Training Objectives 1 q q q Authority and Requirements for Medicaid State Plan Missouri Medicaid State Plan through MO Health. Net Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Healthy Children and Youth (EPSDT in Missouri) State Plan services offered through Department of Health and Senior Services, Division of Senior and Disability Services State Plan Behavioral Health Services MO Health. Net State Plan Durable Medical Equipment Non-Emergency Medical Transportation Five Medicaid waivers operated through MO Department of Health and Senior Services Managed Care in Missouri Health Homes
Missouri Medicaid State Plan 2 State plan services under the authority of Title XIX Social Security Act Federal and state entitlement program Through Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Administered in Missouri by MO Health. Net (Missouri Medicaid authority)
Missouri Medicaid State Plan 3 States must meet certain service requirements: Services Shall be similarly offered in all parts of a state – “statewideness” Provided to all eligible groups must be equal and comparable in scope, intensity, and duration Not have Limitations that discriminate among Medicaid recipients based on medical condition or diagnosis
Missouri Department of Social Services (DSS) Programs Divisions 4 Missouri Department of Social Services Family Support Division MO Health. Net Division Children’s Division of Youth Services
Missouri Department of Social Services (DSS) Medicaid State Plan 5 Family Support Division (FSD) MO Health. Net Division (MHD) Determines Individual’s Eligibility for Missouri’s Medicaid Program Administers the Missouri Medicaid Program State Administrative Authority for all MO Division of DD Waivers and MO Department of Health and Senior Services Waivers
Missouri Medicaid State Plan 6 Missouri Department of Social Services, MO Health. Net Division (MHD) www. dss. mo. gov/mhd/ Medical Services through MO Health. Net State plan offers medical services and items to persons who meet certain eligibility requirements as determined by Missouri Department of Social Services, Family Support Division (FSD) http: //www. dss. mo. gov/fsd/msmed. htm Extensive services covered, such as inpatient and outpatient hospital services, physician, nursing, x-ray and laboratory, ambulance
MO Health. Net Provider Search 7
8 MO Health. Net State Plan and DD Waiver Services CMS requires that any services available in MO Health. Net State Plan that can meet the individual’s assessed need(s), shall first be accessed and exhausted prior to providing MO Division of DD waiver services
MO Health. Net State Plan and 1915 ( c ) Waiver Services 9 CMS Instructions, Technical Guide and Review Criteria for 1915 ( c ) Waivers: Waiver services shall not duplicate state plan services However, 1915 ( c ) waiver services may: Supplement state plan services – surpassing amount, intensity and/or duration (“extended state plan” service) Complement state plan services – waiver services not covered under state plan There are ten 1915 ( c )Waivers in Missouri Five MO Division of DD Waivers Five MO Department of Health and Senior Services Waivers
State Plan and Waiver Services Through Missouri Department of Health and Senior Services (DHSS) 10 DHSS Bureau for Special Health Care Needs Healthy Children and Youth Program Medically Fragile Adult Waiver Division of Senior and Disability Services State plan personal care for adults Aged and Disabled Waiver Independent Living Waiver Adult Day Care Waiver
11 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) available for persons under age 21 who are MO Health. Net eligible Expanded services to benefit the child under SSA 1905 (r) of the Social Security Act authority to “diagnose, treat, or ameliorate” areas identified through screening Needs determined by medical necessity In Missouri, EPSDT is called “Healthy Children and Youth Program” (HCY)
Healthy Children and Youth (HCY) Services Authorized by Bureau for Special Health Care Needs (BSHCN) 12 BSCHN within the DHSS Division of Community and Public Health, Section for Healthy Families and Youth Specific services in HCY are prior authorized by DHSS Bureau for Special Health Care Needs (BSHCN) for children with Fee-for. Service MO Health. Net coverage: Private Duty Nursing Personal Care Aide Advanced Personal Care Aide Skilled Nursing Visits Authorized Registered Nurse Visits Administrative Case Management BSHCN receives the referrals for these six services The referral may come from the family, provider agency, physician or other state agency Authorization of all services is based on medical necessity All HCY services authorized through BSHCN requires a physician’s order
BSHCN Contact Information 13 BSHCN link: http: //health. mo. gov/living/families/shcn/ If questions about BSHCN, contact Jefferson City office: 800 -451 -0669 Can refer you to a BSHCN regional office based on where you reside in the state BSHCN Regional Offices Contact Information: http: //health. mo. gov//living/families/shcn/pdf/ SHCNRegion. Map. pdf
