About The MO HealthNet Division

Administration

The Department of Social Services is officially designated as the single state agency charged with administration of the Missouri Medicaid program. The Missouri Division of Medical Services (DMS) was established within the Department of Social Services on February 27,1985 by the Governor’s executive order. With the passage of Senate Bill 577, The Missouri Health Improvement Act of 2007, effective September 1, 2007 the division’s name changed to the MO HealthNet Division (MHD). The Family Support Division within the Department of Social Services determines participant eligibility for the MO HealthNet programs.

A director, appointed by the director of the Department of Social Services, administers the MO HealthNet Division. The division receives professional and technical consultation from a medical care advisory committee and designated subcommittees representing the major disciplines participating in the program.

Buy-In

As a cost saving measure, a Buy-In provision was added in 1968 whereby the Supplementary Medical Insurance premium (Title XVIII B of the Social Security Act) is paid for participants of Old Age Assistance, Permanently and Totally Disabled, Aid to the Blind, Temporary Assistance for Needy Families, Specified Low Income Medicare Beneficiary and Qualified Medicare Beneficiary who meet the criteria for Medicare coverage. Buy-In permits the State to shift the largest portion of these participants’ medical expenses to the Medicare Program with the State’s responsibility being reduced to the Medicare Part A and B deductible and coinsurance amounts. The payment of the Medicare Part A and B deductible and coinsurance charge is referred to as a crossover claim.

Claims Payment and Encounter Data

Claims for medical services performed by fee-for-service providers and encounter data submitted by MO HealthNet Managed Care health plans are processed by a fiscal agent. The fiscal agent is selected through a competitive bid process. Under the direction of MHD, the fiscal agent operates a computerized claims processing system using claims and reference subsystems, claims data, provider and client eligibility data and an extensive system of edits and audits.

Fee-for-service claims are adjudicated by the fiscal agent to a "pay" or "deny" status and the provider is notified by a remittance advice. The provider is issued a check by the State of Missouri. Providers may select direct deposit of their checks.

Encounter data is submitted electronically by the MO HealthNet Managed Care health plans in the same layouts used for fee-for-service claims. The MO HealthNet Managed Care health plan is responsible for payment of covered benefits for MO HealthNet Managed Care members. The encounter data provides the state with a record of those services that have been provided.

Covered Services

MO HealthNet covered services fall into two categories -- mandatory and optional. Mandatory services are required by the federal government for all states wishing to have a Medicaid program. Optional services may be provided at the state’s discretion.

The benefit matrix shows the various benefits for each of the MO HealthNet programs and if they also have cost sharing or any co-pays.

Exceptions

The MO HealthNet Division may provide coverage through the exceptions process for services not covered by MO HealthNet by authorization of 13 Code of State Regulations 70-2.100. A provider may request coverage for an item or service under certain conditions of unusual or compelling need. The item or service which exceeds the normal MO HealthNet benefits must be needed to sustain the participant’s life, improve the quality of life for the terminally ill, replace an item due to an act of nature or be needed to prevent a higher level of care. No exception can be made for items or services that are restricted by State or Federal law or regulation.

Exception services for individuals under 21 years which are identified as a result of an HCY screening and are determined to be medically necessary are covered under the HCY program.

Healthy Children And Youth Program

The Early Periodic Screening, Diagnosis and Treatment (EPSDT) program was renamed the Healthy, Children and Youth (HCY) Program in Missouri. The HCY program provides services for eligible children and youth, age 0-20 years. The changes were the result of federal legislation contained in the Omnibus Reconciliation Act of 1989 (OBRA 89).

Diagnosis and treatment services had previously been available to MO HealthNet eligible children under an EPSDT Program, however treatment services were limited to those covered under MO HealthNet’s “medicaid state plan”.

The expansion of the EPSDT program under HCY provides that all medically necessary services identified as a result of an HCY screen that are above the scope of the "medicaid state plan" must be covered by the state. As a result, services in some existing programs have been enhanced and several new provider groups have been added.

