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.

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. (1) General Reimbursement Principles.

   1. (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. As described in paragraph (5)(D)2. of this rule, as part of each hospital’s fiscal year-end cost settlement determination, a comparison of total MO HealthNetcovered aggregate charges and total MO HealthNet payments will be made and any hospital whose aggregate MO HealthNet per diem payments exceed aggregate MO HealthNet charges will be subject to a retroactive adjustment.
   2. (B) The Title XIX reimbursement for hospitals located outside Missouri and for federally-operated hospitals in Missouri will be determined as stated in 13 CSR 70-15.190.

   3. (C) The Title XIX reimbursement for hospitals, excluding those located outside Missouri and in-state federal hospitals, shall include per diem payments, outpatient payments, disproportionate share payments as described in this regulation through May 31, 2011, and as described in 13 CSR 70-15.220 beginning June 1, 2011; various MO HealthNet Add-On payments, as described in this rule; or a safety net adjustment, paid in lieu of Direct Medicaid Payments described in section (15) and Uninsured Add-Ons described in this regulation through May 31, 2011, and described in 13 CSR 70-15.220 beginning June 1, 2011. Reimbursement shall be subject to availability of federal financial participation (FFP).

      1. 1. Per diem reimbursement—The per

diem rate is established in accordance with section (3).

1. 2. Outpatient reimbursement is described

in 13 CSR 70-15.160.

1. 3. Disproportionate share reimburse-

ment—The disproportionate share payments described in section (16) and subsection (18)(B), include both the federally-mandated reimbursement for hospitals which meet the federal requirements listed in section (6) and the discretionary disproportionate share payments which are allowable but not mandated under federal regulation. These Safety Net and Uninsured Add-Ons shall not exceed one hundred percent (100%) of the unreimbursed cost for MO HealthNet and the cost of the uninsured unless otherwise permitted by federal law. Beginning June 1, 2011, hospital disproportionate share reimbursements are defined in 13 CSR 70-15.220.

1. 4. MO HealthNet Add-Ons—MO

HealthNet Add-Ons are described in sections (13), (14), (15), (19), and (21) and are in addition to MO HealthNet per diem payments. These payments are subject to the federal Medicare Upper Limit test.

1. 5. Safety Net Adjustment—The pay-

ments described in subsection (16)(A) are paid in lieu of Direct Medicaid Payments described in section (15) and Uninsured Add- Ons described in subsection (18)(B).

1. (2) Definitions.

   1. (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 desk-reviewed Medicare/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 ser- 13 CSR 70-15

vice or item. For purposes of calculating disproportionate share payments and to ensure federal financial participation (FFP), allowable uncompensated costs must meet definitions defined by the federal government.

1. (B) Bad debt. Bad debts should include the costs of caring for patients who have insurance but are not covered for the particular services, procedures, or treatment rendered. Bad debts should not include the cost of caring for patients whose insurance covers the given procedures but limits coverage. In addition, bad debts should 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.
2. (C) Base cost report. Desk-reviewed Medicare/Medicaid cost report. When a facility has more than one (1) cost report with periods ending in the fourth 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 cost report is less than or greater than a twelve- (12-) month period, the data shall be adjusted, based on the number of months reflected in the base cost report to a twelve- (12-) month period.
3. (D) Case mix index. The average Diagnosis Related Grouping (DRG) relative weight as determined from claims information filed with the Missouri Department of Health and Senior Services. This calculation will include both fee-for-service and managed care information. The DRG weight used in the calculation is the same for all years and is the weight that is associated with the latest year of data that is being analyzed (i.e., for SFY 2004, weights for 2003 are applied to all years). The DRG weights will be updated annually using the information published by the Centers for Medicare and Medicaid Services

1. (CMS) in the Federal Register.

   1. (E) 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.
   2. (F) Contractual allowances. Difference be - tween established rates for covered services and the amount paid by third-party payers under contractual agreements.
   3. (G) 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 2552-96 (CMS 2552-96) shall be used for fiscal years ending on or after September 30, 1996. The Medicare/Medicaid Cost Report version 2552-10 (CMS 2552-10) shall be used for fiscal years beginning on and after May 1, 2010.
   4. (H) Critical access. Hospitals which meet the federal definition found in section 1820(c)(2)(B) of the Social Security Act. A Missouri expanded definition of critical access shall also include hospitals which meet the federal definitions of both a rural referral center and sole community provider and is adjacent to at least one (1) county that has a Medicaid eligible population of at least twenty-five percent (25%) of the total population of the county or hospitals which are the sole community hospital located in a county that has a Medicaid population of at least twentyfive percent (25%) of the total population of the county.
   5. (I) Disproportionate share reimbursement. The disproportionate share payments described in section (16), and subsection (18)(B), include both the federally-mandated reimbursement for hospitals which meet the federal requirements listed in section (6) and the discretionary disproportionate share payments which are allowed but not mandated under federal regulation. These Safety Net and Uninsured Payment Add-Ons shall not exceed one hundred percent (100%) of the unreimbursed cost for MO HealthNet and the cost of the uninsured unless otherwise permitted by federal law. Beginning June 1, 2011, disproportionate share reimbursement is described in 13 CSR 70-15.220.

   6. (J) Effective date.

      1. 1. The plan effective date shall be Octo-

ber 1, 1981.

1. 2. The adjustment effective date shall be

thirty (30) days after notification to the hospital that its reimbursement rate has been changed unless modified by other sections of the plan.

1. (K) MO HealthNet inpatient days. MO HealthNet inpatient days are paid MO HealthNet days for inpatient hospital services as reported by the Medicaid Management Information System (MMIS).
2. (L) Medicare rate. The Medicare rate is the rate established on the basis of allowable cost as defined by applicable Medicare standards and principles of reimbursement (42 CFR parts 405 and 413) as determined by the servicing fiscal intermediary based on yearly hospital cost reports.

3. (M) Nonreimbursable items. For purposes of reimbursement of reasonable cost, the following are not subject to reimbursement:

   1. 1. Allowances for return on equity capi-

tal;

1. 2. Amounts representing growth

allowances in excess of the intensity allowance, profits, efficiency bonuses, or a combination of these;

1. 3. Cost in excess of the principal of

reimbursement specified in 42 CFR chapter IV, part 413; and

1. 4. Costs or services or costs and ser-

vices specifically excluded or restricted in this plan or the MO HealthNet hospital provider manual.

1. (N) Per diem rates. The per diem rates shall be determined from the individual hospital cost report in accordance with section

1. (3) of the regulation.

   1. (O) Reasonable cost. The reasonable cost of inpatient hospital services is an individual hospital’s MO HealthNet per diem cost per day as determined in accordance with the general plan rate calculation from section (3) of this regulation using the base year cost report.

   2. (P) Specialty pediatric hospital. An inpatient pediatric acute care facility which—

      1. 1. Is licensed as a hospital by the

Missouri Department of Health and Senior Services under Chapter 197 of the Missouri Revised Statutes;

1. 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

1. 3. Is not licensed to operate more than

sixty (60) inpatient beds.

1. (Q) Trauma hospital. A trauma center designated by the Missouri Department of Health and Senior Services.
2. (R) 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.
3. (S) Children’s hospital. An acute care hospital operated primarily for the care and treatment of children under the age of eighteen (18) years old and which has designated in its licensure application at least sixty-five percent (65%) of its total licensed beds as a pediatric unit as defined in 19 CSR 30-20.021(4)(F).
4. (T) FRA. The Federal Reimbursement Allowance (FRA) is identified in 13 CSR 70- 15.110. Effective January 1, 1999, the assessment shall be an allowable cost.

5. (U) Incorporates by Reference. This rule incorporates by reference the following:

   1. 1. Institutional Provider Manual; and
   2. 2. Medicare/Medicaid Cost Report CMS

2552-96 and CMS 2552-10, which are incorporated by reference and made a part of this rule as published by the Centers for Medicare and Medicaid Services at website http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Paper-Based- Manuals-Items/CMS021935.html, August 1, 2013. This rule does not incorporate any subsequent amendments or additions.

1. (3) Per Diem Reimbursement Rate Computation. Each hospital shall receive a MO HealthNet per diem rate based on the following computation:

   1. (A) The per diem rate shall be determined from the 1995 base year cost report in accordance with the following formula:

      (OC * TI) CMC

      Per Diem= +

MPD MPDC

1. 1. OC—The operating component is the

hospital’s total allowable cost (TAC) less CMC;

1. 2. CMC—The capital and medical edu-

cation component of the hospital’s TAC;

1. 3. MPD—Medicaid inpatient days;
2. 4. MPDC-MPD—Medicaid patient days

for capital costs as defined in paragraph (3)(A)3. with a minimum utilization of sixty percent (60%) as described in paragraph (5)(C)8.;

1. 5. TI—Trend indices. The trend indices

are applied to the OC of the per diem rate. The trend index for SFY 1995 is used to adjust the OC to a common fiscal year end of June 30. The adjusted OC shall be trended through SFY 2001;

1. 6. TAC—Allowable inpatient routine and

special care unit expenses, ancillary expenses, and graduate medical education costs will be added to determine the hospital’s total allowable cost (TAC);

1. 7. The per diem shall not exceed the

average MO HealthNet inpatient charge per diem as determined from the base year cost report and adjusted by the TI; and

1. 8. The per diem shall be adjusted for

rate increases granted in accordance with subsection (5)(F) for allowable costs not included in the base year cost report.

