Articles & Frequently Asked Questions

If you are a DMH Agency or Facility and have any questions please email DMH.MedicaidEligibility@dmh.mo.gov.

Articles

Using Paid Out of Pocket Medical Expenses for Spend Down

Participants who pay-in their spend down to the MO HealthNet Division and also have out-of-pocket medical expenses they must pay can use the out-of-pocket expenses to meet the spend down for up to three future months.  

Types of medical expenses that can be counted to meet the spend down include (but are not limited to):

  • all prescribed drugs, dental, and vision care
  • doctor bills
  • prescribed, over-the-counter nutritional supplements, nutrition replacements, dietary supplements
  • personal care services not currently provided by other federally-funded programs
  • private duty nursing services in the home
  • prosthetic devices
  • hearing aids
  • transportation for medical care (with specific conditions)

The paid bills need to be submitted to the Family Support Division. Bills can be submitted either at a local office, online at the MyDSS page or on the MyDSS portal.

Once the FSD Spend Down unit has documentation of the paid bill, they will notify the MO HealthNet Division (MHD) Premium Collection’s unit and mail an Out-of-Pocket Expenses form (IM-29OPE) to the participant to notify them of the amount allowed. MHD will then reduce the future months spend down amount.  

Spend Down & Premium Amounts in CIMOR

Due to a March 2023 change in the MO HealthNet Premium Collection system, CIMOR will only show the amount of a consumer’s Spend Down, TWHA premium, or CHIP premium if the consumer is the case head (also called head of household, or “primary” member) on their MO HealthNet case.

For married couples this means that CIMOR will not display the Spend Down or TWHA premium for the spouse who is not the case head. 

For CHIP premium children (ME codes 73,74, 75), the premium is not displayed as the parent or guardian is the case head.   

If a consumer’s MO HealthNet is SD, TWHA premium (ME code 85), or CHIP premium (ME codes 73,74,75) they only have coverage for dates they have a lock-in.  If there is no lock-in, the premium has not been paid or the Spend Down has not been met. If there is no lock-in for these cases, there is no coverage.  

If you need to know the premium or Spend Down amount on a case, send the consumer’s name and DCN to DMH.MedicaidEligibilty@dmh.mo.gov requesting we look it up for you.    

Blind Pension and Medicaid for DMH Services

Blind Pension (BP) is a cash grant program for blind people who are ineligible for Supplemental Aid to the Blind (SAB) for reasons other than age or vision (typically income or assets). 

BP recipients receive a cash grant of $917 per month and are automatically enrolled state-only funded MO HealthNet (ME code 02), which covers all services covered by Missouri Medicaid for blind adults EXCEPT:

  • Section 1915(c) home and community based waiver services (including DMH Division of Developmental Disability waivers
  • CPR (Community Psychiatric Rehabilitation)
  • CSTAR (Comprehensive Substance Treatment and Rehabilitation)
  • NEMT (Non-Emergency Medical Transportation)
  • Transplant services

BP recipients who need services not covered by ME code 02 may receive federally matched Medicaid under MHABD (ME code 12) spend down / non-spend down or TWHA (ME code 85 or 86) if they meet the asset limit for MHABD, but a special request must be made as overrides to the Family Support Division eligibility system must be entered.  

                                                                                                           

Contact the DMH Medicaid Eligibility unit if you have a BP recipient (ME code 02) who needs CPR, CSTAR, or DD waiver services for assistance in getting the recipient approved for MHABD.            

 

A sample request form for the participant to sign and submit is available on the DMH Medicaid Eligibility web page. 

Spend Down Provider Form Processing

Family Support Division (FSD) has implemented automated processing of the online MO HealthNet Spend Down Provider form. This improvement to the online form enables participants to have their coverage activated in as little as one business day.

Once the provider submits the online form, the information is considered verified, and the system updates overnight. If the charges meet the participant’s spend-down amount, their coverage will be shown as active in eMOMed the next business day.

This expedited process eliminates the necessity for requesting priority processing through the DMH Medicaid Eligibility unit.

Should coverage not appear in eMOMed within two business days after the online form submission or 30 days following the submission of a paper form, please send an email to DMH.SpendDown@dmh.mo.gov for assistance. It is important to ensure that all necessary steps are taken promptly to avoid any delays in coverage activation.

