Mo healthnet managed care policy statements table of contents



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If a member enrolls with the health plan from another health plan, the health plan shall, within five (5) business days from the date of the state agency’s notification to the health plan of the member’s anticipated enrollment date, contact the member to determine the name of the other health plan in order to request relevant member information from the other health plan.



If the health plan is contacted by a member’s new health plan requesting relevant member information, the health plan shall provide such data to the health plan within five (5) business days of receiving the request. Claims history from CyberAccesssm may be used to fulfill this requirement.



If the health plan becomes aware that a member will transfer to another health plan, the health plan shall contact the other health plan within five (5) business days of becoming aware of the member’s transfer and shall share relevant member information and respond to questions regarding the member’s care needs and services.

The new health plan shall work with out-of-network providers and/or the previous health plan to effect a smooth transfer of care to appropriate in-network providers when a newly enrolled member has an existing relationship with a medical health, behavioral health provider that is not in the health plan's network. At a minimum, the health plan shall (1) facilitate the securing of a member's records from the out-of-network providers as needed, and (2) pay rates comparable to fee-for-service for these records, unless otherwise negotiated.


MANAGED CARE ADMINISTRATIVE PROCEDURE FOR MEMBER TRANSITION OF CARE TO ANOTHER MANAGED CARE HEALTH PLAN
Managed Care Health Plan Responsibilities


  • The current health plan shall notify the new health plan within five (5) business days of becoming aware of any Managed Care health plan member who will or has transferred from the current health plan to another health plan.




  • The current health plan shall email the completed Transition of Care (TOC) Form to the transition of care contact at the new health plan.

To be considered complete each section of the form must contain the requested information or a statement explaining why the information requested has not been provided. See sample form for further explanation.



New Health Plan Responsibilities

  • The new health plan staff shall, within one (1) business day of receiving the Transition of Care form:

  • Evaluate the Transition of Care Form information for need of a clinical review. If the new health plan staff determine a clinical review is needed, the Form will be forwarded to their clinical staff.

Examples of clinical transition include, but are not limited to, any member meeting the behavioral or physical health case or disease management eligibility requirements in the Managed Care Contract section 2.11.1, Care Management and 2.11.2, Disease Management.

  • Examples of Care Management eligibility, include, but are not limited to:

  • Children with elevated blood lead levels;

  • Cancer;

  • Chronic Pain with opioid dependence;

  • Hepatitis C in active treatment;

  • HIV/AIDS;

  • Individuals receiving services through a family-centered community-based coordinated care system that receives grant funds under Section 501(a)(1)(D) of Title V, as defined by the State agency in terms of either program participant or special health care needs;

  • Serious mental illness: Schizophrenia, Schizoaffective disorder, Bipolar Disorder, PTSD, Recurrent Major Depression, and moderate to severe substance use disorder.

  • Examples of Disease Management include, but are not limited to:

  • Major Depression,

  • Asthma,

  • Obesity,

  • Diabetes,

  • Hypertension, or

  • Serious Mental Illness and Substance Use




  • Staff from the new health plan shall be responsible for, but not limited to, the following:

  • Follow up with the former health plan and any other necessary contacts to ensure coordination of all member care needs and services are met.


Transition of Care Form


MEMBER INFORMATION

Member Name:

Last name, first name, middle initial

DCN: Eight figure MO HealthNet number

Reason for Transition:

Gender:

Female    Male DOB:

Enrollment Ended: Date: with Health Plan Name:

Other Insurance Coverage

Yes No Plan Name:

Primary Secondary Group #

Language

  If other, please specify:

Interpreter Needed?: Yes   No 

Caregiver Name:

Address: Street, City, State, Zip Code

Telephone:

PROVIDER INFORMATION ON FILE

PCP:

Name Last name, first name

Ph:

Fax:

Behavioral Health:

Name Last name, first name

Ph:

Fax:

Specialist:

Name Last name, first name

Ph      

Fax:

Specialist:

Name Last name, first name

Ph:

Fax:

CLAIMS INFORMATION / MEDICAL HISTORY

Diagnoses & Codes- Physical & Behavioral Health: All diagnoses with applicable codes for physical and behavioral health.







Medication: All medications listed to include over the counter and herbal medications

MANAGEMENT OF MEMBER

Does the member have any healthcare concerns where he/she may need urgent assistance from a care manager?

