Bill Summary: This legislation provides protections for senior citizens, disabled persons, and children and transfers the Division of Aging to the Department of Health and Senior Services.

ESTIMATED NET EFFECT ON GENERAL REVENUE FUND
FUND AFFECTED	FY 2009	FY 2010	FY 2011
General Revenue	(Unknown but Greater than $850,548)	(Unknown but Greater than $863,640)	(Unknown but Greater than $881,936)
Total Estimated Net Effect on General Revenue Fund	(Unknown but Greater than $850,548)	(Unknown but Greater than $863,640)	(Unknown but Greater than $881,936)

ESTIMATED NET EFFECT ON OTHER STATE FUNDS
FUND AFFECTED	FY 2009	FY 2010	FY 2011
State School Moneys Fund*	$0	$0	$0
Criminal Records Fund	$3,234,000	$501,600	$501,600
Total Estimated Net Effect on Other State Funds	$3,234,000	$501,600	$501,600

* Unknown savings and losses would net to $0. Numbers within parentheses: ( ) indicate costs or losses. This fiscal note contains 16 pages.

ESTIMATED NET EFFECT ON FEDERAL FUNDS
FUND AFFECTED	FY 2009	FY 2010	FY 2011


Total Estimated Net Effect on All Federal Funds	$0	$0	$0

ESTIMATED NET EFFECT ON FULL TIME EQUIVALENT (FTE)
FUND AFFECTED	FY 2009	FY 2010	FY 2011
General Revenue	Unknown but Greater than 8.71 FTE	Unknown but Greater than 8.71 FTE	Unknown but Greater than 8.71 FTE
Federal	Unknown but Greater than 3.29 FTE	Unknown but Greater than 3.29 FTE	Unknown but Greater than 3.29 FTE
Total Estimated Net Effect on FTE	Unknown but Greater than 12 FTE	Unknown but Greater than 12 FTE	Unknown but Greater than 12 FTE

☐ Estimated Total Net Effect on All funds expected to exceed $100,000 savings or (cost).

☒ Estimated Net Effect on General Revenue Fund expected to exceed $100,000 (cost).

ESTIMATED NET EFFECT ON LOCAL FUNDS
FUND AFFECTED	FY 2009	FY 2010	FY 2011
Local Government	Unknown	$0	$0

Officials from the Department of Public Safety, Office of Administration, Office of the State Courts Administrator, Office of Prosecution Services and the Department of Labor and Industrial Relations each assume the proposal would have no fiscal impact on their respective agencies.

Officials from the Office of the Attorney General assume any potential costs arising from this proposal can be absorbed with existing resources.

Officials from the Office of the Secretary of State (SOS) state many bills considered by the General Assembly include provisions allowing or requiring agencies to submit rules and regulations to implement the act. The SOS is provided with core funding to handle a certain amount of normal activity resulting from each year’s legislative session. The fiscal impact for this fiscal note to the SOS for Administrative Rules is less than $2,500. The SOS recognizes that this is a small amount and does not expect that additional funding would be required to meet these costs. However, the SOS also recognizes that many such bills may be passed by the General Assembly in a given year and that collectively the costs may be in excess of what the office can sustain with the core budget. Therefore, the SOS reserves the right to request funding for the cost of supporting administrative rules requirements should the need arise based on a review of the finally approved bills signed by the governor.

Oversight assumes the SOS could absorb the costs of printing and distributing regulations related to this proposal. If multiple bills pass which require the printing and distribution of regulations at substantial costs, the SOS could request funding through the appropriation process. Any decisions to raise fees to defray costs would likely be made in subsequent fiscal years.

Officials from the Department of Mental Health (DMH) state the DMH and its service providers are currently required to perform background checks of prospective employees, including sex offenders. There should be no fiscal impact resulting from this proposal.

