Inpatient Hospital Services Reimbursement Methodology

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 publication of the entire text of the material that 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) General Reimbursement Principles. (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. (B) The Title XIX reimbursement for hospitals, excluding those located outside Missouri, shall include the payments as outlined below. Reimbursement shall be subject to availability of federal financial participation (FFP). 1. Inpatient reimbursement methodologies are established in accordance with sections (4), (5), and (6). 2. Outpatient reimbursement is established in accordance with 13 CSR 70-15.160. 3. Supplemental payments, graduate medical education (GME) payments, and psych adjustment payments are estab lished in accordance with 13 CSR 70-15.015. 4. Disproportionate share hospital (DSH) payment is established in accordance with 13 CSR 70-15.220. 5. Upper payment limit (UPL) payment is established in accordance with 13 CSR 70-15.230. (C) The Title XIX reimbursement for hospitals located outside Missouri will be established in accordance with 13 CSR 7015.190. (2) Definitions. (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 audited 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 service or item. (B) Bad debt. Bad debts include the costs of caring for patients who have insurance but are not covered for the particular services, procedures, or treatment rendered. Bad debts do not include the cost of caring for patients whose insurance covers the given procedures but limits coverage. In addition, bad debts do 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. (C) Base year cost report. Audited Medicaid cost report from the third prior calendar year. If a facility has more than one (1) cost report with periods ending in the third 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 year cost report is less than or greater than a twelve- (12-) month period, the data shall be adjusted, based on the number of days reflected in the base year cost report to a twelve- (12-) month period. Any changes to the base year cost report after the division issues a final decision on assessment or payments will not be included in the calculations. (D) 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. (E) Contractual allowances. Difference between established rates for covered services and the amount paid by third-party payers under contractual agreements. (F) 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 2552-10 (CMS 2552-10) shall be used for fiscal years beginning on and after May 1, 2010. (G) Division. Unless otherwise designated, division refers to the MO HealthNet Division (MHD), a division of the Department of Social Services charged with the administration of the MO HealthNet program. (H) Diagnosis Related Group (DRG) relative weight. A numerical value that reflects the relative resource intensity or costliness of treating patients within a specific DRG compared to the average inpatient case. (I) Medicaid inpatient days. Medicaid inpatient days are paid Medicaid days for inpatient hospital services as reported by the Medicaid Management Information System (MMIS). (J) Nonreimbursable items. For purposes of reimbursement of reasonable cost, the following are not subject to reimbursement: 1. Allowances for return on equity capital; 2. Amounts representing growth allowances in excess of the intensity allowance, profits, efficiency bonuses, or a combination of these; 3. Cost in excess of the principal of reimbursement specified in 42 CFR chapter IV, part 413; and 4. Costs or services specifically excluded or restricted in this rule or the MO HealthNet hospital provider manual. (K) Reasonable cost. The reasonable cost of inpatient hospital services is an individual hospital’s Medicaid cost per day as determined in accordance with section (4) of this regulation using the base year cost report. (L) Specialty pediatric hospital. An inpatient pediatric acute care facility which— 1. Is licensed as a hospital by the Missouri Department of Health and Senior Services under Chapter 197 of the Missouri Revised Statutes; 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 3. Is not licensed to operate more than sixty (60) inpatient beds. (M) 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. (N) Federal reimbursement allowance (FRA). The fee assessed to hospitals for the privilege of engaging in the business of providing inpatient health care in Missouri. The FRA shall be an allowable cost to the hospital. The FRA is identified in 13 CSR 70-15.110. Effective January 1, 1999, the assessment shall be an allowable cost. (O) Incorporation by reference. This rule incorporates by ref erence the following: 1. The Hospital Manual as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, July 1, 2025. This rule does not incorporate any subsequent amendments or additions; 2. Chapter 40 of The Provider Reimbursement Manual — Part 2, that includes the CMS 2552-10 cost report form and instructions, as published by the Centers for Medicare & Medicaid Services (CMS), 7500 Security Boulevard, Baltimore, MD 21244, February 21, 2024. This rule does not incorporate any subsequent amendments or additions; 3. 