Missouri

Missouri

Missouri requires CONs within five broad categories—hospital beds, beds outside hospitals, equipment, facilities and services. Missouri maintains 91 CON requirements which are primarily focused on nursing facilities, long-term care facilities and hospitals, and the construction of new hospitals. For example, a private physician’s office can purchase an MRI scanner without obtaining a CON, but a skilled nursing facility or a long-term care hospital must obtain a CON before purchasing the same MRI scanner. Missouri further maintains many specific expenditure minimums, although they are not always standardized. If an intermediate care facility wants to acquire a CT scanner, the CON requirement is not triggered unless the scanner will cost more than $400,000. In comparison, if a long-term hospital wants to purchase the same CT scanner, it must apply for a CON regardless of cost.

COVID-19 Response

As of May 15, 2020, Missouri had not suspended any CON requirements in response to COVID-19.

Application Process

In Missouri, the CON application review process takes up to four months. Mo. Rev. Stat. § 197.330(1)(1), (4)–(5). Applications for full review must be submitted at least 71 days prior to each Missouri Health Facilities Review Committee meeting, and expedited applications must be submitted by the 10th day of each month. Mo. Code Regs. tit. 19, § 60-50.420(1). Expedited applications only apply to limited circumstances, such as renovation of long-term care facilities or replacement of specific types of equipment. See Mo. Code Regs. tit. 19, § 60-50.300(5). The fee for a CON application is $1,000 or 0.1% of the total cost of the proposed project. Mo. Rev. Stat. § 197.315(10). Competitors can intervene in the application process and offer evidence or argument as to why an application should be denied. Mo. Stat. § 197.330(1), (3)–(5).

CON? Number of CONs Moratoria Temporary COVID-19 response:
Hospital Beds Yes 5 – No action
Beds Outside Hospitals Yes 16 – No action
Equipment Yes 40 – No action
Facilities/ Buildings Yes 25 – No action
Services Yes 5 – No action
Emergency Medical Transport No – – –

Note: these citations are accurate as of May 2020.

A private physician’s office can purchase an MRI scanner without obtaining a CON, but a skilled nursing facility or a long-term care hospital must obtain a CON before purchasing the same MRI scanner.

Missouri CONs in Detail

Category

Types of CONs

Citation

Hospital Beds

1.Acquisition of beds in a long-term care hospital, at any cost.

Mo. Code Regs. tit. 19,

§ 60-50.400(6)(F)(4)

2.A reallocation by an existing long-term care hospital of licensed beds among major types of services by more than 10 beds or more than 10% of the total licensed bed capacity, whichever is less, over a 2-year period.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(g), 197.366(3)

3.A reallocation by an existing long-term care hospital of licensed beds from one physical facility or site to another by more than 10 beds or more than 10% of the total licensed bed capacity, whichever is less, over a 2-year period.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(g), 197.366(3)

4.Expansion of long-term care beds in a hospital that costs $600,000 or more.

Mo. Rev. Stat. 197.366(2);

Mo. Code Regs. tit. 19,

§ 60-50.400(6)(F)(7)

5.Expansion of long-term care beds in a hospital that exceeds 10 beds or 10% of that facility’s existing licensed capacity, whichever is less.

Mo. Rev. Stat. 197.366(2);

Mo. Code Regs. tit. 19,

§ 60-50.400(6)(F)(7)

Beds Outside Hospitals

Any change in a nursing home’s licensed bed capacity which increases the total number of beds by more than 10 or more than 10% of the total bed capacity, whichever is less, over a 2-year period, which includes:

1.Residential care facilities.

2.Assisted living facilities.

3.Intermediate care facilities.

4.Skilled nursing facilities.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(e), 198.015(1)

Category

Types of CONs

Citation

Beds Outside Hospitals

A reallocation by an existing nursing home of licensed beds among major types of services by more than 10 beds or more than 10% of the total licensed bed capacity, whichever is less, over a 2-year period, which includes:

5.Residential care facilities.

6.Assisted living facilities.

7.Intermediate care facilities.