Officials from the Office of the State Public Defender (SPD) state for purposes of the proposal, the SPD cannot assume existing staff will provide competent, effective representation for any new cases arising where indigent persons are charged with the proposed new crimes

While the number of new cases may be too few or uncertain to request additional funding for this specific proposal, the SPD will continue to request sufficient appropriations to provide competent and effective representation in all of the SPD cases.

Oversight assumes the SPD could absorb the additional caseload that may result from this proposal within existing resources. Oversight assumes any significant increase in the workload of the SPD would be reflected in future budget request.

Officials from the Department of Health and Senior Services assume the changes in section 192.2178 will require hospitals, long-term care facilities, and adult day care providers to obtain background screening information that includes a check of the Department of Mental Health Employee Disqualification Registry.

Long-term care, adult day care, and hospitals are not required to use the Family Care Safety Registry for background screenings and tend not to do so. DHSS believes the vast majority of the repeat background screenings required by Section 192.2178 will be requested through the Department of Public Safety. DHSS does not anticipate the bill having a fiscal impact on the Division of Regulation and Licensure.

The assumption is made that any increase in revenue to the DPS, Missouri State Highway Patrol will be reflected in the Department of Public Safety's fiscal note response.

Officials from the Department of Corrections (DOC) state the proposal includes penalty provision up through a class B felony. The fiscal impact for DOC per year is unknown, less than $100,000.

Officials from the Department of Elementary and Secondary Education (DESE) assume there is no state cost to the foundation formula associated with this proposal. Should the new crimes and amendments to current law result in additional fines or penalties, DESE cannot know how much additional money might be collected by local governments or the DOR to distribute to schools. To the extent fine revenues exceed 2004-2005 collections, any increase in this money distributed to schools increases the deduction in the foundation formula the following year. Therefore the affected districts will see an equal decrease in the amount of funding received through the formula the following year; unless the affected districts are hold-harmless, in which case the districts will not see a decrease in the amount of funding received through the formula

(any increase in fine money distributed to the hold-harmless districts will simply be additional money). An increase in the deduction (all other factors remaining constant) reduces the cost to the state of funding the formula.

According to the Department of Health and Senior Services, the estimated number of persons that are currently employed and will be subject to this new legislation is approximately 228,000. Approximately 100,000 of these 228,000 employees have had background checks performed pursuant to other statutory requirements and will not be part of the initial check process stipulated in this proposed legislation (228,000 - 100,000 = 128,000).

Additionally, it is assumed there will be a 10% turnover rate for these healthcare workers; therefore, 22,800 additional background checks will be needed annually. Each background check costs $20.00 for the state fingerprint check and an additional $19.25 for the nationwide federal check. Of which, the state pays the FBI $17.25.

128,000 healthcare workers x $39.25 (state/federal background check) $ 5,024,000

128,000 healthcare workers x $17.25 (federal background check charge) $ 2,208,000

Officials from the Department of Social Services - Children’s Division (DSS-CD) assume the proposal will require additional staff to work a minimum of three hours to locate a placement with a grandparent.

In Fiscal Year 2006, the CD had 6,130 children enter into care. This proposal would require at least three (3) additional hours per placement to attempt to locate a grandparent.

This calculates to: 6,130 children X 3 hours = 18,390 additional staff hours. 18,390 ÷ 2,080 (number of full-time annual hours) = 8.84 or 9 additional Children Service workers. Additionally, 1 Children's Services Supervisor (7 Children Service Workers to 1 Supervisor ratio) and 2 Senior Office Support Staff (6 Professional Staff to 1 Office Support staff ratio) would be required. This is a total of 12 additional staff.

If a grandparent were unable to be located within those three (3) hours, the fiscal impact would be much greater. Therefore, the CD is submitting a cost of unknown greater than $620,498 for FY 2009.

Oversight notes that states can earn the federal medical assistance percentage (FMAP) on Medicaid program expenditures. The FMAP used in the DSS-CD response is a 73/27 split between General Revenue Funds and Federal Funds.