Physical Health Yes No If yes, describe concerns: Document reasons for urgent need for care management.
Behavioral Health Yes No If yes, describe concerns: Document reasons for urgent need for care management.

Member enrolled in:

Care Management

Yes No Type: Physical and Behavioral Health

Comments: Lead care management began on date-day/month/year with elevated blood lead level of__. Last lead level was __drawn on date: day/month/year. Next action date: day/month/year and describe action to be taken. Describe status at time of transfer. Behavioral Health care management for ADHD. Start date: day/month/year. Next action date: day/month/year and describe action to be taken. Name of therapist and psychiatrist. Next appointment dates: For therapist: day/month/year. For psychiatrist. Day/month/year. Status at time of transfer.

Primary Care Health Home

Yes No Clinic Name:

Comments: Date started in PCHH day/month/year. Document diagnosis that qualifies person for PCHH. Document coordinated activities with health home. Name of health plan care manager. Document the care management activities of the PCHH. Name of PCHH care manager.

Next action date: day/month/year and describe action to be taken. Status at time of transfer.

Disease Management Program

Yes No Type:

Comments: Identify which disease qualifies for disease care management program. Day/month/year started. Actions taken. Name of care manager.

Status at time of transfer.

CMHC Health Home



Yes No

CMHC Name:

Comments: Started in CMHC on day/month/year. Document diagnosis that qualifies person for CMHC. Document health plan coordinated activities with CMHC. Document the care management activities of the CMHC. Next action date: day/month/year and describe action to be taken. Status at time of transfer.

Health Coaching

Yes No Type:

Comments: Name of health coach, qualifying diagnosis for health coaching, day/month/year started, and actions taken. Status at time of transfer.

Member enrolled in:

Specify Yes, No, Unk, or NA

Date of Records or Conversations shared with Receiving Providers

Comments – list name of vendor/facility and any other comments

WIC

Yes

day/month/year

Name of Agency, start and end date (if applicable). Name of formula provided. Status at time of transfer.

First Steps (MO)

Yes

day/month/year

Name of person providing services, start and end date (if applicable). Description of activities provided. Status at time of transfer.

Individual Education Plan

Yes

day/month/year

Identify date of plan-how long plan is applicable, name of school. Provide plan if available. If not available, description of activities/services identified by the plan. Status at time of transfer.

Individual Family Service Plan

Yes

day/month/year

Identify date of plan-how long plan is applicable. Provide plan if available. If not available, description of activities/services identified by the plan. Status at time of transfer.

Parents as Teachers

Yes

day/month/year

Provide start/end date (if applicable). Name of Parents as Teachers staff. Document services provided. Status at time of transfer.

Mental Health Regional Center

Yes

day/month/year

Name of Center and description of services being provided- date started/and end date (if applicable). Name of staff/s assigned to member. Status at time of transfer.

Physical Therapy

Yes

day/month/year

Name and contact information of agency and staff providing services. Description of services being provided-date started/and end date (if applicable). Status at time of transfer. Number of hours provided by school (if applicable) and number of hours provided by health plan. Document if same or different provider for school and health plan.

Occupational Therapy

Yes

day/month/year

Name and contact information of agency and staff providing services. Description of services being provided-date started/and end date (if applicable). Status at time of transfer. Number of hours provided by school (if applicable) and number of hours provided by health plan. Document if same or different provider for school and health plan.

Speech Therapy

Yes

day/month/year

Name and contact information of agency and staff providing services. Description of services being provided-date started/and end date. Status at time of transfer. Number of hours provided by school (if applicable) and number of hours provided by health plan. Document if same or different provider for school and health plan.

Durable Medical Equipment (DME)

Yes

day/month/year

Name and contact information of agency and staff providing DME. Description of DME being provided-date started/and end date (if applicable). Status at time of transfer.

Home Health Agency

Yes

day/month/year

Name and contact information of agency and staff providing services. Description of services being provided-date started/and end date (if applicable). Status at time of transfer

Managed Care Plan Representative

Name of Health Plan Representative/Care Manager:


Telephone:


Fax:


Email address:


Name of person/s Transfer of Care Form faxed/emailed to:

  1. Name of all the providers and the date the TOC Form was distributed to them, their telephone and fax numbers and email address.