42 CFR Chapter IV, Part 413, as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, DC 20408, October 1, 2024. This rule does not incorporate any subsequent amendments or additions. Only the cost principles from 42 CFR 413 are incorporated by reference; 4. The Missouri Inpatient (IP) APR-DRG Calculator as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, July 1, 2025. This rule does not incorporate any subsequent amendments or additions; 5. The Medicare Inpatient Prospective Payment System (IPPS) FY 2025 Table 2 Case-Mix Index and Wage Index Table by CMS Certification Number (CCN) as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, October 2, 2024. This rule does not incorporate any subsequent amendments or additions; and 6. The Medicare IPPS FY 2025 Table 3 Wage Index Table by CBSA as published by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, October 2, 2024. This rule does not incorporate any subsequent amendments or additions. (3) Reporting Requirements. (A) Cost reports. 1. Each hospital participating in the MO HealthNet program shall submit a cost report in the manner prescribed by the division. 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. All cost reports shall be submitted and certified by an officer or administrator of the hospital. B. If a cost report is more than ten (10) days past due, the division may withhold fifty thousand dollars ($50,000) in MO HealthNet payments from the hospital until the hospital submits the cost report. If the MO HealthNet payment is less than fifty thousand dollars ($50,000), the entire payment will be withheld. Upon the division’s or its authorized contractor’s receipt of the cost report prepared in accordance with this regulation, the payment that was withheld will be released to the hospital. C. A single extension, not to exceed thirty (30) days, may be granted upon the request of the hospital and the approval of the division when the hospital’s operation is significantly affected due to extraordinary circumstances over which the hospital 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. 2. The change of control or ownership of 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 or ownership within five (5) calendar months after the close of the reporting period. A. Upon learning of a change of control or ownership, the division may withhold fifty thousand dollars ($50,000) of the next available MO HealthNet payment from the hospital identified in the current MO HealthNet participation agreement until the 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 hospital identified in the current MO HealthNet participation agreement. B. The division may, at its discretion, delay the withholding of funds specified in subparagraph (3)(A)2.A. 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 entities may provide adequate assurances. The buying entity 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. 3. The termination of or by a hospital of participation in the MO HealthNet program requires that the hospital submit a cost report for the period ending with the date of termination within five (5) calendar months from the date of the CMS tieout notice. No extension in the submitting of cost reports shall be allowed when a termination of participation has occurred. A. Upon learning of the termination, the division may withhold fifty thousand dollars ($50,000) of the next available MO HealthNet payment from the hospital until the cost report is filed. If the MO HealthNet payment is less than fifty thousand dollars ($50,000), the entire payment will be withheld. Upon the division’s or its authorized contractor’s receipt of the cost report prepared in accordance with this regulation, the payment that was withheld will be released to the hospital. 4. Amended cost reports or other supplemental. The division or its authorized contractor will notify the hospital by letter when the audit of its cost report is completed. Since this data will be used in the calculation of per diem rates, and other Medicaid payments, the hospital shall review the audited cost report data and submit amended or corrected data to the division or its authorized contractor within fifteen (15) days. Data received after the fifteen- (15-) day deadline will not be considered by the division for per diem rates, or other Medicaid 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. (B) Records. 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. 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: A. A separate log for each fiscal year must be maintained by either date of service or date of payment 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 log should be used to complete the Medicaid worksheet in the hospital’s cost report; B. 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 C. Not to be included in the logs are denied claims or line item charges. This would include payments for hospital-based physicians and certified registered nurse anesthetists billed by the hospital on a professional services claim or payments for services provided by the hospital through enrollment as a MO HealthNet provider-type other than hospital. 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 (3)(B)1. of this rule. (C) Cost report audits. 