Mo healthnet managed care policy statements table of contents



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MO HEALTHNET MANAGED CARE POLICY STATEMENTS

TABLE OF CONTENTS


AIDS WAIVER 3

AMBULATORY SURGICAL CENTER 5

ANESTHESIA SERVICES 6

ASTHMA EDUCATION 9

BEHAVIORAL HEALTH 10

BEHAVIORAL HEALTH FEE-FOR-SERVICE COORDINATION 13

CERTIFIED NURSE MIDWIFE 25

COMMUNICATION PLAN 27

COMPREHENSIVE DAY REHABILITATION 32

DIABETES SELF-MANAGEMENT TRAINING 41

DURABLE MEDICAL EQUIPMENT 43

EPSDT/HCY SCREENING SERVICES 45

FAMILY PLANNING 47

FRAUD, WASTE, AND ABUSE 49

The health plan may use the template provided in Provider and Subcontractor Disclosure located and periodically updated on the MO HealthNet website at Health Plan Reporting Schedule and Templates (http://dss.mo.gov/business-processes/managed-care/health-plan-reporting-schedules-templates/) to memorialize these screenings. The health plan shall deny credentialing or re-credentialing to any subcontractor that falls within this section. In addition, the health plan shall terminate the provider contract of any subcontractor for which a check reveals that the subcontractor falls within this section. 54

HEARING AID 55

HOME BIRTH SERVICES 58

HOME HEALTH 61

HOSPICE 64

HOSPITAL (INPATIENT/OUTPATIENT) 66

HYSTERECTOMY SERVICES 70

MATERNITY PRE-NATAL CARE AND DELIVERY 72

NEWBORN ENROLLMENT 75

OBESITY TREATMENT 78

OPTICAL PROGRAM 79

PERSONAL CARE 82

PODIATRY SERVICES 91

PRIVATE DUTY NURSING 92

RADIOLOGY AND LABORATORY SERVICES 93

SAFE/CARE EXAMS 95

SCHOOL BASED SERVICES 97

Dental Services 97

Individualized Family Service Plan 97

Individualized Education Program 97

IFSP or IEP Services 98

TRANSITION OF CARE 99

The MO HealthNet Managed Care health plans are required to ensure an orderly and smooth transfer of responsibility and continuity of care for Managed Care members transitioning out of the health plan and into another Managed Care health plan. The health plans are required to facilitate continuity of care for medically necessary covered services. 99

TRANSITION FROM A MO HEALTHNET MANAGED CARE HEALTH PLAN TO ANOTHER MO HEALTHNET MANAGED CARE HEALTH PLAN 99

MANAGED CARE ADMINISTRATIVE PROCEDURE FOR MEMBER TRANSITION OF CARE TO ANOTHER MANAGED CARE HEALTH PLAN 100

Managed Care Health Plan Responsibilities 100

New Health Plan Responsibilities 100

TRANSITION OF PREGNANT WOMEN INTO MO HEALTHNET MANAGED CARE HEALTH PLANS 105

TRANSPLANTS 107

Kidney/Pancreas 109

TRANSPORTATION SERVICES EMERGENCY AND NON-EMERGENCY 110

VACCINES FOR CHILDREN 114


AIDS WAIVER


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are not required to provide services included in the AIDS Waiver. Members enrolled in the AIDS Waiver will be disenrolled once identified. MO HealthNet Managed Care health plans are required to provide services that non-Aids Waiver members with HIV/AIDS require. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity.
The AIDS Waiver program provides services in addition to the standard MO HealthNet benefit package. These services are covered by MO HealthNet as a cost effective alternative to nursing home placement. Services available to members with HIV/AIDS or disabling related illnesses are private duty nursing, waiver personal care, waiver attendant care and supplies (diapers, underpads, and gloves).
PROGRAM LIMITATIONS
Children age 0-20 are not enrolled in the AIDS Waiver program as they receive the same services as a HCY benefit through the MO HealthNet Managed Care health plan when medically necessary. Members with ME codes of 02, 08, 52, 57, 64, and 65 are not eligible for services through the AIDS Waiver program.
Members who are 21 years of age or older that receive services through the AIDS Waiver program will be disenrolled from MO HealthNet Managed Care once identified. AIDS Waiver members are not readily identifiable based on their type of assistance code. There is no automated means within the fee-for-service system to show that members are in the AIDS Waiver. During the transition from MO HealthNet Managed Care to fee-for-service, MO HealthNet Division will reimburse AIDS Waiver services fee-for-service. All other covered services will be the responsibility of the MO HealthNet Managed Care health plan until such time as the member is disenrolled from the MO HealthNet Managed Care health plan.
A member is determined to be eligible for the AIDS Waiver if they have an AIDS or HIV diagnosis, would otherwise require nursing home care, and have a need for at least one of the services covered through the AIDS Waiver. Members are assessed for waiver eligibility by care managers who contract with the Department of Health and Senior Services.
MO HealthNet Managed Care health plans may have members with an HIV/AIDS diagnosis who do not wish to participate in the AIDS Waiver.
The AIDS Waiver does not cover Protease inhibitors. Protease inhibitors are a regular state plan benefit, reimbursable through the pharmacy program. Protease inhibitors are not the responsibility of the MO HealthNet Managed Care health plans and are reimbursable on a fee-for-service basis for MO HealthNet Managed Care members.

