1) State: Missouri
2) Own or Federal Exchange? Federal Exchange
Source: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/missouri.html
3) Medicaid Expansion? No
Source: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/missouri.html
4) In all cases – need to designate if rules are associated with Federal or State mandates/coverage
5) What are Medicaid eligibility criteria?

To be eligible for one of the coverages of Missouri Medicaid or SCHIP (called HealthNet) you 1)
must be a Missouri resident, 2) in most cases, you must meet financial eligibility requirements
(explained in the chart above), and 3) meet one or more of the categories below:
o a family living with children under the age of 19 years
o
a pregnant woman with or without children
o
o
o
o
o
o

a person who is long-term unemployed
a disabled person
an adult who is working for a qualified employer
a person who is HIV positive
a child under the age of 19 years
an adult caretaker relative living with children under 19 years of age when neither
parent is living in the home
o elderly (65 or older)
o a woman with breast or cervical cancer
o a person in need of long-term care
There are also specific asset rules related to real estate, bank accounts, and securities shown on
the website below.
Source: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward2014/Downloads/Medicaid-and-CHIP-Eligibility-Levels-Table.pdf
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/missouri.html
http://aspe.hhs.gov/poverty/14poverty.cfm
6) What kind of coverage is available for mental health care?

All approved plans regardless of Federal or State-run Exchanges must cover the same package of
10 benefits, called essential health benefits.
1. Outpatient services, such as doctor visits or tests done outside a hospital. This includes
fertility treatments.
2.
3.
4.
5.
6.
7.
Emergency services
Hospital stays, including weight loss surgery
Pregnancy and baby care
Mental health and substance abuse services, including behavioral health treatment
Prescription drugs, including generic and certain brand-name drugs
Rehab and habilitative services, those that help people recover from an accident or
injury and those that help people with developmental issues.
8. Lab tests
9. Preventive and wellness services, along with those that help people manage chronic
conditions. This includes contraceptives, hormone replacement therapy, and wigs for
people who are balding.
10. Services for children, including dental and eye care (but not eyeglasses)
Source: www.healthcare.gov
7) What kind of coverage is available for substance abuse treatment?

Medicaid must cover some types of services, which are shown below under mandatory services,
and Medicaid may cover some other types of services, which are shown below under the state
of Missouri. Only those types of services that include mental health or substance abuse services
are shown in the charts.
Source: http://store.samhsa.gov/shin/content/NMH05-0202/NMH05-0202-MO.pdf
8) Does the state allow the court to order treatment and still have it paid by Medicaid?

The court can order treatment and have it paid by Medicaid if the services are covered by
Medicaid. (shown in the charts in question 7)
9) What happens to the health care coverage when a participant is sanctioned to jail (not prison)? How
many days can someone be incarcerated before s/he loses their coverage?

Federal health programs will not pay for your care, but jails and prisons are responsible for
providing essential health and mental health services to all inmates. You have a constitutional
right to treatment while in jail or prison and can request it. Medicaid does not pay for any
services while you are in jail or prison. Many states will take your name off their Medicaid list
when you are incarcerated and you will have to re-apply when you are out of jail.

Detainees may apply for Medicaid and CHIP at any point. However, if determined eligible for
Medicaid, eligibility must be suspended while incarcerated, and health care services cannot be
covered by Medicaid until release, except for off-site inpatient medical care lasting 24 hours or
more.

Federal Medicaid law and the regulations promulgated by the Centers for Medicare and
Medicaid Services (CMS) govern when and how individuals both lose access to federal Medicaid
when they are incarcerated and when full coverage can be restored or established for released
inmates. These rules are quite complex and are intertwined with rules of other federal benefit
programs.

Medicaid law requires a discontinuation of federal payment for services (known as federal
financial participation, or FFP) once an individual is in a public institution, including a jail or
prison. However, federal rules on Medicaid eligibility are different from those governing
federal payment for services. While the law prohibits federal payment for services furnished to
anyone incarcerated in jail or prison, it does not require that individuals lose their Medicaid
eligibility.