  2. Day/month/year to parent/guardian with all available contact information; phone, fax, and email address.

  3. To the new health plan staff and date, with all contact information; phone, fax, and email address.

      

Telephone:      

Fax:

E-mail address:

TRANSITION OF PREGNANT WOMEN INTO MO HEALTHNET MANAGED CARE HEALTH PLANS


PROGRAM DESCRIPTION
Transition of pregnant women into MO HealthNet Managed Care health plans will be an ongoing occurrence as members often become eligible as a result of their pregnancy. The MO HealthNet Managed Care health plans shall allow pregnant members to continue to receive services from their behavioral health provider, without any form of prior authorization, until the birth of the child, cessation of the pregnancy, or loss of MO HealthNet eligibility. The pregnant woman in her third trimester may elect to continue her established relationship with a provider for prenatal and obstetrical care regardless if the provider is in the MO HealthNet Managed Care health plan network or out of the MO HealthNet Managed Care health plan network. A relationship between a member and a provider is demonstrated by the member obtaining at least three prenatal visits from that provider.
Case Examples

Case One: The member is in her third trimester and currently receiving prenatal services. She has either selected a MO HealthNet Managed Care health plan or was auto-assigned. She wants to receive obstetrical services from an in-plan provider.
MO HealthNet Managed Care Health Plan Responsibility: The MO HealthNet Managed Care health plan does not require a referral from the member’s assigned or selected PCP. The MO HealthNet Managed Care health plan reimburses the in-network provider at the MO HealthNet Managed Care health plan’s negotiated rates.
Case Two: The member is in her third trimester and currently receiving prenatal services. She either selected a MO HealthNet Managed Care health plan or was auto-assigned. She wants to continue to receive obstetrical services from an out-of -plan provider.
MO HealthNet Managed Care Health Plan Responsibility: The MO HealthNet Managed Care health plan does not require a referral from the member’s assigned or selected PCP. The MO HealthNet Managed Care health plan reimburses the provider out-of-network rates. If the provider only has admitting privileges in an out-of-network hospital, the MO HealthNet Managed Care health plan is obligated to attempt to work with the out-of-network hospital and agree on a fee schedule. Reimbursement rates to either out-of-network hospitals or providers cannot be less than current fee-for-service rates.
Transportation is the responsibility of the MO HealthNet Managed Care health plan. MO HealthNet Managed Care members with ME codes 73 through 75 and 97 are not eligible for non-emergency transportation.
NOTE: Providers should encourage pregnant women with ME code 71, 72, 73, 74, 75, or 97 to apply for regular MO HealthNet.
TRANSPLANTS
PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are not required to provide transplants. MO HealthNet Managed Care health plans are required to provide pre-surgery assessment/evaluation, care and post transplant discharge follow up care. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Covered transplants include: heart, lung, liver, kidney, pancreas, small bowel, and stem cell transplants (including bone marrow, peripheral, and cord blood stem cell) or any transplant approved by the MO HealthNet Division (MHD).
Transplant services provided by MO HealthNet Fee-For-Service are the organ/stem cell procurement charges and the inpatient stay for the transplant from the date of transplant through the date of discharge. In addition to services covered as part of the transplant, MO HealthNet Fee-For-Service covers the transplant surgeon's fee, all physician, lab, etc. charges incurred during the transplant stay (date of transplant through date of discharge).
If there is a significant change in diagnosis not related to the transplant during the transplant stay, the health plan will be responsible for those services not related to the transplant. Any additional services not related to the transplant will be considered post-transplant services and the responsibility of the health plan.

According to 42 CFR 431.51, MHD must ensure freedom of choice of providers for services provided to members when those services are paid on a fee-for-service basis. When the MO HealthNet Managed Care health plan identifies a member as a potential transplant candidate, the MO HealthNet Managed Care member must be referred to an approved MO HealthNet transplant facility of their choice without regard to MO HealthNet Managed Care health plan preference. If a member is being referred to an out-of-state or non-approved MO HealthNet transplant facility for the transplant assessment/evaluation, the MO HealthNet Managed Care plan must notify the MO HealthNet transplant coordinator with this information prior to services being rendered.


MO HealthNet Managed Care health plans are required to provide pre-surgery assessment/evaluation and care (excluding the organ procurement or stem cell harvest), post-transplant discharge follow-up care after the inpatient transplant discharge.

