Mo. Code Regs. tit. 9 § 45-7.010

Current through Register Vol. 50, No. 1, January 2, 2025

Section 9 CSR 45-7.010 - Developmental Disabilities Health Home

PURPOSE: This rule establishes the requirements for designation as a Developmental Disabilities (DD) Health Home by the Missouri Department of Mental Health (DMH), Division of Developmental Disabilities (Division of DD), for the Missouri Department of Social Services (DSS), MO HealthNet Division (MHD), to support individuals with intellectual and developmental disabilities who have chronic conditions and are served by the Division of DD.

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) Definitions.

(A) Behavioral Health-The promotion of mental health, resilience, and well-being, the treatment of mental health and substance use disorders, and the support of individuals who experience and/or are in recovery from these conditions, along with their family or other natural supports, and communities.

(B) Centers for Medicare & Medicaid Services (CMS)-CMS is a federal agency within the United States Department of Health and Human Services that administers Medicaid programs.

(C) Chronic or At-Risk Conditions-For the purpose of DD Health Home eligibility, chronic or at-risk conditions are as follows:

1. Intellectual and/or developmental disability;

2. Diabetes;

3. Asthma;

4. Cardiovascular disease (CVD) or hypertension;

5. Chronic obstructive pulmonary disease (COPD);

6. Overweight (body mass index (BMI)>25);

7. Dementia;

8. Dependent on a ventilator;

9. One (1) of the Fatal Five Plus conditions or one (1) or more chronic conditions that could lead to one (1) of the following Fatal Five Plus conditions:

A. Pulmonary aspiration;

B. Bowel obstruction;

C. Gastroesophageal reflux disease (GERD);

D. Seizures;

E. Sepsis;

F. Dehydration;

10. Tobacco use;

11. Diagnosis of Autism Spectrum Disorder; and

12. Healthcare level of 3 or greater as identified by the Health Risk Screening Tool.

(D) EMR-Electronic medical records, also referred to as electronic health records (EHR).

(E) Health Home-A Health Home provides coordination of health care to individuals with chronic physical and/or behavioral health conditions, using a partnership or team approach between the Health Home team and individuals in order to achieve improved health care, to avoid preventable hospitalizations and emergency department use.

(F) DD Health Home Enrollees-Individuals eligible for Division of DD services with one (1) or more chronic/at risk conditions as defined in enrollment/eligibility criteria section.

(G) DD Health Home Provider-DD Contracted Targeted Case Management (TCM) and/or DD Home and Community Based Services (HCBS) certified or accredited waiver providers who meet criteria for DD health home provider eligibility.

(H) DD Health Home Team-DD Health Home core team shall consist of the following staff: Health Home Director, Nurse Care Manager, Physician Consultant (Advanced Practice Registered Nurse (APRN) as substitute and defined in the DD Health Home Provider Operations Manual), Specialized Healthcare Consultant, and DD Health Home Facilitator. Based on the unique needs of the individual, additional staff may be identified.

(I) Health Risk Screening Tool-The Health Risk Screening Tool (HRST) is a tool used to provide early detection of health risks and destabilization.

(J) Health Risk Support Plan (HRSP)-The HRSP are standardized electronic templates in the department's identified system which is a component of the individual's Individual Support Plan (ISP) and serves to identify implementation strategies to mitigate risk and improve health outcomes.

(K) Intellectual and/or Developmental Disability (IDD)- Adults and youth who meet the Missouri state statute definition of Developmental Disability, section 630.005(9), RSMo. "Developmental disability," a disability that is attributable to intellectual disability, cerebral palsy, epilepsy, head injury or autism, or a learning disability related to a brain dysfunction; or any other mental or physical impairment or combination of mental or physical impairments; and is manifested before the individual attains age twenty-two (22); and is likely to continue indefinitely; and results in substantial functional limitations in two (2) or more of the following areas of major life activities: self-care; receptive and expressive language development and use; learning; self-direction; capacity for independent living or economic self-sufficiency; mobility; and reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, habilitation or other services which may be of lifelong or extended duration and are individually planned and coordinated.

(L) Missouri Department of Social Services (DSS), MO HealthNet Division (MHD)-Single State Medicaid authority.