8.Skilled nursing facilities.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(g), 197.366(1), 198.015(1)

A reallocation by an existing nursing home of licensed beds from one physical facility or site to another by more than 10 beds or more than 10% of the total licensed bed capacity, whichever is less, over a 2-year period, which includes:

9.Residential care facilities.

10.Assisted living facilities.

11.Intermediate care facilities.

12.Skilled nursing facilities.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(g), 197.366(1), 198.015(1)

A project that involves additional beds in a nursing home that costs $600,000 or more, which includes:

13.Residential care facilities.

14.Assisted living facilities.

15.Intermediate care facilities.

16.Skilled nursing facilities.

Mo. Rev. Stat. § 198.015(1);

Mo. Code Regs. tit. 19,

§ 60-50.400(6)(F)(6)

Equipment

Acquisition by a residential care facility of major medical equipment costing more than $400,000, which includes following:

1.Cardiac catheterization.

2.Computed tomography.

3.Gamma knife.

4.Lithotropsy.

5.Magnetic resonance imaging.

6.Linear accelerator.

7.Positron emission tomography/computed tomography.

8.Evolving technology.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(a), (6)(a), 198.015(1);

Mo. Code Regs. tit. 19,

§§ 60-50.300(11), 60-50.400(6)(F)(3)

Acquisition by an assisted living facility of major medical equipment costing more than $400,000, which includes following:

9.Cardiac catheterization.

10.Computed tomography.

11.Gamma knife.

12.Lithotropsy.

13.Magnetic resonance imaging.

14.Linear accelerator.

15.Positron emission tomography/computed tomography.

16.Evolving technology.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(a), (6)(a), 198.015(1);

Mo. Code Regs. tit. 19,

§§ 60-50.300(11), 60-50.400(6)(F)(3)

Category

Types of CONs

Citation

Equipment

Acquisition by an intermediate care facility of major medical equipment costing more than $400,000, which includes the following:

17.Cardiac catheterization.

18.Computed tomography.

19.Gamma knife.

20.Lithotropsy.

21.Magnetic resonance imaging.

22.Linear accelerator.

23.Positron emission tomography/computed tomography.

24.Evolving technology.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(a), (6)(a), 198.015(1);

Mo. Code Regs. tit. 19,

§§ 60-50.300(11), 60-50.400(6)(F)(3)

Acquisition by a skilled nursing facility of major medical equipment costing more than $400,000, which includes the following:

25.Cardiac catheterization.

26.Computed tomography.

27.Gamma knife.

28.Lithotropsy.

29.Magnetic resonance imaging.

30.Linear accelerator.

31.Positron emission tomography/computed tomography.

32.Evolving technology.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(a), (6)(a), 198.015(1);

Mo. Code Regs. tit. 19,

§§ 60-50.300(11), 60-50.400(6)(F)(3)

Acquisition by a long-term care hospital of major medical equipment, at any cost, which includes the following:

33.Cardiac catheterization.

34.Computed tomography.

35.Gamma knife.

36.Lithotropsy.

37.Magnetic resonance imaging.

38.Linear accelerator.

39.Positron emission tomography/computed tomography.

40.Evolving technology.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(a), (6)(b); 198.015(1)

Mo. Code Regs. tit. 19,

§§ 60-50.300(11), 60-50.400(6)(F)(4)

Facilities/Buildings

1.Construction of a new hospital that costs more than $1 million.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(a), (6)(c), 197.366(4)

Development of a new nursing home that costs more than $1 million, which includes:

2.Residential care facilities.

3.Assisted living facilities

4.Intermediate care facilities.

5.Skilled nursing facilities.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(a), (6)(c), 197.366(1), 198.015(1)

Category

Types of CONs

Citation

Facilities/Buildings

6.Development of a new long-term care hospital.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(a), (6)(c), 197.366(3);

Mo. Code Regs. tit. 19,

§ 60-50.400(6)(F)(1)

Acquisition, including acquisition by lease, of any nursing home for more than $1 million, which includes:

7.Residential care facilities.

8.Assisted living facilities.

9.Intermediate care facilities.

10.Skilled nursing facilities.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(b),(6)(c), 197.366(1), 198.015(1)

11.Acquisition, including acquisition by lease, of any long-term care hospital for more than $1 million.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(b),(6)(c), 197.366(3)

Any capital expenditure by or on behalf of a nursing home that exceeds $600,000, which includes:

12.Residential care facilities.

