MO HealthNet Managed Care Overview
The Department of Social Services, MO HealthNet Division (MHD) (formerly known as the Division of Medical Services) operates a Health Maintenance Organization (HMO)-style managed care program called MO HealthNet Managed Care.
The State of Missouri contracts with MO HealthNet Managed Care health plans (also referred to as Managed Care Organizations (MCOs)) to provide health care services to enrollees. MO HealthNet Managed Care health plans are paid a monthly capitation payment for each enrollee they serve.
Participation in MO HealthNet Managed Care is mandatory for certain Managed Care Population within the regions in operation. MO HealthNet Managed Care members are automatically enrolled into a MO HealthNet Managed Care health plan.
Once enrolled, members have 90 days to choose a different MO HealthNet Managed Care health plan for any reason if they would like to. Once the 90-day change period ends, the member is locked into the MO HealthNet Managed Care health plan for one year unless they have “just cause” to ask for a change and it is approved. Examples of “just cause” include:
- The member’s Primary Care Provider is no longer in their MO HealthNet Managed Care health plan (but is with another plan)
- The member needs to transfer to another MO HealthNet Managed Care health plan to ensure continuity of care
- There has been an act of cultural insensitivity that negatively impacts the member’s ability to get care and cannot be resolved by the MO HealthNet Managed Care health plan
- A child is in the state’s custody (foster care) or receives adoption subsidy (these children can change health plans as often as necessary)
Additionally, each year members have an annual open enrollment period, and during that time they may choose to transfer to a different MO HealthNet Managed Care health plan for any reason.
Services are monitored for quality, member satisfaction, and contract compliance. Quality is monitored through various on-going methods, like:
- MCO Health Employer and Data Information Set (HEDIS) indicator reports
- Annual reviews
- Enrollee grievances and appeals
- Targeted record reviews
- Annual external quality reviews
Consumer input into services, processes, and programs is obtained through meetings of the MO HealthNet Member Forum and from annual member satisfaction surveys. Other ways satisfaction is measured includes the percentage of MO HealthNet Managed Care members who selected their own MCO; the low percentage of MO HealthNet Managed Care members who requested transfers; and the low percentage of MO HealthNet Managed Care members randomly assigned.
In addition to quality assessment and member satisfaction monitoring, MCO compliance with contractual requirements is a primary method of measuring attainment of managed care goals. Contractual compliance monitoring begins with the issuance of the Request for Proposal (RFP) and continues with the review of proposals submitted, assessment of MCO provider networks, and readiness reviews of MCOs' operations.
The state realizes that the keys to a successful managed care program include the provision of quality services, the satisfaction of members, and the involvement of stakeholders. To connect with stakeholders and encourage involvement, the state formed a MO HealthNet Member Forum to advise the Director of the MO HealthNet Division (MHD) on issues relating to member participation in the MO HealthNet Managed Care Program.
The committee meets periodically throughout the year and consists of a minimum of 15 members and advocates. As the state develops and refines educational materials, the MHD Member Forum is instrumental in making recommendations to enhance consumer education as well as any changes needed to improve either the care provided or the way care is delivered
In an effort to involve various stakeholders, especially those with special health care needs, the state has used the following forums:
- Quarterly meetings with provider groups, such as physicians, dentists, hospice providers, the Drug Utilization Review Board, the MO HealthNet All Plan Administrators, the MO HealthNet Medical Directors, the MHD Member Forum, and the QA&I Advisory Group and related subgroups
- Frequent interactions with the State’s Advocates for Family Health (ombudsmen services) regarding ways to help individuals access care easier and ways to coordinate care with other state agencies
- Publication of the RFP online
- Publication of provider bulletins online about MO HealthNet Managed Care issues
- Collaboration and regular meetings with Department of Health and Senior Services (DHSS), Department of Mental Health (DMH), and the Department of Elementary and Secondary Education (DESE), as well as with sister agencies within the Department of Social Services
After comments are gathered from these stakeholders, policy is developed or changed to incorporate suggestions that impact the MO HealthNet Managed Care Program. For instance, the QA&I Advisory Group recommended and the state implement guidance on intensity of care decisions regarding the hospital care of premature infants and guidance on approving speech therapies that are duplicated by those therapies specified in an Individual Education Plan (IEP). As another example, the state and DMH worked with the MCOs and the MO HealthNet Member Forum (previously known as the Consumer Advocacy Project) to develop protocols for how to coordinate mental health care provided by the MCOs and DMH.
In addition to these ongoing activities, a large amount of information was gathered by the state during the testimony and hearings held on House Bill (HB) 335. HB 335 passed the Missouri General Assembly in 1997 and addressed managed care issues such as patient’s rights, grievances and appeals, the definition of an emergency, network adequacy, and enrollee notice in utilization review decisions. Hundreds of providers, advocates, and citizens (including those with special health care needs) testified on this legislation. The testimony helped shape this law, which has been incorporated into the state’s contracts with MCOs.
Children’s Health Insurance Program (CHIP)
Missouri’s Children’s Health Insurance Program (CHIP) was a Medicaid expansion implemented on September 1, 1998 through a waiver under Section 1115 of the Social Security Act and a Title XXI Plan that covers children under the age of 19 in families with a gross income of 300 percent of the Federal poverty level (FPL). The Uninsured Parents Program, implemented in February 1999, a subgroup of the Managed Care Program, provided health insurance for some uninsured parents through an 1115 Demonstration Waiver. The Uninsured Parents Program was discontinued effective July 1, 2005. Coverage for both the CHIP Program and the Uninsured Parents Program was provided through the Managed Care delivery system in areas of the State covered by the Section 1915(b) waiver and through the Fee-For-Service Program in the reminder of the State. Uninsured women who lost their eligibility 60 days after the birth of their child were covered for women’s health services for an additional year, regardless of their income level. This population received services through the Fee-For-Service Program. Uninsured Women continue to receive services through a section 1115 family planning demonstration.
Missouri submitted a combination Children’s Health Insurance Program (CHIP) State Plan under Title XXI of the Social Security Act for the Children’s Health Insurance Program May 31, 2007. The Centers for Medicare and Medicaid Services (CMS) approved Missouri’s CHIP State Plan on September 28, 2007, with an effective date of September 1, 2007. Title XXI provides funds to states to enable them to provide health assistance to uninsured, low-income children in an effective and efficient manner.