.010(6).

(3) The payment for authorized outpatient hospital services provided by an out-of-state hospital shall be the lower of— (A) The outpatient reimbursement as described in 13 CSR 70-15.160; or (B) The amount of total charges billed by the hospital.

(4) Disproportionate Share Hospital (DSH) Payments. Out-ofstate hospitals do not qualify for DSH payments.

(5) Definitions.

(A) The definitions from regulation 13 CSR 70-15.010 are incorporated as 13 CSR 70-15.190.

(B) Out-of-state is defined as not within the physical boundaries of Missouri.

(C) Usual and customary charge is the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service.

rule filed April 15, 2004, effective Oct. 30, 2004. Emergency amendment filed June 16, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 16, 2022, effective Jan. 30, 2023.

Emergency amendment filed June 20, 2025, effective July 7, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

13 CSR 70-15.200 Payment Policy for a Preventable Serious Adverse Event or Hospital or Ambulatory Surgical Center- Acquired Condition {#sec-13-csr-70-15.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.200}

(Rescinded June 30, 2012)

History

• AUTHORITY: section 208.201, RSMo Supp. 2008. Original rule filed Nov. 17, 2008, effective June 30, 2009. Rescinded: Filed Nov. 30, 2011, effective June 30, 2012.

13 CSR 70-15.220 Disproportionate Share Hospital (DSH) {#sec-13-csr-70-15.220 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.220}

Payments

PURPOSE: This rule implements a new state methodology for paying Disproportionate Share Hospital (DSH) payments in order to comply with the new federally required DSH audit standards. The

regulation provides for an interim adjustment to DSH payments and provides for final adjustment to DSH payments based upon the federally mandated DSH audits.

(1) General Reimbursement Principles.

(A) In order to receive federal financial participation (FFP), disproportionate share hospital (DSH) payments are made in compliance with federal statutes and regulations. Section 1923 of the Social Security Act (42 U.S. Code) describes the hospitals that must be paid DSH payments and those that the state may elect to pay DSH payments.

(B) Federally deemed DSH hospitals. The state must pay DSH payments to hospitals that meet the specific obstetric requirements set forth below in paragraph (1)(B)1. and have either a Medicaid inpatient utilization rate (MIUR) at least one (1) standard deviation above the state mean or a low-income utilization rate (LIUR) greater than twenty-five percent (25%).

The state shall not make DSH payments in excess of each hospital’s estimated hospital-specific DSH limit.

1. Obstetrics requirements and exemptions.

A. Hospitals must have two (2) obstetricians, with staff privileges, who agree to provide non-emergency obstetric services to Medicaid eligibles. Rural hospitals, as defined by the federal Executive Office of Management and Budget, may qualify any physician with staff privileges as an obstetrician.

B. Hospitals are exempt from the obstetric requirements if the facility did not offer non-emergency obstetric services as of December 22, 1987.

C. Hospitals are exempt if inpatients are predominantly under eighteen (18) years of age.

(C) State-elected DSH payments. The state may elect to make disproportionate share payments to hospitals that meet the obstetric requirements set forth in paragraph (1)(B)1. and have a MIUR of at least one percent (1%).

(D) Section 1923(g) of the Social Security Act (Act) limits the amount of DSH payments states can pay to each hospital and earn FFP. To be in compliance with the Act, DSH payments shall not exceed one hundred percent (100%) of the uncompensated care costs of providing hospital services to Medicaid and uninsured individuals. Hospital-specific DSH limit calculations must comply with the federal DSH rules (42 CFR 447, Subpart E and 42 CFR 455, Subpart D). If the disproportionate share payments exceed the hospital-specific DSH limit, the difference shall be deducted from disproportionate share payments or recouped from future payments.

(E) All DSH payments in the aggregate shall not exceed the federal DSH allotment within a state fiscal period. The DSH allotment is the maximum amount of DSH payments a state can distribute each year and receive FFP.

(F) The state must submit an annual independent audit of the state’s DSH program to the Centers for Medicare & Medicaid Services (CMS). FFP is not available for DSH payments that are found to exceed the hospital-specific eligible uncompensated care cost limit. All hospitals that receive DSH payments are subject to the independent federal DSH audit.

(G) Hospitals qualify for DSH for a period of one (1) state fiscal year and must requalify at the beginning of each state fiscal year to continue to receive disproportionate share payments.

(2) Definitions.

(A) Annual independent DSH audit. The annual independent DSH audit is the annual independent certified audit of the state DSH payments as required by the federal DSH audit rule 42 CFR 455.301 through 42 CFR 455.304. The annual independent DSH audit also includes the reporting requirements of 42 CFR 447.299. The annual independent DSH audit may also be referred to as the federally mandated annual independent DSH audit or independent federal DSH audit.

(B) Division. Unless otherwise specified, division refers to the MO HealthNet Division, the division of the Department of Social Services charged with the administration of Missouri’s MO HealthNet Program.

(C) Estimated Medicaid net cost. Estimated Medicaid net cost is defined per 42 CFR 447.299(c)(6), (7), and (10) and 42 CFR 447.295. The estimated Medicaid net cost is determined by using Medicare cost reporting methodologies described in this rule and is calculated using data reported on the state DSH survey.

1. The estimated Medicaid net cost shall be trended as set forth in subsection (2)(Y).

(D) Estimated uninsured uncompensated care cost. Estimated uninsured uncompensated care cost is defined per 42 CFR 447.295 and 42 CFR 447.299(c)(12)–(15).

1. The estimated uninsured uncompensated care cost shall be trended as set forth in subsection (2)(Y).

(E) Federal DSH allotment. The maximum amount of DSH a state can distribute each year and receive federal financial participation (FFP) in the payments in accordance with 42 CFR 447.297 and 42 CFR 447.298.

(F) Hospital DSH liability. The hospital DSH liability is the amount of DSH overpayments subject to recoupment as determined from the final annual independent DSH audit. It is the lesser of the total longfall or the DSH payments paid for the SFY.

(G) Hospital-specific DSH limit. The hospital-specific DSH limit is the sum of the Medicaid uncompensated care cost plus the uninsured uncompensated care cost and is calculated each year. The source for this calculation is as follows:

1. Actual hospital-specific DSH limit. The actual hospitalspecific DSH limit is determined from the final annual independent DSH audit; and 2. Estimated hospital-specific DSH limit. The estimated hospital-specific DSH limit is calculated by the state using data from the state DSH survey, other Medicaid payments, and data provided in the most recent independent DSH audit, if applicable, which is used in determining the interim DSH payments.

(H) Incorporation by reference. This rule incorporates by reference the following:

1. 42 CFR Chapter IV, Part 447, as published by the Office 2. 42 CFR Chapter IV, Part 455, as published by the Office 3. The state DSH survey template and instructions as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, April 22, 2025. This rule does not incorporate any subsequent amendments or additions; and 4. The alternate state DSH survey supplemental template and instructions as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, May 21, 2025. This rule does not incorporate any (I) Individuals without health insurance or other third-party coverage for the services received.

2. Individuals who have no health insurance or other source of third-party coverage for the specific inpatient or outpatient hospital services they received during the year are considered uninsured. As set forth in CMS’ final rule published in the Federal Register, December 3, 2014, for 42 CFR 447.295, a service-specific approach must be used to determine whether an individual is uninsured. The service-specific coverage determination can occur only once per individual per service provided and applies to the entire service, including all elements as that service, or similar services, would be defined by MO HealthNet. Determination of an individual’s third-party coverage status is not dependent on receipt of payment by the hospital from the third party.

3. The costs for inpatient and outpatient hospital services provided to individuals without health insurance or other thirdparty coverage for the inpatient or outpatient hospital services they received during the year are considered uninsured and included in calculating the hospital-specific DSH limit.

4. The following costs shall be considered uninsured and included in calculating the hospital-specific DSH limit:

A. Costs for services provided to individuals whose benefit package does not cover the hospital service received.

If the service is not included in an individual’s health benefits coverage through a group health plan or health insurer, and there is no other legally liable third party, the hospital services are considered uninsured costs; and B. Costs for services provided to individuals who have reached lifetime insurance limits for certain services or with exhausted insurance benefits at the time of service. When a lifetime or annual coverage limit is imposed by a third-party payer, specific services beyond the limit would not be within the individual’s health benefit package from that third-party payer and would be considered uninsured costs, as long as the benefits were exhausted when the patient was admitted; and C. For American Indians/Alaska Natives, Indian Health Services (IHS) and tribal coverage is only considered thirdparty coverage when services are received directly from IHS or tribal health programs or when IHS or a tribal health program has authorized coverage through the contract health service 4. The costs associated with the following shall not be included as uninsured costs:

A. Bad debts or unpaid coinsurance/deductibles for individuals with third-party coverage. Administrative denials of payment or requirements for satisfaction of deductible, copayment, or coinsurance liability do not affect the determination that a specific service is included in the health benefits coverage; and B. Unpaid balances due for claims denied by the thirdparty payer for billing discrepancies, which include but are not limited to denials due to lack of pre-authorization, denials due to timely filing, denials due to lack of medical necessity, etc.; and C. Prisoners. Individuals who are inmates in a public institution or are otherwise involuntarily in secure custody as a result of criminal charges are considered to have a source of third-party coverage. However, an individual can be included as uninsured if a person has been released from secure custody and is referred to the hospital by law enforcement or corrections authorities and is admitted as a patient rather than an inmate to the hospital.

5. These definitions, and the resulting uninsured costs includable in calculating the hospital-specific DSH limit, are subject to change based on any federal DSH audit regulation changes. The division reserves the right to determine whether changes in federal DSH audit regulation will be applied to the interim DSH payment calculations.

(J) Institution for Mental Diseases (IMD) DSH allotment. The IMD DSH allotment is a portion of the state-wide DSH allotment and is the maximum amount set by the federal government that may be paid to IMD hospitals. Any unused IMD DSH allotment not paid to IMD hospitals for any plan year may be paid to hospitals that are under their projected hospitalspecific DSH limit.

(K) Inpatient and outpatient hospital services. For purposes of determining the estimated hospital-specific DSH limit and the actual hospital-specific DSH limit, the inpatient and outpatient hospital services are limited to inpatient and outpatient hospital services included in the approved Missouri Medicaid State Plan.

(L) Lifetime or annual health insurance coverage limit. An annual or lifetime limit, imposed by a third-party payer, that establishes a maximum dollar value, or maximum number of specific services on a lifetime or annual basis, for benefits received by an individual.

(M) Longfall. The longfall is the total amount a hospital has been paid for inpatient and outpatient hospital services (including all DSH payments) in excess of their hospital-specific DSH limit. The source for this calculation is as follows:

1. Actual longfall. The actual longfall is based on the annual independent DSH audit; and 2. Estimated longfall. The estimated longfall is calculated by the state using data from the state DSH survey, other Medicaid payments, and data provided in the most recent independent DSH audit, if applicable.

(N) Low income utilization rate (LIUR). The LIUR shall be 1. As determined from the state DSH survey, the LIUR shall be the sum (expressed as a percentage) of the fractions, A. Total MO HealthNet patient revenues (TMPR) paid to the hospital for patient services under a state plan plus the amount of the cash subsidies (CS) directly received from state and local governments, divided by the total net revenues (TNR)

(charges, minus contractual allowances, discounts, and the like) for patient services plus the CS; and B. The total amount of the hospital’s charges for inpatient services attributable to charity care (CC) less inpatient cash subsidies (ICS) directly received from state and local governments in the same period, divided by the total amount of the hospital’s inpatient charges (THC) for patient services.

The total patient charges attributed to CC shall not include any contractual allowances and discounts other than for indigent patients not eligible for MO HealthNet under a state plan.

LIUR = ((TMPR + CS) / (TNR + CS)) + ((CC – ICS) / (THC))

(O) Medicaid inpatient utilization rate (MIUR). The MIUR shall be calculated as follows:

1. As determined from the state DSH survey, the MIUR will be expressed as the ratio of total Medicaid eligible inpatient hospital days (TMID) provided under a state plan divided by the provider’s total number of inpatient hospital days (TNID); and 2. The state’s mean MIUR will be expressed as the ratio of the sum of the total number of the Medicaid days for all Missouri hospitals divided by the sum of the total patient days for the same Missouri hospitals. Data for hospitals no longer participating in the program will be excluded.

MIUR = TMID / TNID

(P) Medicaid state plan year. Medicaid state plan year coincides with the twelve- (12-) month period for which a state calculates DSH payments. For Missouri, the Medicaid state plan year coincides with its state fiscal year (SFY) and is July 1 through June 30.

(Q) Medicare cost reporting methodologies. Medicaid and uninsured costs will be determined utilizing Medicare Cost Report (form CMS 2552) methodologies. The Medicaid Cost Report is completed using the Medicare Cost Report form CMS 2552, using the Medicare cost reporting methodologies.

Based on these methodologies, the costs included in the DSH payment calculation will reflect the Medicaid and uninsured portion of total allowable hospital costs from the Medicare Cost Report or the Medicaid Cost Report, as applicable. Costs such as the Missouri Medicaid hospital provider tax FRA are recognized as allowable costs for Medicaid and DSH program purposes and apportioned to Medicaid, uninsured, Medicare, and other payers following the cost finding principles included in the cost report, applicable instructions, regulations, and governing statutes.

(R) New facility. A new hospital determined in accordance with 13 CSR 70-15.010 without a base year cost report.

(S) Other Medicaid payments. For purposes of determining estimated hospital-specific DSH limits, the other Medicaid payments include any non-claim specific Medicaid payment made to a hospital for inpatient or outpatient hospital services including but not limited to Direct Medicaid, acuity adjustment payment, poison control payment, stop loss payment, graduate medical education (GME), children’s outliers, cost settlements, and upper payment limit (UPL) payments, if applicable, will be included in the annual independent DSH audit. Any other payments made with state only funds are not required to be offset in determining the hospital-specific DSH limit.

(T) Out-of-state DSH payments. DSH payments received by a Missouri hospital from a state other than Missouri.

(U) Section 1011 payments. Section 1011 payments are made to a hospital for costs incurred for the provision of specific services to specific aliens to the extent that the provider was not otherwise reimbursed for such services. Because a portion of the Section 1011 payments are made for uncompensated care costs that are also eligible under the hospital-specific DSH limit, a defined portion of the Section 1011 payments must be recognized as an amount paid on behalf of those uninsured.

(V) Shortfall. The shortfall is the hospital-specific DSH limit in excess of the total amount a hospital has been paid for inpatient and outpatient hospital services (including all DSH payments). The source for this calculation is as follows:

1. Actual shortfall. The actual shortfall is based on the annual independent DSH audit; and 2. Estimated shortfall. The estimated shortfall is calculated by the state using data from the state DSH survey, and other Medicaid payments.

(W) State DSH survey. Beginning with SFY 2017, the state DSH survey shall be the most recent DSH survey collected during the independent DSH audit of the fourth prior SFY (i.e., the most recent survey collected by the independent DSH auditor for the SFY 2019 independent DSH audit will also be used to calculate the interim DSH payment for SFY 2023). The survey shall be referred to as the SFY to which payments will relate.

(X) Taxable revenue. Taxable revenue is the hospital’s total inpatient adjusted net revenues plus outpatient adjusted net revenues determined in accordance with 13 CSR 70-15.110, paragraph (1)(A)13.

(Y) Trends. A trend of one and a half percent (1.5%) will be applied to the hospital’s estimated Medicaid net cost and the estimated uninsured uncompensated care cost (UCC) from the year subsequent to the state DSH survey period to the current SFY (i.e., the SFY for which the interim DSH payment is being determined). The first year’s trend shall be adjusted to bring the facility’s cost to a common fiscal year end of June 30 and the full trends shall be applied for the remaining years. The trends shall be compounded each year to determine the total cumulative trend.

(Z) Uninsured revenues. Payments received on a cash basis that are required per 42 CFR 455.301 through 42 CFR 455.304 and 42 CFR 447.299 to be offset against the uninsured cost to determine the uninsured net cost include any amounts received by the hospital, by or on behalf of either self-pay or uninsured individuals during the SFY under audit.

(3) Interim DSH Payments.

(A) Beginning with SFY 2013, interim DSH payments shall be calculated on an annual basis and will be based on the state’s calculations using data provided in the state DSH survey for the applicable SFY, and estimated other Medicaid payments calculated by the division in accordance with 13 CSR 70-15.010, 13 CSR 70-15.015, and 13 CSR 70-15.230 for the applicable SFY.

(B) The interim DSH payments will be calculated as follows:

1. The estimated hospital-specific DSH limit is calculated as follows:

A. Estimated Medicaid net cost from the state DSH survey calculated in accordance with subsection (2)(C);

B. Less estimated other Medicaid payments calculated by the division in accordance with 13 CSR 70-15.010, 13 CSR 70- 15.015, and 13 CSR 70-15.230;

C. Equals estimated Medicaid uncompensated care cost;

D. Plus estimated uninsured uncompensated care cost from the state DSH survey calculated in accordance with subsection (2)(E);

E. Equals estimated hospital-specific DSH limit;

2. The estimated uncompensated care costs potentially eligible for MHD interim DSH payments excludes out-of-state DSH payments and is calculated as follows:

A. Estimated hospital-specific DSH limit;

B. Less estimated out-of-state (OOS) DSH payments;

C. Equals estimated uncompensated care cost (UCC) net of OOS DSH payments;

3. Hospitals determined to have a negative estimated UCC net of OOS DSH payments (payments exceed costs) will not receive interim DSH payments because their estimated payments for the SFY are expected to exceed their estimated hospital-specific DSH limit; and 4. Qualified DSH hospitals determined to have a positive estimated UCC net of OOS DSH payments (costs exceed payments) will receive interim DSH payments. The interim DSH payments are subject to the federal DSH allotment, the availability of state funds, and the estimated hospital-specific DSH limits less estimated OOS DSH payments. The interim DSH payments will be calculated as follows:

A. Interim DSH payments to qualified DSH hospitals determined to have a positive estimated UCC net of OOS DSH payments will be calculated as follows:

(I) Up to one hundred percent (100%) of the available federal DSH allotment will be allocated to each hospital with a positive estimated UCC net of OOS DSH payments, and the allocation shall result in each hospital receiving the same percentage of their estimated UCC net of OOS DSH payments.

The allocation percentage will be calculated at the beginning of the SFY by dividing the available federal DSH allotment to be distributed by the total hospital industry’s positive estimated UCC net of OOS DSH payments; and (II) The allocated amount will then be reduced by one percent (1%) for hospitals that do not contribute through a plan that is approved by the director of the Department of Health and Senior Services to support the state’s poison control center and the Primary Care Resource Initiative for Missouri (PRIMO) and Patient Safety Initiative.

(C) Hospitals may elect not to receive an interim DSH payment for a SFY by completing a DSH waiver form. This includes federally deemed hospitals that do not have uncompensated care costs to justify the receipt of an interim DSH payment.

Hospitals that elect not to receive an interim DSH payment for a SFY must notify the division, or its authorized agent, that it elects not to receive an interim DSH payment for the upcoming SFY. If a hospital does not receive an interim DSH payment for a SFY, it will not be included in the independent DSH audit related to that SFY and will not be eligible for final DSH audit payment adjustments related to that SFY unless it submits a request to the division to be included in the independent DSH audit. If the request is approved by the division, the hospital must submit all necessary data elements to the independent DSH auditor in order to be included in the audit and eligible for final DSH payment adjustments.

(D) Disproportionate share payments will coincide with the semimonthly claim payment schedule.

(E) New facilities that do not have a Medicare/Medicaid cost report on which to base the state DSH survey will be paid the estimated hospital-specific DSH limit less OOS DSH payments based on the estimated state DSH survey.

(F) Interim DSH payments for hospital mergers.

1. Hospitals that merge prior to the beginning of the SFY.

Hospitals that merge their operations under one (1) Medicare and MO HealthNet provider number shall have their interim DSH payment determined based on adding each hospital’s state DSH survey to yield a combined state DSH survey and applying the same calculations in subsection (3)(B).

2. Hospitals that merge after the beginning of the SFY. The interim DSH payments that have been determined separately for the hospitals will be added together and paid to the surviving hospital effective with the approval date of the merger.

(G) Interim DSH payment adjustments.

1. To minimize hospital longfalls, interim DSH payments made to hospitals will be revised if changes to federally mandated DSH audit standards are enacted during a SFY, updated for Medicaid expansion until it is captured in the required state DSH survey, or any changes in Medicaid reimbursement until it is captured in the required state DSH survey. These revisions are to serve as interim adjustments until the federally mandated DSH audits are complete. DSH audits are finalized three (3) years following the SFY year-end reflected in the audit. For example, the SFY 2019 DSH audit will be finalized in calendar year (CY) 2022.

(4) Department of Mental Health (DMH) Hospitals DSH Adjustments and Payments.

(A) Beginning in SFY 2026, the DMH hospitals interim DSH payments will be calculated in accordance with subsection (3)

(B). Additional adjustments may be done based on the results of the federally mandated DSH audits as set forth below in subsection (5)(A).

(5) Final DSH Adjustments.

(A) Final DSH adjustments will be made after actual cost data is available and the annual independent DSH audit is completed. Annual independent DSH audits are completed three (3) years following the state fiscal year-end reflected in the audit. For example, final DSH adjustments for SFY 2022 DSH payments will be made following the completion of the annual independent DSH audit in 2025 (SFY 2026).

(B) Final DSH adjustments may result in a recoupment for some hospitals and additional DSH payments for other hospitals based on the results of the annual independent DSH audit as set forth below:

1. Hospital DSH liabilities are overpayments which will be recouped. If the annual independent DSH audit reflects that a facility has a hospital DSH liability, it is an overpayment to the hospital and is subject to recoupment. The hospital’s DSH liability shown on the final independent DSH audit report that is required to be submitted to CMS by December 31 will be due to the division by September 30 of the following year;

2. Any overpayments that are recouped from hospitals as the result of the final DSH adjustment will be redistributed to hospitals that are shown to have a total shortfall. These redistributions will occur proportionally based on each hospital’s total shortfall to the total shortfall, not to exceed each hospital-specific DSH limit less OOS DSH payments;

3. Redistribution payments to hospitals that have a total shortfall must occur after the recoupment of hospital DSH liabilities. However, total industry redistribution payments may not exceed total industry recoupments collected to date;

4. If the amount of DSH payments to be recouped as a result of the final DSH adjustment is more than can be redistributed, the entire amount in excess of the amount able to be redistributed will be recouped and the federal share will be returned to the federal government. The state share of the final DSH recoupments that has not been redistributed to hospitals with DSH shortfalls may be used to make a hospital upper payment limit payment and/or a state-only quality improvement payment to all non-DMH hospitals. The stateonly quality improvement payment will be paid proportionally to non-DMH hospitals based on the number of hospital staffed beds to total staffed beds for the same state fiscal year the final DSH adjustment relates to. Staffed beds are reported on the Missouri Annual Licensing Survey which is mandated by the Department of Health and Senior Services in accordance with 19 CSR 10-33.030;

5. If the Medicaid program’s original interim DSH payments did not fully expend the federal DSH allotment for any plan year, the remaining DSH allotment may be paid to hospitals that are under their hospital-specific DSH limit as determined from the annual independent DSH audit. These payments will occur proportionally based on each hospital’s shortfall to the total shortfall, not to exceed each hospital’s hospital-specific DSH limit less OOS DSH payments;

6. If the Medicaid program’s original DSH payments did not fully expend the federal Institute for Mental Disease (IMD) DSH allotment for any plan year, the remaining IMD DSH allotment may be paid to IMD hospitals that are under their projected hospital-specific DSH limit. These payments will occur proportionally based on each hospital’s estimated shortfall to the total estimated shortfall, not to exceed each hospital’s estimated hospital-specific DSH limit less OOS DSH payments; and 7. Bankrupt-liquidation or closed hospitals are not eligible for final DSH redistributions or unspent allotment payments.

(6) State DSH Survey Reporting Requirements.

(A) Beginning in SFY 2016, each hospital must complete and submit the state DSH survey set forth in subsection (2)(W) (i.e., required state DSH survey) to the independent DSH auditor, the MO HealthNet Division’s authorized agent, in order to be considered for an interim DSH payment for the subsequent SFY (i.e., DSH surveys collected during SFY 2016 will be used to calculate SFY 2017 interim DSH payments). The independent DSH auditor will distribute the state DSH survey template to the hospitals to complete and will notify them of the due date, which shall be a minimum of thirty (30) days from the date it is distributed. However, the state DSH survey is due to the independent DSH auditor no later than March 1 preceding the beginning of each state fiscal year for which the interim DSH payment is being calculated (i.e., the state DSH survey used for SFY 2017 interim DSH payments will be due to the independent DSH auditor no later than March 1, 2016). Hospitals that do not submit the state DSH survey by March 1 will not be eligible to receive an interim DSH payment for that SFY. The division may grant an industry-wide extension on the March 1 deadline due to unanticipated circumstances that affect the industry as a whole. The independent DSH auditor may perform an initial review of the required state DSH survey submitted by the hospital and make preliminary adjustments for use in calculating the interim DSH payment. The independent DSH auditor shall provide the hospital with any preliminary adjustments that are made for review and comment prior to the data being provided to MHD for use in calculating the interim DSH payment for the SFY. Additional or revised audit adjustments may be made to the DSH survey for purposes of the independent DSH audit.

1. A new facility that does not have cost report data for the fourth prior year may complete the state DSH survey using actual, untrended cost and payment data from the most recent twelve- (12-) month cost report filed with the division.

2. A new facility that has not yet filed a twelve- (12-) month Medicaid cost report with the division may complete the state DSH survey using facility projections to reflect anticipated operations for the interim DSH payment period. Trends shall not be applied to the data used to complete the state DSH survey. Interim DSH payments determined from this state DSH survey are limited to the industry average estimated interim DSH payment as set forth in subsection (3)(E).

3. Hospitals may elect not to receive an interim DSH payment for a SFY by completing a DSH waiver form. Hospitals that elect not to receive an interim DSH payment for a SFY must notify the division, or its authorized agent, that it elects not to receive an interim DSH payment for the upcoming SFY. If a hospital does not receive an interim DSH payment for a SFY, it will not be included in the independent DSH audit related to that SFY, and will not be eligible for final DSH audit payment adjustments related to that SFY unless it submits a request to the division to be included in the independent DSH audit. If the request is approved by the division, the hospital must submit all necessary data elements to the independent DSH auditor in order to be included in the audit and eligible for final DSH payment adjustments.

4. If a hospital received an interim DSH payment and later determined that it did not have uncompensated care costs for Medicaid and the uninsured to support part or all the interim DSH payment that it received or is receiving, the hospital may request that the interim DSH payments be stopped or it may return the entire interim DSH payment it received.

5. Exceptions process to use alternate data for interim DSH A. A hospital may submit a request to the division to have its interim DSH payment based on alternate data as set forth below rather than the state DSH survey required to be submitted for the year (i.e., required state DSH survey) if it meets the criteria for any of the circumstances detailed below in subparagraph (6)(A)5.D. The request must include an explanation of the circumstance, the impact it has on the required state DSH survey period, and how it causes the data to be materially misstated or unrepresentative. The division shall review the facility’s request and may, at its discretion and for good cause shown, use the alternate data in determining the interim DSH payment for the SFY. The division shall notify the facility of its decision regarding the request.

(I) Alternate state DSH survey. A state DSH survey completed using the actual, untrended cost and payment data from the most recent twelve- (12-) month cost report filed with the division. Any hospital requesting an exception must complete an alternate state DSH survey. If the most recent full-year cost report filed with the division does not reflect the impact of any material changes, a supplemental schedule, as defined below, may be completed and submitted in addition to the alternate state DSH survey. If the impact of any changes is reflected in the most recent full-year cost report filed with the division, the facility may only use the alternate state DSH survey.

(II) Alternate state DSH survey supplemental schedule.

A supplemental schedule developed by the division to recognize material changes that have occurred at a hospital that are not yet reflected in the hospital’s alternate state DSH survey. The supplemental schedule uses the data from the alternate state DSH survey as the basis and includes additional fields to reflect changes that occurred subsequent to the alternate state DSH survey period through the SFY for which the interim DSH payment is being calculated. The blank alternate state DSH survey supplemental schedule is referred to as the alternate state DSH survey supplemental template.

B. The provider must submit both the required state DSH survey and the alternate data for review to determine if the facility meets the criteria set forth below in subparagraph (6)(A)5.D.

C. The interim DSH payment based on the applicable alternate data shall be calculated in the same manner as the interim DSH payment based on the required state DSH survey, except for the trends applied to the alternate data as noted below in parts (6)(A)5.C.(I) and (II). The allocation percentage calculated at the beginning of the SFY year as set forth in part (3)(B)4.A.(I) shall be applied to the estimated UCC net of OOS DSH payments based on the alternate data to determine the preliminary interim DSH payment.

(I) Alternate state DSH survey. The trends applied to the alternate state DSH survey shall be from the year subsequent to the alternate state DSH survey period to the current SFY for which the interim DSH payment is being determined.

(II) Alternate state DSH survey supplemental schedule.

Trends shall not be applied to an alternate state DSH survey supplemental schedule since it incorporates changes from the full-year cost report period through the SFY for which the interim DSH payment is being calculated.

D. Following are the circumstances for which a provider may request that its interim DSH payment be based on alternate data rather than the required state DSH survey, including the criteria and other requirements:

(I) Extraordinary circumstances. A provider may request that alternate data be used if the facility experienced an extraordinary circumstance during or after the required state DSH survey report period up to the SFY for which the interim DSH payment is being calculated that caused the required DSH survey report period to be materially misstated and unrepresentative. If circumstances found in items (6)

(A)5.D.(I)(a)I.-IV. below are applicable, the facility may complete and submit the applicable alternate data.

(a) Extraordinary circumstances include unavoidable circumstances that are beyond the control of the facility and include the following:

I. Act of God (i.e., tornado, hurricane, flooding, earthquake, lightning, natural wildfire, etc.);

II. War;

III. Civil disturbance; or IV. If the data to complete the required state DSH survey set forth in subsection (2)(W) is not available due to a change in ownership because the prior owner is out of business and is uncooperative and unwilling to provide the necessary data.

(b) A change in hospital operations or services (i.e., terminating or adding a service or a hospital wing; or, a change of owner, except as noted in item (6)(A)5.D.(I)(a)

IV., manager, control, operation, leaseholder or leasehold interest, or Medicare provider number by whatever form for any hospital previously certified at any time for participation in the MO HealthNet program, etc.) does not constitute an extraordinary circumstance.

(c) Both the required state DSH survey and the alternate data must be submitted to the independent DSH auditor and the division, respectively, no later than March 1 if the alternate data is to be used to determine the interim DSH payment at the beginning of the SFY.

(d) A hospital may submit a request to use alternate data due to extraordinary circumstances after March 1, but the alternate data and the resulting interim DSH payment will be subject to the same requirements as the interim DSH payment adjustments noted below in subparts (6)(A)5.D.(II)(a)-(c). The requests relating to extraordinary circumstances received after the March 1 deadline will be included with the interim DSH payment adjustments requests in part (6)(A)5.D.(II) in distributing the unobligated DSH allotment and available state funds remaining for the SFY;

(II) Interim DSH payment adjustment.

(a) The division will process interim DSH payment adjustments once a year. After all requests are received, the division will determine whether revisions to the interim DSH payments are appropriate. Any revisions to the interim DSH payments are subject to the unobligated DSH allotment remaining for the SFY and availability of state funds.

(b) The request, including the alternate data, must be submitted to the division by December 31 of the current SFY for which interim DSH payments are being made.

(c) To the extent that state funds are available, the DSH allotment for the SFY that has not otherwise been obligated will be distributed proportionally to the hospitals determined to meet the above criteria, based on the difference between the preliminary interim DSH payment based on the alternate data and the original interim DSH payment; and (III) If a provider received an exception that allows it to use alternate data for interim DSH payment purposes under paragraph (6)(A)5. in the prior SFY, it may continue to use alternate data for its interim DSH payment until the required state DSH survey reflects the annual impact of the change. The alternate state DSH survey supplemental schedule should be used until the most recent cost report on file with the division reflects the annual impact of the change. Both the required state DSH survey and the applicable alternate data must be submitted to the independent DSH auditor and the division no later than March 1 preceeding the beginning of each SFY for which the interim DSH payment is being made.

rule filed May 20, 2011, effective June 1, 2011, expired Nov. 28, 2011.

Original rule filed May 20, 2011, effective Jan. 30, 2012. Emergency amendment filed June 20, 2012, effective July 1, 2012, expired Dec. 28, 2012. Amended: Filed April 2, 2012, effective Oct. 30, 2012.

Amended: Filed Jan. 13, 2015, effective Sept. 30, 2015. Amended:

Filed Feb. 1, 2016, effective July 30, 2016. Amended: Filed Dec. 30, 2016, effective Aug. 30, 2017. Emergency amendment filed June 16, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 16, 2022, effective Jan. 30, 2023. Amended: Filed Jan. 18, 2024, effective Aug. 30, 2024. Emergency amendment filed June 20, 2025, effective July 8, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan. 30, 2026. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.158, RSMo 1967; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.158, 208.201, and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2025. Emergency

13 CSR 70-15.230 Upper Payment Limit (UPL) Payment Methodology {#sec-13-csr-70-15.230 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.230}

PURPOSE: This rule establishes a methodology for determining Upper Payment Limit (UPL) payments provided to state government-owned hospitals beginning July 1, 2022.

(1) General Principles.

(A) Hospital Upper Payment Limit (UPL) payments cannot exceed the Medicare Upper Payment Limit as authorized by federal law and included in Missouri’s State Plan.

(2) Beginning with SFY 2023, state government-owned hospitals will be paid an interim payment semi-monthly up to the estimated inpatient (IP) UPL gap.

(A) Prior to each SFY, the division shall calculate the estimated Medicaid payments for the coming SFY for each hospital.

The total estimated Medicaid payments for each hospital shall be subtracted from the hospital’s IP UPL calculated in accordance with the methodology set forth below, then summed to calculate the IP UPL gap. The IP UPL gap is reduced by the estimated inpatient fee-for-service Graduate Medical Education (GME) payments for the coming SFY for each hospital to calculate the total amount of funding available.

The previous SFY’s payments are compared to current SFY’s estimated claims-based payments and when the estimated current year payments are less than prior year payments, that hospital is eligible for a UPL payment. The available IP UPL gap is distributed to each eligible hospital based on the percent to total of the available room in the prior year and current year comparison. The available gap under the IP UPL for each eligible hospital will be aggregated to create the supplemental payment amount. The total calculated supplemental payment amount will be paid to eligible hospitals.

1. The IP UPL will be determined based on the hospital’s Medicaid inpatient costs using Medicare cost reporting principles. All Medicare cost report worksheet, column, or line references are based upon the Medicare Cost Report (MCR)

CMS 2552-10 and should be adjusted for any CMS-approved successor MCR. The amount that Medicare would pay shall be A. Using Medicare cost report data within the previous two (2) years of the IP UPL demonstration dates in accordance with IP UPL guidelines set by CMS, Total Medicare Costs shall be derived from the reported Inpatient Hospital Cost on the following cost report variable locations:

(I) Worksheet D-1, Hospital/IPF/IRF Components, Column 1, Line 49;

(II) Plus Organ Acquisitions Cost from all applicable Worksheets D-4, Column 1, Line 69; and (III) Plus GME Aggregated Approved Amount from Worksheet E-4, Column 1, Line 49;

B. Total Medicare Patient Days shall be derived from Worksheet S-3, Part I, Column 6, Lines 14, 16, and 17 of the same cost report as the Total Medicare Costs;

C. A calculated Medicare Cost Per Diem shall be calculated by dividing the Total Medicare Costs by the hospital’s Total Medicare Patient Days;

D. The calculated Medicare Cost Per Diem shall be multiplied by the total Medicaid Patient Days from a twelve- (12-) month data set from the prior two (2) years of the IP UPL demonstration dates in accordance with the IP UPL guidelines set by CMS to derive the hospital’s IP UPL.

(I) The data source for the Medicaid Patient Days and Total Medicaid Payments shall be from the state’s Medicaid Management Information System (MMIS) claims data;

E. The calculated IP UPL shall be inflated from the midpoint of the hospital’s cost report period to the midpoint of the IP UPL demonstration period using the CMS Prospective Payment System (PPS) hospital market basket index; and F. If payments in this section would result in payments to any category of hospitals in excess of the IP UPL calculation required by 42 CFR 447.272, payments for each eligible hospital receiving payments under this section will be reduced proportionately to ensure compliance with the IP UPL.

(3) Beginning with SFY 2026, state government-owned hospitals will be paid a final payment up to the final IP UPL gap.

rule filed May 20, 2011, effective Jan. 30, 2012. Emergency amendment filed June 14, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 14, 2022, effective Jan. 30, 2023. Emergency amendment filed July 26, 2024, effective Aug. 9, 2024, expired Feb. 27, 2025. Amended: Filed July 26, 2024, effective Feb. 28, 2025. Amended: Filed Aug. 18, 2025, effective March 30, 2026. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993,

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2025. Emergency rule filed May 20, 2011, effective July 1, 2011, expired Dec. 28, 2011. Original

Chapter 20 Pharmacy Program

13 CSR 70-20.031 List of Drugs for Which Prior Authorization Is Required and Drugs Excluded from Coverage Under the MO HealthNet Pharmacy {#sec-13-csr-70-20.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.031}

13 CSR 70-20.032 List of Excludable Drugs Excluded From Coverage Under the MO {#sec-13-csr-70-20.032 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.032}

13 CSR 70-20.033 Medicaid Program Coverage of Investigational Drugs Used in the Treatment of Acquired Immunodeficiency Syndrome (AIDS) {#sec-13-csr-70-20.033 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.033}

13 CSR 70-20.034 List of Non-Excludable Drugs for Which Prior Authorization Is {#sec-13-csr-70-20.034 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.034}

13 CSR 70-20.040 Five Prescription Limit Per Month Per Recipient {#sec-13-csr-70-20.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.040}

13 CSR 70-20.045 Maximum Day Supply Limit on Prescriptions Reimbursed by the {#sec-13-csr-70-20.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.045}

13 CSR 70-20.071 Multiple Source Drugs for Which There Exists a Federal Upper Limit {#sec-13-csr-70-20.071 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.071}

13 CSR 70-20.100 Missouri Nonsteroidal Anti-Inflammatory Drug List {#sec-13-csr-70-20.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.100}

13 CSR 70-20.110 Medicaid Program Coverage of Approved Drugs for Treatment of Acquired Immunodeficiency Syndrome (AIDS) {#sec-13-csr-70-20.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.110}

13 CSR 70-20.120 Medicaid Program Coverage of Anti-Ulcer Preparations Denny Hoskins (3/31/25) {#sec-13-csr-70-20.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.120}

13 CSR 70-20.010 Participating Drug Vendors {#sec-13-csr-70-20.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.010}

History

• AUTHORITY: section 207.020, RSMo 1986. This rule was previously filed as 13 CSR 40-81.011. Original rule filed Nov. 13, 1978, effective Feb. 11, 1979. Rescinded: Filed March 2, 2018, effective Sept. 30, 2018.

13 CSR 70-20.030 Drugs Covered by the MO HealthNet Division {#sec-13-csr-70-20.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.030}

PURPOSE: This rule implements recent changes in drug coverage as mandated by the Centers for Medicare & Medicaid Services (CMS).

(1) Drugs covered under the MO HealthNet Division must meet the definition of a prescribed drug as defined in 42 CFR 440.120(a), as amended, or a covered outpatient drug as defined in the Social Security Act, section 1927(k)(2) and section 1927(k)(4), as amended. sections 208.152 and 208.153, RSMo Supp. 2024.* This rule was previously filed as 13 CSR 40-81.010. Original rule filed Jan. 21, 1964, effective Jan. 31, 1964. Amended: Filed March 30, 1964, effective April 10, 1964. Amended: Filed April 27, 1965, effective May 7, 1965. Amended: Filed Dec. 7, 1966, effective Dec. 17, 1966.

Amended: Filed Oct. 11, 1967, effective Oct. 21, 1967. Amended:

Filed Oct. 19, 1967, effective Oct. 29, 1967. Amended: Filed Jan. 22, 1968, effective Feb. 2, 1968. Amended: Filed Aug. 24, 1968, effective Sept. 4, 1968. Amended: Filed April 16, 1970, effective April 26, 1970. Amended: Filed Feb. 16, 1971, effective Feb. 26, 1971.

Amended: Filed Jan. 3, 1973, effective Jan. 13, 1973. Amended: Filed Feb. 6, 1975, effective Feb. 16, 1975. Amended: Filed March 9, 1977, effective June 11, 1977. Amended: Filed June 13, 1977, effective Oct. 1, 1977. Amended: Filed March 13, 1978, effective June 11, 1978.

Amended: Filed Feb. 1, 1979, effective May 11, 1979. Emergency amendment filed July 26, 1979, effective Aug. 1, 1979, expired Oct. 10, 1979. Amended: Filed July 16, 1979, effective Oct. 11, 1979.

Emergency amendment filed Aug. 11, 1981, effective Aug. 21, 1981, expired Nov. 11, 1981. Amended: Filed Aug. 11, 1981, effective Nov. 12, 1981. Emergency amendment filed Dec. 21, 1981, effective Jan. 1, 1982, expired April 10, 1982. Emergency amendment filed Jan. 21, 1982, effective Feb. 1, 1982, expired April 10, 1982. Amended:

Filed Dec. 21, 1981, effective April 11, 1982. Emergency amendment filed July 22, 1982, effective Aug. 1, 1982, expired Nov. 10, 1982.

Amended: Filed July 22, 1982, effective Nov. 11, 1982. Emergency amendment filed Sept. 30, 1982, effective Oct. 10, 1982, expired Jan. 28, 1983. Amended: Filed Jan. 14, 1983, effective May 12, 1983.

Amended: Filed July 13, 1983, effective Oct. 13, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired March 30, 1984. Emergency amendment filed March 21, 1984, effective March 31, 1984, expired July 11, 1984. Amended: Filed March 21, 1984, effective July 12, 1984. Emergency amendment filed April 20, 1984, effective May 1, 1984, expired July 11, 1984.

Amended: Filed June 13, 1984, effective Sept. 14, 1984. Amended:

Filed Sept. 12, 1984, effective Jan. 12, 1985. Amended: Filed Jan. 15, 1985, effective April 11, 1985. Amended: Filed April 16, 1985, effective July 11, 1985. Amended: Filed Oct. 2, 1985, effective Jan. 1, 1986. Amended: Filed April 16, 1986, effective July 1, 1986.

Amended: Filed Sept. 17, 1986, effective Dec. 1, 1986. Amended:

Filed Nov. 14, 1986, effective Feb. 12, 1987. Emergency amendment filed Dec. 18, 1986, effective Jan. 1, 1987, expired Feb. 11, 1987.

Amended: Filed Feb. 18, 1987, effective May 1, 1987. Amended:

Filed April 17, 1987, effective July 1, 1987. Amended: Filed June 16, 1987, effective Sept. 1, 1987. Amended: Filed Aug. 18, 1987, effective Nov. 12, 1987. Amended: Filed Dec. 1, 1987, effective Feb. 11, 1988.

Amended: Filed April 4, 1988, effective July 1, 1988. Amended:

Filed July 15, 1988, effective Oct. 13, 1988. Amended: Filed Sept. 15, 1988, effective Dec. 11, 1988. Amended: Filed April 4, 1989, effective July 1, 1989. Amended: Filed June 6, 1989, effective Sept. 1, 1989.

Amended: Filed June 30, 1989, effective Oct. 1, 1989. Amended:

Filed Nov. 15, 1989, effective Feb. 1, 1990. Amended: Filed Feb. 16, 1990, effective May 1, 1990. Amended: April 18, 1990, effective June 30, 1990. Amended: Filed Aug. 10, 1990, effective Dec. 31, 1990.

Emergency amendment filed Dec. 21, 1990, effective Jan. 1, 1991, expired April 30, 1991. Emergency rescission and rule filed March 21, 1991, effective March 31, 1991, expired July 28, 1991. Emergency rescission filed April 2, 1991, effective April 12, 1991, expired Aug. 9, 1991. Emergency rule filed April 2, 1991, effective April 13, 1991, expired Aug. 10, 1991. Emergency amendment filed June 21, 1991, effective July 1, 1991, expired Aug. 10, 1991. Emergency rescission filed July 31, 1991, effective Aug. 11, 1991, expired Dec. 6, 1991. Rescinded: Filed March 21, 1991, effective Sept. 30, 1991.

Emergency rule filed July 31, 1991, effective Aug. 11, 1991, expired Dec. 7, 1991. Readopted: Filed July 15, 1991, effective Jan. 13, 1992.

Emergency amendment filed Sept. 23, 1991, effective Oct. 3, 1991, expired Dec. 7, 1991. Emergency rule filed Nov. 27, 1991, effective Dec. 8, 1991, expired April 5, 1992. Emergency amendment filed March 24, 1992, effective April 1, 1992, expired July 29, 1992.

Emergency amendment filed June 16, 1992, effective July 1, 1992, expired Oct. 28, 1992. Amended: Filed March 24, 1992, effective Sept. 6, 1992. Emergency amendment filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency amendment filed Jan. 15, 1993, effective Jan. 29, 1993, expired May 28, 1993.

Amended: Filed June 16, 1992, effective April 8, 1993. Emergency amendment filed March 19, 1993, effective April 1, 1993, expired July 29, 1993. Emergency amendment filed June 18, 1993, effective July 1, 1993, expired Oct. 28, 1993. Amended: Filed April 6, 1993, effective Dec. 9, 1993. Rescinded and readopted: Filed Oct. 15, 1993, effective June 6, 1994. Amended: Filed June 29, 2000, effective Dec. 30, 2000. Amended: Filed Aug. 28, 2018, effective April 30, 2019.

Amended: Filed Aug. 16, 2024, effective April 30, 2025. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-20.031 List of Drugs for Which Prior Authorization Is Required and Drugs Excluded from Coverage Under the MO HealthNet Pharmacy Program {#sec-13-csr-70-20.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.031}

PURPOSE: This rule establishes a listing of drugs and categories of drugs for which prior authorization is required in order for them to be reimbursable and for which reimbursement is not available under the MO HealthNet Pharmacy Program.

(3/31/25) Denny Hoskins (1) Exclusions—As used in section 208.152.1(12), RSMo, any “abortifacient drug or device” includes: mifepristone when used to induce an abortion; misoprostol when used to induce an abortion; manual vacuum aspirator (MVA) when used to induce an abortion; or any drug or device approved by the federal Food and Drug Administration (FDA) that the FDA has found on or after the effective date of section 208.152.1(12), RSMo, that is intended to cause the destruction of an unborn child as defined in section 188.015, RSMo.

(2) Exclusions—As specified in the Social Security Act, Section 1927(d)(1)(B), states may exclude or otherwise restrict coverage of certain covered outpatient drugs. Section 1927(d)(2) of the Social Security Act provides a listing of the categories of drugs that states may exclude. Drugs included on this list may be excluded from coverage entirely or restricted by diagnosis as determined by the state.

(3) As specified in Section 1927(d)(1) of the Social Security Act, states may subject to prior authorization any covered outpatient drug. Any such prior authorization program shall comply with the requirements of Section 1927(d)(5) of the Social Security Act.

(4) List of drugs or categories of drugs for which prior authorization is required for certain specified indications, and those which are excluded from reimbursement through the MO HealthNet Pharmacy Program shall be made available through— (A) MO HealthNet provider manuals, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/manuals/, September 27, 2018.

This rule does not incorporate any subsequent amendments or additions;

(B) Provider Bulletins, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://dss.mo.gov/ mhd/providers/pages/bulletins.htm, September 27, 2018. This

rule does not incorporate any subsequent amendments or additions; or (C) Forms, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/ manuals/presentation/forms.jsp, September 27, 2018. This rule does not incorporate any subsequent amendments or additions.

(5) The division reserves the right to effect changes in the list of drugs for which prior authorization is required and for which reimbursement is not available by amending this rule.

Emergency amendment filed Nov. 21, 2000, effective Dec. 1, 2000, expired May 29, 2001. Amended: Filed June 29, 2000, effective Feb. 28, 2001. Emergency amendment filed June 7, 2002, effective July 1, 2002, expired Dec. 27, 2002. Amended: Filed June 11, 2002, effective Jan. 30, 2003. Amended: Filed Jan. 16, 2007, effective July 30, 2007. Amended: Filed Sept. 16, 2013, effective March 30, 2014.

Amended: Filed Sept. 27, 2018, effective May 30, 2019. Emergency amendment filed Oct. 21, 2021, effective Nov. 4, 2021, expired May 2, 2022. Amended: Filed Oct. 21, 2021, effective April 30, 2022. *Original authority: 1.205, RSMo 1986; 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993,

History

• AUTHORITY: sections 1.205, 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021. Original rule filed Dec. 13, 1991, effective Aug. 6, 1992. Amended: Filed May 15, 1992, effective Jan. 15, 1993. Amended: Filed March 1, 1996, effective Oct. 30, 1996. Amended: Filed May 27, 1999, effective Dec. 30, 1999.

13 CSR 70-20.032 List of Excludable Drugs Excluded From Coverage Under the MO HealthNet Pharmacy Program {#sec-13-csr-70-20.032 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.032}

(Rescinded January 30, 2019)

Original rule filed Dec. 13, 1991, effective Aug. 6, 1992. Amended:

Filed June 30, 2000, effective Feb. 28, 2001. Emergency amendment filed June 7, 2002, effective July 1, 2002, expired Dec. 27, 2002.

Amended: Filed June 11, 2002, effective Jan. 30, 2003. Amended:

Filed Jan. 16, 2007, effective July 30, 2007. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Rescinded: Filed June 8, 2018, effective Jan. 30, 2019.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013.

13 CSR 70-20.033 Medicaid Program Coverage of Investigational Drugs Used in the Treatment of Acquired Immunodeficiency Syndrome (AIDS) {#sec-13-csr-70-20.033 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.033}

Emergency rule filed Dec. 15, 1995, effective Jan. 1, 1996, expired June 28, 1996. Original rule filed Dec. 15, 1995, effective July 30, 1996. Rescinded: Filed March 2, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: sections 208.152, 208.153 and 208.201, RSMo 1994.

13 CSR 70-20.034 List of Non-Excludable Drugs for Which Prior Authorization Is Required {#sec-13-csr-70-20.034 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.034}

(Rescinded May 30, 2019)

2008. Emergency rule filed Nov. 21, 2000, effective Dec. 1, 2000, expired May 29, 2001. Original rule filed June 29, 2000, effective Feb. 28, 2001. Emergency amendment filed June 7, 2002, effective July 1, 2002, expired Dec. 27, 2002. Amended: Filed June 11, 2002, effective Jan. 30, 2003. Amended: Filed Jan. 16, 2007, effective July 30, 2007. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010.

Rescinded: Filed Sept. 27, 2018, effective May 30, 2019.

History

• AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp.

13 CSR 70-20.040 Five Prescription Limit Per Month Per Recipient {#sec-13-csr-70-20.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.040}

(Rescinded January 30, 2019)

Amended: Filed Jan. 15, 1985, effective April 11, 1985. Amended:

Filed April 16, 1985, effective July 11, 1985. Amended: Filed Oct. 2, 1985, effective Jan. 1, 1986. Amended: Filed April 16, 1986, Denny Hoskins (4/30/25) effective July 1, 1986. Emergency amendment filed Dec. 18, 1986, effective Jan. 1, 1987, expired Feb. 11, 1987. Amended: Filed Sept. 17, 1986, effective Dec. 1, 1986. Amended: Filed Nov. 14, 1986, effective Feb. 12, 1987. Amended: Filed Feb. 18, 1987, effective May 1, 1987. Emergency amendment filed Dec. 18, 1986, effective Jan. 1, 1987, expired Feb. 11, 1987. Amended: Filed April 17, 1987, effective July 1, 1987. Amended: Filed June 16, 1987, effective Sept. 1, 1987.

