Fee-For-Service Participants FAQs

How can I find out if I have MO HealthNet coverage?

You need to be approved for MO HealthNet before you can receive services. If you do not currently have health care through MO HealthNet, you will need to see if you qualify and apply for services.

Once your application has been processed, you will receive a letter from the Family Support Division. If you are eligible, you will receive a MO HealthNet Identification Card and information explaining the medical services available to you.

If you have questions about your coverage or if you would like to check the status of your application, contact the Family Support Division at 1-855-373-4636 or check your benefits online. You can also contact the MO HealthNet Participant Services Unit at 1-800-392-2161.

I am receiving Medicare. Can I also receive MO HealthNet? How do they work together?

Yes, you can receive both Medicare and MO HealthNet. Medicare is handled at the federal level and MO HealthNet is handled at the state level.

If you receive both, Medicare is primary. This means Medicare will be billed first. MO HealthNet will be billed last and will pay the coinsurance and deductible amounts on Medicare covered services. There is no duplication of payment for services.

If you have chosen a Health Maintenance Organization (HMO) for your Medicare coverage, there will be no coinsurance or deductible payments assigned; however, you will be responsible for a copayment for services provided. MO HealthNet will not assume responsibility for copayment amounts for Medicare HMO/MO HealthNet participants unless you are enrolled in the Qualified Medicare Beneficiary Program. Providers may bill you for this charge.

I am receiving Medicare and I need assistance with my premiums, what should I do?

You will need to apply for the Qualified Medicare Beneficiary (QMB) program through Family Support Division. If approved Medicaid will start paying for your Part A and/or Part B premiums.

I am receiving Medicare and the state was paying for my Medicare premiums but it has stopped, what should I do?

You would need to contact Family Support Division to verify that you still have eligibility. Or you can call the Medicare Buy-In unit at 573-751-9312 for assistance.

Can I have a private insurance plan with my MO HealthNet?

You may have private insurance as long as being uninsured is not a condition of your eligibility for MO HealthNet. You must report a private insurance plan to the Family Support Division by calling 1-855373-4636. You can also report your private insurance plan information to the MO HealthNet Participant Services Unit at 1-800-392-2161.

If you call 1-800-392-2161 from a touch tone phone you can choose option 2, enter your eight digit MO HealthNet number and then hear the private insurance plan listed.

MO HealthNet may be able to help pay your private insurance plan premiums and copays through the Health Insurance Premium Payment (HIPP) Program. For more information about the HIPP Program, contact the Third Party Liability Unit at 573-751-2005.

What does MO HealthNet pay for?

MO HealthNet does not cover everything, and there are many types of eligibility within MO HealthNet. The Participant Handbook explains the services you can get. To find out what you are eligible for, you can call the MO HealthNet Participant Services Unit at 1-800-392-2161.

Some eligibility types have more benefits than others. Some services are not covered for all participants, such as:

  • Dental
  • Optical
  • Audiology (hearing aids)
  • Some durable medical equipment
  • Rehabilitation services
  • Comprehensive day rehabilitation
  • Diabetes self-management training
  • Foot care
  • Medical transportation
  • Coaching and services to help you quit smoking
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 health care provider and call the MO HealthNet Participant Services Unit at 1-800-392-2161. They can tell you if the procedure is covered and if there are any special rules about that procedure.

How can I tell if a specific prescription drug is covered?

If you want to find out if a prescription drug is covered, you should get the National Drug Code from your doctor or pharmacist and contact the Participant Services Unit at 1-800-392-2161.

Has prescription drug coverage changed?

Although your basic prescription drug benefits have not changed, the MO HealthNet program has had to take steps to deal with the increasing cost of medication. Just as other insurance companies have done, MO HealthNet is now using a Preferred Drug List. The Preferred Drug List makes many prescription drugs available to you without taking any extra steps. Some medications may require your doctor or pharmacist to make a special request.

Because of these changes, you may at times find that your pharmacy will need to ask your doctor to allow a different medication to be filled. This will only happen when there is another prescription drug available that is equally safe and effective, but less expensive.

Your doctor and pharmacy will also receive information about the MO HealthNet Preferred Drug List. They will be able to check online or call a toll-free help desk if they have questions about a prescription drug. In some cases, special exceptions to the Preferred Drug List may be allowed for certain conditions, if requested by your doctor and approved.