EPSDT and DD Waiver Services 14 If service available to child under state plan or expanded EPSDT, it may not be covered through the waiver for the child There are services which can be distinctly provided in a waiver that serves children, such as respite, and not duplicate what is in EPSDT In a waiver that serves just children (e. g. , MOCDD), similar services in EPSDT cannot be furnished in the waiver (e. g. , OT, PT, ST) If a waiver covers both children and adults, any waiver services that could be furnished in accordance with 1915 ( r ) of SSA shall be limited to adults because comparable services are available for children under EPSDT
Basic Personal Care-Agency Model (State Plan) 15 Authorized through Missouri Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) Medically oriented services provided to assist with activities of daily living Personal care services are provided in accordance with a service plan approved by the state or ordered by a physician Person assessed to have “impairments and unmet needs”, where if it were not for Personal Care services the person would need hospital or long-term care facility services Reasonable and necessary and with the intent to sustain or improve the person’s functional capacity Meet individual physical needs – not for purposes of general housekeeping
Basic Personal Care-Agency Model (State Plan) 16 Services provided in the person’s home Provided by a qualified individual who is not a family member or member of household Basic Personal Care Examples of reimbursable tasks May include Advanced Personal Care Services Examples include use of a lift for transfer, assist with oral medications prepared by LPN, passive range of motion according to care plan May include an authorized nurse visit(s) Only DHSS or designee conducts assessments and determines a person’s eligibility for state plan personal care, type, amount, etc. Division of DD Support Coordinator may refer persons to DHSS and document the determination made by DHSS
Basic Personal Care-Agency Model (State Plan) 17 Code of State Regulation Provider Manual-Section 13 -Benefits and Limitations http: //www. sos. mo. gov/adrules/csr/current/13 csr/ 13 c 70 -91. pdf http: //manuals. momed. com/collections/collection_ per/Personal_Care_Section 13. pdf DHSS DSDS Home and Community Based Manual http: //health. mo. gov/seniors/hcbsmanual/ind ex. php Click on Basic Personal Care-Agency Model (State Plan)
18 State Plan Personal Care Referral and Authorization Referral and authorization Process differs for individuals up to age 21 Provider or BSHCN may receive a referral from family, physician, hospital, other state agency, etc. Provider requests approval through BSHCN For individuals age 21 and older DHSS Case Manager initially receives referral, conducts assessment for Personal Care service eligibility, and notifies provider of authorization
Basic Personal Care-Agency Model (State Plan) and Division of DD Waiver Services 19 DD waiver Personal Assistant may be authorized when: The person’s need is outside the State Plan Personal Care limits Individual requires Personal Assistant outside of their residence. Example: Limits on number of Personal Care units are reached and/or more assistance with ADLs and/or IADL’s is needed Caregivers under State Plan Personal Care – Agency Model cannot accompany the person outside of the home Person has behavioral or medical needs, and they require a more highly trained personal assistant than is available under state plan (requires documentation in the Individual Support Plan to validate need for behavioral/medical service through Division of DD) When the personal assistant worker is related to the participant Caregivers under State Plan Personal Care-Agency Model cannot hire family members to provide Personal Care
Personal Care-Consumer Directed Model (State Plan)(CDS) 20 A person with a physical disability can hire, train, supervise, and direct persons to provide their state plan personal care DHSS determines person’s eligibility for CDS Eligibility Criteria: At least age 18 Physical disability Be able to self-direct their own care MO Health. Net eligibility Meet Nursing Facility Level of Care
Personal Care-Consumer Directed Model (State Plan)(CDS) 21 Person exercises individual choice when choosing who provides personal care A family member may be hired to be a personal care support through CDS, but cannot be the participant’s spouse or legally responsible relative Person self-directing is the Employer of Record CDS participant selects an HCBS provider, enrolled with MO Health. Net as a CDS provider. Payment is sent to HCBS provider to process employee payroll on behalf of the participant (Employer of Record) Types of Personal Care CDS tasks included but not limited to assistance with self-care, passive range of motion, mobility/transfer, turning/positioning
