MO HealthNet Organization

Cost Recovery Unit

The Cost Recovery Unit administers a successful and aggressive cost recovery programs to offset MO HealthNet expenditures by third party liability (TPL). TPL refers to the legal obligation of other third party resources (TPRs) to pay the medical claims of MO HealthNet participants prior to MO HealthNet coverage. A few common TPRs are Medicare, health insurance, workers' compensation, automobile medical insurance, homeowner’s insurance, malpractice, product liability, medical support orders, and probate. The function of TPL within the MO HealthNet program is to ensure these resources are utilized as a primary source of payment in lieu of taxpayer dollars.

Program Integrity

The Program Integrity Unit (PIU) monitors MO HealthNet program compliance by MO HealthNet providers and participants. The PIU conducts post-payment reviews of MO HealthNet claims to assure that appropriate payments were made and that providers are billing and providing services in accordance with federal and state regulations and MO HealthNet requirements. The PIU also monitors claims and responds to referrals where potential MO HealthNet fraud or abuse may be attributed to a participant.

Based on a preliminary review of reports and referrals, PIU makes the determination on what enforcement activities to pursue. These enforcement activities range from education, demand of repayment, suspension, closed-end agreements, prepayment review, participant lock-in, to referral to the Medicaid Fraud Control Unit (MFCU), within the State Office of Attorney General in the case of providers or the MO HealthNet Investigation Unit (MIU), within the Department of Social Services, in the case of participants.

Managed Care Rate Setting

This unit is responsible for developing the capitation rates for the Managed Care Program, the Non-Emergency Medical Transportation (NEMT) Program, and the Program of All Inclusive Care for the Elderly (PACE) Program. The unit works closely with the contracted actuary in evaluating MO HealthNet fee-for-service expenditures to determine the financial impact of implementing policy alternatives and evaluating the cost effectiveness of MO HealthNet Managed Care, NEMT, and PACE.

Institutional Reimbursement Unit

The Institutional Reimbursement Unit is further divided into the following units:

Budget

This unit is responsible for developing and tracking the division’s annual budget request and subsequent appropriations. The unit is responsible for preparation of quarterly estimates and expenditure reports required by the Centers for Medicare and Medicaid Services (CMS). During the legislative session, the unit is also responsible for reviewing all bills affecting the division, preparing fiscal notes and attending hearings as assigned.

Payment Systems

This unit is responsible for coordinating and implementing the more advanced modifications to the MMIS. The implementation of the requirements of the Health Insurance Portability and Accountability Act (HIPAA) is an example of an advanced modification to the MMIS. The unit ensures that a structured approach is used so as not to disrupt any of the automated MO HealthNet claims processing and the information retrieval system currently in place.

Medicaid Management Information System (MMIS)

This unit is responsible for oversight and monitoring of the MO HealthNet Fiscal Agent contract and Clinical Management Services and System for Pharmacy and Prior Authorization (CMSP) contracts. The unit acts as the liaison between the division and the fiscal agent and CMSP contractor. The unit is responsible for maintaining the claims processing system by reviewing claims payment issues, establishing corrective action plans and designating specific tasks to the fiscal agent and the CMSP contractor. This unit is also responsible for processing ad hoc requests from other units within the division.

Provider Enrollment

This unit is responsible for enrolling and dis-enrolling providers. The unit maintains all updates and changes to the provider enrollment files and processes direct deposit applications. The unit responds to provider inquiries and notifies providers when their application is processed and when a provider number is issued. The unit is also responsible for entering rate changes for providers and developing a system whereby much of the provider enrollment process can be completed electronically.

MO HealthNet Managed Care (formerly MC+ Managed Care)

This section is responsible for administration of the MO HealthNet Managed Care Program which operates under a 1915(b) Freedom of Choice Waiver. This unit is also responsible for developing new policies and procedures for the MO HealthNet Managed Care Program. This program provides MO HealthNet Managed Care services to enrollees in four broad groups:

1. MO HealthNet for Families
2. MO HealthNet for Kids
3. MO HealthNet for Pregnant Women
4. Children in state custody

Managed Care Contract Compliance

This unit is responsible for monitoring contracts administered by the Program Management section. Staff monitor the MO HealthNet Managed Care contracts to ensure the Managed Care Organizations (MCOs) are adhering to the terms and conditions of their agreements. The unit ensures that the MCOs adhere to service access guidelines, verify provider networks and handle complaints against the MCOs. The unit also works with the Department of Insurance, Financial Institutions, and Professional Registration to assure MCOs are in compliance with state insurance rules and regulations related to travel distance standards and provider network adequacy.

Quality Assessment

This unit performs research and data analysis to address monitoring and oversight requirements established by CMS. The unit utilizes a collaborative process to develop and implement strategies to improve the health status of MO HealthNet participants which includes coordination with advisory groups, other state agencies, MCOs, providers and the public. The unit is also responsible for researching, assessing, evaluating and reporting information regarding the quality of care provided to MO HealthNet Managed Care members and Fee-For-Service participants.

MO HealthNet Operations

This unit is responsible for collecting, organizing, and evaluating data pertaining to enrollment, disenrollment, and financial aspects of the MO HealthNet Managed Care Program and the Medical Case Management Program. The unit monitors MO HealthNet Managed Care and Medical Case Management enrollment and makes corrections as necessary. Staff interacts with the MO HealthNet Managed Care health plans, the MO HealthNet Managed Care enrollment broker, the Family Support Division, and various units within MHD to ensure that enrollment and the financial aspects of enrollment are correct. The unit produces a number of reports related to enrollment in MO HealthNet Managed Care and Medical Case Management. They are also the primary contact for the Program of All-Inclusive Care for the Elderly, the 1915(b) Waiver, and the 1115 Waiver.

