MO HealthNet (Missouri Medicaid) Frequently Asked Questions

MO HealthNet (Missouri Medicaid) Frequently Asked Questions

If you do not have health insurance or need help paying for your health care, you may be eligible for coverage through Missouri’s Medicaid program, called MO HealthNet. Eligibility for MO HealthNet coverage depends on your income, age, health, and individual needs. Review the eligibility requirements to determine your eligibility.

To determine if you are eligible and to apply, visit Apply for MO HealthNet. You can apply through the online portal, by phone at (855) 373-9994, or download and print the application using Adobe Reader.

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):

 

man in wheelchair with a nurse

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

 

mother with two kids

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
What services does MO HealthNet cover?

MO HealthNet covers services that help you live a long and healthy life. Services are meant to prevent and treat illness and correct or limit disability.

The following are some examples of covered services. Services may be limited or not covered based on your eligibility.

  • Ambulance
  • Ambulatory surgical center
  • Behavioral health services
  • Birthing centers
  • Comprehensive day rehabilitation
  • Dental
  • Diabetic supplies and equipment
  • Diabetes self-management training
  • Doctor’s office visits
  • Durable medical equipment (oxygen, wheelchair, walker)
  • Healthy Children & Youth Program
  • Emergency room
  • Family planning
  • Hearing aids and related services
  • Home health services
  • Hospice, in the last six months of life
  • Hospital, when overnight stay is required
  • Laboratory tests and x-rays
  • Maternity benefits, nurse midwife
  • Mental health and substance abuse
  • Nursing Facility
  • Outpatient, when overnight stay is required
  • Personal care
  • Podiatry
  • Pharmacy
  • Transplant and related services
  • Transportation to medical appointments
  • Vision

Additional information can be found on the Covered Services chart. 

What happens after I apply for MO HealthNet?

Once you have applied, the Family Support Division (FSD) will let you know what might be needed to process your application. The time it takes to process your application may vary, and if FSD has to make an eligibility decision based on a disability, it may take longer than usual. If you do not receive anything from FSD after 45 days, you can Contact FSD. 

Once your application has been processed, you will receive a letter from FSD that lets you know if you are eligible for MO HealthNet coverage. If you are approved, you will receive a MO HealthNet Identification Card and information explaining the type of services and coverage you have. You will need to follow the instructions in the letter in order for your coverage to begin.

If you are enrolled in a MO HealthNet Managed Care health plan, you will get an assignment letter in the mail about the health plan you were assigned to and the date your services will begin. You can start getting care once you receive your assignment letter.

Your new health plan will send you a welcome packet, a Managed Care health plan card, and a member handbook with information about your services. Always carry both your Managed Care health plan and your MO HealthNet ID cards with you and show them each time you get care. Call the phone number on your health plan card if you have any questions about your health plan.

How can I check the status of my application or ask questions about my coverage?

You can receive assistance in the following ways:

  • Online: Visit mydss.mo.gov to apply for benefits, check your status, report a change, or learn more about MO HealthNet coverage
  • Call: (855) 373-4636
  • Chat Online: Visit mydss.mo.gov and select DSS Chat to get answers about your case or general information
  • In Person: Visit your local FSD Resource Center
  • Text: For answers to basic questions that are not case-specific, Monday through Friday from 6:00 am to 6:00 pm, text (855) 684-9242.
Do I have to be in a Managed Care health plan?

You may choose to opt-out, or not enroll in a Managed Care program if you meet one of the following conditions:

  • Eligible for Supplemental Security Income (SSI) benefits
  • Children who are enrolled in the Special Health Care Needs program
  • Disabled and 18 or younger

Call the Managed Care Enrollment helpline at (800) 348-6627 or the Family Support Information Center at (855) 373-4636 for assistance.

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

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

If you receive both, Medicare is the 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.

If you have chosen a Medicare Advantage Health Plan, also called Part C, for your Medicare coverage, MO HealthNet will only pay coinsurance or deductible payments if you are also enrolled in the Medicare Savings Program under Qualified Medicare Beneficiary (QMB). MO HealthNet will not assume responsibility for the Medicare coinsurance and deductible amounts for Medicare Advantage Health Plan/Part C without being eligible for QMB.

MO HealthNet will not pay the Medicare coinsurance and deductibles for Nursing Home Room and Board or Inpatient Room and Board charges.

The different Medicare plans are explained in the Medicare Savings Program section of the Fee For Service Participant Handbook.

What if I am approved for MO HealthNet and also have private insurance?

If you have other insurance, we need to know.

The provider must bill your private insurance before billing MO HealthNet Fee-For-Service or the Managed Care plan.

It is important to keep your insurance information up to date. If you have a change,  enroll with private insurance, or if you no longer have private insurance, you need to report the change in one of these ways:

  • Report a change online (For assistance, watch this short video)
  • Call the Family Support Division at (855) 373-4636
  • Visit your Family Support Division local office

To determine if your private insurance is already on file with MO HealthNet, call (800) 392-2161, option 2, and enter the eight-digit MO HealthNet number found on your MO HealthNet ID Card.

If you’re assigned to a Managed Care Health plan, you can also call the Managed Care Enrollment helpline at (800) 348-6627 for additional assistance.

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 Cost Recovery Unit at (573) 751-2005 or email MHD.HIPP@dss.mo.gov.

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.

If I am approved for MO HealthNet, do I have to pay a premium?

Based on your family’s income and family size, you may need to pay a monthly premium. The letter you get from the Family Support Division about your eligibility will tell you if you need to pay a premium prior to your coverage beginning. If you have any questions about premiums, call (877) 888-2811.

You may not be required to pay a premium if your child is a member of a federally-recognized American Indian or Native Alaskan tribe and you provide proof of membership. For more information, refer to the MO HealthNet Guide to Managed Care.

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.