  • Pre-surgery assessment/evaluation and care includes inpatient, outpatient, and physician services for the assessment and evaluation of the transplant member. Even though performed during the pre-transplant period, the transplant facility will bill the organ procurement or stem cell harvest to MHD.

  • Post-transplant discharge follow-up care includes all necessary medical services provided after the inpatient transplant discharge. To assure continuity of care, the primary care provider must be allowed to refer a transplant member to the transplant facility for follow-up transplant care.



Current Fee-For-Service guidelines for transplant coverage include:

  • Organ transplants-The member must meet the transplant facility protocol and be accepted as a transplant member;

  • Bone marrow transplants:

    • Members for bone marrow or peripheral stem cell transplantation must meet the member selection criteria established by the performing transplant facility;

    • Each request for coverage is reviewed by a physician and when deemed necessary, by a bone marrow transplant consultant. The recommendations of the physician or consultant are the basis for authorization or denial of the request for coverage.

  • Transplants must be prior authorized by MHD and must be performed at MHD approved transplant facilities.


Approved Fee-For-Service Transplant Facilities

Bone Marrow

Barnes-Jewish Hospital (Adult)-St. Louis, MO

Cardinal Glennon Children's Hospital-St. Louis, MO

Children's Mercy Hospital of K.C.-Kansas City, MO

Kansas University Medical Center-Kansas City, KS

St. Jude Children’s Research Hospital-Memphis, TN

St. Louis Children's Hospital-St. Louis, MO

St. Louis University-St. Louis, MO

St. Luke's Hospital/The Cancer Institute-Kansas City, MO

University of Nebraska-Omaha, NE


Heart

Barnes-Jewish Hospital*-St. Louis, MO

Cardinal Glennon Children's Hospital*-St. Louis, MO

Children’s Mercy Hospital – Kansas City, MO

St. Louis Children's Hospital-St. Louis, MO

St. Louis University-St. Louis, MO

St. Luke's Hospital of K. C. *-Kansas City, MO

University of Nebraska*-Omaha, NE


Kidney

Barnes-Jewish Hospital*-St. Louis, MO

Cardinal Glennon Children's Hospital*-St. Louis, MO

Children's Mercy Hospital of K.C.*-Kansas City, MO

Kansas University Medical Center*-Kansas City, KS

St. Louis Children's Hospital*-St. Louis, MO

St. Louis University*-St. Louis, MO

St. Luke's Hospital of K.C.*-Kansas City, MO

University of Missouri-Columbia*-Columbia, MO

University of Nebraska*-Omaha, NE



Kidney/Pancreas
Barnes-Jewish Hospital*-St. Louis, MO

Kansas University Medical Center*-Kansas City, KS

St. Louis University*-St. Louis, MO

University of Nebraska*-Omaha, NE


Liver

Barnes-Jewish Hospital*-St. Louis, MO

Cardinal Glennon Children's Hospital*-St. Louis, MO

Children’s Mercy Hospital-Kansas City, MO

Kansas University Medical Center*-Kansas City, KS

St. Louis Children's Hospital-St. Louis, MO

St. Louis University*-St. Louis, MO

St. Luke’s Hospital of K.C. – Kansas City, MO

University of Nebraska*-Omaha, NE

Lung

Barnes-Jewish Hospital*-St. Louis, MO

St. Louis Children's Hospital-St. Louis, MO
Heart/Lung

Barnes-Jewish Hospital*-St. Louis, MO


Intestine

Indiana University Health Inc. – Indianapolis, IN

University of Nebraska*-Omaha, NE
*Medicare-Certified Transplant Facility
Requests for transplants involving transplant facilities not listed and/or outside of Missouri will be considered on a case-by-case basis. Documentation from the referring physician to MHD indicating why the transplant member must have the procedure performed at an out-of-state facility must accompany the request.
MISCELLANEOUS
Refer to the Transplant Provider Manual and Bulletins located at the MO HealthNet Division website www.dss.mo.gov/mhd for detailed and specific information regarding benefits and limitations of the program. Special bulletins may also be referred online for additional information.