1. The examination or inspection of a hospital’s cost report, files, and any other supporting documentation by the division or its authorized contractor. The division or its authorized contractor may perform the following types of audits: A. Level I audit—Requires a more narrow scope of review of hospital cost reports, files, and any other additional information requested and submitted to the division or its authorized contractor. The limited review may include items such as comparative analysis of a hospital’s cost report data to industry data, a review of a hospital’s prior year data to determine any outliers that may warrant further review, requesting additional details of the reported information, all of which could lead to potential adjustment(s) after such further review, as well as making standard adjustments, etc. Level I audits may be provided off-site; B. Level II audit—Requires a desk review of hospital cost reports, files, and any other additional information requested and submitted to the division or its authorized contractor. The desk review may include review procedures in a level I audit plus a more detailed analysis of a hospital’s cost report data to identify items that would require further review including requesting additional details of the reported information, documentation to support amounts reflected in the cost report, etc. Level II audits may be provided off-site; or C. Level III audits—Requires an in-depth audit, includ ing an on-site review, of hospital cost reports, files, and any other additional information requested and submitted to the division or its authorized contractor. The level III audit will require an in-depth analysis of a hospital’s cost report data and an on-site verification of cost report items deemed necessary through a risk assessment or other analyses, etc. Level III audits will require some portion of the hospital’s records review be provided on-site. (4) Inpatient Per Diem Reimbursement Methodology. Effective for admit dates beginning July 1, 2025, the Missouri hospitals listed in subsection (4)(A) will continue to be reimbursed under the inpatient per diem reimbursement methodology and shall receive a Missouri Medicaid per diem rate as calculated in subsection (4)(B). (A) The following hospitals will continue to be reimbursed under the inpatient per diem reimbursement methodology: 1. In-state specialty pediatric hospitals; 2. In-state pediatric hospitals that are licensed for fewer than fifteen (15) beds and specialized in pediatric orthopedic care; 3. In-state free-standing psychiatric hospitals; 4. In-state free-standing rehabilitation hospitals; 5. In-state free-standing long-term acute care (LTAC) hospitals; and 6. In-state hospitals enrolled in Medicaid on or after January 1, 2025, that have eighty percent (80%) or greater pa tient mix in mental health and substance abuse. (B) The per diem shall be determined from the base year cost report in accordance with the following formula: PER DIEM = ((TAC / MPD) * TI) + MIP FRA 1. MIP FRA—Medicaid inpatient share of Federal Reimbursement Allowance (FRA). The Medicaid inpatient share of the FRA assessment will be calculated by dividing the hospital’s Medicaid fee-for-service (FFS) and managed care (MC) inpatient days from the base year cost report by total hospital inpatient days from the base year cost report to arrive at the Medicaid utilization percentage. This percentage is then multiplied by the inpatient FRA assessment for the current SFY to arrive at the increased allowable Medicaid cost. This cost is then divided by the estimated Medicaid FFS and MC days for the current SFY to arrive at the increased Medicaid cost per day. The estimated Medicaid FFS and MC days are paid days from the second prior calendar year; 2. MPD—Medicaid FFS inpatient days from the base year cost report; 3. TI—Trend indices. The trend indices are applied to the TAC per day of the per diem rate. The trend index for the base year is used to adjust the TAC per day to a common fiscal year end of June 30. The adjusted TAC per day shall be trended through the current SFY; 4. TAC—Medicaid allowable inpatient routine and special care unit costs, and ancillary costs, from the base year cost report, will be added to determine the hospital’s Medicaid total allowable cost (TAC); 5. The per diem for private free-standing psychiatric hospitals shall be the greater of one thousand one hundred ninety-four dollars and twenty-two cents ($1,194.22) or the per diem as calculated in subsection (4)(B); 6. The per diem shall not exceed the average Medicaid inpatient charge per diem as determined from the base year cost report and adjusted, by the TI, except for federally deemed critical access hospitals whose Medicaid FFS charges equal sixty percent (60%) or less of its Medicaid FFS costs; 7. The per diem shall be adjusted for rate increases granted in accordance with subsections (4)(D) and (4)(E); and 8. If the hospital does not have a base year cost report, the inpatient per diem will be the weighted average statewide per diem rate as determined in section (5). (C) Trend indices (TI). For trend indices for SFY 2018 and forward, refer to the Hospital Market Basket index as published in Healthcare Cost Review by Institute of Health Systems, or equivalent publication, regardless of any changes in the name of the publication or publisher, for each SFY. (D) Adjustments to rates. A hospital’s inpatient per diem rate may be adjusted only under the following circumstances: 1. When information contained in the cost report is found to be intentionally misrepresented, such adjustment shall be made retroactive to the date of the original rate. Such adjustment shall not preclude the division from imposing any sanctions authorized by any statute or regulation; and 2. When a rate reconsideration is granted in accordance with subsection (4)(E). (E) Rate reconsideration. 