MO HealthNet coverage is automatically available to all recipients of MO HealthNet, Nursing Care, Home and Community-based Services, Supplemental Aid to the Blind, Blind Pension, and Adult Supplemental Payments.
The purpose of the MO HealthNet program is to provide medical services to persons who meet certain eligibility requirements as determined by FSD. The goals of the MO HealthNet program are to promote good health, to prevent illness and premature death, to correct or limit disability, to treat illness, and to provide rehabilitation to persons with disabilities. Eligible persons receive a "MO HealthNet Identification Card" or a letter from the Family Support Division.
The Family Support Division (FSD) determines client eligibility for the MO HealthNet program: the MO HealthNet Division administers the MO HealthNet program including establishment of benefit coverage, rates, claims processing, and all other aspects of daily operations.
Medical Care Services Provided
(each service is subject to certain limitations)
- inpatient hospital care;
- outpatient hospital services, including diagnostic services rendered through a hospital outpatient department or clinic;
- laboratory and x-ray services when prescribed by a physician, and provided by either physicians, clinics, x-ray facilities, independent diagnostic testing facilities or laboratories;
- nursing home services for person who are in a home which has professional license from the Missouri Department of Health and Senior Services, or who are in the extended care facility of a licensed hospital. Each such facility must also meet federal nursing home standards;
- physician’s services whether furnished in the office, home, hospital, nursing home, or elsewhere. The only physicians who can receive payment are those licensed as M.D.’s or D.O.’s ;
- dental services **;
- drugs and medicines that have been prescribed by a physician, dentist, or podiatrist, and that are obtained from a licensed pharmacy (or certain dispensing physicians where pharmacies are not available);
- emergency ambulance services;
- audiology services and hearing aids **;
- podiatry services;
- ambulatory surgical services;
- personal care and adult day health care services provided in the home as an alternative to nursing home care;
- durable medical equipment and certain prosthetic and orthotic devices **;
- home health care services;
- optometric services and eyeglasses;
- family planning services;
- rehabilitative services as therapies for adaptive training in the use of prosthetic and orthotic devices, braces, and artificial larynxes;
- nurse midwife services in the office, hospital;
- hospice services;
- case management services for pregnant women;
- services provided at a Federally Qualified Health Center (FQHC) or at a Rural Health Clinic (RHC);
- community psychiatric rehabilitation services;
- comprehensive day rehabilitation services for head injured **;
- comprehensive substance treatment and rehabilitation (C-STAR);
- transplant services;
- certified nurse practitioner services;
- other home and community based services through MO HealthNet waivers to person 65 and older, persons with AIDS, or mentally retarded/developmentally disabled individuals;
- early and periodic screening, diagnosis and treatment (EPSDT) of eligible person under 21 years of age. In Missouri, this program is called "Healthy Children and Youth" (HCY). The following services are available for children age 0 through 20 years:
- speech therapy
- occupational therapy
- physical therapy
- psychology counseling
- private duty nursing
- case management services
- other medically necessary services
- screening services including
- physical development
- anticipatory guidance
- lead assessment
** Services are limited for adults who are not in a category of assistance for pregnant women or the blind.
MHD pays only the deductibles and co-insurance when any of the above items are covered by Title XVIII (Medicare) of the Social Security Act. MHD also pays the monthly premium for Medicare supplementary medical insurance for eligible assistance recipients age 65 or older and for certain blind or disabled persons. If an eligible person has other medical insurance, that insurance company must be billed before Medicaid is billed.
Obtaining Needed Medical Services
Some persons receive MO HealthNet benefits through a "fee for service" arrangement, while others receive benefits through a managed care plan.
Persons receiving MO HealthNet through fee for service have freedom to choose any vendor of needed services except that the chosen provider must be enrolled to participate in the MO HealthNet vendor plan in order for benefits to be used. Otherwise, the person receiving the services must bear the responsibility for medical expenses incurred. MO HealthNet pays only providers of services and does not make direct payments to person for their medical expenses. (There may be some restrictions placed on a person’s freedom of provider choice if it appears that there may be abuse or unjustified use of services.)
Persons receiving MO HealthNet through managed care must obtain all needed services through a health plan, physician sponsor, or other designated single source of total health care. MO HealthNet pays a capitation fee for each individual enrolled in a managed care program.