Section 208.930

Title XII PUBLIC HEALTH AND WELFARE

Chapter 208

Effective - 11 Jul 2019, 4 histories, see footnote   

  208.930.  Consumer-directed personal care assistance services, reimbursement for through eligible vendors — eligibility requirements — documentation — service plan required — premiums, amount — annual reevaluation — denial of benefits, procedure — expiration date. — 1.  As used in this section, the term "department" shall mean the department of health and senior services.

  2.  Subject to appropriations, the department may provide financial assistance for consumer-directed personal care assistance services through eligible vendors, as provided in sections 208.900 through 208.927, to each person who was participating as a non-MO HealthNet eligible client pursuant to sections 178.661 through 178.673^* on June 30, 2005, and who:

  (1)  Makes application to the department;

  (2)  Demonstrates financial need and eligibility under subsection 3 of this section;

  (3)  Meets all the criteria set forth in sections 208.900 through 208.927, except for subdivision (5) of subsection 1 of section 208.903;

  (4)  Has been found by the department of social services not to be eligible to participate under guidelines established by the MO HealthNet plan; and

  (5)  Does not have access to affordable employer-sponsored health care insurance or other affordable health care coverage for personal care assistance services as defined in section 208.900.  For purposes of this section, "access to affordable employer-sponsored health care insurance or other affordable health care coverage" refers to health insurance requiring a monthly premium less than or equal to one hundred thirty-three percent of the monthly average premium required in the state's current Missouri consolidated health care plan.

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Payments made by the department under the provisions of this section shall be made only after all other available sources of payment have been exhausted.

  3.  (1)  In order to be eligible for financial assistance for consumer-directed personal care assistance services under this section, a person shall demonstrate financial need, which shall be based on the adjusted gross income and the assets of the person seeking financial assistance and such person's spouse.

  (2)  In order to demonstrate financial need, a person seeking financial assistance under this section and such person's spouse must have an adjusted gross income, less disability-related medical expenses, as approved by the department, that is equal to or less than three hundred percent of the federal poverty level.  The adjusted gross income shall be based on the most recent income tax return.

  (3)  No person seeking financial assistance for personal care services under this section and such person's spouse shall have assets in excess of two hundred fifty thousand dollars.

  4.  The department shall require applicants and the applicant's spouse, and consumers and the consumer's spouse, to provide documentation for income, assets, and disability-related medical expenses for the purpose of determining financial need and eligibility for the program.  In addition to the most recent income tax return, such documentation may include, but shall not be limited to:

  (1)  Current wage stubs for the applicant or consumer and the applicant's or consumer's spouse;

  (2)  A current W-2 form for the applicant or consumer and the applicant's or consumer's spouse;

  (3)  Statements from the applicant's or consumer's and the applicant's or consumer's spouse's employers;

  (4)  Wage matches with the division of employment security;

  (5)  Bank statements; and

  (6)  Evidence of disability-related medical expenses and proof of payment.

  5.  A personal care assistance services plan shall be developed by the department pursuant to section 208.906 for each person who is determined to be eligible and in financial need under the provisions of this section.  The plan developed by the department shall include the maximum amount of financial assistance allowed by the department, subject to appropriation, for such services.

  6.  Each consumer who participates in the program is responsible for a monthly premium equal to the average premium required for the Missouri consolidated health care plan; provided that the total premium described in this section shall not exceed five percent of the consumer's and the consumer's spouse's adjusted gross income for the year involved.

  7.  (1)  Nonpayment of the premium required in subsection 6 shall result in the denial or termination of assistance, unless the person demonstrates good cause for such nonpayment.

  (2)  No person denied services for nonpayment of a premium shall receive services unless such person shows good cause for nonpayment and makes payments for past-due premiums as well as current premiums.

  (3)  Any person who is denied services for nonpayment of a premium and who does not make any payments for past-due premiums for sixty consecutive days shall have their enrollment in the program terminated.

  (4)  No person whose enrollment in the program is terminated for nonpayment of a premium when such nonpayment exceeds sixty consecutive days shall be reenrolled unless such person pays any past-due premiums as well as current premiums prior to being reenrolled.  Nonpayment shall include payment with a returned, refused, or dishonored instrument.

  8.  (1)  Consumers determined eligible for personal care assistance services under the provisions of this section shall be reevaluated annually to verify their continued eligibility and financial need.  The amount of financial assistance for consumer-directed personal care assistance services received by the consumer shall be adjusted or eliminated based on the outcome of the reevaluation.  Any adjustments made shall be recorded in the consumer's personal care assistance services plan.

  (2)  In performing the annual reevaluation of financial need, the department shall annually send a reverification eligibility form letter to the consumer requiring the consumer to respond within ten days of receiving the letter and to provide income and disability-related medical expense verification documentation.  If the department does not receive the consumer's response and documentation within the ten-day period, the department shall send a letter notifying the consumer that he or she has ten days to file an appeal or the case will be closed.

  (3)  The department shall require the consumer and the consumer's spouse to provide documentation for income and disability-related medical expense verification for purposes of the eligibility review.  Such documentation may include but shall not be limited to the documentation listed in subsection 4 of this section.

  9.  (1)  Applicants for personal care assistance services and consumers receiving such services pursuant to this section are entitled to a hearing with the department of social services if eligibility for personal care assistance services is denied, if the type or amount of services is set at a level less than the consumer believes is necessary, if disputes arise after preparation of the personal care assistance plan concerning the provision of such services, or if services are discontinued as provided in section 208.924.  Services provided under the provisions of this section shall continue during the appeal process.

  (2)  A request for such hearing shall be made to the department of social services in writing in the form prescribed by the department of social services within ninety days after the mailing or delivery of the written decision of the department of health and senior services.  The procedures for such requests and for the hearings shall be as set forth in section 208.080.

  10.  Unless otherwise provided in this section, all other provisions of sections 208.900 through 208.927 shall apply to individuals who are eligible for financial assistance for personal care assistance services under this section.

  11.  The department may promulgate rules and regulations, including emergency rules, to implement the provisions of this section.  Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.  Any provisions of the existing rules regarding the personal care assistance program promulgated by the department of elementary and secondary education in title 5, code of state regulations, division 90, chapter 7^**, which are inconsistent with the provisions of this section are void and of no force and effect.

  12.  The provisions of this section shall expire on June 30, 2025.

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(L. 2005 S.B. 74 & 49 § 1, A.L. 2006 S.B. 1084, A.L. 2007 S.B. 577, A.L. 2019 S.B. 514)

Effective 7-11-19

Expires 6-30-25

*Sections 178.661 to 178.673 were repealed by S.B. 539, 2005.

**Rules moved to 19 CSR 15-8, effective 8-29-05.