1. (B) Trend Indices (TI). Trend indices are determined based on the four- (4-) quarter average DRI Index for DRI-Type Hospital Market Basket as published in Health Care Costs by DRI/McGraw-Hill for each State Fiscal Year (SFY) 1995 to 1998. Trend indices starting in SFY 1999 will be determined based on CPI Hospital indexed as published in Health Care Costs by DRI/McGraw-Hill, or equivalent publication, regardless of any changes in the name of the publication or publisher, for each State Fiscal Year (SFY). Trend indices starting in SFY 2016 will be determined based on 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, for each State Fiscal Year (SFY).

   1. 1. The TI are—

      1. A. SFY 1994—4.6%
      2. B. SFY 1995—4.45%
      3. C. SFY 1996—4.575%
      4. D. SFY 1997—4.05%
      5. E. SFY 1998—3.1%
      6. F. SFY 1999—3.8%
      7. G. SFY 2000—4.0%
      8. H. SFY 2001—4.6%
      9. I. SFY 2002—4.8%
      10. J. SFY 2003—5.0%
      11. K. SFY 2004—6.2%
      12. L. SFY 2005—6.7%
      13. M. SFY 2006—5.7%
      14. N. SFY 2007—5.9%
      15. O. SFY 2008—5.5%
      16. P. SFY 2009—5.5%
      17. Q. SFY 2010—3.9%
      18. R. SFY 2011—3.2%—The 3.2%

trend shall not be applied in determining the per diem rate, Direct Medicaid payments, or uninsured payments.

1. S. SFY 2012—4.0%
2. T. SFY 2013—4.4%
3. U. SFY 2014—3.7%
4. V. SFY 2015—4.3%
5. W. SFY 2016—2.5%
6. X. SFY 2017—2.7%
7. 2. The TI for SFY 1996 through SFY

1998 are applied as a full percentage to the OC of the per diem rate and for SFY 1999 the OC of the June 30, 1998, rate shall be trended by 1.2% and for SFY 2000 the OC of the June 30, 1999, rate shall be trended by 2.4%. The OC of the June 30, 2000, rate shall be trended by 1.95% for SFY 2001.

1. 3. The per diem rate shall be reduced as

necessary to avoid any negative Direct Medicaid payments computed in accordance with subsection (15)(B).

1. 4. A facility previously enrolled for par-

ticipation in the MO HealthNet Program, which either voluntarily or involuntarily terminates its participation in the MO HealthNet Program and which reenters the MO HealthNet Program, will receive the same inpatient rate and outpatient rate as the previous owner/operator. Such facility will also receive the same Direct Medicaid Add-On Payment and Uninsured Add-On Payment as the previous owner/operator if the facility reenters the MO HealthNet Program during the same state fiscal year. If the facility does not reenter during the same state fiscal year, the Direct Medicaid Add-On Payment and Uninsured Add-On Payment will be determined based on the applicable base year data (i.e., fourth prior year cost report for the Direct Medicaid Payment; see 13 CSR 70- 15.220 for the applicable data for the Uninsured Add-On Payment). If the facility does not have the applicable base year data, the Direct Medicaid Add-On Payment and the Uninsured Add-On Payment will be based on the most recent audited 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 payments are being determined.

1. (4) Per Diem Rate—New Hospitals.

   1. (A) Facilities Reimbursed by Medicare on a Per Diem Basis. In the absence of adequate cost data, a new facility’s MO HealthNet rate shall be determined as set forth below in subsection (4)(B).

   2. (B) Facilities Reimbursed by Medicare on a DRG Basis. In the absence of adequate cost data, a new facility’s initial MO HealthNet rate shall be ninety percent (90%) of the average-weighted, statewide per diem rate for the year it became certified to participate in the MO HealthNet program until a prospective rate is determined on the facility’s rate setting cost report as set forth below in paragraph (4)(B)1. The facility’s rate setting cost report shall be the first full fiscal year cost report. If the facility’s first full fiscal year cost report does not include any Medicaid costs, the facility shall continue to receive the initial rate, and the prospective rate will be determined from the facility’s second full fiscal year cost report. If the facility’s second full fiscal year cost report does not include any Medicaid cost, the initial rate shall become the facility’s prospective rate and shall be effective the date the facility was enrolled in the MO HealthNet program. The effective date for facilities whose prospective rate was based on the rate setting cost report shall be the first day of the SFY that the rate setting cost report is the base year cost report for determining the Direct Medicaid Add-On Payment.

      1. 1. Prospective Per Diem Reimbursement

Rate Computation. Each new hospital shall receive a MO HealthNet prospective per diem rate based on the sum of the following components:

1. A. Total Allowable Cost, less

Graduate Medical Education cost, adjusted by the Trend Indices included in subsection (3)(B) from the year subsequent to the rate setting cost report period through the state fiscal year for which the rate is being determined, divided by Medicaid Inpatient Days; plus

1. B. Graduate Medical Education cost

divided by Medicaid Inpatient Days.

1. 2. The per diem rate shall not exceed the

average MO HealthNet inpatient charge per day as determined from the rate setting cost report as adjusted by the applicable Trend Indices.

1. 3. The per diem rate shall be adjusted

for rate increases granted in accordance with subsection (5)(F) for allowable costs not included in the rate setting cost report.

1. 4. The per diem rate shall be reduced as

necessary to avoid any negative Direct Medicaid Payments computed in accordance with subsection (15)(B).

1. (C) In addition to the MO HealthNet rate determined by either subsection (4)(A) or (4)(B), the MO HealthNet per diem rate for a new hospital licensed after February 1, 2007, shall include an adjustment for the hospital’s estimated Direct Medicaid Add-On Payment per patient day, as determined in subsection (15)(C), until the facility’s prospective rate is set in accordance with subsection (4)(B). The facility’s Direct Medicaid Add-On adjustment will then no longer be included in the per diem rate but shall be calculated as a separate Add-On Payment, as set forth in section (15). 13 CSR 70-15

1. (5) Reporting Requirements.

   1. (A) Cost Reports.

      1. 1. Each hospital participating in the MO

HealthNet program shall submit a cost report in the manner prescribed by the state MO HealthNet agency. 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 single extension, not to exceed thirty (30) days, may be granted upon the request of the hospital and the approval of the MO HealthNet Division when the provider’s operation is significantly affected due to extraordinary circumstances over which the provider 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.

1. 2. The change of control, ownership, or

termination of or by 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, ownership, or termination within five (5) calendar months after the close of the reporting period. No extensions in the submitting of cost reports shall be allowed when a termination of participation has occurred.

1. A. 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 MO HealthNet program, the division will withhold all remaining payments from the selling provider until the cost report is filed. Upon receipt of a cost report prepared in accordance with this regulation, any payment that was withheld will be released to the selling provider.

1. B. If the director of the Institutional

Reimbursement Unit does not receive, in writing, notification of a change of control or ownership upon learning of a change of control or ownership, fifty thousand dollars ($50,000) of the next available MO HealthNet payment, after learning of the change of control or ownership, will be withheld from the provider identified in the current MO HealthNet participation agreement until a 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 provider identified in the current MO HealthNet participation agreement.

1. C. The MO HealthNet Division may,

at its discretion, delay the withholding of funds specified in subparagraphs (5)(A)2.A. and B. 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 provider may provide adequate assurances. The buying provider 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.

1. 3. All cost reports shall be submitted

and certified by an officer or administrator of the provider. Failure to file a cost report, within the period prescribed in this subsection, may result in the impositions of sanctions as described in 13 CSR 70-3.030.

1. 4. Amended cost reports or other sup-

plemental. The division will notify hospital by letter when the desk review of its cost report is completed. Since this data may be used in the calculation of per diem rates, direct payments, trended costs, or uninsured add-on payments, the hospital shall review the desk review data and the schedule of key data elements and submit amended or corrected data to the division within fifteen (15) days. Data received after the fifteen- (15-) day deadline will not be considered by the division for per diem rates, direct payments, trended costs, or uninsured 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.

1. (B) Records.

