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Training Objectives Authority and Requirements for Medicaid State Plan

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Presentation on theme: "Training Objectives Authority and Requirements for Medicaid State Plan"— Presentation transcript:

1 Training Objectives Authority and Requirements for Medicaid State Plan
Missouri Medicaid State Plan through MO HealthNet Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Healthy Children and Youth (EPSDT in Missouri) State Plan services offered through Department of Health and Senior Services, Division of Senior and Disability Services State Plan Behavioral Health Services MO HealthNet State Plan Durable Medical Equipment Non-Emergency Medical Transportation Five Medicaid waivers operated through MO Department of Health and Senior Services Managed Care in Missouri Health Homes

2 Missouri Medicaid State Plan
State plan services under the authority of Title XIX Social Security Act Federal and state entitlement program Through Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Administered in Missouri by MO HealthNet (Missouri Medicaid authority)

3 Missouri Medicaid State Plan
States must meet certain service requirements: Services Shall be similarly offered in all parts of a state – “statewideness” Provided to all eligible groups must be equal and comparable in scope, intensity, and duration Not have Limitations that discriminate among Medicaid recipients based on medical condition or diagnosis

4 Missouri Department of Social Services (DSS) Programs Divisions
Family Support Division MO HealthNet Division Children’s Division Division of Youth Services

5 Missouri Department of Social Services (DSS) Medicaid State Plan
Family Support Division (FSD) Determines Individual’s Eligibility for Missouri’s Medicaid Program MO HealthNet Division (MHD) Administers the Missouri Medicaid Program State Administrative Authority for all MO Division of DD Waivers and MO Department of Health and Senior Services Waivers

6 Missouri Medicaid State Plan
Missouri Department of Social Services, MO HealthNet Division (MHD) Medical Services through MO HealthNet State plan offers medical services and items to persons who meet certain eligibility requirements as determined by Missouri Department of Social Services, Family Support Division (FSD) Extensive services covered, such as inpatient and outpatient hospital services, physician, nursing, x-ray and laboratory, ambulance

7 MO HealthNet Provider Search

8 MO HealthNet State Plan and DD Waiver Services
CMS requires that any services available in MO HealthNet State Plan that can meet the individual’s assessed need(s), shall first be accessed and exhausted prior to providing MO Division of DD waiver services

9 MO HealthNet State Plan and 1915 ( c ) Waiver Services
CMS Instructions, Technical Guide and Review Criteria for 1915 ( c ) Waivers: Waiver services shall not duplicate state plan services However, 1915 ( c ) waiver services may: Supplement state plan services – surpassing amount, intensity and/or duration (“extended state plan” service) Complement state plan services – waiver services not covered under state plan There are ten 1915 ( c )Waivers in Missouri Five MO Division of DD Waivers Five MO Department of Health and Senior Services Waivers

10 State Plan and Waiver Services Through Missouri Department of Health and Senior Services (DHSS)
Bureau for Special Health Care Needs Healthy Children and Youth Program Medically Fragile Adult Waiver Division of Senior and Disability Services State plan personal care for adults Aged and Disabled Waiver Independent Living Waiver Adult Day Care Waiver

11 Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) available for persons under age 21 who are MO HealthNet eligible Expanded services to benefit the child under SSA 1905 (r) of the Social Security Act - authority to “diagnose, treat, or ameliorate” areas identified through screening Needs determined by medical necessity In Missouri, EPSDT is called “Healthy Children and Youth Program” (HCY)

12 Healthy Children and Youth (HCY) Services Authorized by Bureau for Special Health Care Needs (BSHCN)
BSCHN within the DHSS Division of Community and Public Health, Section for Healthy Families and Youth Specific services in HCY are prior authorized by DHSS Bureau for Special Health Care Needs (BSHCN) for children with Fee-for-Service MO HealthNet coverage: Private Duty Nursing Personal Care Aide Advanced Personal Care Aide Skilled Nursing Visits Authorized Registered Nurse Visits Administrative Case Management BSHCN receives the referrals for these six services The referral may come from the family, provider agency, physician or other state agency Authorization of all services is based on medical necessity All HCY services authorized through BSHCN requires a physician’s order