(M) Social Determinants of Health (SDOH), the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, racism, climate change, and political systems.

(2) Developmental Disabilities Health Home Qualifications

(A) Initial Provider Qualifications. In addition to being a DD service provider of TCM or DD HCBS waiver services, each DD Health Home provider must meet state qualifications, which may be amended from time to time as necessary and appropriate, but minimally require that each Health Home-

1. Must be enrolled in Missouri's Medicaid program and agree to comply with all Medicaid program requirements;

2. DD Health Home providers can either directly provide, or subcontract for the provision of DD Health Home services. The DD Health Home remains responsible for all DD Health Home program requirements, including services performed by the contractor;

3. Have strong, engaged leadership personally committed to and capable of leading the DD Health Home through the transformation process and sustaining transformed DD Health Home processes as demonstrated through-

A. The provider designation review;

B. Agreement to participate in learning activities, including in-person sessions and regularly scheduled phone calls; and

C. Provider leadership, in collaboration with the state, have presented the state-developed introductory presentation to Missouri's DD Health Home initiative to provider staff and board of directors;

4. Meet the state's minimum access requirements as follows: Prior to implementation of DD Health Home service coverage, provide assurance of enhanced individual access to the health team, including the development of alternatives to face-to-face visits, such as telephone or email, twenty-four (24) hours per day seven (7) days per week;

5. Actively use MHD and DMH information technology (IT) systems to conduct care coordination and prescription monitoring for Medicaid individuals;

6. Utilize the department's identified system to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and maintain other items as required by the department;

7. Routinely use an electronic health management tool to determine individualized health risks (i.e., Health Risk Screening Tool (HRST));

8. Routinely use an electronic health management tool to determine problematic prescribing patterns;

9. Conduct wellness interventions as indicated based on the individual's level of risk;

10. Agree to convene regular, ongoing, and documented internal DD Health Home team meetings to plan and implement DD Health Home healthcare goals and objectives of ongoing practice transformation;

11. Agree to participate in CMS and state-required evaluation activities;

12. Agree to develop required reports describing DD Health Home activities, efforts, and progress in implementing DD Health Home services;

13. Maintain compliance with the terms and conditions as a DD Health Home provider or risk termination as a provider of DD Health Home services;

14. Present a proposed DD Health Home service delivery model the department determines will have a reasonable likelihood of being cost-effective. Cost effectiveness will be determined based on the size of the proposed DD Health Home, Medicaid caseload, percentage of caseload with eligible chronic conditions of individuals, and other factors to be determined by DMH.

(B) Ongoing Provider Qualifications. Each provider must also-

1. Continue to have a strong, engaged leadership personally committed to and capable of leading the DD Health Home through the transformation process and sustaining transformed DD Health Home processes as evidenced by successful participation in the leadership training and learning collaborative developed for DD Health Home;

2. Coordinate care and build relationships with regional hospital(s) or hospital system(s) to develop a structure for transitional care planning, including communication of inpatient admissions of DD Health Home individuals, and maintain a mutual awareness and collaboration to identify individuals seeking emergency department services who might benefit from connection with a DD Health Home, and encourage hospital staff to notify the area DD Health Home staff of such opportunities;

3. Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process;

4. Demonstrate development of fundamental DD Health Home functionality through an assessment process to be applied by Division of DD;

5. Demonstrate significant improvement on clinical indicators specified by and reported to Division of DD;

6. Submit data reports as required by DSS and/or Division of DD;

7. Provide DD Health Home services that demonstrate overall cost effectiveness;

8. Participate in technical assistance conference calls and webinars as requested by DSS and/or Division of DD;

9. Meet standards as determined by DMH.

(3) Scope of Services. This section describes the activities Division of DD providers will be required to engage in, and the responsibilities they will fulfill, if recognized as a DD Health Home.