   1. 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. Separate logs for inpatient and outpatient services should be maintained for MO HealthNet participants covered by managed care. 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:

1. A. A separate MO HealthNet log for

each fiscal year must be maintained by either date of service or date of payment by MO HealthNet 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 MO HealthNet log should be used to complete the Medicaid worksheet in the hospital’s cost report;

1. B. Data required to be recorded in

logs for each claim include:

1. (I) Participant name and MO

HealthNet number;

1. (II) Dates of service;
2. (III) If inpatient claim, number of

days paid for by MO HealthNet, classified by adults and peds, each subprovider, newborn, or specific type of intensive care;

1. (IV) Charges for paid inpatient days

and inpatient ancillary charges for paid days classified by cost center as reported in the cost report or allowed outpatient services, classified by cost center as reported on cost report;

1. (V) Noncovered charges combined

under a separate heading;

1. (VI) Total charges;
2. (VII) Any partial payment made by

third-party payers (claims paid equal to or in excess of MO HealthNet payment rates by third-party payers shall not be included in the log); (VIII) MO HealthNet payment received or the adjustment taken; and

1. (IX) Date of remittance advice

upon which paid claim or adjustment appeared;

1. C. 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

1. D. Not to be included in the outpa-

tient log are claims or line item outpatient charges denied by MO HealthNet or claims or charges paid from an established MO HealthNet fee schedule. This would include payments for hospital-based physicians and certified registered nurse anesthetists billed by the hospital on a professional services claim, payments for certain specified clinical diagnostic laboratory services, or payments for services provided by the hospital through enrollment as a MO HealthNet provider-type other than hospital outpatient.

1. 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 (5)(B)1. of this rule.

1. 3. Records to support and document

Disproportionate Share Hospital (DSH) payments must be maintained and available for future federal audits. Records used to complete DSH audit surveys shall be kept seven (7) years following the final DSH audit. For example, the SFY 2011 state DSH survey will use 2009 cost data which must be maintained seven (7) years following the completion of the 2014 DSH audit (2022). Records provided by hospitals to the state’s independent auditor shall also be maintained for seven (7) years following the completion of the final federal 2014 DSH audit.

1. 4. The MO HealthNet Division shall

retain all uniform cost reports submitted for a period of at least three (3) years following the date of submission of the reports and will maintain those reports pursuant to the recordkeeping requirements of 42 CFR 413.20. If an audit by, or on behalf of, the state or federal government has begun but is not completed at the end of the three- (3-) year period, or if audit findings have not been resolved at the end of the three- (3-) year period, the reports shall be retained until resolution of the audit findings.

1. 5. The MO HealthNet Division shall

maintain any responses received on this plan, subsequent changes to this plan, and rates for a period of three (3) years from the date of receipt.

1. (C) New, Expanded, or Terminated Services. A hospital, at times, may offer to the public new or expanded inpatient services which may require Certificate of Need

1. (CON) approval, or may permanently terminate a service.

   1. 1. 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.

1. 2. Nonstate 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 Certificate of Need (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.

1. 3. A hospital (state or nonstate) 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 desk review and audit. Upon completion of the desk review and audit, the hospital’s inpatient reimbursement rates 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 (direct Medicaid payments). Failure to submit a request shall not prohibit the division from reducing the rate in the case of a terminated service.

1. 4. Failure to submit a budget concerning

terminated services may result in the imposition of sanctions as described in 13 CSR 70- 3.030.

1. 5. The effective date for any increase

granted under this subsection shall be no earlier than the first day of the month following the MO HealthNet Division’s final determination on rate reconsideration.

1. 6. Any inpatient rate reconsideration

request for new, expanded, or terminated services must be submitted in writing to the MO HealthNet Division and must specifically and clearly identify the issue and total dollar amount involved. The total dollar amount must be supported by generally accepted accounting principles. The hospital shall demonstrate the adjustment is necessary, proper, and consistent with efficient and economical delivery of covered patient care services. The hospital will be notified in writing of the agency’s decision 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. If the state does not respond within the sixty- (60-) day period, the request shall be deemed denied.

1. 7. Rate adjustments 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 skilled nursing facility (SNF) and swing bed cost) to total hospital cost as submitted on the most recent cost report filed with the agency as of the review date divided by total acute care patient days including all special care units and nursery, but excluding swing bed days.

1. 8. Total acute care patient days (exclud-

ing 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 sixty-five (365) days. If the days, including neonatal units, are less than sixty percent (60%), the sixty percent (60%) number plus newborn days will be used to determine the rate increase. This computation will apply to capital costs only.

1. 9. 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.

1. (D) Audits.

   1. 1. A comprehensive hospital audit pro-

gram shall be established in cooperation with the Missouri Medicare fiscal intermediary. Under the terms of the Common Audit Agreement, the Medicare intermediary shall perform the following:

1. A. Desk review all hospital cost

reports;

1. B. Determine the scope and format

for on-site audits;

1. C. Perform field audits when indicat-

ed in accordance with Title XIX principles; and

1. D. Submit to the state agency the final

Title XVIII cost report with respect to each provider.

1. 2. The state agency shall review audited

Medicare/Medicaid cost reports for each hospital’s fiscal year in accordance with 13 CSR 70-15.040.

1. 3. Annual DSH audits are completed by

an independent auditor in accordance with federal DSH audit standards. Hospitals receiving DSH payments are subject to the annual DSH audit.

1. (E) Adjustments to Rates. The prospectively determined individual hospital’s reimbursement rate may be adjusted only under the following circumstances:

   1. 1. When information contained in the

cost report is found to be intentionally misrepresented. The adjustment shall be made retroactive to the date of the original rate. This adjustment shall not preclude the MO HealthNet Division from imposing any sanctions authorized by any statute or rule;

1. 2. When rate reconsideration is granted

in accordance with subsection (5)(F);

1. 3. When the Medicare per diem rate is

changed by the servicing fiscal intermediary based on a new audit finding for the base year. This adjustment may be applied and effective no earlier than the first day of the month following notification by the MO HealthNet Division; or

1. 4. When a hospital documents to the

MO HealthNet Division a change in its status from nonprofit to proprietary, or from proprietary to nonprofit, its direct Medicaid payments for the state fiscal year will be adjusted to take into account any change in its MO HealthNet inpatient allowable costs due to the change in its property taxes. The MO HealthNet share of the change in property taxes will be calculated for the state fiscal year in which the change is reported by multiplying the increase or decrease in property taxes applicable to the current state fiscal year by the ratio of allowable MO HealthNet inpatient hospital costs to total costs of the facility. (For example, if the property taxes are assessed starting January 1 for the calendar year, then one-half (1/2) of the calendar year property taxes will be used to calculate the additional inpatient direct Medicaid pay- 13 CSR 70-15

ments for the period of January 1 to June 30.)

1. (F) Rate Reconsideration.

   1. 1. Rate reconsideration may be request-

ed under this subsection for changes in allowable cost which occur subsequent to the base period described in subsection (3)(A). The effective date for any increase granted under this subsection shall be no earlier than the first day of the month following the MO HealthNet Division’s final determination on rate reconsideration.

1. 2. The following may be subject to

review under procedures established by the MO HealthNet Division:

1. A. New, expanded, or terminated ser-

vices as detailed in subsection (5)(C);

1. B. When the hospital experiences

extraordinary circumstances which may include, but are not limited to, an act of God, war, or civil disturbance; and

1. C. Per diem rate adjustments for crit-

ical access hospitals.

1. (I) Critical access hospitals meeting

either the federal definition or the Missouri expanded definition may request per diem rate adjustments in accordance with this subsection. The per diem rate increase will result in a corresponding reduction in the direct Medicaid payment.

1. (a) Hospitals which meet the

federal definition as a critical access hospital will have a per diem rate equal to one hundred percent (100%) of their estimated MO HealthNet cost per day as determined in section (15).

1. (b) Hospitals which meet the

Missouri expanded definition as a critical access hospital will have a per diem rate equal to seventy-five percent (75%) of their estimated MO HealthNet cost per day as determined in section (15). This includes new hospitals meeting the Missouri expanded definition as a critical access hospital whose interim MO HealthNet rate was calculated in accordance with subsection (15)(C).

1. 3. The following will not be subject to

review under these procedures:

1. A. The use of Medicare standards and

reimbursement principles;

1. B. The method for determining the

trend factor;

1. C. The use of all-inclusive prospec-

tive reimbursement rates; and

1. 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 MO HealthNet program, except a review may be conducted when a hospital changes from nonprofit to proprietary or vice versa to recognize the change in its property taxes, see paragraph (5)(E)4.

1. 4. As a condition of review, the MO

HealthNet Division may require the hospital to submit to a comprehensive operational review. The review will be made at the discretion of the MO HealthNet Division and may be performed by it or its designee. The findings from any such review may be used to recalculate allowable costs for the hospital.

1. 5. The request for an adjustment must

be submitted in writing to the MO HealthNet Division and must specifically and clearly identify the issue and the total dollar amount involved. The total dollar amount must be supported by generally acceptable accounting principles. The hospital shall demonstrate the adjustment is necessary, proper, and consistent with efficient and economical delivery of covered patient care services. The hospital will be notified in writing of the agency’s decision 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. If the state does not respond within the sixty- (60-) day period, the request shall be deemed denied.

1. (G) Sanctions. Sanctions may be imposed against a provider in accordance with 13 CSR 70-3.030 and other applicable state and federal regulations.

1. (6) Disproportionate Share and Direct Medicaid Qualifying Criteria. Effective June 1, 2011, disproportionate share payment methodology and criteria that must be met to receive DSH payments are described in 13 CSR 70-15.220. The definitions set forth in this section (6) will continue to be used to determine eligibility for Direct Medicaid Payments (section (15)) and the Safety Net adjustment (section (16)).

