Missouri Medicaid Program Changes SFY 2006
Senate Bill 539 was passed by the 93rd General Assembly and becomes effective August 28, 2005. The bill eliminates certain optional Medicaid services for adults. The Department of Social Services budget bill (HB11) is still pending the signature of the governor so additional changes may occur. The Division of Medical Services plans to implement all changes on September 1, 2005.
Medical Services Reduction
Services reduced or eliminated for adult Medicaid recipients except for those in the categories of assistance for pregnant women, the blind, and nursing facility residents:
- Comprehensive Day Rehabilitation - eliminated
- Dental Services (including dentures) - Adult coverage is limited to treatment for trauma or disease/medical related
- Durable Medical Equipment - eliminated, (examples of eliminated equipment include, but are not limited to, wheel chair accessories and batteries, three wheeled scooters, decubitus care cushions and mattresses, patient lifts, trapeze, all body braces (orthotics), hospital beds and side rails, commodes, catheters, canes, crutches, walkers, parenteral and enteral nutrition, artificial larynx, and augmentative communication devices.
NOTE: Oxygen and respiratory equipment is covered except for CPAP, BiPAP, and nebulizers)
- Rehabilitation Services (i.e. occupational, speech or physical therapy) - eliminated
- Diabetes Self Management Training - eliminated
- Audiology-hearing aids and associated testing services - eliminated
- Optical Services - eliminated (except for one eye exam every two years)
- Foot Care Services - procedure codes 11719, 11720, 11721, 11750, and 29540 will no longer be covered
Reminder - Medicaid/MC+ children and those in the assistance categories for pregnant women, blind recipients, and nursing facility residents will still be covered for the above services.
Prior Authorizations
All Prior Authorizations for the above services will end August 31, 2005. Services will not be paid if they are for dates of service after August 31, 2005 even if they were previously approved. Items that were ordered or fabricated prior to September 1 will be paid.
Copayments
Copayments are due at the time of service or at a later date. Providers may not deny or reduce services on the basis of the recipient's inability to pay the copayment amount when charged. If it is the routine business practice of a provider to discontinue future services to an individual with uncollected debt, the provider may include uncollected copayments under this practice. The following services are subject to the copayment requirement:
- All optometric services (eye exam every two years);
- Inpatient hospital services;
- Hospital outpatient, clinic or emergency services; and
- All physician-related services
There are exemptions to the copayment requirement. They include, but are not limited to, the following:
- Recipients under 19 years of age;
- Managed Care enrollees;
- Persons receiving Medicaid under a category of assistance for pregnant women or the blind;
- Services to residents of a skilled nursing facility; intermediate care nursing home; residential care home; adult boarding home or psychiatric hospital;
- Services to recipients who have both Medicare and Medicaid if Medicaid covers the service and provides payment;
- Emergency or transfer inpatient hospital admissions;
- Emergency services provided in a hospital outpatient clinic or emergency room to treat a life threatening condition;
- Certain therapy services (physical therapy, chemotherapy, radiation therapy, psychotherapy, and chronic renal dialysis) except when provided as an inpatient hospital service;
- Family planning services;
- Services provided to pregnant women, directly related to the pregnancy or complications of the pregnancy;
- Foster Care recipients;
- In-Home/Personal care services;
- Hospice services;
- Medically necessary services identified through an Early Periodic Screening, Diagnosis and Treatment screen (EPSDT);
- Mental Health services;
- Medicaid Waiver services
Pharmacy
The recipient portion of the pharmacy prescription dispensing fee ($.50 - $2.00) is not changed.
A provider bulletin with specific details is expected to be available no later than July 15, 2005, and may be viewed at www.dss.mo.gov/dms.
updated 7/11/05