(A) Division of DD Health Home Services. The DD Health Home Team shall assure the following health services are received, as necessary, by all individuals served in the DD Health Home:

1. Comprehensive care management. Comprehensive care management services include-

A. Determining level of participation in care management services based upon individualized information provided through the HRST and HRSP, and other individual information;

B. Assessment of preliminary service needs which includes reviewing and identifying gaps in the overall person-centered plan which may include the HRSP and Behavior Support Plan (BSP);

C. DD Health Home development of individual DD Health Home healthcare goals, preferences, and optimal clinical outcomes;

D. Assigning health team roles and responsibilities;

E. Developing guidelines for health teams to follow across risk levels or health conditions;

F. Monitoring of individual and population health status and service use to determine adherence to or variance from DD Health Home healthcare goals and identified service needs identified in the overall person-centered plan; and

G. Developing and disseminating reports that indicate the individual's progress toward meeting outcomes for individual satisfaction, health status, service delivery, and costs.

2. Care coordination. Care coordination is the implementation of the overall individual person-centered plan with active individual and family involvement through appropriate linkages, referrals, coordination, and follow-up to needed services and supports. Care coordination is designed to be delivered in a flexible manner best suited to the individual's preferences and to support DD Health Home healthcare goals that have been identified by developing linkages and skills in order to allow the individual to reach their full potential and increase their independence in obtaining and accessing services. Specific activities include but are not limited to-

A. Participating in hospital discharge processes to support the individual's transition to the community;

B. Communicating and consulting with the individual, providers, and collateral contacts; and

C. Facilitating regularly scheduled interdisciplinary team meetings to review person-centered plans and assess progress toward identified DD Health Home healthcare goals.

3. Health promotion. Health promotion shall minimally consist of educating and engaging the individual in making decisions that promote independent living skills and lifestyle choices that achieve the following goals:

A. Good health;

B. Proactively managing chronic conditions;

C. Identifying risk factors early; and

D. Screening for emerging health problems.

4. Health promotion services include but are not limited to-

A. Promoting the individual's education of their chronic conditions;

B. Developing self-management plans with the individual;

C. Conducting medication reviews and regimen compliance;

D. Providing support to the individual for improving social networks and health-promoting lifestyle interventions, including but not limited to preventative health practices for the IDD population, nutritional counseling, obesity reduction and prevention, and increasing physical activity; and

E. Assisting the individual to participate in DD Health Home healthcare goal planning with an emphasis on person-centered empowerment and the development of health literacy skills to help the individual understand and self-manage chronic health conditions.

5. Comprehensive transitional care from inpatient to other settings. Comprehensive transitional care services include but are not limited to-

A. Facilitating the individual's transition between care levels, such as a hospital, nursing facility and residential supports, or when opting for a new DD Health Home provider;

B. Collaborating and establishing relationships with the individual's physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the overall person-centered plan. Specific focus is on increasing the individual's ability to manage care and live safely in the community, and shift the use of reactive care and treatment to proactive health promotion and self-management;

C. Communicating with and educating the individual and providers located at the setting from which the individual is transitioning, and at the setting to which the individual is transitioning;

D. Ensuring the individual's prompt access to follow-up care after discharge (e.g., care record from discharge entity, medication reconciliation, reviewing person-centered plan to assure access to needed community services, appointment scheduling); and

E. Providing care coordination services designed to streamline person-centered plans, reduce hospital admissions, ease the transition to long term services and supports, and interrupt patterns of frequent hospital emergency department use.

6. Individual and family support. Individual and family support is intended to assist the individual to facilitate and maintain quality of life and explore community options to promote overall quality of life through health stabilization and improved health outcomes. Activities include but are not limited to-

A. Educating and guiding in self-advocacy support with the individual;

B. Increasing the individual's health literacy skills and ability to self-manage their care;

C. Identifying resources for the individual to address the gaps identified in the overall person-centered plan to improve his or her overall health and ability to function within his or her family and in the community;

D. Educating the individual on the importance of obtaining and adhering to medications and other prescribed treatments; and

E. Assisting the individual with developmental disabilities for whom primary services needs are more directly related to treatment (e.g., treatment for a behavioral health condition and/or particular healthcare condition(s)), referring and coordinating with the approved care management entity for the MO Community Mental Health Center (CMHC) Health Care Home or MO Primary Care Health Home for services more directly related to those aforementioned conditions.