HCY programs:

Additional benefits have been added for children in the following programs:

The HCY program provides all MO HealthNet eligible children with appropriate full health screens and subsequent treatment for identified health problems. Components of a full health screen are: interval history; physical examinations, anticipatory guidance, laboratory tests, immunizations, lead screening, development/personal social/language, fine/gross motor, hearing, vision, and dental. A full screen may be provided by a MO HealthNet enrolled physician, a nurse practitioner or nurse midwife when it is within their scope of practice. Partial and inter-periodic screenings are available from a wide range of health care professionals.

MO HealthNet Managed Care (formerly MC+ Managed Care)

Effective September 1, 1995, the state of Missouri introduced a new health care delivery program called MC+ Managed Care to serve certain participants that meet specified eligibility criteria. The goal is to improve the accessibility and quality of health care services for Missouri’s MO HealthNet and state aid eligible populations, while reducing the costs of providing that care. The state intends to achieve this goal by enrolling eligible participants in MO HealthNet Managed Care health plans that contract with the state to provide a specified scope of benefits to each enrolled participant in return for a capitated payment made on a per member, per month basis.

The program was designed through a collaborative process that included feedback from the provider, consumer and health plan communities, state of Missouri government agencies and the Centers for Medicare and Medicaid Services (CMS) formerly known as Health Care Financing Administration (HCFA).

The MO HealthNet Managed Care health plan is required to provide most of the basic benefits as identified by the state plan for adults and all medically necessary services for children under the age of 21. Other services previously not covered under MO HealthNet may be provided to participants if the health plan determines it is a suitable, appropriate and cost effective approach to providing a covered service.

MO HealthNet Managed Care has been implemented as follows:

Managed Care Region Implementation Date Counties Included

The Eastern Region was implemented September 1, 1995 and included the following counties: Franklin, Jefferson, St. Charles, St. Louis, and St. Louis City. On December 1, 2000, five new counties were added to the region: Lincoln, St Francois, Ste. Genevieve, Warren, and Washington. On January 1, 2008, the following three counties were added to the MO HealthNet Eastern Managed Care region: Madison, Perry and Pike.

The Central Region was implemented March 1, 1996 and included the following counties: Chariton, Randolph, Monroe, Saline, Howard, Boone, Audrain, Pettis, Cooper, Moniteau, Cole, Callaway, Montgomery, Morgan, Camden, Miller, Osage and Gasconade. On January 1, 2008, the following ten counties were added to the MO HealthNet Central Managed Care region: Benton, Laclede, Linn, Macon, Maries, Marion, Phelps, Pulaski, Ralls, and Shelby.

The Western Region was implemented January 1, 1997 and included the following counties: Jackson, Platte, Clay, Ray, Lafayette, Johnson and Cass. In February 1999, the service area was expanded to include Henry and St. Clair counties. On January 1, 2008, the following four counties were added to the MO HealthNet Western Managed Care region: Bates, Cedar, Polk and Vernon.

The Northwestern Region was implemented January 1, 1997 and included the following counties: Andrew, Atchison, Buchanan, Caldwell, Carroll, Clinton, Davies, DeKalb, Gentry, Grundy, Harrison, Holt, Livingston, Mercer, Nodaway, and Worth. All participants returned to fee for service by December 1998.

The participants who are eligible for inclusion in MO HealthNet Managed Care health plans are divided into three groups:

Children in the care and custody of Children’s Division receive all mental health services on a fee-for-services basis when provided by a MO HealthNet enrolled mental health provider. Physical, occupational and speech therapy services that are provided for children as identified in an Individual Education Plan or Individual Family Support Plan are provided on a fee-for-service basis when provided by a MO HealthNet enrolled provider.

MO HealthNet Eligibles

In Missouri there are many federal and state funded programs available to individuals who meet basic categorical eligibility criteria. For further information on MO HealthNet programs in Missouri, see "Puzzled by the Terminology?" . MO HealthNet refers to the statewide medical assistance programs for elderly and disabled individuals, low-income families, pregnant women and children. MO HealthNet individuals receive their care through either the FFS delivery system or the Managed Care delivery system, depending on where the individual lives in the state. MO HealthNet benefits are available to those persons who are determined eligible for the following types of assistance.