If you are denied a prescription drug your doctor has requested, you should check with your doctor or pharmacist to find out why.

How can I find a doctor that takes MO HealthNet?

If you need help finding a Primary Care Provider (doctor) who accepts MO HealthNet, you can search for one online by name or by county, or you can call us at 1-800-392-2161 for help.

Not all health care providers who are enrolled are taking new patients. You must contact the provider and ask if they are taking new MO HealthNet patients.

Do I need a referral to see a specialist?

You should check with the health care provider you want to see. The MO HealthNet Fee-For-Service Program does not require a referral, but your health care provider may require one. Your provider should know if your procedure has special rules, such as a prior authorization or special forms. Your health care provider is responsible to make sure the rules are followed.


 


What should I do if I receive a bill or if there is a charge on my credit report?

You should first ask the provider to bill MO HealthNet. It is up to you to be sure the provider knows you have MO HealthNet. If they billed MO HealthNet and still billed you, send the bill or a copy of the bill to:
Participant Services Unit:
PO Box 3535
Jefferson City, MO 65102

Include a note with the patient name and MO HealthNet number when you mail the bill. The bill will be reviewed and it will be decided whether you must pay the bill or not.

I don't think my claim should be denied. What can I do?

When a request for services is denied, reduced, or terminated, you have the right to a state fair hearing. If you do not receive a letter giving you 90 days to request a hearing, you should contact the MO HealthNet Participant Services Unit at 1-800-392-2161 and ask them to review the denial.

If the decision is made that the denial is correct, you will be given 90 days to request a state fair hearing. At the hearing, you will have to explain why the decision should be changed. You do not need an attorney, but you can get an attorney or anyone you want to help you at the hearing.

Can I get help with non-emergency medical transportation?

Assistance for Non-Emergency Medical Transportation (NEMT) is available if:

  • You do not have another way to reach your appointment
  • You are eligible for MO HealthNet Fee-for-Service on the date the transportation is provided (unless you are enrolled in certain limited benefit plans)
  • You have a scheduled appointment with a MO HealthNet enrolled provider for a MO HealthNet covered service

You should call the Non-Emergency Medical Transportation number at 1-866-269-5927 at least five calendar days before your appointment to arrange transportation to your appointment. Help is available through this number Monday through Friday from 8 a.m. to 5 p.m. for regular scheduled appointments. You may call this number 24 hours a day, seven days a week for urgent appointments or hospital discharges.

Can I use my MO HealthNet if I travel out of state?

Services outside the United States, District of Columbia, and the following territories are not covered:

  • Northern Mariana Islands
  • American Samoa
  • Guam
  • Puerto Rico
  • The Virgin Islands.

Emergency: Emergency services are covered as long as the health care provider treating you out of state agrees to enroll with MO HealthNet and accept the amount. Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in any of the following:

  • Placing the patient’s health in serious jeopardy
  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part

Non-Emergency: Non-Emergency out of state is defined as “not within the physical boundaries of Missouri or any of the states that border Missouri.” If you would like to see and out-of-state health care provider for non-emergency MO HealthNet covered services, it must be approved before you receive the services. To get approval for out of state services, your health care provider must fax a written request to 573-526-2471 or submit a request by mail to:

MO HealthNet Division
Participant Services Unit
Attn: Supervisor
PO Box 6500
Jefferson City, MO 65102

The written request must include a brief past medical history, services attempted in Missouri, where the services are being requested, who will provide them, and why the service cannot be done in Missouri. The out of state provider must also agree to enroll with MO HealthNet and accept the MO HealthNet amount.

What should I do if I lose my MO HealthNet card?

If you lose your MO HealthNet ID card, call the Family Support Division Information Center at 1-855373-4636. Help is available from 7:30 a.m. to 5:30 p.m., Monday through Friday.

How do I report a Change?

It is very important to report any changes in your circumstances as they may affect your eligibility. It is also important to report any changes to your contact information to be sure you get important notices about your eligibility and services.

If you have a change in circumstances or your address or phone number changes, you can report the change online or you can call the Family Support Division Information Center at 1-855-373-4636. Help is available through the Family Support Division Information Center from 7:30 a.m. to 5:30 p.m., Monday through Friday.