Medical assistance--regulations as to costs and manner--federalmedical insurance benefits may be provided.
208.153. 1. Pursuant to and not inconsistent with the provisions ofsections 208.151 and 208.152, the MO HealthNet division shall by rule andregulation define the reasonable costs, manner, extent, quantity, quality,charges and fees of MO HealthNet benefits herein provided. The benefitsavailable under these sections shall not replace those provided under otherfederal or state law or under other contractual or legal entitlements ofthe persons receiving them, and all persons shall be required to apply forand utilize all benefits available to them and to pursue all causes ofaction to which they are entitled. Any person entitled to MO HealthNetbenefits may obtain it from any provider of services with which anagreement is in effect under this section and which undertakes to providethe services, as authorized by the MO HealthNet division. At thediscretion of the director of the MO HealthNet division and with theapproval of the governor, the MO HealthNet division is authorized toprovide medical benefits for participants receiving public assistance byexpending funds for the payment of federal medical insurance premiums,coinsurance and deductibles pursuant to the provisions of Title XVIII B andXIX, Public Law 89-97, 1965 amendments to the federal Social Security Act(42 U.S.C. 301, et seq.), as amended.
2. Subject to appropriations and pursuant to and not inconsistentwith the provisions of this section and sections 208.151 and 208.152, theMO HealthNet division shall by rule and regulation developpay-for-performance payment program guidelines. The pay-for-performancepayment program guidelines shall be developed and maintained by theprofessional services payment committee, as established in section 208.197.Providers operating under a risk-bearing care coordination plan and anadministrative services organization plan shall be required to participatein a pay-for-performance payment program, and providers operating under thestate coordinated fee-for-service plan shall participate in thepay-for-performance payment program. Any employer of a physician whosework generates all or part of a payment under this subsection shall passthe pertinent portion, as defined by departmental regulation, of thepay-for-performance payment on to the physician, without any correspondingdecrease in the compensation to which that provider would otherwise beentitled.
3. MO HealthNet shall include benefit payments on behalf of qualifiedMedicare beneficiaries as defined in 42 U.S.C. section 1396d(p). Thefamily support division shall by rule and regulation establish whichqualified Medicare beneficiaries are eligible. The MO HealthNet divisionshall define the premiums, deductible and coinsurance provided for in 42U.S.C. section 1396d(p) to be provided on behalf of the qualified Medicarebeneficiaries.
4. MO HealthNet shall include benefit payments for Medicare Part Acost sharing as defined in clause (p)(3)(A)(i) of 42 U.S.C. 1396d on behalfof qualified disabled and working individuals as defined in subsection (s)of section 42 U.S.C. 1396d as required by subsection (d) of section 6408 ofP.L. 101-239 (Omnibus Budget Reconciliation Act of 1989). The MO HealthNetdivision may impose a premium for such benefit payments as authorized byparagraph (d)(3) of section 6408 of P.L. 101-239.
5. MO HealthNet shall include benefit payments for Medicare Part Bcost sharing described in 42 U.S.C. Section 1396(d)(p)(3)(A)(ii) forindividuals described in subsection 2 of this section, but for the factthat their income exceeds the income level established by the state under42 U.S.C. Section 1396(d)(p)(2) but is less than one hundred and tenpercent beginning January 1, 1993, and less than one hundred and twentypercent beginning January 1, 1995, of the official poverty line for afamily of the size involved.
6. For an individual eligible for MO HealthNet under Title XIX of theSocial Security Act, MO HealthNet shall include payment of enrolleepremiums in a group health plan and all deductibles, coinsurance and othercost-sharing for items and services otherwise covered under the state TitleXIX plan under Section 1906 of the federal Social Security Act andregulations established under the authority of Section 1906, as may beamended. Enrollment in a group health plan must be cost effective, asestablished by the Secretary of Health and Human Services, beforeenrollment in the group health plan is required. If all members of afamily are not eligible for MO HealthNet and enrollment of the Title XIXeligible members in a group health plan is not possible unless all familymembers are enrolled, all premiums for noneligible members shall be treatedas payment for MO HealthNet of eligible family members. Payment fornoneligible family members must be cost effective, taking into accountpayment of all such premiums. Non-Title XIX eligible family members shallpay all deductible, coinsurance and other cost-sharing obligations. Eachindividual as a condition of eligibility for MO HealthNet benefits shallapply for enrollment in the group health plan.
7. Any Social Security cost-of-living increase at the beginning ofany year shall be disregarded until the federal poverty level for such yearis implemented.
8. If a MO HealthNet participant has paid the requested spenddown incash for any month and* subsequently pays an out-of-pocket valid medicalexpense for such month, such expense shall be allowed as a deduction tofuture required spenddown for up to three months from the date of suchexpense.