DSS H.R.1 Implementation

H.R.1(2025) is a sweeping budget reconciliation bill that makes significant changes to tax law, social programs, and spending. It was signed into federal law July 1, 2024 and contains changes to Medicaid and SNAP financing, eligibility, and operational requirements. The Missouri Department of Social Services has established a hub (linked in the blue box above) to share how the DSS is planning to implement H.R.1. It contains resources to help understand how the bill affects Missourians along with a timeline highlighting the effective dates of key provisions.
The changes that directly affect MO HealthNet eligibility are:
Non-Citizen Changes
• Effective Oct. 1, 2026, Medicaid and CHIP eligibility will be limited to lawful permanent residents (after a five-year waiting period), Cuban and Haitian entrants, and individuals from the Compacts of Free Association nations (the Marshall Islands, Micronesia, and Palau). Individuals in any other immigration status (including refugees, asylees, domestic violence victims, and victims of trafficking) will no longer be eligible.
Other Changes
• Effective Jan. 1, 2027, work requirements for the Adult Expansion Group (AEG) go into effect. Adults (age 19-64) must complete 80 hours per month of work, education, or community service to be eligible for AEG. There will be limited exemptions. The U.S. Department of Health and Human Services (HHS) must issue a federal rule by June 1, 2026 on the work requirements.
• Effective Jan. 1, 2027, AEG eligibility renewals must be done every 6 months, rather than annually as required for all other Medicaid categories.
• Effective Jan. 1, 2027, (for applications submitted on or after this date) retroactive Medicaid is reduced from up to three months to one month for AEG and two months for all other categories.
• Effective: Oct. 1, 2028, cost-sharing for AEG participants with income above 100% of the Federal Poverty Level will be required. Maximum cost-sharing is $35 per service and 5% of income. Excludes services such as primary care, behavioral health, and those provided in Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Certified Community Behavioral Health Clinics (CCBHCs).

DMH Consumers Due for Annual Review Report

Beginning on May 15 2023 DMH will resume production the report of Consumers Due for Annual Review. As in the past, this report will be placed in each agency/facility’s reports folder in the FTE portal.
The report has been revised to better provide information due to the changes FSD has made in how the Annual Reviews will be completed. The report now will only show those consumers who need to submit a renewal form for the next month.
The information on the report has been adjusted so it will now correctly show the “due date” as the last date the form can be received to allow coverage to be continued uninterrupted.
The 5/15/23 report will list consumers who need to return a renewal form by 06/30/23.

PRESUMPTIVE ELIG. & PHARMACY BILLING

Presumptive Eligibility (PE) allows consumers to gain immediate access to medical services while an application is submitted to be processed for ongoing MO HealthNet coverage. Consumers can greatly benefit from PE because it allows them to start on the medications they need more quickly, instead of waiting for the Family Support Division to process their application.
The PE form, once completed, will have the consumer’s DCN on it. The DCN is what the pharmacy will use to build insurance coverage into the pharmacy system for processing. Depending on the processing time for the PE application some early claims may not process immediately, but the PE form verifies the active coverage and the pharmacy can use the information provided by the PE form to reprocess the claim after a few days if it does not process correctly.
PE ensures reimbursement to MO HealthNet pharmacy providers for any covered medication dispensed to the patient. If a patient presents a pharmacy provider with a PE-3 or PE-3 TEMP, the pharmacy can bill for covered medications provided to the patient. The PE eligibility must be processed by a worker and entered into the MO HealthNet system, and so will not immediately show as available in the point-of-sale pharmacy system. However, these forms are proof of valid coverage, and once issued they guarantee eligibility after the date on the form.

When billing MO HealthNet for services provided to PE patients, pharmacy providers should make a copy of the PE-3 and PE3TEMP forms for their files. This serves as documentation of the consumer’s eligibility. So long as the service is on or provided after the date on the PE-3 and PE-3 TEMP forms, MO HealthNet guarantees reimbursement for any covered medication dispensed. This also includes medications that generally require prior authorization.
Once the DCN is active, the pharmacy should reprocess any unpaid claims for the individual from the date range on the PE forms. If a denial occurs when reprocessing the pharmacy should call or submit a backdate request to MO HealthNet Pharmacy Administration at (573) 751-6963 or MHD.PharmacyAdmin@dss.mo.gov.

TIP: When possible work with a local pharmacy to establish a relationship and refer your consumers to that pharmacy. Because this is a more unusual type of coverage some pharmacies may need education before accepting PE forms in order to dispense medication, and this could lead to delays in the dispensing of medication where there should not be delays.