State Only Funded Categories of Assistance

Medicaid Waivers

Congress enacted Section 2176 of Public Law 97-35 of the Social Security Act, entitled the Omnibus Budget Reconciliation Act. Through this enactment in 1981, certain statutory limitations have been waived in order to give states, who have received approval from the Department of Health and Human Services, the opportunity for innovation in providing home and community based services to eligible persons who would otherwise require institutionalization in a nursing facility, hospital or intermediate care facility for the mentally retarded (ICF/MR). Currently, Missouri has approval to provide services under the following waivers:

For further information, read Missouri 1915c Home & Community Based Services Waivers.

Nursing Home - Supplemental Nursing Care Program

Under the Supplemental Nursing Care Program (also known as cash grant), individuals meeting eligibility requirements as determined by the Family Support Division (FSD) and residing in a Residential Care Facility (RCF), licensed but not Title XIX (MO HealthNet) certified, may receive a cash payment. The maximum cash payment by FSD is established by Missouri statute. All assistance payments to persons in this cash grant program are entirely from state funds. Being eligible to receive a cash payment also allows the participant to be eligible for MO HealthNet services.

Nursing Home -Title XIX

Nursing Home Reform, also known as Omnibus Budget Reconciliation Act of 1987, established a Pre-Admission Screening and Resident Review (PASARR) process that is designed to address the specific needs of the mentally retarded, developmentally disabled, and mentally ill who either reside in a nursing home or are requesting admittance to a nursing home. The goal of the screening process is to insure appropriate placement of individuals in a setting in which their specialized needs can be met.

Pharmacy and Clinical Services Program

The MO HealthNet Pharmacy and Clinical Services Program oversees outpatient prescription drug reimbursement for fee-for-service eligibles. Effective January 1, 1991, the Omnibus Budget Reconciliation Act of 1990 (OBRA-90) pharmacy provisions significantly expanded the coverage to include reimbursements for all drug product of manufacturers who have entered into a rebate agreement with the Federal Department of Health and Human Services (HHS) and that are dispensed by qualified providers. States have the authority for certain exceptions and to exclude from coverage certain specified categories of drugs. In addition, OBRA-90 included provisions requiring both a prospective and retrospective drug use review program.

Prior Authorization/Clinical and Fiscal Editing — Covered outpatient drugs may be subject to Point-of-Sale clinical, fiscal, or prior authorization editing. Clinical edits are designed to enhance patient care and optimize the use of program funds through therapeutically prudent use of pharmaceuticals. Point-of-sale (POS) pharmacy claims are routed through an automated computer system to apply edits specifically designed to ensure effective and appropriate drug utilization. In most cases, these edits will be transparent to providers and participants. The goal of these edits is to encourage cost effective therapy within the selected drug class.

MO HealthNet’s improved POS computer system allows each claim to be referenced against the participant’s pharmacy claims history, medical claims history (including ICD-9 codes), and procedural data (CPT codes) transparently. For those patients that meet any of the approval criteria, the claim will be paid automatically. In the rare instances when a phone call is necessary, our responsive hotline call center is available seven day a week, which allows providers prompt access to a paid claim for the requested product. In addition to receiving messages regarding the outcome of the claims processing and the reimbursement amount, pharmacy providers receive prospective drug use review alert messages for their information at the time the prescriptions are dispensed.

Plastic Card

MO HealthNet provides all participants with a plastic identification card with a magnetic strip for swipe devices. As a result, providers have access to the most up-to-date benefit information. Providers may access eligibility information via a point-of-service terminal that generates a detailed printout of all eligibility information, or they can call the Interactive Voice Response (IVR) Unit’s telephone number at 573/635-8908. Providers can also access eligibility information at the MO HealthNet billing Web site.

Poverty Level Needs And Income Standards

One of the factors of eligibility in Missouri is the comparison of income to a need standard. Income must be below the need standard in order to qualify for assistance. The Family Support Division Web site has the current Federal Poverty Guidelines.