TRANSPORTATION SERVICES EMERGENCY AND NON-EMERGENCY


PROGRAM DESCRIPTION
MO HealthNet Managed Care health plans are required to provide emergency medical transportation by ground or air (when medically necessary and appropriate). Non-emergency medical transportation (NEMT) must be provided to MO HealthNet Managed Care members who do not have the ability to provide their own transportation to and from health care services including health care services that are carved out of the MO HealthNet Managed Care contracts. Ancillary services related to the NEMT must also be provided.
NEMT services are covered for all Managed Care ME Codes except:

  • NEMT services are not covered for MO HealthNet Managed Care members with ME codes 08, 52, 57, 64, and 73-75 and 97.


NEMT TRANSPORTATION REQUIREMENTS

MO HealthNet Managed Care health plans must arrange NEMT services for MO HealthNet Managed Care members accessing MO HealthNet covered services. In addition, MO HealthNet Managed Care health plans must arrange NEMT services for one parent/guardian and/or an attendant, if requested or appropriate, to accompany children under the age of 21. Members under the age of 17 will require the presence of a parent/guardian or another adult while being transported. Transportation will not be provided for a child under the age of 17 who is unaccompanied unless they are an emancipated minor. MO HealthNet Managed Care health plans must ensure that NEMT services are available 24 hours per day, 7 days per week, when medically necessary.


MO HealthNet Managed Care health plans are not required to provide transportation to MO HealthNet Managed Care members with access to free transportation at no cost to them, however, such MO HealthNet Managed Care members may be eligible for ancillary services. Also, MO HealthNet Managed Care health plans are not required to provide NEMT services to pharmacy services or to Durable Medical Equipment providers that provide free delivery or mail order services.
Some services already include NEMT. The MO HealthNet Managed Care health plan is not responsible to provide NEMT to these services. Examples are: Comprehensive Substance Treatment and Rehabilitation (CSTAR) services; hospice services; Developmental Disability (DD) Waiver services; adult day care services; and services provided in your home. School districts must supply a ride to a child's Individual Education Program (IEP) services. Transportation to CSTAR assessments and CSTAR medication services is covered by the Department of Mental Health CSTAR program and is not the responsibility of the Managed Care health plan. Transportation to Community Psychiatric Rehabilitation (CPR) medication services is covered by the Department of Mental Health CPR program and is not the responsibility of the Managed Care health plan. The Managed Care health plan is responsible for covering all other transportation services to behavioral health services except for psychosocial rehabilitation and community support.
The MO HealthNet Managed Care health plans must arrange the least expensive and most appropriate mode of transportation based on the MO HealthNet Managed Care member’s medical needs. The modes of transportation that may be utilized include, but are not limited to:

  • Public transit/bus tokens

  • Gas reimbursement shall be made at no less than the IRS standard mileage rate for medical reasons in effect on the date of service. The reimbursement methodology must be consistent for each member in a region.

  • Para-lift van

  • Taxi

  • Ambulance

  • Stretcher van

  • Multi-passenger van

The MO HealthNet Managed Care health plan must not utilize public transit for the following situations:



  • High-risk pregnancy

  • Pregnancy after the eighth month

  • High risk cardiac conditions

  • Severe breathing problems

  • More than three block walk to the bus stop

The MO HealthNet Managed Care health plan shall limit members to no more than three (3) transportation legs per day without requiring prior authorization.


NEMT ANCILLARY SERVICE REQUIREMENTS

In addition to authorizing the transportation services, the MO HealthNet Managed Care health plan shall authorize and arrange the least expensive and most appropriate ancillary services if:



  • The medical appointment requires an overnight stay, and

  • Volunteer, community, or other ancillary services are not available at no charge to the MO HealthNet Managed Care member.

For members under the age of 21, ancillary services may include an attendant and/or one parent/guardian to accompany the child.


The MO HealthNet Managed Care health plan shall authorize and arrange ancillary services for one parent/guardian when the child is inpatient in a hospital setting and meets the following criteria:

  • Hospital does not provide ancillary services without cost to the member's parent/guardian, and

  • Hospital is more than 120 miles from the member's residence, or

  • Hospitalization is related to a MO HealthNet covered transplant service.

If the MO HealthNet Managed Care member meets the criteria specified above, the MO HealthNet Managed Care health plan shall also authorize and arrange ancillary services to eligible MO HealthNet Managed Care members who have access to free transportation at no charge to the MO HealthNet Managed Care member or receive transportation from a Public Entity and such ancillary services were not included as part of the transportation service.
NEMT DEFINITIONS
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