13.Assisted living facilities.

14.Intermediate care facilities.

15.Skilled nursing facilities.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(c), (6)(a), 197.366(1), 198.015(1);

Mo. Code Regs. tit. 19,

§ 60-50.400(6)(F)(6)

16.Any capital expenditure by or on behalf of a long-term care hospital that exceeds $1 million.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(c), (6)(c), 197.366(3)

Predevelopment activities (expenditures for architectural designs, plans, working drawings and specifications and any arrangement or commitment made for financing) by or on behalf of a nursing home that exceed $150,000, which includes:

17.Residential care facilities.

18.Assisted living facilities.

19.Intermediate care facilities.

20.Skilled nursing facilities.

Mo. Rev. Stat. §§ 197.315(1), 197.305(9)(d), (12), 197.366(1), 198.015(1)

21.Predevelopment activities (expenditures for architectural designs, plans, working drawings and specifications and any arrangement or commitment made for financing) by or on behalf of a long-term care hospital that exceed $150,000.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(d),(12), 197.366(3)

Expansion of an existing nursing home that costs $600,000 or more, which includes:

22.Residential care facilities.

23.Assisted living facilities.

24.Intermediate care facilities.

25.Skilled nursing facilities.

Mo. Rev. Stat. 198.015(1);

Mo. Code Regs. tit. 19,

§ 60-50.400(6)(F)(7)

Category

Types of CONs

Citation

Services

Health services offered by a nursing home which were not offered on a regular basis in the nursing home within the previous year, which includes:

1.Residential care facilities.

2.Assisted living facilities.

3.Intermediate care facilities.

4.Skilled nursing facilities.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(f), 197.366(1), 198.015(1)

5.Health services offered by a long-term care hospital which were not offered on a regular basis in the long-term care hospital within the previous year.

Mo. Rev. Stat.

§§ 197.315(1), 197.305(9)(f), 197.366(3)

Emergency Medical Transport

No CONs in this category.

Missouri CON Exceptions

No CON Required For:

Citation

1.Home health services.

Mo. Rev. Stat.

§ 197.305(9)(f)

Nonsubstantive projects, which include:

2.An expenditure which is required solely to meet federal or state requirements or involves predevelopment costs or the development of a health maintenance organization.

3.The construction or modification of nonpatient care services, including parking facilities, sprinkler systems, heating or air-conditioning equipment, fire doors, food service equipment, building maintenance, administrative equipment, telephone systems, energy conservation measures, land acquisitions, medical office buildings and other projects of a similar nature.

4.Expenditure for construction, equipment, or both, due to an act of God or a normal consequence of maintenance, but not replacement, of health care facilities, beds or equipment.

Mo. Code Regs. tit. 19,

§§ 60-50.400(7),

60-50.300(13)

5.Expenditures for new institutional health services below the applicable expenditure minimum of $1 million.

Mo. Rev. Stat.

§§ 197.305(6),(9), 197.315(1)

6.Capital expenditures under the expenditure minimum.

7.Development of a new facility under the applicable expenditure minimum.

8.Acquisition of a facility under the applicable expenditure minimum.

9.Acquisition of major medical equipment under the applicable expenditure minimum.

Mo. Rev. Stat.

§ 197.305(6)

10.A nursing facility returning, after it has shifted from a skilled to an intermediate level of care, to the higher level of care.

Mo. Rev. Stat.

§ 197.315(12)

11.The transfer of ownership of an existing and operational health care facility in its entirety.

Mo. Rev. Stat.

§ 197.315(14)

12.The purchase and operation of research equipment to be used in a clinical trial (but a CON must be obtained for continued use in the facility after the clinical trial is completed).

Mo. Rev. Stat.

§ 197.315(18)(1)

13.The purchase and operation of equipment to be used by an academic health center operated by the state.

Mo. Rev. Stat.

§ 197.315(18)(2)

14.Operating nursing homes for the care and treatment of AIDS patients only.

Mo. Rev. Stat.

§ 197.316

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