What Is The Legal Authority For MO HealthNet Managed Care?
MO HealthNet Managed Care operates under federal regulatory authority and federal and state statutory authority. The statutory and regulatory authority is cited below.
- State Statute:
- RSMo. 208.166 This section of the Missouri Revised Statutes provides the Department of Social Services or its designated division authority to purchase medical services for recipients of public assistance from prepaid health plans, health maintenance organizations, health insuring organizations, preferred provider organizations, individual practice associations, local health units, community health centers, or primary care physician sponsors;
- Federal Law:
- Social Security Act Sections:
- 1115 Section 1115 of the Social Security Act provides the Secretary of Health and Human Services with broad authority to authorize experimental, pilot, or demonstration project(s) which, in the judgment of the Secretary,(are) likely to assist in promoting the objectives of (the Medicaid statute). The authority provides flexibility, under the Secretary’s discretion, for the provision of services that are not otherwise matchable and allows for the expansion of eligibility for those who would otherwise not be eligible for the Medicaid program. The demonstration must be budget neutral over the life of the project (generally 5 years). The demonstrations cannot be expected to cost the Federal government more than it would cost without the waiver.
- 1902(a)4 A State plan for medical assistance must provide such methods of administration as are found by the Secretary to be necessary for the proper and efficient operation of the plan.
- 1903(m) This section of the Social Security Act specifies the conditions under which the Secretary of Health and Human Services may make payment to States for Medicaid managed care services.
- 1915(b) States are permitted to waive statewideness, comparability of services, and freedom of choice. 1915(b) waivers are limited in that they apply to existing Medicaid eligible beneficiaries, authority under this waiver cannot be used for eligibility expansions. A 1915(b) waiver program cannot negatively impact beneficiary access, quality of care of services, and must be cost effective (cannot cost more than what the Medicaid program would have cost without the waiver). There are four 1915(b) Freedom of Choice Waivers:
- (b)(1) mandates Medicaid Enrollment into managed care
- (b)(2) utilize a "central broker"
- (b)(3) uses cost savings to provide additional services
- (b)(4) limits number of providers for services
- 1932 The Balanced Budget Act of 1997 (BBA) enacted section 1932. Among other things, section 1932 permits States to require most groups of Medicaid beneficiaries to enroll in managed care arrangements without waiver authority granted under section 1915(b) or 1115(a) of the Act; establishes new requirements for managed care enrollment and choice of coverage; requires specified information to enrollees and potential enrollees; added increased protections for those enrolled in managed care arrangements; requires States to develop and implement quality assessment and improvement strategies for managed care arrangements; and provides for external, independent review of managed care activities.
- Federal Regulations:
- 42 CFR 438 This final rule was published June 14, 2002 and amended the Medicaid regulations to implement the provisions of the Balanced Budget Act of 1997 (BBA). These regulations were effective on August 13, 2002. States had until August 13, 2003 to bring aspects of their State managed care program into compliance with the final rule provisions.