Amended: Filed Aug. 18, 1987, effective Nov. 12, 1987. Amended:

Filed Dec. 1, 1987, effective Feb. 11, 1988. Amended: Filed April 15, 1988, effective July 1, 1988. Amended: Filed July 15, 1988, effective Oct. 13, 1988. Amended: Filed July 15, 1988, effective Oct. 13, 1988.

Amended: Filed Sept. 15, 1988, effective Dec. 11, 1988. Amended:

Filed April 4, 1989, effective July 1, 1989. Amended: Filed June 6, 1989, effective Sept. 1, 1989. Amended: Filed June 30, 1989, effective Oct. 1, 1989. Amended: Filed Nov. 15, 1989, effective Feb. 1, 1990.

Amended: Filed Aug. 13, 1990, effective Dec. 31, 1990. Emergency amendment filed Dec. 21, 1990, effective Jan. 1, 1991, expired April 30, 1991. Emergency amendment filed March 21, 1991, effective April 1, 1991, expired July 29, 1991. Amended: Filed March 13, 1991, effective Oct. 31, 1991. Rescinded: Filed June 8, 2018, effective Jan. 30, 2019.

History

• AUTHORITY: sections 208.153, RSMo Supp. 1991 and 208.201, RSMo Supp. 1987. This rule was previously filed as 13 CSR 40- 81.012. Emergency rule filed Oct. 21, 1981, effective Nov. 1, 1981, expired Feb. 10, 1982. Original rule filed Oct. 21, 1981, effective Feb. 11, 1982. Amended: Filed March 14, 1984, effective June 11, 1984. Amended: Filed June 12, 1984, effective Sept. 14, 1984.

13 CSR 70-20.042 Automatic Refill Program {#sec-13-csr-70-20.042 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.042}

PURPOSE: This rule establishes the regulatory basis to prohibit automatic refill of prescriptions by providers for MO HealthNet participants.

(1) Automatic Refill Program.

(A) MO HealthNet does not allow automatic refills or automatic shipments of medications, devices, or supplies.

MO HealthNet does not pay for any prescription without an explicit request from a participant or the participant’s responsible party, such as a caregiver, for each refilling event.

Participants and providers cannot waive the explicit refill request requirement and enroll in an automatic refill program.

(B) This ban on automatic refills shall include all MO HealthNet participants, including dual eligible participants and participants with other primary insurance.

(C) A nurse or other authorized agent of the facility may initiate a request for a refill for a participant residing in a skilled nursing facility, group home, or assisted living arrangement.

1. Cycle filling for a participant residing in a skilled nursing facility, group home, or assisted living arrangement does not constitute an automatic refill program as long as the pharmacy and facility staff have a policy and procedure in place to prevent medication that is discontinued or otherwise unneeded from being billed to MO HealthNet. Cycle-fill medication that does not follow the policy and procedure between the pharmacy and facility may be subject to administrative action.

(D) Any prescription filled without a request from a participant or the participant’s responsible party may be subject to recoupment. Any provider who pursues an automatic refill policy may be subject to administrative action.

Filed Nov. 6, 2023, effective May 30, 2024. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. Original rule filed Dec. 15, 2022, effective July 30, 2023. Amended:

13 CSR 70-20.045 Maximum Day Supply Limit on Prescriptions Reimbursed by the MO HealthNet Division {#sec-13-csr-70-20.045 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.045}

PURPOSE: This rule establishes a thirty-one- (31-) day supply maximum restriction per dispensing on prescriptions reimbursed by the MO HealthNet Division (MHD).

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated (1) The maximum days’ supply for prescriptions dispensed on behalf of a participant eligible for any fee-for-service programs is a maximum of thirty-one (31) days, except for those prescriptions under the provisions of this rule. MHD providers may dispense prescriptions in quantities less than a thirty-one- (31-) day supply if ordered by the prescriber, except as specified elsewhere in this rule.

(2) Prescriptions that are exempt from the thirty-one- (31-) day supply limit and therefore may be dispensed in quantities exceeding a thirty-one- (31-) day supply are made available in the MHD Pharmacy Manual. The MHD Pharmacy Manual is incorporated by reference in this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, April 15, 2024. This

rule does not incorporate any subsequent amendments or additions. The division reserves the right to effectuate changes in the list of prescriptions and categories exempt from the thirty-one- (31-) day supply limit by amending this rule.

(3) All spend down participants are exempt from the MHD thirty-one- (31-) day supply limit on pharmacy services.

(4) Exemptions from the thirty-one- (31-) day supply limit may be given with prior authorization by the MHD to prevent a higher level of care.

(5) Prescriptions identified by 13 CSR 70-20.047 are exempt from the thirty-one- (31-) day supply limit. sections 208.152 and 208.153, RSMo Supp. 2024.* Emergency rule filed Nov. 21, 2000, effective Dec. 1, 2000, expired May 29, 2001.

Original rule filed June 29, 2000, effective Feb. 28, 2001. Amended:

Filed Dec. 5, 2000, effective June 30, 2001. Amended: Filed April 18, 2018, effective Nov. 30, 2018. Amended: Filed Jan. 15, 2021, effective July 30, 2021. Amended: Filed Oct. 23, 2024, effective May 30, 2025. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993,

13 CSR 70-20.047 Ninety-Day Supply Requirement for Select Prescriptions {#sec-13-csr-70-20.047 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.047}

PURPOSE: This rule establishes a ninety- (90-) day supply (4/30/25) Denny Hoskins requirement per dispensing on select prescriptions reimbursed by the MO HealthNet Division (MHD) on behalf of participants eligible for MO HealthNet.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated (1) MHD participating pharmacies shall dispense a ninety- (90-) day supply of select prescriptions to a participant eligible for fee-for-service programs. Prescriptions subject to this ninety- (90-) day supply requirement are included in the 90-Day Supply Medication List, and incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://mydss.mo.gov/media/pdf/90-daysupply-medication-list-1, November 15, 2021. This rule does not incorporate any subsequent amendments or additions. sections 208.152 and 208.153, RSMo Supp. 2024.* Original rule filed Jan. 15, 2021, effective July 30, 2021. Amended: Filed Sept. 9, 2024, effective April 30, 2025. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-20.050 Return of Drugs {#sec-13-csr-70-20.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.050}

PURPOSE: This rule establishes that pharmacies must give the MO HealthNet Division credit for any unused portion of the drug that is reusable in accordance with applicable federal or state law.

(1) The return and reuse of drugs must follow guidelines set by the State Board of Pharmacy in 20 CSR 2220-3.040, as amended.

(2) The pharmacy must give the MO HealthNet Division credit for all reusable items (any unused portion) not taken by the MO HealthNet participant. In instances in which charges have been submitted prior to the return of an item, the pharmacy shall file an adjustment prorated to the quantity of the drug used by the MO HealthNet participant.

Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed April 18, 2018, effective Nov. 30, 2018. Amended: Filed May 28, 2021, effective Nov. 30, 2021. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. Original rule filed Dec. 15, 2000, effective July 30, 2001. Amended:

13 CSR 70-20.060 Professional Dispensing Fee {#sec-13-csr-70-20.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.060}

PURPOSE: The MO HealthNet Division establishes the amount of the fee reimbursable for the professional dispensing of each MO HealthNet covered prescription by a pharmacy provider.

(1) Between April 1, 2017 and January 31, 2021, a professional dispensing fee shall be added to the MO HealthNet maximum allowable payment for MO HealthNet reimbursable prescriptions filled or refilled by a pharmacy provider as follows:

(A) Out-of-state pharmacy providers receive a professional dispensing fee of nine dollars fifty-five cents ($9.55);

(B) In-state pharmacy providers receive a professional dispensing fee of fourteen dollars thirty-seven cents ($14.37);

(C) In-state pharmacy providers receive a preferred generic product incentive fee of five dollars zero cents ($5.00); and (D) The professional dispensing fees as provided in this

rule shall not be included in the computation of the MO HealthNet maximum allowable drug payment for participant cost-sharing purposes.

(2) Effective February 1, 2021, a professional dispensing fee shall be added to the MO HealthNet maximum allowable payment for MO HealthNet reimbursable prescriptions filled or refilled by a pharmacy provider as follows:

(A) Out-of-state pharmacy providers receive a professional dispensing fee of eight dollars and eighty-five cents ($8.85);

(B) In-state pharmacy providers receive a professional dispensing fee of twelve dollars and twenty-two cents ($12.22), plus an adjustment to account for the costs of the Missouri Pharmacy Reimbursement Allowance attributable to Medicaidreimbursed prescriptions;

(C) The professional dispensing fee as provided in this rule shall not be added to prescriptions reimbursed at the usual and customary charge submitted by the provider; and (D) The professional dispensing fees as provided in this

rule shall not be included in the computation of the MO HealthNet maximum allowable drug payment for participant cost-sharing purposes.

(3) Effective April 1, 2017, all pharmacy providers supplying prescribed MO HealthNet covered drugs to participants in long-term care facilities shall receive an additional fifty cent (50¢) dispensing fee per claim provided they— (A) Dispense medication in a drug distribution system(s) which meets minimum standards of container packaging (at least class B as defined in United States Pharmacopeia XXI);

(B) Certify to the MO HealthNet Division, on a form, and in the manner prescribed by the division, that they— 1. Provide this dispensing service to their long-term care facility resident patients;

2. Provide emergency services twenty-four (24) hours a day with seven (7) days a week availability; and 3. Have the ability and willingness to assist in accessing medications through the MO HealthNet Exception Process; and (C) Indicate, as prescribed by the MO HealthNet Division, on each claim that the prescription was provided in packaging Denny Hoskins (5/31/25) qualifying for the dispensing fee add-on to a participant in a long-term care facility.

(4) A professional dispensing fee shall be added to maintenance medications no more frequently than once every twenty-five (25) days. “Maintenance medications” are defined as drugs that have a common indication for treatment of a chronic disease, and the therapeutic duration is expected to exceed one year.

This is determined by a First DataBank drug code maintenance indicator of “1.”

Amended: Filed Sept. 26, 2013, effective March 30, 2014. Emergency amendment filed Jan. 13, 2021, effective Feb. 1, 2021, expired July 30, 2021. Amended: Filed Jan. 13, 2021, effective July 30, 2021. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. Original rule filed Dec. 15, 1987, effective March 11, 1988.

13 CSR 70-20.070 Drug Reimbursement Methodology {#sec-13-csr-70-20.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.070}

PURPOSE: This rule establishes the basis and the method for pricing all drug claims in Missouri under the Title XIX Medicaid program. The purchase of a computer-generated tape, with weekly updates, will make it possible to utilize the computer for review purposes, which greatly increases the speed with which claims can be paid.

(1) The MO HealthNet Division will obtain, by contract with a reputable medical publishing company, a weekly computergenerated tape which will provide the information needed to price all fee-for-service Medicaid drug claims. The tape will contain National Drug Code (NDC), drug name, drug strength, dosage form, package size, the prices set by direct-selling manufacturers (direct prices), Wholesaler Acquisition Cost (WAC), federal Health and Human Services upper limits for specified multiple source drugs (FUL), and National Average Drug Acquisition Cost (NADAC). A multiple source drug is defined as a drug marketed or sold by two (2) or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two (2) or more different proprietary names or both under a proprietary name and without that name.

(2) The MO HealthNet Division will add the Missouri Maximum Allowable Cost (MMAC) limits, for multiple source drugs as defined, to the data shown on the tape described in section (1) of this rule.

(3) Effective December 16, 2018, reimbursement for covered drugs will be determined by applying the following hierarchy method:

(A) National Average Drug Acquisition Cost (NADAC); if there is no NADAC;

(B) Missouri Maximum Allowed Cost (MAC); if no NADAC or MAC;

(C) Wholesale Acquisition Cost (WAC); or (D) The usual and customary (U&C) charge submitted by the provider if it is lower than the chosen price (NADAC, MAC, or WAC).

1. U&C is defined as the provider’s charge to the general public that reflects all discounts or programs such as, but not limited to, discount programs, membership programs, price matching programs, or any other program offered by the provider to initiate a reduced price for product costs available to the general public, a special population, or an inclusive category of customers, on the date of service.

2. General public is defined as those patients that pay for their prescriptions and the prescription is not processed by a third-party which includes both governmental and nongovernmental payers.

(4) Reimbursement for covered drugs for 340B providers as defined in 42 U.S.C. 256b(a)(4) and 42 U.S.C. 1396r-8(a)(5)(B) who carve-in for Medicaid will be calculated according to 13 CSR 70-20.075.

(5) The professional dispensing fee will be calculated according to 13 CSR 70-20.060.

Filed May 3, 1988, effective July 28, 1988. Emergency amendment filed Dec. 21, 1990, effective March 17, 1991, expired April 30, 1991.

Emergency amendment filed March 6, 1991, effective March 17, 1991, expired July 14, 1991. Emergency amendment filed Sept. 4, 1991, effective Sept. 17, 1991, expired Jan. 14, 1992. Amended: Filed Sept. 4, 1991, effective Jan. 13, 1992. Amended: Filed Dec. 5, 2000, effective June 30, 2001. Amended: Filed July 19, 2018, effective March 30, 2019. Emergency amendment filed April 26, 2021, effective July 1, 2021, expired Feb. 24, 2022. Amended: Filed April 26, 2021, effective Nov. 30, 2021. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2015, 2018, 2021; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021. This rule was previously filed as 13 CSR 40-81.150. Original rule filed April 23, 1979, effective Aug. 11, 1979. Emergency amendment filed Sept. 9, 1981, effective Oct. 1, 1981, expired Dec. 10, 1981. Amended: Filed Sept. 9, 1981, effective Dec. 11, 1981. Emergency amendment filed Oct. 19, 1987, effective Oct. 29, 1987, expired Feb. 25, 1988. Amended: Filed Dec. 1, 1987, effective Feb. 11, 1988. Emergency amendment filed March 29, 1988, effective April 8, 1988, expired Aug. 5, 1988. Amended:

13 CSR 70-20.071 Multiple Source Drugs for Which There Exists a Federal Upper Limit on Reimbursement {#sec-13-csr-70-20.071 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.071}

Emergency rule filed Oct. 19, 1987, effective Oct. 29, 1987, expired Feb. 25, 1988. Emergency amendment filed Oct. 29, 1987, effective Nov. 8, 1987, expired March 6, 1988. Original rule filed Dec. 1, 1987, effective Feb. 11, 1988. Emergency amendment filed June 21, 1988, effective July 1, 1988, expired Oct. 28, 1988. Amended: Filed Aug. 16, 1988, effective Oct. 29, 1988. Emergency amendment filed May 12, 1989, effective June 1, 1989, expired Sept. 23, 1989. Amended:

Filed May 12, 1989, effective Aug. 11, 1989. Amended: Filed Nov. 15, 1989, effective Feb. 1, 1990. Amended: Filed April 18, 1990, effective June 30, 1990. Emergency amendment filed Aug. 20, 1990, effective Sept. 1, 1990, expired Dec. 30, 1990. Amended: Filed Sept. 5, 1990, effective Feb. 14, 1991. Emergency amendment filed Dec. 20, 1990, effective Dec. 31, 1990, expired April 29, 1991. Emergency amendment filed March 21, 1991, effective March 31, 1991, expired July 28, 1991. Amended: Filed April 2, 1991, effective Oct. 31, 1991.

Emergency amendment filed Dec. 4, 1992, effective Dec. 15, 1992, expired April 13, 1993. Emergency rescission and emergency rule filed April 2, 1993, effective April 13, 1993, expired Aug. 10, 1993.

Amended: Filed Aug. 27, 1993, effective May 9, 1994. Amended:

(5/31/25) Denny Hoskins Filed Sept. 26, 2013, effective March 30, 2014. Rescinded: Filed March 2, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013.

13 CSR 70-20.075 340B Drug Pricing Program {#sec-13-csr-70-20.075 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.075}

PURPOSE: This rule establishes the payment methodology for 340B-covered entities as defined in section 1927(a)(5)(B) of the Social Security Act that choose to carve-in Medicaid.

(1) Covered entities that choose to carve-in Medicaid must provide the Health Resources and Services Administration (HRSA) with their National Provider Identification (NPI) and their MO HealthNet Division (MHD) provider number for each site that carves-in for inclusion in the HRSA Medicaid Exclusion File. MHD requires the MHD provider number to be included on the Medicaid Exclusion File to identify providers that carve-in Medicaid and to prevent duplicate discounts. A duplicate discount is defined as a covered entity receiving a discounted drug through the 340B program from the manufacturer, and MHD receives a rebate through the Medicaid Drug Rebate Program from the manufacturer for the same claim. Covered entity is defined in section 376.414.1(2), RSMo.

(2) Covered entities must identify 340B-purchased drugs using the Submission Clarification Code or modifier code on each claim that was 340B-purchased.

(3) Failure to include the appropriate identifier on a 340B-purchased drug will result in MHD collecting a rebate on the claim, resulting in a potential duplicate discount. A duplicate discount may subject the covered entity to audit penalties.

MHD will deny claims identified as 340B-purchased drugs at the claim level from providers who have yet to notify HRSA of carve-in status.

(4) Reimbursement for 340B-identified covered drugs for 340B providers as defined in section 376.414.1(2), RSMo, who carvein for Medicaid will be determined by applying the following method:

(A) MHD will reimburse 340B-purchased drugs dispensed by pharmacy providers at their actual acquisition cost, up to the 340B Maximum Allowable Cost (340B MAC) (calculated ceiling price) plus a professional dispensing fee. Covered entities must bill no more than their actual acquisition cost plus the professional dispensing fee.

1. MHD defines the 340B MAC (calculated ceiling price) as the Average Manufacturer Price (AMP) minus Unit Rebate Agreement (URA) as reported by the Centers for Medicare & Medicaid (CMS) quarterly.

2. MHD defines actual acquisition cost as the invoice cost for the National Drug Code (NDC) per billing unit. This does not include timely pay discounts or discounts paid as a rebate on a separate invoice for volume-based purchases.

3. MHD calculates the professional dispensing fee according to 13 CSR 70-20.060; and (B) MHD will reimburse physician-administered drugs purchased through the 340B program at the lesser of the Physician-Administered 340B MAC or the actual acquisition cost submitted by the provider. MHD does not apply a professional dispensing fee to physician-administered drugs.

4. MHD adds six percent (6%), up to six hundred dollars ($600), to the 340B MAC to calculate the physician-administered 340B MAC.

(5) MHD does not allow 340B contract pharmacies to carve-in under this policy.

(6) MHD may carve-out certain medications and categories of medications from 340B participation for MHD reimbursement.

Medications subject to the carve-out will be reimbursed according to 13 CSR 70-20.070. The following medications and categories of medications are carved-out of reimbursement through the 340B program:

(A) Drugs approved by the FDA for the treatment of obesity; and (B) Cell and gene therapies.

section 208.153, RSMo Supp. 2024.* Emergency rule filed April 26, 2021, effective July 1, 2021, expired Feb. 24, 2022. Original rule filed April 26, 2021, effective Nov. 30, 2021. Emergency amendment filed Nov. 21, 2024, effective Dec. 9, 2024, expired June 6, 2025.

Amended: Filed Nov. 21, 2024, effective June 30, 2025. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-20.080 Labeling of Medicaid Prescriptions {#sec-13-csr-70-20.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.080}

(Rescinded December 9, 1993)

Original rule file Oct. 24, 1974, effective Nov. 3, 1974. Rescinded:

Filed April 6, 1993, effective Dec. 9, 1993.

History

• AUTHORITY: sections 207.020, RSMo 1986 and 208.153, RSMo Supp. 1991. This rule was previously filed as 13 CSR 40-81.030.

13 CSR 70-20.100 Missouri Nonsteroidal Anti-Inflammatory Drug List {#sec-13-csr-70-20.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.100}

(Rescinded September 30, 1991)

This rule was previously filed as 13 CSR 40-81.013. Original rule filed Feb. 18, 1987, effective June 1, 1987. Amended: Filed April 4, 1989, effective July 1, 1989. Amended: Filed Aug. 13, 1990, effective Dec. 31, 1990. Emergency rescission filed March 21, 1991, effective March 31, 1991, expired July 28, 1991. Rescinded: Filed March 21, 1991, effective Sept. 30, 1991.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 1989.

13 CSR 70-20.110 Medicaid Program Coverage of Approved Drugs for Treatment of Acquired Immunodeficiency Syndrome (AIDS) {#sec-13-csr-70-20.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.110}

(Rescinded September 30, 1991)

History

• AUTHORITY: sections 208.153, RSMo 1986 and 208.201, RSMo Supp. 1988. Emergency rule filed July 9, 1987, effective July 19, 1987, expired Nov. 15, 1987. Original rule filed July 31, 1987, effective Nov. 12, 1987. Amended: Filed Nov. 15, 1989, effective Feb. 1, 1990. Emergency rescission filed March 21, 1991, effective March 31, 1991, expired July 28, 1991. Rescinded: Filed March 21, 1991, effective Sept. 30, 1991.

13 CSR 70-20.120 Medicaid Program Coverage of Anti-Ulcer Preparations {#sec-13-csr-70-20.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.120}

(Rescinded June 29, 1989)

Denny Hoskins (6/30/25)

Amended: Filed March 16, 1989. Emergency rescission filed April 7, 1989, effective April 20, 1989, expired Aug. 17, 1989. Rescinded:

Filed April 7, 1989, effective June 29, 1989.

History

• AUTHORITY: sections 208.153, RSMo 1986 and 208.201, RSMo Supp. 1987. Original rule filed Oct. 18, 1988, effective Jan. 1, 1989.

13 CSR 70-20.200 Prescription Prior Authorization Process {#sec-13-csr-70-20.200 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.200}

PURPOSE: This rule establishes the MO HealthNet Division (MHD) process by which drugs may be restricted under Section 4401 of P.L. 101-508 (Omnibus Budget Reconciliation Act of 1990) and is determined to be appropriate for inclusion as a regular benefit of the MHD or through prior authorization.

(1) All persons eligible for medical assistance benefits shall have access to all pharmaceutical products for which there is federal financial participation except those drugs that may be restricted under Section 4401 of P.L. 101-508 (Omnibus Budget Reconciliation Act of 1990). MHD shall review drugs that may be restricted and present to the Prior Authorization Committee for possible inclusion as a regular benefit of MHD program or through prior authorization.

(2) MHD may require prior authorization for pharmaceutical products. MHD bases any restriction on medical and clinical criteria and Missouri-specific data. MHD shall develop this medical and clinical criteria based on predetermined standards consistent with the following:

(A) The American Hospital Formulary Service Drug Information;

(B) The United States Pharmacopoeia Drug Information; and (C) Peer-reviewed medical literature.

(3) MHD shall review drugs used to treat rare medical conditions with the Advisory Council on Rare Disease and Personalized Medicine. MHD shall develop medical and clinical criteria and make recommendations to the Advisory Council on Rare Disease and Personalized Medicine. MHD will present any proposals reviewed by the Advisory Council on Rare Disease and Personalized Medicine to the Prior Authorization Committee and Drug Utilization Review Board.

(4) The Prior Authorization Committee and Drug Utilization Review shall hold a public hearing at least once every quarter during which MHD shall make recommendations to the board and any final decision by MHD to require prior authorization for that pharmaceutical product, class, or category.

(5) MHD shall post the tentative meeting agenda on the MHD website (https://mydss.mo.gov/mhd/pharmacy-committees) at least seven (7) days before the meeting, and the agenda will include the therapeutic classes MHD plans to discuss.

(A) MHD shall place the specific preferred drug list classes to be considered at the next regularly scheduled Prior Authorization Committee meeting on the current agenda or posted on the website approximately seven (7) days before the next scheduled meeting.

(B) Any interested party shall be granted the opportunity for clinically relevant public comment for up to three (3) minutes per drug under review by the Prior Authorization Committee.

The responsibility of scheduling the presentation shall rest with the interested party. Interested parties representing a manufacturer shall be granted three (3) minutes in the aggregate per therapeutic class under review by the Prior Authorization Committee.

(C) After considering all presented information, the Prior Authorization Committee may recommend alterations to the proposal. The committee shall make their final recommendation to the MHD by a majority vote of the committee members present thereto in a recorded roll call vote.

(6) MHD shall coordinate the implementation of any changes after all recommendations have been reviewed. All pertinent information relating to the edit implementation schedule and the edit criteria shall be made available to the public by reasonable means, including but not limited to posting on the MHD website following the Prior Authorization Committee meeting.

(7) On an annual basis, the Prior Authorization Committee shall review all prior authorization criteria in place quarterly and may schedule more frequently if new clinical or fiscal information is available.

(8) Unless MHD is addressing an urgent market change, MHD shall not otherwise restrict the prescribing and dispensing of covered outpatient prescription drugs under this rule without consulting the Prior Authorization Committee.

(9) When implementing the provisions of this rule, Missouri-specific data shall consider use and cost data, pharmacoeconomic information, and prudent utilization of state funds, and shall include medical and clinical criteria.

(10) MHD may impose limitations on the minimum or maximum quantities per prescription, early refill, or the number of refills if such limitations are necessary to discourage waste and may address instances of fraud or abuse by individuals.

section 208.153, RSMo Supp. 2024.* Original rule filed Feb. 3, 1992, effective Aug. 6, 1992. Emergency amendment filed May 22, 2002, effective June 1, 2002, expired Nov. 27, 2002. Amended: Filed June 3, 2002, effective Nov. 30, 2002. Amended: Filed Dec. 14, 2004, effective June 30, 2005. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed Sept. 16, 2020, effective March 30, 2021. Amended: Filed Dec. 17, 2024, effective July 30, 2025. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-20.250 Prior Authorization of New Drug Entities or New Drug Dosage Form {#sec-13-csr-70-20.250 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.250}

PURPOSE: This rule outlines how new drugs or new drug dosage forms of existing drugs may be subject to prior authorization before payment by MO HealthNet Division (MHD).

(1) New drug entities and new drug product dosage forms of existing drug entities are eligible to be covered, as defined in 13 CSR 70-20.030, and shall comply with prior authorization requirements imposed by MHD, in compliance with federal law.

(2) Prior authorization shall continue on new drug entities and new drug product dosage forms of existing drugs until reviewed by MHD and MHD eliminates the prior authorization or makes a final determination to require continued prior authorization. MHD shall consider known cost and utilization data, medical and clinical criteria, and prudent utilization (6/30/25) Denny Hoskins of state funds in the review. Interested parties may present clinical data to MHD.

(3) The review referenced in section (2) shall begin within thirty (30) business days after MHD receives notice through the weekly national compendia file of the availability of the drug entity on the market and if the drug is eligible to be covered as defined in 13 CSR 70-20.030, whichever is later. The review shall take no more than forty-five (45) business days from the start of the review. Upon completion of the review, MHD shall remove the prior authorization requirements or refer the new drug or new drug dosage form to the Prior Authorization Committee with a recommendation for continued prior authorization. MHD recommendations regarding continued prior authorization of a new drug or new drug dosage form shall be made in writing to the Prior Authorization Committee. A copy shall be available to the public before the Prior Authorization Committee meeting in which the continued prior authorization is to be discussed.

(4) The Prior Authorization Committee shall consider any recommendations related to continued prior authorization requirements of a new drug or new drug dosage form no later than one hundred ninety (190) calendar days after the new drug review is completed. The Prior Authorization Committee shall allow three (3) minutes for any interested parties who have notified MHD before the scheduled meeting to comment about such proposed prior authorization requirements.

(5) If the Prior Authorization Committee finds that utilization and cost data, pharmacoeconomic information, and medical and clinical implications of restriction are documented and prior authorization is warranted, the Prior Authorization Committee shall make a recommendation to MHD. Such recommendation shall be provided to MHD prior to MHD making a final determination. MHD shall provide notice of the final determination through the Department of Social Services, MHD website at https://mydss.mo.gov/mhd/pharmacy-clinicaledits-pdl.

(6) If, after the hearing referenced in section (5) above, prior authorization of the new drug or new drug dosage form is required, the prior authorization requirement shall be reviewed at least once every twelve (12) months by the Prior Authorization Committee.

section 208.153, RSMo Supp. 2024.* Emergency rule filed May 22, 2002, effective June 1, 2002, expired Nov. 27, 2002. Original rule filed June 3, 2002, effective Nov. 30, 2002. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed Jan. 20, 2021, effective July 30, 2021. Amended: Filed Oct. 16, 2024, effective May 30, 2025. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-20.300 Retrospective Drug Use Review Process {#sec-13-csr-70-20.300 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.300}

PURPOSE: This rule establishes the MO HealthNet Division (MHD) process by which the Drug Utilization Review Board is established as required by Section 4401 of P.L. 101-508 (Omnibus Budget Reconciliation Act of 1990) and by section 208.175, RSMo.

(1) Drug Utilization Review (DUR) Board. This rule establishes a MO HealthNet DUR Board in the Department of Social Services, MO HealthNet Division. The board shall be composed as specified in section 208.175, RSMo.

(2) The board members shall elect a chairperson.

(3) The DUR Board shall meet at least once every ninety (90)

days. A quorum of two-thirds (2/3) of the total members, including no fewer than three (3) physicians and three (3) pharmacists, is required for the board to act in its official capacity.

(4) Members shall serve four- (4-) year terms, except the terms of the original members, two (2) shall be appointed for a term of two (2) years, three (3) shall be appointed for a term of three (3) years, and three (3) shall be appointed for a term of four (4) years. Members may be reappointed, provided that minimum qualifications for membership continue to be met. Nominations shall be referred for final appointment by the governor subject to advice and consent of the senate. As vacancies occur, the DUR Board shall solicit and select a slate of nominees.

(5) The members of the DUR Board shall receive no compensation for their services other than reasonable expenses incurred in performing their official duties.

(6) The DUR Board shall hold a public hearing during which MHD shall make recommendations to the board.

(7) MHD shall make available any changes recommended by the DUR Board via the approved minutes of the DUR Board meeting in a timely fashion, at least thirty (30) days before the implementation of the recommendations.

(8) The DUR Board shall provide, either directly or through contracts between MHD and accredited health-care schools, state medical societies, or state pharmacist associations or societies, or other appropriate organizations, for educational outreach programs as required by P.L. 101-508, Section 4401, to educate practitioners on common drug therapy problems and improve prescribing and dispensing practices. This outreach shall include an educational newsletter to MHD providers including appropriate drug use guidelines and MHD utilization statistics. The board activities shall consist of— (A) Establishment and implementation of medical standards and criteria for the prospective and retrospective DUR program;

(B) Development, selection, application, and assessment of educational interventions for physicians, pharmacists, and participants that improve care; and (C) Administration of the Drug Prior Authorization Process as outlined in 13 CSR 70-20.200.

(9) As specified by P.L. 101-508, Section 4401, the DUR Board shall monitor drug use and prescribing and dispensing practices in the MHD program. This monitoring shall include reviewing and refining therapeutic criteria modules used in retrospective and prospective DUR and overseeing retrospective DUR intervention methods.

(10) The DUR Board shall advise MHD regarding all activities associated with the DUR process, including identifying types of intervention methods ranging from letters to physicians and pharmacists, face-to-face education, and educational symposiums for targeted providers. The board shall provide educational support and guidance as needed by the review committees. The review committees, in turn, shall report intervention results and make recommendations to the board based on these results.

(11) Patterns of inappropriate or aberrant prescribing or dispensing shall be identified and referred to the board to formulate targeted education.

(12) Agency Responsibility Regarding Confidentiality of Information. All information concerning applicants and MHD participants shall be confidential, and any disclosure of this information shall be restricted to purposes directly related to the administration of the medical assistance program.

Purposes directly related to administration of the medical assistance program include— (A) Establishing eligibility;

(B) Determining the amount of medical assistance;

(C) Providing services for recipients; and (D) Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the program.

History

• AUTHORITY: sections 208.175, 208.201, and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2024. Original rule filed Dec. 14, 1992, effective June 7, 1993. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed Sept. 16, 2020, effective March 30, 2021. Amended: Filed Oct. 23, 2024, effective May 30, 2025. Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.175, RSMo 1992, amended 1993, 2011, 2014; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-20.310 Prospective Drug Use Review Process and Patient Counseling {#sec-13-csr-70-20.310 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.310}

PURPOSE: This rule establishes provisions for prospective drug use review and patient counseling for MO HealthNet Division (MHD) participants, as required by Section 4401 or Public Law 101-508 (Omnibus Budget Reconciliation Act of 1990) and by section 208.176, RSMo.

(1) Prospective Drug Use Review (DUR). This rule establishes a MHD prospective drug use review process within the Department of Social Services, MHD, as specified in section 208.176, RSMo.

(2) Electronic Point-of-Sale Review. MHD shall provide for electronic point-of-sale review before each prescription is dispensed to a MHD participant or MHD participant’s responsible party on the date of service. MHD shall provide electronic point-of-sale screening for potential drug therapy problems using the approved clinical modules on the date of service.

(3) Electronic Point-of-Sale Review Available for MHD Participants. The pharmacy point of service system will provide the following reviews:

(A) Drug Disease Contraindications.

1. Drug (actual) disease precaution.

2. Inferred drug disease precaution;

(B) Drug to Drug Interactions;

(C) Side Effects.

1. Additive toxicity side effects.

2. Medical condition/additive side effect.

3. Side effect.

4. Drug indicated for the side effect of the previously prescribed drug;

(D) Dose Range Checking.

1. High dose alert.

2. Low dose alert;

(E) Minimum/Maximum Daily Dose.

1. High dose alert.

2. Low dose alert;

(F) Duplicate Therapy Checking.

1. Therapeutic duplication.

2. Ingredient duplication; and (G) Duration of Therapy.

3. Excessive duration alert.

(4) MHD Patient Counseling. As part of the prospective DUR program, participating pharmacies shall perform patient counseling according to the standards established by the Board of Pharmacy under 20 CSR 2220-2.190.

(5) MHD Patient Profiles. The term “reasonable effort” means that each time a MO HealthNet patient or caregiver presents a prescription, the pharmacist or pharmacist’s designee should request profile information verbally or in writing. Pharmacies must make a reasonable effort to obtain records and maintain patient profiles containing, at a minimum:

(A) The name, address, telephone number, date of birth (or age), and gender of the patient;

(B) Individual medical history, if significant, including disease states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices; and (C) Pharmacist’s comments relevant to the individual’s drug therapy.

(6) Documentation of Offer to Counsel. The pharmacist shall document for each MHD patient’s prescription uniformly whether the offer to counsel was accepted or refused by the patient or the patient’s agent.

(7) Provider Responsibility Regarding Confidentiality of MO HealthNet Beneficiary Information. All information concerning applicants and participants of medical services shall be confidential. Any disclosure of this information by the pharmacy provider shall be restricted to purposes directly related to the treatment of the patient and promotion of improved quality of care or conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the program. The confidential information includes— (A) Names and addresses;

(B) Social Security number;

(C) Medical services provided;

(D) Social and economic conditions or circumstances;

(E) Medical data, including diagnosis and history of disease or disability;

(F) Any information received for verifying income eligibility; and (G) Any information received in connection with the identification of legally liable third-party resources.

section 208.153, RSMo Supp. 2024.* Original rule filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed Sept. 16, 2013, effective March 30, 2014. Amended: Filed Nov. 27, 2019, effective June 30, 2020. Amended: Filed Dec. 17, 2024, effective July 30, 2025.

(12/31/25) Denny Hoskins *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007,

13 CSR 70-20.320 Pharmacy Reimbursement Allowance {#sec-13-csr-70-20.320 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.320}

PURPOSE: This rule establishes a Pharmacy Federal Reimbursement Allowance and the methodologies to determine the formula for the amount of allowance each pharmacy is required to pay for the privilege of providing outpatient prescription drugs.

(1) Pharmacy Reimbursement Allowance (PRA). PRA shall be assessed as described in this section.

(A) Definitions.

1. Department—Department of Social Services.

2. Director—Director of Department of Social Services.

3. Division—MO HealthNet Division.

4. Gross retail prescription receipts—For ease of administration for the department as well as the industry, this shall be an annual amount. The basis of tax in any fiscal year will be the gross prescription sales of the last calendar year prior to the previous fiscal year.

(B) Each pharmacy engaging in the business of providing outpatient prescription drugs in Missouri to the general public shall pay a PRA.

1. The PRA owed for existing pharmacies shall be calculated by multiplying the pharmacy’s total gross retail prescription receipts by the tax rate determined by the department. Subject to the limitations established in section 338.520, RSMo, such said tax rate shall be uniform and shall not exceed five percent (5%).

2. The PRA shall be divided by and collected over the number of months for which the PRA is effective.

3. The initial PRA owed by a newly licensed pharmacy shall be calculated by estimating the total prescription sales and multiplying the estimate by the rate determined by the department, as described in paragraph (1)(B)1.

4. If a pharmacy ceases to provide outpatient prescription drugs to the general public, the pharmacy is not required to pay the PRA during the time it did not provide outpatient prescription drugs.

5. If the pharmacy reopens, it shall resume paying the PRA.

It shall owe the same PRA as it did prior to closing, if the PRA has not changed per paragraph (1)(B)1.

(C) Each pharmacy shall submit an affidavit to the department with the following information:

1. Pharmacy name;

2. Contact;

3. Telephone number;

4. Address;

5. Federal tax ID number;

6. MO HealthNet pharmacy number (if applicable);

7. Pharmacy sales (total);

8. MO HealthNet pharmacy sales;

9. Number of paid MO HealthNet prescriptions; and 10. Gross receipts attributable to prescription drugs that are delivered directly to the patient via common carrier, by mail, or a courier service.

(D) The department shall prepare a confirmation schedule of the information provided by each pharmacy and the amount of PRA that is due from the pharmacy.

(E) Each pharmacy shall review the information prepared by the department and the amount of PRA calculated by the department to verify that the information is correct.

1. If the information supplied by the department is incorrect, the facility within thirty (30) calendar days of receiving the confirmation schedule must notify the division and explain the correction.

2. If the division does not receive corrected information within thirty (30) calendar days, it will be assumed to be correct, unless the pharmacy files a protest in accordance with subsection (2)(D) of this regulation.

(2) Payment of the PRA.

(A) Offset.

1. Each pharmacy may request that its PRA offset against any MO HealthNet payment due to that pharmacy.

A. A statement authorizing the offset must be on file with the division before any offset may be made relative to the PRA by the pharmacy.

B. Assessments shall be allocated and deducted over the applicable service period.

C. Any balance due after the offset shall be remitted to the director of the Department of Revenue and be deposited in the state treasury to the credit of the Pharmacy Reimbursement Allowance Fund.

D. If the remittance is not received before the next MO HealthNet payment cycle, the division shall offset the balance due from that check.

(B) Check.

1. If no offset has been authorized by the pharmacy, the division will begin collecting the pharmacy reimbursement allowance on the first day of each month for the preceding months.

2. The PRA shall be remitted by the pharmacy to the department. The remittance shall be made payable to the director of the Department of Revenue and be deposited in the state treasury to the credit of the Pharmacy Reimbursement Allowance Fund.

(C) Failure to comply with this request for information or failure to pay the PRA.

1. If a pharmacy fails to comply with a request for information from the MO HealthNet Division or fails to pay its PRA within thirty (30) days of notice, the PRA shall be delinquent.

2. For any delinquent PRA, the department may— A. Proceed to enforce the state’s lien of the property of the pharmacy;

B. Cancel or refuse to issue, extend, or reinstate the MO HealthNet provider agreement; or C. Seek denial, suspension, or revocation of license granted under Chapter 338, RSMo.

3. The new owner, as a result of a change in ownership, shall have his/her PRA paid by the same method the previous owner elected.

(D) Each pharmacy, upon receiving written notice of the final determination of its PRA, may file a protest with the director of the department setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the department. The director of the department shall reconsider the determination and, if the pharmacy so requested, grant the pharmacy a hearing to be held within forty-five (45) days after the protest was filed, unless extended by agreement between the pharmacy and the director. The director shall issue a final decision within forty-five (45) days of the completion of the hearing. After a final decision by the director, a pharmacy’s appeal of the director’s final decision shall be to the Administrative Hearing Commission in accordance with section 208.156, RSMo, and

section 621.055, RSMo.

(E) PRA Rates.

1. The PRA tax rate will be a uniform effective rate of one and twenty hundredths percent (1.20%) with an aggregate annual adjustment, by the MO HealthNet Division, not to exceed five hundredths percent (.05%) based on the pharmacy’s total prescription volume.

2. Beginning January 1, 2019, the PRA tax rate will be a uniform effective rate of one and forty-three hundredths percent (1.43%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume.

3. Beginning July 1, 2022, the PRA tax rate will be a uniform effective rate of thirty-seven hundredths percent (0.37%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume.

4. Beginning July 1, 2023, the PRA tax rate will be a uniform effective rate of fifty-two hundredths percent (0.52%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume.

5. Beginning January 1, 2024, the PRA tax rate will be a uniform effective rate of forty-nine hundredths percent (0.49%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume.

6. Beginning July 1, 2025, the PRA tax rate will be a uniform effective rate of two percent (2%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed two percent (2%) based on the pharmacy’s total prescription volume.

7. The maximum rate shall be five percent (5%).

Amended: Filed Nov. 3, 2003, effective April 30, 2004. Emergency amendment filed Sept. 12, 2008, effective Sept. 22, 2008, expired March 20, 2009. Amended: Filed Sept. 12, 2008, effective April 30, 2009. Amended: Filed July 1, 2009, effective Jan. 30, 2010.

Emergency amendment filed Dec. 1, 2009, effective Jan. 1, 2010, expired June 29, 2010. Amended: Filed Dec. 1, 2009, effective June 30, 2010. Emergency amendment filed June 17, 2010, effective July 1, 2010, expired Dec. 27, 2010. Amended: Filed April 26, 2019, effective Nov. 30, 2019. Amended: Filed March 2, 2023, effective Oct. 30, 2023. Amended: Filed Feb. 21, 2024, effective Aug. 30, 2024.

Emergency amendment filed June 23, 2025, effective July 8, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan. 30, 2026. *Original authority: 208.201, RSMo 1987, amended 2007; 338.505, RSMo 2002; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201, 338.505, and 660.017, RSMo 2016. Emergency rule filed June 20, 2002, effective July 1, 2002, expired Feb. 27, 2003. Original rule filed July 15, 2002, effective Feb. 28, 2003. Amended: Filed Feb. 3, 2003, effective Aug. 30, 2003.

13 CSR 70-20.330 Medication Therapy Management (MTM) {#sec-13-csr-70-20.330 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.330}

Program

PURPOSE: This rule establishes the regulatory basis for the administration of the MO HealthNet Medication Therapy Management (MTM) program, including designation of professional persons who may perform medication therapy management services and defined covered services within the program.

(1) Administration. The Medication Therapy Management (MTM) program shall be administered by the Department of Social Services, MO HealthNet Division. The MTM services covered, the program limitations, and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO HealthNet Division, and shall be included in the pharmacy provider manual and provider bulletins, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at dss.mo.gov/mhd/ index.htm, September 1, 2015. This rule does not incorporate any subsequent amendments or additions.

(2) Persons Eligible. A person who is eligible for Title XIX (Medicaid) or Title XXI (State Children’s Health Insurance Program) or Blind Pension and who meets certain diseasebased criteria included in their health profile.

(3) Provider Participation. To be eligible for participation in the MO HealthNet MTM program, a provider must be a qualified Missouri licensed pharmacist and have an active MO HealthNet provider status, and must have successfully completed two (2) hours of ACPE (Accreditation Counsel for Pharmacy Education) accredited continuing education focused on the administration of MTM approved by the MO HealthNet Division.

(4) Medication Therapy Management Services. MTM Services are available to any currently eligible non-managed care MO HealthNet participant for whom the qualifying pharmacist receives a MO HealthNet directed electronic drug utilization review (DUR) message through a Point-of-Sale transaction. MO HealthNet uses a clinically based rules engine that juries which participants require MTM interventions based on nationally accepted evidence-based guidelines. Pharmacists are then messaged about only those participants who are identified for one (1) or more issues pertinent to the evidence-based criteria. The rules engine uses current nationally accepted evidence-based guidelines for clinically appropriate drug therapy, and applies this criteria to thirty-six (36) months of paid participant claims data which includes drugs, diagnoses, and procedures. When an eligible participant meets certain disease-based criteria a pharmacist may perform a wide variety of MTM services directed by MO HealthNet to address specific treatment needs, such as:

(A) Counseling participants on the importance of medication adherence (alerting participants to missed dosages and refills);

(B) Providing medication education;

(C) Providing self-care education for specific chronic conditions;

(D) Contacting physicians to schedule diagnostic testing;

(E) Contacting physicians to make drug therapy recommendations; or (F) Connecting participants with other community-based resources as needed.

(12/31/25) Denny Hoskins (5) The service is comprised of the following components:

(A) Assessing a participant’s health status;

(B) Developing a medication treatment plan;

(C) Monitoring and evaluating a participant’s response to therapy;

(D) Providing a comprehensive medication review to identify, resolve, and prevent medication-related problems;

(E) Documenting the care provided and communicating essential information to a participant’s primary care providers;

(F) Providing oral education and training to enhance participant understanding and appropriate use of medications;

(G) Providing information, support services, and resources to enhance participant adherence to therapeutic regimens; and (H) Coordinating and integrating MTM services within the broader health care services provided to a participant.

(6) Reimbursement. Pharmacists will receive the payment for participating in MTM. The payment is contingent upon the provider logging on to the electronic web tool to view, reserve, and complete interventions. Once an intervention is complete, providers will submit an electronic medical claim to MO HealthNet. The payment status of these claims will be reflected on the provider’s remittance advice. The fee schedule is available at dss.mo.gov/mhd/providers/pages/cptagree.htm.

History

• AUTHORITY: section 208.201, RSMo Supp 2013. Original rule filed July 30, 2015, effective Jan. 30, 2016. Original authority: 208.201, RSMo 1987, amended 2007.

13 CSR 70-20.340 National Drug Code Requirement {#sec-13-csr-70-20.340 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-20.340}

PURPOSE: This rule implements the National Drug Code (NDC) requirement for all medications administered in the clinic or outpatient hospital setting. The Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for certain physicianadministered drugs.

(1) Drug charges submitted by providers on an electronic Professional or Institutional ASC X12 837 Health Care claim transaction or manually entered on a medical or outpatient claim into the MO HealthNet Division’s (MHD) billing website eMOMED (www.emomed.com) must be billed with a valid Healthcare Common Procedure Coding System (HCPCS) procedure code and a valid NDC for all medications administered to MHD participants in the clinic or outpatient hospital setting. MHD must collect the eleven- (11-) digit NDC on all outpatient drug claims submitted to MHD from all providers for rebate purposes to receive federal financial participation. Providers can find the NDC on the medication’s packaging, and must submit the NDC in the five (5) digit – four (4) digit – two (2) digit format. If the NDC does not appear in the five (5) digit – four (4) digit – two (2) digit format on the packaging, zero(s) (0) may be entered in front of the section that does not have the required number of digits. The MHD denies medical or outpatient claim lines submitted with a HCPCS procedure code without the corresponding NDC. For medical or outpatient claims correctly submitted with the appropriate HCPCS procedure code and the corresponding NDC, the system automatically generates a separate drug claim for the NDC to process as a pharmacy claim. It will appear as a separate claim on your Remittance Advice. The MHD will drop the corresponding line with the HCPCS procedure code and NDC from the medical or outpatient claim. If an NDC is not provided, the HCPCS procedure code will remain on the claim to report the denied line. All claims must be billed with the proper NDC quantities, not the HCPCS quantities. For drugs without a valid HCPCS procedure code, revenue code 0250, “General Classification: Pharmacy,” must be used with the appropriate NDC. Only drugs and items used during outpatient care in the hospital are covered. MHD does not cover takehome medications and supplies under the Hospital Program.

rule filed June 19, 2015, effective July 1, 2015, expired Dec. 28, 2015.

Original rule filed July 1, 2015, effective Feb. 29, 2016. Amended:

Filed Sept. 27, 2018, effective May 30, 2019. Amended: Filed Jan. 16, 2020, effective Aug. 30, 2020. Amended: Filed Oct. 20, 2023, effective May 30, 2024. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993,

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Emergency

Chapter 25 Physician Program

13 CSR 70-25.110 Payment for Early Periodic Screening, Diagnostic, and Treatment {#sec-13-csr-70-25.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.110}

13 CSR 70-25.120 MO HealthNet (Medicaid) Payment for Certain Services Furnished by Certain Physicians in Calendar Years 2013 and 2014 13 CSR 70-25.140 {#sec-13-csr-70-25.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.120}

13 CSR 70-25.150 Payment Policy for Asthma Education and In-Home Environmental Denny Hoskins (5/31/26) {#sec-13-csr-70-25.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.150}

13 CSR 70-25.100 Abortions {#sec-13-csr-70-25.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.100}

PURPOSE: This rule complies with Federal Law and rules relating to abortions and maintains compliance with the requirements of the Title XIX program which provides funding for needy persons in the state.

(1) No funds appropriated for the payment of medical claims shall be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term and a physician has found and certified in writing to the Medical Services Division that, on the basis of his/her professional judgment, the mother’s life would be endangered if the fetus were carried to term. The certification shall set out the name, address and medical assistance number of the patient.

Filed Nov. 20, 1980, effective March 12, 1981. Emergency amendment filed July 9, 1981, effective July 21, 1981, expired Oct. 10, 1981.

Amended: Filed July 9, 1981, effective Oct. 11, 1981. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982 and 1986.

History

• AUTHORITY: section 207.020, RSMo 1986. This rule was previously filed as 13 CSR 40-81.101. Emergency rule filed July 2, 1980, effective July 12, 1980, expired Oct. 12, 1980. Original rule filed July 2, 1980, effective Oct. 11, 1980. Emergency amendment filed Nov. 20, 1980, effective Nov. 30, 1980, expired March 11, 1981. Amended:

13 CSR 70-25.110 Payment for Early Periodic Screening, Diagnostic, and Treatment Program Services {#sec-13-csr-70-25.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.110}

PURPOSE: This rule establishes the basis and criteria for payment of screenings and related services resulting from the Early Periodic Screening, Diagnosis, and Treatment Program. 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) The Department of Social Services shall administer an Early Periodic Screening, Diagnostic, and Treatment (EPSDT)

Program. In Missouri, the EPSDT Program is administered as the Healthy Children and Youth (HCY) Program. The EPSDT/HCY Program provides comprehensive and preventive health care services for MO HealthNet-eligible persons under twenty-one (21) years of age, including those in the legal custody of the Department of Social Services or any division of the department at no cost to the child or to the parents or guardians if they accept the offer of this service. 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 HCY provider manual, revised September 1, 2023, which is incorporated by reference in this rule as published by Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or additions.

(2) The EPSDT Program shall make a general physical examination available to eligible participants. The components of the general physical examination shall include a comprehensive health and developmental history, a comprehensive unclothed physical examination, appropriate immunizations, laboratory tests, health education, a vision screen, a dental screen, and hearing services. These screens will be made available at the frequency recommended by Bright Futures/American Academy of Pediatrics and the American Academy of Pediatric Dentists.

(A) Interperiodic screenings outside the recommendations of Bright Futures/American Academy of Pediatrics or the American Academy of Pediatric Dentists are available when medically indicated.

(B) Partial screens for vision, hearing, dental, unclothed physical examination, an interval history, appropriate laboratory tests, immunizations, developmental/mental health assessment, and anticipatory guidance shall be reimbursable services.

(3) Providers of the screening services must be enrolled MO HealthNet providers operating within their legal scope of practice.

(4) The MO HealthNet program will provide reimbursement for prescribed, medically necessary treatment identified as a result of the screening if the treatment is a covered service under

Section 1905(a) of the Social Security Act. “Medically necessary” is defined as service(s) furnished or proposed to be furnished that is (are) reasonable and medically necessary for the prevention, diagnosis, or treatment of a physical or mental illness or injury; to achieve age appropriate growth and development; to minimize the progression of a disability; or to attain, maintain, or regain functional capacity; in accordance with accepted standards of practice in the medical community of the area in which the physical or mental health services are rendered; and service(s) could not have been omitted without adversely affecting the participant’s condition or the quality of medical care rendered; and the service(s) is (are) furnished in the most appropriate setting. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Any service authorized must be effective in addressing the participant’s need. Services may require prior-authorization to assure medical necessity.