MISCELLANEOUS


The AIDS Waiver Manual can be referenced online at the MO HealthNet Division website www.dss.mo.gov/mhd for additional information. Special bulletins may also be referred online for additional information.

AMBULATORY SURGICAL CENTER


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide Ambulatory Surgical Center program services. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. The Ambulatory Surgical Center (ASC) program provides a place for operative procedures that can be safely performed in an outpatient setting. The procedures must be able to be completed within the maximum time of 90 minutes (42 CFR 416.65). This is the maximum length of time that a member may be placed under anesthesia in an ASC. The ASC program closely approximates the coverage of Medicare in identifying the procedures that may be performed in an ASC.
Providers must be Medicare certified as an ASC and licensed by the Department of Health and Senior Services. Providers are required to have an agreement with a local hospital for purposes of providing emergency medical coverage on an as needed basis.
Note: Physician’s professional services are reimbursed directly to the physician or other provider performing the service.
MISCELLANEOUS
The Ambulatory Surgical Center Manual can be referenced online at the MO HealthNet Division website www.dss.mo.gov/mhd for additional information. Special bulletins may also be referred online for additional information.
ANESTHESIA SERVICES
PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide anesthesia services. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Anesthesia services are covered when performed by an anesthesiologist, anesthesiologist assistant (AA), or certified registered nurse anesthetist (CRNA). Medical direction of anesthetists by an anesthesiologist is also a covered service.
The concurrent medical direction of at least two (2), but not more than four (4), anesthetists is covered if the following additional requirements are met.
For each member, the physician:


  • performs and documents a pre-anesthetic examination and evaluation

  • prescribes the anesthesia plan;

  • personally participates in the most demanding procedures in the anesthesia plan, including induction and emergency;

  • ensures that all procedures in the anesthesia plan that he/she does not perform are performed by a qualified individual;

  • monitors the course of anesthesia administration at frequent intervals;

  • remains physically present and available for immediate diagnosis and treatment of emergencies; and

  • provides indicated post-anesthesia care.

PROGRAM LIMITATIONS


Administration of local infiltration, digital block, or topical anesthesia by the operating surgeon or obstetrician is included in the surgery or delivery fee. A separate fee for administration is non-allowed.
The anesthesia agents or supplies used when performing any surgical procedure in the office are included in the reimbursement for the surgical procedure and are not covered separately.
Local anesthesia is included in the procedure/surgery if provided in the physician's office. If provided in an Ambulatory Surgical Center or outpatient department of the hospital, it is included in the facility charge. If provided on an inpatient basis, it is included in the accommodation revenue code for the facility.
There may be an occasional need for anesthesia during CT scan services as a result of medically necessary circumstances, (i.e. child with hyperactivity or behavioral health conditions, etc.).
Medical direction or supervision of students in a teaching, training, or other setting is not covered.
Anesthesiologists may only report one procedure per date of service (operative setting). When anesthesia is administered for multiple surgical procedures for the same member on the same date of service during the same operative setting, only the major surgical procedure should be reported.
Many anesthesia services are provided under difficult circumstances depending on factors such as the extraordinary condition of the member, notable operative conditions, or unusual risk factors. The following qualifying circumstances significantly impact on the character of the anesthetic service provided. These procedures are not reported alone but are reported in addition to the appropriate anesthesia procedure code and appropriate modifier.
PROC CODE DESCRIPTION

99100 Anesthesia for patient of extreme age, under one year and over seventy.

99116 Anesthesia complicated by utilization of total body hypothermia.

99135 Anesthesia complicated by utilization of controlled hypotension.

99140 Anesthesia complicated by emergency conditions (specify).
When reporting one of the above procedure codes, the maximum quantity is always 1, as reimbursement is based on a fixed maximum allowable amount. Do not use the anesthesia modifiers, AA, QK, QC or QZ when billing for these specific procedures.
Consent forms for anesthesia services for surgical procedures requiring Certification of Medical Necessity for Abortion, Sterilization Consent, or Acknowledgement of Receipt of Hysterectomy Information must be properly executed.
Anesthesia for dental services is covered for those members who are unable to cooperate in a dentist office due to age, handicap, or psychological problems. Anesthesia when administered by a dentist or oral surgeon is reportable as a dental service using CDT codes. When performed by an anesthesiologist, AA or CRNA, CPT codes are used.
Any surgical procedure listed as non-covered for surgery is also non-covered for anesthesiology. The provider of anesthesia services will be responsible to ensure the procedure is a covered service.
Anesthesiologist monitoring telemetry in the operating room is non-covered.
Routine resuscitation of newborn infants is included in the fee for the administration of the obstetrical anesthesia in low-risk patients.
Anesthesiologist, AA, and CRNA services are not covered in the recovery room.

Anesthesia should be billed using the appropriate CPT anesthesia procedure codes (00100-01999) with one of the following appropriate modifiers:


AA – Anesthesia services performed personally by the anesthesiologist.

QK – Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.

QX – CRNA/AA service; with medical direction by a physician.

QZ – CRNA service; without medical direction by a physician.


MISCELLANEOUS
The Physicians Manual can be referenced online at the MO HealthNet Division website www.dss.mo.gov/mhd for additional information. Special bulletins may also be referred online for additional information.

