Managed Care Plan Basics Frequently Asked Questions

The MO HealthNet Managed Care Program works to:

• Improve health care quality
• Improve access to needed services
• Increase the efficiency of health care delivery for eligible low-income custodial parents, pregnant women and children
• Control the Program’s rate of cost increase

If you apply for healthcare benefits with the State of Missouri, and you fall in one of the following eligibility groups, you will be assigned to a comprehensive, qualified Managed Care health plan.

• MO HealthNet for Families
• Children’s Health Insurance Program (CHIP)
• MO HealthNet for Kids
• MO HealthNet for Pregnant Women
• Show Me Healthy Babies
• Adults Age 19 to 64 Without Disabilities

If you fall in to one of the categories below, you will be automatically enrolled in Show Me Healthy Kids (SMHK):

• Children in the care and custody of the Missouri Department of Social Services
• Children or youth in alternative care
• Children receiving adoption or legal guardianship subsidy
• Former foster care youth under the age of 26, who were in foster care on their 18th birthday and covered by MO HealthNet (Missouri Medicaid), and who meet other eligibility criteria
• Former foster care youth under the age of 26, who were in foster care on their 18th birthday and covered by Medicaid from another state, and who are not currently eligible for Medicaid coverage under another program

For a list of Frequently Asked Questions regarding SMHK, visit: https://www.homestatehealth.com/members/healthy-kids.html

You need to be approved for the Missouri Medicaid program, called MO HealthNet, before you can receive services. If you do not currently have health care through MO HealthNet, you will need to see if you are eligible and if so, apply for services. Once your application has been processed, you will receive a letter from the Missouri Family Support Division (FSD). If you are eligible, you will receive a MO HealthNet Identification Card and information explaining the medical services available to you.

If you have questions about your coverage or if you would like to check the status of your application, contact FSD at 1-855-373-4636 or check the status of your benefits online at myDSS.

After you are enrolled with a MO HealthNet Managed Care health plan, they will send you a welcome kit that tells you about your MO HealthNet Managed Care benefits. All MO HealthNet Managed Care health plans are required to offer the same services. Some of the services include:

• Doctor visits (i.e., well checks, mammograms, cancer screenings)
• Hospital stays and emergency care (inpatient/outpatient services)
• Approved specialists care (with your provider’s referral)
• Behavioral health and substance abuse services
• Coaching and services to help you quit smoking
• Other services, such as dental, eye care, medical equipment, and family planning

Services may be limited based on your eligibility group or age, and some services may require prior approval. It is important to work with your health care provider to find out if a service you need is covered. For more information about the MO HealthNet Managed Care Program and the services available, review your health plan’s member handbook:

• Healthy Blue
• United HealthCare
• Home State Health
• Show Me Healthy Kids (managed by Home State Health)

You may choose to opt out, or not enroll in Managed Care if you meet one of the following:

• Eligible for Supplemental Security Income (SSI) benefits
• Children who are enrolled in the Special Health Care Needs program
• Disabled and 18 or younger

If you have questions or would like to opt out of Managed Care, please call 1-800-348-6627.

You may not be able to get services through a MO HealthNet Managed Care health plan due to certain situations, like a medical condition, or maybe you get help through Managed care and already receive certain benefits, like Supplemental Security Income. You would instead get services through the MO HealthNet Fee-For-Service Program.

You may be exempt from Managed Care if you are in one of the following programs:

• MO HealthNet for People with Disabilities
• MO HealthNet for the Blind and Visually Impaired
• MO HealthNet for Seniors
• Aids Waiver Program
• Breast or Cervical Cancer Treatment Program
• Uninsured Women’s Health Services Program
• Have Medicare coverage

For a list of Frequently Asked Questions regarding the MO HealthNet Fee-For Service Program, visit: https://dss.mo.gov/mhd/files/FAQ-Fee-For-Service-Participants.pdf

MO HealthNet has three general health plans managed by United Healthcare, Healthy Blue, and Home State Health. Home State Health also manages Show Me Healthy Kids, which provides health care to Missouri children in care and custody. All of the MO HealthNet Managed Care health plans are required to provide the same benefits and services. You may be covered by one of the MO HealthNet Managed Care health plans or through the MO HealthNet Fee-For-Service program.