Individuals can retain their status as a Medicaid-eligible person while in jail or prison. States
must use appropriate administrative measures to ensure that no Medicaid claims are filed with
the federal government while the individual is incarcerated, but they can temporarily suspend
an eligible individual from payment status without terminating them totally from the program.
In addition, before terminating someone, states must meet certain federal requirements:
o
States must continue Medicaid to all eligible individuals “until they are found ineligible.”
o
A state cannot terminate an individual from Medicaid until it has conducted a
redetermination of their eligibility, including an ex-parte review.
o
States “have an obligation under federal law to ensure that their computer systems are
not improperly denying enrollment in, or terminating persons from Medicaid.
Source: ACA Jails pdf, http://www.kitsapgov.com/pubdef/Forms/LinkClick.Benefits.pdf,
http://www.bazelon.org/LinkClick.aspx?fileticket=_Ns68MefCJY%3D&tabid=441
10) What happens to an individual’s coverage when they get a new job? (Or lose a job?) Are there any
“grace periods” of coverage?

If a person has insurance through the Marketplace, getting or losing a job will not affect an
individual’s coverage. The person will need to update their information on the Marketplace
when changes occur because subsidies will be adjusted.

If a person has insurance through their job and lose the job, COBRA continuation coverage may
be available. COBRA, which generally applies to employers with 20 or more employees, allows
the individual and his/her family to continue the same group health coverage. An individual’s
cost for coverage may be higher than what the individual was paying before (and is usually
higher than the cost for coverage under special enrollment in a spouse’s plan), but generally the
cost is lower than that for private, individual health insurance coverage. The plan should send a
notice regarding the availability of COBRA coverage. After this notice is provided, the individual
generally has 60 days to elect coverage and it is then available retroactive to the loss of
coverage. COBRA coverage typically lasts 18 months, but may last longer in certain
circumstances.

Once someone is enrolled in Medicaid, they must renew their eligibility at least once a year or
when there is a change in their circumstances, such as an increase or decrease in any public
assistance.
Source: http://www.dol.gov/ebsa/newsroom/fsjobloss.html
11) Are there restrictions related to treatment providers for probationers, substance abuse, or mental
health treatment? Will only certain providers be covered?

The Department of Social Services is officially designated as the single state agency charged with
administration of the Missouri Medicaid program, HealthNet. Approved, enrolled MO HealthNet
Program providers of service provide services. Those who participate in the MO HealthNet
Program agree to accept MO HealthNet payment as reimbursement in full for any services
provided to MO HealthNet participants. A participant cannot be billed for the difference
between the MO HealthNet payment and the provider’s billed charges. MO HealthNet Managed
Care services are provided in accordance with the terms and conditions of the contract between
MHD and the MO HealthNet Managed Care health plans. Participants enrolled in MO HealthNet
Managed Care access services through the health plan’s provider network. The health plan
network may include providers not enrolled in the fee-for-service program.
Source: http://dss.mo.gov/mhd/general/pages/about.htm
12) Is there coverage for residential substance abuse treatment? What are the parameters?

Yes, to obtain inpatient psychiatric services, a beneficiary must be medically certified as
requiring that level of care, services must be prescribed by a physician, and the Medicaid
agency's designated agent must authorize the admission and the length of stay. (see question 7)
Source: http://store.samhsa.gov/shin/content/NMH05-0202/NMH05-0202-MO.pdf
13) What is the process and what are the regulations for treatment providers to be able to participate?

In MO Drug Courts, a treatment provider will be responsible for providing all necessary
treatment services for the client or be able to refer (with approval of the court) to special
treatment services as needed. One treatment professional will be assigned to provide the initial
assessment of the client prior to the first court appearance. Another person will be responsible
for providing the treatment services. Reports from the treatment provider will be required by
each court date. The provider will be a key member of the drug court team and is required to
attend all drug court dates and staffing prior to court. All treatment providers must meet
requirements by the state of Missouri to practice and are likely enrolled in MO HealthNet
Program to provide services.
Source: http://www.modrugcourts.org/showpage.php?page=4
14) Is dental care covered?


Dental care is an option in the Marketplace, but is not included in the basic plan (except for
children). Up to $3,000 is provided for dental care due to accidental injury NOT related to
chewing/biting
Dental services are covered by MO Medicaid Services but are limited for adults who are not in a
category of assistance for pregnant women or the blind.
Source: www.healthcare.gov
15) What is the basic primary medical care coverage? Are well-women check-ups included? Is birth
control included?
Yes for both. See question 6.
16) How does family member coverage work?

Go to the healthcare.gov website, choose your state and apply for family coverage. All of the
plans will cover the 10 essential benefits listed above. On the first step, if you and your family is
not eligible for subsides through the healthcare.gov website, it will take you to the Missouri
Medicaid website to apply for family coverage. Because Missouri did not expand Medicaid,
there will be people who fall in the coverage gap between 100-138% of the FPL.
Source: www.healthcare.gov