Medical assistance--regulations as to costs and manner--federalmedical insurance benefits may be provided.
208.153. 1. Pursuant to and not inconsistent with the provisions ofsections 208.151 and 208.152, the MO HealthNet division shall by rule andregulation define the reasonable costs, manner, extent, quantity, quality,charges and fees of MO HealthNet benefits herein provided. The benefitsavailable under these sections shall not replace those provided under otherfederal or state law or under other contractual or legal entitlements ofthe persons receiving them, and all persons shall be required to apply forand utilize all benefits available to them and to pursue all causes ofaction to which they are entitled. Any person entitled to MO HealthNetbenefits may obtain it from any provider of services with which anagreement is in effect under this section and which undertakes to providethe services, as authorized by the MO HealthNet division. At thediscretion of the director of the MO HealthNet division and with theapproval of the governor, the MO HealthNet division is authorized toprovide medical benefits for participants receiving public assistance byexpending funds for the payment of federal medical insurance premiums,coinsurance and deductibles pursuant to the provisions of Title XVIII B andXIX, Public Law 89-97, 1965 amendments to the federal Social Security Act(42 U.S.C. 301, et seq.), as amended.
2. Subject to appropriations and pursuant to and not inconsistentwith the provisions of this section and sections 208.151 and 208.152, theMO HealthNet division shall by rule and regulation developpay-for-performance payment program guidelines. The pay-for-performancepayment program guidelines shall be developed and maintained by theprofessional services payment committee, as established in section 208.197.Providers operating under a risk-bearing care coordination plan and anadministrative services organization plan shall be required to participatein a pay-for-performance payment program, and providers operating under thestate coordinated fee-for-service plan shall participate in thepay-for-performance payment program. Any employer of a physician whosework generates all or part of a payment under this subsection shall passthe pertinent portion, as defined by departmental regulation, of thepay-for-performance payment on to the physician, without any correspondingdecrease in the compensation to which that provider would otherwise beentitled.
3. MO HealthNet shall include benefit payments on behalf of qualifiedMedicare beneficiaries as defined in 42 U.S.C. section 1396d(p). Thefamily support division shall by rule and regulation establish whichqualified Medicare beneficiaries are eligible. The MO HealthNet divisionshall define the premiums, deductible and coinsurance provided for in 42U.S.C. section 1396d(p) to be provided on behalf of the qualified Medicarebeneficiaries.
4. MO HealthNet shall include benefit payments for Medicare Part Acost sharing as defined in clause (p)(3)(A)(i) of 42 U.S.C. 1396d on behalfof qualified disabled and working individuals as defined in subsection (s)of section 42 U.S.C. 1396d as required by subsection (d) of section 6408 ofP.L. 101-239 (Omnibus Budget Reconciliation Act of 1989). The MO HealthNetdivision may impose a premium for such benefit payments as authorized byparagraph (d)(3) of section 6408 of P.L. 101-239.
5. MO HealthNet shall include benefit payments for Medicare Part Bcost sharing described in 42 U.S.C. Section 1396(d)(p)(3)(A)(ii) forindividuals described in subsection 2 of this section, but for the factthat their income exceeds the income level established by the state under42 U.S.C. Section 1396(d)(p)(2) but is less than one hundred and tenpercent beginning January 1, 1993, and less than one hundred and twentypercent beginning January 1, 1995, of the official poverty line for afamily of the size involved.
6. For an individual eligible for MO HealthNet under Title XIX of theSocial Security Act, MO HealthNet shall include payment of enrolleepremiums in a group health plan and all deductibles, coinsurance and othercost-sharing for items and services otherwise covered under the state TitleXIX plan under Section 1906 of the federal Social Security Act andregulations established under the authority of Section 1906, as may beamended. Enrollment in a group health plan must be cost effective, asestablished by the Secretary of Health and Human Services, beforeenrollment in the group health plan is required. If all members of afamily are not eligible for MO HealthNet and enrollment of the Title XIXeligible members in a group health plan is not possible unless all familymembers are enrolled, all premiums for noneligible members shall be treatedas payment for MO HealthNet of eligible family members. Payment fornoneligible family members must be cost effective, taking into accountpayment of all such premiums. Non-Title XIX eligible family members shallpay all deductible, coinsurance and other cost-sharing obligations. Eachindividual as a condition of eligibility for MO HealthNet benefits shallapply for enrollment in the group health plan.
7. Any Social Security cost-of-living increase at the beginning ofany year shall be disregarded until the federal poverty level for such yearis implemented.
8. If a MO HealthNet participant has paid the requested spenddown incash for any month and* subsequently pays an out-of-pocket valid medicalexpense for such month, such expense shall be allowed as a deduction tofuture required spenddown for up to three months from the date of suchexpense.
