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State of Missouri Physician Manual

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State of Missouri Physician Manual STATE OF MISSOURI PHYSICIAN MANUAL Physician Archived SECTION 1-PARTICIPANT CONDITIONS OF PARTICIPATION ........................................13 1.1 INDIVIDUALS ELIGIBLE FOR MO HEALTHNET, MANAGED CARE OR STATE FUNDED BENEFITS........................................................................................................................13 1.1.A DESCRIPTION OF ELIGIBILITY CATEGORIES.............................................................13 1.1.A(1) MO HealthNet...............................................................................................................13 1.1.A(2) MO HealthNet for Kids.................................................................................................14 1.1.A(3) Temporary MO HealthNet During Pregnancy (TEMP)................................................16 1.1.A(4) Voluntary Placement Agreement for Children .............................................................16 1.1.A(5) State Funded MO HealthNet.........................................................................................17 1.1.A(6) MO Rx...........................................................................................................................17 1.1.A(7) Women’s Health Services .............................................................................................18 1.1.A(8) ME Codes Not in Use ...................................................................................................18 1.2 MO HEALTHNET AND MO HEALTHNET MANAGED CARE ID CARD......................18 1.2.A FORMAT OF MO HEALTHNET ID CARD .......................................................................19 1.2.B ACCESS TO ELIGIBILITY INFORMATION.....................................................................20 1.2.C IDENTIFICATION OF PARTICIPANTS BY ELIGIBILITY CODES ...............................20 1.2.C(1) MO HealthNet Participants ...........................................................................................20 1.2.C(2) MO HealthNet Managed Care Participants..................................................................20 1.2.C(3) TEMP ............................................................................................................................20 1.2.C(4) Temporary Medical Eligibility for Reinstated TANF Individuals................................21 1.2.C(5) Presumptive Eligibility for Children .............................................................................21 1.2.C(6) Breast or Cervical Cancer Treatment Presumptive Eligibility......................................21 1.2.C(7) Voluntary Placement Agreement ..................................................................................21 1.2.D THIRD PARTY INSURANCE COVERAGE ......................................................................22 1.2.D(1) Medicare Part A, Part B and Part C ..............................................................................22 1.3 MO HEALTHNET, STATE FUNDED MEDICAL ASSISTANCE AND MO HEALTHNET MANAGED CARE APPLICATION PROCESS .................................................22 1.4 AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN CHILDREN ...........23 1.4.A NEWBORN INELIGIBILITY ..............................................................................................24 1.4.B NEWBORN ADOPTION ......................................................................................................24 1.4.C MO HEALTHNET MANAGED CARE HEALTH PLAN NEWBORN ENROLLMENT..24 1.5 PARTICIPANTS WITH RESTRICTED/LIMITED BENEFITS ..........................................25 1.5.A LIMITED BENEFIT PACKAGE FOR ADULT CATEGORIES OF ASSISTANCE .........25 1.5.B ADMINISTRATIVE PARTICIPANT LOCK-IN .................................................................27 1.5.C MO HEALTHNET MANAGED CARE PARTICIPANTS .................................................27 1.5.C(1) Home Birth Services for the MO HealthNet Managed Care Program..........................29 1.5.D HOSPICE BENEFICIARIES ................................................................................................29 1.5.E QUALIFIED MEDICARE BENEFICIARIES (QMB) .........................................................30 1.5.F WOMEN’S HEALTH SERVICES PROGRAM (ME CODES 80 and 89)...........................31 1.5.G TEMP PARTICIPANTS........................................................................................................31 1.5.G(1) TEMP ID Card ..............................................................................................................32 1.5.G(2) TEMP Service Restrictions ...........................................................................................33 1.5.G(3) Full MO HealthNet Eligibility After TEMP .................................................................33 Archived - 04##2016 Last Updated - 04/4/2016 2 Physician Archived 1.5.H PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) .....................33 1.5.I MISSOURI'S BREAST AND CERVICAL CANCER TREATMENT (BCCT) ACT ..........34 1.5.I(1) Eligibility Criteria...........................................................................................................35 1.5.I(2) Presumptive Eligibility ...................................................................................................35 1.5.I(3) Regular BCCT MO HealthNet .......................................................................................35 1.5.I(4) Termination of Coverage................................................................................................36 1.5.J TICKET TO WORK HEALTH ASSURANCE PROGRAM ................................................36 1.5.J(1) Disability ........................................................................................................................36 1.5.J(2) Employment ...................................................................................................................36 1.5.J(3) Premium Payment and Collection Process.....................................................................37 1.5.J(4) Termination of Coverage................................................................................................37 1.5.K PRESUMPTIVE ELIGIBILITY FOR CHILDREN..............................................................37 1.5.K(1) Eligibility Determination ..............................................................................................38 1.5.K(2) MO HealthNet for Kids Coverage ................................................................................39 1.5.L MO HEALTHNET COVERAGE FOR INMATES OF A PUBLIC INSTITUTION ...........39 1.5.L(1) MO HealthNet Coverage Not Available .......................................................................40 1.5.L(2) MO HealthNet Benefits .................................................................................................40 1.5.M VOLUNTARY PLACEMENT AGREEMENT, OUT-OF- HOME CHILDREN'S SERVICES ......................................................................................................................................41 1.5.M(1) Duration of Voluntary Placement Agreement..............................................................41 1.5.M(2) Covered Treatment and Medical Services....................................................................41 1.5.M(3) Medical Planning for Out-of-Home Care.....................................................................42 1.6 ELIGIBILITY PERIODS FOR MO HEALTHNET PARTICIPANTS ................................42 1.6.A DAY SPECIFIC ELIGIBILITY ............................................................................................43 1.6.B SPENDDOWN.......................................................................................................................44 1.6.B(1) Notification of Spenddown Amount .............................................................................45 1.6.B(2) Notification of Spenddown on New Approvals ............................................................45 1.6.B(3) Meeting Spenddown with Incurred and/or Paid Expenses............................................46 1.6.B(4) Meeting Spenddown with a Combination of Incurred Expenses and Paying the Balance .....................................................................................................................................................46 1.6.B(5) Preventing MO HealthNet Payment of Expenses Used to Meet Spenddown...............46 1.6.B(6) Spenddown Pay-In Option ............................................................................................47 1.6.B(7) Prior Quarter Coverage .................................................................................................48 1.6.B(8) MO HealthNet Coverage End Dates .............................................................................48 1.6.C PRIOR QUARTER COVERAGE .........................................................................................48 1.6.D EMERGENCY MEDICAL CARE FOR INELIGIBLE ALIENS ........................................49 1.7 PARTICIPANT ELIGIBILITY LETTERS AND CLAIMS CORRESPONDENCE...........49 1.7.A NEW APPROVAL LETTER ................................................................................................50 1.7.A(1) Eligibility Letter for Reinstated TANF (ME 81) Individuals .......................................50 1.7.A(2) BCCT Temporary MO HealthNet Authorization Letter...............................................50 1.7.A(3) Presumptive Eligibility for Children Authorization PC-2 Notice.................................51 1.7.B REPLACEMENT
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