MO HealthNet Managed Care Overview
The Department of Social Services, MO HealthNet Division (MHD) (formerly known as the Division of Medical Services) operates a Health Maintenance Organization (HMO)-style managed care program called MO HealthNet Managed Care.
The State of Missouri contracts with MO HealthNet Managed Care health plans (also referred to as Managed Care Organizations (MCOs)) to provide health care services to enrollees. MO HealthNet Managed Care health plans are paid a monthly capitation payment for each enrollee they serve.
Participation in MO HealthNet Managed Care is mandatory for certain Managed Care Population within the regions in operation. MO HealthNet Managed Care members are automatically enrolled into a MO HealthNet Managed Care health plan.
Once enrolled, members have 90 days to choose a different MO HealthNet Managed Care health plan for any reason if they would like to. Once the 90-day change period ends, the member is locked into the MO HealthNet Managed Care health plan for one year unless they have “just cause” to ask for a change and it is approved. Examples of “just cause” include:
- The member’s Primary Care Provider is no longer in their MO HealthNet Managed Care health plan (but is with another plan)
- The member needs to transfer to another MO HealthNet Managed Care health plan to ensure continuity of care
- There has been an act of cultural insensitivity that negatively impacts the member’s ability to get care and cannot be resolved by the MO HealthNet Managed Care health plan
- A child is in the state’s custody (foster care) or receives adoption subsidy (these children can change health plans as often as necessary)
Additionally, each year members have an annual open enrollment period, and during that time they may choose to transfer to a different MO HealthNet Managed Care health plan for any reason.
Services are monitored for quality, member satisfaction, and contract compliance. Quality is monitored through various on-going methods, like:
- MCO Health Employer and Data Information Set (HEDIS) indicator reports
- Annual reviews
- Enrollee grievances and appeals
- Targeted record reviews
- Annual external quality reviews
Consumer input into services, processes, and programs is obtained through meetings of the MO HealthNet Member Forum and from annual member satisfaction surveys. Other ways satisfaction is measured includes the percentage of MO HealthNet Managed Care members who selected their own MCO; the low percentage of MO HealthNet Managed Care members who requested transfers; and the low percentage of MO HealthNet Managed Care members randomly assigned.
In addition to quality assessment and member satisfaction monitoring, MCO compliance with contractual requirements is a primary method of measuring attainment of managed care goals. Contractual compliance monitoring begins with the issuance of the Request for Proposal (RFP) and continues with the review of proposals submitted, assessment of MCO provider networks, and readiness reviews of MCOs' operations.
The state realizes that the keys to a successful managed care program include the provision of quality services, the satisfaction of members, and the involvement of stakeholders. To connect with stakeholders and encourage involvement, the state formed a MO HealthNet Member Forum to advise the Director of the MO HealthNet Division (MHD) on issues relating to member participation in the MO HealthNet Managed Care Program.
The committee meets periodically throughout the year and consists of a minimum of 15 members and advocates. As the state develops and refines educational materials, the MHD Member Forum is instrumental in making recommendations to enhance consumer education as well as any changes needed to improve either the care provided or the way care is delivered
In an effort to involve various stakeholders, especially those with special health care needs, the state has used the following forums:
- Quarterly meetings with provider groups, such as physicians, dentists, hospice providers, the Drug Utilization Review Board, the MO HealthNet All Plan Administrators, the MO HealthNet Medical Directors, the MHD Member Forum, and the QA&I Advisory Group and related subgroups
- Frequent interactions with the State’s Advocates for Family Health (ombudsmen services) regarding ways to help individuals access care easier and ways to coordinate care with other state agencies
- Publication of the RFP online
- Publication of provider bulletins online about MO HealthNet Managed Care issues
- Collaboration and regular meetings with Department of Health and Senior Services (DHSS), Department of Mental Health (DMH), and the Department of Elementary and Secondary Education (DESE), as well as with sister agencies within the Department of Social Services
After comments are gathered from these stakeholders, policy is developed or changed to incorporate suggestions that impact the MO HealthNet Managed Care Program. For instance, the QA&I Advisory Group recommended and the state implement guidance on intensity of care decisions regarding the hospital care of premature infants and guidance on approving speech therapies that are duplicated by those therapies specified in an Individual Education Plan (IEP). As another example, the state and DMH worked with the MCOs and the MO HealthNet Member Forum (previously known as the Consumer Advocacy Project) to develop protocols for how to coordinate mental health care provided by the MCOs and DMH.
