Updates to Coverage of Continuous Glucose Monitors (CGMs)

Updates to Coverage of Continuous Glucose Monitors (CGMs):

Effective August 29, 2024, MO HealthNet will expand coverage of Continuous Glucose Monitors (CGMs) to participants currently diagnosed with Gestational Diabetes allowing this vulnerable population to obtain a CGM without a prior authorization.  Claims for a CGM will auto-approve if the participant has had a gestational diabetes diagnosis billed to MO HealthNet recently OR if the pharmacy submits the appropriate gestational diabetes diagnosis code with the claim.

PACE Benefit Table

Program of All-Inclusive Care for the Elderly (PACE) Benefit Table

The Program of All-Inclusive Care for the Elderly (PACE) is administered by MO HealthNet and Medicare to provide comprehensive health care, social, recreational, and wellness services to its participants. One of the main goals of PACE is to allow older adults to live safely in their homes instead of nursing facilities. As of May 3, 2024, PACE organizations are active in St. Louis and Kansas City, with a new PACE organization coming to the Springfield area later this year.

Nursing Home Room and Board

With the exception of certain hospice stays, nursing home room and board is covered under fee-for-service (FFS) regardless of whether the resident is in a Managed Care health plan. Participants who are enrolled in a Managed Care health plan, and who are seeking admission into a nursing home, will remain in a their Managed Care health plan until a nursing home level of care is determined, or for 60 calendar days, whichever comes first.

Durable Medical Equipment (DME) Program Policy Clarification for Custom and Power Wheelchairs Provided in a Skilled Nursing Facility

MO HealthNet has updated the Durable Medical Equipment (DME) Provider Manual to clarify policy related to the physician face-to-face evaluation when providing custom and power wheelchairs in a skilled nursing facility.  The policy clarification can be found in Section 13.18.C of the manual located here.

Nursing Facilities and Patient Surplus

Patient surplus or “patient liability” is the participant’s income less certain deductions; i.e., personal allowance, medical insurance and any allotments to a spouse and/or eligible dependents and is computed by an FSD caseworker. It is a federal requirement that the MO HealthNet payment to a nursing home be reduced by the patient surplus. MO HealthNet payment to a nursing home is not collected by the nursing facility the first month a participant is admitted if admission is after the first day of the month.

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