22 Personal Care-Consumer Directed Model (State Plan)(CDS) Code of State Regulation for CDS http: //www. sos. mo. gov/adrules/csr/cu rrent/19 csr/19 c 15 -8. pdf DHSS DSDS Home and Community Based Manual http: //health. mo. gov/seniors/hcbsma nual/index. php Click on Personal Care-Consumer Directed Model (State Plan)
Personal Care-Consumer Directed Model (State Plan)and Division of DD Self-Directed Services 23 If a person is enrolled with Personal Care Consumer-Directed Model (State Plan), they cannot receive self-directed services through the Division of DD
State Plan Personal Care and DD Waiver Services 24 When a person’s need for personal assistance is strictly related to ADL’s and can be met through State Plan Personal Care program, the person will not be eligible for Division of DD waiver Personal Assistant service in accordance with requirement that state plan services must first be exhausted before waiver services can be provided State Plan Personal Care cannot be provided for anyone who is authorized to receive DD waiver Group Home or ISL Service Persons authorized Division of DD Host Home/Companion services are not eligible for State Plan Personal Care
DHSS, Division of Senior and Disability Services Home and Community Based Services Manual 25 For further information about and how to access DHSS Division of Senior and Disability (DSDS) services http: //health. mo. gov/seniors/hcbs Referrals for Home and Community Based Services (HCBS) can be called in to DSDS by phone at 866 -8353505 DSDS HCBS Regional Evaluation Teams contact information is also in this link-to call for assistance with referrals Also provides information for entities that are interested in becoming service providers
DD Waiver Providers and DHSS Home and Community Based Service providers 26 Division of DD waiver providers may wish to enroll with MO Health. Net as providers of Home and Community Based Services authorized through DHSS Advantage: Can better ensure consistency in services for participants receiving both State Plan Personal Care-Agency Model and Personal Assistant through the Division of DD Waiver
DHSS Home and Community Based Service providers 27 Providers of State Plan Personal Care and other Home and Community Based services authorized through the Department of Health and Senior Services are required to enroll with Missouri Medicaid Audit and Compliance MO Health. Net Enrollment http: //mmac. mo. gov/
Home and Community Based Provider Requirements 28 http: //mmac. mo. gov/providers/providerenrollment/home-and-community-basedservices/ http: //www. sos. mo. gov/adrules/csr/current /19 csr/19 c 15 -7. pdf
MO Health. Net Behavioral Health Services 29 Medically necessary mental health services for MO Health. Net eligible persons Services include but are not limited to: Diagnostic assessment Psychological testing Individual Therapy Family Therapy Group Therapy
MO Health. Net Behavioral Health Services 30 MO Health. Net Behavioral Health services be may included in the school based services program for public schools Only services identified in the Individualized Education Plan will be reimbursable Link to Behavioral Health Services Manual: http: //manuals. momed. com/collections/collecti on_psy/Behavioral_Health_Services_Section 13. pdf For Behavioral Health Services Questions – Contact Provider Education at 573 -751 -6683
MO Health. Net Durable Medical Equipment (DME) 31 MO Health. Net State Plan covers a wide variety of medical equipment and supplies for both children and adults Services must be provided by a MO Health. Net enrolled DME provider Some items require prior authorization Some items require pre-certification; a real time authorization process initiated by a physician utilizing an on-line tool called Cyber. Access. SM Although Division of DD Support Coordinators cannot pre-certify or pre-authorize DME, they can help facilitate these processes
Durable Medical Equipment Resources 32 Before requesting any type of medical equipment or supplies through any Division of DD waiver, the Support Coordinator should check for potential coverage through MO Health. Net State plan by reviewing the DME provider manual http: //207. 15. 48. 5/collections/collection_dme/Dura ble_Medical_Equipment_Section 13. pdf http: //manuals. momed. com/collections/collection_ dme/Durable_Medical_Equipment_Section 19. pdf
DME for Children Through Age 20 33 Examples include but are not limited to: Incontinence supplies Bath and shower chairs Pediatric hospital beds Nutrition Enteral feeding supplies Nasogastric tubing Metabolic formula
DME for Children and Adults 34 Examples include but are not limited to: Augmentative communication devices Canes and crutches Commodes, bed pans, urinals Supplies for decubitus care Diabetic shoes and inserts Hospital beds Orthotics and repairs Ostomy supplies
