Missouri – EPSDT
- As of July 1, 2011, there were 895,998 beneficiaries enrolled in the state’s Medicaid program, known as MO HealthNet; 406,796 of these individuals were enrolled in managed care. Medicaid beneficiaries who receive supplemental security income (SSI), meet the medical definition for SSI, or are eligible for adoption subsidy benefits are not required to enroll in managed care.
- Physical, behavioral, and oral health benefits are provide through 12 Medicaid-only managed care organizations (MCOs).
- 447,317 beneficiaries received transportation services through a prepaid ambulatory health plan (PAHP).
- Children with developmental disabilities may be eligible to receive services from the state’s five Medicaid Home and Community Based Waiver programs, which include the Comprehensive waiver, the Missouri Children with Developmental Disabilities Waiver, the Support Waiver, the Autism Waiver, and the Partnership for Hope Waiver.
As of 2012, 693,684 individuals were eligible for Missouri’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT) program, known as Healthy Children and Youth (HCY). According to 416 data from 2012, the state achieved an EPSDT screening ratio of 100% and a participant ratio of 74%. 229,450 children received dental services of any kind, with 205,884 receiving preventive dental services.
Last updated September 2014
Missouri Medicaid defines medically necessary services as those that are:
“reasonable and medically necessary for the prevention, diagnosis, or treatment of a physical or mental illness or injury; to achieve age appropriate growth and development; to minimize the progression of a disability; or to attain, maintain, or regain functional capacity; in accordance with accepted standards of practice in the medical community of the area in which the physical or mental health services are rendered; and service(s) could not have been omitted without adversely affecting the participant’s condition or the quality of medical care rendered; and service(s) is(are) furnished in the most appropriate setting. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity, and aren’t mainly for the convenience of you or your doctor.”
Missouri’s administration rules on EPSDT echo the federal definition of medical necessity for children, stating that “Medical and dental services which Section 1905(a) of the Social Security Act permits to be covered under MO HealthNet and which are necessary to treat or ameliorate defects, physical, and mental illness or conditions identified by an EPSDT screen are covered regardless of whether or not the services are covered under the Medicaid state plan. “
MO HealthNet collects and publishes HEDIS data on Medicaid managed care plans. Measures collected include:
Behavioral health and substance abuse services provided by MO HealthNet managed care plans include outpatient facility, psychiatry, psychology, and counseling services; for children in the care and custody of the state, these services are reimbursed on a fee-for-services basis. Psychology services for children under the age of 21 are covered by the HCY program.
Support to Providers
MO HealthNet produced a chapter within its provider manual on the Health Children and Youth Program. The chapter includes information on medical necessity, screening components, and general program requirements.
Support to Families
The Missouri Department of Social Services operates a Healthy Children and Youth Program website that includes informationon how to access services, covered services, and a frequently asked questions section. Medicaid beneficiaries can also search for a participating managed care provider using a state developed search tool.
Passed in 2007, Senate Bill 577 requires MO HealthNet to provide all beneficiaries with a health care home in order to improve access to care that is coordinated and person-centered. In 2011, Missouri received CMS approval to implement two Section 2703 Health Homes for enrollees with behavioral health and physical health conditions. For more information on Missouri’s health home initiatives, visit the NASHP health homes page.
Children eligible for the Healthy Children and Youth program receive care coordination services from Special Health Care Needs (SHCN) Public Health Nurse Service Coordinators. Services include health care assessments, home visits, transition planning, family support, and assistance in establishing a medical home.
– See more at: https://nashp.org/epsdt/Missouri#sthash.hShy2dzA.dpuf