Pregnant women and children may qualify for MO HealthNet only (no cash payment) under comparisons of income to the higher percentages of federal poverty level based on the child’s age. Pregnant women and infants under age one may qualify under the poverty program if they have income of less than 185% of the federal poverty level. Children ages 1-5 are eligible at 133% of the poverty level. Children age 6-18 are eligible at 100% of the poverty level.

Uninsured children in families with income above Medicaid poverty standards may qualify for MO HealthNet for Kids (SCHIP) if their family’s gross income is below 300% of the federal poverty level.

Elderly, blind and disabled individuals — The non-spend down income limit is 85% of the federal poverty level. Persons above the non-spend down income limit must incur medical expenses (spend down) equal to the amount their income exceeds the limit before they are eligible.

MO HealthNet for Families (MAF) provides healthcare coverage for families with income that does not exceed the July 16, 1996 Aid to Families with Dependent Children (AFDC) income standards.

Program Expenditures

The MO HealthNet program is jointly funded by state and federal dollars. To see how MO HealthNet dollars are spent, see "Where do the MO HealthNet dollars go?" .

Provider Participation

Approved, enrolled MO HealthNet Program providers of service provide services. Those who participate in the MO HealthNet Program agree to accept MO HealthNet payment as reimbursement in full for any services provided to MO HealthNet participants. A participant cannot be billed for the difference between the MO HealthNet payment and the provider’s billed charges. MO HealthNet Managed Care services are provided in accordance with the terms and conditions of the contract between MHD and the MO HealthNet Managed Care health plans. Participants enrolled in MO HealthNet Managed Care access services through the health plan’s provider network. The health plan network may include providers not enrolled in the fee-for-service program.

Participant Eligibility

An individual may apply for medical assistance at the county Family Support Division (FSD) office in which (s)he resides, or in some cases at outreach sites. Applications for MO HealthNet Managed Care may be made by phone by calling (888) 275-5908 or by mailing a completed MO HealthNet Managed Care application to a MO HealthNet Managed Care Service Center. If the individual is determined eligible, the individual or family receives an approval letter from the FSD county office that is valid until they are issued a MO HealthNet identification card with the next regular payroll. Participants eligible for MO HealthNet Managed Care must enroll in a health plan. The MO HealthNet Managed Care participant must present the MO HealthNet card and the MO HealthNet Managed Care health plan card each time a medical service is rendered.

Third Party Liability (TPL)

Third party liability (TPL) refers to the legal obligation of other third party resources (TPRs) to pay the medical claims of MO HealthNet participants prior to MO HealthNet coverage. A few common TPRs are Medicare, health insurance, workers’ compensation, automobile medical insurance, homeowner’s insurance, malpractice, product liability, medical support orders, and probate. The function of Third Party Liability within the MO HealthNet program is to ensure these resources are utilized as a primary source of payment in lieu of taxpayer dollars.

TPL Information is obtained by the FSD eligibility specialist primarily during the MO HealthNet eligibility determination process. Supplementing this initial contact are data matches with both private and public entities, edits within the claims processing system, direct inquiries to participants, non-custodial parents and other potential liable parties, and a contingency fee contract for identification and recovery of funds the state is unable to pursue.

Cost savings originate from two methods. They are (1) cost avoidance and (2) benefit recovery.

  1. Cost avoidance occurs when claims are either denied in order for the provider to pursue recovery from the TPR or when the MO HealthNet payment is cutback by the amount the TPR paid for the service. This method of cost savings is the most cost effective and must be utilized whenever possible. There are certain claims that are not eligible for cost avoidance due to federal regulation or when it is not cost effective to perform this method. This procedure is known as the Bypass Provision.
  2. Benefit recovery occurs after MO HealthNet issues payment to the provider for a covered service. The Cost Recovery Unit pursues direct reimbursement of the MO HealthNet payment from the liable TPR. The most common reason to utilize benefit recovery arises when the TPR is not identified until after MO HealthNet has issued payment for the covered service.