PURPOSE: This rule delineates the process for submitting a Letter of Intent to begin the Certificate of Need (CON) review process and outlines the projects subject to CON review.

1. (1) Applicants shall submit by mail, fax, or email a Letter of Intent (LOI) to begin the Certificate of Need (CON) review process so that it is received at the CON office at least thirty (30) days prior to the submission of the CON application and will remain valid for six (6) months.
2. (2) Once filed, a LOI may be amended, except for project address, not later than ten (10) days in advance of the CON application filing, or it may be withdrawn at any time without prejudice.
3. (3) A long-term care (LTC) bed replacement sought pursuant to section 197.318, RSMo, requires a CON application if the capital expenditure for such bed replacement exceeds six hundred thousand dollars ($600,000) but allows for shortened information requirements and review time frames.

4. (4) The Certificate of Need Program (CONP) staff, as an agent of the Missouri Health Facilities Review Committee (committee), will review LOIs according to the following provisions:

   1. (A) Major medical equipment is reviewed as an expenditure on the basis of cost, regardless of owners or operators, or location (mobile or stationary);
   2. (B) The CONP staff shall test the LOI for applicability in accordance with statutory provisions for expenditure minimums, exemptions, and exceptions; SENIOR SERVICES
   3. (C) If the test verifies that a statutory exception or exemption is met on a proposed project, or the proposed cost is below all applicable expenditure minimums, the committee chair may issue a Non-Applicability CON letter indicating the application review process is complete; otherwise, the CONP staff shall add the proposal to a list of Non-Applicability proposals to be considered at the next regularly scheduled committee meeting;
   4. (D) If an exception or exemption is not verified, and if the proposal is above any applicable expenditure minimum, then a CON application will be required for the proposed project;

   5. (E) A Non-Applicability CON letter will be valid subject to the following conditions:

      1. 1. Any change in the project scope, including change in

type of service, cost, operator, ownership, or site, could void the effectiveness of the letter and require a new review; and

1. 2. Final project costs with third-party verification must be

provided on a Periodic Progress Report (Form MO 580-1871), included herein; and

1. (F) A CON application must be made if—

   1. 1. The project involves the development of a new hospital

costing one (1) million dollars or more, except for a facility licensed under Chapter 197, RSMo, meeting the requirements described in 42 CFR, section 412.23(e);

1. 2. The project involves the acquisition or replacement of

major medical equipment in any setting not licensed under Chapter 198, RSMo, costing one (1) million dollars or more;

1. 3. The project involves the acquisition or replacement of

major medical equipment for a health care facility licensed under Chapter 198, RSMo, costing four hundred thousand dollars ($400,000) or more;

1. 4. The project involves the acquisition of any equipment

or beds in a long-term care hospital meeting the requirements found in 42 CFR section 412.23(e) at any cost;

1. 5. The project involves a capital expenditure for renovation

or modernization, but not additional beds, by or on behalf of an existing health care facility licensed under Chapter 198, RSMo, costing six hundred thousand dollars ($600,000) or more;

1. 6. The project involves additional LTC (licensed or certified

residential care facility, assisted living facility, intermediate care facility, or skilled nursing facility) beds licensed under Chapter 198, RSMo, that either—

1. A. Costs six hundred thousand dollars ($600,000) or

more; or

1. B. Exceeds ten (10) beds or ten percent (10%) of that

facility’s existing licensed bed capacity, whichever is less.

1. 7. The project involves the development of a new LTC

facility (licensed or certified residential care facility, assisted living facility, intermediate care facility, or skilled nursing facility) licensed under Chapter 198, RSMo, costing six hundred thousand dollars ($600,000) or more.

1. (5) Nonsubstantive projects are waived from review by the authority of section 197.330.1(8), RSMo, and any applicant seeking such a determination shall submit information through the LOI process. A project meeting the definition of a nonsubstantive project shall be posted for review on the CON website at least twenty (20) days in advance of the committee meeting when the project is scheduled to be confirmed by the committee. SENIOR SERVICES FACILITIES REVIEW COMMITTEE FACILITIES REVIEW COMMITTEE SENIOR SERVICES SENIOR SERVICES FACILITIES REVIEW COMMITTEE FACILITIES REVIEW COMMITTEE

AUTHORITY: section 197.320, RSMo 2016.* Original rule filed June 2, 1994, effective Nov. 30, 1994. Emergency amendment filed Nov. 16, 1995, effective Nov. 26, 1995, expired May 23, 1996. Amended: Filed Nov. 15, 1995, effective April 30, 1996. Emergency amendment filed Nov. 26, 1996, effective Dec. 6, 1996, expired June 3, 1997. Emergency rescission filed Aug. 29, 1997, effective Sept. 8, 1997, expired March 6, 1998. Emergency rule filed Aug. 29, 1997, effective Sept. 8, 1997, terminated Sept. 21, 1997. Emergency rule filed Sept. 11, 1997, effective Sept. 21, 1997, expired March 19, 1998. Rescinded and readopted: Filed Aug. 29, 1997, effective March 30, 1998. Emergency rescission and rule filed June 29, 1999, effective July 9, 1999, expired Jan. 5, 2000. Rescinded and readopted: Filed June 29, 1999, effective Jan. 30, 2000. Emergency rescission and rule filed Dec. 14, 2001, effective Jan. 1, 2002, expired June 29, 2002. Emergency amendment filed Dec. 16, 2002, effective Jan. 1, 2003, expired June 29, 2003. Rescinded and readopted: Filed Dec. 14, 2001, effective June 30, 2002. Amended: Filed April 12, 2004, effective Nov. 30, 2004. Emergency amendment filed Aug. 14, 2006, effective Aug. 28, 2006, expired Feb. 23, 2007. Amended: Filed Aug. 14, 2006, effective March 30, 2007. Amended: Filed Oct. 1, 2010, effective May 30, 2011. Amended: Filed Aug. 9, 2019, effective March 30, 2020. Amended: Filed June 29, 2022, effective Jan. 30, 2023. Amended: Filed Aug. 19, 2025, effective April 30, 2026.

*Original authority: 197.320, RSMo 1979, amended 1993, 1995, 1999.