Mo healthnet managed care policy statements table of contents



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MO HEALTHNET MANAGED CARE ADULT PREGNANT MEMBERS WITH ME CODES 18, 43, 44, 45, 61, 95, 96, and 98


The MO HealthNet Managed Care health plan is responsible for coverage of dentures and treatment of trauma to the mouth, jaw, teeth or contiguous sites, as a result of injury and all other Medicaid State Plan dental services for pregnant members with ME Codes 18, 43, 44, 45, 61, 95, 96, and 98. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity.

MO HEALTHNET MANAGED CARE ADULT MEMBERS (Age 21 AND OVER)


The MO HealthNet Managed Care health plan is responsible for treatment of trauma to the mouth, jaw, teeth or contiguous sites, as a result of injury or services when the absence of dental treatment would adversely affect a pre-existing medical condition. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity.
MEDICATIONS

Medications prescribed by a dentist for MO HealthNet Managed Care health plan members of any age are the responsibility of the MO HealthNet Fee-For-Service Program. Refer to the MO HealthNet Fee-For-Service Provider Manual for pharmacy coverage requirements.


PROGRAM LIMITATIONS

MO HealthNet limitations for certain dental services include, but are not limited to, specific time intervals, age, or primary or permanent teeth.


PRIOR AUTHORIZED SERVICES

If the MO HealthNet Managed Care health plan approves special dental service(s)/item(s) such as dentures for members which are delivered or placed after enrollment in the MO HealthNet Managed Care health plan ends, the MO HealthNet Managed Care health plan who approves the dental service(s)/item(s) such as dentures is responsible for payment. This does not apply to orthodontia service(s)/items(s).


MISCELLANEOUS

The Dental Provider Manual and the Dental Fee Schedule can be referenced online at the MO HealthNet Division website www.dss.mo.gov/mhd. Dental and Special bulletins may also be referred online for additional information.

DIABETES SELF-MANAGEMENT TRAINING


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide diabetes self-management training services for child members under 21 years of age and adult pregnant women with ME codes 18, 43, 44, 45, 61, 95, 96, and 98 with gestational, Type 1 or Type II diabetes. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Services include an initial assessment that must be at least one hour, and two education sessions of at least 30 minutes. The education sessions may be provided on an individual basis or in a group session of no more than 8 members.
The following professionals provide the service:


  • Certified Diabetes Educator (CDE): Must hold current certification from the National Certification Board for Diabetes Educators (NCBDE) through the American Association of Diabetes Educators (AADE). The CDEs practice under the Scope of Practice for Diabetes Educators developed by AADE.

  • Registered Dietician (RD): Must hold current certification from the Commission on Dietetic Registration through the American Dietetic Association (ADA). The RDs practice under American Dietetic Association Standards of Professional Practice by the ADA.

  • Registered Pharmacist (RPh): Must be a currently licensed pharmacist and must have completed the National Community Pharmacists Association (NCPA) “Diabetes Care Certification Program” OR completed the American Pharmaceutical Association (AphA)/AADE certification program “Pharmaceutical Care for Patients with Diabetes”.

PROGRAM LIMITATIONS


The program covers training upon initial diagnosis of diabetes, any significant change in the member’s symptoms, conditions, or treatment, and when there is a documented need for re-education or refresher training. A prescription from a physician or other health care provider with prescribing authority is required.
The initial assessment may only be performed by a physician or certified diabetes educator. One assessment per lifetime is covered.
The subsequent education visits may be provided by a CDE, RD, or RPh as described above. Education visits are limited to two per rolling year, per member, and may be a combination of group and individual visits. Additional visits require documentation of medical necessity from a physician or health care provider with prescribing authority.
MISCELLANEOUS
Information pertaining to diabetic supplies and equipment is found in the Durable Medical Equipment policy statement. The Physicians Manual can be referenced online at the MHD website www.dss.mo.gov/mhd for additional information. Please reference Section 13.71, Diabetic Self-Management Training. Special bulletins may also be referred online for additional information.

DURABLE MEDICAL EQUIPMENT


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide Durable Medical Equipment (DME) items. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. These items must be for use in the MO HealthNet Managed Care member's home when ordered by the MO HealthNet Managed Care member's PCP or nurse practitioner. DME is equipment that is necessary and reasonable for the treatment of the member's illness or injury or to improve the functioning of a malformed or permanently inoperative body part.
PROGRAM LIMITATIONS
Benefits under the DME program are limited to the following:


  • All medically necessary non-sterile ostomy supplies for ostomies are covered;

  • Augmentative communication devices;

  • Equipment such as wheelchairs, walkers (including batteries and accessories), hospital beds, canes, crutches, and decubitus care equipment;

  • Ventilators;

  • CPAP and BiPap devices;

  • Respiratory equipment;

  • Diabetic equipment and supplies (For MO HealthNet Managed Care health plan information, effective March 6, 2004, and thereafter, the FFS Program covers diabetic equipment and supplies under the Pharmacy program rather than under the DME program for those members not enrolled in Managed Care. The MO HealthNet Managed Care health plan may choose to offer diabetic equipment and supplies (excluding diabetic testing supplies which are included in the pharmacy carve-out) as either a DME or Pharmacy benefit.);

  • Orthotic and prosthetic devices;

  • Six prosthetic sheaths and socks are allowed per limb, per member per 12 month period;

  • Orthopedic shoes are covered only if they are an integral part of a brace. “Integral” means that the shoes are necessary for completeness of the brace;

  • Orthopedic shoes for a member with a diagnosis of diabetes are covered. The shoes do not have to be an integral part of a brace; and

  • Home parenteral nutrition.



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