13 BSHCN Contact Information BSHCN link: If questions about BSHCN, contact Jefferson City office: Can refer you to a BSHCN regional office based on where you reside in the state BSHCN Regional Offices Contact Information: SHCNRegionMap.pdf

14 EPSDT and DD Waiver Services
If service available to child under state plan or expanded EPSDT, it may not be covered through the waiver for the child There are services which can be distinctly provided in a waiver that serves children, such as respite, and not duplicate what is in EPSDT In a waiver that serves just children (e.g., MOCDD), similar services in EPSDT cannot be furnished in the waiver (e.g., OT, PT, ST) If a waiver covers both children and adults, any waiver services that could be furnished in accordance with 1915 ( r ) of SSA shall be limited to adults because comparable services are available for children under EPSDT

15 Basic Personal Care-Agency Model (State Plan)
Authorized through Missouri Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) Medically oriented services provided to assist with activities of daily living Personal care services are provided in accordance with a service plan approved by the state or ordered by a physician Person assessed to have “impairments and unmet needs”, where if it were not for Personal Care services the person would need hospital or long-term care facility services Reasonable and necessary and with the intent to sustain or improve the person’s functional capacity Meet individual physical needs – not for purposes of general housekeeping

16 Basic Personal Care-Agency Model (State Plan)
Services provided in the person’s home Provided by a qualified individual who is not a family member or member of household Basic Personal Care Examples of reimbursable tasks May include Advanced Personal Care Services Examples include use of a lift for transfer, assist with oral medications prepared by LPN, passive range of motion according to care plan May include an authorized nurse visit(s) Only DHSS or designee conducts assessments and determines a person’s eligibility for state plan personal care, type, amount, etc. Division of DD Support Coordinator may refer persons to DHSS and document the determination made by DHSS

17 Basic Personal Care-Agency Model (State Plan)
Code of State Regulation 3c70-91.pdf Provider Manual-Section 13-Benefits and Limitations per/Personal_Care_Section13.pdf DHSS DSDS Home and Community Based Manual ex.php Click on Basic Personal Care-Agency Model (State Plan)

18 State Plan Personal Care Referral and Authorization
Process differs for individuals up to age 21 Provider or BSHCN may receive a referral from family, physician, hospital, other state agency, etc. Provider requests approval through BSHCN For individuals age 21 and older DHSS Case Manager initially receives referral, conducts assessment for Personal Care service eligibility, and notifies provider of authorization

19 Basic Personal Care-Agency Model (State Plan) and Division of DD Waiver Services
DD waiver Personal Assistant may be authorized when: The person’s need is outside the State Plan Personal Care limits Example: Limits on number of Personal Care units are reached and/or more assistance with ADLs and/or IADL’s is needed Individual requires Personal Assistant outside of their residence. Caregivers under State Plan Personal Care – Agency Model cannot accompany the person outside of the home Person has behavioral or medical needs, and they require a more highly trained personal assistant than is available under state plan (requires documentation in the Individual Support Plan to validate need for behavioral/medical service through Division of DD) When the personal assistant worker is related to the participant Caregivers under State Plan Personal Care-Agency Model cannot hire family members to provide Personal Care

20 Personal Care-Consumer Directed Model (State Plan)(CDS)
A person with a physical disability can hire, train, supervise, and direct persons to provide their state plan personal care DHSS determines person’s eligibility for CDS Eligibility Criteria: At least age 18 Physical disability Be able to self-direct their own care MO HealthNet eligibility Meet Nursing Facility Level of Care

21 Personal Care-Consumer Directed Model (State Plan)(CDS)
Person exercises individual choice when choosing who provides personal care A family member may be hired to be a personal care support through CDS, but cannot be the participant’s spouse or legally responsible relative Person self-directing is the Employer of Record CDS participant selects an HCBS provider, enrolled with MO HealthNet as a CDS provider. Payment is sent to HCBS provider to process employee payroll on behalf of the participant (Employer of Record) Types of Personal Care CDS tasks included but not limited to assistance with self-care, passive range of motion, mobility/transfer, turning/positioning

