Mo healthnet managed care policy statements table of contents



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Children under the age of 21


Benefits under the DME program for children under the age of 21 may only be limited by medical necessity. Medically necessary items or services identified as a result of a physician or health care provider visit or exam must be covered for members under the age of 21. DME benefits for children include items for children such as diapers, medical supplies, enteral nutrition, PKU nutrition, and positioning equipment.
MISCELLANEOUS
The Durable Medical Equipment Provider Manual, Clinical Criteria Documents, and Bulletins can be referenced at the MO HealthNet Division website, www.dss.mo.gov/mhd. Special bulletins may also be referred online for additional information.

EPSDT/HCY SCREENING SERVICES


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are responsible for ensuring that Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screens are performed on MO HealthNet Managed Care members under the age of 21. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity.
This program is referred to nationally as the EPSDT Program. In Missouri, this program is referred to as the Healthy Children and Youth (HCY) Program. Missouri follows the American Academy of Pediatrics' (AAP), July 1991, schedule for preventive pediatric health care as a minimum standard for frequency of providing full HCY screens.
The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that MO HealthNet provide medically necessary services to children from birth through age 20 years which are necessary to treat or ameliorate defects, physical or behavioral health, or conditions identified by an EPSDT screen regardless of whether or not the services are covered under the Medicaid State Plan. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. The MO HealthNet Managed Care health plan is responsible for providing all EPSDT/HCY services for their eligible members.
A full EPSDT/HCY screening must include the following components:


  • A comprehensive unclothed physical examination;

  • A comprehensive health and developmental history including assessment of both physical and behavioral health development;

  • Health education (including anticipatory guidance);

  • Appropriate immunizations according to age;

  • Laboratory tests as indicated (appropriate according to age and health history unless medically contraindicated);

  • Lead screening according to established guidelines;

  • Hearing screen;

  • Vision screen;

  • Dental screen.

Appropriate providers may provide partial screens, which are segments of the full screen. The purpose of this is to increase access to care to all children. Providers of partial screens are required to have a referral source for the full screen. For MO HealthNet Managed Care health plan members, this should be the primary care provider who may be a physician, nurse practitioner or midwife. A partial screen does not replace the need for a full medical screen that includes all of the above components. See Section 9 of the MO HealthNet provider manual for specific information on partial screens.


MO HealthNet Managed Care health plans are responsible for required immunizations and recommended laboratory tests. Lab services performed during the screen are reported separately. MO HealthNet Managed Care health plans must provide immunizations in accordance with the Advisory Committee on Immunization Practices (ACIP) guidelines and acceptable medical practice. MO HealthNet Managed Care health plans are to report vaccines according to the guidelines outlined in the Vaccine for Children Program policy statement.
If a problem is detected during a screening examination, the child must be evaluated as necessary for further diagnosis and treatment services. The MO HealthNet Managed Care health plan is responsible for the further diagnosis and treatment services.
The medical record must document that all required components of the screening were performed. If for some reason a small portion of a component of the screen was not performed, the medical record must document why it was not provided and that follow-up is required. Use of the Lead Screening Guide is mandatory for all children age 6-72 months and must be retained in the medical record in paper or electronic format. The Healthy Children and Youth Screening and Lead Risk Assessment Guides are available in an electronic format through MO HealthNet’s Web tool, CyberAccesssm.
MISCELLANEOUS
Reference Section 9 of the Missouri MO HealthNet Provider Manual for Healthy Children and Youth Program; Healthy Children and Youth Screening Guides; and periodicity schedule that is available 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.

FAMILY PLANNING


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide family planning services. 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 health plans must provide freedom of choice for family planning and reproductive health services which may be accessed out of network. Examples of reproductive health services are: contraception management, insertion of contraceptive implant, IUD, Depo Provera Injections, Pap test, pelvic exams, Sexually Transmitted Diseases (STD’s) testing, and family planning counseling/education on various methods of birth control. Sterilization procedures are not covered for members under the age of 21. The member must sign the (Sterilization) Consent Form at least 30 days but not more than 180 days prior to the date of the sterilization procedure.
The MO HealthNet Managed Care health plans must ensure:

  • All lab and x-ray services provided as part of a family planning encounter are payable as family planning services;

  • HIV blood screening testing performed as part of a package of screening testing and counseling provided to women and men in conjunction with a family planning encounter is payable as family planning services;

  • A pregnancy test is family planning related: if provided at the time at which family planning services are initiated for an member; at points after the initiation of family planning services where the member may not have used the particular family planning method properly; or where the member is having an unusual response to the family planning method;

  • Services are provided/prescribed by physician/advanced practice nurse for medically approved diagnosis, treatment, counseling, drug, supply, or device to members of childbearing age;

  • For family planning purposes, sterilization shall only be those elective sterilization procedures performed for the purpose of rendering a member permanently incapable of reproducing and must always be reported as family planning services, in accordance with mandated federal regulations 42 CFR 441.250 - 441.259;

  • The (Sterilization) Consent Form, PSFL-200, meets all the criteria required by the Centers for Medicare and Medicaid Services in 42 CFR 441.250 through 441.259;

  • A properly completed (Sterilization) Consent Form, PSFL-200, is obtained from the performing provider.