(5) Medical and dental services that Section 1905(a) of the Social Security Act permits to be covered under MO HealthNet and that are medically necessary to treat or ameliorate defects, physical, and mental illness, or conditions identified by an EPSDT screen are covered regardless of whether the Medicaid state plan covers the services. Services provided under this program will be sufficient in amount, duration, and scope to reasonably achieve their purpose. Services beyond the scope of the Medicaid state plan that a screening identifies as needed require a plan of care. The plan of care must identify the treatment needs of the child in regard to amount, scope, and prognosis. Certain services and equipment require approval prior to provision of the service as a condition of reimbursement. Prior authorization is used to promote the most effective and appropriate use of available services and to determine the medical necessity of the service. Services may be made available in an inpatient, outpatient office, or home setting depending upon (5/31/26) Denny Hoskins the medical condition of the participant and availability of services.

Amended: Filed Feb. 26, 2021, effective Aug. 30, 2021. Amended:

Filed Dec. 16, 2025, effective June 30, 2026. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.152 and 208.153, RSMo Supp. 2025, and sections 208.201 and 660.017, RSMo 2016. This rule was previously filed as 13 CSR 40-81.015. Original rule filed Jan. 15, 1985, effective April 11, 1985. Amended: Filed Jan. 13, 1992, effective Sept. 6, 1992. Amended: Filed Aug. 15, 2008, effective Feb. 28, 2009.

13 CSR 70-25.120 MO HealthNet (Medicaid) Payment for Certain Services Furnished by Certain Physicians in Calendar Years 2013 and 2014 {#sec-13-csr-70-25.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.120}

(Rescinded September 30, 2018)

2013. Original rule filed Oct. 10, 2013, effective April 30, 2014.

Rescinded: Filed March 2, 2018, effective Sept. 30, 2018.

History

• AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp.

13 CSR 70-25.130 Diabetes Prevention Program {#sec-13-csr-70-25.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.130}

PURPOSE: The purpose of this rule is to establish the Department of Social Services’ MO HealthNet Division guidelines regarding coverage and reimbursement for Diabetes Prevention Program services. The goal of this policy is to improve health outcomes for the adult population at risk for developing diabetes by managing obesity and associated co-morbidities.

(1) Administration. The Diabetes Prevention Program (DPP) shall be administered by the MO HealthNet Division. The diabetes prevention program services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual, which is incorporated by reference and made part of this rule as published by Howerton Court, Jefferson City, MO 65109 on January 6, 2025.

This rule does not incorporate any subsequent amendments or additions. Diabetes Prevention Program services covered by the MO HealthNet program shall include only those which are clearly shown to be medically necessary.

(A) In the administration of the rule, “Diabetes Prevention Program” or “DPP” means a structured, lifestyle change program specifically developed and recognized by the Centers for Disease Control and Prevention (CDC) to prevent type 2 diabetes. The program is intended for people who have prediabetes or are at risk for type 2 diabetes, but who do not already have diabetes, to promote lifestyle changes that decrease the progression to type 2 diabetes. The program services include group support and lifestyle changes such as eating healthier foods, reducing stress, and increasing physical activity.

(2) Provider Participation. To be eligible for participation as a provider in the MO HealthNet Diabetes Prevention Program— (A) DPP service providers must be enrolled as MO HealthNet providers; and (B) DPP service providers must have a level of recognition from the CDC’s Diabetes Prevention Recognition Program. The CDC regulates the standards needed for recognition.

(3) Participant Criteria. Any person who is an eligible Missouri Medicaid participant who meets the following criteria shall be eligible to receive these services:

(A) Be twenty-one (21) years old or older;

(B) Not currently pregnant;

(C) Have, as of the date of attendance at the first core session, a BMI equal to or greater than twenty-five (25) or twenty-three (23) if of Asian descent;

(D) Have no previous diagnosis of type one (1) or two (2) diabetes with the exception of gestational diabetes; and (E) Have, within the last twelve (12) months— 1. Hemoglobin A1C test with a value of five and seventenths percent (5.7%) to six and four-tenths percent (6.4%);

2. A fasting plasma glucose of one hundred (100) mg/dl to one hundred twenty-five (125) mg/dl; or 3. Two (2) hour plasma glucose of one hundred forty (140) to one hundred ninety-nine (199) mg/dl after the seventy-five (75) oral glucose tolerance test.

(4) Diabetes Prevention Program Services.

(A) DPP Services are structured interventions that include lifestyle, behavior-counseling focusing on weight reduction and lifestyle changes. A prescriber provider’s referral, utilizing the eligibility criteria set forth by the CDC, is required for the participant to be eligible for this program. The prescribing provider will need to prescribe the service in the participant’s plan of care during a regular office visit. A prescribing provider is defined as a licensed practitioner authorized to prescribe within their scope of practice either directly or by protocol consistent with their scope of practice under state law.

1. DPP core services period that includes a twelve (12) month period of intervention with a minimum of twenty-two (22) sessions and a maximum of twenty-six (26) sessions.

A. During months one (1) through six (6) of the DPP core services period, DPP service providers will be required to provide a minimum of sixteen (16) weekly sessions utilizing CDC-approved DPP core module curriculum.

(I) This curriculum provides counseling that focuses on, but is not limited to, information about type two (2) diabetes and how to prevent it, self-monitoring weight and food intake, healthy eating, introduction to physical activity, dealing with lifestyle changes, developing lasting lifestyle changes, and stress management.

B. During months seven (7) through twelve (12) of the DPP core services period, DPP service providers will be required to provide a minimum of six (6) monthly sessions utilizing CDCapproved DPP core maintenance module curriculum.

(I) This curriculum provides counseling that focuses on maintaining long-term dietary changes, increased physical activity, and behavior change strategies for continued weight loss.

Denny Hoskins (10/31/25)

C. DPP core services period also includes, but is not limited to, weight monitoring and tracking, physical activity tracking, and caloric intake tracking as required.

2. DPP ongoing maintenance period includes access to one (1) year of ongoing maintenance sessions to eligible participants.

A. The ongoing maintenance sessions are done in three- (3-) month intervals for a maximum of four (4) sessions during months thirteen (13) through twenty-four (24).

B. In order to qualify for the ongoing maintenance sessions after the initial twelve (12) month program, the participant must achieve one (1) of the following:

(I) A minimum weight loss of five percent (5%) of baseline body weight at the end of the first twelve (12) months;

(II) A modest reduction in hemoglobin A1C of at least two-tenths of a percent (0.2%).

C. If a participant does not meet the weight-loss threshold, the prescribing provider shall perform the necessary lab work to rule out the presence of other conditions (e.g., endocrine disorders) that may complicate efforts to reduce weight and, if present, should request to continue, if appropriate, diabetes prevention program services for the identified condition(s).

D. For participants that are eligible for the ongoing maintenance sessions, a referral for the additional twelve (12) months of ongoing maintenance sessions from the prescribing provider is needed in the treatment record.

(B) Additional diabetes prevention services, including core sessions and ongoing maintenance sessions beyond the initial allocation must be requested and deemed medically necessary.

(C) A participant that is unable to meet and/or maintain the criteria for the additional twelve (12) months of ongoing maintenance sessions has the option, after twelve (12) months, to re-enroll in the diabetes prevention program starting with the first twelve (12) months if the participant meets the established criteria.

(5) Records Retention and Documentation Requirements.

(A) Providers who provide Diabetes Prevention Program services shall follow section 13 CSR 70-3.030.

(B) The DPP provider must retain the prescribing provider’s referral.

(C) The DPP provider must complete and retain an evaluation at the end of twelve (12) months to determine the appropriateness for continuation to the ongoing maintenance services.

(D) Once the services are complete, the prescribing provider shall maintain a treatment record outlining how the participant will maintain weight loss.

rule filed Feb. 7, 2020, effective Aug. 30, 2020. Amended: Filed May 12, 2025, effective Nov. 30, 2025.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

13 CSR 70-25.140 Biopsychosocial Treatment of Obesity for Youth and Adults {#sec-13-csr-70-25.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.140}

PURPOSE: This rule establishes the MO HealthNet payment policy for the biopsychosocial treatment of obesity for youth and adult participants. The goal of this policy is to improve health outcomes for both the youth and adult population by managing obesity and associated co-morbidities.

(1) Administration. The MO HealthNet Division, Department of Social Services, shall administer Biopsychosocial Treatment of Obesity for Youth and Adult participants. Biopsychosocial treatment of obesity services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual and Behavioral Health Services Manual. The MO HealthNet Physician Provider Manual is incorporated by reference and made part of this

rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, May 6, 2025, and available at https://mydss.mo.gov/ media/pdf/physicians-provider-manual. This rule does not incorporate any subsequent amendments or additions. The MO HealthNet Behavioral Health Services Provider Manual is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, May 2, 2025, and available at https://mydss.mo.gov/media/pdf/behavioral-health-services-manual. This rule does not incorporate any subsequent amendments or additions. Biopsychosocial treatment of obesity services covered by the MO HealthNet program shall include only those which are shown to be medically necessary.

(A) In the administration of the rule, the following definitions are used:

1. “Biopsychosocial Treatment of Obesity” means using a combination of obesity screenings and Intensive Behavioral Therapy (IBT) to promote lifestyle changes leading to weight loss for adult participants, and weight loss or weight stabilization for youth participants. Medical Nutrition Therapy (MNT) is a recommended but optional component of the treatment.

A. “Adult Intensive Behavioral Therapy (IBT)” means obesity management by utilizing intensive multicomponent, behavior-based weight loss interventions that promote and sustain weight loss in adult participants.

B. “Youth Intensive Behavioral Therapy (IBT)” means obesity management by utilizing comprehensive, intensive behavior-based weight loss interventions that can include multi-component family-based behavioral treatment (FBT) interventions tailored to participant needs targeting both the parent/guardian and the youth;

2. “Body Mass Index (BMI)” means a measure that relates body weight to height and is calculated by dividing weight in kilograms (kg) by the square of height in meters (expressed in kg/m2).

A. “Body Mass Index (BMI) Percentile” means the range of BMI values as expressed in percentiles for age and gender as plotted on the pediatric BMI chart.

B. “Pediatric Body Mass Index (BMI) Chart” means a graphic display of normal progressive changes in body mass index for the pediatric population ages two (2) to twenty (20) years of age;

3. “Medical Nutrition Therapy (MNT)” means nutritional (10/31/25) Denny Hoskins diagnostic, therapy, and counseling services furnished by a licensed registered dietitian or registered dietitian nutritionist, and includes a review of nutritional health, eating habits, and development of an individualized nutrition plan; and 4. “Qualified University” means a United States regionally accredited college, university, or foreign equivalent, or an academic university-based medical center affiliated with such a university.

(2) Provider Participation. To be eligible to provide services for the MO HealthNet Biopsychosocial Treatment of Obesity Program— (A) All Biopsychosocial Treatment of Obesity service providers must be enrolled as MO HealthNet providers;

(B) To provide MNT for obesity, a practitioner is required to meet the following criteria:

1. Have a current license to practice as a Licensed Registered Dietitian or Registered Dietitian Nutritionist in the state in which they practice;

2. Meet one (1) of the following requirements:

A. Have a minimum of one thousand (1,000) hours of experience delivering weight management treatment for individuals, families, or youth with obesity within the past five (5) years;

B. Earned a Commission on Dietetic Registration (CDR)

Certificate of Training in Obesity for Pediatrics and Adults;

C. Earned a CDR Specialist Certification in Obesity and Weight Management (CSOWM);

D. Earned a CDR Adult Weight Management Certificate of Training;

E. Earned a CDR Childhood and Adolescent Weight Management Certificate of Training; or F. Completed a state qualified training program in obesity treatment for adults and/or children; and 3. Once certification is obtained, licensed dietitians who provide MNT under this program must complete a minimum of three (3) hours of continuing education specific to obesity or weight management every two (2) years;

(C) To provide individual and/or group IBT and/or FBT, a practitioner is required to meet the following criteria:

1. Have a current license to practice as one (1) of the following provider types: psychiatrist, clinical social worker, psychologist, or professional counselor, marital and family therapist, or psychiatric advanced practice registered nurse.

Licensed dietitians are eligible to provide group IBT and/or FBT if they meet the requirements of paragraphs (2)(C)2.B. and (2)

(C)3. of this rule;

2. Meet one (1) of the following requirements:

A. Have one thousand (1,000) hours of experience delivering weight management behavioral treatment for individuals, families, and/or youth with obesity within the past five (5) years; or B. Complete a qualified training program that addresses delivery of behaviorally based intervention for adult and/or youth participants diagnosed with obesity; and 3. Once certification is obtained, licensed professionals who provide IBT and/or FBT under this program must complete a minimum of six (6) hours of continuing education credits specific to obesity or weight management every two (2) years for the patient population served, either youth or adult or both.

(3) Participant Criteria. Any person who is determined eligible for MO HealthNet benefits by the Family Support Division and who also meets the following criteria shall be deemed eligible to receive these services:

(A) Be under twenty-one (21) years of age for youth services or twenty-one (21) years of age or older for adult services;

(B) Not currently pregnant; and (C) Have obesity by meeting the following criteria:

1. For youth participants a body mass index (BMI) percentile equal to or greater than the ninety-fifth (95th) percentile for age and gender on the pediatric body mass index (BMI) chart; and 2. For adult participants a body mass index (BMI) equal to or greater than thirty (30).

(4) Biopsychosocial Treatment of Obesity Services.

(A) Biopsychosocial Treatment of Obesity Services provide behavioral health and, whenever possible, adjunctive medical nutrition therapy services, coordinated by the primary care or referring physician, or other licensed practitioner of the healing arts, to facilitate behavior change to manage obesity and associated co-morbidities. Biopsychosocial treatment of obesity requires a referral from a physician or other practitioner of the healing arts as part of an office visit for evaluation and management.

1. The youth benefit includes a twelve- (12-) month period of intervention with a maximum of— A. Five (5) hours of individual IBT;

B. Twenty-four (24) hours of group IBT; and C. Two (2) hours and fifteen (15) minutes of MNT.

2. If the youth is not making adequate progress with weight loss or weight stabilization, the IBT provider shall consult with the referring provider who shall perform the necessary lab work to rule out the presence of other conditions (e.g., endocrine disorder) that may complicate weight management and, if present, shall treat the medical condition while the youth continues to participate in the biopsychosocial treatment.

3. The adult benefit includes a twelve- (12-) month period of intervention with a maximum of— A. Four (4) hours of individual IBT;

B. Eleven (11) hours of group IBT; and C. Two (2) hours and fifteen (15) minutes of MNT.

4. If the adult is not making adequate progress with weight loss, the IBT provider shall consult with the referring provider who shall perform the necessary lab work to rule out the presence of other conditions (e.g., endocrine disorder) that may complicate efforts to reduce weight and, if present, shall treat the medical condition while the adult continues to participate in the biopsychosocial treatment.

(5) Documentation Requirements for Biopsychosocial Treatment of Obesity.

(A) The participant’s treatment record shall contain the following documentation, at a minimum:

1. The referring provider’s referral;

2. The medical nutritional assessment completed by the dietitian, if participant is receiving MNT services;

3. The initial behavioral assessment completed by the behavioral health practitioner;

4. Progress notes that include the following information from each visit:

A. A measured weight and calculated BMI for adult participants or BMI percentile for youth participants;

B. Progress the youth/parent/participant is making towards weight management goals;

C. Challenges (e.g., social determinants) the participant is facing and proposed solutions;

D. Recommendations for treatment/care plans; and E. Collaborative efforts between the providers delivering primary care; MNT, if applicable; and IBT;

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5. A final evaluation report detailing the extent of healthier weight over the treatment period, progress with metabolic, social, and behavior change endpoints, challenges to maintaining healthier weight, and any future recommendations for maintaining a healthier weight in the context of identified challenges. The evaluation shall be shared with the referring provider.

(6) Reimbursement Methodology.

(A) MO HealthNet provides reimbursement to enrolled practitioners delivering biopsychosocial treatment of obesity for youth and adults and who are currently licensed, certified, and in good standing with the state.

(B) Reimbursement for services is made on a fee-for-services

basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider’s actual billed charge (should be the provider’s usual and customary charge to the general public for the service), or the maximum allowable per unit of service.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2024. Original rule filed Aug. 27, 2020, effective March 30, 2021. Amended: Filed March 10, 2025, effective Oct. 30, 2025. Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

13 CSR 70-25.150 Payment Policy for Asthma Education and In-Home Environmental Assessments {#sec-13-csr-70-25.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.150}

PURPOSE: This rule establishes the MO HealthNet payment policy for Asthma Education and In-Home Environmental Assessments to improve the health of MO HealthNet’s youth participants that have uncontrolled asthma.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated (1) Administration. Asthma Education and In-Home Environmental Assessment services shall be administered by the MO HealthNet Division. Asthma education and inhome environmental assessments services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/manuals/, May 14, 2021.

This rule does not incorporate any subsequent amendments or additions. Asthma Education and In-Home Environmental Assessment services covered by the MO HealthNet program shall include only those which are clearly shown to be medically necessary.

(A) The following definition(s) will be used in administering this rule:

1. “Asthma Education” means direct training of the patient and family by qualified asthma education provider in areas including, but not limited to, avoiding triggers, medication compliance, proper use of inhalers, and use of durable medical equipment;

2. “In-Home Environmental Assessment” means thorough and detailed analysis of the home environment by a qualified environmental assessment provider evaluating for asthma triggers including, but not limited to, rodent excrement, mites, animal dander, insects, dust, mold with recommendations for remedial actions.

(2) Asthma Education and In-Home Environmental Assessment Services. Asthma Education and In-Home Environmental Assessment Services are interventions for increasing control of asthma symptoms in high risk youth.

(A) A prescribing provider’s referral is required as part of a normal office visit for evaluation and management for both asthma education and in-home environmental assessment.

The prescribing provider will need to prescribe the service in the participant’s plan of care.

(B) As part of the referral, the prescribing provider determines and specifies the level and type of asthma education and in-home environmental assessment based on available history and in consultation with asthma educators and in-home environmental assessors, as needed.

(C) A prescribing provider is defined as a licensed practitioner authorized to prescribe within their scope of practice either directly or by protocol consistent with their scope of practice under state law.

(D) Asthma education. Asthma educators may bill for— 1. Asthma education non-physician, (thirty- (30-) minute sessions, twice per year); or 2. Preventive medicine counseling, individual, (fifteen- (15-) minute sessions four (4) times per year); or 3. Preventive medicine counseling, individual, (thirty- (30-) minute sessions twice per year); or 4. Self-Management Education using standardized effective curriculum, individually, either incident to a clinical encounter or as preventative service (ninety- (90-) minute session once per year).

5. The annual limit for asthma education visits will be dependent on the codes used, but shall not exceed one (1) hour per year with the exception of one (1) ninety- (90-) minute self-management session.

(E) Asthma Environmental Assessment.

1. An asthma environmental assessor may bill for an asthma environmental assessment non-physician, two (2) assessments per year.

2. Asthma environmental assessments may include, but are not limited to, a thorough assessment of the home including home history and ownership, building occupant behaviors and job history, home cleaning techniques, laundry processes, pets and pests histories, kitchen processes, structure deficiencies, ventilation and moisture conditions, conducting and recording basic air sampling procedures, and examination of the external environment of the home to identify and support the reduction of disease causing agents leading to medical complications of asthma.

3. In-home assessments for asthma triggers do not include remediation of issues identified in the home.

(9/30/25) Denny Hoskins 4. Annual limit for asthma environmental assessment services shall not exceed two (2) in-home environmental assessments.

(F) The prescribing provider will need to seek prior authorization for asthma education and in-home environmental assessment services from MO HealthNet prior to starting the program.

(G) Any additional asthma education and environmental in-home assessments beyond the initial allocation will need an additional prior authorization and be deemed medically necessary.

(3) Participant Criteria. In order to qualify for, and receive, asthma education and/or in-home environmental assessments, the participant must have a primary diagnosis of asthma and meet the MO HealthNet Division’s (MHD) definition of a youth participant with uncontrolled asthma or at risk for an exacerbation of asthma by meeting the following criteria:

(A) Be currently enrolled in MO HealthNet;

(B) Be twenty (20) years of age or younger; and (C) Have had one (1) of the following events related to asthma in the last twelve (12) months:

1. One (1) or more inpatient hospital stays;

2. Two (2) or more Emergency Department (ED) visits;

3. Three (3) or more urgent care visits; or 4. One (1) ED visit or one (1) urgent care visit related to asthma with a high rate of short-acting beta-agonist inhaler fills and/or low rates of inhaled corticosteroid refills.

(4) Provider Participation. To be eligible for participation as a provider in the MO HealthNet Asthma Education and In-Home Environmental Assessment services— (A) All asthma education and in-home environmental assessment service providers must be enrolled as MO HealthNet providers; and (B) A qualified provider must meet the minimum education and certification requirements to qualify as a provider of asthma education and/or in-home environmental assessments set forth in this subsection.

1. Asthma Education— A. Asthma educators must have the credentials set forth in this subsection— (I) Shall be certified by a national program or a state program. Eligibility criteria for admission into the certification programs are determined by the administrator of the program;

(II) Asthma educators must have one (1) of the following certifications in good standing:

(a) Current and active National Asthma Educator Certification (AE-C).

I. These providers must maintain the national certification determined by The National Asthma Educator Certification Board; and (b) State certification. The provider must have a current certificate from a Missouri state training program.

2. In-Home Environmental Assessments— A. Asthma In-Home Environmental Assessors must have the credentials set forth in this subsection:

(I) Shall be certified by a national program or a state program. Eligibility criteria for admission into the certification programs are determined by the administrator of the program;

(II) An In-Home Environmental Assessor must have one (1) of the following certifications in good standing:

(a) National Certification— I. Renewal of National Environmental Health Association (NEHA) Healthy Home Specialist; or II. Building Performance Institute (BPI) Healthy Home Evaluator Micro-Credential; and B. State Certification. The provider must have a current certificate from a Missouri state training program.

(I) A Missouri state certificate program means a program provided by an accredited institute of higher education, such as a university, that provides a training program utilizing curriculum incorporating similar guidelines to national certification programs. It is preferable that the curriculum is also accredited. Upon successful completion of the training program a certificate must be provided. A certificate means that the student has successfully completed the training program and is competent to provide in-home environmental assessment.

(II) Mentor program for asthma educators. A mentee is someone who is working towards a certificate. Once certified, the asthma educator can become a mentor for individuals that are seeking their national certification. Mentors, who must be an enrolled Medicaid provider, can have a maximum of three (3) mentees at a time. Mentors have the capability of billing MHD for their services, while mentees cannot. Services provided by a mentee under the supervision of the mentor can be billed to MHD by the mentor. The asthma education activities and interventions of the mentee shall be performed pursuant to the mentor’s order, control, and full professional responsibility.

(5) Qualifying Academic University-based Centers function to track and ensure current certification of asthma education providers and asthma environmental assessors by providing MHD with the following services:

(A) The qualified academic university-based centers must maintain a website with an up-to-date provider list for physicians and their offices to utilize to consult asthma educators and asthma in-home environmental assessors to provide services to participants once a prior authorization has been approved.

1. The qualified academic university-based center responsible for tracking asthma in-home environmental assessors must maintain an up-to-date list of all certified in-home environmental assessors in the state; and A. The academic university-based center responsible for tracking asthma in-home environmental assessors must meet the following criteria:

(I) Serve as a contractor for the Centers for Disease Control (CDC) National Asthma Control Program (NACP) funded by Missouri Asthma Prevention and Control Program (MAPCP);

(II) Provide a vital linkage between health care providers and public health resources through a Central Access Point (CAP);

(III) Maintain a comprehensive database that contains information on individuals trained specific to Home Environmental Assessments (HEAs) for asthma trigger identification and reduction in the home setting; and (IV) Track quality indicators and collect required outcomes data.

2. The qualified academic university-based center responsible for tracking asthma educators must maintain an up-todate list of all trained asthma educators in the state.

A. The academic university-based center responsible for tracking asthma educators must meet the following criteria:

(I) Serve as the contractor for the CDC NACP funded MAPCP;

(II) Maintain a comprehensive database that contains information on individuals trained receiving Expert Panel Report 3 (EPR-3) compliant asthma training;

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(III) Staff providing the training must be a Certified Asthma Educator as recognized by the National Association of Asthma Educators; and (IV) Provide training that focuses on educational/ behavioral objectives in four (4) key areas— (a) Inhaled corticosteroid adherence;

(b) Inhalation technique;

(c) Environmental trigger reduction; and (d) Importance of regular check-ups with assessment of lung function and asthma control.

rule originally filed as 13 CSR 70-3.260. Original rule filed June 23, 2016, effective Jan. 30, 2017. Moved to 13 CSR 70-25.150 and amended: Filed Aug. 27, 2021, effective March 30, 2022.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. This

13 CSR 70-25.160 Doula Services {#sec-13-csr-70-25.160 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-25.160}

PURPOSE: This rule establishes the Department of Social Services’ MO HealthNet Division guidelines regarding coverage and reimbursement for community doula services. The goal of these services is to provide a stable source of psychosocial support and education throughout the perinatal period and during the birth utilizing specially trained lay providers to enhance relevant knowledge and encourage healthy behaviors that can lead to improved pregnancy-related outcomes.

(1) Administration. Doula services shall be administered by the MO HealthNet Division. Doula services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual, which is incorporated by reference and made part of this rule as published by Howerton Court, Jefferson City, MO 65109, and is available at its website https://mydss.mo.gov/media/pdf/physicians-provider-manual, August 6, 2024. This rule does not incorporate any subsequent amendments or additions.

(A) In the administration of the rule, “doula services” means services that provide a stable source of psychosocial support and education throughout the perinatal period and during the birth utilizing trained providers, community-based doulas, with the aim of improving a range of maternal and infant health outcomes by enhancing relevant knowledge and encouraging healthy behaviors. Doula services are available to all pregnant women, prenatally, during delivery, and throughout the postpartum period as medically necessary preventive services when recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law and provided in accordance with currently accepted standards of medical or professional practice. This includes twelve (12) months after delivery.

(2) Provider Participation. To be eligible for participation in the doula services program— (A) Doula providers must be enrolled as MO HealthNet providers;

(B) All doula providers must be at least eighteen (18) years of age and must possess a current certificate issued by a national or Missouri-based doula training organization whose curriculum meets the following definition and standards:

1. Curriculum that covers a doula’s role, which includes breastfeeding support, perinatal mood and anxiety disorders, anticipatory care strategies, cultural competency, how to deliver perinatal education and support, how to increase client autonomy during birth, and how to support clients who may need additional care;

2. Understanding the importance of health-related social needs, including navigation of social services, trauma-informed care, and strategies specific to the community served;

3. The student must successfully complete the training program and be deemed competent to provide doula services.

Certification is attained after evaluation by a birth professional or trainer;

4. Completion of at least six (6) continuing education unit (CEU) hours per year on topics related to the components listed in paragraphs (2)(B)1. and (2)(B)2., or equivalent continuing education as specified by the training organization; and 5. Holds liability insurance as an individual or through a supervising organization; and (C) For doulas whose training came from another source, or from multiple sources, MO HealthNet will determine eligibility for reimbursement as follows:

5. If there exists any statewide organization composed of doula trainers from three (3) or more independent, well-established doula training organizations located in Missouri whose

purpose includes validation of core competencies of trainings, then MO HealthNet may verify that an individual’s training and experience satisfies the above-stated criteria through a public roster maintained by such an organization; and 2. If no such organization exists, future doula training organizations must prove that their training satisfies the above definition in order to be added to the written policy guide, which will include a list of all approved certification programs qualifying under subsections (2)(B) and (2)(C).

(3) Participant Eligibility. Any pregnant woman who is eligible for Title XIX benefits from the Family Support Division (FSD) and seeks doula services described in this rule shall be deemed eligible to receive these services.

(4) Doula Services.

(A) Doula services are available to all pregnant women, prenatally, during delivery, and throughout the postpartum period. This includes twelve (12) months after delivery. Doula services include a combined total of six (6) prenatal and postpartum support sessions, one (1) birth attendance, and up to two (2) visits for general consultation on lactation. Community navigation services that occur outside these billable visits may be billed up to ten (10) times total over the course of the pregnancy and postpartum period. The focus of these services is to provide a stable source of psychosocial support and education in an informal setting utilizing trained non-medical, non-clinical providers, with the aim of reducing allostatic load and oxidative stress, enhancing relevant knowledge, and (9/30/25) Denny Hoskins encouraging healthy behaviors that can lead to improved pregnancy-related outcomes (in particular, reduced preterm birth rates, reduced low-birthweight rates, reduced maternal morbidity and mortality, and reduced infant mortality). Reduced Caesarian section rates, improved maternal satisfaction with the birth experience, increased breastfeeding initiation and continuation rates, and enhanced parenting knowledge and confidence are also intended outcomes. Doula services available for reimbursement include— 1. Prenatal support sessions—promoting health literacy and knowledge of what to expect during pregnancy and birth; what experiences are normal during pregnancy; how to relay concerns to providers, and providing information on topics such as nutrition, exercise, tobacco cessation, self-monitoring of existing health risks or conditions, in a manner that is culturally relevant and that is targeted to Medicaid participants.

A doula may attend the participant’s obstetric (OB) visits in a supportive role;

2. Community navigation of social services and assistance programs—taking a community-based approach to connect expecting women and families with available resources, including understanding the services and supports available to pregnant and postpartum women on Medicaid and facilitating access to those resources based upon an assessment of social service needs;

3. Attendance and support during birth—providing information about what to expect during birth, helping create a birth plan, and attending the birth to provide non-medical comfort measures, information, emotional support and advocacy throughout the labor, including support of personal and cultural preferences regarding childbirth and support of those who may otherwise feel disconnected from or marginalized by the healthcare system;

4. Lactation education and support—may include any of the following— A. A session during pregnancy that is primarily focused on the health benefits of breastfeeding for both mother and infant;

B. Attending the mother and infant immediately after birth to provide guidance and goal setting to promote breastfeeding;

C. Providing ongoing support and education during pregnancy on the health benefits of breastfeeding; and D. Providing ongoing general education, support, and referral to licensed lactation professionals if/when services are needed; or 5. Postpartum support sessions—helping women know what to expect, what is normal, how to relay concerns to providers; aiding the transition back to well-woman care, family planning, screening for postpartum depression; providing information on topics such as safe sleep, preventing unintended child injuries, nutrition, positive parenting skills; education about breastfeeding rights; and goal setting for the future including continuing education, finding employment and childcare, and transition to other insurance as needed.

(5) Records Retention. Providers who provide doula services must follow 13 CSR 70-3.030.

(6) Reimbursement Methodology.

(A) MO HealthNet provides reimbursement to enrolled providers providing doula services who currently hold a certificate as described in subsection (2)(B) and are in good standing with the state.

(B) Reimbursement for services is made on a fee-for-services

basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider’s actual billed charge (should be the provider’s usual and customary charge to the general public for the service) or the maximum allowable per unit of service. Reimbursement shall only be made for services authorized by MO HealthNet or its designee. Services will be paid at the Medicaid fee schedule rate and will be published at https://mydss.mo.gov/mhd/cpt.

rule filed Aug. 7, 2024, effective April 30, 2025.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

Chapter 26 Federally-Qualified Health Centers Services

13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services {#sec-13-csr-70-26.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-26.010}

PURPOSE: This rule implements the payment methodology for federally-qualified health center services pursuant to section 6404 of the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239).

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) Pursuant to the Omnibus Reconciliation Act of 1989, this regulation provides the payment methodology used to reimburse federally-qualified health centers (FQHCs) the allowable costs which are reasonable for the provision of FQHC-covered services to MO HealthNet participants.

(2) General Principles.

(A) The MO HealthNet program shall reimburse FQHC providers based on the reasonable cost of FQHC-covered services related to the care of MO HealthNet participants (within program limitations) less any copayment or deductible amounts which may be due from MO HealthNet participants effective for services on and after July 1, 1990.

(B) Reasonable costs shall be determined by the MO HealthNet Division based on desk reviews of the applicable cost reports and may be subject to adjustment based on field audits. Reasonable costs shall not exceed the Medicare cost principles set forth in 42 CFR

Part 413.

(C) Reasonable costs shall be apportioned to the MO HealthNet program based on a ratio of covered charges for MO HealthNet participants to total charges. Charges mean the regular rate for various services which are established uniformly for both MO HealthNet participants and other patients. MO Health- Net charges shall include MO HealthNet managed care charges for covered services.

(D) An FQHC shall submit a MO Health- Net cost report in the manner prescribed by the state MO HealthNet agency. The cost report shall be submitted within five (5) months after the close of the FQHC’s reporting period. An extension may be granted upon the request of the FQHC and the approval of the MO HealthNet Division with an agreed upon date of completion. The request must be in writing and postmarked prior to the first day of the sixth month following the FQHC’s fiscal year end.

1. An FQHC may be exempt from filing a Missouri Medicaid Title XIX Cost Report if MO HealthNet reimbursement is twenty-five thousand dollars ($25,000) or less for the facility’s reporting period. The facility must submit a request to the division to waive the cost report filing requirement within five (5) calendar months after the close of the facility’s reporting period. To request an exemption for the cost report filing requirement, the following information must be submitted to the division for review and approval:

A. A Low or No Missouri Medicaid Utilization Waiver Request Form. This form may be obtained from the division. The form must be fully completed and signed by an officer or administrator; and B. Worksheet S series of the Medicare Cost Report. The Worksheet S must be completed and signed by an officer or administrator.

(E) An FQHC cost report shall be submitted and certified by an officer or administrator of the provider. Failure to file a cost report within the prescribed period, except as expressly extended in writing by the state agency, may result in the imposition of sanctions as described in 13 CSR 70-3.030.

(F) Authenticated copies of agreements and other significant documents related to the provider’s operation and provision of care to MO HealthNet participants must be included with the cost report at the time of filing unless current and accurate copies have already been filed with the division. Material which must be submitted includes, but is not limited to, the following as applicable:

1. Audited financial statements prepared by an independent accountant and submitted to the MO HealthNet Division when available, including explanatory notes, disclosure statements, and management letter;

2. Contracts or agreements involving the purchase of facilities or equipment during the cost reporting period if requested by the division, the department, or its agents;

3. Contracts or agreements with related parties;

4. Schedule A detailing all grants, gifts, donations, and income from endowments, including amounts, restrictions, and use;

5. Explanations of grants, gifts, donations, or endowments for which related expenses have not been offset on Worksheet 1-B of the MO HealthNet Division FQHC cost report. If subsequently requested by the division or its contracted agents, documentation of related expenditures will also be submitted;

6. Leases or rental agreements, or both, related to the activities of the provider;

7. Management contracts; and 8. Working trial balance actually used to prepare the cost report with line number tracing notations or similar identifications.

(G) Records.

1. Maintenance and availability of records.

A. A provider must keep records in accordance with generally accepted accounting principles (GAAP) and maintain sufficient internal control and documentation to satisfy audit requirements and other requirements of this rule, including reasonable requests by the division or its authorized agent for additional information.

B. Adequate documentation for all line items on the cost report shall be maintained by a provider. Upon request, all original documentation and records must be made available for review by the division or its authorized agent at the same site at which the services were provided. Copies of documentation and records shall be submitted to the division or its authorized agent upon request.

C. Records of related organization, as defined by 42 CFR 413.17, must be available upon demand.

D. The division shall retain all uniform cost reports submitted by the FQHCs for seven (7) years after the final settlement relating to a cost report is finalized, including the resolution of any subsequent appeals or other administrative actions pertaining to the cost report.

E. Each facility shall retain all financial information, data, and records relating to the operation and reimbursement of the facility for seven (7) years after the final settlement relating to a cost report is finalized, including the resolution of any subsequent appeals or other administrative actions pertaining to the cost report, and shall maintain those reports pursuant to the record-keeping requirements of 42 CFR 413.20.

2. Adequacy of records.

A. The division may suspend reimbursement or reduce payments to the appropriate fee schedule amounts if it determines that the FQHC does not maintain records that provide an adequate basis to determine payments under MO HealthNet.

B. A suspension or reduction will continue until the FQHC demonstrates, to the division’s satisfaction, that it has an ongoing and current process in place to ensure the maintenance of adequate records.

(H) Audits.

1. Any cost report submitted may be subject to field audit by the division or its authorized agent.

2. A provider shall have available at the field audit location one (1) or more knowledgeable persons authorized by the provider and capable of explaining the provider’s accounting and control system and cost report preparation, including all attachments and allocations.

3. If a provider maintains any records or documentation at a location which is not the same as the site where services were provided, the provider shall transfer the records to the same facility at which the services were provided, or the provider must reimburse the division or its authorized agent for reasonable travel costs necessary to perform any part of the field audit in any off-site location, if the location is acceptable to the division.

(I) Change in Provider Status. The next payment due the provider after the division has received the notification of the termination of participation in the MO HealthNet program or change of ownership may be held by the division until the cost report is filed.

Upon receipt of a cost report prepared in accordance with this rule, the payments that were withheld will be released.

(3) Nonallowable Costs. Any costs which exceed those determined in accordance with the Medicare cost reimbursement principles set forth in 42 CFR Part 413 are not allowable in the determination of a provider’s total reimbursement. In addition, the following items specifically are excluded in the determination of a provider’s total reimbursement:

(A) Grants, gifts, and income from endowments will be deducted from total operating costs. Exceptions— 1. Grants awarded directly to an FQHC by federal government agencies, such as the Health Resources and Services Administration (HRSA) and Public Health Service;

2. Grants received by an FQHC from the Missouri Primary Care Association (MPCA) in accordance with contractual agreements between the MO HealthNet Division and MPCA;

3. Grants to FQHCs for covered services provided to uninsured patients resulting in uninsured FQHC charges that are included on Worksheet 2 of the MO HealthNet Division FQHC cost report;

4. Grants or incentive payments for the meaningful use of electronic health records (EHR) systems which are either paid directly to FQHCs or assigned to FQHCs by their performing providers; and 5. Payments to FQHCs for participation in MO HealthNet Division Medical Home initiatives.

(B) The value of services provided by nonpaid workers, including members of an organization having an agreement to provide those services;

(C) Bad debts, charity, and courtesy allowances;

(D) Return on equity capital;

(E) Attorney fees related to litigation involving state, local, or federal governmental entities, and attorney fees which are not related to the provision of FQHC services;

(F) Late charges and penalties; and (G) Research costs.

(4) Interim Payments.

(A) FQHC services shall be reimbursed on an interim basis up to ninety-two percent (92%) of charges for covered services billed to the MO HealthNet program. Interim billings will be processed in accordance with the claims processing procedures for the applicable programs.

(B) An FQHC contracted with a MO HealthNet managed care health plan shall be eligible for supplemental reimbursement of up to ninety-two percent (92%) of managed care charges. The supplemental reimbursement shall make up the difference between what the FQHC would have been paid by the division based on the FQHC’s managed care charges for a reporting period and payments made to the FQHC during the reporting period by the managed care health plans for covered services rendered to managed care participants as set forth in the Managed Care contract. The supplemental reimbursement shall occur pursuant to the schedule agreed to by the division and the FQHC, but shall occur no less frequently than every four (4) months. Supplemental reimbursement shall be requested by the FQHC on forms provided by the division. Supplemental reimbursement for managed care charges shall be considered interim reimbursement of the FQHC’s MO HealthNet costs.

(5) Final Settlement.

(A) An annual desk review will be completed following submission of the FQHC’s Medicaid cost report. The total reimbursement amount due the FQHC for covered services furnished to MO HealthNet participants is based on the allowable costs from the Medicaid cost report. The MO HealthNet Division will make an additional payment to the FQHC when the allowable reported MO HealthNet costs exceed interim payments made for the cost-reporting period. The FQHC must reimburse the division when its allowable reported MO HealthNet costs for the reporting period are less than interim payments.

(B) The annual desk review may be subject to adjustment based on the results of a field audit which may be conducted by the division or its contracted agents.

(C) Cost reports must be fully, clearly, and accurately completed. If any additional information, documentation, or clarification requested by the division or its contracted agents is not provided within fourteen (14) days of the date of receipt of the division’s request, payments may be withheld from the facility until the information is submitted.

(D) Notification of Final Settlement.

1. The division will notify an FQHC by letter of a cost report final settlement after completion of the division’s cost report desk review. The division’s notification letter will include the desk review which details the adjustments the division made to the facility’s cost report, the calculation of the final settlement, and a Settlement Agreement, which the facility will sign and return to the division indicating it agrees with the final settlement calculation. The division’s written notice to the FQHC shall indicate if the final settlement results in the following:

A. Underpayments. If the total reimbursement due the FQHC exceeds the interim payments made for the reporting period, the division makes a lump-sum payment to the FQHC to bring total payments into agreement with total reimbursement due the FQHC; and B. Overpayments. If the total interim payments made to an FQHC for the reporting period exceed the total reimbursement due the FQHC for the period, the division arranges with the FQHC for repayment of the overpayment either by having it offset against the FQHC’s subsequent interim payments, having the FQHC repay by sending the division a payment, or a combination of offset and payment.

2. The FQHC shall review the division’s notification letter and attachments and respond with a signed Settlement Agreement indicating it has accepted the final settlement within fifteen (15) calendar days of receiving the final settlement letter. If the FQHC believes revisions to the division’s desk review and/or final settlement are necessary before it can accept the settlement, it must submit additional, amended, or corrected data within the fifteen- (15-) day deadline. Data received from the 4CODE OF STATE REGULATIONS (4/30/19) JOHNR. ASHCROFT FQHC after the fifteen- (15-)day deadline may not be considered by the division in determining if revisions to the final settlement are needed unless the FQHC requests and receives an extension for submitting additional information prior to the end of the fifteen- (15-) day deadline. If the fifteen- (15-) day deadline passes without a response from the provider, the division will proceed with processing the final settlement as set forth in the division’s notification letter, and the final settlement shall be deemed final. The division may not accept an amended cost report or any other additional information to revise the cost report or final settlement after the final settlement is finalized.

(6) Payment Assurance.

(A) The state will pay each FQHC, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the FQHC according to the standards and methods set forth in the regulations implementing the FQHC Reimbursement Program.

(B) FQHC services provided for those participants having available Medicare benefits shall be reimbursed by MO HealthNet to the extent of the coinsurance and deductible as imposed under Title XVIII.

(C) Where third-party payment is involved, MO HealthNet will be the payer of last resort.

(D) Regardless of changes of ownership, management, control, or leasehold interests by whatever form for any FQHC previously certified for participation in the MO Health- Net program, the division will continue to make all the Title XIX payments directly to the entity with the FQHC’s current provider number and hold the entity with the current provider number responsible for all MO HealthNet liabilities.

Filed July 30, 2002, effective Jan. 30, 2003.

Amended: Filed Jan. 14, 2005, effective July 30, 2005. Amended: Filed June 2, 2008, effective Dec. 30, 2008. Amended: Filed June 17, 2011, effective Dec. 30, 2011. Amended:

Filed Sept. 18, 2018, effective May 30, 2019. *Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Emergency rule filed June 4, 1990, effective July 1, 1990, expired Oct. 28, 1990. Original rule filed June 4, 1990, effective Nov. 30, 1990. Amended: Filed Sept. 4, 1991, effective Jan. 13, 1992. Amended:

Chapter 30 Podiatry Program

13 CSR 70-30.010 Podiatric Services Program {#sec-13-csr-70-30.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-30.010}

PURPOSE: This rule establishes the basis for administering the podiatric service, including the designation of professional persons who may perform the examination and the fees paid for the necessary services.

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) Persons Eligible for Podiatric Services.

Any person who is eligible for Title XIX benefits from the Family Support Division and who is found to be in need of podiatric services in accordance with the procedures described in this rule.

(2)

Payment will be made for services by podiatrists who have an agreement with the MO HealthNet Division to the extent that those services are covered under the guidelines established by the MO HealthNet Division through— (A) MO HealthNet provider manuals, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO Health- Net Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/manuals/, September 27, 2018; or (B) Provider Bulletins, which are incorporated by reference and made a part of this

rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://dss.mo.gov/mhd/providers/pages/bulletins.htm, September 27, 2018. This rule does not incorporate any subsequent amendments or additions.

(3) Payments will be on a fee basis, and fees will be established by the MO HealthNet Division which shall not exceed Title XVIII reimbursement levels. Payment will be on a vendor payment basis.

Emergency amendment filed May 18, 1979, effective July 1, 1979, expired Sept. 13, 1979. Amended: Filed May 18, 1979, effective Sept. 14, 1979. Emergency amendment filed Feb. 5, 1991, effective Feb. 15, 1991, expired Feb. 24, 1991. Emergency amendment filed Feb. 14, 1991, effective Feb. 24, 1991, expired June 14, 1991. Amended: Filed June 2, 2008, effective Nov. 30, 2008. Amended:

Filed Oct. 31, 2008, effective May 30, 2009.

Amended: Filed Sept. 27, 2018, effective May 30, 2019. *Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.

JOHNR. ASHCROFT(4/30/19)

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. This rule was previously filed as 13 CSR 40-81.130. Original rule filed Dec. 1, 1978, effective March 11, 1979.

Chapter 35 Dental Program

13 CSR 70-35.010 Dental Benefits and Limitations, MO HealthNet Program {#sec-13-csr-70-35.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-35.010}

PURPOSE: This rule describes the dental services for which the MO HealthNet Division shall pay when the service is provided to an eligible assistance participant; the service is provided by a licensed dentist, licensed dental hygienist, or licensed and certified dental specialist who has entered into an agreement for that purpose with the division; and the service is listed as a covered item in the MO HealthNet Dental Manual sponsored by the division. The MO HealthNet Dental Manual describes the dental services which shall be paid under limitations and those which shall not be paid under present conditions.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet dental program shall be administered by the MO HealthNet Division, Department of Social Services. The dental services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Dental Provider Manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at www.dss.mo.gov/mhd, May 2, 2016. This rule does not incorporate any subsequent amendments or additions. Dental services covered by the MO HealthNet program shall include only those which are clearly shown to be medically necessary. The division reserves the right to effect changes in services, limitations, and fees with proper notification to MO HealthNet dental providers.

(2) Provider Participation. A dentist shall be licensed by the dental board of the state in which s/he is practicing and shall have signed a participation agreement to provide dental services under the MO HealthNet program.

An oral surgeon or other dentist specialist shall be licensed in his/her specialty area by the dental board of the state in which s/he is practicing. In those states not having a specialty licensure requirement, the dentist specialist shall be a graduate of and hold a certificate from a graduate training program in that specialty in an accredited dental school.

In either case, the dental specialist shall have signed a participation agreement to provide dental services under the MO HealthNet program. A dental hygienist shall be licensed by the dental board of the state for at least three (3) consecutive years and practicing in a public health setting to provide fluoride treatments, teeth cleaning, and sealants to MO HealthNet/MO HealthNet for Kids eligible children ages zero (0) to twenty (20).

(3) Participant Eligibility. The MO HealthNet dental provider shall ascertain the patient’s MO HealthNet status before any service is performed. The participant’s MO Health- Net/MO HealthNet for Kids eligibility is determined by the Family Support Division.

The participant’s eligibility shall be verified from a current MO HealthNet/MO HealthNet for Kids identification card or a letter of new approval in the participant’s possession. The patient must be a MO HealthNet eligible participant under the MO HealthNet/MO HealthNet for Kids program on the date the service is performed. The MO HealthNet Division is not allowed to pay for any service to a patient who is not eligible under the MO HealthNet/MO HealthNet for Kids program.

(A) Coverage of dental services for adults is limited to certain categories of service and may require prior authorization: trauma of the mouth, jaw, teeth, or other contiguous sites as a result of injury; treatment of a disease/medical condition without which the health of the individual would be adversely affected; preventive services; restorative services; periodontal treatment; oral surgery; extractions; radiographs; pain evaluation and relief; infection control; and general anesthesia. Further detail on covered adult dental services may be referenced at www.dss.mo.gov/mhd.

(4) Prior Authorization. When prior authorization is required, the form provided by the MO HealthNet Division or its contracted agent shall be used. The dental service shall not be started until written approval has been received. Telephone approval shall not be given. Prior authorization shall be effective for a period of one hundred twenty (120) days from the date of written approval. Prior authorization approves the medical necessity of the requested dental service. It shall not guarantee payment for that service as the patient must be a MO HealthNet eligible participant on the date the service is performed.

The division reserves the right to request documentation regarding any specific request for prior authorization.

(5) Orthodontia Services. When an eligible participant is believed to have a condition that may require orthodontic treatment, the attending dentist should refer the participant to a qualified dentist or orthodontist for preliminary examination to determine if the treatment will be approved. The fact that the participant has moderate or even severe orthodontic problems, or has been advised by a dentist or orthodontist to have treatment is not, by itself, a guarantee that the patient will qualify for orthodontia services through MO HealthNet. Coverage is determined solely by meeting the criteria listed below in subsections (5)(A) and (5)(B) or (5)(C).

(A) To be eligible for orthodontia services, the participant must meet all of the following general requirements:

1. Be under twenty-one (21) years of age; and 2. Have good oral hygiene documented in the child’s treatment plan; and 3. Have permanent dentition. Exceptions to having permanent dentition are as follows:

A. Participant has a primary tooth retained due to ectopic or missing permanent tooth; or B. Participant may have primary teeth present if they have cleft palate, severe traumatic deviations, or an impacted maxillary central incisor; or C. Participant may have primary teeth if they are thirteen (13) years of age or older.

(B) The determination whether or not a participant will be approved for orthodontic services shall be initially screened using the Handicapping Labio-Lingual Deviation (HLD) Index. The HLD Index must be fully completed in accordance with the instructions. The division will approve orthodontic services when the individual meets all of the criteria in subsection (5)(A) above and one (1) of the criteria listed in paragraphs 1. to 7. below— 1. Has a cleft palate;

2. Has a deep impinging overbite when the lower incisors are damaging the soft tissue of the palate (lower incisor contact only on the palate is not sufficient);

3. Has a cross-bite of individual anterior teeth when damage of soft tissue is present;

4. Has severe traumatic deviations;

5. Has an over-jet greater than nine millimeters (9 mm) or reverse over-jet of greater than three and one-half millimeters (3.5 mm);

6. Has an impacted maxillary central incisor; or 7. Scores twenty-eight (28) points or greater on the HLD Index.

(C) If the participant meets the criteria in subsection (5)(A) above but does not meet any of the criteria in subsection (5)(B), the division will consider whether orthodontic services should be provided based upon other evidence that orthodontic services are medically necessary— 1. The division shall consider additional information of a substantial nature about the presence of severe deviations affecting craniofacial health. Other deviations shall be considered to be severe if, left untreated, they would cause irreversible damage to the teeth and underlying structures, result in disease related bone and tooth loss, or craniofacial deformities associated with developmental disabilities in chewing or speaking.

2. Other evidence shall include information of a substantial nature about the presence of a medical condition which is directly affected by the condition of the mouth or underlying structures. Orthodontic treatment shall be considered to be medically necessary if, without the orthodontic treatment, the medical condition would be adversely affected and would result in pain, infection, illness, or significant and immediate impact on the normal function of the body and the individual’s ability to function. In addition, such orthodontic treatment must be demonstrated to be 1) of clear clinical benefit to the eligible participant; 2) Appropriate for the injury or illness in question; and 3) Conform to the standards of generally accepted orthodontic practice as supported by applicable medical and scientific literature. In addition to documentation from an orthodontist or dentist, a recommendation for orthodontic treatment in relation to a medical condition must also be supported by documented evidence of the medical condition from a licensed medical doctor, board certified to diagnose the medical condition.