7. Referral to community and social support services. Referral to community and social support services involves identifying gaps in the overall person-centered plan that are connecting the individual to community based resources and referrals that support Social Determinants of Health (SDOH). It also includes identifying resources to reduce barriers that will promote the individual's overall quality of life through health stabilization and improved overall health outcomes.

(B) DD Health Home Administration. Each DD Health Home provider shall employ a DD Health Home Director. The DD Health Home core team shall consist of the following staff: Nurse Care Manager, Physician Consultant (APRN as a substitute and defined in the DD Health Home Provider Operations Manual), Specialized Healthcare Consultant, and DD Health Home Facilitator. Based on the unique needs of the individual, additional staff may be identified.

(C) Learning Activities. The MO DD Health Homes will be supported as the state continually assesses the DD Health Homes to determine training needs. DD Health Homes will participate in a variety of centralized learning supports including but not limited to learning collaboratives, webinars, training and technical assistance including peer-led training and community resources.

(D) Department's Identified System. DD Health Homes shall utilize the department's identified system approved by the Division of DD. The department's identified system is a system for tracking information the Division of DD deems critical to the management of the health of the population being served through the DD Health Home, including dates of delivered and needed services, laboratory values needed to track chronic conditions, and other measures of health status. The department's identified system shall be used for-

1. Tracking;

2. Risk stratification;

3. Analysis of population health status and individual needs; and

4. Reporting as specified by the Division of DD.

(E) Data Reporting. DD Health Homes shall be required to submit the following reports to the Division of DD as specified:

1. Monthly updates identifying the DD Health Home's staffing patterns, enrollment status, hospital follow-ups, and notifications provided to primary healthcare providers; and

2. Other reports as specified by the Division of DD.

(4) Patient Eligibility and Enrollment. This section describes eligibility and enrollment requirements for DD Health Home.

(A) Eligibility. Individuals eligible for Division of DD services shall meet the following criteria to be eligible for services from a designated DD Health Home:

1. Have a chronic condition of intellectual and/or developmental disability; and

2. Have or be at risk of developing one (1) of the following conditions:

A. Diabetes;

B. Asthma;

C. Cardiovascular disease (CVD) or hypertension;

D. Chronic obstructive pulmonary disease (COPD);

E. Overweight (body mass index (BMI)>25);

F. Dementia;

G. Dependent on a ventilator;

H. One (1) of the Fatal Five Plus conditions or one (1) or more chronic conditions that could lead to one (1) of the following Fatal Five Plus conditions:

(I) Pulmonary aspiration;

(II) Bowel obstruction;

(III) Gastroesophageal reflux disease (GERD);

(IV) Seizures;

(V) Sepsis;

(VI) Dehydration;

I. Tobacco use;

J. Diagnosis of Autism Spectrum Disorder; or

K. Healthcare level of 3 or greater as identified by the Health Risk Screening Tool.

(B) Enrollment Requirements. Individuals eligible for DD Health Home services will be assigned to eligible providers. Upon enrollment, individuals assigned to a DD Health Home will be informed by the Department of Mental Health. The notice will describe assignment of the individual to a DD Health Home, provide a brief description of DD Health Home services, and describe the process for the individual to change DD Health Home provider, and opt-out of receiving services from the assigned DD Health Home provider.

(5) DD Health Home Provider Designation Process.

(A) The Division of DD shall establish procedures under which a Medicaid-enrolled provider attains designation as a DD Health Home provider.

1. The designation process shall be person-centered and serve the following critical purposes-

A. To determine how well DD Health Home providers fulfill their responsibilities to individuals enrolled in a DD Health Home; and

B. To determine systems changes and practices needed so that DD Health Home providers will be more responsive to the individual's needs;

2. DD Health Home providers shall demonstrate innovation and initiative in pursuing, as well as commitment toward continuous quality improvement in realizing best practices and outcomes associated with-

A. Health Home core functional components-

(I) Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered Health Home services;

(II) Coordinate access to high quality health care services informed by evidence-based clinical practice guidelines;

(III) Coordinate access to preventive and health promotion services, including prevention of mental illness and substance use disorders;

(IV) Coordinate and provide access to behavioral health services, including mental health and substance use;

(V) Coordinate access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care;

(VI) Coordinate access to chronic disease management, including self-management support to individuals and their families;

