Frequently Asked Questions About MO HealthNet Coverage
If you are approved for MO HealthNet coverage, you will either be assigned to a Managed Care health plan or you will receive Fee for Service coverage. You may be eligible for MO HealthNet coverage if you are a(n):
Fee-For-Service
- Senior (age 65 and older)
- Person with a disability
- Blind or visually impaired adult
- Woman (under age 65) with breast or cervical cancer
Managed Care
- Pregnant woman including her newborn
- Child (birth to age 18)
- Parent with children in the home
- Adult (age 19-64) without a disability
- How can I find a doctor who takes MO HealthNet?
If you need help finding a doctor who accepts MO HealthNet, you can search online by provider type, health plan, specialty, provider name, and/or location. You may also call (800) 392-2161 for assistance.
Not all healthcare providers who are enrolled with MO HealthNet may be taking new patients. You must contact the provider and ask if they are taking MO HealthNet patients.
- Do I need a referral to see a specialist?
You should check with your Primary Care Provider or your MO HealthNet Managed Care health plan to see if you need a referral to see a specialist.
The MO HealthNet Fee For Service Program (Straight Medicaid) does not require a referral, but your healthcare provider may require one. Your provider should know if your procedure has special rules, such as prior authorization or special forms. Your healthcare provider is responsible for making sure the rules are followed.
If you are enrolled with a Managed Care health plan, visit Contact Your Health Plan for contact information for each health plan.
- How can I tell if a specific procedure is covered?
To find out if a specific procedure is covered, you should get the five-digit procedure code from your healthcare provider and call the MO HealthNet Participant Services Unit at (800) 392-2161. They can determine if you are eligible for the procedure based on your coverage category and if there are any special rules about that procedure.
Services may be limited based on your eligibility group or age, and some services may require prior approval. It is important to work with your healthcare provider to find out if a service you need is covered. For more information about the services available, review the applicable handbook:
- How can I tell if a specific prescription drug is covered?
The best way to determine if your prescription is covered is to have the pharmacy submit the claim to MO HealthNet. If MO HealthNet denies the claim, your pharmacy should call your doctor to get the prescription changed, or the pharmacy can call MO HealthNet for prior authorization. If your pharmacy is unable to assist you, contact Pharmacy Administration at (573) 751-6963.
- How do I know if my prescription drug is covered by MO HealthNet?
The MO HealthNet Fee For Service Program has a Preferred Drug List (PDL). Most drugs on the PDL can be filled without taking any extra steps. Some prescriptions require your provider or pharmacist to make a special request before they are filled. Exceptions to the PDL may be allowed for certain conditions. Your provider must ask for a special approval.
Your pharmacy may need to ask your provider to allow a different medication to be filled. This will happen when there is another drug that is equally safe and effective, but also less expensive.
If you are denied a drug your doctor has requested, check with your provider or pharmacist to find out why.
- How do I report a change that may affect my healthcare coverage?
You must report the following changes to the Family Support Division (FSD) immediately:
- Name, address, phone number changes
- Start or stop private or group insurance
- New household members, including a baby
- Household member left
- Income
- Pregnancy
- Vehicles
- Resources
- Shelter expenses
- Dependent care expenses
- Child Support expenses
To report these changes, complete the Report A Change form online, call the Family Support Division at (855) 373-4636, or visit your local office. Help is available through the FSD Information Center from 7:30 a.m. to 5:30 p.m., Monday through Friday.
- What happens if my situation changes and I am no longer eligible for a Managed Care Plan?
Your coverage may be changed from a Managed Care plan to MO HealthNet Fee-For-Service for the following reasons:
- You are no longer in a group that receives services through MO HealthNet Managed Care (pregnant, child age birth to 18, family or an adult age 19 to 64 without a disability)
- You are approved for Medicare coverage
- You enter the AIDS Waiver Program
Call the MO HealthNet Managed Care Enrollment Helpline at (800) 348-6627 or the Family Support Information Center at (855) 373-4636 for more information or if you have questions regarding your health care options.
- I am receiving Medicare and I need assistance with my premiums and/or deductibles, what should I do?
Contact the Family Support Division at (855) 373-4636 or visit your local office to determine if you are still eligible for Medicare. You can also contact the Medicare Buy-In unit at (573) 751-9312 for assistance.
You may qualify for the Medicare Savings Program under Qualified Medicare Beneficiary (QMB) which may reimburse you for your premiums and out of pocket expenses. To be eligible, you must be:
- A US citizen (or qualified non-citizen) and Missouri resident
- Have Medicare Part A
- Meet certain income and resource requirements
QMB helps you pay for:
- Medicare Part A and Part B premiums
- Medicare deductibles
- Coinsurance for Medicare covered services
If approved for QMB, you should always show your provider your QMB card. For more information, visit Programs for Seniors & Individuals with Disabilities. Call the Family Support Division at (855) 373-4636 or visit your local office to see if you are eligible.