22 Personal Care-Consumer Directed Model (State Plan)(CDS)
Code of State Regulation for CDS rent/19csr/19c15-8.pdf DHSS DSDS Home and Community Based Manual ual/index.php Click on Personal Care-Consumer Directed Model (State Plan)

23 Personal Care-Consumer Directed Model (State Plan)and Division of DD Self-Directed Services
If a person is enrolled with Personal Care Consumer-Directed Model (State Plan), they cannot receive self-directed services through the Division of DD

24 State Plan Personal Care and DD Waiver Services
When a person’s need for personal assistance is strictly related to ADL’s and can be met through State Plan Personal Care program, the person will not be eligible for Division of DD waiver Personal Assistant service in accordance with requirement that state plan services must first be exhausted before waiver services can be provided State Plan Personal Care cannot be provided for anyone who is authorized to receive DD waiver Group Home or ISL Service Persons authorized Division of DD Host Home/Companion services are not eligible for State Plan Personal Care

25 DHSS, Division of Senior and Disability Services Home and Community Based Services Manual
For further information about and how to access DHSS Division of Senior and Disability (DSDS) services Referrals for Home and Community Based Services (HCBS) can be called in to DSDS by phone at DSDS HCBS Regional Evaluation Teams contact information is also in this link-to call for assistance with referrals Also provides information for entities that are interested in becoming service providers

26 DD Waiver Providers and DHSS Home and Community Based Service providers
Division of DD waiver providers may wish to enroll with MO HealthNet as providers of Home and Community Based Services authorized through DHSS Advantage: Can better ensure consistency in services for participants receiving both State Plan Personal Care-Agency Model and Personal Assistant through the Division of DD Waiver

27 DHSS Home and Community Based Service providers
Providers of State Plan Personal Care and other Home and Community Based services authorized through the Department of Health and Senior Services are required to enroll with Missouri Medicaid Audit and Compliance MO HealthNet Enrollment

28 Home and Community Based Provider Requirements
enrollment/home-and-community-based- services/ 19csr/19c15-7.pdf

29 MO HealthNet Behavioral Health Services
Medically necessary mental health services for MO HealthNet eligible persons Services include but are not limited to: Diagnostic assessment Psychological testing Individual Therapy Family Therapy Group Therapy

30 MO HealthNet Behavioral Health Services
MO HealthNet Behavioral Health services be may included in the school based services program for public schools Only services identified in the Individualized Education Plan will be reimbursable Link to Behavioral Health Services Manual: on_psy/Behavioral_Health_Services_Section13. pdf For Behavioral Health Services Questions – Contact Provider Education at

31 MO HealthNet Durable Medical Equipment (DME)
MO HealthNet State Plan covers a wide variety of medical equipment and supplies for both children and adults Services must be provided by a MO HealthNet enrolled DME provider Some items require prior authorization Some items require pre-certification; a real time authorization process initiated by a physician utilizing an on-line tool called CyberAccessSM Although Division of DD Support Coordinators cannot pre-certify or pre-authorize DME, they can help facilitate these processes

32 Durable Medical Equipment Resources
Before requesting any type of medical equipment or supplies through any Division of DD waiver, the Support Coordinator should check for potential coverage through MO HealthNet State plan by reviewing the DME provider manual ble_Medical_Equipment_Section13.pdf dme/Durable_Medical_Equipment_Section19.pdf

33 DME for Children Through Age 20
Examples include but are not limited to: Incontinence supplies Bath and shower chairs Pediatric hospital beds Nutrition Enteral feeding supplies Nasogastric tubing Metabolic formula

34 DME for Children and Adults
Examples include but are not limited to: Augmentative communication devices Canes and crutches Commodes, bed pans, urinals Supplies for decubitus care Diabetic shoes and inserts Hospital beds Orthotics and repairs Ostomy supplies