The biggest difference between the health plans is which doctor works with each plan. Doctors may work with only one, more than one, or with all of the health plans. This is why it is important to see which health plan your current doctor works with if you are enrolled in MO HealthNet coverage and would like to continue receiving health care services through the same doctor.

If your Primary Care Provider (doctor) is not currently working with a MO HealthNet Managed Care health plan, you can ask them to join by requesting your doctor contact the health plan directly.

If you are enrolled in MO HealthNet and your doctor chooses not to work with a MO HealthNet Managed Care health plan, you will need to find a doctor that does. After you are assigned to a health plan, you will receive information from the plan about how to pick or change your Primary Care Provider.

You may also find a doctor by using the provider search on the health plan’s website or by calling your health plan directly.

If you cannot decide on a doctor in your health plan network, your MO HealthNet Managed Care health plan can help you find one.

If you have other health insurance, MO HealthNet needs to know so your claims can be paid correctly. Please call 1-800-348-6627 to report your other health insurance. You can also report this to the Family Support Division by calling 1-855-373-4636.

Not necessarily. Even if everyone in your household is eligible for MO HealthNet, everyone may not receive their health care services through the Managed Care Program. Some individuals will be exempt, some will not be enrolled because of a medical condition or other reason, and some may have the option to choose. They would instead get their health care services through the MO HealthNet Fee-For-Service Program.

Based on your family’s income and family size, your family may need to pay a monthly premium. After you apply, the letter you receive from the Family Support Division about your eligibility will tell you if you need to pay a premium.

If you have questions about premiums, call MO HealthNet Participant Services at 1-800-392-2161.

If you lose your MO HealthNet ID card, call the Family Support Division Information Center at 1-855-373-4636. Help is available through the Family Support Division Information Center from 7:30 a.m. to 5:30 p.m., Monday through Friday.

As a MO HealthNet Managed Care health plan member, you have certain rights that protect the quality of care you receive from your health plan. You have the right to:

• Be treated with respect and dignity
• Receive needed medical services
• Privacy and confidentiality (including minors) subject to state and federal laws
• Select your own primary care provider
• Refuse treatment
• Receive information about your health care and treatment options
• Participate in decision-making about your health care
• Have access to your medical records and to request changes
• Have someone act on your behalf if you are unable to do so
• Be free of restraint or seclusion from a provider who wants to:
  • Make you do something you should not do
  • Punish you
  • Get back at you
  • Make things easier for him or her
• September 2022
  • Be free to exercise these rights without retaliation
  • Receive one copy of your medical records once a year at no cost

As a MO HealthNet Managed Care health plan member, you also have certain responsibilities:

• Report any important changes to the Family Support Division online at mydss.mo.gov or by calling 855-373-4636:
  • The birth of a baby
  • A new dependent
  • A change in your income
  • A new address
  • A new phone number
• Be knowledgeable about your medical coverage
• Get routine and ongoing care from your providers
• Contact your primary care provider first when needing care
• Only use the emergency room in an emergency
• Make and keep appointments, or call ahead to cancel
• Carry your current MO HealthNet ID Card and your MO HealthNet Managed Care health plan card at all times and present them at your appointments

Visit https://dss.mo.gov/mhd/healthcare-benefit.htm or contact:

MO HealthNet Managed Care Enrollment Helpline: 1-800-348-6627
Call for help with changing a health plan or finding a primary care provider. The Enrollment Helpline is open from 7:00 a.m. to 6:00 p.m., Monday through Friday (except holidays).

MO HealthNet Participant Services Unit: 1-800-392-2161
Call for questions about eligibility, pharmacy or premium payments.

MO HealthNet Health Plans:
Call if you need help finding a provider or if you have questions about your coverage or any unpaid medical bills.

Hearing or Speech Impaired
If you are deaf, hard-of-hearing, deaf-blind or have difficulty speaking, call Relay Missouri:
1-800-735-2466 (Voice)
1-800-735-2966 (Text Phone)