- What should I do if I receive a bill or if there is a charge on my credit report that I don’t think I owe?
You should first ask the provider to bill MO HealthNet. It is your responsibility to ensure the provider knows you have MO HealthNet coverage. If they billed MO HealthNet and still billed you, send the bill or a copy of the bill to the Participant Services Unit, PO Box 3535, Jefferson City, MO 65102. Include in writing the patient name and MO HealthNet number.
The bill will be reviewed. It will be decided whether it is your duty to pay the bill or not. If you were enrolled in an MO HealthNet managed care health plan on the date of service, you should contact the plan at the telephone number on the back of your managed care health insurance card for assistance.
- Can I change my MO HealthNet managed care health plan?
You may change MO HealthNet managed care health plans for any reason during the first 90 days after you become a MO HealthNet managed care health plan member. Call the MO HealthNet Managed Care Enrollment Helpline at 1-800-348-6627.
You may be able to change MO HealthNet managed care health plans after 90 days. Some reasons for changing include:
- You have moved out of the MO HealthNet managed care area
- Your primary care provider is no longer with your MO HealthNet managed care health plan and is in another MO HealthNet managed care health plan
- Your specialist or other health care provider from whom you are currently getting services is no longer with your plan and is in another MO HealthNet Managed Care health plan
You will have a 30-day open enrollment period once a year. Members may change MO HealthNet managed care health plans during their annual open enrollment period. You may contact the MO HealthNet Managed Care Enrollment Helpline at (800) 348-6627.
- How can I find out when my MO HealthNet managed care health plan’s open enrollment period is?
You should receive a letter in the mail with open enrollment dates. You may also call the MO HealthNet Managed Care Enrollment Helpline at (800) 348-6627 or the MO HealthNet Participant Services Unit at (800) 392-2161 or (573) 751-6527.
- How can I change my MO HealthNet managed care health plan primary care provider?
You have a right to change the primary care provider in your MO HealthNet managed care health plan. You can change at least two times each year. Some MO HealthNet managed care health plans may allow more. To change your primary care provider or to find out more about your MO HealthNet managed care health plan, call the membership services number on your managed care health insurance card.
- How do I get help with transportation to a medical appointment?
The Non-Emergency Medical Transportation (NEMT) Program arranges transportation for you so you can get to your medical appointments. Transportation is not provided for some services, and you may be asked to get a note from your provider if they are over a certain number of miles away from your home. Services are available 24 hours per day, 7 days a week. NEMT is not for emergencies. If you have an emergency, call 911 or your local emergency phone number.
To schedule a ride, you must be covered by MO HealthNet on the day you get the service. To see if you are eligible, call (866) 269-5927 any time, any day. Trips that are not urgent can be scheduled Monday thru Friday, 8:00 am to 5:00 pm. You should schedule your ride at least two days before your appointment for rides in Clay, Jackson, Jefferson, St. Charles, St. Louis counties or St. Louis City. If you are in any other county, you should schedule your ride at least three days before your appointment, unless you need to go to urgent care or you are being discharged from the hospital.
For more information, refer to Need a Ride?
For more information, review the NEMT section of the Fee for Service Participant Handbook or visit mtm-inc.net/missouri.
- Can I use my MO HealthNet if I travel out of state?
If you get medical care in a state that borders Missouri (Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma, and Tennessee), the service will be covered by MO HealthNet as long as the following requirements are met:
- You have MO HealthNet coverage on the date of service
- The service you receive is a MO HealthNet covered service
- The provider is enrolled with MO HealthNet
To get out-of-state non-emergency medical services in a state that does not border Missouri, a written request must be submitted by a doctor and faxed to (573) 526-2471 or mailed to the Constituent Services Unit, PO Box 6500, Jefferson City MO 65102.
Approval for out-of-state services expires 180 days from the date the service was approved by MO HealthNet.
- My provider said a claim for a service I received was denied. What should I do?
Managed Care plan members should contact the member services number on the back of your MO HealthNet Managed Care health plan ID card to file an appeal. You may also ask for a state fair hearing within 120 days from the date of your Notice of Appeal resolution letter from the Managed Care health plan. For more information, refer to the MO HealthNet Guide to Managed Care.
Fee-For-Service participants should call Participant Services at (800) 392-2161 or email Ask.MHD@dss.mo.gov. For more information, refer to Your Guide to the MO HealthNet Fee-For-Service Program.