Frequently Asked Participant Questions
How can I become eligible for MO HealthNet?
To find out if you qualify, to apply, or to change your eligibility for MO HealthNet, you should contact the Family Support Division office in the county where you live. Check your telephone book under the name of your county or the FSD Web site for a list of Family Support offices.
What does MO HealthNet pay for?
MO HealthNet does not cover everything. There are many types of eligibility within MO HealthNet. Some eligibility types have more benefits than others. Some services such as dental, optical, audiology (hearing aids), some durable medical equipment, rehabilitation services, comprehensive day rehabilitation, diabetes self management training, foot care and medical transportation are not covered for all participants.
The Participant Handbook explains the services you can get or to find out what you are eligible for, you should call the MO HealthNet Participant Services Unit at 1-800-392-2161 or 573/751-6527. If you are enrolled in a MO HealthNet managed care health plan you should contact the membership services number on your managed care health insurance card.
How can I find out if I have MO HealthNet coverage?
You should have received a red or white plastic insurance card.
To find out if your coverage is active you can contact your local Family Support Division or call the MO HealthNet Participant Services Unit at 1-800-392-2161 or 573/751-6527.
If you have a touch tone telephone the 800 number can be used to find out if you are eligible by choosing option 1 and entering your eight digit MO HealthNet number.
How can I check on my MO HealthNet application?
To check on your MO HealthNet application, please call the FSD Information Center, 855-373-4636.
How can I find a doctor that takes MO HealthNet?
For help in finding any type of provider that takes MO HealthNet you can use the MO HealthNet Provider Search where you can search by name or by county.
Not all providers who are enrolled are taking new patients. You must ask the provider if they are taking new MO HealthNet patients.
If you are enrolled in a MO HealthNet managed care health plan you should contact the membership services number on your managed care health insurance card and ask for help to find a doctor or other provider.
What is co-pay?
Co-payments are small amounts you may have to pay for services you receive that range from fifty cents ($0.50) to ten dollars ($10.00). The provider will tell you how much you owe. You are responsible to pay the co-payments at the time of service or when billed by the provider.
What are the services subject to co-pay?
Co-pays will apply to the following hospital & physician related services:
|Inpatient Hospital Services||$ 10.00|
|Outpatient or Emergency Room Services||$ 3.00|
|Physician Services||$ 1.00|
|Clinic Services||$ .50|
|X-ray and Laboratory Services||$ 1.00|
|Nurse Practitioner Services||$ 1.00|
|CRNA Services/Anesthesiologist Assistant||$ .50|
|Rural Health Clinic Services||$ 2.00|
|Case Management Services||$ 1.00|
|Federally Qualified Health Care Services||$ 2.00|
|Psychology Services||$ 2.00|
|Non-Emergency Medical Transportation||$ 2.00|
For Dental, Optical and Podiatry services the following co-pays apply:
|If MO HealthNet pays the following amount for a service:||Co-pay amount owed|
|$10.00 or less||$ .50|
|$10.01 to $25.00||$ 1.00|
|$25.01 to $50.00||$ 2.00|
|$50.01 or more||$ 3.00|
Does everyone pay a co-pay?
Not everyone has to pay a co-pay. Please refer to the Participant Handbook for a complete list of exceptions to paying co-pay.
What should I do if I receive a bill or if there is a charge on my credit report?
You should first ask the provider to bill MO HealthNet. It is your duty to be sure the provider knows you have MO HealthNet. If they billed MO HealthNet and still billed you, send the bill or a copy of the bill to the Participant Services Unit, PO Box 3535, Jefferson City, MO 65102. Include a note with the patient name and MO HealthNet number.
The bill will be reviewed. It will be decided whether it is your duty to pay the bill or not. If you were enrolled in an MO HealthNet managed care health plan on the date of service, you should contact the plan at the telephone number on the back of your managed care health insurance card.
How can I tell if a specific procedure is covered?