ASTHMA EDUCATION


PROGRAM DESCRIPTION
PLACEHOLDER

BEHAVIORAL HEALTH

PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide behavioral health (which encompasses mental health and substance use disorder treatment) services included in the comprehensive benefit package for members in Category of Aid (COA) 1, 2 and 5. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Please refer to the policy statement on Behavioral Health Fee-For-Service Coordination for information on specific behavioral services that are not included in the comprehensive benefit package.
MO HealthNet Managed Care health plan policies and procedures shall permit members to contact an in-network behavioral health provider directly without a referral or authorization from the primary care provider and shall provide for the authorization of at least four visits annually without prior authorization requirements.
Outpatient Facility, Psychiatry, Psychology, and Counseling

MO HealthNet Managed Care health plans are required to provide psychiatry, psychology, counseling, and outpatient facility services in accordance with the Medicaid State Plan for members in Category of Aid (COA) 1, 2 and 5. Medicaid State Plan psychiatry services are included under the physician program. Please refer to the Physician/Advanced Practice Nurse Services, Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs) policy statement for more detail regarding physician services. Please refer to the policy statement on Behavioral Health Fee-For-Service Coordination for information on specific behavioral health services that are not included in the comprehensive benefit package.


HCY Behavioral Health Services for Children

The MO HealthNet Managed Care health plans are required to provide the following behavioral health services in accordance with the Medicaid State Plan for child members under the age of 21. The following are included in HCY services:




  • Psychological services include testing, assessment, evaluation, and development of a treatment plan and treatment of behavioral health conditions;

  • Counseling services cover counseling for behavioral health conditions,;

  • Psychotherapy for Crisis is a face-to-face contact to diffuse a situation of immediate crisis. The situation is of significant severity to pose a threat to the member’s well being or is a danger to him/her self or others;

  • Developmental/Behavioral health screen is a screening of social/language development and fine/gross motor skill development.

The following are behavioral health procedures covered under HCY:



  • 99429 59 -- EPSDT Developmental/Behavioral health partial screen without a referral for further medical services;

  • 99429 59 UC -- EPSDT Developmental/Behavioral health partial screen with a referral for further medical services;

  • 90791– Assessment (psychiatric diagnostic evaluation);

  • 90792- Assessment (psychiatric diagnostic evaluation with medical services);

  • 90832– Psychotherapy 30 minutes;

  • 90834–Psychotherapy 45minutes;




  • 90846-– Family therapy without member present;

  • 90847 – Family therapy with member present;

  • 90853 – Group therapy;

  • 96101-– Psychological testing;

  • 90839– Psychotherapy for Crisis.


Psychiatric Inpatient Facility

In the Fee-For-Service Program, services provided in a psychiatric hospital are covered for members below the age of 21 and members 65 years and older. Inpatient psychiatric services must involve “active treatment,” which means implementation of a professionally developed and supervised individual plan of care. Members between 21 and 64 access psychiatric inpatient care through acute care hospitals.


Detoxification Services

MO HealthNet Managed Care health plans are required to provide detoxification services during the intoxication and/or withdrawal stages of a substance use disorder. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. The initial length of stay is limited to three (3) days. The attending physician or hospital may request additional days if extended acute care are medically necessary.
Court Ordered Services

MO HealthNet Managed Care health plans are required to provide services in the comprehensive benefit package that are court ordered and for involuntary commitments (including 96 hour detention) regardless of medical necessity.


Smoking Cessation

MO HealthNet Managed Care health plans are not required to provide smoking cessation behavioral intervention services to MO HealthNet Managed Care enrollees. MO HealthNet Fee-For-Service will provide those services on a fee-for-service basis.


Children in Category of Aid 4

MO HealthNet Managed Care health plans are not required to provide behavioral health services for members in COA 04 (children in the care and custody of the State). MO HealthNet Fee-For-Service will provide those services on a fee-for-service basis. For inpatient claims with dual diagnoses (physical and behavioralrelated), the MO HealthNet Managed Care health plan shall be financially responsible for all inpatient hospital days if the primary, secondary, or tertiary diagnosis is a combination of physical and behavioral health disorders. These admissions are subject to the prior authorization and concurrent review process identified by the MO HealthNet Managed Care health plan.


School Based Services

For a child who is receiving behavioral health services identified in the child's Individualized Education Program (IEP), the services are billed fee-for-service and are not the responsibility of the MO HealthNet Managed Care health plan. Please refer to the policy statement on School Based Services for further information.


PROGRAM LIMITATIONS


  • Inpatient care that is not medically necessary and services provided at a non- acute care level are not covered;

  • Neuropsychological evaluations are not covered.