  • All exams, laboratory, and x-ray services for family planning purposes are covered for children and adults.

Federal regulations 42 CFR 441.250 - 441.259 require the following:



  • Informed consent has been given;

  • The member must sign the (Sterilization) Consent Form at least 30 days but not more than 180 days prior to the date of the sterilization procedure. The day after the signing is considered the 1st day when counting the 30 days. The only exceptions to this time requirement are premature delivery or emergency abdominal surgery:

    • For premature delivery, the consent form must be completed and signed by the member at least 72 hours prior to sterilization and at least 30 days prior to the expected date of delivery;

    • For emergency abdominal surgery, the consent form must be completed and signed by the member at least 72 hours prior to the sterilization procedure.

  • The member must be at least 21 years of age on the date of signing the consent form;

  • The member must be mentally competent;

  • The following procedures require a (Sterilization) Consent Form, PSFL-200:

    • Vasectomy, unilateral or bilateral (separate procedure), including post-op semen examination(s);

    • Laparoscopy, surgical-with fulguration of oviducts (with or without transection);

    • Laparoscopy, surgical-with occlusion of oviducts by device (e.g., band, clip, or Falope ring);

    • Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral;

    • Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure);

    • Ligation or transection of fallopian tube(s) when done at the time of cesarean section or intra-abdominal surgery (not a separate procedure);

    • Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach;

PROGRAM LIMITATIONS


These services are not covered.

  • condoms and family planning devices or supplies available as non-prescribed, over-the-counter products;

  • reversal of a sterilization procedure;

  • abortions for the purpose of family planning because abortions are not family planning services, and should not be reported as such;

  • hysterectomies for the purpose of family planning;

  • Procreative management, i.e. tubal reversal, artificial insemination, etc.

MISCELLANEOUS


The Physician’s Manual, the Certified Nurse Midwife Manual and the (Sterilization) Consent Form, PSFL-200 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.
Refer to the MO HealthNet Managed Care Physician/Advanced Practice Nurse Services Policy Statement and bulletins for additional information.
FRAUD, WASTE, AND ABUSE

PROGRAM DESCRIPTION


In accordance with 42 CFR Parts 438 and 455, MO HealthNet Managed Care contract requirements and policy statements regarding fraud, waste, and abuse, the MO HealthNet Managed Care health plans must perform fraud, waste, and abuse prevention, coordination, detection, investigation, enforcement activities, and report to and cooperate with the Department of Social Services, MO HealthNet Division (DSS/MHD), MO HealthNet Managed Care Unit, specifically the Missouri Medicaid Audit and Compliance (MMAC) Unit and other key stakeholders as appropriate.
DEFINITIONS OF FRAUD, WASTE, AND ABUSE

The first step in combating fraud, waste, and abuse (FWA) is deterrence. It is equally important to to identify FWA when it occurs. This section provides definitions of FWA to assist in prevention, coordination, detection, investigation, and enforcement as well as reporting responsibilities.


MO HealthNet/MO HealthNet Managed Care Fraud -- Any type of intentional deception or misrepresentation made by an entity or person in a MO HealthNet Managed Care health plan with the knowledge that the deception could result in some unauthorized benefit to the entity, himself, or some other person.
MO HealthNet/MO HealthNet Managed Care Abuse -- Practices in the MO HealthNet Managed Care health plan that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the MO HealthNet Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations for health care. A MO HealthNet Managed Care health plan, contractor, subcontractor, provider, or MO HealthNet Fee-For-Service/MO HealthNet Managed Care member, among others, can commit the abuse. It also includes beneficiary practices in the MO HealthNet Managed Care health plan that results in unnecessary cost to the MO HealthNet program or MO HealthNet Managed Care health plan, contractor, subcontractor, or provider. It should be noted that MO HealthNet funds paid to a MO HealthNet Managed Care health plan, then passing to subcontractors, are still MO HealthNet funds from a fraud and abuse perspective.
KEY STAKEHOLDERS IN CONTROLLING FRAUD, WASTE, AND ABUSE

There are several key stakeholders who have roles and responsibilities in controlling fraud, waste, and abuse. Key stakeholders include, but are not limited to:




  • MO HealthNet Division (MHD) MO HealthNet Managed Care Unit

  • Missouri Medicaid Audit and Compliance (MMAC) Unit

  • Family Support Division (FSD)

  • MO HealthNet Managed Care health plans

  • State Medicaid Fraud Control Unit (MFCU) (Provider Fraud-Attorney General’s Office)

  • DSS MO HealthNet Investigation Unit (MIU)


PROCEDURE

Each MO HealthNet Managed Care health plan shall implement internal controls, policies and procedures for prevention, coordination, detection, investigation, enforcement and reporting of fraud, waste, and abuse (FWA) in accordance with the MO HealthNet Managed Care contract and the MO HealthNet Managed Care health plan’s FWA plan. The health plan’s FWA plan must designate a compliance officer and compliance committee which are responsible for the FWA program and activities.



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