DME for Children and Adults 35 Patient trapeze lifts Hydraulic patient lifts Prosthetics and repairs Walkers Wheelchairs, including manual, power chairs, scooters and accessories NOTE: Vehicle modifications such as wheel chair lifts are not covered by state plan, and may be covered through the Division of DD waivers
Incontinence Supplies for Adults 36 MO Health. Net may cover incontinence supplies, when medically necessary, for adults NOT participating in a DD waiver Adults enrolled in any Division of DD waiver requiring incontinence supplies will have this need met through their waiver The need for incontinence supplies alone does not justify enrollment in a Division of DD waiver
DME Contact Information 37 Individuals and families contact Participant services at 800 -3922161 Regional Offices and providers contact Provider Communications Unit at 573 -7512896 for general program information
Non-Emergency Medical Transportation (NEMT) 38 NEMT used for MO Health. Net-eligible persons or persons in a MO Health. Net managed care plan who do not have access to free appropriate transportation to and from MO Health. Net covered services NEMT provides for arrangement of transportation and ancillary services Person in a MO Health. Net managed care plan gets NEMT from the health plan Ancillary services: If away from home overnight, NEMT may assist with meals and lodging http: //dss. mo. gov/mhd/participants/pages/medtrans. htm
Non-Emergency Medical Transportation (NEMT) 39 NEMT may use public transportation and other sources such as bus tokens, vans, taxis If person has their own car, or if a friend or neighbor provides transportation – may be able to get help with gasoline costs NEMT are for services near where person lives; if provider far away, may need approval from physician
How is NEMT Accessed? 40 For regular appointments: Must arrange NEMT at least 5 days before health care appointment Call 866 -269 -5927, M-F, 8 -5 p. m. For “urgent care appointments” NEMT may be arranged sooner if a medical problem comes up and physician says person can be seen Call 866 -269 -5927, 24 hours/day, 7 days/week If an emergency, dial 911 or local emergency phone number
How is NEMT Accessed? 41 Charge is $2 for each NEMT trip NEMT cannot be denied if one cannot pay $2 No $2 charge if person: Is under age 19 Pregnancy Is blind Lives in a nursing home Uses public transportation, bus tokens, or if receives help to pay for gasoline
NEMT Will Not Provide a MO Health. Net Participant a Ride to These Services 42 Pharmacy Certain DME Services provided in the individual’s home such as personal care Adult Day Health Care services DD Waiver Services Some Comprehensive Substance Treatment Abuse and Rehabilitation (CSTAR) services Some Community Psychiatric Rehabilitation (CPR) services
MO Health. Net Exceptions Process 43 MHD may authorize payment for an essential non-covered medical service or item Reviewed on a case-by-case basis Exceptions requests only accepted from authorized health care prescribers licensed as a physician or advanced practice nurse
MO Health. Net Exceptions Process 44 Exceptions Process: http: //207. 15. 48. 5/collections/collection_rhp/General_Section 20. pdf Frequently Asked Questions: http: //www. dss. mo. gov/mhd/faq/pages/faqexcept. htm Participant contact for Exceptions Process: Participant Service Agent 800392 -2161
Medicaid Waivers Through MO DHSS 45 May be an option for persons with developmental disabilities if determined to most effectively meet their unique needs Medically Fragile Adult Waiver Aged and Disabled Waiver Independent Living Waiver Adult Day Care Waiver AIDS Waiver
Medically Fragile Adult Waiver 46 Intended for persons served in the HCY Program who turn age 21 (hence, no longer eligible for HCY Program) Operated through MO DHSS BSHCN Services offered include: Private Duty Nursing Specialized Medical Equipment and Supplies Attendant Care Services Requires prior authorization through DHSS BSHCN
Aged and Disabled Waiver 47 Intended for MO Health. Net eligible persons aged 63 and older Operated through DHSS DSDS Meet Nursing Facility Level of Care Services offered include: Homemaker Services Chore Services Respite Care Services Advanced Respite Care Nurse Respite Care Home Delivered Meals Adult Day Care All waiver services must be authorized by a DSDS prior to service delivery DHSS DSDS Home and Community Based Manual http: //health. mo. gov/seniors/hcbsmanual/index. php Click on each of the services in the Aged and Disabled Waiver
Independent Living Waiver 48 Intended for MO Health. Net eligible persons aged 18 -64 years who have a physical disability (and possibly a cognitive disability) Persons who have also have a cognitive impairment must have had the onset on or after age 22 Persons who turn age 65 while enrolled in this waiver may stay on the waiver Operated through MO DHSS DSDS Services include: Consumer-directed personal care Persons must be able to self-direct their own care ILW provides additional personal care when state plan limits associated with CDS are exhausted Case Management Environmental Accessibility Adaptations Specialized Medical Equipment Specialized Medical Supplies DHSS DSDS Home and Community Based Manual http: //health. mo. gov/seniors/hcbsmanual/index. php Click on the Independent Living Waiver