35 DME for Children and Adults
Patient trapeze lifts Hydraulic patient lifts Prosthetics and repairs Walkers Wheelchairs, including manual, power chairs, scooters and accessories NOTE: Vehicle modifications such as wheel chair lifts are not covered by state plan, and may be covered through the Division of DD waivers

36 Incontinence Supplies for Adults
MO HealthNet may cover incontinence supplies, when medically necessary, for adults NOT participating in a DD waiver Adults enrolled in any Division of DD waiver requiring incontinence supplies will have this need met through their waiver The need for incontinence supplies alone does not justify enrollment in a Division of DD waiver

37 DME Contact Information Individuals and families contact Participant services at Regional Offices and providers contact Provider Communications Unit at for general program information

38 Non-Emergency Medical Transportation (NEMT)
NEMT used for MO HealthNet-eligible persons or persons in a MO HealthNet managed care plan who do not have access to free appropriate transportation to and from MO HealthNet covered services Person in a MO HealthNet managed care plan gets NEMT from the health plan NEMT provides for arrangement of transportation and ancillary services Ancillary services: If away from home overnight, NEMT may assist with meals and lodging

39 Non-Emergency Medical Transportation (NEMT)
NEMT may use public transportation and other sources such as bus tokens, vans, taxis If person has their own car, or if a friend or neighbor provides transportation – may be able to get help with gasoline costs NEMT are for services near where person lives; if provider far away, may need approval from physician

40 How is NEMT Accessed? For regular appointments:
Must arrange NEMT at least 5 days before health care appointment Call , M-F, 8-5 p.m. For “urgent care appointments” NEMT may be arranged sooner if a medical problem comes up and physician says person can be seen Call , 24 hours/day, 7 days/week If an emergency, dial 911 or local emergency phone number

41 How is NEMT Accessed? Charge is $2 for each NEMT trip
NEMT cannot be denied if one cannot pay $2 No $2 charge if person: Is under age 19 Pregnancy Is blind Lives in a nursing home Uses public transportation, bus tokens, or if receives help to pay for gasoline

42 NEMT Will Not Provide a MO HealthNet Participant a Ride to These Services
Pharmacy Certain DME Services Services provided in the individual’s home such as personal care Adult Day Health Care services DD Waiver Services Some Comprehensive Substance Treatment Abuse and Rehabilitation (CSTAR) services Some Community Psychiatric Rehabilitation (CPR) services

43 MO HealthNet Exceptions Process
MHD may authorize payment for an essential non-covered medical service or item Reviewed on a case-by-case basis Exceptions requests only accepted from authorized health care prescribers licensed as a physician or advanced practice nurse

44 MO HealthNet Exceptions Process
Frequently Asked Questions: Participant contact for Exceptions Process: Participant Service Agent

45 Medicaid Waivers Through MO DHSS
May be an option for persons with developmental disabilities if determined to most effectively meet their unique needs Medically Fragile Adult Waiver Aged and Disabled Waiver Independent Living Waiver Adult Day Care Waiver AIDS Waiver

46 Medically Fragile Adult Waiver
Intended for persons served in the HCY Program who turn age 21 (hence, no longer eligible for HCY Program) Operated through MO DHSS BSHCN Services offered include: Private Duty Nursing Specialized Medical Equipment and Supplies Attendant Care Services Requires prior authorization through DHSS BSHCN

47 Aged and Disabled Waiver
Intended for MO HealthNet eligible persons aged 63 and older Operated through DHSS DSDS Meet Nursing Facility Level of Care Services offered include: Homemaker Services Chore Services Respite Care Services Advanced Respite Care Nurse Respite Care Home Delivered Meals Adult Day Care All waiver services must be authorized by a DSDS prior to service delivery DHSS DSDS Home and Community Based Manual Click on each of the services in the Aged and Disabled Waiver