Program Relations

The Program Relations Unit is further divided into the following units:

Fee-For-Service Program Operations

This unit is responsible for research, analysis, development, implementation and monitoring various benefit programs within the division, including the prior authorization process for approval of medically necessary items and services which are not typically reimbursed by MO HealthNet. Staff in this unit also interact with advisory committees to obtain guidance in complicated health care issues, coordinate and assist in the development of training packages, write and revise program manuals and bulletins pertaining to program policy, procedure and operations, and monitor and evaluate program effectiveness by tracking utilization patterns.

Fee-For-Service Program Development

This unit is responsible for researching state and federal regulations, Centers for Medicare and Medicaid Services (CMS) directives and rulings, and reviewing Medicaid programs implemented by other states. The unit analyzes data and legislation, coordinates special projects and works with other state agencies and units within the division to implement new MO HealthNet programs including the development of new manuals and procedures. Staff in this unit also aid in the implementation of major changes to existing MO HealthNet programs.

Pharmacy and Medical Pre-Certification Hotline

This unit operates a toll-free hotline for providers to request authorization for claims on drug products processing through clinical, fiscal, Preferred Drug List (PDL), and prior authorization edits; medical precertifications, and durable medical equipment precertification. Hotline staff process requests using an internet-based rules engine tool, specifically designed to apply edits to ensure effective and appropriate utilization. This unit also processes requests for the Exceptions Program for essential medical items or services which are not typically reimbursed through the MO HealthNet program. Insulin pump prior authorizations are also processed within this unit.

Pharmacy (fiscal)

This unit is responsible for conducting fiscal analyses on proposed and existing cost-containment initiatives, maintaining and developing report systems, overseeing payments for contracted services, and tracking fiscal data for the program. This group assists in the preparation of fiscal notes, annual budget preparation, and reviews proposed legislation on pharmacy related issues. In addition, this unit administers the Pharmacy Provider Tax program and nursing home returns.

Pharmacy (clinical)

This unit is responsible for the implementation and maintenance of clinical program initiatives. This group oversees the clinical review of all new drug products, conducts drug pricing research including the Missouri Maximum Allowable Cost (MAC) program, and updates the website with clinical program specifics such as the preferred lists for Diabetic Testing Supplies and Over-the-Counter and Cough and Cold Products. The clinical unit performs evidence-based clinical drug reviews pared them with available pharmacoeconomic data and presents this information to the division’s advisory groups. This unit responds to provider’s claims and program inquiries both written and by phone offering provider education; and conducts pre-payment and post-payment reviews to detect incorrect claims billings.

Pharmacy Rebate

This unit is responsible for the collection of rebates from pharmaceutical manufacturers contracted with the Centers for Medicare and Medicaid Services (CMS) to participate in the Drug Rebate Program. Manufacturers are invoiced quarterly by the unit for products dispensed during the period. As payments are received, disputes are identified and the unit researches any product disputed by the manufacturer. Disputes are resolved with the manufacturer to collect the fullest rebate possible. A similar process is used to collect state preferred drug list (PDL) supplemental rebates. This unit is also responsible for collecting rebates for the Missouri Rx Plan.

Psychology Program

The Psychology Program is part of the Clinical Services Unit and maintains oversight of the purchase and delivery of psychological services on behalf of MO HealthNet’s population. The Psychology Program develops and implements policy to insure services which are medically necessary, appropriate, and cost effective. In addition, the Psychology Program utilizes a clinical review process which examines utilization of services. Clinical oversight promotes the utilization of best practice approaches while improving the quality of care to MO HealthNet’s population. Clinical expertise is made available to division and departmental staff via consultation on issues related to the Psychology Program.

Missouri Rx Plan

The Missouri Rx Plan (MORx) is Missouri’s State Pharmacy Assistance Program replacing the Missouri Senior Rx Program. MORx was created by the 93rd General Assembly to coordinate benefits with Medicare’s (Part D) Prescription Drug Program, and to provide additional assistance for prescription drug costs to Missourians in need. MORx pays for 50% of members' out of pocket costs remaining after their Medicare Prescription Drug Plan pays. It pays for 50% of the deductible, 50% of the co-pays before the coverage gap, 50% of the coverage gap, and 50% of co-pays in the catastrophic coverage. MORx does not pay for the Medicare Part D Plan’s monthly premium.

• MORx uses the formulary of the Medicare Prescription Drug Plans. Any drug covered by a member’s Medicare Drug Plan will also be covered by the MORx plan.
• MORx works with all Medicare Prescription Drug Plans.
• Dual eligible members will continue to have coverage for Medicare-excluded drugs through MO HealthNet. Medicare-excluded drugs include specific over-the-counter drugs, vitamins, minerals, limited cough and cold drugs, benzodiazepines and barbiturates as they are currently covered by MO HealthNet, as noted on the MO HealthNet Division Pharmacy pages.
• Extra help with paying for Medicare Part D costs is available from the Social Security Administration (SSA) for individuals with low income and limited assets. All dual eligibles automatically qualify for the extra help in paying for their premiums and co-pays. Other individuals may submit an application for extra help to the SSA.

Pre-Certification for Medical Services and Equipment

Pre-certification serves as a utilization management tool, allowing payment for services and equipment that are medically necessary, appropriate and cost-effective without compromising the quality of care to MO HealthNet participants. MO HealthNet and ACS Heritage, Inc. have introduced an electronic health record program. The online tool called CyberAccess is available to providers to request or check status of a pre-certification request.