   1. (A) Inpatient hospital providers may qualify as a Disproportionate Share Hospital

2. (DSH) based on the following criteria. Hospitals shall qualify as Disproportionate Share Hospitals for a period of only one (1) state fiscal year and must requalify at the beginning of each state fiscal year to continue their disproportionate share classification—

   1. 1. 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;

1. 2. As determined from the fourth prior

year desk-reviewed cost report, the facility must have either—

1. A. 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) 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;

TMD = MIUR TNID

or

1. B. 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:

1. (I) Total MO HealthNet patient rev-

enues (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

1. (II) The total amount of the hospi-

tal’s charges for patient services attributable to charity care (CC) (care provided to individuals who have no source of payment, third-party, or personal resources) 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;

TMPR + CS CC − CS LIUR = + TNR + CS THC

1. 3. As determined from the fourth prior

year desk-reviewed cost report, the hospital—

1. A. Has an unsponsored care ratio of

at least ten percent (10%). The unsponsored care ratio is determined as the sum of bad debts and CC divided by TNR and also meets either of the criteria in paragraph (6)(A)2.; or

1. B. Ranks in the top fifteen (15) in the

number of Medicaid inpatient days provided by that hospital compared to Medicaid patient days provided by all hospitals, and the hospitals also have a Medicaid nursery utilization ratio greater than thirty-five percent (35%) as computed by dividing Title XIX nursery and neonatal days by total nursery and neonatal days; or

1. C. Operated a neonatal intensive care

unit with a ratio of Missouri Medicaid neonatal patient days to Missouri Medicaid total patient days in excess of nine percent (9%) reported or verified by the division from the fourth prior year cost report;

1. 4. As determined from the fourth prior

year desk-reviewed cost report—

1. A. The acute care hospital has an

unsponsored care ratio of at least sixty-five percent (65%) and is licensed for less than fifty (50) inpatient beds; or

1. B. The acute care hospital has 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%); or

1. C. The hospital is owned or operated

by the Board of Curators as defined in Chapter 172, RSMo, and the Missouri Rehabilitation Center created by Chapter 199, RSMo, or their successors; or

1. D. The hospital is a public hospital

operated by the Department of Mental Health primarily for the care and treatment of mental disorders; and

1. 5. As determined from the fourth prior

year desk-reviewed cost report, hospitals which annually provide more than five thousand (5,000) Title XIX days of care and whose Title XIX nursery days represent more than fifty percent (50%) of the hospital’s total nursery days.

1. (B) Those hospitals which meet the criteria established in paragraphs (6)(A)1., (6)(A)2., and (6)(A)4. shall be deemed safety net hospitals. Those hospitals which meet the criteria established in paragraphs (6)(A)1. and (6)(A)3. shall be deemed first tier Disproportionate Share Hospitals (DSH). Those hospitals which meet only the criteria established in paragraphs (6)(A)1. and (6)(A)2. or (6)(A)1. and (6)(A)5. shall be deemed second tier DSH.
2. (C) A hospital not meeting the requirements in subsection (6)(A), but has a Medicaid inpatient utilization percentage of at least one percent (1%) for Medicaid-eligible participants may at the option of the state be deemed a Disproportionate Share Hospital (DSH). These facilities may receive only the DSH payments identified in section (18).
3. (D) Specialty pediatric hospitals shall not qualify for disproportionate share payments by meeting the state defined requirements. However, they will qualify for disproportionate share payments if they meet the federal requirements as defined in paragraphs (6)(A)1. and (6)(A)2.
4. (E) Hospitals shall not send amended cost reports or other data necessary for qualification for disproportionate share classification for purposes of rate reconsideration unless the reports or other necessary data are received within sixty (60) days of the date of the division’s notification of the final determination of the rate.
5. (F) Hospital-Specific DSH Cap. Unless otherwise permitted by federal law, disproportionate share payments shall not exceed one hundred percent (100%) of the unreimbursed cost for MO HealthNet and the cost of the uninsured. The hospital-specific DSH cap shall be computed by combining the estimated unreimbursed MO HealthNet costs for each hospital, as calculated in section (15), with the hospital’s corresponding estimated uninsured costs, as determined in section (18). If the sum of disproportionate share payments exceeds the estimated hospital-specific DSH cap, the difference shall be deducted in order as necessary from safety net payments, other disproportionate share lump sum payments, direct Medicaid payments, and if necessary, as a reduced per diem. All DSH payments in the aggregate shall not exceed the federal DSH allotment within a state fiscal period. Effective June 1, 2011, hospital-specific DSH limits shall be calculated in accordance with federally-mandated DSH audit standards as described in 13 CSR 70-15.220.

1. (7) Outlier Adjustment for Children Under the Age of Six (6).

   1. (A) Effective for admissions beginning on or after July 1, 1991, outlier adjustments 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 disproportionate share requirements in subsection (6)(A) and, for MO HealthNet-eligible infants under the age of one (1), will be made to any other MO HealthNet hospital except for specialty pediatric hospitals.

      1. 1. The following criteria must be met for

the services to be eligible for outlier review:

1. A. The patient must be a MO

HealthNet-eligible infant under the age of one (1) year, or for disproportionate share hospitals a MO HealthNet-eligible child under the age of six (6) years, for all dates of service presented for review;

1. B. Hospitals requesting outlier review

for children one (1) year of age to children under six (6) years of age must have qualified for disproportionate share status under section (6) of this plan for the state fiscal year corresponding with the fiscal year end of the cost report referred to in paragraph (7)(A)5.; and

1. C. One (1) of the following conditions

must be satisfied:

1. (I) The total reimbursable charges

for dates of service as described in paragraph (7)(A)3. must be at least one hundred fifty percent (150%) of the sum of total third-party liabilities and MO HealthNet inpatient claim payments for that claim; or

1. (II) The dates of service must

exceed sixty (60) days and less than seventyfive percent (75%) of the total service days was reimbursed by MO HealthNet.

1. 2. Claims for all dates of service eligible

for outlier review must—

1. A. Have been submitted to the MO

HealthNet Division fiscal agent or the managed care health plan in their entirety for routine claims processing, and claim payment must have been made before the claims are submitted to the division for outlier review; and

1. B. Be submitted for outlier review

with all documentation as required by the MO HealthNet Division no later than ninety (90) days from the last payment made by the fiscal agent or the managed care health plan through the normal claims processing system for those dates of service.

1. 3. Information for outlier reimburse-

ment processing will be determined from claim charges and MO HealthNet payment data, submitted to the MO HealthNet Division fiscal agent or managed care health plan, by the hospital through normal claim submission. If the claim information is determined to be incomplete as submitted, the hospital may be asked to provide claim data directly to the MO HealthNet Division for outlier review.

1. 4. The claims may be reviewed for—

   1. A. Medical necessity at an inpatient

hospital level-of-care;

1. B. Appropriateness of services pro-

vided in connection with the diagnosis;

1. C. Charges that are not permissible

per the MO HealthNet Division; policies established in the institutional manual and hospital bulletins; and

1. D. If the hospital is asked to provide

claim information, the hospital will need to provide an affidavit vouching to the accuracy of final payments by the MO HealthNet Division, managed care health plans, and other third-party payors. The calculation of outlier payments will be based on the standard hospital payment defined in subparagraph (7)(A)6.B.

1. 5. After the review, reimbursable costs

for each claim will be determined using the following data from the most recent Medicaid hospital cost report filed by June 1 of each year:

1. 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;

1. B. Ancillary cost-to-charge ratios

applied to claim ancillary charges determined eligible for reimbursement per the outlier review; and

1. C. No cost will be calculated for 13 CSR 70-15

items such as malpractice insurance premiums, interns and residents, professional services, or return on equity.

1. 6. Each state fiscal year, outlier adjust-

ment payments for each hospital will be made for all claims submitted before March 1 of the preceding state fiscal year which satisfy all conditions in paragraphs (7)(A)1.–4. The payments will be determined for each hospital as follows:

1. A. Sum all reimbursable costs per

paragraph (7)(A)5. for all applicable outlier claims to equal total reimbursable costs;

1. B. For those claims, subtract third-

party payments and MO HealthNet payments, which includes both per diem payments and Direct Medicaid Add-On payments, from total reimburseable costs to equal excess cost; and

1. C. Multiply excess costs by fifty per-

cent (50%).

1. (B) Effective for admissions beginning on or after July 1, 1997, outlier adjustments shall also be made for MO HealthNet participants enrolled in managed care. All criteria listed under subsection (7)(A) applies to managed care outlier submissions.
2. (C) Effective for admissions beginning on or after May 1, 2017, outlier adjustments will only be made for the fee for service claims. All criteria listed under subsection (7)(A) will continue to be applied to the fee for service outlier submissions.

1. (8) Payment Assurance.