To learn if a specific procedure is covered you should get the five digit procedure code from your doctor or other medical provider and then call the MO HealthNet Participant Services Unit at 1 800 392 2161 or 573/751 6527. They can tell you if the procedure is covered and if there are any special rules about that procedure.
If you want to find out if a drug is covered, you should get the National Drug Code (NDC) from your doctor or pharmacist and contact the Participant Services Unit. If you are enrolled in a MO HealthNet managed care health plan you should contact the membership services number on your managed care health insurance card.
Can I get help with non-emergency medical transportation?
Assistance for non-emergency medical transportation (NEMT) is available if
- You do not have another way to reach your appointment,
- You are eligible for MO HealthNet Fee for Service on the date the transportation is provided under a federal aid category, and
- You have a scheduled appointment with a MO HealthNet enrolled provider for a MO HealthNet covered service.
You should call the NEMT number at 1-866-269-5927 at least five calendar days before to arrange transportation to your appointment. You may call this number Monday through Friday 8:00 a.m. to 5:00 p.m. for regular scheduled appointments. You may call this number 24 hours a day, seven days a week for urgent appointments or hospital discharges.
If you are enrolled in a MO HealthNet managed care health plan you should contact the membership services number on your managed care health insurance card. Some managed care health plans will have the phone number for transportation on your managed care health insurance card.
When can I change my MO HealthNet managed care health plan?
You may change MO HealthNet managed care health plans for any reason during the first 90 days after you become a MO HealthNet managed care health plan member. Call the MO HealthNet Managed Care Enrollment Helpline at 1-800-348-6627.
You may be able to change MO HealthNet managed care health plans after 90 days. Some reasons for changing include: you have moved out of the MO HealthNet managed care area; your primary care provider is no longer with your MO HealthNet managed care health plan and is in another MO HealthNet managed care health plan; or your specialist or other health care provider from whom you are currently getting services is no longer with your plan and is in another MO HealthNet Managed Care health plan.
You will have a 30-day open enrollment period once a year. Members may change MO HealthNet managed care health plans during their annual open enrollment period and children in Category of Aid 04—State care and custody may change MO HealthNet managed care health plans as often as circumstances necessitate. You may contact the MO HealthNet Managed Care Enrollment Helpline at 1-800-348-6627.
How can I find out when my MO HealthNet managed care health plan’s open enrollment period is?
You should receive a letter in the mail with open enrollment dates. You may also call the MO HealthNet Managed Care Enrollment Helpline at 1-800-348-6627 or the MO HealthNet Participant Services Unit at 1-800-392-2161 or 573/751-6527.
How can I change my MO HealthNet managed care health plan primary care provider?
You have a right to change the primary care provider in your MO HealthNet managed care health plan. You can change at least two times each year. Some MO HealthNet managed care health plans may allow more. Children in state custody may change their primary care provider as often as necessary. To change your primary care provider or to find out more about your MO HealthNet managed care health plan, call the membership services number on your managed care health insurance card.
Do I need a referral to see a specialist?
If you are in a MO HealthNet managed care health plan, you should check with your primary care provider (PCP) or your MO HealthNet managed care health plan.
If you are MO HealthNet fee–for–service, you should check with the provider you want to see. The MO HealthNet fee-for-service programs do not require a referral but the provider may require one. Your provider should know if your procedure has special rules. Special rules may include a prior authorization or special forms. The provider is responsible to make sure the rules are followed.
What should I do if I lose my MO HealthNet card?
To report a loss of your MO HealthNet card you should contact your local Family Support Division office in the county where you live. Check your telephone book under the name of your county or the FSD Web site for a list of Family Support offices.
Can I use my MO HealthNet if I travel out of state?
Services outside the United States, District of Columbia, and the following territories: Northern Mariana Islands, American Samoa, Guam, Puerto Rico, and the Virgin Islands are not covered.
Emergency: Emergency services are covered as long as the out of state treating provider agrees to enroll and accept the MO HealthNet amount. Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:
- Placing the patient’s health in serious jeopardy; or
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part.
