The Medicaid program, enacted by Congress through Title XIX of the Social Security Act in 1965 at the same time as Medicare, exists as the largest of the federal-state partnerships for low-income people. Nationally, Medicaid and the Children’s Health Insurance Program (CHIP) provide public health insurance coverage to over 70 million low-income Americans,1 including working families, seniors, and individuals with diverse physical and mental disabilities. The federal government offers matching funds to states to support the financing of Medicaid. Each state administers its own Medicaid program. The federal Centers for Medicare and Medicaid Services (CMS) monitors state-run programs and establishes requirements for service delivery and quality, funding, and eligibility standards. State participation is voluntary, and all states have participated since 1982. Missouri’s participation in Medicaid (called MO HealthNet in Missouri) began in 1967.
Overview of MO HealthNet The Missouri Department of Social Services (DSS), the state plan MO HealthNet Division administers the provision and payment of services for Missouri’s MO HealthNet program. The DSS Family Support Division (FSD) determines MO HealthNet eligibility for individuals and families.
In general, MO HealthNet covers low-income children; their parents, guardians, or caretakers; pregnant women; and aged, blind, or disabled individuals. in addition, certain income and resource criteria must be met as well. Income criteria are largely based on federal poverty levels established by the federal government. Resource criteria (i.e., savings and other countable assets) largely apply only to aged, blind, and disabled people applying for MO HealthNet.
Parents, Children, and Pregnant Women
Children represent the largest demographic group served by Missouri state plan, with almost 63 percent of all MO HealthNet enrollees being age 18 or younger, with provisions for pediatric care. Pregnant women who meet certain income criteria are also eligible for coverage during their pregnancy and postpartum. Aged Approximately 78,100 Missourians age 65 and over were covered by MO HealthNet in SFY 2016. Eligible individuals must meet the income and resource requirements of the program. Missouri seniors can also “spend down” their incomes to qualify for MO HealthNet. In some cases, MO HealthNet assists seniors in paying their Medicare premiums, copayments, and deductibles to healthcare providers. People who are eligible for cash assistance through the federal Supplemental Security Income (SSI) program automatically qualify for MO HealthNet on the basis of disability. Other individuals who meet the SSI disability definition are also eligible as long as their income does not exceed 85 percent of the Federal Poverty Level (FPL) for disabled individuals and 100 percent of FPL for those who are blind. Additional people can qualify by spending down their incomes on medical expenses. Some people with a disability also receive MO HealthNet assistance to help pay their Medicare premiums, copayments, and deductibles.
People may have medical expenses deducted from income calculations to “spend down” to eligible levels. The Income Guidelines listed for Pregnant Women excludes Missouri’s Show-Me Health Babies Program, which provides pregnancy-related services to women with incomes between 201 and 305% FPL. Children, Pregnant Women, and Parents are subject to a 5% income disregard as a result of changes made in the Affordable Care Act to amend the Modified Adjusted Gross Income used to determine eligibility.
MO HealthNet Programs
MO HealthNet refers to the statewide medical assistance programs for elderly and disabled persons, low-income families, pregnant women, and children. MO HealthNet enrollees receive their health care through either the fee-for-service or the managed care delivery systems. MO HealthNet includes both federally matched and state only funded programs. The following sections discuss the six largest programs that together covered about 93 percent of the individuals enrolled in MO HealthNet in SFY 2016.
1. MO HealthNet for the Aged, Blind, or Disabled
MO HealthNet for the Aged, Blind, or Disabled (MHABD) is a state program provides Medicaid coverage to individuals who meet the requirements of Old Age Assistance (OAA), Permanently and Totally Disabled (PTD), or Aid to the Blind. These Missourians account for about 25 percent of all MO HealthNet consumers. Individuals who are over 65 or disabled and have incomes up to 85 percent of FPL qualify automatically, while others qualify for MHABD by spending down their incomes on medical expenses each month. Persons who are blind automatically qualify for MO HealthNet if they have incomes up to 100 percent of FPL. These individuals may also spend down on medical care and other expenses to qualify.