MANAGED CARE CHANGE 2023

On 02/19/23 MO HealthNet Division switched to a new contractor a new contractor (AHS) for managed care enrollment and premium collections.
This change has caused some participants who had previously opted out of managed care to be auto-enrolled into a managed care plan. People who have been opted into a managed care plan but who need to be fee-for-service will need to opt out again.
An individual may choose to be in the MO HealthNet fee-for-service program rather than managed care program if at least one of the following criteria is met:
• Eligible for Supplemental Social Security (SSI)
• Meet the SSI disability definition as determined by the Missouri Department of Social Services
• Individual is a child with special health care needs
• Individual is disabled and 18 or younger
• Receiving foster care or adoption assistance
• Individual is in foster care or in out-of-home placement
In the event that opting out is due to meeting the SSI disability definition as determined by the Missouri department of Social Services, the consumer will be asked to provide medical records to support this.
If any of the above criteria is true for the consumer you are assisting, they can contact the Managed Care Enrollment Helpline at 1-800-348-6627. The helpline can help answer questions about opting out, and help to begin that process. The hours for the helpline are 7:00am to 6:00pm, Monday - Friday except state holidays.

Understanding the MO HealthNet Application Process (Newsletter Issue 6, 12/09/2022)

Missouri now uses a single application form to apply for Medicaid. Applying online or by mail will begin the application process. Once the application is received, FSD will screen the application to see if the applicant is eligible as a child (if under 19), a pregnant woman (if pregnancy is claimed), as a parent/caretaker (if a child under age 19 is in the home), or in the adult expansion group (if age 19-64 and ineligible as a pregnant woman or parent/caretaker).


If during the initial eligibility check it is determined that the applicant is age 65+ or claiming disability and/or blindness the application will ALSO be evaluated for eligibility in the categories for the Aged, Blind, and Disabled.
Visit our website for more information about Applying for MO HealthNet.

Learn More about Presumptive Eligibility (Newsletter Issue 6, 12/09/2022)

Presumptive Eligibility allows eligible individuals to gain immediate access to medical services temporarily while a full application is submitted and processed to establish on-going Medicaid coverage.


Providers do not need access to FAMIS or MEDES in order to submit the memorandum of agreement (MOA) to do Presumptive Eligibility. Also staff do not need access to MEDES or FAMIS to do the actual PE determinations, but having access is beneficial in two ways:

  • A person can only receive PE once during a pregnancy and only once in 12 months for children and the other adult categories. In CIMOR and eMOMed, the ME code identifies when a person has received PE as a pregnant woman (58, 59, 94) or child (87). However, PE for parents/caretakers, former foster care youth, or AEG use the same ME code as those regular categories (05, 38, and E2). When the 05, 38, or E2 are for PE, they have a TOA of “P” on the record but this is not displayed in CIMOR or eMOMed. You only see the TOA on the MO HealthNet MXIX screen which you can access through FAMIS.

  • It allows you to track the progress of the regular application.


    Although PE determinations are not done for the MO HealthNet based on disability eligibility category (ME code 13), many (perhaps most) of DBH consumers with a disability will qualify for PE in the Adult Expansion Group. The only ones who would not are the ones who are receiving Medicare or have income above the AEG monthly income limit ($1,563 for a single person, $2,106 for a married couple). While SSI recipients cannot receive regular AEG (and must be approved as ME 13), they are eligible for AEG-PE as the PE application asks for the amount income but not the source or SSI status.


    Additional information about presumptive eligibility and the process to enroll as a Qualified Entity is available on the DMH website’s Medicaid Information for DMH Agencies and Providers page under Presumptive Eligibility.

HIPP Changes (Newsletter Issue 6, 12/09/2022)

The Health Insurance Premium Payment (HIPP) program is a MO HealthNet program that pays for the cost of health insurance premiums for certain MO HealthNet participants. The program purchases health insurance for MO HealthNet-eligible participants when it is determined cost effective.


Effective 1/1/23 the HIPP program will not cover MO HealthNet participants who are:

  • eligible for or enrolled in Medicare
  • eligible for or enrolled in a MO HealthNet Managed Care plan,
  • who have a health insurance policy which is court ordered.

Any participant who is eligible in a family MO HealthNet category (children, pregnant women, parents, adult expansion group) are eligible for enrollment in a MO HealthNet Managed Care plan, and so no longer be covered by the HIPP program.


MO HealthNet Division has notified the effected participants that HIPP will stop paying their premiums.


At least some of the insurance plans have contacted the participants to see if they wish to pay the premium in order to continue/keep their active coverage.


Discontinuing the private insurance will not affect the participants Medicaid eligibility or coverage. If the private insurance is dropped, services that would have been billed to the private insurance will be billed to Medicaid for the costs not covered by Medicare.

1619(B) Status (Newsletter Issue 6, 12/09/2022)

Section 1619(b) of the Social Security Act allows certain disabled individuals who no longer qualify for SSI due to income from employment to remain eligible for Medicaid/MO HealthNet. Individuals who have 1619 status continue to meet the SSI disabilities requirements for purposes for MO HealthNet Disabled coverage.