1. Rate reconsideration may be requested under this subsection for changes in allowable costs which occur subsequent to the base year cost report described in subsection (4)(B). The effective date for any increase granted under this subsection shall be no earlier than the first day of the month following the division’s final determination of the rate reconsideration. 2. The following may be subject to review under procedures established by the division: A. New or expanded inpatient services. A hospital, at times, may offer to the public new or expanded inpatient services which may require certificate of need (CON) approval. (I) 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. (II) Non-state 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 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. (III) A hospital (state or non-state) 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 review. Upon completion of the review, the hospital’s inpatient reimbursement rate 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. (IV) Rate reconsiderations 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 SNF and swing bed cost) to total hospital cost as submitted on the most recent cost report filed with the division or its authorized contractor as of the review date divided by total acute care patient days including all special care units and nursery, but excluding swing bed days. The most recent cost report filed must be audited prior to the finalization of the rate reconsideration. (V) Total acute care patient days (excluding 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 sixtyfive (365) days. If the total acute care patient days (excluding nursery and swing bed days) are less than sixty percent (60%) of total possible bed days, the sixty percent (60%) number plus nursery days will be used to determine the rate increase. If the total acute care patient days (excluding nursery and swing bed days) are at least sixty percent (60%) of total possible bed days, the total acute care patient days plus nursery days will be used to determine the rate increase. This computation will apply to capital costs only. (VI) 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; and B. When the hospital experiences extraordinary circumstances which may include but are not limited to an act of God, war, or civil disturbance. 3. The following will not be subject to review under these procedures: A. The use of Medicare standards and reimbursement principles; B. The method for determining the trend factor; C. The use of all-inclusive prospective reimbursement rates; and 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 Medicaid program. 4. The request for a rate reconsideration must be submitted in writing to the division and must specifically and clearly identify the project and the total dollar amount involved. The total dollar amount must be supported by generally accepted accounting principles. The hospital shall demonstrate the rate reconsideration is necessary, proper, and consistent with efficient and economical delivery of covered patient care services. The hospital will be notified of the division’s decision in writing 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. (5) Inpatient Per Diem Reimbursement Rate Computation for New Hospitals. Effective for admit dates beginning July 1, 2025, for new Missouri hospitals that continue to be reimbursed under the per diem reimbursement methodology, each new Missouri hospital’s rate setting cost report shall be the first full fiscal year cost report, which includes inpatient Medicaid costs, otherwise the hospital shall continue to receive the weighted average statewide per diem rate as determined below. (A) Free-standing psychiatric hospitals. In the absence of adequate cost data, a new hospital’s Medicaid rate shall be one hundred percent (100%) of the maximum per diem rate for a free-standing psychiatric hospital, excluding the state psychiatric hospitals, until a prospective rate is determined on the hospital’s rate setting cost report, in accordance with section (4). (B) Long-term acute care hospitals. In the absence of ade quate cost data, a new hospital’s Medicaid rate shall be one hundred percent (100%) of the weighted average statewide per diem rate for long-term acute care hospitals until a prospective rate is determined on the hospital’s rate setting cost report, in accordance with section (4). (C) Rehabilitation hospitals. In the absence of adequate cost data, a new hospital’s Medicaid rate shall be one hundred per cent (100%) of the weighted average statewide per diem rate for rehabilitation hospitals until a prospective rate is determined on the hospital’s rate setting cost report, in accordance with section (4). (6) Inpatient Diagnosis Related Group (DRG) Reimbursement Methodology. Effective for discharge dates beginning July 1, 2025, Missouri hospitals shall be reimbursed under the DRG reimbursement methodology using components from the base year cost report and claims data period. Those components are from the following data sources: (A) Historical claims data: FFS claims and MC encounter data from MMIS for SFY 2024. 