   1. (A) 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 Program.
   2. (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 third-party payments are provided in the MO HealthNet program provider manuals.
   3. (C) Regardless of changes of ownership, management, control, operation, or leasehold interests by whatever form for any hospital previously certified for participation in the MO HealthNet program, the department will continue to make all the Title XIX payments directly to the entity with the hospital’s current provider number and hold the entity with the current provider number responsible for all MO HealthNet liabilities.
2. (9) Provider Participation. Payments made in accordance with the standards and methods described in this rule are designed to enlist participation of a sufficient number of hospitals in the 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.
3. (10) Payment in Full. Participation in the program shall be limited to hospitals who accept as payment in full for covered services rendered to MO HealthNet participants the amount paid in accordance with the rules implementing the Hospital Reimbursement Program.
4. (11) Plan Evaluation. Documentation will be maintained to effectively monitor and evaluate experience during administration of this plan.

5. (12) Inappropriate Placements.

   1. (A) The hospital per diem rate as determined under this plan and in effect on October 1, 1981, shall not apply to any participant who is receiving inpatient hospital care when s/he is only in need of nursing home care.

      1. 1. If a hospital has an established inter-

mediate 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.

1. 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.

1. (13) Trauma Add-On Payments. Hospitals that meet the following will receive additional Add-On payments.

   1. (A) Criteria for Qualifying to Receive Add- On Payments for Trauma:

      1. 1. Hospital must be a Level I, II, or III

trauma center as designated by the Missouri Department of Health and Senior Services; or

1. 2. Hospital with an emergency depart-

ment in a county that does not have a trauma center.

1. (B) Trauma Add-On Computation. Each state fiscal year, to be effective July 1 of that state fiscal year, the division will calculate the trauma Add-On payments for qualifying hospitals as follows:

   1. 1. The case mix index for MO

HealthNet patients will be determined for the fourth prior year and the second prior year based on a federal fiscal year;

1. 2. The percentage change will be calcu-

lated for the same time period above and then inflated by one and one-half (1.5) to estimate a percentage change from the fourth prior year through the prior year (for example, for SFY 2004, the percentage change for 2000 to 2002 will be inflated to estimate a percentage change from 2000 through 2003);

1. 3. If this estimated percentage change is

positive, the hospital’s current year trended cost per day prior to the assessment per day and utilization adjustment per day (estimated for SFY 2004 using the 2000 cost report with some exceptions) will be inflated by the same amount to arrive at the current year case mix adjusted cost per day;

1. 4. The difference between the current

year case mix adjusted cost per day and the current year trended cost per day prior to the assessment per day and utilization adjustment per day will be multiplied by the current year’s estimated MO HealthNet days, resulting in the trauma Add-On payment to the hospital; and

1. 5. For subsequent years, the calculation

of the trauma Add-On payment will be determined in the same manner. However, payments will be the greater of the current year calculated payment or the previous year’s payment.

1. (C) Trauma Payment Adjustment Option.

   1. 1. If the qualifying hospital for the trau-

ma Add-On payment has a declining case mix index for three (3) consecutive years, the hospital will no longer be eligible to receive the trauma add-on payment.

1. (D) Trauma Add-On payments and trauma outlier payments will be subject to appropriations. If the amount appropriated is less than the base year amount, the current year’s payments for both trauma Add-Ons and trauma outliers will be prorated based on the ratio of trauma Add-On payments to trauma outlier payments in the base year.
2. (E) Effective July 1, 2011, trauma Add-On payments will be replaced with Upper Payment Limit payments as described in 13 CSR 70-15.230.

1. (14) Trauma Outlier Payments.

   1. (A) Outlier adjustments for trauma inpatient services involving exceptionally high cost for MO HealthNet-eligible participants will be made to hospitals meeting the criteria established below:

      1. 1. Hospital must be a Level I, II, or III

trauma center as designated by the Missouri Department of Health and Senior Services.

1. (B) Claims for all dates of service eligible for trauma outlier review must—

   1. 1. Have been submitted to the MO

HealthNet Division fiscal agent in their entirety for routine claims processing, and claim payment must have been made before the claims are submitted to the division for outlier review; and

1. 2. Be submitted for outlier review with

all documentation as required by the MO HealthNet Division by the end of the third quarter of the current state fiscal year. The prior year’s information will be used to determine the trauma outlier payment for the current state fiscal year (for example, SFY 2004 trauma outlier payments will be based on 2003 data). Out-of-state trauma claims may be included.

1. 3. The claims for trauma inpatient ser-

vices may include services provided to MO HealthNet-eligible individuals from states outside Missouri when provided in a Missouri hospital.

1. 4. The claim must be an inpatient that

originated in the hospital emergency room or a direct admit from another hospital’s emergency room and must have a diagnosis code that is included in the table of valid trauma diagnosis codes listed below—

800.00–959.99 980.00–981.99 983.00–983.99 986.00–987.99 989.00–989.99 991.00–994.99 E800.00–E999.99

1. 5. The payment for the claim as deter-

mined by the product of days of service times the appropriate year cost per day (including the assessment per day and the utilization adjustment per day) must be less than the cost of the claim as determined by product of charges times the hospital specific cost-tocharge ratio.

1. (C) Trauma outlier payments for qualifying hospitals will be determined as follows:

   1. 1. Multiply charges on claim by hospital

specific second prior year cost to charge ratio to determine patient-specific trauma costs;

1. 2. Multiply days of care by the appropri-

ate year’s cost per day including the assessment per day and utilization adjustment per day (estimated for SFY 2004 using the 2000 cost report with some exceptions) to determine patient-specific payments; and

1. 3. Determine difference between trauma

costs and payments.

1. (D) The MO HealthNet Division will require a signed affidavit attesting to the validity of the data.
2. (E) Trauma Add-On payments and trauma outlier payments will be subject to appropriations. If the amount appropriated is less than the base year amount, the current year’s payments for both trauma Add-Ons and trauma outliers will be prorated based on the ratio of trauma Add-On payments to trauma outlier payments in the base year.
3. (F) Effective July 1, 2011, trauma Add-On payments will be replaced with Upper Payment Limit payments as described in 13 CSR 70-15.230.

1. (15) Direct Medicaid Payments.

   1. (A) Direct Medicaid Payments. Direct Medicaid payments will be made to hospitals for the following allowable MO HealthNet costs not included in the per diem rate as calculated in section (3):

      1. 1. The increased MO HealthNet costs

resulting from the FRA assessment becoming an allowable cost on January 1, 1999;

1. 2. The unreimbursed MO HealthNet

costs applicable to the trend factor which is not included in the per diem rate;

1. 3. The unreimbursed MO HealthNet

costs for capital and medical education not included in the trended per diem cost as a result of the application of the sixty percent (60%) minimum utilization adjustment in paragraph (3)(A)4.;

1. 4. The increased cost per day resulting

from the utilization adjustment. The increased cost per day results from lower utilization of inpatient hospital services by MO HealthNet participants now covered by a managed care health plan;

1. 5. The poison control adjustment shall

be determined for hospitals which operated a poison control center during the base year and which continues to operate a poison control center in a MO HealthNet managed care region; and

1. 6. The increased cost resulting from

including out-of-state MO HealthNet days in total projected MO HealthNet days.

1. (B) Direct Medicaid payment will be computed as follows:

   1. 1. The MO HealthNet share of the inpa-

tient FRA assessment will be calculated by dividing the hospital’s inpatient Medicaid patient days by the total inpatient hospital patient days from the hospital’s base cost report to arrive at the inpatient Medicaid utilization percentage. This percentage is then multiplied by the inpatient FRA assessment for the current SFY to arrive at the increased allowable MO HealthNet costs for the inpatient FRA assessment. The MO HealthNet share of the outpatient FRA assessment will be calculated by dividing the hospital’s outpatient MO HealthNet charges by the total outpatient hospital charges from the base cost report to arrive at the MO HealthNet utilization percentage. This percentage is then multiplied by the outpatient FRA assessment for the current SFY to arrive at the increased allowable MO HealthNet costs for the outpatient FRA assessment;

1. 2. The unreimbursed MO HealthNet

costs are determined by subtracting the hospital’s per diem rate from its trended per diem costs. The difference is multiplied by the estimated MO HealthNet patient days for the current SFY plus the out-of-state days from the fourth prior year cost report trended to the current SFY. The estimated MO HealthNet patient days for the current SFY shall be the better of the sum of the Fee-for- Service (FFS) days plus managed care days or the days used in the prior SFY’s Direct Medicaid payment calculation. The FFS days are determined from a regression analysis of the hospital’s FFS days from February 1999 through December of the second prior SFY. The managed care days are based on the FFS days determined from the regression analysis, as follows: The FFS days are factored up by the percentage of FFS days to the total of FFS days plus managed care days from the hospital’s fourth prior year cost report. The difference between the FFS days and the FFS days factored up by the FFS days’ percentage are the managed care days.

1. A. Effective January 1, 2010, the

estimated MO HealthNet patient days shall be the better of the sum of the FFS days plus managed care days or the days used in the prior SFY’s Direct Medicaid payment calculation (i.e., for SFY 2010, prior SFY would be SFY 2009) adjusted downward by twentyfive percent (25%) of the difference between the sum of the FFS days plus managed care days and the days used in the prior SFY’s Direct Medicaid payment calculation.