MISCELLANEOUS


The MO HealthNet Managed Care health plan network must include (although not be limited to) Qualified Behavioral Health Professionals (QBHP) substance use disorder or co-occurring treatment professionals that are certified by the Missouri Credentialing Board as defined in the contract.
As noted in the contract, the state agency, in conjunction with the Department of Mental Health, has developed community-based services with an emphasis on the least restrictive setting. The MO HealthNet Managed Care health plan shall consider, when appropriate, using such services in lieu of using out-of-home placement settings for members.
Please refer to the policy statement on Behavioral Health Fee- For-Service Coordination for information on specific behavioral health services that are not included in the comprehensive benefit package.
Please reference Section 13 of the Missouri MO HealthNet Hospital Manual for details regarding benefits and limitations in the hospital program. Special bulletins may also be referred online for additional information.
The Behavioral Health Services and Physician Manuals can be referenced online at the MO HealthNet Division website www.dss.mo.gov/mhd for additional information. Special bulletins may also be referred online for additional information.
BEHAVIORAL HEALTH FEE-FOR-SERVICE COORDINATION
PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are not required to provide Comprehensive Substance Treatment and Rehabilitation (CSTAR), Community Psychiatric Rehabilitation (CPR), targeted care management (TCM), DD Home and Community Based Waiver services offered through the Department of Mental Health (DMH), and Applied Behavior Analysis (ABA) services. The MO HealthNet Fee-For-Service Program will provide those services on a fee-for-service basis when provided by DMH certified providers or, in the case of ABA, when provided by MO HealthNet enrolled providers.
CSTAR, CPR, TCM, DD Home and Community Based Waiver Services, and ABA services are available to individuals who meet the eligibility criteria for these specific services on the same basis as the services are available to MO HealthNet/MO HealthNet Fee-For-Service referrals. For individuals enrolled in MO HealthNet Managed Care, application can be made for CSTAR, CPR, and related TCM services by the guardian in conjunction with the MO HealthNet Managed Care health plan. Applications for DD Home and Community Based Waiver Services may be made by the guardian or with assistance from the MO HealthNet Managed Care health plan for individuals, by contacting the local DD Regional Office. All ABA services require precertification.
Each MO HealthNet Managed Care health plan should work with DMH providers and regional offices in their area to develop protocols to assist in coordination of services and identify needs and capacity for these services. Referrals from MO HealthNet Managed Care health plans will be accepted as the current capacity of these services allows. If access to these services is not available at the time of referral, the MO HealthNet Managed Care health plan remains responsible for provision of all medically necessary services included in the comprehensive benefit package.
Comprehensive Substance Treatment and Rehabilitation (CSTAR)

CSTAR programs provide services to MO HealthNet members who are assessed as needing substance use treatment. CSTAR programs provide a continuum of treatment services and supports tailored to the needs of the member.


The following populations have first priority for service: 1) pregnant women; 2) post-partum women; 3) IV Drug Users, and 4) HIV patients. Referrals from MO HealthNet Managed Care health plans will be accepted as the current capacity of these services allows.

  • Non-Emergency Medical Transportation (NEMT) is available to use as an option to assist clients enrolled in the CSTAR program in accessing their assessments and medication services appointments with their physician or advance practice nurse who is managing and prescribing their medications. NEMT does not include visits for methadone dosing or the administration of other medications.

  • CSTAR services are “carved out” of the MO HealthNet Managed Care Program and are administered separately by the Department of Mental Health’s Division of Behavioral Health.

  • CSTAR MO HealthNet-enrolled providers are reimbursed on a fee-for-service basis by the Division of Behavioral Health.

  • It is essential for quality of care that there is timely communication among the CSTAR providers, the MO HealthNet Managed Care health plans, and their behavioral health subcontractors.

A protocol for coordinating care for pregnant members accessing CSTAR services is outlined below.




  • A substance use screening form is completed by a primary care provider or other practitioner to determine whether a substance use disorder is present.

  • A positive response to one or more questions should lead to brief intervention, further assessment or referral to a CSTAR provider.

  • Brief intervention is defined as advising the member to abstain from alcohol or other drugs.

  • Referral to a CSTAR provider by the MO HealthNet Managed Care health plan participating provider should occur when (1) There is a need for more thorough assessment, (2) The member has failed to cut down or remain abstinent, or (3) The member has a substance use disorder that is evident based upon evaluation and history.

  • The CSTAR provider will obtain a signed multiple party consent form from the client that will allow them to communicate with the MO HealthNet Managed Care health plan.

  • The CSTAR provider will provide notice to the MO HealthNet Managed Care health plan of the date of admittance. Following discharge of the client, a copy of the discharge plan will be provided to the MO HealthNet Managed Care health plan or their behavioral health subcontractor.

  • CSTAR providers and MO HealthNet Managed Care health plans shall collaborate to obtain needed psychiatric services for CSTAR enrolled patients.


Community Psychiatric Rehabilitation (CPR)

The DMH/Division of Behavioral Health through its Administrative Agents provide CPR which includes a range of essential community-based mental health services designed to maximize independent functioning and promote the recovery and self-determination of individuals. In addition, they are designed to increase interagency coordination and collaboration in all aspects of the treatment planning process. Ultimately they help to reduce inpatient hospitalizations and out-of-home placements.




  • CPR is carved out of the MO HealthNet Managed Care Program. The MO HealthNet Fee-For-Service Program will reimburse CPR certified providers according to the terms and conditions of the MO HealthNet program.

  • It is essential for quality of care that open and consistent dialogue exists between the CPR providers, the MO HealthNet Managed Care health plan and its behavioral health subcontractors.

  • The MO HealthNet Managed Care health plan and its mental health subcontractors will refer members seeking CPR services to a CPR certified provider. The CPR provider will conduct an assessment to determine eligibility and the appropriate level of care.

  • If the member refuses to receive care at a CPR provider, the MO HealthNet Managed Care health plan remains responsible for providing psychiatric services as required by the contract and may provide alternative services to divert the member from higher levels of care.