3. In addition, the division may consider information of a substantial nature about the presence of mental, emotional, and/or behavioral problems, disturbances, or dysfunctions, as defined in the most current edition of the Diagnostic Statistical Manualof the American Psychiatric Association, and which may be caused by the participant’s daily functioning as it relates to a dentofacial deformity. The MO HealthNet Division will only consider cases where a diagnostic evaluation has been performed by a licensed psychiatrist or a licensed psychologist who has accordingly limited his or her practice to child psychiatry or child psychology. The evaluation must clearly and substantially document how the dentofacial deformity is related to the child’s mental, emotional, and/or behavioral problems and must clearly and substantially document that orthodontic treatment is medically necessary and will significantly ameliorate the problems.

4. Orthodontic treatment shall not be considered to be medically necessary when— A. The orthodontic treatment is for aesthetic or cosmetic reasons only; or B. The orthodontic treatment is to correct crowded teeth only, if the child can adequately protect the periodontium with reasonable oral hygiene measures; or C. The child has demonstrated a lack of motivation to maintain reasonable standards of oral hygiene and oral hygiene is deficient.

(D) Transfer Participants.

1. A participant who becomes MO HealthNet eligible and is already receiving orthodontic treatment through an entity other than a State Medicaid Agency must demonstrate that the need for service requirements specified in subsection (5)(A) and subsection (5)(B) or (5)(C) of these regulations were met before orthodontic treatment commenced, meaning that prior to the onset of treatment the participant would have met the need for service requirements.

2. A participant who becomes MO HealthNet eligible and is already receiving orthodontic treatment through the Medicaid Agency in another state may continue to receive covered orthodontic treatment services through MO HealthNet Division.

(6) Services, Covered and Noncovered. The MO HealthNet Dental Provider Manualshall provide the detailed listing of procedure codes for services covered by the MO Health- Net Dental Program. Pricing information can be obtained from the fee schedule posted at www.dss.mo.gov/mhd/providers/pages/cptagree.htm.

(7) General Regulations. General regulations of the MO HealthNet program apply to the dental program.

(8) Records Retention. Sanctions may be imposed by the MO HealthNet agency against a provider for failing to make available, and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO HealthNet records in compliance with 13 CSR 70-3.030. These records must be retained for five (5) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

Amended: Filed March 30, 1964, effective April 9, 1964. Amended: Filed April 27, 1965, effective May 7, 1965. Amended: Filed Dec. 7, 1966, effective Dec. 17, 1966.

Amended: Filed Oct. 13, 1967, effective Oct. 23, 1967. Amended: Filed Jan. 22, 1968, effective Feb. 1, 1968. Amended: Filed Aug. 24, 1968, effective Sept. 3, 1968. Amended:

Filed April 16, 1970, effective April 26, 1970. Amended: Filed Feb. 16, 1971, effective Feb. 26, 1971. Amended: Filed Jan. 3, 1973, effective Jan. 13, 1973. Amended:

Filed Feb. 6, 1975, effective Feb. 16, 1975.

Amended: Filed July 9, 1976, effective Oct. 11, 1976. Amended: Filed Feb. 7, 1977, effective May 11, 1977. Amended: Filed Nov. 14, 1977, effective Feb. 11, 1978. Emergency rescission filed June 14, 1979, effective July 31, 1979, expired Sept. 13, 1979. Emergency

rule filed June 14, 1979, effective Aug. 1, 1979, expired Sept. 13, 1979. Rescinded and readopted: Filed June 14, 1979, effective Sept. 14, 1979. Emergency amendment filed April 10, 1981, effective April 20, 1981, expired July 10, 1981. Amended: Filed April 10, 1981, effective July 11, 1981. Emergency amendment filed Sept. 18, 1981, effective Oct. 1, 1981, expired Jan. 13, 1982. Amended: Filed Sept. 18, 1981, effective Jan. 14, 1982. Amended: Filed July 15, 1991, effective Nov. 30, 1991. Amended: Filed Aug. 14, 1992, effective Feb. 26, 1993. Emergency amendment filed June 27, 2002, effective July 7, 2002, terminated Dec. 17, 2002. Emergency amendment filed Aug. 19, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006.

Amended: Filed June 15, 2005, effective Jan. 30, 2006. Amended: Filed Aug. 17, 2009, 4CODE OF STATE REGULATIONS (10/31/16) JASONKANDER effective Feb. 28, 2010. Amended: Filed Sept. 28, 2011, effective May 30, 2012. Amended:

Filed April 1, 2016, effective Nov. 30, 2016. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: section 208.152, RSMo Supp. 2015, and sections 208.153 and 208.201, RSMo Supp. 2013. This rule was previously filed as 13 CSR 40-81.040. Original rule filed Jan. 21, 1964, effective Jan. 31, 1964.

Chapter 40 Optical Program

13 CSR 70-40.010 Optical Benefits and Limitations—MO HealthNet Program {#sec-13-csr-70-40.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-40.010}

PURPOSE: This rule establishes the basis for administering the Optical Program under the MO HealthNet program, including the designation of professional persons who may perform optical services; services which are covered, noncovered, and limitations within the program; and the method of reimbursement.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The Department of Social Services, MO HealthNet Division shall administer the Optical Program. The Department of Social Services, MO HealthNet Division shall determine, and include in the Optical Provider manual, the optical services covered and not covered, the program limitations, and the maximum allowable fees for all covered services. The Optical Provider manual 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 http://manuals.momed.com/collections/collection_opt/print.pdf November 24, 2020.

This rule does not incorporate any subsequent amendment or additions. Services covered shall include only those which are clearly shown to be medically necessary.

(2) Participants Eligible. Any participant who is eligible for MO HealthNet benefits as determined by the Family Support Division and who is found to be in need of optical services as described in this regulation subject to the limitations set forth in subsections (7)(A)–(X).

(3) Provider Participation. To be eligible for participation in the MO HealthNet Optical Program, a provider must meet the criteria specified for his/her profession as follows:

(A) An optometrist must be a duly licensed Doctor of Optometry (OD) to participate in the MO HealthNet program, must be licensed in accordance with the licensing provisions of the state in which s/he practices, and must have a current MO HealthNet participation agreement and provider number;

(B) A physician must be a duly licensed Doctor of Medicine (MD) or Doctor of Osteopathy (DO) to participate in the MO HealthNet program, must be licensed in accordance with the licensing provisions of the state in which s/he practices, and must have a current MO HealthNet participation agreement and provider number;

(C)

A clinic can participate in the Optical Program if it has a current MO HealthNet Program clinic number. In addition to the clinic number, each of the performing optometrists must have an effective participation agreement and MO HealthNet program provider number. Reimbursement may be made to the clinic for all covered services provided at the clinic; and (D) An optician, optical dispenser, or manufacturer of prosthetic eyes must have a current MO HealthNet participation agreement and provider number.

(4) Types of Service Reimbursed by the MO HealthNet Program for Each Profession.

(A) Optometrist or Clinic.

1. Eye examinations.

2. Refractions.

3. Eyeglasses.

4. Prosthetic eyes.

5. Special ophthalmological services.

(B) Opticians or Optical Dispensers.

1. Eyeglasses.

2. Prosthetic eyes.

(C) Manufacturers of Prosthetic Eyes— Prosthetic Eyes.

(D) Physicians (MD or DO).

1. Eye examinations.

2. Refractions.

3. Eyeglasses (Must be enrolled as an Optical provider).

4. Prosthetic eyes (Must be enrolled as an Optical provider).

5. Special ophthalmological services.

(5) Reimbursement. MO HealthNet reimbursement will be the lower of the provider’s usual and customary charge to the general public or the MO HealthNet allowable amount.

(6) Covered Services.

(A) Complete or limited eye examination.

(B) Eye refraction.

(C) Eyeglasses.

(D) Frames.

(E) Temple.

(F) Lenses, single vision.

(G) Lenses, bifocal.

(H) Lenses, trifocal.

(I) Lenses, cataract.

(J) Special frames.

(K) Special lenses.

(L) Miscellaneous repairs.

(M) Scleral cover shell, stock, or custom.

(N) Prosthetic eye, plastic, or custom.

(O) Prosthetic eye, refitting.

(P) Prosthetic eye check/polishing/cleaning.

(Q) Rose I and Rose II tints.

(R) Photochromatic lenses.

(S) Orthoptic and/or pleoptic training, with continuing optometric direction and evaluation (visual therapy/training).

(T) Fitting of contact lens for treatment of disease, including supply of lens (therapeutic bandage lens).

(U) Visual field examination with optometric diagnostic evaluation; tangent screen, autoplot, or equivalent.

(V) Electro-oculography, with medical diagnostic evaluation.

(W) Visually evoked potential (response) study, with medical diagnostic evaluation.

(X) Quantitative perimetry, for example, several isopters on Goldmann perimeter or equivalent.

(Y) Static and kinetic perimetry or equivalent.

(Z) Serial tonometry with optometric diagnostic evaluation (separate procedure), one (1) or more sessions, same day.

(AA) Tonography with optometric diagnostic evaluation, recording indentation tonometer method or perilimbal suction method.

(BB) Color vision examination, extended, for example, anomaloscope or equivalent.

(CC) Dark adaptation examination, with optometric diagnostic evaluation.

(7) Program Limitations.

(A) Optical Program services require precertification. Pre-certification serves as a utilization management tool, allowing payment for services that are medically necessary, appropriate, and cost effective without compromising the quality of care to participants.

An enrolled optical provider must initiate requests for pre-certification and MO Health- Net must issue approval before delivery of service. The pre-certification medical criteria can be found in the Optical Provider Manual identified in section (1) of this rule.

(B) One (1) comprehensive or one (1) limited eye examination is allowed per two (2) years (within a twenty-four- (24-) month period of time) under the MO HealthNet program. Eligible children, pregnant women, individuals residing in a nursing home, and blind persons are allowed one (1) comprehensive or one (1) limited eye examination per year (within a twelve- (12-) month period of time) under the MO HealthNet program. Payment for a comprehensive eye examination will be made only if six (6) or more of the following procedures have been performed:

1. Refraction far point and near point;

2. Case history;

3. Visual acuity testing;

4. External eye examination;

5. Pupillary reflexes;

6. Ophthalmoscopy;

7. Ocular motility testing;

8. Binocular coordination;

9. Vision fields;

10. Biomicroscopy (slit lamp);

11. Tonometry;

12. Color vision; and 13. Depth perception.

(C) If fewer than six (6) of these are performed, a limited examination must be billed.

(D) Eligible children, pregnant women, individuals residing in a nursing home, and blind persons may be allowed additional eye examinations during the year (within a twelve- (12-) month period of time) if medically necessary (that is, cataract examination, prescription change of 0.50 diopters or greater).

(E) Eyeglasses are covered by the MO HealthNet program for MO HealthNet eligible participants when the prescription is at least 0.75 diopters for one (1) eye or 0.75 diopters for each eye.

(F) Only one (1) pair of eyeglasses is allowed every two (2) years (within any twenty-four- (24-) month period of time) for MO HealthNet eligible participants.

(G) The original eyeglass prescription and laboratory invoices listing costs for optical materials, lenses, and/or frames provided; and the charge for grinding, edging, or assembling of glasses must be kept on file by the provider for six (6) years and furnished to the MO HealthNet Division or its representative upon request.

(H) Special frames are covered under the MO HealthNet program if they are required for medical reasons. Special frames may be authorized if the patient requires special lenses (plus or minus 4.00 diopters for one (1) eye or plus or minus 4.00 diopters for each eye and are extra thick or heavy), the structure of the patient’s face requires special frames (a very large face, wide-set eyes), or the patient needs glasses with pads because of nose surgery.

(I) Special lenses are covered under the MO HealthNet program if they are medically justified and the prescription is plus or minus 4.00 diopters for one (1) eye or plus or minus 4.00 diopters for each eye, cataract lenses, or special bifocal lenses (for example, plastic Executive lenses).

(J) Plastic lenses may be dispensed under the MO HealthNet program. Reimbursement will be at the same rate as comparable glass lenses. Additional payment will be allowed for plastic lenses that meet the definition of special lenses and are medically justified.

(K) Photochromatic lenses are covered only if medically necessary.

(L) Tinted lenses (Rose I and Rose II) are covered if medically necessary.

(M) Replacement of optical materials and repairs in excess of program limitations may be covered if medically necessary, or required for employment training, or educational purposes, as follows:

1. Replacement of complete eyeglasses (frames and lenses).

A. Lenses and frames broken (participant must show provider the broken glasses or the MO HealthNet program will not pay for the glasses).

B. Lost.

C. Destroyed.

D. Stolen.

E. Repair of existing glasses would exceed the MO HealthNet allowable amount for new frames and lenses;

2. Lenses—if medically necessary.

A. Scratched.

B. Broken.

C. Prescription change of at least 0.50 diopters or greater; or 3. Frames—Temples, fronts, or both broken and repair would exceed the MO HealthNet allowable amount for new frames.

(N) Repair of frames or replacement of parts of frames (temples) are covered as follows:

1. The cost of the repairs do not exceed the MO HealthNet allowable amount for new frames; and 2. Repair would provide a serviceable frame for the participant.

(O) Temples may never be billed in addition to complete new eyeglasses and new frames.

(P) An eye refraction may be reimbursed in addition to a comprehensive or limited eye examination. Because an eye refraction is not covered by Medicare but is covered by MO HealthNet, providers may bill MO HealthNet for an eye refraction when the patient has Medicare and MO HealthNet coverage.

(Q) Eyeglasses may be covered by MO HealthNet for a prescription of less than 0.75 diopters if medically necessary. Eyeglasses less than 0.75 diopters will be approved for the following reasons:

1. Child age twenty (20) and under who requires glasses for school performances;

2. Visual acuity 20/40 or less; or 3. Protective eyewear for participants with sight in only one (1) eye.

(R) Any warranties extended by optical companies for optical materials to private-pay patients must also apply to those same materials dispensed to MO HealthNet participants.

(S) The MO HealthNet program allows one (1) prosthetic eye per eye (one (1) left and one (1) right) within a five- (5-) year period. If the prosthetic eye is lost, destroyed, cracked, or deteriorated, payment will be allowed for replacement.

(T) Optometrists may be reimbursed for visual therapy training when there is a prognosis for substantial improvement or correction of an ocular or vision condition. These conditions include amblyopia, eccentric (nonfoveal) monocular fixation, suppression, inadequate motor or sensory fusion, and strabismus (squint). The number of training sessions is limited to one (1) per day, two (2) per week, and a maximum of twenty (20) sessions. If the patient shows significant improvement after the initial twenty (20) sessions and the optometrist feels that further progress could be made, additional training sessions not to exceed a total of forty (40) sessions may be provided.

(U) Fitting of contact lens for treatment of disease, including supply of lens (therapeutic bandage lens) is covered if it is prescribed by a physician (MD or DO) or optometrist (OD) as a bandage to cover a diseased condition of the eye, such as a bandage over an abrasion of the skin. The lens must be plain with no corrective power. Diagnosis for which the lens should be reimbursed are Bullous Kerotopathy, Corneal Ulcers, Ocular Pemphigoid, and other corneal exposure problems.

(V) Visual field examination with optometric diagnosis evaluation, tangent screen autoplot, or equivalent is covered when performed by an optometrist.

(W) Quantitative perimetry, for example, several isopters on Goldmann perimeter, or equivalent is covered.

(X) Serial tonometry with optometric diagnostic evaluation (separate procedure), one (1) or more sessions on the same day is covered when performed by an optometrist. Routine tonometry is included in the reimbursement for a comprehensive examination and cannot be billed separately.

(8) Noncovered Services.

(A) Eyeglass frames with hearing aids attached.

(B) Optical services or materials provided (9/30/21) JOHN R. ASHCROFT to a participant who was not eligible on the date the service was provided or the optical materials were delivered to the patient.

(C) Sales or use tax on optical materials (the participant is not responsible for and may not be billed for such taxes).

(D) Contact lenses other than for medical purposes as described above in subsection (7)(T).

(E) Sunglasses.

(F) Lenses exceeding 65 mm in diameter or frames for such lenses.

(G) Temporary lenses for cataract lenses.

(H) Eyeglass cases.

(I) Monicals.

(J) Magnifiers.

(K) Eye medications.

(L) Repair of old frames if the repair exceeds the cost of new frames.

(M) Replacement of optical materials resulting from patient abuse.

(N) Optical materials which are not medically necessary.

(O) Nose pads.

(P) Eyeglass adjustments.

(Q) Optical materials not meeting MO HealthNet Division standards.

(R) Lenses or frames supplied incorrectly to the provider by the supplier or manufacturer.

(S) Replacement of lenses, complete eyeglasses, frames, or prosthetic eyes supplied incorrectly to participant by optical provider.

(T) Optical materials in excess of those authorized within the benefit period.

(9) General Regulations. This rule shall not encompass all of the general regulations of the MO HealthNet program. These regulations, however, shall be in effect for the optical section of the overall program.

(10) Records Retention. MO HealthNet may impose sanctions against a provider for failure to make available or disclose to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO Health- Net records, in compliance with 13 CSR 70- 3.030. Providers must retain these records for six (6) years from the date of service. Fiscal and medical records must coincide with, and fully document, services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request.

Emergency amendment filed June 27, 2002, effective July 7, 2002, terminated Feb. 23, 2003. Amended: Filed July 15, 2002, effective Feb. 28, 2003. Amended: Filed March 3, 2003, effective Oct. 30, 2003. Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 1, 2005, effective Nov. 30, 2005. Emergency amendment filed June 15, 2006 effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed May 15, 2006, effective Nov. 30, 2006. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed Oct. 10, 2013, effective April 30, 2014.

Amended: Filed March 5, 2021, effective Oct. 30, 2021. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021. This rule was previously filed as 13 CSR 40-81.170. Emergency rule filed April 10, 1981, effective April 20, 1981, expired July 10, 1981. Original rule filed April 10, 1981, effective July 11, 1981.

Chapter 45 Hearing Aid Program

13 CSR 70-45.010 Hearing Aid Program {#sec-13-csr-70-45.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-45.010}

PURPOSE: This rule is to establish the regulatory basis for the administration of the Hearing Aid Program, including the method of purchasing hearing aids; designation of professional persons who may perform the medical ear examination and testing; and the method of reimbursement for the aids and related services. More specific details of the conditions for provider participation, criteria and methodology of provider reimbursement, participant eligibility and amount, duration, and scope of services covered are included in the provider program manual.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The Hearing Aid Program shall be administered by the Department of Social Services, MO HealthNet Division. The services and items covered and not covered, the program limitations, and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO HealthNet Division through the hearing aid manual 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 dss.mo.gov/mhd, May 13, 2020. This rule does not incorporate any subsequent amendments or additions.

(2) Participants Eligible. The MO HealthNet Program pays for approved MO HealthNet services for hearing aid services when furnished within the provider’s scope of practice to MO HealthNet eligible participants under the age of 21 or participants receiving MO HealthNet under a category of assistance for pregnant women, blind participants, or skilled nursing facility residents. The participant must be eligible on the date the service is furnished. Participants may have specific limitations for hearing aid services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the provider program manual. The provider shall ascertain the patient’s MO HealthNet and managed care or other lock-in status before any service is performed. The participant’s eligibility shall be verified in accordance with methodology outlined in the hearing aid manual.

(3) Prior Authorization of Hearing Aids. All hearing aids and related services require prior authorization with the exception of hearing evaluation for the purpose of prescribing a hearing aid, post-fitting evaluations, post-fitting adjustments, repairs to hearing aids no longer under warranty, and special tests for ruling out retrocochlear involvement. All hearing aid program services provided to participants in nursing facilities require prior authorization.

(4) Hearing Evaluation Requirements. A hearing evaluation for the purpose of obtaining a hearing aid must be performed by an audiologist, hearing instrument specialist, or physician (MD or DO) prior to the submission of a Prior Authorization Request form. This testing, when administered for the purpose of prescribing a hearing aid, will be reimbursed by the MO HealthNet program. Testing performed in relation to a medical or surgical diagnosis or treatment for hearing deficits or related medical problems for purposes other than determining the need for a hearing aid is a noncovered service and is not reimbursable by the MO HealthNet Hearing Aid Program.

The hearing evaluation performed for the purpose of obtaining a hearing aid must include, at a minimum, air conduction thresholds, bone conduction thresholds (with masking when necessary), speech reception thresholds, and speech discrimination scores. The results obtained from these basic hearing tests must be clear and internally consistent, and must demonstrate that a hearing aid is needed, that it will benefit the participant and will support the recommendation of which ear is to be fitted. Testing must be provided in accordance with sound professional practice and the standards under which the provider is licensed.

(5) Hearing Loss (HL) Requirement. A participant’s pure-tone average (PTA) must be thirty decibels (30dB) HL or greater in the better ear to qualify for a hearing aid. The PTA is the average air-conduction threshold for five hundred (500), one thousand (1,000), and two thousand (2,000) Hertz (Hz) measured with an earphone. Word recognition must be tested with a minimum of twenty-five (25) phonetically balanced word lists.

(6) Medical Ear Examination Requirements.

The participant must receive a medical ear examination for pathology or disease by a physician licensed as an MD or DO. The medical ear examination must be performed within six (6) months prior to the date a hearing aid is dispensed.

(7) Obtaining and Fitting the Aid. Only after receipt of an approved Prior Authorization Request form should the provider proceed with the fitting and dispensing of the hearing aid.

(8) Post-fitting Evaluation. A post-fitting evaluation will be performed no sooner than fourteen (14) days or later than thirty (30) days after the hearing aid is dispensed. If the hearing aid is not providing adequate and substantial correction of the loss, reimbursement will not be made for the hearing aid.

(9) Reimbursement for Hearing Aids and Related Services. Payment will be made for each unit of service or item provided in accordance with the fee schedule determined by the MO HealthNet Division. Providers must bill their costs for the hearing aids.

Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charge.

(10) Services/Items Provided in a Nursing Home. A request for hearing evaluation for the purpose of prescribing a hearing aid must originate with the participant and must proceed with the participant’s full knowledge and consent. All hearing aids and related services performed or provided in a nursing home, boarding home, domiciliary home, or institution require prior authorization as specified in section (3), with the exception that hearing evaluation for the purpose of prescribing a hearing aid being performed in these places of service also requires prior authorization.

(11) Binaural Hearing Aids. Binaural hearing aids may be covered by MO HealthNet if medically necessary and if prescribed by an otolaryngologist, otologist, or otorhinolaryngologist.

(12) Replacement Hearing Aids. Prior authorization may be granted for a second hearing aid within four (4) years if the first hearing aid was lost, destroyed, or ceased to function effectively and cannot be repaired.

(13) Hearing Aid Repairs. MO HealthNet covers necessary repairs to any eligible participant’s hearing aid that is no longer under warranty. The warranty period on new hearing aids or repairs will be for one (1) year from the date the hearing aid is dispensed.

The methods of reimbursement for repairs are as follows:

(A) Out-of-shop Repairs. Necessary repairs made out-of-shop, where the hearing aid must be sent out to the manufacturer or repair lab, will be reimbursed at twenty dollars ($20) plus the invoiced cost of the repair. The twenty dollars ($20) covers the provider’s cost for postage and processing.

Included also is any postage for returning the hearing aid to the provider, any insurance fee charged, and a six- (6-) month warranty; and (B) In-shop Repairs. Necessary repairs made in-shop will be reimbursed at the provider’s cost for parts plus a reasonable charge for labor. The state consultant will determine the reasonable charge for labor.

Repairs will be considered as in-shop repairs for— 1. Any repair made in the provider’s office;

2. Any repair made in a provider-owned and/or operated repair or manufacturing lab; or 3. Any repair made by a provider who is employed by or affiliated with another provider who owns or operates a repair or manufacturing lab.

(14) Post-fitting Adjustments. A maximum of three (3) post-fitting adjustments or hearing aid repairs or any combination totaling three (3) are covered in a twelve- (12-) month period. Minor adjustments and repairs such as the following must be billed as a post-fitting adjustment:

(A) Reprogramming or adjusting the frequency response of the hearing aid;

(B) Modifying an earmold;

(C) Checking that the ear, earmold, and tubing are not occluded with ear wax;

(D) Removing of ear wax from the earmold and tubing;

(E) Venting earmold or closing vent;

(F) Adjusting maximum power output;

(G) Reinstructing the patient in the use and care of the hearing aid;

(H) Changing microphone filters or receivers;

(I) Conducting hearing retests;

(J) Evaluating the electroacoustic hearing aid; or (K) Cleaning the hearing aid.

(15) Basic Program Limitations. Benefits under the hearing aid program are limited by the following:

(A) A participant is entitled to one (1) new hearing aid and related services (testing, earmold, fitting, dispensing, and post-fitting evaluation) per four (4) years;

(B) Backup or spare hearing aids are noncovered regardless of when the first hearing aid was dispensed:

(C) Any hearing aid for the purpose of binaural amplification must be prescribed by an otolaryngologist, otologist, or otorhinolaryngologist;

(D) All repairs for hearing aids must include a six- (6-) month warranty;

(E) MO HealthNet will not reimburse for repairs to a hearing aid that is five (5) years of age or older; and (F) A new hearing aid will not be purchased within six (6) months of the repair of an old hearing aid.

(16) Records Retention. The MO HealthNet Division may impose sanctions against a provider for failing to make available, and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO HealthNet records in compliance with 13 CSR 70-3.030. Providers must retain these records for six (6) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency.

Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this

regulation.

rule filed June 1, 1979, effective Sept. 14, 1979. Emergency amendment filed April 10, 1981, effective April 20, 1981, expired July 10, 1981. Amended: Filed April 10, 1981, effective July 11, 1981. Rescinded and readopted: Filed July 18, 1989, effective March 1, 1990. Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 29, 2005, effective Jan. 30, 2006. Amended: Filed June 15, 2006, effective Dec. 30, 2006. Amended:

Filed March 17, 2008, effective Oct. 30, 2008. Amended: Filed Oct. 10, 2013, effective April 30, 2014. Amended: Filed May 13, 2020, effective Nov. 30, 2020. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

(10/31/20) JOHN R. ASHCROFT

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2020. This rule was previously filed as 13 CSR 40-81.120. Emergency rule filed June 1, 1979, effective June 11, 1979, expired Sept. 13, 1979. Original

Chapter 50 Hospice Services Program

13 CSR 70-50.010 Hospice Services Program {#sec-13-csr-70-50.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-50.010}

PURPOSE: This rule establishes the MO HealthNet payment policy for the Hospice Program. The goal of the Hospice Program is to meet the needs of participants with life-limiting illnesses and to help their families cope with related problems. Hospice care is an approach to treatment that recognizes that the impending death of an individual warrants a change in focus from curative care to palliative care.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The Hospice Program shall be administered by the Department of Social Services, MO HealthNet Division.

The medical services covered and not covered, the program limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Hospice Provider Manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/collections/collection_hos/print.pdf, November 25, 2020. This rule does not incorporate any subsequent amendments or additions. Hospice services covered by the MO HealthNet program shall include only those that are clearly shown to be medically necessary. The division reserves the right to affect changes in services, limitations, and fees with proper notification to MO HealthNet hospice providers.

(2) Persons Eligible. Participants eligible for medical assistance benefits from the Department of Social Services are certified by a physician to be terminally ill with a medical prognosis of life expectancy of six (6) months or less if the illness runs its normal course and who elects hospice benefits is eligible.

The individual must agree to seek only palliative care for the duration of the hospice enrollment with the following exception:

(A) Hospice services for a child under twenty-one (21) years of age may be concurrent with the care related to curative treatment of the condition for which a diagnosis of a terminal illness has been made.

(3) Enrollment of Participant. The components involved in hospice enrollment are— physician certification; election procedures, including election statement, revocation, and change; the assignment of an attending physician; and the development of the plan of care.

(A) Physician Certification. The hospice must obtain the certification that an individual is terminally ill in accordance with the following procedures:

1. Prior to billing for the first period of hospice coverage (ninety (90) days), the hospice must obtain, written certification statements signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the individual’s attending physician (if that attending physician is other than a hospice staff member). The certification must include the statement that the individual’s medical prognosis is a life expectancy of six (6) months or less if the illness runs its normal course and the signature(s) of the physician(s). If the hospice does not obtain written physician certification within two (2) days of the initiation of hospice care, a verbal physician certification must be obtained within the two (2) days. Payment will not be made for days prior to the written certification if the verbal certification requirement is not met.

2. For any subsequent period of hospice coverage, the hospice must obtain, no later than two (2) calendar days after the beginning of that period, a written certification statement prepared by the medical director of the hospice or the physician member of the hospice’s interdisciplinary group. The certification must include the statement that the individual’s medical prognosis is a life expectancy of six (6) months or less if the illness runs its normal course and the signature of the physician. The hospice must maintain the certification statements.

(B) Election Procedures. To elect hospice services, an individual must file a Hospice Election Statement with a MO HealthNet participating hospice provider. An election may also be filed by a representative acting pursuant to state law. With respect to an individual granted the power of attorney for the participant, state law determines the extent to which the individual may act on the patient’s behalf.

1. Election period. An election to receive hospice care will be considered to continue through the initial election period and through any subsequent election periods without a break in care as long as the individual remains in the care of the hospice and does not revoke the election.

2. Waiver of MO HealthNet fee-for-service payments related to the terminal illness.

In order to elect hospice services, the individual must waive all rights to MO HealthNet payments for services that would be covered under the Medicare program for the duration of the election of hospice care for the following services:

A. Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice); and B. Any MO HealthNet services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition, or that are equivalent to hospice care except for services— (I) Provided (either directly or under arrangement) by the designated hospice;

(II) Provided by another hospice under arrangements made by the designated hospice;

(III) Provided by the individual’s attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services; or (IV) Provided to a child under twenty-one (21) and such services are curative treatment services for the condition for which a diagnosis of terminal illness has been made, as required by the federal Patient Protection and Affordable Care Act (PPACA), P.L. 111-148, section 2302.

3. Election, revocation, and change of hospice.

A. Election periods. An individual may elect to receive hospice care during one (1) or more of the following election periods:

(I) An initial ninety- (90-) day period;

(II) A subsequent ninety- (90-) day period; and (III) Unlimited subsequent sixty- (60-) day periods.

B. Election statement. The election statement must include the following items of information:

(I) Identification of the particular hospice that will provide care to the individual;

(II) The individual’s or representative’s acknowledgment that s/he has been given a full understanding of hospice care;

(III) The individual’s or representative’s acknowledgment that s/he understands that certain MO HealthNet services are waived by the election;

(IV) The effective date of the election;

(V) The name of the attending physician;

(VI) The signature of the individual or representative; and (VII) The signature of the witness when the participant’s representative signs the form.

C. Revocation. An individual or representative may revoke the election of hospice care at any time. To revoke the election of hospice care, the individual, or representative, must file a revocation of hospice benefit statement with the hospice. This statement must include a signed statement that the individual revokes the election for MO HealthNet coverage of hospice care for the remainder of that election period. The date that the revocation is to be effective is the date of the signature or may be a later date subsequent to the date of signature. The individual forfeits coverage for any remaining days in that election period. The individual or representative may not designate an effective date earlier than the date that the revocation statement is signed.

Upon revoking the election of MO HealthNet coverage of hospice care for a particular election period, an individual resumes MO HealthNet coverage of the benefits waived when hospice care was elected. An individual may elect at any time to receive hospice coverage for any other hospice election periods for which s/he is eligible.

D. Change of Hospice. An individual may change, once in each election period, the designation of the particular hospice from which s/he elects to receive hospice care. The change of the designated hospice is not considered a revocation of the election. To change the designation of hospice providers, the individual must file with the hospice from which s/he has received care and with the newly designated hospice a signed statement that includes the following information: the name of the hospice from which the indi vidual has received care, the name of the hospice from which s/he plans to receive care, and the date the change is to be effective.

(C) Attending Physician. The attending physician is a doctor of medicine or osteopathy and is identified by the individual, at the time s/he elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care. The attending physician is the participant’s physician of choice who participates in the establishment of the plan of care and works with the hospice team in caring for the patient. The physician continues to give the medical orders and may have privileges in the hospice inpatient care. MO HealthNet will make payments directly to a hospice participant’s attending physician if the physician is not employed by the hospice provider.

(D) Plan of Care. The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services and the patient's need for physical, psychosocial, emotional, and spiritual care.

This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

The hospice registered nurse must complete an initial assessment within forty-eight (48) hours after the election of hospice care. The hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than five (5) calendar days after the election of hospice care. The hospice must designate an interdisciplinary group or groups which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient.

The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less than every fifteen (15) calendar days.

The plan of care must be maintained in the patient's record and made available to the MO HealthNet Division or its agent upon request.

(4) Provider Participation. To be eligible for participation in the MO HealthNet Hospice Program, a provider must meet the following criteria:

(A) Be certified as a Medicare hospice provider;

(B) Be licensed by the Missouri State Department of Health and Senior Services as a hospice provider; and (C) Be enrolled as a MO HealthNet hospice provider.

(5) Benefits and Limitations. All services must be performed by appropriately qualified personnel. Nursing care, medical social services, and counseling are core hospice services and must routinely be provided directly by hospice employees. A hospice must ensure that substantially all the core services are routinely provided directly by hospice employees.

A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. If contracting is used, the hospice must maintain professional, financial, and administrative responsibility for the services and must assure that the qualifications of staff and services provided meet all requirements. Hospice covered services are identified in section 13 of the MO HealthNet Hospice Provider Manual which may be referenced at www.dss.mo.gov/mhd. The individual's plan of care must specify what hospice services are needed.

(6) Non-covered services are identified in

section 13 of the MO HealthNet Hospice Provider Manual which may be referenced at www.dss.mo.gov/mhd.

(7) Reimbursement. Hospice services, as defined in this rule and provided by qualified providers, shall be reimbursed for dates of service beginning on or after May 15, 1989. The reimbursement rate for hospice services includes all covered services related to the treatment of the terminal illness, including the administrative and general supervisory activities performed by physicians who are employees of or working under arrangements made with the hospice. These activities would generally be performed by the physician serving as the medical director and the physician member of the hospice interdisciplinary group. Group activities would include participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care, and establishment of governing policies. The costs for these services are included in the reimbursement rates for routine home care, continuous home care, and inpatient respite care.

(A) A per-diem rate for each day on which hospice services are provided will be established based on the Title XVIII Medicare rate for the specific hospice based on the level of care provided— 1. Routine home care;

2. Continuous home care. A minimum of eight (8) hours of continuous care must be provided during a twenty-four (24)-hour period;

3. General inpatient care; and 4. Inpatient respite care. Reimbursement is limited to five (5) days per calendar month and to the mandatory inpatient day limit.

(1/29/22) JOHN R. ASHCROFT

(B) Nursing Home Room and Board. MO HealthNet-eligible individuals residing in MO HealthNet-certified NFs who meet the hospice eligibility criteria may elect MO HealthNet hospice care services. In addition to the routine home care or continuous home care per diem rates, an amount may be paid to the hospice to cover the nursing home room and board costs. The hospice will reimburse the nursing home.

1. There must be a written agreement between the hospice and the nursing home under which the hospice takes full responsibility for the professional management of the individual’s hospice care and the nursing home agrees to provide room and board to the individual. The hospice and the nursing home will retain a copy of the agreement.

2. For purposes of the MO HealthNet hospice benefit, a NF can be considered the individual’s residence.

3. Payment for nursing facility (NF) room and board will be determined in accordance with rates established under section 1902(a)(13) of the Social Security Act. It is the responsibility of the hospice provider to be aware of the NF reimbursement rate and whether it is a final rate or if it is subject to change. The MO HealthNet Division may recoup payments made to hospice providers for NF room and board if the nursing facility reimbursement rate changes retroactively.

(C) Physician Services. MO HealthNet will reimburse the hospice provider for certain physician services, such as direct patient care services, furnished to individual patients by hospice employees and for physician services furnished under arrangements made by the hospice unless the patient care services were furnished on a volunteer basis. MO HealthNet will reimburse the hospice for attending physician services when the physician is employed by the hospice. These physician services will be reimbursed in accordance with MO HealthNet reimbursement policy for physician services based on the lower of the actual charge or the MO Health- Net maximum allowable amount for the specific service.

(D) Limitation on Payments for Inpatient Care. Payments to hospice providers for inpatient care must be limited according to the number of days of inpatient care furnished to MO HealthNet patients. During the twelve- (12-) month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed twenty percent (20%) of the aggregate total number of days of hospice care provided to all MO HealthNet participants during that same period. This limitation is applied once each year, at the end of the hospice’s cap period (11/1–10/31). For purposes of this computation, if it is determined that the inpatient rate should not be paid, any days for which the hospice receives payment at a home care rate will not be counted as inpatient days. Any excess reimbursement will be refunded by the hospice.

(8) Cost Sharing. Hospice services shall be exempt from these Medicaid cost-sharing requirements as may be otherwise applicable to a comparable service when provided other than as a hospice service.

(9) General Regulations. General regulations of the MO HealthNet program apply to the hospice program.

(10) Records Retention. Sanctions may be imposed by the MO HealthNet agency against a provider for failing to make available, and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet payments, whether or not the records are comingled with non-Title XIX (Medicaid) records in compliance with 13 CSR 70-3.030. These records must be retained for six (6) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency.

Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this

regulation.

Amended: Filed June 18, 1991, effective Dec. 9, 1991. Amended: Filed Sept. 2, 1993, effective April 9, 1994. Amended: Filed Aug. 24, 2001, effective March 30, 2002. Amended:

Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed July 9, 2021, effective Feb. 28, 2022. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021. Emergency rule filed May 17, 1989, effective May 27, 1989, expired Sept. 13, 1989. Original rule filed May 17, 1989, effective Aug. 11, 1989.

Chapter 55 Nurse-Midwife Program

13 CSR 70-55.010 MO HealthNet Program Benefits for Nurse-Midwife Services {#sec-13-csr-70-55.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-55.010}

PURPOSE: This rule establishes the MO HealthNet payment policy for the Nurse-Midwife Services Program. The goal of the Nurse-Midwife Services Program is to provide care of a pregnant woman and her unborn/newborn infant throughout the maternity cycle.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The Nurse-Midwife Program shall be administered by the Department of Social Services, MO HealthNet Division. The medical services covered and not covered, the program limitations, and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO HealthNet Division, and shall be included in the Nurse-Midwife Program provider manual, 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 http://manuals.momed.com/collections/collection_nmw/print.pdf, November 25, 2020. This rule does not incorporate any subsequent amendments or additions.

(2) Persons Eligible. Any person who is eligible for MO HealthNet benefits from the Department of Social Services and is in need of medical services in accordance with the procedures described in this regulation.

(3) Provider Participation. To be eligible for participation in the MO HealthNet Nurse- Midwife Program, a provider must meet the following criteria:

(A) Be currently licensed and maintain an active license as a registered nurse.

1. A nurse-midwife who resides in or outside Missouri and who practices in whole or in part in Missouri must be a currently licensed registered nurse (RN) in Missouri.

2. A nurse-midwife who provides services, in whole or in part, to MO HealthNet participants in a state other than Missouri must be a currently licensed registered nurse (RN) in that state and be legally authorized under that state’s law to practice as a nursemidwife; and (B) Be currently certified and maintain active certification by the American College of Nurse-Midwives.

(4) MO HealthNet reimbursement for nursemidwives will be limited to the following types of care in accordance with federal and state laws. The MO HealthNet Nurse-Midwife Provider Manual will contain a listing of covered and noncovered services:

(A) Complete care, management and monitoring of a woman in the absence of medical complications and her unborn/newborn infant throughout the course of the normal cycle of gestation including pregnancy, labor and delivery, and the initial post-delivery/postpartum period not to exceed six (6) weeks; and (B) Routine post-delivery care of the neonate, including physical examination of the baby and conference with parents.

(5) Nurse-midwives may be reimbursed by MO HealthNet for services performed in the following locations:

(A) Inpatient hospital;

(B) Outpatient hospital;

(C) Office; and (D) Home.

(6) Reimbursement. MO HealthNet reimbursement for service(s) rendered will be the lower of the provider’s usual and customary charge to the general public or the MO HealthNet maximum allowable amount.

(7) General Regulations. This rule shall not encompass all of the general regulations of the MO HealthNet Program. These regulations, however, shall be in effect for nursemidwife services.

Amended: Filed July 9, 2021, effective Feb. 28, 2022. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021. This rule was previously filed as 13 CSR 40-81.045. Original rule filed Sept. 1, 1987, effective Dec. 1, 1987. Emergency amendment filed Nov. 18, 1987, effective Dec. 1, 1987, expired March 30, 1988. Amended: Filed Nov. 19, 1987, effective March 11, 1988. Amended: Filed May 14, 2009, effective Nov. 30, 2009.

Chapter 60 Durable Medical Equipment Program

13 CSR 70-60.010 Durable Medical Equipment Program {#sec-13-csr-70-60.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-60.010}

PURPOSE: This rule establishes the regulatory basis for the administration of the MO HealthNet durable medical equipment program, designation of professional persons who may dispense durable medical equipment, and the method of reimbursement for durable medical equipment. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available under the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of the conditions for provider participation, criteria, and methodology of provider reimbursement, participant eligibility and amount, duration, and scope of services covered are included in the durable medical equipment provider program manual and bulletins which are incorporated by reference in this rule and available at the website www.dss.mo.gov/mhd.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet Durable Medical Equipment (DME) program shall be administered by the Department of Social Services, MO HealthNet Division. The services and items covered and not covered, the program limitations, and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO Health- Net Division and shall be included in the DME provider manual, 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 http://manuals.momed.com/collections/collection_dme/print.pdf, September 6, 2019. This rule does not incorporate any subsequent amendments or additions.

(2) Persons Eligible. Any person who is eligible for MO HealthNet benefits as determined by the Family Support Division is eligible for DME when the DME is medically necessary. DME must be prescribed by the participant’s physician and reviewed by the physician annually. Covered services are limited as specified in the DME provider manual.

(3) Reimbursement. Payment will be made for each unit of service or item provided in accordance with the fee schedule determined by the MO HealthNet Division. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charge. Reimbursement for DME services is made on a fee-for-service basis. The MO HealthNet maximum allowable fee for a unit of service has been determined by the MO HealthNet Division to be a reasonable fee, consistent with efficiency, economy, and quality of care. Sales tax is not covered by MO HealthNet, nor can it be billed to the participant. Providers must accept the MO HealthNet payment as the full and complete payment and may not accept additional payment from the participant. Charges for shipping, freight, COD, handling, delivery, and pickup are included in the reimbursement for items covered under the DME program and are not billable to the MO HealthNet participant.

(4) Definition for Durable Medical Equipment and appliances. DME is equipment and appliances that can withstand repeated use, can be reusable or removable, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of a disability, illness, or injury, and is appropriate for use in any setting in which normal life activities take place as defined in 42 CFR 440.70(c)(1). All requirements of the definition must be met in order for the equipment to be covered by MO HealthNet. 42 CFR 440.70 is published by the Federal Register, at https://www.ecfr.gov/. A copy of 42 CFR 440.70 as of January 3, 2020, is incorporated by reference and made part of this

rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://dssruletracker.mo.gov/dssproposed-rules/welcome.action. This rule does not incorporate subsequent amendments or additions.

(5) Provider Participation.

(A) The following types of providers may be reimbursed by MO HealthNet for items covered under the DME program if they are enrolled MO HealthNet DME providers and enrolled with Medicare as a durable medical equipment prosthetic and orthotic supplier: rental and sales providers, prosthetic fabricators, rehabilitation centers, orthotic fabricators, physicians (includes M.D., D.O., podiatrists—may dispense orthotic devices and artificial larynx), advanced practice nurses in a collaborative practice arrangement, pharmacies, and hospitals.

(B) MO HealthNet participants are required to obtain services from Missouri or bordering state providers. MO HealthNet will consider enrollment of an out-of-state (non-bordering) durable medical equipment provider only if— 1. Medicare covered services are provided to patients who have both MO Health- Net and Medicare; or 2. The item needed is not available or does not have a comparable substitute from Missouri or bordering state providers.

(C) If the provider requests authorization for equipment or supplies for a MO Health- Net patient who is not also Medicare eligible or requests authorization for services that are available or have a comparable substitute in Missouri or a bordering state, the out-of-state (non-bordering) provider may be subject to sanctions and any amounts paid by the MO HealthNet Division will be recouped.

(D) The enrolled MO HealthNet provider shall agree to— 1. Keep any records necessary to disclose the extent of services the provider furnishes to participants; and 2. On request, furnish to the MO HealthNet Division or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan.

(6) Covered Services. It is the provider’s responsibility to determine the coverage benefits for a MO HealthNet eligible participant based on his or her type of assistance as outlined in the DME manual. Reimbursement will be made to qualified participating DME providers only for DME items, prescribed by the participant’s physician to be medically necessary. Specific procedure codes that are (7/31/20) JOHN R. ASHCROFT covered under the DME program are listed in

Section 19 of the DME provider manual, which is incorporated by reference and made a part of this rule. These items must be suitable for use in any setting in which normal life activities take place, as defined in 42 CFR 440.70(c)(1) when ordered in writing by the participant’s physician. Although an item is classified as DME, it may not be covered in every instance. Coverage is based on the fact that the item is reasonable and necessary for treatment of the illness or injury, or to improve the functioning of a malformed or permanently inoperative body part, and the equipment meets the definition of DME.

Even though a DME item may serve some useful medical purpose, consideration must be given by the physician and the DME supplier to what extent, if any, it is reasonable for MO HealthNet to pay for the item as opposed to another realistically feasible alternative pattern of care. Consideration should be given by the physician and the DME supplier as to whether the item serves essentially the same purpose as equipment already available to the participant. If two (2) different items each meet the need of the participant, the less expensive item must be employed, all other conditions being equal.

(7) Documentation. The DME provider and physician shall document how they determined the least expensive, feasible alternative for treatment of the disability, illness or injury, or to improve the functioning of a malformed or permanently inoperative body part and maintain documentation in compliance with 13 CSR 70-3.030.

(8) Durable medical equipment for participants who are in a nursing facility or inpatient hospital. DME is not covered for those participants residing in a nursing home.

DME is included in the nursing home per diem rate and not paid for separately with the exception of custom and power wheelchairs, prosthetic devices, and ventilators. DME that is used while the participant is in inpatient hospital care is not paid for separately under the DME program. These costs are recognized as part of the hospital’s inpatient per diem rate.

(9) Face-to-face encounter and documentation requirements.

(A) For certain items of DME, a face-to-face encounter is required, as indicated in 42 CFR 440.70(g)(1). A list of DME items subject to faceto-face encounter requirements may be found at https://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/Medicare- FFS-Compliance-Programs/Medical- Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html, revised March 26, 2015. A copy of the list of DME items subject to face-to-face encounter requirements as of January 3, 2020, is incorporated by reference and made part of this

rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://dssruletracker.mo.gov/dssproposed-rules/welcome.action. This rule does not incorporate subsequent amendments or additions.

(B) No Medicaid payment for items of DME for which a face-to-face encounter is required shall be made unless there is documentation of a face-to-face encounter that meets the following criteria:

1. Related to the primary reason the beneficiary requires medical equipment;

2. Occurs no more than six (6) months prior to the written order;

3. Occurs prior to the date of service delivery; and 4. Conducted by a physician (M.D. or D.O.) or one (1) of the following non-physician practitioners (NPP):

A. A nurse practitioner working in collaboration with a physician;

B. A clinical nurse specialist working in collaboration with a physician; or C. A physician assistant, under the supervision of a physician.

(C) The physician responsible for ordering the DME service must document the face-toface encounter which is related to the primary reason the participant requires the DME.

If an allowed NPP performs the face-to-face encounter, the clinical findings of that faceto-face encounter must be communicated to the enrolled ordering physician and be incorporated into the ordering physician’s medical record for the participant.

(D) The DME provider must ensure that it has received the face-to-face documentation for each item of DME and for each participant for whom it is required. The DME provider must maintain the documentation in the participant’s record or files at their own location. The documentation must include the following:

1. The clinical findings of the face-toface encounter substantiating the need for the DME;

2. The primary reason that the DME is required;

3. The name, signature, and credentials of the practitioner who conducted the face-toface encounter; and 4. The date of the face-to-face encounter; or 5. The documentation requirements in paragraph (D)1.-4. above may be met when incorporated into the pre-certification process, as approved by MHD.

(E) If a Medicare face-to-face encounter document has already been provided for the same participant episode of care, it will also suffice as the MO HealthNet face-to-face documentation requirement.

(10) Non-Covered Items. MO HealthNet does not cover items which primarily serve the following purposes: personal comfort, convenience, education, hygiene, safety, cosmetic, new equipment of unproven value, and equipment of questionable current usefulness or therapeutic value. Specific items which are generally not covered can be found in Section 13.32 of the DME manual. Examples of noncovered items are: air conditioners, computers (unless determined to be used for an augmentative communication device), electric bathtub lifts, elevators, furniture, toys, home modifications, refrigerators, seat lift chairs, stair lifts or glides, treadmill, water softening systems, wheelchair lifts, wheelchair ramps, whirlpool tubs, or pumps.

(11) Medicare/Medicaid Crossovers. For participants having both Medicare and MO HealthNet eligibility, the MO HealthNet program pays the lesser of the amounts indicated by Medicare to be deductible and/or coinsurance due on the Medicare allowed amount or the difference between the amount paid by Medicare and the MO HealthNet allowed amount.

(12) Records Retention. Sanctions may be imposed by the MO HealthNet Division against a provider for failing to make available, and disclosing to the MO HealthNet Division or its authorized agents, all records relating to services provided to MO Health- Net participants or records relating to MO HealthNet payments, whether or not the records are commingled with non-Title XIX (Medicaid) records in compliance with 13 CSR 70-3.030. These records must be retained for five (5) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request.

Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 15, 2005, effective Dec. 30, 2005. Emergency amendment filed June 15, 2006, effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed May 15, 2006, effective Nov. 30, 2006. Amended:

Filed Jan. 9, 2009, effective July 30, 2009.

Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed Jan. 16, 2020, effective Aug. 30, 2020. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. Original rule filed Nov. 1, 2002, effective April 30, 2003.

Chapter 65 Rehabilitation Center Program

13 CSR 70-65.010 Rehabilitation Center Program {#sec-13-csr-70-65.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-65.010}

PURPOSE: This rule establishes the regulatory basis for the administration of the rehabilitation center program. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available through the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services, and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.

Specific details of provider participation, criteria and methodology for provider reimbursement, participant eligibility, and amount, duration, and scope of services covered are included in the rehabilitation center provider manual which is available at the website dss.mo.gov/mhd.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material.

The entire text of the rule is printed here.

(1) Administration. The MO HealthNet rehabilitation center program shall be administered by the Department of Social Services, MO HealthNet Division. The rehabilitation center services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the rehabilitation center provider manual, 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, and at its website at http://manuals.momed.com/collections/collection_reh/pr int.pdf , November 24, 2020. This rule does not incorporate any subsequent amendments or additions. Rehabilitation center services shall include only those that are clearly shown to be medically necessary as determined by the treating physician. The division reserves the right to effect changes in services, limitations, and fees with notification to rehabilitation center providers by amending this rule.

(2) Persons Eligible. The MO HealthNet Rehabilitation Program pays for the adaptive training of MO HealthNet participants who receive a prosthetic/orthotic device. In addition, rehabilitation centers may provide physical, occupational, and speech therapy to children under the age of twenty-one (21) when medically necessary as determined by the treating physician. The Omnibus Reconciliation Act of 1989 (OBRA-89) mandated that MO Health- Net covered services be provided based on medical necessity as determined by the treating physician in a healthy children and youth screening. The participant must be eligible on the date service is furnished. Participants may have specific limitations to rehabilitation center program services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on his or her type of assistance as outlined in the rehabilitation center provider manual. The provider shall ascertain the patient’s MO HealthNet/MO HealthNet Managed Care status before any service is performed. The participant’s eligibility shall be verified in accordance with methodology outlined in the rehabilitation center provider manual.

(3) Provider Participation.

(A) To be eligible for participation in the MO HealthNet rehabilitation center program, a provider must meet the criteria specified for his or her profession as outlined in the rehabilitation center provider manual and be an enrolled MO HealthNet provider.

(B) The enrolled MO HealthNet provider shall agree to— 1. Keep any records necessary to disclose the extent of services the provider furnishes to participants; and 2. On request, furnish to the Department of Social Services or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan.