1. (I) The FFS days plus managed

care days are determined as follows: The FFS days are determined by applying a trend to the second prior Calendar Year (CY) days (i.e., for SFY 2010, second prior CY would be 2008) as determined from the state’s Medicaid Management Information System (MMIS). The trend is determined from a regression analysis of the hospital’s FFS days from February 1999 through December of the second prior CY. The managed care days are based on the FFS days determined from the regression analysis, as follows: The FFS days are factored up by the percentage of FFS days to the total of FFS days plus managed care days from the hospital’s fourth prior year cost report. The difference between the FFS days and the FFS days factored up by the FFS days’ percentage are the managed care days.

1. (II) The days used in the prior

SFY’s Direct Medicaid payment calculation adjusted downward by twenty-five percent (25%) are determined as follows: The days used in the prior SFY’s Direct Medicaid payment calculation are compared to the sum of the FFS days plus managed care days as determined in part (15)(B)2.A.(I). If the hospital has greater estimated days as used in the prior SFY’s Direct Medicaid payment calculation than the sum of the FFS days plus managed care days as determined in part (15)(B)2.A.(I), the difference between the days is multiplied by twenty-five percent (25%), and this amount is removed from the estimated days used in the prior SFY’s Direct Medicaid payment calculation to arrive at the current year’s estimated days.

1. B. Effective July 1, 2010, the estimat-

ed MO HealthNet patient days shall be the better of the sum of the FFS days plus managed care days or the days used in the SFY 2009 Direct Medicaid payment calculation adjusted downward by fifty percent (50%) of the difference between the sum of the FFS days plus managed care days and the days used in the SFY 2009 Direct Medicaid pay- 13 CSR 70-15

ment calculation.

1. (I) The FFS days plus managed

care days are determined as set forth in part (15)(B)2.A.(I).

1. (II) The days used in the prior

SFY’s Direct Medicaid payment calculation adjusted downward by fifty percent (50%) are determined as follows: The days used in the prior SFY’s Direct Medicaid payment calculation are compared to the sum of the FFS days plus managed care days as determined in part (15)(B)2.A.(I). If the hospital has greater estimated days as used in the prior SFY’s Direct Medicaid payment calculation than the sum of the FFS days plus managed care days as determined in part (15)(B)2.A.(I), the difference between the days is multiplied by fifty percent (50%) and this amount is removed from the estimated days used in the prior SFY’s Direct Medicaid payment calculation to arrive at the current year’s estimated days.

1. C. Effective July 1, 2011, the estimat-

ed MO HealthNet patient days shall be the better of the sum of the FFS days plus managed care days or the days used in the SFY 2009 Direct Medicaid payment calculation adjusted downward by seventy-five percent (75%) of the difference between the sum of the FFS days plus managed care days and the days used in the SFY 2009 Direct Medicaid payment calculation.

1. (I) The FFS days plus managed

care days are determined as set forth in part (15)(B)2.A.(I).

1. (II) The days used in the prior

SFY’s Direct Medicaid payment calculation adjusted downward by seventy-five percent (75%) are determined as follows: The days used in the prior SFY’s Direct Medicaid payment calculation are compared to the sum of the FFS days plus managed care days as determined in part (15)(B)2.A.(I). If the hospital has greater estimated days as used in the prior SFY’s Direct Medicaid payment calculation than the sum of the FFS days plus managed care days as determined in part (15)(B)2.A.(I), the difference between the days is multiplied by seventy-five percent (75%) and this amount is removed from the estimated days used in the prior SFY’s Direct Medicaid payment calculation to arrive at the current year’s estimated days.

1. D. Effective July 1, 2012, the estimat-

ed MO HealthNet patient days shall be the sum of the FFS days plus managed care days. The FFS days plus managed care days are determined as set forth in part (15)(B)2.A.(I).

1. E. The trended cost per day is calculat-

ed by trending the base year costs per day by the trend indices listed in paragraph (3)(B)1., using the rate calculation in subsection (3)(A). In addition to the trend indices applied to inflate base period costs to the current fiscal year, base year costs will be further adjusted by a Missouri Specific Trend. The Missouri Specific Trend will be used to address the fact that costs for Missouri inpatient care of MO HealthNet residents have historically exceeded the compounded inflation rates estimated using national hospital indices for a significant number of hospitals. The Missouri Specific Trend will be applied at one and one-half percent (1.5%) per year to the hospital’s base year. For example, hospitals with a 1998 base year will receive an additional six percent (6%) trend, and hospitals with a 1999 base year will receive an additional four and onehalf percent (4.5%) trend.

1. (I) Effective for dates of service

beginning July 1, 2010, the Missouri Specific Trend shall no longer be applied to inflate base period costs.

1. F. For hospitals that meet the require-

ments in paragraphs (6)(A)1., (6)(A)2., and (6)(A)4. of this rule (safety net hospitals), the base year cost report may be from the third prior year, the fourth prior year, or the fifth prior year. For hospitals that meet the requirements in paragraphs (6)(A)1. and (6)(A)3. of this rule (first tier Disproportionate Share Hospitals), the base year operating costs may be the third or fourth prior year cost report. The MO HealthNet Division shall exercise its sole discretion as to which report is most representative of costs. For all other hospitals, the base year operating costs are based on the fourth prior year cost report. For any hospital that has both a twelve- (12-) month cost report and a partial year cost report, its base period cost report for that year will be the twelve- (12-) month cost report.

1. G. The trended cost per day does not

include the costs associated with the FRA assessment, the application of minimum utilization, the utilization adjustment, and the poison control costs computed in paragraphs (15)(B)1., 3., 4., and 5.;

1. 3. The minimum utilization costs for

capital and medical education is calculated by determining the difference in the hospital’s cost per day when applying the minimum utilization, as identified in paragraph (5)(C)4., and without applying the minimum utilization. The difference in the cost per day is multiplied by the estimated MO HealthNet patient days for the SFY;

1. 4. The utilization adjustment cost is

determined by estimating the number of MO HealthNet inpatient days the hospital will not provide as a result of the managed care health plans limiting inpatient hospital services. These days are multiplied by the hospital’s cost per day to determine the total cost associated with these days. This cost is divided by the remaining total patient days from its base period cost report to arrive at the increased cost per day. This increased cost per day is multiplied by the estimated MO HealthNet days for the current SFY to arrive at the MO HealthNet utilization adjustment.

1. A. Effective January 1, 2010, hospi-

tals other than safety net hospitals as defined in subsection (6)(B) will receive sixty-seven percent (67%) of the utilization adjustment calculated in accordance with paragraph (15)(B)4. Safety net hospitals will continue to receive one hundred percent (100%) of the adjustment calculated in accordance with paragraph (15)(B)4.

1. B. Effective July 1, 2010, hospitals

other than safety net hospitals as defined in subsection (6)(B), children’s hospitals as defined in subsection (2)(S), and specialty pediatric hospitals as defined in subsection (2)(P) will receive thirty-four percent (34%) of the utilization adjustment calculated in accordance with paragraph (15)(B)4. Children’s hospitals and specialty pediatric hospitals will receive fifty percent (50%) of the adjustment calculated in accordance with paragraph (15)(B)4. Safety net hospitals will continue to receive one hundred percent (100%) of the adjustment calculated in accordance with paragraph (15)(B)4.

1. C. Effective July 1, 2011, the utiliza-

tion adjustment will no longer apply to any hospital other than safety net hospitals as defined in subsection (6)(B), children’s hospitals as defined in subsection (2)(S), and specialty pediatric hospitals as defined in subsection (2)(P). Children’s hospitals and specialty pediatric hospitals will continue to receive fifty percent (50%) of the adjustment calculated in accordance with paragraph (15)(B)4. Safety net hospitals will continue to receive one hundred percent (100%) of the adjustment calculated in accordance with paragraph (15)(B)4.;

1. 5. The poison control cost shall reim-

burse the hospital for the prorated MO HealthNet managed care cost. It will be calculated by multiplying the estimated MO HealthNet share of the poison control costs by the percentage of managed care participants to total MO HealthNet participants; and

1. 6. Prior to July 1, 2006, the costs for

including out-of-state Medicaid days is calculated by subtracting the hospital’s per diem rate from its trended per diem cost and multiplying this difference by the out-of-state Medicaid days from the base year cost report. Effective July 1, 2006, the costs for including out-of-state Medicaid days is calculated by subtracting the hospital’s per diem rate from its trended per diem cost and multiplying this difference by the out-of-state Medicaid days as determined from the regression analysis performed using the out-of-state days from the fourth, fifth, and sixth prior year cost reports.