Adult Day Care Waiver 49 Intended for MO Health. Net eligible persons aged 1863 years who meet Nursing Facility Level of Care Operated through MO DHSS DSDS Sole service is Adult Day Care Effective 1/1/13 For persons over age 63, the Adult Day Care service has been added to the DHSS Aged and Disabled Waiver Adult Day Care waiver service replaces MO state plan Adult Day Health Care service - which will end 6/30/13 DHSS DSDS Home and Community Based Manual http: //health. mo. gov/seniors/hcbsmanual/index. php Click on the Adult Day Care Waiver
DHSS Home and Community Based Services and Division of DD Waivers 50 A person can only be enrolled in one waiver at a given time It is important for the Support Coordinator to determine if the person is receiving Home and Community Based services through State Plan and/or DHSS waivers
MO Health. Net Managed Care 51 Participation in a Managed Care plan is mandatory for certain eligibility groups in some regions of the state Website for Medicaid Eligibility codes in Managed Care Participants who receive SSI, meet the SSI disability definition, or who receive adoption subsidy may choose to opt out of Managed Care and receive services on a Fee-for-Service basis http: //dss. mo. gov/mhd/mc/pages/population. htm Managed Care plans are responsible for all acute, primary, rehabilitative, preventive care, and some mental health services for enrollees Managed care services: http: //dss. mo. gov/mhd/mc/pdf/services. pdf
MO Health. Net Managed Care 52 When assisting someone who is enrolled with a Managed Care plan to access MO Health. Net State Plan services, Support Coordinators will need to contact the individual’s Managed Care plan Website for Managed Care benefit information and health plan contact and program information Link to MO Health. Net “Puzzled by the Terminology? ” document http: //dss. mo. gov/mhd/mc/index. htm http: //dss. mo. gov/mhd/providers/pdf/puzzledterm. pdf Managed Care plans are not responsible for Division of DD waivers
Health Home 53 Health Home is a new service added to MO Health. Net State Plan in 2012 Health homes provide chronic disease management to people with co-occurring chronic physical or mental health conditions Health homes provide a Care Team of qualified health professionals to assist the participant to achieve and maintain better health and wellness
Health Homes are NOT 54 Health homes are NOT a place of residence. People may live alone in a house or apartment, with family or others, or in a DD group home and still qualify for health home without having to move Health Homes are NOT managed care. Health home participants are not restricted in their choice of medical and specialty providers, including DD waiver providers
Health Homes, continued 55 Health homes DO NOT duplicate or supplant support coordination provided by DD Regional Offices, SB 40 Boards, or any TCM provider Health home care managers coordinate locally with other providers involved with a participant, including the TCM provider, the DD waiver provider, the physician, and other medical professionals
Health Homes, continued 56 Health homes have proven to have a positive impact on people’s health, through Reducing unnecessary use of emergency rooms Avoiding preventable hospital admissions More appropriate prescriptions – reduction of prescriptions for off-label use, and reducing the incidence of drug-to-drug interactions Reducing preventable surgeries
Health Homes, continued 57 Participants in health homes must have two pre-existing medical conditions or Diabetes alone to be eligible for the health home services
Health Homes, continued 58 Missouri has two health home programs Behavior health homes serve people with serious mental illness and/or substance abuse and other co-occurring conditions Behavioral Health home services are provided by community mental health centers Primary Care health homes serve people with certain physical health conditions Primary Care health homes include several federally qualified health centers and other medical systems meeting health home provider criteria
Health Homes, continued 59 What chronic conditions qualify? Serious Mental Health Condition Asthma Substance Abuse Disorders Diabetes Cardiovascular Disease – including hypertension Overweight (BMI>25) Developmental Disabilities Smoking or Diabetes* *qualifies a person for being at risk of having a second chronic condition
Health Homes 60 For more information about health homes, please visit this website: http: //dmh. mo. gov/about/chiefclinicaloffice r/healthcarehome. htm
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