MO HealthNet Managed Care Overview

The Department of Social Services, MO HealthNet Division (MHD) (formerly known as the Division of Medical Services) operates a Health Maintenance Organization (HMO) style managed care program called MO HealthNet Managed Care. The State of Missouri contracts with MO HealthNet Managed Care health plans (also referred to as Managed Care Organizations (MCOs)) to provide health care services to enrollees. MO HealthNet Managed Care health plans are paid a monthly capitation payment for each enrollee they serve.

Participation in MO HealthNet Managed Care is mandatory for certain eligibility groups within the regions in operation. MO HealthNet Managed Care eligibles are given 15 calendar days from the time of their eligibility determination to select a MO HealthNet Managed Care health plan. Children in the care and custody of the State of Missouri have 90 calendar days to choose a MO HealthNet Managed Care health plan. All members of a family are encouraged to select the same MO HealthNet Managed Care health plan but it is not mandatory. If a MO HealthNet Managed Care health plan is not chosen, one is automatically assigned.

Once enrolled in a MO HealthNet Managed Care health plan, enrollees have a 90-day change period to transfer to a different MO HealthNet Managed Care health plan for any reason. Once the 90-day change period ends, the enrollee is locked into the MO HealthNet Managed Care health plan for one year. There is an annual open enrollment period at their anniversary date at which time they may choose to transfer to a different MO HealthNet Managed Care health plan for any reason. Enrollees may change MO HealthNet Managed Care health plans at other times for just cause. Examples of just cause are: (1) provider with whom the enrollee has an established relationship is no longer in their MO HealthNet Managed Care health plan but does participate in another MO HealthNet Managed Care health plan; (2) transfer to another MO HealthNet Managed Care health plan is necessary to ensure continuity of care; and (3) an act of cultural insensitivity that negatively impacts the enrollee’s ability to obtain care and cannot be resolved by the MO HealthNet Managed Care health plan. Children in Care and Custody of the State may change MO HealthNet Managed Care health plans as often as circumstances necessitate.

Services are monitored for quality, enrollee satisfaction, and contract compliance. Quality is monitored through various on-going methods including, but not limited to, MCO Health Employer and Data Information Set (HEDIS) indicator reports, annual reviews, enrollee grievances and appeals, targeted record reviews, and annual external quality reviews.

Consumer input into services, processes, and programs is obtained through quarterly meetings of the MO HealthNet Consumer Advisory Committee (CAC) and from annual enrollee satisfaction surveys.

Other measurements of enrollee satisfaction include the percentage of MO HealthNet Managed Care enrollees who selected their own MCO; the low percentage of MO HealthNet Managed Care enrollees who requested transfers; and the low percentage of MO HealthNet Managed Care enrollees randomly assigned.

In addition to quality assessment and enrollee satisfaction monitoring, MCO compliance with contractual requirements is a primary method of measuring attainment of managed care goals. Contractual compliance monitoring begins with the issuance of the Request for Proposal (RFP) and continues with the review of proposals submitted, assessment of MCO provider networks, and readiness reviews of MCOs' operations.

The State realizes that the keys to a successful managed care program include the provision of quality services, the satisfaction of enrollees, and the involvement of stakeholders. In awareness of the importance of stakeholder involvement, the State formed an MO HealthNet Consumer Advisory Committee (CAC) to advise the Director of the MO HealthNet Division (MHD) on issues relating to enrollee participation in the MO HealthNet Managed Care Program. The committee meets quarterly. The committee meets twice in Jefferson City, once in Kansas City and, once in St. Louis. The committee consists of a minimum of fifteen enrollees and advocates. As the State develops and refines educational materials, the CAC is instrumental in making recommendations to enhance consumer education as well as any changes needed to improve either the care provided or the way care is delivered

In an effort to involve various stakeholders, especially those persons with special health care needs, the State has used the following forums:

After comments are gathered from these stakeholders, policy is developed or changed to incorporate suggestions that impact the MO HealthNet Managed Care Program. For instance, the QA&I Advisory Group recommended and the State implemented the following protocols: guidance on intensity of care decisions regarding the hospital care of premature infants and guidance on approving speech therapies that are duplicated by those therapies specified in an Individual Education Plan (IEP). As another example, the State and DMH worked with the MCOs and the MO HealthNet Consumer Advocacy Project to develop protocols for how to coordinate mental health care provided by the MCOs and DMH.

In addition to these on-going activities, a large amount of information was gathered by the State during the testimony and hearings held on House Bill (HB) 335. HB 335 passed the Missouri General Assembly in 1997 and addressed managed care issues such as patient’s rights, grievances and appeals, the definition of an emergency, network adequacy, and enrollee notice in utilization review decisions. Literally hundreds of providers, advocates, and citizens (including those with special health care needs) testified on this legislation. The testimony helped shape this law, which has been incorporated into the State’s contracts with MCOs.

Children’s Health Insurance Program (CHIP)

Missouri’s Children’s Health Insurance Program (CHIP), was a Medicaid expansion implemented on September 1, 1998 through a waiver under Section 1115 of the Social Security Act and a Title XXI Plan that covers children under the age of 19 in families with a gross income of 300 percent of the Federal poverty level (FPL). The Uninsured Parents Program, implemented in February 1999, a subgroup of the Managed Care Program, provided health insurance for some uninsured parents through an 1115 Demonstration Waiver. The Uninsured Parents Program was discontinued effective July 1, 2005. Coverage for both the CHIP Program and the Uninsured Parents Program was provided through the Managed Care delivery system in areas of the State covered by the Section 1915(b) waiver and through the Fee-for-Service Program in the reminder of the State. Uninsured women who lost their eligibility sixty (60) days after the birth of their child were covered for women’s health services for an additional year, regardless of their income level. This population received services through the Fee-For-Service Program. Uninsured Women continue to receive services through a section 1115 family planning demonstration.

Missouri submitted a combination Children’s Health Insurance Program (CHIP) State Plan under Title XXI of the Social Security Act for the Children’s Health Insurance Program May 31, 2007. The Centers for Medicare and Medicaid Services (CMS) approved Missouri’s CHIP State Plan on September 28, 2007, with an effective date of September 1, 2007. Title XXI provides funds to states to enable them to provide health assistance to uninsured, low-income children in an effective and efficient manner