48 Independent Living Waiver
Intended for MO HealthNet eligible persons aged years who have a physical disability (and possibly a cognitive disability) Persons who have also have a cognitive impairment must have had the onset on or after age 22 Persons who turn age 65 while enrolled in this waiver may stay on the waiver Operated through MO DHSS DSDS Services include: Consumer-directed personal care Persons must be able to self-direct their own care ILW provides additional personal care when state plan limits associated with CDS are exhausted Case Management Environmental Accessibility Adaptations Specialized Medical Equipment Specialized Medical Supplies DHSS DSDS Home and Community Based Manual Click on the Independent Living Waiver

49 Adult Day Care Waiver Intended for MO HealthNet eligible persons aged years who meet Nursing Facility Level of Care Operated through MO DHSS DSDS Sole service is Adult Day Care Effective 1/1/13 For persons over age 63, the Adult Day Care service has been added to the DHSS Aged and Disabled Waiver Adult Day Care waiver service replaces MO state plan Adult Day Health Care service - which will end 6/30/13 DHSS DSDS Home and Community Based Manual Click on the Adult Day Care Waiver

50 DHSS Home and Community Based Services and Division of DD Waivers
A person can only be enrolled in one waiver at a given time It is important for the Support Coordinator to determine if the person is receiving Home and Community Based services through State Plan and/or DHSS waivers

51 MO HealthNet Managed Care
Participation in a Managed Care plan is mandatory for certain eligibility groups in some regions of the state Participants who receive SSI, meet the SSI disability definition, or who receive adoption subsidy may choose to opt out of Managed Care and receive services on a Fee-for-Service basis Website for Medicaid Eligibility codes in Managed Care Managed Care plans are responsible for all acute, primary, rehabilitative, preventive care, and some mental health services for enrollees Managed care services:

52 MO HealthNet Managed Care
When assisting someone who is enrolled with a Managed Care plan to access MO HealthNet State Plan services, Support Coordinators will need to contact the individual’s Managed Care plan Website for Managed Care benefit information and health plan contact and program information Link to MO HealthNet “Puzzled by the Terminology?” document Managed Care plans are not responsible for Division of DD waivers

53 Health Home Health Home is a new service added to MO HealthNet State Plan in 2012 Health homes provide chronic disease management to people with co-occurring chronic physical or mental health conditions Health homes provide a Care Team of qualified health professionals to assist the participant to achieve and maintain better health and wellness

54 Health Homes are NOT Health homes are NOT a place of residence. People may live alone in a house or apartment, with family or others, or in a DD group home and still qualify for health home without having to move Health Homes are NOT managed care. Health home participants are not restricted in their choice of medical and specialty providers, including DD waiver providers

55 Health Homes, continued
Health homes DO NOT duplicate or supplant support coordination provided by DD Regional Offices, SB 40 Boards, or any TCM provider Health home care managers coordinate locally with other providers involved with a participant, including the TCM provider, the DD waiver provider, the physician, and other medical professionals

56 Health Homes, continued
Health homes have proven to have a positive impact on people’s health, through Reducing unnecessary use of emergency rooms Avoiding preventable hospital admissions More appropriate prescriptions – reduction of prescriptions for off-label use, and reducing the incidence of drug-to-drug interactions Reducing preventable surgeries

57 Health Homes, continued
Participants in health homes must have two pre-existing medical conditions or Diabetes alone to be eligible for the health home services

58 Health Homes, continued
Missouri has two health home programs Behavior health homes serve people with serious mental illness and/or substance abuse and other co-occurring conditions Behavioral Health home services are provided by community mental health centers Primary Care health homes serve people with certain physical health conditions Primary Care health homes include several federally qualified health centers and other medical systems meeting health home provider criteria

59 Health Homes, continued
What chronic conditions qualify? Serious Mental Health Condition Asthma Substance Abuse Disorders Diabetes Cardiovascular Disease – including hypertension Overweight (BMI>25) Developmental Disabilities Smoking or Diabetes* *qualifies a person for being at risk of having a second chronic condition

60 Health Homes For more information about health homes, please visit this website: /healthcarehome.htm


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