(VII) Coordinate access to individual and family supports, including referral to community, social support, and recovery services;

(VIII) Coordinate access to long-term care supports and services;

(IX) Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical healthcare-related needs and services;

(X) Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate; and

(XI) Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level; and

B. Service delivery system principles-

(I) Demonstrate clinical competency for serving the complex needs of health home enrollees using evidence based protocols;

(II) Demonstrate the ability for effectively coordinating the full range of medical, behavioral health, long-term services and supports, and social services for medically complex individuals with chronic conditions;

(III) Provide Health Home services that operate under a "whole-person" approach to care using a comprehensive needs assessment and an integrated person-centered care planning process to coordinate care;

(IV) Have conflict of interest safeguards in place to assure enrollee rights and protections are not violated, and that services are coordinated in accordance with enrollee needs expressed in the person-centered care plan;

(V) Provide access to timely health care twenty-four (24) hours a day, seven (7) days a week to address any immediate care needs of their Health Home enrollees;

(VI) Have in place operational protocol, as well as communication procedures to assure care coordination across all elements of the healthcare system (hospitals, specialty providers, social service providers, other community based settings, etc.);

(VII) Have protocols for ensuring safe care transitions, including established agreements and relationships with hospitals and other community-based settings;

(VIII) Establish a continuous quality improvement program that includes a process for collection and reporting of Health Home data for quality monitoring and program performance; permits evaluation of increased coordination and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level;

(IX) Use data for population health management, tracking tests, referrals and follow-up, and medication management;

(X) Use health information technology to link services and facilitate communication among interdisciplinary team members and other providers to coordinate care and improve service delivery across the care continuum.

3. Upon initial application and on a biennial basis thereafter, all DD Health Home providers shall seek DD Health Home designation under this section except those providers appropriately accredited by nationally recognized accrediting bodies for DD Health Homes approved by Division of DD shall not be required to seek designation. The division director shall issue a DD Health Home designation to providers successfully completing the process and requirements of this section.

(B) The Division of DD recognizes and deems as designated a provider that has attained full accreditation under standards for DD Health Home from a nationally recognized accrediting body. The deemed provider must-

1. Submit to the Division of DD a copy of the most recent accreditation survey report and verification of the accreditation time period and dates within thirty (30) calendar days of receipt from the accrediting body.

2. Notify the Division of DD when accreditation surveys are scheduled or when the accrediting body makes complaint investigation visits.

3. Notify the Division of DD of any changes in accreditation status during the time period of accreditation and resurvey.

4. Identify the Division of DD as a primary stakeholder for contact by the accrediting body during survey and resurvey data-gathering processes.

5. The Division of DD may conduct a scheduled or unscheduled survey of an accredited DD Health Home provider at any time to monitor ongoing compliance with the standards and requirements. If any survey finds conditions that are not in compliance with applicable standards, the Division of DD may require corrective action steps and may change the provider's designation status consistent with procedures set out in this rule.

(C) Participation in Designation. Participation may entail responding to surveys and requests for interviews with DD Health Home staff and individuals served. Providers shall provide all requested information as directed by the Division of DD. A provider must engage in the designation process in good faith. The provider must provide information and documentation that is accurate and complete. Failure to participate in good faith, including falsification or fabrication of any information used to determine compliance with requirements, may be grounds to deny issuance of or to revoke designation.

1. The Division of DD shall conduct a comprehensive survey at an organization for the purpose of determining compliance with DD Health Home standards, standards of care, program/service rules, and other requirements, except as stipulated in paragraph (5)(A)3.

A. The Division of DD shall provide advance notice and scheduling of routine, planned surveys.

B. The Division of DD shall notify the applicant regarding survey date(s), procedures, and a copy of any survey instrument that may be used. Survey procedures will include but are not limited to interviews with provider staff, individuals being served, and other interested parties; review of provider administrative records necessary to verify compliance with requirements; and review of personnel records and service documentation.

C. The applicant agrees, by act of submitting a DD Health Home application, to allow and assist Division of DD representatives in fully and freely conducting these survey procedures, initially and ongoing, and to provide Division of DD representatives reasonable and immediate access to premises, individuals, and requested information.