Non-Emergency: Non-Emergency out of state is defined as “not within the physical boundaries of Missouri or any of the states that border Missouri”. All non-emergent, MO HealthNet covered services that are to be obtained out of state must be approved before the services are received. To get the approval for out of state services a written request must be sent by a physician to:
MO HealthNet Division
Participant Services Unit
PO Box 6500
Jefferson City, MO 65102
The request may also be faxed to 573/526-2471. The written request must include a brief past medical history, services attempted in Missouri, where the services are being requested and who will provide them, and why the service cannot be done in Missouri. The out of state provider must agree to enroll and accept the MO HealthNet amount.
If you are enrolled in a MO HealthNet managed care health plan your primary care provider (PCP) should contact the MO HealthNet managed care health plan for prior authorization.
Has prescription drug coverage changed for MO HealthNet fee-for-service patients?
Although your basic drug benefits have not changed, the MO HealthNet program has had to take steps to deal with the increasing cost of drugs. Just as other insurance companies have done, MO HealthNet is now using a "Preferred Drug List" (PDL). The PDL makes many drugs available to you without taking any extra steps. Some drugs may require your doctor or pharmacist to make a special request.
Because of these changes, you may at times find that your pharmacy will need to ask your doctor to allow a different medication to be filled. This will only happen when there is another drug that is equally safe and effective, but also less expensive.
Your doctor and pharmacy will also receive information about the MO HealthNet PDL. They will be able to check the Internet or call a toll-free help desk if they have questions about your drugs. In some cases, special exceptions to the PDL may be allowed for certain conditions, if requested by your doctor and approved.
If you are denied a drug your doctor has requested, you should check with your doctor or pharmacist to find out why.
I am receiving Medicare. Can I also receive MO HealthNet? How do they work together?
Yes, you can receive both Medicare and MO HealthNet. Medicare is handled at the federal level and MO HealthNet is handled at the state level. Medicare is primary. This means Medicare will be billed first. MO HealthNet will be billed last and will pay the Medicare co-insurance and deductible amounts on Medicare covered services. There is no duplication of payment for services.
If you have chosen a Health Maintenance Organization (HMO) for your Medicare coverage, there will be no coinsurance or deductible payments assigned, however, you will be responsible for a co-payment for services provided. MO HealthNet will not assume responsibility for co-payment amounts for Medicare HMO/MO HealthNet participants unless you are enrolled in the Qualified Medicare Beneficiary Program. Providers may bill you for this charge.
Can I have a private insurance plan with my MO HealthNet?
You may have private insurance with your MO HealthNet as long as being uninsured is not a condition of your eligibility. It is your duty to report a private insurance plan to your Family Support Division eligibility specialist. You can also report your private insurance plan information to the MO HealthNet Participant Services Unit at 1-800-392-2161 or 573/751-6527. If you have a touch tone telephone the 800 number can be used to hear the private insurance plan listed by choosing option 2 and entering your eight digit MO HealthNet number.
The MO HealthNet program may be able to help pay your private insurance plan premiums and copays. For information about the Health Insurance Premium Payment (HIPP) program, you should contact the Third Party Liability Unit at 573/751-2005.
I don't think my claim should be denied. What can I do?
When a request for services is denied, reduced, or terminated, you have the right to a state fair hearing. If you do not receive a letter giving you 90 days to request a hearing, you should contact the MO HealthNet Participant Services Unit at 1-800-392-2161 or 573/751-6527. You should ask them to review the denial.
If the decision is made that the denial is correct, you will be given 90 days to request a state fair hearing. At the hearing, you will have to explain why the decision should be changed. You do not need an attorney but you can get an attorney or anyone you want to help you at the hearing.
If you are enrolled in a MO HealthNet managed care health plan you should contact the membership services number on the back of your card to file an appeal. You may also ask for a state fair hearing within 90 days from the date of your Notice of Action letter from the managed care health plan.