(4) Covered Services. The participant shall have a referral for speech therapy services from a MO HealthNet enrolled primary care provider. The participant shall have a prescription for occupational and physical therapy services from a MO HealthNet enrolled primary care provider.

(5) Reimbursement. Payment will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for rehabilitation center services. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charges. Rehabilitation services are only payable to an enrolled, eligible, participating provider.

(6) Documentation. For physical, occupational, and speech therapy services, the MO HealthNet Division requires that the following documentation be included in the participant’s record:

(A) Participant’s complete name;

(B) Date the service was provided;

(C) Actual treatment provided for the participant (more than “treatment given”) on the specific date of service;

(D) Individual or group therapy (the provider must document the type of therapy given);

(E) The time the service was delivered must be clearly documented in the client record (e.g., 4:00–4:15 p.m.); providers cannot bill for charting time, only the time they spend doing the therapy;

(F) The signature of the therapist who provided the service; and (G)

The official Individual Education Plan (IEP) or Individual Family Services Plan (IFSP) which must be in the record when billing therapy with a TM or TR modifier.

(7) Records Retention. These records must be retained for six (6) years from the date of service. Fiscal and medical records coincide with, and fully document, services billed to the MO HealthNet Division. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended: Filed Aug. 15, 2014, effective Feb. 28, 2015. Amended: Filed Jan. 10, 2022, effective July 30, 2022. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

(6/30/22) JOHN R. ASHCROFT

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. Original rule filed Nov. 1, 2002, effective April 30, 2003.

Chapter 70 Therapy Program

13 CSR 70-70.010 Therapy Program {#sec-13-csr-70-70.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-70.010}

PURPOSE: This rule establishes the regulatory basis for the administration of the therapy program. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available through the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of provider participation, criteria, and methodology for provider reimbursement, participant eligibility, and amount, duration, and scope of services covered are included in the therapy provider program manual, which is available at the website www.dss.mo.gov/mhd.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet therapy program shall be administered by the Department of Social Services, MO HealthNet Division. The therapy services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the Therapy Provider Manual, 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 http://manuals.momed.com/collections/collection_the/print. pdf, January 31, 2023. This rule does not incorporate any subsequent amendments or additions. Therapy services shall include only those which are clearly shown to be medically necessary as determined by the physician, advanced practice registered nurse, or other practitioner of the healing arts.

The division reserves the right to effect changes in services, limitations, and fees with notification to therapy providers by amending this rule.

(2) Participants Eligible. Medically necessary therapy services as determined by the physician, advanced practice registered nurse, or other practitioner of the healing arts are covered for individuals under the age of twenty-one (21). The Healthy Children and Youth (HCY) Program (also known as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)) ensures a comprehensive, preventive health care program for MO HealthNet eligible children under the age of twenty-one (21) years. The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that MO HealthNet-covered services be provided, based on medical necessity as identified in a HCY (EPSDT) well-visit and interperiodic screening. These services include physical, occupational, and speech/language therapy services. The participant must be eligible on the date the service is furnished. Participants may have specific limitations to therapy program services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the Therapy Provider Manual. The provider shall ascertain the patient’s MO HealthNet status before any service is performed.

The participant’s eligibility shall be verified in accordance with methodology outlined in the therapy provider program manual.

(3) Provider Participation.

(A) To be eligible for participation in the MO HealthNet therapy program, a provider must meet the criteria specified for his or her profession as outlined in the therapy provider program manual and be an enrolled MO HealthNet provider.

(B) To be eligible for participation in the MO HealthNet therapy program as a therapy assistant, a provider must be licensed according to state law and provide services under the direction of a qualified therapist.

(C) The enrolled MO HealthNet provider shall agree to— 1. Keep any records necessary to disclose the extent of services the provider furnishes to participants; and 2. On request furnish to the Department of Social Services or state Medicaid Fraud Control Unit any informa tion regarding payments claimed by the provider for furnishing services under the plan.

(4) Covered Services. The participant shall have a referral for speech therapy services from a MO HealthNet-enrolled physician, advanced practice registered nurse, or other practitioner of the healing arts. The participant shall have a prescription for occupational and physical therapy services from a MO HealthNet-enrolled physician, advanced practice registered nurse, or other practitioner of the healing arts.

(5) Reimbursement. Payment will be made in accordance with the established fee as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for therapy services. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charges. Physical, occupational, and speech therapy services are only payable to the enrolled, eligible, participating provider. The MO HealthNet program cannot reimburse for services performed by non-enrolled persons.

(6) Documentation. For physical, occupational, and speech therapy services, the MO HealthNet Division requires compliance with 13 CSR 70-3.030 and that the following documentation be included in the participant’s record:

(A) First name, last name, and either middle initial or date of birth of the MO HealthNet participant;

(B) Date the service was provided (month/day/year);

(C) An accurate, complete, and legible description of each service(s) provided for the participant (more than “treatment given”) on the specific date of service;

(D) Individual or group therapy (the provider must document the type of therapy given);

(E) The actual begin and end time taken to deliver the service must be clearly documented in the client record (e.g., 4:00–4:15 p.m.); providers cannot bill for charting time, only the time they spend doing the therapy;

(F) The signature of the enrolled therapist or enrolled therapy assistant who provided the service;

(9/30/23) John R. Ashcroft (G) The official Individual Education Plan (IEP) or Individual Family Services Plan (IFSP) which must be in the record when billing therapy with a WQ modifier;

(H) The setting in which the service was rendered; and (I) The plan of treatment, evaluation(s), test(s), findings, results, and prescription(s) as necessary.

(7) Records Retention. Sanctions may be imposed by the Department of Social Services against a provider for failing to make available, and disclosing to the Department of Social Services or its authorized agents, all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet payments, whether or not the records are commingled with non-Title XIX (Medicaid) records in compliance with 13 CSR 70-3.030. These records must be retained for six (6) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

Filed June 1, 2006, effective Dec. 30, 2006. Amended: Filed Oct. 15, 2008, effective May 30, 2009. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed July 16, 2021, effective Feb. 28, 2022. Amended: Filed March 2, 2023, effective Oct. 30, 2023. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. Original rule filed Nov. 1, 2002, effective May 30, 2003. Amended:

Chapter 90 Home Health Program

13 CSR 70-90.010 Home Health-Care Services {#sec-13-csr-70-90.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-90.010}

PURPOSE: This rule provides the regulatory basis for payment for home health-care services provided to MO HealthNet-eligible participants.

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) An otherwise eligible MO HealthNet participant is eligible for MO HealthNet reimbursement on his/her behalf for home health services if all the conditions of subsections (1)(A)–(C) are met— (A) The services are prescribed by the participant’s physician, a nurse practitioner, a clinical nurse specialist, or a physician assistant within the scope of practice authorized under state law, who documents a face-to-face patient encounter occurred in accordance with 42 CFR 440.70(f). If a Medicare face-to-face encounter document has already been provided for the same participant episode of care, it will suffice as the MO HealthNet face-to-face documentation requirement;

(B) The services are provided in accordance with a written plan of care which clearly documents the need for services and is reviewed by the ordering practitioner at least every sixty (60) days; and (C) The services are provided in the participant’s place of residence as specified in 42 CFR 440.70(c) by a qualified person in the employ of or under contract to a Medicare-certified home health agency which is also licensed by Missouri and enrolled with the MO HealthNet program. 42 CFR 440.70 as published by the Federal Register, at https://www.ecfr.gov/, September 19, 2022, is incorporated by reference and made a part of this rule.

A copy of 42 CFR 440.70 is available at the Department of Social Services, MO HealthNet Division, 615 Howerton Ct., Jefferson City, MO 65109, and at its website at https://dssruletracker. mo.gov/dss-proposed-rules/welcome.action. This rule does not incorporate any subsequent amendments or additions.

(2) Home health services include the following services and items:

(A) Intermittent skilled nursing care which is reasonable and necessary for the treatment of an injury or illness;

(B) Physical, occupational, or speech therapy when the following conditions are met:

1. The participant is an eligible child, pregnant woman, or blind person; and 2. Physical, occupational, or speech therapy reasonable and necessary for restoration to an optimal level of functioning following an injury or illness, in accordance with limitations set forth in section (8) of this rule;

(C) Physical, occupational, or speech therapy when the following conditions are met:

1. The participant is age nineteen (19) or over and under age sixty-five (65) and enrolled under the Medicaid eligibility criteria for the adult expansion group as described in Article IV section 36(c) of the Missouri Constitution; and 2. Physical, occupational, or speech therapy is a habilitative service that will help the individual keep, learn, or improve skills and functioning for daily living, in accordance with limitations set forth in section (9) of this rule;

(D) Intermittent home health aide; and (E) Supplies identified as specific and necessary to the delivery of a participant’s nursing care and prescribed in the plan of care. Supplies are health care related items that are consumable or disposable, or cannot withstand repeated use by more than one (1) individual, that are required to address an individual medical disability, illness, or injury. Medical supplies are classified as— 1. Routine—medical supplies used in small quantities for patients during the usual course of most home visits; or 2. Non-routine—medical supplies needed to treat a patient’s specific illness or injury in accordance with the physician’s plan of care and meet further conditions discussed in more detail below.

(3) To qualify as skilled nursing care or as physical, occupational, or speech therapy under subsection (2)(A) or subsection (2)(B) and to be reimbursable under the MO HealthNet Home Health Program, a service must meet the following criteria:

(A) The service must require performance by an appropriate licensed or qualified professional to achieve the medically desired result. Determination that a professional is required to perform a service will take into account the nature and complexity of the service itself and the condition of the patient as documented in the plan of care;

(B) The service must generally consist of no more than one (1) visit per discipline per day, as further defined in section (6); and (C) The service must constitute active treatment for an illness or injury and be reasonable and necessary. To be considered reasonable and necessary, services must be consistent with the nature and severity of the individual’s illness or injury, his/her particular medical needs, and accepted standards of medical practice. Services directed solely to the prevention of illness or injury will neither meet the conditions of subsection (2)(A) or subsection (2)(B), nor be reimbursed by the MO HealthNet Home Health Program.

(4) Necessary items of durable medical equipment and appliances prescribed by the physician as a part of the home health service are available to participants of home health services through the MO HealthNet Durable Medical Equipment Program subject to the limitations of amount, duration, and scope where applicable.

(5) The services of a home health aide must be reasonable and necessary to maintain the participant at home, be based on the participant’s illness or injury, and there must be no other person available who could and would perform the services. The duties of the aide shall include the performance of procedures such as, but not limited to, the extension of covered therapy services, personal care, ambulation, and exercise and certain household services essential to health care. The services of the aide must be supervised by a registered nurse or other appropriate professional staff member, whose visits will not be separately reimbursed unless a covered skilled nursing or therapy service as prescribed on the plan of care is performed concurrently. Participants eligible for the State Plan Personal Care Program in need of the services covered in this section who will not concurrently receive home health skilled nursing or physical, occupational, or speech therapy, must receive any services in this section that are covered under the State Plan Personal Care program through the State Plan Personal Care (5/31/23) John R. Ashcroft Program.

(6) The unit of service for both professional and home health aide services is a visit. A visit is a personal contact for a period of time, not to exceed three (3) continuous hours, in the patient’s place of residence, made for the purpose of providing one (1) or more covered home health services. The combined total of all skilled nurse and home health aide visits reimbursed on behalf of a MO HealthNet participant may not exceed one hundred (100) visits per calendar year.

(A) Where two (2) or more staff are visiting concurrently to provide a single type of service, or where one (1) staff provides more than one (1) type of service or where one (1) staff is present in the home only to supervise another, only one (1) visit is reimbursable by MO HealthNet.

(B) Unless the plan of care documents a specific need for more than one (1) visit per day, MO HealthNet will reimburse only one (1) visit per day for each of the following: skilled nurse, home health aide, physical therapist, occupational therapist, or speech therapist.

(C) When more than one (1) visit per day is medically required and documented by the plan of care, each single visit will be counted toward the combined total limit of one hundred (100). Documentation submitted with a claim supporting extended daily visits, multiple visits per day, or both does not override the one hundred (100) visit per calendar year limitation. For example: A patient requires a visit for a procedure that takes one (1) hour in the morning and requires another visit for a procedure that takes one (1) hour in the afternoon. Each visit may be reimbursed, but two (2) visits will be counted toward that participant’s total home health visits for that year.

(7) To be reimbursed by MO HealthNet, all home health services and supplies must be provided in accordance with a written plan of care authorized by the ordering practitioner.

The criteria for the development of the written plan of care and changes to the written plan of care through interim order(s) are described in the MO HealthNet Division Home Health Provider Manual. The MO HealthNet Division Home Health Provider Manual 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 http://manuals.momed.com/manuals/, September 21, 2022. This rule does not incorporate any subsequent amendments or additions. Plans of care and interim order(s) are to be maintained in the client record.

(8) Skilled therapy services as described in subsection (2)(B) will be considered reasonable and necessary for treatment if the conditions of paragraphs (8)(A)1.–4. are met.

(A) The services— 1. Must be consistent with the nature and severity of the illness or injury and the participant’s particular medical needs;

2. Must be considered, under accepted standards of medical practice, to be specific and effective treatment for the patient’s condition;

3. Must be provided with the expectation of good potential for rehabilitation, based on assessment made by the ordering practitioner; and 4. Are necessary for the establishment of a safe and effective maintenance program, or for teaching and training a caregiver.

(B) Therapy services may be delivered for one (1) certification period (up to sixty (60) days), if services are initiated within sixty (60) days of onset of the condition or within sixty (60) days from date of discharge from the hospital, if the participant was hospitalized for the condition. Prior authorization to continue therapy services beyond the initial certification period may be requested by the home health provider. Prior authorization requests will be reviewed by the MO HealthNet Division, and approval or denial of the continuation of services will be based on the following criteria:

1. The service must be consistent with the nature and severity of the illness or injury and the participant’s particular medical needs;

2. The services are considered, under accepted standards of medical practice, to be specific and effective treatment for the patient’s condition; and 3. The services must be provided with the expectation, based on the assessment made by the ordering practitioner, that the participant’s condition will improve materially in a reasonable and generally predictable period of time, or are necessary to the establishment of a safe and effective maintenance program.

(9) The combination of physical, occupational, and speech therapy as described in subsection (2)(C) of this rule is limited to a total of twenty (20) visits inclusive of services from all MO HealthNet providers per year.

Amended: Filed June 16, 1987, effective Nov. 1, 1987. Amended:

Filed Dec. 5, 1988, effective Feb. 24, 1989. Amended: Filed April 4, 1989, effective June 29, 1989. Amended: Filed Dec. 13, 1991, effective May 14, 1992. Emergency amendment filed Nov. 18, 1993, effective Dec. 1, 1993, expired Dec. 9, 1993. Amended: Filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed Jan. 15, 2004, effective Aug. 30, 2004. Emergency amendment filed Aug. 15, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 1, 2005, effective Dec. 30, 2005. Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010.

Amended: Filed April 1, 2010, effective Nov. 30, 2010. Amended:

Filed May 1, 2015, effective Nov. 30, 2015. Amended: Filed Dec. 10, 2019, effective June 30, 2020. Emergency amendment filed Oct. 5, 2021, effective Oct. 20, 2021, expired April 17, 2022. Amended: Filed Oct. 5, 2021, effective April 30, 2022. Amended: Filed Oct. 25, 2022, effective June 30, 2023. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2022. This rule was previously filed as 13 CSR 40-81.056. Original rule filed April 14, 1982, effective July 11, 1982. Rescinded and readopted: Filed April 2, 1986, effective July 1, 1986. Amended: Filed Nov. 4, 1986, effective Feb. 1, 1987.

13 CSR 70-90.020 Home Health-Care Services Reimbursement {#sec-13-csr-70-90.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-90.020}

PURPOSE: This rule establishes the methodology where a MO HealthNet maximum allowable fee for service is determined on an annual basis by the MO HealthNet Division.

(1) MO HealthNet reimbursement for covered home health services provided to eligible individuals shall be made at the lower of— (A) The provider’s billed charge for the service; or (B) The MO HealthNet maximum allowable fee for service.

The fee schedule is available at www.dss.mo.gov/mhd/providers/ index.htm.

(2) MO HealthNet reimbursement for covered non-routine supplies is the lower of— (A) The provider’s billed charge for the non-routine supply; or (B) The home health non-routine supply cost. The home health non-routine supply cost is defined as the invoiced acqui sition cost of the supply multiplied by two (2) to cover the cost for overhead (including taxes and shipping). Invoiced acquisi tion cost is defined as the amount shown on the invoice received for purchase of the supply which must include any reduction in cost the provider receives (i.e., discounts, allowances) and does not include shipping or sales tax.

section 208.152, RSMo Supp. 2014.* This rule was previously filed as 13 CSR 40-81.057. Original rule filed May 11, 1984, effective Aug. 11, 1984. Amended: Filed Dec. 18, 1991, effective Aug. 6, 1992.

Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended:

Filed May 1, 2015, effective Nov. 30, 2015. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993; 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; and 208.201, RSMo 1987, amended 2007.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013, and

Chapter 91 Personal Care Program

13 CSR 70-91.020 Mental Health Residential Personal Care Program {#sec-13-csr-70-91.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-91.020}

13 CSR 70-91.010 Personal Care Program {#sec-13-csr-70-91.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-91.010}

PURPOSE: Personal care services are medically-oriented services provided in the individual’s home, or in a licensed Residential Care Facility I or II to assist with activities of daily living to meet the physical needs of the individual. Personal care services are authorized by a physician in accordance with a plan of care or otherwise authorized in accordance with a service plan approved by the state. This rule establishes the basis for administering the personal care program, including the criteria providers of the service must meet, criteria a recipient of the service must meet, and criteria and method of reimbursement for the services.

Specific details of the amount, duration, scope, and limitations of services covered are included in the provider program manuals.

(1) Persons Eligible for Personal Care Services. Any person who is determined eligible by the Family Support Division for Title XIX benefits and is found to be in medical need of personal care services as an alternative to institutional care.

Persons must be assessed, approved, and case-managed by the Department of Health and Senior Services or its designee as described in this rule to be eligible for personal care services.

Eligibility procedures for personal care services are as follows:

(A) Requirements for Personal Care Services.

1. The participant must need an institutional level of care which is defined as twenty-four- (24-) hour institutional care on an inpatient or residential basis in a hospital or nursing facility (NF) and approved by the Department of Health and Senior Services or its designee.

2. Level of care will be determined by the Department of Health and Senior Services or its designee.

3. The participant must agree to an in-home assessment performed by the Department of Health and Senior Services or its designee of his/her physical, social, and functional ability to benefit from personal care services;

(B) Obtaining Personal Care Services. 1 . If the participant meets all of the eligibility and assessment criteria, the Department of Health and Senior Services or its designee will develop an initial personal care plan to authorize personal care services on a scheduled basis to eligible participants in their own homes, licensed Residential Care Facilities (RCFs) I or II, or Assisted Living Facilities (ALFs) as an alternative to twenty-four- (24-) hour institutional care on an inpatient or residential basis in a hospital or NF. The Department of Health and Senior Services or its designee will forward a copy of the personal care plan to the participant’s attending physician and to the personal care provider who will be delivering care. Upon the receipt of the personal care plan, the provider of care must initiate care within ten (10) calendar days of receipt and the physician must register any comments or requests for changes within thirty (30) days of receipt or the personal care plan will stand as written by the Department of Health and Senior Services or its designee.

2. The personal care plan will be developed in collaboration with and signed by the participant. The plan will include an identification of the services and tasks to be provided, frequency of services, and the maximum number of units of service for which the participant is eligible per month.

3. A new in-home assessment and personal care plan may be completed by the Department of Health and Senior Services or its designee as needed to redetermine need for personal care services or to adjust the monthly amount of authorized units. The service provider must always have an active service plan. Only the Department of Health and Senior Services or its designee, not the service provider, may increase the overall maximum number of units for which the individual is eligible per month. Any service plan developed in accordance with paragraphs (1)(B)2. and 3. is a state-approved service plan.

4. The participant will be informed of the option of services available to him/her in accordance with the level-ofcare determination and assessment findings; and (C) Discontinuing Personal Care Services. The following policies and procedures for discontinuing personal care services shall be followed:

5. Services for a participant shall be discontinued by a provider agency under the following circumstances:

A. When the participant’s case is closed by the Department of Health and Senior Services or its designee;

B. When the provider learns of circumstances that require the closure of a case for reasons including but not limited to death entry into a nursing home, or the participant no longer needs services. In these circumstances, the provider shall notify the Department of Health and Senior Services or its designee in writing and request that the participant’s services be discontinued;

C. When the participant is noncompliant with the agreed-upon plan of care. Noncompliance requires persistent actions by the participant or family which negate the services provided by the agency. After all alternatives have been explored and exhausted, the provider shall notify the Department of Health and Senior Services or its designee in writing of the noncompliant acts and request that the participant’s services be discontinued;

D. When the participant or participant’s family threatens or abuses the personal care aide or other agency staff to the point where the staff’s welfare is in jeopardy and corrective action has failed. The provider shall notify the Department of Health and Senior Services or its designee of the threatening or abusive acts and may request that the service authorization be discontinued;

E. When a provider is unable to continue to meet the maintenance needs of a participant. In these circumstances, the provider shall notify the Department of Health and Senior Services or its designee in writing and request that the participant’s services be discontinued; or F. When a provider is unable to continue to meet the maintenance needs of a participant whose plan of care requires advanced personal care services. In these circumstances the provider shall provide written notice of discharge to the participant or participant’s family and the Department of Health and Senior Services or its designee at least twenty-one (21) days prior to the date of discharge. During this twentyone- (21-) day period, the Department of Health and Senior Services or its designee shall assist in making appropriate arrangements with the participant for transfer to another agency, institutional placement, or other appropriate care.

Regardless of circumstances, the personal care provider must continue to provide care in accordance with the plan of care for these twenty-one (21) days or until alternate arrangements can be made by the Department of Health and Senior Services or its designee, whichever comes first; and 2. Discontinuing services for a participant still in need of assistance shall occur only after appropriate conferences with the Department of Health and Senior Services or its designee, participant, and participant’s family.

(2) Basic personal care services are medically-oriented, maintenance services to assist with the activities of daily living when this assistance does not require devices and procedures related to altered body functions.

(A) To be eligible for basic personal care, an individual must be in need of personal care services as an alternative to institutional care as specified in section (1) of this rule.

(B) The following activities constitute basic personal care services and shall be provided according to the plan of care:

1. Assistance with dietary needs, including meal preparation and cleanup, and assistance with eating/feeding;

2. Assisting with dressing and grooming, including helping with dressing and undressing, combing hair, and nail care;

3. Assisting with bathing and personal hygiene, including assisting with bathing, shampooing hair, oral hygiene and denture care, and shaving;

4. Assisting with toileting and continence, including assisting in going to the bathroom, and changing bed linen.

This category may also include the changing of beds for persons with medically related limitations that prohibit the completion of this task;

5. Assisting with mobility and transfer, including assisting with transfer and ambulation when participants can at least partially bear own weight;

6. Assisting with medication, including assisting with the self-administration of medicine, applying nonprescription topical ointments or lotions; and 7. Medically related household tasks, including approved homemaker and chore tasks.

(C) The encouragement and instruction of participants in selfcare may be a component of any other task as described above; however, encouragement and instruction do not constitute a task in and of themselves.

(3) Criteria for Providers of Personal Care Services.

(A) The provider of personal care services must have a valid participation agreement with the Department of Social Services, Missouri Medicaid Audit and Compliance Unit. The issuance of the participation agreement is dependent upon acceptance of an application for enrollment by the Missouri Medicaid Audit and Compliance Unit. The provider must submit to the Missouri Medicaid Audit and Compliance Unit the written proposal required to become a Title XX in-home services provider and be approved to provide Title XX in-home services. Once approved to provide Title XX in-home services by the Missouri Medicaid Audit and Compliance Unit, the provider will be allowed to execute a Title XIX participation agreement with the Missouri Medicaid Audit and Compliance Unit. Thereafter, a provider is not required to actually accept or deliver services to participants who are authorized for both programs or to participants who are authorized for Title XX services only. For residential care facilities that wish to provide services only to the eligible residents of their own facility, only the verification of a state residential care facility license authorized by the Department of Health and Senior Services, Division of Regulation and Licensure, will be required for the Medicaid enrollment application. Providers must maintain their approval to participate as a Title XX provider, whether or not they actually serve Title XX eligible participants, in order to remain qualified to participate in the Title XIX (Medicaid)

Personal Care Program.

(B) The providers must agree to comply with any evaluation conducted by the Missouri Medicaid Audit and Compliance Unit. The Missouri Medicaid Audit and Compliance Unit may, in accordance with the protective service mandate (Chapter 192, RSMo), take action to protect participants from providers who are found to be out of compliance with the requirements of its regulations and of any other regulations applicable to the Personal Care Program, when such noncompliance is determined by the Missouri Medicaid Audit and Compliance Unit to create a risk of injury or harm to participants. Evidence of such risk may include unreliable or inadequate provider documentation of services or training due to falsification or fraud, the provider’s failure to deliver services in a reliable and dependable manner, or use of personal care aides who do not meet the minimum training standards of this regulation.

Immediate action by the Missouri Medicaid Audit and Compliance Unit may include but is not limited to— 1. Removing the provider from any list of providers and, for participants who request the unsafe and noncompliant provider, informing the participants of the determination of noncompliance after which any informed choice will be honored by the Department of Health and Senior Services or its designee; or 2. Informing current participants served by the provider of the provider’s noncompliance and that the Division of Senior and Disability Services has determined the provider unable to deliver safe care. Such participants will be allowed to choose a different provider from the list maintained by the Department of Health and Senior Services or its designee, which will then be immediately authorized to provide service to them.

(C) The provider agency must be available to provide care in accordance with the personal care plan, utilizing universal precaution procedures as defined by the Centers for Disease Control and Prevention.

(D) The provider agency must monitor the overall physical care needs of the participant. If the participant’s condition warrants, contact the participant’s physician and inform the Department of Health and Senior Services or its designee when additional case management activities by the Department of Health and Senior Services or its designee are required.

1. Prior to the delivery of service, the personal care aide shall receive a copy of the care plan for the participant and be provided with information about the participant in order to appropriately deliver services to meet the needs of the participant.

(E) For newly employed aides, the provider agency must, at a minimum, provide twelve (12) hours of orientation training, within thirty (30) days of employment.

1. In calculating these hours, the following requirements shall apply:

A. At least two (2) hours orientation to the provider agency and the agency’s protocols for handling emergencies;

B. With a minimum of six (6) hours of training being completed prior to participant contact;

C. Four (4) hours of required orientation may be waived with adequate documentation in the employee’s records that the aide received similar training during the previous twelve (12) months, with the exception of the statutorily required dementia training;

D. If an aide is a certified nurse assistant (CNA), licensed practical nurse, or registered nurse, the provider agency may waive all hours of orientation training, with the exception of the two (2) hours’ provider agency orientation and the statutorily required dementia training, with adequate documentation placed in the aide’s personnel record. The documentation shall include the employee’s license or certification number, which must be current and in good standing at the time the training was waived.

2. An additional five (5) hours of in-service training annually are required after the first twelve (12) months of employment. The provider may waive the required annual five (5) hours of in-service training and require only two (2) hours of refresher training annually when the aide has been employed for three (3) years and has completed fifteen (15) hours of inservice training. In-service training curricula shall include updates on Alzheimer’s disease and related dementia.

3. Personal care aides employed by an RCF II or ALF are exempt from the training requirements defined in paragraphs (3)(E)1. and 2. of this rule if they have completed the training requirements described in subdivisions (9) and (10) of subsection 3 of section 198.073, RSMo.

4. The provider agency shall have written documentation of all basic and in-service training provided which includes, at a minimum, a report of each employee’s training in that employee’s personnel record. The report shall document the dates of all classroom or on-the-job training, trainer’s name, topics, number of hours and location, the date of the first participant contact, and shall include the aide’s signature.

If a provider waives any in-service training, the employee’s training record shall contain supportive data for the waiver.

(F) The requirements that have been adopted by the Division of Senior and Disability Services at 19 CSR 15-7.021(18)(A) through (Q) and (18)(T) through (W) shall apply to all providers of personal care services and advanced personal care services.

(G) The provider agency must employ an administrative supervisor of the day-to-day delivery of direct personal care services possessing at least the following qualifications:

1. Be at least twenty-one (21) years of age; and 2. Shall be a registered nurse (RN) who is currently licensed in Missouri; or have at least a baccalaureate degree; or be a licensed practical nurse (LPN) who is currently licensed in Missouri with at least one (1) year of experience with the care of the elderly, or individuals with disabilities or medically complex conditions; or have at least two (2) years’ experience with the care of the elderly, or individuals with disabilities or medically complex conditions.

(H) The supervisor’s responsibilities shall include, at a minimum, the following:

1. Establish, implement, and enforce a policy governing communicable diseases that prohibits provider staff contact with participants when the employee has a communicable condition, including colds or flu. Assure that reporting requirements governing communicable diseases, including hepatitis and tuberculosis, as set by the Missouri Department of Health and Senior Services (19 CSR 20-20.020), are carried out;

2. Monitor the provision of services by the personal care worker to assure that services are being delivered in accordance with the personal care plan. This shall be primarily in the form of an at least monthly review and comparison of the worker’s records of provided services with the personal care plan. The monitoring reports shall be available for review by the Departments of Social Services and Health and Senior Services upon request. Documentation, including the reason, must be kept on authorized services/units not delivered;

3. Make an on-site visit at least annually to evaluate each personal care worker’s performance and the adequacy of the service plan, including review of the plan of care with the participant. The personal care worker may or may not be present for this evaluation. A written record of the evaluation shall be maintained in the personnel file of the personal care worker.

This record must contain, at a minimum, the participant’s name and address, the date and time of the visit, personal care worker’s name, observations related to the participant’s receipt of care plan delivery, the participant’s satisfaction of the personal care worker’s performance, and the adequacy of the service plan. In addition, the evaluation shall be signed and dated by the supervisor who prepared it and by the personal care worker. If the required evaluation is not performed or not documented, the personal care worker’s qualifications to provide the services may be presumed inadequate and all payments made for services by that personal care worker may be recouped;

4. Approve, in advance, all changes to the plan of care based on supervisory on-site visits, information from the personal care worker, or observation by the RN, or a combination of these. Approval of changes shall be noted and dated in the participant’s file;

5. Make appropriate recommendations to the Department of Health and Senior Services or its designee including proposed increase, reduction, or termination of services; or need for increased Department of Health and Senior Services involvement based on supervisory on-site visits, review of reports, information from the personal care worker, observation by the RN; or a combination of these;

6. Be available for regular case conferences with the Department of Health and Senior Services or its designee; and 7. Assist in orientation and personal care training for personal care workers.

(I) If the supervisor is not an RN, the provider agency must have a designated RN currently licensed in Missouri either on staff or employed as a consultant.

(J) The RN’s responsibilities shall include to initial and review all on-site visit reports made by the administrative supervisor.

If supervised by an RN, an LPN or Graduate Nurse (GN) may perform the RN supervisory activities described in this section.

(K) An in-home personal care worker(s) shall meet the following requirements:

1. Be at least eighteen (18) years of age;

2. Be able to read, write, and follow directions; and 3. May not be a family member of the participant for whom personal care is to be provided. A family member is defined as a spouse; parent; sibling; child by blood, adoption, or marriage (step-child); grandparent; or grandchild.

(4) Reimbursement.

(A) Payment will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division.

1. A unit of service is fifteen (15) minutes.

2. Documentation for services delivered by the provider must include the following:

A. The participant’s name and Medicaid number;

B. The date of service;

C. The time spent providing the service which must be documented in one (1) of the following manners:

(I) When a personal care aide is providing services to one (1) individual in a private home setting and devotes undivided attention to the care required by that individual, the actual clock time the aide began the services for that visit shall be documented as the start time, and the actual clock time the aide finished the care for the visit shall be documented as the stop time per Electronic Visit Verification (EVV) regulation 13 CSR 70-3.320; and (II) When the personal care services are provided in a congregate living setting, such as RCFs I and II or ALFs, when on-site supervision is available and personal care aide staff will divide their time among a number of individuals, the following must be documented: all tasks performed for each participant by date of service and by staff shifts during each twenty-four- (24-) hour period;

D. A description of the service; and E. The name of the personal care aide who provided the service.

3. A provider may not bill time spent in the delivery of service of less than one (1) unit of service for any participant.

However, time spent in the delivery of service of less than one (1) full unit for any participant may be accrued by the provider to establish a unit of service. In no event may time spent in the delivery of service be accrued beyond the last day of the calendar month in which such services were rendered.

4. The fee per unit of service will be based on the determination by the state agency of the reasonable cost of providing the covered services on a statewide basis and within the mandatory maximum payment limitations.

(B) Conditions for Reimbursement.

1. The personal care plan will be the authorization for payment of service.

2. The total monthly payment for basic personal care services made on behalf of an individual who requires basic personal care only cannot exceed sixty percent (60%) of the average statewide monthly cost for care in a nursing facility as defined in 13 CSR 70-10.010(4)(Q) (excluding intermediate care facilities for individuals with intellectual disabilities (ICFs/IID)).

3. The average monthly cost to the state for care in an NF as defined in 13 CSR 70-10.010(4)(Q) (excluding ICFs/IID) will be established in the month of May of each state fiscal year which will become effective on July 1 of the following state fiscal year.

4. Payment will be made on the lower of the established rate per service unit or the provider’s billed charges.

5. Rates will be established for personal care services in private homes, licensed RCFs I and II, and ALFs.

(5) Advanced personal care services are maintenance services provided to a participant in the participant’s home to assist with activities of daily living when this assistance requires devices and procedures related to altered body functions.

(A) Persons Eligible for Advanced Personal Care Services.

Any person who is determined eligible for Title XIX benefits from the Family Support Division, found to be in need of personal care services as an alternative to institutional care as specified in section (1) of this rule, and who requires devices and procedures related to altered body functions is eligible for advanced personal care services.

(B) The following activities constitute advanced personal care services and shall be provided according to the plan of care:

1. Routine personal care of persons with ostomies (including tracheostomies, gastrostomies, colostomies all with well-healed stoma), which includes changing bags and soap and water hygiene around ostomy site;

2. Personal care of persons with external, indwelling, and suprapubic catheters, which include changing bags and soap and water hygiene around site;

3. Removal of external catheters, inspect skin and reapply catheter;

4. Administration of prescribed bowel programs, including use of suppositories and sphincter stimulation per protocol and enemas (prepacked only) without contraindicating rectal or intestinal conditions;

5. Application of medicated (prescription) lotions, ointments or dry, aseptic dressings to unbroken skin including stage I decubitus;

6. Application of aseptic dressings to superficial skin breaks or abrasions as directed by a licensed nurse;

7. Manual assistance with noninjectable medications as set up by a licensed nurse;

8. Passive range of motion (nonresistive flexion of joint within normal range) delivered in accordance with the care plan; and 9. Use of assistive device for transfers.

(C) Instruction and encouragement to the participant in ways to become more self-sufficient in advanced personal care may be a component of all tasks as described above; however, instruction and encouragement in and of themselves do not constitute a task.

(D) Advanced Personal Care Plans. Plans of care which include advanced personal care services must be developed by the provider agency RN in collaboration with state agency staff or its designee.

(E) Criteria for Providers of Advanced Personal Care Services.

Providers of advanced personal care must meet all criteria for providers of personal care services described in section (3) of this rule. Providers must sign an addendum to their Title XIX Personal Care Provider Agreement and must possess a valid contract with the Missouri Medicaid Audit and Compliance Unit to provide Title XX services including advanced personal care services. Residential care facilities wishing to provide advanced personal care services to the eligible residents of their own facility only may do so with a signed addendum to their Title XIX Personal Care Provider Agreement.

1. All advanced personal care aides employed by the provider must be an LPN or a certified nurse assistant, or a competency-evaluated home health aide having completed both written and demonstration portions of the test required by the Missouri Department of Health and Senior Services and 42 CFR 484.80, or have successfully completed personal care aide training. In addition, advanced personal care aides may not be related to the participant to whom they provide personal care, as defined in paragraph (3)(K)3. of this rule.

2. Personal care providers are required to provide training to advanced personal care aides, in addition to the orientation training described in section (3) of this rule. The additional training shall consist of a minimum of six (6) hours and must be completed prior to the provision of any advanced personal care tasks. Providers may waive this six (6) hours of training if one (1) of the following are met:

A. The proposed advanced personal care (APC) aide is an LPN or CNA currently licensed or registered in the state of Missouri; or B. The proposed advanced personal care aide has previously completed advanced personal care training from a Medicaid or Social Services Block Grant (SSBG) in-home provider agency, and that same personal care aide has been employed by a Medicaid or SSBG in-home provider agency as an advanced personal care aide within the prior six (6) months.

3. Advanced personal care aides employed by an RCF II are exempt from the training requirements defined in paragraphs (5)(E)1. and 2. of this rule if they have completed the training requirements described in subdivisions (9) and (10) of subsection 3 of section 198.073, RSMo, as amended.

4. The additional advanced personal care training must include, at a minimum, the following topics:

A. Observation of the participant and reporting observation;

B. Application of ointments/lotions to unbroken skin;

C. Manual assistance with oral medications;

D. Prevention of decubiti;

E. Bowel routines (rectal suppositories, sphincter stimulation);

F. Enemas;

G. Personal care for persons with ostomies and catheters;

H. Proper cleaning of catheter bags;

I. Positioning and support of the participant;

J. Range of motion exercises;

K. Application of nonsterile dressings to superficial skin breaks; and L. Universal precaution procedures as defined by the Centers for Disease Control and Prevention.

5. Advanced personal care tasks as specified at (5)(B)1. through 9. shall not be assigned to or performed by any advanced personal care aide who is not a licensed nurse until the aide has been fully trained to perform the task, the RN, LPN, or GN has personally observed successful execution of the task and the RN, LPN, or GN has personally certified this in the aide’s personnel record. An LPN or GN observing the execution of a task must be trained in the APC tasks and observed by the RN supervisor for successful completion of each task, and the RN supervisor must personally certify this in the LPN’s or GN’s personnel record. Only RN visits necessary for task observation and certification in the home may be prior authorized and billed to MO HealthNet Division as an authorized nurse visit, as described in section (6) of this rule. RN task observation and certification in a laboratory, or other non-home setting, may not be billed.

6. The RN, LPN, or GN may observe the execution of any of the tasks in a participant’s home or lab setting. However, it is the responsibility of the provider to ensure the aide is properly trained to execute tasks that may have variation from the lab setting to the participant’s home setting.

7. For participants receiving advanced personal care services, it is required that on-site RN visits be conducted at intervals of no greater than six (6) months. During these visits, the RN must conduct and document an evaluation of the participant’s condition, continued eligibility for the program, and the adequacy of the care plan. The RN must sign the evaluation and the provider shall maintain documentation of the evaluation in the participant’s record. The evaluation must be produced upon request of the Division of Senior and Disability Services or the Missouri Medicaid Audit and Compliance Unit.

(F) Reimbursement.

1. Payment for advanced personal care services will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division. The fee per unit (fifteen (15) minutes) of service will be based on the determination of the state agency of the reasonable cost of providing the covered services on a statewide basis and within the mandatory maximum payment limitations.

2. Conditions for reimbursement.

A. An advanced personal care plan is required. It is to be developed by the Department of Health and Senior Services or its designee in cooperation with the provider agency’s RN. The provider agency is responsible for obtaining the participant’s physician’s approval for the plan.

B. The total monthly payment for advanced personal care services as described in this section and for personal care services as described in sections (1)–(7) of this rule made on behalf of an individual cannot exceed one hundred percent (100%) of the average statewide monthly cost for care in an NF as defined in 13 CSR 70-10.010(4)(Q) (excluding ICFs/IID).

C. The average monthly cost to the state for care in an NF, as defined in 13 CSR 70-10.010(4)(Q) (excluding ICF/IID), will be established in the month of May of each state fiscal year, which will become effective on July 1 of the following state fiscal year.

D. Payment will be made on the lower of the established rate per service unit or the provider’s billed charges.

3. Rates will be established for personal care services in private homes, licensed RCFs I and II, and ALFs.

(6) Separately Authorized Nurses Visits.

(A) The provisions of paragraph (3)(H)3. notwithstanding, reimbursement will be made for visits by nurse to particular participants with special needs when the visits are prior authorized by the Department of Health and Senior Services or its designee. Providers of personal care services must have the capacity to provide these authorized nurse visits in addition to the nonauthorized nurse visits required by subsection (3)

(J). Anytime an authorized nurse visit is made, the nurse shall also, in addition to other duties, evaluate the adequacy of the plan of care, including a review of the plan of care with the participant.

(B) To be eligible to receive the authorized nurse visit, the participant must— 1. Be determined eligible for Title XIX benefits from the Family Support Division and found to be in need of personal care services as an alternative to institutional care as specified in section (1) of this rule;

2. Have no other person available who could and would provide the services;

3. Require one (1) or more of the services described in subsection (6)(D) as an alternative to institutionalized care; and 4. Meet any additional criteria of need set forth in subsection (6)(D).

(C) The services provided during the authorized nurse visit shall not include any service which the participant would be eligible to receive under either the Medicare (Title XVIII) or Medicaid (Title XIX) Home Health programs. The services listed in subsection (6)(D) do not qualify, by themselves, for reimbursement under either program. However, should a participant otherwise be eligible for home health services, then those services listed in paragraphs (6)(D)1.–4. will be provided by the home health agency and not under the Personal Care Program.

(D) The services of the nurse shall provide increased supervision of the aide, assessment of the participant’s health, and the suitability of the care plan to meet the participant’s needs. These services also shall include any referral or follow-up action indicated by the nurse’s assessment. These services, in addition, must include one (1) or more of the following where appropriate to the needs of the participant and authorized by the Department of Health and Senior Services or its designee:

1. The RN may fill insulin syringes in advance per manufacturer’s instructions for participants with diabetes who can self-inject the medication but cannot fill their own syringe.

This service would include monitoring the participant’s continued ability to self-administer the insulin;

2. The RN may set up oral medications in divided daily compartments for a participant who self-administers prescribed medications but needs assistance and monitoring due to a minimal level of disorientation or confusion;

3. The RN may monitor a participant’s skin condition when a participant is at risk of skin breakdown due to immobility, incontinency, or both;

4. The RN may provide nail care for a participant with diabetes or other medically contraindicating conditions if the participant is unable to perform this task;

5. The RN will be authorized to visit all personal care participants who also receive advanced personal care as described in section (4) of this rule, on a monthly basis, to evaluate the adequacy of the authorized services to meet the needs and conditions of the participant and to assess the advanced personal care aide’s ability to carry out the authorized services;

6. The RN may provide on-the-job training to advanced personal care aides as described in paragraph (5)(E)6. of this

rule;

7. The visits authorized under section (6) may be carried out by an LPN or GN, if under the direction of an RN; or 8. The RN may be authorized to provide other services in other situations, subject to the conditions set forth in subsection (6)(C).

(E) Payment for the authorized nurse visit will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division.

1. A unit of service is the visit. No minimum or maximum time is required to constitute a visit.

2. The maximum number of units which a participant can receive is twenty-six (26) within a six- (6-) month period of time.

The cost of the nurse visits are not included in the spending cap set forth in paragraph (4)(B)2. but must be included in the spending cap specified at subparagraph (5)(F)2.B.

(F) Documentation of the authorized nurse visit shall include written notes and observations. These will be maintained in the participant’s file. In addition, notes of any verbal communication and copies of any written communications with the participant’s physician or other health care professional concerning the care of that participant also will be maintained in the participant’s file.

Amended: Filed May 11, 1984, effective Aug. 11, 1984. Emergency amendment filed June 25, 1986, effective July 5, 1986, expired Nov. 2, 1986. Amended: Filed July 25, 1986, effective Oct. 11, 1986.

Emergency amendment filed Sept. 1, 1989, effective Sept. 11, 1989, expired Jan. 7, 1990. Amended: Filed Oct. 3, 1989, effective Dec. 28, 1989. Emergency amendment filed July 31, 1992, effective Aug. 10, 1992, expired Dec. 7, 1992. Emergency amendment filed Nov. 25, 1992, effective Dec. 8, 1992, expired April 6, 1993. Amended:

Filed July 31, 1992, effective April 8, 1993. Emergency amendment filed June 18, 1993, effective July 1, 1993, expired Oct. 28, 1993.

Emergency amendment filed Sept. 2, 1993, effective Oct. 1, 1993, expired Jan. 28, 1994. Emergency amendment filed Feb. 2, 1994, effective Feb. 12, 1994, expired June 11, 1994. Amended: Filed Sept. 2, 1993, effective April 9, 1994. Emergency amendment filed April 4, 1994, effective May 1, 1994, expired Aug. 28, 1994. Amended:

Filed April 4, 1994, effective Oct. 30, 1994. Emergency amendment filed Oct. 14, 1994, effective Oct. 24, 1995, expired Feb. 20, 1995.

Emergency amendment filed March 31, 1995, effective April 13, 1995, expired Aug. 10, 1995. Amended: Filed Oct. 21, 1994, effective June 30, 1995. Amended: Filed Aug. 1, 1996, effective March 30, 1997. Amended: Filed Aug. 29, 1997, effective April 30, 1998.

Amended: Filed Dec. 15, 1997, effective July 30, 1998. Amended:

Filed Dec. 15, 2000, effective June 30, 2001. Amended: Filed Jan. 15, 2004, effective Aug. 30, 2004. Amended: Filed April 29, 2005, effective Oct. 30, 2005. ** Amended: Filed Feb. 6, 2023, effective Aug. 30, 2023. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; and 208.159, RSMo 1979. **Pursuant to Executive Order 21-07, 13 CSR 70-91.010, paragraph (1)(B)3. and subparagraph (1)

(C)1.F. was suspended from April 30, 2020 through May 1, 2021. Pursuant to Executive Order 21-09, 13 CSR 70-91.010, paragraph (1)(B)1., subsections (3)(E) and (3)(G), paragraphs (3)(H)2., (3)(H)3., (3)(J)1., (3)(K)3., and (3)(K)4., subparagraph (4)(A)2.F., paragraphs (4)(B)1.-2., subparagraphs (5)

(F)2.A.-B., and subsection (5)(E) was suspended from April 30, 2020 through December 31, 2021.

History

• AUTHORITY: section 208.152, RSMo Supp. 2022, and sections 208.153 and 208.159, RSMo 2016. This rule was previously filed as 13 CSR 40-81.125. Original rule filed April 14, 1982, effective July 11, 1982. Amended: Filed May 13, 1983, effective Aug. 11, 1983.

13 CSR 70-91.020 Mental Health Residential Personal Care Program {#sec-13-csr-70-91.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-91.020}

(Rescinded June 30, 2018)

rule filed July 6, 1993, effective July 30, 1993, expired Nov. 26, 1993. Original rule filed March 16, 1993, effective Oct. 10, 1993.

Rescinded: Filed Nov. 3, 2017, effective June 30, 2018.

History

• AUTHORITY: sections 208.152, RSMo Supp. 1993, 208.153, RSMo Supp. 1991 and 208.201, RSMo 1987. Emergency rule filed March 18, 1993, effective April 1, 1993, expired July 29, 1993. Emergency

13 CSR 70-91.030 Personal Care Assistance {#sec-13-csr-70-91.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-91.030}

(Rescinded December 30, 2010)

rule filed Oct. 3, 1994, effective Nov. 1, 1994, expired Jan. 29, 1995. Original rule filed Oct. 28, 1994, effective June 30, 1995.

Amended: Filed March 2, 1998, effective Sept. 30, 1998. Amended:

Filed Jan. 15, 2004, effective Aug. 30, 2004. Rescinded: Filed June 10, 2010, effective Dec. 30, 2010.

History

• AUTHORITY: sections 208.153 and 208.201, RSMo 2000. Emergency

Chapter 92 Adult Day Health Care Program

13 CSR 70-92.010 Adult Day Health Care Program {#sec-13-csr-70-92.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-92.010}

(Rescinded December 30, 2015)

rule filed May 13, 1983, effective Aug. 11, 1983. Amended: Filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed Dec. 14, 2007, effective July 30, 2008. Rescinded:

Filed July 1, 2015, effective Dec. 30, 2015.

JASONKANDER(11/30/15)

History

• AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2007 and sections 208.159 and 208.168, RSMo 2000. This rule was previously filed as 13 CSR 40-81.126. Original

Chapter 93 Medicaid Clinic Program

13 CSR 70-93.010 Reimbursement for Medicaid Children’s Clinic Services {#sec-13-csr-70-93.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-93.010}

(Rescinded August 30, 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

13 CSR 70-93.020 Reimbursement for Medicaid Family Health Clinic Program {#sec-13-csr-70-93.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-93.020}

(Rescinded August 30, 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 JOHNR. ASHCROFT(7/31/18)

SOCIAL SERVICES

13 CSR 70-93.010 Reimbursement for Medicaid Children’s Clinic Services {#sec-13-csr-70-93.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-93.010}

(Rescinded August 30, 2018)

1987. Emergency rule filed Jan. 15, 1993, effective Feb. 2, 1993, expired June 1, 1993.

Emergency rule filed June 11, 1993, effective June 21, 1993, expired Oct. 18, 1993. Original rule filed March 2, 1993, effective Aug. 9, 1993. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: section 208.201, RSMo Supp.

13 CSR 70-93.020 Reimbursement for Medicaid Family Health Clinic Program {#sec-13-csr-70-93.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-93.020}

(Rescinded August 30, 2018)

Emergency rule filed Oct. 31, 1995, effective Nov. 10, 1995, expired April 28, 1996. Original rule filed June 30, 1995, effective Jan. 30, 1996. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: section 208.201, RSMo 1994.

Chapter 94 Rural Health Clinic Program

13 CSR 70-94.010 Independent Rural Health Clinic Program {#sec-13-csr-70-94.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-94.010}

PURPOSE: This rule establishes the regulatory basis for Title XIX Medicaid payment for Independent Rural Health Clinic Services.

(1) Authority. This is the payment methodology used to reimburse providers in the MO HealthNet Independent Rural Health Clinic (RHC) program.

(2) Qualifications. For a clinic to qualify for participation in the MO HealthNet independent RHC program, the clinic must be an independent facility, which means that the clinic may not be part of a hospital. However, a clinic may be located in the same building as a hospital, as long as there is no administrative, organizational, financial, or other connection between the clinic and the hospital.

(3) General Principles.

(A) The MO HealthNet program shall reimburse independent RHC providers based on the reasonable cost of RHC-covered services related to the care of MO HealthNet participants (within program limitations) less any copayment or other third party liability amounts which may be due from MO HealthNet participants.

(B) Reasonable costs shall be determined by the MO HealthNet Division based on desk review of the applicable cost reports and shall be subject to adjustment based on field audit.

Reasonable costs shall not exceed the Medicare cost principles set forth in 42 CFR part 413.

(4) Definitions. The following definitions shall apply for the

purpose of this rule:

(A) Desk review. The MO HealthNet Division’s review of a provider’s cost report without on-site audit;

(B) Division. Unless otherwise designated, division refers to the MO HealthNet Division, the division of the Department of Social Services charged with administration of the MO HealthNet program;

(C) Facility fiscal year. A facility’s twelve- (12-) month fiscal reporting period;

(D) Generally accepted accounting principles (GAAP).

Accounting conventions, rules, and procedures necessary to describe accepted accounting practice at a particular time promulgated by the authoritative body establishing those principles;

(E) Medicaid cost report. The documents used for the purpose of reporting the cost of rendering both covered and non-covered services for the facility’s fiscal year shall be the Medicare cost report forms CMS-222-92 and all worksheets supplied by the division. If the Medicare CMS-222-92 is superseded by an alternate Medicare developed cost reporting tool during a facility’s fiscal year, that tool must be used for the facility’s fiscal year; and (F) Provider or facility. An independent RHC with a valid MO HealthNet participation agreement in effect with the Department of Social Services for the purpose of providing RHC services to Title XIX eligible participants.