In addition to these ongoing activities, a large amount of information was gathered by the state during the testimony and hearings held on House Bill (HB) 335. HB 335 passed the Missouri General Assembly in 1997 and addressed managed care issues such as patient’s rights, grievances and appeals, the definition of an emergency, network adequacy, and enrollee notice in utilization review decisions. Hundreds of providers, advocates, and citizens (including those with special health care needs) testified on this legislation. The testimony helped shape this law, which has been incorporated into the state’s contracts with MCOs.
References
Children’s Health Insurance Program (CHIP)
Missouri’s Children’s Health Insurance Program (CHIP) was a Medicaid expansion implemented on September 1, 1998 through a waiver under Section 1115 of the Social Security Act and a Title XXI Plan that covers children under the age of 19 in families with a gross income of 300 percent of the Federal poverty level (FPL). The Uninsured Parents Program, implemented in February 1999, a subgroup of the Managed Care Program, provided health insurance for some uninsured parents through an 1115 Demonstration Waiver. The Uninsured Parents Program was discontinued effective July 1, 2005. Coverage for both the CHIP Program and the Uninsured Parents Program was provided through the Managed Care delivery system in areas of the State covered by the Section 1915(b) waiver and through the Fee-For-Service Program in the reminder of the State. Uninsured women who lost their eligibility 60 days after the birth of their child were covered for women’s health services for an additional year, regardless of their income level. This population received services through the Fee-For-Service Program. Uninsured Women continue to receive services through a section 1115 family planning demonstration.
Missouri submitted a combination Children’s Health Insurance Program (CHIP) State Plan under Title XXI of the Social Security Act for the Children’s Health Insurance Program May 31, 2007. The Centers for Medicare and Medicaid Services (CMS) approved Missouri’s CHIP State Plan on September 28, 2007, with an effective date of September 1, 2007. Title XXI provides funds to states to enable them to provide health assistance to uninsured, low-income children in an effective and efficient manner.
History of MO HealthNet Managed Care
In 1995, Missouri requested and received approval to implement a managed care program, MC+ Managed Care, in the Eastern region of the State. Waiver authority was granted under Section 1915(b) of the Social Security Act for Managed Care Organizations (MCOs) to provide contracted services to certain targeted groups of Medicaid eligibles. The mandatory target groups included the Temporary Assistance for Needy Families (TANF) Adults and Children, Medicaid for Pregnant Women (MPW), Refugees, Medicaid for Children, and Children in State Care and Custody.
Effective September 1, 1998 Missouri’s health insurance program for uninsured children known as "MC+ for Kids" began and was added as an additional mandatory target group. Effective February 1, 1999 uninsured parents eligible under Missouri’s 1115 Waiver were added as an additional mandatory target group. Medicaid eligibles in the targeted groups who receive Supplemental Security Income (SSI), meet the medical definition for SSI, or are eligible for adoption subsidy benefits may choose not to enroll or voluntarily disenroll from the MC+ Managed Care Program at anytime.
During December 2001, uninsured custodial parents below 100% of the Federal poverty level under the 1115 waiver were transitioned to eligibility under Section 1931 with coverage under the 1915(b) Waiver population, with an effective date of January 1, 2002. Between 2002 through 2005, budget actions lowered the eligibility standards at which time coverage ended for this group of uninsured parents.
Effective July 1, 2006, not all Managed Care health plans provide pharmacy coverage. Enrollees in Managed Care health plans that provide pharmacy coverage use the Managed Care health plan pharmacy network. Managed Care enrollees in health plans that do not provide pharmacy coverage use Medicaid Fee-For-Service enrolled pharmacy providers.
Effective September 1, 2007, Missouri’s Medicaid program was renamed MO HealthNet. The term MC+ was no longer used to reference health care programs or health care delivery services and MC+ Managed Care became MO HealthNet Managed Care.
Effective October 1, 2009, MO HealthNet Managed Care members receive pharmacy benefits through MO HealthNet Fee-For-Service.