2. Qualified Medicare Beneficiary The federal government requires that state Medicaid programs pay Medicare premiums, deductibles, or coinsurance for qualified people enrolled in Medicare Parts A or B. The Missouri Qualified Medicare Beneficiary (QMB) program pays for Medicare premiums, deductibles, and coinsurance for eligible persons enrolled in Medicare Part A with incomes up to 100 percent of FPL. Approximately 14,400 individuals received benefits through the QMB program in SFY 2016. Additionally, Missouri has a Specified Low Income Medicare Beneficiary (SLMB) program that pays for all or part of the Medicare Part B premiums for persons whose incomes are more than 100 percent of FPL, but less than 175 percent of FPL. Approximately 24,500 individuals received assistance in SFY 2016 under the SLMB program. What’s Meant by “Spending Down”? Spending down refers to the amount of medical expenses that an individual must pay each month before becoming eligible for coverage through Medicaid. The total that must be spent down equals the amount by which an individual’s or couple’s net income exceeds the income eligibility requirement for a given Medicaid program. An individual’s spend down obligation can be met by: • submitting incurred medical expenses to their caseworker on a monthly basis; or paying the monthly spend down amount to the MO HealthNet Division, similar to an insurance premium payment. 2015-2016 MO HealthNet Enrollee Growth Seniors Persons With Disabilities Pregnant Women & Custodial Parents All Enrollees Children 2.2% 0.5% 19.7% 9.2% 10.0% 4 Missouri Medicaid Basics
3. MO HealthNet for Kids (Medicaid) This program provides health insurance coverage for children under age 19 whose net family income does not exceed: • 201 percent of FPL for children under age 1, and • 153 percent of FPL for children ages 1-18. Approximately 510,295 low-income Missouri children have health insurance coverage through this MO HealthNet program. This population represents 53 percent of all MO HealthNet recipients. (Note: About half of these children are classified under MO HealthNet for Families – Children because their parents are also eligible for MO HealthNet; however, they are eligible because of the above income requirements.)
4. MO HealthNet for Kids (CHIP) Using its allocated CHIP funds, Missouri expanded its existing Medicaid program for low-income children in 1998. This CHIP expansion extended health coverage to low-income children with family income up to 305 percent of FPL. The MO HealthNet for Kids (CHIP) program provides the same health services as those covered under MO HealthNet for Kids (Medicaid), except that CHIP kids are not eligible for nonemergency medical transportation. Based on an income scale, some individuals covered under Missouri’s CHIP program must pay premiums. Premiums paid per family per month range from $14 to $305 (see chart). Approximately 28,300 children had coverage under the MO HealthNet for Kids (CHIP) program in Missouri in SFY 2016. This number represents about 3 percent of the total MO HealthNet population.
5. MO HealthNet for Families – Adults Low-income parents and caretakers are covered through the MO HealthNet for Families (MHF) adult program. Parents with incomes up to the 1996 Aid to Families with Dependent Children (AFDC) income level (about 22 percent of FPL) are eligible for the program. In SFY 2016, about 94,300 adults had health insurance coverage through the MHF program. This group represents approximately 8 percent of all MO HealthNet recipients in the state of Missouri. 6. MO HealthNet for Pregnant Women Pregnant women with family incomes up to 201 percent of FPL qualify for Medicaid coverage under the MO HealthNet for Pregnant Women (MPW) program. Qualification under this category includes 60-day postpartum coverage even with subsequent increases in family income. Approximately 26,400 women received insurance benefits under this program during SFY 2016.