Medical assistance--regulations as to costs and manner--federalmedical insurance benefits may be provided.
208.153. 1. Pursuant to and not inconsistent with the provisions ofsections 208.151 and 208.152, the MO HealthNet division shall by rule andregulation define the reasonable costs, manner, extent, quantity, quality,charges and fees of MO HealthNet benefits herein provided. The benefitsavailable under these sections shall not replace those provided under otherfederal or state law or under other contractual or legal entitlements ofthe persons receiving them, and all persons shall be required to apply forand utilize all benefits available to them and to pursue all causes ofaction to which they are entitled. Any person entitled to MO HealthNetbenefits may obtain it from any provider of services with which anagreement is in effect under this section and which undertakes to providethe services, as authorized by the MO HealthNet division. At thediscretion of the director of the MO HealthNet division and with theapproval of the governor, the MO HealthNet division is authorized toprovide medical benefits for participants receiving public assistance byexpending funds for the payment of federal medical insurance premiums,coinsurance and deductibles pursuant to the provisions of Title XVIII B andXIX, Public Law 89-97, 1965 amendments to the federal Social Security Act(42 U.S.C. 301, et seq.), as amended.
2. Subject to appropriations and pursuant to and not inconsistentwith the provisions of this section and sections 208.151 and 208.152, theMO HealthNet division shall by rule and regulation developpay-for-performance payment program guidelines. The pay-for-performancepayment program guidelines shall be developed and maintained by theprofessional services payment committee, as established in section 208.197.Providers operating under a risk-bearing care coordination plan and anadministrative services organization plan shall be required to participatein a pay-for-performance payment program, and providers operating under thestate coordinated fee-for-service plan shall participate in thepay-for-performance payment program. Any employer of a physician whosework generates all or part of a payment under this subsection shall passthe pertinent portion, as defined by departmental regulation, of thepay-for-performance payment on to the physician, without any correspondingdecrease in the compensation to which that provider would otherwise beentitled.
3. MO HealthNet shall include benefit payments on behalf of qualifiedMedicare beneficiaries as defined in 42 U.S.C. section 1396d(p). Thefamily support division shall by rule and regulation establish whichqualified Medicare beneficiaries are eligible. The MO HealthNet divisionshall define the premiums, deductible and coinsurance provided for in 42U.S.C. section 1396d(p) to be provided on behalf of the qualified Medicarebeneficiaries.
4. MO HealthNet shall include benefit payments for Medicare Part Acost sharing as defined in clause (p)(3)(A)(i) of 42 U.S.C. 1396d on behalfof qualified disabled and working individuals as defined in subsection (s)of section 42 U.S.C. 1396d as required by subsection (d) of section 6408 ofP.L. 101-239 (Omnibus Budget Reconciliation Act of 1989). The MO HealthNetdivision may impose a premium for such benefit payments as authorized byparagraph (d)(3) of section 6408 of P.L. 101-239.
5. MO HealthNet shall include benefit payments for Medicare Part Bcost sharing described in 42 U.S.C. Section 1396(d)(p)(3)(A)(ii) forindividuals described in subsection 2 of this section, but for the factthat their income exceeds the income level established by the state under42 U.S.C. Section 1396(d)(p)(2) but is less than one hundred and tenpercent beginning January 1, 1993, and less than one hundred and twentypercent beginning January 1, 1995, of the official poverty line for afamily of the size involved.
6. For an individual eligible for MO HealthNet under Title XIX of theSocial Security Act, MO HealthNet shall include payment of enrolleepremiums in a group health plan and all deductibles, coinsurance and othercost-sharing for items and services otherwise covered under the state TitleXIX plan under Section 1906 of the federal Social Security Act andregulations established under the authority of Section 1906, as may beamended. Enrollment in a group health plan must be cost effective, asestablished by the Secretary of Health and Human Services, beforeenrollment in the group health plan is required. If all members of afamily are not eligible for MO HealthNet and enrollment of the Title XIXeligible members in a group health plan is not possible unless all familymembers are enrolled, all premiums for noneligible members shall be treatedas payment for MO HealthNet of eligible family members. Payment fornoneligible family members must be cost effective, taking into accountpayment of all such premiums. Non-Title XIX eligible family members shallpay all deductible, coinsurance and other cost-sharing obligations. Eachindividual as a condition of eligibility for MO HealthNet benefits shallapply for enrollment in the group health plan.
7. Any Social Security cost-of-living increase at the beginning ofany year shall be disregarded until the federal poverty level for such yearis implemented.
8. If a MO HealthNet participant has paid the requested spenddown incash for any month and* subsequently pays an out-of-pocket valid medicalexpense for such month, such expense shall be allowed as a deduction tofuture required spenddown for up to three months from the date of suchexpense.