D. The surveyor(s) shall hold entrance and exit conferences with the organization to discuss survey arrangements and survey findings, respectively. If there are any deficiencies found during the survey, the provider will be required to submit a plan of correction before designation can be approved.

E. If a plan of correction is not required, the Division of DD shall issue DD Health Home designation to the provider's director within thirty (30) calendar days after the exit conference, indicating the DD Health Home provider can provide Health Home services.

F. Division of DD will identify and set timelines for issues/enhancements to be addressed with the DD Health Home provider. At the discretion of the Division of DD, a followup review will be completed once issues have been addressed. If issues/enhancements have been satisfactorily addressed, Division of DD will issue DD Health Home designation to the provider.

(I) The report shall note all deficiencies identified during the survey.

(II) The Division of DD shall send a notice of deficiency and the report.

(III) The DD Health Home provider shall make the report available to their staff and to the public upon request.

(IV) Within thirty (30) calendar days of the date that a notice of deficiency and the report is presented to the DD Health Home provider, the provider shall submit to the Division of DD a plan of correction. The plan must address each deficiency, specifying the method of correction and the date the correction shall be completed. The provider will work with the Division of DD to develop a plan of correction. No correction date will exceed ninety (90) calendar days.

(V) Within fifteen (15) calendar days after receiving the plan of correction, the Division of DD shall notify the DD Health Home provider of its decision to approve or require revisions of the proposed plan.

(VI) The Division of DD will assure that the plan of correction has been implemented and deficiencies corrected. Division of DD shall determine if it is necessary to make a return visit to the DD Health Home provider based on the criteria of the plan of correction.

(VII) In the event that the provider has not submitted a plan of correction acceptable to Division of DD within forty-five (45) calendar days of the original date that written notice of deficiencies was presented by certified mail to the DD Health Home provider, it shall be subject to expiration or denial of designation.

G. The Division of DD may grant designation on a temporary, initial, conditional, deemed, or compliance status. The Division of DD will notify the Division of DD Director of any change in the status of a provider.

(I) Temporary status may be granted to a DD Health Home provider if the designation process has not been completed prior to the expiration of an existing designation and the applicant is not at fault for failure or delay in completing the designation process.

(II) Initial status for a period of not exceeding one (1) year may be granted to a new provider based on a designation review which finds the program in compliance with requirements related to policy and procedure, facility, trainings and personnel to begin providing services. The initial designation will be awarded for one (1) year and a follow-up visit will occur prior to the initial designation expiration date to ensure the DD Health Home provider is demonstrating continued improvement and functionality.

(a) In the Division of DD's initial determination and granting of initial designation, the provider shall not be expected to fully comply with those standards which reflect ongoing program activities.

(b) The Division of DD shall conduct a comprehensive survey of the initially designated provider and shall make further determination of the provider's designation status no later than the expiration date of the initial designation.

(III) Conditional status may be granted to a provider following a survey by the Division of DD that determines that there are pervasive and/or significant deficiencies with standards that may affect quality of care to individuals and there is reasonable expectation that the provider can achieve compliance within a stipulated time period. The Division of DD may consider patterns and trends of performance identified during the survey.

(a) The period of conditional status shall not exceed one hundred eighty (180) calendar days. The Division of DD may directly monitor progress, may require the provider to submit progress reports, or both.

(IV) The Division of DD shall conduct a further survey within the one hundred eighty (180)-day period and make a further determination of the provider's compliance with standards.

(V) Designation status may be awarded to a provider for a period of two (2) years following a survey by the Division of DD that determines the provider meets all standards relating to quality of care and the safety, health, rights, and welfare of individuals served.

H. If deficiencies are cited during a survey, any and all such deficiencies must be corrected in accordance with the plan of correction prior to the Division of DD awarding designation status.

I. The Division of DD may investigate any complaint regarding the operation of a designated or deemed provider. If conditions are found that are not in compliance with applicable requirements, the Division of DD may, at its sole discretion for deemed providers, notify the accrediting body of any concerns.