1. (C) For new hospitals that do not have a base cost report, Direct Medicaid Payments shall be estimated as follows:

   1. 1. Hospitals receiving Direct Medicaid

Payments shall be divided into quartiles based on total beds;

1. 2. Direct Medicaid Payments shall be

individually summed by quartile and then divided by the total beds in the quartile to yield an average Direct Medicaid Payment per bed;

1. 3. The number of beds for the new hos-

pital without the base cost report shall be multiplied by the average Direct Medicaid Payment per bed to determine the hospital’s estimated Direct Medicaid Payment for the current state fiscal year; and

1. 4. For a new hospital licensed after

February 1, 2007, estimated total Direct Medicaid Payments for the current state fiscal year shall be divided by the estimated MO HealthNet patient days for the new hospital’s quartile to obtain the estimated Direct Medicaid adjustment per patient day. This adjustment per day shall be added to the new hospital’s MO HealthNet rate as determined in section (4), so that the hospital’s Direct Medicaid Payment per day is included in its per diem rate, rather than as a separate Add- On Payment. When the hospital’s per diem rate is determined from its fourth prior year cost report in accordance with sections (1)– (3), the facility’s Direct Medicaid Payment will be calculated in accordance with subsection (15)(B) and reimbursed as an Add-On Payment rather than as part of the per diem rate. If the hospital is defined as a critical access hospital, its MO HealthNet per diem rate and Direct Medicaid Payment will be determined in accordance with subsection (5)(F).

1. 5. A facility previously enrolled for par-

ticipation in the MO HealthNet Program, which either voluntarily or involuntarily terminates its participation in the MO HealthNet Program and which reenters the MO HealthNet Program, shall have its Direct Medicaid Payments determined in accordance with paragraph (3)(B)4.

1. (16) Safety Net Adjustment. A safety net adjustment, in lieu of the Direct Medicaid Payments and Uninsured Add-Ons, shall be provided for each hospital which qualified as disproportionate share under the provision of paragraph (6)(A)4. The safety net adjustment payment shall be made prior to the end of each federal fiscal year.

   1. (A) The safety net adjustment for facilities which qualify under subparagraph (6)(A)4.B. or (6)(A)4.C. of this regulation shall be computed in accordance with the Direct Medicaid Payment calculation described in section (15) and the uninsured costs calculation described in subsection (18)(D) of this regulation. The safety net adjustment will include the last three (3) quarters of the SFY ending June 30 and the first quarter of the next SFY beginning July 1 to correspond with the FFY of October 1 to September 30.
   2. (B) The safety net adjustment for facilities which qualify under subparagraph (6)(A)4.D. of this regulation shall be computed in accordance with the Direct Medicaid payment calculation described in section (15) and up to one hundred percent (100%) of the uninsured costs calculation described in subsection (18)(B) of this regulation. The safety net adjustment will include the last three (3) quarters of the SFY ending June 30 and the first quarter of the next SFY beginning July 1 to correspond with the FFY of October 1 to September 30.
   3. (C) The state share of the safety net adjustment for hospitals described in subparagraphs (6)(A)4.A. and (6)(A)4.D. shall come from cash subsidy (CS) certified by the hospitals. If the aggregate CS are less than the state match required, the total aggregate safety net adjustment will be adjusted downward accordingly, and distributed to the hospitals in the same proportions as the original safety net adjustments.
   4. (D) Notwithstanding subsection (16)(B), the safety net adjustment for governmental facilities in state fiscal year 2004 and 2005 shall be up to one hundred seventy-five percent (175%) of unreimbursed Medicaid costs plus one hundred seventy-five percent (175%) of the uninsured costs calculation described in subsection (18)(B) subject to the state’s disproportionate share allotment and Institution for Mental Diseases (IMD) cap. The safety net adjustment shall be on a state fiscal year basis in these years.
   5. (E) Effective June 1, 2011, DSH payment calculations and criteria are described in 13 CSR 70-15.220.
2. (17) OBRA 93 Limitation. In accordance with OBRA 93, disproportionate share payments shall not exceed one hundred percent (100%) of the unreimbursed cost for MO HealthNet and the cost of the uninsured, unless otherwise permitted by federal law.

3. (18) In accordance with state and federal laws regarding reimbursement of unreimbursed costs and the costs of services provided to uninsured patients, reimbursement for each State Fiscal Year (SFY) (July 1–June 30) shall be determined as follows:

   1. (A) Medicaid Add-Ons for Shortfall. The Medicaid Add-On for the period of July 1, 1998 to December 31, 1998 will be based on fifty percent (50%) of the unreimbursed Medicaid costs as calculated for SFY 98 (Medicaid Shortfall); and

   2. (B) Uninsured Add-Ons. The hospital shall receive eighty-nine percent (89%) of the uninsured costs prorated over the SFY. Hospitals which contribute through a plan approved by the director of health to support the state’s poison control center, the Primary Care Resource Initiative for Missouri (PRIMO), and Patient Safety Initiatives shall receive ninety percent (90%) of its uninsured costs prorated over the SFY. DMH hospitals shall receive up to one hundred percent (100%) of their uninsured costs. The uninsured Add-On will include:

      1. 1. The Add-On payment for the cost of

the uninsured will be based on a three (3) year average of the fourth, fifth, and sixth prior base year cost reports. For any hospital that has both a twelve- (12-) month cost report and a partial year cost report, its base period cost report for that year will be the twelve- (12-) month cost report. Cost of the uninsured is determined by multiplying the charges for charity care and allowable bad debts by the hospital’s total cost-to-charge ratio for allowable hospital services from the base year cost report’s desk review. The cost of the uninsured is then trended to the current year using the trend indices reported in subsection (3)(B). Allowable bad debts do not include the costs of caring for patients whose insurance covers the particular service, procedure, or treatment;

1. 2. An adjustment to recognize the unin-

sured patients’ share of the FRA assessment not included in the desk-reviewed cost. The FRA assessment for uninsured patients is determined by multiplying the current FRA assessment by the ratio of uninsured days to total inpatient days from the base year cost report;

1. 3. The difference in the projected

General Relief per diem payments and trended costs for General Relief patient days;

1. 4. The increased costs per day resulting

from the utilization adjustment in subsection (15)(B) is multiplied by the estimated uninsured days; and

1. 5. Notwithstanding any other provision,

the Add-On payment for the cost of the uninsured for any public hospital that is not a safety net hospital in state fiscal year 2004 and 2005 shall be up to one hundred seventyfive percent (175%) of the uninsured costs calculation described in this paragraph subject to the state’s disproportionate share allotment and IMD cap. The Add-On for hospitals other than safety net hospitals shall be on a state fiscal year basis in these years.

1. (C) For new hospitals that do not have a base cost report, uninsured payments shall be estimated as follows:

   1. 1. Hospitals receiving uninsured pay-

ments shall be divided into quartiles based on total beds;

1. 2. Uninsured payments shall be individ-

ually summed by quartile and then divided by the total beds in the quartile to yield an average uninsured payment per bed;

1. 3. The numbers of beds for the new hos-

pital without the base cost report shall be multiplied by the average uninsured payment per bed; and

1. 4. A facility previously enrolled for par-

ticipation in the MO HealthNet Program, 13 CSR 70-15

which either voluntarily or involuntarily terminates its participation in the MO HealthNet Program and which reenters the MO HealthNet Program, shall have its uninsured payments determined in accordance with subsection (18)(C).

1. (D) Uninsured Add-Ons effective July 1, 2005 for all facilities except DMH safety net facilities as defined in subparagraph (6) (A)4.D. DMH safety net facilities will continue to be calculated in accordance with subsection (18)(B). The Uninsured Add-On for all facilities except DMH safety net facilities will be based on the following:

   1. 1. Determination of the cost of the unin-

sured—

1. A. Allocate the uninsured population

as determined from the Current Population Survey (CPS), Annual Social and Economic Supplement (Table HI05) as published by the U.S. Census Bureau, to the same categories of age (COA) and age groups as the managed care rate cells as determined by the Managed Care Unit of the MO HealthNet Division;

1. B. Determine the total annual project-

ed cost of the uninsured population by multiplying the number of uninsured for each rate cell by the average contract per member per month (PMPM) for that individual managed care rate cell multiplied by twelve (12); and

1. C. Determine the amount of the total

annual projected cost of the uninsured population that is related to hospital services by multiplying the total annual projected cost of the uninsured population as calculated in paragraph (18)(D)1. above by the percentage of the contract PMPM for each individual rate cell that is related to hospital services. This would be the maximum amount of Uninsured Add-On payments that could be made to hospitals. This amount is also subject to the DSH cap;

1. 2. Proration to individual hospitals of

the cost of the uninsured calculated in paragraph (18)(D)1.

1. A. Determine each individual hospi-

tal’s Uninsured Add-On payment by dividing the individual hospital’s uninsured cost as determined from the three- (3-) year average of the fourth, fifth, and sixth prior base-year cost reports by the total uninsured cost for all hospitals as determined from the three- (3-) year average of the fourth, fifth, and sixth prior base-year cost reports, multiplied by either the total annual projected cost of the uninsured population that is related to hospital services or the DSH cap for hospitals whichever is lower. The DSH cap for hospitals is the federal DSH allotment less the IMD allotment less other DSH expenditures.

1. B. Hospitals which qualify as safety

net hospitals under subparagraphs (6)(A)4.B. and C. shall receive payment of one hundred percent (100%) of their proration. The percentage of proration payable to non-safety net hospitals shall be eighty-nine percent (89%), unless the hospital contributes 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), in which case they shall receive ninety percent (90%);

1. 3. For new hospitals that do not have a

base cost report, uninsured payments shall be estimated as follows:

1. A. Hospitals receiving uninsured pay-

ments shall be divided into quartiles based on total beds;

1. B. Uninsured payments shall be indi-

vidually summed by quartile and then divided by the total beds in the quartile to yield an average uninsured payment per bed; and

1. C. The numbers of beds for the new

hospital without the base cost report shall be multiplied by the average uninsured payment per bed.