  • The MO HealthNet Managed Care health plan and the CPR provider are jointly responsible for coordinating services which may include participation in Family Support Teams for children/youth to outline the individual’s needs, strengths, and services/supports across all involved parties.

  • The CPR provider and MO HealthNet Managed Care health plan are responsible for documentation of services provided and denial of any services.


Targeted Care Management (TCM)

TCM services include the following:



  1. Arrangement, coordination, and participation in the assessment to ensure that all areas of the individual’s and family’s life are assessed to determine unique strengths and needs;

  2. Coordination of the service plan implementation, including linking individuals and families to services, arranging the supports necessary to access resources, and facilitating communication between service providers;

  3. Monitoring the service delivery plan with the individual and family participation to determine the adequacy and sufficiency of services and supports, goal attainment, need for additional assistance, and continued appropriateness of services and goals; and

  4. Documentation of all aspects of intensive targeted care management services including case openings, participation in assessments, plans, referrals, progress notes, contacts, rights and grievance procedures, discharge planning, and case closure.




  • TCM services are carved out of the MO HealthNet Managed Care program. MO HealthNet Fee-For-Service will reimburse TCM services provided by DMH/Division of Behavioral Health Administrative Agents.

  • The MO HealthNet Managed Care health plan and its behavioral health subcontractors will refer members seeking TCM services to the appropriate administrative agent/community mental health center (CMHC) in the area. The CMHC will conduct an assessment to determine if the individual meets criteria as having a serious emotional disorder or serious behavioral health disorder and is eligible for TCM.

  • The MO HealthNet Managed Care health plan remains responsible for all services included in the comprehensive benefit package.

  • The MO HealthNet Managed Care health plan and CMHC are jointly responsible for coordinating services which may include participation in Family Support Teams to outline the individual’s and family’s needs, strengths and services/supports across all involved parties.

  • The TCM provider and MO HealthNet Managed Care health plan are responsible for documentation of services provided and denial of any services.



Developmental Disabilities (DD) Home and Community Based Waivers:

The Division of DD administers five MO HealthNet Home and Community Based Waivers. Individuals eligible for MO HealthNet and who have intellectual/developmental disabilities may apply to participate in the DD Comprehensive Waiver or the DD Community Support Waiver, Partnership for Hope Waiver, or the Autism Waiver. The Missouri Children’s Developmental Disabilities Waiver (aka Lopez Waiver) serves children who are not otherwise eligible for MO HealthNet, and therefore does not apply to the MO HealthNet population. The Division of DD’s Regional Offices serve as gatekeepers for accessing waiver participation.


Individuals must have intellectual/developmental disabilities that result in functional limitations in three or more areas. The individuals must also be determined to qualify for Intermediate Care Facility for the Intellectually/developmentally disabled (ICF/ID) institutional services, and would otherwise require those services, but for receipt of services through the waiver. The five DD waivers contain services including but not limited to: Transportation, Personal Assistant, Community Specialist, Support Broker, Behavior Analysis Service, Professional Assessment and Monitoring, Person Centered Strategies Consultation, Environmental Accessibility Adaptations, Specialized Medical Equipment and Supplies. Residential Supports are only available in the Comprehensive Waiver. The provision of service through any of these DD waivers must be determined necessary to avoid institutionalization. Participants in the Support Waiver are limited to an annual service package that does not exceed $28,000; Autism Waiver not to exceed $22,000; and the Partnership for Hope not to exceed $12,000. Exceptions to these cost limitations can be granted on a case by case basis to assure health and safety. The average cost of all participants in the Comprehensive Waiver cannot exceed the average cost of all participants in the ICF/ID program.
Every individual who is determined eligible for Division of DD services is eligible for care management services. Care management for individuals who are MO HealthNet eligible, including participants in DD Home and Community Based Waivers, is provided as Targeted Care Management. Targeted Care management services are provided by Qualified Developmental Disabilities Professionals (QDDPs) employed by the Division’s regional offices and County Senate Bill 40 Boards and other not for profit entities that contract with the Division of DD to provide care management services.
ABA Services
In order to be eligible for ABA services, participants must be under 21 and have a diagnostic evaluation performed by a licensed physician or licensed psychologist, resulting in a diagnosis of Autism Spectrum Disorder (ASD), and recommending ABA services as medically necessary. The diagnostic evaluation should be performed in accordance with Autism Spectrum Disorders: Missouri Best Practice Guidelines for Screening, Diagnosis, and Assessment, published by the Missouri Autism Guidelines Initiative. These guidelines can be found at: http://autismguidelines.dmh.mo.gov/pdf/Guidelines.pdf. All ABA services require precertification, and instructions for requesting precertification are found in this bulletin: http://dss.mo.gov/mhd/providers/pdf/bulletin38-15_2015oct20.pdf.

Services Funded Through General Revenue (GR)

Comprehensive Psychiatric Services (CPS) provides an array of GR services that are not MO HealthNet covered and are, therefore, not considered an entitlement and may have limited capacity. The availability and capacity of any specific GR service varies across geographic areas. These services include but are not limited to:



  • Respite Care

  • Residential Care


General Procedures:

  • Any individual in Missouri may access these GR services based on eligibility and availability of the service as well as availability of funding.

