History of MO HealthNet Managed Care

In 1995, Missouri requested and received approval to implement a managed care program, MC+ Managed Care, in the Eastern region of the State. Waiver authority was granted under Section 1915(b) of the Social Security Act for Managed Care Organizations (MCOs) to provide contracted services to certain targeted groups of Medicaid eligibles. The mandatory target groups included the Temporary Assistance for Needy Families (TANF) Adults and Children, Medicaid for Pregnant Women (MPW), Refugees, Medicaid for Children, and Children in State Care and Custody.

Effective September 1, 1998 Missouri’s health insurance program for uninsured children known as "MC+ for Kids" began and was added as an additional mandatory target group. Effective February 1, 1999 uninsured parents eligible under Missouri’s 1115 Waiver were added as an additional mandatory target group. Medicaid eligibles in the targeted groups who receive Supplemental Security Income (SSI), meet the medical definition for SSI, or are eligible for adoption subsidy benefits may choose not to enroll or voluntarily disenroll from the MC+ Managed Care Program at anytime.

During December 2001, uninsured custodial parents below 100% of the Federal poverty level under the 1115 waiver were transitioned to eligibility under Section 1931 with coverage under the 1915(b) Waiver population, with an effective date of January 1, 2002. Between 2002 through 2005, budget actions lowered the eligibility standards at which time coverage ended for this group of uninsured parents.

Effective July 1, 2006, not all Managed Care health plans provide pharmacy coverage. Enrollees in Managed Care health plans that provide pharmacy coverage use the Managed Care health plan pharmacy network. Managed Care enrollees in health plans that do not provide pharmacy coverage use Medicaid Fee-For-Service enrolled pharmacy providers.

Effective September 1, 2007, Missouri’s Medicaid program was renamed MO HealthNet. The term MC+ was no longer used to reference health care programs or health care delivery services and MC+ Managed Care became MO HealthNet Managed Care.

Effective October 1, 2009, MO HealthNet Managed Care members receive pharmacy benefits through MO HealthNet Fee-For-Service.

Eastern Region

Beginning in September 1995, seven MCOs (HealthCare USA, Care Partners, Mercy Health Plans, Community Care Plus, Prudential Health Care, Humana, and GenCare) served enrollees in the Eastern region counties of St. Louis, St. Charles, Jefferson, and Franklin and St. Louis City. Two of the original MCOs (GenCare and Humana) withdrew in 1997. Effective February 1, 2000, HealthCare USA purchased Prudential’s Medicaid business. Prudential enrollees were given an opportunity to choose a participating MCO other than Prudential.

Effective December 1, 2000, the counties of Lincoln, St. Francois, Ste. Genevieve, Warren, and Washington were included in the Eastern region. The following changes were made to the benefit package: Developmentally Disabled (DD) participants and participants with Third Party Liability (TPL) were no longer carved out; any adoption subsidy child could opt out; the state did not administer a reinsurance program; and the 30/20 limitation on mental health services was eliminated.

Care Partners chose not to rebid their contract that expired December 31, 2002. The following MCOs served Managed Care enrollees in the Eastern region from January 2003 through June 2006: Community Care Plus, HealthCare USA, and Mercy Health Plans.

Effective July 1, 2006, Mercy MC+ and Community CarePlus formed a new health plan called Mercy CarePlus.

Harmony Health Plan of Missouri was awarded a Managed Care contract effective July 1, 2006.

January 1, 2008, the following three counties were added to the MO HealthNet Eastern Managed Care region: Madison, Perry and Pike. HealthCare USA does not provide services in Madison or Perry counties.

Effective October 1, 2008, Mercy CarePlus was renamed Molina Healthcare of Missouri.

The Eastern MO HealthNet Managed Care health plans providing services effective October 1, 2009 are as follows:

• Harmony Health Plan of Missouri
• HealthCare USA
• Missouri Care Health Plan
• Molina HealthCare of Missouri

Central Region

Missouri received 1915(b) waiver modification approval to expand the Managed Care Program to the Central region in March 1996. Three MCOs (HealthCare USA, GenCare, and Blue Choice) served enrollees in the following eighteen counties: Audrain, Boone, Callaway, Camden, Chariton, Cole, Cooper, Gasconade, Howard, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis, Randolph, and Saline. GenCare and Blue Choice chose not to rebid their contracts that expired February 28, 1998. Effective March 1, 1998, the participating MCOs were Care Partners, HealthCare USA, and Missouri Care. There was no change in the counties served. Contracts were rebid effective March 1, 2001. Participating MCOs were Missouri Care and HealthCare USA. Care Partners chose not to rebid their contract. The following changes were made to the benefit package: MRDD participants were no longer carved out; any adoption subsidy child could opt out; reinsurance was offered through the State but MCOs opted to purchase from an outside entity; and the 30/20 limitation on the mental health services was eliminated.

