STATE OF MISSOURI PHYSICIAN MANUAL Physician SECTION 1-PARTICIPANT CONDITIONS OF PARTICIPATION ........................................22 1.1 INDIVIDUALS ELIGIBLE FOR MO HEALTHNET, MANAGED CARE OR STATE FUNDED BENEFITS........................................................................................................................22 1.1.A DESCRIPTION OF ELIGIBILITY CATEGORIES.............................................................22 1.1.A(1) MO HealthNet...............................................................................................................22 1.1.A(2) MO HealthNet for Kids.................................................................................................23 1.1.A(3) Temporary MO HealthNet During Pregnancy (TEMP)................................................25 1.1.A(4) Voluntary Placement Agreement for Children .............................................................25 1.1.A(5) State Funded MO HealthNet.........................................................................................25 1.1.A(6) MO Rx...........................................................................................................................26 1.1.A(7) Women’s Health Services .............................................................................................26 1.1.A(8) ME Codes Not in Use ...................................................................................................27 1.2 MO HEALTHNET AND MO HEALTHNET MANAGED CARE ID CARD......................27 1.2.A FORMAT OF MO HEALTHNET ID CARD .......................................................................28 1.2.B ACCESS TO ELIGIBILITY INFORMATION.....................................................................29 1.2.C IDENTIFICATION OF PARTICIPANTS BY ELIGIBILITY CODES ...............................29 1.2.C(1) MO HealthNet Participants ...........................................................................................29 1.2.C(2) MO HealthNet Managed Care Participants..................................................................29 1.2.C(3) TEMP ............................................................................................................................29 1.2.C(4) Temporary Medical Eligibility for Reinstated TANF Individuals................................30 1.2.C(5) Presumptive Eligibility for Children .............................................................................30 1.2.C(6) Breast or Cervical Cancer Treatment Presumptive Eligibility......................................30 1.2.C(7) Voluntary Placement Agreement ..................................................................................30 1.2.D THIRD PARTY INSURANCE COVERAGE ......................................................................31 1.2.D(1) Medicare Part A, Part B and Part C ..............................................................................31 1.3 MO HEALTHNET, STATE FUNDED MEDICAL ASSISTANCE AND MO HEALTHNET MANAGED CARE APPLICATION PROCESS .................................................31 1.4 AUTOMATIC MO HEALTHNET ELIGIBILITY FOR NEWBORN CHILDREN ...........32 1.4.A NEWBORN INELIGIBILITY ..............................................................................................33 1.4.B NEWBORN ADOPTION ......................................................................................................33 1.4.C MO HEALTHNET MANAGED CARE HEALTH PLAN NEWBORN ENROLLMENT..33 1.5 PARTICIPANTS WITH RESTRICTED/LIMITED BENEFITS ..........................................34 1.5.A LIMITED BENEFIT PACKAGE FOR ADULT CATEGORIES OF ASSISTANCE .........34 1.5.B ADMINISTRATIVE PARTICIPANT LOCK-IN .................................................................36 1.5.C MO HEALTHNET MANAGED CARE PARTICIPANTS .................................................36 1.5.C(1) Home Birth Services for the MO HealthNet Managed Care Program..........................38 1.5.D HOSPICE BENEFICIARIES ................................................................................................38 1.5.E QUALIFIED MEDICARE BENEFICIARIES (QMB) .........................................................39 1.5.F WOMEN’S HEALTH SERVICES PROGRAM (ME CODES 80 and 89)...........................40 1.5.G TEMP PARTICIPANTS........................................................................................................40 PRODUCTION : 09/09/2021 2 Physician 1.5.G(1) TEMP ID Card ..............................................................................................................41 1.5.G(2) TEMP Service Restrictions ...........................................................................................42 1.5.G(3) Full MO HealthNet Eligibility After TEMP .................................................................42 1.5.H PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) .....................42 1.5.I MISSOURI'S BREAST AND CERVICAL CANCER TREATMENT (BCCT) ACT ..........43 1.5.I(1) Eligibility Criteria...........................................................................................................43 1.5.I(2) Presumptive Eligibility ...................................................................................................44 1.5.I(3) Regular BCCT MO HealthNet .......................................................................................44 1.5.I(4) Termination of Coverage................................................................................................45 1.5.J TICKET TO WORK HEALTH ASSURANCE PROGRAM ................................................45 1.5.J(1) Disability ........................................................................................................................45 1.5.J(2) Employment ...................................................................................................................45 1.5.J(3) Premium Payment and Collection Process.....................................................................45 1.5.J(4) Termination of Coverage................................................................................................46 1.5.K PRESUMPTIVE ELIGIBILITY FOR CHILDREN..............................................................46 1.5.K(1) Eligibility Determination ..............................................................................................47 1.5.K(2) MO HealthNet for Kids Coverage ................................................................................47 1.5.L MO HEALTHNET COVERAGE FOR INMATES OF A PUBLIC INSTITUTION ...........48 1.5.L(1) MO HealthNet Coverage Not Available .......................................................................49 1.5.L(2) MO HealthNet Benefits .................................................................................................49 1.5.M VOLUNTARY PLACEMENT AGREEMENT, OUT-OF- HOME CHILDREN'S SERVICES ......................................................................................................................................50 1.5.M(1) Duration of Voluntary Placement Agreement..............................................................50 1.5.M(2) Covered Treatment and Medical Services....................................................................50 1.5.M(3) Medical Planning for Out-of-Home Care.....................................................................50 1.6 ELIGIBILITY PERIODS FOR MO HEALTHNET PARTICIPANTS ................................51 1.6.A DAY SPECIFIC ELIGIBILITY ............................................................................................52 1.6.B SPENDDOWN.......................................................................................................................53 1.6.B(1) Notification of Spenddown Amount .............................................................................54 1.6.B(2) Notification of Spenddown on New Approvals ............................................................54 1.6.B(3) Meeting Spenddown with Incurred and/or Paid Expenses............................................54 1.6.B(4) Meeting Spenddown with a Combination of Incurred Expenses and Paying the Balance .....................................................................................................................................................55 1.6.B(5) Preventing MO HealthNet Payment of Expenses Used to Meet Spenddown...............55 1.6.B(6) Spenddown Pay-In Option ............................................................................................56 1.6.B(7) Prior Quarter Coverage .................................................................................................56 1.6.B(8) MO HealthNet Coverage End Dates .............................................................................57 1.6.C PRIOR QUARTER COVERAGE .........................................................................................57 1.6.D EMERGENCY MEDICAL CARE FOR INELIGIBLE ALIENS ........................................57 1.7 PARTICIPANT ELIGIBILITY LETTERS AND CLAIMS CORRESPONDENCE...........58 1.7.A NEW APPROVAL LETTER ................................................................................................59 1.7.A(1) Eligibility Letter for Reinstated TANF (ME 81) Individuals .......................................59 PRODUCTION : 09/09/2021 3 Physician 1.7.A(2) BCCT Temporary MO HealthNet Authorization Letter...............................................59 1.7.A(3) Presumptive Eligibility for Children Authorization PC-2 Notice.................................59 1.7.B REPLACEMENT