Officials from the Department of Social Services (DSS) assume the proposal requires services that can be defined as medically necessary as well as services that are not medically necessary. The MO HealthNet Division (MHD) already reimburses for services that are medically necessary and some services with other specific criteria but does not reimburse for non-medically necessary services.

MHD already provides home visits for medically fragile infants, low birth weight infants, infants diagnosed with failure to thrive and mothers with substance abuse diagnoses. Current programs are the Maternity and Post Discharge Home Visit program; the Healthy Children and Youth program; and the Children's Services Home Health program. In addition, the Department of Mental Health (DMH) provides substance abuse treatment through the Comprehensive Substance Treatment and Rehabilitation (CSTAR) program which is reimbursed by MHD. With the exception of the Maternity and Post-Discharge and CSTAR programs Home Health services must be medically necessary.

The Maternity and Post Discharge Home Visit program allows a minimum of two visits, at least one of which shall be in the home in accordance with maternal and neonatal physical assessments by a registered nurse. This program is available for mothers whose hospital stay was less than 48 hours for a vaginal delivery or less than 96 hours for a cesarean section delivery.

The Healthy Children and Youth (HCY) Program offers Home Health services through the 1989 OBRA mandate expanding Medicaid services for children based on solely documented medical need.

The Children's Services Home Health program provides services for low birth weight babies and babies diagnosed with failure to thrive. These services are solely for medical need and are not reimbursable for social or emotional issues that may affect the participant's medical condition. Services include up to twelve visits over eight weeks without regard to homebound status and possible additional services based on certain criteria.

In addition, CSTAR services are available through the DMH and reimbursed by the MHD. CSTAR provides a specialized substance abuse treatment program for women and their children with services offered with or without residential support in accordance with eligibility criteria. Priority is given to women who are pregnant, postpartum or have children in their care or custody.

Since these services are already available to MO HealthNet participants who meet either the medically necessary criteria or other specific criteria it is assumed there will be no additional fiscal impact unless there is increased utilization of these services. If there is an increase in utilization then an unknown cost is assumed.

Services that are non-medically necessary are not covered under current programs. Therefore, there will be a fiscal impact for those services. At-risk infants or their mothers for whom services may not be available would have to receive services through a referral to another agency or program or under a waiver program through MO HealthNet.

For the sake of perspective if only one percent of the infants eligible for MO HealthNet born in 2006 met the at-risk descriptions in the proposal aside from the medically fragile definitions there would be about 380 infants eligible annually for these non-medically necessary services. This minimum estimate is based on the number of infants born in Missouri who were MO HealthNet eligible in 2006 (37,965 X 1% = 380). It is assumed that this would be the fewest number of children who would participate.

It is assumed that these infants would receive five skilled nurse visits every twelve months for the two years they are in the program. This estimate is based on historical data published by existing programs in the private sector. It is further assumed that these 380 infants would remain in the program for two years and then exit the program. It is also assumed that in each successive year of the program a new group of 380 infants would enter the program. Therefore, in the first year of the program there would be a minimum of 380 infants and in subsequent years there would be a minimum of 760 (380 X 2 = 760) infants participating. Skilled nurse home visits are currently reimbursed at a rate of $63.27 per visit (15 minutes to 3 hours).

The FY09 cost includes five skilled nurse visits for 380 infants for the first twelve months of their participation in the program for a total cost in the first year of $100,067. Since this is the fewest number of infants expected in the program and the utilization is not definitely known the cost will be unknown greater than $100,067.

The FY10 cost includes five skilled nurse visits for the 380 infants from the previous year (their second twelve months of participation) as well as all first year costs for the new group of 380 infants. The cost would be unknown greater than $250,967.

The FY11 cost includes five skilled nurse visits for the 380 infants from the previous year (their second twelve months of participation) as well as all first year costs for the new group of 380 infants. The cost would be unknown greater than $262,261.

It is assumed that the DSS will apply for a Section 1115 demonstration waiver to implement the portion of this program that requires non-medically necessary services and that DSS will receive a federal match for those services.