  • Individual/families may be assessed a monthly fee for these GR services under the State’s Standard Means Test.

  • Individuals are assessed for eligibility and prioritized based upon acuity of clinical need and access to other health coverage and supports. There is no entitlement or guarantee of access to these services for any individual.

  • Individuals enrolled in MO HealthNet Managed Care may access these GR services under the above conditions. MO HealthNet Managed Care health plans are encouraged to develop plans with the appropriate community mental health center(s) in their geographic catchment area to aid in the assessment of the geographic area’s capacity needs.

  • MO HealthNet Managed Care health plans may also provide similar services if cost effective as a diversion from more intensive levels of care.

  • If an individual is placed on a waiting list for any of these GR services due to capacity limitations, the MO HealthNet Managed Care health plan remains responsible for the services covered under the comprehensive benefit package.

  • The MO HealthNet Managed Care health plan must demonstrate the need for the additional GR services to be provided by the CMHC.

  • The CMHC is responsible for determining eligibility for service provision, and in conjunction with the legal guardian in determining the appropriate level and types of services to be provided.


Child/Adolescent Procedures:

  • When a child is receiving services through CPS, the administrative agent shall facilitate a Family Support Team to develop a coordinated treatment plan. Team members should include the youth when appropriate, the youth’s parents or legal guardian, and all involved parties including the MO HealthNet Managed Care health plan’s clinical representative. The health plan staff shall actively participate in all Family Support Team meetings as the health plan remains responsible for coordination of care if the child is receiving intensive services through the administrative agents Community Psychiatric Rehabilitation (CPR) Programs.

  • The administrative agent will notify all parties, including the MO HealthNet Managed Care health plan representative of the first Family Support Team meeting.

  • After the first meeting, it is the responsibility of the MO HealthNet Managed Care health plan representative to inform the administrative agent how they wish to receive notification of future Family Support Team meetings as it was noted above that the health plans shall continue to provide intensive care management when a child/youth is in the CPR program.

  • Services identified in the coordinated treatment plan that are covered by the MO HealthNet Managed Care health plan will be provided by the network of the MO HealthNet Managed Care health plan.

  • The administrative agent shall coordinate with the MO HealthNet Managed Care health plan for authorization of these services.

  • The administrative agent shall document the involvement of the MO HealthNet Managed Care health plan in the record as well as authorization of the medically necessary services, and if denied, the reason for denial and any alternative services authorized.


Child Inpatient and Residential Services:

  • If a child enrolled with a MO HealthNet Managed Care health plan requires and is receiving inpatient psychiatric hospitalization, it is the MO HealthNet Managed Care health plan’s responsibility, in conjunction with the contracted inpatient provider, to plan for and obtain appropriate aftercare services.

  • If a recommendation has been made for residential placement due to the intensity and/or chronicity of the child’s needs, a referral can be made to the CMHC for residential treatment services.

  • It is the responsibility of the MO HealthNet Managed Care health plan to obtain all necessary information required to complete the application for placement through the Division of Behavioral Health and to demonstrate that community-based and less restrictive treatment options have been attempted in the care of the member and have not been successful, AND that there are no appropriate services that might otherwise be available to keep the member in his or her home and community.

  • The CMHC will conduct an assessment to determine if the child requires out of home placement, and is eligible for CPS funding.

  • Funding for residential care is limited as well as the availability of residential beds that would meet the child’s specific, individualized needs. Until an appropriate residential bed is available and funding has been obtained for residential services, the MO HealthNet Managed Care health plan is responsible for providing all services that are included in the comprehensive benefit package. It should be noted that residential services are not in any way an entitlement through CPS. If the community mental health center does not have the funding, or does not agree with a recommendation for residential placement, there is not mandate that the CMHC admit to residential. It would then remain the responsibility of the health plan to meet all the healthcare needs of the child.

  • If and when the child is placed in residential care through the Administrative Agent, the MO HealthNet Managed Care health plan is responsible for providing all services that are included in the comprehensive benefit package. That would include continuing to provide intensive care management since the child is receiving an intensive level of care.

  • If a MO HealthNet Managed Care enrolled child is receiving residential services through CPS, at least one month prior to the scheduled discharge the administrative agent shall communicate with the appropriate clinical representative from the MO HealthNet Managed Care health plan regarding the status of the child and aftercare planning.


Transition From MO HealthNet Managed Care to MO HealthNet Fee-For-Service

MO HealthNet Managed Care health plans remain responsible for all medically necessary services included in the comprehensive benefit package until the member is finally disenrolled from the MO HealthNet Managed Care health plan.

 For children known to be at risk to be disenrolled or to choose to opt-out, MO HealthNet Managed Care health plans and DMH providers will offer and encourage a Family Support Team Treatment Plan as described above.
MISCELLANEOUS
The DD Waiver, CSTAR, and Community Psychiatric Rehabilitation (CPR) program manuals can be accessed online at the MO HealthNet Division www.dss.mo.gov/mhd for additional information. Special bulletins may also be referred online for additional information.


DEPARTMENT OF MENTAL HEALTH PROTOCOL DEFINITIONS
Care Management

The arrangement and coordination of an individual’s treatment and rehabilitation needs, as well as other medical, social, and educational services and supports; coordination of services and support activities; monitoring of services and support activities to assess the implementation of the client’s individualized plan and progress towards outcomes specified in the plan.