J. The Division of DD may conduct a scheduled or unscheduled survey of a provider at any time to monitor ongoing compliance with the standards and requirements. If any survey finds conditions that are not in compliance with applicable standards, the Division of DD may require corrective action steps and may change the provider's designation status consistent with procedures set out in this rule.

K. The Division of DD may deny issuance of and may revoke designation based on a determination that includes but is not limited to-

(I) The nature of the deficiencies results in substantial probability of or actual jeopardy to individuals being served;

(II) Serious or repeated incidents of abuse or neglect of individuals being served or violations of rights have occurred;

(III) Fraudulent fiscal practices have transpired or significant and repeated errors in billings to the Division of DD have occurred;

(IV) Failure to participate in the designation process in good faith, including falsification or fabrication of any information used to determine compliance with requirements;

(V) The nature and extent of deficiencies results in the failure to conform to the standards of the program being offered; or

(VI) Compliance with standards has not been attained by an organization upon expiration of conditional designation.

L. An organization which has had designation denied or revoked may meet with the Division of DD Director or designee to appeal the decision to revoke designation.

(I) The provider must notify the department's division director or designee in writing within ten (10) business days of the date on the termination letter. The appeal shall include the following-

(a) The name of the provider;

(b) The name and contact information of the person requesting the appeal;

(c) The reasons for appealing the decision; and

(d) Any documentation that supports the provider's position.

(II) The meeting shall take place within seven (7) business days from the date of the request.

(III) Within seven (7) business days of the meeting, the division director or designee shall make a final determination as to whether the decision remains in effect. The provider shall be notified of this decision by regular and certified mail.

(IV) The decision of the division director or designee shall be the final decision of the department.

M. A designation is valid only as long as the provider meets standards of care and other requirements.

N. The provider shall maintain the designation issued by the Division of DD in a readily available location.

O. Within seven (7) business days of the time a designated provider organization is discontinued, moved to a new location, or has a change in accreditation status, the provider shall provide written notice to the Division of DD of any such change.

P. The Division of DD shall designate only the provider(s) named in the application.

Q. The provider(s) may not transfer designation without the written approval of the department.

R. Within seven (7) calendar days of the effective date that a designated provider is sold or undergoes a change of ownership, the provider shall submit a written notice to the division of any such change. A change in ownership is considered to have occurred under the following circumstances:

(I) A new corporation, partnership, limited partnership, limited liability company, or other entity assumes ownership of the operation;

(II) An individual incorporates or forms a partnership;

(III) With respect to a designated provider which is a general partnership, a change occurs in the majority interest of the partners;

(IV) With respect to a designated provider which is a limited partnership, a change occurs in the majority interest of the general or limited partners;

(V) With respect to a designated provider which is a corporation, a change occurs in the persons who own, hold, or have the power to vote the majority of any class of stock issued by the corporation.

(VI) A designated provider's change of Federal Employer Identification Number (FEIN).

S. The organization must comply with other applicable requirements as set forth in 9 CSR 10-5.220 Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(6) Demonstrated Evidence of DD Health Home Transformation.

(A) Providers are required to demonstrate evidence of transformation to the DD Health Home model on an ongoing basis using measures and standards established by the Division of DD and communicated to the providers. Transformation to the DD Health Home service delivery model is exhibited when a provider-

1. Demonstrates development of fundamental DD Health Home functionality initially upon enrollment, one (1) year prior to the expiration of the initial designation, and biennially thereafter, based on an assessment process determined by the Division of DD. Additional reviews may be indicated on a case-by-case basis. Providers must demonstrate continued improvement and functionality for as long as they maintain their DD Health Home designation; and

2. Demonstrates progress toward established goals and objectives related to the clinical indicators as determined by Division of DD.

(B) Notification of Staffing Changes. Providers are required to notify the Division of DD within seven (7) business days of staff changes in the DD Health Home Director, Physician Consultant (APRN as substitute), Nurse Care Manager(s), and DD Health Home Facilitator.

(C) Providers shall work cooperatively with the Division of DD to support approved training, technology, and administrative services required for ongoing implementation and support of the DD Health Homes.

(7) Health Home Payment Components. This section describes the payment process for Developmental Disabilities Health Homes.

(A) General.