Total costs: FY09 (10 months) unknown greater than $100,067 ($36,835 GR); FY10 cost is unknown greater than $250,967 ($92,381 GR); and FY11 total cost is unknown greater than $262,261 ($96,539 GR). A 4.5% inflation factor was applied to FY10 and FY11 costs.

Oversight notes that states can earn the federal medical assistance percentage (FMAP) on Medicaid program expenditures. The Social Security Act requires the Secretary of Health and Human Services to calculate and publish the actual FMAP each year. The FMAP is calculated using economic indicators from state and the nation as a whole. Missouri’s FMAP for FY09 is a 63.19% federal match. The state matching requirement is 36.81%. Oversight assumes there will be no federal funds available for the non-medically necessary services in FY09 because of the time it will take DOS to apply for and get approval for a Section 1115 demonstration waiver.

Hospitals, long-term care facilities and adult day cares will be required to obtain updated background screenings in order to be in compliance with provisions of Section 192.2178.

The proposed legislation changes the laws regarding protections for vulnerable adults and children. Adds reducing the incidents of financial exploitation of the elderly to the public education and awareness program administered by the Department of Health and Senior Services

This legislation transfers the Division of Aging from the Department of Social Services to the Department of Health and Senior Services (Section 192.2000).

This legislation transfers the powers, duties, and functions of the Board of Nursing Home Administrators to the Department of Health and Senior Services from the Department of Social Services (Section 192.2000.9).

This legislation revises the definition of "protective services" to mean a service provided by the state or other governmental or private organizations or individuals which are necessary for the eligible adult to meet his or her essential human needs (Section 192.2003).

This legislation grants immunity from civil and criminal liability for any person making a report of abuse or neglect to the Department of Health and Senior Services unless the person acts negligently, recklessly, in bad faith, or with malicious purpose (Sections 192.2103.5 and 192.2150.11).

This legislation defines "consumer," "in-home services," "misappropriation," "personal care attendant," "principal," "patient," "provider," and "resident" relating to abuse and neglect of the elderly, the disabled, and children (Section 192.2150).

This legislation requires any health service provider, health service vendor employee, personal care attendant, or any person having reasonable cause to believe that a patient or consumer has been a victim of misappropriation of a patient's money or property or has falsified documents verifying delivery of health care services must report the information to the Department of Health

and Senior Services within 24 hours of discovering the act (Sections 192.2150.2 and 192.2150.3).

This legislation requires the Department of Health and Senior Services, upon receipt of an imminent danger report, to initiate a thorough investigation promptly, but removes the 24-hour time requirement. If an investigation indicates a crime has occurred, the appropriate law enforcement agency and the prosecutor must be notified. The Department must notify the resident's legal representative of the report and investigation status when it involves a resident who has been appointed a guardian and/or conservator or who is incapacitated and resides at a

state-licensed facility. The Department may also notify the resident's family members or guardians (Section 192.2150.6 and 192.2150.7).

This legislation requires the Department of Health and Senior Services to keep confidential the names of individuals submitting abuse and misappropriation reports unless the complainant agrees to the disclosure of his or her name; it is necessary to prevent further abuse and neglect, misappropriation of funds, or document falsification; the name of the complainant is lawfully

subpoenaed; the release of a name is required by the Administrative Hearing Commission; or the release of a name is requested by the Department of Social Services for the purpose of

This legislation requires the Department of Health and Senior Services to add persons who have falsified documents verifying service delivery to consumers or have misappropriated property or moneys belonging to consumers to the employee disqualification list (Section 192.2150.12).

This legislation protects a patient and the patient's family members or an employee from eviction, harassment, or retaliation due to the filing of a report of a violation or suspected violation of the

This legislation requires potential patients and consumers whose services are funded by the MO HealthNet Program to be checked against the sexual offender registry and requires the Department of Health and Senior Services to notify providers at the time of referral if a patient or consumer is on the registry (Section192.2150.15).