1. Future updates will utilize FFS claims and MC encounter data from MMIS for the second full prior calendar year (i.e., for SFY 2027, calendar year 2024 paid claims will be utilized); (B) Cost report data: The fourth prior year cost reports. 1. Future updates will utilize the third prior year audited cost reports available as of January 31 prior to the beginning of the SFY; (C) Labor portion and wage index: Federal fiscal year (FFY) 2025 inpatient prospective payment system (IPPS) wage data. 1. Future updates will be obtained from the final rule or any subsequent correction notice that is available as of January 31 prior to the beginning of the SFY; (D) Hospitals reimbursed under DRG— 1. All hospitals except for those listed in subsection (4)(A); (E) DRG grouper type. 1. The DRG grouper utilized to classify cases into DRG categories will be the Solventum All-Patient Refined (APR) DRG. 2. The version utilized is 42, released on October 1, 2024; (F) Statewide base rates development. 1. Statewide base rates. A. The base year claims data (FFS claims and MC encounters) is repriced under the current reimbursement methodology. This base year repricing establishes the intended budget for the DRG system. The in-state hospital data and out-of-state hospital data is separated and, utilizing the DRG formula, a base rate is iterated for each set of claims data; (G) Hospital base rate components. 1. Statewide base rate. A. Two (2) base rates are established for reimbursement in the DRG system. One (1) for in-state hospitals and one (1) for out-of-state hospitals. 2. Wage index. A. For Medicare IPPS hospitals, the wage index is based on the Medicare IPPS post-reclass effective as of the October prior to the beginning of the SFY. B. For non-Medicare IPPS hospitals, the wage index is based on the Medicare IPPS for the hospital’s Medicare Corebased Statistical Area (CBSA) effective as of the October prior to the beginning of the SFY. C. In-state federally deemed critical access hospitals (CAH) will have their wage index set to 1.000, regardless of their assigned CBSA. 3. Hospital DRG rate add-ons. A. Free-standing in-state children’s hospitals will receive a two thousand five hundred dollar ($2,500) rate add-on to their base rate. B. In-state federally deemed CAHs will receive a one thousand five hundred dollar ($1,500) rate add-on to their base rate. C. Indirect Medical Education (IME) Factor. (I) In-state hospitals with approved medical education programs identified in the Medicare cost report will have an IME add-on to their base rate. The IME formula is calculated from the base year cost report as follows: (a) Full-time employee (FTE) counts: Worksheet S-3, Lines 14, 16, and 17, Column 9. I. Updated FTEs can be submitted to the division if a hospital meets the criteria in 13 CSR 70-15.015(9)(D); (b) Sum of hospital beds: Worksheet S-3, Lines 14, 16, and 17, Column 2; and (c) Formula: Round (1.35 * ((1 + (FTE counts / hospital beds)).405 – 1),4) * 50%. 4. Hospital specific base rates. A. Each hospital will have a specific base rate calculated based on the following formula: (I) Adjust the statewide base rate by the wage index. (a) Wage adjusted rate = (statewide base rate * labor portion * wage index) + (statewide base rate * (1 – labor portion)); (II) Add IME (if applicable) to the wage adjusted rate. (a) IME and wage adjusted rate = wage adjusted rate * IME factor; and (III) Add children’s or CAH add-on (if applicable). (a) Hospital specific rate = IME and wage adjusted rate + children’s or CAH add-on; (H) Hospital cost-to-charge ratios (CCR). 1. Utilizing the base year cost reports, hospital specific CCRs are established. A. Costs: Worksheet D-1, Line 49, Title XIX (if there is not Title XIX, then Title XVIII is utilized). B. Charges: Worksheet D-3, Lines 30–35, and 202, Column 2, Title XIX (if there is no Title XIX, then Title XVIII is utilized); (I) Transfer payments. 1. Transfers shall be identified as claims with a discharge status of 02, 05, and 66 and not having an assigned DRG of 580 or 581. 2. The reimbursement to hospitals for inpatient services provided to claims identified as transfers shall be the lesser of A. or B. below: A. The DRG amount. (I) Formula: Hospital Specific Base Rate * DRG relative weight; and B. The amount in subparagraph (6)(I)2.A. divided by the assigned DRGs average length of stay (ALOS) multiplied by the claims length of stay (LOS) plus one (1). (I) Formula: (DRG payment / DRG ALOS) * (LOS + 1); (J) Outlier payments. 