Residential Treatment

This service consists of domiciliary care provided those who have been discharged from a mental health facility and those who would, without such services require inpatient care. Service provided includes room, board and habilitative services.


Respite Care – Youth

Temporary care provided by trained, qualified personnel, on a time limited basis, with the purpose of meeting family needs and providing behavioral health stabilization for families with children with severe emotional disturbance (SED). The service must be prescribed in the treatment or service plan as an essential clinical or supportive intervention for children and youth with SED under the age of 18. Respite may be provided in or out of the client’s home, community or at a DMH licensed site. Respite care supports the family or primary caregiver in maintaining a child with SED at home.


Targeted Care Management

Care management services include the following:



  • Arrangement, coordination, and participation in the assessment to ensure that all areas of the individual’s and family’s life are assessed to determine unique strengths and needs;

  • Coordination of the service plan implementation, including linking individuals and families to services, arranging the supports necessary to access resources and facilitating communication between service providers;

  • Monitoring the service deliver plan with the individual and family participation to determine the adequacy and sufficiency of services and supports, goal attainment, need for additional assistance and continued appropriateness of services and goals; and

  • Documentation of all aspects of intensive targeted care management services including case openings, participation in assessments, plan, referrals, progress notes, contact, rights and grievance procedures, discharge planning and case closure.


Administrative Agent

The agency provides a consortium of treatment services to consumers (both children and adults). The administrative agent and its approved designee are authorized by the Division of Behavioral Health as entry and exit points into the state behavioral health service delivery system for a geographic service area defined by the Division of Behavioral Health.


Family Assistance Worker

These services are provided for a child/adolescent. The services can be provided in the home or in a variety of settings, i.e., school, travel to and from school, home, social/peer settings, or in a group or one-to –one supervision. Services may be provided during varying hours of the day to best fit the need of the child/adolescent/family. Activities provided in the delivery of services may include home living and community skills, communication and socialization, and leisure activist for the child/adolescent.


The Family Assistance worker can provide one-on-one services to assist the child/adolescent with activities of daily living or to assure arrival at school or other commitments. The worker can teach appropriate social skills through hands-on experiences: i.e., displaying appropriate social interactions with the child/adolescent, or resolving conflicts with sibling or peers, etc. Other referral agencies used may include leisure community resources, recreation therapy itself, appropriate school resources, or other available community resources.
Family Support

Activities are designed to develop a support system for parents and caregivers of children and transitional age youth up to age 21 who have a serious emotional disturbance. Activities must be directed and authorized by the treatment plan. Activities may include, but are not limited to, problem solving skills, emotional support, disseminating information, linking to services and parent-to-parent guidance.


Community Psychiatric Rehabilitation (CPR):

A certified CPR program provides the following services:



  • Evaluation services--determines whether the individual is eligible for admission to the CPR program and that the individual is among the priority populations of Comprehensive Psychiatric Services.

  • Community Support--activities designed to ease an individual’s immediate and continued adjustment to community living by coordinating delivery of behavioral health services with services provided by other practitioners and agencies and monitoring client progress in organized treatment programs.

  • Family Support – This service may involve a variety of related activities to the development or enhancement of the service delivery system. Activities are designed to develop a support system for parents of children who have a serious emotional disturbance. Activities must be directed and authorized by the treatment plan. Activities may include, but are not limited to, problem solving skills, emotional support, disseminating information, linking to services and parent to parent guidance.

  • Intensive Community Psychiatric Rehabilitation -- level of support designed to help consumers who are experiencing an acute psychiatric condition, alleviating or eliminating the need to admit them into a psychiatric inpatient or residential setting. It is a comprehensive, time limited, community-based service delivered to consumers who are exhibiting symptoms that interfere with individual/family life in a highly disabling manner.

  • Psychosocial Rehabilitation (PSR) -- Services cover a combination of goal-oriented service functions delivered through a group activity in the context of a therapeutic community which promotes development of a personal support system, social skill development, training and rehabilitation in community living skills and pre-vocational skills according to individual need.

  • A CPR program must be certified by the Department of Mental Health or accredited by the Council on Accreditation of Rehabilitation Facilities (CARF), The Joint CommissionTJC, or Council on Accreditation (COA).

  • Family Support Team-- Comprised of the child, family, care manager/service worker, and representatives of other involved agencies (e.g., behavioral health plan, Children’s Division, Division of Youth Services, courts, schools) and other involved individuals (neighbors, minister). Teams are formed around the specific needs of an individual child and family therefore, the size and membership of the team varies. This team carries out and supports the service planning and delivery process.


Child/Youth Eligibility Criteria for Community Psychiatric Services

Serious Emotional Disturbance is a term used to describe children and youth who have serious disturbances in psychological growth. There are a number of characteristics that may distinguish these youth. The definition of serious emotional disturbance in the State of Missouri is defined as:



    • Children and youth under 18 years.