This legislation specifies that any person failing to file a required report within the time guidelines and any person or provider who misuses or diverts the consumer's use of any personal property or money or falsifies service delivery documents will be guilty of a class A misdemeanor. Any provider or employee who knowingly conceals abuse or neglect that results in the death or serious injury of a patient will be guilty of a class D felony (Sections 192.2153.1 -

This legislation authorizes the Department of Health and Senior Services to assess a $1,000 fine on any provider who willfully and knowingly fails to report known abuse by an employee (Section 192.2153.4).

This legislation specifies that any person or entity who unlawfully discloses information from the employee disqualification list will be guilty of an infraction; and upon request from the Division of Employment Security within the Department of Labor and Industrial Relations, the Department of Social Services must provide copies of employee investigation reports of those on the list. Those persons on the list cannot be paid from public moneys for personal care assistant services (Sections192.2153.11 - 192.2153.13).

This legislation requires health care providers or employment agencies to inquire to the Department of Health and Senior Services if a full or part-time applicant for employment which involves consumer contact is on the employee disqualification list prior to hiring the applicant (Section 192.2178.3).

This legislation prohibits, as of August 28, 2008, a provider from hiring any person with a disqualifying history unless the person has submitted an approved good cause waiver. Providers cannot continue to employ people who were employed prior to August 28, 2008, with disqualifying backgrounds after March 1, 2009, unless the person submits an approved good cause waiver prior to January 1, 2009. An employer who knowingly hires a person who is a

registered sexual offender on or after August 28, 2008, will be guilty of a class A misdemeanor (Sections 192.2178.7 and 192.2178.8).

This legislation specifies that a consumer-directed service consumer or hospice will be guilty of a class A misdemeanor if it does not request a background screening check from the family care safety registry prior to allowing the employee to have contact with an in-home patient (Section 192.2178.9).

This legislation prohibits any state or federal funding for personal care assistance services if the attendant is on the employee disqualification list; is a registered sexual offender; or has a

disqualifying criminal history, unless a good cause waiver is obtained (Section 208.909.4).

This legislation defines "related personal care" as care provided for a person with a physical or medical disability by an adult relative as it relates to the Family Care Safety Act (Section 210.900.2).

This legislation requires any person responsible for the care of a person 60 years of age or older who has cause to suspect that the person has been abused, neglected, or financially exploited by a person, firm, or corporation to make a report to the Department of Health and Senior Services (Section 565.188.1).

This legislation adds home nursing visits and follow-up care as needed until an infant's second birthday for certain at-risk newborns to the list of covered services under the MO HealthNet Program. The MO HealthNet Division within the Department of Social Services is required to request the appropriate waivers or state plan amendments from the federal Department of Health and Human Services to provide these services. (Section 208.152)

This legislation is not federally mandated, would not duplicate any other program and would not require additional capital improvements or rental space.

FISCAL IMPACT - State Government	FY 2009 (10 Mo.)	FY 2010	FY 2011

GENERAL REVENUE FUND

Savings - Department of Elementary and Secondary Education
Reduced appropriations to State School Moneys Fund	$0	Unknown	Unknown

Costs - Department of Corrections
Incarceration/Probation Costs	(Less than $100,000)	(Less than $100,000)	(Less than $100,000)

Costs - Department of Mental Health
Program Costs - Amendment #6	(Unknown but Greater than $100,000)	(Unknown but Greater than $100,000)	(Unknown but Greater than $100,000)

Costs - Department of Health and Senior Services
Program Costs - Amendment #6	(Unknown but Greater than $100,000)	(Unknown but Greater than $100,000)	(Unknown but Greater than $100,000)

Costs - Department of Social Services
Personal Service - Emergency Placement	(Unknown but Greater than $226,255)	(Unknown but Greater than $279,763)	(Unknown but Greater than $288,156)
Fringe Benefits - Emergency Placement	(Unknown but Greater than $100,050)	(Unknown but Greater than $123,711)	(Unknown but Greater than $127,423)
Equipment and Expense - Emergency Placement	(Unknown but Greater than $124,176)	(Unknown but Greater than $67,785)	(Unknown but Greater than $69,818)




