Missouri Administrative Code

Plan for Long-Term Care Department of Social Services. Representatives of participating facilities will have an opportunity to make recommendations. PURPOSE: This rule establishes a payment plan for nursing All these changes will be subject to approval by the secretary home care …

Facility Reimbursement Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 13 CSR 70-10.017 Nursing Facility Invasive Ventilator Program . . . . . . . . . . . . . . . . . . . . . . . . 65

Nursing Facility Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

for ICF/IID Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Intellectually Disabled Individuals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 13 CSR 70-10.050 Pediatric Nursing Care Plan (Rescinded August 30, 2018) . . . . . . . . . . . . 105

Providers must file the cost report on forms provided by and in (Rescinded August 30, 2018) accordance with the procedures of the department. AUTHORITY: sections 208.153, 208.159 and 208.201, RSMo 2000. (C) Department. The department, unless otherwise specified, Original rule fil…

ICF/MR Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Absences Due to Hospital Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 13 CSR 70-10.080 Prospective Reimbursement Plan for HIV Nursing Facility Services . . . . 112

Nursing Facility Services exception of state programs such as Vocational Rehabilitation and the Missouri Crippled Children’s Services. PURPOSE: This rule establishes a payment plan for HIV nursing (E) The Medicaid reimbursement rate shall be the lower of: facility services. The p…

Health Services in Title XIX Reimbursement Rate Setting . . . . . . . . . . . .127 13 CSR 70-10.110 Nursing Facility Reimbursement Allowance . . . . . . . . . . . . . . . . . . . . . . . .127 13 CSR 70-10.120 Reimbursement for Nurse Assistant Training . . . . . . . . . . . . . . …

*Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007. PURPOSE: This regulation is necessary to outline the provisions allowed in House Bill 1362. 13 CSR 70-10.100 Limitation on Allowable Capital Cost PUBLISHER’S …

Training to nursing facilities with valid provider agreements certified by the Department of Social Services, Missouri Medicaid Audit PURPOSE: This rule establishes a methodology for payment of and Compliance (MMAC) for participation in the MO HealthNet nurse assistant training a…

(Rescinded June 30, 2018) nursing facility must be enrolled in the Medicaid program at the time the UPL payments are calculated and made. AUTHORITY: sections 208.153, 208.159 and 208.201, RSMo 2000. 1. A public nursing facility is defined as being owned or Emergency rule filed No…

efits and Limitations PURPOSE: This rule establishes the benefits and limitations for administering the Mis- souri 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 Hea…

Methodology provider manual and detailed on the audited Medicaid cost report. Penalties or incentive payments as a result of Medicare PURPOSE: This rule establishes the legal basis for the administration target rate calculations shall not be considered allowable costs. of the sta…

14, 1999, effective July 30, 1999. Amended: Filed May 14, 1999, effective Nov. 30, 1999. Amended: Filed May 14, 1999, effective Nov. PURPOSE: This rule provides for the calculation of the Direct 30, 1999. Emergency amendment filed June 18, 1999, effective June Medicaid payments m…

Validation Review of Hospital Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 13 CSR 70-15.030 Payment and Payment Limitations for Inpatient Hospital Care . . . . . . . . . 21 13 CSR 70-15.040 Hospital Outpatient Settlements . . . . . . . . . . . . . . . . . .…

Inpatient Hospital Care 11, 1981. Amended: Filed Nov. 20, 1981, effective March 11, 1982. Amended: Filed April 14, 1982, effective July 11, 1982. Emergency PURPOSE: This rule establishes payment and payment limitations amendment filed Nov. 24, 1982, effective Dec. 4, 1982, expire…

Twenty-One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Services (Rescinded December 30, 2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

and Continued Days of Stay (Rescinded May 30, 2020) . . . . . . . . . . . . . . . 25 13 CSR 70-15.100 Unreimbursed Care Payment Methodology . . . . . . . . . . . . . . . . . . . . . . . . . 25 13 CSR 70-15.110 Federal Reimbursement Allowance (FRA) . . . . . . . . . . . . . . . . …

the Cost of Care to the Uninsured Provided by Physicians Not Employed by the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Employed by the Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 13 CSR 70-15.190 Out-of-State Hospital Services Reimbursement Plan . . . . . . . . . . . . . . . . . . 31 Denny Hoskins (2/28/26) CODE OF STATE REGULATIONS 1 Secretary of…

Ambulatory Surgical Center-Acquired Condition (Rescinded June 30, 2012) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 13 CSR 70-15.220 Disproportionate Share Hospital (DSH) Payments . . . . . . . . . . . . . . . . . . . . 32 13 CSR 70-15.230…

Payments Services (CMS). FFP is not available for DSH payments that are found to exceed the hospital-specific eligible uncompensated PURPOSE: This rule implements a new state methodology for care cost limit. All hospitals that receive DSH payments are paying Disproportionate Shar…

odology E. The calculated IP UPL shall be inflated from the midpoint of the hospital’s cost report period to the midpoint PURPOSE: This rule establishes a methodology for determining of the IP UPL demonstration period using the CMS Prospective Upper Payment Limit (UPL) payments p…