Delivery Systems
Missouri’s MO HealthNet program works to promote good health, to prevent illness and premature death, to correct or limit disability, to treat illness, and to provide rehabilitation to persons with disabilities. Health services covered by MO HealthNet can be split into two benefit packages: 1) Primary and Acute Health Care and 2) Long-Term Care. Primary and Acute Health Care MO HealthNet’s Primary and Acute Health Care package provides physician, hospital, laboratory, pharmacy, preventive, and other services. People have access to these services through either the fee-for-service system or the managed care system, depending on the MO HealthNet program for which they are eligible. All MO HealthNet enrollees, however, must obtain prescriptions through the traditional fee-for-service system. Fee-for-Service In Missouri, all individuals under the MHABD program participate in the fee-for-service system regardless of their county of residence. Prior to 2017, MO HealthNet children and parents that lived in counties other than those designated as managed care counties participated in the fee-for-service system. Missouri DSS, through the use of a claims processing fiscal agent, paid for services based on an established fee schedule. As of May 1, 2017, all children*, parents, and pregnant women will participate in Missouri’s Medicaid managed care system. MO HealthNet Managed Care The MO HealthNet managed care system (formerly known as MC+) started in 1995 when Missouri DSS first contracted with managed care plans in an effort to improve the accessibility and quality of health care services for Missouri’s MO HealthNet populations, while reducing the costs of providing care. Missouri initially used managed care plans to deliver Medicaid benefits to children, families, and pregnant women across a specific geographic corridor representing 54 counties and the cities of St. Louis, Kansas City, Columbia, and Jefferson City (see map on pg. 6). In 2015, Missouri’s state budget included an allocation for statewide Medicaid managed care in all 114 counties and the city of St. Louis for that same population. In response to this legislation, Missouri began revising its MO HealthNet Health Plan request for proposals (RFP) to include the expanded geographic region. The newest RFP was released in April 2016, with awards given to three managed care companies in October 2016. Services reflected in the contract are scheduled to begin May 1, 2017. MO HealthNet Managed Care Regions Beginning May 1, 2017 Current East Current West New Central Southwest Expansion * Children with disabilities have the option to use fee-for-service or managed care. MO HealthNet Managed Care Counties Prior to May 1, 2017 MO HealthNet Managed Care Plans as of May 2017: 1. Home State Health Plan (Centene) 2. Missouri Care (WellCare) 3. UnitedHealthcare of the Midwest Spring 2017 7 The contracted MO HealthNet managed care health plans provide a particular range of benefits to each enrolled recipient in return for a capitated payment made on a per member per month basis. The new state system, along with federal regulatory changes, mandate different safeguards to ensure beneficiaries obtain accessible care. Additional information on the requirements of managed care plans can be found in the MFH publication, Medicaid Managed Care Final Rule: Implications for Missouri at http://mffh.org/MMC. All MO HealthNet recipients must enroll in a managed care health plan if they fit into one of the following eligibility categories: parents/caretakers, children, pregnant women, and refugees; • other MO HealthNet children who are in the care and custody of the state and receive adoption subsidy assistance; and • CHIP children. Approximately 506,800 Missourians were enrolled in one of the three contracted MO HealthNet managed care plans in SFY 2016. This number will substantially increase with statewide enrollment and will likely cover more than 700,000 people.
Long-Term Care
MO HealthNet provides long-term care services to people who have chronic or disabling conditions and meet certain “level of care” criteria requiring skilled nursing and/or nursing facility services. These services fall into two categories based on the setting of service delivery. Medicare and private insurance rarely cover long-term care services; therefore, Medicaid typically becomes the primary source of coverage.
Facility-Based Care
Facility-based nursing care covers services provided in certain residential settings and accounts for one of the largest portions of MO HealthNet costs. Medicaid also covers care in residential facilities for eligible people with developmental disabilities, including intellectual disability. To qualify, individuals need a planned program of active treatment, must live in a licensed facility, and must meet certain other criteria. A large majority of Missourians living in intermediate care facilities for individuals with intellectual disabilities are MO HealthNet consumers.
Community-Based Care Community-based care in Missouri’s MO HealthNet program supports a number of Home-and Community-Based (HCB) waivers that allow certain consumers to receive care in their homes or in the community rather than in a nursing facility or other institution. HCB services, available on a limited basis (i.e., a specific number of slots for each type of HCB waiver), have eligibility requirements based on income, resources, and level of care required.