FISCAL IMPACT - State Government (continued)	FY 2009 (10 Mo.)	FY 2010	FY 2011

Costs - Department of Social Services (continued)
Program Costs - Home Nursing Visits	(Unknown but Greater than $100,067)	(Unknown but Greater than $92,381)	(Unknown but Greater than $96,539)
Total Costs - DSS	(Unknown but Greater than $550,548)	(Unknown but Greater than $563,640)	(Unknown but Greater than $581,936)
FTE Change - DSS	Unknown but Greater than 8.71 FTE	Unknown but Greater than 8.71 FTE	Unknown but Greater than 8.71 FTE

ESTIMATED NET EFFECT ON GENERAL REVENUE FUND	(Unknown but Greater than $850,548)	(Unknown but Greater than $863,640)	(Unknown but Greater than $881,936)




STATE SCHOOL MONEYS FUND

Savings - Department of Elementary and Secondary Education
Reduced distributions to local school districts	$0	Unknown	Unknown

Losses - Department of Elementary and Secondary Education
Reduced appropriations from General Revenue Fund	$0	(Unknown)	(Unknown)

ESTIMATED NET EFFECT ON STATE SCHOOL MONEYS FUND	$0	$0	$0




FISCAL IMPACT - State Government (continued)	FY 2009 (10 Mo.)	FY 2010	FY 2011

CRIMINAL RECORDS FUND

Income - Department of Public Safety/Missouri State Highway Patrol
Revenue from Background Checks	$5,769,750	$894,900	$894,900

Costs - Department of Public Safety/Missouri State Highway Patrol
Background Checks Costs	($2,535,750)	($393,300)	($393,300)

ESTIMATED NET EFFECT ON CRIMINAL RECORDS FUND	$3,234,000	$501,600	$501,600





FEDERAL FUNDS

Income - Department of Social Services
Federal Assistance	Unknown but Greater than $170,016	Unknown but Greater than $336,445	Unknown but Greater than $348,916

Costs - Department of Social Services
Personal Service - Emergency Placement	(Unknown but Greater than $85,391)	(Unknown but Greater than $105,586)	(Unknown but Greater than $108,753)
Fringe Benefits - Emergency Placement	(Unknown but Greater than $37,760)	(Unknown but Greater than $46,690)	(Unknown but Greater than $48,091)
Equipment and Expense - Emergency Placement	(Unknown but Greater than $46,865)	(Unknown but Greater than $25,583)	(Unknown but Greater than $26,350)




FISCAL IMPACT - State Government (continued)	FY 2009 (10 Mo.)	FY 2010	FY 2011

Costs - Department of Social Services (continued)
Program Costs - Home Nursing Visits	$0	(Unknown but Greater than $158,586)	(Unknown but Greater than $165,722)
Total Costs - DSS	(Unknown but Greater than $170,016)	(Unknown but Greater than $336,445)	(Unknown but Greater than $348,916)
FTE Change - DSS	Unknown but Greater than 3.29 FTE	Unknown but Greater than 3.29 FTE	Unknown but Greater than 3.29 FTE

ESTIMATED NET EFFECT ON FEDERAL FUNDS	$0	$0	$0

Estimated Net FTE Change for Federal Funds	Unknown but Greater than 3.29 FTE	Unknown but Greater than 3.29 FTE	Unknown but Greater than 3.29 FTE

FISCAL IMPACT - Local Government	FY 2009 (10 Mo.)	FY 2010	FY 2011

POLITICAL SUBDIVISIONS

Revenues - School Districts
Income from fines	Unknown	Unknown	Unknown

Losses - School Districts
Reduced distributions from State School Moneys Fund	$0	(Unknown)	(Unknown)

ESTIMATED NET EFFECT ON POLITICAL SUBDIVISIONS	Unknown	$0	$0