(5) Administrative Actions.

(A) Annual Cost Report.

1. Each independent RHC shall complete a Medicaid cost report for the RHC’s twelve- (12-) month fiscal period.

2. Each RHC is required to complete and submit to the division an Annual Cost Report, including all worksheets, attachments, schedules, and requests for additional information from the division. The cost report shall be submitted on forms provided by the division for that purpose.

A. An independent RHC may be exempt from filing a Medicaid cost report if there is no MO HealthNet reimbursement for the reporting period and the facility does not plan to bill the MO HealthNet program for any claims for the reporting period. The facility must submit a request to the division to waive the cost report filing requirement within five (5) calendar months after the close of the facility’s reporting period. To request an exemption for the cost report filing requirement, the following information must be submitted to MHD for review and approval:

(I) A Low or No Missouri Medicaid Utilization Waiver Request Form. This form may be obtained from the division.

The form must be fully completed and signed by an officer or administrator; and (II) Worksheet S series of the Medicare Cost Report.

The applicable parts of the Worksheet S must be completed and signed by an officer or administrator.

3. All cost reports shall be completed in accordance with the requirements of this rule and the cost report instructions.

Financial reporting shall adhere to GAAP except as otherwise specifically indicated in this rule.

4. The cost report shall be submitted within five (5) calendar months after the close of the reporting period. An extension may be granted upon the request of the RHC and the approval of the division with an agreed upon date of completion.

The request must be received in writing by the division prior to the end of the five (5) calendar-month period after the close of the reporting period.

5. In a change of ownership, the cost report for the closing period must be submitted within forty-five (45) calendar days of the effective date of the change of ownership, unless the change in ownership coincides with the seller’s fiscal year end, in which case the cost report must be submitted within five (5) months after the close of the reporting period. No extensions in the submitting of cost reports shall be granted when a change in ownership has occurred.

6. Cost reports shall be submitted and certified by an officer or administrator of the provider. Failure to file a cost report within the prescribed period, except as expressly extended in writing by the state agency, may result in the imposition of sanctions as described in 13 CSR 70-3.030.

7. Authenticated copies of agreements and other significant documents related to the provider’s operation and provision of care to MO HealthNet participants must be attached to the cost report at the time of filing unless current and accurate copies have already been filed with the division. Material which must be submitted includes, but is not limited to, the following:

A. Audit, review, or compilation statement prepared by an independent accountant, including disclosure statements and management letter;

B. Contracts or agreements involving the purchase of facilities or equipment during the past five (5) years if requested by the division, the department, or its agents;

C. Contracts or agreements with owners or related parties;

D. Contracts with consultants;

E. Schedule detailing all grants, gifts, and income from endowments, including amounts, restrictions, and use;

(11/30/24) John R. Ashcroft F. Documentation of expenditures, by line item, made under all restricted and unrestricted grants, gifts, or endowments;

G. Statement verifying the restrictions as specified by the donor, prior to donation, for all restricted grants;

H. Leases or rental agreements, or both, related to the activities of the provider;

I. Management contracts;

J. Provider of service contracts; and K. Working trial balance actually used to prepare cost report with line number tracing notations or similar identifications.

8. Under no circumstance will the division accept amended cost reports for final settlement determination or adjustment after the date of the division’s notification of the final settlement amount.

(B) Records.

1. Maintenance and availability of records.

A. A provider must keep records in accordance with GAAP and maintain sufficient internal control and documentation to satisfy audit requirements and other requirements of this rule, including reasonable requests by the division or its authorized agent for additional information.

B. Adequate documentation for all line items on the cost report shall be maintained by a provider. Upon request, all original documentation and records must be made available for review by the division or its authorized agent at the same site at which the services were provided. Copies of documentation and records shall be submitted to the division or its authorized agent upon request.

C. Records of related organization, as defined by 42 CFR 413.17, must be available upon demand.

D. The division shall retain all uniform cost reports submitted by the independent RHCs for seven (7) years after the final settlement relating to a cost report is finalized, including the resolution of any subsequent appeals or other administrative actions pertaining to the cost report.

E. Each facility shall retain all financial information, data, and records relating to the operation and reimbursement of the facility for seven (7) years after the final settlement relating to a cost report is finalized, including the resolution of any subsequent appeals or other administrative actions pertaining to the cost report, and will maintain those reports pursuant to the record-keeping requirements of 42 CFR 413.20.

2. Adequacy of records.

A. The division may suspend reimbursement or reduce payments to the appropriate fee schedule amounts if it determines that the RHC does not maintain records that provide an adequate basis to determine payments under MO HealthNet.

B. The suspension or reduction continues until the RHC demonstrates to the division’s satisfaction that it does, and will continue to, maintain adequate records.

(C) Audits.

1. Any cost report submitted may be subject to field audit by the division or its authorized agent.

2. A provider shall have available at the field audit location one (1) or more knowledgeable persons authorized by the provider and capable of explaining the provider’s accounting and control system and cost report preparation, including all attachments and allocations.

3. If a provider maintains any records or documentation at a location which is not the same as the site where services were provided, the provider shall transfer the records to the same facility at which the services were provided, or the provider must reimburse the division or its authorized agent for reasonable travel costs necessary to perform any part of the field audit in any off-site location, if the location is acceptable to the division.

(D) Change in Provider Status. The next payment due the provider after the division has received the notification of the termination of participation in the MO HealthNet program or change of ownership may be held by the division until the cost report is filed. Upon receipt of a cost report prepared in accordance with this rule, the payments that were withheld will be released.

(6) Nonallowable Costs. Cost not reasonably related to RHC services shall not be included in a provider’s costs. Nonallowable cost areas include, but are not limited to, the following:

(A) Grants, gifts and income from endowments will be deducted from total operating costs;

(B) Bad debts, charity, and courtesy allowances;

(C) Return on equity capital;

(D) Capital cost increases due solely to changes in ownership;

(E) Amortization on intangible assets, such as goodwill, leasehold rights, covenants, but excluding organizational costs;

(F) Attorney fees related to litigation involving state, local, or federal governmental entities and attorney’s fees which are not related to the provision of RHC services, such as litigation related to disputes between or among owners, operators, or administrators;

(G) Central office or pooled costs not attributable to the efficient and economical operation of the facility;

(H) Costs such as legal fees, accounting and administration costs, travel costs, and the costs of feasibility studies which are attributable to the negotiation or settlement of the sale or purchase of any capital asset by acquisition or merger for which any payment has been previously made under the program;

(I) Late charges and penalties;

(J) Finder’s fees;

(K) Fund-raising expenses;

(L) Interest expense on intangible assets;

(M) Religious items or supplies or services of a primarily religious nature performed by priests, rabbis, ministers, or other similar types of professionals. Costs associated with portions of the physical plant used primarily for religious functions are also nonallowable;

(N) Research costs;

(O) Salaries, wages, or fees paid to nonworking officers, employees, or consultants;

(P) Value of services (imputed or actual) rendered by nonpaid workers or volunteers; and (Q) Costs of services performed in a satellite clinic, which does not have a valid MO HealthNet participation agreement with the Department of Social Services for the purpose of providing RHC services to Title XIX-eligible participants.

(7) Interim Payments.

(A) Independent RHCs, unless otherwise limited by regulation, shall be reimbursed on an interim basis by MO HealthNet at the Medicare RHC rate. Interim payments shall be reduced by copayments and other third party liabilities.

(B) An independent RHC contracted with a MO HealthNet managed care health plan shall be eligible for supplemental reimbursement up to its interim Medicare RHC rate. The supplemental reimbursement shall make up the difference between what the independent RHC would have been paid by the division based on the independent RHC’s Medicare rate and the total managed care health plan payments made to the Denny Hoskins (8/31/25) clinic during the reporting period for covered services rendered to MO HealthNet managed care participants as set forth in the Managed Care contract. The supplemental reimbursement shall occur pursuant to the schedule agreed to by the division and the independent RHC but shall occur no less frequently than every four (4) months. Supplemental reimbursement shall be requested by the independent RHC on forms provided by the division. Supplemental reimbursement for managed care charges shall be considered interim reimbursement of the independent RHC’s MO HealthNet costs.

(8) Final Settlement.

(A) Final Settlement Determination. The state agency shall perform an annual desk review of the Medicaid cost reports for each RHC’s fiscal year and shall make the necessary payment adjustments (i.e., an additional payment or a recoupment), in order that the RHC’s net reimbursement shall equal reasonable costs as described in this section.

1. The total reimbursement amount due the RHC for covered services furnished to MO HealthNet participants is based on the allowable costs from the Medicaid cost report and is calculated as follows:

A. The average cost per visit is calculated by dividing the total allowable cost incurred for the reporting period by total visits for RHC services furnished during this period. The average cost per visit is subject to tests of reasonableness which may be established in accordance with this rule or incorporated in the Allowable Cost per visit as determined on Worksheet C, Part I, line 9 of the cost report; and B. The total cost of RHC services furnished to MO HealthNet participants is calculated by multiplying the allowable cost per visit by the number of MO HealthNet visits for covered RHC services.

2. The total reimbursable cost is compared to the total interim payments made to the RHC during the reporting period for MO HealthNet participants to determine the amount of the final settlement owed to or due from the RHC. The total interim payments include the amount paid by the division as determined from the division’s Medicaid Management Information System (MMIS) reports, the health plan payments as set forth in the Managed Care contract, and third party liability payments.

3. The total reimbursement will be subject to adjustment based on the results of a field audit which may be conducted by the MO HealthNet Division or its contracted agents.

(B) Notification of Final Settlement.

1. The division will notify the RHC by letter of a cost report final settlement after the division completes the desk review of the cost report. The division’s notification letter will include the calculation of the final settlement and a Settlement Agreement, which the facility will sign and return to the division indicating it agrees with the final settlement calculation.

The division’s written notice to the RHC shall indicate if the final settlement results in the following:

A. Underpayments. If the total reimbursement due the RHC exceeds the interim payments made for the reporting period, the division makes a lump-sum payment to the RHC to bring total payments into agreement with total reimbursement due the RHC; and B. Overpayments. If the total interim payments made to a RHC for the reporting period exceed the total reimbursement due the RHC for the period, the division arranges with the RHC for repayment of the overpayment either by having it offset against the RHC’s subsequent interim payments, having the RHC repay by sending the division a payment, or a combination of offset and payment.

2. The RHC shall review the division’s notification letter and attachments and respond with a signed Settlement Agreement indicating it has accepted the final settlement within fifteen (15) calendar days of receiving the final settlement letter. If the RHC believes revisions to the division’s desk review and final settlement are necessary before it can accept the settlement, it must submit additional, amended, or corrected data within the fifteen- (15-) day deadline. Data received from the RHC after the fifteen- (15-) day deadline may not be considered by the division in determining if revisions to the final settlement are needed unless the RHC requests and receives an extension for submitting additional information prior to the end of the fifteen- (15-) day deadline. If the fifteen- (15-) day deadline passes without a response from the provider, the division will proceed with processing the final settlement as set forth in the division’s notification letter, and the final settlement shall be deemed final. The division may not accept an amended cost report or any other additional information to revise the cost report or final settlement after the final settlement is finalized.

(C) The annual desk review will be subject to adjustment based on the results of a field audit which may be conducted by the division or its contracted agents.

(9) Payment Assurance.

(A) The state will pay each RHC, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the RHC according to the standards and methods set forth in the regulations implementing the RHC Reimbursement Program.

(B) RHC services provided for those participants having available Medicare benefits shall be reimbursed by MO HealthNet to the extent of the coinsurance and deductible as imposed under Title XVIII.

(C) Where third-party payment is involved, MO HealthNet will be the payer of last resort.

(D) Regardless of changes of ownership, management, control, leasehold interests by whatever form for any RHC previously certified for participation in the MO HealthNet program, the division will continue to make all the Title XIX payments directly to the entity with the RHC’s current provider number and hold the entity with the current provider number responsible for all MO HealthNet liabilities.

rule filed Aug. 20, 1993, effective Sept. 18, 1993, expired Jan. 15, 1994. Emergency rule filed Jan. 19, 1994, effective Jan. 29, 1994, expired Jan. 31, 1994. Original rule filed Aug. 20, 1993, effective Jan. 31, 1994. Amended: Filed Aug. 15, 2008, effective Feb. 28, 2009.

Amended: Filed Oct. 17, 2018, effective June 30, 2019. *Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Emergency

13 CSR 70-94.020 Provider-Based Rural Health Clinic {#sec-13-csr-70-94.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-94.020}

PURPOSE: This rule establishes the regulatory basis for Medicaid payment for services provided through the Provider-Based Rural Health Clinic Program.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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 (8/31/25) Denny Hoskins 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) General Principles.

(A) The MO HealthNet program shall reimburse Provider- Based Rural Health Clinics (PBRHC) based on the reasonable cost incurred by the PBRHC to provide covered services, within program limitations, related to the care of MO HealthNet participants less any copayment or other third-party liability amounts that may be due from the MO HealthNet-eligible individual.

(B) Reasonable costs shall not exceed the Medicare cost principles set forth in 42 Code of Federal Regulations (CFR) Parts 405 and 413, except the Medicare cost limits or caps imposed under 42 CFR 405.2462 will not apply to the prospective rates calculated by the MO HealthNet Division.

(C) Non-allowable Costs. Costs not related to PBRHC services shall not be included. Non-allowable cost areas include, but are not limited to, the following:

1. Federal Reimbursement Allowance (FRA) Tax;

2. Bad debts, charity care, and courtesy allowances;

3. Capital cost increases due solely to changes in ownership;

4. Amortization on intangible assets, such as goodwill, leasehold rights, covenants, but excluding organizational costs;

5. Attorney fees related to litigation involving state, local, or federal governmental entities and attorney’s fees that are not related to the provision of PBRHC services, such as litigation related to disputes between or among owners, operators, or administrators;

6. Central office or pooled costs not attributable to the efficient and economical operation of the PBRHC;

7. Costs such as legal fees, accounting costs, administration costs, travel costs, and the costs of feasibility studies that are attributable to the negotiation or settlement of the sale or purchase of any capital asset by acquisition or merger for which any payment has been previously made under the program;

8. Late charges and penalties;

9. Finders fees;

10. Fund-raising expenses;

11. Interest expense on intangible assets;

12. Religious items or supplies, or services of a primarily religious nature performed by priests, rabbis, ministers, or other similar types of professionals. Costs associated with portions of the physical plant used primarily for religious functions are also non-allowable;

13. Research costs;

14. Salaries, wages, or fees paid to non-working officers, employees, or consultants;

15. Value of services (imputed or actual) rendered by nonpaid workers or volunteers; and 16. Costs of services performed in a satellite clinic, which does not have a valid MO HealthNet participation agreement with the Department of Social Services for the purpose of providing PBRHC services to MO HealthNet participants.

(2) Definitions.

(A) Alternative Prospective Payment System (APPS) rate.

A reimbursement rate that is an alternative to the standard Prospective Payment System (PPS) rate established in accordance with section 1902(bb) of the Social Security Act.

(B) Audit. The division’s or its authorized contractor’s audit of a hospital’s Medicaid cost report.

(C) Base Years FY 1 and FY 2 for current providers. Fiscal years 1999 and 2000.

(D) Base Years FY 1 and FY 2 for new providers who do not have a 1999 and 2000 cost report. Two (2) fiscal years subsequent to the first year of business as a PBRHC.

(E) Change in scope of service. A change in the type, intensity, duration, or amount of service.

(F) Division. Unless otherwise designated, division refers to the MO HealthNet Division, a division of the Department of Social Services charged with the administration of the MO HealthNet program.

(G) Fiscal Year (FY). The clinic’s fiscal reporting period that corresponds with the fiscal year of the hospital where the clinic is based.

(H) Fourth prior year cost report. The Medicaid cost report for the fourth year prior to the SFY that the rate is effective (i.e., for SFY 2025, the fourth prior year cost report is the FY 2021 cost report).

(I) Generally Accepted Accounting Principles (GAAP).

Accounting conventions, rules, and procedures necessary to describe accepted accounting practice at a particular time promulgated by the authoritative body establishing those principles.

(J) Incorporation by reference. This rule incorporates by reference the following:

1. 42 CFR Chapter IV, Part 405, which is incorporated 700, Washington, DC 20408, October 1, 2023, and available at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/

part-405. This rule does not incorporate any subsequent 2. 42 CFR Chapter IV, Part 413, which is incorporated 700, Washington, DC 20408, October 1, 2023, and available at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/

part-413. This rule does not incorporate any subsequent 3. 42 CFR Chapter IV, Part 491, which is incorporated 700, Washington, DC 20408, October 1, 2024, and available at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/

part-491. This rule does not incorporate any subsequent 4. The Rural Health Clinic Provider Manual 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, September 1, 2023, and available at https://mydss.mo.gov/media/pdf/rural-healthclinic-provider-manual. This rule does not incorporate any subsequent amendments or additions.

(K) Medicaid Cost Report. Shall be the cost report defined in

13 CSR 70-15.010 Inpatient Hospital Services Reimbursement Methodology, and Missouri’s supplemental cost report schedules. Each PBRHC shall be individually listed on the hospital’s Medicaid cost report. {#sec-13-csr-70-15.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-15.010}

(L) Medicare Economic Index (MEI). Percentage increase for primary care services.

1. SFY 2024 = 3.8%

2. SFY 2025 = 4.6%

3. SFY 2026 = 3.5%

(M) PBRHC. A clinic that is an integral part of a hospital, Denny Hoskins (8/31/25) eligible for certification as a Medicare rural health clinic in accordance with 42 CFR Parts 405 and 491, and operates with other departments of a hospital.

(N) Prospective Payment System (PPS) Rate. A reimbursement rate established in accordance with section 1902(bb) of the Social Security Act.

(O) Provider or facility. A PBRHC with a valid MO HealthNet participation agreement in effect with the Department of Social Services for the purpose of providing PBRHC services to MO HealthNet eligible participants.

(P) Third prior year cost report. The Medicaid cost report for the third year prior to the SFY that the rate is effective (i.e., for SFY 2025, the third prior year cost report is the FY 2022 cost report).

(Q) Cost-to-charge ratio (CCR). The CCR is determined by dividing the PBRHC cost by the PBRHC charges from the hospital’s Medicaid Cost Report Worksheet C Part I.

(3) Reimbursement Methodologies. Effective for dates of service on or after January 1, 2025, PBRHCs shall be reimbursed for covered services furnished to eligible Missouri Medicaid participants under a prospective payment system (PPS). An alternative prospective payment system (APPS) will also be determined for each PBRHC. The payment amount determined under this methodology is agreed to by the division and the PBRHCs and results in a payment to the PBRHC of an amount which is at least equal to the PPS rate, with no retrospective settlement.

(A) Prospective Payment System (PPS). Effective for dates of service on or after January 1, 2025, a PPS rate will be set for each PBRHC according to the methodology outlined below:

1. Determination of final PPS base rate.

A. The final PPS base rate for each PBRHC that has base years FY 1 and FY 2 for current providers will be calculated using the Medicaid cost report as follows:

(I) Total allowable cost equals the allowable cost from base year FY 1 for current providers plus the allowable cost from base year FY 2 for current providers;

(II) Total allowable visits equal the allowable visits from base year FY 1 for current providers plus the allowable visits from base year FY 2 for current providers; and (III) The final PPS base rate equals total allowable cost divided by total allowable visits.

B. The final PPS base rate for each PBRHC that has base years FY 1 and FY 2 for new providers will be calculated using the Medicaid cost report as follows:

(I) Total allowable cost equals the allowable cost from base year FY 1 for new providers plus the allowable cost from base year FY 2 for new providers;

(II) Total allowable visits equal the allowable visits from base year FY 1 for new providers plus the allowable visits from base year FY 2 for new providers; and (III) The final PPS base rate equals total allowable cost divided by total allowable visits.

C. The division shall adjust the final PPS rate— (I) By the percentage increase in the MEI applicable to the PBRHC services on July 1 of each year;

(II) In accordance with subsection (3)(C) below— (a) Upon request and documentation by a PBRHC that there has been a change in scope of services;

(b) Upon review and determination by the division that there has been a change in scope of services; and 2. Determination of interim PPS base rate for a new PBRHC.

A. Until a final PPS rate is established, the division shall calculate an interim PPS rate based on the average final PPS rates based on the managed care organization region where the PBRHC is located.

(B) Alternative Payment Methodology (APM). Effective for dates of service on or after January 1, 2025, PBRHCs may be paid an APPS rate. PBRHCs must agree to the APM in order to receive payment in accordance with the APM and the amount paid under the APM must be at least equal to the PPS rate. To choose this method, the PBRHC must make this selection on the written memorandum form provided by the division.

1. Determination of APPS base rate.

A. The final APPS base rate will be calculated for each PBRHC as follows:

(I) Total allowable cost equals the allowable cost from the third prior year Medicaid cost report plus the allowable cost from the fourth prior year Medicaid cost report;

(II) Total allowable visits equal the allowable visits from the third prior year Medicaid cost report plus the allowable visits from the fourth prior year Medicaid cost report; and (III) PPS base rate equals total allowable cost divided by total allowable visits.

B. The division shall adjust the final APPS rate— (I) By the percentage increase in the MEI applicable to the PBRHC services on July 1 of each year;

(II) In accordance with subsection (3)(C) below— (a) Upon request and documentation by a PBRHC that there has been a change in scope of services;

(b) Upon review and determination by the division that there has been a change in scope of services; and (III) If necessary, as a result of a desk review or audit.

C. The final APPS rate will be rebased every five (5) years (i.e., SFY 2030 will be the first year of rebasing).

2. Determination of interim APPS base rate for a new PBRHC.

A. Until a final APPS rate is established, the division shall calculate an interim APPS rate based on the average final APPS rates based on the managed care organization region where the PBRHC is located.

(C) Change in scope of service.

1. To receive a PPS rate adjustment for a proposed increase or decrease in the scope of covered PBRHC services in a future FY as compared to the current year, a provider shall be required to submit a proposal which should include enough information to facilitate an evaluation of the proposed change and its effect on the rate. Any rate change would be effective on the first of the month following the division’s decision.

2. To receive an APPS rate adjustment for a proposed increase or decrease in the scope of covered PBRHC services in a future FY as compared to the current year, a provider shall be required to submit a proposal which should include enough information to facilitate an evaluation of the proposed change and its effect on the rate. Any rate change would be effective on the first of the month following the division’s decision. In addition to a change of scope, PBRHCs will have the opportunity to submit a request to increase the APPS rate if costs exceed the APPS rate by fifteen (15) percent or more.

Again, documentation must be provided to determine the case for reconsideration of the APPS rate. Any rate change would be effective on the first of the month following the division’s decision.

3. A change in scope of service shall be restricted to— A. Adding or terminating a covered service;

B. Increasing or decreasing the intensity of a covered service; or C. A statutory or regulatory change that materially (8/31/25) Denny Hoskins impacts the costs or visits of a PBRHC.

4. The following items individually shall not constitute a change in scope:

A. A general increase or decrease in the costs of existing services;

B. A reduction or an expansion of hours per day, days per week, or weeks per year;

C. An addition of a new site that provides the same Medicaid covered services;

D. A wage increase;

E. A renovation or other capital expenditure;

F. A change in ownership; or G. An addition or termination of a service provided by a non-licensed professional or specialist.

5. A change in covered services shall be either— A. An addition of a covered service restricted to the addition of a licensed professional staff member who can perform a Medicaid covered service that is not currently being performed within the PBRHC by a licensed professional employed or contracted by the PBRHC; or B. The termination of a covered service restricted to the deletion of a licensed professional staff member who can perform a Medicaid covered service that was being performed within the PBRHC by the licensed professional staff member.

6. A change in intensity shall— A. Increase or decrease the existing final rate by at least five (5) percent;

B. Last at least twelve (12) months; and C. Be submitted to the division in writing.

7. A requested change in scope of service shall— A. Increase or decrease the existing final rate by at least five (5) percent;

B. Last at least twelve (12) months; and C. Be submitted to the division in writing.

8. A PBRHC that requests a change in scope of service shall submit the following documents to the division within six (6) months of the change in scope of service:

A. A narrative describing the change in scope of service;

B. Budgeted expenditures and change in total number of visits; and C. A signed letter requesting the change in scope.

(D) PBRHCs that are an integral part of an out-of-state hospital shall be reimbursed a per visit rate based on the state-wide average rate of PBRHCs that are an integral part of in-state hospitals.

(4) Final Settlement Calculations. Final settlements will only be calculated for dates of service prior to January 1, 2025.

(A) For cost reports with a FY ending in 2021 and forward, the final settlement is calculated as follows:

1. The audited Medicaid cost report that includes each PBRHC’s fiscal year shall be used to calculate the final settlement, in order that the PBRHC’s net reimbursement shall equal reasonable costs as described in this section;

2. Fee-for-service (FFS) section.

A. The division takes the PBRHC’s allowable Medicaid charges from services paid on a percentage basis multiplied by the PBRHC’s cost-to-charge ratio to determine the PBRHC’s cost.

From this cost, the PBRHC claims payments are subtracted. The difference is either an overpayment or an underpayment;

3. Managed care section.

A. The division uses the PBRHC Form from the Medicaid Supplemental Packet, which is filed with the hospital cost report, and associated detail for the PBRHC facility to determine charges. These charges are multiplied by the PBRHC’s cost-tocharge ratio to determine the PBRHC’s cost. From this cost, the PBRHC payments associated with above charges are subtracted.

If applicable, then subtract any interim payments paid prior to the final settlement. The difference is either an overpayment or an underpayment; and 4. Final settlement amount.

A. The division adds together the overpayment or underpayment from the FFS section and the managed care section and then subtracts any advanced settlement payments, if applicable, to come up with a total overpayment or underpayment which will be the final settlement amount.

(B) For cost reports with a FY ending in 2020 and prior, the final settlement is calculated as follows:

1. The audited Medicare Notice of Program Reimbursement (NPR) cost report that includes each PBRHC’s fiscal year shall be used to calculate the final settlement, in order that the PBRHC’s net reimbursement shall equal reasonable costs as described in this section. The provider shall provide the NPR upon request from the division;

2. Fee-for-service section.

A. The division takes the PBRHC’s allowable Medicaid charges from services billed under this rule multiplied by the PBRHC’s Medicare NPR cost-to-charge ratio to determine the PBRHC’s cost. From this cost, the PBRHC FFS claims payments are subtracted. The difference is either an overpayment or an underpayment;

3. Managed care section.

A. The division uses the PBRHC Form from the Medicaid Supplemental Packet, which is filed with the hospital cost report, and associated detail for the PBRHC facility to determine charges. These charges are multiplied by the PBRHC’s cost-tocharge ratio to determine the PBRHC’s cost. From this cost, the PBRHC payments associated with above charges are subtracted.

If applicable then subtract any interim payments paid prior to the final settlement. The difference is either an overpayment or an underpayment; and 4. Final settlement amount.

A. The division adds together the overpayment or underpayment from the FFS section and the managed care section and then subtracts any advanced settlement payments, if applicable, to come up with a total overpayment or underpayment which will be the final settlement amount.

(5) Reconciliation.

(A) The division shall send written notice to the hospital, of which the PBRHC is an integral part, of the following:

1. Underpayments. If the total reimbursement due the PBRHC exceeds the interim payments made for the reporting period, the division makes a lump-sum payment to the PBRHC to bring total interim payments into agreement with total reimbursement due to the PBRHC; and/or 2. Overpayments. If the total interim payments made to the PBRHC for the reporting period exceed the total reimbursement due from the PBRHC for the period, the division arranges with the PBRHC for repayment through a lump-sum refund or, if that poses a hardship for the PBRHC, through offset against subsequent interim payments or a combination of offset and refund.

(6) Payment Assurance. The state will pay each PBRHC, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the PBRHC according to the standards and methods set forth in the regulations implementing the PBRHC Reimbursement Program.

rule filed June 30, 1995, effective Jan. 30, 1996. Amended: Filed May 14, 1999, effective Nov. 30, 1999. Amended: Filed Aug. 15, 2008, effective Feb. 28, 2009. Amended: Filed April 7, 2021, effective Nov. 30, 2021. Emergency amendment filed March 3, 2025, effective March 17, 2025, expired Sept. 12, 2025. Amended: Filed March 3, 2025, effective Sept. 30, 2025. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

13 CSR 70-94.030 Transformation of Rural Community Health (ToRCH) {#sec-13-csr-70-94.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-94.030}

PURPOSE: This rule establishes the Transformation of Rural Community Health (ToRCH) program. The purpose of ToRCH is to direct new resources to rural communities that commit to addressing social conditions that lead to poor health.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) This rule implements the Transformation of Rural Community Health (ToRCH) program. ToRCH is a hub-based model that is designed to allow rural communities to have the flexibility to address health-related social needs (HRSN) among their MO HealthNet populations in a manner that focuses on improving health outcomes. ToRCH will integrate social care supports into clinical care, so that clinical outcomes are less likely to be compromised by social challenges. ToRCH will also create a new role for rural health care providers, and a new path to sustainability for these providers.

(2) Definitions. For purposes of this rule, the following words and phrases are defined as follows:

(A) “Community” shall mean a county or group of counties considered by the ToRCH entity as its core service region, and for whose health outcomes the leadership board will be held accountable;

(B) “Community Based Organization (CBO)” shall mean a public or private not-for-profit entity that provides specific services or resources to the community or targeted population within the community;

(C) “Community Health Needs Assessment” shall mean a community-wide assessment that identifies key health needs and issues through systemic, comprehensive data collection and analysis;

(D) Emergency Department Prevention Quality Indicators (ED PQIs) are measures developed by the Agency for Healthcare Research and Quality (AHRQ) that assess whether visits for a set of chronic and ambulatory care sensitive conditions that could have been more appropriately treated in a primary care setting occurred;

(E) “Health-related social needs (HRSN)” shall mean an individual’s unmet, adverse social conditions that contribute to poor health. These needs can include, but are not limited to— 1. Food insecurity;

2. Housing instability;

3. Unemployment or under-employment; or 4. A lack of reliable transportation;

(F) Pediatric Quality Indicators (PDIs), also developed by AHRQ, focus on quantifying potentially preventable complications and iatrogenic events for pediatric patients treated in hospitals and on preventable hospitalizations among pediatric patients, taking into account the special characteristics of the pediatric population;

(G) Prevention Quality Indicators (PQIs) are measures developed by AHRQ. A composite measure assesses whether hospitalizations occurred as a result of complications from chronic conditions that would likely have been preventable due to better condition management;

(H) “Rural community health hub” shall mean a partnership among the ToRCH entity, primary care, behavioral health, and community-based organizations, to provide communitylevel care management services, including but not limited to strategic coordination of community-based services;

(I) “ToRCH entity” shall mean the leader of a rural community health hub that will provide community-level care management services, i.e., strategic coordination of community-based services that primary care partners are then able to utilize in a systematic way to more fully achieve the goals of primary care case management on an individual patient level. A ToRCH entity shall be located in a county deemed eligible for ruraltargeted funding by the Federal Office of Rural Health Policy at the time of its application. Selection criteria for ToRCH entities are specified in section (4); and (J) “ToRCH model” shall encompass the ToRCH entity and its partners, operating a rural community health hub, making strategic and data-informed decisions in order to earn valuebased payments as described in this rule.

(3) ToRCH entities shall provide primary care case management (PCCM) services as defined at 42 U.S.C. section 1396d(t) (2011), as well as utilize a waiver under the Social Security Act, section 1915(b) (1921) to address HRSN at a rural community level. This includes but is not limited to— (A) The strategic coordination of community-based services to allow primary care providers to utilize these services in a systematic way to more fully support positive health outcomes on the individual patient level;

(B) Engaging Community Based Organization (CBO) partners to participate in a Community Information Exchange (CIE) platform;

1. The purpose of the CIE platform is, in part, to allow ToRCH entities to locate HRSN services that case managers and other screening providers can use to better coordinate HRSN services across multiple CBOs, and to monitor enrolled participants in need of these services;

2. Furthermore, the CIE platform is designed to send referrals for HRSN services from medical or clinical providers to CBOs and track the resolution of each referral, to aggregate referral activity at the community level, to pre-screen for eligibility, to manage ToRCH model invoicing, and to assess ToRCH model performance; and 3. ToRCH entities shall agree to use the CIE platform designated by MHD; and (C) Paying for HRSN services that correlate with better health outcomes and reductions in health care spending.

(4) ToRCH entity selection criteria.

(A) A ToRCH entity shall be located in a county deemed eligible for rural-targeted funding by the Federal Office of (8/31/26) Denny Hoskins Rural Health Policy at the time of its application.

(B) A ToRCH entity shall be a hospital, a federally qualified health center, a rural health clinic, or a local public health agency.

(C) A prospective ToRCH entity shall apply to participate by submitting a Preparation, Approach, and Implementation Plan based on the following criteria:

1. Provide a well-thought-out plan for the creation of a Leadership Board to oversee and administer all aspects of the ToRCH model at the rural community level.

A. This plan shall identify the organizations and the individuals who the provider intends to participate in the Leadership Board.

B. The Leadership Board shall include hospital leaders necessary to successfully administer the program, as approved by the division.

C. The Leadership Board shall consist of organizations across all domains (hospital, primary care, behavioral health, local public health agency (LPHA), and social care organizations).

D. The Leadership Board shall have a defined structure that includes voting policies for decisions related to ToRCH, defined meeting frequency, recording of minutes, and other procedures common to similar types of bodies and which acknowledges the fiduciary responsibility and risk-bearing status of the ToRCH entity.

E. The purpose of the Leadership Board shall be to harness the members’ knowledge of their community and their clinical expertise to strategically focus on HRSN services likely to have the greatest influence on hospital outcomes and population health;

2. Provide a list of existing and potential partners with strong letters of support from at least one (1) from each domain: primary care, behavioral health, CBOs, and local public health agencies;

3. Demonstrate CBOs’ current readiness and anticipated needs for support, including technical assistance;

4. Use a Community Health Needs Assessment (or other similar report) to identify the challenges and unmet needs of the community, demonstrating understanding of local population health concerns and providing a preliminary indication of which population health goals the community health hub may wish to prioritize through the ToRCH model;

5. Provide a written statement of commitment to data sharing among clinical partners, and indicate how data will be shared at the individual or aggregate level; and 6. Demonstrate a strong commitment by leadership through one (1) or more letters of support that— A. Express a vision and enthusiasm for the model and a willingness to be held accountable;

B. Discuss the team (with relevant skills) who will be running the model;

C. Describe current efforts to screen/address Social Determinants of Health (SDoH) in the community; and D. Describe insights gained from the interactive Community Information Exchange (CIE) demonstration or other data sources.

(D) A prospective ToRCH entity shall provide a narrative that demonstrates a full understanding of the ToRCH model as follows:

1. How the flexibility and customizability of the model will be used to address community needs that connect back to the overarching health goals;

2. The specific actions that the provider will take to achieve the health goals;

3. How data will be used to inform and guide efforts;

4. How course corrections will be made; and 5. How the strengths of the rural community will be leveraged.

(5) A ToRCH entity shall enter into a Participation Agreement with the MO HealthNet Division for the operation of a ToRCH program by the provider. The Participation Agreement (12/07/2023) is incorporated by reference in this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://mydss.mo.gov/mhd/ToRCH, on May 1, 2024.

This rule does not incorporate any subsequent amendments or additions.

(A) Participation agreements shall include details on data sharing requirements and responsibilities among ToRCH hub clinical partners and with the division, as well as enumerating requirements and responsibilities for financial reporting and attestation of ToRCH model activities.

(B) A Participation Agreement shall be valid only in geographic areas in which the division has approved the ToRCH entity under this rule.

(C) A Participation Agreement may contain additional terms and conditions agreed to by the parties if the terms and conditions are consistent with the provisions of the Social Security Act, section 1915(b) (1981) waiver, this rule, and relevant state or federal law.

(6) Payment Methodology.

(A) Payments to a ToRCH entity in good standing will vary over time. Payments in year N are indicated as “ToRCH(N)” and are determined according to the following formula:

ToRCH(1) = CBF(1) + CSS + SB3(1)

ToRCH(2) = CBF(2) + CSS + SB3(2) + PH(2) + AV(2) + AH(2)

ToRCH(3) = CBF(3) + CSS + SB3(3) + PH(3) + AV(3) + AH(3) + SS(3)

ToRCH(4) = CBF(4) + CSS + SB3(4) + PH(4) + AV(4) + AH(4) + SS(4)

ToRCH(5+) = CSS + PH(5+) + SS(5+).

(B) The components identified in subsection (6)(A) are defined as follows:

1. CBF—Capacity Building Funds. The amount in model years one (1) and two (2) is one hundred sixty thousand dollars ($160,000) per year for a small rural county, two hundred forty thousand dollars ($240,000) for a medium rural county, and three hundred twenty thousand dollars ($320,000) for a large rural county. In year three (3), the amount is reduced by onethird (1/3). In year four (4), the amount is reduced by two-thirds (2/3). In year five (5) and beyond, the amount is zero (0). These amounts are to be trended forward for inflation for additional cohorts after the first cohort and are to be awarded to local CBOs that agree to participate in the ToRCH model according to guidance established by the division. For purposes of this

rule— A. A small rural county shall mean a rural county with a population of less than fifteen thousand (15,000);

B. A medium rural county shall mean a rural county with a population from fifteen thousand (15,000) to twentynine thousand nine hundred ninety-nine (29,999); and C. A large rural county shall mean a rural county with a population of at least thirty thousand (30,000);

2. CSS—Community Strategy Services. This amount is comprised of two (2) actuarily determined components to deliver community strategy services. The first is a base allocation that supports two (2), three (3), or four (4) full-time personnel (for small, medium, or large counties, respectively) to administer and manage the ToRCH model; the second covers screening and referral activities for MO HealthNet participants, multiplied by the most recent quarter’s enrollment data for the ToRCH county or counties, and payable quarterly;

3. SB3—Supplemental B3 services and activities. In model years one (1) and two (2), this is a budgeted amount to be used by the ToRCH entity to provide supplemental services in accordance with section 1915(b)(3) of the Social Security Act. In year three (3), as the funding source for these services and activities begins to transition to Shared Savings (SS), the amount is reduced by one-third (1/3). In year four (4), the amount is reduced by two-thirds (2/3). In year five (5) and beyond, the amount is reduced to zero (0);

4. PH—Population health incentive payments. For each of the identified population health goals referenced in the ToRCH entity’s Participant Agreement, an incentive payment of two percent (2%) of the program’s actual expenditures, excluding capacity building, if the goal for the prior year is met and of three percent (3%) if the goal is exceeded. Thus, the value of PH(2) equals up to fifteen percent (15%) of the total amount spent for CSS and HRSN services (the latter being no greater than SB3(1)). The value of PH(3) equals up to fifteen percent (15%) of the total amount spent for CSS and HRSN services (the latter being no greater than SB3(2)). The value of PH(4) equals up to fifteen percent (15%) of the total amount spent for CSS and HRSN services (the latter being no greater than the sum of SB3(3) and SS(3)). The value of PH(5) equals up to fifteen percent (15%) of the total amount spent for CSS and HRSN services (the latter being no greater than the sum of SB3(4) and SS(4)). The value of PH(6+) equals up to fifteen percent (15%) of the total amount spent on CSS and HRSN services (the latter being no greater than SS(5+));

5. AV—Avoided visits incentive payments. Based on calculations of avoidable emergency department visits, a pool is created across the ToRCH cohort, i.e., across all ToRCH entities that are in the same model year. Using Emergency Department Prevention Quality Indicators (ED PQIs), hospital services are probabilistically identified as potentially avoidable, and the dollar amount associated with these services is calculated at baseline and after each model year for services that occurred in the ToRCH hospital. The combined reductions achieved by all hospitals achieving reductions will comprise the Avoided Visits Pool. First, these changes are expressed as percentage changes for each hospital, negative numbers representing better performance. The percentage change for any hospital with worse performance is set to zero. Second, these percentage changes are summed to determine the total percent change across the cohort. Third, each hospital’s share of the total percent change is calculated as the ratio of the above two (2) steps. Fourth, this share is multiplied by the total value of the reduction achieved across the cohort to determine a prorated share of the reduction, assuming any reductions occurred, and the Pool value is therefore positive. AV for each hospital equals its prorated share of the reduction, or zero if the Pool value is zero. Original values for the first cohort will refer to calendar year 2023 measurements. (Note: if a ToRCH entity is not a hospital, then it will not participate in the Avoided Visits Pool.);

6. AH—Avoided hospitalization incentive payments. Based on calculations of avoidable hospitalizations, a pool is created across the ToRCH cohort, i.e., across all ToRCH entities that are in the same model year. Using Prevention Quality Indicators (PQIs) and area-level Pediatric Quality Indicators (PDIs), hospital services are identified as potentially avoidable, and the dollar amount associated with these services is calculated at baseline and after each model year for services that occurred in the ToRCH hospital. The combined reductions achieved by all hospitals achieving reductions will comprise the Avoided Hospitalizations Pool. First, these changes are expressed as percentage changes for each hospital, negative numbers representing better performance. The percentage change for any hospital with worse performance is set to zero. Second, these percentage changes are summed to determine the total percent change across the cohort. Third, each hospital’s share of the total percent change is calculated as the ratio of the above two (2) steps. Fourth, this share is multiplied by the total value of the reduction achieved across the cohort to determine a prorated share of the reduction, assuming any reductions occurred, and the Pool value is therefore positive. AH for each hospital equals its prorated share of the reduction, or zero if the Pool value is zero. Original values for the first cohort will refer to calendar year 2023 measurements. (Note: if a ToRCH entity is not a hospital, then it will not participate in the Avoided Hospitalization Pool.); and 7. SS—Shared savings payments—Beginning in year three (3), ToRCH entities will be eligible for shared savings payments based upon the estimated savings that MHD calculates as occurring through reductions in all-cause hospitalization (inpatient and outpatient) among the MO HealthNet residents of the ToRCH community. The estimate will be calculated relative to the utilization of MO HealthNet residents of rural, non-ToRCH counties and will be adjusted for the demographic composition of the county, including differences in enrollment by category of aid. To phase in the shared savings component of the ToRCH model, SS(3) will be, at minimum, equal to twenty percent (20%) of the calculated amount saved between years one (1) and two (2). SS(4) will be, at minimum, forty percent (40%) of the calculated amount saved between years two (2) and three (3).

SS(5) will be, at minimum, sixty percent (60%) of the calculated amount saved between years three (3) and four (4). For N>5, SS(N) will be, at minimum, sixty percent (60%) of the calculated amount saved between years N minus two (2) and N minus one (1). When the PH incentive payments are added, the total shared savings rate may be up to seventy-five percent (75%);

(C) The Participation Agreement shall include detailed examples of the methodology described above, including trend rates and algorithms used, in order to ensure clarity for the ToRCH entities.

section 208.153, RSMo Supp. 2025.* Emergency rule filed April 22, 2024, effective May 6, 2024, expired Nov. 1, 2024. Original rule filed April 22, 2024, effective Dec. 30, 2024. Amended: Filed Feb. 26, 2026, effective Sept. 30, 2026. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and

Chapter 95 Private Duty Nursing Care Under the Healthy Children and Youth Program

13 CSR 70-95.010 Private Duty Nursing {#sec-13-csr-70-95.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-95.010}

PURPOSE: This rule establishes the basis for MO HealthNet enrollment and reimbursement of providers of private duty nursing care for children under Missouri’s Healthy Children and Youth Program.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) Service Definition. Private duty nursing is the provision of individual and continuous care (in contrast to part-time or intermittent care) under the direction of the participant’s, physician, by licensed nurses acting within the scope of the Missouri Nurse Practice Act. Services within the MO HealthNet private duty nursing program include:

(A) Shift care by a registered nurse (RN); and (B) Shift care by a licensed practical nurse (LPN).

(2)

Persons Eligible for Private Duty Nursing Care. MO HealthNet-eligible children under the age of twenty-one (21) may be eligible for private duty nursing care under the Healthy Children and Youth Program (HCY) when there is a medical need for a constant level of care, exceeding the family’s ability to independently care for the child at home on a long-term

basis without the assistance of at least a four- (4-) hour shift of home nursing care per day. Private duty nursing services for children are prior authorized by the Bureau of Special Health Care Needs of the Department of Health and Senior Services.

(3) Criteria for Providers of Private Duty Nursing Care for Children.

(A) A provider of private duty nursing care must have a valid MO HealthNet Private Duty Nursing Provider Agreement in effect with the Department of Social Services, Missouri Medicaid Audit and Compliance Unit (MMAC). To enroll, the applicant must be a Medicare-certified and MO HealthNetenrolled home health agency, or be accredited by Joint Commission for Accreditation of Health Organization (JCAHO), or be accredited by Community Health Accreditation Partner (CHAP), or submit a Private Duty Nursing Provider Agreement Addendum to MMAC Provider Enrollment.

(4) Administrative Requirements for Private Duty Nursing Providers.

(A) The provider shall immediately notify the MMAC of any change in location, telephone number, or administrative or corporate status. A thirty- (30-) day written notice to the MMAC will be required of the provider prior to the voluntary termination of the provider agreement.

(B) The provider shall maintain bonding, personal and property liability, and medical malpractice insurance coverage on all employees involved in delivering nurse service in the home.

(C) The provider must have the capability to provide nursing staff outside of regular business hours, on weekends and on holidays to provide services in accordance with the plan of care authorized by the Bureau of Special Health Care Needs for each client.

(D) The provider must have a policy for responding to emergency situations. Services reimbursed by MO HealthNet may not exceed the prior authorization approved by the Bureau of Special Health Care Needs, therefore, any emergency situation resulting in service delivery beyond the limits of the prior authorization must be reported in writing to the Bureau of Special Health Care Needs within seventy-two (72) hours.

(E) The provider shall have a written statement of the participant’s Bill of Rights, which shall be given to the caretaker (if the participant is a minor) at the time the service is initiated.

(F) The provider shall have a written grievance policy which shall be provided to each participant or caretaker upon initiation of services. The grievance policy must also include the phone number of the Bureau of Special Health Care Needs and the MO HealthNet Division.

(G) The provider must report all instances of possible child abuse or neglect to the Child Abuse and Neglect (CA/N)

Hotline, 1-800-392-3738. Any suspected abuse or neglect by a caretaker, including private duty nursing staff, must be reported according to 210.110–210.189, RSMo, the Child Abuse Law. Failure to report by a mandatory reporter (private duty nursing staff would be considered mandatory reporters) is a violation of 210.115, RSMo, and could be subject to prosecution.

(H) The provider must maintain Missouri Corporate Good Standing status with the Office of the Missouri Secretary of State.

(5) Qualification Requirements for Private Duty Nursing Direct Care Staff and Supervisors.

(A) For nursing staff, the provider agency shall show evidence in the personnel record that the employee’s licensure status with the Missouri Board of Nursing is current.

(B) Upon initial employment, the provider shall document that at least two (2) employment or personal references (not to include relatives) were contacted prior to that employee delivering direct care services.

(C) The provider will be responsible for assuring and documenting that the nurse’s health permits performance of the required activities and does not pose a health hazard.

Service delivery shall be prohibited when the employee has a communicable condition.

(6) Requirements for Training for Private Duty Staff.

(A) All direct care staff (LPNs and RNs) must have at least four (4) hours of orientation training prior to service provision.

Orientation training should include general information about the MO HealthNet Private Duty Nursing Program, the HCY program, relationship of the provider agency with the MO HealthNet Division and the Bureau of Special Health Care Needs, the prior authorization process, child abuse/neglect indicators and reporting, participant rights, participant grievance procedures, internal agency policy, and a review of universal precaution procedures as defined by the Center for Disease Control.

(B) Prior to delivering services, LPNs must demonstrate competency in each task required by the plan of care. The competency demonstration must be conducted by an RN and must be documented in the LPN’s personnel file.

(C) All direct care staff must have a certificate in either (1/29/23) John R. Ashcroft cardiopulmonary resuscitation (CPR) or basic certified lifesupport (BCL).

(7) Requirements for Supervision of Private Duty Nursing Staff.

(A) Each agency shall employ an RN, with three (3) years’ nursing (RN and/or LPN) experience, to act as supervisor to all other nursing staff. One (1) year of experience must either be in supervisory position or in the field of pediatric nursing. The RN supervisor will be responsible for case conferences with staff nurses and documenting the conferences, assuring the competency of staff, training and orientation, and evaluation of direct care staff. An LPN with three (3) years’ experience may act as the assistant supervisor under the RN supervisor. One (1) year of experience must be in high acuity pediatric nursing care in a hospital, home care agency, or residential setting.

The assistant nursing supervisor may be responsible for case conferences with staff nurses, documenting the conferences, developing plan of care after the initial plan of care has been established by an RN, orientation, training, and evaluation of direct care staff and other duties delegated by the nursing supervisor.

(B) All nursing staff providing direct care shall have an annual performance evaluation completed by a licensed nurse supervisor, maintained in the personnel record.

(C) Frequency of supervisory visits.

1. Participants of private duty nursing care shall have a personal visit with assessment by a licensed nurse supervisor at least once every sixty (60) days if the participant is authorized for LPN service. Supervisory visits by a nurse will not be separately reimbursed.

2. Patients who have received RN shift care through the Private Duty Nurse Program or intermittent visits by an RN under the home health program (if those services were provided by an agency affiliated with the private duty provider) are not required to have a separate supervisory visit.

3. Supervisory visits, or explanation of why there are no separate supervisory visits for the month (that is, RN shifts were delivered), are to be documented in the participant record.

(8) Requirements for the Contents of Medical Records.

Appropriate medical records for each MO HealthNet participant served must be maintained at the private duty nursing agency. Records shall be kept confidential and access shall be limited to private duty nursing staff and representatives of the Departments of Social Services and Health and Senior Services.

(A) Medical records shall contain the following:

1. Identifying information about the participant, such as name, birthdate, MO HealthNet participant identification number, caretaker, and emergency contact person;

2. All forms or correspondence to and from the Bureau of Special Health Care Needs regarding the services which have been prior authorized;

3. Signed orders, under the direction of the participant’s physician, prior to service delivery which must be updated each time the prior authorization is due for approval by the Bureau of Special Health Care Needs;

4. Consent from the child’s legal custodian for treatment prior to service delivery;

5. The plan of care, documenting the amount, duration, and scope of the service. The level of care indicated in the plan of care (RN or LPN) must be based on acceptable standards of nursing practice. Reimbursement is based on the prior authorization approved by the Bureau of Special Health Care Needs, with that prior authorization based upon the plan of care, specifying the number of units and the skill level of the service, for periods of up to six (6) months;

6. Daily documentation of all services provided and any supervisory visits;

7. Documentation of the LPN’s competency demonstration before an RN when the plan of care includes the services of an LPN as required in subsection (6)(B); and 8. Documentation that a copy of the participant’s Bill of Rights was given to the participant, parent, or guardian.

(9) Reimbursement.

(A) Payment will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division.

1. A unit of service is fifteen (15) minutes.

2. The fee per unit of service will be based on the determination by the state agency of the reasonable cost of providing the covered services on a statewide basis and within the mandatory maximum payment limitations.

3. Payment will be made on the lower of the established rate per service unit or the provider’s billed charges. The charge billed to MO HealthNet may not be more than a provider’s ordinary charge to the general public for the same services.

(B) Conditions for Reimbursement.

1. Services will be authorized by the Bureau of Special Health Care Needs prior to delivery, in accordance with a private duty nursing care plan, specifying the amount, duration, and scope of services. The prior authorization will be the basis for reimbursement.

2. A MO HealthNet Division enrolled PDN agency may be reimbursed for PDN services rendered by a legal guardian or family member. A family member is defined as a parent; sibling; child by blood, adoption, or marriage; spouse; grandparent or grandchild. The PDN caregiver who delivers the direct care must have a valid RN or LPN license in the State of Missouri and be employed by the MO HealthNet Division enrolled PDN provider.