1619(b) coverage through MO HealthNet is only available to individuals who received MO HealthNet in the month immediately preceding the month of attaining SSA 1619 status. This means that the claimant must have had active coverage in the month before they were approved for 1619 status and would need to apply based on other criteria, such as low income or disability.


There is no Medicaid income limit for 1619 individuals; their eligibility is determined by SSA. Individuals with 1619(b) have a lower resource limit, $2,000 for an individual and $3,000 for a couple. This is based on the SSI resource limits.


The Social Security Administration determines who meets SSA 1619(b) eligibility and will notify the individual by mail of eligibility. The individual should provide FSD a copy with this letter so that the case can be adjusted.

Reinstatement of Medicaid After Department of Corrections Incarceration Ends (Newsletter Issue 4, 09/09/2022)

When a Medicaid participant is incarcerated in a Missouri Department of Corrections (DOC) facility or a local jail for longer than 30 days, DOC or the jail is to report the incarceration and then their Medicaid coverage is suspended. This is done by the MO HealthNet Division (MHD) locking them into an Incarcerated status.


When FSD receives a report from DOC or the jail that participant is going to be released, they will have MHD end the Incarcerated lock-in which reactivates coverage effective the date of release after completing a redetermination (without requiring a new application).


DOC or the jail may report the pending release up to 45 days prior to the planned release date.


Sometimes DOC (or jail) fails to notify FSD of the release and when providers see the participant the Incarcerated lock-in is still in effect.
When this occurs and it has been over a couple of weeks since the release, the provider should assist the participant with completing a Reporting Release of MO HealthNet Participant (IM-152) form and submit it to FSD at the email address on the form.


The IM-152 form can also be used when an Incarcerated lock-in has ended, but there is information that the participant was released prior to the lock-in end date.

Frequently Asked Questions 

I have questions about Medicaid Expansion

The Missouri Department of Social Services has a comprehensive FAQ document available for providers, and that can be found here: Frequently Asked Questions: Adult Expansion for Providers

They have also put together a Frequently Asked Question document for participants, which can be found here: Frequently Asked Questions: Adult Expansion for Participants

What is needed for former Sheltered Workshop employees to have their current income excluded when establishing the spend down or premium?
  • Most recent 30 days paystubs from the sheltered workshop.
  • A letter from Department of Elementary and Secondary Education (DESE) or the sheltered workshop stating the participant is employed by the sheltered workshop or is eligible for extended employment at a sheltered workshop.
  • A DESE form certifying eligibility for extended employment at a sheltered workshop.
  • Pay stubs or other documentation that shows the participant worked at a sheltered workshop within the last 12 months.
How can we help our consumers apply when we are not seeing them in person?

We strongly encourage all DMH agencies and providers to have the consumers they are assisting sign an authorized representative form designating the agency as the authorized representative for MO HealthNet eligibility.


Once this form is completed and signed by both the client and the authorized representative, the application can be completed with the client over the phone and submitted online, or printed and signed by the authorized representative. 

What are the benefits to becoming an authorized representative?
  • The IM-6AR Appointing an Authorized Representative form should be used if the application has already been submitted and the "Appendix C" was not included with the application.
  • The agency will receive copies of all letters and requests for information sent to the client for Medicaid cases based on disability, blindness or being over age 65 as those letters are system generated.
  • The agency should receive copies of all letters requests for information sent to the client for Family Medicaid cases (children, parents, pregnant women).  However, the although the Family MO HealthNet  letters are system generated, copies to the authorized representative have to be sent manually, so some may be missed.
  • The authorized representative may sign applications for the client.
If an individual age 22-65 in a State Mental Hospital is diagnosed with COVID-19 and moved to a hospital outside of the of the SMH can they qualify for MO HealthNet?

No. Regardless of admission to a hospital the individual will be considered residents of the SMH. In order to qualify for MO HealthNet they must be officially discharged. 

How can we submit applications without going to a local FSD resource center?

Apply using the DSS online portal for all applications. If you cannot apply online the next best option is to scan and upload the application using the FSD Upload Portal.

How can we submit verification without going to a resource center?

Submit documents or applications along with the client's date of birth and SSN or DCN by:

Upload: https://mydssupload.mo.gov/UploadPortal

Fax: 573-526-9400

Mail: Family Support Division
PO Box 2700
Jefferson City, MO 65102

I need to speak to someone at FSD. How do I reach them?

You can call 1-855-FSD-INFO but if you are a contracted agency or provider we strongly encourage you to email us at DMH.MedicaidEligibility@dmh.mo.gov. We do have a FSD worker at Central Office and typically can assist you with questions about DMH consumers quicker than calling the call center.