1. All payments to a DD Health Home are contingent on the program meeting the DD Health Home requirements set forth in their Health Home applications, as determined by the state of Missouri. Failure to meet such requirements is grounds for revocation of Health Home status and for termination of payments.

2. Reimbursement for DD Health Home services will be in addition to a provider's existing reimbursement for services and procedures and will not change existing reimbursement for services and procedures that are not part of the DD Health Home.

3. The Division of DD reserves the right to make changes to the payment methodology.

(B) Types of Payments.

1. Clinical Care Management per Member per Month (PMPM) payment. Missouri will pay DD Health Homes the cost of staff primarily responsible for delivery of services not covered by other reimbursement (Health Home Director, Physician Consultant (APRN as substitute), Nurse Care Manager, Specialized Healthcare Consultant and DD Health Home Facilitator), whose duties are not otherwise reimbursable by MO HealthNet. In addition, the DD Health Home PMPM will include Health Home specific training, technical assistance, administration, and data analytics. Staff costs are based on the Bureau of Labor Statistics data. All DD Health Home providers will receive the same PMPM rate. The PMPM method will be reviewed periodically to determine the rate is economically efficient and consistent with quality of care.

(C) Minimum Criteria for Payment.

1. The individual is identified as meeting the DD Health Home eligibility criteria on the state-run DD Health Home department's identified system.

2. The individual is enrolled with a designated billing DD Health Home provider, and is enrolled in only one (1) Health Home at a time, regardless of type.

3. The minimum DD Health Home service required to merit payment of the PMPM is that the individual has received care management monitoring for treatment gaps that was documented or another DD Health Home service was provided that was documented.

4. The DD Health Home will report that the minimal service required for the PMPM rate payment occurred on a monthly DD Health Home attestation report.

(D) Except as otherwise noted in the plan, state-developed PMPM rates are the same for both governmental and private providers of DD Health Home services.

(8) Policies and Procedures. The organization shall maintain a policy and procedure manual which accurately describes and guides the operation of its services and promotes compliance with applicable regulations. The policy and procedure manual shall be readily available to staff and the public upon request and shall include but is not limited to-

(A) The DD Health Home provider will develop policies and procedures in accordance with 9 CSR 10-5 to include-

1.9 CSR 10-5.190 Background Screening Requirements;

2.9 CSR 10-5.200 Report of Complaints of Abuse, Neglect and Misuse of Funds/Property;

3.9 CSR 10-5.206 Report of Events; and

4.9 CSR 10-5.220 Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR;

(B) The DD Health Home provider will develop policies and procedures to address the following:

1. Opt-out process for individuals that otherwise qualify for DD Health Home services;

2. Transfer and discharge processes for DD Health Home individuals;

3. Primary care physician referrals;

4. Primary care physician or other specialty care coordination;

5. Twenty-four (24) hour coverage in accordance with paragraph (2)(A)3. of this rule;

6. Prescription monitoring;

7. Health Risk Screening Tool and routine monitoring;

8. Quality assurance/quality improvement process as related to DD Health Home;

9. Guidelines to follow across risk levels or health conditions;

10. Follow-up care after discharge related to transitional care;

11. Training requirements for DD Health Home staff;

12. DD Health Home data reporting;

13. Composition of DD Health Home team;

14. Notification of DD Health Home staffing changes;

15. Utilization of the department's identified system;

16. Complaints and grievances; and

17. Attestation and documentation.

(9) Incorporation by Reference. This rule incorporates by reference the following:

(A) The DD Health Home Provider Operations Manual is incorporated by reference and made a part of this rule as published May 15, 2024, by the Department of Mental Health, Division of Developmental Disabilities, at its website at https://dmh.mo.gov/dev-disabilities/health-home. This rule does not incorporate any subsequent amendments or additions to this publication.

(10) Electronic Medical Records. DD Health Home providers are required to utilize and maintain electronic medical records of all individuals served. Electronic medical records systems must comply with state and federal regulations.

9 CSR 45-7.010

Adopted by Missouri Register July 1, 2024/volume 49, Number 13, effective 7/1/2024, exp. 8/30/2024 (Emergency).

Amended by Missouri Register August 15, 2024/volume 49, Number 16, effective 9/30/2024.