3. PDN services provided by a family member or legal guardian for a single participant or multiple participants with the same residence may not exceed twelve (12) hours per day up to a maximum of forty (40) hours per week. A family member or legal guardian shall not provide more than forty (40) hours of service in a seven- (7-) day period. For a family member or legal guardian, forty (40) hours is the total amount allowed regardless of the number of children who receive services.

( 10) MO HealthNet Private Duty Nursing Provider Manual. The Department of Social Services, MO HealthNet Division, shall administer the MO HealthNet Private Duty Nursing program.

The services covered and not covered, the program limitations, and the maximum allowable fees for all covered services shall be included in the Private Duty Nursing provider manual, 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 http://manuals.momed.com/collections/ collection_pdn/print.pdf, August 1, 2022. This rule does not incorporate any subsequent amendments or additions.

Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended:

Filed Dec. 14, 2007, effective June 30, 2008. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed April 21, 2020, effective Nov. 30, 2020. Amended: Filed Aug. 1, 2022, effective Feb. 28, 2023. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2022. Original rule filed Sept. 2, 1993, effective April 9, 1994. Amended: Filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed Jan. 15, 2004, effective Aug. 30, 2004.

Chapter 96 Medicaid Primary and Prenatal Care Clinic Program

13 CSR 70-96.010 Reimbursement for Medicaid Primary and Prenatal Care Clinic Program {#sec-13-csr-70-96.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-96.010}

(Rescinded June 30, 2018)

1987. Emergency rule filed Jan. 14, 1994, effective Feb. 2, 1994, expired June 1, 1994.

Emergency rule filed May 23, 1994, effective June 2, 1994, expired Sept. 29, 1994.

Emergency amendment filed June 21, 1995, effective July 1, 1995, expired Oct. 28, 1995.

Original rule filed Jan. 14, 1994, effective Aug. 28, 1994. Rescinded: Filed Nov. 3, 2017, effective June 30, 2018.

JOHNR. ASHCROFT(5/31/18)

History

• AUTHORITY: section 208.201, RSMo Supp.

Chapter 97 Health Insurance Premium Payment (HIPP) Program

13 CSR 70-97.010 Health Insurance Premium Payment (HIPP) {#sec-13-csr-70-97.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-97.010}

Program

PURPOSE: This rule establishes that the Department of Social Services, MO HealthNet Division shall pay for the cost of enrolling an eligible MO HealthNet participant in a group or individual health insurance plan when the MO HealthNet Division determines it is cost-effective to do so.

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) Definitions.

(A) “Group health insurance” shall mean any plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer’s employees, former employees, or the families of the employees or former employees. A group health plan must meet section 5000(b)(1) of the Internal Revenue Code of 1986, as amended, and include continuation coverage pursuant to Title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974, as amended. Participation in a health insurance plan that is not group health insurance as defined in this section is not a condition of MO HealthNet eligibility.

(B) “Participant” shall mean MO HealthNet enrollee eligible for comprehensive or full coverage under Medicaid.

(2) Condition of Eligibility. An individual eligible for MO HealthNet, or a person acting on the participant’s behalf, shall cooperate in providing information necessary for the MO HealthNet Division to establish availability and cost-effectiveness of group health insurance by completing the Application for Health Insurance Premium Payment (HIPP) Program, Form MO886-3179(2-98). As a condition of MO HealthNet eligibility, persons who are not enrolled in an available group insurance plan which the division has determined is cost-effective, and who are otherwise eligible for MO HealthNet, shall apply for enrollment in the plan.

(A) The Department of Social Services, MO HealthNet Division shall pay all enrollee premiums and deductibles, coinsurance and other cost-sharing obligations for items and services otherwise covered under the MO HealthNet program.

Payment of these items is considered as payment for medical assistance; the group health insurance is the primary payer to MO HealthNet. Only coverage of services not provided under the group health plan, but to which the individual is entitled under the MO HealthNet program, shall be provided under MO HealthNet as wrap-around coverage.

(B) When an applicant, participant, parent, guardian, or caretaker fails to provide information necessary to determine availability and cost-effectiveness of group health insurance, MO HealthNet benefits of the applicant, participant, parent, guardian, or caretaker shall be denied unless good cause for failure to cooperate is established. If an applicant, participant, parent, guardian, or caretaker fails to enroll in a group health insurance plan that has been determined cost-effective, or disenrolls from a group health insurance plan the department has determined cost-effective MO HealthNet benefits of the applicant, participant, parent, guardian, or caretaker shall be terminated unless good cause for failure to cooperate is established. Good cause for failure to cooperate shall be established when the applicant, participant, parent, guardian, or caretaker demonstrates one (1) or more of the following conditions exist:

1. There was a serious illness or death of the applicant, participant, parent, guardian, or caretaker or a member of the applicant’s, participant’s, parent’s, guardian’s, or caretaker’s family.

2. There was a family emergency or household disaster such as a fire, flood, or tornado;

3. The applicant, participant, parent, guardian, or caretaker offers a good cause beyond the applicant’s, participant’s, parent’s, guardian’s, or caretaker’s control; and 4. There was a failure to receive the department’s request for information or notification for a reason not attributable to the applicant, participant, parent, guardian, or caretaker.

Lack of a forwarding address is attributable to the applicant, participant, parent, guardian, or caretaker.

(C) MO HealthNet benefits of a child shall not be denied or terminated due to the failure of the parent, guardian, or caretaker to cooperate. Additionally, the MO HealthNet benefits of the spouse of the employed person shall not be denied or terminated due to the employed person’s failure to cooperate when the spouse cannot enroll in the plan independently of the employed person.

(3) Cost-effectiveness. Enrollment in a health insurance plan is considered cost-effective when the cost of paying the premiums, coinsurance, deductibles, and other cost-sharing obligations, and additional administrative costs is likely to be less than the amount paid for an equivalent set of MO HealthNet services. When determining the cost-effectiveness of the health insurance plan, the following data shall be considered:

(A) The cost of the insurance premium, coinsurance, and deductible;

(B) The scope of services covered under the insurance plan;

(C) The average anticipated MO HealthNet utilization, by age, sex, geographic location, and coverage group, for persons covered under the insurance plan;

(D) The specific health-related circumstances of the persons covered under the insurance plan; and (E) Annual administrative expenditures of an amount determined by the MO HealthNet Division per MO HealthNet participant covered under the health insurance policy.

(4) Coverage of Non-MO HealthNet-Eligible Family Members.

When it is determined to be cost-effective, the department shall pay for health insurance premiums for non-MO HealthNeteligible family members if a non-MO HealthNet-eligible family member must be enrolled in the health plan in order to obtain coverage for the MO HealthNet-eligible family members. When the department determines the health insurance plan or policy not to be cost-effective due to the cost of paying for non-MO HealthNet-eligible family members, the department shall con sider the cost of the insurance premiums for the policyholder and MO HealthNet-eligible family members only in the determi nation. This exception shall only apply if the option is available with the health insurance plan. However, the needs of the non-MO HealthNet-eligible family members shall not be taken (5/31/23) John R. Ashcroft into consideration when determining cost-effectiveness, and payments for deductibles, coinsurances, or other cost-shar ing obligations shall not be made on behalf of family members who are not MO HealthNet-eligible.

(5) Exceptions to Payment. Premiums shall not be paid for health insurance plans under any of the following circumstances:

(A) The insurance plan is designed to provide coverage only for a temporary period of time (for example, thirty to one hundred eighty (30–180) days);

(B) The insurance plan is a school plan offered on the basis of attendance or enrollment at the school;

(C) The premium is used to meet a spend-down obligation when all persons in the household are eligible or potentially eligible only under the spenddown program. When some of the household members are eligible for full MO HealthNet benefits, the premium shall be paid if it is determined to be cost-effective when considering only the persons receiving full MO HealthNet coverage. In those cases, the premium shall not be allowed as a deduction to meet the spenddown obligation for those persons in the household participating in the spenddown program. As long as the health insurance premium is not used as a deduction to income when determining client participation in the MO HealthNet program, then spenddown coverage shall not exclude a MO HealthNet eligible individual from participating in the HIPP program;

(D) The insurance plan is an indemnity policy which supplements the policyholder’s income or pays only a predetermined amount for services covered under the policy (for example, fifty dollars ($50) per day for hospital services instead of eighty percent (80%) of the charge);

(E) CHIP-eligible participants;

(F) Medicare;

(G) Court-ordered health insurance;

(H) The persons covered under the plan are not MO HealthNeteligible on the date the decision regarding eligibility for the HIPP program is made; or (I) The participant is enrolled in a MHD managed care plan.

(6) Duplicate Policies. When more than one (1) health insurance plan or policy is available, the Department of Social Services, MO HealthNet Division shall pay only for the most cost-effective plan.

(7) Discontinuance of Premium Payments. When all MO HealthNet-eligible members covered under the health insurance plan lose MO HealthNet eligibility, premium payments shall be discontinued as of the month of MO HealthNet ineligibility. When only some of the MO HealthNet-eligible members covered under the health insurance plan lose MO HealthNet eligibility, a review shall be completed in order to ascertain whether payment of the health insurance premium continues to be cost-effective.

(8) Effective Date of Premium Payment. The effective date of premium payments for cost-effective health insurance plans shall be determined as follows:

(A) Premium payments for cost-effective health insurance plans shall begin with the month the HIPP program application is received by the department, or the effective date of eligibility, whichever is later. If the person is not currently enrolled in the cost-effective health insurance plan, premium payments shall begin in the month in which the first premium payment is due after enrollment occurs; and (B) In no case shall payments be made for premiums which are used as a deduction to income when determining client participation in the MO HealthNet program.

(9) Method of Premium Payment. Payments of health insurance premiums will be made directly to the insurance carrier except as follows:

(A) The department may arrange for payment to the employer to circumvent a payroll deduction;

(B) When the employer will not agree to accept premium payments from the department in lieu of a payroll deduction to the employee’s wages, the department shall prospectively pay the policyholder directly for payroll deductions or for payments made directly to the employer for the payment of health insurance premiums;

(C) When premium payments occur through an automatic withdrawal from a bank account by the insurance carrier, the department may prospectively pay the policyholder for said withdrawals;

(D) When the department is otherwise unable to make direct premium payments because the health insurance is offered through a contract that covers a group of persons identified as individuals by reference to their relationship to the entity, the department shall prospectively pay the policyholder for premium payments made to the entity; and (E) Participants shall provide documentation to the department of the monthly premium paid by payroll deduction or bank account auto-withdrawal. This documentation must be received by the department on a monthly basis. Failure to provide this documentation on a timely basis may result in non-payment of the HIPP premium by the department or exclusion from the HIPP program.

(10) Reviews of Cost-Effectiveness. Reviews of cost-effectiveness will be completed at least every six (6) months for employer-related group health plans and annually for nonemployer-related group health plans. Additionally, redeterminations shall be completed whenever a predetermined premium rate, deductible, or coinsurance increases, some of the persons covered under the policy lose full MO HealthNet eligibility, there is a change in MO HealthNet eligibility, loss of employment when the insurance is through an employer, or there is a decrease in the services covered under the policy. Participants shall report all changes concerning health insurance coverage to the local Family Support Division’s office within ten (10) days of the change.

(11) Notices.

(A) Notice shall be provided to the household under the following circumstances:

1. To inform the household of the initial decision on cost-effectiveness and premium payment (Form MO886- 3180(02/05) or Form MO886-3181(02/05));

2. To inform the household that premium payments are being discontinued because MO HealthNet eligibility has been lost by all persons covered under the policy (Form MO886-3182(02/05)); or 3. The policy is no longer available to the family (for example, the employer drops insurance coverage or the policy is terminated by the insurance company, Form MO886-3182(02/05)).

(B) A timely notice shall be provided to the household informing them of a decision to discontinue payment of the health insurance premium because the department has determined the policy is no longer cost-effective (Form MO886-3182(02/05)).

(C) Notice of appeal and hearing rights are as provided for in 208.080, RSMo.

(12) Premium or Rate Refunds. The department shall be entitled to any premium refund due to overpayment of premium or payment of an inactive policy for any time period for which the department paid the premium. The department shall be entitled to any rate refund made when the health insurance carrier determines a return of premiums to the policyholder is due, because of lower than anticipated claims, for any time period for which the department paid the premium.

(13) Administration. HIPP Program information and forms are currently located and can be accessed on the MO HealthNet Division’s website at www.dss.mo.gov/mhd.

(14) Dental and Vision Benefits. Dental and vision insurance policies will not be eligible for premium assistance unless the benefits are part of the medical policy and cannot be separated from the medical policy premium. Dental and vision benefits will be provided to participants through wrap-around coverage.

(15) Cost Sharing. The department must be notified three (3) weeks prior to a Medicaid-covered service to receive prospective payment for any cost sharing obligation. Payment for cost sharing related to services obtained without notice to the department will be reimbursed. Documentation supporting the services occurred, and cost sharing payment was made, must be submitted to the department by the end of the month following the date of service.

Amended: Filed Feb. 1, 2008, effective Aug. 30, 2008. Amended:

Filed Dec. 1, 2010, effective June 30, 2011. Amended: Filed Oct. 31, 2022, effective June 30, 2023. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012, 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016. Original rule filed June 30, 1994, effective Jan. 29, 1995. Emergency amendment filed Aug. 19, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 1, 2005, effective Nov. 30, 2005.

Chapter 98 Behavioral Health Services

13 CSR 70-98.020 Prior Authorization Committee for Non-Pharmaceutical Behavioral {#sec-13-csr-70-98.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-98.020}

13 CSR 70-98.015 Behavioral Health Services Program {#sec-13-csr-70-98.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-98.015}

PURPOSE: This rule establishes the regulatory basis for the program requirements of the MO HealthNet behavioral health services program.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet behavioral health services program shall be administered by the Department of Social Services, MO HealthNet Division (MHD). The services covered and not covered and the limitations under which services are covered shall be determined by MHD and shall be included in the MO HealthNet Behavioral Health Services Provider Manual, May 2, 2025, and the Physician Provider Manual, May 6, 2025, which are incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or additions. Behavioral health services shall include only those which are clearly shown to be medically necessary.

(2) Persons Eligible. The MO HealthNet Program pays for approved MO HealthNet behavioral health services when furnished within the provider’s scope of practice. The participant must be eligible on the date the service is furnished.

Participants may have specific limitations for behavioral health services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the provider manual.

The provider shall ascertain the patient’s MO HealthNet and managed care or other lock-in status before any service is performed. The participant’s MO HealthNet eligibility shall be verified in accordance with methodology outlined in the provider manual. Eligible participants shall have access to non-pharmaceutical behavioral health services when they are determined medically necessary using the appropriate diagnostic criteria as follows:

(A) For individuals aged six (6) years and over, providers shall use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR ), which is incorporated by reference in this rule as published by American Psychiatric Association Publishing, 800 Maine Avenue SW, Suite 900, Washington, DC 20024, March 16, 2022. A copy of the DSM-5- TR is available for review at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or editions;

(B) For individuals under the age of six (6) years, it is recommended and preferred that providers use the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5 ), which is incorporated by reference in this rule as published by Zero to Three, 1255 23rd Street NW, Suite 350, Washington, DC 20037, December 8, 2016. A copy of the DC:0-5 is available for review at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or editions; and (C) Use of the DSM-5-TR will be allowed when assessing children zero through five (0–5) years of age until January 1, 2029, at which time the DC:0-5 will become required.

(3) Provider Participation. To be eligible to participate as a MO HealthNet provider of behavioral health services, a provider must meet the qualifications specified by the state agency for his or her profession and be an enrolled MO HealthNet provider.

(A) The enrolled MO HealthNet provider shall comply with the following requirements:

1. Maintain adequate documentation and adequate records in accordance with 13 CSR 70-3.030(2)(A); and 2. On request furnish to the MO HealthNet agency, the Medicaid Audit and Compliance Unit, or State Medicaid Fraud Control Unit any information regarding payments claimed by the provider for furnishing services under the plan.

rule filed Nov. 14, 2003, effective June 30, 2004. Amended: Filed Oct. 30, 2007, effective April 30, 2008. Amended: Filed June 2, 2008, effective Nov. 30, 2008. Amended: Filed Oct. 31, 2008, effective May 30, 2009. Amended: Filed Sept. 26, 2013, effective March 30, 2014. Amended: Filed Oct. 1, 2018, effective May 30, 2019.

Amended: Filed Aug. 16, 2024, effective April 30, 2025. Amended:

Filed Dec. 23, 2025, effective July 30, 2026. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

13 CSR 70-98.020 Prior Authorization Committee for Non- Pharmaceutical Behavioral Health Services {#sec-13-csr-70-98.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-98.020}

(Rescinded November 30, 2024)

rule filed Jan. 15, 2004, effective Aug. 30, 2004. Amended: Filed Oct. 30, 2007, effective April 30, 2008. Amended: Filed Oct. 10, 2013, effective April 30, 2014. Amended: Filed Oct. 1, 2018, effective May 30, 2019. Rescinded: Filed May 6, 2024, effective Nov. 30, 2024.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

13 CSR 70-98.030 Applied Behavior Analysis Services {#sec-13-csr-70-98.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-98.030}

PURPOSE: This rule establishes the regulatory basis for coverage and reimbursement for applied behavior analysis services under the Medicaid state plan.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that 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) Definitions.

(6/30/26) Denny Hoskins (A) “Applied Behavior Analysis (ABA)” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior. ABA does not include psychological testing, personality assessment, intellectual assessment, neuropsychological assessment, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, or counseling.

(B) “ABA Assessment for Intervention Planning” means assessment that is conducted according to best practice guidelines and considers the individual’s specific strengths and concerns to inform the intervention planning process.

(C) “ABA intervention” means a type of intervention that involves directly and objectively measuring potential target behaviors and environmental events that influence them; constructing detailed, individualized behavior analytic treatment plans; using reinforcement and other scientifically validated procedures to build functional skills and reduce behaviors that jeopardize health, safety, and independent functioning; managing treatment environments to maximize client progress; implementing treatment protocols repeatedly, frequently, and consistently; measuring target behaviors directly and frequently; and adjusting treatment protocols based on data.

(D) “Licensed Psychologist (LP)” means an individual who is currently licensed by the psychology board of the state in which the individual is practicing.

(E) “Autism Spectrum Disorder (ASD)” as defined in the most recent edition of Diagnostic and Statistical Manual of Mental Disorders.

(F) “Best practice guidelines” means guidelines described in the Missouri Autism Guidelines Initiative’s publications entitled Autism Spectrum Disorders: Missouri Best Practice Guidelines for Screening, Diagnosis, and Assessment as published by the Missouri Department of Mental Health at their website at https:// www.autismguidelines.dmh.mo.gov/pdf/Guidelines.pdf, 2010, and Autism Spectrum Disorders: Guide to Evidence-Based Interventions as published by the Missouri Department of Mental Health at their website at https://www.autismguidelines.dmh. mo.gov/documents/Interventions.pdf, 2012. These guidelines are incorporated by reference and made a part of this rule and a copy of each is available for reference at the MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This

rule does not incorporate any subsequent amendments or additions.

(G) “Diagnostic evaluation” means evaluation conducted according to best practice guidelines in order to determine if an ASD is present;

(H) “Licensed Assistant Behavior Analyst (LABA)” means an individual who is currently licensed to practice applied behavior analysis under the supervision of a licensed behavior analyst by the behavior analyst board under which the individual is practicing.

(I) “Licensed Behavior Analyst (LBA)” means an individual who is currently licensed by the behavior analyst board of the state in which the individual is practicing.

(J) “Technician” means an individual who is credentialed by the Behavior Analyst Certification Board (BACB) as a Registered Behavior Technician (RBT ).

(2) Administration.

(A) The MO HealthNet ABA program shall be administered by the Department of Social Services, MO HealthNet Division. ABA services covered and not covered and the limitations under which services are covered shall be determined by the MO HealthNet Division and shall be included in the MO Health- Net provider manual, 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 http://manuals.momed. com/collections/collection_psy/print.pdf, August 25, 2022. This

rule does not incorporate any subsequent amendments or additions.

(3) Participant Criteria.

(A) In order to qualify for and receive ABA services, a MO HealthNet participant must meet all of the following criteria:

1. Be under twenty-one (21) years of age;

2. Exhibit the presence of excesses and/or deficits of behaviors that significantly interfere with home or community activities (examples include but are not limited to aggression, self-injury, and elopement); and 3. Have a diagnostic evaluation performed by a licensed physician or licensed psychologist, resulting in a diagnosis of ASD, and recommending ABA services as medically necessary.

(4) Provider Criteria.

(A) To direct, supervise, and render ABA services, a professional shall meet the following specifications:

1. Be currently licensed as an LBA or LP;

2. In order to be reimbursed by the MO HealthNet Division for ABA services, an LP must have ABA in his/her education, training, and experience;

3. Be covered by professional liability insurance [to] with minimum limits of one (1) million dollars per occurrence, three (3) million dollars aggregate;

4. Have no sanctions or disciplinary actions by the applicable state licensing board or the BACB;

5. Have no current overpayment(s) due MO HealthNet and no Medicare or Medicaid sanctions or exclusions from participation in federally funded programs; and 6. Be currently enrolled with MO HealthNet as a provider.

(B) Assistant behavior analysts who render or supervise ABA services shall meet the following qualifications:

1. Be currently licensed as an LABA;

2. Be currently supervised by an LBA.

A. The supervisory relationship must be documented in writing;

3. Be covered by professional liability insurance with minimum limits of one (1) million dollars per occurrence, three (3) million dollars aggregate;

4. Have no sanctions or disciplinary actions by the state licensing board or BACB;

5. Have no current overpayment(s) due MO HealthNet and no Medicaid or Medicare sanctions or exclusions from participation in federally funded programs; and 6. Be currently enrolled with MO HealthNet as a provider.

(C) Technicians who render ABA services shall— 1. Be credentialed by the BACB as an RBT ;

2. Work under the supervision of an LBA, LP (if officially granted supervisory privileges by the BACB), or LABA to the extent allowed for holders of the latter credential and at the discretion of the supervising LBA. RBT s are required by the BACB to be supervised by LBAs who are also Board Certified Behavior Analysts, Board Certified Behavior Analysts-Doctoral, Board Certified Assistant Behavior Analysts, or members of a professional group officially granted supervisory privileges by the BACB.

A. The supervisory relationship must be documented in writing; and 3. Have no current overpayment(s) due MO HealthNet and no Medicaid or Medicare sanctions or exclusions from participation in federally funded programs.

(5) Covered Services and Limitations.

(A) MO HealthNet covered ABA services (ABA assessment for intervention planning and ABA intervention) must be— 1. Medically necessary;

2. Precertified by MO HealthNet or its designee;

3. Delivered in accordance with the participant’s treatment plan; and 4. Overseen and delivered by providers who meet criteria specified herein.

(B) Medical necessity for initial ABA assessment for intervention planning shall be determined based on a diagnostic evaluation. Medical necessity for periodic reassessments shall be determined based on rationale for reassessment, to include but not limited to such considerations as readministration of tools, new behavior observed, new environment and participant responding differently, or lack of adequate progress. Medical necessity for ABA intervention shall be determined based on an ABA assessment for intervention planning for initial intervention. Medical necessity for continued ABA intervention beyond the initial precertification period shall be determined based upon requested documentation including but not limited to updated treatment plan and progress graphs. If progress is not evident, identification of barriers to progress and strategies to improve effectiveness of interventions are required.

(C) ABA intervention services may be precertified for a time period not to exceed one hundred eighty (180) days. Services provided without precertification shall not be considered for reimbursement, except in the case of retroactive MO HealthNet eligibility.

(D) Service Limitations.

1. Services shall be based upon the individual needs of the child and must give consideration to the child’s age, school attendance requirements, and other daily activities as documented in the treatment plan.

2. Services must be delivered in a clinically appropriate setting for the behavior being treated.

(6) Not Medically Necessary/Non-Covered Services. The following services do not meet medical necessity criteria, nor qualify as MO HealthNet covered ABA services:

(A) Intervention services rendered when measurable functional improvement is not expected and services are not necessary to maintain function or prevent deterioration;

(B) Services that are solely educational are not covered. ABA treatment goals, objectives, and procedures that may be related in some way to educational activities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered;

(C) Services that are solely vocational or recreational are not covered. ABA treatment goals, objectives, and procedures that may be related in some way to vocational or recreational activities but are medically necessary to address the deficits and symptoms of ASD in an individual are covered; and (D) Custodial care is not an ABA service and is not covered as

part of this benefit. Developing, restoring, or maintaining selfhelp, daily living, or safety skills as part of an ABA treatment plan does not constitute custodial care and are covered.

(7) ABA Treatment Plan.

(A) ABA intervention services shall be rendered in accordance with the individual’s treatment plan. The treatment plan shall— 1. Be person centered and individualized;

2. Be developed by an LBA or LP;

3. Be based on the ABA assessment for intervention planning;

4. Include assessment and treatment protocols for addressing each of the target behaviors;

5. Include training to enable LABAs and RBT s to implement assessment and treatment protocols;

6. Include training and support to enable parents and other caregivers to participate in treatment planning and treatment plan implementation;

7. Include care coordination involving the parents or caregiver(s), school, state disability programs, and others as applicable; and 8. Be consistent with applicable professional standards and guidelines relating to the practice of ABA as well as state Medicaid laws and regulations and applicable Missouri licensure laws and regulations.

(8) Reimbursement Methodology.

(A) MO HealthNet shall provide reimbursement for ABA services to enrolled LBAs or LPs who are currently licensed and in good standing with the state. Payment for services rendered by LABAs shall be made to the LBA supervising and employing these personnel. Payment for services rendered by technicians shall be made to the LBA or LP supervising and employing these personnel. If the LBA or LP operates through an agency or corporate entity, payment may be made to that agency or entity. Reimbursement for ABA services shall not be made to or for services rendered by a parent, a legal guardian, or other legally responsible person.

(B) Reimbursement for ABA services is made on a fee-for-services basis. The maximum allowable fee for a unit of service has been determined by the MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care.

Payment for covered services is the lower of the provider’s actual billed charge (should be the provider’s usual and customary charge to the general public for the service), or the maximum allowable per unit of service. Reimbursement shall only be made for services precertified by MO HealthNet or its designee.

(C) The fee schedule and any annual/periodic adjustments to the fee schedule are published at https://dss.mo.gov/mhd/ providers/pages/cptagree.htm. The fee schedule is incorporated by reference and made a part of this rule as published by the Department of Social Services, Division of Legal Services, 221 West High Street, Jefferson City, MO 65101, at its website at https://apps.dss.mo.gov/fmsFeeSchedules/default.aspx, August 25, 2022. This rule does not incorporate any subsequent amendments or additions.

rule filed Dec. 14, 2015, effective July 30, 2016. Amended: Filed Aug. 25, 2022, effective March 30, 2023. *Original authority: 208.201, RSMo 1987, amended 2007; 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 208.201 and 660.017, RSMo 2016. Original

Chapter 99 Comprehensive Day Rehabilitation

13 CSR 70-99.010 Comprehensive Day Rehabilitation Program {#sec-13-csr-70-99.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-99.010}

PURPOSE: This rule establishes the regulatory basis for the administration of the Comprehensive Day Rehabilitation Program. This

rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available under the MO HealthNet program as may be necessary to safeguard against unnecessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of provider participation, criteria and methodology for provider reimbursement, participant eligibility, and amount, duration, and scope of services covered are included in the Comprehensive Day Rehabilitation Program manual, which is incorporated by reference in this rule and available at the website www.dss.mo.gov/mhd.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet Comprehensive Day Rehabilitation Program shall be administered by the Department of Social Services, MO HealthNet Division. The Comprehensive Day Rehabilitation services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet provider manuals, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website http://manuals.momed.com/manuals/, September 6, 2019. This rule does not incorporate any subsequent amendments or additions. Comprehensive Day Rehabilitation Program services shall include only those services that are prior authorized by the MO HealthNet Division or its designee.

(2) Persons Eligible. Prior authorized Comprehensive Day Rehabilitation services are covered for individuals with disabling impairments as the result of a traumatic head injury that are under the age of twenty-one (21), blind, or pregnant. The program provides intensive, comprehensive services designed to prevent or minimize chronic disabilities while restoring the individual to an optimal level of physical, cognitive, and behavioral function. Emphasis in the program is on functional living skills, adaptive strategies for cognition, memory or perceptual deficits, and appropriate interpersonal skills. The participant must be eligible on the date the service is furnished. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the Comprehensive Day Rehabilitation Program manual. The provider shall ascertain the patient’s MO Health- Net/managed care status before any service is performed. The participant’s eligibility shall be verified in accordance with methodology outlined in the Comprehensive Day Rehabilitation Program manual.

(3) Provider Participation. To be eligible for participation in the MO HealthNet Comprehensive Day Rehabilitation Program, a provider must have the certificate of accreditation (CARF) from the Rehabilitation Accreditation Commission, employ and retain qualified/licensed head injury professionals qualified to render the services covered through the Comprehensive Day Rehabilitation Program, be a free standing rehabilitation center or in an acute hospital setting with space dedicated to head injury rehabilitation, and be an enrolled MO HealthNet provider.

(4) Prior Authorization. Comprehensive Day Rehabilitation services must be prior authorized by the MO HealthNet Division or its designee in order for the provider to receive reimbursement. The request is reviewed by a medical consultant, and the provider is notified if the request is approved or, if not approved, the reason for denial. No more than six (6) months of services will be approved. It is possible to receive an additional six- (6-) month authorization if the patient is showing progress toward treatment goals. The maximum period of Comprehensive Day Rehabilitation services covered is one (1) year.

(5) Covered Services. Comprehensive Day Rehabilitation Program services are covered for half-day (three (3) to four (4) hours) and full day (five (5) or more hours) units when the participant meets the admission criteria and is prior authorized by the MO HealthNet Division or its designee.

(6) Reimbursement. Payment will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for Comprehensive Day Rehabilitation services. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charges.

Comprehensive Day Rehabilitation Program services are only payable to the enrolled, eligible, participating provider. The MO HealthNet program cannot reimburse for services performed by non-enrolled providers.

(7) Documentation Requirements for Comprehensive Day Rehabilitation Program.

(A) The following must be maintained in the participant’s clinical record:

1. Presenting complaint/request for assistance;

2. Relevant treatment history and background information;

3. Reported physical/medical/cognitive/psychological complaints;

4. Pertinent functional weaknesses and strengths;

5. Findings from formal assessments;

6. Plan of care;

7. Interview and behavioral observations;

8. Diagnostic formulation;

9. Recommendations for further evaluation and/or treatment needs; and 10. Dates of periodic review of the plan of care.

(8) Records Retention. These records must be retained for six (6) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request.

Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a (2/28/21) JOHN R. ASHCROFT violation of this regulation.

Filed Oct. 30, 2007, effective April 30, 2008.

Amended: Filed Sept. 16, 2020, effective March 30, 2021. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.164, RSMo 1982, amended 1995; 208.201, RSMo 1987, amended 2007; 208.631, RSMo 1998, amended 2002, 2006, 2007, 2014; 208.633, RSMo 1998; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: section 208.152, RSMo Supp. 2020, and sections 208.153, 208.164, 208.201, 208.631, 208.633, and 660.017, RSMo 2016. Emergency rule filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Original rule filed June 1, 2005, effective Nov. 30, 2005. Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended:

Chapter 100 Missouri Rx Plan

13 CSR 70-100.010 Missouri Rx Plan Benefits and Limitations {#sec-13-csr-70-100.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 70-100.010}

PURPOSE: This rule establishes the benefits and limitations for administering the Missouri Rx Plan and Missouri’s State Pharmacy Assistance Program.

(1) Administration. The Missouri Rx Plan shall be administered by the Department of Social Services, MO HealthNet Division.

(2) Definitions.

(A) Dual eligible—An individual who is eligible for both Medicare and Medicaid.

(B) Missouri Rx Plan—The state pharmacy assistance program administered by the Department of Social Services, MO Health- Net Division.

(C) Out-of-pocket costs—The co-pays required for prescription drug. The Missouri Rx Plan does not pay for the Medicare Part D monthly premium.

(3) Individuals who are enrolled in Medicare and MO HealthNet (dual eligibles) are deemed to have enrolled in the Missouri Rx Plan.

(4) Benefit Limits.

(A) The Missouri Rx Plan shall pay fifty percent (50%) of the member’s out-of-pocket costs for prescription drugs covered by the Medicare Prescription Drug Program and by the members Medicare Part D Plan formulary.

(B) Members with a MO HealthNet spenddown requirement must meet the spenddown at least once during the calendar year for the Missouri Rx Plan to pay fifty percent (50%) of the member’s out-of-pocket costs.

(C) The Missouri Rx Plan shall have the

(5) Termination from the Program.

(A) A member shall be terminated from the Missouri Rx Plan if he or she no longer meets the MO HealthNet or Medicare eligibility requirements.

History

• authority to change the benefit limits at any time to achieve program cost control.
• AUTHORITY: sections 208.201, 208.782, 208.786, and 660.017, RSMo 2016. Original rule filed Aug. 15, 2014, effective Feb. 28, 2015. Amended: Filed Sept. 22, 2021, effective April 30, 2022. Original authority: 208.201, RSMo 1987, amended 2007; 208.782, RSMo 2005; 208.786, RSMo 2005; and 660.017, RSMo 1993, amended 1995.

Division 73 Missouri Board of Nursing Home Administrators

Chapter 1 Moved to 19 CSR 73-1.010

13 CSR 73-1.010 General Organization {#sec-13-csr-73-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-1.010}

(Moved to 19 CSR 73-1.010)

MATTBLUNT(7/31/03)

Chapter 1óOrganization and Description of Board13 CSR 73-1

Chapter 2 General Rules (Moved to 19 CSR 73-2)

13 CSR 73-2.020 Procedures and Requirements for Licensure of {#sec-13-csr-73-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.020}

13 CSR 73-2.060 Registration of Training Agencies and Single Offering Providers {#sec-13-csr-73-2.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.060}

13 CSR 73-2.065 Reciprocity Approval of Continuing Education Programs 2CODE OF STATE REGULATIONS (7/31/03) MATTBLUNT {#sec-13-csr-73-2.065 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.065}

13 CSR 73-2.100 Restoration and Rehabilitation of Suspended/Revoked Licenses MATTBLUNT(7/31/03) {#sec-13-csr-73-2.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.100}

Chapter 2óGeneral Rules13 CSR 73-2 Title 13óDEPARTMENT OF SOCIAL SERVICES Division 73óMissouri Board of Nursing Home Administrators

Chapter 2óGeneral Rules

13 CSR 73-2.010 Definitions {#sec-13-csr-73-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.010}

(Moved to 19 CSR 73-2.010)

13 CSR 73-2.015 Fees {#sec-13-csr-73-2.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.015}

(Moved to 19 CSR 73-2.015)

13 CSR 73-2.020 Procedures and Requirements for Licensure of Nursing Home Administrators {#sec-13-csr-73-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.020}

(Moved to 19 CSR 73-2.020)

13 CSR 73-2.025 Licensure by Reciprocity {#sec-13-csr-73-2.025 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.025}

(Moved to 19 CSR 73-2.025)

13 CSR 73-2.030 Examination {#sec-13-csr-73-2.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.030}

(Rescinded August 11, 1980)

Original rule filed March 5, 1974, effective March 15, 1974. Rescinded: Filed May 13, 1980, effective Aug. 11, 1980.

History

• AUTHORITY: section 344.070, RSMo 1978.

13 CSR 73-2.031 Prescribed Course of Instruction and Training {#sec-13-csr-73-2.031 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.031}

(Moved to 19 CSR 73-2.031)

13 CSR 73-2.040 Board {#sec-13-csr-73-2.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.040}

(Rescinded August 11, 1980)

Original rule filed March 5, 1974, effective March 15, 1974. Rescinded: Filed May 13, 1980, effective Aug. 11, 1980.

History

• AUTHORITY: section 344.070, RSMo 1978.

13 CSR 73-2.041 Cumulative Point-Value System {#sec-13-csr-73-2.041 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.041}

(Rescinded November 30, 2001)

1997. Original rule filed May 13, 1980, effective Aug. 11, 1980. Amended: Filed April 14, 1983, effective July 11, 1983.

Amended: Filed Oct. 16, 1985, effective March 14, 1986. Amended: Filed Jan. 3, 1992, effective May 14, 1992. Amended:

Filed April 30, 1998, effective Oct. 30, 1998.

Rescinded: Filed April 30, 2001, effective Nov. 30, 2001.

History

• AUTHORITY: section 344.070, RSMo Supp.

13 CSR 73-2.050 Renewal of Licenses {#sec-13-csr-73-2.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.050}

(Moved to 19 CSR 73-2.050)

13 CSR 73-2.051 Retired Licensure Status {#sec-13-csr-73-2.051 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.051}

(Moved to 19 CSR 73-2.051)

13 CSR 73-2.055 Renewal of Expired License {#sec-13-csr-73-2.055 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.055}

(Moved to 19 CSR 73-2.055)

13 CSR 73-2.060 Registration of Training Agencies and Single Offering Providers {#sec-13-csr-73-2.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.060}

(Moved to 19 CSR 73-2.060)

13 CSR 73-2.065 Reciprocity Approval of Continuing Education Programs {#sec-13-csr-73-2.065 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.065}

(Rescinded July 30, 1996)

1993. Original rule filed April 18, 1990, effective Nov. 30, 1990. Rescinded: Filed Jan. 31, 1996, effective July 30, 1996.

History

• AUTHORITY: section 344.070, RSMo Supp.

13 CSR 73-2.070 Examination {#sec-13-csr-73-2.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.070}

(Moved to 19 CSR 73-2.070)

13 CSR 73-2.080 Temporary Emergency Licenses {#sec-13-csr-73-2.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.080}

(Moved to 19 CSR 73-2.080)

13 CSR 73-2.085 Public Complaints {#sec-13-csr-73-2.085 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.085}

(Moved to 19 CSR 73-2.085)

13 CSR 73-2.090 Disciplinary Action {#sec-13-csr-73-2.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.090}

(Moved to 19 CSR 73-2.090)

13 CSR 73-2.095 Standards of Professional Conduct {#sec-13-csr-73-2.095 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.095}

(Moved to 19 CSR 73-2.095)

13 CSR 73-2.100 Restoration and Rehabilitation of Suspended/Revoked Licenses {#sec-13-csr-73-2.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.100}

(Moved to 19 CSR 73-2.100)

13 CSR 73-2.105 Disciplinary Proceedings {#sec-13-csr-73-2.105 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.105}

(Moved to 19 CSR 73-2.105)

13 CSR 73-2.110 Display of License {#sec-13-csr-73-2.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.110}

(Moved to 19 CSR 73-2.110)

13 CSR 73-2.120 Duplicate License {#sec-13-csr-73-2.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.120}

(Moved to 19 CSR 73-2.120)

13 CSR 73-2.130 Notice of Change of Address {#sec-13-csr-73-2.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 73-2.130}

(Moved to 19 CSR 73-2.130)

Division 100 Veterans' Affairs

Chapter 1 Veterans' Affairs

13 CSR 100-1.010 Division of Veterans’ Affairs {#sec-13-csr-100-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 100-1.010}

(Rescinded June 28, 1990)

MATTBLUNT(7/31/02)

History

• AUTHORITY: section 536.023(3), RSMo 1986. Original rule filed Dec. 29, 1975, effective Jan. 9, 1976. Rescinded: Filed March 22, 1990, effective June 28, 1990.

Chapter 2 Federal Soldiers' Home

13 CSR 100-2.010 Federal Soldiers’ Home {#sec-13-csr-100-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 100-2.010}

(Rescinded June 28, 1990)

Filed March 22, 1990, effective June 28, 1990.

MATTBLUNT(7/31/02)

History

• AUTHORITY: section 212.130, RSMo 1986 and Omnibus State Reorganization Act of 1974. This rule was previously filed as 13 CSR 100-2.010. Original rule filed Dec. 29, 1975, effective Jan. 9, 1976. Rescinded:

Division 110 Division of Youth Services

Chapter 1 Organization and Description

13 CSR 110-1.010 General Organization {#sec-13-csr-110-1.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-1.010}

PURPOSE: The purpose of this regulation is to comply with section 536.023, RSMo Supp. 1999 which requires each agency to adopt as a rule a description of its operation and the methods where the public may obtain information or make submissions or requests.

(1) The Division of Youth Services is a division of the Department of Social Services.

(A) The division is responsible for the development and administration of an effective state-wide comprehensive program of youth services. This includes, but is not limited to:

1. Providing for the reception, classification, care, activities, education and rehabilitation of all youth committed to the division;

2. Administering the interstate compact on juveniles;

3. Collecting statistics and information relating to the nature, extent and causes of, and conditions contributing to, the delinquency of youth;

4. Evaluating existence and effectiveness of delinquency prevention and rehabilitation programs;

5. Preparing a master plan for the development of a state-wide comprehensive system of delinquency prevention, control and rehabilitation services;

6. Providing from funds specifically appropriated by the legislature for this purpose, financial subsidies to local units of government for the development of communitybased treatment services;

7. Developing written instructional, informational and standard-setting materials relating to state and local delinquency prevention, control and rehabilitation programs, as provided for in these rules;

8. Cooperating with and assisting other public and voluntary agencies and organizations in the development and coordination of such programs; and 9. Upon request, assisting local units of government in the development of community-based treatment services and providing technical assistance and consultation to law enforcement officials, juvenile courts and other community child care agencies.

Filed Feb. 10, 2000, effective Aug. 30, 2000. *Original authority: 210.570, RSMo 1955; 210.610, RSMo 1979; 219.016, RSMo 1975, amended 1993, 1995; 219.021, RSMo 1975, amended 1980, 1981, 1987, 1993, 1995; 219.036, RSMo 1975, amended 1993; 219.041, RSMo 1975; 219.051, RSMo 1975.

Rebecca McDowell Cook (7/31/00)

History

• AUTHORITY: sections 210.570, 210.610, 219.036.7, 219.041.2 and 219.051, RSMo 1994. 219.016.6, 219.021.2, and 219.021.8, RSMo Supp 1999. Original rule filed Aug. 13, 1976, effective Dec. 15, 1976. Amended:

Chapter 2 Classification Services and Residential Care

13 CSR 110-2.020 Classification and Assignment from Reception Centers {#sec-13-csr-110-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.020}

13 CSR 110-2.040 Classification Criteria for Placement into Division of {#sec-13-csr-110-2.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.040}

13 CSR 110-2.120 Administrative Decisions Affecting the Rights of Youth in DYS JOHNR. ASHCROFT(10/31/18) {#sec-13-csr-110-2.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.120}

SOCIAL SERVICES

Residential Care

13 CSR 110-2.010 Regional Classification Services {#sec-13-csr-110-2.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.010}

PURPOSE: The purpose of this rule is to establish guidelines and lines of authority for the classification procedure when a youth is classified from one of the juvenile courts by a regional administrator or his/her designee.

(1) Each regional administrator or his/her designee, subject to all other divisional rules and policies, has full authority to assign youth to any residential unit or appropriate other placement. Classification criteria to be used is contained in 13 CSR 110-2.040.

(2) After a determination of the type of program in which a youth could best function, if it is determined s/he could best function in a community-based program, the assignment will be made in the following priority order:

(A) If a vacancy exists in the youth’s home community, the regional administrator should assign the youth to a program in that community;

(B) If no vacancy exists in a local program, the assignment can be made on a regional

basis; and (C) When none of the circumstances in (2)(A)–(B) exist, the youth can be assigned to a community-based program regardless of the location as long as the regional administrator still considers the assignment in the best interest of the youth.

(3) The division will inform the juvenile court of where the youth is to be delivered and will ensure that all the appropriate records are delivered with the youth.

History

• AUTHORITY: section 219.036, RSMo 1994. Jan. 9, 1976. Amended: Filed Feb. 10, 2000, Original authority: 219.036, RSMo 1975, amended 1993,

13 CSR 110-2.020 Classification and Assignment from Reception Centers {#sec-13-csr-110-2.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.020}

Jan. 9, 1976. Rescinded: Filed Feb. 10, 2000,

History

• AUTHORITY: section 219.036, RSMo 1986.

13 CSR 110-2.030 Special or Unique Service Needs {#sec-13-csr-110-2.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.030}

PURPOSE: This rule establishes the guidelines and lines of authority for youth who are in need of services that are not generally provided by this agency. This would include such things as psychological disorders, intellectual disabilities, specialized foster home care, special medical needs, etc.

(1) The regional administrators or their designees are responsible for making the initial determination that special services are necessary for a particular youth.

(2) When the division finds that a youth committed to its custody is in need of care of treatment other than that which the division is equipped to provide, the division may apply to the court which committed such youth requesting an order relieving the division of custody. If a change of custody is not ordered by the court, the division shall ensure the youth is provided special services within the division’s capability.

(3) Requests for psychiatric evaluations and developmental disability evaluations are to be made in accordance with the Department of Mental Health’s established catchment area guidelines.

(4) Upon receipt of the evaluation recommendation, the regional administrators or their designees will review the evaluation recommendation and take appropriate action to see that the necessary services are provided. If the services can be provided directly by the division then such services will be utilized.

If such services cannot be provided directly by the division or if they can be provided in a more economical, effective, or practical manner by a contract provider pursuant to

section 217.036, RSMo, the regional administrator or designee will initiate the necessary paperwork to obtain such services from a contract provider.

(5) The service coordinator’s supervisor shall keep the regional administrator apprised of status changes of youth and any problems they may encounter.

Feb. 10, 2000, effective Aug. 30, 2000.

13 CSR 110-2.040 Classification Criteria for Placement into Division of Youth Services (DYS) Programs {#sec-13-csr-110-2.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.040}

PURPOSE: Classification criteria shall provide broad guidelines for adequately assessing the individual need for services and appropriate placement for each youth committed to Division of Youth Services.

(1) A medical, psychological, and social history shall be developed for each youth by the service coordinator. Areas to be considered in developing this history are listed as follows:

(A) Medical History. Special medical needs shall be evaluated to determine if such needs can be met by Division of Youth Services (DYS). If the needs can be met by DYS, then they should be identified, treated, and explained in meaningful terms as to the impact they may have on the treatment process;

(B) Psychological History. If a youth’s psychological history reveals the need for additional assessment, the following areas may be evaluated through formal or informal testing:

1. Intellectual functioning;

2. Educational achievement;

3. Screening for organic impairment;

4. Drug abuse screening; and 5. Behavioral observation and personal interview. This information shall be gathered through personal contact with parents, guardians, teachers, juvenile court staff, and relevant others. This will assist the service coordinators in their efforts to properly match the youth with the service category to which they may be assigned; and (C) Social History.

5. An evaluation of relevant past history should include retrieval and evaluation of any pertinent information in social histories, court records, school files, etc.

6. An evaluation of the present environment should include pertinent information concerning home, school, and community conditions having an effect on classification.

(2) After developing an adequate individual

history, the service coordinator should determine services most appropriate as itemized in the following Division of Youth Services (DYS) continuum:

(A) Community-Based. Services provided with supervision to maintain the youth in their own home or community placement;

(B) Community-Based Residential. When community-based services do not meet the needs of the youth, community-based residential services are provided in DYS group homes or non-DYS group home settings such as, special contractual residential services; and (C) Moderate/Secure Residential Treatment.

When community-based or community-based residential services do not meet the needs of the youth or the community, services are provided to the youth in an appropriate moderate/secure residential treatment facility.

(3) To be eligible for community-based services as provided in subsections (2)(A) and (B) of this rule, the youth must meet the following guidelines:

(A) Have the ability to acceptably control themselves in an open community environment where supervisory controls are minimal;

(B) Be willing to participate in a community program; and (C) Prior or committing offenses cannot be such that community reaction to the youth’s immediate return to the community would negate any benefit the child might receive from community placement.

(4) General guidelines for classification and initial assignment of youth to a moderate/secure residential treatment facility are listed as follows:

(A) There are no known community services presently available that will effectively provide for the youth’s needs;

(B) Direct intervention through residential treatment would increase the likelihood of successful community placement; and (C) General community safety issues have been considered.

Feb. 10, 2000, effective Aug. 30, 2000.

13 CSR 110-2.050 Transfers Between DYS Residential and/or Community Based Programs {#sec-13-csr-110-2.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.050}

PURPOSE: This rule protects the rights and ensures the appropriate treatment of youth moved from one Division of Youth Services (DYS) program to another. The procedure is to be used if a youth has been inappropriately classified into a program or if the program is not meeting the youth’s needs.

(1) An administrative transfer may be effected when a change in placement, either interagency or intragency, may better serve the needs of the youth. An administrative transfer is a transfer from one (1) foster home to another, from one (1) community-based facility to another, or from one (1) medium or secure care facility to another.

(A) Such a transfer may be effected when one (1) or more of the following conditions are present:

1. An opening exists in a similar placement that is closer to the youth’s home community;

2. A placement in a different area would provide access to a program(s) and that would be of special benefit to the youth; and 3. There is evidence the youth has potential to benefit from the program offered in his/her current placement but either internal or external forces make it difficult for them to obtain maximum value from the placement.

(B) The youth, their parent(s) or guardian(s) or site supervisor or service coordinator may request an administrative transfer in writing to the regional administrator or their designee.

The regional administrator or their designee shall review the request and, if appropriate, authorize the transfer. In determining whether a transfer is appropriate, the following information as relevant in reaching a conclusion shall be considered:

1. Reasons offered both in support of and in opposition to the transfer;

2. Evaluation of the progress of the youth in the current placement; and 3. Availability of space in other programs and approval of the receiving facility manager. If this transfer is across regional lines, then the appropriate regional administrator or their designee shall be involved.

(C) The regional administrator or their designee shall notify, in writing, the youth, their parent(s) or guardian(s), and site supervisor or service coordinator of the decision as to whether the transfer is approved or disapproved and the reason therefore. The decision shall be made within five (5) working days of the request and a copy of the transfer shall be included in the youth’s case record.

(2) A vertical transfer is a transfer from a community-based program to any DYS residential program.

(A) A vertical transfer may be effected when—1) the youth poses a danger to the safety of other persons, employees, the site, or the community; or 2) the youth will benefit more from the program(s) offered at the recommended site than from the program(s) offered in the current placement.

(B) The following procedures must be followed for a vertical transfer:

1. The youth, parent(s) or guardian(s), site supervisor, or service coordinator may request a transfer;

2. The request shall be in writing to the regional administrator or their designee and shall state the reasons the transfer is being requested;

3. Upon receipt of the request, the regional administrator or their designee shall appoint a hearing officer and one (1) or more parties who are neutral and objective to hold a hearing;

4. The hearing officer shall set a date for a hearing on the question of transfer. This hearing shall be held within fifteen (15) calendar days from the date the request is received;

5. The youth, parent(s) or guardian(s) of the youth, and the site supervisor or service coordinator shall be given adequate and timely notice of the time and place of the hearing and of the reasons therefore, stated with specificity, that the transfer has been requested; and 6. The youth and the parent(s) or guardian(s) of the youth shall also be notified that the youth has the right to present evidence, to confront and cross-examine witnesses, and to remain silent at the hearing.

Further, the youth shall have the right to request a staff member or a parent(s) or guardian(s) or attorney to represent him/her at this hearing.

(C) Only information introduced as evidence at the hearing shall be considered by the hearing officer(s). The following are considered relevant to the determination: the treatment needs of the youth; and whether other programs, either community-based or residential, would provide a program(s) better suited to the needs of the youth.

(D) Within five (5) working days of the hearing, the hearing officer(s) shall notify, in writing, the youth, the parent(s) or guardian(s) of the youth, and the person who has physical custody of the youth of its decision and the reasons therefore.

(E) A vertical transfer shall not be authorized as punishment.

(3) An interagency transfer is a transfer from a program or facility operated by or under the control of the division to a program or facility operated by or under the control of another agency.

(A) An interagency transfer may be effected when the division lacks the programs or services to promote the rehabilitation of the youth and another childcaring agency is equipped to provide these programs or services.

(B) The director or their designee may 4CODE OF STATE REGULATIONS (10/31/18) JOHNR. ASHCROFT authorize an interagency transfer if, after a careful examination of the youth’s needs, they determine that the transfer should be effected. After a decision for transfer is made, the youth, their parent(s) or guardian(s), and the service coordinator will be notified of the decision and the reasons for the transfer. One (1) copy of the notice will be retained in the youth’s case record.