The following MCOs served managed care enrollees in the Central region from January 2003 through June 2006: HealthCare USA and Missouri Care.

Effective July 1, 2006 Mercy MC+ and Community CarePlus formed a new health plan called Mercy CarePlus.

January 1, 2008, the following ten counties were added to the MO HealthNet Central Managed Care region: Benton, Laclede, Linn, Macon, Maries, Marion, Phelps, Pulaski, Ralls, and Shelby.

Effective October 1, 2008, Mercy CarePlus was renamed Molina Healthcare of Missouri.

The Central MO HealthNet Managed Care health plans providing services effective October 1, 2009 are as follows:

• HealthCare USA
• Missouri Care Health Plan
• Molina HealthCare of Missouri

Western and Northwestern Regions

An additional waiver modification was requested and approved to expand the MC+ Managed Care Program to the Western and Northwestern regions of the state in January 1997. This expansion replaced the Medicaid Managed Care Program for AFDC participants in Jackson County that was implemented in January 1984.

Western Region

The Western region originally consisted of Cass, Clay, Jackson, Johnson, Lafayette, Platte, and Ray counties. Participating MCOs were HealthNet, Family Health Partners, FirstGuard, and Blue Advantage+Plus. In February 1999, the service area was expanded to include Henry and St. Clair counties with the MCOs remaining the same. The DD population was included as an eligible group. The state did not administer a reinsurance program.

HealthNet chose not to rebid their managed care contract, which expired January 31, 2002. The following MCOs served Managed Care enrollees in the Western region from January 2003 through June 2006: Blue Cross Blue Shield of Kansas City-Blue Advantage Plus, Family Health Partners, FirstGuard, and HealthCare USA.

Effective July 1, 2006 Mercy MC+ and Community CarePlus formed a new health plan called Mercy CarePlus.

February 1, 2007, HealthCare USA purchased FirstGuard Health Plan. FirstGuard is no longer a participating health plan for the Western region.

January 1, 2008, the following four counties were added to the MO HealthNet Western Managed Care region: Bates, Cedar, Polk and Vernon. Blue-Advantage Plus of Kansas City does not provide services in Bates, Cedar, Polk, or Vernon counties.

Effective October 1, 2008, Mercy CarePlus was renamed Molina Healthcare of Missouri.

*Effective July 1, 2008, Blue-Advantage Plus of Kansas City excluded pharmacy.

The Western MO HealthNet Managed Care health plans providing services effective October 1, 2009 are as follows:

• Blue Advantage Plus of Kansas City—does not provide services in Bates, Cedar, Polk, or Vernon counties.
• Children’s Mercy Family Health Partners
• HealthCare USA
• Missouri Care Health Plan
• Molina HealthCare of Missouri

Effective February 1, 2012, Children’s Mercy Family Health Partners in the Western Region of Missouri is no longer a participating Managed Care Health Plan because of a merger with HealthCare USA Health Plan.

The Western MO HealthNet Managed Care health plans providing services effective February 01, 2012 are as follows:

• Blue Advantage Plus of Kansas City—does not provide services in Bates, Cedar, Polk, or Vernon counties.
• HealthCare USA
• Missouri Care Health Plan
• Molina HealthCare of Missouri

Medicaid Managed Care for AFDC Participants (Jackson County Only)

In July 1982, Missouri received a four year federal demonstration grant to implement a managed health care program for Aid to Families with Dependent Children (AFDC) participants in Jackson County. Enrollment into the program began January 1984 with full enrollment achieved in the first quarter of 1985. The original demonstration grant was extended to December 31, 1986, at which time the established program began operating under a waiver issued by the authority of Section 1915(b) of the Social Security Act and enrollment was mandatory. The goal of the program was to furnish improved quality, continuity, and accessibility of health care services to enrollees, while providing the State with significant cost savings.

This Managed Health Care Program was a health care delivery system for AFDC participants where primary care services were provided by four prepaid health plans and approximately 30 individual physicians called physician sponsors. The four prepaid health plans were reimbursed on a capitated basis and the physician sponsors were reimbursed on a Fee-For-Service basis and received an additional $3.00 per enrollee per month for serving as the case manager. Each AFDC participant chose either a health plan or a physician sponsor, who was responsible for coordinating the health care provided to the participant. Medical services offered under the Missouri Medicaid Program were also available to managed health care enrollees; however, the majority of these services were either obtained through or referred by the chosen health plan or physician sponsor.

Northwestern Region

The Northwestern region was composed of Andrew, Atchison, Buchanan, Caldwell, Carroll, Clinton, Davies, DeKalb, Gentry, Grundy, Harrison, Holt, Livingston, Mercer, Nodaway, and Worth counties. Blue Advantage+ Plus and Community Health Plan chose not to contract with the State and all enrollees reverted back to Fee-For-Service on December 1, 1998.