Eastern Region
Beginning in September 1995, seven MCOs (HealthCare USA, Care Partners, Mercy Health Plans, Community Care Plus, Prudential Health Care, Humana, and GenCare) served enrollees in the Eastern region counties of St. Louis, St. Charles, Jefferson, and Franklin and St. Louis City. Two of the original MCOs (GenCare and Humana) withdrew in 1997. Effective February 1, 2000, HealthCare USA purchased Prudential’s Medicaid business. Prudential enrollees were given an opportunity to choose a participating MCO other than Prudential.
Effective December 1, 2000, the counties of Lincoln, St. Francois, Ste. Genevieve, Warren, and Washington were included in the Eastern region. The following changes were made to the benefit package: Developmentally Disabled (DD) participants and participants with Third Party Liability (TPL) were no longer carved out; any adoption subsidy child could opt out; the state did not administer a reinsurance program; and the 30/20 limitation on mental health services was eliminated.
Care Partners chose not to rebid their contract that expired December 31, 2002. The following MCOs served Managed Care enrollees in the Eastern region from January 2003 through June 2006: Community Care Plus, HealthCare USA, and Mercy Health Plans.
Effective July 1, 2006, Mercy MC+ and Community CarePlus formed a new health plan called Mercy CarePlus.
Harmony Health Plan of Missouri was awarded a Managed Care contract effective July 1, 2006.
January 1, 2008, the following three counties were added to the MO HealthNet Eastern Managed Care region: Madison, Perry and Pike. HealthCare USA does not provide services in Madison or Perry counties.
The MO HealthNet Managed Care health plans effective January 1, 2008
| Eastern MO HealthNet Managed Care Health Plans | Pharmacy Option |
|---|---|
| HealthCare USA | Included |
| Molina Healthcare of Missouri (formerly Mercy CarePlus) | Included |
| Harmony Health Plan of Missouri | Included |
Effective October 1, 2008, Mercy CarePlus was renamed Molina Healthcare of Missouri.
The Eastern MO HealthNet Managed Care health plans providing services effective October 1, 2009 are as follows:
- Harmony Health Plan of Missouri
- HealthCare USA
- Missouri Care Health Plan
- Molina HealthCare of Missouri
Central Region
Missouri received 1915(b) waiver modification approval to expand the Managed Care Program to the Central region in March 1996. Three MCOs (HealthCare USA, GenCare, and Blue Choice) served enrollees in the following eighteen counties: Audrain, Boone, Callaway, Camden, Chariton, Cole, Cooper, Gasconade, Howard, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis, Randolph, and Saline. GenCare and Blue Choice chose not to rebid their contracts that expired February 28, 1998. Effective March 1, 1998, the participating MCOs were Care Partners, HealthCare USA, and Missouri Care. There was no change in the counties served. Contracts were rebid effective March 1, 2001. Participating MCOs were Missouri Care and HealthCare USA. Care Partners chose not to rebid their contract. The following changes were made to the benefit package: MRDD participants were no longer carved out; any adoption subsidy child could opt out; reinsurance was offered through the State but MCOs opted to purchase from an outside entity; and the 30/20 limitation on the mental health services was eliminated.
The following MCOs served managed care enrollees in the Central region from January 2003 through June 2006: HealthCare USA and Missouri Care.
Effective July 1, 2006 Mercy MC+ and Community CarePlus formed a new health plan called Mercy CarePlus.
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 MO HealthNet Managed Care health plans effective January 1, 2008
| Central MO HealthNet Managed Care Health Plans | Pharmacy Option |
|---|---|
| HealthCare USA | Included |
| Missouri Care | Included |
| Molina Healthcare of Missouri (formerly Mercy CarePlus) | Included |
Effective October 1, 2008, Mercy CarePlus was renamed Molina Healthcare of Missouri.
The Central MO HealthNet Managed Care health plans providing services effective October 1, 2009 are as follows:
- HealthCare USA
- Missouri Care Health Plan
- Molina HealthCare of Missouri
Western and Northwestern Regions
An additional waiver modification was requested and approved to expand the MC+ Managed Care Program to the Western and Northwestern regions of the state in January 1997. This expansion replaced the Medicaid Managed Care Program for AFDC participants in Jackson County that was implemented in January 1984.