(4) Appeal of a Transfer Decision. When the decision is made to transfer the youth, the youth and the parent(s) or guardian(s) of the youth shall be notified of the right to petition the director for a hearing to review the decision in accordance with 219.051, RSMo.

Rescinded and readopted: Filed May 30, 1979, effective Sept. 14, 1979. Amended:

Filed Feb. 10, 2000, effective Aug. 30, 2000. *Original authority: 219.021, RSMo 1975, amended 1980, 1981, 1987, 1993, 1995, 2015; 219.036, RSMo 1975, amended 1993; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 219.021.4, 219.036, and 660.017, RSMo 2016. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976.

13 CSR 110-2.060 Furlough Policies and Procedures {#sec-13-csr-110-2.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.060}

PURPOSE: Furloughs granted to youth residing in Division of Youth Services (DYS) facilities should be purposeful and constructive supplements to the treatment program. Only through well-justified deliberation should furloughs be granted.

(1) Requests for furloughs require verbal and written approval by the service coordinator with written notification to identified officials, parent(s) or guardian(s), courts, and those that require notification under the law pertaining to victim’s rights.

(2) Upon approval of the request for furlough, the service coordinator or facility manager shall arrange for transportation.

(3) A furlough authorization form should be prepared to accompany the youth. (The form should identify the youth, state the date, and

purpose of the furlough, and include the name and phone number of the DYS residential facility authorizing the furlough.)

(4) If a youth fails to return from a furlough at the designated time, the youth is required to call the DYS facility manager or the service coordinator to provide justification for the delay and to establish an estimated time of return. If the youth does not notify the DYS facility manager or the service coordinator or fails to provide satisfactory justification for the delay, the DYS facility manager or the service coordinator shall determine the youth to be a runaway and shall contact law enforcement and request the apprehension and detention of the youth pending the return of the youth to the division. The DYS facility manager or the service coordinator shall submit a critical incident report.

Feb. 10, 2000, effective Aug. 30, 2000.

Amended: Filed Aug. 8, 2018, effective March 30, 2019.

13 CSR 110-2.070 Day Release Procedures {#sec-13-csr-110-2.070 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.070}

Filed Feb. 10, 2000, effective Aug. 30, 2000.

History

• AUTHORITY: sections 219.021 and 219.036, RSMo 1986. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Rescinded:

13 CSR 110-2.080 Runawayand Absconding Youth {#sec-13-csr-110-2.080 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.080}

PURPOSE: This rule establishes formal procedures to be followed when a youth runs away from a residential facility or has absconded from community care or aftercare, and is apprehended. It is recognized that local procedures followed in these circumstances vary from facility-to-facility. Each facility shall write procedures which can be logically and consistently followed.

(1) These procedures are to be followed in the case of runaways.

(A) Immediately upon the discovery and verification that a youth has run away, the premises shall be secured and an immediate search will be conducted. The local police shall be notified and given the information necessary to help locate the youth.

(B) Upon apprehension or return to placement the case will be reassessed and necessary treatment intervention made and documented.

(C) If the youth is not apprehended during the initial search period, then the need for a pickup and detention warrant will be ascertained.

(D) A critical incident report shall be prepared by the site supervisor or service coordinator. Upon apprehension, the pickup order/warrant will be canceled and notification given to appropriate local law enforcement, local juvenile officer, parent(s)/guardian(s), and service coordinator.

(E) If the youth is not apprehended or does not return within fourteen (14) days, the youth will be placed on the inactive roll by the Division of Data Processing until apprehension or appropriate discharge.

(F) In the event the youth is not apprehended, has reached age seventeen (17), has passed the discharge date of any determinate sentence, if applicable, and has been on runaway status for six (6) consecutive months, the Division Director, Deputy Director, Regional Administrator, or Deputy Compact Administrator shall discharge the youth.

(2) These procedures are to be followed when a youth absconds from aftercare.

(A) Upon notification that a youth has absconded, the service coordinator shall assess the immediate situation, consulting with parent(s) or guardian(s) and the service coordinator’s supervisor to determine the necessary intervention. Upon completion of the assessment, if appropriate, the service coordinator shall request the apprehension and detention of the youth by law enforcement.

(B) Upon apprehension or return to placement, the case will be reassessed and necessary treatment intervention documented.

(C) If the youth is apprehended before central office has been notified of the runaway, this fact should be indicated on the report. If the youth was not apprehended and central office was notified, then a follow-up report should be sent to the appropriate supervisor indicating the youth is back in DYS custody.

(D) In the event a pickup order/warrant was issued, a letter will be sent to officially cancel the pickup order/warrant.

(E) If a letter was sent to various officials and the parent(s)/guardian(s) notifying them of the youth’s abscondence, a letter will also be sent to notify them that the youth has been apprehended.

(F) In the event a youth is not apprehended, has reached age seventeen (17), has passed the discharge date of any determinate sentence, if applicable, and has been on abscondence status for three (3) consecutive months, the Division Director, Deputy Director, Regional Administrator, or Deputy Compact Administrator shall discharge the youth.

Feb. 10, 2000, effective Aug. 30, 2000.

13 CSR 110-2.090 Hazardous Placement Policy {#sec-13-csr-110-2.090 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.090}

Jan. 9, 1976. Rescinded: Filed Feb. 10, 2000,

History

• AUTHORITY: section 219.036, RSMo 1986.

13 CSR 110-2.100 Grievance Procedures for Committed Youth In Residential Facilities {#sec-13-csr-110-2.100 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.100}

PURPOSE: This rule insures that youth in Division of Youth Services (DYS) residential facilities have a process to submit grievances, and establishes a formal procedure for DYS to respond to those grievances.

(1) Any youth who has a grievance may submit their grievance in written form to the group leader or first line supervisor. Following receipt of the written grievance,the group leader and first line supervisor shall discuss the matter within five (5) working days and then subsequently interview the youth. A written decision shall be issued to the youth within three (3) working days after the interview. Copies of this decision shall be distributed to the youth, parent(s)/guardian(s), service coordinator, site supervisor, and regional administrator. If the decision is not satisfactory to the youth, the youth may present the grievance to the site supervisor, or next supervisor in line within five (5) days of the original decision. The site supervisor may—a) review the grievance and, after meeting with staff, prepare a response within five (5) working days; or b) convene a grievance committee of three (3) staff members, one (1) of which is the designated chairperson, to hear the grievance. The youth will be advised of the date the grievance committee will consider their complaint and the youth may request that any person represent them at the hearing. The youth will have the right to cross-examine, call witnesses, or present any testimony in their behalf.

(2) The findings of the grievance committee will be final. Records of action taken will be kept on file for future reference concerning policy or future complaints on the part of the youth. The youth will be given a copy of the findings and of other information they desire.

(3) The grievance committee should be appointed by the site supervisor of the facility. The membership of this committee should represent a cross-section of the facility. This committee shall consist of impartial members and this impartiality will be monitored by the site supervisor. Provision to disqualify any member who is directly involved in a particular grievance should be established.

(4) It shall be the duty of the site supervisor of each program to oversee the implementation of the grievance procedure and interpret to youth and staff the following areas which will be considered for grievances: 1) physical abuse; 2) staff allowing physical abuse to a youth by another youth; 3) lack of medical or dental treatment; 4) no opportunity for three (3) meals per day; 5) verbal abuse by staff; 6) lack of opportunity for recreational activities;

7. lack of opportunity for education; 8) infringements upon religious tenets; and 9) discrimination based upon a youth’s race, color, religion, sex, national origin, age, or disability.

(5) If in the implementation of this procedure, a staff member practices prejudice against the youth who has filed the grievance and this prejudice is found to be a result of the youth’s complaint, the staff member concerned shall be subject to immediate dismissal.

Feb. 10, 2000, effective Aug. 30, 2000.

13 CSR 110-2.110 Responsibilities of Facility Managers {#sec-13-csr-110-2.110 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.110}

(Rescinded August 30, 2018)

Jan. 9, 1976. Amended: Filed Feb. 10, 2000, effective Aug. 30, 2000. Rescinded: Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: section 219.036, RSMo 1994.

13 CSR 110-2.120 Administrative Decisions Affecting the Rights of Youth in DYS Facilities {#sec-13-csr-110-2.120 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.120}

PURPOSE: This rule standardizes procedures and establishes safeguards for the youth in those areas of treatment where the rights of the youth in residence in a Division of Youth Services (DYS) facility may be an issue.

These areas include: mailing; visitation privileges; and containment.

(1) Mailing. The Division of Youth Services (DYS) reserves the authority to inspect mail of youth in DYS residential care facilities for the purpose of detecting contraband. Mail may be opened in the presence of the youth for this purpose only. Mail between youth and attorney will not be subject to the inspection.

(2) Visitations. The Division of Youth Services recognizes the importance of family visits with the youth as a means of maintaining and improving family relationships. Each Division of Youth Services residential facility shall establish a regular visiting schedule for the purpose of maintaining order in the treatment program. Each youth and their family are to be advised in writing of the regular visiting hours at the time the youth is received at the facility.

(3) Containment. Corporal punishment or physical abuse of a youth shall not be permitted. Physical restraint, if necessary, may be used for the purpose of containment only and only then when the youth being restrained is involved in a serious incident (for example, a youth assaults another person, damages property, hurts him/herself, or runs away). Failure of an employee to abide by this policy is cause for dismissal.

Amended: Filed Feb. 10, 2000, effective Aug. 30, 2000. Amended: Filed Aug. 8, 2018, effective March 30, 2019. *Original authority: 219.036, RSMo 1975, amended 1993; 219.051, RSMo 1975; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 219.036, 219.051, and 660.017, RSMo 2016. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976.

13 CSR 110-2.130 Release of Youth from DYS Facilities {#sec-13-csr-110-2.130 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.130}

PURPOSE: This rule provides an administrative procedure for the release of youth from Division of Youth Services (DYS) facilities.

(1) Release to aftercare supervision shall be made under the following procedure:

(A) When it has been determined by the service coordinator and/or the facility that a youth is eligible for release to aftercare, the service coordinator assigned to the case shall provide an aftercare plan and submit all required Division of Youth Services (DYS) paperwork to the service coordinator supervisor. The service coordinator shall notify the 6CODE OF STATE REGULATIONS (2/28/19) JOHNR. ASHCROFT parent(s)/guardian(s) and the community and the committing court; and (B) Conditions of Aftercare Supervision.

Transfer to aftercare supervision is a trial home placement. The rules of placement to which the child shall agree prior to this transfer shall be the principal conditions of this transfer and violation of these conditions may result in revocation of aftercare supervision.

The rules established by the division are as follows:

1. I will obey all city, state, and federal laws;

2. I will report to the service coordinator as directed and immediately report any changes in residence, school, employment, or other status;

3. I will not leave the state of Missouri, or alter any conditions of my placement agreement without the advance permission of the service coordinator;

4. I will obey the rules and instructions of my parents, foster parents, or guardian. I will advise my service coordinator immediately if any problems arise in this area;

5. I understand that I am under the supervision of the DYS until discharged; and 6. Other special rules or conditions may be invoked to meet specific adjustment problems of the youth in the community.

(2) Interstate Placement. The same release procedure as intrastate placement is to be followed; however, arrangements are to be made and approved by the interstate compact unit.

(3) Transfer to other DYS Facilities (Refer to transfer procedures 13 CSR 110-2.050).

(4) Transfer to a non-DYS Facility (Refer to 13 CSR 110-2.030).

(5) Direct Discharge. Upon determining that the youth is no longer in need of supervision as recommended by the service coordinator and approved by the regional administrator, the youth shall be discharged directly from the facility without aftercare.

(6) Expiration of Commitment. All youths under DYS jurisdiction may be discharged upon reaching their eighteenth birthday.

(7)

Notification of Termination of DYS Supervision. Missouri statutes provide that the division is required to immediately notify, in writing, the youth, their parent(s) or guardian(s), the victim’s rights respondent, and the committing court of the termination of its supervision over the youth.

Feb. 10, 2000, effective Aug. 30, 2000.

13 CSR 110-2.140 Confidentiality of Case Records {#sec-13-csr-110-2.140 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.140}

PURPOSE: The purpose of this rule is to regulate the disclosure of information contained in records of the division relating to youths committed to the division.

(1) Except as otherwise provided in this regulation, information contained in the records of the division relating to any youth committed to it shall be confidential.

(2) Authorized Disclosures.

(A) The parents or legal guardians of a youth committed to the division shall be entitled to full disclosure of all information and records pertaining to the youth, unless otherwise specifically restricted by law. Any youth who was formerly committed to the division may request a copy of his or her records upon reaching the age of eighteen (18) years. The division may require the request be made in writing and shall require proof of the requester’s identity by either the presenting of a photo identification card or a notarized request before any such records are released.

Fees for such copies may be levied in accordance with 13 CSR 5-1.030.

(B) Inquiries from the Social Security Administration. Information pertaining to a youth previously or currently committed to the division who has or may receive Social Security benefits may be disclosed in response to inquiries of the Social Security Administration (SSA) regarding establishment or maintenance of those benefits. Responses to inquiries of the SSA pursuant to this section shall not require a written authorization from the youth or, where applicable, the parent or legal guardian thereof, permitting the disclosure of confidential information to the SSA.

(C) Release of Information to Law Enforcement. Information pertaining to a youth may only be released to law enforcement pursuant to the provisions of section (4) below with the following exceptions: The Director of the Division of Youth Services (DYS), in his or her sole discretion, is authorized to release to appropriate law enforcement personnel information concerning a youth when the director determines that the information involves a matter of public safety to include, but not necessarily limited to: maintaining security in DYS facilities, protecting the safety of other youth within DYS facilities, the commission of a crime, a credible threat to commit a criminal offense, or to assist in the location and return of a missing or runaway youth.

(D) Release of Information to Medical Service Providers. The Division of Youth Services shall have full authority to release information to individuals and entities who need the information to provide services to or on behalf of a youth in DYS custody, or a DYS staff member to include, but not be limited to: first responders, medical care providers, mental health care providers, dental care providers, and other persons providing medical or mental health care for a youth.

(E) Release of Information to Educational Institutions. The Division of Youth Services shall have full authority to release information to individuals and entities with a need for the information to provide educational services for a youth.

(F) Release of Information to Emergency Personnel in a Medical or Natural Disaster Emergency. The Division of Youth Services shall have full authority to release information to individuals and entities who have a need for the information in order to provide emergency care for the youth in the event of a medical or natural disaster.

(G) Judicial Proceedings. The division may release any record or information pursuant to an order of a court of competent jurisdiction as may be authorized by this regulation or otherwise specifically authorized by law, including any verbal order issued by a judge directing the release of the record or information during a court hearing.

(H) Regulatory Oversight. The division may release any record or information deemed necessary to complete an audit or other regulatory oversight inspection required by state or federal law.

(3) Information pertaining to any youth who was formerly committed to the division may be disclosed to those persons or agencies actively involved in providing care or treatment services to the former client or his/her family provided that a release of information has been signed by the former client’s parent or guardian or the former client. Information pertaining to any youth currently committed to the division may be disclosed to those persons or agencies actively involved in providing care or treatment services to the client or his/her family at the discretion of the division.

(A) Inquiries from Elected Officials.

Information pertaining to a youth previously or currently committed to the division may be disclosed in response to inquiries of elected officials of the state, or their staff members, submitted to the division on behalf of a 8CODE OF STATE REGULATIONS (2/28/19) JOHNR. ASHCROFT constituent residing within the jurisdiction said official represents with the consent of the subject youth, if over the age of eighteen (18) years, or the parent(s)/legal guardian of the subject youth if still a minor. Responses to inquiries of elected officials pursuant to this subsection shall not require a written authorization from the subject youth or his/her parent(s)/legal guardian permitting the disclosure of confidential information to the elected official, but division staff must receive at least a verbal consent to do so from the subject youth, if over the age of eighteen (18) years, or the parent(s)/legal guardian of the subject youth if still a minor, before divulging any case information. For any information obtained from the division under this subsection, elected officials shall be subject to the same disclosure restrictions and confidentiality requirements that apply to the division and shall be notified of such, verbally or in writing, by division staff prior to divulging any requested case information.

(B) Documentation Requirements. In the event division staff rely upon the verbal authorization of the subject youth, if over the age of eighteen (18) years, or the parent(s)/legal guardian of the subject youth, if still a minor, to divulge any case information to an elected official under the authority granted above in subsection (3)(A), and/or a verbal notification of the disclosure restrictions and confidentiality requirements incumbent upon receipt of case information required above in subsection (3)(A), division staff shall immediately memorialize such verbal communication(s) in the case file. Such memorialization shall be in the form of a memorandum for record setting forth the date and time of the communication, the name of the individual granting consent and/or receiving the notification, the information authorized to be disclosed and/or the contents of the notification disseminated, the purpose of the disclosure, and the printed name and signature of the staff member making the disclosure and/or notification, as applicable to the case at hand.

(4) Youth intake and furlough dates may be shared with law enforcement officials, including juvenile officers and prosecutors, upon request.

(5) Subject to the restrictions of applicable law, information contained in the records of the division may be released to any person engaged in bona fideresearch purpose, with the permission of the division director; provided, however, that no information identifying the youth shall be made available to the researcher, unless the division determines that the identifying information is essential to the research or evaluation and the researcher provides the division adequate assurances that the confidentiality of said information shall be maintained. The division shall require the researcher to execute a confidentiality agreement, complete an Application to Conduct Research/Study form and the researcher shall complete and comply with the terms of the application.

Amended: Filed Feb. 10, 2000, effective Aug. 30, 2000. Amended: Filed March 31, 2017, effective Oct. 30, 2017. *Original authority: 219.061, RSMo 1975, amended 1994

History

• AUTHORITY: sections 219.061.3 and 660.017, RSMo 2016. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976.

13 CSR 110-2.150 Division of Youth Services Staff Training Programs {#sec-13-csr-110-2.150 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-2.150}

PURPOSE: The purpose of this rule is to provide for the establishment of comprehensive training programs for staff of the division and of other agencies and organizations, public and private, engaged in activities relating to the prevention of delinquency and the provision for care and treatment to delinquent youth.

(1) The division will establish comprehensive training programs for its staff, employed or to be employed.

(2) The division will also be responsible for extending training opportunities to other public and private youth serving agencies, which are offering delinquency prevention and delinquency rehabilitative treatment services to youth within the state as funds for such training are made available. The division, in conjunction with these public and private agencies, will initiate and facilitate an assessment of training needs. After the assessment all needs will be prioritized, and appropriate training will be jointly planned and initiated by qualified Division of Youth Services (DYS) staff, qualified staff or agencies served and/or by purchase of services from other qualified training consultants.

History

• AUTHORITY: section 219.016, RSMo Supp. 1999. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed Feb. 10, 2000, effective Aug. 30, 2000. Original authority: 219.016, RSMo 1975, amended 1993, 1995.

Chapter 3 Case Management

13 CSR 110-3.020 Aftercare Involvement During Residential Treatment {#sec-13-csr-110-3.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.020}

13 CSR 110-3.050 Instructions for the Implementation of Revocation Procedure SOCIAL SERVICES Youth Services {#sec-13-csr-110-3.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.050}

13 CSR 110-3.010 Comprehensive Individual Treatment Plans {#sec-13-csr-110-3.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.010}

PURPOSE: The purpose of this rule is to standardize the investigation into the pertinent circumstances of the youth’s background to facilitate appropriate treatment and aftercare planning.

(1) A comprehensive individual treatment plan (CITP) shall be developed by Division of Youth Services for the purpose of meeting individual youth and family needs. The CITP also serves to record case activity and fulfill requirements for official notifications.

(A) CITP procedures are— 1. The Division of Youth Services shall initiate the development of a written CITP within thirty (30) days of the commitment date. The treatment plan should involve the youth and their parent(s) or guardian(s). The CITP shall be completed within forty-five (45) days of commitment and distributed to the youth, family, court, and facility;

2. Involvement of the parent(s) or guardian(s) is encouraged;

3. Information contained in the CITP includes, but is not limited to:

A. Assessment, including youth and family strengths, needs, and trauma history;

B. Youth history, including core issues, and history with other systems such as mental health, Children’s Division, and Juvenile Courts;

C. Education;

D. Youth’s medical health/mental health needs; and E. Transition Planning;

4. The service coordinator will include the preliminary possibilities for the youth’s placement;

5. The Division of Youth Services will finalize aftercare placement planning for the youth prior to release from residential or community care;

6. The Division of Youth Services will reexamine the youth’s CITP when deemed necessary, but in no case to exceed intervals greater than six (6) months; and 7. The youth, the youth’s parent(s) or legal guardian(s), and other members of the youth’s family, when appropriate, shall be consulted whenever the CITP is reviewed.

Should youth or their families disagree with the content developed or information contained in the CITP they may petition the director for a hearing under section 219.051.1(1), RSMo.

History

• AUTHORITY: sections 219.036, 219.051, and Dec. 30, 1975, effective Jan. 9, 1976. 30, 2000. Amended: Filed Oct. 1, 2018, effective May 30, 2019. Original authority: 219.036, RSMo 1975, amended 1993; 219.051, RSMo 1975; and 660.017, RSMo 1993, amended 1995.

13 CSR 110-3.015 Safe Schools Act Procedures {#sec-13-csr-110-3.015 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.015}

(Rescinded April 30, 2019)

Original rule filed Feb. 10, 2000, effective Aug. 30, 2000. Rescinded: Filed Aug. 28, 2018, effective April 30, 2019.

History

• AUTHORITY: section 219.036, RSMo 1994.

13 CSR 110-3.020 Aftercare Involvement During Residential Treatment {#sec-13-csr-110-3.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.020}

(Rescinded April 30, 2019)

Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed Feb. 10, 2000, effective Aug. 30, 2000. Rescinded: Filed Aug. 28, 2018, effective April 30, 2019.

History

• AUTHORITY: section 219.036, RSMo 1994.

13 CSR 110-3.030 Aftercare Supervision {#sec-13-csr-110-3.030 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.030}

PURPOSE: The purpose of this rule is to outline responsibilities and procedures for the supervision of youth in aftercare.

(1) Community Placement. The Division of Youth Services will ensure the appropriate treatment services are in place for the youth and his/her family.

(2) Placement with Alternative Caregivers.

Except in cases of emergency, children under Division of Youth Services supervision and placed in alternative caregiver homes funded by DYS shall be so placed only after an evaluation of the home has been completed. This evaluation shall include, but not be limited to, the adequacy of the home, family stability and composition, and the motivation and ability of the alternative caregivers to provide care. An alternative caregiver may be a relative or a person who is not related to the youth but has a close relationship with the youth or the youth’s family.

(A) Preparation for Placement. The Division of Youth Services shall prepare the family and the youth for the impending placement. That preparation may include, but not be limited to, the following:

1. Counseling and training with the alternative caregivers;

2. Preplacement visits between the youth and the alternative caregivers;

3. Explanation of agency rates of payment and guidelines for expenditures of money on the youth’s behalf;

4. Evaluation of any other income the youth might have, such as Social Security benefits, Veteran’s Administration benefits, etc., as well as the youth’s family’s financial situation. The applicability of these funds to the youth’s needs will be determined by the regional administrator; and 5. Discussion of arrangement for payment of special needs, such as, medical expenses, educational, or therapeutic, etc.

(3) Contractual Residential Services. The Division of Youth Services may utilize contractual residential services when it determines that the youth’s needs are beyond the scope of services available at a Division of Youth Services’ operated facility or space is not available at a Division of Youth Services’ facility in close proximity to the youth’s home or family.

(4) Return to Facility (Shelter). A temporary return of the youth in aftercare to the facility for reasonable cause may be permitted upon the recommendation of the service coordinator with the approval of the regional administrator. Reasonable cause is to be determined only upon the basis of need for alternative placement with none immediately available.

When the youth is returned for shelter, every effort is to be made by the service coordinator to complete alternate placement plans within thirty (30) days. Shelter placements may extend beyond thirty (30) days with approval by the regional administrator. When a placement is established by the service coordinator, the service coordinator will notify the facility and make arrangements for the youth to be released with the approval of the service coordinator’s supervisor.

(5) Return to Facility (Revocation). Procedure for the return of youths held in violation of the conditions of aftercare supervision is outlined in 13 CSR 110-3.040.

(6) Discharges from Aftercare Supervision.

Section 219.026, RSMo, requires the division to immediately notify in writing the youth, his/her parent(s) or guardian(s), victim’s rights respondent, and the committing court of the termination of its supervision over the youth.

History

• AUTHORITY: sections 219.016, 219.036, and Dec. 30, 1975, effective Jan. 9, 1976. 30, 2000. Amended: Filed Oct. 30, 2018, effective June 30, 2019. Original authority: 219.016, RSMo 1975, amended 1993, 1995; 219.036, RSMo 1975, amended, 1993; and 660.017, RSMo 1993, amended 1995.

13 CSR 110-3.040 Revocation of Aftercare Supervision {#sec-13-csr-110-3.040 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.040}

PURPOSE: The purpose of this rule is to provide a standard procedure for the apprehension, detention, and revocation of youth on aftercare.

(1) The director, at any time after the youth is placed in aftercare and before order of discharge is issued, may request the apprehension and detention of the youth by law enforcement without notice to the youth. Any service coordinator assigned to supervise youth in aftercare, or any other employee designated by the director, may apprehend a youth without a warrant or may issue such warrant to law enforcement officials, when in the judgment of the service coordinator, the youth has violated the conditions of his/her placement and his/her presence in the community is considered dangerous to him/herself or to the community, or when the youth may flee the jurisdiction of the division. When the youth is detained, the service coordinator shall present to the detaining authority a statement of the circumstances of the violation.

(2) Revocation Hearing. Whenever revocation of aftercare is to be considered, an employee of the aftercare services of the Division of Youth Services (DYS) shall hold a revocation hearing to determine if there is reasonable cause to believe that the youth has violated an aftercare condition.

(A) At no time shall the hearing officer be the youth’s service coordinator assigned to supervise the youth. Any other service coordinator or supervisor may act in this capacity, except that the designation as the hearing officer of a supervisor giving direct supervision to the service coordinator assigned to supervise the youth should be avoided.

(B) The revocation hearing is an informal inquiry. The rules of evidence and right to subpoena do not apply. The hearing is to be held promptly and reasonably near the place of violation or detention.

(C) The youth and his/her parent(s) or guardian(s), or the person with whom the youth has been placed, or other responsible adult, as well as a victim who has requested notification per 595.209, RSMo, shall be given notice that the hearing will take place and that the purpose of the hearing is to determine whether there is reasonable cause to believe that the youth is in violation of the conditions of aftercare supervision and aftercare supervision should be revoked.

(D) At the hearing, the youth, his/her parent(s) or guardian(s), or a responsible adult, and legal counsel, if any, may appear and speak in the youth’s behalf. They may bring and present documents and other evidence relating to the allegation against the youth.

They may present witnesses in victim’s behalf, but testimony of the witnesses must be relevant to the alleged violation. The youth may request that persons, who have given evidentiary testimony on which the allegation is based, be made available for questioning in the youth’s presence at the hearing; however, if the hearing officer determines that the informant would be subject to risk or harm if his/her identity were disclosed, the hearing officer may excuse the informant from confrontation or cross-examination by the youth, his/her parent(s) or guardian(s), responsible adult, or counsel.

(E) The hearing officer shall prepare a written summary of the hearing including an explanation of the evidence presented by the youth and by the service coordinator. Based on the information before him/her, the hearing officer will determine whether there is reasonable cause to revoke the youth’s aftercare supervision.

(F) A determination that reasonable cause exists is sufficient to warrant the youth’s continued detention and the youth shall be returned to a facility of the Division of Youth Services.

(G) If the hearing officer does not find reasonable cause to revoke aftercare supervision, the youth will be returned to active aftercare supervision. Further conditions for supervision may be imposed on the youth.

(3) Director’s Hearing or Review. If the youth is returned to a facility of DYS, the youth and his/her parent(s) or guardian(s) will be given an opportunity to petition on a form provided by the division for a director’s hearing prior to the final decision on revocation of aftercare supervision by the director or his/her designated representative. If the youth or his/her parent(s) or guardian(s) do not petition for a director’s hearing, the director, or the director’s designee, will review the findings of the revocation hearing and other pertinent case material and will then make a final decision regarding the recommendation for revocation of aftercare supervision.

(A) If the youth or his/her parent(s) or guardian(s) petition for a director’s hearing, the director, or the director’s designee, shall convene a hearing at the facility where the youth resides within thirty (30) days of the receipt of the written request for a hearing.

(B) The youth or his/her parent(s) or guardian(s) shall have the right to be represented by counsel, call and question witnesses, and cross-examine those witnesses appearing against the youth. DYS shall not bear the cost or expenses of witnesses or attorneys requested by the youth or his/her parent(s) or guardian(s). This is an informal inquiry. The rules of evidence and right to subpoena witnesses do not apply.

(C) The individual conducting the director’s hearing shall deliver the decision in writing to the youth or his/her parent(s) or guardian(s) within fifteen (15) days of the close of the director’s hearing. The decision shall clearly set forth the evidence presented, a summary of the testimony elicited, and the findings, conclusion, and decision of the individual conducting the hearing.

History

• AUTHORITY: sections 219.016, 219.036, and Dec. 30, 1975, effective Jan. 9, 1976. 30, 2000. Amended: Filed Sept. 27, 2018, effective May 30, 2019. Original authority: 219.016, RSMo 1975, amended 1993, 1995; 219.036, RSMo 1975, amended 1993; and 660.017, RSMo 1993, amended 1995.

13 CSR 110-3.050 Instructions for the Implementation of Revocation Procedure {#sec-13-csr-110-3.050 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.050}

(Rescinded May 30, 2019)

Rescinded: Filed Oct. 11, 2018, effective May 30, 2019.

History

• AUTHORITY: sections 219.036 and 219.051, RSMo 1994. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed Feb. 10, 2000, effective Aug. 30, 2000.

13 CSR 110-3.060 Grievance Procedure for Youth in Aftercare {#sec-13-csr-110-3.060 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-3.060}

PURPOSE: This rule insures that when youth in aftercare have a grievance, the division has a process for submitting and responding to those grievances.

(1) Grievances. Should a youth on aftercare, the youth’s parent(s)/guardian(s), or foster parent(s), have a grievance concerning treatment, supervision, or the lack thereof, or 4CODE OF STATE REGULATIONS (5/31/19) JOHNR. ASHCROFT other relevant concerns, they may file a grievance in writing with the appropriate supervisor. The grievance shall be handled through an informal process. The supervisor will make a decision and advise the youth and the service coordinator with regard to the decision made in the matter. Appropriate written records will be maintained concerning disposition of the matter. If the decision is not satisfactory to the youth, the youth’s parent(s)/guardian(s), or foster parent(s), they may present the grievance to the regional administrator or designee for review and final decision. The decision of the regional administrator or designee will be the final decision of the division.

(2) Instructions. The administrators of each program will oversee the implementation of the grievance procedure. The following areas will be considered for grievances:

(A) Physical abuse by staff;

(B) Staff allowing physical abuse to a youth by another youth in aftercare;

(C) Repeated verbal abuse by staff, such as the use of profanity or ill-temper in giving direction and guidance;

(D) Discrimination based upon a youth’s race, color, religion, sex, national origin, age, or disability;

(E) Lack of opportunity to receive adequate supervision by an aftercare worker (in accordance with current caseload standards); and (F) Disagreement with placement decision or special conditions of aftercare supervision.

(3) Staff Prejudice. If in the implementation of this procedure, a staff member practices prejudice against the youth who has filed the grievance and this prejudice is found to be a result of the youth’s complaint, the staff member concerned shall be subject to immediate dismissal.

Amended: Filed Sept. 18, 2018, effective May 30, 2019. *Original authority: 219.036, RSMo 1975, amended 1993 and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 219.036 and 660.017, RSMo 2016. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Amended: Filed Feb. 10, 2000, effective Aug. 30, 2000.

Chapter 4 Interstate Compact on Juveniles

13 CSR 110-4.010 Operational Procedures of the Interstate Compact on Juveniles JOHNR. ASHCROFT(7/31/18) {#sec-13-csr-110-4.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-4.010}

SOCIAL SERVICES on Juveniles

13 CSR 110-4.010 Operational Procedures of the Interstate Compact on Juveniles {#sec-13-csr-110-4.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-4.010}

(Rescinded August 30, 2018)

Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: sections 210.570 and 219.036, RSMo 1986. Original rule filed Dec. 30, 1975, effective Jan. 9, 1976. Rescinded:

Chapter 5 Dual Jurisdiction

13 CSR 110-5.010 Dual Jurisdiction Procedures {#sec-13-csr-110-5.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-5.010}

PURPOSE: The purpose of this rule is to define dual jurisdiction and its provisions and procedures.

(1) Section 211.073, RSMo, provides that a court may, in a case when the offender is under eighteen (18) years of age and has been transferred to a court of general jurisdiction pursuant to

section 211.071, RSMo, and whose prosecution results in a conviction or plea of guilty, invoke dual jurisdiction of both the criminal and juvenile codes. The court is authorized to impose a juvenile disposition under section 211.073, RSMo, and simultaneously impose an adult criminal sentence, the execution of which shall be suspended. Successful completion of the juvenile disposition ordered shall be a condition of the suspended adult criminal sentence. The court may order an offender into the custody of the Division of Youth Services if— (A) A facility is designed and built by the division specifically for these offenders and the division determines that space is available, based on the design capacity, in the facility; and (B) The division agrees to such placement.

(2) The director or his/her designee shall interview and evaluate the offender to determine if the offender is appropriate for the dual jurisdiction program pursuant to section 211.073, RSMo.

(3) Upon approval or disapproval of the offender for dual jurisdiction commitment, the division director shall submit notification to the court for the reasons and conditions thereof.

(4) If there is probable cause to believe that the offender has violated a condition of the suspended sentence or has committed a new offense, the court shall conduct a hearing on the violation charged, unless the offender waives such hearing. If the violation is established, the court may revoke the juvenile disposition, impose the adult criminal sentence, or enter such other order that they may see fit.

(5) When the offender has received a suspended sentence pursuant to section 211.073, RSMo, and the division determines that the youth is beyond the scope of its treatment programs, the division may petition the court for a transfer of custody of the offender. The court shall— (A) Revoke the suspension and direct that the offender be taken into immediate custody of the Department of Corrections; or (B) Direct that the offender be placed on probation.

(6) When an offender reaches the age of eighteen (18), the court shall hold a hearing. After such hearing the court shall— (A) Revoke the suspension and direct that the offender be taken into immediate custody of the Department of Corrections;

(B) Direct that the offender be placed on probation; or (C) Direct that the offender remain in the custody of the Division of Youth Services if the division agrees to such placement.

(7) The division shall petition the court before it releases an offender who has remained in its custody until the age of twenty-one (21). The court shall— (A) Revoke the suspension and direct that the offender be taken into immediate custody of the Department of Corrections; or (B) Direct that the offender be placed on probation.

(8) If the suspension of the adult criminal sentence is revoked, all time served by the offender under the juvenile disposition shall be credited toward the adult criminal sentence imposed.

History

• AUTHORITY: section 211.073, RSMo Supp. 2022, and sections 219.016 and 219.036, RSMo 2016. Original rule filed Feb. 10, 2000, effective Aug. 30, 2000. Amended: Filed Nov. 3, 2022, effective May 30, 2023. Original authority: 211.073, RSMo 1955, amended 1998, 2013, 2018; 219.016, RSMo 1975, amended 1993, 1995; 219.036, RSMo 1975, amended 1993.

Chapter 6 Juvenile Crime Bill

13 CSR 110-6.010 Juvenile Crime Bill Provisions and Procedures {#sec-13-csr-110-6.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-6.010}

(Rescinded August 30, 2018)

Filed Jan. 16, 2018, effective Aug. 30, 2018.

History

• AUTHORITY: sections 211.068, 211.071, 211.073, 211.141, 211.171, 211.181, 211.321 and 219.021, RSMo Supp. 1999 and 219.036, RSMo 1994. Original rule filed Feb. 10, 2000, effective Aug. 30, 2000. Rescinded:

Chapter 7 Juvenile Court Diversion

13 CSR 110-7.010 Community-Based Diversionary Programs {#sec-13-csr-110-7.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-7.010}

PURPOSE: This rule establishes standards of eligibility and operation of Community-Based Diversionary Programs funded through grants from the Division of Youth Services pursuant to section 219.041, RSMo.

(1) The Division of Youth Services (DYS) is authorized under section 219.041, RSMo, to administer a Juvenile Court Diversion Grant Program (JCD Grant Program) for the purpose of assisting local units of government in the development and implementation of community-based treatment programs for the care and treatment of youth.

(2) The goal of the program is to support juvenile courts to serve youth on a local level so that youth may be afforded the necessary services through their local courts in order that they can remain in the community rather than being exposed to a larger segment of the juvenile justice system.

(3) The Director of DYS may designate an employee of the division to act as the authorized representative of the division for the purpose of entering into and administering contractual services agreements between the division and a local juvenile court.

(4) The local juvenile court shall not supplant funds because of the implementation of the JCD Grant Program in accordance with section 219.041.8, RSMo.

(5) The standards for the JCD Grant Program shall be— (A) Preference will be given to programs that are consistent with the evidence-based and promising-practices approach described in the Office of Juvenile Justice and Delinquency Prevention’s Model Programs Guide.

(B) Each program initiated with JCD Grant Funds shall contain projects within one (1) or more of the following focus areas:

1. School and education support programs, including day treatment services and other community-based programs, that provide educational and treatment services to youth to keep them productively involved in their local communities;

2. Counseling/treatment services, including sex offender treatment and supervision services providing community-based sexoffense specific treatment groups, parent support groups, and in-home therapy and supervision to pre-and post-adjudicated juvenile sex offenders;

3. Family support/preservation, including family therapy and support services, to assist youth in working through family issues and providing tools to resolve conflict;

4. Supplemental court services/supervision/gang prevention, including communitybased supervision of assigned youth during the evenings and weekends when youth are at the greatest risk to engage in unproductive and unlawful behavior. This includes the monitoring of assigned youth to ensure that they are complying with the conditions of their community placement and the provision of supportive services such as parent education, crisis intervention, mentoring, and skillbuilding as needed; and it includes mentoring services by which volunteer mentors are recruited, trained, matched with troubled youth, and supported in their work with them. Participating youth may be under either formal or informal supervision by the court during their time in the program;

5. Restorative justice services by which juvenile offenders are held accountable and educated as to the far-reaching impact of their behaviors; and 6. Private care diversion services designed for those youth who require structured residential services specialized in providing treatment for their complex needs.

Under this program, youth are served in alternative living centers without committing them to the care and supervision of DYS.

(C) Projects shall fall within a general program description supported by organizations such as the Office of Juvenile Justice and Delinquency Prevention. Projects may provide for— 1. Educational services/tutoring;

2. School/court liaisons;

3. Day treatment/alternative schools;

4. Jobs/vocational training/job placement;

5. Recreational/after school programs;

6. Truancy prevention;

7. Suspension/expulsion alternatives;

8. Violence prevention;

9. Community group counseling;

10. Anger management;

11. Mental health services;

12. Substance abuse prevention;

13. Sex offender therapy;

14. Prevention education/treatment;

15. Mentoring/advocacy;

16. Family therapy;

17. Family support preservation;

18. Parenting skills;

19. Family mediation;

20. Teen court;

21. Electronic monitoring/intensive supervision;

22. Gang prevention/intervention;

23. Drug court;

24. Gang education;

25. Restitution program services;

26. Community service;

27. Victim mediation;

28. Community accountability program services;

29. Alternative residential placement;

30. Purchased residential care (foster/shelter); and 31. Other model programs providing probation, supervision, family support, or restorative justice services.

(6) For those projects where youth will be placed in residential care with a private contractor, the contractor must have and maintain a license in good standing from the Department of Social Services, Children’s Division.

The JCD Grant recipient must have a written agreement in place with each contractual residential care provider that requires the provider to notify the JCD Grant recipient within ten days of any change in the provider’s licensing status. The JCD Grant recipient shall then notify DYS of any change in the provider’s licensing status within ten days and shall arrange for alternative placement of the youth unless an express written waiver is provided by the DYS.

(7) Applications for the JCD Grant Program shall be made in writing by the local JCD Grant Program Planning Committee. Each application shall include a completed application form and a written report containing a program description, method of implementation, and a proposed budget of all projects proposed to be funded.

(8) The local juvenile court judge shall appoint a planning committee (JCD Grant Program Planning Committee) whose membership shall be representative of the community’s population as required by section 219.041.3, RSMo. The JCD Grant Program Planning Committee shall consist of at least three and no more than seven members.

Members may include the juvenile court judge or his/her designee, the juvenile officer or his/her designee, a representative from a local school district, or a parent of a child who has received services from the juvenile court. Other people may include the chief court administrator, school superintendent or his/her designee, or any local or community leader that focuses on the well-being of youth and their families and is supported by their local juvenile court. The committee shall actively participate in the formulation of plans for the proper expenditure of funds and shall cooperate and assist the juvenile court judge in the implementation of these plans.

Members of this committee shall receive no compensation for their service on the committee.

(9) The local JCD Grant Program Planning Committee shall submit to the director a grant application form with a written report containing a program description, method of implementation, and a proposed budget of all projects proposed to be funded. The information provided shall list— (A) The specific services that will be provided through the use of the grant funds;

(B) The exact parameters of these services;

(C) The total amount of monies requested;

(D) The apportionment of monies for each service;

(E) The steps that will be taken to implement the program and the timeline for the full implementation of the program;

(F) The number of youth to be served;

(G) The description of the performance and the outcome measures that the grantee will use in evaluating the effectiveness of the program; and (H) The local juvenile court programming and commitment history, including program outcomes, effective utilization of funding, and diversion history.

(10) The recipient of a grant must permit the director of DYS or his/her designee to visit and inspect each project funded by the JCD Grant Program. The recipient of a grant must account for the monies, provide performance statistics, and make the books and records of the program open to DYS or the Department of Social Services for inspection and monitoring upon request. Upon a written recommendation from DYS for needed changes or improvements in a funded project, the grant recipients shall make the necessary changes to the project. The recipient of a grant must allow DYS to monitor all functions of programs developed with JCD Grant Funds.

Juvenile court staff must assist and cooperate with division staff in monitoring programs and in determining if the program is operating according to the contractual agreement negotiated between both parties.

(11) When the director determines that there are reasonable grounds to believe that a grant recipient is not in compliance with the operating standards established by this

regulation, the following may occur:

(A) The director may give thirty (30) days written notice to the grant recipient that the director is terminating the grant;

(B) The director may give thirty (30) days written notice to the grant recipient that the director is suspending all or a portion of any grant subsidy payment until the required standard of operation has been met;

(C) A revocation or suspension shall have immediate effect when the director has reason to believe the grant was obtained by fraud, trick, misrepresentation, or concealment of any material fact; the grant was issued by inadvertence or mistake and the grant recipient was not qualified to receive the grant; or the grant recipient has endangered the safety of a youth;

(D) Whenever the director terminates or suspends a JCD Grant, the notice will be sent via certified mail and the JCD Grant recipient who is aggrieved by the action may request an informal, administrative review before the director or the director’s designee;

(E) The JCD Grant recipient must make a written request for an administrative review within ten (10) business days of receipt of the notice of the termination or suspension. The grant recipient shall submit the grounds for error, along with any supporting documentation to the director;

(F) The director or the director’s designee may then review the request based upon the written submission or, at the request of the grantee, hold an informal meeting to discuss the grantee’s concerns. The hearing shall be informal, the rules of evidence will not apply, and there is no right to subpoena witnesses;

(G) At the sole discretion of the director, the director may allow the JCD Grant recipient an opportunity to cure any deficiencies in the standard of operation of the recipient’s program pending the administrative review; and (H) DYS shall be authorized to recoup funds from the JCD Grant recipient if DYS determines, after an administrative hearing, that funds were improperly expended.

4CODE OF STATE REGULATIONS

(5/31/19) JOHNR. ASHCROFT

History

• AUTHORITY: sections 219.036, 219.041, and 660.017, RSMo 2016. Original rule filed Nov. 30, 2018, effective June 30, 2019. Original authority: 219.036, RSMo 1975, amended 1993; 219.041, RSMo 1975; and 660.017, RSMo 1993, amended 1995.

Chapter 8 Youth Finances

13 CSR 110-8.010 Division of Youth Services Trust Fund Program {#sec-13-csr-110-8.010 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-8.010}

PURPOSE: This rule provides a program for youth in the Division of Youth Services (DYS) residential care to access funds, for reasonable purposes, as deemed appropriate by the division, in the DYS Trust Fund created by

section 219.095, RSMo. The DYS Trust Fund is a special class of trust funds to be used to account for all wages earned by residential youth and for other funds provided for the use and benefit of residential youth, excluding monies received by the DYS on behalf of youth from the Social Security Administration. This rule describes how the DYS establishes and maintains bank accounts to account for monies received for residential youth, except for monies received from the Social Security Administration.

(1) As used in this regulation, unless the context clearly indicates otherwise, the following terms mean:

(A) “Residential Youth” means a youth who has been committed to the Division of Youth Services (DYS) in the manner authorized by law, and who is placed in residential care;

(B) “Trust Fund” means a bank account established by the DYS for the receipt and disbursement of youth monies received while in residential placement, excluding payments made to youth in DYS custody by the Social Security Administration; and (C) “Youth” means a person under twentyone (21) years of age committed to the custody of DYS.

(2) When a youth is placed in the legal custody of the DYS, DYS shall receive and hold all youth wages or other monies provided to residential youth, excluding monies received by the Social Security Administration, in a DYS Trust Fund for the duration of the time that the youth is in DYS residential care.

(3) A DYS Trust Fund will be established for each DYS residential facility to hold all youth wages or other monies provided to residential youth, excluding payments made to youth in DYS custody by the Social Security Administration.

(A) The DYS Trust Fund, whenever possible, shall be a non-interest bearing checking account.

(B) The Director of DYS or the Director’s designee shall authorize opening of each account and shall be the opening signatory on each account.

(C) Each facility will designate two (2) employees to be authorized to sign for the deposit and withdrawal of funds after an account is established. The director shall approve the designated employees.

(4) Each DYS Trust Fund shall have the following process for the receipt and the tracking of funds:

(A) There shall be a general fund ledger to track all deposits and all withdrawals from the trust fund;

(B) There shall be individual ledgers for each residential youth who has monies deposited into the fund.

1. Wages from the any program established under section 219.091, RSMo, will be received by DYS on behalf of the youth and will be deposited into the trust fund. Each youth will be provided a receipt showing the deposit of funds in the trust fund.

2. Residential youth will also be provided a receipt for any other monies deposited into the DYS Trust fund on their behalf while residing in the facility; and (C) Each facility shall have one (1) receipt book to track deposits into the DYS Trust Fund. An entry detailing the date, time, amount, source of funds, and identification of the youth on whose behalf the monies are deposited will be made in the receipt book every time money is received on behalf of the youth.

(5) Each trust fund shall have the following process for the withdrawal of funds:

(A) Residential youth may withdraw monies with the approval of their group leader to ensure appropriate use and alignment with the comprehensive individual treatment plan;

(B) Each facility shall have one ledger to track all withdrawals from the DYS Trust Fund. An entry detailing the date, time, amount, name of the youth, and purpose for the transaction shall be made in the ledger every time money is disbursed from the fund; and (C) Upon release into the community, a check for the full balance shall be provided to the youth for the balance of funds on the youth’s individual ledger.

(6) Reconciliation:

(A) The trust fund’s receipt book and general ledger shall be reconciled on a monthly

basis with the bank statement;

(B) Each individual ledger shall be reconciled on a monthly basis with the general ledger; and (C) DYS and the Division of Finance and Administrative Services of the Department of Social Services may audit the books of each trust fund at any time.

(7) Each DYS youth involved in residential treatment services will participate in a personal finance curriculum, which will focus on wise money management.

(8) Unclaimed Trust Fund Balance. DYS shall promptly disburse any balance of monies accumulated in the youth’s account in the manner required by law when the youth is released from DYS residential care or upon death of the youth.

rule filed Dec. 19, 2018, effective July 30, 2019. *Original authority: 219.016, RSMo 1975, amended 1993, 1995; 219.036, RSMo 1975, amended 1993; 219.091, RSMo 1995, amended 2015; and 660.017, RSMo 1993, amended 1995.

History

• AUTHORITY: sections 219.016, 219.036, 219.091, and 660.017, RSMo 2016. Original

13 CSR 110-8.020 Division of Youth Services Child Benefits Program {#sec-13-csr-110-8.020 omnilex-key=us-mo-regs-official--title-13--13 CSR 110-8.020}

PURPOSE: The purpose of this rule is to account for monies received by the Division of Youth Services (DYS) from the Social Security Administration when the DYS has been named the representative payee of a residential youth. The DYS Child Benefits Fund is established within the State Treasury for depositing of payments from the Social Security Administration to youth in DYS custody.

Monies deposited in this fund shall be used only for the purposes specified by federal or state law or by these regulations. Monies in this special trust fund are not deemed to be state funds.

(1) As used in this regulation, unless the context clearly indicates otherwise, the following terms mean:

(A) “Benefit” means monies received on behalf of a youth from the Social Security Administration;

(B) “Youth” means a person under twentyone (21) years of age committed to the custody of the Division of Youth Services (DYS); and (C) “Residential Youth” means a youth who has been committed to the DYS in the manner provided by law, and who is placed in residential care.

JOHNR. ASHCROFT(6/30/19)

(2) The Fiscal Liaison for the DYS is responsible for establishing centralized methods to oversee the accounting of receipts and disbursements from this fund. Such methods require that— (A) There shall be an individual ledger for each youth receiving benefits when DYS has been appointed as Representative Payee for a youth in custody. The ledger shall contain all deposits and withdrawals of the youth’s money;

(B) There shall also be a control ledger to track all deposits and withdrawals from the fund; and (C) The control ledger shall be reconciled monthly with the individual ledger and the fund balance.

(3) Receipts from the Social Security Administration.

(A) All funds directly received by DYS as payee for a residential youth shall be deposited into the DYS Child Benefits Fund.

(B) Any checks received by the DYS from the Social Security Administration will be sent to the Division of Finance and Administrative Services (DFAS) for deposit into the DYS Child Benefits Fund.

(4) Utilization of the Child Benefits Fund.

(A) Monies deposited in this fund shall be used only for the purposes authorized by federal and state law, or by regulation of the DYS.

(B) Each facility with a youth receiving a Social Security benefit shall be issued a purchasing card designated solely for the use of the Social Security benefits of a youth in custody.

(C) Authorized DYS facility staff may make purchases for the youth receiving benefits up to the amount held in the youth’s fund based on need. All purchases shall be approved by the facility manager or his or her designee. Youth will not be provided with cash.

(5) Payments from the Child Benefits Fund include:

(A) Facility staff for each facility shall submit monthly purchasing card statements to DYS Central Office, along with copies of receipts from purchases;

(B) If funds are available, payments from the DYS Child Benefits Fund shall be made to off-set any purchases made for the youth in custody with the purchasing card; and (C) All expenditures shall be posted to the applicable individual ledgers and the control ledger.

(6) Removal of DYS as Representative Payee.

(A) DYS will resign as representative payee upon the release of a youth from residential care.

(B) DYS will submit to the Social Security Administration a written request to resign as representative payee, along with a check for the remaining balance in the youth’s individual ledger and any documentation requested by the Social Security Administration concerning all account activity as may be required by federal law.

4CODE OF STATE REGULATIONS

(6/30/19) JOHNR. ASHCROFT

History

• AUTHORITY: sections 219.016, 219.036, and 660.017, RSMo 2016. Original rule filed Dec. 19, 2018, effective July 30, 2019. Original authority: 219.016, RSMo 1975, amended 1993, 1995; 219.036, RSMo 1975, amended 1993; and 660.017, RSMo 1993, amended 1995.