1. (E) Uninsured Add-Ons effective July 1, 2009, for all facilities except Department of Mental Health (DMH) safety net facilities as defined in subparagraph (6)(A)4.D. DMH safety net facilities will continue to be calculated in accordance with subsection (18)(B). The Uninsured Add-On for all facilities except DMH safety net facilities will be based on the following:

   1. 1. Determination of the cost of the unin-

sured—

1. A. Allocate the uninsured population

as determined from the Current Population Survey (CPS), Annual Social and Economic Supplement (Table HI05) as published by the U.S. Census Bureau, to the same categories of age (COA) and age groups as the managed care rate cells as determined by the Managed Care Unit of the MO HealthNet Division;

1. B. Determine the total annual project-

ed cost of the uninsured population by multiplying the number of uninsured for each rate cell by the average contract per member per month (PMPM) for that individual managed care rate cell multiplied by twelve (12); and

1. C. Determine the amount of the total

annual projected cost of the uninsured population that is related to hospital services by multiplying the total annual projected cost of the uninsured population as calculated in paragraph (18)(E)1. above by the percentage of the contract PMPM for each individual rate cell that is related to hospital services. This would be the maximum amount of uninsured add-on payments that could be made to hospitals. This amount is also subject to the DSH cap; and

1. 2. Proration to individual hospitals of

the cost of the uninsured calculated in paragraph (18)(E)1.—

1. A. Determine each individual hospi-

tal’s Uninsured Add-On payment by dividing the individual hospital’s uninsured cost as determined from the three- (3-) year average of the fourth, fifth, and sixth prior base-year cost reports by the total uninsured cost for all hospitals as determined from the three- (3-) year average of the fourth, fifth, and sixth prior base-year cost reports, multiplied by either the total annual projected cost of the uninsured population that is related to hospital services or the DSH cap for hospitals, whichever is lower. The DSH cap for hospitals is the federal DSH allotment less the IMD allotment less any redirections of DSH for Medicaid coverage of uninsured individuals as authorized by appropriation;

1. B. Hospitals which qualify as safety

net hospitals under subparagraphs (6)(A)4.B. and C. shall receive payment up to one hundred percent (100%) of their proration. The percentage of proration payable to non-safety net hospitals shall be up to ninety-nine percent (99%), unless the hospital contributes 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, in which case they shall receive up to one hundred percent (100%);

1. 3. For new hospitals that do not have a

base-year cost report, uninsured payments shall be estimated as follows:

1. A. Hospitals receiving uninsured pay-

ments shall be divided into quartiles based on total beds;

1. B. Uninsured payments shall be indi-

vidually summed by quartile and then divided by the total beds in the quartile to yield an average uninsured payment per bed; and

1. C. The numbers of beds for the new

hospital without the base cost report shall be multiplied by the average uninsured payment per bed.

1. (F) Uninsured Add-On payments will coincide with the semimonthly claim payment schedule established by the MO HealthNet fiscal agent. Each hospital’s semimonthly add-on payment shall be the hospital’s total cost of the uninsured as determined in section

1. (18) divided by the number of semimonthly pay dates available to the hospital in the state fiscal year.

   1. (G) Effective June 1, 2011, DSH payment calculations and criteria are described in 13 CSR 70-15.220.

2. (19) MO HealthNet GME Add-On—A MO HealthNet Add-On determined for Graduate Medical Education (GME) costs shall be allocated based on the estimated effect of implementation of a MO HealthNet managed care system in accordance with this section.

   1. (A) The MO HealthNet GME Add-On for MO HealthNet participants covered under a Managed Care Plan shall be determined using the base year cost report and paid in quarterly installments. The base year cost report shall be the fourth prior fiscal year (i.e., the base year for SFY 1999 is the FY 1995 cost report). The hospital per diem shall continue to include a component for GME related to MO HealthNet participants not included in a managed care system.

      1. 1. Total GME cost shall be multiplied by

a managed care allocation factor which incorporates the estimated percentage of the hospital’s MO HealthNet population included in a managed care system and the estimated implementation date for a managed care system. For example: If a hospital has 1) an annual GME cost of one hundred thousand dollars ($100,000), 2) forty percent (40%) of their MO HealthNet days are related to MO HealthNet participants eligible for MO HealthNet managed care, and 3) the projected implementation date for managed care is October 1, 1995; the prorated GME Add-On is thirty thousand dollars ($30,000).

1. 2. The annual GME Add-On shall be

paid in quarterly installments.

1. (20) Hospital Mergers. Hospitals that merge their operations under one (1) Medicare and MO HealthNet provider number shall have their MO HealthNet reimbursement combined under the surviving hospital’s (the hospital whose Medicare and MO HealthNet provider number remains active) MO HealthNet provider number.

   1. (A) The disproportionate share status of the merged hospital provider shall be—

      1. 1. The same as the surviving hospital’s

status was prior to the merger for the remainder of the state fiscal year in which the merger occurred; and

1. 2. Determined based on the combined

desk-reviewed data from the appropriate cost reports for the merged hospitals in subsequent fiscal years.

1. (B) The per diem rate for merged hospitals shall be calculated—

   1. 1. For the remainder of the state fiscal

year in which the merger occurred by multiplying each hospital’s estimated MO HealthNet paid days by its per diem rate, summing the estimated per diem payments and estimated MO HealthNet 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. This merged rate will also be used in fiscal years following the effective date.

1. (C) The Direct Medicaid Payments, Uninsured Add-On Payments, and GME payments, if the surviving facility continues the GME program, shall be—

   1. 1. Combined under the surviving hospi-

tal’s MO HealthNet provider number for the remainder of the state fiscal year in which the merger occurred; and

1. 2. Calculated for subsequent state fiscal

years based on the combined data from the appropriate cost report for each facility.

1. (D) Merger of Children’s Acute Care Hospital. When an acute care children’s hospital merges with another acute care hospital, all the provisions in subsection (20)(A) shall apply, except the MO HealthNet provider number for the children’s hospital will remain active. The only payments made under the children’s provider number will be the per diem and outpatient payments. The Direct Medicaid payments and Uninsured Add-On payments will be made under the MO HealthNet number associated with the surviving Medicare provider number.

2. (E) Merger of State Hospitals.

   1. 1. A state hospital is defined as a hospi-

tal which is either owned or operated by the DMH or owned or operated by the board of curators as provided for in Chapters 172 and 199, RSMo.

1. 2. When a hospital owned or operated

by the DMH merges with a hospital owned or operated by the board of curators, the per diem rate effective with the date of the merger shall be the surviving state hospital’s per diem rate prior to the merger and not calculated as defined in subsection (20)(B).

1. 3. When a hospital owned or operated

by the DMH merges with a hospital owned or operated by the board of curators, the Direct Medicaid Payments effective with the date of merger shall be calculated using the surviving state hospital’s trended cost per day from the surviving hospital’s base-year cost report, the surviving hospital’s per diem rate, and the combined estimated MO HealthNet patient days for both hospitals.

1. 4. When a hospital owned or operated

by the DMH merges with a hospital owned or operated by the board of curators, the Uninsured Add-Ons effective with the date of the merger shall be the Uninsured Add-On for the surviving hospital as determined from the surviving hospital’s base-year cost reports in accordance with subsection (18)(D).

1. (21) Enhanced Graduate Medical Education

2. (GME) Payment—An enhanced GME payment shall be made to any acute care hospital that provides graduate medical education (teaching hospital).

   1. (A) The enhanced GME payment shall be computed in accordance with subsection (21)(B). The payment shall be made following the end of the state fiscal year. The enhanced GME payment for each state fiscal year shall be computed using the most recent cost data available when the enhanced GME payment is computed. If the cost report is less than or more than a twelve- (12-) month period, the cost report data will be adjusted to reflect a twelve- (12-) month period. The state share of the enhanced GME payment to a hospital that has cash subsidies shall come from funds certified by the hospital.
   2. (B) The enhanced GME payment will be computed by first determining the percentage difference between the McGraw-Hill CPI index for hospital services and Medicare update factors applied to the per resident amounts from 1986 to the most recent SFY. For example, the percentage difference has been computed to be eighty-five and sixtytwo one-hundredth percent (85.62%) for SFY 2000. The percentage difference is then multiplied by the MO HealthNet share of the aggregate approved amount reported on worksheet E-3 part IV and E-3 part VI of the Medicare cost report (HCFA 2552-96) and worksheet E-4 of the Medicare cost report (CMS 2552-10) for the fourth prior fiscal year and trended to the current state fiscal year. The resulting product is the enhanced GME payment.

AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013, and section 208.152, RSMo Supp. 2015.* 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. 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. 13 CSR 70-15 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 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. *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 1967, 1973, 1989, 1990, 1991, 2007, 2012; and 208.201, RSMo 1987, amended 2007.