Western Region
The Western region originally consisted of Cass, Clay, Jackson, Johnson, Lafayette, Platte, and Ray counties. Participating MCOs were HealthNet, Family Health Partners, FirstGuard, and Blue Advantage+Plus. In February 1999, the service area was expanded to include Henry and St. Clair counties with the MCOs remaining the same. The DD population was included as an eligible group. The state did not administer a reinsurance program.
HealthNet chose not to rebid their managed care contract, which expired January 31, 2002. The following MCOs served Managed Care enrollees in the Western region from January 2003 through June 2006: Blue Cross Blue Shield of Kansas City-Blue Advantage Plus, Family Health Partners, FirstGuard, and HealthCare USA.
Effective July 1, 2006 Mercy MC+ and Community CarePlus formed a new health plan called Mercy CarePlus.
February 1, 2007, HealthCare USA purchased FirstGuard Health Plan. FirstGuard is no longer a participating health plan for the Western region.
January 1, 2008, the following four counties were added to the MO HealthNet Western Managed Care region: Bates, Cedar, Polk and Vernon. Blue-Advantage Plus of Kansas City does not provide services in Bates, Cedar, Polk, or Vernon counties.
Effective October 1, 2008, Mercy CarePlus was renamed Molina Healthcare of Missouri.
The MO HealthNet Managed Care health plans effective January 1, 2008
| Western MO HealthNet Managed Care Health Plans | Pharmacy Option |
|---|---|
| Children's Mercy Family Health Partners | Included |
| Blue-Advantage Plus of Kansas City, see note | Excluded* |
| Molina Healthcare of Missouri (formerly Mercy CarePlus) | Included |
| HealthCare USA | Included |
*Effective July 1, 2008, Blue-Advantage Plus of Kansas City excluded pharmacy.
The Western MO HealthNet Managed Care health plans providing services effective October 1, 2009 are as follows:
- Blue Advantage Plus of Kansas City—does not provide services in Bates, Cedar, Polk, or Vernon counties.
- Children’s Mercy Family Health Partners
- HealthCare USA
- Missouri Care Health Plan
- Molina HealthCare of Missouri
Effective February 1, 2012, Children’s Mercy Family Health Partners in the Western Region of Missouri is no longer a participating Managed Care Health Plan because of a merger with HealthCare USA Health Plan.
The Western MO HealthNet Managed Care health plans providing services effective February 01, 2012 are as follows:
- Blue Advantage Plus of Kansas City—does not provide services in Bates, Cedar, Polk, or Vernon counties.
- HealthCare USA
- Missouri Care Health Plan
- Molina HealthCare of Missouri
Medicaid Managed Care for AFDC Participants (Jackson County Only)
In July 1982, Missouri received a four year federal demonstration grant to implement a managed health care program for Aid to Families with Dependent Children (AFDC) participants in Jackson County. Enrollment into the program began January 1984 with full enrollment achieved in the first quarter of 1985. The original demonstration grant was extended to December 31, 1986, at which time the established program began operating under a waiver issued by the authority of Section 1915(b) of the Social Security Act and enrollment was mandatory. The goal of the program was to furnish improved quality, continuity, and accessibility of health care services to enrollees, while providing the State with significant cost savings.
This Managed Health Care Program was a health care delivery system for AFDC participants where primary care services were provided by four prepaid health plans and approximately 30 individual physicians called physician sponsors. The four prepaid health plans were reimbursed on a capitated basis and the physician sponsors were reimbursed on a Fee-For-Service basis and received an additional $3.00 per enrollee per month for serving as the case manager. Each AFDC participant chose either a health plan or a physician sponsor, who was responsible for coordinating the health care provided to the participant. Medical services offered under the Missouri Medicaid Program were also available to managed health care enrollees; however, the majority of these services were either obtained through or referred by the chosen health plan or physician sponsor.
Northwestern Region
The Northwestern region was composed of Andrew, Atchison, Buchanan, Caldwell, Carroll, Clinton, Davies, DeKalb, Gentry, Grundy, Harrison, Holt, Livingston, Mercer, Nodaway, and Worth counties. Blue Advantage+ Plus and Community Health Plan chose not to contract with the State and all enrollees reverted back to Fee-For-Service on December 1, 1998.