1. Cost outlier payments are an additional payment made at the time a claim is processed for exceptionally costly services. A. A cost outlier threshold shall be established for each DRG at the time the DRG relative weights are calculated, using the same information used to establish the relative weights. The cost threshold is the greater of thirty thousand dollars ($30,000) or mean cost for the DRG plus 1.96 standard deviation. B. Charges for non-covered services and services not reimbursed under the inpatient DRG methodology shall be deducted from the total billed charges. The remaining billed charges are converted to cost using the hospital specific CCR. C. If the net cost for the claim exceeds the cost outlier threshold, a cost outlier payment is made at eighty percent (80%) of the costs above the threshold. D. DRGs excluded from cost outliers. (I) Mental Health and Substance Abuse DRGs. (a) DRGs 750-1 through 776-4. 2. Day outlier payments are an additional payment made at the time a claim is processed for exceptionally long lengths of stay in the Mental Health and Substance Abuse DRGs (DRGs 750-1 through 776-4). A. A day outlier threshold shall be established for each DRG at the time the DRG relative weights are calculated, using the same information used to establish the relative weights. The day threshold is the ALOS of the DRG. B. A day outlier per diem payment may be made for covered days in excess of the day outlier threshold at the rate of five hundred dollars ($500) per day; (K) Policy adjustors. Claims for inpatient stays that meet certain criteria will qualify for further adjustments to the pay ments. 1. Pediatric. A. Adjustment factor: 1.70. B. Qualifying criteria: The DRG’s assigned service cate gory is Pediatric. 2. General Medicine. A. Adjustment factor: 1.31. B. Qualifying criteria: The DRG’s assigned service cate gory is General Medicine. 3. Mental Health and Substance Abuse. A. Adjustment factor: 1.92. B. Qualifying criteria: The DRG’s assigned service cate gory is Mental Health and Substance Abuse. 4. Obstetrics. A. Adjustment factor: 1.27. B. Qualifying criteria: The DRG’s assigned service cate gory is Obstetrics; (L) Example DRG claim calculation. (M) New hospitals shall be assigned the following DRG payment components: 1. Statewide base rate based upon their in-state or out-ofstate status; 2. Wage index based upon the CBSA in which the hospital resides; 3. Hospital specific CCR based upon their most recently filed cost report. A. In the absence of a cost report, the following CCR will be utilized: (I) In-state: The average CCR of all in-state hospitals reimbursed by DRG until a cost report has been filed with the division; and (II) Out-of-state: The average urban CCR in the state the hospital resides, as found in the Medicare prospective payment system (PPS) annual release documents; 4. Base rate add-ons. A. For new in-state hospitals only, base rate add-ons will be considered based upon the designation of the hospital. (I) New free-standing in-state children’s hospitals will be eligible for the children’s base rate add-on. (II) New in-state federally deemed CAHs will be eligible for the CAH base rate add-on. (7) Hospital Mergers. Hospitals that merge their operations under one (1) Medicare and Medicaid provider number shall have their Medicaid reimbursement combined under the surviving hospital’s (the hospital’s whose Medicare and Medicaid provider number remained active) Medicaid provider number. (A) The per diem rate for merged hospitals shall be calcu lated— 1. For the remainder of the SFY in which the merger occurred, the merged rate is calculated by multiplying each hospital’s estimated Medicaid paid days by its per diem rate, summing the estimated per diem payments and estimated Medicaid 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; or 2. For subsequent SFYs, the per diem rate will be based on the combined data from the base year cost report for each facility. (8) Payment Assurance. 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. (9) Inappropriate Placements. (A) The hospital inpatient reimbursement as determined under this plan shall not apply to any participant who is receiving inpatient hospital care when the participant is only in need of nursing home care. 1. If a hospital has an established intermediate 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. 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. AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2025.* 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. 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 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. Emergency amendment filed June 20, 2017, effective July 1, 2017, expired Feb. 22, 2018. Amended: Filed June 20, 2017, effective Jan. 30, 2018. Emergency amendment filed June 21, 2018, effective July 1, 2018, expired Feb. 28, 2019. Amended: Filed June 21, 2018, effective Jan. 30, 2019. Amended: Filed April 30, 2020, effective Nov. 30, 2020. Emergency amendment filed June 14, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 14, 2022, effective Jan. 30, 2023. Amended: Filed Oct. 23, 2023, effective May 30, 2024. Emergency amendment filed July 26, 2024, effective Aug. 9, 2024, expired Feb. 27, 2025. Amended: Filed Oct. 23, 2024, effective May 30, 2025. Emergency amendment filed June 23, 2025, effective July 8, 2025, expired Feb. 26, 2026. Amended: Filed Feb. 19, 2026, effective Aug. 30, 2026. *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, 2016, 2018, 2021, 2023, 2024, 2025; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.