    • Children and youth exhibiting substantial impairment in their ability to function at a developmentally appropriate level due to the presence of a serious psychiatric disorder. They must exhibit substantial impairment in two or more of the following areas:

      • Self care including their play and leisure activities;

      • Social relationships: ability to establish or maintain satisfactory relationships with peers and adults;

      • Self direction: includes behavioral controls, decision making, judgment, and value systems;

      • Family life: ability to function in a family or the equivalent of a family (for a child birth through six years, consider behavior regulation and physiological, sensory, attentional, motor or affective processing and an ability to organize a developmentally appropriate or emotionally positive state);

      • Learning ability;

      • Self expression: ability to communicate effectively with others

    • Children and youth who have a serious psychiatric disorder as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). An “exclusive” diagnosis of Z Code, conduct disorder, mental retardation, developmental disorder, or substance use disorder as determined by a Department of Mental Health, Comprehensive Psychiatric Services Provider does not qualify as a serious emotional disturbance. Children from birth through three years may qualify with an Axis I or Axis II diagnosis as defined in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC-03).

    • Children and youth whose inability to function, as described, require behavioral health intervention. Further, judgment of a qualified behavioral health professional should indicate that treatment has been or will be required longer than six months.

    • Children and youth who are in need of two or more State and/or community agencies or services to address the youth’s serious psychiatric disorder and improve their overall functioning.

Serious emotional disturbance occurs more predictably in the presence of certain risk factors. These factors include family history of mental health conditions, physical or sexual abuse or neglect, alcohol or other substance use disorders, and multiple out of home placements. While these risk factors are not classified as specific criteria in the definition of serious emotional disturbance, they should be considered influential factors.



Adult Eligibility Criteria for Community Psychiatric Services

Serious and Persistent Mental Illness is a term used to describe adults suffering from severe, disabling mental illness. Must be age 18 years or over and meet each of the three criteria:



    • Adults exhibiting substantial impairment in each of the following areas:

      • Social role functioning—ability to functionally sustain the role of worker, student or homemaker; and

      • Daily living skills—ability to engage in personal care (grooming, personal hygiene, etc.) and community living activities ( handling personal finances, using community resources, performing household chores, etc.) at an age-appropriate level.

    • Adults with a primary diagnosis of one of the DSM-V Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Revised in 2013 listed below:

      • Schizophrenia disorder,

      • Delusional (paranoid) disorder,

      • Schizoaffective disorder,

      • Bipolar disorder,

      • Atypical psychosis,

      • Major depression, recurrent

      • Major depression, single episode (age 60 and over),

      • Obsessive-compulsive disorder,

      • Post-traumatic stress disorder,

      • Borderline personality disorder,

      • Generalized anxiety disorder,

      • Severe phobic disorder.

    • The individual must also meet at least one of the following criteria:

      • Has undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime (e.g. crisis response services, alternative home care, partial hospitalization or inpatient hospitalization.

      • Has experienced an episode of continuous, supportive residential care, other than hospitalization, for a period long enough to have significantly disrupted the normal living situation.

      • Has exhibited the disability specified in bullets above for a period of no less than a year.

      • The Daily Living Activities (DLA-20©) functional assessment may be used as an alternate means to establish eligibility for Community Psychiatric Rehabilitation programs, in accordance with DMH policy.

CERTIFIED NURSE MIDWIFE


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide certified nurse midwife services. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Certified nurse midwives may furnish all medically necessary services that are within their scope of practice. Prenatal care, deliveries, and postpartum care are within the scope of practice of a certified nurse midwife and are covered benefits. The scope of practice for certified nurse midwives is limited to females 15 years of age and over. A certified nurse midwife may also provide newborn care to infant's age 0 through 2 months.
Certified nurse midwives may provide family planning services and well woman checks within their scope of practice. The MO HealthNet Managed Care health plans must cover family planning services even when provided out of plan. In addition to the office visit, covered family planning services include: contraceptive implant (including insertion and removal), Medroxyprogesterone Acetate injections, oral contraceptives, and insertion of an intrauterine device. Also covered are any lab and x-ray procedures related to family planning and/or well woman checks. Refer to the Family Planning Policy Statement for additional information.
Covered Services


  • Services include management and provision of the care of a pregnant woman and her unborn/newborn infant throughout the maternity cycle which includes pregnancy, labor, and post partum care not to exceed 6 weeks for the woman and eight weeks (2 months) for the infant;

  • Prenatal Care includes history, physical, nutrition counseling, blood pressure, fetal heart tones, and routine lab;

  • Vaginal Delivery with or without episiotomy and/or forceps or breech delivery and six weeks post-partum care;

  • Global Care includes all prenatal, delivery, and post-partum care;

  • Newborn Care Physical exam or HCY screen, Hospital care   limited to one visit per day;

  • Family Planning may be provided within the scope of practice. This service must be covered by the MO HealthNet Managed Care health plan regardless whether or not the certified nurse midwife is enrolled with the MO HealthNet Managed Care health plan. This includes all laboratory and prescriptions related to the family planning service;

  • EPSDT/HCY Screens may be provided by a certified nurse midwife to female patients 15-20 years of age and infants 0-2 months of age if within the scope of practice. Refer to the EPSDT/HCY Policy Statement for specific information;

  • Well Woman Checks (within the scope of practice) and related laboratory and prescriptions.

MISCELLANEOUS
Refer to the MO HealthNet Managed Care Physician/Advanced Practice Nurse Services Policy Statement for additional information on this benefit package.
The Certified Nurse Midwife Manual can be referenced online at the MO HealthNet Division website www.dss.mo.gov/mhd for additional information. Special bulletins may also be referred online for additional information.

COMMUNICATION PLAN



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