(Rescinded December 30, 2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 13 CSR 70-2.100 Title XIX Procedure of Exception to Medical Care Services Limitations . . . . . 3

Care Services Limitations scope of a medical discipline included in the MO HealthNet program and which does not represent a departure from the PURPOSE: This rule establishes the basis, procedure, and criteria accepted standards and precepts of good medical practice; where the sta…

Marrow/Stem Cell Transplants and Related Medical Services . . . . . . . . . . . . . 4 Denny Hoskins (5/31/26) CODE OF STATE REGULATIONS 1 Secretary of State 13 CSR 70-2—DEPARTMENT OF SOCIAL SERVICES DIVISION 70—MO HEALTHNET DIVISION TITLE 13—DEPARTMENT OF SOCIAL SERVICES that spe…

(Rescinded September 30, 2018) 1987, effective Sept. 1, 1987. Amended: Filed Aug. 18, 1987, effective Nov. 12, 1987. Amended: Filed Dec. 1, 1987, effective Feb. 11, 1988. AUTHORITY: section 207.020, RSMo 1986. This rule was previously Amended: Filed April 4, 1988, effective July …

Division 30, 1990. Amended: Filed Aug. 10, 1990, effective Dec. 31, 1990. Emergency amendment filed Dec. 21, 1990, effective Jan. 1, 1991, PURPOSE: This rule implements recent changes in drug coverage expired April 30, 1991. Emergency rescission and rule filed March as mandated b…

Excluded from Coverage Under the MO HealthNet Pharmacy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

HealthNet Pharmacy Program (Rescinded January 30, 2019) . . . . . . . . . . . 4

Treatment of Acquired Immunodeficiency Syndrome (AIDS) (Rescinded September 30, 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Required (Rescinded May 30, 2019) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

(Rescinded January 30, 2019) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 13 CSR 70-20.042 Automatic Refill Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

(2) Prescriptions that are exempt from the thirty-one- (31-) day supply limit and therefore may be dispensed in quantities PURPOSE: This rule establishes the regulatory basis to prohibit exceeding a thirty-one- (31-) day supply are made available automatic refill of prescriptions…

MO HealthNet Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 13 CSR 70-20.047 Ninety-Day Supply Requirement for Select Prescriptions . . . . . . . . . . . . . . 5 13 CSR 70-20.050 Return of Drugs . . . . . . . . . . . . . . . . .…

plus an adjustment to account for the costs of the Missouri PURPOSE: This rule establishes that pharmacies must give the MO Pharmacy Reimbursement Allowance attributable to Medicaid- HealthNet Division credit for any unused portion of the drug that reimbursed prescriptions; is re…

(C) Indicate, as prescribed by the MO HealthNet Division, on PURPOSE: The MO HealthNet Division establishes the amount of each claim that the prescription was provided in packaging 6 CODE OF STATE REGULATIONS (4/30/25) Denny Hoskins Secretary of State 13 CSR 70-20—DEPARTMENT OF S…

effective Dec. 11, 1981. Emergency amendment filed Oct. 19, 1987, PURPOSE: This rule establishes the basis and the method for effective Oct. 29, 1987, expired Feb. 25, 1988. Amended: Filed Dec. pricing all drug claims in Missouri under the Title XIX Medicaid 1, 1987, effective Fe…

on Reimbursement (Rescinded September 30, 2018) . . . . . . . . . . . . . . . . . . 7 13 CSR 70-20.075 340B Drug Pricing Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Denny Hoskins (12/31/25) CODE OF STATE REGULATIONS 1 Secretary of Sta…

(Rescinded September 30, 1991) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Acquired Immunodeficiency Syndrome (AIDS) (Rescinded September 30, 1991) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

(Rescinded June 29, 1989) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 13 CSR 70-20.200 Prescription Prior Authorization Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 13 CSR 70-20.250 Prior Authorization of New Drug E…

after all recommendations have been reviewed. All pertinent PURPOSE: This rule establishes the MO HealthNet Division (MHD) information relating to the edit implementation schedule process by which drugs may be restricted under Section 4401 of and the edit criteria shall be made a…

(5) MHD shall post the tentative meeting agenda on the MHD or New Drug Dosage Form website (https://mydss.mo.gov/mhd/pharmacy-committees) at least seven (7) days before the meeting, and the agenda will PURPOSE: This rule outlines how new drugs or new drug dosage include the thera…

PURPOSE: This rule establishes the MO HealthNet Division (MHD) (10) The DUR Board shall advise MHD regarding all activities process by which the Drug Utilization Review Board is established associated with the DUR process, including identifying types as required by Section 4401 o…

Patient Counseling document for each MHD patient’s prescription uniformly whether the offer to counsel was accepted or refused by the PURPOSE: This rule establishes provisions for prospective drug use patient or the patient’s agent. review and patient counseling for MO HealthNet …

correct, unless the pharmacy files a protest in accordance with PURPOSE: This rule establishes a Pharmacy Federal Reimbursement subsection (2)(D) of this regulation. Allowance and the methodologies to determine the formula for the amount of allowance each pharmacy is required to …